Treatment and Recovery in America

April  10-­‐12,  2012  Walt  Disney  World  Swan  Resort  

Substance Abuse in the United States:

When and How to Use Medication Assisted

Treatments Elinore F. McCance-Katz, MD, PhD

Professor of Psychiatry University of California San Francisco

Accepted Learning Objectives: 1.  Define  when  and  how  medica>on-­‐assisted  treatment  methodologies  for  successful  recovery  of  opioid  addic>on  should  be  used.  2.  Explain  how  to  improve  access  and  quality  of  care  through  strategic  planning  and  community-­‐wide  coordina>on  with  local  and  state  agencies.  3.  Describe  behavioral  health  issues  faced  by  individuals  within  the  correc>ons  system  and  devise  strategies  to  adequately  address  these  clinical  needs  aHer  incarcera>on.  

Learning Objectives: To gain an understanding of: Recent Advances in Recognition and Treatment of

Substance Use Disorders SBIRT: What is it and how can it improve medical

care and reduce costs? Review some of the basics of substance abuse

treatment that can be accomplished in primary care and other medical settings –  Screening –  Brief intervention/motivational interviewing –  Referral to substance abuse treatment settings when

needed –  Pharmacotherapy for substance use disorders that

can be undertaken in the primary care setting

Disclosure Statement

•  All presenters for this session, Dr. Elinore McCance-Katz and Gregory C. Warren, have disclosed no relevant, real or apparent personal or professional financial relationships.

Disclosures

Grant Funding from: National Institutes of Health

National Institute on Drug Abuse National Institute on Alcohol Abuse and Alcoholism

Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment

What is SBIRT?

SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur.

Why Do We Need SBIRT? Problem Substance Use is Prevalent in Americans

SAMHSA, National Survey on Drug Use and Health, 2010

SBIRT Components

•  Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.

•  Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.

•  Referral to treatment provides those identified as needing more extensive treatment with access to speciality care.

Is SBIRT Effective?

•  SBIRT research has shown that large numbers of individuals at risk of developing serious alcohol or other drug problems may be identified through primary care screening.

•  Interventions such as SBIRT have been found to: –  Decrease the frequency and severity of drug and alcohol use, –  Reduce the risk of trauma –  Increase the percentage of patients who enter specialized

substance abuse treatment. –  Be associated with

•  fewer hospital days •  fewer emergency department visits •  net-cost savings to the health care system from

these interventions

What are the Benefits and Screening and Brief Intervention?

•  Strong evidence for the effectiveness of brief interventions with alcohol and tobacco use, growing support for use with other substances.

•  Minimal amount of time needed to conduct brief interventions.

•  Low-cost/cost-effective. For each dollar spent, it has been estimated that $2–$4 (per person) have been saved in terms of health costs and costs related to workforce productivity.

Fleming, 2002; Gentilello, et al., 2005

How to Rapidly Screen for Alcohol Problems

Single Question with high sensitivity/specificity: •  In the past year, have you had any times when

you had 5 (for women, 4) or more drinks at one sitting?

•  If yes, explore drinking, offer advice for cutting back or stopping, if evidence of dependence refer to substance abuse treatment facility

•  Note: a single question does not make a diagnosis, but indicates a need for further screening

What Can the Primary Care Physician Use to Treat Substance Use

Disorders?

Pharmacotherapy Review

General Considerations for SUD Pharmacotherapy

"   Tobacco:  Relapse  Preven>on-­‐Yes,  for  office-­‐based/outpa>ent  prac>ce  

"   Alcohol   Acute  withdrawal  (usually  done  inpa>ent)   Relapse  Preven>on-­‐Yes,  for  office-­‐based/outpa>ent  prac>ce  

"   Opiates   Acute  withdrawal  (oHen  done  inpa>ent,  but  can  be  outpa>ent  

procedure)   Relapse  Preven>on-­‐Yes,  for  office-­‐based/outpa>ent  prac>ce    

"   Cocaine/Methamphetamines/S>mulants   No  FDA  approved  medica>ons  for  withdrawal  symptoms  or  

relapse  preven>on  

Cigare'e  Smoking  

Cigare'e  Smoking  

Cigarette Smoking

Cigare'e  Smoking  

Cigare'e  Smoking  

Cigarette Smoking Varenicline    

 Nico>ne  par>al  agonist   Decreases  craving  to  smoke   May  be  useful  in  co-­‐occurring  tobacco  dependence  and  alcohol  abuse  

 Twice  daily  oral  medica>on  to  be  started  1  week  before  quit  date  (.5  mg/d  x  3;  .5  BID  x  3;  1  mg  BID)  

 Length  of  Treatment:  12  weeks   Monitor  for  depression/suicidal  thinking   No  abuse  liability  

Maintenance Medications To Prevent Relapse To Alcohol Use (FDA approved)

• Disulfiram • Naltrexone (oral and injectable) • Acamprosate

Disulfiram "   How  it  Works:  Blocks  alcohol  metabolism  leading  to  increase  in  blood  

acetaldehyde  levels;  aims  to  mo>vate  individual  not  to  drink  because  they  know  they  will  become  ill  if  they  do  

"   Disulfiram/ethanol  reac>on:  flushing,  weakness,  nausea,  tachycardia,  hypotension      Treatment  of  alcohol/disulfiram  reac>on  is  suppor>ve  (fluids,  oxygen)    

