Transcript Opioid Abuse and Dependence - University of Colorado Denver

Opioid Abuse and Dependence
Ingrid Binswanger, MD, MPH
Division of General Internal Medicine
Division of Substance Dependence
UCD School of Medicine
Eric Ennis, LCSW, CAC III
Director of Adult Outpatient Services
Senior Instructor of Psychiatry
Addiction Research and Treatment Services (ARTS)
Objectives
1.
Be familiar with current trends in opioid abuse and
dependence, and make accurate diagnoses of opioid
and other substance involvement
2.
Understand psychosocial and pharmacologic treatment
options for patients with substance abuse/dependence
3.
Be familiar with services available for opioid dependent
patients in the Denver metro area, and how to assist in
the coordination of care
4.
Initiate a conversation about how we can better manage
our patients with opioid abuse/dependence and
coordinate care with treatment services
Extent of the Problem
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3 million have used heroin
Opioid dependence related to
pharmaceutical agents increasing in
prevalence
Medical complications of opioid use and
dependence are common and serious
250000
200000
Drug Abuse-Related
ED Visits Involving
Narcotic Analgesics:
1995-2006
150000
100000
50000
0
1995 1996 1997 1998 1999 2000 2001 2002
2004 2005 2006
Source: SAMHSA, The DAWN Report: Narcotic Analgesics, August, 2008.
Unintentional pharmaceutical
overdose deaths, West Virginia
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550% increase in overdose mortality, 1999-2004
295 decedents in 2006
93% associated with opioid analgesics, only
44% were prescribed
63% associated with pharmaceutical diversion
21% associated with doctor shopping
Substance Abuse by DSM Criteria
A maladaptive pattern of substance use leading to clinically significant
impairment or distress
One (or more) of the following, within a 12-month period:
(1)
(2)
(3)
(4)
Recurrent substance use resulting in failure to fulfill major role
obligations at work, school, or home
Recurrent substance use in situations in which it is physically
hazardous
Recurrent substance-related legal problems
Continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the
effects of the substance
Symptoms have never met the criteria for substance dependence for this
class of substance
Substance Dependence by DSM
criteria
A maladaptive pattern of substance use leading to clinically significant
impairment or distress
Three (or more) of the following, occurring in same 12-month period:
1. Tolerance
2. Withdrawal
3. The substance is taken in larger amounts or over a longer period than was
intended
4. Persistent desire or unsuccessful efforts to cut down or control substance
use
5. A great deal of time is spent on activities necessary to obtain the
substance, use the substance, or recover from its effects
6. Important social, occupational, or recreational activities are given up or
reduced
7. The substance use is continued despite knowledge of having a persistent
physical or psychological problem likely to have been caused or
exacerbated by the substance
Drug Dependence is a Chronic
Medical Illness
Requires
Screening and prevention
 Long-term care strategies
 Medication management
 Continued monitoring
 Empathy and patience
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McLellan AT, Lewis DC, O’Brien CP, Kleber HD;
Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000
Compliance & Chronicity
Chronic Illness
Medication
Compliance
Relapse within
1 year
Diabetes
<60%
30-50%
Hypertension
<40%
50-70%
Asthma
<40%
50-70%
Diet or Behavioral
Changes
<30%
McLellan AT, Lewis DC, O’Brien CP, Kleber HD;
Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000
Screening for opioid dependence
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History – Screening tools are available for opioid
misuse, e.g. Physician Opioid Therapy Questionnaire
Physical exam – signs of intoxication or withdrawal or
use
Lab tests
 Urine toxicology screening may be helpful
What should I counsel my opioiddependent patient about?
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Opioid dependence is a chronic disease which
requires ongoing treatment
Overdose risk is substantial
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Combinations of drugs increase risk
Release from jail/prison associated
Leaving drug treatment associated
HIV and hepatitis risk from sharing needles
and paraphernalia
What screening should I perform
on my opioid dependent patient?
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HIV
Hepatitis B S Ag
Hepatitis C Ab
Latent TB infection
What vaccinations should I give my
opioid dependent patient?
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Hepatitis A and B
Tetanus
Therapeutic Options
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Psychosocial interventions
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Contingency management
Individual, group and family counseling
Motivational interviewing
Case management
12-step interventions
Pharmacological interventions
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Methadone (can be used for taper as well)
Buprenorphine (can be used for taper as well)
Naltrexone (also used for alcohol dependence in oral and
injectable forms)
Evidence supports psychosocial
interventions in addition to
medications
Maintenance: Cochrane review suggests
improvements in number of participants
abstinent at follow-up
Detoxification: Improvements in opiate use,
compliance with treatment, and completion
of treatment
Amato, 2008
Contingency Management
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Re-arranging the reinforcers in a person’s
environment
Incentives or rewards to encourage
specific behaviors
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Vouchers, prizes, group acknowledgements,
take-home dosing privileges, family privileges
Methadone Maintenance for
Opioid Dependence: Benefits
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Reduced drug use
Reduced criminality
Improved health (reduced utilization of
health care)
Improved functioning
Public health gains (HIV, Hepatitis,etc.)
