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1
A Focus on Local, Regional and Global Tools
for Caring for Clients with Opioid Addictions
Dana Murphy-Parker, MS, CRNP, PMHNP-BC, CARN-AP
Carmel Clancy, PhD, RN, BSc (Hons), FPH
The International Nurses Society on Addictions
September 28, 20152
Disclosures
• Dana Murphy-Parker, MS, CRNP, PMHNP-BC, CARN AP
• No Disclosures
• Carmel Clancy
• No Disclosures
3
PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership
with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American
Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of
Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American
Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and
Southeast Consortium for Substance Abuse Training (SECSAT).
For more information visit: www.pcss-o.org
For questions email: [email protected]
Twitter: @PCSSProjects
Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) from SAMHSA. The
views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department
of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.4
Target Audience
• The overarching goal of PCSS-O is to offer evidence-based
trainings on the safe and effective prescribing of opioid medications
in the treatment of pain and/or opioid addiction.
• Our focus is to reach providers and/or providers-in-training from
diverse healthcare professions including physicians, nurses,
dentists, physician assistants, pharmacists, and program
administrators.
5
PCSS-O Colleague Support Program
• PCSS-O Colleague Support Program is designed to offer general information to health
professionals seeking guidance in their clinical practice in prescribing opioid
medications.
• PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management.
• Our mentoring approach allows every mentor/mentee relationship to be unique and
catered to the specific needs of both parties.
• The mentoring program is available at no cost to providers.
• Listserv: A resource that provides an “Expert of the Month” who will answer questions
about educational content that has been presented through PCSS-O project. To join email: [email protected].
For more information on requesting or becoming a mentor visit:
www.pcss-o.org/colleague-support
6
Educational Objectives
• At the conclusion of this activity participants should
be able to:
• Incorporate updates of ASAM’s Press Conference and Stakeholder
Summit held in Washington, D.C. on September 24, 2015.
• Discuss ASAM’s National Practice Guideline for the Use of Medications,
pocket guide, mobile phone application, slide deck and future educational
opportunities.
• Increase knowledge of online networking tools, specifically ‘wikis’ and
their role in building international co-operation from diverse cultural
communities in the area of addiction
• Share ‘initial lessons’ from GAaP’s first 6 months of operation: planning
and set up
• Explore with participants the challenges and possibilities particularly
focusing on the impact of such methodology on achieving wider
engagement on a global public health issue and enhancing inter-
professional learning.
7
Definitions: No doubt, this is a Medical Disorder: A
Neurobiological Disorder
• ASAM defines addiction as “a primary, chronic disease of brain reward,
motivation, memory, and related circuitry,” with a “dysfunction in these
circuits” being reflected in “an individual pathologically pursuing reward
and/or relief by substance use and other behaviors.”
• The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
(DSM-5) states Substance Use Disorder is a cluster of cognitive,
behavioral, and physiological symptoms indicating that the individual
continues using the substance despite significant substance-related
problems.
• “Opioid use disorder” (OUD) include.
� Opioid Use Disorder
� Opioid Intoxication
� Opioid Withdrawal
� Other Opioid-Induced Disorders
� Unspecified Opioid-Related Disorders
8
What is this about?
The ASAM National Practice
Guideline for the Use of
Medications in the Treatment of
Addiction Involving Opioid Use
The ASAM National Practice
Guideline is the 1st to include all
FDA-approved medications in
single document
13
Journal of Addictions Medicine
(2015)
Just published:
Kampman, K. & Jarvis, M. (2015). American Society of
Addiction Medicine (ASAM) National Practice
Guidelines for the Use of Medications in the Treatment
of Addiction Involving Opioid Use. Journal of Addiction
Medicine, 9 (5). September/October 2015.
http://www.asam.org/practice-support/guidelines-and-
consensus-documents/npg
14
Psychosocial Treatment in Conjunction
With Medications for the Treatment of Opioid
Use Disorder
A review of the literature on the efficacy of psychosocial
treatment to be used in conjunction with Medication Assisted
Treatment (MAT) of opioid use disorder was conducted.
