Buprenorphine Treatment in Primary Care

Transcription

1 Buprenorphine Treatment in Primary Care Learning Collaborative Thursday March 13, 2:30 Amanda Risser MD MPH Assistant Professor OHSU Family Medicine

2 OUTLINE Opiate addiction Opiate maintenance therapy How buprenorphine works Detox ( induction ) and maintenance Office Based treatment at Richmond

3 Opiates Heroin Opium Morphine Oxycodone Oxycontin Vicodin Fentanyl Codeine Demerol Hydrocodone Dilaudid Buprenorphine Stadol

4 Opiate Use, opiate addiction: Scope of the Problem in Oregon o Oregon s drug-related mortality has been twice the US rate every year since 1999 o 9.2% of people aged meet DSM-IV criteria for drug abuse or dependence o Oregon has higher rates of marijuana, meth, and illicit use of prescription opiates o Non-medical use of prescription opiates for Oregonians 12 or older is 5.7% (national 4.8%) (Oregon Department of Human Services-2007)

5 Heroin Overdose Deaths September 13, 2010 The Oregonian Multnomah County Deputy District Attorney Ryan Lufkin s Overdose Book

6 Raw Number 200 Trend of unintentional poisoning deaths associated with prescription opioids compared to heroin Oregon Rx opioids Heroin Year Oxman, Guernsey- data from Oregon Medical

7 Raw Number 80 Trend of unintentional poisoning deaths associated with prescription opioids compared to heroin Multnomah County Rx opioids Heroin Year Oxman, Guernsey- data from Oregon Medical Examiner

8 FIGURE 1. Rate* of unintentional drug overdose deaths United States, MMWR, January 13, 2012 /61(01);10-13

9 FIGURE 2. Number of unintentional drug overdose deaths involving opioid analgesics, cocaine, and heroin United States, MMWR, January 13, 2012 /61(01);10-13

10 Percentage of patients and prescription drug overdoses, by risk group United States MMWR, January 13, 2012 / 61(01);10-13

11 Opiate Use and Addiction in US Pregnancies 4.5 % pregnant women in the US reported use of illicit drugs in the past month Opiate use in pregnancy: 1% - 21% Estimated 3,000 pregnant women on methadone maintenance therapy High rates of comorbid infectious disease: 27% prevalence of HIV in pregnant women in one NYC day treatment program 30% 80% of pregnant women in treatment are involved in crime Outcomes are poor for incarcerated women and their babies Refs: National Survey of Drug Use and Health from Substance Abuse and Mental Health Services Administration (SAMHSA) 2009; Cochrane 2009; Daley et al 2001

12 Medication Assisted Treatment Healthier choice than drug of abuse Prevent withdrawal sxs Less intoxication Different milieu of use Usually methadone, increasingly buprenorphine Maintenance connects patients with supportive services Methadone maintenance programs federally mandated to minimize diversion, highly regulated

13 Benefits of Methadone Maintenance 30 years of history with methadone maintenance Beneficial in decreasing: Opiate use Criminal activity Death Needle sharing HIV seroconversion Long duration of therapy (lifelong?) most beneficial Only 10% of heroin addicts are involved in it Ref: Cochrane Review 2009

14 Harms of methadone maintenance Risk of overdose death esp. in combination with other drugs, benzodiazepines, opiate relapse Prolongs the QT interval, risk of arrhythmia Restrictive: daily dosing, program requirements Difficult to access: transportation, geographically restricted Center for illegal activities Stigma Dependence

15 (click above to view abstract and article) Oh Canada!

