Addressing the Opioid Crisis In Colorado

1. Addressing the Opioid Crisis In Colorado IT MATTTRs2 SIM CLS Nov 3, 2017

2. Objectives

3. We want you to walk away with better answers to these questions What is the scale of the opioid epidemic nationally and here in Colorado? How did we get here? What was medicine’s roll in creating the problem? How does addiction happen? How do overdoses happen? How can your practice address the issue? Where might medication assisted treatment fit? What help can practices receive through SIM and other statewide initiatives?

4. What is the scale of the opioid epidemic nationally and here in Colorado?

5. Why are we here? • Opioid Use Disorder (OUD) has seen an epidemic rise in the United States over the past decade. • More than 250 million prescriptions for opioids are written each year along with increasing rates of illegal heroin use. • More than 4 million Americans report using prescription pain medicine for non-medical reasons. • Colorado recently ranked as high as number 2 in the nation for rates of self-reported nonmedical use of prescription pain killers. • More Americans die each year of drug overdose than motor vehicle accidents. Opioid overdoses killed 41 Coloradans per month in 2014. • Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United StatesResults from the 2014 National Survey on Drug Use anHealth(HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/data/ • http://archive.samhsa.gov/data/2k12/NSDUH115/sr115-nonmedical-use-pain-relievers.htm. Accessed February 2, 2016. • http://www.coloradohealthinstitute.org/key-issues/detail/community-health/colorado-county-drug-overdose-death-rate. Accessed February 12, 2016.

6. Overdose death rates: U.S.

7. Colorado Counties: Overdose death rates 2002 Colorado Health Institute. More at: https://www.coloradohealthinstitute.org/research/colorado-county-drug-overdose-death-rate

8. Colorado Counties: Overdose death rates 2014 Colorado Health Institute. More at: https://www.coloradohealthinstitute.org/research/colorado-county-drug-overdose-death-rate

9. Slide from Colorado Health Institute. https://www.coloradohealthinstitute.org/research/colorado-county-drug-overdose-death-rate Data source: Colorado Department of Public Health and the Environment, Vital Statistics

10. Slide from Colorado Health Institute. https://www.coloradohealthinstitute.org/research/colorado-county-drug-overdose-death-rate Data source: Colorado Department of Public Health and the Environment, Vital Statistics

11. Slide from Colorado Health Institute. https://www.coloradohealthinstitute.org/research/colorado-county-drug-overdose-death-rate Data source: Colorado Department of Public Health and the Environment, Vital Statistics

12. Slide from Colorado Health Institute. https://www.coloradohealthinstitute.org/research/colorado-county-drug-overdose-death-rate Data source: Colorado Department of Public Health and the Environment, Vital Statistics

13. Slide from Colorado Health Institute. https://www.coloradohealthinstitute.org/research/colorado-county-drug-overdose-death-rate Data source: Colorado Department of Public Health and the Environment, Vital Statistics

14. Takeaways • Drug overdoses in Colorado are at an all-time high. • This epidemic impacts all Coloradans, but some groups are impacted more than others. Credit: Colorado Health Institute

15. How did we get here? Timeline of an epidemic

16. Timeline of an epidemic 1980s: First articles published questioning conventional wisdom of ‘opiophobia’ • No evidence of opioid abuse in chronic users • Advocates for use of opioids to alleviate suffering • 1983: MS Contin released

17. The “study” that started it all NEJM. 1980.

18. Timeline of an epidemic 1990s: • Physician thought leaders (supported by Pharma) spread gospel of opioid safety & efficacy • 1996: Oxycontin released • For moderate to severe pain, incl. MSK conditions • Marketed as unlikely to cause addiction because of long half-life • Jury awards for pain under-treatment • Increasing focus on palliative care

19. Timeline of an epidemic 2000’s: • “Pill mills” develop, especially Rust Belt & South • Overdose death rates rise • Mexican black tar heroin spreads into small markets • The “pizza delivery” method • Targets municipalities with high rates of opioid dependence

20. Overdose death rates: U.S.

21. Medicine’s role in the opioid epidemic “Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium” -Sydenham, 1680

22. What we were taught was all wrong • Pain must be aggressively assessed and treated • “5th Vital Sign” campaign • Opioids are effective for chronic pain • Opioids are safe for chronic pain • Opioids are easy to discontinue if ineffective

23. The Results • Many patients inappropriately started and maintained on opioids • Providers don’t set goals regarding pain control, function • Providers don’t monitor appropriately • Urine toxicology testing • Prescription drug monitoring program Korff MV, et al. Clin J Pain. Jul-Aug 2008;24(6):521-527. Martin BC, et al. Gen Intern Med. Dec 2011;26(12):1450-1457.

24. The Results https://www.colorado.gov/pacific/sites/default/files/PW_ISVP_Colorado%20Rx%20Drug%20Data%20Profile.pdf

25. Sources of diverted opioids

26. Mid-Point Summary • Medicine contributed profoundly to the opioid epidemic by liberal opioid prescribing practices • Inappropriate initiation, maintenance, monitoring • Hundreds of thousands of people now opioid-dependent • Tens of thousands with opioid use disorder • Many more opioid dependent/addicted through secondary acquisition/diversion

27. How does addiction happen? Opioids & the Neurobiology of Addiction

28. A word about terminology • “Addiction” may be used to describe the disease, but the terms “addict” and “addicted” are considered pejorative and are no longer recommended • “Substance use disorder” has replaced “substance abuse” and “substance dependence” • Mild SUD = substance abuse = addiction • Moderate or severe SUD = substance dependence = addiction

