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Three Subgroups of Opioid Addiction

1. Smallest group, longtime, primarily blacks and Latinos, started on heroin in then 70’s and 80’s

2. Middle group, largely rural and suburban, almost all white, in their 20’s to 40’s, many began on prescription opioids, used recreationally or prescribed by a physician. As prescription meds became more expensive, they switched to heroin

3. Largest group in their mid-40’s through their 80’s have been on opioids for years and largely invisible. They never move to heroin and cause of death is heart disease or infection in which their opioid use is a contributing factor. Their deaths vastly undercounted.

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The Great American Relapse: An Old Sickness has Returned to Haunt a

New Generation – Group 2The face of heroin use in America has changed utterly.• Forty or fifty years ago people addicted to heroin were overwhelmingly

male, disproportionately black, and very young (the average age of first use was 16). Most came from poor inner-city neighborhoods• These days, more than half are women, and 90% are white. The drug has

crept into the suburbs and the middle classes. And although users are still mainly young, the age of initiation has risen: most first-timers are in their mid-20s• The case of unintended consequences: many current heroin addicts are

people for whom the restrictions on prescription opioids created decreased availability and increased cost

Heroin• Heroin is a powerful opiate drug. • Looks like a white or brownish powder, or as the black sticky

substance known on the streets as “black tar heroin.” • It is diluted with other drugs or with sugar, starch, powdered milk, or

quinine before injecting, smoking, or snorting. • More recently mixed with fentanyl• Some of the physical symptoms of heroin use are euphoria,

drowsiness, respiratory depression, constricted pupils, nausea, and dry mouth.• A heroin overdose causes slow and shallow breathing, blue lips and

fingernails, clammy skin, convulsions, coma, and can be fatal.• Most people who inject heroin report misuse of prescription opioids

before starting to use heroin.

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Risk Factors for Developing Opioid Dependence• Having depression, anxiety or other mental health illness• Adults with MH conditions receive 51.4% of the total opioid

prescriptions distributed in the U.S. each year• Said another way, 16% of Americans with MH disorders receive over

half of the opioids prescribed in the U.S. • A personal and/or family history of alcohol or substance abuse • A history of physical, mental or sexual abuse (TRAUMA)• Long term use of opioid pain medications • U.S. veterans are twice as likely to OD on opioids as general

population• Study participants who reported past-year marijuana use in their

initial interview were 2.6 times more likely to initiate opioid abuse compared to non-marijuana users and 2.2 times more likely than non-users to become addicted (using DSM IV criteria) to opioids, including heroin at follow-up.

Chronic Pain

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CDC Recommendation for the Treatment of Chronic Pain• Non-opioid therapy is preferred for treatment of chronic pain• Opioids should be used only when benefits for pain and function are expected

to outweigh risks• Before starting opioids, establish treatment goals with patients and consider

how opioids will be discontinued if benefits do not outweigh risks• Prescribe the lowest effective dosage, carefully reassess benefits and risks when

considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible• Evaluate benefits and harms of continued opioid therapy with patients every 3

months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages• For patients with opioid use disorder, offer or arrange evidence-based

treatment, such as medication-assisted treatment with buprenorphine or methadone

Non-pharmacological Treatments• Low-impact aerobic exercise (e.g., brisk walking, swimming, water

aerobics, or bicycling)• Cognitive Behavioral Therapy (CBT)• Biofeedback• TENS units• Interdisciplinary rehabilitation• Exercise• Mindfulness• Weight loss (particularly for chronic back problems)• Patient education• Physical Therapy (PT)• THE PROBLEM: Many of these are not reimbursed by insurance

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Non-Opioid Medications• Acetaminophen (Tylenol)• OTC non-steroidal anti-inflammatories (NSAIDs) – Naproxen

(Aleve), ibuprophen (Advil, Motrin), Aspirin• Rx. non-steroidal anti-inflammatories – diclofenac, Celebrex • Gabapentin/pregabalin (for neuropathic pain)• Tricyclic antidepressants Amitriptyline, Imipramine (Tofranil)• Serotonin/Norephinephrine reuptake inhibitors (SNRIs) -

Pristiq, Cymbalta, Effexor• Topical agents (lidocaine, capsaicin, NSAIDs)

