Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID: 24308-23985

AR-IMPACT Team Members Michael Cucciare, PhD Johnathan Goree, MD Corey Hayes, PharmD Teresa Hudson, PharmD, PhD Shona Ray-Griffith, MD Leah Tobey, PT, DPT Masil George, MD Graduate Student: Andrea Melgar-Castillo

Flow of the Case Conferences General Information: 5 minutes Topic Presentation: 20 minutes Case Conference: 25 minutes Feedback and Thoughts on Future Sessions: 5 minutes

AR-IMPACT website: arimpact.uams.edu AR-IMPACT email address: AR-IMPACT@uams.edu Twitter: @ArkansasImpact Joining the Conference: Click to join: https://join.uams.edu/invited.sf?secret=YtVKQkHsoWTgJaguonymZw&id=415081971 Or call in: 1-844-885-1319, then enter 415081971

Faculty Disclosure of Financial Relationships: The planners of this RSS, Corey Hayes, Michael Cucciare, Johnathan Goree, Leah Tobey, Teresa Hudson, Marti Morrison and Cathy Buzbee have no financial relationships with commercial interests to disclose. A planner and the speaker of this RSS, Shona Ray-Griffith, MD, has a financial relationship with a commercial interest to disclose: Neuronetics, Inc. – Contracted Research. The accreditation compliance reviewers of this RSS, Karen Fleming and Courtney Bryant, have no financial relationships with commercial interests to disclose.

Continuing Education Accreditation: In support of improving patient care, University of Arkansas for Medical Sciences is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation: The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1 ANCC contact hour. Nurses must attend the entire session in order to receive credit. This knowledge-based activity will provide pharmacists up to 1.0 contact hours or 0.1 CEU. ACPE# JA0000298-0000-18-040-L01-P AAFP Credit: Submit your AMA credit Pharmacists: Please email us your NABP number and month and day of birth

Other General Information CISCO IPhone App CISCO Meeting Information Please mute your microphone in CISCO Able to ask questions through CISCO Chat

University of Arkansas for Medical Sciences Addiction Shona Ray-Griffith, MD Assistant Professor University of Arkansas for Medical Sciences

Disclosures I receive clinical trial support from Neuronetics. I have received clinical trial support from Sage Therapeutics. Neither will be discussed today.

Objectives Define DSM-5 definition of substance use disorders Present ‘real world’ case

Addiction Previously Substance Abuse or Dependence DSM-5 reclassified as Substance Use Disorders A cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant problems Substances results in direct activation of brain reward system

Substance Use Disorders Not to be confused with substance-induced disorders Intoxication Withdrawal Other substance/medication-induced mental disorders Substance induced depressive disorder Substance induced psychotic disorder

10 Drug Classes Alcohol Caffeine* Cannabis Tobacco Opioids Inhalants Sedatives, hypnotics, and anxiolytics Stimulants Hallucinogens Other

Diagnosis 4 Major Areas Severity Impaired control Social impairment Risky Use Pharmacological criteria Severity Mild = 2 or 3 symptoms Moderate = 4 or 5 symptoms Severe = More than 6 symptoms

Diagnosis – Criterion A Impaired control Social impairment Use in larger amounts or over a longer period than originally intended Persistent desire to cut down or regulate use or multiple unsuccessful efforts to decrease or discontinue use Spending a great deal of time obtaining, using, or recovering from use Intense desire or urge for the drug Fail to fulfill major role obligations at work, school, or home Continue use despite persistent or recurrent social or interpersonal problems Important social, occupation, or recreational activities may be given up or reduced

Diagnosis – Criterion A Risky use Pharmacological criteria Recurrent use in situations where it is physically hazardous Continued use despite persistent or recurrent physical or psychological problem Tolerance Withdrawal Neither are necessary for diagnosis Symptoms of tolerance/withdrawal occurring during appropriate medical treatment with prescribed medications are specifically not counted when diagnosing a substance use disorder

Real Case Presentation Name and Details have been altered

Case Presentation – Ms. Zoey HPI: 25 y.o. CF G4P3 24 weeks gestation who presents upon referral from Ob with 5 year history of chronic pain. Upper and lower back pain began after delivering 5 y/o daughter. Pain is "pins and needles" in the middle of her shoulder blades. She also reports right sided buttocks pain with radiation into leg. Ob began treating her with PT and hydrocodone. She was then referred to pain management and managed on hydrocodone for the next year. She was then evaluated by rheumatologist for RA and fibromyalgia and prescribed oxycodone 15mg po QID.

