Responding to the Opioid Epidemic Jessica Gray, MD Addiction Medicine Fellow Boston Medical Center ROME New England August 17, 2017 Disclosures for Jessica Gray, MD No conflicts Learning Objectives Describe the current state of the opioid epidemic in MA Review existing treatment options for opioid use disorder Incorporate prevention and management of opioid use disorder in your clinical practice 1
Update on MA Opioid Epidemic Opioid Related Overdose Deaths Among Massachusetts Residents In 2016 an average of 5.6 people died from opioid overdose EVERY DAY in Massachusetts http://www.mass.gov/eohhs/gov/departments/dph/stop addiction/current statistics.html May 2017 Opioid Overdose Death Rates, by MASS County January 2011 December 2013 January 2014 December 2016 http://www.mass.gov/eohhs/docs/dph/stop addiction/current statistics/overdose deaths by county including map may 2017.pdf 2
Overdose Death Rate by State in 2010 and 2015 http://www.mass.gov/eohhs/gov/departments/dph/stop addiction/current statistics.html CDC Mass DPH mixed methods investigation that included death record reviews and qualitative interviews with people who use opioids and had either witnessed or survived an overdose Illicitly manufactured fentanyl (IMF) responsible for 69% of opioid overdose deaths Overdoses involving IMF are acute and rapid A person overdosing on regular dope [heroin] leans back and drops and then suddenly stops talking in a middle of a conversation and you look over and realize that they re overdosing. Not like with fentanyl. I would say you notice it [a fentanyl overdose] as soon as they are done [injecting the fentanyl]. They don t even have time to pull the needle out [of their body] and they re on the ground. 3
Treatment What is Recovery? SAMHSA Working Definition SAMHSA, 2012 Natural History of Opioid Use Withdrawal Normal Euphoria Acute use Tolerance and Physical Dependence Chronic use 4
Opioid Detox Outcomes Low rate of engagement in further treatment High rates of relapse post detox 27% on day of discharge 65% within 1 month 90% within 1 year Increased risk of overdose due to decreased tolerance Bailey GL J Subst Abuse Treatment 2013 Maintenance Treatment for Opioid Dependence Withdrawal Normal Euphoria Chronic use Maintenance with Opioid Agonist Language: Medications for OUD 5
Medications for Opioid Use Disorder Methadone (opioid agonist) Most rigorous evidence Must be dosed at federally regulated OTP Buprenorphine (partial opioid agonist) Primary care /office based models improve access Equally effective to moderate doses of methadone for abstinence, treatment retention, decreased cravings Naltrexone (opioid antagonist) Office based treatment Not for withdrawal treatment Choosing a Medication Deciding between methadone, buprenorphine, and naloxone depends on: Patient preference, past experience Access to treatment setting Ease of withdrawal Risk of overdose 4 Goals of Medication for Opioid Use Disorder Relief of withdrawal symptoms Low dose methadone (30 40mg), buprenorphine Opioid blockade High dose methadone (>60 80mg), buprenorphine, naltrexone Reduce opioid craving High dose methadone (>60 80mg), buprenorphine, naltrexone* Restoration of reward pathway Long term (>6 months) methadone, buprenorphine, naltrexone 6
Methadone Maintenance: Highly structured Proper dosing for OUD 20 40 mg for acute withdrawal > 80 mg for craving, opioid blockade Duration of action 24 36 hours to treat OUD 6 8 hours to treat pain Observed daily administration Take homes Daily nursing assessment Weekly counseling Individual or group Drug testing Psychiatric services Medical services JAMA 1965 Extensive Research on Effectiveness Increases treatment retention Decreases illicit opioid use Decreases hepatitis and HIV seroconversion Decreases criminal activity Increases employment Improves birth outcomes Increases overall survival (Sordo L et al. BMJ 2017) On ave, 25 fewer deaths/1000 person yr vs discontinue methadone Mortality risk <1/3 of that expected with no methadone treatment Methadone Maintenance Limitations Highly regulated Narcotic Addict Treatment Act 1974 Created methadone clinics (Opioid Treatment Programs) Separate system not involving primary care or pharmacists Limited access Inconvenient and highly punitive Mixes stable and unstable patients Lack of privacy No ability to graduate from program Stigma I don t believe in methadone 7
OUD and OAT Capacity Past year opioid abuse/dependence Agonist capacity Treatment Gap=914,000 Maximum potential bupe capacity OTP patients on methadone Jones CM et al. Am J Public Health. 2015 Relapse Etiology and Length of Treatment Protracted abstinence syndrome Derangement of endogenous opioid receptor system Symptoms include: Generalized malaise, fatigue, insomnia Poor tolerance to stress and pain Opioid craving Conditioned cues (triggers) Priming with small dose of drug So, how long should maintenance treatment last? Long enough Incorporating Screening, Prevention and Harm Reduction in Your Practice 8
