Noel Schenk MD Davis Behavioral Health
Michael Botticelli Director of National Drug Control Policy
What is Addiction? Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain; they change its structure and how it works. These brain changes can be long lasting and can lead to many harmful, often self-destructive, behaviors. -National Institute on Drug Abuse (NIDA) https://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction-basics
Brain Changes Opiate Addiction Drugs (and other pleasurable stimuli food, sex, etc.) activate dopamine in reward regions Repeated use lowers levels of D2 receptors Ventral tegmental and ventral striatum (binge/intoxication) Amygdala (withdrawal/negative affect) Orbitofrontal cortex-dorsal striatum, prefrontal cortex, basolateral amygdala, hippocampus, insula (preoccupation/anticipation) Cingulate gyrus, dorsolateral prefrontal and inferior frontal cortices (disrupted inhibitory control) Koob, George F., and Nora Volkow D. "Neurocircuitry of Addiction." Neuropsychopharmacology 35.4 (2010): 1051. Print
Addiction & Other Chronic Illness Addiction Asthma Hypertension Diabetes Type I Diabetes Type II Heritability 0.34 (heroin) 0.36-0.70 0.25-0.50 0.30-0.55 0.80 Behavioral Component trying drug salt sensitivity/ weight/exercise diet diet/weight/ Exercise Relapsed/yr 40-60% 50-70% 50-70% 30-50% Mclellan, A. Thomas, et al. "Drug Dependence, a Chronic Medical Illness." Jama 284.13 (2000): 1689-695. Print.
Evaluation of a Hypothetical Treatment 9 8 7 6 5 4 3 2 1 0 Hypertension Treatment 9 8 7 6 5 4 3 2 1 0 Addiction Treatment Mclellan, A. Thomas. "Have We Evaluated Addiction Treatment Correctly? Implications from a Chronic Care Perspective." Addiction 97.3 (2002): 249-52. Print.
Deaths Involving Opioid Analgesics and Heroin: United States 20000 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 4030 1960 18893 10574 Opioid Analgesic Heroin http://www.cdc.gov/nchs/data/health_policy/aadr_drug_poisoning_invo lving_oa_heroin_us_2000-2014.pdf
Utah Prescription Opioid Deaths by Year 350 300 326 290 250 200 236 150 100 50 0 60 2000 2002 2004 2006 2008 2010 2012 2014 Complete Health Indicator Report of Drug Overdose and Poisoning Incidents. (n.d.). Retrieved August 13, 2016, from http://ibis.health.utah.gov/indicator/complete_profile/poidth.html
Neonatal Abstinence Syndrome Utah 5 Incidence per 1000 hospital births 4 4.1 3 2 1 0 0.8 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Ko, Jean Y., et al. "Incidence of Neonatal Abstinence Syndrome 28 States, 1999 2013." MMWR. Morbidity and Mortality Weekly Report MMWR Morb. Mortal. Wkly. Rep. 65.31 (2016): 799-802. Print.
Utah and Opioid Abuse 2014, 32% of Utah adults had been prescribed an opioid pain medication in the last 12 months In Utah, 24 die each month from prescription drug overdoses Utah ranked 4th in the U.S. for drug poisoning deaths from 2012-2014, which have outpaced deaths due to firearms, falls, and motor vehicle crashes Prescription Drug Overdoses. (n.d.). Retrieved August 13, 2016, from http://www.health.utah.gov/vipp/topics/prescription-drug-overdoses/
Utah and Opioid Abuse In Utah, the top five circumstances observed in prescription opioid deaths were: 65% substance abuse problem 62% mental illness 61% physical health problem 16% history of alcohol dependence or problem 10% history of suicide attempt Prescription Drug Overdoses. (n.d.). Retrieved August 13, 2016, from http://www.health.utah.gov/vipp/topics/prescription-drug-overdoses/
Buprenorphine Versus Placebo Effectiveness Low dose (2-6mg) RR 1.5 remain in treatment No difference in UA positive for opioids Medium Dose (7-15mg) RR 1.74 remain in treatment No difference in UA positive for opioids High Dose (>16mg) RR 1.82 remain in treatment SMD -1.17 change in UA positive for opioids Mattick, Richard P, et al. "Buprenorphine Maintenance versus Placebo or Methadone Maintenance for Opioid Dependence." Cochrane Database of Systematic Reviews Reviews (2014): n. pag. Web.
Urine Testing for Opioids 25.00% 20.00% 15.00% 17.80% 20.70% 10.00% 5.00% 5.80% 0.00% % Clean UA's Buprenorphine Buprenorphine/Naloxone Placebo Fudala, Paul J. et al. "Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone." New England Journal of Medicine N Engl J Med 349.10 (2003): 949-58. Print.
Long Term Maintenance 18-42 month follow-up 77% remained on continuous buprenorphine Those on continuous buprenorphine more likely: Report abstinence from all substances Have an AA affiliation Be employed Parran, T.v., et al. "Long-term Outcomes of Office-based Buprenorphine/naloxone Maintenance Therapy." Drug and Alcohol Dependence 106.1 (2010): 56-60. Print.
Long Term Maintenance 1 Year follow-up versus placebo 75% retention in buprenorphine group, 0% in placebo UA negative 75% in patients remaining in treatment 2-5 year follow up 91% of UA negative Kakko, Johan, et al. "1-year Retention and Social Function after Buprenorphineassisted Relapse Prevention Treatment for Heroin Dependence in Sweden: A Randomised, Placebo-controlled Trial." The Lancet 361.9358 (2003): 662-68. Print Fiellin, David A., et al. "Long-Term Treatment with Buprenorphine/Naloxone in Primary Care: Results at 2 5 Years." Am J Addict American Journal on Addictions 17.2 (2008): 116-20. Print.
