1. Opioid Abuse and Dependence
Ingrid Binswanger, MD, MPH
Division of General Internal Medicine
Division of Substance Dependence
UCD School of Medicine
Eric Ennis, LCSW, CAC III
Director of Adult Outpatient Services
Senior Instructor of Psychiatry
Addiction Research and Treatment Services (ARTS)

2. Objectives
Be familiar with current trends in opioid abuse and dependence, and make accurate diagnoses of opioid and other substance involvement
Understand psychosocial and pharmacologic treatment options for patients with substance abuse/dependence
Be familiar with services available for opioid dependent patients in the Denver metro area, and how to assist in the coordination of care
Initiate a conversation about how we can better manage our patients with opioid abuse/dependence and coordinate care with treatment services

3. Extent of the Problem 3 million have used heroin
Opioid dependence related to pharmaceutical agents increasing in prevalence
Medical complications of opioid use and dependence are common and serious

4. Source: SAMHSA, The DAWN Report: Narcotic Analgesics, August, 2008.
Drug Abuse-Related ED Visits Involving Narcotic Analgesics:
Source: SAMHSA, The DAWN Report: Narcotic Analgesics, August, 2008.

5. Unintentional pharmaceutical overdose deaths, West Virginia
550% increase in overdose mortality,
295 decedents in 2006
93% associated with opioid analgesics, only 44% were prescribed
63% associated with pharmaceutical diversion
21% associated with doctor shopping

6. Substance Abuse by DSM Criteria
A maladaptive pattern of substance use leading to clinically significant impairment or distress
One (or more) of the following, within a 12-month period:
Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home
Recurrent substance use in situations in which it is physically hazardous
Recurrent substance-related legal problems
Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
Symptoms have never met the criteria for substance dependence for this class of substance

7. Substance Dependence by DSM criteria
A maladaptive pattern of substance use leading to clinically significant impairment or distress
Three (or more) of the following, occurring in same 12-month period:
Tolerance
Withdrawal
The substance is taken in larger amounts or over a longer period than was intended
Persistent desire or unsuccessful efforts to cut down or control substance use
A great deal of time is spent on activities necessary to obtain the substance, use the substance, or recover from its effects
Important social, occupational, or recreational activities are given up or reduced
The substance use is continued despite knowledge of having a persistent physical or psychological problem likely to have been caused or exacerbated by the substance

8. Drug Dependence is a Chronic Medical Illness
Requires
Screening and prevention
Long-term care strategies
Medication management
Continued monitoring
Empathy and patience
McLellan AT, Lewis DC, O’Brien CP, Kleber HD; Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000

9. Compliance & Chronicity
Chronic Illness
Medication Compliance
Relapse within 1 year
Diabetes
<60%
30-50%
Hypertension
<40%
50-70%
Asthma
Diet or Behavioral Changes
<30%
Slide Provided by: Peter Banys, M.D., Assoc. Clinical Prof. of Psychiatry, University of California at San Francisco, VA Medical Center, San Francisco.
McLellan AT, Lewis DC, O’Brien CP, Kleber HD; Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000

10. Screening for opioid dependence
History – Screening tools are available for opioid misuse, e.g. Physician Opioid Therapy Questionnaire
Physical exam – signs of intoxication or withdrawal or use
Lab tests
Urine toxicology screening may be helpful

11. What should I counsel my opioid-dependent patient about?
Opioid dependence is a chronic disease which requires ongoing treatment
Overdose risk is substantial
Combinations of drugs increase risk
Release from jail/prison associated
Leaving drug treatment associated
HIV and hepatitis risk from sharing needles and paraphernalia

12. What screening should I perform on my opioid dependent patient?
HIV
Hepatitis B S Ag
Hepatitis C Ab
Latent TB infection