The review was partially funded by National Institute of Drug
Abuse (NIDA).
Methodology of this review can be found with the ASAM journal
article previously mentioned.
A full article on the literature review will be published in a
subsequent Journal of Addiction Medicine edition.
15
Categories covered in the National
Practice Guidelines
Assessment
Diagnosis
Treatment
16
ASSESSMENT
The first clinical priority should be given to identifying and making appropriate referral for any
urgent or emergent medical or psychiatric problem(s), including drug-related impairment or
overdose.
Completion of the patient’s medical history should include screening for concomitant medical
conditions, including infectious diseases (hepatitis, HIV, and TB), acute trauma, and pregnancy.
(The leading causes of death in people using opioids for nonmedical purposes are overdose and
trauma).
A physical examination should be completed as a component of the comprehensive assessment
process. The prescriber (the clinician authorizing the use of a medication for the treatment of
OUD) may conduct this physical examination him/herself, or, in accordance with the ASAM
Standards1, ensure that a current physical examination is contained within the patient medical
record before a patient is started on a new medication for the treatment of his/her addiction.
Initial laboratory testing should include a complete blood count, liver function tests, and tests for
hepatitis A, B, C and HIV. Testing for TB and sexually transmitted infections should also be
considered. Hepatitis A and B vaccination should be offered, for those who are pregnant and the
general population.
17
Diagnosis
Other clinicians may diagnose OUD, but confirmation of the diagnosis by the provider with
prescribing authority, and who recommends medication use, must be obtained before
pharmacotherapy for OUD commences.
OUD is primarily diagnosed on the basis of the history provided by the patient and a
comprehensive assessment that includes a physical examination.
Validated clinical scales that measure withdrawal symptoms may be used to assist in the evaluation
of patients with OUD: Examples include;
The Objective Opioid Withdrawal Scale (OOWS)a
The Subjective Opioid Withdrawal Scale (SOWS)a
The Clinical Opioid Withdrawal Scale (COWS)a
Visit www. GuidelineCentral.com/OUD for calculators
Urine drug testing during the comprehensive assessment process, and frequently during treatment,
is recommended. 18
Symptoms of Opioid Intoxication
Drooping eyelids
Constricted pupils
Reduced respiratory rate
Scratching (due to histamine release)
Head nodding
19
Withdrawal Signs
OOWS SOWS COWS
Yawning
Rhinorrhea
Piloerection (observe
arm)
Perspiration
Lacrimation
Tremor (hands)
Mydriasis
Hot and cold flushes
Restlessness
Vomiting
Muscle twitches
Abdominal cramps
Anxiety
I feel anxious.
I feel like yawning.
I’m perspiring.
My eyes are tearing.
My nose is running.
I have goose flesh.
I am shaking.
I have hot flashes.
I have cold flashes.
My bones and muscles ache.
I feel restless.
I feel nauseous.
I feel like vomiting.
Pulse
Sweating
Restlessness
Pupil size
Bone or joint aches
Rhinorrhea
Tearing
GI upset
Tremor of outstretched hands
Yawning
Anxiety or irritability
Gooseflesh skin
20
Treatment Setting
Clinicians should consider the patient’s preferences, past treatment history, and
treatment setting when deciding between the use of methadone, buprenorphine, and
naltrexone in the treatment of addiction involving opioid use.
The treatment setting described as Level 1 treatment in the ASAM Criteria may be a
general outpatient location such as a clinician’s practice site.
The setting as described as Level 2 in the ASAM Criteria may be an intensive outpatient
treatment or partial hospitalization program housed in a specialty addiction treatment
facility, a community mental health center, or another setting.
The ASAM Criteria describes Level 3 or Level 4 treatment respectively as a residential
addiction treatment facility or hospital.
