Transcript of HOPE for Opioid Use Disorders NAMI Southwest Ohio May 12, 2015 Clifford Q Cabansag, MD, DABAM, CTTS...
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- HOPE for Opioid Use Disorders NAMI Southwest Ohio May 12, 2015
Clifford Q Cabansag, MD, DABAM, CTTS Addiction Medicine Physician,
Tobacco Treatment Specialist
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- Disclosures NONE
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- Disclosures NONE
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- Objectives At the end of this session each participant will be
able to: Discuss the language and appropriate terminology of
substance use disorders State the incidence, prevalence and death
rates of opioid use disorders nationally, regionally and locally
Identify available FDA approved medications for treatment of opioid
use disorders & their mechanisms of action
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- The Power of Language Addict Addicted to _ Addiction Alcoholic
Clean Dirty Drug habit Drug Seeker Pt with a substance use disorder
Has a ___ use disorder Substance use disorder Pt with an alcohol
use disorder Neg; Free of illicit substances Pos; Active use
Substance use disorder Relief seeking
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- The Power of Language Drug Abuser Former Maintenance Pain
Seeker Recreational Reformed Replacement Substance Abuser Pt with
SUD In sustained remission Medication Asstd Treatment Relief /
Treatment Seeking Non-medical use In remission MAT Pt with SUD
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- Terminology Chronic Disease Model Derogatory language only
perpetuates stigma Dependence & Abuse not in DSM-5 Use disorder
mild, moderate or severe Classification based on # of criteria
Addiction Dependence Tolerance Withdrawal Opiate vs. opioid
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- Chronic Disease Model
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- DSM-5 Criteria Substance Use Disorders A maladaptive pattern of
substance use leading to clinically significant impairment or
distress, as manifested by 2 (or more) of the following occurring
within a 12-month period: Severity specifiers based on 11 criteria
Merging DSM-IV abuse & addiction criteria minus legal Mild: 2-3
criteria Moderate: 4-5 criteria Severe: 6 or more criteria
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- Questions (For discussion: Addiction ~ Substance Use Disorder)
What must be present to have dependence? Arent dependence and
addiction the same? Is it possible to have dependence w/o
addiction? To have addiction without dependence? What about
tolerance & withdrawal?
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- Answers Tolerance Same amount of substance insufficient Greater
amount to achieve previous effect Withdrawal Characteristic
sequelae after discontinuation Typically opposite effects of
substance activity Classic examples: alcohol & opioids Atypical
example: cannabis Using similar substance to relieve symptoms
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- Answers In order to have dependence: MUST have both tolerance
AND withdrawal Physiologic symptomatology So it IS possible to have
dependence WITHOUT Addiction / Substance Use Disorder Examples:
caffeine; hospice & chronic pain pts So what makes the
difference between having only dependence but not an
addiction?
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- Answers The LOSS OF CONTROL & Aberrant Behavior So
Dependence Addiction/Substance Use DisO BUT Dependence + Aberrant
Behavior = SUD
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- MAT and Abstinence Q: How does the Hazelden Betty Ford
Foundation define abstinence for someone on buprenorphine/naloxone?
A: A person who has an opioid use disorder and is taking medication
under the advice and care of a physician to treat the disease is
not unlike a post-surgery patient who is using pain medication. If
used as directed and not for the purpose of becoming intoxicated,
the medication greatly assists in recovery. Recovery defined by the
establishment of new behaviors in this manner is necessary. We view
those working a recovery program while using buprenorphine/naloxone
as prescribed as being in recovery, and our goal is abstinence.