Over-the-Counter Pain Pills• Drugstore pain pills as effective as opioids in ER patients• Emergency rooms are where many patients are first introduced to powerful

opioid painkillers, but what if doctors offered over-the-counter pills instead?• A new study tested that approach on patients with broken bones and sprains

and found pain relievers sold as Tylenol and Motrin worked as well as opioids at reducing severe pain• Ibuprofen and acetaminophen affect different pain receptors in the body so

using the two drugs together may be especially potent (a pill combining ibuprofen and acetaminophen is available in other countries)• The results challenge common ER practice for treating short-term, severe pain

and could prompt changes that would help prevent new patients from becoming addicted

• JAMA, 11/2/17

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Social Capital and the Opioid Crisis

• New studies Strengthen ties between loss, pain and drug use• SOCIAL LOSSES CONTRIBUTING TO CRISIS• Stagnating wages• Fraying ties among people• For every 1% increase in unemployment in the U.S., opioid overdose

death rates rose by 4% (e.g., Appalachia)• The counties with the lowest rates of social capitol, including people’s

trust in one another and participation in civic matters such as voting, had the highest rates of overdose deaths• From 1999 to 2014, showed counties with the highest rates of social

capital were 83% LESS LIKELY to be among those with the highest levels of overdose

Let’s Avoid Simplistic Explanations for Our Opioid Epidemic

The current opioid epidemic is multi-factorial and there are multiple causes that interact with one another including:• A culture of avoidance of any pain or discomfort• Direct-to-consumer marketing by pharmaceutical companies• Pharmaceutical companies marketing to physicians• The message of “pain as the fifth vital sign” (JCAH)• Physician overprescribing• The unintended consequences of attempts to control prescription

opioids (movement to heroin)• Individuals’ vulnerabilities• Treatment of addiction as if it is an acute illness• Reimbursement for treatment as if it is an acute illness• Social Capitol

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Interventions

• Limiting opioid prescriptions • Treatment for opioid overdose•General treatment for substance use disorders•Addiction treatment (MAT) for Opioid use disorder

OPIOID OVERDOSE

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Overdose

• Overdose has quadrupled, 1999 > 2015

• Currently (2019) 130 deaths a day from opioids

• There are so many deaths, some coroners are running out of room for bodies (Dayton, OH)

• In the worst-case scenario is that toll could spike to 250 deaths a day, if potent synthetic opioids like fentanyl and carfentanil continue to spread

• Opioids could kill nearly 500,000 Americans in the next decade

• The use of naloxone (injection & nasal spray) to reverse overdose

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Overdose

•Many overdoses occur in cars immediately after a drug buy• Buyers may be from outside the city where the drug deal

took place• Others are from outside the county where the drug deal

took place

Increased Risk for Opioid OD

• Opioid dependent dependent individuals who have not used opioids in some time

• Novice users• Release from jail/prison after a period of abstinence• Discharge from an abstinence-based treatment program• Discharge (routine or non-routine) from MAT with a period

of no use of opioids• Use of synthetic opioids such as fentanyl and carfentanil• Concurrent use of opioids with benzodiazepines and/or alcohol• Rapid tapers

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Rapid Opioid Tapers in Medically Supervised Withdrawal Settings

• There potential severe harms associated with use of rapid tapers.• Rapid tapers provide a source of overdose potential• Given the increased overdose risk, tapers should be avoided

and continuing care strategies, such as maintenance pharmacotherapy, should be initiated.

Increased Risk for Opioid OD• Risk factors associated with heroin and opioid overdose

include:• a history of prior overdose• opioid dose and type• duration of use• a history of incarceration or arrest• injection drug use• consumption of alcohol• the use of benzodiazepines/sedatives• use of fentanyl or other analogues (e.g., carfentanil)

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Signs of Opioid Overdose

• The face is extremely pale and/or feels clammy to the touch• The body goes limp• The fingernails or lips have a purple or blue color• Start vomiting or making gurgling noises• Cannot be awakened or are unable to speak• Breathing or heartbeat slows or stops

Most Common Opioids Overdosed

• Prescription opioid abuse more common than heroin (approximately 2:1)

• The most common drugs involved in prescription opioid overdose deaths include:

- Methadone (from pain management doctors rather than methadone clinics)

- Oxycodone (such as OxyContin®)

- Hydrocodone (such as Vicodin®)

• As many as 1 in 4 people who receive prescription opioids long term for non-cancer pain in primary care settings struggle with addiction.

• Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids.

