Kaiser Permanente Department of Addiction Medicine Panel May 21, 2010

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1 Youth and Opiates Kaiser Permanente Department of Addiction Medicine Panel May 21, 2010

2 Panel Members Dr. Brad Anderson Kathy Tomlin Jeff Beatty Phil Anderson

3 Panel Program Introduce to KP-AM Suboxone Treatment Program for Young Adults Presentation from Dr. Anderson Description of Program Review of Specialized Group Service Questions/Comments

4 Well I never cared much for whiskey Cause it only made daddy mean Wrapped a little bit tight, they tell me For the methamphetamine Then my cousin come up from Knoxville And he taught me a thing or two Now I m headed nowhere but downhill With the Oxycontin Blues Oxycontin Blues, Steve Earle

5 Opioid id Addiction Trends in the Northwest t Major shift in choice of opioid for those with addiction in the past 15 years % heroin,10% Rx % Rx,10% heroin Major shift in age of those presenting with opioid addiction 1995 primarily 40+ y.o primarily 16 y.o. to mid twenties

6 Opium poppy Papaver somniferum

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8

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16 morphine CH N 3 H O H O O H

17 naloxone CH2 CH=CH 2 N OH H O H O O

18 naltrexone CH 2 N OH H O H O O

19 naltrexone CH 2 N OH CH 3 C(CH 3 ) 3 OH H O O H O CH 3

20 buprenorphine CH 2 N OH CH 3 C(CH 3 ) 3 OH H O O H O CH 3

21

22 Suboxone Puts switch in the halfway yposition WITHDRAWAL RELIEF

23 Clinical Opiate Withdrawal Scale C.O.W.S. Patients are given a score based upon the severity of eleven different withdrawal symptoms. 1. Pulse 5. Restlessness 9. Muscle/joint/bone aches 2. GI symptoms 6. Yawning 10. Goosebumps 3. Sweating 7. Pupil size 11. Runny nose/tearing 4. Shakes 8. Anxiety

24 Begin Suboxone when light switch is at least halfway off COWS of 8 to 10 For short acting opiates, this is typically between 12 to 24 hours after last use. For methadone it can take longer to reach this point, so start low, go slow is recommended with the last dose being at least 48 hours ago. Daily dose should ideally be less than 20mg in order to switch to Suboxone. o

25 DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 AM 4 mg 8mg 10 mg 12 mg 12 mg PM 2 mg 2 mg 2 mg 2 mg Total 8 mg 10 mg 12 mg 12 mg

26 The goal of therapy is to get to a dose with no withdrawal and no cravings. This can usually be achieved with a once daily dose. If a patient finds split dosing works better, they should rigorously adhere to this schedule every day. This maintenance dose is recommended for at least 6 months. Ad detox is typically done with a two week ktaper.

27 Got a dollar bill in my pocket Got half a tank in my truck Gonna go and pawn Grandma s locket Hell, maybe it ll change my luck Ain t nothin gonna be right no how Cause I know I can t ever lose This devil that s draggin me down And the Oxycontin Blues Oxycontin Blues, Steve Earle

28 Opioid Dependence Physical dependence - a physiological state of adaptation to opioids Withdrawal syndrome with abstinence Relief of withdrawal with reintroduction As little as two weeks at therapeutic doses

29 Opioid Dependence Psychological dependence - subjective sense of need for opioids Positive effects Avoidance of negative effects associated with abstinence

30 Opioid Dependence Physical dependence does not equal psychological dependence. Physical dependence usually accompanies psychological dependence.

31 Addiction A primary, chronic disease with - genetic, - psychosocial and - environmental factors influencing its development and manifestations. It is often progressive, fatal and characterized by - impaired control, - preoccupation with use and - continued use despite adverse consequences. These symptoms may be continuous or periodic.

32 Addiction Latin for given over or awarded to, from ad - to + dicere - say, pronounce U2 - lifeless lifeline, running to stand still C.S. Lewis - an ever increasing craving for an ever diminishing pleasure.

33 Kaiser Addiction Medicine Opioid Treatment Program Suboxone Medical Appointment Hospital Admission Counseling Orientation Substance Abuse Evaluation & Treatment Planning Lifestyle Treatment OPTIONS TAU-Youth Group Individual/Family

34 PITA APPOINTMENT Post Induction Treatment Appointment Motivational Counseling Appointment that: Support and engages in the treatment process Identifies dose, medical and counseling expectations Normalize and motivate experience Provides time to adjustment of addiction Assesses willingness and readiness Assign to appropriate track of treament

35 Suboxone Group Topics o Lifestyle o Stages of Change o Neuroscience o Confidence/ Desire to Change o Triggers o Pharmacology Assessment Review

36 Suboxone Group Topics o Values o Good / Not So Good o Auto Pilot / Mindfulness o Relapse Prevention o Instilling Hope / Future Goals o Support Systems / Relationships

37 Patient Evaluation Data Therapeutic Empathy Group Leaders were: Warm, supportive and concerned Treated me with respect Listened Understood how I felt inside Support of the Group Felt Close to others in group Group members were; Warm, supportive and concerned

38 Patient Evaluation Data Patient Participation Able to talk about problems Able to express feelings Actively involved Negative Feelings in Group Group Leaders did not understand me Discomfort in Group Agreement with leadership

39 Patient Group Evaluations

40 Written Comments What I liked least: members rambling, speed of group, worksheets, room was hot, What I liked best Comfort, able to talk, new people, having focused discussions, members and not being judged, material, size, coping skills, being able to talk about things I can t talk about elsewhere, structure, recovery info

41 Written Comments What I want more information on Life after subx, opiate chemistry, statistical information about opiate/drug use, how to handle boredom, managing anxiety, church

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