The Prescription Drug Epidemic:

The Prescription Drug Epidemic: Pills, Addictions, Deaths. What To Do About it? Michael M. Miller, MD, FASAM, FAPA 33rd Annual Behavioral Health & Addictive Disorders Conference U.S. Journal Training, Inc. February 14, 2012

Michael M. Miller, MD, FASAM, FAPAmmiller@rogershospital.orgMedical Director, Herrington Recovery Center (HRC)Rogers Memorial HospitalOconomowoc, WisconsinAssociate Clinical ProfessorUniversity of Wisconsin School of Medicine and Public HealthAssociate Clinical ProfessorMedical College of Wisconsin, Dept of Psychiatry & Behavioral HealthPast President and Board ChairWisconsin and American Societies of Addiction MedicineAt-Large DirectorAmerican Board of Addiction Medicine

Rogers treats children, adolescentsand adults with:• Anxiety disorders• Mood disorders• Eating disorders• Substance-use disorders 800-767-4411 rogershospital.org

Psychiatry (MD, DO)(General, Adult, Child/Adolescent, Geriatric, Forensic, Addiction)A medical specialty of physicians devoted to the diagnosisand treatment of mental disorders, usingpsychotherapy, medications, and other somatic therapies

Clinical Psychology (PhD, PsyD)A mental health discipline in which individuals with a doctoraldegree in psychology from an accredited professional schoolof psychology (the scientific study of the behavior ofindividuals and their mental processes) evaluate and treatchildren, adolescents, and adults using clinicalinterviews, psychological testing, and variousindividual, group, couples and family therapies.

Addiction Medicine:The specialty of medicine devoted todiagnosis, treatment, prevention, education, epidemiology, research, and public policy advocacy regarding addiction andother substance-related health conditions

How to Identify a Physician Recognized forExpertise in the Diagnosis and Treatment ofAddiction and Substance-related HealthConditions (ASAM Public Policy Statement)www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html

www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html• Completion of a residency/fellowship in Addiction Medicine or Addiction Psychiatry• Certification in Addiction Medicine by the American Society of Addiction Medicine (ASAM)• Subspecialty certification in Addiction Psychiatry by the American Board of Psychiatry and Neurology (ABPN)• A Certificate of Added Qualification in Addiction Medicine conferred by the American Osteopathic Association (AOA)• Board Certification in Addiction Medicine by the American Board of Addiction Medicine (ABAM)

Scope of Practice for Addiction MedicinePhysicians (ABAM)The addiction medicine physician provides medical care withinthe bio-psycho-social framework for persons with addiction,for the individual with substance-related health conditions,for persons who manifest unhealthy substance use, and forfamily members whose health and functioning are affected bysomeone‘s substance use or addiction.

Scope of Practice for Addiction MedicinePhysicians (ABAM)The addiction medicine physician is specifically trained in awide range of prevention, evaluation and treatment modalitiesaddressing substance use and addiction in ambulatory caresettings, acute care and long-term care facilities, psychiatricsettings, and residential facilities.Addiction medicine specialists often offer treatment forpatients with addiction or unhealthy substance use who haveco-occurring general medical and psychiatric conditions.

Prelude• Pain and addiction are both commonly experienced conditions.• General medical physicians, e.g. those in primary care or in emergency department settings, are called upon to treat patients with pain complaints and/or with substance use disorders—but they have had inadequate training in medical school and residency to address these presentations.

Prelude• There was great concern in the 1990s that physicians were overly/unnecessarily hesitant to prescribe opioid analgesics, even to patients with cancer, even to patients who were terminal.• A response was a public policy initiative to work with professional societies, licensure boards, and accreditation agencies to promote ‗balance‘ in opioid prescribing.

Prelude• A result was a major increase in recognition of pain as a focus of clinical care, but also a major increase in the number of opioid prescriptions written• Pain Medicine has expanded as a medical specialty, but specialists/subspecialists are unable to meet the demand for care—thus, patients on chronic opioid analgesic therapy present to emergency departments and 1° care, presenting new kinds of challenges

Prelude• There has also been an increase in recognition of substance use issues as a focus of clinical care• Addiction Medicine has expanded as a medical specialty, but specialists/subspecialists are unable to meet the demand for care; there has been a push to train generalists to become prescribers of buprenorphine and naltrexone, and patients methadone, Suboxone® (buprenorphine) and Vivitrol® (naltrexone) present to emergency departments and primary care—presenting new kinds of challenges

Prelude• Physicians who specialize in the treatment of pain and those who specialize in the treatment of addiction have been struck with how under-recognized these conditions have been in general medical settings – in response, there have been efforts to improve the recognition of these treatable states, so that suffering can be minimized and functioning enhanced, for individuals and for populations.

Inadequacy of docs to evaluate/manage pain• Too few specialists in Pain Med• Inadequate training on basic concepts of management• Many patients• Docs flooded with ‗demand‘ and ‗entitlement mentality‘

Inadequacy of docs to evaluate/manage addiction• Too few specialists in Addiction Med• Inadequate training on basic concepts of management• Many patients – most unrecognized• Docs flooded with ‗med-seeking patients‘ and patients with ‗dysfunctional behaviors‘• Docs, like the public, often don‘t distinguish between addiction and ‗unauthorized substance use‘

Under-responding to pain…• Comprehensive Cancer Center, UW-Madison• Pain Policy Project – UW-Madison• Survey of cancer patients, domestically and internationally• Survey of State Medical Board practice• Attention to ―opioiphobia‖ on the part of docs• Education to docs re: pain and pain meds• Policy changes at FSMB and JCAHO – a call for ―balance‖

Joint Commission Standard PC.01.02.07 ―The hospitalassesses and manages the patients pain‖Rationale for the Standard:• Patients can expect that their health care providers will ask them about whether they have pain. When pain is identified the individual is assessed based on his or her clinical presentation and in accordance with the care, treatment, and services provided by the organization.

Joint Commission Pain StandardEvidence of Performance:1 The hospital conducts a comprehensive pain assessment that is consistent with its scope of care, treatment, and services and the patient‘s condition. (See also PC.01.02.01, EP 2; RI.01.01.01, EP 8)2 The hospital uses methods to assess pain that are consistent with the patient‘s age, condition, and ability to understand.3 The hospital reassesses and responds to the patient‘s pain, based on its reassessment criteria.4 The hospital either treats the patient‘s pain or refers the patient for treatment.

