Addressing Opiate Abuse and Dependence in Inpatient Psychiatric Settings

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1 Addressing Opiate Abuse and Dependence in Inpatient Psychiatric Settings Mark Hurst, MD Medical Director Ohio Department of Mental Health Columbus, Ohio

2 Opioid addicted patients in psychiatric hospitals All patients admitted to psychiatric hospitals must meet psychiatric admission criteria: They must have a mental illness: Mental illness means a substantial disorder of thought, mood, perception, orientation, or memory that grossly impairs judgment, behavior, capacity to recognize reality, or ability to meet the ordinary demands of life. ORC AND

3 Opioid addicted patients in psychiatric hospitals Their symptoms are of sufficient severity that they cannot be safely treated in a setting other than an inpatient facility, namely Dangerous to self Dangerous to others Unable to care for basic needs Represents a threat to rights and privileges of others

4 Opioid addicted patients in psychiatric hospitals Individuals with substance use disorders alone would NOT meet these criteria and would not be appropriate for treatment in a psychiatric facility, however: Co occurring addiction and psychiatric disorder is common and is associated with worse outcomes, including suicide and other self-harm, violence and accidental death.

5 Opioid addicted patients in psychiatric hospitals We must be prepared to: Assess Provide basic treatment to stabilize Provide more specific treatment and/or refer as needed and appropriate for an individual The addiction treatment provided in a psychiatric hospital for such individuals will differ from that provided in a substance abuse treatment facility in terms of character and intensity

6 Overview of Opioids

7 Opioids Opioid medications are invaluable in the treatment of acute, severe pain, as cough suppressants and as adjuncts to general anesthesia Opioids include opium and compounds derived opium as well as semisynthetic and synthetic compounds that have similar structure and function

8 Opioids Opioid abuse and dependence have been problematic for centuries Main classes of opioid abusers: Street (usually heroin) abusers Medical abusers Routes of administration: Oral, IV, IM, SC, IN, Smoking, PR

9 Historical Aspects of Opioid Use The watershed event was in the US Civil War, when morphine entered into wide use with the introduction of the hypodermic needle Increased rates of morphine use lead to addiction increasing addiction, including in higher income patients, many of whom were introduced to the drugs by their physicians for menstrual pain and menopausal symptoms. The widespread use of opiates and increasing rates of addiction led to restrictive laws and policies which effectively criminalized addiction.

10 Historical Aspects of Opioid Use Harrison Narcotics Act (1914) prohibited the prescribing of narcotics (opiates) to addicts. Physicians decreased prescribing for fear of prosecution

11 Historical Perspective Patients continued to become addicted to opiates. No consistently effective treatment developed or utilized until 1974 with the first methadone maintenance programs 2002: Buprenorphine treatment (office based) expanded availability of effective pharmacological treatment for opiate addiction Late 1990s-early 2000s: Increased emphasis on undertreatment of pain

12 1990s-2010s Explosion of Opiate Use and Addiction Emphasis on treatment of pain led to belief that non-malignant pain should be treated utilizing the same principles as those for treating cancer pain There was belief that those with pain were less likely to abuse opiates (wrong) New, more potent and high dose opiates were developed and aggressively marketed Joint Commission promulgated Pain Management Standards that became effective Jan 1, 2001

13 1990s-2000s Supply of opiates increased markedly Simultaneously, the rates of addiction to opiates and death rates due to poisoning by opiates also increased. Noted nationwide, including in Ohio. In 2006, deaths involving prescription opioid analgesics surpassed those for other illicit drugs: 1.63 times number cocaine-associated deaths 5.88 times the number heroin-related deaths Risk increases at morphine doses >50 mg

14 Nonmedical Use of Pain Relievers in Past Year among Persons Aged 12 or Older, by Substate Region: Percentages, Annual Averages Based on 2004, 2005, and 2006 NSDUHs Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2004, 2005, and 2006.