The venue in which treatment is provided is as important as the specific medication
selected.
21
Treatment Setting, con’t
Opioid Treatment Programs offer daily supervised dosing of methadone, and increasingly of buprenorphine.
Naltrexone can be prescribed in any setting by any clinician with the authority to prescribe any medication.
In accordance with federal law (21 CFR §1306.07), Office-Based Opioid Treatment (OBOT), which provides
medication on a prescribed weekly or monthly basis, is limited to buprenorphine.
Clinicians should consider a patient’s psychosocial situation, co-occurring disorders, and risk of diversion when
determining whether Opioid Treatment Programs (OTP) or OBOT is most appropriate.
•OBOT may not be suitable for patients with active alcohol use disorder or sedative, hypnotic, or anxiolytic
use disorder (or who are in the treatment of addiction involving the use of alcohol or other sedative drugs,
including benzodiazepines or benzodiazepine receptor agonists). It may also be unsuitable for persons who
are regularly using alcohol or other sedatives but do not have addiction or a specific substance use disorder
related to that class of drugs.
� The prescribing of benzodiazepines or other sedative-hypnotics should be used with extreme caution in
patients who are prescribed methadone or buprenorphine for the treatment of an OUD
22
FDA Approved Medications for
Opioid Use Disorder
Methadone
Buprenorphine (In ASAM’s pocket guide, reference to buprenorphine is for the
combination buprenorphine/naloxone formulations. If the single reference is made to
buprenorphine, it is referred to as buprenorphine monoproduct.
Naltrexone, both the oral and the injectable (Vivitrol)
Naloxone
The Guideline Committee recommends the inclusion of clonidine as a practice to support
opioid withdrawal. Clonidine is not FDA-approved for the treatment of opioid withdrawal but it
has been extensively used off-label for this purpose. Clonidine may be used orally or trans-
dermally at doses of 0.1–0.3 mg every 6–8 hours with a maximum dose of 1.2 mg daily to assist in
the management of opioid withdrawal symptoms. Its hypotensive effects often limit the amount
that can be used.
Clonidine can be combined with other non-narcotic medications targeting specific opioid
withdrawal symptoms such as benzodiazepines for anxiety, loperamide for diarrhea,
acetaminophen or nonsteroidal anti-inflammatory medications (NSAIDs) for pain, and ondansetron
or other agents for nausea.
23
Venue for Treatment Setting
Opioid Treatment Programs offer daily supervised dosing of
methadone, and increasingly of buprenorphine.
Naltrexone can be prescribed in any setting by any clinician with
the authority to prescribe any medication.
In accordance with federal law (21 CFR §1306.07), Office-Based
Opioid Treatment (OBOT), which provides medication on a
prescribed weekly or monthly basis, is limited to buprenorphine.
Clinicians should consider a patient’s psychosocial situation, co-
occurring disorders, and risk of diversion when determining
whether Opioid Treatment Programs (OTP) or OBOT is most
appropriate.
24
Current Prescribers for
BuprenorphineTime
Frame
30 patient
certified
% 100 patient
certified
% Total
Past 30
days
Past 60
days
Past 90
days
Last year
Current
314
488
910
3,037
20,722
68.4%
60%
65.6%
67.1%
67.9%
145
325
478
1,489
9,801
31.6%
40.0%
34.4%
32,9%
32.1%
459
813
1,388
4,526
30,523
25
The TREAT ACT
Introduced in July, 2014 by Senator Edward J. Markey (D-Massachusetts) introduced the Recovery
Enhancement for Addiction Treatment (TREAT ACT).
This bill will increase the number of patients that qualified physicians could treat for opioid
dependency and, for the first time, allow certain nurse practitioners and physician assistants to treat
patients by allowing other prescribers to prescribe buprenorphine.