There have been effortsto improve the case-findingby docs of cases of pain The Joint Commission Standard ―Pain as the 5th vital sign‖

PAIN ASSESSMENT: THE FIFTH VITAL SIGNCalifornia Assembly Bill 791 was signed into law by Governor GrayDavis, to be effective January 1, 2000.Section 1254.7 was added to the Health and Safety Code (HSC) as partof this bill. HSC 1254.7 reads:(a) It is the intent of the Legislature that pain be assessed and treated promptly, effectively, and for as long as pain persists.(b) Every health facility licensed pursuant to this chapter shall, as a condition of licensure, include pain as an item to be assessed at the same time as vital signs are taken. The health facility shall insure that pain assessment is performed in a consistent manner that is appropriate to the patient.The pain assessment shall be noted in the patient‟s chart in a mannerconsistent with other vital signs.

PAIN ASSESSMENT: THE FIFTH VITAL SIGNCalifornia Assembly Bill 791 was signed into law by Governor GrayDavis, to be effective January 1, 2000.This legislative mandate is consistent with state and federal concerns regardingappropriate pain management for all persons. The Veterans Administration hasadopted similar policies, referring to pain as the fifth vital sign.In 1994, the BRN adopted a pain management policy for RN practice and painmanagement curriculum guidelines for nursing programs. Both of thesedocuments include a standard of care for California RNs of assessing pain andevaluating response to pain management interventions using a standard painmanagement scale based on patient self-report. Nursing programs need tointegrate pain as the fifth vital sign into their curriculum and health facilitiesneed to educate staff regarding pain management. It is now required that allhealth care staff record pain assessment each time that vital signs are recordedfor each patient.

Measuring Pain as the 5th Vital Sign DoesNot Improve Quality of Pain Management• Mularski RA, White-Chu F,Overbay D, Miller, L, Asch SM, Ganzini L.• Journal of General Internal Medicine 21(6): 607–612. (2006)

Over-responding to pain…• Joint Commission standard: a ―right‖ to pain mgmt?• Proliferation of interventional pain clinics• Proliferation of opioid prescribing and ―pill mills‖• Under-attention to non-interventional approaches, non- opioid pharmacotherapy, non-pharmacological therapy• Expanding incidence of diversion, misuse, overdose, mortality, and cases of addiction

How did we get here?• More prescribers – Explosion of prescribing by primary care• More milligrams – Availability of new drug formulations: MS Contin, OxyContin, fentanyl in patch form• More patients – Aging population: more aches/pains – Successful expansion of markets by direct-to-consumer advertising

Increasing Use of Prescribed OpioidsManchikanti & Singh 2008Slide thanks to Marv Seppala, MD, Hazelden Foundation

Retail Sales of Opioid Medications (grams of medication 1997-2005) 1997 2005 % of Change Methadone 518,737 5,362,815 933% Oxycodone 4,449,562 30,628,973 588% Fentanyl Base 74,086 387,928 423% Hydromorphone 241,078 781,287 244% Hydrocodone 8,669,311 25,803,544 198% Morphine 5,922,872 15,054,846 154% Meperidine 5,765,954 4,272,520 -26% Codeine 25,071,410 18,960,038 -24%http:www.deadiversion.usdoj.gov/arcos/retail_drug_summary/index.htmlTable thanks to Marv Seppala, MD, Hazelden Foundation

Annual Numbers of New Nonmedical Users ofPsychotherapeutics: 1965-20002001 National Household Survey on Drug Abusehttp://www.oas.samhsa.gov/NHSDA/2k1NHSDA/vol1/toc.htm#v1Thanks to Marv Seppala, MD, Hazelden Foundation

Scope of the Problem• Between 1992 and 2003: – U.S. population increase of 14% – No. people abusing controlled prescription drugs jumped 81% 2x > than marijuana 5x > than cocaine 60x > than heroin• Prescription pain medications (Opioids) are now the 4th most abused substances in the U.S. – Behind marijuana, alcohol, and tobacco• Misuse of painkillers represents 3/4 of the overall problem of prescription drug abuse• Prescription medications are now the leading cause of accidental death for ages 18-34Drug Enforcement Administration www.justice.gov/deaThanks to Marv Seppala, MD, Hazelden Foundation

Persons Admitted for Addiction Treatment areMore Often Having Diagnoses of Opioid Use Disorder• The proportion of all SUD treatment admissions where opioid analgesic abuse or dependence is mentioned, increased more than four-fold between 1998 and 2008.• The proportion of SUD treatment admissions for persons ages 12-24 where opioid analgesic abuse or dependence is mentioned, increased more than eight-fold between 1998 and 2008.

Emergency Department Visits DAWN Data 1995 - 2005

Treatment Admissions for Pain Medications• The proportion of all substance abuse treatment admissions (that reported any pain medication abuse) increased more than four-fold between 1998 and 2008.• The increase in those age 12-24 increased approximately eight-fold.

―Non-Medical Use‖ of Prescription Opioids• Where are these medications coming from? How many patients who had an overdose ever had a legitimate prescription for the medication they overdosed on?• What do persons report is the source of the prescription opioids that they‘re using? – Their own doctor? – A family member who got it from their own doctor? – A friend who got it from their own doctor? – A dealer? – Multiple sources?

The ―One Doctor‖ Source forPrescription Drugs• According to NSDUH 2008 data, only 1 in 20 nonmedical users (4.3%) of prescription pain relievers got them from a drug dealer.• In most cases, prescription drugs obtained for nonmedical purposes originated from a single doctor – rather than from multiple sources (the Rx could have been written for them, or could have been obtained from a different ―legitimate patient‖ of a single prescriber who authorized it in the course of routine medical/dental practice)

JAMA Article April 2011 plus editorial byVolkow and McLellanFrom 1991 to 2009, prescriptions for opioid analgesicsincreased almost threefold, to over 200 million. According tothe Drug Abuse Warning Network system, which monitorsdrug-related emergency department visits and drug-relateddeaths, emergency room visits related to the nonmedical useof pharmaceutical opioids has doubled between 2005 and2009.

