MAT 101: TREATMENT OF OPIOID USE DISORDER WITH SPECIAL EMPHASIS ON BUPRENORPHINE/NALOXONE ICADD May 22, 2018 Alicia Carrasco, MD Debby Woodall, LCSW, ACADC Magni Hamso, MD, MPH Terry Reilly Health Services University of Washington Boise Internal Medicine Residency
No relevant disclosures. DISCLOSURES
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LEARNING OBJECTIVES Understand the scope of the opioid overdose epidemic Define opioids, opioid use disorder (OUD), addiction and recovery Identify evidence-based treatment options for OUD Understand why buprenorphine/naloxone is an effective treatment for OUD
SCHEDULE Introductions 10 minutes Overview 30-45 minutes Group Work 30 min Report Back and Summary 15min
WHAT ARE OPIOIDS? Prescription pain medicines such as hydrocodone (Norco), oxycodone, morphine, fentanyl Illegal drugs such as heroin Stimulate the opioid receptor in the brain to decrease pain, as side effects make people feel good (euphoria) and slow breathing (overdose risk)
Surgeon General s Report 2016
OPIOID USE DISORDER A problematic pattern of opioid use leading to clinically significant impairment or distress is manifested by two or more of the following within a 12-month (with 2-3 = mild, 4-5 = moderate, 6+ severe): A.Impaired control: 1. taking more or for longer than intended 2. unsuccessful efforts to stop or cut down use 3. spending a great deal of time obtaining, using, or recovering from use 4. craving for substance. B. Social impairment: 5. failure to fulfill major obligations due to use 6. continued use despite problems caused or exacerbated by use 7. important activities given up or reduced because of substance use. C. Risky use: 8. recurrent use in hazardous situations 9. continued use despite physical or psychological problems that are caused or exacerbated by substance use. D. Pharmacologic dependence: 10. tolerance to effects of the substance 11. withdrawal symptoms when not using or using less.
ASAM DEFINITION OF ADDICTION a primary, chronic disease of brain reward, motivation, memory, and related circuitry pathologically pursuing reward and/or relief of withdrawal symptoms by substance use without treatment or engagement in recovery activities, addiction is progressive and can result in disability & death.
ASAM DEFINITION OF RECOVERY a process of sustained action that addresses the biological, psychological, social and spiritual disturbances aims to improve the quality of life... is the consistent pursuit of abstinence
TREATMENT OF OPIOID USE DISORDER
PATIENT CASE 27yo with diabetes, depression/anxiety, IV heroin use comes in to see you. Heroin x 10yrs, mostly IV Multiple admissions for detox Couch surfing.
Harm Reduction TREATMENT OPTIONS Naloxone for reversal of opioid overdose; low & slow ; not alone Needles/Injection technique HIV/HCV testing HAV/HBV vaccines
Detox TREATMENT OPTIONS Studies limited by lack of long-term follow-up May work for motivated individuals with short substance use history and low level of dependence High risk of overdose after any period of abstinence, without MAT
TREATMENT OPTIONS Detox Psychosocial interventions Limited effectiveness on own Can help with detox Recommended in addition to MAT
TREATMENT OPTIONS Detox Psychosocial interventions Medication Assisted Treatment
MEDICATION ASSISTED TREATMENT BupPractice 2013
Opioid antagonist NALTREXONE* Oral daily dosing or once monthly intramuscular injection Blocks intoxicating/reinforcing effects of opioids May work in highly motivated individuals with strong support and limited substance use Some interest pre-release, to reduce overdose High relapse rates, very limited evidence Increased risk of overdose after antagonist wears off *Naloxone is short-acting injectable or intranasal version used for reversal of opioid overdose
METHADONE Opioid agonist Benefits Stay in treatment Decreased heroin use Decreased criminal activity Improved mortality Decreased HIV & HCV Typical dose 80-120mg/d Barriers Stigma Daily dosing Expensive
BUPRENORPHINE/NALOXONE
BUPRENORPHINE/NALOXONE Partial opioid agonist Stimulates receptors only so far, almost eliminating risk of overdose (ceiling effect) Binds receptors so tightly, that no other opioids can get in, also reducing risk of overdose Mixed with naloxone, to prevent misuse/diversion
KAKKO ET AL. LANCET 2003
FIELIN ET AL. JAMA 2014
SAMHSA EVALUATION OF DATA WAIVER PROGRAM 2006
SAMHSA EVALUATION OF DATA WAIVER PROGRAM 2006
SAMHSA EVALUATION OF DATA WAIVER PROGRAM 2006
SCHWARTZ ET AL. AJPH 2012
TSUI ET AL. JAMA 2014
SORDO ET AL. BMJ 2017
PATIENT CASE 27yo man with diabetes, depression/anxiety, IV heroin use comes in to see you. Heroin x 10yrs, mostly IV Multiple admissions for detox Couch surfing.
REQUIREMENTS Moderate to severe opioid use disorder Interest in treatment <60mg methadone/day, <1g heroin/day*
CONTRAINDICATIONS Chronic pain on opioids** Severe alcohol use disorder Severe benzodiazepine use disorder Severe psychiatric illness Severe hepatitis/impaired hepatic function
OFFICE-BASED THERAPY Licensed provider Buprenorphine agreement Induction Maintenance & monitoring
LICENSED PROVIDER 8hr online training (24hrs NP/PA) DEA-X number 30 patients the first year, then 100 per year; can apply to increase to 275 Random audits by the DEA Trainings buprenorphine.samhsa.gov FREE: pcss.now.org
BUPRENORPHINE AGREEMENT Goals and expectations Frequent visits Regular urine drug testing Regular PMP reports Stopping parameters
INDUCTION 12-24 hours since last opioid Mild-moderate withdrawal to avoid precipitated withdrawal Limited prescription with clear parameters for uptitration: 8mg on day 1, 16mg on day 2, 24mg on day 3 if persistent withdrawal symptoms, use clonidine, loperamide, ibuprofen If wake up able to eat breakfast, likely reached correct dose
PATIENT CASE Our patient returns to clinic three days after starting home induction. Has titrated dose up to 24mg/6mg per day, taking two 8mg/2mg tabs in the AM and one in the PM Denies withdrawal symptoms or cravings.
MAINTENANCE Every 1-2 weeks until stable, then monthly Counseling Regular urine drug testing
SUMMARY Understand the scope of the opioid overdose epidemic Define opioids, opioid use disorder (OUD), addiction and recovery Identify evidence-based treatment options for OUD Understand why buprenorphine/naloxone is an effective treatment for OUD
GROUP TIME! Break into groups to discuss cases Spend about 10 minutes per case Report back to big group around 4:45pm
THANK YOU MHAMSO@TRHS.ORG ACARRASCO@TRHS.ORG DWOODALL@TRHS.ORG
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