Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

SAEM KEYNOTE

No description
by

Shara Martel

on 29 March 2018

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of SAEM KEYNOTE

Treatment of Opioid Use Disorder
Professor and Chair
Department of Emergency Medicine


Yale
SCHOOL OF MEDICINE
Governor Dannel Malloy's Strategic Initiative
Alcohol and Drug Policy Council
Department of Mental Health and Addiction Services
Department of Children and Families
Department of Public Health
Department of Correction


Emergency Physicians as Innovators, Policymakers and Heroes
May 16, 2018
only 1 in 5 get treatment
NSDUH
Why the ED?
Because that's where the patients are!
DAWN, SAMHSA 2013
Treatment seeking
Overdose
Screening
Evidence Based Practices
Heroin OD deaths during expansion of methadone & buprenorphine in Baltimore 1995-2009
What is effective treatment for opioid use disorders?
Behavioral
Therapy
MAT
Medication
What is NOT considered evidence based treatment?
Detoxification only
Abstinence-oriented therapy
Mutual support programs
Naloxone (Narcan)
Schwartz, AJPH, 2013
Advantages of Opioid Agonist Treatment (MAT)
Reduction in illicit substance use
Less viral hepatitis, HIV, & IV drug use complications
Reduction in risk of opioid overdose and death
Reduction in risky behaviors
Reduced risk of legal consequences
More time available to
-Have sustainable relationships
-Find gainful employment
-Deal with other medical problems
Medication

for
Addiction Treatment
How much counseling with buprenorphine or methadone?
Systematic review of 34 randomized clinical trial, 3777 patients receiving buprenorphine or methadone with basic versus additional structured counseling

“Present evidence suggests that adding psychosocial support does not change the effectiveness of retention in treatment and opioid use during treatment.”

Innovative Interventions
Initiating Treatment

Direct
Linkage
Treat opioid overdose as any
other emergency
Options for ED providers:
Referral
Initiation of
buprenorphine
(FDA 2002 Specially trained MDs/Exemptions)

Buprenorphine
Semisynthetic
25 to 50 times more potent than morphine


Formulations
72-hour rule
Title 21, Code of Federal Regulations, Part 1306.07(b)

Allows to administer (but not prescribe) narcotic drugs for the purpose of relieving acute withdrawal symptoms while arranging for the patient's referral for treatment

Not more than 1-day's medication may be administered or given to a patient at one time

Patient must return to ED each day for no more than 72 hours

This 72-hour period cannot be renewed or extended.

A Randomized Trial of ED-Initiated
Interventions for Opioid Dependence
D’Onofrio, G., O’Connor, P.G., Pantalon, M.V., Chawarski, M.C., Busch, S.H., Owens, P.H., Bernstein, S.L. and Fiellin, D.A.
Past 7 Day illicit Opioid Use
Reduces Inpatient Addiction Treatment
Conclusion
The Opioid Crisis From
Research to Practice
How do we apply this to the real world and move forward?
Why is this different than any other acute emergency??
Examples of Acute Emergencies
Stroke
STEMI
Overdose
Observation
& home w/
instructions
Facilitated
Referral
Naloxone
Prescription
Observation
& Initiate Tx
Emergent
Care
Reduce
OD Deaths
Reduce OD Risk
Safe Prescribing
Data Sharing
Reducing the stigma
Access to MAT
Increase Access to Naloxone
Accelerate opioid overdose survivors’ entry into opioid agonist treatment
Naloxone distribution to high-risk individuals
Minimize financial or logistical barriers to naloxone
Reduce receipt of opioids > 90 milligram of morphine equivalents, while preserving function
Decreasing opioid and benzodiazepine co-prescribing and co-use

Reduce Overdose Risk
Those at Highest Risk for Overdose
Prior non-fatal opioid overdose
Opioid use disorder leaving controlled settings (e.g. residential treatments, detoxification, incarceration) who have lowered opioid tolerance
Prescribed doses of opioid analgesics greater than 90 milligram morphine equivalents (MME) per day
Taking (co-prescription or co-use) opioids and benzos
Alcohol and opioids
Injecting opioids
Exposed to high potency opioids (fentanyl, W-18)
Low levels of physical tolerance (new initiates)
Sleep disordered breathing (e.g. sleep apnea)