Clients on maintenance doses of buprenorphine will be expected to
pursue 12-Step based counseling and ultimately to taper off the
medication, but Seppala says of this group, They will be taking the
medication for probably months.* *Addiction Professional, November
7, 2013
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- Backlash Instead of an abstinence model, Betty Ford and
Hazelden are embracing what is known as a harm-reduction form of
treatment using pharmaceutical interventions. These medical based
treatments use pharmaceuticals like methadone or Suboxone, and
other drugs, to limit the harm or negative consequences of
substance abuse, attempting to keep the individual using a
pharmaceutical in smaller amounts than their drug of choice, less
often, and staying addicted to the pharmaceutical substitute, but
using enough of a substitute not to get dope sick. This is an
evidence-based treatment, and one that pharmaceutical companies are
pushing as they stand to make millions of dollars from the sale of
harm-reduction pharmaceutical products. Hazelden supports
medication-based treatments for harm reduction, which is in truth
only replacing one drug for another drug. Psychology Today, January
7, 2015
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- Exchanging one drug for another Is there dependence? Yes, but
recall dependence substance use disorder Was the medication
obtained illegally? No; like other medications obtained by
prescription Doesnt MAT make people high/euphoric? Routinely, No;
may be some mild elevation of mood with first dose in pt opioid
nave pt but not thereafter Doesnt MAT promote self-medication? No;
pts are monitored regularly and carefully in accordance with
evidence-based practice
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- Exchanging one drug for another MAT Decreases impulsive
substance behaviors Increases employability Decreases overall chaos
Helps to develop structure Improves relationships Decreases
HIV/HepC transmission In short MAT improves overall function and
helps pts live a normal and productive life
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- Exchanging one drug for another MAT Decreases impulsive
substance behaviors Decreases deaths Decreases criminal activity
Increases retention in treatment Increases engagement in socially
productive roles Increases employability Decreases overall chaos
Helps to develop structure Decreases HIV/HepC transmission In short
MAT can help improve overall function and pts living a normal and
productive life
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- Tomato Tomahto OpiATES 20+ Natural derivatives of Papaver
somniferum Psychoactive: morphine / codeine / thebaine OpiOIDS Any
ligand capable of binding opioid receptor By default all opiates
included ALL opiates are OPIOIDS Only SOME opioids are OPIATES
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- Opiates & Opioids Opiates Morphine, Codeine & Thebaine
Semi-synthetic opioids Derived from natural opiate substrates
Morphine -> diacetylmorphine(heroin), hydromorphone Codeine
-> hydrocodone & oxycodone Thebaine -> buprenorphine
Fully synthetic opioids Fentanyl, methadone, meperidine &
propoxyphene Endogenous opioids produced in vivo endorphins,
enkephalins, dynorphins & endomorphins
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- Trade name vs. Generic MS Contin = Morphine Sulphate CONTINuous
release Vicodin/Lortab = hydrocodone + acetaminophen Percocet =
oxycodone + acetaminophen Darvocet = propoxyphene + acetaminophen
OxyContin = oxycodone (CONTINuous release) Dilaudid = hydromorphone
Darvon/Actiq/Duragesic patch = fentanyl Demerol = meperidine
Lomotil = diphenoxylate
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- Take a Deep Breath
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- Deaths from Prescription Opioid Overdose 44 people die in US
daily due to Rx opioid OD From 1999-2013: Mostly 25-54 years old
(but ODs among 55-64 7x) Non-Hispanic whites 4.3x from 1.6 to
6.8/100k Non-Hispanic blacks >2x from 0.9 to 2.5/100k Hispanics
