Rationale for and approach to treating Opiate Use Disorders Gavin Bart, MD PhD FACP DFASAM Director, Division of Addiction Medicine Department of Medicine Hennepin County Medical Center Associate Professor of Medicine University of Minnesota bartx005@umn.edu
Outline Scope of the problem Approaches to treatment Special populations Getting started
1-Year Prevalence of Drug Use National Survey on Drug Use and Health 2012 Alcohol Use ~ 173 million Alcohol Dependence 1:21 Cocaine Use ~ 5 million Cocaine Dependence 1:6 Heroin Use ~ 0.68 million Heroin Dependence 1:2 Marijuana ~ 32 million Marijuana Dependence 1:12 Prescription Opioids ~13 million Prescription Opioid Dependence 1:8 NSDUH 2012
Opiate Deaths in Minnesota CDC WONDER Online Database, released January 2013. Data are compiled from Compressed Mortality File 1999-2010 Series 20 No. 2P, 2013. Accessed at http://wonder.cdc.gov/cmf-icd10.html on Apr 16, 2014 3:50:35 PM
MN Opiate Treatment Admissions 14000 12000 10000 Heroin Other opiates MAT admissions Total opiate 8000 6000 4000 2000 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to 2011
NA/AA is not Treatment Is peer support AA participants do better than drop outs Little evidence that it is effective
Cancer Support Group
Cardiac Rehab
Coordinated care
Natural History of Opiate Addiction California study of 581 male heroin addicts admitted 1962-1964 (n=581) Drug overdose 21.6% Liver disease 15.2% Murder Suicide 19.5% Accident Hser et al. 2001
Opiate Addiction and Death Global analysis of over 100,000 addicts 15x greater chance of dying than age and gender matched non addicts Overdose Accidents/trauma Suicide 3.5x greater chance of death if not in tx 2.4x greater chance of death if not on MAT Dagenhardt et al. 2011
Behavioral Treatment Alone Inadequate evidence to prove effectiveness Contingency and Reinforcement-based treatment better than counseling alone Best abstinence-based treatment available 83% failed within 2 years Farrell 2010; Pescor, 1943; Vaillant 1973;
Natural history of opiate addiction Lexington study of opiate addicts admitted 1936-1940 (n=4766) 6 month to 5 year follow up after discharge Voluntary patients (n=272) Intention to treat: 82.9% failed 17.1% met treatment goal 19.3% lost to follow up 10.8% dead 52.8% relapse Average time to relapse 25.1 months 17.1% abstinent Pescor, 1943
Death After Behavioral Treatment Time after discharge Risk of Death CI (95%) 4 weeks 29.9 13.4-66.5 5-26 weeks 1.7 0.4-7.0 26-52 weeks 1.5 0.4-6.0 1-2 years 2.7 1.3-5.6 Mean age 31 years (17-49) Time in treatment 54 weeks (0-172) Increased 4 week mortality not explained by Age Time in treatment / leaving treatment early Time in prison Past overdoses Alcohol use Ravndal and Amundsen DAD,2010
Detoxification Medications are superior to none Retention in detox Withdrawal severity Clonidine methadone buprenorphine
After Detoxification Gossop et al. 1987
After Detoxification Most will use again (80% within 4 weeks) Subsequent detox even less successful Half meet DSM criteria again 9x greater risk of death Day and Strang 2011; Gossop et al. 1987; Cornish et al. 2010; Nosyk et al. 2014
Methadone Treatment Short-term methadone 80% failed within 2 years After methadone 9 x death in first 2 weeks 3.5 x death in first 2 years Vaillant 1973; Sees 2000; Cornish 2010; Woody 2007
Remaining in treatment (nr) Buprenorphine Treatment 20 15 10 5 0 Control Buprenorphine 0 50 100 150 200 250 300 350 Treatment duration (days) Kakko et al. 2003
Buprenorphine Taper v Maintenance Fiellin et al. 2014
Prescription Drug Addiction: Buprenorphine Treatment Percent with good outcome 4 week taper: 6.7% 3 months on then 1 month taper: 48.2% Good outcome 8 weeks after taper: 8.6% No difference between MD and MD+counselor Weiss et al. 2011
Death On and Off Medication Treatment Time Mortality/100 person years Adjusted mortality Weeks 1-2 on 1.70 3.11 Weeks 3-4 on 1.32 2.38 > 4 weeks on 0.62 1.00 Weeks 1-2 off 4.80 9.01 Weeks 3-4 off 4.25 8.01 > 4 weeks off 0.95 1.91 1 yr OAT has 85% chance of reducing death Tapered OAT did not improve mortality Mortality not affected by # of treatment episodes Cornish et al. BMJ,2010
Medications Reduce Death Schwartz et al. Am J Pub Health 2013
Extended Release Naltrexone Krupitsky et al. 2011
Special Considerations
Adolescent Opiate Addiction 78% dropped out of 14-day buprenorphine detox 30% dropped out of 12-weeks buprenorphine Woody et al. 2008
Addiction s Other Diseases Early treatment reduces hepatitis C and HIV risk 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% HCV HIV-1 <20 20-29 30-39 40-49 >50 Age at admission into MMT (years) Piccolo et al. 2002
Methadone Buprenorphine and Pregnancy Standard of care for treatment in pregnancy Does not cause birth defects Codeine may cause congenital heart defects Untreated addiction can cause fetal growth problems No bad effect on infant development Growth Intelligence Health http://www.acog.org/resources-and-publications/committee-opinions/committee-on-health-care-for- Underserved-Women/Opioid-Abuse-Dependence-and-Addiction-in-Pregnancy
ASAM National Guideline
Don t ask Don t know In the past 12 months, have you: Used any of the following medications just for the feeling, to get high, or more often or in larger doses than prescribed? opiates pain relievers (OxyContin, Vicodin, Percocet, Suboxone, Methadone) In the past 3 months, have you (each yes gets 1 point): Used an opioid-containing medication not as prescribed or without a prescription? (separate question for heroin) Have you tried and failed to control, cut down or stop using an opioid medication? Has anyone expressed concern about your use of an opioid medication? Rx opiates: Score of 2 has PPV 0.79 and NPV 0.99 Heroin: Score of 2 has PPV 0.93 and NPV 0.99
Screen positive Assess interest in change Discuss harms and relate to medical/psychiatric issues Discuss safe use Prescribe naloxone rescue kit Establish diagnosis Assess for consequences HIV, HBV, HCV, STI Other drug use (ask and drug screening) Check prescription monitoring database Shared decision making on next steps
The Right Treatment for the Right Patient, Right? Socioeconomic status Family support Employed Mental health Youth Criminal justice
Conclusion Opiate addiction is treatable Medications work best Maintenance works best Patient need to make informed choices
Resources TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs http://www.ncbi.nlm.nih.gov/books/nbk64164/ ASAM National Practice Guideline http://www.asam.org/quality-practice/guidelines-andconsensus-documents/npg/supplement Providers Clinical Support System for Medication Assisted Treatment http://pcssmat.org/