1. Addiction Medicine Update
David Best, DO, MS, ABAM
Board Certified in Family Practice
Board Certified in Addiction Medicine
September 16, 2017

2. Objectives 1.) Discuss CDC opioid guidelines and mortality data
2.) Discuss importance of taking a good history, using screening tools and how addiction can affect nursing home patients
3.) Discuss how addiction is a chronic illness and treatment plan should be designed accordingly
4.) Discuss treatment options
5.) Case study and Questions

3. CDC Guidelines 2016 CLINICAL REMINDERS
• Opioids are not first-line or routine therapy for chronic pain
• Establish and measure goals for pain and function
• Discuss benefits and risks and availability of nonopioid therapies with patient

4. CDC Guidelines (cont.) CLINICAL REMINDERS
• Use immediate-release opioids when starting
• Start low and go slow
• When opioids are needed for acute pain, prescribe no more than needed
• Do not prescribe ER/LA opioids for acute pain
• Follow-up and re-evaluate risk of harm; reduce dose or taper and discontinue if needed

5. CDC Guideline (cont.) CLINICAL REMINDERS
• Evaluate risk factors for opioid-related harms
• Check PDMP for high dosages and prescriptions from other providers
• Use urine drug testing to identify prescribed substances and undisclosed use
• Avoid concurrent benzodiazepine and opioid prescribing • Arrange treatment for opioid use disorder if needed

6. Guidelines Applicable to LTC patients?
Some guidelines are and some are not.
In LTC facility patients have supervised dosing and diversion of medication is (hopefully) not a problem.
Non-opioids may be higher risk than opioids in LTC patients: NSAIDs causing GI bleeds and renal failure for example
Palliative care and hospice care patients
Morphine Equivalent daily dose limit of 90mg should be seen as a guideline, not an absolute.

7. Substance Use Disorders (SUDs)
Nicotine
Alcohol
Opioids
Stimulants
Benzodiazepines
Other

9. Addiction
Is a primary, chronic and relapsing brain disease characterized by an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Definition from American Society of Addiction Medicine (ASAM)
In 2015 it was estimated that 20.5 Million Americans 12 and older had a substance use disorder
52,404 lethal overdoses in 2015

10. Opioid Use Epidemic
Opioids – prescription and illicit – are the main driver of drug overdose deaths.
28,647 opioid involved deaths in 2014
33,091 in 2015
This represents 63.1% of all drug related deaths in the US in 2015
Quadruple number of deaths since 1999

11. 16.3 deaths per 100,000 in US in 2015
State level data (2015 drug overdose deaths)
Top Five in deaths per 100,000 population
West Virginia 41.5
New Hampshire 34.3
Kentucky 29.9
Ohio 29.9
Rhode Island 28.2
Michigan is #16 at 20.4 deaths per 100,000 with total of 1980 deaths in 2015

12. Disturbing Trends
Overall increase in deaths: 400% increase from 1999 to 2015
Much of increase is due to synthetic opioids such as fentanyl and heroin
Unfortunately a decrease in the amount of opioid prescribing that has been seen since 2013 has been met with an increase in heroin use.
Expect to see patients with SUD in the extended care facility setting

13. Risk Factors Family History of substance use disorder
History of anxiety, depression, ADHD
Adverse Childhood Experiences (ACE)
Environment and socioeconomic stressors
Chronic Pain: 11% who use prescribed opioids have Opioid Use Disorder
Gavin Bart, MD (2012): Medication Maintenance for Opiate Addictions: The Foundation of Recovery, Journal of Addictive Diseases, 31:3,

14. Alcohol Facts and Statistics
70.1% of adults reported that they drank in the last year.
56% within the last month (2015 NIH survey)
15.1 million adults have alcohol use disorder (AUD)
88,000 people die each year from alcohol related causes
4th leading preventable cause of death
In 2010, alcohol misuse cost $249 billion in the US
National Institute on Alcohol Abuse and Alcoholism (NIAAA)

15. Morbidity from AUD and SUD
Medical care for acute and chronic conditions in persons with addictive disorders can be fragmented and inefficient. Multi-system involvement needs to be recognized.
Cardiovascular (tobacco related)
Pulmonary (tobacco, marihuana)
Hepatic (alcohol, IV drug use and hep C)
Neurologic (Wernicke syndrome, dementia)
Infectious (HIV, Hep C)
Musculoskeletal (trauma from MVA, falls)
Psychiatric (bipolar, PTSD, borderline personality)

16. Chronic Disease Model needs to be followed!
Addiction Treatment faces challenges that other chronic illnesses do not
Impact of addiction is more visible and less socially acceptable. The stigma of Opioid Use Disorder (OUD) can be very problematic in getting proper treatment.
Expectation that patients with OUD will remain symptom free after treatment ends
Chapter 31: Quality Improvement for Addiction Treatment; Principles of Addiction Medicine The Essentials; 2011.

17. Necessary for treatment of SUD patient
Treat the whole patient
Know their history
Have empathy
Recognize and respect where patient is coming from
Goal is to restore function (In life, at work, with family)
Need for individualized treatment plan

18. Screening and Diagnostic Tools
DIRE Score for chronic opioid prescribing
DAST-10
DSM 5
Can be used in office based practice, hospital practice and long-term care facility practice.
Different strategy for long-term vs. rehab patients
With Rehab patient will need to help transition patient back to outpatient clinical setting
Need to know where to refer for proper treatment of SUD

19. DIRE Score DIRE Purpose & Evidence:
Purpose: The Diagnosis, Intractability, Risk, Efficacy (DIRE) tool assesses the risk of opioid abuse and suitability of candidates for long-term opioid therapy
Target population: Adults
Evidence:
Validated by six experts studying patient case vignettes (Passik et al. 2008).
Showed sensitivity, efficacy, specificity and high internal consistency (Belgrade et al. 2006)
Advantages/Limitations Advantages
Specifically designed for primary care use (Passik et al. 2008)
Patient's DIRE score correlates well with patient compliance and efficacy of long-term opioid therapy (Belgrade et al. 2006)
Limitations
Prospective validation needed (Passik et al. 2008).