JAMA Article April 2011 plus editorial byVolkow and McLellan• The sample included 79.5 million prescriptions dispensed in the United States during 2009, which represent almost 40 percent of all the opioid prescriptions filled nationwide.• Most abusers report getting these medications from friends and relatives who had been prescribed opioids, or they are abusing their own medications.• The records show that approximately 56 percent of painkiller prescriptions were given to patients who had filled another prescription for pain from the same or different providers within the past month.

JAMA Article April 2011 plus editorial byVolkow and McLellan• Nearly 46 percent of opioid prescriptions were given to patients between ages 40 and 59, and most of those were from primary care providers.• Nearly 12 percent of opioids prescribed were to young people aged 10-29. Dentists were the main prescribers for youth aged 10-19 years old.

It‘s not just diversion and misuseIt‘s O.D.s and Overdose Deaths

Accidental Deaths Due to Prescribed Opioids• Between 1999 and 2002: – The number of opioid analgesic poisonings on death certificates increased 91.2% – Heroin poisonings increased 12.4% – Cocaine poisonings increased 22.8%• 2007: The second leading cause of injury/death (after motor vehicle accidents)• 2009: The number of deaths secondary to prescription drugs was 4 times the number due to illicit drugs.Machikanti 2007 MMWR 7/8/11Slide thanks to Marv Seppala, MD, Hazelden Foundation

Opioid Deaths are #1 Rx Drug DeathsPrescription Opioid O.D. Deaths Outpace Heroin Deaths

The CDC used death certificates to determine that there were 45,000traffic accident deaths in 2006 and about 39,000 drug-induced deaths—pooled US data

Responding to the epidemic• Return to restrictive prescribing practices and opiophobia• Training of prescribers re: reasonable limits on numbers of doses/refills authorized• Recognition of data on efficacy: what really is ‗best practice‘?• Making medication formulations more safe• Practices to better manage supplies in the community – Lock Your Meds, Take Back your meds, safe disposal of medication supplies

Responding to the epidemic The White House Office of National Drug Control Policy (ONDCP) ―EPIDEMIC: RESPONDING TO AMERICA‘S PRESCRIPTION DRUG ABUSE CRISIS‖http://whitehousedrugpolicy.gov/publications/pdf/rx_abuse_plan.pdf

ONDCP Strategy on PDA• Education: patients, parents, youth, and health care professionals• Monitoring: Prescription Drug Monitoring Programs (PDMPs), multi-state data-sharing• Rx Disposal• Enforcement

Responding to the epidemic• Controlled Substances Workgroup (CSW), Prevention Committee, Wisconsin State Council on Alcohol and Other Drug Abuse (SCAODA)• California http://www.adp.ca.gov/Director/pdf/Prescription_Drug_Task_Force.pdf• Ohio http://www.odh.ohio.gov/features/odhfeatures/drugod/drugoverdose.aspx• Maryland http://www.oag.state.md.us/Reports/PrescriptionDrugAbuse.pdf• Washington State• Medical Society of Georgia Foundation

ONDCP Strategy on PDA:Health Provider Education• Work with Congress to amend Federal law to require practitioners (such as physicians, dentists, and others authorized to prescribe) who request DEA registration to prescribe controlled substances to be trained on responsible opioid prescribing practices as a precondition of registration. This training would include assessing and addressing signs of abuse and/or dependence. (ONDCP/FDA/DEA/SAMHSA)• Require drug manufacturers, through the Opioid Risk Evaluation and Mitigation Strategy (REMS), to develop effective educational materials and initiatives to train practitioners on the appropriate use of opioid pain relievers. (FDA/ONDCP/SAMHSA)

ONDCP Strategy on PDA:Health Provider Education• Federal agencies that support their own healthcare systems will increase continuing education for their practitioners and other healthcare providers on proper prescribing and disposal of prescription drugs. (VA/HHS/IHS/DOD/BOP)• Work with appropriate medical and healthcare boards to encourage them to require education curricula in health professional schools (medical, nursing, pharmacy, and dental) and continuing education programs to include instruction on the safe and appropriate use of opioids to treat pain while minimizing the risk of addiction and substance abuse

Prescription Drug Monitoring Programs(PDMP)• The National All Schedules Prescription Electronic Reporting (NASPER) Act, was signed into law on August 11, 2005 – Authorized $60 million to establish or improve state-run Prescription Drug Monitoring Programs (PDMP) which analyze prescription data – The Department of Justice and SAMHSA continue to fund grants• PDMP can identify individuals, physicians, or pharmacies that have unusual patterns suggesting drug diversion, abuse, or doctor shopping

Prescription Drug Monitoring Programs(PDMPs)• The National All Schedules Prescription Electronic Reporting (NASPER) Act, was signed into law on August 11, 2005 – Authorized $60 million to establish or improve state-run Prescription Drug Monitoring Programs (PDMP) which analyze prescription data – The Department of Justice and SAMHSA continue to fund grants• PDMP can identify individuals, physicians, or pharmacies that have unusual patterns suggesting drug diversion, abuse, or doctor shopping

Responding to the epidemicPDMPs1. What is a prescription drug monitoring program (PDMP)? According to the National Alliance for Model State Drug Laws (NAMSDL), a PDMP is a statewide electronic database which collects designated data on substances dispensed in the state. The PDMP is housed by a specified statewide regulatory, administrative or law enforcement agency. The housing agency distributes data from the database to individuals who are authorized under state law to receive the information for purposes of their profession.2. Does the Drug Enforcement Administration (DEA) oversee PDMPs? The DEA is not involved with the administration of any state PDMP. Q&A on webpage of DEA‘s Office of Diversion Control http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm

Responding to the epidemicPDMPs3. What are the benefits of having a PDMP? The overview provided by NAMSDL clearly identifies the benefits of a PDMP: as a tool used by states to address prescription drug abuse, addiction and diversion, it may serve several purposes such as: – support access to legitimate medical use of controlled substances, – identify and deter or prevent drug abuse and diversion, – facilitate and encourage the identification, intervention with and treatment of persons addicted to prescription drugs, – inform public health initiatives through outlining of use and abuse trends, and – educate individuals about PDMPs and the use, abuse and diversion of and addiction to prescription drugs.

Responding to the epidemicPDMPs4. Which states currently have a PDMP? According to the Alliance of States with Prescription Monitoring Programs, (www.pmpalliance.org) as of October 16, 2011, 37 states have operational PDMPs that have the capacity to receive and distribute controlled substance prescription information to authorized users. Eleven states) and one U.S. territory (Guam), have enacted legislation to establish a PDMP, but are not fully operational.