13. What vaccinations should I give my opioid dependent patient?
Hepatitis A and B
Tetanus

14. Therapeutic Options Psychosocial interventions
Contingency management
Individual, group and family counseling
Motivational interviewing
Case management
12-step interventions
Pharmacological interventions
Methadone (can be used for taper as well)
Buprenorphine (can be used for taper as well)
Naltrexone (also used for alcohol dependence in oral and injectable forms)

15. Evidence supports psychosocial interventions in addition to medications
Maintenance: Cochrane review suggests improvements in number of participants abstinent at follow-up
Detoxification: Improvements in opiate use, compliance with treatment, and completion of treatment
Amato, 2008

16. Contingency Management
Re-arranging the reinforcers in a person’s environment
Incentives or rewards to encourage specific behaviors
Vouchers, prizes, group acknowledgements, take-home dosing privileges, family privileges

17. Methadone Maintenance for Opioid Dependence: Benefits
Reduced drug use
Reduced criminality
Improved health (reduced utilization of health care)
Improved functioning
Public health gains (HIV, Hepatitis,etc.)
Overall health care cost savings

18. Methadone for Opioid Dependence: Risks
Prolonged QT interval: question of what to do for assessment and treatment
Overdose risks: primarily associated with methadone prescribed for pain; treatment decreases risk of overdose from heroin
Diversion concerns?

19. Functional State (Heroin) Functional State (Methadone)
Impact of Short-Acting Heroin versus Long-Acting Methadone on the Functional State of the Patient
"High"
Functional State (Heroin)
(overdose)
"Straight"
"Sick" AM PM AM PM AM
Days
"High"
Functional State (Methadone)
"Straight"
Dole, Nyswander and Kreek, 1966
"Sick" AM PM AM H PM AM
Days

20. Slow “Build-up” of Constant Dose of Methadone to Steady-State
Blood plasma level of methadone
Days Dose constant at 30 mg to steady-state
Opioid Maintenance Pharmacotherapy - A Course for Clinicians

21. Induction / Initial Dosing
Administered under supervision
No signs of sedation or intoxication
Manifestation of withdrawal symptoms
Single dose of mg Methadone, not to exceed 30 mg
Same day adjustment, wait 2-4hrs after initial dose (peak effect), 5-10 mg increase
Maximum dose first day 40 mg
Clinical Pharmacology, Chapter 5, (TIP) Treatment Improvement Protocol #43, FDA Public Health Advisory, November 27, 2006

22. Phases of Methadone Dosing
Payte and Khuri
Opioid Maintenance Pharmacotherapy - A Course for Clinicians

23. l-methadone--µ agonist
___
l-methadone--µ agonist

24. Source: National Center for Health Statistics.

25. Methadone Mortality
Methadone has been increasingly prescribed for pain over the past 6-8 years (oxycontin, costs)
2004 SAMHSA report
Increased prescribing of methadone for pain as the major cause of increased deaths in the United States (700,000 vs. 260,000)
Outpatient treatment providers have used this medication as part of our addiction treatment practice for more than 40 years

26. Methadone Mortality, cont.
Sens. Rockefeller and Kennedy have directed the GAO to conduct a study on methadone-associated mortality in the US. The GAO Report has a tentative publication date of March 2009
Report is also likely to focus on the fact that medical examiners and coroners are still not using any standardized methodologies in reporting such methadone-associated mortalities
New York Times article 8/17/08

27. 2007

28. Buprenorphine
Buprenorphine available as a single agent or as a combined agent with naloxone
Available in sublingual preparation that includes naloxone as a diversion prevention measure
The injectable form of buprenorphine is NOT approved for use in the treatment of addiction

29. Buprenorphine Partial opioid agonist with high affinity for receptor
Low overdose potential
Easier to withdraw from than heroin, methadone, or LAAM

30. Buprenorphine FDA approved for use in addiction treatment
Available from private office-based physicians with
federal waiver, as authorized by the Drug Abuse
Treatment Act of 2000
Currently cost-prohibitive for many patients
Increasing reports of abuse and diversion

31. ==
Buprenorphine

32. University-affiliated treatment
ARTS: Addiction Research and Treatment Services: 3 metro area clinic sites for Medication-Assisted Treatment for opioid dependence

