Medication Assisted Treatment MAT amp Overdose Prevention Michael BacaAtlas MD Addiction Medicine Fellow UNC School of Medicine June 14 2019 Disclosures The presenter has nothing to ID: 814947
Download The PPT/PDF document "Making Sense of the Opioid Epidemic:" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Making Sense of the Opioid Epidemic: Medication Assisted Treatment (MAT) & Overdose Prevention
Michael Baca-Atlas, MDAddiction Medicine FellowUNC School of Medicine
June 14, 2019
Slide2DisclosuresThe presenter has nothing to disclose.
North Carolina Center for Addiction Services
Disclosures
Slide3By the end of this talkDescribe the current state of the
opioid epidemic at the national, state, and local levelsBe familiar with the neurobiology of addiction and how MAT worksDiscuss evidence for MAT and available medications Review best practices for overdose prevention
Objectives
Objectives
Slide4Case: 30 yo female
Took pills from her parents at age 14Transitioned to IV use at age 17 Bought Suboxone on the street
> 5 overdoses, detox admissions
Case
https://deskgram.net/p/1914001632757302179_5338736333
Slide5What are Opioids?
“Natural,” referred to as opiates
Morphine, codeine, opiumSynthetic (partly or completely):
Semisynthetic:
heroin, oxycodone, buprenorphine
Fully Synthetic: fentanyl, tramadol, methadone
Opioids = “Natural” + Synthetic
Terminology
Slide6Opioid History and Policy in the U.S.
Early-Mid 19th CenturyAddiction among Civil War VeteransIsolation of Morphine from Opium 1832
Introduction of the Hypodermic syringe
History and Policy
Slide7Opioid History and Policy in the U.S.
Harrison Narcotics Tax Act of 1914 DATA 2000 WaiverCARA, CDC Chronic Pain Guidelines - 2016NC STOP Act of 2017
History and Policy
Slide8“Triple Wave”
Triple Wave
Slide9Global Perspective
Slide10Source Where Pain Relievers Were Obtained for Most Recent Misuse, 2017
Source for Pain Relievers
Slide11Unintentional overdose deaths involving illicit opioids* have drastically increased since 2013
Slide12Unintentional
Medication & Drug Deaths by County
per 100,000 North Carolina Residents, 2012-2016
Source: Deaths-N.C. State Center for Health Statistics, Vital Statistics, 2012-2016, Unintentional medication and drug overdose: X40-X44/Population-National Center for Health Statistics, 2012-2016
Analysis by Injury Epidemiology and Surveillance Unit
Slide13Slide14For every opioid overdose death, there were nearly2 hospitalizations and 4 ED visits due to opioid overdose
Slide15Brain Disease Model of Addiction
Volkow
and Koob, The Lancet,
2015
Brain Disease Model
Slide16Adverse Childhood Experiences (ACEs)
ACEs
Felitti
et al, AJPM, 1998
Slide17JAMA, 284:1689-1695, 2000
Addiction as a Chronic Disease
Slide18Public Health Paradigm
Public Health Model
Figure 42.2: Substance Misuse and Addiction Framework using the three levels of prevention (primary, secondary, tertiary).
Fraser et al, 2019
Slide19Opioid Use DisorderMost effective treatment is Medication Assisted Treatment
Opioid Addiction Treatment
Slide20How does Medication-Assisted Treatment help?Provides
physiological and psychological stabilization that can allow recovery to take placeReduce/prevent withdrawal
Diminish/eliminate cravings
Block the
euphoric
effect
Restore physiological function
How does it work?
Slide21Is MAT Effective for Opioid Addiction? Decreases
: Illicit use, death rate1HIV, Hep C infections2-4
Crime5
1.Kreek J,
SubstAbuse
Treatment 2002
2.MacArthur, BMJ, 2012
3.Metzgar, Public Health Reports 1998
4. K Page, JAMA IM, 2014
5.Gerstein DR et al, CALDATA General Report, CA
Dept
of Alcohol and Drug Programs, 1994
6.
Mattick
RP et al, Cochrane Database of Systematic Reviews, 2009
7.
