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

2. 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

3. 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

4. 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)

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

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

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

8. 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

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

10. 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

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

12. Definition of Addiction
Continued use despite adverse effects

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Why has this medicine revolutionized opiate dependence treatment?
Buprenorphine

24. 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

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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/ with questions
Prescribing Buprenorphine

36. 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

37. Thank You!