Case Presentation – Ms. Zoey Previous medication: gabapentin, lyrica, flexeril, methocarbamol, amitriptyline, cymbalta. None helpful. Admits to withdrawal symptoms. Denies early refills, doctor shopping, tolerance, or any concern of family/friends. No legal issues. PMP: Reviewed and consistent. Exposures: Smokes 1 ppd. No alcohol or drugs. Negative UDS. PMH/PSH: KOC last month. Pregnancy surprise and wanted. Conceived on mirena. FOB is involved. Plans to breastfeed. Regular ob care. Previous induced FT vaginal births. First was stillbirth due to preeclampsia. Other medical problems include HTN.

Ms. Zoey What signs or symptoms of opioid use disorder are present? Withdrawal symptoms Negative UDS? How would you have handled this presentation? Utility of PT? Is imaging needed?

Case Presentation – Ms. Zoey Plan: Oxycodone 10mg po TID Nortriptyline titration to 30mg po QHS RTC in 4weeks

Case Presentation – Ms. Zoey Follow-up #1 (27 weeks gestation): Presents for an early appointment due to running out of medications early. She reports taking 2 tablets at a time for pain control as one was ineffective. The pain control would last 5-6 hours. 2 weeks ago, she slipped in front of her house. She reports taking 1-2 extra tablets due to this. Has been compliant with nortriptyline. She reports some improvement in burning pain. Has days where she is not bothered by pain. Pain increases with increased physical activity. UDS: Negative

Ms. Zoey Impaired Control What signs or symptoms of opioid use disorder are present? Early appointment Taking more than prescribed Ran out of medications early Negative UDS? What would be your next steps? Impaired Control

Case Presentation – Ms. Zoey Plan: Continue nortriptyline 30mg po QHS Increase oxycodone to 15mg po TID Patient instructed to call before changing medications and other physicians should not adjust current prescriptions. RTC in 4weeks

Case Presentation – Ms. Zoey Follow-up #2 (30 wks gestation): Presents 1 week early for appointment due to running out of medications. She reports taking extra oxycodone at night due to increased pain. She recognizes need to contact physicians but has numerous irrational reasons why she did not. She continues to adequately take care of children and household. UDS: Negative PMH: Seen in ER last week for Braxton Hicks contractions and round ligament pain.

Ms. Zoey Impaired Control What signs or symptoms of OUD are present? Early appointment Taking more than prescribed Ran out of medications early Negative UDS? What would be your next steps? Impaired Control

Case Presentation – Ms. Zoey When discussing concern for her behavior, she admits to worsening depression and crying. She discussed numerous stressors - most financial, relationship, lack of social support. Plan: Increase nortriptyline to 50mg po QHS Continue oxycodone 15mg TID Again reiterated reasons to contact physician in regards to medications. RTC in 2 weeks

Case Presentation – Ms. Zoey Follow-up #3 (33 weeks gestation): Presents with continued psychosocial stressors. She began taking nortriptyline and it does help with sleep, but she denies any improvement in mood. No missed doses or side effects. She denies any problems with oxycodone or pain. She reports continued abdominal cramps but is managing them. She presented with 2 tablets - appropriate. PMH: Ob appointment last Monday - no concerns. UDS: Positive for opiates

Ms. Zoey Thoughts?

Ms. Zoey

Case Presentation – Ms. Zoey Phone Call! Since last appointment, purse was stolen with medications. She filed police report and gave information. Police report was confirmed. Opiates were prescribed until next apointment.

Case Presentation – Ms. Zoey Follow-up #4 (36 weeks gestation): Main complaint is acute CTS. No longer complains of back pain. Since last appointment, purse was stolen with medications. She admits to taking hydrocodone from streets oxycodone QID - over prescribed limits of TID codeine cough syrup X 1 dose No disclosure that nortriptyline was stolen. Noncompliance with TCA labs X 2 appointments. UDS: Negative.

Ms. Zoey Impaired Control + Social Impairment + Risky Use + What signs or symptoms of OUD are present? Taking more than prescribed Ran out of medications early Buying off streets Taking multiple medications Tolerance Negative UDS? What would be your next steps? Impaired Control + Social Impairment + Risky Use + Physiological Symptoms

Case Presentation – Ms. Zoey Plan: Continue nortriptyline 50mg po QHS Subutex 4mg SL BID Transition to substance use disorder clinic 23 (19%) of the opioid group and 10 (8%) in the nonopoid group discontinued study medication Of note, patients reported receiving: Acupuncture, biofeedback, chiropractic or osteopathic manipulation, homeopathy/naturopathy, nutritional advice of counseling, massage, mental health counseling/therapy, personal training/supervised exercise therapy, physical therapy, injections in spine/knee/hip, or other joints, surgery for sine/knee/hip?

Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 24308-23985

Case Conference and Feedback Continuing Education Credit: TEXT: 501-406-0076 Event ID: 24308-23985