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Opioids. ceapa v.2

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Treatment of Opioid Use Disorders

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Opioids. ceapa v.2

  1. 1. Treatment of Opioid Use Disorders ChiefClinicalOfficer ClinicalProfessorofPsychiatry GeorgetownUniversitySchoolof Medicine UniversityofMarylandSchoolof Medicine GeorgeKolodner, M.D.
  2. 2. Opioid Terminology • Opiates: naturally occurring in opium poppy (morphine, codeine) • *Opioids: broader term includes naturally occurring plus synthetics (heroin, methadone, oxycodone) • Narcotics: legal term, includes cocaine
  3. 3. Paradox: Relatively Harmless But Lethal • Not tissue toxic – Compare to alcoholand tobacco – Infectiousdiseases linked to non-sterile needles – Malnutrition linked to dietaryneglect • Acute death by overdose – Downregulationof receptorsduring periods of abstinence lead to re-sensitizing of CNS respiratorycentersin brain stem
  4. 4. Opioid Cautions and Reassurances • 400 BC. Hippocrates: “Use sparingly” • 1853. Hypodermic syringe – “Decreaseaddiction by avoiding stomach” • 1898. Bayer Heroin – “Less addictive than morphine for coughs” – Compare to BayerAspirin
  5. 5. 19th C. Opioid Medication Epidemic • 1870s – 80s: Overuse of hypodermic injection by physicians • 1890’s – 1910s: Change to more balanced prescribing patterns through education and pressureby reform minded physicians and pharmacists – NEJM373:22,2095-7,2015.DavidCourtwright,Preventingand TreatingNarcoticAddiction
  6. 6. Criminalization of Opioid Addiction • 1915: Harrison Narcotic Act was intended to keep narcotic transactions within legitimate medical channels – Actuallyimplemented by TreasuryDepartment in a waythat interferedwith treatmentof addiction • The treatment of addiction is “outside the realm of legitimate medical interest.” – Webb etal vs. United States,1919 Legalto treatpain with opioids but not the addiction which sometimesdeveloped
  7. 7. Opioid Related Overdose Deaths United States, 1999-2013
  8. 8. Death Rates by Age Group from Overdoses of Heroin or Prescription Opioid Pain Relievers (OPR) SOURCE: CDC. Increases in Heroin Overdose Deaths — 28 States, 2010 to 2012 MMWR. 2014, 63:849-854
  9. 9. Rates of Opioid Sales & OD Deaths 1999–2013 0 1 2 3 4 5 6 7 8 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Source:NationalVitalStatisticsSystem,DEA’sAutomationofReportsandConsolidatedOrdersSystem
  10. 10. Government Responses • 2007: FDA given broader powers by Congress to deal with “epidemic” of opioid prescribing – Risk Evaluationand MitigationStrategies (“REMS”) • 2015: Maryland Board of Physicians mandate for one hour of CME per renewal cycle • 2016: Center for Disease Control CDC Guidelines for Prescribing Opioids for Chronic Pain
  11. 11. Risk Evaluation and Mitigation Strategies (“REMS”) • Refers to a variety of measures,beyond traditional package labeling, that the FDA can take to minimize the risks of a particular medication • Major focus has been on extended release, long acting (ER/LA) opioids – Developmentof new formulationsto reduce diversion – Educationof prescribing physicians
  12. 12. CDC Guidelines: Prescription of Opioid Medications for Chronic Pain (January, 2016) 1. Non-pharmacologic and non-opioid pharmacologic therapies are preferred 2. Beforestarting, discuss risks and benefits, reasonablegoals for pain and functioning, and have plan for discontinuation 3. Begin with immediate-releaseinstead of extended-release/long-acting (ER/LA) opioids 4. Periodically reevaluate and work to lower dose or discontinue
  13. 13. CDC Guidelines: Prescription of Opioid Medications for Chronic Pain (January, 2016) 5. Use urine testing before starting and periodically thereafter 6. Use Prescription Drug Monitoring Program (PDMP) 7. Avoid using opioids for patients taking benzodiazepine medication 8. Screen for history of substance use disorder
  14. 14. Confusion Between “Physical Dependence” and “Addiction” • To try reduce confusion, diagnostic terminology was changed in DSM-5 from: • “Opioid (etc.) Dependence/Abuse” to • “Opioid (etc.) Use Disorder” • “Abuse” = “Mild” • “Dependence” = “Moderateor Severe”