slight from 1.7 to 2.1/100k First Nations almost 4x from 1.3 to
5.1/100k > but gap closing 1999-2010 > 400% vs 273% CDC
National Vital Statistics System mortality data, 2015
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- Deaths & ED utilization fr Rx Opioid OD Rx drug ODs leading
cause of injury death 2013 25-64 yr olds drug OD deaths > MV
traffic crashes 2013: 43,982 drug OD deaths Of these, 22,767
(51.8%) related to Rx drugs Of these,16,235(71.3%)opioids;
6,973(30.6%) benzos Opioid + benzo combo common Almost 2 million
12+ yrs old: opioid misuse or depend 2011: 2.5 million drug misuse
ED visits 1.4 million related to Rx drugs 501,2017 visits related
to anxiolytics & sleep aides 420, 040 visits related to opioids
CDC National Vital Statistics System mortality data, 2015
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- Trends in Heroin Use in US: 2002 - 2013 Relatively uncommon ~
Past year users in 2013: 681,000 i.e. 0.3% of pop. 12 years old or
older But % of people using heroin higher in 2013 vs. 2003
Incidence 2013: 169,000 past year heroin initiates Similar # of
initiates in most years since 2002 SAMHSA National Survey on Drug
Use and Health Short Report April 23, 2015
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- Trends in Heroin Use in US: 2002 - 2013
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- Past-Year Nonmedical Pain Reliever Use Among Adolescents, by
National Survey and Gender 20022013
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- Number of unintentional drug OD deaths of Ohio residents and
average crude and age-adjusted annual death rates per 100,000, by
county, 2008-2013
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- 2013 OH Drug OD Data Public health crisis - 413% deaths
1999-2013 Unintentional ODs in 2013 2,110 Highest # deaths on
record, 10.2% from previous Previous high 1,914 deaths in 2012
Almost 6 (5.8) Ohioans died daily - 1 death/4h Unintentional OD
leading cause injury deaths > MVA, suicide and falls Trend since
2007 which continued through 2013
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- 2013 OH Drug OD Data Opioids (Rx + heroin) main factor epidemic
Almost (1,539; 72.9%) ODS involved opioids Up from (1,272; 66.5%)
in 2012 Heroin deaths continued to in 2013 From (233; 16%) in 2008
to (983; 46.6%) in 2013 Surpassed unintentional Rx opioid deaths
More than 2x fatal cocaine deaths MULTIPLE DRUG USE largest
contributor
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- Contributing Factors to Opioid OD Epidemic Changes in pain
management guidelines 1990s PHARMA Aggressive marketing of ER
opioids 1997-2011: 643% Rx opioid g / 100k Ohioans 2012: 67 doses
of Rx opioids / 1 Ohioan Direct consumer marketing Over-prescribing
in general Unscrupulous MDs / Pill Mills Widespread diversion
Mixing of medications
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- 2014
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- Take a Deep Breath
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- Role of MAT Dominant model remains detox Detox w/o subsequent
pharmacologic support Decades of evidence show lack of
effectiveness (Whats the definition of insanity?) Rx to prevent
relapse not offered s/p detox Treatment goal Misplaced emphasis on
becoming drug-free No consideration of risk reduction
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- Role of MAT First few weeks s/p detox Highest risk of OD and
death To pts who want to stop using illicit opioids Imperative to
provide agonist or antagonist Rx Pts who choose agonist treatment
Methadone without withdrawal BUP with at least minimal withdrawal
Harm reduction decreases in: High risk behavior Needle use Life
chaos
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- Detox & Drug-free Approach Traditional model Detox without
subsequent medication support Effective for small subgroup: high
motivation & stable (Flynn et al., 2003; Van den Brink and
Hassen, 2006) Otherwise without medications Up to 90% of detoxd pts
relapse in first 1-2 mos (Weiss et al., 2011; Smyth et al. 2010) Of