PDMPs• In 1992 only 10 states had a PDMP – In 1998, California created its Controlled Substance Utilization Review and Evaluation System (CURES). 7500 pharmacies and 158,000 prescribers report information and can review patient medications.• Now 43 states have operational PDMPs in place• Only 3 states – Kentucky, Nevada & Utah – routinely provide their information proactively to physicians• Rarely is data from Methadone Clinics (Opioid Treatment Programs, OTPs) included in a state‘s PDMP database!

ONDCP Strategy on PDA:Proper Drug Disposal• While the administrative process to establish the DEA medication disposal rule is underway,19 DEA and other Federal agencies shall conduct additional take-back activities. Information about the take-back events shall be distributed to local anti-drug coalitions and other organizations (chain pharmacies, boards of pharmacies, boards of medicine, environmental agencies, etc). (DEA/ONDCP)• Once DEA regulations on controlled substance prescription drug disposal have been established, develop and execute a robust public education initiative to increase public awareness and provide education on new methods of safe and effective drug return and disposal. (ONDCP/ EPA/DEA/FDA/CDC/HHS/SAMHSA/NIDA)• Once DEA regulations have been established, engage PhRMA and others in the private sector to support community-based medication disposal programs. (ONDCP/FDA/DEA/HHS/CDC/ SAMHSA/EPA)

Responding to the epidemicPublic EduationPartnership for a Drug Free America www.drugfree.orgPreventing Teen Abuse of Prescription Drugs• FACT SHEET

Wisconsin State Council on AODASCAODA Prevention CommitteeControlled Substances Workgroup (CSW)http://scaoda.state.wi.us/docs/prevandspfsig/FINAL01032012 CSWReport.pdf

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Fostering Healthy Youth• Recommendation 1: Support communities to foster healthy youth.Priority Area: Community Engagement & Education• Recommendation 2: Launch a public outreach and education campaign.• Recommendation 3: Support community coalitions as the vehicle through which communities will successfully prevent and reduce prescription drug diversion, abuse and overdose deaths.

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Health Care Policy and Practice• Recommendation 4: Mandate education and training health care professionals.• Recommendation 5: Ensure that chronic pain sufferers have safe and consistent access to care.• Recommendation 6: Establish standard prescribing practices for urgent care and emergency departments.• Recommendation 7: Develop standard screening methodologies for drug-testing labs to use in detecting the presence of drugs to include all commonly misused opioids, benzodiazepines, psychostimulants, and related agents, and assure that drug-testing methodologies used in clinical settings and in post-mortem settings (including the State Crime Lab system) are aligned in order to generate the most consistent and useful data.

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Health Care Policy and Practice• Recommendation 8: Develop a standard set of treatment protocols for Opioid Treatment Programs (OTPs).• Recommendation 9: Establish guidelines to reduce the diversion of prescription drugs by those who handle prescription medications in the course of their daily work.• Recommendation 10: Equip health care providers and first responders to recognize and manage overdoses.• Recommendation 11: The Wisconsin Dental Association and Wisconsin Dental Examining Board should endorse the findings of the Tufts Health Care Institute Program on Opioid Risk Management and the School of Dental Medicine, Tufts University.

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Prescription Medication Distribution• Recommendation 12: Convene a work group to develop recommendations to increase security measures in the dispensing of prescriptions for controlled substances.• Recommendation 13: Implement a system to ensure that, for controlled substance prescriptions, patients are identified in a manner similar to photo identification as required to obtain pseudoephedrine.• Recommendation 14: Support a system that increases security and traceability of controlled substances from manufacturer to patient.

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Prescription Medication Disposal• Recommendation 15: Establish a coordinated statewide system for providing secure, convenient disposal of consumer medications from households.• Recommendation 16: Integrate medication collection with the Wisconsin Drug Repository.• Recommendation 17: Create an infrastructure for the destruction of drugs in compliance with state and federal environmental regulations.• Recommendation 18: Identify the causes for prescription drug waste and implement proactive solutions.

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Prescription Medication Disposal• Recommendation 19: Identify a sustainable means for funding collection and disposal in cooperation with key stakeholders including pharmaceutical producers, local governments, law enforcement, waste management companies, health care providers, pharmacies and consumers.• Recommendation 20: Establish a system for effective disposal of consumer medications in all care programs and facilities which complies with state and federal waste management laws.

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Prescription Medication Disposal• Recommendation 21: Establish regulations that would permit registered nurses employed by home health agencies and hospices to transport unused medications, including controlled substances, to designated drug drop-off and disposal facilities, so that when patient medications are no longer needed, such nurses are allowed by law to assist in their safe destruction.

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Law Enforcement and Criminal Justice• Recommendation 22: Build bridges between law enforcement and community-based prevention efforts.• Recommendation 23: Make drugged driving a priority issue.• Recommendation 24: Support drug courts.

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Surveillance System• Recommendation 25: Design and implement an electronic Prescription Drug Monitoring Program (PDMP).• Recommendation 26: Develop a community early warning and monitoring system that tracks use and problem indicators at the local level.• Recommendation 27: Develop a community monitoring and early warning and monitoring system that tracks overdoses at the local level.• Recommendation 28: Improve consistency in reporting drug use and abuse across the state.

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Early Intervention, Treatment & RecoveryAcross Lifespan• Recommendation 29: Establish guidelines to screen for substance use in all health care settings.• Recommendation 30: Promote and support evidence-based screening and early intervention for mental health and substance abuse.

Responding to the epidemic: Wisconsin State CouncilControlled Substances Workgroup RecommendationsPriority Area: Early Intervention, Treatment & RecoveryAcross Lifespan• Recommendation 31: Integrate high quality medication management and psychosocial interventions for substance use disorders so that both are available to consumers as their conditions indicate.• Recommendation 32: Make addiction treatment and recovery support services available both on a stand-alone and integrated basis with primary health care services, as well as in other relevant community settings.

STRETCH!