This legislation is supported by:
The American Medical Association
The American Society of Addictions Medicine
The American Association of Nurse Practitioners
The International Nurses Society on Addictions
Rundio, A (2015). Landmark legislation to expand treatment for heroin and
prescription drug addiction. Journal of Addictions Nursing ,26 (3), pp 157-
158.
26
Obama Administration Makes Big Announcement Addressing
Heroin Epidemic
•This past spring, Sen. Edward Markey (D-Mass.) and Sen. Rand Paul (R-Ky.) introduced legislation that would raise the first-year cap from 30 patients to 100 and offer nurse practitioners and physician assistants the ability to prescribe the medication. After one year, doctors could seek to remove the cap entirely.
•http://www.huffingtonpost.com/entry/obama-administration-heroin_55fa058ee4b0fde8b0ccf192
27
Buprenorphine, a Partial Agonist
Opioid-dependent patients should wait until they are experiencing mild to moderate opioid withdrawal before taking the
first dose of buprenorphine to reduce the risk of precipitated withdrawal.
Generally, buprenorphine initiation should occur at least 6–12 hours after the last use of heroin or other short-acting
opioids, or 24–72 hours after their last use of long-acting opioids such as methadone.
Induction of buprenorphine should start with a dose of 2–4 mg.Dosages may be increased in increments of 2–4 mg.
Clinicians should observe patients in their offices during induction. However, home buprenorphine induction may be considered.
Home-based induction is recommended only if the patient or prescribing physician is experienced with the use of buprenorphine.
Buprenorphine doses after induction and titration should be, on average, ≥8 mg per day. However, if patients are
continuing to use opioids, consideration should be given to increasing the dose by4–8 mg (daily doses of 12–16 mg or higher).
The FDA approves dosing to a limit of 24 mg per day, and there is limited evidence regarding the relative efficacy of higher doses. In addition, the use of higher doses may increase the risk of diversion.
28
Buprenorphine, con’t
When considering a switch from buprenorphine to naltrexone,
7–14 days should elapse between the last dose of buprenorphine
and the start of naltrexone to ensure that the patient is not physically dependent
on opioids prior to starting naltrexone.
When considering a switch from buprenorphine to methadone, there is no
required time delay since the addition of a full mu-opioid agonist to a partial
agonist does not typically result in any type of adverse reaction.
Patients who discontinue agonist therapy and resume opioid use should be
made aware of the risks associated with an opioid overdose, and especially the
increased risk of death.
29
Methadone
Methadone is a treatment option recommended for patients who are physiologically dependent on
opioids, able to give informed consent, and who have no specific contraindications for agonist
treatment when it is prescribed in the context of an appropriate plan that includes psychosocial
intervention.
The recommended initial dose ranges for methadone are from 10–30 mg with reassessment in 3–4
hours, and a second dose not to exceed 10 mg on the first day if withdrawal symptoms are
persisting.
The usual daily dosage of methadone ranges from 60–120 mg. Some patients may respond to lower
doses, and some patients may need higher doses.
Dosage increases in 5–10 mg increments applied no more frequently than every 7 days (depending
on clinical response) are necessary to avoid over-sedation, toxicity, or even iatrogenic overdose
deaths.
The administration of methadone should be monitored because unsupervised administration can
lead to misuse and diversion. OTP regulations require monitored medication administration until
the patient’s clinical response and behavior demonstrates that the prescribing of non-monitored
doses is appropriate.30
Methadone, con’t
Switching from methadone to another medication for the treatment of OUD may be appropriate if
the patient experiences intolerable side effects or is not successful in attaining or maintaining
treatment goals through the use of methadone.
Patients switching from methadone to buprenorphine in the treatment of OUD should be on low
doses of methadone prior to switching medications.
Patients on low doses of methadone (30–40 mg per day or less) generally tolerate transition to
buprenorphine with minimal discomfort, whereas patients on higher doses of methadone may
experience significant discomfort in switching medications.