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Overdose Deaths

• Overdose deaths increased 21% between 2015 and 2016• Two-thirds of overdose deaths (2016), abut 42,000 individuals,

involved opioids• The highest drug death rates were between the ages of 25 and 54• For the last two years, life expectancy in the US fell, much of which is

attributable to overdose deaths• 2015 was the most deaths since the CDC began gathering such

statistics

New Threats• Fetanyl: a powerful synthetic opioid analgesic that is similar to

morphine but is 50 to 100 times more potent. Used to produce anesthesia for surgery and to treat pain before, during and after surgery. Commonly found mixed with heroin in overdose victims. Fentanyl deaths in 2016: up 540% in three years

• Carfentanil: 10,000 times more potent than morphine making it one of the most potent known, and most potent commercially used opioids, as an anesthetic for large animals, e.g., elephants. Not for human consumption.

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Fentanyl• Highly fat-soluble, which allows it to rapidly enter the brain• Leading to a fast onset of effects• This high potency and rapid onset are likely to increase the risk for overdose• The emergence of illicitly manufactured synthetic opioids including fentanyl,

carfentanil• While fentanyl is available as a prescription – primarily used for anesthesia,

treating post-surgical pain, and for the management of pain in opioid-tolerant patients• it is the illicitly manufactured versions that have been largely responsible for

the tripling of overdose deaths related to synthetic opioids in just two years –from 3,105 in 2013 to 9,580 in 2015. Carfentanil is a variety of fentanyl analogue of which there are many

History of Fentanyl Misuse

• The first fentanyl formulation (Sublimaze) received approval by the Food and Drug Administration (FDA) as an intravenous anesthetic in the 1960s. Other formulations, including a transdermal patch, a quick acting lozenge or “lollipop” for breakthrough pain, and dissolving tablet and film, have since received FDA approval.

•Misuse of prescription fentanyl was first described in the mid-1970s among healthcare workers, particularly anesthesiologists and continues to be reported among the people misusing prescription opioids

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History of Fentanyl Misuse• More recently, between April 2005 and March 2007 there was an uptick in

deaths related to illicitly manufactured fentanyl that was traced to a single laboratory in Mexico• Once the laboratory shut down the rate of overdose declined• However, over the last few years there has been a growing production of

illicitly manufactured fentanyl, much of which is imported from China, Mexico, and Canada• The increase in illicitly manufactured fentanyl availability in the U.S. is

reflected by the substantial increase in seizures of fentanyl by law enforcement which jumped from under 1,000 seizures in 2013 to over 13,000 in 2015• Research shows that the increasing availability of illicitly manufactured

fentanyl closely parallels the increase in synthetic opioid overdose deaths in the U.S.•

Potency Fentanyl & Carfentanil

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Potency of FentanylIt would only take 2-3 milligrams of fentanyl to induce respiratory depression, arrest and possibly death (see photo of penny). When visually compared, 2 to 3 milligrams of fentanyl is about the same as five to seven individual grains of table salt.

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Weird?

•Because Nevada had no other drugs to carry out execution by lethal injection after pharmaceutical industry’s opposition to the use of their products in executions, the state is currently planning to use a cocktail for execution including the muscle relaxant, Valium and FENTANYL

An Approach

• In Chicago, in 2013, there were 1,000 opioid overdose deaths of which 8% of were the result of fentanyl• In 2016 there were 1,900 overdose deaths of which almost

half were fentanyl-related• Clinicians in Chicago are contemplating using higher doses

of Suboxone and then introducing Vivitrol

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Risks to First Responders

• Since fentanyl can be ingested orally, inhaled through the nose or mouth, or absorbed through the skin or eyes, any substance suspected to contain fentanyl should be treated with extreme caution as exposure to a small amount can lead to significant health-related complications, respiratory depression, or death. •While pharmaceutical fentanyl in the form of transdermal

patches, sublingual tablets or lollipops is diverted on a small scale, the current increase in opioid-related deaths appears to be driven by illicitly produced fentanyl products.

The Fentanyl Risk to First Responders• An Ohio police officer recently "nearly died from exposure to an

extremely potent opioid" he encountered during a traffic stop.• The officer took precautions by putting on gloves and a mask for

personal protection•When the officer returned to the police station, another officer

pointed out that he had powder on his shirt• Instinctively, he brushed off the powder while not wearing gloves• About an hour later, he collapsed• That officer had to be treated with four doses of naloxone• Luckily, he survived and is recovering

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Risk to Drug Sniffing K-9 Dogs

• Dogs are not looking for drugs with their eyes and feeling with their fingers; they're literally breathing it in and inhaling it and can also be absorbed through their paws• Some police departments started carrying naloxone for their

