Addiction and Recovery Support - The Basics

Transcription

1 Addictions 101: The Basics for Behavioral Health Providers Yngvild Olsen, MD, MPH Behavioral Health Administration Annual Conference May 13, 2015

2 Objectives 1. Define key terms and approaches 2. Review treatment and recovery system design 3. Identify key components 1. Screening and assessment 2. Medications 3. Laboratory monitoring 4. Care coordination

3 Barbara B. 38 year old female who has been using heroin and cocaine intravenously for 20 years, has never been in treatment, has had two prior arrests for possession, serving sentences for both. She has hepatitis C, asthma, and depression but no regular health care. She has been feeling more depressed recently after her mother died over 6 months ago. Is coming to you after friend recommended you for depression treatment. What do you do?

4 Clinical Approach Address acute situations requiring emergency care first Make diagnoses or formulate diagnostic impressions Screening and assessment Identify and discuss treatment and recovery support options Medications Behavioral interventions Recovery support services Overdose prevention including naloxone rescue training Initiate services based on treatment and recovery plans Referrals Care coordination Monitor and reassess for effectiveness and side effects Risk assessment Readjust services as necessary Referrals Care coordination

5 Substance Use Pyramid* Substance Use Disorders (SUD) In Specialty Treatment Not in Treatment Harmful Users Non-harmful or no use *Adapted from Dr. Tom McLellan

6 Public Health Approach Recovery

7 Recovery Oriented System of Care Coordinated network of formal and informal person-centered services and supports that are mobilized to build on the strengths and resiliencies of individuals, families, and communities to improve health, wellness, and quality of life for those impacted by substance misuse and addiction. *Adapted from Maryland ADAA and SAMHSA definitions

8 ROSC Elements as Applied to Treatment Person centered Strengths-based Family and other ally involvement Individualized and comprehensive services across the lifespan Continuity of care Commitment to peer recovery support services Integrated services

9 FORMULATING SUBSTANCE USE DISORDER DIAGNOSES: KEY TERMS AND APPROACHES

10 Addiction A primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.* A chronic, relapsing disease characterized by compulsive drug seeking and use despite harmful consequences as well as neurochemical and molecular changes in the brain.** Symptoms are primarily behaviors *American Society of Addiction Medicine **National Institute on Drug Abuse (NIDA)

11 Substance Use Disorders (SUDs) Group of diagnoses with common predisposing factors, brain dysfunction, and diagnostic features Specified by the specific substance involved Categorized as mild, moderate, or severe Remission from any one SUD characterized as early or sustained

12 Physical Dependence An adaptation of the body to a specific substance so that in the absence of that substance a withdrawal syndrome develops. The withdrawal syndrome may be relieved by readministration of the substance. Tolerance typically develops as a feature of physical dependence Occurs with many categories of medications and substances. This is not the same as addiction!

13 Addiction Vs. Physical Dependence Source: NIDA.

14 Chronic Disease No cure! Goal is life long management Disease severity may change over time but risk of symptom recurrence is always present Effective treatment often combines medications and behavioral interventions Behavior change is a key part of management Behavior change occurs in stages

15 Stages of Behavior Change Individuals sustain and strengthen changes they have made. Precontemplation No intent to change the problem behavior because unaware it is a problem or unwilling to change due to past failed attempts. Maintenance Contemplation Considering behavior change. May be considering specific personal implications of the problem and what the consequences of change might entail. Behavior change has clearly begun. Individuals need skills to implement specific behavior change methods. Action Preparation Ready to change both attitude and behavior. Intend to change soon and have incorporated experiences of previous tries at change. Prochaska and DiClemente TransTheoretical Model of Behavior Change

16 Why do some people develop addiction?

17 Lifetime Prevalence and Odds Ratios of Mental Disorders by Substance Use Disorder: ECA Alcohol Drug Comorbid Disorder % O.R. % O.R. Any mental Schizophrenia Affective Anxiety Antisocial (Regier et al., JAMA 264: , 1990)

18 Genetic Variants of the Human Mu Opioid Receptor: Single Nucleotide Polymorphisms in the Coding Region Including the Functional A118G (N40D) Variant HYPOTHESIS Gene variants: Alter physiology PHYSIOGENETICS Alter response to medications PHARMACOGENETICS Are associated with specific addictions Slide Source: Dr. Kreek Bond, LaForge Kreek, Yu, PNAS, 95:9608, 1998; Kreek, Yuferov and LaForge, 2000

