Opioid Abuse and Dependence

1. 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)

2. Objectives • Be familiar with current trends in opioid abuse and dependence, and make accurate diagnoses of opioid and other substance involvement • Understand psychosocial and pharmacologic treatment options for patients with substance abuse/dependence • Be familiar with services available for opioid dependent patients in the Denver metro area, and how to assist in the coordination of care • Initiate a conversation about how we can better manage our patients with opioid abuse/dependence and coordinate care with treatment services

3. Extent of the Problem • 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

4. Drug Abuse-Related ED Visits Involving Narcotic Analgesics: 1995-2006 1995 1996 1997 1998 1999 2000 2001 2002 2004 2005 2006 Source: SAMHSA, The DAWN Report: Narcotic Analgesics, August, 2008.

5. Unintentional pharmaceutical overdose deaths, West Virginia • 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

6. 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: • 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

7. 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: • Tolerance • Withdrawal • The substance is taken in larger amounts or over a longer period than was intended • Persistent desire or unsuccessful efforts to cut down or control substance use • A great deal of time is spent on activities necessary to obtain the substance, use the substance, or recover from its effects • Important social, occupational, or recreational activities are given up or reduced • 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

8. Drug Dependence is a Chronic Medical Illness Requires • Screening and prevention • Long-term care strategies • Medication management • Continued monitoring • Empathy and patience McLellan AT, Lewis DC, O’Brien CP, Kleber HD; Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000

9. Compliance & Chronicity McLellan AT, Lewis DC, O’Brien CP, Kleber HD; Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000

10. Screening for opioid dependence • 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

11. What should I counsel my opioid-dependent patient about? • Opioid dependence is a chronic disease which requires ongoing treatment • Overdose risk is substantial • Combinations of drugs increase risk • Release from jail/prison associated • Leaving drug treatment associated • HIV and hepatitis risk from sharing needles and paraphernalia

12. What screening should I perform on my opioid dependent patient? • HIV • Hepatitis B S Ag • Hepatitis C Ab • Latent TB infection

13. What vaccinations should I give my opioid dependent patient? • Hepatitis A and B • Tetanus

14. Therapeutic Options • Psychosocial interventions • Contingency management • Individual, group and family counseling • Motivational interviewing • Case management • 12-step interventions • Pharmacological interventions • 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)

15. 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

16. Contingency Management • Re-arranging the reinforcers in a person’s environment • Incentives or rewards to encourage specific behaviors • Vouchers, prizes, group acknowledgements, take-home dosing privileges, family privileges

17. Methadone Maintenance for Opioid Dependence: Benefits • 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

18. Methadone for Opioid Dependence: Risks • 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?

19. Impact of Short-Acting Heroin versusLong-Acting Methadone on the Functional State of the Patient "High" Functional State(Heroin) (overdose) "Straight" "Sick" AM PM AM PM AM Days "High" Functional State(Methadone) "Straight" Dole, Nyswander and Kreek, 1966 "Sick" AM PM AM H PM AM Days

20. Slow “Build-up” of Constant Dose of Methadone to Steady-State Blood plasma level of methadone DaysDose constant at 30 mg to steady-state Opioid Maintenance Pharmacotherapy - A Course for Clinicians

21. Induction / Initial Dosing • 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

22. Phases of Methadone Dosing Payteand Khuri Opioid Maintenance Pharmacotherapy - A Course for Clinicians

23. ___ l-methadone--µ agonist

24. Source: National Center for Health Statistics.

25. Methadone Mortality 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

26. Methadone Mortality, cont. • 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

27. 2007

28. Buprenorphine • 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

29. Buprenorphine • Partial opioid agonist with high affinity for receptor • Low overdose potential • Easier to withdraw from than heroin, methadone, or LAAM

30. 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

31. == Buprenorphine

32. University-affiliated treatment • ARTS: Addiction Research and Treatment Services: 3 metro area clinic sites for Medication-Assisted Treatment for opioid dependence

34. ARTS Outpatient Programs Denver: ARTS Outpatient Clinic 303.388.5894 Aurora: Potomac Street Center 303.283.5991 Lakewood: Westside Center for Change 303.935.7004

35. Other Clinics • 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 • (Denver VA does not offer methadone)

36. Using the 5 A’s in Primary Care Shortcut: • Ask • Advise • Refer Ask Advise Assess Assist Arrange

37. How to get your patients into treatment • 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

38. Costs of treatment and insurance coverage • 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)

39. Communication between PCPs and addiction treatment providers: How do I get information? • 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

40. Relapse: What to expect • 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

41. Services ARTS offers • 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 naltexonefor alcohol dependence

42. How can we serve you better?

43. How can we do a better job of integrating primary care into treatment and treatment into primary care?

44. 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; william.swafford@ucdenver.edu Denver Health: Dr. Carol Traut, 303.436.6392; carol.traut@dhha.org

45. Additional resources • www.artstreatment.org • ACP Pier: http://pier.acponline.org/index.html section on opioid dependence • www.painedu.org • Recommendations fortreating 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/

46. Further questions/comments • Ingrid.Binswanger@ucdenver.edu 303-724-2246 (office) • Eric.Ennis@ucdenver.edu 303.388.5894 (office) 303.523.2505 (cell)

47. 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.