34. ARTS Outpatient Programs
Denver: ARTS Outpatient Clinic
Aurora: Potomac Street Center
Lakewood: Westside Center for Change

35. Other Clinics
Denver Health: Outpatient Behavioral Health Services
Private clinics
Denver Behavioral Health
North Denver Behavioral Health
The Boulder Clinic
(Denver VA does not offer methadone)

36. Using the 5 A’s in Primary Care
Ask
Advise
Assess
Assist
Arrange
Shortcut:
Ask
Advise
Refer

37. How to get your patients into treatment
Instruct patient to call or visit clinic; most clinics require pre-payment of intake fee (access and utilization issues)
Call us to discuss your reasons for referral and any related primary care or pain management issues; we’d love to hear from you!
Encourage patient to sign authorization for release of information* for coordination of care, especially if you are prescribing pain meds, psychotropic meds or other addictive meds, or if you have concerns about misuse of pain meds
*42 CFR Part 2 and HIPAA

38. Costs of treatment and insurance coverage
Insurance coverage and acceptance varies by carrier
Most patients will be assessed a sliding scale fee of about $180 per month for medical and psychosocial services; patients with higher incomes will pay more
ARTS is Kaiser’s exclusive opioid dependence treatment provider (methadone but not buprenorphine/naloxone)

39. Communication between PCPs and addiction treatment providers: How do I get information?
Ask your patient to sign an authorization to release information
We will also ask the same, but patients sometimes refuse our request
Be open to receiving calls from counselors and nurses rather than our Medical Director

40. Relapse: What to expect
Relapse is often a part of the treatment process or course. It is best viewed as a point for useful intervention and treatment plan revision
Relapse Prevention is a curriculum-driven treatment protocol
Relapse Prevention is also a generic term describing a collection of interdependent techniques which are intended to enhance self-control.
Methadone patients who leave treatment prematurely relapse at a very high rate: 82% within 12 months

41. Services ARTS offers Assessment for opioid dependence
Treatment of patients with both prescription and non-prescription opioid abuse and dependence
Answer questions of medication misuse or dependence
Injectable and oral naltexone for alcohol dependence

42. How can we serve you better?

43. How can we do a better job of integrating primary care into treatment and treatment into primary care?

44. Call us with questions
Recognize the difficulties inherent in treating some of these patients,
particularly those with chronic pain and addictive tendencies
ARTS: Dr. Bill Swafford, ;
Denver Health: Dr. Carol Traut, ;

45. Additional resources www.artstreatment.org
ACP Pier: section on opioid dependence
Recommendations for treating patients with chronic pain and potential for medication abuse
Manuals and assessment tools
Clinical roundtable discussion of how to continue to treat patients with both pain and addiction
Providing compassionate care for these difficult to treat patients, while protecting yourself and your patients
Colorado’s prescription drug monitoring program:
Information about obtaining a DEA waiver to prescribe buprenophine:

46. Further questions/comments
(office)
(office)
(cell)

47. References of interest
1. Hall AJ, Logan JE, Toblin RL, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. Dec ;300(22):
2. SAMHSA. The DAWN Report: Narcotic Analgesics 2008.
3. McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. Jama. 2000;284(13):
4. Turk DC, Swanson KS, Gatchel RJ. Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. Clin J Pain. Jul-Aug 2008;24(6):
5. CDC. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures. Recommendations of the Immunization Practices Advisory committee (ACIP). MMWR Recomm Rep. Aug ;40(RR-10):1-28.
6. CDC. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR Morb Mortal Wkly Rep. 2006;55(RR-14):1-24.
7. CDC. Unintentional poisoning deaths--United States, MMWR Morb Mortal Wkly Rep. Feb ;56(5):93-96.
8. Amato L, Minozzi S, Davoli M, Vecchi S, Ferri MM, Mayet S. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database Syst Rev. 2008(4):CD