saffier.aafp slc 2013
DESCRIPTION
Dr. Kenneth Saffier's 2013 SLC presentation on Innovative Opioid Abuse Treatments.TRANSCRIPT
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