Treat Opioid USE DISORDER like the chronic disease it is Help Curb the Epidemic Treat Opioid USE DISORDER like the chronic disease it is Magni Hamso MD MPH FACP Cassi Shelly, RN, NP Clin Asst Prof, UW-Boise Adult Nurse Practitioner, TRHS Medical Director, ID Div of Medicaid PMHNP Candidate magni.hamso@dhw.idaho.gov cshelly@trhs.org @MagniMD

Disclosures No financial disclosures. Will use generic names when possible. Buprenorphine/naloxone instead of Suboxone. “Bupe” for short. ER-naltrexone instead of Vivitrol. “Naltrexone” for short.

Learning Objectives Review the scope of the opioid overdose epidemic Define opioids, opioid use disorder (OUD), addiction & recovery – understand OUD as a chronic disease Review medications for addiction treatment (MAT) Apply principles of quality chronic disease management to OUD Review best practices for treatment of OUD in primary care

The Scope of the Epidemic

Definitions

What are Opioids? Prescription pain medicines such as hydrocodone (Norco), oxycodone, morphine, fentanyl Illegal drugs such as heroin Stimulate the opioid receptor in the brain to decrease pain, as side effects make people feel good (euphoria) and slow breathing (overdose risk)

What is Addiction? “a primary, chronic disease of brain reward, motivation, memory, and related circuitry… …pathologically pursuing reward and/or relief of withdrawal symptoms by substance use… …Without treatment or engagement in recovery, addiction is progressive and can result in disability and death.”

What is Recovery? “a process of sustained action that addresses the biological, psychological, social and spiritual disturbances… …aims to improve the quality of life… …is the consistent pursuit of abstinence.”

Slide Credit: Dr. John Giftos, Clinical Director SUD Treatment, Correctional Health Services

Slide Credit: Dr. John Giftos, Clinical Director SUD Treatment, Correctional Health Services

Slide Credit: Dr. John Giftos, Clinical Director SUD Treatment, Correctional Health Services I would argue that abstinent when on bupe or methadone. Not drug of choice. Not brought up and down – just kept evening. If stop a BP med, BP will go up. Stop insulin, sugars will go up, may even be hospitalized. No different with bupe or methadone for oud.

Opioid Use Disorder Chronic disease of addiction to opioids Terms abuse and dependence confusing and outdated (but still needed for billing) Diagnostic criteria* include: Escalating use & loss of control Continued use despite negative consequences Diminished ability to fulfill societal obligations Tolerance to the effects of the drug Withdrawal symptoms when the drug is stopped *11 criteria per DSM V 2-3 mild 4-5 moderate 6-11 severe

Who is affected?

Who is affected? 70 year-old grandfather, relapsed after 40 years 28 year-old M homeless T1DM 32 year-old pregnant stay-at-home mom on opioids since last c-section 50 year-old M using painkillers after work injury 44 year-old F small business owner

OUD is a Chronic Disease Chronic disease requiring long-term management 28.6 million (10.6% of US population) illicit drug use (NSDUH 2016) 30 million diabetes (NHANES 2015) 2.4 million hepatitis C (CDC 2018) 70,200 overdose deaths 2017 (NIDA) 40,000 breast cancer deaths 2017 (ACS) this is a primary care issue

Medications for Addiction Treatment

Role of Medications Medication for Addiction Treatment Harm Reduction Psychosocial Interventions Housing, Employment, Mental Healthcare Recovery Support Harm Reduction

Role of Medications Opioid Agonist Therapy Methadone Buprenorphine Opioid Antagonist Extended-release Naltrexone

Extended-release Naltrexone ER Naltrexone Opioid Antagonist Once monthly intramuscular injection Blocks intoxicating/reinforcing effects of opioids Some interest pre-release Limited evidence (2 trials compare to standard of care, 25-30% dropped out before first dose) Increased risk of overdose after antagonist wears off Extended-release Naltrexone

