Addiction and Recovery in Primary Care Eric Olson, MD Family Medicine Addiction Medicine October 11, 2016

Recognize that there is hope for recovery from opiate addiction Understand how buprenorphine differs from full opiate agonists and how these differences affect its clinical use Objectives

Definition of Addiction A Brain disease characterized by compulsive, repetitive use of a substance despite adverse consequences. Key: Continued use despite adverse consequences Definition of Addiction

Stages of Recovery (change) Pre-contemplation Contemplation Preparation Action Maintenance Relapse Relapse is an expected part of recovery. Provider’s response can have a huge impact on ultimate success or failure of recovery. Just moving forward is progress (except relapse) Stages of Recovery (change)

What percent of inpatients at a community hospital have an active substance abuse problem? D. 50% Scope of Addiction

What percent of inpatients at a community hospital have an active substance abuse problem? D. 50% Scope of Addiction

What percent of patient encounters in primary care have an active substance abuse problem? 20-30% 50% Scope of Addiction

What percent of patient encounters in primary care have an active substance abuse problem? Estimated that 20-28% of patients presenting to primary care have an active substance abuse problem. (includes tobacco use disorder) Scope of Addiction

Substance abuse often presents with nonspecific complaints Insomnia Headaches Depression Anxiety Chronic pain Patient Presentation

Hey doc, I think I am drinking too much. Can you help me? Hey doc, I am not sleeping well. Can you refill that Valium for me? Hey doc, my migraine medicine isn’t cutting it any more, I need something stronger. How Patients Present

Costs of Addiction Direct medical costs Societal costs Lost work productivity Shortened life expectancy Crime to support drug habit Costs of Addiction

Definition of Addiction Continued use despite adverse effects

Definition of Insanity Continuing the same behavior and expecting different results (Albert Einstein) Definition of Insanity

Coding Update DSM-5 Changes Addiction removed from definitions Substance use disorders now on a continuum Mild/moderate/severe e.g. Opiate Use disorder, moderate Cravings added as a diagnostic criteria Addiction hard to define, often used non-medically, negative connotation. Coding Update

Opiate Use Disorder Heroin (snorted, smoked, IV, SC, IM) Prescription opiates (oxycodone, hydrocodone, hydromorphone, codeine, morphine, fentanyl) Tramadol (not an opiate but acts on mu opioid receptor, abusable, risk of seizures) Physical dependence common, even if used appropriately Opiate Use Disorder

Opiate Dependence History Harrison Act outlawed use of opiates to treat opiate addiction (1914) Methadone developed in Germany pre-WW2 due to shortage of morphine Tested and found effective for opiate addicts (1964) Approved for use in methadone clinics Unpredictable pharmacokinetics, Accumulates rapidly Opiate Dependence History

Opiate Dependence Treatment History DATA 2000 (Drug Abuse Treatment Act) Allowed use of Class 3 or lower medicines to treat opiate dependence Re-classified buprenorphine from class 2 to 3 Requires 8-hr education for MD or DO to use buprenorphine in office setting And what I believe it has done is … Opiate Dependence Treatment History

Opiate Dependence Treatment History DATA 2000 (Drug Abuse Treatment Act) Allowed use of Class 3 or lower medicines to treat opiate dependence Re-classified buprenorphine from class 2 to 3 Requires 8-hr education for MD or DO to use buprenorphine in office setting REVOLUTIONIZED OPIATE DEPENDENCE TREATMENT I believe the best way to share what this has done is to share some patient stories. … Opiate Dependence Treatment History

Buprenorphine Case 1 30 year-old male Acute back injury at 18, MVA at 21 Developed chronic back pain Started on prescription opiates Began buying “oxys” on street Unemployed/”Unemployable” B. Buprenorphine

Buprenorphine Case 1 Started Suboxone approx. 18 months ago Attending NA, obtained sponsor Became re-employed in physically demanding trade Supporting his partner and child States that his chronic back pain is under better control than on previous opiates Buprenorphine