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Overdose Deaths Patients Treated Heroin Overdose Death & Number Treated With Buprenorphine 350 300 250 200 150 100 50 0 12000 10000 8000 6000 4000 2000 0 Heroin overdose deaths Patients treated with buprenorphine Patients treated with methadone Schwartz, Robert P, et al. "Opioid Agonist Treatments and Heroin Overdose Deaths in Baltimore, Maryland, 1995 2009." Am J Public Health American Journal of Public Health 103.5 (2013): 917-22. Print.
Emergency Room Initiated Buprenorphine 100% % engaged in Tx at day 30 80% 78% 60% 40% 20% 37% 45% 0% Buprenorphine Referral Brief Intervention D Onofrio, et al. "Emergency Department Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence." Jama 313.16 (2015): 1636. Print.
Long Term Addiction tx Studies Drug Abuse Reporting Program (DARP) Treatment Outcome Prospective Study (TOPS) Drug Abuse Treatment Outcome Studies (DATOS) National Treatment Outcome Research Study (NTORS) California Drug and Alcohol Treatment Assessment (CalDATA) or California Treatment Outcome Project (CalTOP)
DARP 44,000 Clients 52 Federally funded treatment agencies 12 months percent no longer using daily 64 % Methadone 61 % Treatment Communities 56% Outpatient Treatment stays >90 days associated with favorable outcomes Multiple admissions to treatment, average 6 admissions over 10 years http://www.datos.org/background.html#darp
11,750 clients 41 treatment programs TOPS Those with legal pressure to enter treatment were just as likely to get benefit as those without such pressure http://www.datos.org/background.html#tops1-year
DATOS 10,010 Clients 96 treatment programs Methadone tx for >12 months vs <3 months 4 x less likely to use heroin weekly Residential tx >3 months vs <3 months less likely for weekly cocaine use (14% vs 36%) Less likely heavy alcohol use (11% vs 31%) Less likely predatory illegal acts (12% vs 23%) Less likely Sex related HIV risks (26% vs 33%) Less likely unemployed (71% vs 86%) http://www.datos.org/adults/adults-retention.html
DATOS Outpatient >3 months versus <3 months Less likely weekly cocaine use (14% vs 25%) Less likely heavy alcohol use (13% vs 18%) Less likely to have suicidal thought or attempts (9% vs 14%) Less likely to have sex related HIV risks (19% vs 26%) http://www.datos.org/adults/adults-retention.html
Methadone patients NTORS At one year use compared to intake Heroin 46% Non-prescribed benzo 42% At 4-5 year use compared to intake Heroin 43% Non-prescribed benzo 23% Complete abstinence at 4-5 years: 26% Gossop, Michael, et al.. "The National Treatment Outcome Research Study (NTORS): 4-5 Year Follow-up Results." Addiction 98.3 (2003): 291-303. Print.
CalDATA/CalTOP 2567 clients 43 substance abuse providers 7:1 ration of benefits to cost Ettner, Susan L., et. al. "Benefit-Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment "Pay for Itself"? Health Serv Res Health Services Research 41.1 (2006): 192-213. Print.
Economic Burden $78.5 Billion Florence, Curtis S. et al. "The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013." Medical Care 54.10 (2016): 901-06. Print.
Economic Burden Substance Abuse Treatment, 4% Criminal Justice, 10% Health Insurance, 33% Lost Productivity (non-fatal), 26% Fatal Cost (Lost Productivity and Health Care), 27% Florence, Curtis S. et al. "The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013." Medical Care 54.10 (2016): 901-06. Print.
Opioid Community Collaborative 100% 80% 95% Treatment Retention 84% 79% 60% 40% 59% 32% MAT TAU 20% 17% 0% 3 Months 9 Months 12 Months
Opioid Community Collaborative Treatment Retention DBH 100% 80% 100% 99% 95% 92% 94% 92% 92% 90% 84% 86% 88% 79% 60% 40% 20% 0% 1 2 3 4 5 6 7 8 9 10 11 12 Months
Opioid Community Collaborative 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% MAT Rates of Abstinence 64% TAU
Opioid Community Collaborative 100% 80% 75% 86% 80% 90% 95% 89% 92% 76% 85% 100% 92% 75% 100% 60% 40% 33% 48% 59% 56% 65% 44% 52% 62% 42% 55% 58% 62% 20% 20% 0% 0 2 4 6 8 10 12 Months in treatment Clean UA's opioids Clean UAs all drugs
Opioid Community Collaborative Employment Status after 6+ months MAT Worsened, 0% Stayed the Same, 21% Improved, 79% Improved Stayed the Same Worsened
Opioid Community Collaborative Housing Status after 6+ months MAT Worsened, 7% Stayed the Same, 50% Improved, 43% Improved Stayed the Same Worsened
What is Addiction? Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain; they change its structure and how it works. These brain changes can be long lasting and can lead to many harmful, often self-destructive, behaviors. -National Institute on Drug Abuse (NIDA) https://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction-basics
Naloxone Kits Goal for all patients at DBH with a diagnosis of opioid use disorder to have naloxone kit in their home
Questions?