Confronting the Opioid Epidemic: Suboxone in Primary Care/media/Images/Swedish/CME1/SyllabusPDFs/R3...
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5/25/2016 1 Confronting the Opioid Epidemic: Suboxone in Primary Care Kami Harless, MD
Transcript of Confronting the Opioid Epidemic: Suboxone in Primary Care/media/Images/Swedish/CME1/SyllabusPDFs/R3...
5/25/2016
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Confronting the Opioid Epidemic: Suboxone in Primary Care
Kami Harless, MD
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The Opioid Epidemic
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The Opioid Epidemic
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Washington Epidemic
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King County Epidemic
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King County Epidemic
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Outline
• Opioid dependence treatment options
• Efficacy of treatment options
• Buprenorphine in primary care
• Ideal candidates for buprenorphine
• Unique opportunities for buprenoprhine
• Barriers to success
• The future of medication assisted treatment
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Treatment Options
• Agonist Therapy
– Methadone
– Buprenorphine
– LAAM
– Heroin Maintenance Programs
• Antagonist Therapy: Naltrexone
• Psychosocial Therapy
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Treatment Options
• Agonist Therapy
– Methadone
– Buprenorphine
– LAAM
– Heroin Maintenance Programs
• Antagonist Therapy: Naltrexone
• Psychosocial Treatment
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Efficacy of Buprenorphine
2014 Cochrane Review: 31 trials
– Buprenorphine vs Placebo
• Retention
• Suppression of illicit opioids in urinalysis
– Buprenorphine vs Methadone
• Retention
• Suppression of illicit opioids in urinalysis
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Cochrane Review
• Buprenorphine vs Placebo: – Retention: Bup doses >2mg
– Illicit opioid suppression in UA: Bup doses >16mg
• Buprenorphine vs Methadone: – Retention: Methadone more effective than
flexible dosing buprenorphine
– Illicit opioid suppression in UA: Methadone more effective than flexible dosing buprenorphine
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Cochrane Review
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Making a Case for Buprenorphine
Saftey of agonist therapy: – 2006 New South Wales study
• Overdoses in 9mo period
• RR methadone 4.25
– Pharmacokinetics • Long acting full agonist
• High affinity partial agonist
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Making a Case for Buprenorphine
Patient attitudes: • Reduced number of medical visits • More convenient locations • Removed from illicit drug markets
often around methadone clinics • Improved patient-provider
relationships • Improved sense of autonomy,
support, and trust from their provider
• Reduced stigma
Positive patient-provider relationships
are associated with positive addiction treatment outcomes.
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Who’s A Good Candidate?
Factors indicating good outcome Relative contraindications
Prescription opioid addiction only Dependence on other CNS depressants
Patient highly motivated Multiple previous treatments with frequent relapses
History of reliability and compliance Severe opioid addiction
High functional level: employment/housing High risk environment for relapse
Supportive psychosocial environment Poor support system
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Who’s A Good Candidate?
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Who’s A Good Candidate?
• Targeted marketing to the private sector
• Private Clinics, Out-of-Pocket, Privately Insured
• Caucasian, Employed, “Stable” patients
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Unique Opportunities within the “Safety Net”
• Buprenorphine in Public Sector Healthcare
• Specific characterstics that are especially suited for low-income patient population
• Local/Regional incentives:
– Medicaid formularlies
– State level media campaigns
– Prescriber support networks
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Buprenorphine: Reaching Vulnerable Populations
• Chronic Disease Management
• New York City Harm Reduction Pilot 2005
• Past Incarceration/Recent Release
• San Francisco Department of Public Health
• HIV Treatment
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Buprenorphine: Reaching Vulnerable Populations
• Chronic Disease Management
• New York City Harm Reduction Pilot 2005
• Past Incarceration/Recent Release
• San Francisco Department of Public Health
• HIV Treatment
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Chronic Disease Management
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Buprenorphine: Reaching Vulnerable Populations
• Chronic Disease Management
• New York City Harm Reduction Pilot 2005
• Past Incarceration/Recent Release
• San Francisco Department of Public Health
• HIV Treatment
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NYC Harm Reduction Model
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Buprenorphine: Reaching Vulnerable Populations
• Chronic Disease Management
• New York City Harm Reduction Pilot 2005
• Past Incarceration/Recent Release
• San Francisco Department of Public Health
• HIV Treatment
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Recent Incarceration/Release
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Buprenorphine: Reaching Vulnerable Populations
• Chronic Disease Management
• New York City Harm Reduction Pilot 2005
• Past Incarceration/Recent Release
• San Francisco Department of Public Health
• HIV Treatment
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San Francisco Department of Public Health
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Buprenorphine: Reaching Vulnerable Populations
• Chronic Disease Management
• New York City Harm Reduction Pilot 2005
• Past Incarceration/Recent Release
• San Francisco Department of Public Health
• HIV Treatment
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HIV Treatment
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Barriers to Success
• Access
• Time
• Comfort
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The Future…
• Harm Reduction
• Depot/Implant
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Resources
• Buprenorphine Wavier
• June 2015 Practice Update
• PCSS-B Mentor Site
• Buprenorphine Rounds (Cherry Hill)
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References
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Thank you!
Questions?