K-9s.• This necessary trend is expanding

Fentanyl & Carfentanil• Used in conjunction with heroin or found as an adulterant in

counterfeit pharmaceutical products• Fentanyl is an FDA approved drug for pain management

early 1960s• Carfentanil is NOT approved for human use•Most fentanyl today made in clandestine labs, primarily

China and Mexico •May require multiple administrations of Narcan• Depending on how much the person has used, Narcan may

be unable to reverse overdose

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OPIOID OVERDOSEREVERSAL

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Signs of OVERMEDICATION, which may progress to overdose

• Unusual sleepiness, drowsiness, or difficulty staying awake despite loud verbal stimulus or vigorous sternal rub. • Mental confusion, slurred speech, intoxicated behavior.• Slow or shallow breathing• Fingernails or lips turning blue/purple• Extremely small “pinpoint” pupils, although normal size pupils do

not exclude opioid overdose.• Slow heartbeat, low blood pressure.• Difficulty waking the person from sleep.

Abstinence as a Risk for Overdose•When opioid dependent individuals achieve abstinence

whether by: • abstinence-based treatment• agonist or antagonist treatment• incarceration

• Tolerance decreases• Inmates released from prison without MAT have more than

10 times higher risk of dying from overdose in the first 2 weeks following their release than the general population • Use of opioids at the previous level after abstinence (common

occurrence) may lead to overdose

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Abstinence as a Risk for Overdose

• Requiring people to stop taking their addiction medications is counter-productive and increases the risk of relapse. • Because tolerance to opioids fades rapidly, one episode of

opioid misuse after detoxification can result in life-threatening or deadly overdose.•When a patient’s diabetes is stabilized, you don’t

discontinue their insulin

Naloxone• Naloxone was first synthesized in 1961 and was first approved by

the FDA for usage in 1971• The drug is an opioid antagonist, which means it competes with

opioids already present in the body by binding to opioid receptors in the brain• This prevents the opioid receptors from binding with any further

opiates present so that a person who ingested too much of the substance will not experience overdose from toxicity• The drug not only keeps the body from binding any further

opioids but it also completely counteracts the effect of an opioid overdose.

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Overdose Reversal with Naloxone• The use of naloxone both injection and auto-injection (Evzio)

& nasal spray (Narcan) is increasingly available• For some opioids (e.g., fentanyl), multiple administrations

may be required, and for some it will not reverse the overdose• Some victims dosed with naloxone become upset and angry

because it causes withdrawal• Originally available by prescription only now increasing

available without (CVS & Walgreens) and moving toward making it OTC•Many users go back to using unless there is an available

intervention

Overdose Reversal• In 2017 all states had passed legislation designed to improve

layperson naloxone access • The skill required for naloxone administration is low, and because it

cannot be abused and is pharmacologically inactive in the absence of opioids, even unwarranted administration is unlikely to cause adverse reactions.• In addition, the majority of states now allow individuals to obtain

naloxone from retail pharmacies without a patient-specific prescription• It is also important for first responders to know that, while fentanyl

has a short duration of action (30-90 minutes), it can stay in fat deposits for hours, and patients should be monitored for up to 12 hours after resuscitation.

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Naloxone as Evzio

Naloxone as Narcan

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Opioid OverdoseNaloxone

• An opioid antagonist indicated for the emergency treatment of known or suspected opioid overdose •While the drug was initially only offered through intravenous

injection, it has since been made available in a nasal spray application• Can be given by injection into a muscle, under the skin, into a

vein through an IV or in a nasal spray• This has made administering the drug incredibly easy and

because of this, because it is now given non-medically trained people the ability to dispense the drug

Naloxone

• Is not a controlled substance• Has no abuse potential• If administered to an individual not using opioids, nothing

happens• Can USUALLY immediately reverse opioid overdose• The increasing combination of heroin & fentanyl (100

times more powerful than morphine) or carfentanil (10,000 times more powerful than morphine) and may make Narcan ineffective

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Naloxone Costs

• Narcan costs $150 for two nasal-spray doses• A two-dose Evzio package was priced at $690 in 2014 but is

$4,500 today, a price increase of more than 500% in just over 2 years, but now discounted to first responders•Makes it difficult for first responders

Narcan

• Narcan temporarily blocks or reverses the effects of opioids• In most cases the effect is immediate (within 30 to 40

seconds), blocking the effects of the overdose and allowing the person to breathe again• This gives time to seek emergency medical assistance• Narcan® can be obtained by speaking to your medical

provider

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Opioid OverdoseNaloxone (Narcan)

