Michael Fingerhood MD FACP

None, except strong passion for integrating addiction treatment with primary care

To increase knowledge of epidemic of opioid use disorder

To increase knowledge of treatment of opioid use disorder

To be convinced that integrating treatment for substance (opioid) use disorder with primary care is beneficial (for patient, providers and the health system)

“SWAF”

In 2006, the IOM released a report recommending improvement in coordination of mental health and substance-related services into general health care services:

“Available evidence suggests that integration of mental health and primary care may lead to improved care and quality of life”

“With the advent of health care reform, community-based health centers will be increasing their capacity for behavioral health care. Workforce development and systems factors will need to be addressed in order to make this happen”

“Studies of health delivery, process of care, and health outcomes in integrated clinical settings will be critical to inform the process”

Desire to receive care that will improve health

Ability to receive care based on trust and rapport

Press K, Zornberg G, Geller G, Carrese J, Fingerhood M. What patients with addiction disorders need from their primary care physicians: a qualitative study. Substance Abuse 2016; 37:349-55.

Knowledge about addiction

Duty to treat

Focus on overall health

Engage patients in care

Treat the full scope of illness (isolation, rejection, creating hope)

In 2015, an estimated 25 million persons aged 12 or older (9.4 percent) were current illicit drug users

◦ Despite the high prevalence, the vast majority of individuals who need treatment do not receive it

◦ The economic burden of substance use in the US is estimated at $524 billion/year much of which is attributed to losses in productivity

In 2015, over 4.5 million Americans aged 12 and older met the criteria for substance use disorder related to opiate analgesics, and over 700,000 used heroin in the past year

According to the CDC, drug overdose death rates in the US have more than tripled since 1990 and are at an all-time high, surpassing motor vehicle accident deaths

NSDUH 2011, CDC 2011

1. Boredom from lectures like this

2. Voted for Nixon’s re-election

3.Won a Super Bowl 4.Love Uncle John’s

Band 5.Opioid use

disorder

“Seventy glassine baggies of heroin packed for individual sale — at least 50 of them unopened — were discovered in the $10,000-a-month rental where the Oscar-winning actor was found dead Sunday with a needle stuck in his left arm

Some of the envelopes had the words ‘Ace of Spades’ written on them, and others were stamped with the name ‘Ace of Hearts.’ Both are brands of heroin that are often cut with a powerful pain reliever called fentanyl...”

“Prince died unexpectedly at his home in Minnesota on April 21. According to the Associated Press, Prince died of an overdose from fentanyl, a highly potent opioid”

“According to most firsthand accounts of his days at Johns Hopkins, Halsted was moody, elusive, sarcastic, and prone to dropping out in the middle of an operation ... Most famously, Dr. William Osler recalled in 1890 that he had seen the surgeon having severe chills. Suspecting that Halsted was still addicted to morphine and was going through withdrawal, Osler gained the surgeon's trust and confidence.”

In a secret diary that Osler kept sometime between 1902 and 1905, which was not unsealed until 1969, Osler wrote, "[Halsted] has never been able to reduce the amount to less than three grains [of morphine] daily, on this he could do his work comfortably and maintain his excellent physical vigor. . . I do not think that anyone suspected him — not even Welch."

28F seen for first visit. Able to review in CRISP/PDMP- multiple ER visits for back pain and one opioid overdose, and many filled scripts for oxycodone from many providers. Had abnormal PAP 3 years ago. History of HIV (not addressed) and hypertension (has elevated BP today)

Her agenda- getting script for oxycodone. My agenda- getting her engaged in medical care and treatment for opioid use disorder

First cultivation of opium poppies was in Mesopotamia, approximately 3400 B.C., plant called Hul Gil, the "joy plant”

The Greek gods Hypnos (Sleep), Nyx (Night), and Thanatos (Death) were depicted wreathed in poppies

The Persian physician, al-Razi (845-930 A.D.) made use of opium in anesthesia and recommended its use for the treatment of melancholy.

Between 400 and 1200 AD, Arab traders introduced opium to China.

14th century Ottoman Empire-opium used to treat headache and back pain.

15th century China- first officially recorded use of opium as a recreational drug.

