Opiate Update. Learning Objectives

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1 Wisconsin Public Psychiatry Network Teleconference (WPPNT) This teleconference is brought to you by the Wisconsin Department of Health Services (DHS) Bureau of Prevention, Treatment, and Recovery and the University of Wisconsin Madison, Department of Psychiatry. Opiate Update The Department of Health Services makes no representations or warranty as to the accuracy, reliability, timeliness, quality, suitability or completeness of or results of the materials in this presentation. Use of information contained in this presentation may require express authority from a third party. Erin M. Curtis, MD 1 Learning Objectives Review national and state epidemiology of current opioid epidemic (Substance Abuse and Mental Health Services Administration, 2011) (University of Wisconsin Population Health Institute, 2006) Review definitions and symptoms of abuse, dependence, intoxication, withdrawal, and addiction Understand biological basis for opioid addiction and treatment Appropriately evaluate and refer opioid dependent patients for treatment Discuss pharmacologic and psychosocial treatments for opioid addiction Discuss issues related to treatment in special populations: pregnancy, chronic pain, dual diagnosis National Epidemiologic Trends: Pain Relievers Nonmedical use of prescription drugs was the second most prevalent illicit drug use category among youths and young adults in 2010 The most prevalent category of misused prescription drugs is pain relievers Nonmedical pain reliever use in the past month among youths rate declined from 3.2% in 2002 to 2.5% in 2010 among young adults rate was similar in 2002 (4.1%) and 2010 (4.5%) 3 4 National Epidemiologic Trends: Initiation of Pain Relievers Initiation rates for nonmedical pain reliever use continue to be second only to marijuana rates. 2 million or more new nonmedical pain reliever users each year since 2002 includes over 500,000 who initiate use without ever having used another illicit drug Average age 21.0 years Sustained numbers of new and continuing users have contributed to substantial increases in indicators of problems associated with use, especially among adults: rate of pain reliever dependence for persons aged 12 or older increased from 2002 to 2010 (from 0.4 to 0.6% of the population) number of persons with dependence increased from 936,000 to 1.4 million most of these pain reliever dependent persons were aged 26 or older (56.6 percent), but about one third (463,000) were aged 18 to 25 The number of emergency department visits involving nonmedical use of narcotic pain relievers increased from 145,000 in 2004 to 306,000 in 2008 National Epidemiologic Trends: Heroin In 2010, there were 140,000 persons aged 12 or older who had used heroin for the first time within the past 12 months. The average age at first use among recent initiates aged 12 to 49 was 21.3 years, significantly lower than the 2009 estimate (25.5 years). 5 6

2 National Epidemiologic Trends: Availability 11.6% of youths age indicated that heroin would be fairly or very easily available 14.3% of youths indicated that they had been approached by someone selling drugs in the past month National Epidemiologic Trends: Where do the drugs come from? Among persons aged 12 or older in who used pain relievers nonmedically in the past 12 months: 55.0% from a friend or relative for free 11.4% bought from a friend or relative 4.8% took from a friend or relative without asking 17.3% prescription from one doctor 4.4% from a drug dealer or other stranger 0.4% bought them on the Internet 7 8 Wisconsin Epidemiologic Trends, Rates of illicit drug abuse and dependence mirror national trends. Wisconsin has highest rate of Oxycontin use in last month among people 12 and older 1%. Reported public funds expended for alcohol and other drug abuse treatment rose in Wisconsin from $58.47 million in 1996 to $78.44 million in 2005, an increase of 34% Rate of Drug Related Deaths in US and Wisconsin in 2004 (per 100K people) 9 10 Wisconsin Epidemiology: Dane County According to the Madison Police Department, the number of heroin overdoses in Dane County so far in 2011 is 131, over six times higher than in (The Daily Cardinal, Dec 15, 2011) Heroin has killed more people in Dane County than any other drug in the past five years nearly as many as all other overdose deaths combined. (Wisconsin State Journal, May 5, 2010) Biological Basis: Opiates vs. Opioids Endorphins are endogenous opioid receptor ligands Opiates are drugs that are derived from the Opium poppy plant with or without further synthetic modification. Examples: morphine, codeine, heroin Opioids are any compounds that bind opioid receptors in the brain, and produce effects characteristic of naturally occurring opiates. Includes opiates and endorphins Examples: methadone, fentanyl, oxycodone Relevant in interpreting drug test results! 11 12