Mattick
RP et al, Cochrane Database of Systematic Reviews, 2014
Evidence for MAT
Increases
:
Social functioning and retention in treatment
6-7
Slide22FDA Approved MAT for Opioid Use Disorder
MethadoneBuprenorphineNaltrexone (*
PO, IM)
Pharmacotherapy for Addiction
SAMHSA, TIP Series 63, 2018
Slide23Long-acting, half-life 24-60 hrs
Generally 80-120 mg/dayDangerous in overdose with polysubstanceMethadone
Methadone
full agonist
(
e.g. morphine,
methadone
)
partial agonist
(buprenorphine)
antagonist
(naloxone
,
naltrexone
)
dose
mu opioid
effect
s
Slide24Opioid Treatment Programs
Methadone can
only
be prescribed in a federally-regulated OTP when used for
treatment of addiction
Directly observed therapy
Not reported in PDMP
Not referred
to as “Methadone clinics”
Opioid Treatment Programs (OTPs)
Salsitz
, Mt Sinai J of Medicine, 2000
Slide25Partial mu receptor agonistH
alf-life ~24-36 hrsHigh affinity for the receptorBlocks/displaces other opioidsCan precipitate withdrawal
Buprenorphine
Buprenorphine
full agonist
(
e.g. morphine,
methadone
)
partial agonist
(buprenorphine)
antagonist
(naloxone
,
naltrexone
)
dose
mu opioid
effect
s
SAMHSA, 2018
Orman
&
Keating
, 2009
Slide26Buprenorphine Formulations for OUD
Buprenorphine Formulations
Slide27Buprenorphine: Maintenance vs. Taper
Fiellin
et al., 2014
beginning
of taper
end of
taper
Maintenance vs. Taper
Slide28Full AntagonistFormulationsTablets
: Revia®: FDA approved in 1984Extended-Release intramuscular injection:
Vivitrol
®: FDA approved in
2010
Administration
Abstain from opioids:
> 7 days (short-acting) vs. 10-14 (long-acting)
Naltrexone
Naltrexone
full agonist
(
e.g. morphine,
methadone
)
partial agonist
(buprenorphine)
antagonist
(naloxone
,
naltrexone
)
dose
mu opioid
effect
s
SAMHSA, 2018
Orman
&
Keating
, 2009
Slide29OTP vs. Office Based Outpatient Treatment
Levels of Care
Referring
to a higher
level of
care:
Increased infrastructure
Daily monitoring
Diversion
Feasibility
& Logistics
Slide30ASAM Placement Criteria
Placement Criteria
Slide31Behavioral Health’s Role in OUD TreatmentOptional
psychosocial treatment should be offered in conjunction with pharmacotherapy.A decision to refuse psychosocial treatment/absence of available treatment should not preclude or delay MAT.Refusing psychosocial services should not generally be used as rationale for discontinuing current MAT.
Behavioral Health’s Role
Slide32StigmaHealth related stigma: individuals are devalued, rejected and excluded on the basis of having a socially discredited health condition.
Impact on seeking treatment?Importance of language on shaping our beliefs?
Stigma
Slide33Health Disparities
Traditionally perceived as a white, suburban/rural issueFor African Americans:Emergency room visits increased by 255% (Ford 2015)Overdose deaths doubled in the past 10 years (Ford 2015)
Slide34Young Adults
DATA 2000 authorizes treatment age 16 and older
Buprenorphine -> 16 years of age
Methadone and Naltrexone -> 18
years of
age
CFR 42, 2017
DATA,
2000
Hadland
et al., 2017
Adolescents
New Diagnoses of Opioid Use Disorder in Youth
Slide35MAT in PregnancyMAT = standard of care
Ok to use Suboxone (combo product)Breastfeeding recommendedNeonatal abstinence syndromeNewborns are NOT addicted
Eat, Sleep, Console (ESC)Reducing LOS
Fischer et al.
,1998; Jones
et al., 2010;
Kakko
et al., 2008;
Kraft
et al., 2017
MAT in Pregnancy
Slide36The Rhode Island Experience
MAT in Criminal Justice SystemAll prisoners were screened for Opioid Use DisorderPrisoners on MAT prior to arrest
continued on MATPrisoners with OUD not previously treated were offered MAT prior to release AND post-release.