• Originally, the only people that could give a person the drug were doctors or other medical professionals, but with the growing number of overdoses in this country and the ease with which the drug can be given, this is changing, and because of it, many more lives will be saved.• Evzio is an automatic injector system• Nearly three quarters (73%) of prescriptions for

NARCAN® Nasal Spray have a co-pay of $10 or less

Reversing Overdose with Narcan®

• This gives time to seek emergency medical assistance. Its use is supported by many organizations, including the Office of National Drug Control Policy and the World Health Organization• Narcan® has no potential for abuse and will have no effect if

accidentally administered or self-administered (in the case of a child).• Narcan® can be obtained by speaking to your medical provider• You can also get Narcan® through many states, free of charge.

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Buprenorphine & Overdose

•Because buprenorphine has a higher affinity for the opioid receptors than do other opioids, naloxone may not be as effective at reversing the effects of buprenorphine-induced opioid overdose

Naloxone (Narcan)

• For a person who is experiencing an opioid overdose is, if they are unconscious, they will almost instantly be revived and become conscious• Any distress they were experiencing because of the

overabundance of opioids present in their body will stop immediately and while they may be physically sick, they will not die due to the harmful levels of opioids present• Narcan WILL precipitate opioid withdrawal

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“Dope Sick”

•Why don’t people stop using after an overdose?• “Withdrawal becomes the major deterrent to stop.”• Description of “Dope Sick,”: • The worst flu imaginable• Amplified by a power of 10• Those suffering from opioid addiction never get back the

same feeling of that first high but they are always chasing it.

This Is Narcan, Only the First Step

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The Problem

• Naloxone is only a tourniquet•We aren’t treating addiction, just preventing death• Use is analogous to stop the bleeding from an injury• The injury still needs to be treated• In one community, rescue squad personnel had to use 3

separate naloxone overdose reversals in the same individual during one shift•What NEEDS to happen after the opioid overdose

reversal???

Only A Stop Gap Measure

• A review of emergency medical services data from Massachusetts found that when given naloxone, 93.5% of people survived their overdose. • The research looked at more than 12,000 dosages

administered between July 1, 2013 and December 31, 2015• However, a year after their overdose, 10% of those who had

been given the reversal drug had died• 35% of those who died, died from opioid overdose

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One Recommendation for Post-Opioid Reversal• After overdose medication given, individual is brought to hospital ER for

stabilization• Initiating buprenorphine in emergency setting results in patients more

likely to be connected to treatment.• A peer recovery specialist immediately contacts addict or addict’s

family• The peer recovery specialist will discuss various available treatments

including: detoxification; MAT; recovery support groups and the range of psychosocial treatment options • If needed, the peer recovery specialist will drive the patient to the

selected, available treatment (assumes reimbursement)• Goal is to intervene in the likelihood that the individual will

immediately return to use

1115 Waiver

• Some states have this waiver which allows Medicaid payment for treatment in a residential facility with more than 16 beds

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The Post-Reversal Problem• States have declared the opioid epidemic a public health emergency• This has allowed tightened practices for those prescribing opioids• Some states have received waivers to allow Medicaid to pay for

residential drug treatment• Additional funding has been made available to purchase Narcan• Naloxone reverses 93% of overdoses, but 10% of recipients don't

survive a year• BUT

• There is insufficient treatment capacity• Long waiting lists for the treatment has resulted• There is inadequate reimbursement

One solution to Wait Lists

• Have the person be placed on Suboxone without being enrolled in a programs until that time when there is an opening•While not as effective as being enrolled in a program, it

appears to cut down on overdoses and reduces the number of people lost to the wait list• One model in the Midwest based on Motivational

Interviewing

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Sub-groups of Patients with Opioid Use Disorder (OUD)1. The most common group of patients with OUD also have a history

of other substance use disorders. Most common would be marijuana, alcohol, cocaine and sedatives. While this group has struggled with an addiction to multiple substances, the opioids are the clear drug of choice. Many patients in this group will set all other drugs aside and only use them occasionally once opioids are discovered and available.

2. The second most common group with OUD continues to use other drugs concomitantly with the opioids. They may not identify opioids (or any of the others) as a clear drug of choice. This group will often speedball (mix opioids and cocaine). They also may unfortunately mix alcohol or sedatives with opioids, which is an unfortunate combination.

