Pain, Suffering, Over-Prescribing and Addiction What Have We Done, What Can We Do? January 12, 2016 Trip Gardner, MD Chief Psychiatric Officer PCHC Noah Nesin, MD VP for Medical Affairs PCHC
How Did We End Up Here?
Weird Science
Weird Science No ceiling dose for opioids for chronic pain Essentially no risk of addiction Goal of extinguishing pain Pseudoaddiction
Real Science AHRQ September 30, 2014: Evidence of long-term opioid therapy for chronic pain is very limited, but suggests an increased risk of serious harms that appears to be dose-dependent.
Where Are We? 1991: 76 million opioid Rxs 2011: 219 million opioid Rxs Up to 70% of people with chronic pain are receiving improper treatment (according to NIH).
The Harm
The Harm Risk of addiction is 30 to 40% Drug overdose deaths increased 34% between 2011 and 2014. 208 Mainers died of drug overdose in 2014. 89% of those were prescription drugs. 2947 overdose EMS responses in 2014. 2 pharmacy robberies in 2008, 136 since 2010 40% of crime in Maine related to drug abuse
The Harm 961 babies born with NAS in Maine in 2014 12.9% of babies born in Penobscot County are drug affected. 12% of Maine high school students report nonmedical use of prescription drugs in lifetime, 6% in last month. Maine leads the nation in the rate of prescriptions for long acting opioids (21.8 Rx/100 people vs. national average of 10.3) 265% increase in deaths from prescription opioid overdose in men since 1999, 400% in women
100 Morphine Equivalents What is High Dose?
We Have Not Yet Turned The Corner In Maine we prescribe opioids at a rate of 60.4 pills per capita. In Penobscot County we prescribe opioids at a rate of 63.2 pills per capita.
What Can We Do? 1. Stop over-prescribing 2. Learn how to treat chronic pain 3. Screen for Substance Use Disorder 4. Be willing to diagnose Substance Use Disorder 5. Be willing to refer for proper treatment 6. Apply proven treatments in our practices, with proper support
Challenges Barriers Time $$ Lack of expertise Lack of systems Lack of interest Stigma/Bias Barrier Busters Grants Time Support o ECHO o E-consults o Collaborative Identify champions Ethical appeal Support of skilled MH workers
HOPE Maine Chronic Pain Collaborative Addiction Task Force Community Health Leadership Board HRSA support for FQHCs Community Groups NIDA NE Clinical Trial Network CDC Guidelines, AHRQ, Johns Hopkins guidelines Project ECHO Buprenorphine PainNet Pain e consults Public Discourse Naloxone MEHAF Maine Quality Counts Maine PMP Maine Independent Clinical Information Service Lunder Dineen Health Education Foundation
What is Addiction? Trip Gardner, MD Chief Psychiatric Officer Penobscot Community Health Care
Addiction is American Society of Addiction Medicine April 2011 Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and /or relief by substance use and other behaviors National Institute on Alcohol Abuse and Alcoholism Director Mark Willenbring, MD Wanting the wrong thing very badly National Institute on Drug Abuse Director Nora Volkow, MD The brains of addicted people have been modified by the drug in such a way that absence of the drug makes a signal to their brain that is equivalent to the signal of when you are starving. It is as if the individual was in a state of deprivation, where taking the drug is indispensable for survival. It's as powerful as that.
Addiction is an illness 1784 to 1900 Benjamin Rush 1784 Inquiry into the Effects of Ardent Spirits on the Human Mind and Body Physicians thought chronic inebriety was diseased state characterized by: Biologic predisposition Drug toxicity Pharmacologic tolerance Disease progression Morbid appetite (craving) Loss of volitional control of alcohol/drug intake Pathophysiologic consequences It is curable in the same sense that other diseases are Concern grew among physicians about addiction to drugs other than alcohol, Widespread distribution of opiate- and cocaine-based medicines by a rapidly growing patent drug industry
Addiction is not an illness (1900 1935) Biologic views of addiction fell out of favor and were replaced by: Character problem Moral problem Criminal problem State and national prohibition laws were passed as the solution Addiction treatment institutions closed in great numbers. Harrison Antinarcotic Act if physician to maintains an addict on opioid: Not in good faith medical practice Indictable offense.