16 Buprenorphine: office-based treatment of opiate addiction The Drug Addiction Treatment Act of 2000 (DATA 2000): qualified physicians can treat opiate addiction with FDA approved agonist medications outside of a treatment program Qualifications: addiction medicine specialist or at least 8 hours of training Requirements: ability to refer for addiction treatment, records keeping, complying with standard of practice Special DEA registration and oversight Limit buprenorphine to 100 patients

17 Generic name: buprenorphine Trade names: suboxone, subutex

18 Why is buprenorphine Partial Mu Agonist different? Ceiling effect because of partial agonist (almost) no risk of overdose High affinity for Mu receptor Competes with other opioids and blocks their effects Precipitated withdrawal if taken while receptors filled Must be in moderate withdrawal to get started Shorter acting opiates: hours Methadone: 72+ hours At higher doses- more analgesic effect, higher possibility of euphoric effect

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20 Office Based GUIDELINES

21 Getting Started on buprenorphine: The ideal candidate They want it Can afford it Will benefit from the flexibility Poor access to methadone maintenance Are young and disorganized Will be OK with less treatment mandates Higher risk of relapse, need lower risk drug Prolonged QT syndrome Non-dependent users OK Adolescents under age 18 Pregnant or planning pregnancy?

22 Getting Started: Buprenorphine Induction Not an emergency! (even in pregnancy) Visit before getting started important Urine Drug Screen (UDS)- evaluate for methadone Mutual expectations and informed consent Costs, insurance coverage Arrange induction Discuss plans for treatment or therapy, make referral Many already on it from street purchase

23 Getting Started: Buprenorphine Induction Induction visit UDS- evaluate for methadone Evaluate for withdrawal Administer medication in office until comfortable Many patients very experienced at this Main risk precipitated withdrawal

24 COWS Scale Pulse Sweating Restlessness Pupil size Bone/joint aches Runny Nose, tearing GI upset Tremor Yawning Anxiety Gooseflesh Skin

25 Buprenorphine Follow Up Daily contact X 1-2 days Determination of daily dose, dose adjustment Weekly visits Dose adjustment, monitoring for any adverse effects Visits every 1-3 month Evaluate for relapse, craving: opportunity to change dose, increase support Take care of other chronic health issues Work on goals for sobriety, involvement in treatment Very few discharged from treatment

26 Buprenorphine: optimal duration? Ideal length of treatment not known The longer the better Social context, age, support, treatment, physical symptoms all important At least 6 months Open door for return to treatment Relapse can occur at any time, even after years of abstinence

27 Pain control: Un-planned for (i.e. trauma, fracture, etc) IV fentanyl Increased buprenorphine Planned for (i.e. surgery) Boundaries Small amounts of medication Close follow up Increased support Epidural and spinal anesthesia Lidocaine Chronic pain

28 Opiate withdrawal is risky to pregnancy Dehydration from diarrhea, vomiting, nausea Sympathetic overdrive Fetal withdrawal? Risk of miscarriage, fetal death, stillbirth Preterm labor Better outcomes on maintenance Reduces illicit opiate use Increases prenatal care compliance Improved neonatal outcomes (esp. birthweight) Methadone maintenance gold standard

29 Newly Born and Withdrawing from Painkillers Abby Goodnough and Katie Zezima Published: April 9, 2011

30 Buprenorphine in Pregnancy Not FDA approved in pregnancy- class C Concern about induction, precipitated withdrawal Subutex not suboxone (no naloxone in pregnancy) Transition from methadone to bupe challenging Transition from buprenorphine to methadone challenging Special challenges to office based treatment Benefit to integrated prenatal care and drug treatment

31 Neonatal Abstinence Syndrome Onset depends on half life of drug Monitored by a scoring system Neuro: Irritable, agitated, poor sleep, pronounced tremor, seizure, hyperactive reflex GI: Poor feeding, weight gain, vomiting, diarrhea Requires 1:1 nursing, usually in NICU If medications required: tapering doses of opiates Length of stay can be prolonged Subacute phase lasts up to a year

32 Our Practice 4 providers, 191 pts Dr. Gideonse 92 Dr. Risser 56 Dr. Muench 25 Dr. Frank 31 Dr. Livinston 18

33 Recently developed more explicit guidelines Risk categories: 1 mo, 2 mo, 3 mo follow up (low, med, high) More unstable okay but not long term (i.e. weekly or biweekly visits) Work with a variety of local partners Increasing our explicit collaboration with CODA and Cascadia (ex Bupe group at Cascadia)

