Addiction to Opioids Marvin D. Seppala, MD Chief Medical Officer Mayo Clinic Opioid Conference: Evidence, Clinical Considerations and Best Practice Friday, September 30, 2016
26 y.o. female from South Dakota First addiction treatment 2013, alcohol use disorder Sober and doing well for several months Crushing foot injury, oxycodone provided (without support) Opioid use escalation, then heroin Admit to residential addiction treatment 1/15 Suboxone initiated and transferred to outpatient care and sober housing Missed groups after 2 months of doing relatively well She left sober house and called outpatient program to report moving home Death by opioid overdose within 48 hours of returning to parents home
Become familiar with the demographics of the opioid crisis Become aware of the physician's role in opioid use Become familiar with two medications used for treatment of opioid dependence
Annual Numbers of New Nonmedical Users of Psychotherapeutics: 1965-2000 2001 National Household Survey on Drug Abuse http://www.oas.samhsa.gov/nhsda/2k1nhsda/vol1/toc.htm#v1
Opioid Prescriptions: Total Number Dispensed by U.S. Retail Pharmacies, 1991-2010
A Crisis In 2010, 60% of drug overdose deaths (22,134) involved prescribed medications. Drug overdose became the number one accidental cause of death. Fueled by the dramatic increase in opioid overdose deaths. Prescription opioid overdoses for those 15 and older: 1.6 deaths per 100,000 in 1999-2000 increasing to 6.6 deaths per 100,000 in 2009-2010 CDC
Rates* of opioid pain reliever (OPR) overdose death, OPR treatment admissions, and kilograms of OPR sold: United States, 1999-2010 * Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment admissions, and crude rates per 10,000 population for kilograms of OPR sold. www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm
Overdose Risk and Opioid Dose 100 10 Percent of Person Years 90 80 70 60 50 40 30 20 10 78.3 13.1 5.0 3.5 9 8 7 6 5 4 3 2 1 Odds Ratio 0 1-19 20-49 50-99 100+ Opioid Dosage (mg/d) 0 Percent Use Dunn KM, et al. Ann Intern Med. 2010
Heroin Use Heroin use has doubled among adults 18-25 in the past decade 45% of those using heroin were also addicted to prescription opioids People addicted to prescription opioids are 40 times more likely to become addicted to heroin than matched controls Between 2002 and 2013 heroin related overdose deaths nearly quadrupled CDC Vitalsigns
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Physicians Quandary Related to Pain and Addiction Physicians have little training in addiction and little training in chronic pain. Yet pain is the most common reason for a primary care visit, and addiction is one of the most common illnesses seen in primary care.
Physicians Role in Addiction Nearly 94% of physicians failed to accurately diagnose an alcohol problem in adults in the CASA National Survey of Primary Care Physicians and Patients on Substance Abuse. April 2000
Physicians Role in Addiction Doctors treating 280 people with evidence of alcohol problems followed recommended procedures only 11% of the time. They suggested specific treatment only 5% of the time. This was the least standardized care of all health conditions studied. NEJM June 26, 2003
Effective Treatment of Opioid Use Disorder Methadone Maintenance Buprenorphine Maintenance Extended Release Naltrexone (Vivitrol) Abstinence-based 12 Step treatment Combination treatments
Vivitrol : Extended Release Injectable Naltrexone Opioid receptor blocker (opioid antagonist) Administered by intramuscular injection, once a month Prevents binding of opioids to receptors, eliminating intoxication and reward Has been shown to reduce craving and relapse Has no abuse potential
Injectable Extended Release Naltrexone Naltrexone Placebo Weeks abstinent 90% 35% Opioid free days 99.2% 60.4% Mean change in craving 10.1% 0.7% Median retention 168 days 96 days Lancet 2011; 377:1506-13
Suboxone : Buprenorphine/Naloxone A partial opioid agonist, a maintenance treatment Administered sublingually on a daily basis Binds to and activates opioid receptors, but not to the same degree as true opioid agonists Improves treatment retention, and reduces craving and relapse Illicit use and diversion are likely
Buprenorphine/Naloxone Treatment for Prescription Opioid Dependence: Study 2 phase study: 2 week Bup/Nal stabilization, 2 week taper, 8 week follow-up 12 week Bup/Nal stabilization, 4 week taper, 8 week follow-up 653 treatment seeking outpatients with opioid dependence Randomized to: Standard medication management (SMM) SMM and opioid dependence counseling All participants were referred to self-help groups Arch. Gen. Psych. Vol 68(No.12), Dec 2011
Buprenorphine-Naloxone Results Phase 1 Only 6.6% were successful No difference between SMM and SMM with opioid counseling Phase 2 49.2% successful while using bup-nal No difference between SMM and SMM with opioid counseling Success rates after completion: 8.6% Arch. Gen. Psych. Vol 68(No.12), Dec 2011
What Will You Do? Please Commit to Action! Screen for addiction and alcoholism Refer to an addiction specialist just like any other medical specialty Examine your prescribing practices Learn more about treatment of chronic pain Learn more about pain and addiction Prevent diversion in your medical setting
We are in the midst of a crisis and we are primarily responsible for it There are effective treatments for opioid use disorders We are responsible for solving this crisis
CONTACT INFORMATION Marvin D. Seppala, MD Chief Medical Officer Hazelden Betty Ford Foundation mseppala@hazeldenbettyford.org