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Prescrip(on Pain Medica(on Abuse: The Importance of Treatment
for Opioid Use Disorders Elinore F. McCance-Katz, MD, PhD
Chief Medical Officer Substance Abuse and Mental Health Services Administration
Na#onal RX Drug Abuse Summit Atlanta, GA April 22, 2014
SAMHSA: A PUBLIC HEALTH AGENCY
• Mission: To reduce the impact of hazardous substance use and mental illness on America’s communi#es
• Roles: • Leadership and Voice – Influencing Public Policy • Data and Surveillance • Clinical Educa>on • Public Educa>on and Communica>ons • Regula>on and Standard SeAng • Prac>ce/Services Improvement • Funding -‐ Service Capacity
Past Month Nonmedical Use of Types of Psychotherapeu#c Drugs among Persons Aged 12 or Older: 2002-‐2012
3
+ Difference between this estimate and the 2012 estimate is statistically significant at the .05 level.
Percent Using in Past Month
Pain Relievers
Tranquilizers
Sedatives
Stimulants
Source: National Survey on Drug Use and Health, SAMHSA, 2013.
More Fallout from Prescrip#on Pain Medica#on Abuse
Past Month and Past Year Heroin Use among Persons Aged 12 or Older: 2002-2012
Source: National Survey on Drug Use and Health, SAMHSA, 2013.
Morbidity and Mortality with Prescrip#on Pain Medica#on Abuse
• 2004-‐2011: Increases in Emergency Department visits related to opioid analgesic misuse:
Men: 159% Women: 146% • 2010: Deaths related to opioid analgesic use: 16,651 (313%
increase over past decade); most deaths involved opioids + other drugs/alcohol
• For every death, there were: • 11 treatment admissions • 33 Emergency department visits • 880 non-‐medical users
CDC, 2013, SAMHSA TEDS, 2001-‐11, SAMHSA/DAWN, 2011
Specific Illicit Drug Dependence or Abuse in the Past Year among Persons Aged 12 or Older: 2012
6
Numbers in Thousands
Source: National Survey on Drug Use and Health, SAMHSA, 2013.
SAMHSA’s Efforts to Prevent Prescrip#on Drug Abuse
• Partnerships for Success grants • Prescrip3on Drug Monitoring
Program grants
• Preven3on of Prescrip3on Abuse in the Workplace (PPAW) Technical Assistance Center
• Promo3on of DEA’s na3onal take-‐back day (April 26, 2014)
• Not Worth the Risk, Even If It’s Legal (pamphlet series)
SAMHSA’s Efforts to Curb Prescrip#on Drug Abuse – Prescriber Educa#on
PCSS-O: Focus on Safe Opioid Prescribing www.pcss-o.org
Opioidprescribing.com: focus on CME accredited trainings on safe use of opioids
PCSS-MAT: www.pcssmat.org Focus on Treatment of Opioid Use Disorders
SAMHSA’s Efforts to Prevent Prescrip#on Drug Overdose
• Opioid Overdose Prevention Toolkit - http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA13-4742
• Substance Abuse Prevention and Treatment Block Grant: • Primary prevention funds can be used for
overdose prevention education/training • Treatment block grant funds can be used
for purchase of naloxone and overdose kits.
Interven#ons to Address Misuse of Prescrip#on Medica#ons
• Prescrip#on Drug Monitoring Programs • Intrastate and interstate data
• Enforcement efforts • Community outreach and educa#on
Treatment
• Prescrip#on pain medica#ons and heroin are the same types of drugs: opioids
• Treatments are the same
• Medical Withdrawal (“Detoxifica#on”) • > 90% relapse rate in the year following treatment
• High risk for overdose when relapse occurs • Should not be a stand alone treatment
Treatment
• Combina#on of FDA-‐approved medica#on: • Naltrexone • Methadone • Buprenorphine/naloxone With psychosocial treatments and ancillary treatment components: • Counseling: Coping skills/relapse preven>on • Educa>on • PDMP use • Toxicology screening
Decisions about Medica#on Assisted Treatment
• Naltrexone: • Prevents opioid effects including ‘high’ • Effec>ve in people with strong incen>ves (legal, employment) and in those not wan>ng to use an opioid medica>on
• Tablet and injectable (addresses issues related to adherence)
• Can’t be used in people needing treatment for pain
• Doesn’t help craving
Methadone and Buprenorphine/Naloxone
• Long ac#ng, once daily medica#ons • NOT ‘subs#tu#ng one drug for another’ • Medica#ons are #trated to a therapeu#c dose: • Withdrawal blocked • Craving reduced or stopped • Tolerance occurs so that mood-‐altering effects are diminished
Methadone
• Only available through methadone maintenance programs (MMPs)
• Take home doses con#ngent on progress in treatment • A`ending clinic and counseling • Stopping illicit drug use
• Large majority of methadone deaths are related to methadone prescribed for pain; not from MMPs
Buprenorphine/naloxone
• Opioid par>al agonist: opioid effects not as strong as other opioids: oxycodone, hydrocodone, methadone, heroin
• Binds >ghtly to opioid receptors in the brain so can par>ally block effects of other opioids
• Naloxone reduces risk of injected use in opioid-‐dependent individuals
• Available in outpa>ent seAngs from qualified doctors
Medica#on Assisted Treatment
• Benefits: • Lifestyle stabiliza>on • Improved health and nutri>onal status • Decrease in criminal behavior • Employment • Decrease in injec>on drug use/shared needles: reduc>ons in risk for HIV and viral hepa>>s/medical complica>ons of injec>on drug use
Facts about Medica#on Assisted Treatment (MAT)
• Opioid dependent, pregnant women are at high risk for adverse outcomes without MAT
• The use of MAT by opioid-‐dependent women with children is an effec>ve treatment that helps women in paren>ng their children
• Neonatal abs>nence syndrome (NAS) occurs frequently in infants of mothers treated with MAT; approximately 50% will need treatment Buprenorphine treatment associated with lower severity of NAS symptoms and shorter hospital stays rela>ve to methadone (Jones, et al. 2010)
Myths about MAT
• ‘Detox’ is the best approach to treatment
• People only need a few weeks/months of treatment • Opioid use disorders are chronic, relapsing condi>ons
• No different than other chronic condi>ons: diabetes, high blood pressure, obesity, depression
• Medica#on doses should be ‘held low’ There is no medical basis for: • arbitrary dosing limits—use FDA and SAMHSA guidance • for limi>ng treatment dura>on—let pa>ents and their doctors decide these issues
Ending the Epidemic
• Increase access to treatment: Train physicians and other clinicians who will provide treatment for opioid use disorders
• Con>nue to train healthcare professionals in safe and appropriate use of opioids and alterna>ves to use of opioids for pain
• Con>nue to educate the public about the dangers of misuse of pain medica>ons and safe use when necessary including safe storage and disposal
• Use PDMPs, treatment agreements, and toxicology screens to increase safety
• Provide evidence-‐based treatment to all who need it for as long as it is clinically indicated
Thank you! Elinore.McCance-‐[email protected]