Responding to the epidemic• Community Coalitions (CADCA, others)• Education of Patients by Prescribers• Education of Prescribers re: best practices• Better Data – Mortality statistics – Accurate death certificates – Accurate toxicology at time of death; aligning drug testing procedures for the living and the dead

Responding to the epidemic• Better disposal of unused supplies – If they‘re there, keep ‗em locked – If they‘re not needed, bring them to safe collection site – Change laws/procedures to allow for well-recognized legal collection sites

What about ―going upstream‖ fromtreatment, to PREVENTION?• Reducing availability of prescription drugs for diversion (and misuse, and overdose)?• By educating physicians and dentists to prescribe less often, to authorize smaller supplies, to have fewer refills, and to monitor all patients on such medications?• By educating parents as to their role in keeping drug supplies locked away and safe?

Responding to the epidemicPrevention Strategies: “Lock Up Your Meds”• ―You are the Key‖• National Family Partnership: www.nfp.orgThe responsible parties are: • PARENTS and GRANDPARENTS • PHYSICIANS who can educate parents about their role

www.nfp.org• Affiliates Alert• TVAds• Radio Ads• Multimadia Slide Show• Communication Gap• MEDucation Kit• Logos• Leave Behind Card• Sponsor solicitation slides• Parent Guide Brochure

http://mccrearyrecord.com/x316477008/Are-you-an-Accidental-DealerAre you an ‗Accidental Dealer‘?• Operation UNITE launches prescription awareness campaign• By JANIE SLAVEN News Editor The McCreary County Record Tuesday January 25, 2011, 01:05 PM EST• WHITLEY CITY — A University of Kentucky study has shown rural teenagers in Kentucky are 26 percent more likely to abuse prescription drugs than those living in urban areas.

The CDC is Paying AttentionData from the National Vital Statistics System Mortality File:• From 1999 through 2006, the number of fatal poisonings involving opioid analgesics more than tripled from 4,000 to 13,800 deaths.• Opioid analgesics were involved in almost 40% of all poisoning deaths in 2006. .• In about one-half of the deaths involving opioid analgesics, more than one type of drug was specified as contributing to the death, with benzodiazepines specified with opioid analgesics most frequently.• In 15 states, opioid deaths exceed highway traffic deaths

New Policy Initiative: Washington State• Interagency Guideline on Opioid Dosing for Chronic Non- Cancer Pain• The Washington State Medical Quality Assurance Commission (MQAC)• http://www.wsma.org/medical_professionalism/clinicalresou rces.cfm#painPain_Management_Guidelines• Effective 7.1.11 for DOs, DPMs, DDSs, nurses and osteopathic PAs• Effective 1.2.12 for MDs and their PAs

Responding to the epidemic―Washington State Guidelines‖• Requirements re: patient evaluation and periodic review• Requirements re: signed informed consent, written treatment plans, and written ―treatment agreements‖• Mandatory consultation for any patient that is receiving > 120 mg morphine equivalent dose (MED), with certain exemptions

Equivalent Dose (mg) ChartDoses equal to Dose (mg) per 24 hrMorph 10mg IM IV/IM PO/PRCodeine 130 200Fentanyl 0.1 N/AFentanyl Patch* (mcg/hr*) = *16.7Hydrocodone N/A 30Hydromorphone 1.5 7.5Levophanol 2 4Meperidine 75 300Methadone 10 20Morphine 10 20Nalbuphine 10 N/AOxycodone N/A 30Pentazocine 60 180Propoxyphene N/A 130Sufentanil 0.01-0.02 N/ATramadol N/A (?) 150

Summary: the POLICY side• States and their Medical Licensing Boards are involved, as well as the FSMB• The CDC is involved• The federal treatment agencies are involved (SAMHSA/CSAT)• The federal research agencies are involved (NIDA)• The federal policy agencies are involved (the White House ―Drug Czar‘s Office‖)

Responding to the epidemicCDChttp://www.cdc.gov/media/pressrel/2010/s100603.htm?s_cid=media rel_s100603• CDC Statement Regarding the Misuse of Prescription Drugs (Press Release, June 3, 2010)• November 2011 http://www.cdc.gov/vitalsigns/PainkillerOverdoses/ Prescription Painkiller Overdoses in the US

CDC Vital Signs, November 2011Related Pages• Vital Signs: Overdoses of Prescription Opioid Pain Relievers–United States, 1999– 2008 (link to come): Morbidity and Mortality Weekly Report (MMWR)• CDC Feature- Prescription Painkiller Overdoses in the U.S.• Prescription Painkiller Overdoses in the U.S. – What You Need to Know [PODCAST - 1:15 minutes]• Sobredosis de medicamentos recetados para el dolor en los EE. UU.: Lo que usted necesita saber [PODCAST - 1:39 minutes]• Prescription Painkiller Overdoses in the U.S. – What You Need to Know [PSA - 0:60 seconds]• Policy Impact: Prescription Painkiller Overdoses• Unintentional Poisoning• Home and Recreational Safety

CDC Vital Signs, November 2011Related Pages: On Other Web Sites• The White House - Office of National Drug Control Policy• SAMSHA – Substance Abuse and Mental Health Services Administration• Drug Enforcement Administration – Office of Diversion Control• National Institute on Drug Abuse – Prescription Medications• U.S. Food and Drug Administration - Drugs Information• MedlinePlus - Pain Relievers• MedlinePlus - Prescription Drug Abuse

The Interface of Policy and Practice• If not enough pain is recognized, and not enough pain is treated, is that an ―imbalance‖?• If regulators/criminal justice are trying to control supplies and penalize physicians, is that ―imbalance‖?• If not enough addiction is recognized, if he addictive potential of prescription drugs is under-appreciated, is that ―imbalance‖?

What can we do in the meantime?• There are patients with pain• There are patients who engage in ―non-medical use‖ of pain meds• There are patients who develop addictionWhat can happen in the clinical world to restore balance …and so that we won‟t have “more pain patients” becomingtranslated into “more addiction patients” and “more coroners‟cases”?

