Assessing and Treating Substance Use Disorders

Transcription

1 Assessing and Treating Substance Use Disorders No conflicts to report Matthew Tierney APRN Agenda But First I. Epidemiology and Context II. A Treatment Approach: SBIRT III. Medication Assisted Treatment (MAT) of Substance Use Disorders IV. Other Resources Clinician Educator Motivator Researcher Tools Confidence Interest 1

2 I. EPIDEMIOLOGY AND CONTEXT $600 billion/year Cost addiction treatment reduces health and social costs more than the cost of treatment itself less expensive than alternatives: 1 year methadone maintenance ~$4,700/patient/yr imprisonment ~$24,000/person/yr $1 in addiction treatment yields a return of $4 to $7 in reduced drug-related crime, criminal justice costs, and theft Accessed 11/16/14. Illicit drug use in the past month among individuals aged 12 or older: 2013 Aged 12 or older Aged 12 to 17 Aged 18 or older Substance Number (in thousands) Percent Number (in thousands) Percent Number (in thousands) Percent Illicit drug use 24, % 2, % 22, % Marijuana and hashish 19, % 1, % 18, % Cocaine 1, % % 1, % Inhalants % % % Hallucinoge n 1, % % 1, % Heroin % % % NMU prescriptiontype drugs Pain relievers 6, % % 5, % 4, % % 4, % RecoveryMonth-2014.htm Alcohol use in the past month among individuals aged 12 or older: 2013 Age Aged 12 or older Aged 12 to 17* Aged 18 or older Heavy use Binge use Current use Percent 6.3% Number of adults 16.5 million Percent 22.9% Number of adults 60.1 million Percent 52.2% Number of adults million 1.2% 293, % 1.6 million 11.6% 2.9 million 6.8% 16.2 million 24.6% 58.5 million 56.4% RecoveryMonth-2014.htm million 2

3 Past Year Diagnosis of Substance Use Disorder (SUD) Unmet Treatment Need ~10% of those who need treatment for SUDs receive it* ~ 20.2 million people who needed treatment did not receive it** *in specialty treatment centers. **at a specialty facility in the past year SAMHSA, NSDUH, 2013 Most common reasons for not receiving treatment among individuals aged 12 or older who needed and made an effort to receive treatment but did not receive treatment and felt a need for treatment: annual averages, 2010 to 2013 Reason Percent No health coverage/could not afford 37.3% Not ready to stop using 24.5% Did not know where to go for treatment 9.0% Had health coverage but did not cover treatment or cover costs 8.2% No transportation/inconvenient 8.0% Providers: addressing? Adults age who exceed alcohol limits 49% recalled being asked about their drinking 14% were counseled about it Young adults aged 18 and 25: the most likely to exceed alcohol limits 34% were asked about drinking by their doctors, (compared with 54 percent of adults ages 26 to 39) Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health (NSDUH), 2010 to Hingson et al. J Gen Intern Med Feb;27(2):

4 Provider Impediments Don t feel competent Unrewarding Peripheral to medical matters Lack of role models Lack of skill Lack of education Lack of parity Physician Attitudes Treating drug and alcohol use less satisfying then treating HTN Positive attitude toward treating addiction associated w/ greater professional satisfaction Confidence Perceived responsibility Miller et al. Acad Med May;76(5): Saitz et al J Gen Intern Med May;17(5):373-6 Context for a Solution: Affordable Care Act? Designated SUD treatment as an essential health benefit Facilitates integration Increases access No pre-existing exclusion Primary Care Treatment of SUDs Medical treatment Prevention Patient advocacy Paradigm shift: Maintaining vs. treating addiction 4

5 SUD Integrated with Primary Care Less integrated than mental health Not due to attitudes, but training 20 th Century Treatment Why the History Lesson? The Farms Civil Commitment Programs 1 12 Step 2 Synanon Others. ons-narcotics-farm.html Context: Commerce legal/criminal political Treatment settings Patient restrictions Provider restrictions Context: Medical Setting: Medical Office 1. SAMHSA/CSAT: 2. Narcotics Anonymous, Sixth Edition (2008) Chatsworth, CA: Narcotics Anonymous World Services, Inc., p. 5. 5

6 The Problem: Summary Patients not receiving needed treatment for SUD Those with SUDs have health care costs double those without SUDs are often unaddressed in medical offices but can be II. AN APPROACH: SBIRT SBIRT SBIRT Screening Brief Intervention Referral to Treatment for everyone for those at moderate to high risk for those with severe risk or dependency Public health model designed to provide the following in primary care and other settings: universal screening secondary prevention early intervention treatment Babor et al., 2007; Substance Abuse, 28(3), 7 30; 6