Prevention of substance use disorders Educate patients about early exposure and genetic risk Screen for substance use in all teens and adults Review safe storage and disposal of medications Learn appropriate opioid prescribing Use Prescription Monitoring Program Educate your patients Strong genetic component to SUD Brain development not complete until early 20s ANY early drug exposure increases risk of SUD Public health message: Goal is NO use of substances in youth SUD prevention is not drug by drug, but ANY and ALL drug use Gogtay et al. 2004 Proc. Natl. Acad. Sci. USA 101, 8174 8179 Screen TEENS for Substance use: S2BI In the past year how many times have you used: Tobacco? Alcohol? Marijuana? NONE: Reinforce non use ONCE OR TWICE: (no SUD) Screen for other drugs BRIEF health advice to reduce use and risky behaviors MONTHLY (mild) or WEEKLY (mod severe SUD): Screen for other drugs BRIEF INTERVENTION: assess for problems, advise to quit, make a plan Reduce use and risky behaviors REFER to treatment 9
Review Safe Medication Practices Safe Storage Lock up home medications out of child s reach Keep naloxone with opioid prescriptions Encourage disposal of unused medications Drug takeback events, pharmacy disposal Don t flush medications Learn Appropriate Opioid Prescribing www.scopeofpain.com www.opioidprescribing.com www.pcss o.org Use the Prescription Monitoring Program Review prescription history Address polypharmacy Encourage communication between prescribers Paulozzi et al. Pain Medicine 2011 10
Opioid Use Disorder (OUD) What Can Physicians Do? Buprenorphine waiver Co prescribe Naloxone Overdose response education Discuss safer practices with patients Screen and treat HCV Screen for HIV and offer PEP/PrEP Share mutual support group information Prescribe Naloxone Prescribers may lawfully prescribe and dispense to a person at risk of experiencing an opiate related overdose, family member, friend or other person MA Good Samaritan Law (2012) Protect carrying, administration of naloxone Normalize for the patient Carry naloxone to save a life Patient education videos and materials at prescribetoprevent.org 11
Naloxone formulations Nasal with atomizer Multi step * 1 dose = 2mg/2ml IN $$ Nasal Spray Single Step 1 dose = 4mg/0.1ml IN $$ Auto injector* 1 dose = 0.4mg/1ml IM $$$$ Intramuscular Injection 1 dose = 0.4mg/1ml IM $ Responding to Overdose: Educate your patients PREVENTION (risks) Mixing substances Abstinence- low tolerance Using alone Unknown source Chronic medical disease Long acting opioids last longer RECOGNITION Unresponsive to sternal rub with slowed breathing Blue lips, pinpoint pupils Opioid overdose minutes to hours; Fentanyl overdoseseconds to minutes. RESPONSE (action) Call for help Rescue breathe Administer naloxone, continue breathing Recovery position Stay until help arrives Updated Opioid Associated Life Threatening Emergency (ADULT) Algorithm American Heart Association Guidelines October 2015 https://eccguidelines.heart.org/wp content/uploads/2015/10/2015 AHA Guidelines Highlights English.pdf 12
Harm Reduction Social justice movement for the rights of people who use substances Practical strategies to reduce substance use consequences Interventions guided by risk benefit analysis Meeting patients where they are Abstinence is not a prerequisite for care Harmreduction.org 64% of PWID are infected 80% of new HCV infections are in PWID Comparable SVR rates yet treatment uptake remains low Treatment is prevention ACTIONS: Screen at least annually in PWID Access sterile drug injection equipment and medication for OUD Offer linkage to HCV treatment Dore GJ Ann Intern Med 2016 Grebely Int J Drug Policy 2015 MMWR/CDC December 2015 13
PrEP for prevention of HIV in PWID Daily PrEP can decrease HIV risk by > 90% from sex, >70% from IVDU Indications active injection drug use in last 6 months and HIV+ injecting partner Share injection equipment Active IVDU while in drug treatment Risky sexual practices Once daily dosing of Truvada Part of a prevention package KNOWN HIV EXPOSURE? npep Post Exposure Prophylaxis 28 day ARV treatment after a single high risk event to stop HIV seroconversion MUST initiate within 72 hours of exposure Bangkok Tenofovir Study Lancet 2013; 381: 2083 90 Mutual Support Organizations Support often in context of 12 step groups, Informal, no training, single pathway based on group model Enhance self efficacy Increase behavioral coping skills Facilitate adaptive changes in social network Frequent meeting attendance improves abstinence with or without additional treatment as long as patient engages Role of Physician: Refer, Support Physicians can powerfully influence patient levels of affiliation Give list of local meetings (online or printed booklet) Encourage to go with family/friend, try multiple meetings Help choose meeting types Speaker, discussion, beginners Be open minded Religion Powerlessness Medications 14
Peer Recovery Support Services Support delivered by peers through formal structures, special roles, in various settings (coaches, centers, schools, drop in centers) http://helpline online.com/paths to recovery recovery coaches/ Evidence for Peer Recovery Support Services Recent systematic review identified 9 studies and found that overall, peer support appears to have positive effect on substance use outcomes Limited, weak data varying definitions of peer support, lack of RCTs and comparison groups More evidence needed to determine training, intensity, context and effectiveness among target populations Bassuk EL et al. JSAT 2016; 63:1 9 What Can Physicians Do? Start a dialog with your patients Know your resources Meet the patient where they are Avoid stigma 15
Thank you Jessica.gray@bmc.org 16