use of buprenorphine in the management of opioid ... › ...percent of admissions for substance...
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Use of Buprenorphine in the Management of Opioid Dependence in
Underserved Communities.
David Best, D.O.
Best Medical
Services, PLLC
2-27-13
Family Practice and Addiction Medicine Experience
I Attended Outpatient Based Opioid Treatment (OBOT) Course at AOA Conference in Fall 2004 while a senior family practice resident at Garden City Hospital.
Received waiver to prescribe buprenorphine and started managing patients with opioid dependence under supervision of Dr. Howard Wright at Dearborn Family Clinic.
Moved to Northern Michigan in 2005 and practiced full-time at Bellaire Family Health Center until Fall 2012. Started in private practice in Fall 2012.
Opioid Dependence and Addiction
Defies stereotyping
Review of 725,679 UDS from individuals 50
and over:
– 28.1% of UDS contained non-prescribed drug
– 31.8% of UDS where prescribed drug was not
detected
– 7.6% contained illicit drug – R. Frei. Study: Potential Medication Misuse in Older Pain
Patients. Pain Medicine News. Aug 2012.10-8:1,16.
General Categories at risk
Chronic pain patients who end up mis-using
opioids
Professionals: Doctors, Nurses, Pharmacists
who have access to medications
Recreational use of prescription drugs or use
of illicit drugs.
A Disturbing Trend in Northern Michigan
Percent of Admissions for substance abuse
treatment by substance
– 1997 75.2% alcohol, 1.5% opioids
– 2004 64% alcohol, 10.7% opioids
– 2010 52.6% alcohol, 25.9% opioids
Data from Northern Michigan Substance Abuse Services
(NMSAS) update
OBOT
Office Based Opioid Treatment
FDA approved the use of buprenorphine in the
treatment of opioid dependence in 2002.
Alternative to Methadone maintenance clinics
Increase from 20,000 patients receiving
buprenorphine in 2003 to 600,000 in 2009.
As of 2011 there are 19,500 physicians with
government waiver
Commitment to Improving Community by Providing OBOT
Reduce inappropriate prescribing
Improve access for treatment
Provide treatment for high-risk patients
Improved quality of life for patients and their families
– Less “driving all-over” trying to “score”
– The combination of opioid replacement plus counseling and/or 12-step programs allows patient to get their life in order
Potential Barriers to Care
Distance between home and clinic Between home and addiction counselor
Between addiction counselor and clinic
Lack of Motivation – Not ready for change in behavior
Lack of perceived confidentiality with AA or NA in a small community
Lack of providers providing affordable care
Buprenorphine
Suboxone: buprenorphine/naloxone
– Sublingual tablet or film (8/2mg or 2/0.5mg)
Subutex: buprenorphine
– Sublingual tablet (8mg or 2mg)
Pharmacology - buprenorphine
Mechanism: binds to opioid receptors
– partial mu receptor agonist
– delta receptor agonist
– Kappa receptor antagonist
Metabolism – CYP450; 3A4 substrate
Excretion – bile/feces 68%, urine 27%; ½ life
20-44 hours
Safety
Ceiling effect
– Agonist effect increases linearly until moderate dose
(16-32mg) and then reach a plateau.
– Higher dose unlikely to produce greater effect.
Lower risk of fatal overdose than full agonist
opiates.
Effective treatment because …
Partial mu receptor agonist that can hinder priming for opiates (lack of tolerance build-up)
Kappa receptor antagonistic properties that may improve dysphoric mood – “I feel normal again”
Easier induction than methadone
Greater access for patients than methadone maintenance clinics
– Fareed A. Effect of Buprenorphine Dose on Treatment Outcome. J Subst Abuse Treat 2012; 31:8-18..
Pharmacology - naloxone
Minimal absorption when delivered sublingual
or oral
Mechanism of action – opioid antagonist
Metabolism –liver
Excretion: urine; ½ life 64 minutes
Addiction
Is a disease, not a choice.
Common addictions Alcohol
Opioids
Benzodiazepines
Stimulants
Cocaine
Marijuana
Overeating?
The Limbic System
Group of interconnected deep brain structures,
common to all mammals, and involved in
olfaction, emotion, motivation, behavior and
various autonomic functions.
VTA and NA: Important Parts of Limbic System
Ventral Tegmental Area (VTA)
– Approx. 60% of neurons in this area are
dopaminergic
– Project to prefrontal cortex, caudal brainstem and
several regions in between
Nucleus Acumbens (NA) – pleasure center
Dopamine neurotransmission from VTA to NA
mediates reward properties of food, drugs, sex. – http://en.wikipedia.org/wiki/Ventral_tegmental_area
DSM IV Criteria For Opioid Dependence
– Maladaptive Pattern of opioid use leading to
clinically significant impairment or distress.