"   Side  Effects:      Common:  metallic  taste,  sulfur-­‐like  odor      Rare:  hepatotoxicity,  neuropathy,  psychosis    

"   Contraindica>ons:  cardiac  disease,  esophageal  varices,  pregnancy,  impulsivity,  psycho>c  disorders,  severe  cardiovascular,  respiratory,  or  renal  disease,  severe  hepa>c  dysfunc>on:  transaminases  >  3x  upper  level  of  normal  

"   Avoid  alcohol  and  alcohol  containing  foods    "   Clinical  Dose:  250  mg  daily  (range:  125-­‐500  mg/d)  "   Adherence:  problem;  but  if  drug  is  taken  it  works  well  (Fuller  et  al.  1994;  Farrell  

et  al.  1995);  good  idea  to  start  in  a  substance  abuse  treatment  program  

Naltrexone

"  Potent  inhibitor  of  mu  opioid  receptor  binding   may  explain  reduc>on  of  relapse    

"  because  endogenous  opioids  involved  in  the  reinforcing  (pleasure)  effects  of  alcohol    

 May  explain  reduced  craving  for  alcohol    "  because  endogenous  opioids  may  be  involved  in  craving  alcohol  

How  to  Select  a  Medica5on  for  Alcohol  Use  Disorders  

"  Disulfiram: when the patient is committed to no further drinking; heavy consequences of relapse

"  Naltrexone: for the patient who wants to cut back or get help for craving

"  Acamprosate: naltrexone doesn’t work, patient needs opioid analgesia; disulfiram not an option

Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older:

NSDUH 2010

Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown. 1 The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s Office/Clinic/

Hospital/Pharmacy,” and “Some Other Way.”

Bought/Took from Friend/Relative

14.8%

Drug Dealer/ Stranger

4.4%

Bought on Internet

0.4% Other 1 6.5%

Free from Friend/Relative

7.3%

Bought/Took from

Friend/Relative 4.9%

One One

Doctor 79.4% 79.4%

Drug Dealer/ Stranger

1.6% Other 1 3.5%

Source Where Respondent Obtained

Source Where Friend/Relative Obtained

One Doctor 17.3%

More than One Doctor

1.6% Free from

Friend/Relative 55%

More than One Doctor 3.3%

Why Are Such Large Numbers of Opioid Medications Being Prescribed?

Prescribers have a mandate to relieve pain • But may not receive enough training on the various approaches to treatment of pain

Prescribers have a mandate not to prescribe to those with addiction

• But may not receive enough training on recognition and treatment of substance use disorders

Opioids  for  Pain  Management  

  Chronic opioids for non-malignant pain presents potential problems:  Lack of evidence for efficacy, particularly with

high dose opioid therapy over long periods  Syndrome of rebound pain/hyperalgesic

states produced by opioid use  Withdrawal syndromes masquerading as “pain”

Balantyne et al., 2003

What’s the Best Path?

Naltrexone  

Why is All of This Important? •  Drug and alcohol use disorders affect approximately

10% of Americans •  Screening and early intervention= prevention! •  Substance use disorders are chronic, relapsing diseases

that are likely to recur once diagnosed •  Effective pharmacotherapies are available and can be

implemented in primary care •  Substance abuse can negatively impact other illnesses

present in the patient (e.g.: alcoholic cardiomyopathy, COPD, HIV/AIDS, HCV, other ID) and/or can masquerade as an illness that the patient does not have (e.g.: HTN, seizure d/o, mental disorders)

•  Can contribute to non-adherence to prescribed regimens, toxicities due to drug interactions

Clinical Support Systems Sponsored by Center for Substance Abuse Treatment/SAMHSA

References •  Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for

problem drinkers: long-term efficacy and benefit-cost analysis. Alcoholism: Clinical and Experimental Research 2002; 26: 36-43.

•  Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. JAMA 1997; 277:1039-45.

•  SAMHSA, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication # SMA 11-4658, Rockville, MD Substance Abuse and Mental Health Services Administration, 2011.

•  Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol interventions for trauma patients treatment in emergency departments and hospitals: a cost benefit analysis. Annals of Surgery 2005, 241:541-550.

•  Edwards et al. 2003 •  Fuller RK, et al.: Veterans Administration cooperative study of disulfiram in the treatment of

alcoholism: study design and methodological considerations. Control Clin Trials. 1984 Sep;5(3):263-73

•  O’Farrell TJ, et al.: Disulfiram (antabuse) contracts in treatment of alcoholism. NIDA Res Monogr., 150:65-91, 1995.

•  Garbutt JC, Kranzler HR, O’Malley SS, Gastfriend DR, Pettinati HM, Silverman BL, Loewy JW, Ehrich EW: Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA 2005; 293: 1617-1625.

•  VA/DoD CPG SUDs, www.oqp.med.va.gov/cpg/SUD/SUD_Vase.htm •  Donovan DM, et al.: Combined pharmacotherapies and behavioral interventions for alcohol

dependence (The COMBINE Study): Examination of posttreatment drinking outcomes. J Stud Alcohol Drugs 2008 69: 5-13.

•  Anton RF, et al.: Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized, controlled trial. JAMA 2006 295 (17): 2003-2017.

•  McNicholas, L. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction: A treatment improvement protocol (TIP 40). Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2004.

•  U.S. Public Health Service: A clinical practice guideline for treating tobacco use and •  dependence: A US public health service report. JAMA 2000; 283:3244–3254.