Opioid Use Disorder Treatment and Overdose Interventions

Transcription

1 Opioid Use Disorder Treatment and Overdose Interventions Caleb Banta-Green PhD, MPH, MSW Senior Research Scientist Alcohol & Drug Abuse Institute Affiliate Associate Professor School of Public Health Affiliate Faculty Harborview Injury Prevention & Research Center UNIVERSITY OF WASHINGTON

2 Outline Opioid epidemiology Opioid treatment Utilization Publicly funded Buprenorphine Demand Opioid overdose Overview of response options and resources Opioid use disorder Treatment options

3 Prescribing for most opioids began leveling off around SOURCE: DEA ARCOS- Sales to Hospitals and Pharmacies

4 State crime lab data Police evidence sent by local law enforcement jurisdictions for testing Rough measure of what s available on the street

5 Data source: WA State Patrol- Forensic Lab Services Bureau

6 Data source: WA State Patrol- Forensic Lab Services Bureau

7 Treatment admissions Influenced by demand and availability for treatment Publicly funded treatment data- inpatient, outpatient, and medication assisted treatment Small proportion of buprenorphine admits- included Buprenorphine treatment estimate from Prescription Monitoring Program Based upon prescribing in general medical practice, not in treatment program

8 Data source: DSHS/DBHR TARGET

9 Data source: DSHS/DBHR TARGET

10 Data source: DSHS/DBHR TARGET

11 PRELIMINARY DATA Buprenorphine prescribed by physicians approved to use for addiction treatment Data source: WA DOH PMP Episodes of care beginning between October 1, 2012 and December 31, 2013 were included for those who had no buprenorphine prescriptions between July and September 2012 in order focus the analysis on incident buprenorphine episodes. Follow up data was analyzed through December 31, 2014 allowing at least one year of follow up for all patients.

12 PRELIMINARY DATA Buprenorphine prescribed by physicians approved to use for addiction treatment The average episode length was days (S.D ) with 61.6% of episodes lasting 90 days or less. Cluster analysis for length of episode in days at the episode level Clusters N Mean S.D. Median % of episodes % % %

13 Drug caused deaths involving opioids

14 Rapid changes in opioid use and mortality

15 Age-adjusted Rate per 100,000 Data source: WA State Dept of Health Drug Overdoses, WA, Total Opioid Overdose Prescription Opioid Overdose Heroin Overdose (estimated) Year of Death King County data indicate recent heroin increases mostly <30 years of age

16 Data source: WA State Dept of Health

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20 Opioid overdose risk Heroin Past year 20% non-fatal overdose, 1% fatal overdose (Darke, 1996) Heroin users on methadone maintenance appear to have lower overdose rates than heroin users not on methadone (preliminary data Banta-Green R01DA030351) Rx opioids Chronic/Regular users: Opioid use disorder- Among those entering methadone maintenance therapy half the rate of life time overdose compared to heroin users 25% vs 49% (Banta-Green, unpublished data) Pain patients on 100+ Morphine equivalent dose 2% non-fatal year (Dunn et al., 2010) Acute/Short-term users: Unknown

21 Washington State Laws 2010 RCW Naloxone may be prescribed to anyone at risk for having or witnessing an overdose Good Samaritan protection- neither overdose victim or bystander who seeks aid can be prosecuted for drug possession 2015 HB 1671 effective 7/24/15 Standing order allows protocol so that prescriber can authorize others (including non-licensed) to distribute May prescribe to an entity (not just individual) e.g. police department or homeless shelter

22 WA State Pain Guidelines/Law Educational pilot guidelines updated, more screening tools, resources Law effective Jan for MD s and PA s Applied to chronic opioid non-cancer use Revisions 2015 Acute/peri-operative use introduced Opioid agonist treatment for substance use disorder recommended Co-prescribing naloxone p

23 Clinical considerations- Good candidates for overdose education & take-home-naloxone All Chronic Rx opioid users- Pain/Addiction social circles and their Regardless of dose are excellent candidates due to the total MED dispensed AND risk to patient and social circle All heroin users and their social circles Risk of OD is high for all heroin users. Young, old, opioid naïve, tolerant Interventions may impact OD Risks and fatalities

24 Clinical considerations Setting Emergency department Opioid agonist therapy for addiction Primary care Pharmacy Jail/Prison Community-fixed sites, mobile

25 Naloxone distribution The goal is to get as much naloxone out in the community of chronic opioid users as possible No education mandates necessary BUT if possible want to also include: Advice to call 911, refer to supportive laws if present Hands on practice with naloxone device Education on preventing and recognizing an overdose Rescue breathing training Plan for what to do with the naloxone

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28 WA State DBHR funded with SAMHSA block grant dollars Great desire to implement overdose interventions across State- cost of naloxone is repeatedly raised as the major hurdle for every setting and population

29 Opioid Use Disorder

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34 Goals of Addiction Treatment Provide tools (behavioral change, environmental change, medications) to help patients manage their addiction. Teach patients how to use those tools. Facilitate a continuing care model (addiction is chronic). Collaborate with patients to adapt treatment as their needs and circumstances change.

35 Psychological and Social Problems X Counseling & social supports Addiction Opiate addiction treatment medicines X Brain changes and Dependence

36 Medications in Opioid Use Disorder Treatment Methadone Delivered through approved clinics which have many regulations stipulating counseling services and drug screen urinalyses In larger cities in WA State Buprenorphine (Suboxone, Subutex, Zubsolv ) Mainly delivered through physicians in office-based practice May also be provided through Opioid Treatment Programs Vivitrol extended release naltrexone Delivered through physicians in office-based practice

37 Naltrexone/Vivitrol

38 But aren t they still addicted? What is the definition of addiction? Is it simply physical dependence? How does the change of lifestyle and psychosocial stability associated with long-term medication assisted treatment fit with that definition?

39 Research clearly and consistently shows that medication assisted treatment for opioid use disorders saves lives and money mortality rates were 75 percent higher among those receiving drug-free treatment compared to those receiving buprenorphine or methadone Health Aff August 2011 vol. 30 no

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