29. What are opioids? • Drugs that bind to the opioid receptors • Mu, Kappa, and Delta • Can be naturally-occurring or derivatives of naturally-occurring compounds (“Opiates”) • Morphine • Codeine • Heroin: 10x more potent than morphine • Can be synthetic (“Opioids”) • Fentanyl: 100x more potent than morphine

30. How are opioids used? • Oral • Inhaled/smoked • Intranasal/insufflation/sniffed/snorted • Absorbed through rectal mucosa • Transdermal (skin) through patches • Injected: intravenous, intramuscular, subcutaneous

31. Addiction is… • A chronic, relapsing disease • Strong genetic component • Results in permanent changes in brain structure and function • Characterized by loss of control • Brain is literally hijacked by cravings to use drugs and prevent withdrawal symptoms • Very difficult to treat • Detoxification ≠ Treatment! • High rates of relapse • Best evidence for treatment: counseling + replacement

32. The cycle of addiction • Regular use of opioids produces irreversible changes in the brain • Repeated use of opioids results in: • Neuronal adaptations (downregulation) of the receptors of the mesolimbic dopamine system • Mediates tolerance, withdrawal, and cravings • Explains the chronic and relapsing nature of opioid use disorder • This is the basis of pharmacotherapies to stabilize neuronal changes

33. Anatomy of heroin addiction Borrowed with permission from NOPE-RI

34. How addiction hijacks the brain Koob, 2003

35. Why do people overdose? • Tolerance develops quickly to the pleasurable effects of opioids • Incomplete tolerance to some effects of opioids: • Constipation • Respiratory depression • Opioids block receptors in brainstem that drive breathing • Lack of oxygen causes coma, brain damage, organ failure, death

36. Risk factors for overdose • High doses: especially >100 mg/day of morphine equivalents • Reduction in tolerance: any period of abstinence • Medical illness: chronic pulmonary, kidney, liver disease • Psychiatric disease: major mood disorders, personality disorders • History of other substance use disorder • Mixing drugs: presence of other depressants (alcohol, benzodiazepines)

37. What can a primary care practice do about OUD? Hint: more than we are doing right now.

38. Some places to start . . . • Reduce unnecessary opioid doses • Prescribe harm reduction medications like naloxone (aka Narcan) • Inform patients of the risks of opioids to their health and the health of their family and friends • Work with community to address social factors that underpin the cycle of addiction • Expand access to medication assisted treatment (MAT) for OUD at your site

39. OUD Treatment Options Option A: Detoxification Option B: Maintenance

40. Detoxification vs. maintenance Fiellin D et al. JAMA Intern Med. 2014;174(12):1947-1954.

41. Opioid detoxification: • Potential Candidates • Maintenance treatment not available • Maintenance treatment not wanted or no longer wanted • Predictors of detox failure • History of multiple relapses • Forced tapers • Short duration of abstinence • Uncontrolled co-morbid substance use disorders • Unstable social situation • Pregnancy Detoxification alone is associated with high rates of relapse: choose wisely!

42. Medication-Assisted Treatment

43. Advantages of opioid maintenance • Reduced illicit drug use • Reduced euphoria • Decreased consequences from opioid use • HIV infection • HCV infection • Overdose • Criminal behavior • Extinction of craving, priming, repeated pattern of binge use and withdrawal

44. Opioid maintenance options

45. Methadone • Limited to federally regulated treatment facilities • Pre-specified induction dosing schedules • On-site counseling • Urine toxicology testing • Only 12 in Colorado • Multiple drug interactions • Higher doses (80-100 mg) probably more effective than low-moderate

46. Buprenorphine • Unique features of buprenorphine: • High receptor affinity • Slow receptor dissociation • Partial agonist: ceiling effect • Long half-life: 24-42 hours • DEA Schedule III • DATA 2000: • Allows physicians who meet qualifications to treat opioid addiction • Allows use of Schedule III, IV, or V narcotic medications approved by the FDA specifically for that indication • Can be prescribed outside of the opioid treatment program setting • Buprenorphine is the only narcotic that meets these criteria that primary care can prescribe

47. Why is buprenorphine a great choice? • Can be prescribed in primary care offices • Long half-life prevents roller coaster of withdrawal and craving • High receptor affinity prevents reinforcement in the event of a relapse • Partial activity prevents risk of death from respiratory depression • This drug can stop the cycle of abuse and give people their lives back!

48. Hurdles to buprenorphine access • Physicians must complete 8-hour CSAT waiver training course • In-person or online • Recent legislation enacted to allow Nurse Practitioners and Physician Assistants to prescribe • Must complete 24 hours of training • Prescribing limits: • 35 in 1st year, 100 in 2nd year, then 275 if practicing in a qualified setting

49. Why primary care is perfect for MAT • Providers and staff have long-term relationships with patients • No stigma to having your truck parked at your primary care provider’s office • PCPs are great at managing chronic conditions, like hypertension and diabetes

50. IT MATTTRs: Creating the practice environment conducive to care for OUD using MAT Practice Team Training (MD, PA, NP, front desk, RN, billing, MA, navigators…) Engage the patient in MAT delivered in primary care practices. Screen for OUD in primary care practices. Refer patients to behavioral health in primary care practices. • Care for the practice MAT Team. • Monitor patients in MAT in primary care practices. Diagnose OUD in primary care practices. Prescribe buprenorphine by primary care physicians in primary care practices. Buprenorphine waiver training for providers (MD, DO, PA, NP)