20. DIRE Score

22. DSM 5 Criteria for OUD Opioid Use Disorder Diagnostic Criteria
A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
DSM 5 Criteria for OUD

23. Opioids are often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
4. Craving, or a strong desire or urge to use opioids.
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.

24. 7. Important social, occupational, or recreational activities are given up or reduced.
8. Recurrent opioid use in situations in which it is physically hazardous.
9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Tolerance, as defined by either:
a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of an opioid.
Note: This criterion is not met for those taking opioids solely under appropriate medical supervision.
11. Withdrawal, as manifested by either:
a. The characteristic opioid withdrawal syndrome
b. Opioids are taken to relieve or avoid withdrawal symptoms.

25. Severity of OUD Mild: 2-3 criteria met Moderate: 4-5 criteria met
Severe: 6-11 criteria met

27. Need to reduce treatment gap.
Evidence based treatments are not routinely used for alcohol, drug, and mental health conditions.
12% of patients with OUD get treatment
The IOM has noted that health policy has more impact on patient outcomes than variation in individual practitioner abilities.
Recent examples of improvements are:
Comprehensive Addiction and Recovery Act (CARA)
More funding, new limit for providers is 275 buprenorphine patients
Medicaid Expansion and better coverage for buprenorphine
Mental Health Parity and Addiction Equity Act

28. Prevention of Opioid Use Disorder
CDC prescribing guidelines are a good start
Assess risk vs. benefit of prescribing
Reduce Demand
Better Access to Medication Assisted Treatment
Reduce Supply
law enforcement, reduced prescribing of opioids
Always review benefit vs risk for opioid prescribing(use DIRE score)
Naloxone availability
MAPS Reports
Drug testing
Need for controlled substance agreements

29. Treatments for OUD Standard of care:
Medication Assistance Treatment (MAT)
Methadone Maintenance Treatment
Buprenorphine Maintenance Treatment
Naltrexone oral or injection
Psychosocial Treatment
Cognitive Behavioral Therapy
Supportive Counseling
Mutual Self Help Meeting

30. Why use MAT?
MAT needed due to poor success rate of abstinence based treatment.
Prevention of overdose deaths, prevention of: HIV, HCV
Improved Quality of life for patients and families.

31. Cost Effective
Opioid use disorder treatment reduces illicit opioid use and its associated health and social costs.
Estimated every $1 invested in opioid dependence treatment programs may yield a return of as much as $12 due to:
Reduced drug-related crime, criminal justice costs
Health care savings
2004 WHO/UNODC/UNAIDS position paper. Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention.

32. Harm Reduction
Harm reduction benefits people who use drugs, their families and the community.
Harm reduction reminds clinicians of the supreme importance of keeping drug users alive and avoiding irreversible damage.
Chapter 30, Principles of Addiction Medicine, The Essentials

33. Buprenorphine Maintenance Treatment (BMT)
Evidence for the effectiveness of BMT: High
Improved treatment retention
Reduced illicit opioid use compared with placebo
No reduction in non-opioid illicits however
Psychiatry Serv., 2014 Feb; 65(2)
1 year retention in treatment is 60%
Bart (2012)

34. Methadone Maintenance Treatment (MMT)
Evidence for effectiveness of treatment: High
Clear benefit in terms of retention in treatment and reduced illicit opioid use.
Less clear, but still some benefit: reducing mortality, non-opioid illicit drug use, criminal activity and drug related HIV risk
Limited evidence of dose >100mg or <60mg daily
Psychiatric Serv., 2014 Feb 1; 65(2);

35. Naltrexone
Oral and IM dosage forms indicated for both alcohol and opioid use disorder.
Less clear evidence than MMT or BMT
Potential Benefit for oral formulation vs. placebo for patients who have external mandates (legal requirements)
Injectable naltrexone trial demonstrates benefit vs. placebo. However, high drop- out rate of 45% at 6 months.
ASAM National Practice Guideline, 2015
IM form with 53% retention in treatment at 6 months
20% treatment retention at 1 year with oral naltrexone
Bart (2012)

36. Case Study
31 year-old female who suffered a fall at home in Feb 2015 that resulted in bi- malleolar fracture to right ankle.
Presented for rehab at ECF following ORIF at hospital
History of overdose on benzodiazepines and heroin
PMH: Alcoholism, SUD, anxiety, depression, ADD
Pain being managed with oxycodone
Challenge will be to transition from pain management to opioid maintenance treatment upon d/c home.

37. More history
She was already seeing therapist at Catholic Human Services (for alcoholism)
Pain not well controlled on oxycodone 5mg 1-2 tab every 4 hours
ACE score: 8
DSM 5 she meets at least 5 criteria for OUD (she minimizes severity of her addiction)
Discussion of Buprenorphine maintenance treatment started at initial ECF visit.

38. Buprenorphine maintenance treatment candidate
Due to high tolerance her oxycodone dose was increased and she was then better able to participate in PT/OT
Discharged home in early April and no further full-agonist opioids prescribed
Started on buprenorphine-naloxone 5.7/1.4 two tabs SL daily in April 2015 and she continued this until January 2017.
All 15+ office UDS were consistent with +Bup only
No further injuries noted, back to work as a waitress and she also went back to school

39. Q&A Thank You. David Best, DO, MS, ABAM dkbest_2000@yahoo.com