Identification and Treatment of Opioid Use
Disorders in Primary Care Settings
Kelly S. Barth, DO
Associate Professor, Psychiatry & Internal Medicine
Medical University of South Carolina
17th Annual Primary Care Symposium
February 24, 2018
Conflicts of Interest
-No conflicts
-Will discuss non-FDA indicated use of medications
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Outline
I. Identification of Opioid Use Disorder (OUD) in Primary Care
II. Treating Opioid Use Disorder in Primary Care using Medication
Assisted Treatment (MAT)
III. Future Directions and state-wide opportunities
Diagnosing OUD in Primary Care is Not Easy
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How to Identify OUD in Primary Care
Poor Functioning
› Emotional
› Depression/Anxiety
› Physical
› Sedation/in bed/ED
› Social
› Pt or Family Concern
Aberrant Behaviors
› Running out early
› Rx from another provider
› Use of illicits
Clinical Assessment Screening scales
NIDA Quick Screen
COMM
DAST
SOAPP-R
ORT
DDX for a Poorly-Functioning Pain Patient
Psychiatric co-morbidity
› Depression
› Anxiety, esp early-life trauma
Psychologic co-morbidity
› “Chemical coping”
› Personality disorders
Opioid Use Disorder (OUD)
Pseudoaddiction/tolerance
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Psychotherapy
+/- Meds
Psychotherapy
MAT
Maximize non-
opioids
When does a poorly-functioning patient
with pain “cross the line” to addiction?
Start opioid
Pain
Euphoria
Change source
Tolerance Doc mg Tolerance
Ptmg
Use for stress sleep high
Try to
painsleep
w/d
Return to drug
How does an
OUD start?
Run outearly
RECOGNIZING OUD
Aberrant Behaviors
More clear
Forging
Steal/borrowing
IV use
Obtained on street
Abuse other drugs
Multiple dose
Recurrent Rx loss
Less clear
Request mg
Hoarding
Asking specific Rx
“Doc shopping”*
1-2 dose
Rx another sx
Psychic effects9(Passik & Portenoy 1998)
RECOGNIZING OUDSigns
Intoxication Withdrawal
Pain/Distress
Dilated pupils
GI upset/diarrhea
Goosebumps
Euphoria
Constricted pupils
Slurred speech
The “nods”
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DSM-V Opioid Use Disorder
Maladaptive pattern of use
leading to impairment or distress
▪ Failure to fulfill major role obligations▪ Important social, occupational, or recreational activities are given up
• Tolerance (not with prescribed medications)• Withdrawal (not with prescribed medications)
• Taken in larger amounts or over a longer period than was intended • Persistent desire or unsuccessful efforts to cut down or control use • Great deal of time spent to obtain/use/recover from the substance
• Craving or a strong desire or urge to use a specific substance
• Continued use despite negative consequences • Use despite recurrent physical or psychological problem exacerbated by
the substance • Recurrent use in situations in which it is physically hazardous
Decline in functioning
Loss of control
Continued use despite consequences
Risk Factors for Inadvertent
Prescription Opioid Overdose
▪Higher doses of opioids
▪ 100mg morphine equivalent or higher
▪Using with sedatives or alcohol
▪Co-morbid mental health or medical issues
▪Recent abstinence (recent hospital detox)
▪Other substance abuse
▪Aberrant behavior (running out early)
▪Using aloneBohnert, et al. JAMA. 2011;305(13):1315-1321
Screening Tools
NIDA Single-Question Screener:
“How many times in the past year have you used an illegal drug or
used a prescription medication for non-medical reasons?” (where
a response of ≥1 is considered positive).
Drug Abuse Screening Test -10
Screen & Opioid Assessment For
Patients With Pain—Revised ( SOAPP®-R)
SOAPP-R (con’t)
Current Opioid Misuse Measure - COMM
Opioid Risk Tool (ORT)
▪ Failure to fulfill major role obligations▪ Important social, occupational, or recreational activities are given up
• Tolerance (not with prescribed medications)• Withdrawal (not with prescribed medications)
• Taken in larger amounts or over a longer period than was intended • Persistent desire or unsuccessful efforts to cut down or control use • Great deal of time spent to obtain/use/recover from the substance
• Craving or a strong desire or urge to use a specific substance
• Continued use despite negative consequences • Use despite recurrent physical or psychological problem exacerbated by
the substance • Recurrent use in situations in which it is physically hazardous
Decline in functioning
Loss of control
Continued use despite consequences
PAIN
Approach to the Patient With Addiction + Pain
• Express Concern + Provide Feedback– “I am concerned about your health and safety.”– “This is the 3rd time you have run out of pain medications early.”– “You have been to the ED 6 times in the past 3 months.” – “I am concerned that you are showing several signs of addiction.”
