Treatment andRecovery in America April 10-‐12, 2012 Walt Disney World Swan Resort
Substance Abuse in the United States: When and How to Use Medication Assisted Treatments Elinore F. McCance-Katz, MD, PhD Professor of PsychiatryUniversity of California San Francisco
Accepted Learning Objectives:1. Deﬁne when and how medica>on-‐assisted treatment methodologies for successful recovery of opioid addic>on should be used. 2. Explain how to improve access and quality of care through strategic planning and community-‐wide coordina>on with local and state agencies. 3. Describe behavioral health issues faced by individuals within the correc>ons system and devise strategies to adequately address these clinical needs aHer incarcera>on.
Learning Objectives:To gain an understanding of:Recent Advances in Recognition and Treatment of Substance Use DisordersSBIRT: What is it and how can it improve medical care and reduce costs?Review some of the basics of substance abuse treatment that can be accomplished in primary care and other medical settings – Screening – Brief intervention/motivational interviewing – Referral to substance abuse treatment settings when needed – Pharmacotherapy for substance use disorders that can be undertaken in the primary care setting
Disclosure Statement• All presenters for this session, Dr. Elinore McCance-Katz and Gregory C. Warren, have disclosed no relevant, real or apparent personal or professional financial relationships.
DisclosuresGrant Funding from:National Institutes of Health National Institute on Drug Abuse National Institute on Alcohol Abuse and AlcoholismSubstance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment
What is SBIRT?SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur.
Why Do We Need SBIRT?Problem Substance Use is Prevalent in Americans SAMHSA, National Survey on Drug Use and Health, 2010
SBIRT Components• Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.• Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.• Referral to treatment provides those identified as needing more extensive treatment with access to speciality care.
Is SBIRT Effective?• SBIRT research has shown that large numbers of individuals at risk of developing serious alcohol or other drug problems may be identified through primary care screening.• Interventions such as SBIRT have been found to: – Decrease the frequency and severity of drug and alcohol use, – Reduce the risk of trauma – Increase the percentage of patients who enter specialized substance abuse treatment. – Be associated with • fewer hospital days • fewer emergency department visits • net-cost savings to the health care system from these interventions
What are the Benefits and Screening and Brief Intervention?• Strong evidence for the effectiveness of brief interventions with alcohol and tobacco use, growing support for use with other substances.• Minimal amount of time needed to conduct brief interventions.• Low-cost/cost-effective. For each dollar spent, it has been estimated that $2–$4 (per person) have been saved in terms of health costs and costs related to workforce productivity.Fleming, 2002; Gentilello, et al., 2005
How to Rapidly Screen for Alcohol ProblemsSingle Question with high sensitivity/specificity:• In the past year, have you had any times when you had 5 (for women, 4) or more drinks at one sitting?• If yes, explore drinking, offer advice for cutting back or stopping, if evidence of dependence refer to substance abuse treatment facility• Note: a single question does not make a diagnosis, but indicates a need for further screening
What Can the Primary Care Physician Use to Treat Substance Use Disorders? Pharmacotherapy Review
General Considerations for SUD Pharmacotherapy" Tobacco: Relapse Preven>on-‐Yes, for oﬃce-‐based/outpa>ent prac>ce " Alcohol Acute withdrawal (usually done inpa>ent) Relapse Preven>on-‐Yes, for oﬃce-‐based/outpa>ent prac>ce " Opiates Acute withdrawal (oHen done inpa>ent, but can be outpa>ent procedure) Relapse Preven>on-‐Yes, for oﬃce-‐based/outpa>ent prac>ce " Cocaine/Methamphetamines/S>mulants No FDA approved medica>ons for withdrawal symptoms or relapse preven>on
Cigarette SmokingVarenicline Nico>ne par>al agonist Decreases craving to smoke May be useful in co-‐occurring tobacco dependence and alcohol abuse Twice daily oral medica>on to be started 1 week before quit date (.5 mg/d x 3; .5 BID x 3; 1 mg BID) Length of Treatment: 12 weeks Monitor for depression/suicidal thinking No abuse liability
Maintenance Medications To Prevent Relapse To Alcohol Use (FDA approved) • Disulfiram • Naltrexone (oral and injectable) • Acamprosate
