The Opioid Epidemic
Brian Fuehrlein, MD, PhD Director, Psychiatric Emergency Room, VA Connecticut and Assistant Professor of Psychiatry, Yale University
1 Brian Fuehrlein, Disclosures
• I have no financial relationships to disclose.
The contents of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information.
2 Planning Committee, Disclosures
AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below:
The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this module to disclose: PCSS-MAT lead contributors Frances Levin, MD and Adam Bisaga, MD; AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, Carol Johnson and Justina Pereira.
All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. The content of this CME activity has been reviewed and the committee determined the presentation is balanced, independent, and free of any commercial bias. Speakers will inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products. 3 Target Audience
. The overarching goal of PCSS-MAT is to make available the most effective medication-assisted treatments to serve patients in a variety of settings, including primary care, psychiatric care, and pain management settings.
4 Educational Objectives
At the conclusion of this activity participants should be able to:
. Identify the factors contributing to the opioid epidemic
. Identify risk factors and red flags for the development of opioid use disorder
. Describe how heroin use develops from prescription opioid addiction
. Describe the severity and nature of opioid use disorder and the related high risk behaviors
. Define what treatment is and essential components needed to be evidence based
. Recognize how medication can be a very important part of long-term treatment for opioid use disorders 5 Headlines in Connecticut
. “Panel approves anti-overdose legislation” – CT Post
. “Heroin-related overdose deaths soar in CT” – Hartford Courant
. “Opioid overdoses spiked again last year” – WTNH Conn News
. “Summit held in New London to address heroin epidemic” – Fox 61 News
. “Rep. Courtney seeking emergency money to fight opioid addiction, overdoses” – CT Mirror
. “Pharmacists working to combat opioid overdose” – Uconn Today
. “Drug overdoses keep rising in CT” – CT Post
. “As opioid epidemic grows, Senator Murphy calls for improved access to buprenorphine treatment” – Stratford Star 6 “If you’re over 50 and you wake up in the morning without pain, you might not be alive anymore.” - Anonymous
7 8 9 “We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non- malignant pain and no history of drug abuse.”
10 . Pain was a common pop culture topic of the 1980s and 1990s . This article clearly states that morphine taken for pain is not addictive
11 12
McCaffery, M. & Beebe, A. (1989). Pain: Clinical manual for nursing 13 practice. St. Louis: C.V. Mosby. 14 Purdue Pharma was aggressively marketing OxyContin with celebrity endorsements and free items for prescribers and patients
15 . I Got My Life Back featured the story of patients on OxyContin and a pain specialist discussing its virtues
. Fifteen years after the documentary 2 of the patients were deceased with OUD likely contributing, one developed an OUD but was sober and the other three were alive and well
16 17 18 19 “Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did. We didn’t know then what we know now.”
“I gave innumerable lectures in the late 1980s and 90s about addiction that weren’t true.” 20 Currently
. 2M people have prescription opioid use disorder and 591,000 heroin1
. >33,000 overdose deaths linked to opioids in 20152
. In 2012, 259M prescriptions written for opioids3
. 80% of heroin users start with prescriptions1
. 276,000 adolescents currently misusing opioids and 122,000 already addicted4
. Most adolescents are provided opioids for free from family or friends
1. Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). 2. Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452. 3. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers - United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013 Sep 1;132(1-2):95-100. 21 4. National Institute of Drug Abuse. (2015). Drug Facts: Prescription and Over-the-Counter Medications. Bethesda, MD: National Institute of Drug Abuse.
22 22 23 Opioids
. Full agonists
. Partial agonists
. Antagonists
. Receptor affinity vs strength of action
. Time to peak effect
. Duration of action
24 Opioids
. Naturally Occurring Opioids • morphine, thebaine, codeine
. Semi-Synthetic Opioids • hydrocodone, oxycodone, hydromorphone, oxymorphone
. Synthetic Opioids • buprenorphine, fentanyl, methadone
. Common Trade Names • Oxycodone, Oxycontin, MS Contin, Dilaudid, Norco, Percocet, Lortab, Roxicodone, Duragesic
25 Common Scenario
. A patient presents to the MER with an ankle injury and has a fracture.
