Transcript Opioid dependence and medication assisted treatment

Opioid use disorder and
medication-assisted treatment
Kelsey Van Gorkom, Pharm.D.
PGY-2 Geriatric Specialty Pharmacy Resident
Central Arkansas Veterans Healthcare System
July 13th, 2016
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Objectives
1. Compare and contrast the various agents
used for medication-assisted treatment of
opioid use disorder.
Case #1
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MA is a 66yo M Veteran who works in construction and injured
at a job site. His PCP prescribed oxycodone for pain.
After 2 months, his original dose no longer controlled his pain.
He began increasing his dose on his own and requesting early
refills.
After multiple attempts to get MA to cut down on use, the
PCP stops prescribing oxycodone.
MA wakes up the next morning and has strong cravings, pain,
anxiety, diarrhea. He makes 3 appointments with outside
providers and receives 2 prescriptions for oxycodone.
He learns to crush and snort the medication from a neighbor
for quicker effect.
After being fired for missing work, he feels “out of control” and
that he is “a different person”
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Opioid dependence epidemic
Release of
oxycontin
Pain
5thVS
Pain management opioid safety.VA educational guide. 2014.
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CDC. Opioid painkiller prescribing infographic.
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Criteria of Opioid Use Disorder
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Tolerance/taking larger amounts for longer
time/time spent getting opioids is increased
Recurrent use despite harm
Activities decreased or given up/ attempting
to control unsuccessfully
Social issues/strong desire to use (craving)
Health problems
Dangerous use
Withdrawal
APA: Diagnostic and Statistical Manual of Mental Disorders, 5th edition.
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Treatment of opioid dependence
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Focused on
◦ Psychosocial assistance
◦ Behavioral therapy
◦ Pharmacologic therapy
APA: Diagnostic and Statistical Manual of Mental Disorders, 5th edition.
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Goals of treatment
Reduce dependence on illicit opioids
 Reduce morbidity and mortality caused
by illicit use of opioids
 Improve physical and psychological health
 Reduce criminal behavior
 Improve social functioning
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World Health Organization. 2009.
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Medication-assisted treatment
Underutilized
 Shown to be safe and cost-effective
 Reduces risk of overdose
 FDA approved:
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◦ Buprenorphine
◦ Methadone
◦ Naltrexone
Volkow ND, et al. N Eng J Med. 2014;370(22):2063-6.
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Buprenorphine
Subutrex, Suboxone, Zubsolv
 Partial opioid agonist
 Reduces craving, withdrawal
 Sublingual tablets, buccal film
 Special considerations
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◦ Prescribed by certified physicians
Volkow ND, et al. N Eng J Med. 2014;370(22):2063-6.
Buprenorphine. Micromedex 2.0. Accessed October 20, 2015.
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Buprenorphine
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Advantages:
◦ Quick relief
◦ Lower risk respiratory depression/overdose
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Disadvantages:
◦ Requires mild-moderate withdrawal
◦ Potential for abuse
◦ Naloxone less effective
Connery HS. Harvard Rev Psychiatry. 2015;23(2):63-75.
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Buprenorphine
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Side effects:
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Headache
Constipation
Sleep disorders
Anxiety
Somnolence
PK
◦ Onset: 15min-1hr
◦ T1/2: 31-35 hours
◦ Major CYP 3A4 substrate
Buprenorphine. Micromedex 2.0. Accessed October 20, 2015.
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Buprenorphine + naloxone
4:1 buprenorphine to naloxone
 May be used for discontinuation of
methadone maintenance therapy
 Designed to prevent misuse and diversion
 PK
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◦ Absorption varies
◦ T1/2: 24-42 hours
VA/DoD Buprenorphine Prescribing Criteria. Updated August 2014.
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Methadone
Dolphine, Methadose
 Full opioid agonist
 Reduces opioid craving, withdrawal
 Oral
 Special considerations:
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◦ Available through approved outpatient
programs
Volkow ND, et al. N Eng J Med. 2014;370(22):2063-6.
