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TRANSCRIPT
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Substance Use Disorders: What we need to know
Michael Larson PhDClinical / Health / Pain PsychologistMarshfield Clinic Health System
I, Michael Larson PhD, do NOT have any relevant financial interest or other relationship(s) with a commercial entity producing health-care related product and/or services.
Disclosures Statement
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Discuss background that led to the opioid crisis
Review what opioids are and potential development of an Opioid Use Disorder (OUD) but also discuss general principles of Substance Use Disorders
Discuss CRAVINGS that occur in an OUD
Highlight treatment options for OUD
Objectives – Keep everyone awake after lunch!
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Pain Management Psychologist for 20 years- Oversee Opioid Prescribing for
Chronic Non-Cancer Pain- Psychological Pain Mgt Strategies
Opioid Policy Team for MCHS since 2009
MCHS Director of Controlled Medication Policy since 2016- Trained more than 1500 providers and staff- 55% reduction in opioid prescribing as a system
Worked with buprenorphine / opioid use disorders since 2009
US Patent in Urine Drug Testing (2009) that allows “Level Testing” was used by 2nd largest UDT company for 7 years
Involved in HOPE Consortium since 2015- Focuses on Opioid Use Disorder Treatment- Director of Diversion Prevention
Summary: Involved with many different levels of opioids and treatment
• Opioid Use Disorder (new term used for Opioid Addiction)o Safety Tip: Please avoid the term “addiction” as
that is a derogatory term and adds to the stigma of having a substance use disorder.
• OUD or Substance Use Disorder:o A primary, chronic, and relapsing brain disease
characterized by pathological pursuit of reward/relief by substance use and other behaviors
The Opioid Epidemic: Opioid Use Disorder
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How’d we get here?
Not a “bad doctor” problem
Aggressive Marketing
Decades of PainPain is the 5th
Vital Sign
HCPs learned misinformation
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US medical group that encouraged doctors to prescribe painkillers:• American Pain Society (APS): Group took nearly $1m from
leading opioid manufacturers• But the APS’s greatest impact was in:
• Pushing for pain as a fifth vital sign, a compaignlaunched by its then president, Dr James Campbell, in 1996.
• The society even copyrighted the phrase: “Pain: the 5th Vital Sign.”
Story by Chris McGreal, May 2019, The Guardian
Story by Chris McGreal, May 2019, The Guardian
Former APS presidents include Dr Russell Portenoy, admitted to: overstating claims for the safety and effectiveness of opioids in order to break down what he regarded as unwarranted resistance within the medical profession to prescribing them.
Dr. Portenoy was then paid by Purdue Pharma to help drive sales of OxyContin.
He has now agreed to testify against the drugmaker and other companies, and accused them of overstating the benefits and understating the dangers of opioids.
This week, the APS was named in another report, by two members of Congress, that accused Purdue of corruptly influencing the World Health Organization (WHO) into encouraging the use of opioids .
Story by Chris McGreal, May 2019, The Guardian
Photo by Yana Paskova, The Guardian
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Opioids in America: A Crisis, an epidemic, A National Emergency
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Update from State of Wisconsin: For the first time in recent years, the state has seen a decrease in Opioid Related Deaths (comparing 2018 to 2017). Decrease was about 10%.
• The individual – lives and potential destroyed / at a minimum put on hold
• The children – who is raising them?
• Families – all the lying, stealing and lost trust
• Law enforcement – multiple levels of crime and frustration
• Society – billions spent
• Medical – serious impact across all levels
Beyond death / overdoses: Profound impact on lives
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http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdfhttp://www.the-scientist.com/Feb2014/feature1_pg36full.jpg
• Opioids include the illicit drug heroin as well as prescription pain relievers (e.g., oxycodone, hydrocodone, codeine, morphine, fentanyl)
• Opioids interact with opioid receptors (mu) throughout the body to produce pleasurable effects and relieve pain
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20%
32%
49%
18%17%
20%
31%
49%
14%
7%
26%
34%
40%
12% 13%
0%
10%
20%
30%
40%
50%
60%
One Substance Two Substances Three or More Substances Heroin Methamphetamine
Perc
ent o
f Tot
al
Self-Reported Substance Use
Jan - Jun 2017
Jul - Dec 2017
Jan - Jun 2018
This is not just an Opioid Use Disorder Problem - This is a Substance Use Problem
Data from HOPE Consortium (Price, Iron, Oneida, Vilas and Forest Counties)
Dopamine is our “REWARD” chemical
Less than 35 – do not get out of bed – too depressed
About 110 is highest “body” / natural can produce. The BEST DAY EVER experience
Abusing substances can be 6-10x greater than what the body produces
Methamphetamine can produce level of 1,110!
Substance Use Disorders and Dopamine
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Our brains are not able to handle these substances
This hijacks the system
This is not a willpower or moral issueAs a side issue, our brains are not also able to handle sugar and flour
Cravings compared to:
Craving for water after none for 3 days?
Craving for food after none for 5 days?
Cravings for a person with an Opioid Use Disorder in abstinence?
How intense are the cravings for Opioids for those with OUD?
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• 90+% of all individuals identified with an OUD / SUD have a history of Adverse Childhood Experiences (ACEs) AND/OR have a history of other trauma during young adulthood.
• Safety Tip: We are dealing with individuals that have brain changes due to trauma history during brain development.
