And Clinical Implications Surita Rao MBBS MD FASAM Program Director Psychiatry Residency Training Program Associate Professor of Psychiatry University of Connecticut School of Medicine ID: 755150
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Understanding the Opioid Crisis And Clinical Implications
Surita Rao, M.B.B.S, M.D., FASAM
Program Director, Psychiatry Residency Training Program
Associate Professor of Psychiatry
University of Connecticut School of Medicine
November 12, 2018Slide2
AgendaHistory of Opioid Epidemic
Addiction as a Brain Disorder
Prevalence Rates
Treatment Options
Medications
Psychosocial Options
Q & ASlide3
Opioids Discovered by Humans
The opium poppy is cultivated in lower Mesopotamia. The Sumerians refer to it as Hul Gil, the 'joy plant.‘
The Sumerians would soon pass along the plant and its euphoric effects to the Assyrians.
The art of poppy-culling would continue from the Assyrians to the Babylonians who in turn would pass their knowledge onto the Egyptians
Source: PBS “ frontline” http://www.pbs.org/wgbh/pages/frontline/shows/heroin/etc/history.htmlSlide4
What is Addiction?
According to the American Society of Addiction Medicine:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by
an inability to consistently abstain
impairment in behavioral control
craving
diminished recognition of significant problems with one’s behaviors and interpersonal relationships
a dysfunctional emotional response
Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.Slide5
Addiction : A Brain Disorder
The brain does not know the difference between a legal drug [alcohol, nicotine], illegal drug, prescribed drug or a drug bought on the “street”
There is nothing in science or nature that can re-create the effects of addictive substances on the brainSlide6
Source : CDC [ Centers for disease control]. October 2016Slide7
Source : CDC Prescription drug monitoring programs Slide8Slide9
National Overdose DeathsNumber of Deaths Involving All Drugs
9
63,632
72,306
8
0,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
201
4
2015
2016
Provisional 2017
Total Females Males
Source: National Center for Health Statistics, CDC WonderSlide10Slide11
The total number of opioid pain relievers prescribed in the United States has skyrocketed in the past 25 years The number of prescriptions for opioids (like hydrocodone and oxycodone products) have escalated from around 76 million in 1991 to nearly 207 million in 2013.
The United States is their biggest consumer globally, accounting for almost 100 percent of the world total for Hydrocodone (
e.g.,
Vicodin) and 81 percent for oxycodone (
e.g.,
Percocet).
Prevalence & Rates
[ Source : NIDA National Institute on Drug Abuse. May 14, 2014. Presented by Nora D. Volkow,M.D. Senate Caucus on International Narcotics ControlSlide12
Percentage of the total heroin-dependent sample that used heroin or a prescription opioid as their first opioid of abuse. Data are plotted as a function of the decade in which respondents initiated their opioid abuse. Source: Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years.
JAMA Psychiatry
. 2014;71(7):821-826.Slide13
Heroin Use in the U.S [ CDC]Slide14
Source : NIDA [ National Institute on Drug Abuse] May 14, 2014. presented by Nora D. Volkow, M.D. Senate Caucus on International Narcotics Control
Drastic increases in the number of prescriptions written and dispensed
Greater social acceptability for using medications for different purposes
Aggressive marketing by pharmaceutical companies
These factors together have helped create the broad “environmental availability” of prescription medications in general and opioid analgesics in particular.
Prevalence & RatesSlide15
Heroin Use: Comorbid Substance UseSlide16
Fentanyl
Fentanyl is a powerful synthetic opioid analgesic that is similar to morphine but is 50 to 100 times more potent.
It is a schedule II prescription drug, and it is typically used to treat patients with severe pain or to manage pain after surgery.
It is also sometimes used to treat patients with chronic pain who are physically tolerant to other opioids.
Source: NIDA [ National Institute on Drug Abuse]Slide17
Fentanyl
Prescribed in the form of transdermal patches or lozenges and can be diverted for misuse and abuse in the United States.
