1. Suboxone and Opioid Trends Joseph Merrill M.D., M.P.H. University of Washington June 16, 2009

2. Suboxone and Opioid Trends Suboxone treatment for opioid dependence Limitations of Suboxone in WA State Development of HMC Suboxone Program –Blending of medication assisted Rx and traditional drug treatment Trends in prescription opioid use and problems HMC efforts to improve opioid management

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4. Your Brain on Drugs Today 1-2 Min3-45-6 6-77-88-9 9-1010-2020-30 YELLOW shows places in brain where cocaine goes (striatum) Front of Brain Back of Brain Fowler et al., Synapse, 1989.

5. Addiction as a Brain Disease Key brain pathways involve motivation, salience, memory, and reward Prolonged drug use is associated with changes brain function Changes are pervasive and persist after drug use stops Brain changes demonstrated at molecular, cellular, structural and functional levels These studies provide a rationale for medication- assisted treatment of addiction

6. Opioid Dependence Treatment Methadone Maintenance is best studied Methadone treatment reduces: –Overall and overdose deaths –Drug use –Criminal behavior –Spread of infectious diseases (HIV, TB) Methadone may not be used for addiction treatment outside specially licensed programs

7. Methadone Maintenance Treatment Higher dose treatment improves outcomes Longer duration of treatment improves outcomes Psychosocial services improve outcomes Poor outcomes after discharge from treatment Maintenance superior to supported detox

8. Methadone Maintenance Limitations –Highly structured program (6 days/week) –Limited clinical flexibility and medical services –Expansion often opposed, stigma Ask Methadone Maintenance patients about: –Urine test results, take-home doses –Encourage adequate dose, treatment retention

9. Suboxone for Opioid Addiction New medication for opioid dependence Federal legislation (DATA 2000): –Allows trained MDs to prescribe Schedule III-V drugs approved for addiction treatment –Initially limited to 30 patients/group practice, but now each MD can treat up to 100 patients Safer than methadone With naloxone, reduced abuse potential

10. -10-9-8-7-6-5-4 0 10 20 30 40 50 60 70 80 90 100 Activity Log Dose of Opioid Full Agonist Partial Agonist Antagonist Full Agonist vs Partial Agonist

11. Zubieta et al., 2000

12. Buprenorphine Superior to psychosocial treatment alone Longer treatment duration is more effective Comparable to MMT on most outcomes Not as good at retaining patients Medication cost higher than MMT, but total costs hard to compare in different settings Patients with co-morbid pain and addiction may benefit from physician management

13. Opioid Dependence Treatment Detoxification alone has low success rates No clear guidance on choosing between methadone maintenance and buprenorphine Prescribing buprenorphine requires specific training (8 hours) and a federal waiver Integration with psychosocial treatment is key Buprenorphine access limited by availability of MDs, insurance

14. Washington State Suboxone Policy Limited coverage for CNP, GAU patients Requires enrolment in state certified addiction program and prior authorization Limited to 6 months with one 6-month extension possible after clinical review Maintenance treatment and treatment for pain not covered Some Medicare Part D plans allow unlimited treatment

15. Suboxone at Harborview Initial experience: NIDA trial in primary care Program development with RWJ funding –Piloted in public primary care settings –Public funding with Counseling through ETS Program limitations –Many steps to enter treatment –Quick access difficult in busy public clinics –Separate counseling challenging

16. Harborview Addictions Program State certified intensive outpatient program “Abstinence-based” with 12-step support Strong co-occurring treatment track Multiple services (work, child care, housing) Few patients with opioid addiction Integrated psychiatric services, so comfortable with medications

17. Blending Treatment Models Tension between “abstinence” and harm reduction Limitation in treatment duration favors more intensive approach Emphasis on group versus individual treatment (no benzos, even prescribed) Differences in expectations Program size

18. HMC Suboxone Program Services Integrated medical and psychatric care Two 1.5 hour groups per week Medication dispensing after group One on one counseling Regular urine testing Early review of treatment progress

19. Treatment Continuation Options Abstinence with sober support (AA/NA) Methadone maintenance In-patient treatment with or w/o Suboxone For patients with pain and addiction, return to primary care opioid management if stable If insurance allows, transfer to primary care Suboxone treatment

20. Optimal Patient Selection Short addiction duration or significant recovery without medication assistance No benzodiazepine problem or use, even prescribed Not ambivalent about wanting to stop using all drugs and alcohol Co-morbid medical, psychiatric, pain OK Drug Court is a good match

21. HMC Suboxone Program Accepts patients with public funding Developed within WA State policy limitations Unique blending of treatment approaches Best for patients who are working toward recovery without medication assistance Options for continued medication-assisted treatment are limited