So, what would ―real balance‖ in clinical care look like?• Clear understanding of pain• Clear understanding of addiction and the range of substance use conditions• Balance in prescribing practices--no one is stigmatized, excluded, under-treated• Improved pharmacotherapy of pain and pharmacotherapy of addiction

So, what would ―real balance‖in clinical care look like?• Clear understanding of pain• Clear understanding of addiction and the range us substance use conditions• Balance in prescribing practices• Improved pharmacotherapy of pain and pharmacotherapy of addiction

Pain: Clinical Definition―Whatever the patient states it is unless provenotherwise by poor adherence to the agreedupon medical regimen.‖ – Fishman, et al, Journal of Pain and Symptom Management, Vol. 20 (2000)

Acute Pain vs. Chronic Pain• Acute Pain – Sudden onset, usually sharp in quality – Serves as a warning of disease or a threat to the body – Multiple causes: Broken bones, cuts, burns, surgery, infection…• Chronic Pain – Persists, lasting longer than 3-6 months – Serves no useful purpose; may continue after healing of an injury – Assumes control of the individual(Slide thanks to Marv Seppala, MD, Hazelden Foundation)

Chronic Pain Syndrome• Intractable pain of more than 6 months duration• Marked alteration in behavior, restriction in daily activities• Excessive use of medication and medical services• No clear relationship to organic disorder - multiple nonproductive tests/treatments/surgeriesOffice of Disabilities, Social Security Administration

Chronic Pain by the Numbers• 116 million people in the U.S. suffer from chronic pain• Low back pain is the most common type, affecting 28% of the population• Knee pain is second at 20% of the populationIOM ReportRelieving Pain in America

Characteristics of PatientsReferred to Pain Management(or is this a list of characteristics of patients referred forAddiction Management?)• Report high level of psychological distress• Display high levels of psychopathology• Report high levels of functional impairment• Have work / M.V.A. related injuries• Frequent use of health care system• Complain of constant pain• Have had prior surgery (ies) for pain• Are using narcotic medications

Chronic Pain Syndrome:Common Presentation• Mood disturbance (irritable, depressed, anxious, angry)• Sleep disturbance• Physical deconditioning• Work, vocational, financial, legal issues• Weight changes• Psychiatric illness• Alcohol or other drug misuse/addictionSlide: courtesy of Marv Seppala, MD, Hazelden Foundation

Pain Complaints• The pain is an appropriate/legitimate response to injury/illness/pathophysiology.• The complaint has a legitimate/organic bases but is an amplification of appropriate/legitimate distress.• The complaint represents a psychiatric disorder rather than somatic injury/illness• The complaint is a manifestation of an addictive disorder.

Psychiatric States in which Pain Complaintscan be Manifest• Major depression with somatization• Major depression with psychosis• Conversion disorder• Psychogenic pain disorder• Somatization disorder• Anxiety disorder• Borderline personality, histrionic personality, narcissistic personality, antisocial personality• Munchausen‘s syndrome (factitious disorder)

Manifestation of an addictive disorder• Addiction—out-of-control use; deterioration of functioning over time; continued substance use despite adverse consequences; the substance becomes the central reinforcer in the person‘s life; use in order to experience euphoria or too feel ―normal‖• Often diagnosed longitudinally in the pain patient (the more meds you give, the worse the patient looks and gets, cf. pain disorder where the more meds you give, the better the patient functions (ideally)• Withdrawal—often seen in addiction, but sometimes present without addiction; ‗normal‘ physiological process

Is it Addiction or Pseudoaddiction?• Pseudoaddiction: a syndrome of maladaptive behavior indicating not true addiction, but at attempt on the part of the patient to obtain relief of under-treated pain• Preoccupation, seeking supplies, phone calls between refills, ER visits, and even doctor-shopping and securing illicit supplies, can indicate pseudoaddiction

Is it Addiction or Pseudoaddiction?• Addiction: taking more meds leads to decrease in function• Pseudoaddiction: taking adequate dose of opioids improves function and ends pattern of maladaptive behaviorsREMEMBER: it’s not the medication that’s pathological;opioids are not intrinsically evil!

Addiction vs. Pseudoaddiction• Addiction is diagnosed prospectively: Aberrant behavior worsens despite the best attempts at a rational treatment plan by the physician• Pseudoaddiction is diagnosed retrospectively: Aberrant behavior normalizes with a rational treatment plan.

Pathological Pattern of Use =Misuse, Non-Medical Use• Stealing scripts, forging scripts, altering scripts, calling in scripts• Using via alternate route of administration• Using for an indication other than the intended, e.g., for relief of depression/ anxiety/insomnia/‘stress‘ vs. pain• Amplifying or fabricating symptoms in order to obtain additional supplies

Medication Seeking• Conscious manipulation of healthcare professional – For others – For sale – For self - cases of opioid addiction• Seeking supplies for ―relief use‖ ― Treatment of anxiety ― Treatment of depression ― Treatment of withdrawal

Medication Seeking• Seeking supplies for treatment of general medical condition not actually present – Somatization disorder – Psychogenic pain disorder• Pseudo addiction – seeking medication because of under treatment of legitimate injury/illness

Aberrant Drug-Related BehaviorsMore Predictive Less Predictive• Selling Prescription Drugs • Aggressive complaining about the• Prescription forgery need for higher doses• Stealing or ―borrowing‖ drugs from • Drug hoarding during periods of another patient reduced symptoms• Injecting oral formulations • Requesting specific drugs• Obtaining prescription drugs from non- • Prescriptions from other physicians medical sources • Unsanctioned dose escalation• Concurrent abuse of related illicit drugs • Unapproved use of a drug• Multiple, unsanctioned dose • Reporting psychic effects not intended escalations by the physician• Repeated episodes of lost prescriptions Portenoy 1996

Assessing Aberrant BehaviorWhat does it mean?• Aberrant behavior may mean out of control use of a drug, which is a symptom of addiction• Aberrant behavior may suggest inadequate pain management• ―Aberrant Behavior‖ by a pain patient is not, in and of itself, not diagnostic; it must be interpreted and addressed in the clinical context

True ―Medication Seeking‖• Patient demands one agent only, claims nothing else works.• Patient is impatient and speaks only of meds—not of non- medication approaches, not even of his/her symptoms• Patient returns again and again seeking early supplies, with odd stories (lost/missing).• Patient requests more of the agent even when manifesting impairment from use (sedated, ataxic, incoherent).

