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The Opioid Epidemic

Brian Fuehrlein, MD, PhD

Director, Psychiatric Emergency Room, VA

Connecticut and Assistant Professor of

Psychiatry, Yale University

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Brian Fuehrlein, Disclosures

• I have no financial relationships to disclose.

The contents of this activity may include discussion of off label or investigative drug uses. The

faculty is aware that is their responsibility to disclose this information.

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Planning Committee, Disclosures

AAAP aims to provide educational information that is balanced, independent, objective and free of

bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure

information from all planners, faculty and anyone in the position to control content is provided during

the planning process to ensure resolution of any identified conflicts. This disclosure information is

listed below:

The following developers and planning committee members have reported that they have no

commercial relationships relevant to the content of this module to disclose: PCSS-MAT lead

contributors Frances Levin, MD and Adam Bisaga, MD; AAAP CME/CPD Committee Members

Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD;

and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, Carol Johnson and Justina Pereira.

All faculty have been advised that any recommendations involving clinical medicine must be based

on evidence that is accepted within the profession of medicine as adequate justification for their

indications and contraindications in the care of patients. All scientific research referred to, reported,

or used in the presentation must conform to the generally accepted standards of experimental

design, data collection, and analysis. The content of this CME activity has been reviewed and the

committee determined the presentation is balanced, independent, and free of any commercial bias.

Speakers will inform the learners if their presentation will include discussion of

unlabeled/investigational use of commercial products.

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Target Audience

The overarching goal of PCSS-MAT is to make

available the most effective medication-assisted

treatments to serve patients in a variety of settings,

including primary care, psychiatric care, and pain

management settings.

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Educational Objectives

At the conclusion of this activity participants should be able to:

Identify the factors contributing to the opioid epidemic

Identify risk factors and red flags for the development of opioid use disorder

Describe how heroin use develops from prescription opioid addiction

Describe the severity and nature of opioid use disorder and the related high risk behaviors

Define what treatment is and essential components needed to be evidence based

Recognize how medication can be a very important part of long-term treatment for opioid use disorders

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“Panel approves anti-overdose legislation” – CT Post

“Heroin-related overdose deaths soar in CT” – Hartford Courant

“Opioid overdoses spiked again last year” – WTNH Conn News

“Summit held in New London to address heroin epidemic” – Fox 61 News

“Rep. Courtney seeking emergency money to fight opioid addiction, overdoses” – CT

Mirror

“Pharmacists working to combat opioid overdose” – Uconn Today

“Drug overdoses keep rising in CT” – CT Post

“As opioid epidemic grows, Senator Murphy calls for improved access to buprenorphine

treatment” – Stratford Star

Headlines in Connecticut

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“If you’re over 50 and you wake up in the morning

without pain, you might not be alive anymore.”

- Anonymous

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“We conclude that opioid maintenance therapy can be a safe, salutary and more humane

alternative to the options of surgery or no treatment in those patients with intractable non-

malignant pain and no history of drug abuse.”

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Pain was a common pop culture topic of the 1980s

and 1990s

This article clearly states that morphine taken for

pain is not addictive

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McCaffery, M. & Beebe, A. (1989). Pain: Clinical manual for nursing

practice. St. Louis: C.V. Mosby.

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Purdue Pharma was

aggressively marketing

OxyContin with celebrity

endorsements and free items

for prescribers and patients

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I Got My Life Back featured the story of patients on OxyContin and a

pain specialist discussing its virtues

Fifteen years after the documentary 2 of the patients were deceased

with OUD likely contributing, one developed an OUD but was sober

and the other three were alive and well

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“Did I teach about pain management, specifically about opioid therapy, in a way that

reflects misinformation? Well, against the standards of 2012, I guess I did. We didn’t

know then what we know now.”

“I gave innumerable lectures in the late 1980s and 90s about addiction that weren’t

true.”

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2M people have prescription opioid use disorder and 591,000 heroin1

>33,000 overdose deaths linked to opioids in 20152

In 2012, 259M prescriptions written for opioids3

80% of heroin users start with prescriptions1

276,000 adolescents currently misusing opioids and 122,000 already addicted4

Most adolescents are provided opioids for free from family or friends

Currently

1. Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental

health indicators in the United States: Results from the 2015 National Survey on Drug Use and

Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51).

2. Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths —

United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452.

3. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription

opioid pain relievers - United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013

Sep 1;132(1-2):95-100.

4. National Institute of Drug Abuse. (2015). Drug Facts: Prescription and Over-the-Counter

Medications. Bethesda, MD: National Institute of Drug Abuse.

