Dr. Kenneth Saffier's 2013 SLC PresentationPresentation Transcript
How Innovation Can Save Lives
Ken Saffier, MD
Contra Costa Regional Medical Center and
November 2, 2013
AAFP 2013 State Legislative Conference
I have nothing to disclose.
Overview of this presentation
Introduction and learning objectives
The current opioid epidemic and access crisis
Buprenorphine “101” for the non-addictionist
Medically assisted therapy for drug addiction
Effective communication strategies – Group
visits and motivational interviewing
• Summary and conclusions
By the end of this presentation, participants will be
1. Explain how buprenorphine, a partial opioid
agonist, works and can save lives.
2. Witness and experience the power of patients’
first person perspectives to promote education
and treatment for other patients and
3. Define motivational interviewing and explain
why it is particularly well-suited to helping
people with opioid addiction.
An Epidemic of Opioid Poisoning and
• 13% of 18-25 yo abused prescription drugs
• In 2010, 3,000 died (18-25) from OD, more than
for heroin and cocaine.
– 8 deaths per day
– 250% increase from 1999
• 10,000 men and 6,600 women in 2010 died
from prescription med OD’s.
• More people die from poisonings than from
* Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment admissions, and crude rates per 10,000 population for kilograms sold.
MMWR - November 4, 2011 / 60(43);1487-1492
Lack of Access – A Painful Reality
• Uninsurance associated with 45,000 deaths (1864 yo)in US.
Wilper, AP, et.al. Health Insurance and Mortality in US Adults,
Amer J Pub Health, 2009; 99:2289-2295
• Approximately 10% of those with SUDs receive
specialty care (2.5 of 23.1 million).
• 38% of 1.1 million who felt they needed
treatment had no insurance or funds to pay for
2012 National Survey on Drug Use and Health, US DHHS
Human Opioid Receptors , ,
AA identical in
AA identical in
AA different in
LaForge, Yuferov and Kreek, 2000
Buprenorphine – a partial agonist
High affinity for the mu opioid receptor
Competes with other opioids and blocks their
Can precipitate withdrawal in highly opioid
Slow dissociation from the mu receptor
Prolonged therapeutic effect for opioid
“Ceiling effect” for stimulation of a given
Uses of Buprenorphine
Short acting opioids
Long acting opioids
(As an analgesic (transdermal))
Buprenorphine vs. Placebo
for Heroin Dependence
Remaining in treatment (nr)
Kakko, Lancet 2003
4 Subjects in Control Group Died
Treatment duration (days)
Engaging Patients in Treatment
• Access to health care
• Treatment options, including buprenorphine
• Group visits
• Motivational Interviewing
Buprenorphine Treatment Groups
Began in 2007.
Between 4 – 12 patients/group.
Urine toxicology screening.
Prescriptions written at time of visit or by PCP
• Individual visits before and after group appt.
• Other staff: FM resident, Substance abuse
Additional Tx Components
• Substance abuse counseling, including residential
• Mental health services
• Ongoing regular medical care
• 12 Step programs with sponsors
• Faith-based recovery programs
Patient Survey: n=107
• What’s good about buprenorphine?
– “Saved my life”: 6
– “Allowed me to function”: 20
– “Stay sober and clean”: 22
– “Takes away craving”: 26
– Relief, no withdrawal: 15
– “Miracle drug”: 2
– Blocks other opioids: 4
“How long do you plan to take it?”
• Less than 1 year:
• More than a year with a stop date:
• I don’t know at this time, but I would like
to stop taking it eventually:
• I don’t have a desire to stop taking it
at this time:
• Buprenorphine induction clinics
– Integrated Services Model: Office-based
Buprenorphine Induction Clinic, San Francisco
Dept of Public Health
Hersh, D., et.al. J Psychoactive Drugs, 2011, 43: 136-145
• Nurse care managers (NCM) model
– Expansion to 19 FQCHC’s in MA w/ 1 NCM/center
– Average 75 pts/wk
Alford,DP et.al. Arch Intern Med 2011,171:425-431
Communication That Really Works –
“Motivational interviewing is a person-centered
counseling style for addressing the common
problem of ambivalence about change.”
Miller, WR and Rollnick, S. Motivational Interviewing, 3rd ed., 2013
• Individually and in Groups
• Works well with diverse populations
• Collaborative (and fun)
Which Style Do You Prefer?
Four Processes in MI
Miller and Rollnick, 2013
Summary and Conclusions
• Buprenorphine, a partial opioid agonist, saves
• Access to care and SUD treatment saves lives.
• Group therapy for opioid addiction treatment
with buprenorphine successfully engages
• Motivational interviewing helps people
• To Karen, Rodney, Stephen, Susan and our
patients who are our excellent teachers.
• Mary Jean Kreek, MD, Andrew Saxon, MD
• Gary Larson