Medications for Opioid Use Disorder Charles Brackett, MD, MPH General Internal Medicine, DHMC
Opioid Related Deaths are on the Rise in the US National Vital Statistics System Mortality File
Deaths are the tip of the iceberg SAMHSA NSDUH, DAWN, TEDS data sets Coalition Against Insurance Fraud. Prescription for Peril. http://www.insurancefraud.org/downloads/drugdiversion.pdf 3
Vivek Murthy, M.D., M.B.A. Surgeon General 12/14-4/17 Substance use disorders are one for the most pressing public health crises of our time. They prevent people from living healthy and productive lives and have profound effects on families, friends, and entire communities. We need a cultural shift: addiction is not a character flaw or moral failing. It is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer. 4
Hijacking the Brain
Withdrawal Normal Euphoria Natural History of Opioid Use Disorder Tolerance & Physical Dependence Acute use Chronic use
Drug Dependence, a Chronic Medical Illness -McLellan, JAMA 10/4/02 Acute care paradigm inappropriate Comparable to asthma, htn, DM2 re: Genetic heritability (~50% for OUD) Role of personal responsibility, environment Goal is not cure, but remission/reduction in harms Effective medications are available But only 10-20% of those who need treatment get it Outcomes expectations and measures
Medication Assisted Therapy Full MU Agonist: Methadone Partial MU Agonist: Buprenorphine MU Antagonist: Naltrexone Naltrexone has the highest receptor BINDING AFFINITY, then buprenorphine, then methadone
Naltrexone Opiate receptor antagonist- no effect on craving or withdrawal Can work for patients who are highly motivated or legally mandated to be abstinent in closely supervised settings milder OUD In occupations not permitting OAT: driving, medical Oral: No better than placebo, due to poor adherence Probation: 70% less opiate use, 50% less reincarceration Medical personnel Injectable monthly form: Vivitrol Limited data, low quality studies No head to head trials, until.
Withdrawal Normal Euphoria Opioid Agonist Therapy (OAT) Methadone & Buprenorphine Tolerance & Physical Dependence OAT Acute use Chronic use
OUD is associated with a 10x increase in mortality OAT reduces all cause mortality by 70% reduces overdose mortality by 80% Mortality risk in the 4 weeks immediately after cessation of treatment is high (>30/1000 person years)
Opioid Agonist Treatment Improvements in: Illicit opioid use Other drug use Criminal activity Needle sharing and HIV transmission Pro-social activities Employment Mental health
Methadone Maintenance Full agonist gold standard : 50+ years Can only be administered through OTP Drawbacks: Weight gain, brain fog, hypogonadism Daily observed ingestion initially: transportation/availability for-profit clinics, risk by association Stigma
Buprenorphine Partial agonist with high binding affinity Ceiling effect: blocks effect of other opiates Safer: Overdose unlikely buprenorphine+naloxone (4:1) Generic sublingual pills Suboxone films, Bunavail, Zubsolv Probuphine (6mo implant), Sublocade (7 and 28 day sq)
Prescribing buprenorphine Need a special DEA # DATA 2000: MDs prescribe after 8 hour course CARA 2016: PAs and NPs prescribe after 24 hour course (as of 2/27/17) 30 first year, can then apply to go up to 100 Can prescribe in outpatient setting- PC, psych Greater access/availability, less stigma Schedule III- available in pharmacies: 30d with RF OK to use in hospital for intercurrent illness and dispense 3d without DEA X#
Buprenorphine: taper vs. maintenance Evidence: Psychosocial counseling PLUS Buprenorphine 60-75% pt still in treatment after 1 year Reduced HIV/Hep C infx Fewer ED and Hosp adm Johan Kakko, Kerstin Dybrandt Svanborg, Mary Jeanne Kreek, Markus Heilig.1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial.the Lancet Feb 22, 2003; (361)662-668
MAT vs. PAP Of all the treatments, opioid agonist maintenance treatment is most effective and the most cost effective. Psychosocial service should be made available to all patients, although those who do not take up the offer should not be denied effective pharmacological treatment.