Methadone Buprenorphine Opioid Agonist Therapy Reduce withdrawal symptoms & cravings prevent relapse  allow brain to heal ↓mortality ↓ HIV/HCV ↓ substance use ↓ criminal activity ↑retention in treatment

Opioid Agonist Therapy Methadone Buprenorphine

Opioid Agonist Therapy Methadone Buprenorphine

Methadonea Full agonist Typical dose 80-120mg/d Treatment Program (daily dosing) Stigma More risky, especially during induction phase Better for patients who need more structure, heavier opioid use Buprenorphine Partial agonist Typical dose 16mg/d (max 32) Office based (prescription) Managed like any other chronic illness Protected from overdose (ceiling effect, tight bond) Bound to naloxone to prevent diversion and misuse

Office-based Buprenorphine 8 hour training for MD/DO, 24 hour training for NP/PA (free via www.pccsnow.org, Project ECHO Idaho, H&W) 30 patients year 1, 100 patients year 2, MD/DO can apply for 275 Basic quality metrics to monitor Treatment agreement Regular urine drug screens (every time initially, then ideally random) Regular PMP reports Regular follow up Naloxone DEA simply requires patient list

Office-based Buprenorphine Day 1: Intake (counselor if available & MD visit, agreement, urine drug screen, PMP, labs) Day 4: MD visit Home Induction Week 1: MD (& counselor if available/interested) Week 2/3/4: MD (& counselor if available/interested) Week 6/8: MD (& counselor visit if available/interested) Regular urine drug screens. Monthly visits once patient doing well. Recommend LONG TERM treatment, typically a year or longer; some need lifelong treatment. Everyone can take this on in primary care

Role of Medications Medication for Addiction Treatment Harm Reduction Psychosocial Interventions Housing, Employment, Mental Healthcare Recovery Support Harm Reduction

Harm Reduction Practical strategies & ideas aimed at reducing negative consequences of drug use Meeting users where they are at Substance use a continuum – from severe use to abstinence Complete abstinence not always the goal Empower & give voice to people who use drugs

Harm Reduction Safe injection technique Clean needles HIV, Hepatitis C testing Hepatitis A & B vaccination Naloxone (Narcan) for reversal of opioid overdose Pre-Exposure Prophylaxis for HIV

OUD is a Chronic Disease

1. Use person-first language Treat OUD like the chronic disease it is

1. Use person-first language

2. Normalize medications Medication for Addiction Treatment Psychosocial Interventions Housing, Employment, Mental Healthcare Recovery Support Harm Reduction

2. Normalize medications Encourage patients with OUD to take MAT Get your x-license and prescribe bupe as part of regular primary care practice Know the prescribers in your area

3. Emphasize but don’t require behavioral supports DATA Waiver requires the ability to refer for behavioral health Many patients do well with medications alone Many patients engage more in therapy a few weeks to months into medication treatment If a patient is interested, most data for contingency management & CBT Allows prioritization of a scarce resource to those who need it most Fiellin et al. NEJM 2006; Amato et al. Cochrane 2011; Martin et al. Annals 2018; Tetrault et al. J Subst Abuse Treat 2012; TIP 63 SAMHSA

4. Provide patient-centered care Some patients will want to meet with counselor, some will not Some will be ready to tackle polysubstance use, some will not Some will take longer for their first opioid-free urine Occasional return to use is expected Treatment is long-term (often life-long)

4. Provide patient-centered care Some patients with diabetes will want to meet with the nutritionist or pharmacist, some will not Some will be ready to tackle weight loss and blood pressure, others will not Some will take longer to get sugars under control Occasional bumps in sugars are expected Treatment is long-term (typically life-long)

5. Don’t forget about harm reduction Many things we can do for patients who are not ready for medications Ask about clean needles Offer/refer for HIV & Hepatitis C testing, PrEP Hepatitis A & B vaccination Naloxone (Narcan) for reversal of opioid overdose Pharmacists can dispense without a prescription Use person first language

QUESTIONS? magni.hamso@dhw.idaho.gov CSHELLY@THRS.ORG