Bradley M. Buchheit, MD, MSAssistant Professor of Medicine and Family MedicineMarch 13, 2020

Addiction Medicine:Treatment and Engagement of People Who Use Drugs

(PWUD) in the Primary Care Office

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Disclosure

• I have no actual or potential conflicts of interest in relation to this program/presentation.

• I will not be discussing any unapproved uses of pharmaceuticals or devices.

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Learning ObjectivesAt the conclusion of this activity, participants will be able to:• Perform screening for and diagnosis of substance use

disorders (SUDs) based on DSM-V criteria.• Identify and apply evidence based treatment options for

individuals with common SUDs.• Identify ways of improving engagement of patients with a

SUD in a primary care setting.

Drug Overdose Deaths, US 2017

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Death rate

(per 100,000):

2017 Data, Centers for Disease Control and Prevention (Published December 2018)

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Initiating Treatment1. Identify individuals at risk for a

SUD.2. Accurately diagnose the SUD and

document it appropriately in the patient chart.

3. Initiate evidence-based pharmacologic and psychosocial interventions for SUD.

4. Build rapport with patient, setting the stage for improved engagement in the future.

2015 Data, National Survey on Drug Use and Health – SAMHSA.

Single Item Alcohol Screening Question

Do you sometimes drink beer, wine, or other alcohol beverages?

No Yes

Score of ≥1: continue with assessment i.e. DSM-5 criteria

NoneSensitivity/Specificity:

82%/79%

Smith PC, et al. J Gen Intern Med.

2009

How many times in the past year have you had 5 (men)/4 (all women or men 65+) or more drinks in a day?

Slide modified from

BESST

Single Item Drug Screening Question

How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons*?

Score of ≥1: continue with assessment i.e. DSM-V criteria

None

Smith PC, et al. J Gen Intern Med.

2010

Sensitivity/Specificity: 100%/74%

*without a prescription, used in a way other than prescribed, or for the experience or feeling it caused

Slide modified from

BESST

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Impaired Control1. Using in larger amounts or for longer than intended2. Repeated unsuccessful efforts to cut back or control

use3. Great deal of time spent using, obtaining, recovering4. Craving

Social Impairment1. Social problems/interpersonal issues

caused/exacerbated by use2. Failure to fulfil major obligations at

work/school/home due to substance use3. Important things given up or reduced

by use

Risky Use

1. Being in physically hazardous settings

2. Physical or psychological problems caused or worsened by use

Pharmacological

1. Tolerance

2. Withdrawal Mild 2-3 criteria

Moderate 4-5

Severe 6 or more

DSM-5 Criteria for Substance Use Disorder

Diagnostic and Statistical Manual of Mental Disorders 5, APA, 2013.

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DocumentationType of SUD – eg. alcohol, nicotine, opioid, etc.

Severity of SUD – Mild, Moderate or Severe

Remission status –– Early remission: >3 months but less than 12

months– Sustained remission: >12 months

Other:– On maintenance therapy (opioids only)– In controlled environment

Avoid:“Abuse”

“Dependence”“Misuse”

Psychosocial interventions for SUDTalk Therapy

– Cognitive Behavioral Therapy (CBT)

– Dialectical Behavioral Therapy (DBT)

– Acceptance and Commitment Therapy (ACT)

Self-help/Peer Recovery– Alcoholics Anonymous (AA)– Narcotics Anonymous (NA)– SMART Recovery

UpToDate. Accessed 3/2020.

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Alcohol Use Disorder – TreatmentFirst Line:1. Naltrexone– Check LFTs • Avoid if > 3-5 times the upper

limit of normal– Ensure patient not using opioids– Side Effects: GI upset, nausea,

diarrhea

2. Acamprosate– Check Creatinine• Renally dose if CrCl is 30-50

mL/min• Avoid if CrCl <30 mL/min

– Side Effects: GI upset, nausea, diarrhea

Second Line:1. Disulfiram– Check LFTs– Avoid if history of psychosis,

severe myocardial disease, using alcohol-containing preparations/metronidazole

– Side Effects: bitter taste, disulfiram reaction

UpToDate. Accessed 3/2020.

Efficacy of Medications for Alcohol Use Disorder

“Both acamprosate and oral naltrexone were associated with reduction in return to drinking… Factors such as dosing frequency, potential adverse events, and availability of treatments may guide medication choice.”

Jonas et al. JAMA 2014: 311: 1889-1900.

