Opioid Abuse: How Innovation Can Save Lives

Ken Saffier, MDContra Costa Regional Medical Center and

Health CentersNovember 2, 2013

AAFP 2013 State Legislative Conference

Disclosures

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

Learning Objectives

By the end of this presentation, participants will be able to:

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 professionals.

3. Define motivational interviewing and explain why it is particularly well-suited to helping people with opioid addiction.

An Epidemic of Opioid Poisoning and Overdose Deaths

• 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 MVA’s.

FIGURE 2. Rates* of opioid pain reliever (OPR) overdose death, OPR treatment admissions, and kilograms of OPR sold --- United States, 1999--2010

* 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 (18-64 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 tx.

2012 National Survey on Drug Use and Health, US DHHS

Medically Assisted Treatments

• Alcoholism: naltrexone, acamprosate, disulfiram

• Opioid addiction: – Naltrexone– Methadone: detox, maintenance– Buprenorphine

Buprenorphine 101 – a brief overview

Agonist Heroin, hydrocodone, oxycodone, fentanyl

AntagonistNaloxone, naltrexone

Mixed agonist/antagonistPentozacine, butorphanol (Stadol)

Partial agonistBuprenorphine

Human Opioid Receptors , , and

LaForge, Yuferov and Kreek, 2000

extracellular fluid

cell interior

cell membrane

AA identical in 3 receptors

AA identical in 2 receptors

AA different in 3 receptors

HOOC

H2N

S

S

Buprenorphine – a partial agonist

High affinity for the mu opioid receptorCompetes with other opioids and blocks their

effectsCan precipitate withdrawal in highly opioid

dependent individualsSlow dissociation from the mu receptor

Prolonged therapeutic effect for opioid dependence treatment

“Ceiling effect” for stimulation of a given receptor

-10 -9 -8 -7 -6 -5 -40

10

20

30

40

50

60

70

80

90

100

Intrinsic Activity

Log Dose of Opioid

Full Agonist (Methadone)

Partial Agonist(Buprenorphine))

Antagonist (Naloxone)

Intrinsic mu Activity: Full Agonist (Methadone), Partial Agonist (Buprenorphine), Antagonist (Naloxone)

Uses of Buprenorphine

Buprenorphine detox

Buprenorphine maintenanceShort acting opioidsLong acting opioids

Buprenorphine taper

(As an analgesic (transdermal))

Buprenorphine vs. Placebo for Heroin Dependence

Kakko, Lancet 2003

Treatment duration (days)

Rem

aini

ng in

trea

tmen

t (n

r)

0

5

10

15

20

0 50 100 150 200 250 300 350

Detoxification

Maintenance

4 Subjects in Control Group Died

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

after visit. • Individual visits before and after group appt.• Other staff: FM resident, Substance abuse

counselor (MFT).

AVERAGE PTS/MO/YR EST. PTS/GROUP

2007 12

2008 21

2009 32

2010 48

2011 76

2012 101 (3 months)

3 <1 group/week

5.25 1 group/week

8.0 1 group/week

6.0 2 groups/week

6.3 3 groups/week

6.3 4 groups/week

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? Selected answers:– “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: 15

• More than a year with a stop date: 3• I don’t know at this time, but I would like to stop taking it eventually: 53• I don’t have a desire to stop taking it

at this time: 26

Additional Innovations

• 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

“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?

Dancing Wrestling

Four Processes in MI Miller and Rollnick, 2013

Engaging

Focusing

Evoking

Planning

Summary and Conclusions

• Buprenorphine, a partial opioid agonist, saves lives.

• Access to care and SUD treatment saves lives.• Group therapy for opioid addiction treatment

with buprenorphine successfully engages most patients.

• Motivational interviewing helps people change.

Many Thanks

• To Karen, Rodney, Stephen, Susan and our patients who are our excellent teachers.

• Mary Jean Kreek, MD, Andrew Saxon, MD

• Gary Larson