3. The least common group has OUD with no other history of substance use.

Consequences of Opioid Use

• Fatal traffic accidents• Researchers report a sevenfold increase in the number of

drivers killed in car crashes while under the influence of prescription opioids• Does not include heroin•Many opioid accidents also include alcohol and other

sedatives (benzodiazepines)• Total drug-impaired fatal accidents now exceeds alcohol

impaired fatal accidents

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Consequences of Opioid Use

• Overdose in users• Overdose in children who come in contact with the drugs• Liver damage, especially prevalent in abuse of drugs that

combine opiates with acetaminophen (e.g. Lortabs, Vicodin), usually expressed as 5/325• Brain damage due to hypoxia, resulting from respiratory

depression.• Neonatal Abstinence Syndrome (NAS)

NEONATAL ABSTINENCE SYNDROME (NAS)

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Neonatal Abstinence Syndrome (NAS)• NAS is a group of problems that occur in a newborn who was exposed

to addictive illegal or prescription opioids while in the mother's womb• Almost every drug passes from the mother's blood stream through

the placenta to the fetus. Illicit substances that cause drug dependence and addiction in the mother also cause the fetus to become dependent. At birth, the baby's dependence on the substance continues• NAS is a syndrome of the physical effects that result from depriving an

addict/newborn of the drug to which he or she is habituated.• NAS can last from one week up to many weeks• It is more accurate to described the fetus as physically dependent

than addicted

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Opioid Dependent Pregnant Women• Treatment of opioid dependent pregnant mother with methadone • Treatment of opioid dependent pregnant mother with buprenorphine

(Subutex) not Suboxone• See: Maternal Opioid Treatment: Human Experimental Research

(MOTHER) project. MOTHER is a double-blind, double-dummy, flexible–dosing, parallel-group clinical trial examining the comparative safety and efficacy of methadone and buprenorphine for the opioid dependence treatment among pregnant women and their neonates• While historically methadone was considered the drug of choice for

opioid dependent pregnant women, more recent research indicates the preferred agonist is buprenorphine• NEITHER attempts at abstinence or naltrexone/Vivitrol is

recommended during pregnancy

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Issues other than NAS in Pregnant/Postpartum Opioid Dependent Women

•When withdrawal from an opioid happens to a pregnant woman, it causes the uterus to contract and may bring on miscarriage or premature birth•Mothers taking methadone can still breastfeed. Research has

shown that the benefits of breastfeeding outweigh the effect of the small amount of methadone that enters the breast milk• Long term effects of NAS is unknown

NAS SymptomsCNS dysfunction includes the following features:

• High-pitched cry• Restlessness, with sleep duration less than

1-3 hours after feeding• Hyperactive reflexes• Jitteriness• Tremors• Hypertonia (rigid muscles, difficulty with

mobility and flexing, and muscle tension when resting)• Myoclonic jerks (one or many brief

muscle jerks)• Generalized convulsions

Metabolic, vasomotor, and respiratory disturbances include the following features:

• Sweating• Fever• Mottling• Frequent yawning• Sneezing (>3 times per interval)• Nasal flaring• Respiratory rate greater than 60 breaths

per minute without retractions• Apnea (infant stops breathing for 15 to

20 seconds during sleep)

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NAS SymptomsGI dysfunction includes the

following features:• Excessive (frantic) sucking or rooting• Poor feeding• Hyperphagia (excessive appetite), usually

associated with poor weight gain• Regurgitation or projectile vomiting• Loose or watery stools

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NAS Treatment• An environment that simulates a home nursery with low lighting and

reduced sound. Sound-dampening ceiling tiles and dim lighting decrease stimulation for the baby• Private space that includes rocking chairs in the rooms and sleeping

accommodations for parents are for baby-parent bonding.• The staff-to-patient ratio is also a key component. A baby with NAS

may have her own dedicated nurse, providing almost instant availability should the infant need anything• Pharmacological care, such as morphine, can be used, but the fewer

drugs prescribed the better. • Swaddling, rocking and subdued physical contact between mother

and baby shouldn't be overlooked.

Repercussions of Positive Drug Test in Newborns• Reporting of abuse – In many states, including Massachusetts,

Virginia, Arizona, Ohio and Illinois, it is mandatory that medical professionals who are aware of a positive drug test in a newborn report it to social services. In Alaska, women have been prosecuted for drug use during pregnancy• This report can lead to many consequences for the mother, including

an investigation and the loss of the right to parent her child• These women might not even know they are pregnant during the first

2 or 3 trimesters because they are drug-affected• When they find out, they be reluctant to seek medical care because

of the consequences if they get caught using while pregnant• Mandatory reporting may result in the woman choosing to shun

prenatal care at any point in the pregnancy

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Difference Between Physical Dependence and Addiction

• "PHYSICAL DEPENDENCE" is a physiological state of adaptation to a substance, the absence of which produces symptoms and signs of withdrawal• It is possible to be physically dependent on a drug without

being addicted to it• Physical dependence is the result of physical changes in the

brain.