DSM IV Criteria for Dependence
– Also will have three or more of the following within a
12 month period:
Withdrawal syndrome if substance is stopped. Continued
use to prevent withdrawal
Tolerance – an increased amount needed to achieve
intoxication or diminished effect with continued use of the
same substance
DSM IV Criteria (cont)
Persistent desire or unsuccessful efforts to cut
down or control substance use
A great deal of time spent in obtaining the
substance, using the substance and in
recovering from effects
Social, occupational, and recreational activities
given up
And last but not least …
The substance use is continued despite
knowledge of having physical and
psychological problem that is likely caused by
the substance.
Clay SW: Risk Factors for Addiction. Osteopathic
Family Physician (2010) 2, 41-45.
Opioid Abuse – All the above plus
Have at least one of the following:
– Failure to fulfill major obligations at work, school, or
home
– Recurrent opioid use in hazardous situations
– Opioid related legal problems
– Social problems caused by or exacerbated by opioid
use
Change with DSM V (May 2013)
New classification for addiction problems:
Substance Use and Addictive Disorders
Defines more clearly that addiction is a brain
disease
– No longer will use labeling terms substance
depenence and substance abuse
– Potential to reduce guilt, shame, and stigma
associated with addiction and promote treatment
?Lack of recognition of problem.
Reluctance to treat addiction.
Not doing drug screens. Ignorance is bliss?
Importance of point of care testing
Opportunity to help patients (and families) who
are at great risk.
Treatment can be rewarding and challenging.
Cost Effective Treatment
– Opioid dependence treatment reduces illicit opioid
use and its associated health and social costs.
– Estimated every $1 invested in opioid dependence
treatment programs may yield a return of as much
as $12 due to:
Reduced drug-related crime, criminal justice costs
Health care savings – 2004 WHO/UNODC/UNAIDS position paper. Substitution maintenance
therapy in the management of opioid dependence and HIV/AIDS prevention.
Risk Factors for Addiction
Family
– Parents or siblings use
– Emotional, physical, or sexual abuse
Environment
– Poverty, Peer group use; opioids considered #1 “Gateway
Drug” (WHO document)
Individual
– Anxiety, Depression, ADHD, Poor school performance,
delinquency
Clay SW: Risk Factors for Addiction. Osteopathic Family
Physician (2010) 2, 41-45.
Risk Factor for Addiction: Sexual Abuse
Systematic review shows history of child
sexual abuse is a statistically significant risk-
factor.
Early traumatic experience may contribute to
other forms of psychopathology (PTSD for
example) that then increases risk of substance
abuse. – Maniglio R. The Role of Sexual Abuse in the Etiology of Substance
Related Disorders. J Subst Abuse Treat 2011; 30:216-228.
Get a Thorough History
Why now? In the patient’s words document
their motivations for starting treatment.
Severity and duration of substance abuse.
Environmental factors.
Family life, work life, education and goals.
Current or past involvement with the legal
system.
Patient Treatment Agreement
Review each item with patient.
Need to get commitment from them to:
– Show up for all appointments
– Establish with or continue with substance abuse
treatment program.
– Go to support group meetings: AA or NA
– Urine Drug Screens, pill counts.
Induction on buprenorphine
Typical starting dose is 8-16mg buprenorphine
daily.
Proper treatment will greatly reduce cravings
and provide emotional and physical relief in
patients
Now ready to start recovery
– Counseling and support groups necessary
component of treatment
Gradual Dose Reduction
Within 3-6 months, patient may be ready.
Within 12 months, solid recovery can be reality
and dose often 8-12mg daily.
Long term treatment: For patients with history
of opioid use of long duration and previous
failed abstinence based treatment. Typical
dose 2-12mg daily.
Long Term Treatment
Consider for patient who prior to treatment
have:
– Suffered an overdose
– Potential for loss of family, work, career if relapse
occurs
– Previous Incarceration for narcotic related offenses
“Healing The Addicted Brain”
By.Harold Urschel, MD (2009)
Recommend this book to your patients, to your
colleagues.
Case Studies
3 cases – 1. 34 year-old female with history of multiple pelvic surgeries
and started out on prescribed opioids 10+ years ago.
Struggling with addiction to methadone and heroin.
2. 29 year-old female, 13 weeks pregnant
3. 25 year-old male. More “typical” recreational drug user
(IVDA)
A, 34 year-old female
Seen first in July 2010.
Rx opiates for > 10 years.
– Methadone prescribed until 4 months ago.
