Transcript Patients with Opiate Dependence Suboxoon... 5358KB Feb 13 2017

Patients with Opiate Dependence
Suboxone Case Based
Pearls and Pitfalls
Maine Association of Physician Assistants Winter Conference
February 10, 2017
Kelley Harmon, DO
Maine Dartmouth Family Medicine Residency Program
MaineGeneral Medical Center
Augusta, Maine
Verbal Disclosure
I do not have any real or apparent conflict of interest
that may have a direct bearing on the subject matter of
this continuing education program.
Poll the Audience
What fields of medicine are you representing?
primary care
hospitalist/inpatient
surgery
urgent care/ED
sub-specialty
• Who has cared for opiate dependent patients who
are using suboxone or methadone?
• Anyone interested in getting X waivered?
Objectives
• Introduction/Review of MAT/OAT
• Review Scope of Opiate Addiction in Maine
• Review Cases
– Typical Issues Encountered when Treating
Suboxone Patients
– Atypical Cases and Treatment Strategies
• Discussion/Questions
What is Opiate Assisted
Treatment?
• “OAT” or “MAT” (Medication Assisted Treatment)
– Use of a medication to counter opiate withdrawal
symptoms to assist in opiate dependence/abuse recovery
• Examples:
– Suboxone (buprenorphine-naloxone)
– buprenorphine (“Subutex” although now off market)
– methadone
– Note that the medications help, but the real work is in
substance abuse counseling services and lifestyle change
– Buprenorphine is used in pregnancy
• Reasoning: goal is withdrawal avoidance, and we do not use
suboxone because if suboxone abused, the naloxone portion would
become active and put pt into acute withdrawal.
Pharmacology
Buprenorphine
• partial agonist at the mu opioid receptor:
• high affinity and slow dissociation and can temporarily block other opiates
• receptor activation increases as dose increases until it reaches a plateau (“ceiling
effect”)
– Less likely to be abused.
•
*High affinity will also displace other opiates from mu receptor
– causes withdrawal if recent opiate use.
•
Absorption through GI and mucosal membranes
– but oral formulation has poor bioavailabiltiy because extensive metabolism in GI tract.
– Sublingual form is commonly used and should be completely dissolved under tongue to have
the best effect
Methadone, heroin, morphine
– Full opioid agonists
– continue to create greater receptor activation as the dose increases, without reaching a plateau.
Naloxone (Narcan)
– antagonist that will not produce receptor activation regardless of dosing
History of MDFMR Suboxone
Programs
• Opiate abuse has been an increasing problem in our state since late
1990s, initially with methadone clinics as the only MAT option
• Drug Addiction Treatment Act of 2000 (DATA 2000)-permits
physicians who meet certain qualifications to treat opioid
dependency with narcotic medications approved by the FDA—
including buprenorphine—in treatment settings other than Opiate
Treatment Programs (OTPs).
• Our outpatient practices started prescribing suboxone and subutex
to non-pregnant and pregnant patients respectively in low numbers
in ~2005
– Significant expansions ~2009
– Recent increases in numbers of “X waivered” providers, efforts to
coordinate services
– Group visits for obstetric patients began in 2013
• This is a Harm Reduction model of treatment
Approximately 1,000
pregnant and non-pregnant patients
have been treated for opiate dependence
in our programs.
These patients are from all walks of life, all education
levels, all socioeconomic backgrounds.
Many have significant PTSD.
Don’t underestimate the number of people you encounter
daily in the workplace and your community who have
been personally affected by this epidemic.
“Be kind, for everyone you meet is fighting a hard
battle.”-Philo, Plato
Be Humble.
• There are many, many questions that will come up
when caring for these patients, it’s complex work
and not always intuitive.
• Don’t be afraid to ask for help, those of us that
have made mistakes are happy to help you avoid
the same ones.
• As a provider, you are one part of a large team
coordinating and caring for these patients.
Why Do We Need to Prepare
Ourselves?
• To help be a part of solution for chronic disease affecting
our Maine communities
• To feel comfortable with our own patient population,
recognizing most of us did not get formal training around
opiate dependence
• This is unlike any other chronic disease…this rips families
apart, causes unnatural sudden death at premature ages.