15 Past month reported illicit drug use National survey on drug use and health (NSDUH 2010)

16 Past month specific illicit drug use among persons >12 y.o (NSDUH 2010)

17 Past Month Illicit Drug Use among Persons Aged 12 or Older, by Age:

18 Past Month Illicit Drug Use among Adults Aged 50 to 59:

19 Trend of non-medical use of psychotherapeutics

20 First Specific Drug Associated with Initiation of Illicit Drug or Older: 2009

21 Past Year Initiates of Specific Illicit Drugs among Persons Aged 12 or Older: 2009

22 Past Year Dependence or Abuse of Specific Illicit Drugs: 2009

23 Received Most Recent Treatment in the Past Year for the Use of Pain Relievers

24 ED Visits Due to Non-medical Use of Opiates

25 ED Visits Due to Non-medical Use of Opiates by age and gender

26 ED Visits Due to Non-medical Use of Opiates by Specific Drug

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28 Ohio Unintentional Drug OD Deaths

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30 Opioid Intoxication and Withdrawal Intoxication Euphoria Sedation Slurred speech Constipation Analgesia Decreased respirations Attentional deficits Withdrawal Dysphoria, anxiety Insomnia Diarrhea, nausea, vomiting Muscle and joint pain Diaphoresis Chills Piloerection Tearing Yawning

31 Opioids Effects are mediated through endogenous opioid receptors: Mu: Analgesia, euphoria, respiratory depression, dependence Kappa: Sedation, diuresis Sigma: Dysphoria, hallucinations Delta: Cardiovascular effects, analgesia Tolerance and cross-tolerance exist

32 Opioids Opioid agonists: Morphine Heroin Meperidine Methadone Propoxyphene Oxycodone (including Oxycontin) Hydrocodone Hydromorphone Diphenoxylate Opioid antagonists Naloxone Naltrexone Partial Agonist: Buprenorphine

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41 Effects at opioid receptors

42 Treatment of Opioid addicted patients Assessment Detox Psychiatric Stabilization Discharge Planning/referral

43 Assessment of Opioid Use Disorders General Should be completed by a trained and licensed/certified professional, with a good understanding of biological and psychosocial aspects of addiction Should be a positive, non-confrontational interaction Longitudinal assessment/information is of great value Collateral contacts can also help (including OARRS) Always consider dependence on other drugs

44 Assessment of Opioid Use Disorders In ODMH hospitals, SAMI referral should invariably be made. In all cases, assessment should include: Past treatment history (what helped, what didn t) Level of insight and motivation (Stage)

45 Stages of change Pre-contemplation Contemplation Preparation Action Relapse prevention

46 Substance Dependence (DSM-IV-Tr) 3 of the following in any 12 month period: 1. Tolerance More needed for intoxication Less effect with the same amount of the drug 2. Withdrawal Typical withdrawal syndrome Taking the substance to treat or avoid withdrawal symptoms

47 Substance Dependence-cont d (DSM-IV-Tr) 3. Inability to predict the control of use 4. Unsuccessful attempts at abstinence 5. Significant time spent is substance-related activities 6. Important activities given-up in favor of substance use 7. Continued use despite adverse consequences related to use

48 Substance Dependence (DSM-IV-Tr) Course specifiers: In early full remission In early partial remission In sustained full remission In sustained partial remission On agonist therapy In a controlled environment With or without physiological dependence

49 Substance Abuse (DSM-IV-Tr) Pattern of pathological use and has never met criteria for dependence One of the following in any 12 month period: 1. Repeated inability to fulfill role obligations due to substance use 2. Repeated use of substance in situations where it is physically hazardous 3. Recurrent legal problems secondary to substance use 4. Continued use despite interpersonal problems or social problems related to use

50 Assessment of Opioid Use Disorders (cont d) History Chief complaint Present illness Medical history (conditions needing opioids) Psychiatric history Medications (controlled drugs, drugs which enhance opioid effects) Allergies (look for multiple allergies to controlled drugs) Family history Social history Systems review OARRS Report