Started using IV heroin 3 months ago
Last use of opiates – 3 days ago
Goal: “To not rely on methadone and to feel
normal”
Past Medical History
PMH – pelvic fracture at age 9; chronic pelvic
pain, depression
FH – brother died at age 15, nasopharyngeal
carcinoma; PGF-alcoholic
SH – Married, 2 kids; husband in prison (gets
out in 1 year)
Start OBOT
Suboxone 1/2 tab with elimination of withdrawl
symptoms. Total 1 tab today then 1 bid.
UDS – with methadone and alprazolam
metabolites as expected.
At follow-up four days later: no cravings for
opiates and feeling much better.
Very Motivated
Good participation in substance abuse
counseling: Weekly sessions at Catholic
Human Services
Medicaid approval for 12 months Suboxone.
Recovery
9 months later:
– Taking 1 tab daily.
– Feels isolated with husband still in prison. Financial stress.
Depressed.
– Started on Prozac 20mg daily with good results noted at f/u.
12 months later:
– Recently tapered to 1/2 tab daily.
– Regular exercise: walking, cycling, weights
– Happy that judgement no longer clouded from chronic opiate
use. Would like to continue taper.
Recovery
15 months later – Happy that her husband now also on OBOT
– Stable with ½ tab daily (she felt terrible when trying to taper further)
April 2012 (21 months in recovery) – Distraught over loss of job due to failure to disclose
felony conviction from 15 years prior
– Continues with counseling. She would like to be a mentor or counselor in the future.
Recovery Sustained
Appointments every 6 weeks
Husband (also in recovery) and 4 year-old son
come to every appt.
Now 31 months in recovery and dose is 1/3
film per day.
B, 29 year old pregnant female
Seen first in October 2011
Lives about 70 miles from clinic
13 weeks pregnant
IV Morphine 5 days ago
Prescribed opiates for back pain from 2002 to
2009
Severe cravings
Always worried about slipping up. Ashamed about track marks (admits to sometimes shooting up water due to cravings)
Wants to be able to provide stable home for her children and her fiancee
PMH – Hepatitis C
FH: F-alcoholic; sister: opioid abuse
Social – smokes 1ppd; works as a waitress; on probation now (was in jail for 9 months, got out 5 months ago.)
Early Remission
After 1 week
– Going for weekly counseling sessions and weekly
NA meetings
– Taking buprenorphine 8mg bid. Has cravings when
at work.
– UDS at court was positive for opiates; UDS in my
office +only for buprenorphine
Recovery
After 6 weeks
– Happy to be sober. Brighter affect and more
confident. Feels stable with 12mg daily.
– Had increase cravings after an argument with her
fiancee last week. Talking with her sponsor helped.
– Working full-time.
Success through pregnancy
At 37 weeks. OB visits going well. Denies
cravings with 6mg daily dose.
For about 6 months after delivery of healthy
baby girl she had regular follow-up and
consistent drug screens. I last saw her about 3
months ago.
Had probation violation and went to jail and has not
shown up for appointment at my new office.
H, 24 year old male
Seen first in June 2010
Was taking methadone 10mg 25 tabs daily
until 3 weeks prior. He went 3-4 days without
taking any and had successful induction on
Suboxone at another OBOT provider.
He has been going to NA meetings 2x/week
Sliding fee patient
– Unable to afford full prescription and relapsed after
first week
Switched to my practice due to sliding scale for
office visits and medications. He was paying
$150 per office visit.
Advised to start substance abuse counseling
More History
PMH – Alcohol abuse
FH – Brother(s),Father – substance abuse and
alcoholism
Social – Non-smoker
Occupation – Mason, general construction
A rather rocky start
After 6 weeks of weekly visits
– Continues to have alcohol binges and illicit opiate
use.
– Impaired driving conviction, 15 days in jail
– Near fatal over-dose
– Questionable friends coming with him to our health
center pharmacy
– Back to Detox.
Starting over
November 2010
– No longer wants to get high. Admits that in the past
would use Suboxone as a means to “avoid getting
sick”.
– Learned more about his addiction through his recent
detox.
– Realizes he needs to stay clean to stay alive.
Starting Over
Given Rx for Suboxone 2.5 tabs daily
Going to counseling at Harbor Hall twice per
week and to AA “as often as I can”
Has been exercising and feels better about
this.
Has his old job back
Supportive and responsible girlfriend
Slip-up after sustained remission
September 2011: Admitted to taking morphine on the 3-year anniversary of his older brother’s fatal car accident.
Resumed weekly visits for the next month. Increased frequency of counseling.
Has been on Suboxone for more than 28 months.
Last 15+ months with consistent drug screens
Common Challenges and Successes
Battle between trust and suspicion
Slip-ups vs. complete lack of recovery
Work towards getting better
Employed vs. Unemployed
Better family life
Thank You
“A great many people think they are thinking when they are merely rearranging their prejudices.”
“I will act as if what I do makes a difference.” William James (1842-1910)