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Full agonists

Partial agonists

Antagonists

Receptor affinity vs strength of action

Time to peak effect

Duration of action

Opioids

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Naturally Occurring Opioids

• morphine, thebaine, codeine

Semi-Synthetic Opioids

• hydrocodone, oxycodone, hydromorphone, oxymorphone

Synthetic Opioids

• buprenorphine, fentanyl, methadone

Common Trade Names

• Oxycodone, Oxycontin, MS Contin, Dilaudid, Norco, Percocet, Lortab, Roxicodone, Duragesic

Opioids

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Common Scenario

A patient presents to the

MER with an ankle injury

and has a fracture.

Orthopedics places a cast,

provides a 2-week follow-

up appointment and

prescribes a two-week

supply of OxyContin for

pain.

Does this seem like an

appropriate course of

action?”

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Personal history of a substance use disorder

Family history of a substance use disorder

History of mental illness

History of trauma

Risk Factors

CASAColumbia. (2012). Addiction medicine: Closing the gap between science and practice.

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Level of pain

• Opioids should only be prescribed when needed and in lowest

dose with smallest quantity possible

Prior opioid use history

Complete history of other medications taken

Willingness to try alternatives

Urine drug screen

Check the prescription drug monitoring database in your state

Other Assessment

Clinical Guidelines for the Use of Buprenorphine in the

Treatment of Opioid Addiction. SAMHSA, CSAT.

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Always weigh risks and benefits of opioid use for all patients prior to initiation

Always educate all patients about the risk of developing an SUD

Those with risk factors need assertive education, lower doses, and frequent follow-ups

Avoid unnecessary exposure to opioids, but avoid refusing opioids based on presence of risk factor when patient is in pain

Patient Education

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The patient returns after two weeks.

The cast is removed and the

fractures appears to have healed.

The patient reports continued severe pain.

He is requesting more pain medication saying it was the

only thing that helped.

Now What?

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Red Flags for Opioid Use Disorder

Behaviors

• Angry/hostile/threatening

• Preoccupied with specific medication and dose,

unwilling to try alternatives or allergic to all others

• Reports subjective euphoria with opioids

Objective findings

• Ran out of prescription early

• Has visited other doctors/ERs

• Pain out of proportion to exam findings

Assessments

• Screening tools are effective for assessing and monitoring for opioid use disorder in an objective way but do not confirm an opioid use disorder.

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The CDC offers guidelines for prescribing opioids for chronic pain

• Use non-pharmacologic management and non-opioid pharmacologic management first

• When using opioids, start low and go slow

• Review the PDMP routinely

• Avoid concurrent prescribing of benzodiazepines

• Discontinue when harms outweigh benefits

• Offer or arrange treatment and behavioral therapies for patients with opioid use disorder

Chronic Pain

Dowell, D., et al. CDC guideline for prescribing opioids for chronic pain - United States, 2016.

CDC Recommendations and Reports, 65(1):1-49, 2016.

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Usually starts with prescription opioid

• their own prescription or family/friend

Multiple doctors/ERs until supply runs dry

• “My doctor has no empathy so I will go elsewhere”

Buying pills illegally

• “They are prescription pills and I need them. I

will never use heroin. That is what junkies use”

• Money runs out ($1 per mg for oxycodone on the street)

Switch to heroin (“I will never inject”) Inject heroin (“I will never share needles”)

Share needles

Progression to Heroin

Jones CM. Heroin use and heroin use risk behaviors among nonmedical

users of prescription opioid pain relievers - United States, 2002-2004 and

2008-2010. Drug Alcohol Depend. 2013 Sep 1;132(1-2):95-100.

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Prognosis

Hser, et. al. A 33-Year Follow-up of Narcotic Addicts.

Archives of General Psychiatry, 2001;58:503-508

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IV use

Mixing with benzos/alcohol

Previously resuscitated with

Narcan

High Risk Behaviors

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Do not pick up where you left off

Know your supply

Start low and go slow

Do not mix substances

Do not use alone

Have a Narcan kit

available

Harm Reduction

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“A key driver of the overdose epidemic is underlying

substance-use disorder. Consequently, expanding

access to addiction-treatment services is an essential

component of a comprehensive response.”

Opioid Use Disorder

Volkow, Nora D., et al. "Medication-assisted therapies—tackling the

opioid-overdose epidemic." New England Journal of Medicine 370.22

(2014): 2063-2066.

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“Drug dependence generally has been treated as

if it were an acute illness. Review of results

suggest that long-term care strategies of

medication management and continued monitoring

produce lasting benefits. Drug dependence should be

insured, treated, and evaluated like

other chronic illnesses.”