• This is happening in record numbers.
• It can be among the most rewarding work you do.
http://www.maine.gov/dhhs/samhs/documents/N
SC-State-Profile-FINAL.pdf
Important Numbers….
Opiate abuse during pregnancy nationally has
jumped by 127% between 1998 and 2011.
Opiate abuse during pregnancy in Maine
increased by 20% between 2012-2013.
In 2015, of the infants born in Maine, 995 were
born drug affected-representing now 8%, or
about 1 in 12 of all births in Maine.
31% increase in drug overdose
deaths, reaching new high of
272 fatalities in 2015.
“One person a day is dying from
drug overdose in Maine.”
-Attorney General Janet Mills
Portland Press Herald 11-14-2016
Drug overdose deaths
now surpass MVA deaths.
• Nationwide:
– 47,000 drug overdose deaths in 2014, compared
with 29,000 deaths in vehicle accidents
Portland Press Herald, November 14th, 2016
Tolerance vs. dependence
• Dependence is a naturally occurring
phenomenon which is the predictable outcome
of long term substance use.
• Tolerance is either the need for markedly
increased amounts of the substance to achieve
the desired effect, or, markedly diminished
effect with continued use of the same amount.
19
Abuse vs. Addiction
• Abuse constitutes the pathological use of
drugs, up to, but not including, withdrawal.
• Drug addiction is a disease of the brain and the
associated abnormal behavior is the result of
dysfunction of brain tissue.
20
Defining Opiate Use Disorder
How do you know when opiate abuse
has become opiate use disorder?
Opioid Use Disorder
DSMV Definition
Pattern of opioid use that causes impairment or distress
characterized by the following (at least 2 criteria in 12 month
period):
-Opiates taken in larger amounts or longer period than
intended
-Persistent desire to cut back
-Time spent trying to obtain drugs or recover from the effect
-Cravings
-Interfering with personal life/responsibilities*
-Tolerance
-Withdrawal
Watch Your Language….
• Babies aren’t born “addicted”, they are dependent.
• “Dirty” or “Clean” urine vs. “Inappropriate” or
“Appropriate” Urine
• “Your urine result wasn’t what I expected, can you tell
me about that?”
Remember, open ended questions, supportive language
gathers more information that you need to take care of
your patient.
“Do not look down on someone,
unless you are offering your hand
to help them up.”
Suboxone/Subutex Follow Up Visits
Areas to cover:
-collect urine sample (observed is best)
-How is patient doing on current dose? How is dose taken?
-How frequently is patient being seen for refills recently and why?
-Any report of cravings, drug dreams or withdrawal symptoms?
-Substance abuse counseling (may be individual or group-confirm!)
-Co-occuring mental health issues-Stable? Unstable? Treatment plan
-Side effects (treat constipation!)
-Contraception in place? (long acting is best for females)
Physical exam:
-COWS if concern for withdrawal , signs of intoxication
-Pupils, intranasal, post pharynx
-Heart rate, CV exam, resp exam, abd sounds
-Track marks
Plan ideally includes: Stable vs. unstable, urine results, plan for medication
management, next follow up visit, additional follow up needs (to include OB visit,
mental health visit, increase in level of services, urine confirmations,etc.)
Questions?
Cases
Case #1
26 yo female presents to ED with nausea, vomiting,
diarrhea, body aches, hot/cold sweats. Track marks
noted on her upper extremities and it’s difficult to
get labs and start an IV for the fluids you’ve
ordered.
Urine tox screen (with her permission) is positive
for opiates. When discussing results, patient
becomes tearful and admits to heroin use and has
been sick since last night when her dealer was put in
jail, and she’s ready to get treatment.
Forensic Toxicology - Drugs and Chemicals
Updated: May 01, 2014
Author: Gregory G Davis, MD, MSPH;
Chief Editor: J Scott Denton, MD
Opiate Withdrawal Symptoms
Symptoms are very uncomfortable for patients, but
remember, in and of themselves, are not life threatening.