1874- heroin developed 1898-heroin marketed by Bayer as safe

pediatric cough suppressant

Opiates = naturally present in opium

e.g. morphine, codeine, thebaine

Opioids = manufactured

Semisynthetics are derived from an opiate

Heroin from morphine

Buprenorphine, oxycodone from thebaine

Synthetics are completely man-made to work like opiates

Methadone

Fentanyl

1914- Harrison Narcotics Tax Act

1925- Linder vs United States

1964- Methadone introduced as experimental treatment for opioid addiction

1968- Bureau of Narcotic and Dangerous Drugs formed (changed to DEA in 1973)

1. Tolerance2. Withdrawal3. Larger amounts/longer period than

intended4. Inability to/persistent desire to cut down or

control5. Increased amount of time spent in activities

necessary to obtain6. Social, occupational and recreational

activities given up or reduced7. Use continued despite adverse

consequences

Ask

Survey/screening tools

Clinical assessment

Local medical record

CRISP/PDMP

Search criminal record?

A. Primary care

B. Emergency room

C. Inpatient hospital

D. All places equally

SBIRT

vs

SIT (screen, intervene and treat)

Interventions and education are effective Interventions should emphasize health and

relationship benefits Use family/friends in a positive way Avoid threats- “If you use, you will die” Give hope that life can improve Acknowledge reasons for use, but… Work together to define the benefits of change

1. Accepting powerlessness

2. Disease identification

3. Surrender to a Higher Power

4. Commitment to AA/NA

5. Commitment to abstinence

6. Sober social support

7. Intention to avoid high-risk situations

Stabilize neuronal circuitry◦ Mu occupation/blockade

◦ Cross-tolerant, long-acting

Prevent withdrawal and craving

Extinguish compulsive behavior

Prevent spread of HIV and HCV

Prevent criminal activity

Pure opioid blocker

Available as oral drug and monthly injection

Acceptance poor

Works if part of contingency management

Little evidence for long term efficacy

Opiate dependence is a brain-related medical disorder

Treatment is effective-

“Although a drug-free state represents an optimal treatment goal,

research has demonstrated that this goal cannot be achieved or

sustained by the majority of opiate-dependent people.”

Reduce unnecessary regulation of long-acting agonist

treatment programs

Improve training of health care professionals in treatment

of opiate dependence

Dole, Arch Int Med, 1966

MEDICATIONS

NOT MAT

H H HH

H H HH

H H HH

H H HH

H

H H HH

H H HH

H H HH

H H HH

H

Methadone Regular Outpatient

Baseline

P H HH

H

P HP

H H HH

H H HH

H H H

Methadone No Methadone

After 2 Years

1

32

1- Sepsis & endocarditis

2- Leg amputation

3- Sepsis

P H H

H

P P

P

Methadone No Methadone

After 5 Years

0

5

10

15

20

25

30

35

40

45

Baseline 1 yr. 2 yr. 3 yr.

% s

ero

po

sit

ive

Methadone Out-of-treatment

Less than 20% of opioid dependent persons receiving treatment

Stigma associated with going to a methadone clinic

Highly regulated doses & take homes

Criteria exclude persons under age 18

Ability to get to treatment limited- based on geography and insurance as well

Allowed “Qualified” physicians to treat opioid

dependence outside methadone facilities

1. Addiction certification from approved organization, or

2. Physician in clinical trial of qualifying medication, or

3. Complete 8-hour course from approved organization

DEA issues (free) to qualifying physicians a new

DEA number to use medication for opioid

dependence

As of today, only one medication formulation is

approved for this use

Methadone Clinic Buprenorphine

• Criteria:

Withdrawal

12 months use

• Criteria:

DSM IV

No time criteria

• Dose regulated • MD sets dose

•Age > 18 •Age > 16

• Limited take homes • Take homes (30 days)

• Services “required” • Services must be “available”

Perc

ent

Reta

ined

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

58% Bup

73% Hi Meth

53% LAAM

Stud(9Johnson RE, et al NEJM 2000

Modest agonist activity with ceiling

Long half life

Precipitated withdrawal if taken after full

agonist

Sublingual route of administration

“Combo” tablet with naloxone limits abuse by

injection

No alteration of cognitive functioning

◦ feel “normal”

No organ damage

◦ Early concern of hepatic toxicity unconfirmed

◦ No evidence of QT prolongation

Ceiling prevents respiratory depression/overdose

(Overdose reports with combining use with benzodiazepines)

No clinically significant interactions with other drugs

Done at home

No different than starting blood pressure medication- may need some titration

Much easier than starting insulin (and safer)

Counsel on taking first dose once in withdrawal

Titrate dose up to 16 mg/daily by second day

Phone check ins

One week follow-up

Multicenter randomized clinical trial- n=653

In both phases patients randomized to standard

medical management(SMM) or SMM plus

counseling

In both phases (3 &12 weeks of buprenorphine),

separate counseling did not change outcomes

“You’re not in recovery if you’re on medication”

