Expanding and Improving Treatment: Challenges and Next Steps
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Transcript of Expanding and Improving Treatment: Challenges and Next Steps
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Expanding and Improving Treatment
Challenges and Next Steps
Marc Fishman MD
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Outline
• Limitations of current practice
• The general health care connection
•
The criminal ustice s!stemconnection
• "outh treatment
•
#uilding a $etter treatmentcontinuum
• Next steps
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%elapse prevention medications The standard of care
These are the standard of care:
–Methadone
–
#uprenorphine –Extended&release naltrexone
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If onl! it 'ere that eas!
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Limitations to current
practice
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%elapse prevention medicationIs the standard of care
#ut not ever!one (no's it !et
• )ersuading patients
• )ersuading families• )ersuading criminal ustice s!stem
• )ersuading S*D providers+ especiall!
residential treatment• )ersuading pa!ers
• )ersuading the recover! communit!
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Lin(ages from residential,inpatienttreatment
• Detox 'ithout relapse preventionmedication is unfortunatel! t!pical
• #ut inpatient treatment 'ould $e anideal opportunit! for medicationinduction
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Limitations and unintended
conse-uences
• Medication diversion
• Dropout
•
Su$standard practice• Over&promising
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Duration of treatment.
• Is there an optimal duration.
• Evidence so far suggests longer is$etter+ $ut care should $eindividuali/ed
• %etention under real 'orld conditionsis pro$lematic
• No reason to suppose pre&imposedlimitations helpful
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The criminal ustice
connection
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0%NT0 vs T1* in criminal usticepopulation
XRNTX
TAU
Median time torelapse 2'(s3
4567 765
Opioid neg+ 89'(s
:9; 7<;
Opioid neg+ :='(s
9:
Lee et al6 Extended&%elease Naltrexone to)revent
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The general healthcare
connection
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Aospital initiation of $uprenorphine
• Bell esta$lished e@ectiveness for treatment
seeking pts• Bhat a$out promotion of treatment upstream
at the motivational moment of medical
hospitali/ation to prevent readmission.
545
85
>5
95
75
#upelin(age
Lie$schut/ et al6 ?1M1 Internal
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"outh Treatment
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"oung adults highest prevalenceNon&medical prescription opioids
NSD*A+ 8549
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Features of !outh opioidtreatment
• Famil! leverage 2or not3
• )ush$ac( against sense of parentaldependence and restriction
• Developmental $arriers to treatmentengagement – Invinci$ilit!
– Immaturit! – Salience of $urdens of treatment
• )rominence of co&mor$idit!
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Retention bup treatment
young adults vs older adults
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Famil! Frame'or(
• Treatment often not famil! friendl!+considerations of conJdentialit! andpresumed independence
• #oth families and !outh need a recipefor treatment+ 'ith role deJnitions+expectations+ and responsi$ilities6
• Famil! mo$ili/ation K Medicine ma!help 'ith the receptors+ !ou still haveto parent this dicult !oung person
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#uilding a $etter
treatment continuum
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)roviding a full continuum ofcare
• Inpatient detoxiJcation andsta$ili/ation
• Short term residential treatment
• Long term residential treatment
• Da! treatment , partialhospitali/ation
• 1ssisted living support for outpatienttreatment 2IO) plus, )A) plus3
• %ecover! housing
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Lin(ing patients to medicalcare
• Em$edding medical care in addictionspecialt! settings
• Em$edding opioid treatment forsta$le patients in general medicalsettings
• Medical home models
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Next steps
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Next stepsMedication pipeline
• #uprenorphine implant K )ro$uphine – Stead!+ slo' release deliver!+ < months
duration
• Inecta$le extended release$uprenorphine
• Easier initiation of 0%&NT0
• More potent antagonists
• )revention of stress related relapse
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Next steps Treatment matching and se-uencing
• Bho should get 'hat and 'hen andin 'hat order.
• Bhat are the importantcharacteristics for matching.
• %esponding to traector! – %elapse
– Continuous monitoring for earl! 'arningsigns
1dditional supports
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1dditional supports%esponding to struggling patients
%outinel! and rapidl!• Direct medication administration
• : da! services 'ee(ends and evenings
• Case management services• Famil! and peer supports
• Aousing services
• 1ssertive outreach for extendedengagement
• Flexi$le movement up and do'n a fullcontinuum
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Young adultsOpioid Negative UDS (absent iputed as pos!
" e r # e n t
Treatent $ee%s
4 8 > 9 7 < : = E 45 44 48 4> 49 47 4< 4: 4= 4E 85 84 88 8> 895
45
85
>5
95
75
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1t a crossroads
• 1 national crisis• 1 proven set of $oth old and ne' tools
• #ut alarmingl! poor level of dissemination andadoption+ lac( of coherent deplo!ment
• 1 call to action – Expand access
– Integrate care
– Com$ine 'ith other tools in a full continuum
– Improve e@ectiveness and retention under real'orld conditions
• Be have an o$ligation to do $etterP
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BeGve come a long 'a!Q
#ut 'e have a long 'a! to
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Contact
Marc Fishman MD
?ohns Aop(ins *niversit!Mar!land Treatment Centers ,
Mountain Manor
mJshmanRcomcast6net