Breaking the Glass
Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

Number need to harm (NNH) = 49

Barnett. NEJM 2017;376:663-73

Words Matter
Chronic Pain
Opioid Use Disorder
Experimental Use

The 100 Years Leading to the Current Crisis
Robert Heimer PhD
Professor of Epidemiology & of Pharmacology
Director, CT Emerging Infections Program
20.1 million Americans > 12 with a substance use disorder
2.1 with opioid use disorder
1.8 million involve prescription pain relievers; 0.6 million heroin
3.3 million reported non-medical use of pain relievers in past month

Drug overdose is the leading cause of accidental dealth in the US:
64,070 deaths in 2016
20,145 synthetic opioids other than methadone
15,446 heroin
14,427 natural and semi synthetic opioids
Escalating Opioid Crisis
Basis of Pharmacology
Repeated exposure to short acting opioids leads to neuronal adaptations

Basis of specific pharmacotherapies to stabilize neuronal circuits

Overdose Death Rates
2015
1999
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System

Anxiety
Irritability
Restlessness
Insomnia
Nausea
Abdominal cramps
Aching bones
Aching muscles
Sweating
Drug Cues Stimulate Craving
Showing patients with addiction pictures of things that remind them of drugs (syringes, white powder, etc) dramatically increases blood flow in the amygdala.
In addition to the striatum, the amygdala is important to the genesis of addiction

Opioid Agonist Treatment
Neurobiology Rationale
-Cross-tolerance
prevent withdrawal
relieve craving for opioids
-Narcotic blockade
block or attenuate euphoric effect of exogenous opioids

What does it feel like when taking opioid agonist treatment?

Medication-Assisted Treatment and Opioid Use Before and After Overdose in Pennsylvania Medicaid
Opioid prescribing and MAT changes from before to after overdose among medicaid enrollees who have a 3X higher risk of opioid overdose
Patients continued to have high prescription opioid use, with only slight increases in MAT engagement
Frazier, Winfred, et al. "Medication-Assisted Treatment and Opioid Use Before and After Overdose in Pennsylvania Medicaid." JAMA 318.8 (2017): 750-752.
ED-initiated buprenorphine with primary care follow-up
is superior in:
Engaging Patients in treatment
Reducing days of illicit opioid use
Reducing inpatient addiction treatment
&
Cost-effective compared with referral & brief intervention
Cost-effective acceptability curve: base case analysis.
(a) Willingness-to-pay for a 1 percentage point
increase in the probability a patient is engaged in treatment 30-days post-enrollment.
(b) Willingness-to-pay for 1 additional opioid-free day
in the past 7-days
Impact on Special Populations
Women
Adolescents
Older Adults
Become physically dependent more quickly
Use substances differently...
smaller amounts for a shorter time before dependent
More sensitive to cravings
Death rates from prescription opioid ODs increased 471% (1999-2015)
Final Report: Opioid Use, Misuse, and Overdose in Women. The U.S. Department of Health and Human Services Office on Women's Health (OWH) July 2017
3.6% (891,000) adolescents (ages 12-17) misused opioids in the past year
0.1% (`13,000) current heroin users in the past year.
0.6% (153,000) have opioid use disorder
The OD deaths among adolescents aged 15–19 increased
1.6-3.7 per 100,000 from 1999 to 2015 (CDC 2015)
(NSDUH 2016)
According to the 2014 NSDUH opioid use among adults 50 and older increased from 1% to 2%.
High rates of comorbid illnesses in older populations and the potential for drug interactions has profound implications for the health and well-being of older adults who continue to misuse opioids

SAMHSA: New Report shows that Opioid Misuse Increases among Older Adults. Wednesday, July 26, 2017
Why Fentanyl ?