7 Alcohol Screening Tools * Alcoholism-and-Substance-Abuse-Services--OASAS-.html?soid= &aid=uJW744b_r0M. Accessed 11/16/14. * National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationwide NIAAA survey of 43,093 U.S. adults aged 18 or older. Alcohol Use Disorders Identification Test (AUDIT) Drug Abuse Screening Test (DAST) Alcohol, Smoking, Substance Involvement Screening Test (ASSIST) CAGE Single Question: On any single occasion during the past 3 months, have you had 5 or more drinks containing alcohol? [4 or more for women] RISK INTERVENTION LEVEL OF CARE APPROACH Hospital Low Risk No Further Intervention Medical-Residential Moderate Risk Brief Intervention Residential non-medical Medical Outpatient bio psycho Moderate to High Risk Severe Risk, Dependency Brief Treatment Referral to Specialty Treatment Non-medical outpatient Professional Peer social spiritual *Mee-Lee, D (Ed). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. October 24, 2013 ISBN: * 20Instrument% pdf 7

8 SBIRT Evidence Best for alcohol use Depends on setting, health behavior Using ASSIST and BI in urban primary care: not effective for decreasing drug use 1 III. MEDICATION- ASSISTED TREATMENT (MAT) 1. ASPIRE Clinical Trial. Saitz et al. Jama 2014; 312(5): Accessing MAT There are many reasons why I think PCP's should prescribe SUD-focused meds: the stigma many Vets feel about coming to BH PCP is often in a position to recognize the beginnings of a SUD and get things going for the patient. Professional Correspondence with nurse colleague at New Mexico VAMC. 11/14/14 Medication Assisted Treatment Alcohol: disulfiram; naltrexone; acamprosate Opioids: methadone; buprenorphine; naltrexone Nicotine/smoking: nicotine replacement; varenicline; and bupropion Cannabis: none FDA approved Stimulants: none FDA approved Sedatives/Benzodiazepines: flumazenil; taper 8

9 Medical Treatment for Alcohol Use Underutilized? ALCOHOL 15% of individuals with alcohol abuse or dependence receive treatment (incl self help) The therapeutic nihilism for treatment of alcoholism with available psychopharmacological agents is unfortunately high, just as it is for smoking. -S. Stahl 3): Treatment Options disulfiram (1951) naltrexone Oral (1994) Injectable (2006) acamprosate (2004) Cohen et al(2007). Drug Alcohol Depend;86(2- In US Treatment Facilities* Disulfiram: 16% Naltrexone: 16% 1 Acamprosate: 17% Results Modest effect sizes Low adherence rates Out of Favor *SAMHSA. National Survey on Substance Abuse Treatment Services (n-ssats):2009. Data on Substance Abuse Treatment Facilities. Rochville, MA: USDHHS, publsma Mark et al. /(2003) Drug and Alcohol Dependence 71:

10 Naltrexone 1984: FDA approved for opioid dependence 1994: FDA approved for alcohol dependence Formulations : Oral (ReVia tabs) Depot injection (Vivitrol) -- approved in 2006 NTX Efficacy 28% (NTX) vs. 43% (PCB) return to heavy etoh 59% (NTX) vs. 65% (PCB) return to any etoh 36% NTX patients discontinued treatment before 12 weeks 30% of all trials show no difference between NTX and PCB NTX adherence associated with better outcomes Srisurapanont & Ngamwong (2005) IntJ Neuropsychopharmacol8: Injectable (IM) NTX: Vivitrol Same therapeutic action as oral Injectable microspheres avoid first-pass hepatic metabolism Stable plasma levels for 28 days IM NTX Efficacy IM NTX vs. placebo 32% v 11% abstinent for 24 weeks 70% v 30% no more than 2 heavy drinking days in any 28-day period Median 42 days v 12 days to first drink 181 days v 20 days to first heavy etoh use Fewer drinking days and fewer heavy drinking days/month O Malley et al (2007) J. Clin. Psychopharmacol 27:

11 IM NTX Efficacy Etoh use Decreased drinks per day Decreased heavy drinking days Involvement in AA and intensive outpatient etoh treatment both associated with treatment retention Lee et al (2010). J Subs Abuse Treatment 39: See Ciraulo et al (2008) J Clin Psychiatry 69:2. Summary: Naltrexone Can Reduce Number of days spent drinking amount of alcohol consumed on drinking days excessive and destructive drinking Approved for alcohol dependence in 1951 An aversive agent interesting history Disulfiram Disulfiram Mechanism of Action Disulfiram Alcohol Acetaldehyde Acetic Acid Alcohol Dehydrogenase Acetaldehyde Dehydrogenase 11

12 Disulfiram: good for highly motivated patients Characteristics associated with better disulfiram treatment outcomes: older than 40 longer drinking history socially stable high motivation Alcoholics Anonymous attendance supervised pill taking cognitively intact Suh et al (2006). Clin Psychopharmacol;26: Acamprosate FDA approved for alcohol dependence in 2004 Action not fully understood Some enhancement of GABA receptors Partial NMDA agonist. NMDA modulator: Regulates NMDA subunit synthesis? Witkiewitz et al (2012). TherClin Risk Manag;8:45-53 Acamprosate Efficacy Acamprosate V. Placebo 9% lower risk of returning to any drinking after detoxification. NNT = 9! 9% higher continuous abstinence duration after treatment discontinuation No difference: Return to heavy drinking did not change OPIOIDS Rösner et al (2010). Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD DOI: / CD pub2. 12

13 Opioid Treatment Options Methadone Buprenorphine Naltrexone Methadone Over 1,200 methadone clinics in the USA* Est. 270,000 patients enrolled* 1972: FDA regulations Current Oversight: State laws, SAMHSA (DHHS), and DEA/DOJ. Methadone Effectiveness Reduces heroin use 1 Reduces criminal activity 1 Decreased health treatments 1 Decreased hospitalization 1 Reduces risk of HIV/AIDS and viral hepatitis Reduces risk of IDU-related illness Maintenance associated with less drug use Reduces drug related mortality 2 1) Gerstein et al (1994). Evaluating Recovery Services: The California Drug and Alcohol Treatment Assessment (CALDATA): General Report. California Department of Alcohol and Drug Programs. 2) Clausen et al. Drug Alcohol Depend Apr 1;94(1-3): Barriers and Primary Care Solutions Low access: promote methadone as effective tx Medication side effect: monitor drug interactions and side effects Methadone silo and privacy protections: get ROIs, confer with other providers, use PDMPs Medication only philosophy: promote person-centered treatment philosophy 13

14 Buprenorphine Semi-synthetic derivative of thebaine (an opium alkaloid) Partial μ agonist, antagonizes κ receptor High binding affinity and slow dissociation for μ receptor Sigmoidal dose-response curve: ceiling effect BUPRENORPHINE Half life: 37 hours Side effects: sedation, CNS depression, hypotension Buprenorphine Prescribing FDA approved in 2002 for opiate replacement, schedule III Requires 8 hours special training and DEA waiver MDs only no mid-levels Office-based setting Methadone and Buprenorphine Outcomes Treatment retention: MTD > BUP 1, 2 Reduced opioid use: BUP > MTD 1 Reduced opioid use: BUP = MTD 2 Retention & opiate use: MTD and BUP > placebo (Higher dose > low dose) 2 Adjunctive tx enhances BUP and MTD outcomes 2 MTD & BUP less costly than no tx 2 1.Saxon AJ et al. J Food Drug Anal Dec 21(4):S Connock M et al. Health Technol Assess 2007 Mar;11(9): 1-171, iii-iv. 14

15 Naltrexone FDA approved for relapse prevention Blocks re-enforcing effects of other opioids Eliminate a conditioned response to use opioids use after MAT No tolerance, no dependence Naloxone Reverses Opioid Overdose reduces opiate overdose deaths, results in cost-savings 10,171 overdose reversals 1 APRNs can prescribe Naloxone for their patients at risk for opioid overdose. 1. JAMA. 2012;307(13): * (accessed 4/14/14) * * Monitor Drug Diversion IV. OTHER RESOURCES Access the PDMP Urine Drug Testing Confer with other providers (ROIs) 15

16 Supplemental Treatments Counseling Case management CBT Contingency Management Motivational Interviewing Peer support and mutual help:12 step Relapse prevention therapy Acupuncture Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) Patient-Centered Care I didn t ask for this. I m coming to you for help please be kind to me. What Next? Training & Education MAT, Motivational Interviewing, CBT Expand treatment staff and referrals Integrate and Research Thank You! Saitz et al. Jama 2013; 310(11): The AHEAD randomized trial. 16