Buprenorphine Case 1 Consistently appropriate UDS results Will likely remain on Buprenorphine long-term Sober? In Recovery? Abstinent? This is a good case to discuss 3 important concepts regarding substance abuse treatment. … Buprenorphine

Buprenorphine Case 1 Consistently appropriate UDS results Will likely remain on Suboxone long-term Sober? YES! In Recovery? YES! Abstinent? Not yet … Next I would like to talk about a medicine which could revolutionize how we approach addiction treatment. … Buprenorphine

Why has this medicine revolutionized opiate dependence treatment? Buprenorphine

Buprenorphine Partial agonist at mu opioid receptor Very high affinity Ceiling effect (relatively safe in overdose) Absorbed sublingually Minimal effect orally Active intravenously (can be mis-used) Transdermal patch (for pain, not addiction) (Transdermal patch 20 mcg/hr approx equal to 2 mg/day SL) Buprenorphine

Buprenorphine Case 2 28 year-old male 7-year history of IV heroin use Unemployed/unemployable Started on suboxone Became gainfully employed Buprenorphine

Buprenorphine Case 2 Obtained custody of young daughter Restored his relationship with parents Financially supporting himself and his daughter Returning to school successfully Has tapered to 12% of initial dose Likely to taper off completely over time Buprenorphine

Buprenorphine Challenges What to do with inappropriate UDS results How much treatment to demand Risk Reduction concept Fine-tuning your approach to therapy. Buprenorphine Challenges

Urine Drug Testing Rapid UDS tests Rapid results False-positive and false-negatives common Helpful if results match what the patient says Confirmatory testing expensive Urine Drug Testing

Urine Drug Testing Definitive drug testing More expensive Delayed results More reliable results Useful for making clinical decisions Requiring more intensive treatment Cutting off treatment (Gas chromatography) … UDS testing is a required part of therapy. Need some structure, some flexibility in dealing with results. Urine Drug Testing

Buprenorphine Case #3 68 year-old woman Over 40 year history heroin use Used methadone intermittently for 30 years Continued to use opiates to get high Started Suboxone approx. 10 years ago Remains clean with Suboxone I see some of you math wizards are scratching your heads or snickering. There was significant overlap between the methadone and heroin use. Buprenorphine

Case #3 During 30 years on methadone never stayed consistently clean More stable on Suboxone Relapsed once when tapered down to 2 mg Will likely continue lifelong on Suboxone Next, some parting thoughts about opiate use disorder … Buprenorphine

Opiate Dependence Treatment Barriers Shortage of Buprenorphine Prescribers Insurance Coverage for buprenorphine Fear of treating addicts (You are already treating these patients, whether you know it or not) Opiate Dependence Treatment Barriers

Opiate Dependence Treatment Works! Buprenorphine is not the best option for all opiate addicts Chronic diseases deserve chronic treatment Would you stop treating a diabetic with metformin or insulin because it had failed to “cure” their diabetes Opiate Dependence

Buprenorphine Training MD or DO 8-hour online course Option for a live course (4-hr self-study, 4-hr live portion) Limit 30 active patients (can increase after 1 year) Confluence Health goal is to have at least one buprenorphine prescriber at each primary care team (2 would be better) If there learn more about is enough interest we will look into hosting a local training course. I will be happy to assist any provider who wishes to learn more about buprenorphine. Buprenorphine Training

Prescribing Buprenorphine Start with less challenging patients Consult BMED or CD counselor first Consult with Addiction Medicine if needed I can do induction/stabilization and return patient for maintenance/tapering Call/Email with questions eric.olson@confluencehealth.org 509-665-6087 Prescribing Buprenorphine

Addiction Medicine Referrals Currently very limited access Turning away appropriate candidates every week. I can not come close to meeting the demand for appropriate buprenorphine management in Wenatchee. If time allows … Tobacco … Addiction Medicine Referrals

Thank You!