1. 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:
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2. 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

3. 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

4. AR-IMPACT website: arimpact.uams.edu
AR-IMPACT address:
Joining the Conference:
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Or call in: , then enter

5. 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.

6. 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# JA L01-P
AAFP Credit: Submit your AMA credit
Pharmacists: Please us your NABP number and month and day of birth

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

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

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

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

11. 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

12. 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

13. 10 Drug Classes Alcohol Caffeine* Cannabis Tobacco Opioids Inhalants
Sedatives, hypnotics, and anxiolytics
Stimulants
Hallucinogens
Other

14. 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

15. 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

16. 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

17. Real Case Presentation Name and Details have been altered

18. 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.

19. 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.

20. 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?

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

22. 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

23. 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

24. 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

25. 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.

26. 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

27. 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

28. 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

29. Ms. Zoey
Thoughts?

30. Ms. Zoey

31. 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.

32. 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.

33. 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

34. 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?

35. Questions about the Topic
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36. Case Conference and Feedback
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