Transcript to presentation

Diagnosis And Treatment
Of Prescription Opioid
Dependence
Steven W. Clay, D.O.
Associate Professor, Department of Family
Medicine
Ohio University
College of Osteopathic Medicine
Athens, OH 45701
Overview
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1. Goals of Our Out-Patient Program
2. Presenting the Program
3. Diagnosis
4. Buprenorphine
5. Results So Far
1. Goals of Our Out-Patient
Program
• Turning Lives Around
– Detoxification from Prescription
(& Illicit) Opiates
– Involvement in 12 Step / Other
Programs
– Treatment of Co-Morbidity
Rural Ohio Setting
• Medicaid or No Insurance
• In-Patient Programs: Not Interested
• Out-Patient Treatment: Maybe Available
in Several Weeks to Months
• Drug Screens Only With Cash Up Front
• 20 + Twelve Step Meetings Per Week
(Alcohol or Drugs OK)
2. Presenting the Program
• “Our services in Addiction Medicine are
limited to those needing help with:
– 1. Possible substance abuse or
addiction.
– 2. Getting off addictive drugs with as
little discomfort as possible.
– 3. Buprenorphine treatment for
narcotic addiction recovery.”
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Weeding Out
• “We are NOT a pain treatment center.”
• “We are NOT an in-patient drug
treatment center.”
• “We REQUIRE you to have a personal
physician or we will help you find one.”
• “We REQUIRE a signed written
treatment contract.”
The Rules
• Patients Must follow the rules we set
• Including:
– Attendance at counseling
– Attendance at 12 Step meetings”
• Those who break the contract will no
longer be seen at our office.
• “If you are NOT prepared to follow the
Rules, come back when you are ready!”
Patient Education
• Detox. Only: 97% Relapse By 1 yr.
• Reasons for becoming an addict:
– Genetic, Environmental
– Need to Re-Learn How to Live
Without Drugs
• Need for complete treatment:
– 12 Step & Other Support
3. Diagnosis of Addiction
Disorders
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Risk Factors
Interview
Collateral Information
Establish Use and Consequences
Coexisting Physical / Psych Dz.
DSM-IV / Other Diagnostic List
Addiction Diagnosis
• Dependence / Addiction:
-Preoccupied with
Acquiring / Use
-Compulsive use Despite
Adverse Consequences
-Chronicity and Relapse
Establish Readiness For Change
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1. Pre-Contemplation
2. Contemplation
3. Preparation
4. Action
Prochaska and DiClemente Stages and processes of self-change of Smoking…J of Consult and
Clin Psy 1983
Treatment Matching
• ASAM Criteria For Treatment Matching:
– Consequences of Use
– Family / Other Support
– Financial Support
– Physical / Psychiatric Co-Morbidity
– Relapse Potential
Mee-Lee and Shulman The ASAM Placement Criteria and Matching Patients to Treatment in
Principles of Addiction Medicine 2nd Ed. ASAM 2003
Treatment Matching
• Office Follow-Up to In-Patient
Treatment Based Upon Illness Severity
• Most Followed as Out-Patients Due to
Unavailable:
– Treatment Centers
– Money
– Insurance
Prescription Opiate Addiction
Patient Presentation
• In Contrast to Alcohol / Other Drug
Addiction Patients:
– Opiate Addicts Frequently Admit
Problem and Ask for Help.
