Identification and Treatment of Opioid Use

Disorders in Primary Care Settings

Kelly S. Barth, DO

Associate Professor, Psychiatry & Internal Medicine

Medical University of South Carolina

17th Annual Primary Care Symposium

February 24, 2018

Conflicts of Interest

-No conflicts

-Will discuss non-FDA indicated use of medications

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Outline

I. Identification of Opioid Use Disorder (OUD) in Primary Care

II. Treating Opioid Use Disorder in Primary Care using Medication

Assisted Treatment (MAT)

III. Future Directions and state-wide opportunities

Diagnosing OUD in Primary Care is Not Easy

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How to Identify OUD in Primary Care

Poor Functioning

› Emotional

› Depression/Anxiety

› Physical

› Sedation/in bed/ED

› Social

› Pt or Family Concern

Aberrant Behaviors

› Running out early

› Rx from another provider

› Use of illicits

Clinical Assessment Screening scales

NIDA Quick Screen

COMM

DAST

SOAPP-R

ORT

DDX for a Poorly-Functioning Pain Patient

Psychiatric co-morbidity

› Depression

› Anxiety, esp early-life trauma

Psychologic co-morbidity

› “Chemical coping”

› Personality disorders

Opioid Use Disorder (OUD)

Pseudoaddiction/tolerance

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Psychotherapy

+/- Meds

Psychotherapy

MAT

Maximize non-

opioids

When does a poorly-functioning patient

with pain “cross the line” to addiction?

Start opioid

Pain

Euphoria

Change source

Tolerance Doc mg Tolerance

Ptmg

Use for stress sleep high

Try to

painsleep

w/d

Return to drug

How does an

OUD start?

Run outearly

RECOGNIZING OUD

Aberrant Behaviors

More clear

Forging

Steal/borrowing

IV use

Obtained on street

Abuse other drugs

Multiple dose

Recurrent Rx loss

Less clear

Request mg

Hoarding

Asking specific Rx

“Doc shopping”*

1-2 dose

Rx another sx

Psychic effects9(Passik & Portenoy 1998)

RECOGNIZING OUDSigns

Intoxication Withdrawal

Pain/Distress

Dilated pupils

GI upset/diarrhea

Goosebumps

Euphoria

Constricted pupils

Slurred speech

The “nods”

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DSM-V Opioid Use Disorder

Maladaptive pattern of use

leading to impairment or distress

▪ Failure to fulfill major role obligations▪ Important social, occupational, or recreational activities are given up

• Tolerance (not with prescribed medications)• Withdrawal (not with prescribed medications)

• Taken in larger amounts or over a longer period than was intended • Persistent desire or unsuccessful efforts to cut down or control use • Great deal of time spent to obtain/use/recover from the substance

• Craving or a strong desire or urge to use a specific substance

• Continued use despite negative consequences • Use despite recurrent physical or psychological problem exacerbated by

the substance • Recurrent use in situations in which it is physically hazardous

Decline in functioning

Loss of control

Continued use despite consequences

Risk Factors for Inadvertent

Prescription Opioid Overdose

▪Higher doses of opioids

▪ 100mg morphine equivalent or higher

▪Using with sedatives or alcohol

▪Co-morbid mental health or medical issues

▪Recent abstinence (recent hospital detox)

▪Other substance abuse

▪Aberrant behavior (running out early)

▪Using aloneBohnert, et al. JAMA. 2011;305(13):1315-1321

Screening Tools

NIDA Single-Question Screener:

“How many times in the past year have you used an illegal drug or

used a prescription medication for non-medical reasons?” (where

a response of ≥1 is considered positive).

Drug Abuse Screening Test -10

Screen & Opioid Assessment For

Patients With Pain—Revised ( SOAPP®-R)

SOAPP-R (con’t)

Current Opioid Misuse Measure - COMM

Opioid Risk Tool (ORT)

▪ Failure to fulfill major role obligations▪ Important social, occupational, or recreational activities are given up

• Tolerance (not with prescribed medications)• Withdrawal (not with prescribed medications)

• Taken in larger amounts or over a longer period than was intended • Persistent desire or unsuccessful efforts to cut down or control use • Great deal of time spent to obtain/use/recover from the substance

• Craving or a strong desire or urge to use a specific substance

• Continued use despite negative consequences • Use despite recurrent physical or psychological problem exacerbated by

the substance • Recurrent use in situations in which it is physically hazardous

Decline in functioning

Loss of control

Continued use despite consequences

PAIN

Approach to the Patient With Addiction + Pain

• Express Concern + Provide Feedback– “I am concerned about your health and safety.”– “This is the 3rd time you have run out of pain medications early.”– “You have been to the ED 6 times in the past 3 months.” – “I am concerned that you are showing several signs of addiction.”