51 Signs of Inappropriate Opioid Use Multiple episodes of lost or stolen prescriptions Repeatedly running out of medication early Aggressive complaints about the need for additional prescriptions Drug hoarding during periods of reduced symptoms Urgent calls or unscheduled visits Injecting/snorting opioids intended for oral use Using the medication to achieve euphoric effects Unapproved use of prescribed opioid to self-medicate another problem, such as insomnia Frequently missing appointments unless opioid renewal is expected

52 Signs of Inappropriate Opioid Use Unwillingness to try nonopioid treatments Evidence of withdrawal symptoms visible at appointments Concurrent alcohol or illicit drug abuse Sedation, declining activity, sleep disturbances, or irritability unexplained by the pain or other co-occurring conditions Deterioration of functioning at work, with family, or socially because of medication effects Forging prescriptions or obtaining prescriptions from nonmedical or multiple medical sources Selling prescription medicines

53 Assessment of Opioid Disorders (cont d) Physical findings Unexplained bruises and abrasions Frequent trauma Slurred speech Constricted pupils Memory deficits Track marks Jaundice Murmurs

54 Assessment of Opioid Use Disorders (cont d) Laboratory findings: Increased mean corpuscular volume (MCV) Increased liver enzymes (GTT, SGOT, SGPT) Elevated triglycerides, HDL Elevated uric acid Drug screen/ blood alcohol concentration Hepatitis serology, HIV testing, etc.

55 Urine drug screens Need to come from the person you want to test Sample should be fresh, properly stored, unadulterated Testing facility/equipment certified Person receiving results should understand limitations of testing Opiates: Routine screens may not detect meperidine, oxycodone, fentanyl, tramadol, buprenorphine Poppy seeds can give false positives

56 Detoxification Removing a substance from an individual who is dependent on that substance. This is usually accomplished by tapering that substance itself or by substituting a closely related substance and then tapering it.

57 Detoxification Treatment Goals: Resolve medical and psychiatric problems associated with withdrawal Prevent the development of complications of withdrawal Stop the patient s pattern of abusive substance use during and following detox Enhance factors which promote sobriety Minimize factors which detract from sobriety Engage the patient in formal rehabilitation Prevent the need for repeated detoxification

58 Detoxification Assessment Initial intake assessment Assess for all drugs of abuse, psychiatric illness, social stability, etc. History and physical Baseline rating scales (COWS, SOWS, OOWS) Comprehensive lab profile (SMAC, CBC, UA, TFTs,?EKG,?VDRL,?HIV) Urine drug screen, breathalyzer

59 Detoxification Basic Treatment Complete history and physical Rest, reassurance and good nutrition Adequate, but not excessive hydration Thiamine 100mg IM x 3 days and oral x 30 days Multivitamin with folate and minerals Attempt to avoid other psychotropics in the absence of clear psychiatric disorder

60 Detoxification Rating Scales (COWS, SOWS, OOWS) Withdrawal is multifaceted rating scales consider all of these facets Rating scales do a good job of assessing the severity of withdrawal with high inter-rater reliability Uniform use of rating scale helps to monitor the response to treatment during the course of withdrawal and promote uniform treatment There is a poor correlation between vital signs and severity of withdrawal

61 Opioid Withdrawal DSM-IV Development of withdrawal symptoms after reduction or cessation of prolonged and heavy opioid use or after administration of an opioid antagonist following opioid use

62 Opioid Withdrawal DSM-IV At least 3 of these symptoms Dysphoria Insomnia Muscle aches Tearing, rhinorhea GI symptoms (nausea, vomiting, diarrhea) Yawning Dilated pupils, gooseflesh, sweating Fever

