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Solving the Opioid Crisisthrough intervention and treatment.

Richard Bottner, PA-CAffiliate Faculty, Dell Medical School at University of Texas AustinDirector, Support Hospital Opioid Use Treatment (SHOUT) Texas

No disclosures• Other than I’m really passionate and from

New Jersey.

Brief Case• 42 year-old male with opioid use disorder.• Mom passed away at age 52 from ETOH and Hep C cirrhosis.• Spent over 20 years in and out prison related to substance use.• Admitted for THIRD episode of endocarditis.• Treatment plan includes six weeks of IV antibiotics.• Two weeks into hospitalization, found to have used heroin from street.• Accuses staff of not treating him appropriately / not treating

withdrawal.• Threatens to leave AMA.

What would YOU do?

Objectives• Why address treatment of OUD?• Why buprenorphine?• Why hospitals (and beyond)?• Why replicate the B-Team?

I have a confession. Why address the treatment of OUD?

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1980 1990 2000 2010 2017

NU

MBER O

F DEATH

S (10,000/ line)

HIV deaths, ‘95

70,237 overdose deaths, 2017

*Chart adapted from the New York Times

Gun deaths, ‘93

OD Deaths ↓ 3% – 5%

Methods: National Survey on Drug Use responses from 2002 to 2015 (55,000 annual responses.) Assumed OD stabilization by 2020.

Texas Isn’t THAT Bad, Right?

Texas Health Data…by death certificate.

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Texas Health Data…poison control center phone calls.

Mexican Oxy

Drug Enforcement Agency

Why Buprenorphine?(Suboxone)

Opioid Physiology

XXXOpioid Physiology

Vector Stock

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Opioid Physiology Opioid Physiology

Eventbrite

Opioid Physiology

Vector Stock

Opioid Physiology

EUPHORIA

Opioid Physiology

Medical News

Opioid Physiology

Shutter Stock

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Why buprenorphine?• Partial agonist

– Controls cravings without euphoria• Ceiling effect• High affinity

Vogue

Opioid Agonist Therapy – Medical Benefits

• Reduces mortality• Increases time spent in treatment• Reduces injection and illicit drug use• Reduces HIV, HCV, and bacterial transmission• Increases abstinence

Caldiero (2006), Larochelle (2018), Teesson (2006)

Opioid Agonist Therapy – Psychosocial Benefits

• Promotes return to work and family obligations

• Reduces criminal behavior

National Institute on Drug Abuse. Opioid overdose crisis. March 2018.

Opioid Agonist Therapy – ED Benefits

• Buprenorphine > traditional meds / SBIRT in the ED setting.

• Less likely to return to ED within 30 days.

D’Onofrio G, et al. J Gen Intern Med. 2017;32(6):660-666

Opioid Agonist Therapy – Women’s Health Benefits

• Reduce risk of preterm delivery, miscarriage, low birth weight

• Neonatal abstinence syndrome• Buprenorphine recommended by ACOG

Substance Abuse and Mental Health Services Administration. 2018.

Buprenorphine vs Methadone• Buprenorphine equivalent dose >= 16 mg• Buprenorphine < risk• X-waiver vs methadone clinic

– Access

Mattick R, Breen C, Kimber J, Davoli M. Cochrane. 2004;9(5).

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"Medication-based treatment is effective across all treatment settings studied to date. Withholding or failing to have available… medication for the treatment of

opioid use disorder in any care setting is denying appropriate medical treatment."

Why Hospitals?

Brief Medically Assisted Withdrawal (“detox”):Ineffective

Chutuape, M et al. One-, three-, and six-month outcomes after brief inpatient opioid detoxification. The American Journal of Drug and Alcohol Abuse. Vol 27:1, 2001.

• Experiencing uncomfortable withdrawal and cravings• Motivated for change• Away from triggering environment• Surrounded by supportive staff• Start of ongoing medical treatment• 25-30% of patients leave the hospital against medical advice:

– Withdrawal– Fear of mistreatment– Cravings– Financial and social pressures

Hospitalization: An Opportunity

Lianping Ti et al. AJPH, December 2015

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Liebschutz et al. JAMA Intern Med. 2014 Aug; 174(8): 1369–1376.

Methods: Single center, randomized, from 2009 to 2012, 139 patients

Methods: Retrospective cohort, single academic center, 470 patients over five years.

Quadruple Aim

Image: Kinetix Group

Stigma Reduction and Relapse Rates

McLellan et al., JAMA, 2000.

Why every hospital in the country should have a B-Team.

What is the Buprenorphine Team?