19 Addictive Potential Determinants The faster a drug gets to the brain, the higher addictive potential The shorter acting a drug is, the higher addictive potential More potent drugs have higher addictive potential Takes less of drug to achieve effect

20 The Human Brain

21 The Reward Pathway

22 Barbara B. 38 year old female who has been using heroin and cocaine intravenously for 20 years, has never been in treatment, has had two prior arrests for possession, serving sentences for both. She has hepatitis C, asthma, and depression but no regular health care. She has been feeling more depressed recently after her mother died over 6 months ago. Denies suicidal or homicidal ideation.

23 Screening and Assessment

24 Screening Goals Goals 1. To identify or quantify risk for disease 2. To identify modifiable health risks 3. To assess stage of motivation /readiness for behavior change Assessment Goals 1. To make diagnoses 2. To assess severity of conditions 3. To assess stage of motivation /readiness for behavior change

25 SUD Screening Tools Identify level of risk for SUDs and need for further assessment Validated instruments available CAGE and CAGE-AID AUDIT and AUDIT-C DAST-10 NIDA Quick Screens CRAFFT and DAST-20 (for adolescents) Remember to screen for nicotine use and gambling!

26 Additional Screening Based on epidemiology of population and current age appropriate CDC/USPSTF recommendations Based on public health impact Questionnaires HIV risk Viral hepatitis Other Sexually Transmitted Infections (STIs) Tuberculosis Physical examination Blood pressure Body Mass Index (BMI) Laboratory testing Viral hepatitis serologies HIV antibody Consider RPR for syphilis

27 1. How often do you have a drink containing alcohol? Never (0) Two to four times a month (2) Two to three times per week (3) Four or more times a week (4) 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 (0) 3 or 4 (1) 5 or 6 (2) 7 to 9 (3) 10 or more (4) 3. How often do you have six or more drinks on one occasion? Never (0) Less than Monthly (1) Monthly (2) Two to three times per week (3) Four or more times per week (4) AUDIT-C Add up total score maximum is 12. For men: > 4 is positive. For women: > 3 is positive. Scores of > 8 are indicative of possible alcohol use disorder. 27

28 Assessment Make SUD diagnoses according to DSM 5: 11 criteria Cannot use tolerance and withdrawal for diagnosis if taking opioid under medical supervision and no other criteria present Complete biopsychosocial Identifies spectrum of strengths and problems Severity of disease according to: Addiction Severity Index (ASI and ASI Lite) TAP ASAM 6 dimensions linked to recommendations for levels of care Fagerstrom tobacco tolerance questionnaire

29 ASAM Dimensions 1. Acute intoxication and/or withdrawal potential 2. Biomedical complications and conditions 3. Emotional, behavioral, or cognitive conditions and complications 4. Readiness to change 5. Relapse, continued use, or continued problem potential 6. Recovery/living environment

30 More Barbara B. History Starting drinking at age 12 after gang raped Started using heroin and cocaine at age 15 Overdosed once on heroin and alprazolam Has two children, no longer in her custody Couch surfed between men she meets and her mother who actively drank now homeless Was an Olympic level gymnast Last used heroin and cocaine early this AM No alcohol in 2 weeks I ll do anything it takes SUD DX: severe opioid and cocaine use d/o, ETOH use d/o uncertain severity

31 Barbara B s ASAM Dimension Assessment 1. Acute intoxication/withdrawal risk a. Opioid withdrawal overdose risk is high b. Opioid withdrawal present c. Lower risk for alcohol withdrawal 2. Asthma and hepatitis C 3. Depression with recent increase in symptoms, grief over mother s death 4. Readiness to change is high currently 5. High relapse or continued use potential 6. Recovery environment is poor

32 ASAM Levels of Care Levels 0.5 Early Intervention: Hazardous use Level 1 Outpatient: up to 8 clinical hrs/week Level 2 Intensive Outpatient: 9-20 hrs/week Level 3 Residential Services: Low-intensity Medium-intensity High-intensity Medically monitored high-intensity With or without withdrawal management and access to medical and psychiatric services Opioid treatment services add longer-term medication

33 Treatment Effectiveness Goal of treatment is to return to productive functioning Reduces drug use by 40-60% Drug treatment is as successful as treatment of diabetes, asthma, and hypertension Strongest predictor of recovery is retention in treatment

34 Benefits Of Treatment Reduces risk of HIV infection Reduces risk of infection with hepatitis C and B Increases rates of employment among patients as a group Decreases crime Increases length of life

35 Treatment Outcomes For Tapering off Medication for Opioid Use Disorder In methadone studies, 50-80% relapse within one year after taper 91% of patients receiving buprenorphine for 4 months had relapsed to prescription opioids within 2 months of taper* Opioid overdose fatality rates are 3 to 20 times higher in the month after tapering off than during treatment *Weiss R. et al. NIDA CTN Prescription Opioid Treatment Study.