Addiction is an illness (1935 on) Kinda?Sorta? It is an illness 1935-1938 state addiction hospitals Methadone maintenance Office based opioid treatment with buprenorphine Medication Assisted Treatment of Alcohol Use Disorder SBIRT - Screening Brief Intervention Referral to Treatment in Primary Care Evidenced based psychotherapies are available It is not an illness 65% of those in long term criminal justice have addiction they get little treatment Insurance funding cut > any other illness Evidenced based practice for pain pill prescriptions not applied toxic risks of opioid pain pills not seriously considered Many physicians still don t fully recognize as illness Do not diagnose Document these symptoms in the social history not the medical history
Myths about Addiction 1. People with addiction are bad, crazy, or stupid. 2. Addiction is a willpower problem. 3. People with addiction should be punished, not treated, for using drugs. 4. People with addiction cannot be treated with medications. 5. Addiction does not get better until you hit rock bottom.
Epidemiology
2014 Users - Nationally
2014 Disordered - Nationally 2014-21 million people with diabetes
Maine use higher but diagnoses lower People are using more Alcohol use 59.07% US 52.42% Illicit drug use 13.50% US 9.77% 18-25 = 29.11% 6 TH HIGHEST IN COUNTRY We are not diagnosing Alcohol Use Disorder 5.71% US 6.5% Drug Use Disorder 2.62% US 2.64% Alcohol and/or Drug Use Disorder 7.67% US 8.16% http://www.samhsa.gov/data/sites/default/files/nsduhsaepercents2014.pdf
Benzo Heroin Fentanyl
Risk Factors for Substance Use Disorders Men > Women Physical or sexual abuse when young Younger age of 1 st use Caucasians > Hispanics and African Americans Unemployed Not in stable marriage or cohabiting situation Not graduating college Co-occurring other psychiatric brain disorders
Etiology
Genetic -50 % of the risk Normal At Risk
Environment Factors Stress can turn on genes Adverse childhood events Physical or sexual abuse Modeling Lack of healthy coping skill development Peers who use have more influence in adolescence Drug availability
Developmental Factors Adolescents are most at risk The brain undergoing development Making it easier to develop a long term altered circuit Impulse control centers not fully matured leading to poorer judgement Have less developed healthy coping skills More susceptible to peer pressure
Mechanism
How?
Increase Dopamine > Natural Rewards This translates into a highly rewarding message in our thoughts. The high dopamine environment causes enhanced learning of the conditions associated with the reward so that these conditions serve as triggers for the drive leading to the reward seeking behavior as if it were a basic need for survival.
Why do people with substance use disorders keep using drugs? Long-term drug and alcohol abuse changes in the brain including: Exaggerated drive in response to triggers Inability to exert control over the impulse to use Diminished recognition of adverse consequences Changes persist after a person stops using drugs Psychological stress from work, family problems, psychiatric illness, pain, social or environmental past cues can trigger intense cravings without the individual even being consciously aware of the triggering event
How?
Reward circuit is hyperactive - overactive go Control circuit is impaired damaged stop Disconnection of communication in the circuits
Orbitofrontal Cortex
The brain lights up at the thought
The Disease Deepens As Time Goes On
Tolerance dom-logo
Same as other chronic illnesses
Symptoms and signs of the Illness
Diagnosis Criteria DSM 5 Substance Use Disorder Checklist Worksheet for DSM-5 criteria for diagnosis of Substance Use Disorder Note: In diagnosis substitute specific substance for example if the substance is cannabis the diagnosis would be Cannabis Use Disorder Diagnostic Criteria (Substance Use Disorder requires at least 2 criteria be met within a 12 month period) 1. The substance is often taken in larger amounts or over a longer period of time than intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control the substance use. 3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. 4. Craving, or a strong desire to use the substance. 5. Recurrent substance use resulting in failure to fulfill major role obligations at work, school or home. 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. 7. Important social, occupational or recreational activities are given up or reduced because of the substance use. 8. Recurrent substance use in situations in which it is physically hazardous 9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 10. *Tolerance, as defined by either of the following: (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of the substance 11. *Withdrawal, as manifested by either of the following: (a) the characteristic substance withdrawal syndrome (b) the same (or a closely related) substance are taken to relieve or avoid withdrawal symptoms Meets criteria? Yes No Notes/Supporting information *This criterion is not considered to be met for those individuals taking substances solely under appropriate medical supervision. Severity: Mild: 2-3 symptoms, Moderate: 4-5 symptoms. Severe: 6 or more symptoms Specifiers 1. In early remission no criteria met for 3-12m 2. In sustained remission no criteria for 12m or >
Treatment
Continuum of care same as any other illness Brief education and intervention for those with high risk signs Brief outpatient therapy for those with risky use ( pre diabetes ) Outpatient counseling Medication assisted treatment and outpatient counseling Intensive outpatient Partial hospitalization Hospitalization Hospitalization with intensive long term care
Essentials of Effective Treatment 1. Addiction is a complex but treatable disease of brain function and behavior. 2. No single treatment is appropriate for everyone. 3. Treatment needs to be readily available. 4. Effective treatment attends to multiple needs of the individual. 5. Remaining in treatment for an adequate period of time is critical. 6. Many drug-addicted individuals also have other mental disorders 7. Medically assisted detoxification is only the first stage of addiction treatment. 8. Treatment does not need to be voluntary to be effective. 9. Drug use during treatment must be monitored continuously 10. Like any disease progress in treatment is individualized.