. Orthopedics places a cast, provides a 2-week follow- up appointment and prescribes a two-week supply of OxyContin for pain.
. Does this seem like an appropriate course of action?” 26 Risk Factors
. Personal history of a substance use disorder
. Family history of a substance use disorder
. History of mental illness
. History of trauma
27 CASAColumbia. (2012). Addiction medicine: Closing the gap between science and practice. Other Assessment
. Level of pain • Opioids should only be prescribed when needed and in lowest dose with smallest quantity possible
. Prior opioid use history
. Complete history of other medications taken
. Willingness to try alternatives
. Urine drug screen
. Check the prescription drug monitoring database in your state
28 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. SAMHSA, CSAT. Patient Education
. Always weigh risks and benefits of opioid use for all patients prior to initiation
. Always educate all patients about the risk of developing an SUD
. Those with risk factors need assertive education, lower doses, and frequent follow-ups
. Avoid unnecessary exposure to opioids, but avoid refusing opioids based on presence of risk factor when patient is in pain 29 Now What?
. The patient returns after two weeks.
. The cast is removed and the fractures appears to have healed.
. The patient reports continued severe pain.
. He is requesting more pain medication saying it was the only thing that helped.
30 Red Flags for Opioid Use Disorder
. Behaviors • Angry/hostile/threatening • Preoccupied with specific medication and dose, unwilling to try alternatives or allergic to all others • Reports subjective euphoria with opioids
. Objective findings • Ran out of prescription early • Has visited other doctors/ERs • Pain out of proportion to exam findings
. Assessments • Screening tools are effective for assessing and monitoring for opioid use disorder in an objective way but do not confirm an opioid use disorder.
31 Chronic Pain
. The CDC offers guidelines for prescribing opioids for chronic pain
• Use non-pharmacologic management and non-opioid pharmacologic management first
• When using opioids, start low and go slow
• Review the PDMP routinely
• Avoid concurrent prescribing of benzodiazepines
• Discontinue when harms outweigh benefits
• Offer or arrange treatment and behavioral therapies for patients with opioid use disorder
32 Dowell, D., et al. CDC guideline for prescribing opioids for chronic pain - United States, 2016. CDC Recommendations and Reports, 65(1):1-49, 2016.
Progression to Heroin
. Usually starts with prescription opioid • their own prescription or family/friend
. Multiple doctors/ERs until supply runs dry • “My doctor has no empathy so I will go elsewhere”
. Buying pills illegally • “They are prescription pills and I need them. I will never use heroin. That is what junkies use” • Money runs out ($1 per mg for oxycodone on the street)
. Switch to heroin (“I will never inject”) Inject heroin (“I will never share needles”)
. Share needles
Jones CM. Heroin use and heroin use risk behaviors among nonmedical 33 users of prescription opioid pain relievers - United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013 Sep 1;132(1-2):95-100. Prognosis
Hser, et. al. A 33-Year Follow-up of Narcotic Addicts. 34 Archives of General Psychiatry, 2001;58:503-508
High Risk Behaviors
. IV use
. Mixing with benzos/alcohol
. Previously resuscitated with Narcan
35 Harm Reduction
. Do not pick up where you left off
. Know your supply
. Start low and go slow
. Do not mix substances
. Do not use alone
. Have a Narcan kit available
36 Opioid Use Disorder
“A key driver of the overdose epidemic is underlying substance-use disorder. Consequently, expanding access to addiction-treatment services is an essential component of a comprehensive response.”
Volkow, Nora D., et al. "Medication-assisted therapies—tackling the opioid-overdose epidemic." New England Journal of Medicine 370.22 37 (2014): 2063-2066. Opioid Use Disorder
“Drug dependence generally has been treated as if it were an acute illness. Review of results suggest that long-term care strategies of medication management and continued monitoring produce lasting benefits. Drug dependence should be insured, treated, and evaluated like other chronic illnesses.”