Difference Between Physical Dependence and Addiction

• ”ADDICTION" is characterized by:• Compulsion• Loss of control• Continued use in spite of adverse consequences• Craving

• Addiction can exist with or without physical dependence but is more common with physical dependence

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It is more accurate to describe babies born with NAS

as physically dependent than addicted

TREATMENT OF

OPIOID ADDICTON

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Begins with Comprehensive Assessment

SEARCHING FOR HELP

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Another New(?) Threat• Google found 61 percent of people who went to rehab used the

internet to find treatment — a bigger number by far than those who relied on their family, friends, or doctors• The opioid epidemic spurs illegal/unethical provider behavior• High-jacking on message platforms• Patient brokering (paying for patients)• Bribing patients to come into treatment with cash or drugs• Being passed around between brokers, kept high or even forced into

prostitution• Overutilization of drug testing• Third-party marketers operating referral hotlines• Kicking back a portion of insurance reimbursements for blood, urine,

or genetic testing.

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ASAM Dimension 1: Acute Intoxication/Withdrawal Potential

Withdrawal Management from Opioid Dependence

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Three Goals for Withdrawal Management

• Avoidance of potentially hazardous consequences of discontinuation of drugs of dependence• Facilitation of the patient’s completion of

detoxification and timely entry into continued treatment – The key here is that after detoxification, tolerance goes down and using at the previous level is likely to result on overdose• Promotion of patient dignity and easing discomfort

during the withdrawal process

Detox for Opioid Addicts

• Because of the precipitous drop in tolerance following detoxification with the risk of overdose if the patient uses again, detoxification of individuals addicted to opioids is not recommended UNLESS immediate entry into addiction treatment can be accomplished as in detoxification as part of treatment program• Because of the poor outcomes in abstinence-based

treatment for this population, consideration should be given to induction into agonist treatment (methadone or buprenorphine)

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Assessment Instruments for Opioid Withdrawal

• Subjective Opiate Withdrawal Scale (SOWS)•Objective Opiate Withdrawal Scale (OOWS)•Clinical Opiate Withdrawal Scale (COWS)***•Clinical Instrument for Narcotic Assessment (CINA)

*** considered best

THE BEST PREDICATOR OFCURRENT AND FUTURE

WITHDRAWAL PROBLEMS ARE PAST

WITHDRAWAL PROBLEMS

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Short and Long Acting Opioids

Short –Acting:•Morphine• Oxycodone• HydrocodoneLong-Acting:MethadoneExtended release formulations of fentanyl, morphine,

oxycodone

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Early & Late Symptoms of Opioid Withdrawal

• Early symptoms of withdrawal include:

• agitation, anxiety muscle aches, increased tearing, insomnia, runny nose, sweating, yawning

• Late symptoms of withdrawal include:

• abdominal cramping, diarrhea, dilated pupils, goose bumps (piloerection), nausea, vomiting

Medications to Manage Opioid Withdrawal

• Methadone: Helps reduce cravings and withdrawal symptoms. The

action of methadone is similar to other synthetic (man-made) medicines in the morphine category (opioids). Dose is gradually reduced overtime

• Buprenorphine: Severity of withdrawal is similar for withdrawal managed with buprenorphine compared to methadone, but withdrawal symptoms may resolve more quickly with buprenorphine

• Clonidine: Relative to clonidine, buprenorphine is more effective in ameliorating the symptoms of withdrawal, patients treated with

buprenorphine stay in treatment for longer, particularly in an outpatient setting - used to help reduce anxiety, agitation, muscle aches, sweating, runny nose, and cramping – does not reduce craving