• Safety Tip: o Serious issues with human trafficking occurs within this
population at different levels. o We are seeing more and more impact of this during
treatment (e.g., telehealth, others)
It gets worse: History of Trauma 90+%
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Definition of Negative Reinforcement:
When something aversive is suddenly removed following a specific behavior
Often referred to one trial learning – our brain has a special place for this learning (powerful) - Rat and Electricity example
Withdrawal symptoms (very aversive) and use of substance that alleviates withdrawal (sudden reduction in aversive feelings) very powerful learning impact!
It gets worse – How is Negative Reinforcement Involved?
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Important Safety Tip:
• People do not die (at least not directly) from withdrawal symptoms from opioids
• Nearly everyone going thru severe opioid withdrawal will want to die and will have thoughts of suicide / death
This can become a crisis situation – Need to get patient into treatment to manage the withdrawal symptoms
Motivational Triad:• Avoid Pain: Primary goal of our brain is to avoid pain
• Seek Pleasure / Answer Desire: o This is where dopamine comes in. o Drugs are hijacking this system directly.
• Least Amount of Effort: o Our brain and body want to limit effort and be efficient whenever possible. o Drugs can be obtained / used with very little effort.
• Substance Use – A recipe for disaster:o High Pleasure / Desireo Very low level of Effort o Very little pain (when able to maintain / avoid withdrawal).
The Motivational Triad (how our brain decides what to do)
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How the brain works – Habits (it gets worse)Basics about the Habit Loop (general information):• 300 repetitions to develop a well-
formed habit
• Well-formed Habit – Behavior occurs “without thought” or automatically
• Reward is important – Immediacy and intensity is more powerful
• Punishment after reward has no impact on behavior
• 5 years the brain to “prune” or discard a well-formed habit.
• New habit must develop off of cue.
Habit Loop
2Behavior
3Reward
1Cue
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SHORT-TERM EXPOSURE: Individuals exposed to opioids for a short-term (acute pain) Increased risk with even short-term exposure (must limit exposure)
CHRONIC EXPOSURE: Individuals exposed to opioids chronically (chronic pain) Potential for developing an opioid use disorder 1 in 4 per CDC
NEW PROBLEM – NO MEDICAL INVOLVEMENT: Individuals with no interaction with a medical system have first exposure
from street sources High likelihood of developing an opioid use disorder
Different Parts of the Problem
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• Counseling is the foundation of treatment for OUD.
• Counseling is required to be engaged in any of the Medication Assisted Treatments (MAT)
• We need to encourage everyone involved (MD, DO, PA and NPs) to require the counseling when a person has a Substance Use Disorder
Treatment options for Opioid Use Disorder
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• Vivitrol (injection monthly) or Naltrexone (oral daily pill) –o Can be done by any prescriber but does require that the patient is in
counseling
• Buprenorphine products (Suboxone, Subutex or Zubsolv) –o Stabilizes withdrawal symptoms, reduces cravings and has reduced
likelihood of overdoseo Positive aspects of Buprenorphine Products: Does have a stress response
effect that is particularly helpful for individuals with OUD and Adverse Childhood Event (ACEs) history
• Methadone –o Only allowed to be prescribed for OUD in a federally mandated Opioid
Treatment Program (OTP) o A highly “tethered treatment”, daily or near daily observed dosing, so can
be life limiting
Medication Assisted Treatments for Opioid Use Disorder
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• Allows the person to REDUCE cravings and withdrawal to FOCUS in counseling
• Provides that STRESS SYSTEM RESPONSE that helps those with trauma history, calms the system
• Effective, proven treatment in reducing use
• Keeps clients in treatment - Carrot?
• Blocking agent for other opiates and makes it less likely to be abused (but not impossible)
• If used properly (lowering doses) clients can be tapered off opiates –important in a younger population
• One component of a well-rounded treatment program
Why to use Medication-Assisted Treatment (MAT)
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• Over reliance on medication vs. recovery tools
• Doses can be too high (clients appear ‘stoned’)
• Establishing a pattern of dependence on opiate medications at a young age
• Less clinical data of success in a younger (teen) population
• Opiate replacement may be used inappropriately for a less severe habit
• It is possible to abuse opiate replacement medications (methadone and Suboxone)
Why not to use Medication-Assisted Treatment (MAT)
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• Yes – People are now reporting injecting Suboxone and Subutex. This has been confirmed.
• We have now identified the INJECTION PROFILE to assist in identifying when a patient may be injecting and trigger an Injection Site Diagram to garner supporting evidence.
Buprenorphine – The Injection Profile
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• Injection Profile Specifics:o BUP (parent drug buprenorphine) > NORB (Analyte norbuprenorphine)
o BUP must be higher than expected for prescribed dose (Ratio Z-score > 2.0 in my mind)
o NORB should be on the lower end of the expected range for prescribed dose (may not be fully low but lower end of range)
• EXAMPLE:(*) CONCERN - MAT positive but levels suggest potential INJECTION PROFILE (where either BUP > NORB or BUP is elevated for norm group). BUP Ratio Z-score elevated at +3.23 and NORB Ratio Z-score is low at -1.23, this does strongly fit an injection profile.
Buprenorphine – The Injection Profile
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• Opioid Use Disorders and Substance Use Disorders in general are life disrupting conditions
• Not an issue of Willpower and not a Moral issueo Compassion Indicatedo Understanding required
• Prevention is Critical: o Limiting exposure to these substanceso Too powerful and brain will be hijacked
• Integrated treatment indicated, counseling is the foundation of that treatment
Summary:
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Way too much information• Contact Michael Larson PhD with questions or comments.
• Thank You!
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