“Doc, I feel normal”

“I wake up not sick”

“I have my life back”

Treatment in normal medical settings:

◦ Encourages continuity of medical care

◦ Encourages relationship building

◦ Legitimizes opioid use disorder as a treatable, chronic illness

Treatment duration (days)

Rem

ain

ing in t

reatm

ent

(nr)

0

5

10

15

20

0 50 100 150 200 250 300 350

Bup 6 day detox

Bup Maintenance

4 deaths

0 deaths

Kakko J, Lancet 2003

Opioid Dependence Treatment

in Primary Care

Stein, JGIM 2005

At 24 weeks, 59% remained

in treatment

Buprenorphine Diversion

Cicero, NEJM 2005

OXYCODONE

METHADONE

BUPRENORPHINE

All patients initiated on buprenorphine August

2003 through September 2007

Visits 15 minutes; frequency at discretion of

provider; non-witnessed urines checked for

temperature

Co-morbidities- Heptatitis C-49%; psychiatric

disorders 49%; HIV 14%; chronic pain 18%

Outcomes-

At the end of one year- 145 patients (57%) were

still receiving buprenorphine treatment

Overall 65% of month-long treatment blocks

were opioid negative

Treatment success higher for non-heroin users; all other demographic variables not significantly different

Non-retained patients (109)- 63 lost to f/u; 10 lost insurance; 21 discontinued- 8 transferred to methadone maintenance; 2 had adverse effect; 5 deaths – 3 overdose (none on buprenorphine at time of death); 1 AIDS; 1 cerebral hemorrhage.

Characteristic BUP METH P value

Mean Age 39.7 39.5 0.83

Female 44% 58% 0.001

Insurance

Commercial 41% 1% <0.001

Medicare 20% 3% <0.001

Medicaid 35% 56% <0.001

None 3% 39% <0.001

Employment

Employed 45% 13% <0.001

Unemployed 29% 72% <0.001

Disabled 26% 16% <0.001

65

Characteristic BUP METH P value

Abused Substances

Heroin 83% 86% 0.39

Opioid Rx 29% 9% <0.001

Cocaine 53% 55% 0.73

Benzodiazepines 9% 23% <0.001

Injection drug use 61% 69% 0.051

HIV infection 14% 8% 0.023

Chronic pain 18% 12% 0.063

Recent criminal charges 43% 50% 0.129

66

Maryland Medicaid-Priority Partners MCO 5/1/08-

4/30/11

Buprenorphine n=1292- avg age 35.8, 66%F,61%

White; 36% Baltimore City; 32% rural

Methadone n=2732- avg age 39.0, 69%F, 55%

White, 52% Baltimore City, 11% rural

Both agonists n=348- avg age 36.2, 70%F, 54%

White; 50% Baltimore City, 14% rural

Maryland Medicaid Priority Partners beneficiaries who received a script for buprenorphine between 1/1/08 and 7/31/12and no buprenorphine script in previous 3 months

Only first episodes analyzed

CCP n=137

Non-CCP n=992

6 month retention

80.3% 59.2% p<.001

Any ED visit 12 months

63.5% 60.4% NS

Any acute hospital stay 12 months

15.3% 18.9% NS

Total cost 12 months mean

$10,785 $12,210 P<.001

Prescribing is the easy part

The conversation is the art of medicine (and the fun)

You- “The best thing you can do for yourself is stop drinking”

Person- “I don’t deserve the best, what else can I do?”

What have you done today to make the world a better place?

What have you done today to make today better than yesterday?

Give me an update for your fan club

My patient’s urine drug screen is positive for…

My patient’s urine drug screen is negative for buprenorphine

My patient misses an appointment

My patient asks for a refill early

My patient has an overdose

Work on weight loss

Work on smoking cessation

Work on increasing exercise

Treat hepatitis C

Get better diabetic control

Make sure HIV VL is suppressed

Control blood pressure

Update vaccines

Make sure health maintenance is up to date-PAP, colonoscopy

After 3 months - seen 7 times

On medication for hypertension; adherent with

HAART for HIV and viral load undetectable; had

PAP done. No ER visits.

Doing well on buprenorphine/naloxone. No back

pain. Urine drug screens all negative since the

first visit.

Mood/self-esteem much improved. Better

relationship with family. Working part-time.