36 Percent Positive Effect of Medications on Opioid Use 100 Opioid Positive Urine Specimens LAAM Buprenorphine 20 High Dose Methadone Low Dose Methadone From: Johnson et al., 2000

37 Indications for Medications All patients with opioid use disorder should be offered medication as a component of treatment The choice of medication is a medical decision between a physician and a patient Weighing complete history, physical examination, and relevant laboratory testing Factors to consider Methadone heavily structured and regulated Buprenorphine is expensive but less structured Naltrexone contra-indicated if prescription opioids are part of chronic pain treatment

38 But... Methadone and Suboxone can be abused People can overdose on methadone (not as ( Suboxone easy on Lot of medication interactions with methadone Neither methadone nor Suboxone affect other drugs of abuse

39 Methadone/Buprenorphine and Other Substances Increased risk of acute opioid intoxication if mixed with alcohol Benzodiazepines potentiate sedative effects of opioids Overdoses have occurred in patients on buprenorphine and benzodiazepines Treatment may be needed for other substance use disorders but methadone or buprenorphine should be continued with appropriate dose adjustment to minimize sedation while balancing risk of illicit opioid relapse

40 Medication Options for Alcohol Use Disulfiram (Antabuse) Acamprosate (Campral ) Naltrexone Oral (ReVia ) Injectable (Vivitrol ) Topamax (off-label) Gabapentin (off-label) Disorders

41 How long is treatment needed? Individualized Less than 90 days in any treatment setting is of limited to no effectiveness Studies demonstrate that staying on medication in combination with counseling results in much better outcomes than detox

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43 Protective Factors for Sustained Recovery after Medication Taper 1. Stable housing 2. Outstanding legal issues resolved 3. Employment or education or other activities that provide daily purpose and focus 4. Other medical conditions are stable and being managed 5. Other mental health conditions are stable and being managed 6. Other substance use disorders are stable and being managed 7. Solid recovery support network

44 Substituting one addiction for another? Buprenorphine and methadone treat withdrawal and physical dependence Medications and counseling treat opioid and alcohol addiction On the right dose of medication, people function normally, are not getting high, and are not addicted

45 Components of Comprehensive Drug Addiction Treatment

46 Barbara B. Treatment Options Severe opioid use disorder: Treatment with a medication is recommended Medically monitored residential LOC recommended given: Severity of multiple SUDs with associated risk Presence of co-occurring untreated medical and psychiatric conditions High readiness to change High potential for relapse or continued use Poor recovery environment

47 Monitoring Methods Urine toxicology testing Purpose: Monitor effect of treatment Early identification of use of other substances Two types of assays Immunoassay Specific drug identification

48 Immunoassay Pros Lab or point-of-care Relatively low cost Rapid result with point-of-care test Cons Cross-reactivity Qualitative result only May not detect low levels of drugs Lower sensitivity for semi-synthetic/synthetic opioids

49 Specific Drug Identification Gas chromatography/mass spectroscopy (GC/MS) Liquid chromatography/mass spectroscopy, either single or tandem (LC/MS or LC/MS-MS)

50 Toxicology Test Interpretation Understand whether looking at qualitative or quantitative test result Qualitative test results may or may not represent presence of substance of interest Methadone and buprenorphine do not cross-react with assays for opiates Be aware of cross-reactants Tramadol may cause a false-positive test result for buprenorphine

51 Cross-reactants Opiates Poppy seeds Benzodiazepines Benadryl (at high doses) Oxaprozin Amphetamines Pseudoephedrine Ranitidine PCP Hydroxyzine (in high doses)

52 Monitoring Methods Assess for aberrant drug-taking behaviors Provides information in addition to toxicology testing

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54 Components of Comprehensive Drug Addiction Treatment

55 MANY PATHS TO RECOVERY!