Danger Signs of Abuse / AddictionAsk: ―Have you ever….‖• Had a problem with prescription drug use?• Been treated for addiction to prescription drugs?• Taken __ in doses greater than your doctor ordered?• Taken __ in a way [route of admin.] different than Rx‘d?• Taken any __ even if it was [impairing your function]?• Taken __ for a reason other than what the medicine was intended for, e.g., a pain med for anxiety/sleep?• Gotten a ‗high‘ from taking __, and then taken it in order to get that high? [can be energy boost not just euphoria]

Danger Signs of Abuse / AddictionAsk: ―Have you ever….‖• Used some __ from a friend/family member‘s supplies?• Obtained __ from more than one doctor at once, without the other doctor‘s knowledge/permission?• Made up a symptom in order to get a prescription?• Over-stated a symptom in order to get a prescription?• Bought any supplies from a non-medical source?• Taken any __ from someone‘s medicine cab./ purse?• Altered a prescription? Forged /called in a Rx?• Stolen any __? Stolen a prescription pad?

―Red Flags‖ to look forCheck the patient‘s chronic pain management history forthese ―Red Flags‖ that might point to potential problems:• Excessive use of medications• Lack of progress in physical therapy• Diagnosis of addictive illness including nicotine• Prior injuries/chronic pain condition• Failure to follow up on or irregular attendance with providers for therapy or medical appointments

There are various types of pain,and various terms to describe them• Somatic or visceral pain – Eudynia• Neuropathic pain – Maldynia• Acute pain and chronic pain – Acute injury/inflammation – Pain associated with terminal conditions – Chronic non-cancer pain

There are various types of pain,and various terms to describe them• Psychological pain• Physical pain• Nociceptive pain• Other pathological pain states – Hyperalgesia – Allodynia – Phantom-limb pain

How to approach• Somatic/visceral/nociceptive pain: – Responds well to opioids, NSAIDS, ASA/Tylenol, and probably sedatives• Neuropathic pain: – Responds poorly to opioids, well to tricyclics, anticonvulsants (gabapentin, carbamazepine), Lyrica, Cymbalta• Depression with physical symptoms: – Responds well to SSRIs, TCADs, anticonvulsants, and somewhat to anxiolytics

How to approach• Hyperalgesia responds well to reducing opioids• Psychogenic pain/somatoform disorders require psychotherapy and a long-term relationship; they do not respond well to opioids or other general pharmaco- therapies, and patients are at risk as well for overuse of benzo‘s• Patients with borderline personality, histrionic personality may have somatic pain

Range of Conditions Or, looked at another way:• Use • Use• Misuse• Risky Use • Unhealthy Use• Problem Use – ‗heavy drinking‘ – ‗non-medical use‘• ‗Abuse‘ – ‗use despite consequences‘• Addiction – ‗binge drinking‘• Disability – ‗harmful use‘ (IVDU)• Death • Addictive Use

Addiction is only one of theSubstance-Related Disorders• Addiction (DSM-IV Substance Dependence)• Problem Use (DSM-IV Substance Abuse)• Intoxication States• Withdrawal States• Substance-Induced Medical Problems• Substance-Induced Psychiatric Problems• Health Problems linked to Secondary Use

Terminology is complicatedand not consistentAddiction vs. dependenceAddiction vs. pseudoaddictionDependence vs. abusePhysical vs. psychological

―Physical Dependence‖ =Tolerance and WithdrawalRepeated administration of opioids that activate the mureceptor results in dose-dependent physical dependence andopioid tolerancePhysical dependence and tolerance manifest as characteristicwithdrawal signs and symptoms (the opioid withdrawalsyndrome) upon (1) reduction or cessation of opioiduse/administration or (2) the administration of an antagonist ora partial agonist in a person with established tolerance

What is Addiction?• Substance use (= reward, relief, from alcohol/drugs/behaviors)• Use behaviors and procurement behaviors persist despite problems due to use• Return to use after periods of abstinence, despite previous problems• Inability to consistently control use• Preoccupation with use/procurement; salience of use-related behaviors• Cognitive changes (over-valuation, de-valuation, minimization/denial)• Enhanced cue responsiveness via conditioning and generalization

The Definition of Addiction(ASAM, AAPM, APS – 2001)• Addiction: a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.• Physical Dependence: a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

AddictionIts onset and progression (genesis and pathogensis)result from genetic, psychosocial, and environmental/cultural influences

AddictionNew Definition fromAmerican Society of Addiction Medicinewww.asam.org/DefinitionofAddiction-LongVersion.html

AddictionResults from interactions among• Agents• Biology• Context »Substances »Hosts »Environments

Opioids don‘t cause opioid addictionAddiction arises due to interactions among agents(e.g., opioids), vulnerable hosts (persons with increasedgenetic risks or psychiatric comorbidities), andenvironments (stresses, drug availability, cultural issues).

Prescription OpioidUse/Misuse/Addiction Nathaniel Katz, MD, Tufts University School of Medicine Presentation at APA Meeting 2006

Katz‘s data• 33-45% of persons with opioid use disorder report that their first supply was a prescription from a physician• Rates of co-morbid SUD in chronic pain patients is 20-40%• Most prescription opioid abusers obtain drugs from either their own prescriptions or from prescriptions written for family members of friends• A significant minority of prescription opioid abusers were not at apparent high risk prior to first exposure• Katz, in Clinical Journal of Pain 18:S76 2002: 21% of persons with no ‗aberrant behaviors‘ have a urine drug test positive.

Katz‘s dataWe are lacking data so we can have a more intelligent discussion.Data submitted for publication by Katz et al.:• Opioids dispensed per year USA: 190 mil prescriptions, 9.5 billion doses• Non medical users in last year (NSDUH) = 11 million people• 430 million non-medical use days• Minimum of 430 million abused doses (only 1/day)• Ratio of Non-medical use days to Medical use days = 0.22.

Why a Person with Addiction Would SeekDrugs for Their Own Use• To produce euphoria• To manage an acute opioid withdrawal syndrome• To relieve post-acute opioid withdrawal symptoms

Clinical Management:So, how DO we prescribe ‗properly‘?