those relapse some will die of OD (Kakko et al., 2003)
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- Classification of MAT Rxs Basic schema Action (Route) Duration
of effect Affinity Action (Full) Antagonist (Partial)
Agonist/Antagonist (Full) Agonist
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- Classification of MAT Rxs Duration of effect Short, medium or
long acting Affinity Measure of binding of ligand to receptor (Low)
- High
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- Classification of MAT Rxs Action Antagonist Short-acting:
naloxone IV or IN / Narcan Long-acting: naltrexone po / ReVia
naltrexone IM / Vivitrol
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- Antagonist MAT Recall high relapse rate (~90%) s/p detox
Suitable for mild OUD / early disease process Naltrexone 50 mg po
daily / Revia Blocks agonist effects of illicit opioids PO good for
motivated pts Otherwise increased risk of non-compliance Option:
Naltrexone IM 380 mg monthly / Vivitrol Trial of PO for toleration
before IM Monitor LFTs q3 mos at first then q6 mos Must be opioid
free before initiating
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- Classification of MAT Rxs Action (Partial) Agonist/Antagonist
Action depends on absence or presence of opioids Opioids absent
agonist effect Opioids present antagonist effect Buprenorphine /
Subutex Buprenorphine + Naloxone / Suboxone Route SL films or tabs
High affinity
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- Partial Agonist/Antagonist MAT Buprenorphine FDA approved for
MAT only SL BUP has moderate analgesic properties but NOT approved
for pain BUP monoformulation = Subutex BUP + naloxone = Suboxone
Role of naloxone? Good for moderate OUD Office based More flexible
at best monthly visits (vs. methadone daily) Risk of diversion Low
OD risk (except + benzos and/or EtOH) High affinity Able to block
illicit opioids But potential for precipitated withdrawal
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- Classification of MAT Rxs Action (Full) Agonist Methadone
liquid po for MAT (Methadone / Dolphine tab po for pain) Route both
liquid and tab po Long acting for MAT Intermediate acting for pain
Moderate affinity
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- Full Agonist MAT Methadone liquid only for MAT Restricted
access Methadone Clinics only Less easily diverted For severe OUD
or pt wanting more structure Initially daily Can progress to 1
month supply in 2.5 years At higher doses can blockade other
opioids QTc prolongation at high doses baseline EKG
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- Full Agonist MAT Methadone highest efficacy relieving
withdrawal (Dole and Nyswander, 1960s) Dominant treatment of OUD in
US Highest retention (80% at 6 mos) Decreased HIV & HepC
transmission Interaction with HAART for HIV Maintains physiologic
dependence Risk of overdose during and if dcd
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- Opioid Overdose Opioid antagonists Used to improve breathing
Naloxone Short acting Reverses respiratory suppression > opioid
analgesia May require redosing in cases of massive opioid OD VERY
SAFE non-toxic even at doses multiple x usual dose No effect if no
opioids are present In newborns whose mothers received opioids
Severe withdrawal symptoms with active opioid use Naltrexone
Similar to naloxone but longer duration of action protects pts by
blocking opioids
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- Question 2 pts actively using illicit opioids One takes
Suboxone (BUP + naloxone) The other takes Subutex (BUP only) What
happens in each case? Why?
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- Persons in Substance Use Treatment Receiving Buprenorphine:
Single-Day Counts 20092013
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- Persons in Substance Use Treatment in OTPs Receiving Methadone:
Single-Day Counts 20092013 Source : SAMHSA, Center for Behavioral
Health Statistics and Quality, National Survey of Substance Abuse
Treatment Services, 2009 to 2013.