However, most recent cases of fentanyl-related harm, overdose, and death in the U.S. are linked to illegally made fentanyl.
2
It is sold through illegal drug markets for its heroin-like effect. It is often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge—to increase its euphoric effects.Slide18Slide19
Adolescent Drug Use: NIDA Slide20
Monitoring the Future : NIDA
This year’s Monitoring the Future Survey of drug use and attitudes among American 8
th
, 10
th
, and 12th graders continues to show encouraging news.Decreasing use of alcohol, cigarettes, and misuse of prescription pain relievers.
Stable rates of marijuana use among teens;
Decreasing use of inhalants and synthetic drugs, including K2/Spice and Bath Salts.
A general decline over the last two decades in the use of illicit drugs.
However, the survey highlighted growing concerns over :
The high rate of
electronic cigarette
use and
Softening of attitudes around some types of drug use
, particularly decreases in perceived harm and disapproval of
marijuana use
.Slide21
Opioid Use and TreatmentSlide22
Opioid Dependence: Neurobiology
Mu opioid receptors : Responsible for analgesic [ pain control] effect , the euphoria associated with opioids, addictive properties.
Tolerance and withdrawal
Dopamine: The Reward and reinforcement neurotransmitter of the brain. Involved in addiction to any drug including alcohol or prescribed substances.Slide23
Opioid Withdrawal: Symptoms
It is like having the stomach flu and a upper respiratory infection combined together
Runny nose
Tearing from the eyes
Chills
Muscle aches and pains
Abdominal cramps
Diarrhea
Vomiting
Nausea,
Insomnia
Severe anxiety
Intense cravingSlide24
Opioid Withdrawal: Treatment
Methadone [dosing starts at 25-30 mg and can be reduced by 5 mg each day]. NO real advantage to a longer taper
Buprenorphine [ Start at 4 or 8 mg, taper over 1 week to 6 months]. Longer tapers is done on an outpatient basis
Clonidine
Adjunctive medications : loperamide [ anti diarrheal], dicyclomine [antispasmodic] benzodiazepines [ for insomnia and anxiety], NSAIDS [ chills and body aches]
Psychosocial treatments are crucial
: Group therapy, individual therapy, discharge planning to connect the patient to the next stage of treatment, Family work, family and patient education, relapse prevention therapy [ cognitive behavioral therapy for substance use disorders], Engagement in 12-step meetings [ narcotics anonymous, alcoholics anonymous], relaxation techniques [ meditation, art therapy]Slide25
Opioid Use Disorders: Treatment
Relapse rates following detoxification are high
The best results are from agonist maintenance therapies: methadone and buprenorphine maintenance Slide26
Naltrexone: blocking agent for opioids
Agonist maintenance agents: [ these are also used for detoxification from opioids]
Methadone
Buprenorphine [ Suboxone/ subutex]
P
artial agonist
Acts as a blocker at higher dosages. In the united states Suboxone is mixed with naloxone , so it will induce opioid withdrawal if crushed and injected.
MedicationsSlide27
Opioid Use disorders: Psychosocial Therapies
Referral to a therapist/ counselor specializing in substance use disorders and dual diagnosis. [LADC: licensed drug and alcohol counselor]
The patient will get some psychosocial therapies at the methadone maintenance program or in the suboxone provider’s office. Always find out the details, especially in the suboxone (buprenorphine) provider’s office.
Consider referring to a
residential treatment program
or an partial hospital/day treatment program or an
intensive outpatient program.Does the patient need a referral for
detoxification?
Work with the patient to have
appropriate release of information
signed so that you can communicate with members of the extended treatment team.