• Validate Pain + Set Boundary– “I believe you are suffering/in pain. I can Rx non-opioid pain meds.”– “I cannot safely prescribe you opioids at this time.”
• Provide Education + Support– “I want you to know that there is excellent medication for opioid
addiction that can help with pain and prevent withdrawal. We can try this.”
– “I hope we can continue to work together to get you feeling better.”
HAVING THE CONVERSATION
Empathy (pt is suffering)
Focus = safety & functioning
Professionally set boundary
Lifesaving tx available!
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LIFESAVING TREATMENTS
+ + + + + +
+
+ + + + + + + + +
+ + +
Methadone
Agonist
Buprenorphine
Partial Agonist
Naltrexone
Antagonist
Naltrexone
(Vivitrol®, ReVia®)
Buprenorphine/
Naloxone (Suboxone®)Methadone
Mechanism Opioid antagonist Opioid partial
agonist/partial antagonist
Opioid agonist
Availability Extended-release injection,
tablet
Sublingual, Buccal,
Implant, Injection
For treatment of OUD in a
methadone clinic, usually
in syrup form
Prescribing
RestrictionsNone – any prescriber can
prescribe
Must receive a DATA 2000
waiver to prescribe
Patients must obtain from
a methadone clinic
Initiation Must wait to initiate until
patient has been free of
opioids for 7 to 10 days
Must wait to initiate until
after withdrawal symptoms
have started to appear
May initiate immediately to
avoid withdrawal
Abuse
PotentialNo abuse potential Less likely than
methadone: only a partial
agonist; dissolution and
injection may induce
withdrawal
Low compared to other
opiates
Very low within methadone
clinic
Patient
Population/
Other
–Concomitant alcohol
dependence
–Highly motivated pts
–Patients with mandated
use (medical boards, etc)
–Improving insurance
coverage
–Usually requires pre-
authorization – for now
–Decreases mortality in
heroin users
–Not yet covered by
insurance in SC
(~$15/day)
–Decreases mortality in
heroin users
Medications for the treatment of opioid use disorder
What is Medication-Assisted Treatment (MAT)?
• Addiction is a bio-psycho-social disease
• Medication alone is not sufficient for someone to enter full recovery from addiction
• It is recommended that medications for OUD be combined with psychosocial treatment for best long-term outcomes
Methadone Maintenance Treatment
▪ Lifesaving option for those who need optimum structure▪ Severe addiction▪ Co-morbid personality disorders▪ Polysubstance and/or IV drug use▪ Fail naltrexone and/or Suboxone
▪ Daily dosing in a methadone clinic▪ Counseling provided on-site▪ Those with addiction and severe pain?▪ Weigh risks and benefits▪ Decrease in barriers to care in SC under way
Methadone Clinics
inSC
An Amendment
to the Controlled Substances Act
Allows a waivered physician (DEA “X” number)
to prescribe an opioid (buprenorphine) to a
patient with an opioid use disorder for the
treatment of opioid use disorder, with certain
restrictions.
DRUG ADDICTION TREATMENT ACT OF 2000
• Sublingual buprenorphine has good bioavailability, sublingual naloxone has poor bioavailability.
• Opioid-dependent person takes a buprenorphine/naloxone tablet sublingually, predominantly buprenorphine effect.
• Opioid-dependent person dissolves and injects a buprenorphine/naloxone tablet, predominantly naloxone effect (and precipitated withdrawal).
• Formulation: abuse/diversion deterrant
Buprenorphine/Naloxone
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Buprenorphine/Naloxone Tablets
2mg/0.5mg
8mg/2mg
SUBOXONE Film
For complete Prescribing Information, visit suboxone.com.
SUBOXONE® Sublingual Film is a registered trademark of Reckitt Benckiser (UK) Ltd.
Zubsolv Sublingual Tablets
Available doses (BUP/NX): 1.4 mg / 0.36 mg; 5.7 mg / 1.4 mg
Recommended maintenance dose: 11.4 mg/ 2.8 mg
Bunavail Buccal Film
Available dosages (BUP/NX): 2.1 mg / 0.3 mg; 4.2 mg/0.7 mg; 6.3 mg/ 1.0mg
Recommended maintenance dose: 8.4mg / 1.4mg
Buprenorphine Implant
-6mo maintenance treatment in clinically stable pts on buprenorphine 8 mg or less
Injectable Buprenorphine
• 2 formulations considered by FDA
-Once monthly injection of 100 or 300 mg (Indivior)
-Once weekly injection of 24 or 32 mg (Braeburn)
• Advantages: less opportunity for misuse, diversion and nonadherence
• FDA approved – coming to market soon
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Comparison of risk of death in patients exposed or not exposed to opiate substitution treatment by duration of treatment. (Boxes are interquartile ranges (with median);
lines are 95% confidence intervals)
Cornish, et al. BMJ. 2010 Oct 26;341:c5475.