Overall health care cost savings
Methadone for Opioid
Dependence: Risks
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Prolonged QT interval: question of what
to do for assessment and treatment
Overdose risks: primarily associated with
methadone prescribed for pain; treatment
decreases risk of overdose from heroin
Diversion concerns?
Functional State
(Heroin)
Impact of Short-Acting Heroin versus
Long-Acting Methadone on the Functional
State of the Patient
"High"
"Straight"
"Sick"
AM
PM
AM
PM
AM
Functional State
(Methadone)
Days
"High"
"Straight"
"Sick"
AM
PM
AM
Days
H
PM
AM
Dole,
Nyswander
and Kreek,
1966
Slow “Build-up” of
Constant Dose of
Methadone to Steady-State
Blood
450
plasma
400
level of
methadone 350
ng/ml
300
250
200
150
100
50
0
1
2
3
4
5
6
7
8
Days
Dose constant at 30 mg to steady-state
Opioid Maintenance Pharmacotherapy - A Course for Clinicians
Induction / Initial Dosing
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Administered under supervision
No signs of sedation or intoxication
Manifestation of withdrawal symptoms
Single dose of 20-30 mg Methadone, not to exceed 30
mg
Same day adjustment, wait 2-4hrs after initial dose (peak
effect), 5-10 mg increase
Maximum dose first day 40 mg
Clinical Pharmacology, Chapter 5, (TIP) Treatment Improvement Protocol #43, FDA Public
Health Advisory, November 27, 2006
Phases of Methadone Dosing
PHASE
PURPOSE
RANGE IN MG/
COMMENTS
Initial Dose
Relieve abstinence
symptoms
20-40 mg
Early Induction
Reach established
tolerance level
Plus or minus 5-10
mg q 3-24 hours
Late Induction
Establish adequate
dose (desired effects)
Plus or minus 5-10
mg q 5-10 days
Maintain desired
effects (steady-state
occupation opiate
receptors
Ideally 60-120 mg
May be > 120 or < 60
Maintenance
Payte and Khuri
Opioid Maintenance Pharmacotherapy - A Course for Clinicians
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l-methadone--µ agonist
Source: National Center for Health Statistics.
Methadone Mortality
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Methadone has been increasingly prescribed for
pain over the past 6-8 years (oxycontin, costs)
2004 SAMHSA report
Increased prescribing of methadone for pain as the
major cause of increased deaths in the United
States (700,000 vs. 260,000)
Outpatient treatment providers have used this
medication as part of our addiction treatment
practice for more than 40 years
Methadone Mortality, cont.
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Sens. Rockefeller and Kennedy have directed the GAO
to conduct a study on methadone-associated mortality in
the US. The GAO Report has a tentative publication date
of March 2009
Report is also likely to focus on the fact that medical
examiners and coroners are still not using any
standardized methodologies in reporting such
methadone-associated mortalities
New York Times article 8/17/08
2007
Buprenorphine
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Buprenorphine available as a single agent or as a
combined agent with naloxone
Available in sublingual preparation that includes
naloxone as a diversion prevention measure
The injectable form of buprenorphine is NOT approved
for use in the treatment of addiction
Buprenorphine
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Partial opioid agonist with high affinity for receptor
Low overdose potential
Easier to withdraw from than heroin, methadone, or
LAAM
Buprenorphine
FDA approved for use in addiction treatment
 Available from private office-based physicians with
federal waiver, as authorized by the Drug Abuse
Treatment Act of 2000
 Currently cost-prohibitive for many patients
 Increasing reports of abuse and diversion
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Buprenorphine
University-affiliated treatment
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ARTS: Addiction Research and Treatment
Services: 3 metro area clinic sites for
Medication-Assisted Treatment for opioid
dependence
ARTS Outpatient Programs
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Denver: ARTS Outpatient Clinic
303.388.5894
Aurora: Potomac Street Center
303.283.5991
Lakewood: Westside Center for Change
303.935.7004
Other Clinics
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Denver Health: Outpatient Behavioral
Health Services 303.436.6392
Private clinics
Denver Behavioral Health 303.629.5293
 North Denver Behavioral Health
303.487.7776
 The Boulder Clinic 303.245.0123
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(Denver VA does not offer methadone)
Using the 5 A’s in Primary
Care
Ask
Advise
Assess
Assist
Arrange
Shortcut:
Ask
Advise
Refer
How to get your patients into
treatment
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Instruct patient to call or visit clinic; most clinics require
pre-payment of intake fee (access and utilization issues)
Call us to discuss your reasons for referral and any
related primary care or pain management issues; we’d
love to hear from you!
