Transcript Drug Court Opiates - California Association of Collaborative Courts

The Opioid Epidemic
and Medication Assisted
Treatment
Timothy W. Fong MD
UCLA Addiction Psychiatry
Southern California Collaborative Court
Regional Training
April 16, 2016
Financial Disclosures
Speaker Bureau
Indivior
Research Support
Constellation
Friday Night Live
Onward, Inc.
Overview
• Opioid Dependence
– Opioid Use Disorder
• Screening and Assessment
• Treatment
– Focus on Buprenorphine
Opioid Use Disorder (DSM-5)
• Now, known as Opioid Use Disorder
• Combines Opioid Abuse and Opioid
Dependence
• Aka Opioid Addiction
• 2 out of 11 diagnostic criteria
Opioid Use Disorder
1.
2.
3.
4.
5.
6.
______ is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control _____ use.
A great deal of time is spent in activities necessary to obtain __________ , or recover from its effects.
Craving, or a strong desire or urge to use _____________
Recurrent ______ use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued ______ use despite having persistent or recurrent social or interpersonal problems caused
or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced because of ______
use.
8. Recurrent ______ use in situations in which it is physically hazardous.
9. ______ use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by alcohol.
10.Tolerance, as defined by either of the following:
1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
2. A markedly diminished effect with continued use of the same amount of ______
11.Withdrawal, as manifested by either of the following:
1. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set
for alcohol withdrawal).
2. ______ is taken to relieve or avoid withdrawal symptoms.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,
(Copyright © 2013). American Psychiatric Association. All rights reserved.
Opioid Use Disorder
• Impaired Control (1-4)
– larger amounts than intended
– can’t cut down
– spends a lot of time
– craves
• “ has there has ever been a time when you had
such strong urges to take the drug that you
could not think of anything else”.
Opioid Use Disorder
• Social Impairment (5-7)
– Failure to fulfill life obligations
– Activities given up or reduced
– Social problems
Opioid Use Disorder
• Risky Use (8-9)
– Using in hazardous situations
– Using despite physical or psychological
harm
– “Failure to abstain despite difficulty it is
causing”
Opioid Use Disorder
• Pharmacological Criteria (10-11)
– Tolerance
• Increased dose to achieve effect
• Reduced effect with usual dose
• Differentiate from individual sensitivity
– Withdrawal
• Occurs with decline in blood/tissue levels
The Opioid Epidemic
Signs of the Opioid Epidemic:
More Deaths
• Since 1999, the rate of overdose deaths
involving opioids (prescription opioids
and heroin have quadrupled
• More deaths than MVAs
• > 30,000 per year
• ~78 opioid overdoses per day
• ~4500 deaths in California / year
Signs of the Opioid Epidemic:
Increased Heroin Use
• Past month heroin use, past year heroin
use, and heroin addiction have all since
increased among 18-25 year olds since
2000
• More heroin available on the street
• 80% of heroin initiates used prescription
opiates previously
Signs of the Opioid Epidemic:
Rise of Prescription Opioids
• 2014, ~2 million Americans were
dependent on prescription opioids.
• 1 in 4 people who receive prescription
opioids long term for non-cancer pain in
primary care settings struggles SUD
• Daily, >1,000 people are treated in
emergency departments for misusing
prescription opioids
Obama Administration
Announces Additional
Actions to Address the
Prescription Opioid Abuse
and Heroin Epidemic
March 28, 2016
Action List
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•
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Expand access to treatment
Create MH/SUD Taskforce
Prevent Overdose Deaths (naloxone)
SUD Treatment Parity
Implement Syringe Services Programs
Medical Schools – Mandated Prescriber
Education
Abused Opiates
Prescription Pills
Heroin
Rates of Opioid Sales, OD Deaths, and Treatment, 1999–2010
8
Opioid Sales KG/10,000
Opioid Deaths/100,000
Opioid Treatment Admissions/10,000
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6
Rate
5
4
3
2
1
0
1999
2000
CDC. MMWR 2011
2001
2002
2003
2004
2005
Year
2006
2007
2008
2009
2010
Screening for
Opioid Use Disorders
Aberrant Medication-Taking Behaviors
Differential Diagnosis
• Inadequate analgesia – “Pseudoaddiction”1
• Disease progression
• Opioid resistant pain (or pseudo-resistance)2
• Addiction
• Opioid analgesic tolerance3
• Self-medication of psychiatric and physical
symptoms other than pain
• Criminal intent – diversion
• Use the Current Opiate Misuse Measure
1
Weissman DE, Haddox JD. 1989;
2
Evers GC. 1997;
3
Chang et al. 2007.
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Assessing Signs and
Symptoms of Withdrawal
• Ways to assess
withdrawal
– Written scales
(eg, COWS)
– Clinical experience
• Signs and symptoms
(eg, sweating, pupil size,
runny nose, gooseflesh)
The National Alliance of Advocates for Buprenorphine Treatment. http://www.naabt.org/documents/NAABT_PrecipWD.pdf.
Accessed June 24, 2011.