  15. 15. Physical Dependence • Onset of withdrawal symptoms upon the cessation of a substance – Unmasks neuro-adaptations that have occurred in response to use of substance • Neurobiology – Locus coeruleus (noradrenergic) Irritability,increasedheartrateandBP,hyperalgesia – Rewardcenters(dopaminergic) Anhedonia,depression
  16. 16. Operational Diagnosis of Addiction • Continued use of psychoactivesubstances despite a pattern of adverse consequences – Substance use is under poor control and increasesin volume – The substance occupies a centralplace in the person’s life and leads to behavior that is out of characterand violatesthe person’s usual values • Diagnosis is based on the consequences of using – not on the amount or frequency
  17. 17. 32 23 17 15 11 9 9 5 4 Percentageof Substance Users Who Become Addicted,by Substance
  18. 18. Change in Substance Use by Kolmac Patients 1989 2016 Cocaine 44% 9% Opioids 6% 31% Marijuana 6% 17% Benzodiazepin es 2% 8%
  19. 19. Treatment of Opioid Use Disorders • Withdrawal management is needed more frequently than with substances other than tobacco • “Abstinence-based” treatment has been less successful than for other substances • Controversyabout the balance between therapy and medication • Controversyabout the role of agonist and antagonist medication
  20. 20. Agonists and Antagonists • Full agonist: attachesto opioid receptorand fully activatesit – Opium,morphine,codeine,oxycodone(Oxycontin, Percocet),hydrocodone(Vicodin),methadone • Antagonist: attachesto opioid receptorand blocks it instead ofactivatingit – Naltrexone(Revia,Vivitrol) • Partialagonist: attachesto opioid receptor, partiallyactivatesand blocks it – Buprenorphine(Suboxone)
  21. 21. Antagonists • Naloxone(“Narcan”) – Reversesopioid overdose – Immediateeffectwith short duration – Injectableor nasal • Naltrexone – Used for relapseprevention – Used long term (months to years) – Formulations • Oral(“Revia”) • Depotinjectionlastsfor1month(“Vivitrol”)
  22. 22. Opioids For Addiction Treatment: A Change of Approach • Methadone – 1937.DevelopedinGermanyforpain – 1971.ApprovedinUSAfordetoxificationand maintenanceofopioidaddicts – Highlyrestricteduse–regulatedprograms(OTP) – Nowtakenbyabout250,000patientsinUS • Buprenorphine – 1978.Parenteralformulationforpain – 2000–2003.Approvalforaddictiontreatment – Availableforofficebaseduseby“waivered”prescribers • InitiallyonlyphysiciansbutnowalsoNPsandPAs – Nowtakenbyabout1,000,000patientsinUS
  23. 23. Buprenorphine FDA Approval DEA Schedule III • For pain – Parenteral(Buprenex) – Transdermal(Butrans) • For addiction (buprenorphine waiver and DEA “X” number required) – Sublingual (Suboxone, Zubsolv, generic) – Buccal(Bunavail)
  24. 24. Advantages of Buprenorphine 1. Safer from overdose – Ceilingon respiratorydepression • Benzodiazepinesraiseceiling 2. Rarely causes euphoria unless taken IV – Partialmu agonist 3. Blocks most other opioids – High affinityfor receptorsites 4. Can eliminate all withdrawal symptoms including craving
  25. 25. Experience with Buprenorphine at Kolmac • Compared to naltrexone – Doubling of completionratein rehabilitation phase • Noreductionincompletionrateofnon-opioid patients – Substantial participationin continuing care phase – Reduction in overdose deaths • Improves the patient’s ability to do the psychological work of recovery – Ancillarynot curative
  26. 26. Buprenorphine vs. Methadone in Pregnancy • Same incidence of neonatal abstinence syndrome (NAS) • Less severeNAS with buprenorphine – 89 % less medication – 43% fewerhospital days • More discontinuation of buprenorphine than methadone because of dissatisfaction with medication • Methadone still the official standard of care
  27. 27. Resistance to MAT in Recovery Community • NarcoticsAnonymous • 12-Step based residential rehabilitation programs • Hazelden/Betty Ford Breaking ranks • Forcing redefinition of “recovery” – WilliamWhite: www.williamwhitepapers.com
  28. 28. Modern Addiction Recovery kolmac.com/category/articles Send requests for addiction topics to: gkolodner@kolmac.com Thank You!

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