• Validate Pain + Set Boundary– “I believe you are suffering/in pain. I can Rx non-opioid pain meds.”– “I cannot safely prescribe you opioids at this time.”

• Provide Education + Support– “I want you to know that there is excellent medication for opioid

addiction that can help with pain and prevent withdrawal. We can try this.”

– “I hope we can continue to work together to get you feeling better.”

HAVING THE CONVERSATION

Empathy (pt is suffering)

Focus = safety & functioning

Professionally set boundary

Lifesaving tx available!

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LIFESAVING TREATMENTS

+ + + + + +

+

+ + + + + + + + +

+ + +

Methadone

Agonist

Buprenorphine

Partial Agonist

Naltrexone

Antagonist

Naltrexone

(Vivitrol®, ReVia®)

Buprenorphine/

Naloxone (Suboxone®)Methadone

Mechanism Opioid antagonist Opioid partial

agonist/partial antagonist

Opioid agonist

Availability Extended-release injection,

tablet

Sublingual, Buccal,

Implant, Injection

For treatment of OUD in a

methadone clinic, usually

in syrup form

Prescribing

RestrictionsNone – any prescriber can

prescribe

Must receive a DATA 2000

waiver to prescribe

Patients must obtain from

a methadone clinic

Initiation Must wait to initiate until

patient has been free of

opioids for 7 to 10 days

Must wait to initiate until

after withdrawal symptoms

have started to appear

May initiate immediately to

avoid withdrawal

Abuse

PotentialNo abuse potential Less likely than

methadone: only a partial

agonist; dissolution and

injection may induce

withdrawal

Low compared to other

opiates

Very low within methadone

clinic

Patient

Population/

Other

–Concomitant alcohol

dependence

–Highly motivated pts

–Patients with mandated

use (medical boards, etc)

–Improving insurance

coverage

–Usually requires pre-

authorization – for now

–Decreases mortality in

heroin users

–Not yet covered by

insurance in SC

(~$15/day)

–Decreases mortality in

heroin users

Medications for the treatment of opioid use disorder

What is Medication-Assisted Treatment (MAT)?

• Addiction is a bio-psycho-social disease

• Medication alone is not sufficient for someone to enter full recovery from addiction

• It is recommended that medications for OUD be combined with psychosocial treatment for best long-term outcomes

Methadone Maintenance Treatment

▪ Lifesaving option for those who need optimum structure▪ Severe addiction▪ Co-morbid personality disorders▪ Polysubstance and/or IV drug use▪ Fail naltrexone and/or Suboxone

▪ Daily dosing in a methadone clinic▪ Counseling provided on-site▪ Those with addiction and severe pain?▪ Weigh risks and benefits▪ Decrease in barriers to care in SC under way

Methadone Clinics

inSC

An Amendment

to the Controlled Substances Act

Allows a waivered physician (DEA “X” number)

to prescribe an opioid (buprenorphine) to a

patient with an opioid use disorder for the

treatment of opioid use disorder, with certain

restrictions.

DRUG ADDICTION TREATMENT ACT OF 2000

• Sublingual buprenorphine has good bioavailability, sublingual naloxone has poor bioavailability.

• Opioid-dependent person takes a buprenorphine/naloxone tablet sublingually, predominantly buprenorphine effect.

• Opioid-dependent person dissolves and injects a buprenorphine/naloxone tablet, predominantly naloxone effect (and precipitated withdrawal).

• Formulation: abuse/diversion deterrant

Buprenorphine/Naloxone

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Buprenorphine/Naloxone Tablets

2mg/0.5mg

8mg/2mg

SUBOXONE Film

For complete Prescribing Information, visit suboxone.com.

SUBOXONE® Sublingual Film is a registered trademark of Reckitt Benckiser (UK) Ltd.

Zubsolv Sublingual Tablets

Available doses (BUP/NX): 1.4 mg / 0.36 mg; 5.7 mg / 1.4 mg

Recommended maintenance dose: 11.4 mg/ 2.8 mg

Bunavail Buccal Film

Available dosages (BUP/NX): 2.1 mg / 0.3 mg; 4.2 mg/0.7 mg; 6.3 mg/ 1.0mg

Recommended maintenance dose: 8.4mg / 1.4mg

Buprenorphine Implant

-6mo maintenance treatment in clinically stable pts on buprenorphine 8 mg or less

Injectable Buprenorphine

• 2 formulations considered by FDA

-Once monthly injection of 100 or 300 mg (Indivior)

-Once weekly injection of 24 or 32 mg (Braeburn)

• Advantages: less opportunity for misuse, diversion and nonadherence

• FDA approved – coming to market soon

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Comparison of risk of death in patients exposed or not exposed to opiate substitution treatment by duration of treatment. (Boxes are interquartile ranges (with median);

lines are 95% confidence intervals)

Cornish, et al. BMJ. 2010 Oct 26;341:c5475.