Disulfiram" How it Works: Blocks alcohol metabolism leading to increase in blood acetaldehyde levels; aims to mo>vate individual not to drink because they know they will become ill if they do " Disulﬁram/ethanol reac>on: ﬂushing, weakness, nausea, tachycardia, hypotension Treatment of alcohol/disulﬁram reac>on is suppor>ve (ﬂuids, oxygen) " Side Eﬀects: Common: metallic taste, sulfur-‐like odor Rare: hepatotoxicity, neuropathy, psychosis " Contraindica>ons: cardiac disease, esophageal varices, pregnancy, impulsivity, psycho>c disorders, severe cardiovascular, respiratory, or renal disease, severe hepa>c dysfunc>on: transaminases > 3x upper level of normal " Avoid alcohol and alcohol containing foods " Clinical Dose: 250 mg daily (range: 125-‐500 mg/d) " Adherence: problem; but if drug is taken it works well (Fuller et al. 1994; Farrell et al. 1995); good idea to start in a substance abuse treatment program
Naltrexone" Potent inhibitor of mu opioid receptor binding may explain reduc>on of relapse " because endogenous opioids involved in the reinforcing (pleasure) eﬀects of alcohol May explain reduced craving for alcohol " because endogenous opioids may be involved in craving alcohol
How to Select a Medica5on for Alcohol Use Disorders " Disulfiram: when the patient is committed to no further drinking; heavy consequences of relapse" Naltrexone: for the patient who wants to cut back or get help for craving" Acamprosate: naltrexone doesn t work, patient needs opioid analgesia; disulfiram not an option
Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: NSDUH 2010 Source Where Respondent Obtained Bought on Drug Dealer/ Internet Stranger 0.4% Other 1 More than 4.4% 6.5% Source Where Friend/Relative Obtained One Doctor More than One Doctor 1.6% 3.3% Free fromOne Doctor Free from Friend/Relative 17.3% Friend/Relative 7.3% 55% One One Bought/Took Doctor from Bought/Took 79.4% Friend/Relative from Friend/Relative 79.4% 4.9% 14.8% Drug Dealer/ Stranger Other 1 1.6% 3.5%Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown.1 The Other category includes the sources: Wrote Fake Prescription, Stole from Doctor s Office/Clinic/ Hospital/Pharmacy, and Some Other Way.
Why Are Such Large Numbers of Opioid Medications Being Prescribed?
Prescribers have a mandate to relieve pain • But may not receive enough training on the various approaches to treatment of painPrescribers have a mandate not to prescribeto those with addiction • But may not receive enough training on recognition and treatment of substance use disorders
Opioids for Pain Management Chronic opioids for non-malignant pain presents potential problems: Lack of evidence for efficacy, particularly with high dose opioid therapy over long periods Syndrome of rebound pain/hyperalgesic states produced by opioid use Withdrawal syndromes masquerading as pain Balantyne et al., 2003
Why is All of This Important?• Drug and alcohol use disorders affect approximately 10% of Americans• Screening and early intervention= prevention!• Substance use disorders are chronic, relapsing diseases that are likely to recur once diagnosed• Effective pharmacotherapies are available and can be implemented in primary care• Substance abuse can negatively impact other illnesses present in the patient (e.g.: alcoholic cardiomyopathy, COPD, HIV/AIDS, HCV, other ID) and/or can masquerade as an illness that the patient does not have (e.g.: HTN, seizure d/o, mental disorders)• Can contribute to non-adherence to prescribed regimens, toxicities due to drug interactions
Clinical Support SystemsSponsored by Center for Substance Abuse Treatment/SAMHSA
References• Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcoholism: Clinical and Experimental Research 2002; 26: 36-43.• Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. JAMA 1997; 277:1039-45.• SAMHSA, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication # SMA 11-4658, Rockville, MD Substance Abuse and Mental Health Services Administration, 2011.• Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol interventions for trauma patients treatment in emergency departments and hospitals: a cost benefit analysis. Annals of Surgery 2005, 241:541-550.• Edwards et al. 2003• Fuller RK, et al.: Veterans Administration cooperative study of disulfiram in the treatment of alcoholism: study design and methodological considerations. Control Clin Trials. 1984 Sep;5(3): 263-73• O’Farrell TJ, et al.: Disulfiram (antabuse) contracts in treatment of alcoholism. NIDA Res Monogr., 150:65-91, 1995.• Garbutt JC, Kranzler HR, O Malley SS, Gastfriend DR, Pettinati HM, Silverman BL, Loewy JW, Ehrich EW: Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA 2005; 293: 1617-1625.• VA/DoD CPG SUDs, www.oqp.med.va.gov/cpg/SUD/SUD_Vase.htm• Donovan DM, et al.: Combined pharmacotherapies and behavioral interventions for alcohol dependence (The COMBINE Study): Examination of posttreatment drinking outcomes. J Stud Alcohol Drugs 2008 69: 5-13.• Anton RF, et al.: Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized, controlled trial. JAMA 2006 295 (17): 2003-2017.• McNicholas, L. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction: A treatment improvement protocol (TIP 40). Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2004.• U.S. Public Health Service: A clinical practice guideline for treating tobacco use and• dependence: A US public health service report. JAMA 2000; 283:3244–3254.
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