Prescribing Monthly Injectable Buprenorphine to a High Risk, Homeless Man with ADHD

Jennifer Michaels, MD, FASAM Medical Director, Brien Center, Asst. Professor, University of Mass. Medical School Jessica Kemp, RN, CARN OBOT Nurse Manager, Brien Center No Disclosures Case Presentation

• 31 year-old male referred by primary care 8/2018 • Opioid, benzodiazepine, alcohol, cocaine use disorders • ADHD, PTSD, Anxiety, Chronic Pain • Lost and stolen buprenorphine prescriptions • Barred from all county OBOT clinics and multiple county pharmacies due to disruptive behaviors

• “I do better when I see my doctor a lot” 20 + Medications, compulsive ingestion:

• Buprenorphine 20 mg SL QD • Clonidine 0.2 mg TID • Hydroxyzine 50 mg TID • Duloxetine 30 mg QAM • Fluoxetine 80 mg QD • Olanzapine 5 mg QHS • Gabapentin 800 mg TID • Methocarbamol • Etc. What would you do??? Clinical Management

• Team “Cheers” • Receptionist, medical assistant, RN, recovery coach, APRN, PA, M.D., resident • Respectful, non-judgmental, non-punitive • Low threshold, flexible approach • Frequent visits, short prescriptions • Intensive Community Outreach Patient Selection for Monthly Injectable Buprenorphine

• Patient Education and Preference • Stable dose (8-24 mg/day) • Insurance or approx $1500/month • Stable vs. Unstable lifestyle • Transportation Issues Potential Benefits of Monthly Injectable Buprenorphine

• 1) Enhance adherence • Reduce risk of non-adherence and associated risk of relapse • 10 times > likelihood of relapse when daily adherence < 80%1 • 2) Reduce diversion

• 3) Reduce accidental poisoning in children

• 4) Avoid pharmacy, travel, loss, theft issues

• 5) Avoid ritual of trans-mucosal formulations

1. Tkacz et al. Am J Addict 2011;21:55-62. ADHD and SUD’s

• ADHD: 5-11% children, 60% continue to have symptoms as adults

• Co-morbidity of ADHD and SUDS • 11-23% of adult SUD patients have co-occurring ADHD vs. 2.5-4% community adult samples • Younger drug initiation • Increased psychiatric co-morbidities • Suicide attempts • Lower treatment adherence • Delayed SUD remission

Carpentier, P, Levin, F, 2017. Mariani, J, Levin, F, Am J Addiction, 2007. Lugoboni, F, Co-occurring ADHD symptoms in adults affected by Heroin Dependence, Psychiatry Research, 2016, APA, CDC Challenges of Diagnosis

• SUD symptoms mimic ADHD • Consequences of SUDS and ADHD overlap • Developmental, co-lateral, educational, occupational, family history • Evaluation during substance free period • Formal neuropsychological testing

Crunelle C, et al, International Consensus Statement on Screening, Diagnosis and Treatment pf SUD patients with Comorbid Attention Deficit/Hyperactivity Disorder, European Addiction Research, 2017. Levin F, Upadhyaya, Diagnosing ADHD in Adults with SUD, J Clin Psych, 2007 Barkley R, Brown T, Unrecognized Attention-deficit/Hyperactivity Disorder in Adults Presenting with other Psychiatric Disorders, CNS Spectrum, 2008, Adult ADHD Self-Report Scale Adult ADHD and SUD Treatment

• Integrated Psychiatric/SUD treatment “One Stop Shopping”

• Pharmacology • Stimulants: Long acting formulations • Balance risks vs benefits • atomoxetine • Clonidine • Guanfacine • Bupropion (off label)

• Psychotherapy

Crunelle C, et al, International Consensus Statement on Screening, Diagnosis and Treatment of SUD patients with Comorbid Attention Deficit/Hyperactivity Disorder, European Addiction Research, 2017. Asherson P, et al, Efficacy of Atomoxetine, J of Psychopharm 2014. Prodrug: Lisdexamphetamine, Long acting, osmotic-release system formulation: methylphenidate Treatment Course (So far)

• Interventions: • Dramatically simplified medication regimen • Monthly Injectable Buprenorphine • Long acting amphetamine • Frequent visits in supportive environment focused on patient goals • Outcome: • positive engagement • Enhanced medication adherence • improvement in ADHD symptoms • no behavioral issues • toxicologies negative for substances Summary

• Utility of Monthly Injectable Buprenorphine for high risk populations

• Enhance OBOT engagement for high risk populations • Flexible Team • Lower barriers to access • Community Outreach

• Assess, address co-occurring disorders including ADHD