63 Opioid Withdrawal Time course varies depending on the half-life of the drug Short-acting opioids (heroin, hydrocodone, oxycodone): Begins 6-12 hours after last dose Peaks hours Total duration about 5 days Long-acting opioids (methadone) Onset hours Longer period before peak symptoms of withdrawal Less severe withdrawal syndrome but longer Opioid withdrawal is NOT a life threatening situation, but is exceedingly uncomfortable Always consider addiction to other drugs and treat if needed (especially sedatives)

64 Treatment of Opioid Withdrawal Clonidine: Not a controlled drug No legal restrictions for prescribing Well-tolerated As effective as methadone in head-to head trials Not quite as effective as burenorphine/suboxone combination Can be used in process of transitioning to medication assisted therapy with naltrexone long-acting injection, buprenorphine, methadone, or totally abstinence based-treatment Preferred treatment in psychiatric setting

65 Treatment of Opioid Withdrawal: Clonidine Test dose of 0.1 mg for tolerability. If P<60 or systolic <90 mm Hg, do not use Weight <200 pounds: 0.1 mg qid on days one-four 0.05 mg qid on days mg qid on days 7-8, then stop Decrease/hold dose if bradycardia or hypotension develops Weight >200 pounds: 0.2 mg qid on days one-four 0.1 mg qid on days mg qid on days 7, mg qid on day 8, then stop Decrease/hold dose if bradycardia or hypotension develops

66 Treatment of Opioid Withdrawal: Clonidine Use rating scale to monitor course of withdrawal: If COWS >10, increase dose of clonidine gradually If substantial hypotension, bradycardia, sedatoin develops, decrease dose Can also utilize clonidine patch corresponding to the oral dose Always be sure to taper to avoid rebound hypertension

67 Treatment of Opioid Withdrawal Adjunctive medications for symptom relief: NSAIDS for pain Kaopectate or immodium for diarrhea Hydroxyzine for anxiety or insomnia Benzodiazepines can be used, if needed (WATCH) Decongestants for rhinorhea Phenergan for nausea and vomiting Avoid using needles

68 Treatment of Opioid Withdrawal Agonist therapy: suggest generally avoiding due to numerous potential pitfalls Options: Buprenorphine Approved for office-based treatment of opioid dependence in 2002 Form usually used in addiction treatment is combination of buprenorphine and naloxone (Suboxone) Limits risk of abuse and toxicity in overdose Requires certification of prescribing physician Methadone (requires facility special license) Not to be used for detox without this license

69 Treatment of Opioid Withdrawal: Buprenorphine Patient should be in mild withdrawal and negative for methadone, then give: Day 1 TWO 2mg/0.5mg Suboxone* tablet SL Day 2 ONE 8mg/2mg Suboxone Day 3 TWO 8mg/2mg Suboxone Then decrease by 2mg of Suboxone every one-to two days until the patient is off the medication Can also be used for maintenance, usually at a dose of 16mg/4mg daily Potential for diversion exists *First number reflects buprenorphine dose, second naloxone dose

70 Opioid Withdrawal Pharmacological management other options: Clonidine-naltrexone withdrawal Naloxone precipitated withdrawal under anesthesia Don t even think about using these

71 Special Circumstance: Patients admitted already on MAT Question: An NTP patient has been admitted to a hospital for treatment of a medical condition other than addiction. Can the hospital supply the treatment medication? Answer: Yes. A physician, or authorized hospital staff, may administer or dispense narcotic drugs in a hospital to maintain or detoxify a person as an incidental adjunct to medical or surgical treatment of conditions other than addiction. [21 CFR (c)]

72 Special Circumstance: Patients admitted already on MAT The facility should always confirm the dose of methadone or buprenorphine before prescribing A dose of 40 mg of Methadone can be fatal in a nontolerant individual Don t give a supply of these meds to the patient at discharge Arrange same day follow-up appointment with prescribing outpatient facility Watch sedatives, both inpatient and at discharge