3 Biological Basis: Normal Functions of Opioid System Role of μ opioid receptor and related endorphin systems in normal physiological functions Pain response (including placebo response) Neuroendocrine functions Stress response system (HPA axis) Reproductive function (HPG axis) Immunological function Gastrointestinal function Cardiovascular function Pulmonary function Regulation of mood, affect, cognition, memory Many other neurotransmitter systems interact with opioid system (DA, GABA, glutamate, glycine, endocannabinoid) Biological Basis: The Addiction Cycle (Koob, 2004) DSM IV: Substance Abuse DSM IV: Substance Dependence A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12 month period: 1. resulting in failure to fulfill major role obligations at work, school, or home. 2. in physically hazardous situations 3. substance related legal problems 4. continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance B. Never met criteria for Dependence for this class of substance A maladaptive pattern of substance use impairment clinically significant 12 months with 3 or more of the following: 1. Tolerance a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect. b) Markedly diminished effect with continued use of the same amount of the substance 2. Withdrawal a) The characteristic withdrawal syndrome for the substance b) The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms 3. The substance is often taken in larger amounts or over a longer time than intended 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use 5. A great deal of time is spent in activities necessary to obtain, use, or recover from effects of substance 6. Important social, occupational, or recreational activities are given up or reduced because of substance use 7. Use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance DSM IV: Substance Dependence Course specifiers Early full remission Early partial remission Sustained full remission Sustained partial remission On agonist therapy In a controlled environment DSM IV: Abuse vs Dependence You need not have physical dependence to meet dependence criteria (specifiers: with/without physiologic dependence) You could meet dependence criteria without ever having met criteria for abuse DSM V changes 17 18

4 DSM IV: POP QUIZ! Which of these diagnoses is NOT in the DSM IV? A. Polysubstance abuse B. Polysubstance dependence C. They are both in the DSM IV D. Neither is in the DSM IV DSM IV: Polysubstance Dependence Over 12 months repeatedly using at least 3 groups of substances (nicotine and caffeine don t count) but no single substance predominated Dependence criteria were met as a group but not for any specific substance Overall use of substances causes functional impairment DSM IV: Dependence vs. Addiction DSM IV: Opioid Intoxication The word addiction is not included in DSM IV, likely in effort to decrease stigma. Outside of DSM IV: dependence refers to cascade of neurobiological alterations that occur in response to chronic opioid exposure addiction refers to behavioral and psychological changes with drug craving and compulsive use despite negative consequences All persons requiring opiates or opioids on a chronic basis for pain develop both a tolerance and a dependence, but only very few develop addiction. (Galanter & Kleber, 2008) Mental status changes: initial euphoria followed by: apathy dysphoria psychomotor agitation or retardation impaired judgment, social/occupational functioning Physical exam findings: Pupillary constriction Drowsiness or coma Slurred speech Impaired attention/memory DSM IV: Opioid Withdrawal Beyond DSM IV: Opioid Withdrawal Develops within several days of use (or immediately after Narcan) Dysphoric mood Nausea/vomiting Muscle aches Lacrimation/rhinorrhea Pupillary dilation, piloerection, sweating Diarrhea Yawning Fever Insomnia Majority of withdrawal sx from chronic use of a short acting opioid resolve within 7 14 days Acute withdrawal symptoms from long acting agents takes significantly longer (up to several weeks) Restlessness, irritability, and inability to concentrate may persist for 3 6 months Changes in the HPA axis stress response system remain abnormal for over a year. (Galanter & Kleber, 2008, citing work by Kreek) 23 24

5 Evaluation of the Opioid Addicted Patient Interview Amount used, how obtained, route, h/o overdose, h/o sharing paraphernalia, presence of withdrawal sx, infectious disease history, legal history, spirituality (conflict with AA/NA?), trauma history, comorbid addictions, mental illness, chronic pain, pregnancy status, recovery environment, level of motivation/desire for treatment Mental Status Signs of intoxication or withdrawal, irritability, anxiety, drug craving, SI/HI, coordination (safe driving home from clinic?) Physical Exam Track marks, skin infections, pupils, gooseflesh, yawning, rhinorrhea, lacrimation, restlessness, Laboratory Evaluation Urine drug screen, Hep B/C, HIV Treatment: Components Detox Treatment of addiction Psychosocial rehabilitation Treatment programs (outpatient, IOP, residential) Peer support: 12 Step, SMART, others Family involvement Case management: housing, childcare, transportation, legal Lifestyle management to promote resilience: nutrition, exercise, work life balance FDA approved medications OMT (opioid maintenance therapy) Methadone Suboxone Vivitrol Treatment: Opioid Detox Generally does not warrant inpatient hospitalization Exceptions: Medical complications (intractable n/v, dehydration, diabetic, electrolytes, frail) Psychiatric complications (suicide/homicide, exacerbation of underlying disorder warranting hospitalization) AODA complications (polysub detox including EtOH or sedatives, planned admission for stabilization before entering rehab) Chance of relapse is remarkably high without pharmacologic intervention (methadone, buprenorphine, long acting injectable naltrexone DETOX TREATMENT OF ADDICTION! Treatment: Outpatient prescription meds for opioid detox Clonidine patch 0.1 mg weekly Disp #1 Clonidine 0.1 mg tabs ½ 1 tab PO 3 4x daily PRN, hold if light headed, dizzy upon standing or oversedated Disp #20 Lorazepam 0.5 mg 1 tab PO Q3 4 hrs PRN anxiety, agitation Disp #10 (at your discretion) Dicyclomine 20 mg PO Q6hrs PRN GI cramping Ondansetron 4 mg PO QID PRN nausea/vomiting Disp #20 Trazodone 50 mg QHS PRN insomnia Disp # Treatment: OTC and Home Remedies for Opioid Detox Musculoskeletal pain: Heading pads Ibuprofen and tylenol Warm showers or baths GI distress Loperamide (Imodium) Encourage fluids Easily digested diet Heading pad to abdomen Drug cravings Understand this is a natural occurrence Talk about it with a sober friend Go to AA/NA meeting Safe drug free environment Treatment: Referral to Rehab Using ASAM Placement Criteria 4 levels of care: Level 0.5 Early Intervention Level I Outpatient Treatment Level II Intensive Outpatient Treatment/Partial Hospitalization Level III Residential/Inpatient Treatment Level IV Medically Managed Intensive Inpatient Treatment OMT is considered separately 6 dimensions Acute Intoxication/Withdrawal Potential Biomedical Conditions and Complications Emotional/Behavioral Conditions and Complications Readiness to Change Relapse/Continued Use/Continued Problem Potential Recovery Environment 29 30