Opioid substitution decreases mortality in OUD…

Adjusted risk of death, compared with not being on treatment, during and after opiate substitution treatment.

Cornish, et al. BMJ. 2010 Oct 26;341:c5475.

…while in treatment

OUD VS. DEPENDENCESymptoms

OUD

Loss of control

in function

Use despite negatives

Compulsive use

Craving

Dependence

Tolerance

Withdrawal

No loss of control

Functioning well

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≠

Looking Forward

-Longer-term studies

-Use of naltrexone

-Funding: Training & Support in SC

-Initiating treatment in ED settings

-Outcomes of Policy/Guideline

implementation

Long-term studies

POATS 42-month follow-up (n=375/653)• Long-term outcomes = clear improvement from baseline• 32% were abstinent from opioids & not on agonist

therapy• 29% were receiving opioid agonist therapy, but met no

symptom criteria for current OUD• Agonist treatment was associated with a greater

likelihood of Month-42 abstinence (<.0001)-90/113 (80%) on agonist treatment were abstinent-98/193 (51%) not on agonist treatment were abstinent

• 8% initiated IN heroin use and 10% initiated IV heroin use • 5 deaths

Drug Alcohol Depend. 2015 May 1; 150: 112–119

JAMA Psychiatry. 2017;74(12):1197-1205.

-Sponsored by Norwegian government-Unblinded RTC, daily observed dosing buprenorphine-Mostly IVDU-49/79 (62%) buprenorphine completed 12 week trial-56/80 (70%) naltrexone completed 12 week trial-UDTs weekly, missing counted as +-Mean buprenorphine dose 11mg (avg in Norway 13mg)

Naltrexone XR after outpt detox

Am J Psychiatry 174:5, May 2017

Policy/Guideline Outcomes

• Overdose reversal data– Utilization in medicare population– High resumption of opioids after OD reversal– 93% success rate in preventing death, but 1 in 10

don’t survive the next year

• CDC guideline implementation– Recommendation with highest level of evidence = ID

and treat OUD with MAT– SC MAT guidelines in process– Prescription opioid limitations from payers

Looking Forward - Funding

President’s FY 2017 Budget

› $1 billion to expand access to OUD treatment

› 28k doctors authorized to Rx buprenorphine

› 46% Psychiatrists

› 37% PCPs

› 27% Other specialties

› 6k currently write 90% of total prescriptions

› U.S. Dept HHS proposal

› increase buprenorphine patient prescribing limit

South Carolina

› Expand providers able to prescribe MAT

› Expand # of bup patients/physician to 200

› Expand access to naloxone for OD reversal

› Provide free trainings and support (ECHO)

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329 OUD pts in ED (mostly heroin)

1:1:1: RCT with primary outcome 30d tx retention

Screening + treatment referral (SRT): 38/102 (37%)

SBIRT: 50/111 (45%)

SBIT with bup/nlx: 89/114 (78%)

P<.0001

Project ECHO for Addiction

• Tele-mentoring and Educational Sessions using state-wide tele-conferencing

• First module: Addiction• Anticipated second module: Chronic Pain• Address barriers to implementation of MAT in primary

care– Access to specialty consultation– Prior Authorizations (support and best practice sharing)– Access to mental health care (linking)

• CME provided• www.scmatacess.org

www.scmataccess.org

2/16/18 Overdose Prevention Dr. Kelly Barth

3/2/18 Medication Update: Buprenorphine

Formulations (focus on new monthly

injection)

Dr. Dan McGraw

3/12/18 Urine Drug Testing & Alcohol Testing ECHO Faculty

4/6/18 Motivational Enhancement Techniques

for Primary Care

Caitlin Kratz, MSW

Charleston Center

4/20/18 Tapers: If/How/When Dr. Kelly Barth

5/4/18 Special Populations: Use of

Medication-Assisted Treatment in

Pregnancy

Dr. Constance Guille

Upcoming topics for Project ECHO Opioid Use Disorder

Tele-mentoring and Educational Sessions

Summary

• Identifying and treating OUD with MAT is the most evidence-based intervention in treating those with chronic pain

• Medications for OUD include both opioid and non-opioid treatments – in addition to counseling

• Treating OUD can decrease overdose mortality

• Free training and support is available for providers in SC to treat OUD

Questions?

Slides, scales, and other practice tools

are available on our website:

www.scmataccess.org

Kelly Barth, DO

stephen@musc.edu

(843) 792-5380