Patients switching from methadone to oral naltrexone or extended-release injectable naltrexone
must be completely withdrawn from methadone and other opioids, before they can receive
naltrexone.
The only exception would apply when an experienced clinician receives consent from the patient to
embark on a plan of naltrexone-facilitated opioid withdrawal management.
Patients who discontinue agonist therapy with methadone or buprenorphine and then resume opioid use should be made aware of the risks
associated with opioid overdose, and especially the increased risk of death.
31
Naltrexone, an Opioid Antagonist
Medication
Naltrexone is a recommended treatment in preventing relapse in OUD.
Oral formula naltrexone may be considered for patients where adherence can be
supervised or enforced. Extended-release injectable naltrexone (Vivitrol) may
be more suitable for patients who have issues with adherence.
Oral naltrexone should be taken daily in 50 mg doses, or 3 times weekly in two
100 mg doses followed by one 150 mg dose.
Extended-release injectable naltrexone should be administered every 4 weeks
by deep intramuscular injection in the gluteal muscle at a set dosage of 380 mg
per injection.
32
Naltrexone, con’t
There is no recommended length of treatment with oral naltrexone or extended-release
injectable naltrexone.
Duration depends on clinical judgment and the patient’s individual circumstances.
Because there is no physical dependence associated with naltrexone, it can be stopped
abruptly without withdrawal symptoms.
Switching from naltrexone to methadone or buprenorphine should be planned,
considered, and monitored.
Switching from an antagonist such as naltrexone to a full agonist (methadone) or a
partial agonist (buprenorphine) is generally less complicated than switching from a full
or partial agonist to an antagonist because there is no physical dependence associated
with antagonist treatment and thus no possibility of precipitated withdrawal.
33
Naloxone, an Opioid Antagonist
Medication
Naloxone should be given in case of opioid overdose.
Naloxone can and should be administered to pregnant women in cases of
overdose in order to save the mother’s life.
The Guideline Committee, based on consensus opinion, recommends that
patients who are being treated for OUD and their family members/significant
others be given prescriptions for naloxone. Patients and family
members/significant others should be trained in the use of naloxone in
overdose.
The Guideline Committee, based on consensus opinion, recommends that first
responders such as emergency medical services personnel, police officers, and
firefighters be trained in and authorized to administer naloxone.
34
Naloxone
Naloxone injection
Evzio® (auto-injector)
0.4 mg/0.4 mL
For emergency treatment of overdose
Narcan®, generic
(various)
Opioid depression, diagnosis
of suspected opioid overdose,
There is not yet an FDA-approved intranasal formulation. There are only kits
made available to deliver the injectable formulation intranasally.
35
WHO - 2009
• The Guidelines review the use of
medicines such as methadone, buprenorphine, naltrexone and
clonidine in combination with psychosocial support in the treatment
of people dependent on heroin or other
opioids. Based on systematic reviews of the literature and using the GRADE
approach to determining evidence quality, the guidelines contain specific
recommendations on the range of
issues faced in organizing treatment systems, managing treatment
programmes and in treating people
dependent on opioids.