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- Methadone 40 year follow up
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- Success Stories We dont hear about them When properly treated
Evidenced Based multi-modal therapies In context of therapeutic
alliance such pts practically INDISTINGUASHABLE from general
population
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- OAT Pts Occupations / Fields of Employment Teacher Electrician
Plumber Social Worker Psychologist Chauffer Drug Counselor
Computer/IT Tech Accountant Retail Manager Home Security Systems
Restaurateur Fish Dept Manager Movie Editor PhD Student HVAC Tech
School Principal Artist Advertising VP
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- OAT Pts Occupations / Fields of Employment Bus Driver*
Sanitation Driver* Con Ed Utility* Subway Signal* Sales Secretarial
Administrator Piano Teacher Elevator Repair Lawyer Physician
Landscaper Car Sales/Repair Videographer Heavy Equipment Contractor
Entrepreneur Musician Nurse * Safety Sensitive Employer Aware
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- Conclusions Opioid OD signif cause of preventable deaths Much
confusion/misinformation RE: MAT When used as part of multi-modal
treatment: MAT is effective evidenced based treatment Risk Minimize
/ Safe treatment when Monitored closely Managed carefully Dosed
judiciously In context of therapeutic alliance
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- Our Most Basic Role - To BELIEVE in our patients.. on THEIR
behalf! Ren Magritte La Clairvoyance (1936)
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- References American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders, 5 th Edition, Washington
DC, American Psychiatric Association, 2013. CDC National Vital
Statistics System, mortality data, 2015. Dole VP, Nyswander M: A
Medical Treatment for Diacetylmorphine (Heroin) Addiction, JAMA
193(8):80-84, 1965. Flynn PM, Porto JV, Rounds-Bryant J, and
Kristiansen PL: Costs and benefits of methadone treatment in
DATOSPart 1: Discharged versus continuing patients. Journal of
Maintenance in the Addictions 2(1/2):129150, 2003. Kakko J,
Svanborg KD, Kreek MJ, Heilig M: 1-year retention and social
function after buprenorphine-assisted relapse prevention treatment
for heroin dependence in Sweden: a randomised, placebo-controlled
trial. Lancet. 361(9358):662-8. 2003. Ling W, Hillhouse M, Domier
C, et al.: Buprenorphine tapering schedule and illicit opioid use.
Addiction 104: 256-265, 2009. McLellan AT, Lewis DC, OBrien CP,
Kleber HD: Drug Dependence, a Chronic Medical Illness Implications
for Treatment, Insurance, and Outcomes Evaluation. JAMA,
284:16891695, 2000. Mello NK, Mendelson JH, Kuehnle JC, Sellers MS:
Operant analysis of human heroin self-administration and the
effects of naltrexone, J Pharmacol Exp Ther. 1981 Jan;216(1):45-54.
NIDA Media Guide how to find what you need to know about drug abuse
and addiction, 2014.
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- References Ohio Department of Health, Unintentional Drug
Overdose Death Rates for Ohio Residents by County, 2008-2013. Ohio
Department of Health, 2013 Ohio Drug Overdose Data. Salsitz EA :
Opioid Agonist Therapy The Duration Dilemma. PCSS-MAT Webinar,
3/10/2015. SAMHSA, CBHSQ, National Survey on Drug Use and Health
(NSDUH), 2013. SAMHSA, Center for Behavioral Health Statistics
& Quality, National Survey of Substance Abuse Treatment
Services, 2009-13. SAMHSA, Drug Abuse Warning Network, 2009 &
2011: National Estimates of Drug-Related Emergency Department
Visits SAMHSA, National Survey on Drug Use and Health Short Report,
April 23, 2015. Smyth BP, Fagan J, Kernan K: Outcome of
heroin-dependent adolescents presenting for opiate substitution
treatment, J Subst Abuse Treat. 2012 Jan;42(1):35-44, Epub 2011 Sep
21. Strain EC, Stitzer ML, Liebson IA, Bigelow GE: Comparison of
buprenorphine and methadone in the treatment of opioid dependence,
Am. J. Psychiatry 151: 1025-1030, 1994. Suzuki, J: A Review of
Opioids and Treatment of Opioid Dependence. PCSS-O Webinar,
01/14/2015.
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- References Weiss RD, Potter JS, Fiellin D, Byrne M, Connery HS,
Dickinson W, et al.: A Two-Phase Randomized Controlled Trial of
Adjunctive Counseling during Brief and Extended
Buprenorphine-Naloxone Treatment for Prescription Opioid
Dependence. Arch Gen Psychiatry. 2011; 68(12):123846. Vanden Brink
W, Haasen C: Evidenced-based treatment of opioid-dependent
patients, Can J Psychiatry. 2006 Sep;51(10):635-46..
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