Screen

• Residents• Attendings• Nurses• Social

Workers

Induction

• Clinical Assessment

• Pharmacist Intervention

• Just-In-Time Training

Linkage

• Community MAT visits patient.

• Bridge prescription provided

Institutional education to reduce stigma.

An interprofessional and multidisciplinary hospitalist-led group that works to:

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Creating Barriers To Recovery

Resource Development - 42 y/o AA male w/ PmHx of OUD, from east Austin.- “Hustling” on the street since age 12 – selling marijuana à crack à jail à violence.- Mom passed away at age 52 from ETOH and Hep C cirrhosis.- Has over 10 nieces and nephews.- Admitted for THIRD episode of endocarditis.- Found to have used heroin from street during hospitalization.- About to leave the hospital against medical advice…

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Lessons Learned• This is the new (but not novel) standard

of care• Preliminary results• Building a model for dissemination

Call To Action: Be The ChangeOpioid Use Disorder is a

chronicrelapsingremitting

medical condition.

Call To Action: X-Waiver• PCSS• ASAM• (Me!)

Call To Action: Stay Up To Date

@RichBottner

ContactRichard Bottner, PA-C• Director, The Buprenorphine Team at Dell Seton

Medical Center• Director, Support Hospital Opioid Use Treatment

(SHOUT) Texas at Dell Medical School• Richard.Bottner@austin.utexas.edu• (c) 201-390-9245

ReferencesAaltonen, P. Opioids: Pain, use, and patient management. Purdue University.CDC. (2017, August 30). Understanding the epidemic. Centers for Disease

Control and Prevention. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html.

Chutuape, M., et al. (2001). One-, three-, and six-month outcomes after brief inpatient opioid detoxification. The American Journal of Drug and Alcohol Abuse, Vol 27, 1.

Dowell, D. (2016, December 13). Clinician outreach and communication activity. Center for Disease Control and Prevention.

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ReferencesHassamal, S., Goldenberg, M., Ishak, W., Haglund, M., Miotto, K., & Danovitch, I.

(2017). Overcoming barriers to initiating medication-assisted treatment for heroin use disorder in a general medical hospital: A case report and narrative literature review. Journal of Psychiatric Practice, 23(3), 221–229.

Krebs, E., Enns, B., Evans, E., Urada, D., Anglin, M., Rawson, R., Nosyk, B. (2018). Cost-effectiveness of publicly funded treatment of opioid use disorder in California. Annals of Internal Medicine, 168(1), 10–10. doi:10.7326/M17-0611.

Rosenthal, E. S., Karchmer, A. W., Theisen-Toupal, J., Castillo, R. A., & Rowley, C. F. (2016). Suboptimal addiction interventions for patients hospitalized with injection drug use-associated infective endocarditis. The American Journal of Medicine, 129(5), 481–485. https://doi.org/10.1016/j.amjmed.2015.09.024.

ReferencesPatterson, David. Substance abuse treatment effectiveness. University of

Tennessee.Samet, J. H., Kertesz, S. G. (2018). Suggested paths to fixing the opioid

crisis. JAMA Network Open, 1(2), e180218. doi:10.1001/jamanetworkopen.2018.0218.

Snyder, Hannah. Project SHOUT (Support Hospital Opioid Use Treatment). https://www.projectshout.org/.

Substance Abuse and Mental Health Services Administration. (2016, May 31). Buprenorphine. SAMHSA. Retrieved from https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine.

ReferencesTetrault, J., & Fiellin, D. (2018). More beds or more chairs? Using a science-

based approach to address the opioid epidemic. Annals of Internal Medicine, 168(1), 73–73. doi:10.7326/M17-2854.

Trowbridge, P., Weinstein, Z. M., Kerensky, T., Roy, P., Regan, D., Samet, J. H., & Walley, A. Y. (2017). Addiction consultation services: Linking hospitalized patients to outpatient addiction treatment. Journal of Substance Abuse Treatment, 79, 1–5.

U.S. Food and Drug Administration. (2010, July). Combating misuse and abuse of prescription drugs: Q&A with Michael Klein, PhD

www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM220434.pdf.

References (cont.)• Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder

after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. June 2018. doi:10.7326/M17-3107

• Caldiero RM, Parran TV Jr, Adelman CL, Piche B. Inpatient initiation of buprenorphine maintenance vs. detoxification: can retention of opioid-dependent patients in outpatient counseling be improved? Am J Addict. 2006;15(1):1-7.

• Teesson M, Ross J, Darke S, et al. One year outcomes for heroin dependence: Findings from the Australian Treatment Outcome Study (ATOS). Drug Alcohol Depend. 2006;83(2):174-180. doi:10.1016/j.drugalcdep.2005.11.009