Synthetically created, not reliant on cultivation of poppy plant
More potent and lower cost substance, Higher profit
Can be cut into Heroin or sold in place of Heroin
Can be pressed to resemble counterfeit prescription opioids

Addiction is a disease NOT

a Moral Failing
NSDUH 2016
Addiction is defined as a chronic, relapsing disease
Like diabetes, cancer and heart disease, addiction is
caused by a combination of behavioral,
environmental and biological factors.
Genetic risk factors account for
50%
of the likelihood
that an individual will develop addiction.
ARREST
War on Drugs Led to Mass Incarceration
85% of the U.S prison population is either addicted (65%)
or their lives were affected by substance use (20%)
CASA
Solution
Solution
Start Young With Prevention
TREATMENT
"These medications ... are the current standards of care for reducing illicit opioid use, relapse risk and overdoses... However, limited access... can create barriers to treatment."
Increase access
Language Matters
NY Times, June 11, 2017
Questions????
Inc
Increase Community Understanding of Opioid Use Disorder & Treatment
More Information
Read the CORE initiative
http://www.ct.gov/dmhas/lib/dmhas/publications/core_initiative10.6.16.pdf

Questions?
NEJM, June 2017
Prevalence of chronic pain
Affects over 100 million Americans (1 in 3 people)

25 million American adults suffer from
daily
pain

40 million American adults have
severe
chronic pain

Costs over $600 billion each year in
treatment costs, lost wages, and productivity

Profound neurobiological changes accompany the transition from use to OUD
Symptoms of Opioid Withdrawal

< 1/3 of Drug Treatment Centers Use MAT
Endorsed By
C
onnecticut
O
pioid
RE
sponse
Addiction, 2017
JAMA, 2015
Yale Team
David Fiellin, MD
Gail D'Onofrio, MD, MS
Robert Heimer, PhD
William Becker, MD
Increases data sharing between state agencies regarding opioid abuse & opioid overdose deaths
Accurate Words Matter
CDC WONDER 2017
Taper vs. Ongoing Treatment
Kakko, Lancet 2003
Deaths: Taper - 4/20
Buprenorphine - 0/20
Overdose deaths during expansion
of methadone and buprenorphine in France 1996-2003
Emmanueli, Addiction 2005
Drug users using medication treatment
Intrinsic Activity
Long-term Outcomes
Methods:
24 week open label comparative effectiveness trial at 8
community based inpatient services
Primary Outcome:
Relapse-free survival during 24 weeks of outpatient
treatment. Relapse was 4 consecutive weeks of any non-study opioid use by urine tox or self report or 7 days of self reported use
Findings:
Only 72%

initiated XR-NXT
(204/283) vs
94%
270/287 for BUP-NX p<0.0001
Relapse rates > XR-NTX
than BUP-NX (
65% vs

57%
)
Interpretation:
Once initiated both medications were equally safe and effective
2017
What does it feel like to have opioid use disorder?
From “Narcotic Blockade” by V.P. Dole, M.E. Nyswander and M.J. Krock, 1966, Archives of Internal Med

Days
Objective:
To evaluate the relationship between PDMP and
self report in opioid-dependent ED patients
Results:

Only 36% of patients had at least 1 prescription in the PDMP
Patients with > 15 of 30 days where more likely to have at least 4 PDMP opioid prescriptions (53%) than patients reporting to 1-4 (37%) or zero days (11%)

Conclusions:

PDMPs may be helpful in identifying patients with certain drug-related behaviors, but are
unable to detect many patients with OUD
Past-year Prescription Drug Monitoring Program Opioid Prescriptions and self reported Opioid Use in an Emergency Department Population With Opioid Use Disorder
Dec, 2017
Hawk, K., D'Onofrio, G., Fiellin, D.A., Chawarski, M.C., O'Connor, P.G., Owens, P.H., Pantalon, M.V. & Bernstein, S.L.
Gail D'Onofrio MS, MS
https://losttoopioids.nsc.org/index.html
The Opioid Crisis:
Full transcript