Transcript La Clairvoyance - NAMI Southwest Ohio

HOPE
for
Opioid Use Disorders
NAMI Southwest Ohio
May 12, 2015
Clifford Q Cabansag, MD, DABAM, CTTS
Addiction Medicine Physician, Tobacco Treatment Specialist
Disclosures
• NONE
Disclosures
• NONE
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
The Power of Language
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Addict
Addicted to _
Addiction
Alcoholic
Clean
Dirty
Drug habit
Drug Seeker
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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
The Power of Language
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Drug Abuser
Former
Maintenance
Pain Seeker
Recreational
Reformed
Replacement
Substance Abuser
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Pt with SUD
In sustained remission
Medication Asstd Treatment
Relief / Treatment Seeking
Non-medical use
In remission
MAT
Pt with SUD
Terminology
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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
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Addiction
Dependence
Tolerance
Withdrawal
Opiate vs. opioid
Chronic Disease Model
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
Questions
• (For discussion:
Addiction ~ Substance Use Disorder)
• What must be present to have dependence?
• Aren’t dependence and addiction the same?
• Is it possible to have dependence w/o addiction?
• To have addiction without dependence?
• What about tolerance & withdrawal?
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
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’?
Answers
• The LOSS OF CONTROL & Aberrant Behavior
• So
Dependence ≠ ‘Addiction’/Substance Use DisO
• BUT
Dependence + Aberrant Behavior = SUD
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
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
“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
• Doesn’t MAT make people ‘high’/euphoric?
• Routinely, No; may be some mild elevation of mood with
first dose in pt opioid naïve pt but not thereafter
• Doesn’t MAT promote self-medication?
• No; pts are monitored regularly and carefully in
accordance with evidence-based practice
“Exchanging one drug for another”
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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
“Exchanging one drug for another”
• MAT
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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
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
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
Trade name vs. Generic
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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
Take a Deep Breath
Deaths from Prescription Opioid Overdose
• 44 people die in US daily due to Rx opioid OD
• From 1999-2013:
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Mostly 25-54 years old (but OD’s 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
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
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
Trends in Heroin Use in US: 2002 - 2013
Trends in Heroin Use in US: 2002 - 2013
Trends in Heroin Use in US: 2002 - 2013
Trends in Heroin Use in US: 2002 - 2013
Trends in Heroin Use in US: 2002 - 2013
Trends in Heroin Use in US: 2002 - 2013
Trends in Heroin Use in US: 2002 - 2013
Trends in Heroin Use in US: 2002 - 2013
Trends in Heroin Use in US: 2002 - 2013
Past-Year Nonmedical Pain Reliever Use
Among Adolescents, by National Survey and Gender
2002–2013
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
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
2013 OH Drug OD Data
• Opioids (Rx + heroin) main factor → epidemic
• Almost ¾ (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
Contributing Factors to Opioid OD Epidemic
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Changes in pain management guidelines 1990’s
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
2014
Take a Deep Breath
Role of MAT
• Dominant model remains detox
• Detox w/o subsequent pharmacologic support
• Decades of evidence show lack of effectiveness
• (What’s 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
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
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 detox’d 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)
Classification of MAT Rx’s
• Basic schema
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Action
(Route)
Duration of effect
Affinity
• Action
• (Full) Antagonist
• (Partial) Agonist/Antagonist
• (Full) Agonist
Classification of MAT Rx’s
• Duration of effect
• Short, medium or long acting
• Affinity
• Measure of binding of ligand to receptor
• (Low) - High
Classification of MAT Rx’s
• Action
• Antagonist
• Short-acting: naloxone IV or IN / Narcan
• Long-acting: naltrexone po / ReVia
naltrexone IM / Vivitrol
Antagonist MAT
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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
Classification of MAT Rx’s
• 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
Partial Agonist/Antagonist MAT
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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?
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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
Classification of MAT Rx’s
• Action
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(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
Full Agonist MAT
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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
Full Agonist MAT
• Methadone highest efficacy relieving withdrawal
• (Dole and Nyswander, 1960’s)
• Dominant treatment of OUD in US
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Highest retention (80% at 6 mos)
Decreased HIV & HepC transmission
Interaction with HAART for HIV
Maintains physiologic dependence
Risk of overdose during and if dc’d
Opioid Overdose
• Opioid antagonists
• Used to improve breathing
• Naloxone
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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
Question
• 2 pts actively using illicit opioids
• One takes Suboxone (BUP + naloxone)
• The other takes Subutex (BUP only)
• What happens in each case?
• Why?
Persons in Substance Use Treatment Receiving Buprenorphine:
Single-Day Counts 2009–2013
Persons in Substance Use Treatment in OTPs
Receiving Methadone: Single-Day Counts 2009–2013
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey of Substance Abuse Treatment Services, 2009 to 2013.
Methadone 40 year follow up
Success Stories
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We don’t hear about them
When properly treated
Evidenced Based multi-modal therapies
In context of therapeutic alliance
– such pts practically
INDISTINGUASHABLE from general population
OAT Pts Occupations / Fields of Employment
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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
OAT Pts Occupations / Fields of Employment
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Bus Driver*
Sanitation Driver*
Con Ed Utility*
Subway Signal*
Sales
Secretarial
Administrator
Piano Teacher
Elevator Repair
Lawyer
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Physician
Landscaper
Car Sales/Repair
Videographer
Heavy Equipment
Contractor
Entrepreneur
Musician
Nurse
* Safety Sensitive –
Employer Aware
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
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Monitored closely
Managed carefully
Dosed judiciously
In context of therapeutic alliance
Our Most Basic Role - To BELIEVE in our patients…..
on THEIR behalf!
René Magritte – La Clairvoyance (1936)
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th 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 DATOS—Part 1:
Discharged versus continuing patients. Journal of Maintenance in the Addictions 2(1/2):129–150, 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, O’Brien CP, Kleber HD: Drug Dependence, a Chronic Medical Illness – Implications for Treatment,
Insurance, and Outcomes Evaluation. JAMA, 284:1689–1695, 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.
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.
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):1238–46.
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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