Number Needed to

Treat

Strength of

Evidence

Naltrexone

• Return to any drinking

• Return to heavy

drinking

20

12

Moderate

Moderate

Acamprosate

• Return to any drinking 12 Moderate

Nicotine Use Disorder – TreatmentNicotine Replacement Therapy

– Transdermal patch + ad lib short acting lozenge/gum/inhaler– If smoking >40 cigarettes daily, consider 42mg per day transdermal– Avoid if recent MI (within 2 weeks), serious arrhythmias, unstable

angina– Side effects: insomnia, local site reaction, GI upset

Varenicline– Consider use in combination with NRT during pretreatment time– Dose adjust for severe renal impairment– Side Effects: nausea, headache

Bupropion– Consider use in combination with NRT– Avoid in those with seizure d/o or at risk for seizures,

bulimia/anorexia, MAOi’s in the last 14 days– Side effects: insomnia, seizures, difficulty concentratingKathuria, Leone and Neptune. Curr Opin Pulm Med. 2018.

Opioid Use Disorder – TreatmentMethadone Buprenorphine NaltrexoneFull opioid agonist Partial opioid agonist Opioid antagonistLimited <18 yrs FDA-approved ≥16 yrs FDA-approved ≥18 yrsReduces withdrawal and cravings

Reduces withdrawal and cravings

Reduces cravings only (used incorrectly, causes withdrawal)

Daily dose Daily dose (film/tablet); monthly dose (injection); semi-annual dose (implant)

Daily dose (tablet); monthly dose (injection)

Only administered in person at qualifiedmethadone center

Can be provided by primary care clinician (after obtaining DEA waiver)

Can be provided by primary care clinician (no special training required)

Principles of Addiction Medicine, American Society of Addiction Medicine, 2015.

Efficacy of Medications for Opioid Use Disorder

• Buprenorphine-naloxone & Methadone– Reduce overdose death by 60-80%– Suppression of heroin/illicit opioid use– Improves retention in treatment– Reduce risk of Hep C and HIV

• Naltrexone – extended release, injectable– Difficult to initiate– Difficult to engage patient– Once on medication, reduction in illicit opioid use similar to

buprenorphine

A Guideline for the Clinical Management of Opioid Use Disorder, British Columbia Centre on Substance Use, 2017.Sordo, et al., BMJ 2017;357:j1550.Krawczyk, et al., Addiction 2020.Lee, et al. The Lancet, 2018:391(10118):309-318Larochelle, et al. Ann Intern Med, 2018.

Stimulant Use Disorder – TreatmentContingency Management

Matrix Model

Cocaine– Topiramate

• Reduces cravings• Doses up to 200mg daily• Reduce dose for CrCl <70 mL/min• Beware of drug-drug interactions• Side Effects: drowsiness, anorexia

Methamphetamine– Mirtazapine

• Reduces amphetamine positive urine drug screens• 30mg daily• Side Effects: drowsiness, weight gain

Prince and Bowling, Am Journal of Health-System Pharm, 2018.Coffin, et al., JAMA Psychiatry, 2019.

How do we increase initiation of treatment?Lower barriers to access treatment:

– Increase availability– Decrease cost– Reduce stigma

Payne et al. (Drug and Alcohol Dependence)

– 7 times the odds of initiating medication in a low barrier clinic vs high barrier clinic

Sharma, et al. Curr Psychiatry Rep. 2017Duncan, Mendoza & Hansen. J Addict Med Ther Sci. 2015.Olivia, et al. Curr Psychiatry Rep. 2011.Payne, et al. Drug and Alcohol Dependence. 2019

Is engagement impacted in

the same way as initiation?

They’ve started evidence based treatment, but how do we get them to follow up?

1. VERIFY CONTACT INFORMATION2. VERIFY CONTACT INFORMATION3. VERIFY CONTACT INFORMATION

What has been shown to improve engagement of people who use drugs in a primary care office?

Engaging PWUD in a Primary Care Setting – What Patients Say

Qualitative Study (Neale, Sheard and Tompkins)– More services– Improved services (more flexibility)– Improved staff attitudes (less judgmental and

more understanding)Qualitative Study (Neale, Tompkins and Sheard)

– Reasons for not accessing primary care• Not having health problems that a GP

could/would address• Fear of negative reaction• Fear of having children taken away• Hostile and/or judgmental attitudes• Difficulty with transportation• Limited hours of clinics

Neale, Sheard and Tompkins. Subst Abuse Treat Prev Policy. 2007.Neale Tompkins and Sheard. Heal Soc Care Community. 2008.