Opioid substitution decreases mortality in OUD…
Adjusted risk of death, compared with not being on treatment, during and after opiate substitution treatment.
Cornish, et al. BMJ. 2010 Oct 26;341:c5475.
…while in treatment
OUD VS. DEPENDENCESymptoms
OUD
Loss of control
in function
Use despite negatives
Compulsive use
Craving
Dependence
Tolerance
Withdrawal
No loss of control
Functioning well
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≠
Looking Forward
-Longer-term studies
-Use of naltrexone
-Funding: Training & Support in SC
-Initiating treatment in ED settings
-Outcomes of Policy/Guideline
implementation
Long-term studies
POATS 42-month follow-up (n=375/653)• Long-term outcomes = clear improvement from baseline• 32% were abstinent from opioids & not on agonist
therapy• 29% were receiving opioid agonist therapy, but met no
symptom criteria for current OUD• Agonist treatment was associated with a greater
likelihood of Month-42 abstinence (<.0001)-90/113 (80%) on agonist treatment were abstinent-98/193 (51%) not on agonist treatment were abstinent
• 8% initiated IN heroin use and 10% initiated IV heroin use • 5 deaths
Drug Alcohol Depend. 2015 May 1; 150: 112–119
JAMA Psychiatry. 2017;74(12):1197-1205.
-Sponsored by Norwegian government-Unblinded RTC, daily observed dosing buprenorphine-Mostly IVDU-49/79 (62%) buprenorphine completed 12 week trial-56/80 (70%) naltrexone completed 12 week trial-UDTs weekly, missing counted as +-Mean buprenorphine dose 11mg (avg in Norway 13mg)
Naltrexone XR after outpt detox
Am J Psychiatry 174:5, May 2017
Policy/Guideline Outcomes
• Overdose reversal data– Utilization in medicare population– High resumption of opioids after OD reversal– 93% success rate in preventing death, but 1 in 10
don’t survive the next year
• CDC guideline implementation– Recommendation with highest level of evidence = ID
and treat OUD with MAT– SC MAT guidelines in process– Prescription opioid limitations from payers
Looking Forward - Funding
President’s FY 2017 Budget
› $1 billion to expand access to OUD treatment
› 28k doctors authorized to Rx buprenorphine
› 46% Psychiatrists
› 37% PCPs
› 27% Other specialties
› 6k currently write 90% of total prescriptions
› U.S. Dept HHS proposal
› increase buprenorphine patient prescribing limit
South Carolina
› Expand providers able to prescribe MAT
› Expand # of bup patients/physician to 200
› Expand access to naloxone for OD reversal
› Provide free trainings and support (ECHO)
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329 OUD pts in ED (mostly heroin)
1:1:1: RCT with primary outcome 30d tx retention
Screening + treatment referral (SRT): 38/102 (37%)
SBIRT: 50/111 (45%)
SBIT with bup/nlx: 89/114 (78%)
P<.0001
Project ECHO for Addiction
• Tele-mentoring and Educational Sessions using state-wide tele-conferencing
• First module: Addiction• Anticipated second module: Chronic Pain• Address barriers to implementation of MAT in primary
care– Access to specialty consultation– Prior Authorizations (support and best practice sharing)– Access to mental health care (linking)
• CME provided• www.scmatacess.org
www.scmataccess.org
2/16/18 Overdose Prevention Dr. Kelly Barth
3/2/18 Medication Update: Buprenorphine
Formulations (focus on new monthly
injection)
Dr. Dan McGraw
3/12/18 Urine Drug Testing & Alcohol Testing ECHO Faculty
4/6/18 Motivational Enhancement Techniques
for Primary Care
Caitlin Kratz, MSW
Charleston Center
4/20/18 Tapers: If/How/When Dr. Kelly Barth
5/4/18 Special Populations: Use of
Medication-Assisted Treatment in
Pregnancy
Dr. Constance Guille
Upcoming topics for Project ECHO Opioid Use Disorder
Tele-mentoring and Educational Sessions
Summary
• Identifying and treating OUD with MAT is the most evidence-based intervention in treating those with chronic pain
• Medications for OUD include both opioid and non-opioid treatments – in addition to counseling
• Treating OUD can decrease overdose mortality
• Free training and support is available for providers in SC to treat OUD
Questions?
Slides, scales, and other practice tools
are available on our website:
www.scmataccess.org
Kelly Barth, DO
(843) 792-5380