Encourage patient to sign authorization for release of
information* for coordination of care, especially if you
are prescribing pain meds, psychotropic meds or other
addictive meds, or if you have concerns about misuse of
pain meds
*42 CFR Part 2 and HIPAA
Costs of treatment and insurance
coverage
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Insurance coverage and acceptance varies by
carrier
Most patients will be assessed a sliding scale
fee of about $180 per month for medical and
psychosocial services; patients with higher
incomes will pay more
ARTS is Kaiser’s exclusive opioid dependence
treatment provider (methadone but not
buprenorphine/naloxone)
Communication between PCPs and
addiction treatment providers: How do I
get information?
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Ask your patient to sign an authorization to
release information
We will also ask the same, but patients
sometimes refuse our request
Be open to receiving calls from counselors and
nurses rather than our Medical Director
Relapse: What to expect
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Relapse is often a part of the treatment process or
course. It is best viewed as a point for useful intervention
and treatment plan revision
Relapse Prevention is a curriculum-driven treatment
protocol
Relapse Prevention is also a generic term describing a
collection of interdependent techniques which are
intended to enhance self-control.
Methadone patients who leave treatment prematurely
relapse at a very high rate: 82% within 12 months
Services ARTS offers
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Assessment for opioid dependence
Treatment of patients with both prescription
and non-prescription opioid abuse and
dependence
Answer questions of medication misuse or
dependence
Injectable and oral naltexone for alcohol
dependence
How can we serve
you better?
How can we do a better job of
integrating primary care into
treatment and treatment into
primary care?
Call us with questions
Recognize the difficulties inherent in treating some of these patients,
particularly those with chronic pain and addictive tendencies
ARTS: Dr. Bill Swafford, 303.388.5894; [email protected]
Denver Health: Dr. Carol Traut, 303.436.6392; [email protected]
Additional resources
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www.artstreatment.org
ACP Pier: http://pier.acponline.org/index.html section on opioid dependence
www.painedu.org
 Recommendations for treating patients with chronic pain and potential
for medication abuse
 Manuals and assessment tools
 Clinical roundtable discussion of how to continue to treat patients with
both pain and addiction
 Providing compassionate care for these difficult to treat patients, while
protecting yourself and your patients
www.aatod.org
Colorado’s prescription drug monitoring program:
https://www.coloradopdmp.org/
Information about obtaining a DEA waiver to prescribe buprenophine:
http://buprenorphine.samhsa.gov/
Further questions/comments
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[email protected]
303-724-2246 (office)
[email protected]
303.388.5894 (office)
303.523.2505 (cell)
References of interest
1. Hall AJ, Logan JE, Toblin RL, et al. Patterns of abuse among unintentional
pharmaceutical overdose fatalities. JAMA. Dec 10 2008;300(22):2613-2620.
2. SAMHSA. The DAWN Report: Narcotic Analgesics 2008.
3. McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical
illness: implications for treatment, insurance, and outcomes evaluation. Jama.
2000;284(13):1689-1695.
4. Turk DC, Swanson KS, Gatchel RJ. Predicting opioid misuse by chronic pain
patients: a systematic review and literature synthesis. Clin J Pain. Jul-Aug
2008;24(6):497-508.
5. CDC. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other
preventive measures. Recommendations of the Immunization Practices Advisory
committee (ACIP). MMWR Recomm Rep. Aug 8 1991;40(RR-10):1-28.
6. CDC. Revised Recommendations for HIV Testing of Adults, Adolescents, and
Pregnant Women in Health-Care Settings. MMWR Morb Mortal Wkly Rep.
2006;55(RR-14):1-24.
7. CDC. Unintentional poisoning deaths--United States, 1999-2004. MMWR Morb Mortal
Wkly Rep. Feb 9 2007;56(5):93-96.
8. Amato L, Minozzi S, Davoli M, Vecchi S, Ferri MM, Mayet S. Psychosocial and
pharmacological treatments versus pharmacological treatments for opioid
detoxification. Cochrane Database Syst Rev. 2008(4):CD005031.