Opioid Use Disorder

McLellan, A. Thomas, et al. "Drug dependence, a chronic medical illness: implications

for treatment, insurance, and outcomes evaluation." Jama 284.13 (2000): 1689-1695.

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Opioid Withdrawal

Muscle aches, restlessness, anxiety, lacrimation,

rhinorrhea, sweating, insomnia

Diarrhea, abdominal pain, goose flesh, vomiting,

mydriasis, tachycardia, hypertension

Feels like a very bad flu

While usually not deadly, if often feels like it is

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Typically several days

Either symptom driven

or using buprenorphine

Medically supervised

process

Withdrawal management

does not address the

underlying opioid use disorder

Opioid Withdrawal Management

41 Kakko, Johan, et al. "1-year retention and social function after buprenorphine-assisted

relapse prevention treatment for heroin dependence in Sweden: a randomized, placebo-

controlled trial." The Lancet 361.9358 (2003): 662-668.

Medication Assisted Treatment

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Buprenorphine

Methadone

Extended-Release Naltrexone

Medication Assisted Treatment

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Medication Assisted Treatment

Improves patient survival

Increases retention in treatment

Decreases illicit opioid and other criminal activity

Increases ability to gain and maintain employment

Improves birth outcomes among women who have substance use disorders and are pregnant

Data from Substance Abuse and Mental Health Services Administration

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Many factors contributed to the

current opioid crisis

Risk factors and red flags are

critical to recognize and access

Opioid use disorder is a deadly illness

Detox is not treatment for the underlying opioid use disorder

Maintenance medication is a very important part of long-term

treatment

Summary

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References

CASAColumbia. (2012). Addiction medicine: Closing the gap between science and practice.

Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51).

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. SAMHSA, CSAT

Dowell, D., et al. CDC guideline for prescribing opioids for chronic pain - United States, 2016. CDC Recommendations and Reports, 65(1):1-49, 2016.

Hser, et. al. A 33-Year Follow-up of Narcotic Addicts. Archives of General Psychiatry 2001;58:503-508

Kakko, Johan, et al. "1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial." The Lancet 361.9358 (2003): 662-668.

McCaffery, M. & Beebe, A. (1989). Pain: Clinical manual for nursing practice. St. Louis: C.V. Mosby.

McLellan, A. Thomas, et al. "Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation." Jama 284.13 (2000): 1689-1695.

Porter, J. and Jick, H. Addiction rare in patients treated with narcotics. NEJM 10;302(2):123, 1980

Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452.

Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers - United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013 Sep 1;132(1-2):95-100.

National Institute of Drug Abuse. (2015). Drug Facts: Prescription and Over-the-Counter Medications. Bethesda, MD: National Institute of Drug Abuse.

Volkow, Nora D., et al. "Medication-assisted therapies—tackling the opioid-overdose epidemic." New England Journal of Medicine 370.22 (2014): 2063-2066

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PCSS-MAT Mentoring Program

PCSS-MAT Mentor Program is designed to offer general information to

clinicians about evidence-based clinical practices in prescribing medications

for opioid addiction.

PCSS-MAT Mentors are a national network of providers with expertise in

addictions, pain and evidence-based practices including MAT.

3-tiered approach allows every mentor/mentee relationship to be unique and

catered to the specific needs of the mentee.

No cost.

For more information visit:

pcssmat.org/mentoring

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PCSS Discussion Forum

Have a clinical question?

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Funding for this initiative was made possible (in part) by grant no. 1U79TI026556-01 from SAMHSA. The views expressed in written

conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department

of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the

U.S. Government.

PCSS-MAT is a collaborative effort led by the American Academy of Addiction Psychiatry (AAAP) in

partnership with the: Addiction Technology Transfer Center (ATTC); American Academy of Family

Physicians (AAFP); American Academy of Pain Medicine (AAPM); American Academy of Pediatrics

(AAP); American College of Emergency Physicians (ACEP); American College of Physicians (ACP);

American Dental Association (ADA); American Medical Association (AMA); American Osteopathic

Academy of Addiction Medicine (AOAAM); American Psychiatric Association (APA); American

Psychiatric Nurses Association (APNA); American Society of Addiction Medicine (ASAM); American

Society for Pain Management Nursing (ASPMN); Association for Medical Education and Research in

Substance Abuse (AMERSA); International Nurses Society on Addictions (IntNSA); National

Association of Community Health Centers (NACHC); and the National Association of Drug Court

Professionals (NADCP).

For more information: www.pcssmat.org

Twitter: @PCSSProjects

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PCSS-MAT: Training, Mentoring, Resources