Transcript Peter Mason MD

UNH DEPARTMENT OF NURSING
AND SOUTHERN NH AHEC
ANNUAL CLINICAL SYMPOSIUM
AUGUST 27, 2015
2013 National Survey on Drug Use and Health:
4.9 million current (past month) nonmedical users of
prescription opioids
1.9 million met DSM-IV criteria for opioid use disorder
associated with their use of prescription opioids
More than 0.5 million additional individuals met criteria for
opioid use disorder associated with use of heroin
8.7% of all people surveyed over the age of 12 admitted to any
illicit drug use in the previous month
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MORTALITY—leading causes are overdose and
trauma
320 PEOPLE DIED FROM OPIOID OVERDOSE IN NH
IN 2014
MORBIDITY– injection route use increases the risk of
being exposed to HIV, viral hepatitis and other
infectious agents
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For every 1 overdose death from prescription
painkillers there are…..
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--10 treatment admissions for abuse
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--32 emergency department visits for misuse or abuse
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--130 people who abuse or are dependent
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--825 people who take prescription painkillers for nonmedical use
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--55% are obtained from a friend or relative
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--17% are prescribed by a single provider
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--11% are bought from a friend or relative
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--5% are stolen from a friend or relative
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--4% are obtained from a drug dealer
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Who is responsible?
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Why is it getting worse?
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Why is there an increased sense of urgency?
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What are the characteristics of NH and Northern New
England that make this a particularly difficult problem
to address?
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Few of us screen routinely for alcohol abuse, let
alone for other substance misuse
We tend to utilize a biomedical model which
addresses pathology and morbidity, not at-risk
behavior
We miss many opportunities to work upstream
--Belief that patients lie
--Time constraints
--Fear of questioning patient’s integrity
--Fear of angering the patient
--Uncertainty about treatment
--Personally uncomfortable with the subject
--May encourage the patient to see another clinician
--Belief that insurance doesn’t reimburse clinician time
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Less than 30% of patients adhere to prescribe
medications and diet or behavioral change for
conditions like hypertension, diabetes and asthma.
The same percentage stop drinking when
recommended
There is a 50% recurrence rate
Substance abuse should be insured, monitored, treated
and evaluated like other chronic diseases
Shift from moral failing to a chronic and recurrent
condition:
--Care coordination and behavioral health and medical
health integration
--Expanding treatment options
MAT: burprenorphine, methadone, naltrexone
Intensive Outpatient Programs (IOPs)
Sober housing
Peer recovery
Drug court and treatment in prison
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A public health approach to the delivery of early
intervention and treatment services for at-risk and
substance use dependent individuals
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Identifies and intervenes when necessary
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Universal screening can occur at any medical setting
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SCREENING: To identify patients with moderate-tohigh risk drinking and drug use
BRIEF INTERVENTION: To motivate patients who
screen positive to consider healthier decisions (e.g.
reducing, ceasing or seeking further assessment)
BRIEF TREATMENT AND REFERRAL TO
TREATMENT: To actively link patients to resources
when needed
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Continuum of Use
Low-risk use
High-risk/unhealthy use
Abuse and dependence (substance use disorders)
Continuum of Care
Brief intervention: Motivational conversation with
action plan
Brief treatment: Wrap-around services
Referral to treatment: Detox, treatment types
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More than 34 RCTs in primary care populations
Well-documented effectiveness for moderate to high risk
drinkers with 10-30% alcohol reduction at 6 months
USPSTF gave screening and brief intrervention a Class B
rating—same level as flu shots and cholesterol screenings
Persons with polysubstance use, pre-contemplation, illicit
drug use, or dependent alcohol dx will likely require more
intensive tx to show improvement in risky behavior
CLONIDINE
--alpha adrenergic blocker
--limits autonomic withdrawal (anxiety, agitation,
sweating, cramping)
--does not help with drug craving
--not effective for sustaining recovery
NALTREXONE
--available in both daily PO form and monthly injectable
--opioid equivalent of Antabuse with fewer side effects
--opioid receptor blocker, no agonist activity
--can precipitate significant withdrawal and can’t be used
within 7 days of drug use
--IM form extremely expensive
--high rates of relapse
--strong interest in use with parolees
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METHADONE
--Used in long-term maintenance therapy
--Opioid agonist, prevents withdrawal
--Tolerance attenuates the effects of heroin and other
abused opioids
--”Chipping”—can start and stop it to get high
--Highly regulated, only ~2K slots nationwide
--Stigma
--Exposure to other substance-using patients
--May interfere with work or family commitments
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BUPRENORPHINE
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How does it work?
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Does it have other uses?
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What are the different formulations?
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What’s in a name?
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Subutex
Suboxone
Zubsolv
Narcan
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Can it be abused?
How effective is the naloxone component of
Suboxone?
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How does that effect its street value?
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Is buprenorphine addictive?
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What’s the difference between buprenorphine
and methadone?
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What are “chemical handcuffs?”
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How does the profit motive figure in?
Free standing clinics
 Different formulations of buprenorphine
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What is it?
What is the best clinical setting to provide
Medication Assisted Treatment (MAT)?
Who can prescribe these medications?
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Patient-Provider Contract
Regularly scheduled appointments
Counseling with a Licensed Alcohol and Drug
Counselor (LADC)
Established with a PCP in our practice
Regular communication between the LADC
and me
Regular urine drug screens
Patient will keep appointments with me and
counselor
All prescriptions will be filled at one pharmacy
Patient allows communication between me and
counselor
Patient will not abuse our staff
Patient agrees to random pill counts and urine
drug screens
Patient will not use other illegal substances
Patient will meet financial obligations to practice
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“Successes”
Precarious Recovery
Failures
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No one has the answers (particularly myself)
There is no blueprint (despite the guidelines)
Treatment must be individualized
Patients don’t follow a linear course
Expect lapses, testing and recidivism
Expect to be lied to
This is a life-long chronic disease
Many or most patients will never discontinue
meds
You need to be flexible with contract violations
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There are no slam-dunk predictors of success
or failure
You may need to be satisfied with harm
reduction
Addiction is a family disease—treatment is
prevention
Having a PCP is important
Having a job is important
Encourage openness and family support
Discourage contact with friends who use
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Counseling piece is extremely important
Need to have zero tolerance with certain
aspects of contract---e.g. behavior, paying bills
Need to be consistent—news travels fast on the
street
The personal rewards, when a single patient
stabilizes, are enormous
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Linda Blake, RN
Don West, MD
Ben Nordstrom, MD
Seddon Savage, MD
Laurie Harding, MS, RN
Stephen Elgert MD
Jennifer Gordon, LICSW
My patients
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VT-SBIRT website:
http://sbirt.Vermont.gov/
Yale School of Medicine SBIRT:
http://medicine.yale.edu/sbirt/index.aspx
American Society of Addiction Medicine practice guidelines (May 2015—
excellent review of components of treatment program and pharmacology
of agents):
http://www.asam.org/docs/default-source/practicesupport/guidelines-and-consensus-docs/national-practiceguideline.pdf?sfvrsn=22
Providers’ Clinical Support System for Medication Assisted Treatment
from SAMHSA (superb free tutorials with all kinds of educational
materials):
[email protected]
Feel free to contact me with questions about this presentation, resources
or the Dartmouth COOP Project at:
[email protected]