1 / 29

Treating the Opioid Crisis: Introduction to Medication Assisted Treatment (MAT)

Treating the Opioid Crisis: Introduction to Medication Assisted Treatment (MAT). Dr. Joy P. Alonzo, M. Engineering, PharmD Mental & Behavioral Pharmacotherapy Specialist Texas A&M Health Science Center Director of Spring Outreach Services. Learning Objectives.

constantine
Télécharger la présentation

Treating the Opioid Crisis: Introduction to Medication Assisted Treatment (MAT)

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Treating the Opioid Crisis: Introduction to Medication Assisted Treatment (MAT) Dr. Joy P. Alonzo, M. Engineering, PharmD Mental & Behavioral Pharmacotherapy Specialist Texas A&M Health Science Center Director of Spring Outreach Services

  2. Learning Objectives Examine risk factors & clinical features of Opioid Use Disorder Assess FDA approved pharmacotherapy for OUD Differentiate between treatment strategies for OUD Discuss risk factors associated with MAT & prevention Determine the role of Harm Reduction in OUD

  3. The Problem with Opioids:Different than Other Substances • Pain is subjective – no data to measure outcomes, patients expect to experience no pain, prescribers incentivized to provide opioids. • Changes in regimen cannot be done quickly due to physiologic responses and complexity of involved systems. • Used across various practice specialties, special populations. • Opioids do not have a maximum daily doses like most other medications. • Opioid Induced Hyperalgesia = ongoing or worsening pain. • Can’t get rid of prescription opioids, they have legitimate medical uses & no current credible substitute! (unlike other substances like cocaine/marijuana/meth)

  4. The Opioid Crisis Incentivization of prescribers to provide opioid pain management: TJC standards, MCO Star ratings, guideline recommendations The inherent qualities of opioids can easily contribute to misuse. These qualities include inducing feelings of euphoria and stress relief, as well as side effects such as tolerance and withdrawal. Untreated underlying mood disorder like anxiety/high stress Even when taken as prescribed, patients may still become addicted. ALL OPIOIDS CAUSE: Tolerance/Dependence Not all patients take opioids as prescribed. High pain levels due to untreated illness Illicit opioids (heroin, illicit fentanyl) are cheap and easy to get. Contributing Factors

  5. Opioid Use Disorder Risk Factors • Risk factors for opioid misuse: • Past or current substance use • Chronic Opioid Use • Untreated psychiatric disorders • History of alcohol and/or Benzo use • Youth and adolescents • Social or family environments that encourage misuse. • Comorbid psychiatric illness • Living in rural areas and having low income • History of Incarceration https://www.cdc.gov/rxawareness/pdf/Overview-Rx-Awareness-Resources.pdf

  6. Providing Relief from suffering for patientson the day you see them…MEDICATION ASSISTED TREATMENT

  7. OUD MAT Treatment Goals Always incorporate a patient’s goals when developing a treatment plan, which may include: • Current interest in treatment • Interest in abstinence based treatment versus MAT • Work, community, justice supports • Understand risk/benefits of approaches • Agrees to clinic contract, safety precautions • Adherence • Financial resources • Availability of wrap-around care

  8. Harm Reduction … Incorporates a spectrum of strategies including: safer techniques, managed use, and abstinence Meets people “where they are” but doesn’t leave them there. Applies evidence-based interventions to reduce negative consequences: • Medication Assisted Treatment • Naloxone rescue kits • Syringe exchange programs • PrEP (Pre-exposure prophylaxis for HIV) • Fentanyl test strips • HEP C testing /HIV testing & education on prevention/treatment Works to elicit ANY POSITIVE CHANGE based on individual patient need, circumstance, and readiness to change.

  9. OUD MAT Treatment Goals Objectives of MAT • A collection of Evidence-based treatments to: • Decrease illicit opioid use • Reduce transmission of Hepatitis C • Reduce transmission of HIV • Decrease criminal behavior • Reduce sexual risk behaviors (e.g., trading sex for money/drugs) • Improve social functioning • Retain people in treatment • Decrease overdose and death

  10. OUD Assessment • Psychiatric Assessment • Severe, unstable, untreated illness • Psychoactive medication therapy • Substance Use • Opioid of choice, route, frequency, amount, duration • Other substance use • PMP history • Toxicology screen for substances • Substance Use Treatment • Past treatment types • Results of treatment • Reduction/cessation of use • Duration of cessation • Physical Examination • Vitals • Signs of injection • Edema of extremities • Jaundice • Signs of: abscesses, cellulitis, endocarditis, tuberculosis • Signs of opioid withdrawal or intoxication • Lab tests • BMP/CBC, Viral Hep B/Hep C, HIV, TB • If appropriate, STDs, Pregnancy