Refer to Narcotics anonymous . Some patients go to AA [ alcoholics Anonymous]
Family education and involvement. Nar-Anon or Al-AnonSlide28
Opioid Use disorders: Psychosocial therapies
Utilizing twelve step therapy
Encourage patient to make a plan of which NA /AA meetings they will attend [time, place, how it will fit into their schedule, transportation]
Encourage patient to share and process feelings and thoughts about the experience in the meeting
Coaching to get a sponsor, teach the patient how to stand up in an NA/AA meeting and ask for a
“phone list”.
Coach patients on how to integrate into AA meetings, offer to make coffee as away to manage social anxiety.Slide29
Opioid Use disorders: Psychosocial Therapies
Relapse prevention [cognitive behavioral therapy for substance use disorders]
People, places and things
HALT
[Hungry, angry, lonely tired]
Learning techniques to help cope with cravings and triggers [internal and external] and not relapse. For example, taking a longer route back home from work to avoid the liquor store.Slide30
Evidence-Based Practices Directive client-centered approach that focuses on uncovering and resolving ambivalence about changing substance use in a manner that increases the patient’s internal motivation for and commitment to change: avoids confronting resistance.
Focuses on relapse prevention and the reversing of maladaptive thoughts and beliefs that support substance use.
Reinforces the Alcoholics/Narcotics Anonymous approach to abstinence, Outside participation in 12-Step groups essential. May include couples sessions.
Cognitive-behavioral approach combined with sessions with support network (family, friends, etc.). May be combined with disulfiram.
DA combination of cognitive-behavioral therapy groups, family education groups, social support groups, individual counseling, regular drug testing, and option 12-Step attendance.
Motivational enhancement therapy
Cognitive-behavioral therapy
12-Step facilitation therapy
Network therapy
Matrix Model
Cognitive Contingency Model
Reinforce the achievement of interim goals (e.g., drug-free urine tests) with intermittent tangible rewards of increasing value. Slide31
Evidence-Based Practices 5-to 15-minute motivational/educational office-based intervention: may include one or more in-person or telephone follow-up contacts.
Strong emphasis on abstinence, preventing replapses, problem-solving, and involvement in 12-Step groups.
A service delivery model for patients with chronic mental illness and substance abuse in which the same provider team delivers both mental health and substance abuse treatment.
A number of different models.
Brief advice or intervention
Group and individual drug counseling
Integrated treatment
Couples and family therapies Slide32
Opioid Use Disorder: Case Example
24 year old , married white female , with opioid dependence [ heroin, oral opioid analgesics]. She is the mother of two young toddlers , an 18 month old daughter and a 3 year old son. Prior to entering treatment in a residential treatment program for mothers with substance use disorder, she and her husband and children were living in family shelter.
Her husband is also addicted to opioids and has now entered treatment at a different residential facility. Prior to entering treatment, he was having an affair with a woman also living at the family shelter. When patient found out, there was a physical fight between her and the other woman at the shelter, witnessed by her children.
In her initial appointment with the addiction psychiatrist she cautiously shared that she had started a “maintenance program” of her own with street buprenorphine after finding out that she was pregnant. She had settled on a dose of 8 mg daily of the “street bought” buprenorphine.
She has bipolar disorder type II or NOS [ diagnosis unclear] and Post traumatic stress disorder. She is prescribed, a atypical antipsychotic [ quetiapine], is on buprenorphine [ as opiate agonist maintenance therapy] and oxcarbazepine (mood stabilizers). She and her husband had a planned therapeutic leave, to spend an afternoon in the park with their children, to help with family bonding. Patient now reports that she is two months pregnant.Slide33
She was connected to a buprenorphine prescriber in the community who took her public sector insurance. She signed releases of information for the provider, which was a requirement, in order to be on agonist maintenance therapy and participate in this residential mothers program.
Her counselor also reached out to the counselor taking care of her husband in his residential program.
Some family meetings were planned with her husband. Some of these would be phone conference calls.
She was diagnosed with bipolar disorder NOS and Post traumatic stress disorder.
Opioid Use Disorder: Case ExampleSlide34