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-...
Accepted Learning Objectives:1.	  Define	  when	  and	  how	  medica>on-­‐assisted	  treatment	  methodologies	  for	  succ...
Learning Objectives:To gain an understanding of:Recent Advances in Recognition and Treatment of  Substance Use DisordersSB...
Disclosure Statement•  All presenters for this session, Dr. Elinore   McCance-Katz and Gregory C.   Warren, have disclosed...
DisclosuresGrant Funding from:National Institutes of Health National Institute on Drug Abuse National Institute on Alcohol...
What is SBIRT?SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treat...
Why Do We Need SBIRT?Problem Substance Use is Prevalent in Americans      SAMHSA, National Survey on Drug Use and Health, ...
SBIRT Components•  Screening quickly assesses the severity of   substance use and identifies the appropriate   level of tr...
Is SBIRT Effective?•  SBIRT research has shown that large numbers of   individuals at risk of developing serious alcohol o...
What are the Benefits and Screening        and Brief Intervention?•  Strong evidence for the effectiveness of brief   inte...
How to Rapidly Screen for Alcohol               ProblemsSingle Question with high sensitivity/specificity:•  In the past y...
What Can the Primary Care Physician   Use to Treat Substance Use            Disorders?         Pharmacotherapy            ...
General Considerations for SUD              Pharmacotherapy"   Tobacco:	  Relapse	  Preven>on-­‐Yes,	  for	  office-­‐based/...
Cigaree	  Smoking	  
Cigaree	  Smoking	  
Cigarette Smoking
Cigaree	  Smoking	  
Cigaree	  Smoking	  
Cigarette SmokingVarenicline	  	       Nico>ne	  par>al	  agonist	       Decreases	  craving	  to	  smoke	       May	  ...
Maintenance Medications To Prevent Relapse To         Alcohol Use (FDA approved)      • Disulfiram      • Naltrexone (oral...
Disulfiram"   How	  it	  Works:	  Blocks	  alcohol	  metabolism	  leading	  to	  increase	  in	  blood	      acetaldehyde	...
Naltrexone"  Potent	  inhibitor	  of	  mu	  opioid	  receptor	  binding	       may	  explain	  reduc>on	  of	  relapse	  ...
How	  to	  Select	  a	  Medica5on	  for	         Alcohol	  Use	  Disorders     	  "  Disulfiram: when the patient is   com...
Source Where Pain Relievers Were       Obtained for Most Recent Nonmedical Use       among Past Year Users Aged 12 or Olde...
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 treatmen...
Opioids	  for	  Pain	  Management                                            	      Chronic opioids for non-malignant pai...
What s the Best Path?
Naltrexone	  
Why is All of This Important?•  Drug and alcohol use disorders affect approximately   10% of Americans•  Screening and ear...
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     probl...
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
Elinore McCance-Katz
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Elinore McCance-Katz

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Treatment and Recovery in America
National Rx Drug Abuse Summit 4-10-12

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Elinore McCance-Katz

  1. 1. Treatment andRecovery in America April  10-­‐12,  2012   Walt  Disney  World  Swan  Resort  
  2. 2. 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
  3. 3. 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.  
  4. 4. 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
  5. 5. 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.
  6. 6. 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
  7. 7. 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.
  8. 8. Why Do We Need SBIRT?Problem Substance Use is Prevalent in Americans SAMHSA, National Survey on Drug Use and Health, 2010
  9. 9. 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.
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. What Can the Primary Care Physician Use to Treat Substance Use Disorders? Pharmacotherapy Review
  14. 14. 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  
  15. 15. Cigaree  Smoking  
  16. 16. Cigaree  Smoking  
  17. 17. Cigarette Smoking
  18. 18. Cigaree  Smoking  
  19. 19. Cigaree  Smoking  
  20. 20. 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  
  21. 21. Maintenance Medications To Prevent Relapse To Alcohol Use (FDA approved) • Disulfiram • Naltrexone (oral and injectable) • Acamprosate
  22. 22. 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  
  23. 23. 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  
  24. 24. 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
  25. 25. 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.
  26. 26. Why Are Such Large Numbers of Opioid Medications Being Prescribed?
  27. 27. 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
  28. 28. 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
  29. 29. What s the Best Path?
  30. 30. Naltrexone  
  31. 31. 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
  32. 32. Clinical Support SystemsSponsored by Center for Substance Abuse Treatment/SAMHSA
  33. 33. 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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