Policy implications for Medication treatment

for Opioid Use DisorderA Project RAMP Resource

Adam J. Gordon, MD MPH FACP DFASAM CMROJanuary 2018

CONFLICT OF INTEREST AND DISCLOSURE

• Dr. Gordon has no fiduciary conflicts of interest• Some of the material presented herein has been previously published

from work at the University of Pittsburgh, University of Utah, and the Veterans Health Administration

• The views expressed in this presentation are Dr. Gordon’s and do not necessarily reflect the position or policy any institution, agency, or government

• Buprenorphine (BUP) = buprenorphine + naloxone unless otherwise stated

OBJECTIVES

• Introduce clinical perspectives of opioid use, misuse, and opioid use disorder

• Provide a rationale introducing addiction treatment into health care environments (and primary care environments)

• Discuss policy issues associated with opioid use disorder treatment

INTRODUCTIONS

What is addiction?

ADDICTION IS A BRAIN DISEASE

DSM5 OPIOID USE DISORDER

1. Failure to fulfill role obligations at work, school, or home2. Recurrent use in hazardous situations3. Continued use despite substance-related social or interpersonal problems4. Tolerance5. Withdrawal/physical dependence6. Loss of control over amount of substances consumed7. Preoccupation with controlling substance use8. Preoccupation with substance use activities9. Impairment of social, occupational, or recreational activities 10. Use is continued despite persistent problems related to substance use11. Craving or a strong desire to use a substance

American Psychiatric Association, DSM-V 2013

Criteria:2-3 (mild)4-5 (moderate)6 or more (severe)

Who is a typical person with addiction?

What is an opioid?

SIMPLE:

• Prescription pain medications• Naturally occurring substances• Synthetic substances

• Illicitly used• Prescription pain medications

Compton WM. NEJM. 2016

Compton WM. NEJM. 2016

Youth: Some staggering numbers

• ~ 70% of high school students tried alcohol• ~ 50% will have taken an illegal drug• ~ 40% will have smoked a cigarette

• ~ 14%-20% will have used a prescription drug for a nonmedical purpose in prior year

• 72% of those with non-medical use obtained them from home (6% from friends)

Johnston LD, et.al. Monitoring the Future National results on Adolescent drug use: Overview of Key findings, 2013 NIH/NIDA, Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide, 2014

Ontario Student Drug Use and Health Survey, 2011Brands B et.al. Nonmedical use of opioid analgesics among Ontario students. Canadian Family Physician. Vol 56. 256-62. March 2010

Adolescents TREATED Differ from Adults in Substances Most Abused

SAMHSA, Center for Behavioral Statistics and Quality, NSDUH, 2013NIH/NIDA, Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide, 2014

OverDose Deaths in the US (Today)

www.cdc.gov

So There is a Problem:

How do you fix it?

www.cdc.gov

Is Addiction a Primary Care problem?

• Opioids are “environmentally available”• drastic increases in the number of prescriptions written and dispensed

• From 76 million to 207 million (1991 to 2013) • aggressive marketing by pharmaceutical industry• greater social acceptability for using medications for different purposes

Volkow ND, presentation to the Senate Caucus on International Narcotics Control, 2014

• CDC

Not all on the patient!Providers need to face reality…

• Dated providers• Duped providers• Dishonest providers• Disabled providers• Medication mania• Hypertrophied enabling• Confrontation phobia

Office-Based Settings for Addiction

• Addiction treatment for can be provided in office-based settings similar to treatments for

• Like other medical and mental health disorders

• Barriers to initiate or provide addiction care occur when providers in office-based settings attempt to make these environments “feel” like formal substance abuse treatment program environments

• These environments are different!• It hard to replicate an addiction treatment environment• “Keep it simple” and “grow from experience”

Move from Education to Integration

• Change the culture• Team care and at least interdisciplinary approaches• Addiction is important and must be addressed

• Empower all providers to address addiction• Active training and retraining of wrap around services

• Physician targets • Primary care addiction expertise (ABAM/ASAM)• Encourage buprenorphine waivered clinicians • Offer pharmacotherapy

• Address “vulnerability” in specialized clinics • Provide easy linkages to addiction and mental health care• Don’t build a new system of care, do what you do but do it for patients with

addiction

Move from Education to Integration

• Integration and Coordination of Care is important• Addiction occurs in a variety of settings• Pain and addiction competency should be universal• Integration of pain and addiction services into Primary Care is important

• BUT CHALLENGING !!!

• No easy answers to patient complexity• Addiction impacts health and healthcare engagement• Big gaps in the evidence-base on pain and addiction and how to

address concurrent problems• Patient centered care is important

Primary Care Environment

Time to step up…

Can Substance Use Disorders be Managed Using the Chronic Care

Model?

Review and Recommendations from a NIDA Consensus Group

McLellan. Public Health Reviews, 2014

How do you treat Opioid Use Disorder?

Scientifically Based Non-Pharmacologic Approaches to Addiction Treatment

• Brief Interventions (BIs)• Cognitive-behavioral therapy (CBT)• Community reinforcement (CR)• Motivational enhancement therapy (MET)• Contingency management (CM)• Systems treatment

• Behavioral couples therapy• Multidimensional family therapy

• 12-step facilitation (TSF)NIDA, 1999 and Onken L, 2002

Buprenorphine Products

• Buprenorphine (2002 approved)• Indication: Opioid use disorder• Tablets available

• Buprenorphine/Naloxone (2002 approved)• Indication: Opioid use disorder• SL/Buccal Tablets and Film available

• Buprenorphine IV (1981 approved) • Indication: Pain

• Buprenorphine Patches (2010 approved) • Indication: Pain

• Buprenorphine Implants (2016 approved) • Indication: Opioid use disorder

• Buprenorphine Depot Injections (Under review)• Indication: Opioid use disorder

In the Veterans Administration…

Buprenorphine Works

Fiellin et.al. NEJM. 2015

Dick AW, et.al. Growth In Buprenorphine Waivers For Physicians Increased Potential Access To Opioid Agonist Treatment, 2002–11. Health Affairs. 2015

No Help!

Helps!

What is the relationship

between prescription

opioid use and heroin?

Is reducing the supply of opioids

the answer?

Will control of opioids

prescribed help?

Kertesz S. Substance Abuse. 2017

Barriers to Care - 1

• COMPLEXITY OF CARE FOR PATIENTS WITH ADDICTIONS

Barriers to Care - 2

• PROVIDER STIGMA

Barriers to Care - 3

• TIME & REIMBURSEMENT

Barriers to Care - 4

• PATIENT FEARS & NOTIONS

Facilitators of Integration - 1

• PROMOTE PATIENT-CENTERED ENGAGEMENT

Facilitators of Integration - 2

PAIN & ADDICTION PROVIDER EDUCATION

Facilitators of Integration - 3

• INTEGRATED SYSTEMS and RECORD SHARING

Facilitators of Integration - 4

• ELIMINATE SILOS of CARE & PROMOTE INTERDISCIPLINARITY

DISCUSSION

Further questions, please contact me!

gordona@medschool.pitt.edu or adam.gordon@hsc.utah.edu

Or contact the Project RAMP office…