Treatment Gaining the ability to stop abusing drugs is just one part of a long and complex recovery process. When people enter treatment for a substance use disorder, addiction has often taken over their lives. The compulsion to get drugs, take drugs, and experience the effects of drugs has dominated their every waking moment, and abusing drugs has taken the place of all the things they used to enjoy doing. It has disrupted how they function in their family lives, at work, and in the community, and has made them more likely to suffer from other serious illnesses. Because addiction can affect so many aspects of a person s life, treatment must address the needs of the whole person to be successful. This is why the best programs incorporate a variety of rehabilitative services into their comprehensive treatment regimens. Treatment counselors may select from a menu of services for meeting the specific medical, psychological, social, vocational, and legal needs of their patients to foster their recovery from addiction. Medications Used To Treat Drug Addiction Detoxification Medications Tobacco Use Disorder Nicotine replacement therapies, Bupropion, Varenicline Opioid Use Disorder Methadone, Buprenorphine, Naltrexone Alcohol Use Disorder Naltrexone, Disulfiram, Acamprosate Evidenced Based Psychological Therapies Cognitive Behavioral Therapy Seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs. Contingency Management Uses positive reinforcement such as providing rewards or privileges for remaining drug free, for attending and participating in counseling sessions, or for taking treatment medications as prescribed. Motivational Enhancement Therapy Uses strategies to evoke rapid and internally motivated behavior change to stop drug use and facilitate treatment entry. Family Therapy (especially for youth) approaches a person s drug problems in the context of family interactions and dynamics that may contribute to drug use and other risky behaviors.
Methadone and buprenorphine are not heroin/opioid substitutes. Prescribed under monitored, controlled conditions Heroin causes immediate "rush," that wears off quickly and ends in a "crash. Cycle of euphoria, crash, and craving is a hallmark of addiction Methadone/buprenorphine - gradual onsets of action producing stable levels Patients maintained on these medications no rush, no desire to use Dampens or suppresses the euphoric effects of other opioids Help to stabilize individual functioning, allowing treatment of their problems Allows patients to hold jobs, avoid street crime and violence, and reduce their exposure to HIV/Hepatitis Allows patients to engage more readily in counseling and other behavioral interventions essential to recovery.
Aftercare As is the case with all chronic diseases the condition must be monitored and managed over time to: Decrease the frequency and intensity of relapses Sustain periods of remission Optimize the person s level of functioning during periods of remission Frequently done in groups Continuing care for chronic disease same as you would for diabetes
Outcomes
Recovery Best achieved through a combination of: Self management Social support Professional care Right medicine with right counseling gives leg up in recovery The chronic nature of the disease means that relapsing to drug abuse is possible, with symptom recurrence rates similar to those for diabetes, hypertension, and asthma
Outcomes 33% remission 30-40 % substantial improvement 20-30% little to no improvement
Outcomes as good as other chronic diseases
ADDICTION RECOVERY IS ASSOCIATED WITH DRAMATIC IMPROVEMENTS IN ALL LIFE AREAS Criminal justice system involvement decreases 10 fold Steady employment increases by over 50% Emergency departments decreases 10 fold Paying bills on time, paying back personal debt doubles Planning for the future increases 3-fold Involvement in domestic violence decreases Volunteering in the community increases 3-fold Voting increases to > 80% Untreated mental health problems decrease 4- fold Further their education or training by 2 fold Report paying taxes, having good credit Start and own business - 39.1% after 10y Participation in family activities increases to 95%. Laudet A; Life in Recovery Report on Survey Findings, FACES ANDVOICES OF RECOVERY.org, April 2013
Same determinants of health for all illnesses
Outcome misperception Studies of treatment done on those with the most severe illnesses Mild to Moderate AUD gets better but we don t usually measure unlike diabetes, hypertension Most people do recover but it is a social secret because of stigma We should measure outcome like other medical disorders by reduction of disease related adverse outcomes