INTEGRATING SCREENING AND TREATMENT OF OPIOID ADDICTION

INTO PRIMARY CARE PRACTICES

UNH DEPARTMENT OF NURSING AND SOUTHERN NH AHEC ANNUAL

CLINICAL SYMPOSIUMAUGUST 27, 2015

SCOPE OF PROBLEM

2013 National Survey on Drug Use and Health:

4.9 million current (past month) nonmedical users of prescription opioids

1.9 million met DSM-IV criteria for opioid use disorder associated with their use of prescription opioids

More than 0.5 million additional individuals met criteria for opioid use disorder associated with use of heroin

8.7% of all people surveyed over the age of 12 admitted to any illicit drug use in the previous month

RISKS OF NON-MEDICAL USE OF OPIOIDS

MORTALITY—leading causes are overdose and trauma

320 PEOPLE DIED FROM OPIOID OVERDOSE IN NH IN 2014

MORBIDITY– injection route use increases the risk of being exposed to HIV, viral hepatitis and other infectious agents

THE DRUG ABUSE “PYRAMID”

For every 1 overdose death from prescription painkillers there are…..

--10 treatment admissions for abuse

--32 emergency department visits for misuse or abuse

--130 people who abuse or are dependent

--825 people who take prescription painkillers for non- medical use

WHERE ARE PEOPLE GETTING PRESCRIPTION DRUGS OF ABUSE?

--55% are obtained from a friend or relative

--17% are prescribed by a single provider

--11% are bought from a friend or relative

--5% are stolen from a friend or relative

--4% are obtained from a drug dealer

WHERE DID THE PROBLEM COME FROM?

Who is responsible?

Why is it getting worse?

Why is there an increased sense of urgency?

What are the characteristics of NH and Northern New England that make this a particularly difficult problem to address?

HOW GOOD ARE WE AT IDENTIFYING THE PROBLEM IN OUR PATIENTS?

Few of us screen routinely for alcohol abuse, let alone for other substance misuse

We tend to utilize a biomedical model which addresses pathology and morbidity, not at-risk behavior

We miss many opportunities to work upstream

PERCEIVED BARRIERS TO ASKING ABOUT SUBSTANCE USE

--Belief that patients lie--Time constraints--Fear of questioning patient’s integrity--Fear of angering the patient--Uncertainty about treatment--Personally uncomfortable with the subject--May encourage the patient to see another clinician--Belief that insurance doesn’t reimburse clinician time

ADDICTION IS SIMILAR TO OTHER CHRONIC HEALTH CONDITIONS

Less than 30% of patients adhere to prescribe medications and diet or behavioral change for conditions like hypertension, diabetes and asthma.

The same percentage stop drinking when recommended

There is a 50% recurrence rate

Substance abuse should be insured, monitored, treated and evaluated like other chronic diseases

PARADIGM SHIFT=INNOVATIVE APPROACHES

Shift from moral failing to a chronic and recurrent condition:

--Care coordination and behavioral health and medical health integration

--Expanding treatment options MAT: burprenorphine, methadone, naltrexone Intensive Outpatient Programs (IOPs) Sober housing Peer recovery Drug court and treatment in prison

WHAT IS SBIRT?

A public health approach to the delivery of early intervention and treatment services for at-risk and substance use dependent individuals

Identifies and intervenes when necessary

Universal screening can occur at any medical setting

S-BI-RT

SCREENING: To identify patients with moderate-to-high risk drinking and drug use

BRIEF INTERVENTION: To motivate patients who screen positive to consider healthier decisions (e.g. reducing, ceasing or seeking further assessment)

BRIEF TREATMENT AND REFERRAL TO TREATMENT: To actively link patients to resources when needed

SBIRT Addresses Both

Continuum of Use Low-risk use High-risk/unhealthy use Abuse and dependence (substance use

disorders)

Continuum of Care Brief intervention: Motivational conversation

with action plan Brief treatment: Wrap-around services Referral to treatment: Detox, treatment types

HOW EFFECTIVE IS SBIRT?