61% Reduction in Opioid Overdose Deaths
The Rhode Island Experience
Green et al, 2018
Slide37Physiology of Overdose
Opioids affect part of the brain regulating respiration
Fentanyl-induced chest wall rigidity
Complications of non-fatal overdose
Koo, Open
Anesthesiology Journal, 2011
Physiology of Overdose
Slide38Best Practices for Opioid Overdose Prevention
Primary PreventionOpioid StewardshipPrevention of ACEsAdolescent Risk ReductionIncreasing Access to Treatment (MAT
)Reduce MAT Stigma Harm Reduction Strategies
Naloxone Distribution
Overdose Education
911 Good Samaritan Laws/Bystander Assistance
Screening for Fentanyl
Overdose prevention
Slide39Naloxone No
effect other than blocking opioids Good safety profile No potential for abuse
Auto-injector
Evzio
®
Kaleo
Inc.
Narcan
®
Nasal Spray
Adapt
Pharma
Intramuscular Injection
Various Companies
Slide40Naloxone
Naloxonesaves.org (standing order)N.C. Good Samaritan/Naloxone Access Laws
Slide41Slide42Conclusions: MAT & Overdose Prevention
National, state, and local data suggest rising unintentional overdose deaths related to polysubstance use. MAT has consistently demonstrated better long-term
outcomes than no MAT (detox).
Buprenorphine and naltrexone have some significant advantages in terms of safety profile over methadone
.
Overdose prevention entails primary prevention, increasing treatment access, and harm reduction.
Conclusions
Slide43Resources
Contact: michael_baca-atlas@med.unc.edu
Slide44ReferencesMattick, R. P., Breen, C., Kimber, J., & Davoli
, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2014(2), 1–84. Sees, K. L., Delucchi, K. L., Masson, C., Rosen, A., Clark, H. W., Robillard, H., … Hall, S. M. (2000). Methadone maintenance vs 180-day psychosocially enriched detoxifcation for treatment of opioid dependence: A randomized controlled trial. JAMA, 283(10), 1303–1310. Nielsen, S.,
Larance, B., Degenhardt, L., Gowing, L., Kehler
, C., &
Lintzeris
, N. (2016). Opioid agonist treatment for pharmaceutical opioid dependent people. Cochrane Database of Systematic Reviews, 2016(5), 1–61.
Mattick
, R. P., Breen, C., Kimber, J., &
Davoli
, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2014(2). CD002207.
Degenhardt
, L., Randall, D., Hall, W., Law, M., Butler, T., & Burns, L. (2009). Mortality among clients of a state-wide opioid pharmacotherapy program over 20 years: Risk factors and lives saved. Drug and Alcohol Dependence, 105(1–2), 9–15.
Metzger, D. S., Woody, G. E., McLellan, A. T., O’Brien, C. P.,
Druley
, P.,
Navaline
, H., …
Abrutyn
, E. J. (1993). Human immunodefciency virus seroconversion among intravenous drug users in- and out-of-treatment: An 18-month prospective follow-up. Journal of Acquired Immune
Defciency
Syndromes, 6(9), 1049–1056.
Ball, J. C., & Ross, A. (1991). The effectiveness of methadone maintenance treatment. New York, NY: Springer
Verlag
.
Lee, J. D.,
Nunes
, E. V., Jr., Novo, P.,
Bachrach
, K., Bailey, G. L., Bhatt, S., …
Rotrosen
, J. (2018). Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): A
multicentre
, open-label,
randomised
controlled trial. Lancet, 391(10118), 309–318.
Tanum
, L.,
Solli
, K. K., Latif, Z. E.,
Benth
, J. Š.,
Opheim
, A., Sharma-
Haase
, K., …
Kunøe
, N. (2017). The effectiveness of injectable extended-release naltrexone vs daily buprenorphine-naloxone for opioid dependence: A randomized clinical
noninferiority
trial. JAMA Psychiatry, 74(12), 1197–1205.
https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/opioid-use-disorder_technical-brief.pdf
Andrilla
CHA,
Coulthard
C, Larson EH. Changes in the Supply of Physicians with a DEA DATA Waiver to Prescribe Buprenorphine for Opioid Use Disorder. Data Brief #162. Seattle, WA: WWAMI Rural Health Research Center, University of Washington, May 2017.