Pharmacotherapy for
Opioid Use Disorder
Opioid Use Disorder
Treatment Goals
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Treat withdrawal
Reduce cravings
Block euphoria from opiates
Improve quality of life
Engage in treatment
Medication Approaches
• Action
– (Full) Antagonist:
• Naltrexone, Naloxone
– (Partial) Agonist/Antagonist
• Buprenorphine
– (Full) Agonist
• Methadone
FDA-Approved Medications
Drug of Abuse Brand Name
Generic
Opiates
Buprenorphine/
Naloxone
Suboxone
Subutex
Methadone
Revia
Naltrexone
Vivitrol
Naltrexone
Methadone
•
•
•
•
•
Methadone liquid
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
•
•
•
•
•
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
Methadone
Effects last 24 hours that allow functioning
Withdrawal symptoms are slower and
milder
Advantages:
Cannot be injected
Longer duration than Heroin
Controlled dispensing
Federal – Opioid Treatment Program
Typical Clinic
Methadone
Maintenance Therapy “MMT”
The patient remains physically
dependent on an opioid but is freed
from the uncontrolled, compulsive &
disruptive behavior.
- Improved subjects health
- Decreased criminal activity
- Increased employment
Opioid Antagonist: Naltrexone
Opioid Blockade
FDA Approved for Alcohol
Prevents relapse
Strong Anti-Craving
Minimized overdose risk; especially after
detox
Highly Motivated
Does not want agonist therapy
Injectable NTX Provides a
Sustained-Release of Medication
1. Dunbar JL, et al. Alcohol Clin Exp Res. 2006;30:480-490.
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IM Naltrexone Eliminates Daily
Adherence Decisions1
• Naltrexone utilizes a delivery system that
– Provides a month of medication in a single dose
• Adherence to any treatment program
is essential for successful outcomes
• Administration by a healthcare provider ensures
that the patient receives the medication as directed
“…addressing patient adherence systematically will
2
maximize the effectiveness of these medications.”
–Updated NIAAA Clinician’s Guide
1. Dean RL. Front Biosci. 2005;10:643-655.
2. NIAAA. 2007. NIH publication 07-3769.
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Buprenorphine
(2002)
Overview
• Office-based treatment
• Physicians prescribing must have
certification from DEA (30 -100 pt. Limit)
• Manages withdrawal
• Used as a maintenance therapy
• Limited abuse potential
Pharmacology
• Semi-synthetic morphine alkaloid
• Partial agonist at mu receptor
– Ceiling effects
• Antagonist at kappa receptor
• Schedule III
• Over 20 years of research
Pharmacology
• High affinity
– Competes with other opioids
• Slow dissociation
– Prolonged effect
• Poor oral bioavailability (1st pass)
• 50-70% SL bioavailbility
• Duration of action
– Onset 30-60 min
– Peak 1-4 hours
– Half-life: >30 hours
Full vs. Partial Agonist
Formulations
Sublingual
Subutex (Buprenorphine)
2mg, 8mg
Suboxone (Bup + Naloxone 4:1)
2mg/0.5 mg , 4mg / 1mg
8mg/2mg, 12 mg/3 mg
Film Strips
Formulations
• Available as parenteral analgesic
(Buprenex) which is NOT approved for
opioid addiction
Safety
• SE: H/A, WD sx, pain, nausea,
dysphoria
• IV misuse + benzos = possible CNS
depression
• Category C in pregnancy (no studies)
• Some reports of hepatitis
• Physical Dependence Potential
Dosing Schedule
Day of
Dosing
1
Dosing Schedule
2
Day 1 dose + 4 mg
prn q4 hours
Day 2 dose + 4 mg
prn q4 hours
Day 3-7 dose
3-7
7-10
4 mg q2 hrs prn
Recommended
daily dose
12-16 mg
16-24 mg
16-32 mg
16-32 mg
Treatment Outcomes
Kakko,
2003
Positive Impact of MedicationAssisted Treatment
• ~ 2 million Americans are dependent on opioid
prescription painkillers or heroin
• Over 900,000 patients were treated with
buprenorphine/naloxone in 2010
• Buprenorphine/naloxone is safe and an effective
treatment for opioid dependence
• Treatment
– is cost-effective
– can improve functioning across several
psychosocial parameters
Opioid Overdose
• Naloxone
– 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
Overdose Education and
Naloxone Distribution (OEND)
• Naloxone (injectable and nasal spray)
– Reverses opiate overdoses
• In early 2015, California law allows
pharmacists to distribute naloxone
directly to patients
Naloxone Formulations
Generic
Injection Solution: 0.4 MG/1 ML, 1 MG/1 ML
Evzio
Injection Solution: 0.4 MG/0.4 ML
Narcan
Nasal Spray: 4 MG/0.1 ML
Provider Toolbox
Controlled Substance
Utilization Review and
Evaluation System (CURES)
Proper Drug Disposal
(DEA/FDA)
1. Medicine Take Back Programs
2. Transfer to DEA-authorized collection
sites
3. Dispose in Trash
Mix with unpalatable substance,
seal, throw, de-identify
4. FLUSH Controlled Substances!
CDC Guideline for
Prescribing Opioids for
Chronic Pain —
United States, 2016
Treatment Referrals
• SAMHSA Treatment Locator
– http://findtreatment.samhsa.gov
– 1-800-662-HELP
• NIDA Clinical Trials Network
– www.drugabuse.gov
• American Academy of Addiction
Psychiatry
• American Society of Addiction Medicine
Further Reading
• National Institute on Drug Abuse
– www.nida.nih.gov
• American Academy of Addiction Psychiatry
– www.aaap.org
• Substance Abuse and Mental Health Service
Administration
– www.samhsa.gov
Contact Information
Timothy Fong MD
UCLA Addiction Medicine Clinic
310-825-9989 (appts)
310-825-1479 (office)
[email protected]
uclagamblingprogram.org