36
UK
• 2007 edition
• New guidelines coming
out in early 2016
• Addresses
management of opi
37
Primary Care Setting - UK
38
Australia
39© Middlesex University
GAaP History and Background
• Although established formally in May 2014 the origins and idea for GAaP have been around a long time, primary through ongoing collaboration between Dana Murphy-Parker and Carmel Clancy since 1998
• GAaP has been initially supported via small grants via Middlesex University
• 4 founding members of GAaP are drawn from UK, USA, Brazil and New Zealand
Presentation title |
3
40© Middlesex University
Some of the GAaP members…
Presentation title |
4
41© Middlesex University
Who is GAaP
|
4
University San Paolo
GAaP Brazil
Middlesex University
GAaP UK
Drexel UniversityGAaP USA
Matua Raki
GAaP New Zealand
NCETA,
GAaP Australia
Potential members coming online
GAaP China
GAaP Israel
GAaP Ireland
GAaP S. KoreaGAaP Japan
Nordland Hospital,
GAaP Norway
Universiteti Planetari I
Tiranes
GAaP Albania
42© Middlesex University
Structure
• Each country has an identified GAaP Co-ordinating Centre – e.g. GAaP USA is Drexel University (contact person Dana Murphy-Parker [email protected])
• The Co-ordinating Centre has a responsibility to set up a GAaP Country Reference Group – these groups must be interdisciplinary, members should have a background in addiction, and be representative of different types of facilities e.g. universities; practice; policy; research etc
• The GAaP co-ordinating centers meet online employing the use of a WIKI platform and Skype
Presentation title |
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43© Middlesex University
Our Vision for GAaP
• Explore addiction issues across countries e.g. policies; service user lived experience; treatment – comparing differences and similarities
• Raise the profile of addiction – including an aspect of ‘activism’
• Establish joint workforce guidelines – standardization of preparation for professionals working in the field of addiction - ‘Getting it into the Water Supply’
• Provide a virtual room for everyone to enter to discuss the issues as outlined above
• Become a knowledge Hub
• Become a vehicle/platform to transfer ‘best practice’ or explore what ‘good looks like’ |
4
44© Middlesex University
• To provide a platform communication tool to raise awareness and explore brief interventions; psychosocial issues; pharmacology
• To be a global online ‘classroom’
• A place to increase curiosity/increasing competencies directly in the field
• A community of practice and a resource tool, which can be sliced in different ways
• An Intersection between policy/clinical/academic communities
• A global knowledge network finding synergies
|
4
45© Middlesex University
Key Strategic Areas
• Practice
• Education
• Research
• Policy
• Workforce Planning
|
4
46© Middlesex University
Methodology for staying connected
& working together
|
4
Wiki (online network
community)
Off line linking e.g. conferences;
staff & student
exchanges
Jointly delivered
on-line courses
47© Middlesex University
It is not without its challenges
• Slow burner
• Techno issues – access issues; variation in level of members expertise
• The world clock – I’m awake, you’re asleep!
• Finding the time
• Funding issues and volunteer syndrome
Presentation title |
4
48© Middlesex University
First major project
• MOOC (Massive Open Online Course)
• Falling Down – Older People and Problematic Substance Use
• Course release/ teaching starts on 7th of March until 10 April 2016.
49© Middlesex University
Broad Learning Outcomes for
MOOC
• 1. To explore problematic substances use in relation to older people and their carers through current research, practice and service user and carers perspectives.
• 2. To promote awareness of current challenges when working with problematic substance use in ageing contexts for practitioners working with problematic substance use and for those working in ageing services who may not have a detailed knowledge of this issue.
• 3. To identify the scope of the issue within an international and national context and to identify the need for further knowledge, skills, service development and partnerships as well as future research and guidance in order to meet these challenges
• . 50
References
ASAM (2015). National Practice Guidelines and Associated Products at Press Conference and Stakeholder
Summit on September 24, 2015. Retrieved at Website,
http://www.asam.org/magazine/read/article/2015/09/24/national-practice-guideline-and-associated-products-at-
press-conference-and-stakeholder-summit
Department of Health (England) and the devolved administrations (2007). Drug Misuse and Dependence: UK
Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh
Assembly Government and Northern Ireland Executive.
Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care. Available at
: http://www.skillsconsortium.org.uk/intervention-details.aspx?p=8&d=0&int=52
Rundio, A (2015). Landmark legislation to expand treatment for heroin and prescription drug addiction.
Journal of Addictions Nursing ,26 (3), pp 157-158.
World Health Organization (WHO) (2009). Guidelines for psychosocially assisted pharmacological treatment of
persons dependent on opioids. Retrieved at: http://www.who.int/hiv/pub/idu/opioid/en/