73 Treatment other than detox Involve with SAMI programming Individual counseling (motivational interviewing, groups, 12-step, etc. Address reasons for admission: Psychiatric symptoms and syndromes: Psychotherapies Medication for psychiatric disorders Syndromes vs. symptoms Avoid controlled drugs unless clearly indicated Avoid non-controlled drugs with propensity for abuse» Quetiapine, sedating antidepressants, gabapentin, etc.» Stabilize medical issues

74 Special Case: pain and addiction Pain management in addicted patients should be addressed on a case-by-case basis Many patients who are drug seeking are experiencing genuine pain Pain associated with detox is genuine and time-limited to the detox period. Pain will be prolonged if treatment with opiate class medications occurs

75 Special Case: pain and addiction Some will have chronic pain in need of treatment in addition to pain of withdrawal Pain should be assessed: History/description Outside records Diagnostic studies Pain should be addressed following assessment with appropriate modalities (usually not opioids for non-malignant pain) Unrelieved pain is a risk factor for relapse Acute pain should be treated as in individuals without addiction though higher doses may be needed. Special situation with methadone and buprenorphine

76 Special Case: pain and addiction Opiates should be discontinued if: Prescription forgery Diversion or trading drugs Inappropriate use Continue to treat pain using non-controlled drugs

77 Treatment other than detox For individuals with severe mental illness and addiction, the ideal treatment is Integrated Dual Diagnosis Treatment (IDDT) Addiction treatment for patients without SMD can be initiated in the psychiatric facility, but the primary focus is stabilization of the psychiatric symptoms to permit definitive treatment in a facility with primary focus of addiction treatment Follow-up should address both psychiatric disorder and addiction

78 Treatment of Opioid addicted patients Discharge Planning/referral: Enhance factors supporting recovery Mitigate factors promoting relapse Consideration of medication assisted therapy (MAT) Referral for addiction treatment and psychiatric follow-up, if needed.

79 Common factors in relapse Protracted abstinence syndrome Chronic use promotes aberrations of the endogenous opioid receptor system. Common symptoms: Malaise and fatigue insomnia Decreased pain tolerance Decreased stress tolerance Drug craving Priming with small dose of drug Conditioned cues Stress

80 Role of Medication Assisted Therapy The risk of relapse among individuals with Opioid addiction is exceedingly high (up to 90%) over the course of a year Medication Assisted Therapy (MAT) can appreciably decrease risk of relapse and and associated morbidity and mortality MAT alone is not adequate treatment

81 MAT (continued) MAT does have role in the treatment of individuals with opioid addiction, including those who are dually diagnosed Medications to reduce relapse: Medications to treat primary psychiatric condition Antagonist therapy (naltrexone) Partial agonist therapy (buprenorphine) Full agonist therapy (methadone)

82 MAT (continued) Treatment should always be initiated with consideration of potential risks and benefits of treatment. Availability of treatment following discharge must also be considered prior to initiating treatment with medication. Treatment may not be available due to lack of resources in various areas: Lack of certified treatment providers Lack of financial resources to cover medication

83 Specific MATs to consider Medications to treat co-occurring psychiatric disorders Usual medications to treat psychiatric conditions should be utilized when a diagnosis is present Controlled drugs should be avoided due to risk of abuse and potential to be used to augment effects of other drugs Consider interactions with other MATs, if under consideration, as well as interaction with illicit drugs Watch non-controlled prescribed drugs that are themselves abused or augment other drugs

84 MATS that affect the opioid receptor Pure antagonist: naltrexone Partial agonist: buprenorphine Pure agonist: methadone Goals Opioid blockade Decrease drug craving Decrease risk of relapse d/t protracted withdrawal

85 Effects at opioid receptors

86 Specific MATs to consider Opioid antagonists: naltrexone Oral (duration of action hours) Long-acting injection (Vitrol-duration of action 4 weeks and currently expensive) FDA approved, but least well-studied of MATs Also FDA approved for treatment of Alcohol Dependence Oral naltrexone has demonstrated decreased relapse rates in highly motivated/supervised patients (healthcare professionals-80% success) Must be off opioids 7-10 days before starting