Early symptoms of withdrawal:
-Agitation
-Anxiety
-Muscle aches
-Increasing tearing
-Insomnia
-Runny nose
-Sweating
-Yawning
Late symptoms of withdrawal:
Abdominal cramping
Diarrhea
-Dilated pupils
-Goose bumps (piloerection)
-Nausea
-Vomiting
Clinical Opioid Withdrawal Scale
– Resting pulse: patient sitting/lying > 1 min. (0,1,2,4).
• Note pt also likely to be hypertensive.
–
–
–
–
–
–
–
–
–
–
Sweating: over past ½ hour. (0,1,2,3,4)
Restlessness: observation during assessment. (0,1,3,5)
Pupil size. (0,1,2,5)
Bone/joint aches: only those related to withdrawal. (0,1,2,4)
Runny nose/tearing: not colds/allergies. (0,1,2,4)
GI upset: over last ½ hour. (0,1,2,3,5)
Tremor: observation of outstretched hands. (0,1,2,4)
Yawning: observation during assessment. (0,1,2,4)
Anxiety/irritability. (0,1,2,4)
Gooseflesh skin. (0,3,5)
– Score: 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe;
more than 36 = severe withdrawal.
What do you do?
• Further history/questions
• Physical exam
– COWS
• Assessment
• Plan
Plan
Treat symptomatically
-fluids for dehydration
-analgesics (NSAIDS)
-withdrawal pack
-consider baseline labs or refer to PCP
-pregnancy test
Connect to treatment-know your local resources!
The “Withdrawal Pack”
*Consider some or all of these meds based on the patient’s symptoms:
Clonidine (Catapres) 0.1 mg tab; take 1 tab TID prn withdrawal sx. Disp: #20
(relief of chills, piloerection, insomnia, restless legs, anxiety, palpitations)
MOA: Sympatholytic, anti-hypertensive med (central alpha agonist)
Trazadone 50 mg tab; take ½-1 tab at hs prn insomnia.
Disp: #10
MOA: SARI-serotonin antagonist and reuptake inhibitor, has anxiolytic and hypnotic effects
Immodium (loperamide) 2 mg tab;take 1 tab after each loose stool. Disp: #10
MOA: Opioid receptor antagonist, acts on mu receptor at the myenteric plexus of large intestine
Dicyclomine (Bentyl)20 mg tab, take 1 tab with each meal (TID) for nausea. Disp:
#20
MOA: Blocks acetylcholine action at parasympathetic sites in smooth muscle, secretory glands and the CNS
Methocarbamol 750 mg tab, take 1 tab QID prn muscle spasm. Disp:#20
MOA: Causes skeletal muscle relaxation by general CNS depression
Case #2
42 year old male comes into the walk in clinic on
a Saturday morning because he missed his
appointment on Thursday at his addiction
specialist where he would have picked up his
prescription through the following week. He
thought he could get through the weekend but is
feeling poorly and would like a prescription from
you to get him to an appointment on Monday.
What do you do?
• Further history/questions
• Physical exam
– COWS
• Assessment
• Plan
Plan
Check PMP
Collect Utox
Treat symptomatically
-withdrawal pack
Release to his suboxone provider, plan follow up in
their office.
Case #3
R.M. is a 36yo male who presented to the ED
with acute left flank pain, frequent painful
urination with hematuria, n/v and fever to 102°F.
PMH significant for history of prescription drug
abuse (vicodin), has been on Buprenorphine
8mg/Naloxone 2mg SL twice a day for past 18
months.
Diagnosed with pyelonephritis and left kidney
stone in ED.
Admitted for IV antibiotics, hydration, pain control,
and is now ready for discharge from the hospital
with planned outpatient urology appointment and
consideration of lithotripsy.
At signout, there’s some discussion about risks…
What to do?
Options/Approaches to Acute Pain
for patients on Buprenorphine
• "Treat through": Continue Buprenorphine and provide
additional opioids as needed
– (anticipating possible higher than usual doses for non-opiate
naïve patients).
• Discontinue buprenorphine and treat acute pain for usual
expected course, then restart buprenorphine after acute
condition is resolved.