  11. Assessment of Opioid Withdrawal COWS • Clinical Opiate Withdrawal Scale (COWS) • Clinician-rated tool to assess opioid withdrawal symptoms • Items are scored 0 to 5 based on intensity of symptoms, higher score, greater intensity • Scoring: • 5-12: Mild • 13-24: Moderate • 25-36: Moderately severe • >36: Severe

  12. Medications for Opioid Use Disorder • Long term maintenance therapy (18mos or more) • 3 FDA approved medications : • Methadone • Buprenorphine • Naltrexone • Detox: is not treatment, management of withdrawal • Inpatient vs. outpatient • Strategies are colloquial, include a variety of medication management techniques, often feature titration of clonidine, clonazepam, symptomatic treatments

  13. MAT : Place in the “toolbox” • One of the many tools in the “recovery toolbox”. • Reduce cravings which can help stabilize & strengthen coping capacity. • Increase periods of abstinence & instill a sense of self-efficacy . • Allows patients to focus on behavioral therapies. • Improve clinical outcomes for patients & reduce impact on families.

  14. Methadone • Regulation: strict federal guidelines dictate eligibility for methadone treatment, prescribing circumstances, and access. • Benefit: prevents withdrawal symptoms, reduces cravings, reduces euphoria of subsequent opioid use, high efficacy in opioid use disorder • Risk: possible overdose risk, misuse, hyperalgesia, cardiac arrhythmias, dependence AGONIST: long acting activation of receptor

  15. Methadone: Special Considerations • Synthetic, slow acting full mu-opioid receptor agonist • Half-life 24-36 hours • Blocks euphoric effects of self administered opioids • Eliminates cravings for opioids • Used for treatment of substance use disorder since 1960’s • Only available through licensed Opioid Treatment Programs (OTP) • Dispensed @ OTP daily initially • Patients can progress to receiving “take-home doses” AGONIST: long acting activation of receptor

  16. Buprenorphine • Regulation: certified and specially trained clinician; patient limits in treatment (DEA X Waiver) , CIII, can be prescribed by in clinic, dispensed by community pharmacy • Benefits: Detox and maintenance therapy, craving reduction, combined with naloxone to prevent misuse, good efficacy in opioid use disorder • Several dosage forms including daily oral (tabs, films, SL), long-acting implant, long acting injectable. Some mixed with naloxone • Risks: • Must initiate brief withdrawal (4-12 hours), misuse risk, street value due to withdrawal aid, dependence PARTIAL AGONIST: partial activation, partial blockade

  17. Buprenorphine: Special Considerations When prescribing buprenorphine to treat OUD outside of an OTP , physician must have a DATA 2000 Waiver, also called an “X-DEA number”  EXCEPTION if using buprenorphine in hospital setting in accordance with the opioid withdrawal facility approved order set DATA 2000 Waiver can be obtained by any physicianby taking an 8-hour online course (DEA X Waiver) • Must complete buprenorphine training • https://www.aaap.org/clinicians/education-training/mat-waiver-training/ Allows you to treat 30 patients with buprenorphine in year 1, and 100 patients starting in year 2 As of 8/2016, specific providers can treat up to 275 patients per year In May of 2018, NPs and PAs can complete 24hrs of training to obtain waiver

  18. Buprenorphine Induction & Treatment • Urine specimen @ each visit, clinic agreement • Psychosocial treatment required • Typically 3rd party payer requirement • When stable, advance treatment • Give 2 week supply • If relapse, resume weekly visits • Must initiate withdrawal (4~12 hours since last opioid dose) • Induction achieved with 4-8 mg of buprenorphine • Induction accomplished in a couple of days • Patients come to office weekly to start • 1 week supply of medication

  19. Buprenorphine Maintenance • Maintenance dose ~12-24mg per day • Patients can successfully be maintained at lower doses • Typically take oral dosage forms daily, but can take every other day (T1/2=36 hours) • Concerns of risk of diversion at higher levels • Possible Adverse Effects: • Diaphoresis • Constipation • Headache • Insomnia • Nausea / Vomiting • Hypotension • Sexual dysfunction • Seizures • Hepatitis, hepatotoxicity

  20. http://pcssmat.org/wp-content/uploads/2015/02/PCSSMAT-Implementing-Antagonist-with-Case.Bisaga.CME_.pdfhttp://pcssmat.org/wp-content/uploads/2015/02/PCSSMAT-Implementing-Antagonist-with-Case.Bisaga.CME_.pdf