• Rapid Opiate Detoxification: NOT RECOMMENDED

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Rapid Opiate Detoxification• In the ultra rapid detoxification (UROD) procedure, opiate detoxification is

induced by the use of a bolus injection of very high doses of an opiate antagonist (naloxone) under general anesthesia or heavy sedation followed by a slow infusion of low-dose naloxone.• The 4-hour procedure is carried out in an intensive care unit and the

patient requires 1 to 2 days of hospitalization for a full treatment protocol.• Proponents of the procedure claim that complete accelerated

detoxification is attained, the patient experiences no withdrawal symptoms, physical dependency is eliminated, and the psychological craving for drugs is greatly reduced.• However, experts prominent in the field of opiate addiction in 1996

reported their concerns about UROD stating that detoxification is not a cure for opiate addiction and that medication without psychosocial support has little impact on opiate addiction• This style of opioid detox does not significantly benefit the individual. In

fact, it could trigger other complications like symptoms of delirium

Post-Withdrawal Treatment

ASAM Dimension 5: Relapse, Continued Use,

Continued Problem Potential

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The Most Common Current Approach to the Treatment for All Addictive Disorders Is

Psychosocial Treatment

Psychosocial Treatment

•Was the original therapeutic approach to addiction• AA 1935

• The basis for older and many/most current treatment programs• A Twelve Step disease model approach• Initially most counselors were not clinicians but provided

treatment out of their own recovery experience• Over time, more clinical approaches and evidence-based

treatment• Emphasis on the power of the group to change behavior

(group therapies)

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Elements of Psychosocial Treatment• Medical history including infectious diseases (hepatitis, HIV, TB), trauma

and pregnancy (ASAM Dimension 2 & 3)• Physical examination (ASAM Dimension 2)• Clinical laboratory testing including CBC & liver function (ASAM Dimension

2)• Women tested for pregnancy (ASAM Dimensions 1 & 2)• Drug testing (ASAM Dimensions 1, 2 & 5)• Evaluation of addiction to, or past or current use of other substances

(ASAM Dimension 1, 4 & 5) or results of previous attempts at recovery• Assessment of co-occurring mental health disorders (ASAM Dimension 3)• Assessment of readiness to change (ASAM Dimension 4)• Assessment of tobacco use (ASAM Dimension 1, 2 & 5)• Assessment of environmental factors (ASAM Dimension 6)

Psychosocial Interventions

• Psychosocial interventions have generally been found to be effective. • Some interventions, such as cognitive behavior therapy,

motivational interviewing, contingency management and relapse prevention, appear to be effective across many drugs of abuse• Psychological treatment is more effective when prescribed

with anti-addiction medications than when medication or psychological treatment is used alone• This is particularly true for opiate users.

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Challenges of Psychosocial Treatment Alone for Opioid Dependence

• Psychosocial support alone has high relapse rate1

• Opioid dependent patients treated in inpatient treatment - had early relapse post-discharge (i.e., a return to daily opiate use). • Follow-up interviews 91% reported a relapse, and the initial

relapse occurred within one week in 59% of cases

• Dependence drives a desire for intoxication

• High rates of AMA discharges (inpatient) & drop-out (outpatient) from opioid dependence treatment makes success more difficult

References:1. National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert 6. October 1989.

Comparison MAT vs. Behavioral Treatment

•Medicaid claims 52,278 Massachusetts beneficiaries 2004-2010 –•Being in MAT reduced risk relapse 50% vs behavioral

tx– Longer in treatment the lower the risk of relapse– MAT expenditures/month $155, $233 lower than behavior tx alone

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It’s Not 1960 Any Longer• Patients back then starting using much later• They were “rehabilitatable,” now many only “habilitatable”• Patients with co-occurring mental health or legal problems were not

generally referred or admitted to addiction treatment programs resulting in an unintended less pathological treatment population• Lack of employment or intact family was generally the result of use • Educational issues were not as commonly a problem then

For all these reasons, psychosocial treatment alone then worked better than today

- Yet, in spite of our best efforts using psychosocial treatment, most patients will drink/use again- If we use abstinence as the sole outcome measure, outcome for addiction treatment is less positive than for 10 different types of cancer (5 year outcomes)

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What can we add to psychosocial treatment

to improve outcome?

Recovery Support Services (RSS)Rather than treatment interventions, they are

assistance with:• Housing (for the homeless)• Transportation • Childcare• Vocational Training (for the unemployed)• Employment (for the unemployed/ex-felons)• Education (for those without a H.S diploma or GED)• Financial Counseling/Aid• Legal Aid• Parenting Training• Literacy training

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RSS Importance

• For many patients, particularly in the public sector, Recovery Support Services (which includes case management), may be as, or even more important, than treatment

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Without these needed services,here is where we are:

Demographic Predictors of Poor Treatment Outcome

(both MH & SA)

1. Under 25 years of age2. Never married or having lived as

married3. Unemployed4. No high school diploma or GED