Connery HS. Harvard Rev Psychiatry. 2015;23(2):63-75.
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Methadone
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Advantages
◦ Can be initiated at any time
◦ Highest rate of retention
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Disadvantages
◦ Takes time to achieve steady state
◦ Legal restrictions
Connery HS. Harvard Rev Psychiatry. 2015;23(2):63-75.
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Methadone
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Side effects
◦ QT prolongation
◦ Respiratory depression
◦ Hypotension
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PK
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Rapid absorption, initial effects 30 min
High degree of variability
T1/2: 22hours
CYP 3A4, 2C19 substrate
Methadone. Micromedex 2.0. Accessed October 20, 2015.
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Naltrexone
Depade, ReVia,Vivitrol
 Opioid antagonist
 Competitively blocks reinforcing effects of
opioid agonists
 Oral/injection
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Volkow ND, et al. N Eng J Med. 2014;370(22):2063-6.
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Naltrexone
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Advantages
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No known diversion value
Minimal abuse potential
Blocks opioid effects for 24-48 hours
Available as long-acting injection
Also approved for alcohol dependence
Disadvantages
◦ Requires prolonged abstinence
◦ Requires naltrexone challenge
VA/DoD Naltrexone Prescribing Criteria. Updated January 2014.
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Naltrexone
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Side effects
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Injection site reactions
Opioid withdrawal
N/V/D
Arthralgia
PK
◦ Not metabolized by CYP P450 (less drug
interactions)
VA/DoD Naltrexone Prescribing Criteria. Updated January 2014.
Opioid abstinence rates with
medication compared to
nonmedication
Medication
Percentage opioid
free on medication
Percentage opioid free
on placebo/detoxification
Naltrexone ER 36%
23%
Buprenorphine 20-50%
/naloxone
60%
6%
Methadone
30%
60%
20%
Connery HS. Harvard Rev Psychiatry. 2015;23(2):63-75.
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Selecting an agent
Availability and access
 Clinical setting
 Patient/family preferences
 Occupational risk
 Medical/psychiatric illnesses
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Connery HS. Harvard Rev Psychiatry. 2015;23(2):63-75.
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Clinical Pearls
Agent selection is patient-specific
 Withdrawal is precipitated if
buprenorphine is started with opioids still
present
 Methadone has highest rate of treatment
retention
 Use caution when prescribing methadone
to elderly patients
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Question #1
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MA You decide to treat MA as an
outpatient. He lives in a rural area, and is
unable to come to daily clinic visits. What
medication would you recommend for
OUD?
A.
B.
C.
D.
E.
Methadone
Buprenorphine/naloxone
Naloxone
Naltrexone
Clonidine
Opioid dependence and
medication assisted treatment
Kelsey Van Gorkom, Pharm.D.
PGY-2 Geriatric Specialty Pharmacy Resident
Central Arkansas Veterans Healthcare System
July 13th, 2016
References
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Connery HS. Medication-assisted treatment of opioid use disorder: review of the
evidence and future directions. Harvard Rev Psychiatry. 2015;23(2):63-75.
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Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies-tackling the
opioid overdose epidemic. N Eng J Med. 2014;370(22):2063-6.
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CDC. Opioid painkiller prescribing infographic. Available at
http://www.cdc.gov/vitalsigns/opioid-prescribing/images/map_970px.jpg Accessed
October 12, 2015.
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VA/DoD Buprenorphine Prescribing Criteria. Updated August 2014.
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VA/DoD Naltrexone Prescribing Criteria. Updated January 2014.
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VA/DoD Naloxone kit Prescribing Criteria. Updated May 2015.
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VA Academic Detailing Service. Pain Management Opioid Safety Educational Guide. July
2014. Available at
http://www.va.gov/PAINMANAGEMENT/docs/OSI_1_Toolkit_Pain_Educational_Guide.p
df. Accessed October 16, 2015.
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Hser YI, Saxon AJ, Huang D, et al. Treatment retention among patients randomized to
buprenorphine/naloxone compared to methadone in multi-site trial. Addiction.
2014;109(1):79-87.
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