– Friends, Family Refer Patients
– The Word Goes Out in the
Addiction Community
4. Buprenorphine
• Subutex:
– Buprenorphine SL
• Suboxone:
– Buprenorphine / Naloxone SL
– 4 / 1 Ratio
Buprenorphine Clinical practice Guidelines SAMHSA 2000
Buprenorphine
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Opioid Partial Agonist
High Affinity Mu Binding
Will Displace Many Other Opiates
Maximum Effect About 30-40 mg
Methadone Equivalent
• SL Absorption Acceptable
Buprenorphine Clinical practice Guidelines SAMHSA 2000
Naloxone
• Opioid Antagonist
• Will Displace Other Opiates and Initiate
Withdrawal
• Poor SL Absorption
• If Taken IV With Buprenorphine, Will
Negate Agonist Actions
Buprenorphine Clinical practice Guidelines SAMHSA 2000
Transfer to Buprenorphine
• Last Week Dose Is What Counts
• From Methadone: Taper By Program:
– 5-10 mg Per Week of Daily Dose
– Goal 30-40 mg Per Day
• From Oxycodone (etc.):
– Many Stop or Taper Before Being Seen
– Adjust Daily Dose to PO Equivalent
– Snorted (X 0.6), IV (X 1.5)
Transfer to Buprenorphine
• Suboxone Used Initially:
– Less Risk in Office (Theft)
• Half to One 8/2 SL Tablet After:
– 48 Hrs. Without Methadone
– 24 Hrs. Without Oxycodone (Etc.)
• Follow With 8/2 to 16/4 SL Daily
• Information Given and Contract Signed
Follow-up Care
• 1-2 Weeks Initially
• MUST:
– Go To 12 Step Meetings
– Keep Appointments
– Not Use
• Occasional Dosage Adjustments
• Then Seen Monthly
Non-Compliance
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Relapse is Part of the Disease
Most Admit Mistakes
I Usually Will Give One Second Chance
Look For Progress Not Perfection
Limited Use of Urine Toxicology
Screens Due to Cost
Tapering Buprenorphine
• Decrease By ½ Dose Monthly
• Some Can Rapidly Come Off:
1-2 Weeks
• Some Take Months
• Variation Based on Patient Preference
and Involvement in 12 Step Programs
5. Results So Far
Results So Far
• Opiate Addicts Presenting to University
Medical Associates Addiction Medicine
• Inclusion Criteria:
– Opiate Use > 20mg / Day Methadone
– Non-Pregnant
– Willing to Follow Rules
• 41 Consecutive Opiate Addicts Placed
on Buprenorphine
Results
• Mean Age 33, Range 18 to 56
• 63% Male
-SAMHSA 2002 Drug Use Survey:
Illicit Drug Use 62.1% Male
• Mean Methadone Equivalent Dose Per
Day = 88.5 mg
(%) Family History:
Alcohol, Drug & Psych Disorders
35
34
30
25
22
20
14
15
10
10
10
5
5
5
0
0
NEG
A
D
AD
P
AP
DP
ADP
Psychiatric Diagnosis (%)
60
53
50
40
24
30
20
17
20
7
10
5
0
ANY SMI
ANX
DYS
MDD
BIP
SAMHSA
SMI
Drugs/Pain Prior to Opiates (%)
60
60
50
40
30
20
20
15
10
5
0
POLY
PAIN
P+P
NO PR
Opiate Progression (%)
80
70
73
60
50
40
30
20
7
5
15
10
0
PRES
PR 2 STR
STR
STR 2 PR
Opiate of Choice (%)
60
58
50
40
32
30
20
10
5
2.5
2.5
Oxy + H
Other
0
Oxycod
Oth pres
Heroin
Administration Route (%)
60
51
50
40
29
30
20
12
7
10
2.5
0
PO
Snrt
IV
Chew
Tea
Detoxed. Before Treatment (%)
80
75
70
60
50
40
30
20
20
5
10
0
0
NONE
METHDONE
INPT
OUTPT
12 Step Attendance (%)
45
44
40
35
30
25
29
20
20
15
10
7
5
0
FREQ
OCCAS
NONE
UNKN
Results (%)
60
53
50
40
30
22
20
15
10
10
0
TAPER
COMPLETE
RELAPSE
UNKNOWN
O.B.O.T. in S.E. Ohio
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Mean Age 33
63% Male
Mean Methadone Equiv. 88 mg
34% Negative Family History
Addiction/Psych Disorders
• 54% Some Mental Illness
O.B.O.T. in S.E. Ohio
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80% Common Drug Use Progression
90% Prescription Addiction
75% No Previous Detoxification
64% At Least Tried 12 Step Programs
63% Tapering or Completed Program
37% Relapsed or Presumed Relapsed