34 Our Clinical Guidelines Informed by TIPS Harm reduction language Risk benefit: individual and community A work in progress

35 Upcoming Planned Innovations Group prenatal with outpatient/inpatient pathways Telemedicine Research

36 Addictions Treatment System and Health System Transformation Planning for Change Susan Myers, Director, Department of County Human Services; Devarshi Bajpai, Mental Health and Addictions Services Division; Ginger Martin, Deputy Director, Department of Community Justice January 28, 2014

37 Title // Drivers of change 2

38 Addictions Treatment System // Overview of Presentation Review of Addictions Treatment System; Mandate and Scope of System Addictions Treatment System Background Current State What s Changing Desired Future State 3

39 Addictions Treatment System // Background Addiction a chronic condition often requiring lifelong management Treatment Compliance Rates Relapse Rates Diabetes = <50% Hypertension = <30% Asthma = <30% Diabetes = 30-50% Hypertension = 50-60% Asthma = 60-80% Addiction = 30-50% Addiction = 40-70% 4

40 Addictions Treatment System // Mandate and Scope Goals of Addictions Treatment Recovery Preventing chronic and infectious disease Preventing homelessness Reducing criminal activity Reducing child abuse and neglect 5

41 Addictions Treatment System // Mandate and Scope Addictions Treatment in Multnomah County Addictions Treatment System is made up of the following components Prevention Sobering Detox Residential Treatment Outpatient Treatment Recovery Services Funding streams Federal Substance Abuse Block Grant/ Medicaid State General Fund County General Fund 6

42 Addictions Treatment System // Mandate and Scope Does treatment achieve its goals? Reentry Enhancement Coordination program (2011)- 27% reduction in criminal recidivism compared to a similar group of offenders. Each dollar invested saved $6.73 in criminal justice and victimization costs. STOP Court (2007)- saved $79 million over a 10 year period compared to business as usual. CCC Mentor and Housing Programs (2008)- average participant had 589 days clean and sober at follow up, only one of 87 was actively using. 7

43 Addictions Treatment System // Current State Current System of Care Provider Agencies What we buy How providers get paid 8

44 Addictions Treatment System // Current State Current Contracted Services: DCHS and DCJ VOA CODA DePaul Lifeworks NW Cascadia Central City Concern NARA Avel Gordly Center Treatment Services NW CRC Health Oregon Quest Recovery Services/ Housing Outpatient Residential Prevention Detox/ Sobering 9

45 Addictions Treatment System // Current State Current System Detox Residential Treatment Outpatient Treatment Recovery Support OHP Uninsured Physical Health Plan County County $9.1 m 1,550 Physical Health Plan County County $1.4 m $3.55 m 2,400 $4.65 m 4,785

46 Addictions Treatment System // What is Changing The Affordable Care Act: Medicaid expansion means more of our clients will have insurance coverage Mental Health and Addictions treatment included in the 10 essential health benefits Health insurance likely to cover only shorter stays in residential treatment Treatment for many criminal risk factors will not be covered 11

47 Changing Addictions Treatment System // What is Changing Many supports that our clients need to be successful won t be paid for by Medicaid: Supported Housing Child Care Peer Support CCO Medicaid Dollars Employment Support 12

48 Addictions Treatment System // What is Changing Current System Detox Residential Treatment Outpatient Treatment Recovery Support OHP Physical Health Plan Physical Health Plan County??? Uninsured County County

49 Addictions Treatment System // Desired Future State Desired System OHP Uninsured Detox Physical Health Plan DCJ/DCHS Residential Treatment DCJ/DCHS Day Treatment + Housing Day Treatment Housing Outpatient Treatment Physical Health Plan DCJ/DCHS Recovery Support DCJ/DCHS Reinvestment

50 Changing Addictions Treatment System // Desired Future State Future of Addictions Treatment System Comprehensive continuum of care Clean and sober housing capacity Recovery supports such as child care, job assistance, transportation, peer mentoring Treatment for criminality integrated with addictions treatment 15

51 Changing Addictions Treatment System // Thank you for your continued support Questions? 16