• Split the daily dose of buprenorphine to 3-4 doses/day to
help treat acute pain (but recognize that maintenance dose
will not cover pain)
Acute Pain Misconceptions in MAT
• Maintenance opioid agonist provides analgesia
• Use of opioids for analgesia may result in
addiction relapse
• Additive effects of opioid analgesics and MAT
my cause respiratory and CNS depression
• Pt may be manipulating/drug seeking
Reducing Risks
• Check PMP
• Short term script for narcotics for anticipated
pain as outpatient (no more than 7 days)
• Ask patient about their own concerns
-avoid prior drug of choice
-choose med that can be detected
• Early follow up with PCP/suboxone provider
– Utox, pill counts at follow up appointments
• Communication! (D/C summary, phone call)
Pain Ladder
“Climb down”
 Upon DC, if needed limit opioids to 7d, then
review
 Baseline Opioid F/U
 Tramadol
 Gabapentin/TCA
 NSAIDS
 Acetaminophen
 Other Modalities
 Manipulation
Case #4
What does this mean?
You obtain a random urine screen for a patient that is on
maintenance treatment for buprenorphine and there was a
question of whether the patient might be diverting
medications.
Urine tox screen (observed) is negative for opiates, and
positive for buprenorphine.
You obtain a buprenorphine confirmation and find that there is
-buprenorphine present at a level of 15ng/ml as well as
-norbuprenorphine at a level of 66ng/ml.
Opioid Metabolites Chart
Parent Drug
Expected metabolites
Heroin
Morphine
Codeine
Hydrocodone
Hydromorphone
Oxycodone
Fentanyl
Morphine, 6-MAM
Morphine, possibly Hydromorphone
Codeine, morphine
Hydrocodone, Hydromorphone
Hydromorphone
Oxycodone, Oxymorphone
Fentanyl, Norfentanyl
Buprenorphine
Buprenorphine, norbuprenorphine
Case #5
Patient admitted with
Altered Mental Status…..
Urine Drug Screen (UDS) demonstrated
positive opiate
positive buprenorphine
Opiate confirmation and heroin confirmation follow
up testing demonstrated
positive 6-mono-acetyl-morphine
positive morphine
codeine
hydromorphone
What combination of substances
did this patient take?
• Buprenorphine
– (expected metabolite of buprenorphine)
• 6-monoacetylmorphine
– (expected metabolite of heroin),
• Morphine
– (expected metabolite of heroin, morphine, and/or codeine)
• Codeine
– (expected metabolite of codeine), and
• hydromorphone
– (expected metabolite of hydromorphone, hydrocodone, and/or possibly
morphine).
ANSWER: buprenorphine, heroin (morphine likely from this), codeine
(tylenol #3), and dilaudid or vicodin
Case #6
• Patient comes in for a 24h admission for
dehydration and is due for her 8am dose of
suboxone 8mg SL.
– You are unsure if you can prescribe this since you
don’t have your “X” license.
– What do you do?
If you are providing INPATIENT care, you can prescribe
methadone or buprenorphine for all appropriate diagnoses,
medication comes from hospital pharmacy.
OUTPATIENT
-Suboxone and buprenorphine can only be prescribed by X
waivered providers.
-PA and NP providers currently prescribe suboxone and
buprenorphine under supervision of physicians…..pending
new legislation…
-Methadone can only be prescribed for pain by providers that
are not working at federal clinics licensed for its use for opiate
dependence.
Case #7
Friday afternoon…….
• A patient comes in for a “GI bug”, and you treat her for
nausea and vomiting symptoms. You also notice track
marks on her arms and hands and ask more about this, and
she states her cats have been scratching her.
• Urine pregnancy screen comes back positive. You deliver
this information to her and ask how she feels about this.
She breaks down in tears and tells you about daily heroin
use, how she tried to quit on her own and was worried she
was pregnant, does not want to be doing this, was afraid to
tell you about it earlier, wants to get into a treatment
program.
• Case management is available to meet with her and discuss
options while you go to see another patient
Case #7 (cont.)
• Programs are reviewed with patient and she feels she is
most interested in outpatient treatment. Next
appointment available is Monday afternoon, and she’s
willing and able to come to this.