More than 34 RCTs in primary care populations

Well-documented effectiveness for moderate to high risk drinkers with 10-30% alcohol reduction at 6 months

USPSTF gave screening and brief intrervention a Class B rating—same level as flu shots and cholesterol screenings

Persons with polysubstance use, pre-contemplation, illicit drug use, or dependent alcohol dx will likely require more intensive tx to show improvement in risky behavior

Rx AVAILABLE FOR TREATMENT OF OPIOID ADDICTION

CLONIDINE --alpha adrenergic blocker --limits autonomic withdrawal (anxiety, agitation, sweating, cramping) --does not help with drug craving --not effective for sustaining recovery

NALTREXONE --available in both daily PO form and monthly injectable --opioid equivalent of Antabuse with fewer side effects --opioid receptor blocker, no agonist activity --can precipitate significant withdrawal and can’t be used within 7 days of drug use --IM form extremely expensive --high rates of relapse --strong interest in use with parolees

MORE EFFECTIVE MEDICAL TREATMENTS

METHADONE --Used in long-term maintenance therapy --Opioid agonist, prevents withdrawal --Tolerance attenuates the effects of heroin and

other abused opioids --”Chipping”—can start and stop it to get high --Highly regulated, only ~2K slots nationwide --Stigma --Exposure to other substance-using patients --May interfere with work or family commitments

MORE EFFECTIVE MEDICAL TREATMENTS

BUPRENORPHINE

How does it work?

Does it have other uses?

What are the different formulations?

What’s in a name? Subutex Suboxone Zubsolv Narcan

BUPRENORPHINE

Can it be abused?

How effective is the naloxone component of Suboxone?

How does that effect its street value?

Is buprenorphine addictive?

BUPE V METHADONE

What’s the difference between buprenorphine and methadone?

What are “chemical handcuffs?”

How does the profit motive figure in? Free standing clinics Different formulations of buprenorphine

MEDICATION ASSISTED TREATMENT

What is it?

What is the best clinical setting to provide Medication Assisted Treatment (MAT)?

Who can prescribe these medications?

KEY COMPONENTS OF OUR PROGRAM

Patient-Provider Contract Regularly scheduled appointments Counseling with a Licensed Alcohol and

Drug Counselor (LADC) Established with a PCP in our practice Regular communication between the

LADC and me Regular urine drug screens

KEY COMPONENTS OF THE CONTRACT

Patient will keep appointments with me and counselor

All prescriptions will be filled at one pharmacyPatient allows communication between me and

counselorPatient will not abuse our staffPatient agrees to random pill counts and urine

drug screensPatient will not use other illegal substancesPatient will meet financial obligations to

practice

CASES

“Successes” Precarious Recovery Failures

LESSONS LEARNED

No one has the answers (particularly myself) There is no blueprint (despite the guidelines) Treatment must be individualized Patients don’t follow a linear course Expect lapses, testing and recidivism Expect to be lied to This is a life-long chronic disease Many or most patients will never discontinue

meds You need to be flexible with contract

violations

LESSONS LEARNED

There are no slam-dunk predictors of success or failure

You may need to be satisfied with harm reduction

Addiction is a family disease—treatment is prevention

Having a PCP is important Having a job is important Encourage openness and family support Discourage contact with friends who use

LESSONS LEARNED

Counseling piece is extremely important Need to have zero tolerance with certain

aspects of contract---e.g. behavior, paying bills

Need to be consistent—news travels fast on the street

The personal rewards, when a single patient stabilizes, are enormous

ACKNOWLEDGEMENTS

Linda Blake, RN Don West, MD Ben Nordstrom, MD Seddon Savage, MD Laurie Harding, MS, RN Stephen Elgert MD Jennifer Gordon, LICSW My patients

WANT TO LEARN MORE?

VT-SBIRT website: http://sbirt.Vermont.gov/ Yale School of Medicine SBIRT: http://medicine.yale.edu/sbirt/index.aspx American Society of Addiction Medicine practice guidelines

(May 2015—excellent review of components of treatment program and pharmacology of agents):

http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/national-practice-guideline.pdf?sfvrsn=22

Providers’ Clinical Support System for Medication Assisted Treatment from SAMHSA (superb free tutorials with all kinds of educational materials):

pcssmat@aaap.org Feel free to contact me with questions about this

presentation, resources or the Dartmouth COOP Project at: petermason68@gmail.com

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