87 More on opioid antagonists Block effects of a dose of opiate and prevents impulsive use of drug Oral dose: 50 mg daily 100 mg every 2 days 150 mg every third day Side effects: liver toxicity and sedation Injected naltrexone: 380 mg every four weeks

88 Long-acting Injected Naltrexone

89 Specific MATs to consider Treatment with agonist or partial agonist: In almost all circumstances, it is most appropriate to refer the patient to a facility with the ability to both initiate and maintain treatment following discharge than to initiate treatment in the psychiatric hospital Pitfalls to starting in the hospital: Certification of prescribing physician What to do about discharge supply/prescription? Role if follow-up falls through Under no circumstances can methadone be initiated in the psychiatric hospital for maintenance addiction treatment due to need for specific licensure

90 Things to know about methadone Best studied and longest used medication for treatment of opioid addiction Schedule II and only used in certified centers Not substituting one addiction for another Higher doses used (>60 mg) Risk of increased QT interval in doses >100 mg) Approved in pregnancy

91 Things to know about methadone Good candidates: > 18 years Greater than 1 year of opioid dependence Medical compromise Infectious disease (HIV, Hep B or C) Pregnant women

92 Things to know about methadone Benefits: Lifestyle stabilization Improved health and nutrition Decrease in criminal behavior Employment Decrease in injection drug use/shared needles No evidence of long-term adverse effects

93 Things to know about methadone Decrease methadone levels: Pentazocine Phenytoin Carbamazepine Rifampin Efavirenz Nevirapine Lopinavir (Kaletra) Increase methadone levels: Ciprofloxacin Fluvoxamine Other drugs that inhibit 2D6, 3A4, 2B6 (Paroxetine, fluoxetine)

94 Specific MATs to consider Buprenorphine Approved for office-based treatment of opioid addiction in 2002 COULD be initiated inpatient, but should not be initiated without written confirmation of accepting outpatient clinician following discharge Prescribing inpatient physician must be specifically certified by CSAT/DEA

95 Things to know about buprenorphine Induction: Day 1 Day 2 Day 3 TWO 2mg/0.5mg Suboxone* tablet SL ONE 8mg/2mg Suboxone TWO 8mg/2mg Suboxone Little effect on respiratory function or cardiac function Can be used in pregnancy (buprenorphine without naloxone)

96 Mu Opioid Receptor Availability (Greenwald et al. 2003)

97 And before the patient leaves the hospital The key to success is follow-up after discharge. It is unlikely that a brief inpatient psychiatric hospitalization alone will lead to sustained sobriety in the absence of a tight follow-up plan. Treatment should address both MI and SA issues, ideally in an integrated approach. If not available, other modalities should be used to assure that both issues are dealt with

98 And before the patient leaves the hospital Assure that the patient has an adequate, but not excessive supply of discharge medications Avoid benzodiazepines as discharge medications Implicated as a co-factor in accidental opioidrelated deaths Assure that the patient and family are aware of emergency resources

99 And before the patient leaves the Deal with stashes hospital Question: The most common source of abused prescription drugs is: 1. Script doctors 2. Street pushers 3. Medications given or stolen from friends and family 4. Medication stolen from hospitals

100 Answer: 3. Friends and family Advise the patient and family to get rid of any remaining medications or illicit drugs due to this risk (PLUG: Nationwide Prescription Drug Take-Back Day is this Saturday, April 28) Advise the patient and family that the patient has been withdrawn from opiates and no longer has tolerance. This means if they return to use, it will take less to get high and even a low dose could kill them (This really happens)

101 Summary Opioid addiction is rampant in the United States. A relatively small number of total individuals who are opioid addicted will be hospitalized in psychiatric facilities, but these increasing numbers stress the importance of appropriate assessment and management within these facilities, with emphasis on referral to appropriate continuing care after discharge.

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