• Her heroin supplier was just put in jail, so she has no
access and is worried she’ll lose the baby from
withdrawal symptoms over the weekend, and asks if
you could just please prescribe something for her to
keep her out of withdrawal, like “vics” or “percs”?
• What do you do?
• What do you NOT do?
Options for Pregnant Patients
Seeking Help
• Feels like emergency in the moment to you and the patient, but slow
down and avoid crisis mode
• Evaluate medical complaints/symptoms, treat symptoms, admit only if
medical necessity
• Understand drug of choice, why seeking treatment
• Evaluate if appropriate for outpatient treatment-seek advice (arrange
intake eval by provider and/or Vermont Protocol)
• If stable as outpatient, recommend “do what you need to do to stay out
of withdrawal”
• Obtain utox
• Consider inpatient stabilization options (not many in Maine)
*DO NOT prescribe opiate to keep patient out of withdrawal, it is illegal to
prescribe opiate for the sole purpose of keeping patient out of withdrawal.
Buprenorphine in Pregnancy
• Special Considerations
– Avoidance of Withdrawal is the key
– Limits ability of provider to discontinue
medication or taper medication
– Once established on a prescribed dose, refills
should be given until patient is able to be evaluated
What is considered “first line”
treatment for opiate dependence in
pregnancy?
A. Methadone
or
B. Buprenorphine
Answer: Methadone
Barriers to Methadone Treatment
• Access issues
– (but remember transportation is
surmountable)
• Stigma
• Privacy
Buprenorphine In Pregnancy
Goal of treatment is withdrawal
avoidance
• Not many providers in the state, although
increasing
• Great deal of education needed regarding issues
specific to pregnancy and newborn period
• Likely will be first line treatment as more data
collected
*Buprenorphine (“subutex”), not suboxone is used
in pregnancy to avoid acute withdrawal in case
suboxone is used inappropriately.
True or False: Patients should be instructed to swallow
buprenorphine, and as an example, you would order it like
this: buprenorphine 8mg po daily.
False
Buprenorphine (subutex) and suboxone should
be taken sublingually (dissolve under
tongue)….remember poor GI availability
Side Effects of Buprenorphine
• Constipation is a COMMON side effect:
Anticipate this and manage with
– miralax (polyethylene glycol or PEG)
– Senna
– colace (docusate)
– Or dulcolax (bisacodyl).
• Somnolence (but not as much as methadone)
• CYP450 Medications
Discussion/Questions?
References
O'Connor, A. B., & Alto, W. A. The outpatient treatment manual for the care of opioid dependent pregnant women with buprenorphine.
September 2013.
SNUGGLE ME Guidelines (undergoing update)
•
Substance Abuse and Mental Health Services Administration (SAMHSA) https://www.samhsa.gov/
•
16h course (8h online, 8h in person class)
•
Providers’ Clinical Support System For Medication Assisted Treatment (PCSS)http://pcssmat.org/
•
Fundamentals of Substance Abuse Practice Johnson, Jerry L.
•
“Drug overdose deaths in Maine now averaging 1 a day”, Portland Press Herald November 14, 2016
•
UptoDate/Lexicomp www.uptodate.com/home
•
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
American Psychiatric Association, Arlington, VA 2013.
•
Maine Prescription Monitoring Program http://www.maine.gov/dhhs/samhs/osa/data/pmp/index.htm
•
http://www.maineseow.com/Documents/SEOW%20EpiProfile%202016%20FINAL.pdf
•
http://store.samhsa.gov/product/Clinical-Guidelines-for-the-Use-of-Buprenorphine-in-the-Treatment-of-OpioidAddiction/SMA05-4003
•
http://store.samhsa.gov/product/Use-of-Buprenorphine-in-the-Treatment-of-Opioid-Addiction-ClinicalGuidelines/KAPT40
http://pcssmat.org/wp-content/uploads/2014/02/5B-DSM-5-Opioid-Use-Disorder-Diagnostic-Criteria.pdf
•
Remember Us….
Maine Dartmouth Family Medicine
Residency
MaineGeneral Medical Center
Thank You!