Management• Treat acute pain as acute pain• Give thoughtful consideration to the likelihood that a non- opioid (e.g., NSAID) may be effective• If authorizing an opioid write for only a reasonable number of doses, and if you have no established relationship with the patient, no refills

Management• If it‘s chronic pain, are you sure that opioids will make a long-term difference?• Might we all change our thinking, and if we do use opioids when ‗chronic pain‘ is clearly the problem, might we envision only a short-term trial and make this clear to the patient?• Place the prescribing of opioids into a context, including treatment agreements and monitoring

Management• Is there a ―treatment agreement‖ or ―pain contract‖ in place? – Are you operating within the parameters of the treatment agreement? – Are you operating outside of the parameters of the treatment agreement?• What is the patient ―being held to‖ and what is the prescriber ―being held to‖

Provider Obligations• Keep clear records of # of pills authorized per office visit, number of refills, date that the authorization is expected to last until• Monitor clinical progress: keep clear records of the patient‘s response to treatment – Symptom reduction – Functional impairment• Utilize collaterals to validate patient self-reports• Monitor adherence and non-adherence via drug testing• If the patient violates the contract, do you do what the contract says you will do in response to that?

Management• ‗Lost supplies‘ – listen to story; your response is a judgment call – fill for 1-2 days only: get management back in the hands of the regular Rx-er• ‗Violated contract / loss of provider‘ – listen to story; your response is a judgment call – fill for 1-2 days only: get management back in the hands of the PCP – you don‘t have to given an opioid; you can respond to the patient‘s loss of regular / legitimate opioid supplies, and offer to manage any acute withdrawal

Management:Tips for Prescribers• Maybe the most therapeutic thing you can do is not to give an opioid• RECALL: the WAY you do this is a key• Be THERAPEUTIC: You are a Physician, not a prosecutor or jail deputy !

Managing Acute Pain without Opioids• NSAIDs• Acetaminophen• Flexeril / Skelaxin / Baclofen• Think before prescribing Fiorinal – it‟s not a „pain medicine‟, it‟s a BARB

Managing Chronic Pain without Opioids• TCAD‘s• Cymbalta• Lyrica• Neurontin and other anticonvulsants

Managing Pain With Opioids Short-acting, adequate potency Long-acting (Levodromeran) Methadone for Pain

Methadone• Excellent pain control, long acting• Increasingly used because of low cost (Medicare Part D; any managed pharmacy benefit plan)• Can be LETHAL• Must ―start low, go slow‖• Starting dose in methadone clinics / OTP‘s• Starting dose in pain practice / primary care

Equivalent Dose (mg) ChartDoses equal to Dose (mg) per 24 hrMorph 10mg IM IV/IM PO/PRCodeine 130 200Fentanyl 0.1 N/AFentanyl Patch* (mcg/hr*) = *16.7Hydrocodone N/A 30Hydromorphone 1.5 7.5Levophanol 2 4Meperidine 75 300Methadone 10 20Morphine 10 20Nalbuphine 10 N/AOxycodone N/A 30Pentazocine 60 180Propoxyphene N/A 130Sufentanil 0.01-0.02 N/ATramadol N/A (?) 150

Managing Opioid Withdrawal without focusingon managing pain• Maybe the acute problem isn‘t the underlying pain condition, but the symptoms resulting from a cutting off of opioid analgesic supplies• Traditional methods: clonidine and supplemental agents; Ultram® can be used but that is associated with drug- linking and diversion among addicts

Do treat acute pain• Even if patient has history of addiction• Even if patient is on methadone• Even if patient is on Suboxone (this probably requires use of fentanyl) – But the first intervention should be to divide the dose of Suboxone or methadone• Even if the patient is on naltrexone (Vivitrol)

Do your best to not use opioids to treat‗psychic pain‘• Is it really depression you‘re treating?• Is it really anxiety you‘re treating?• Is it really a somatoform disorder you‘re treating?

Buprenorphine• OBOT—office based opioid treatment• Special DEA registration of the provider• Clinics are not regulated, prescribers are• Sublingual tablets, but use of new ―film‖ can reduce diversion

Buprenorphine• It IS AN OPIOID – it is a ―partial agonist‖ at the mu opioid receptor (the ―morphine‖ receptor)• Thus, it can treat pain, in the absence of addiction – Buprenex – Butrans – Suboxone, Subutex• While special DEA registration is required of the provider who prescribes for addiction, no special DEA registration is required when prescribing for pain management only• It can treat pain and addiction in the patient who has both

Intrinsic Activity: Full Agonist (Morphine), PartialAgonist (Buprenorphine), Antagonist (Naloxone) 100 90 Full Agonist (Morphine) 80 70Intrinsic Activity 60 Partial Agonist 50 (Buprenorphine) 40 30 20 10 Antagonist (Naloxone) 0 -10 -9 -8 -7 -6 -5 -4 Log Dose of Opioid

Responding to the Epidemic• Treat Opioid Addiction with Buprenorphine! Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence A 2-Phase Randomized Controlled Trial Roger D. Weiss, MD; Jennifer Sharpe Potter, PhD; David A. Fiellin, MD; Marilyn Byrne, MSW; Hilary S. Connery, MD, PhD; William Dickinson, DO; John Gardin, PhD; Margaret L. Griffin, PhD; Marc N. Gourevitch, MD, MPH; Deborah L. Haller, PhD; Albert L. Hasson, MSW; Zhen Huang, MS; Petra Jacobs, MD; Andrzej S. Kosinski, PhD; Robert Lindblad, MD; Elinore F. McCance-Katz, MD; Scott E. Provost, MSW; Jeffrey Selzer, MD; Eugene C. Somoza, MD, PhD; Susan C. Sonne, PharmD; Walter Ling, MD Arch Gen Psychiatry. Published online November 7, 2011. doi:10.1001/archgenpsychiatry.2011.121

Now available in a sublingual film• Generic buprenorphine is available, but not recommended• Still, many hurdles to overcome re: stigma, misunderstandings, discrimination• Limitations of access – ‗off formulary‘ – ‗caps‘ on daily doses, monthly doses, duration of therapy, via Medicaid and private insurers/PRMs

Suboxone® Film (sub-lingual)

Pharmacotherapy Approaches to OpioidDependenceAgonist Maintenance Treatment• Methadone (full agonist)• Buprenorphine (partial agonist)Antagonist Maintenance Treatment• Naltrexone (oral = ReVia®)• Naltrexone (long-acting injectable = Vivitrol®)

Herrington Recovery Center

Thank you! Michael M. Miller, MD, FASAM, FAPA Medical Director Herrington Recovery Center 262-646-1056 mmiller@rogershospital.org

Rogers treats children, adolescentsand adults with:• Anxiety disorders• Mood disorders• Eating disorders• Substance-use disorders 800-767-4411 rogershospital.org

The Prescription Drug Epidemic:

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