Engaging PWUD in a Primary Care Setting – What Providers Say

Qualitative Study (Woolhouse, Brown and Thind)

– Improved engagement with: • Continuity of care• “Meeting people where

they were at” (finding common ground)

Woolhouse, Brown and Thind. Annals of Family Medicine. 2011.

Engaging PWUD in a Primary Care Setting – The Evidence

1. Provider/staff stigma impact patient engagement

2. Building rapport with PWUD improve patient engagement.

3. Collaborative care/Chronic Disease Management (CDM) for patients with SUDs in primary care.

4. Naloxone counseling for harm reduction improves engagement.

Provider StigmaSystematic Review of 28 studies:

– Negative attitudes of health professionals towards patients with substance use disorders are common

– Consequences for healthcare delivery:• patients who reported greater

perceived discrimination by health professionals and dissatisfaction with the treatment, were less likely to complete their treatment

• clinicians unwittingly impose their beliefs and prejudice on patients with substance use disorders, resulting in impeding collaboration between professional and patient

Van Boekel LC, et al. Drug Alcohol Depend. 2013.

WORDS MATTER

Provider Rapport

Mixed Methods – focus groups, surveys and qualitative interviews

– rapport is influenced by:• drug-related behaviors• addiction severity• provider expertise• patient-centered care• perceived discrimination

– Which influenced:• patient compliance• timing of care (fewer after

hours visits to ED)• criminal activity (39% vs 65%)

“I go in to see my family doctor, when he comes

through the door he’s got a smile on his face ‘How you

doing [Bob]?’ You go in through the emergency, it’s

‘What’s the problem?’ it’s not a person thing it’s an object

thing.”

“You can tell. Just this or this or for example when they say someone’s a racist you can’t

see it but you can tell so it’s the same notion here. You just can tell if they’re a human being,

it’s just a certain sense of, you know, a sixth sense of you can tell who’s treating you right or

who’s not.”

Salvalaggio G, et al. SAGE Open. 2013.

Collaborative Care/Chronic Disease Management (CDM)

• RCT at a FQHC – Usual care (UC) vs Collaborative Care (CC)– CC arm had care managers who met with patients – encouraged to participate in 6

session psychotherapy session and meet with addiction specialist• Entered into database and contacted when missed appointment, etc.

– CC group had higher rates of pharmacotherapy uptake (39% vs 16.8%), abstinence at 6 months (32.8% vs 22.3%), initiation (31.6% vs 13.7%) and engagement (15.5% vs 4.2%)

• Prospective Cohort Study in BMC Internal Medicine Clinic – CDM vs UC– CDM consisted of nurse care manager, addiction specialist, and SW– Offered pharmaco- and psychosocial therapy as well as help with concrete social

service needs– 2 times the odds of being on pharmacotherapy in CDM group– 45% initiated on treatment within 14 days and 81% with continued engagement (>2

visits)

Watkins KE, et al. JAMA Intern Med. 2017.Kim, et al. Drug Alcohol Depend. 2011.

Harm Reduction – Naloxone

Naloxone counseling done in health centers – Team: physician, pharmacist and SW– Providers and patients were

surveyed • Improved provider comfort with

discussing naloxone with patients and provider satisfaction

• Patients report comfort discussing illicit opioid use and concern for addiction with providers

Han, et al. Fam Med. 2017.

Overdose Prevention & Safe Injecting• Use under DIRECT observation• Tester shots• Don’t mix drugs• 9-1-1 and rescue breathing• Overdose risk is higher out of

detox/residential/incarceration• Naloxone

• Standing order

•Do NOT re-use needles

•Do NOT share needles

•Do NOT re-use or share “cooking” supplies

•Use alcohol prep pad on skin before injection

•Do not roll cotton in fingers

•Use sterile water

•Do not use lemon juice or vinegar for injection of cocaine/crack use ascorbic acid

•Counsel patients about PrEP

Engaging PWUD in a Primary Care Setting – Learned Experience

• Co-located mental health treatment– Warm hand-offs– Psychiatry and talk therapy availability

• Co-located hepatitis C treatment– PCPs that treat addiction also treat HepC– “one stop shop”

• Harm reduction teaching and healthcare maintenance– Safe injection practices and overdose

prevention– Ensure up to date on screening and

vaccines• Patient-Physician relationship

So what does this mean for

your clinic and how can you

improve treatment

initiation and engagement of people who use

drugs?