https://nctopps.ncdmh.net/ProviderQuery/Index.aspx
Ranapurwala, S. I., Shanahan, M. E., Alexandridis, A. A., Proescholdbell, S. K., Naumann, R. B., Edwards, D., Jr, & Marshall, S. W. (2018). Opioid Overdose Mortality Among Former North Carolina Inmates: 2000–2015. American Journal of Public Health, 108(9), 1207–1213. Knudsen HK, Abraham AJ, Roman PM. Adoption and implementation of medications in addiction treatment programs. J Addict Med. 2011 Mar;5(1):21- 7. doi: 10.1097/ADM.0b013e3181d41ddb. PMID: 21359109Friedmann PD, Schwartz RP. Just call it "treatment". Addiction Science & Clinical Practice. 2012;7:10. doi: 10.1186/1940- 0640-7-10. PMID: 23186149.Saitz R. Things that Work, Things that Don't Work, and Things that Matter--Including Words. J Addict Med. 2015 NovDec;9(6):429-30. doi: 10.1097/adm.0000000000000160. PMID: 26517322.https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorderhttps://dpt2.samhsa.gov/treatment/directory.aspx
https://nctopps.ncdmh.net/ProviderQuery/ProviderQuery.aspx
Substance Abuse and Mental Health Services Administration. Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) Series 63, Executive Summary. HHS Publication No. (SMA) 18-5063EXSUMM. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.
Hawk KF,
Vaca
FE,
D'Onofrio
G. Reducing Fatal Opioid Overdose: Prevention, Treatment and Harm Reduction Strategies.
Yale J
Biol
Med
. 2015;88(3):235–245. Published 2015 Sep 3.
Fraser
, Michael R, et al. “Chapter 42.”
The Practical Playbook II: Building Multisector Partnerships That Work
, Oxford University Press, 2019
.
Schiller EY, Mechanic OJ. Opioid Overdose. [Updated 2019 Mar 2]. In:
StatPearls
[Internet]. Treasure Island (FL):
StatPearls
Publishing; 2019 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK470415
/
https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf
References
Slide45UNC ECHO for MAT
UNC ECHO for MAT Telementoring
(not Telemedicine)
Case Based Learning: Spokes from the community bring cases for discussion
Short
didactic
Currently
4
ECHO
clinics for MAT:
Tues
12:00 pm
–
1:00 pm
Wed
12:30 pm
–
1:30 pm
Fri 8:30 am – 9:30 am (Intro)
Fri 12:00 pm – 1:00 pm (ED)
www.echo.unc.edu
echo@unc.edu
Slide46Myths and Realities
Wakeman, NEJM, 2018
Slide47Psychiatric Disorders and Opioid Addiction
Disorder
Prevalence
References
Major Depression
Lifetime
38-56%; 20-50%
Havard et al, 2006;
Nunes et al, 2004
Current
16-30%; 10-20%
19.8% males;
31.1% females
Darke et al, 2009
Anxiety Disorders
Lifetime
13.2-24.5%
Rounsaville, 1982
PTSD
Lifetime
11-20%; 40%
Villagomez, 1995; Darke et al, 2004
Bipolar Disorder
<5%
Fudala & Woody, 2002
Psychotic disorders
<5%
Fudala & Woody, 2002
Borderline PD
46%
Darke et al, 2004
Antisocial PD
20-50%; 72%
Fudala & Woody, 2002;
Darke et al, 2004
ADHD
5.22%
Arias et al, 2008
Slide48Availability of Substance Abuse Treatment Facilities, SAMHSA
Source: Behavioral Health Treatment Services Locator – SAMHSA, Substance Abuse Treatment Facilities, Accessed 10/2017. Medication Assisted Therapy, Opioid Treatment Program Directory – SAMHSA, Accessed 10/2017.
*Substance abuse treatment facilities must meet certain eligibility criteria to be listed on the SAMHSA website; not all facilities are in-patient; see notes for more details.
Slide49Best Practices for Responding to Opioid Overdose
Event = Overdose
Host/Person
w/ SUD
Agent (Opioid)
Physical Environment
Social Environment
Pre-Event
Naloxone
education
Safe prescribing
Safe storage/
disposal
Fentanyl drug testing
Fentanyl test strips
PDMP
Safe
injection sites
Naloxone
rx
Address
Stigma
Train providers
SDH
Bystander naloxone
Event
Naloxone dose(s)
BLS
Test
“shot”
Push slowly
EMS/LE
Naloxone
Avoid
using alone
Good Samaritan Laws
Post-Event
Pt
Readiness
Treatment access (MAT)
Post-overdose
response
Residential programs
w/ MAT
Peer Support
LEAD programs