6 Treatment: Referral to Rehab Treatment: Referral to Rehab Other factors often considered: Location/availability of appropriate treatment center Insurance benefits/cost Patient preference Involuntary commitment Bottom line: ASAM Placement Criteria represent gold standard for matching patients to treatment and confers best prognosis When compromise is necessary: Patients should be given a clear recommendation based on ASAM criteria Rationale for deviation from this recommendation based on other considerations should be clearly documented in records Additional considerations Programs vary in their philosophies regarding maintenance medications and various psychotherapeutics and pain medications Programs vary in their accessibility for special populations Dual diagnosis Women s special needs: Childcare? Trauma/recovery emphasis? Integration with corrections Availability of Suboxone prescribers and methadone clinics varies significantly based on region of Wisconsin Vivitrol? Get to know the programs in your area! Treatment: Methadone Treatment: Suboxone ALWAYS CALL THE CLINIC! Medical issues Full agonist pharmacology Long half life=high potential for OD during titration How they look at peak (4 hrs after dose) is how they will look at steady state QT prolongation, sex hormone changes, oversedation Patient education I m just trading one addiction for another Harm reduction philosophy Legal issues Difference between prescribing for treatment of addiction vs pain Starting vs continuing therapy in hospitalized patients ROIs to speak with providers Admission criteria: age 18 or older, daily use for 1 year or more, certain exceptions Suboxone vs. Subutex vs. buprenorphine Medical: Partial agonist pharmacology d/c before surgery, or not Precipitated w/d Override with fentanyl Don t mix with benzos Considered a potentially lifelong medication (controversial) Legal: need X number to legally prescribe for addiction treatment AAAP course is highly recommended 30/100 pt max Restrictions do not apply when treating for pain (use buprenorphine instead and clearly document) Treatment: Vivitrol (long acting injectable naltrexone) Recent FDA approval for use in opiates Legally uncomplicated Medical controversy Complications: Injection site sterile abscess Eosinophilic pneumonitis Hepatic injury Opioid blockade: Requires long washout period (time windows differ depending on previously used opiate) Planning for elective surgery In emergency situation, anesthesiologist may use fentanyl to override in ICU setting Impact on endogenous endorphins (it s complicated ) Barriers Patients fear it and tend to choose alternatives Noncompliance Cost Treatment: Pregnancy OMT is treatment of choice in pregnancy Methadone has largest evidence basis and is still the approved treatment Subutex gaining ground Risk to fetus Neonatal abstinence syndromes Rapid admission to methadone clinic clinician should contact State Methadone Authority Tanya K. Bakker 1 W. Wilson, Room 850 Madison, WI Telephone: (608) Fax: (608) tanya.bakker@wisconsin.gov 35 36

7 Treatment: Additional Special Populations Dual Diagnosis Chronic Pain Adolescents References American Psychiatric Association. (2000). DSM IV TR. Arlington, VA: American Psychiatric Association. Galanter, M., & Kleber, H. D. (2008). Textbook of Substance Abuse Treatment. Washington, DC: American Psychiatric Publishing. Girard, S., & Harvey, T. (2011, December 15). Heroin 'epidemic' hits home. The Daily Cardinal. Kittner, G. (2010, May 5). Hooked on Heroin: Dane County's Deadliest Drug. Wisconsin State Journal. Ries, R. K., Fiellin, D. A., Miller, S. C., & Saitz, R. (2009). Principles of Addiction Medicine (Fourth Edition ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Substance Abuse and Mental Health Services Administration. (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H 41, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. University of Wisconsin Population Health Institute. (2006). Impact of Alcohol and Illicit Drug Use in Wisconsin. Department of Population Health Sciences. Madison, WI: University of Wisconsin School of Medicine and Public Health