Medication Assisted Treatment and Harm Reduction

1. Medication Assisted Treatment and Harm Reduction P. Eric Konicki, M.D.

2. Disclosures: • Current research support: Department of Veterans Affairs, Cooperative Studies Program • No financial conflicts of interest to disclose • The use of medications advocated in this talk is within the scope of the FDA-approved package insert

3. OBJECTIVES: • Review the opioid use epidemic • Discuss the harm reduction model of Substance Use Disorder Treatment • Describe medication-assisted treatment (MAT) of Opioid Use Disorder

4. The true aim of medicine is surely not to make men virtuous; it is to safeguard and rescue them from the consequences of their vices. —H. L. Mencken

5. U.S. Drug Overdose Fatalities1980 to 2016

6. Percent Change Drug Mortality1980 to 2014

7. Average Age-Adjusted Unintentional Drug Overdose Death Rate by County (Per 100,000, 2011-2016)

8. Populations of Opiate Abusers • There is a continuum of opiate abuse • Infrequent use escalates to regular abuse and addiction • At some point user becomes dependent

9. Volkow ND et al. N Engl J Med 2016;374:363-371. Stages of the Addiction Cycle

10. Natural History of Untreated Opioid Addiction n = 581 ♂ heroin addicts Hser et al, Arch Gen Psychiatry, 2001

11. Receptor-Ligand Interactions

13. Harm Reduction Treatment Model

14. What Is Harm Reduction? • Harm reduction is a set of practical strategies that reduce negative consequences of drug use • Continuum of strategies • From “safer use” • To “managed use” • & total abstinence Source: The Harm Reduction Coalition, NYC

15. Overdose Education and Naloxone Distribution (OEND) • Numerous agencies advocating for overdose education and consideration/distribution of naloxone • VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide • SAMHSA Opioid Overdose Prevention Toolkit • AMA and APHA policy statements • Advisory Council on the Misuse of Drugs • In 2010, Scotland became first country to implement a national naloxone program

16. Rationale for OEND • Overdose usually witnessed • Death takes a while (1 to 3 hrs) • EMS not routinely accessed • Naloxone very safe and very effective • More rapid reversal with naloxone improves outcomes • Community-level mortality reduced • Training is feasible and relatively short Davidson et al., J Urban Health, 2003; Gonzva, Am J Emerg Med, 2013; McGregor, Addiction 1998; Piper et al., Harm Reduction J, 2007; Sporer, Ann Intern Med 1999; Strang et al., BMJ, 1996; Walley et al., BMJ, 2013

17. Naloxone is a highly effective treatment for reversing opioid overdose if administered at time of overdose It takes 1 – 3 hours to die from an opioid overdose Naloxone acts quickly, usually within 5 minutes Naloxone’s effects start to wear off after ~30 minutes and are gone by ~90 minutes

18. Effectiveness Among Community-Based Opioid Overdose Prevention Programs Providing Naloxone Centers for Disease Control and Prevention, MMWR, 61(6), Feb 2012

20. Office-Based Buprenorphine Treatment

21. Introduced in United States in 1947 by Eli Lilly Initially, for managing chronic pain Shown to reduce crime, mortality rate and costs to society of Heroin addiction (Dole & Nyswander) Decreases likelihood Heroin dependent patient will use Heroin Methadone

22. Buprenorphine • Used as parenteral analgesic in Europe (1º England) for cancer pain and in obstetrics • 0.4 mg Buprenorphine IM equianalgesic with 10 mg Morphine IM • Analgesia lasts longer (6 hours) • Never caught on in USA • May produce less respiratory depression than pure opioid agonists

23. Opioid Treatment: Changing Approach

24. Drug Abuse Treatment Act (DATA) of 2000 • Allowed “Qualified” practitioners to treat opioid dependence outside methadone facilities • Addiction certification from approved organization, or • Physician in clinical trial of qualifying medication, or • MD complete 8-hour and APN complete 24-hour course from approved organization • DEA issues a new DEA number to qualifying practitioners to use medication for opioid dependence • As of today, only one medication formulation is approved for this use

25. Buprenorphine Properties • Partial-agonist • Less reinforcing than a full agonist-milder effects • Easier withdrawal • Safety – overdose ceiling effect • High affinity for the opiate receptor • Long duration of action (24-72 hr) • Strong safety profile • Little respiratory depression • Little overdose potential

26. Effectiveness of MAT Treatment Kakko et al. Lancet 2003; 361:662-668.

27. Most often heard quote with MAT “I feel like a normal person” • Treatment of a chronic disease in normal medical settings: • Encourages continuity of medical/specialty care • Encourages relationship building with clinicians • Legitimize opioid dependence as a normal, treatable, chronic illness

28. Buprenorphine: Reduces Other Drug Use Fudala, NEJM 2003

29. Opioid Dependence Treatment in Primary Care At 24 weeks, 59% remained in treatment Stein, JGIM 2005

30. MAT Treatment in Clinical Practice

31. Useful Websites • Buprenorphine Information: www.buprenorphine.samhsa.gov • NIAAA Web site: http://www.niaaa.nih.gov/ • Medication information: http://www.suboxone.com • Physician Clinical Support System (PCSS)-National Mentor for Physicians Treating Opiate Dependence. http://www.PCSSmentor.org