McLellan, A. Thomas, et al. "Drug dependence, a chronic medical illness: implications 38 for treatment, insurance, and outcomes evaluation." Jama 284.13 (2000): 1689-1695. Opioid Withdrawal
. Muscle aches, restlessness, anxiety, lacrimation, rhinorrhea, sweating, insomnia
. Diarrhea, abdominal pain, goose flesh, vomiting, mydriasis, tachycardia, hypertension
. Feels like a very bad flu
. While usually not deadly, if often feels like it is
39 Opioid Withdrawal Management
. Typically several days
. Either symptom driven or using buprenorphine
. Medically supervised process
. Withdrawal management does not address the underlying opioid use disorder
40 Medication Assisted Treatment
Kakko, Johan, et al. "1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomized, placebo- 41 controlled trial." The Lancet 361.9358 (2003): 662-668.
Medication Assisted Treatment
. Buprenorphine
. Methadone
. Extended-Release Naltrexone
42 Medication Assisted Treatment
. Improves patient survival
. Increases retention in treatment
. Decreases illicit opioid and other criminal activity
. Increases ability to gain and maintain employment
. Improves birth outcomes among women who have substance use disorders and are pregnant
43
Data from Substance Abuse and Mental Health Services Administration Summary
. Many factors contributed to the current opioid crisis
. Risk factors and red flags are critical to recognize and access
. Opioid use disorder is a deadly illness
. Detox is not treatment for the underlying opioid use disorder
. Maintenance medication is a very important part of long-term treatment 44 References
. CASAColumbia. (2012). Addiction medicine: Closing the gap between science and practice. . Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). . Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. SAMHSA, CSAT . Dowell, D., et al. CDC guideline for prescribing opioids for chronic pain - United States, 2016. CDC Recommendations and Reports, 65(1):1-49, 2016. . Hser, et. al. A 33-Year Follow-up of Narcotic Addicts. Archives of General Psychiatry 2001;58:503-508 . Kakko, Johan, et al. "1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial." The Lancet 361.9358 (2003): 662-668. . McCaffery, M. & Beebe, A. (1989). Pain: Clinical manual for nursing practice. St. Louis: C.V. Mosby. . McLellan, A. Thomas, et al. "Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation." Jama 284.13 (2000): 1689-1695. . Porter, J. and Jick, H. Addiction rare in patients treated with narcotics. NEJM 10;302(2):123, 1980 . Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452. . Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers - United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013 Sep 1;132(1- 2):95-100. . National Institute of Drug Abuse. (2015). Drug Facts: Prescription and Over-the-Counter Medications. Bethesda, MD: National Institute of Drug Abuse. . Volkow, Nora D., et al. "Medication-assisted therapies—tackling the opioid-overdose epidemic." New England Journal of Medicine 370.22 (2014): 2063-2066
45
PCSS-MAT Mentoring Program
. PCSS-MAT Mentor Program is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid addiction.
. PCSS-MAT Mentors are a national network of providers with expertise in addictions, pain and evidence-based practices including MAT.
. 3-tiered approach allows every mentor/mentee relationship to be unique and catered to the specific needs of the mentee.
. No cost.
For more information visit:
pcssmat.org/mentoring
46
PCSS Discussion Forum
Have a clinical question?
47 PCSS-MAT is a collaborative effort led by the American Academy of Addiction Psychiatry (AAAP) in partnership with the: Addiction Technology Transfer Center (ATTC); American Academy of Family Physicians (AAFP); American Academy of Pain Medicine (AAPM); American Academy of Pediatrics (AAP); American College of Emergency Physicians (ACEP); American College of Physicians (ACP); American Dental Association (ADA); American Medical Association (AMA); American Osteopathic Academy of Addiction Medicine (AOAAM); American Psychiatric Association (APA); American Psychiatric Nurses Association (APNA); American Society of Addiction Medicine (ASAM); American Society for Pain Management Nursing (ASPMN); Association for Medical Education and Research in Substance Abuse (AMERSA); International Nurses Society on Addictions (IntNSA); National Association of Community Health Centers (NACHC); and the National Association of Drug Court Professionals (NADCP).
For more information: www.pcssmat.org
Twitter: @PCSSProjects
Funding for this initiative was made possible (in part) by grant no. 1U79TI026556-01 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. 48
PCSS-MAT: Training, Mentoring, Resources
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