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Overview of Opioid Use Disorder
Sarah Wakeman, MD, FASAMMedical Director,
Mass General Substance Use Disorder InitiativeAssistant Professor, Harvard Medical School
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Disclosures
Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest
to disclose.
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Increase in Opioid
Prescribing Was Correlated with Overdose & Rx
OUD
Paulozzi LJ, Jones C, Mack K, Rudd R. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep 2011;60:1487–92.
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Dowell D. Underlying Factors in Drug Overdose Deaths JAMA. Published online October 11, 2017. doi:10.1001/jama.2017.15971
Copyright 2017 American Medical Association. All Rights Reserved.
Ongoing Death Toll Due to Heroin/Fentanyl
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Decrease in Rx Opioid Access, Increase in Initiation of Heroin
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What is Effective Treatment?
PharmacotherapyFull opioid agonist: methadonePartial opioid agonist: buprenorphineOpioid antagonist: naltrexone
PsychosocialInterventions
CBT, MI/MET, CM, TSF
Recovery Supports
AA, NA, SMART recoveryRecovery coaches
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Why Do People Use Opioids?W
ithdr
awal
Nor
mal
Eup
horia
Chronic useAcute use
Tolerance and Physical Dependence
To feel good
To feel better
Slide courtesy of Drs. Alford and Walley
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Opioid Agonist Maintenance Treatment for Severe Opioid Use DisorderW
ithdr
awal
Nor
mal
Eup
horia
Chronic use Maintenance
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Details of Treatment
• Agonist treatment consists of daily methadone or buprenorphine– Stable level of opioid effect is experienced as neither
intoxication nor withdrawal, but as “normal”– Requires waivered prescriber or opioid treatment program
• The aims of agonist maintenance treatment include: – reduction or cessation of illicit opioids and associated risks– improvement in psychological and physical health
• Antagonist treatment consists of once monthly injection– Anyone can prescribe naltrexone
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Detoxification versus Maintenance
• Pharmacological management:– tapering with methadone or buprenorphine– sudden opioid cessation and use of alpha‐2 adrenergic agonists to relieve symptoms
• Most patients resume opioid use after detoxification
• Detoxification alone should not be promoted as effective treatment
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Opioid Detoxification Ineffective
Chutuape et al. Am J Drug Alcohol Abuse. 2001 Feb;27(1):19‐44.
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Behavioral Treatments
• Evidence‐based interventions either skills‐based or utilize incentives
• Goal to engage people in treatment, change attitudes and behaviors related to substance use, and increase skills to manage stress & cravings
• Cognitive‐behavioral therapy:– skills to manage cravings, identify and avoid high risk situations, utilize
self‐monitoring • Motivational Enhancement Therapy:
– resolve ambivalence through eliciting reasons for change, strengthening motivation, and developing a plan for change
• Contingency Management:– rewards for engaging in treatment or not using substances
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Pharmacology of Treatments
Antagonist(naltrexone)
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Goal of Medications for Addiction Treatment
Relieve withdrawal symptoms
Block effects of other opioids
Reduce cravings
Restore normal reward pathway
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0
0.5
1
1.5
2
2.5
Treatment waitlist During treatment Off treatment
Methadone in Norway: Clausen et al. Addiction 2009
OD de
aths per 100
pys
Opioid Agonist Therapy Saves Lives
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Deaths Increase When Medication Stopped
In Treatment Out of TreatmentOverdose Mortality 1.4 4.6
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Rate per 100
0 pe
rson
yearsOverdose Mortality
N=15 831 people treated with buprenorphine over 1.1‐4.5 years (Sordo BMJ. 2017 Apr 26;357:j1550.)
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Relapse & Cost Reduced with Methadone or Buprenorphine
Clark RE et al. J Subst Abuse Treat. 2015 Oct;57:75‐80
•Relapse reduced by 50%•Costs $153 to $223 lower per month
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Head to Head Comparison: buprenorphine vs XR‐naltrexone
https://www.recoveryanswers.org/research‐post/suboxone‐vs‐vivitrol‐head‐head‐comparison/Lee JD et al. The Lancet. 2017 Nov 14. pii: S0140‐6736(17)32812‐X
Buprenorphine XR‐naltrexone
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Medications for Addiction Treatment Work
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Psychosocially Assisted Pharmacotherapy
“Of all the treatments, opioid agonist maintenance treatment is most
effective… psychosocial services should be made available to all patients,
although those who do not take up the offer should not
be denied effective pharmacological treatment.”
http://www.who.int/substance_abuse/publications/opioid_dependence_guidelines.pdf
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Hospitalized patients
• Initiating methadone in hospital: – 82% present for follow‐up addiction care
• Initiating buprenorphine vs detox: – Bupe: 72.2% enter into treatment after discharge– Detox : 11.9% enter treatment after discharge
J Gen Intern Med. Aug 2010; 25(8): 803–808; JAMA Intern Med 2014 Aug;174(8):1369‐76.)
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Treatment in the ER
• 78% vs 37% engaged in buprenorphine treatment
• Fewer days of self‐reported opioid use
D'Onofrio et al. JAMA 2015 Apr 28;313(16):1636‐44
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Treatment in Primary Care
No difference in self reported opioid use, opioid abstinence, study completion, or cocaine abstinence between the 2 groups
Fiellin DA et al. Am J Med 126:1 2013
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You Need a Pulse to Get Into Recovery!
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Prevention
Treatment
Harm Reduction
•Judicious opioid prescribing
•Address risk factors for development of OUD
•Immediate access to opioid agonist therapy
•Reduce stigma
•Naloxone•Syringe exchange•Safe consumption sites
Big Picture: Addressing the Opioid Overdose Crisis