Action Steps1. Ensure adequate screening2. Accurately diagnose and document3. Provide evidence based treatment for SUDs early4. Use person first, non-stigmatizing language and train

ALL staff on addiction to improve patient encounters5. Ensure continuity of care (provider availability) and

work on building rapport with patients who use drugs6. Counsel patients who use drugs on use of naloxone,

overdose prevention and safe injection practices7. Consider co-location of mental health services and

hepatitis C treatment

Thank You

References

• Massachusetts Department of Public Health. Data Brief: Opioid-Related Overdose Deaths Among Massachusetts Residents.; 2019. • UpToDate. www.uptodate.com. Accessed March 3, 2020.• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5.; 2014. doi:10.1176/appi.books.9780890425596.744053 • Kathuria H, Leone FT, Neptune ER. Treatment of tobacco dependence: Current state of the art. Curr Opin Pulm Med. 2018;24(4):327-334. doi:10.1097/MCP.0000000000000491 • Sharma A, et al. Update on barriers to pharmacotherapy for opioid use disorders. Curr Psychiatry Rep. 2017;19(6):35. doi: 10.1007/s11920-017-0783-9. • Duncan LG, Mendoza S, Hansen H. Buprenorphine maintenance for opioid dependence in public sector healthcare: benefits and barriers. J Addict Med Ther Sci. 2015;1(2):31–36.• Oliva EM, et al. Barriers to use of pharmacotherapy for addiction disorders and how to overcome them. Curr Psychiatry Rep. 2011;13(5):374–381. doi: 10.1007/s11920-011-0222-2.• Payne BE, Klein JW, Simon CB, et al. Effect of lowering initiation thresholds in a primary care-based buprenorphine treatment program. Drug Alcohol Depend. 2019;200(March):71-

77. doi:10.1016/j.drugalcdep.2019.03.009• Neale J, Sheard L, Tompkins CN. Factors that help injecting drug users to access and benefit from services: A qualitative study. Subst Abuse Treat Prev Policy. 2007;2(31).• Neale J, Tompkins C, Sheard L. Barriers to accessing generic health and social care services: A qualitative study of injecting drug users. Heal Soc Care Community. 2008;16(2):147-

154. doi:10.1111/j.1365-2524.2007.00739.x • Woolhouse S, Brown JB, Thind A. ‘Meeting People Where They’re At’: Experiences of Family Physicians Engaging Women Who Use Illicit Drugs. Ann Fam Med. 2011;9(3):244-249. • Van Boekel LC, Brouwers EPM, Van Weeghel J, Garretsen HFL. Stigma among health professionals towards patients with substance use disorders and its consequences for

healthcare delivery: Systematic review. Drug Alcohol Depend. 2013;131(1-3):23-35. doi:10.1016/j.drugalcdep.2013.02.018• Salvalaggio G, McKim R, Taylor M, Cameron Wild T. Patient–provider rapport in the health care of people who inject drugs. SAGE Open. 2013;3(4). doi:10.1177/2158244013509252 • Han JK, Hill LG, Koenig ME, Das N. Naloxone Counseling for Harm Reduction and Patient Engagement. Fam Med. 2017;49(9):730-733.

http://www.ncbi.nlm.nih.gov/pubmed/29045991. • Watkins KE, Ober AJ, Lamp K, et al. Collaborative care for opioid and alcohol use disorders in primary care: The SUMMIT randomized clinical trial. JAMA Intern Med.

2017;177(10):1480-1488. doi:10.1001/jamainternmed.2017.3947 • Kim TW, Saitz R, Cheng DM, Winter MR, Witas J, Samet JH. Initiation and Engagement in Chronic Disease Management Care for Substance Dependence. Drug Alcohol Depend.

2011;115:80-86. doi:10.1038/mp.2011.182.doi • Coffin PO, Santos G, Hern J, et al. Effects of Mirtazapine for Methamphetamine Use Disorder Among Cisgender Men and Transgender Women Who Have Sex With Men: A Placebo-

Controlled Randomized Clinical Trial. JAMA Psychiatry. Published online December 11, 2019. doi:10.1001/jamapsychiatry.2019.3655• Valerie Prince, Pharm.D., BCPS, FAPhA, Kellie C. Bowling, Pharm.D., Topiramate in the treatment of cocaine use disorder, American Journal of Health-System Pharmacy, Volume 75,

Issue 1, 1 January 2018, Pages e13–e22, https://doi.org/10.2146/ajhp160542