  21. Candidates for Naltrexone (Antagonist • Patients not able to be on agonist (buprenorphine or methadone) • High motivation for abstinence • Profession where treatment with agonist controversial • Patients successful on agonist but want to try abstinence • Failed prior treatment with agonist • Abstinent, but at risk for relapse • Patients for whom relapse would be disastrous • Patient with less severe form of disorder • Short history of use, lower level of use

  22. Naltrexone • Limitations: requires completed withdrawal (7-14 days) from opioids (will precipitate withdrawal if taken with opioids in the system); requires highly motivated patient • Benefits: prevents opioid intoxication and dependence, reinforces abstinence, efficacy in opioid use disorder, no addiction potential, long acting injectable, drop out rate as high as 70-80% due to withdrawal as necessity prior to initiation. 39% drop out with injectable. • Risks: may have increase risk of death from overdose due to decrease in tolerance with receptor blockade (depending upon dose of opioid used in relapse) ANTAGONIST: no activation, blocks opioids

  23. Naltrexone Induction No single best method but rather a set of approaches/tools that can be individualized to individual patient and the treatment team Effective method will balance the degree of discomfort and the duration of treatment Available as PO and long-acting injectable product • PO rarely used in treatment of OUD Side effects: • Nausea/vomiting • Injection site reactions • Serious adverse effects: Hepatic injury @ high dose, suicidality Contraindications/Monitoring • Elevated LFTs/Hepatic dysfunction • CrCl < 50ml/min • Recent opioid use (requires opioid wash out 7-14 days) • Pain requiring opioids

  24. Naltrexone Clinical Challenges Protracted Withdrawal: Naltrexone Flu Patients who start naltrexone right after detoxification commonly experience “flu-like” signs and symptoms: • Somatic complaints: insomnia, GI distress, hyperalgesia, anergia • Anxiety, irritability, dysphoria, anhedonia • Severity may be lower if naltrexone is started 10-14 days after completion of detoxification (but many relapse by then) Partially alleviated with aggressive symptomatic treatment, • Insomnia (v. frequent, often severe): zolpidem, trazodone, quetiapine • GI distress: Ranitidine, PPIs • Anxiety/hyperarousal: clonazepam, clonidine Most of these symptoms remit after 2-4 weeks • True prolonged symptoms are rare and likely reflect additional psychopathology Persistent/protracted withdrawal vs. acute effects of naltrexone • Negative mood and vegetative symptoms are significantly higher in participants who are receiving higher dose of naltrexone

  25. Naltrexone Clinical Challenges Testing the Blockade • 50% of patients “test” blockade same day of discharge, test 1-3 times w/ low dose of opioid Managing Relapse • Increased craving, use in week 3-4, may need oral supplementation • Missing doses/injections: sign of relapse • Blockade 2-3 days after stopping oral med, and 5-6 weeks after injectable doses • May need re-stabilization/detox • Residential treatment/sober house • Transition to agonist

  26. Naltrexone Safety Concerns: Overdose Risk of overdose is significant if patient decides to stop taking naltrexone, stop attending treatment and resumes opioid use Provide detailed description of risks (signed consent for treatment), continue discussing risks in patients who continue use: • “I understand that after I stop naltrexone I may be more sensitive to the effects of heroin and any other narcotics. The amount of heroin or narcotics I may have been using on a routine basis before I started naltrexone, might now cause overdose and death. I fully understand the nature and seriousness of this possible consequence. If I am not sure that I can avoid opiate use, I understand that I can be referred to alternative treatment programs, such as a methadone maintenance, which is an effective treatment for heroin dependence and has a reduced risk of fatal overdose.” Consider transition onto agonist to decrease risk of overdose if unable to comply with NTX Fear of overdose applies to any completed detoxification or discontinuation of agonist maintenance. Naltrexone, especially long-acting, actually PROTECTS against overdose

  27. Co-Prescribe Naloxone for all OUD patients • Naloxone – short acting medication to remove opioid from opioid receptor, reverses opioid overdose • Co-Prescribing naloxone (NARCAN) is a best practice • Train Patient, care givers on use of naloxone to reverse overdose

  28. Resources for the Clinician Medication-Assisted Treatment of Opioid Use Disorder Pocket Guide • https://store.samhsa.gov/system/files/sma16-4892pg.pdf Opioid Treatment Program Directory • https://dpt2.samhsa.gov/treatment/ Buprenorphine Waiver Management (X Waiver or DATA 2000) • https://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/training-materials-resources/buprenorphine-waiver Implementing Medication-Assisted Treatment for Opioid Use Disorder in Rural Primary Care: • https://integrationacademy.ahrq.gov/sites/default/files/mat_for_oud_environmental_scan_volume_1_1.pdf Prescribe to Prevent • https://prescribetoprevent.org/

  29. Questions or Comments jalonzo@tamhsc.edu

More Related