Successful Treatment of Opioid Use Disorders in Military and Veteran Populations CAPT Chideha Ohuoha MD MPH, Chief, Addiction Medicine, Fort Belvior Community.

Successful Treatment of Opioid Use Disorders in Military and Veteran Populations
CAPT Chideha Ohuoha MD MPH, Chief, Addiction Medicine, Fort Belvior Community Hospital, DoD Anthony Dekker DO, Addiction Medicine, NAVAHCS, AZ November 29, 2017, National Harbor

Disclosures CAPT Ohuoha has no interest to disclose.
Anthony Dekker has no interest to disclose. AMUS and PESG staff have no interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. PESG, AMSUS, planning committee members and all accrediting organizations do not support or endorse any product or service mentioned in this activity.

Learning Objectives At the conclusion of this activity, the participant will be able to: The learner will be able to recognize opioid use disorders. The learner will be able to identify medication treatment interventions for opioid use disorders The learner will be able to discuss how to treat and care the patient with opioid use disorders.

Evaluation and Treatment of Substance Abuse in Active Duty Service Members
CAPT Chideha Ohuoha MD MPH Addiction Medicine Fort Belvoir Community Hospital AMSUS 29 NOV 17

EVALUATION AND TREATMENT OF SUBSTANCE USE DISORDERS (SUD) IN ACTIVE DUTY MILITARY (CO-OCCURING DISORDERS) PREVALENCE Estimates indicate about 23.4 million veterans and 2.2 million service members including the National Guard and Reserves. 1.2 million have been deployed to Iraq and Afghanistan. About 20% of Iraq and Afghanistan veterans have mood symptoms (MDD, PTSD, Anxiety) Rates of Co-Occurring Disorders in these recent veterans have not been established fully but 75% of Vietnam veterans with lifetime PTSD had Co-Occurring SUDs Veterans with mood disorders have a higher prevalence of SUDs, other psychiatric symptoms, traumatic experiences, legal problems and worse general health. Patients with PTSD have been shown to be up to 14 times more likely to have SUD than those without PTSD (Ford et al 2007) Little information exists on the use of illicit drugs among active duty personnel (crime, separation). Iatrogenic opioid prescription drug abuse in a survey among active duty personnel indicates an 11% prevalence of misuse. AMSUS 29 NOV 17

EVALUATION AND TREATMENT OF SUBSTANCE USE DISORDERS (SUD) IN ACTIVE DUTY MILITARY (CO-OCCURING DISORDERS) AGE DISTRIBUTION OF PSYCHOLOGICAL STRESS In the NSDUH data collected in , 7% of veterans aged 18 years and older had experienced significant psychological stress in 1 year and 7.1 percent of these met criteria for SUD, 1.5% had Co-Occurring SUD and SPD. Those between had higher rates of Co-Occurring Disorders than older veterans Family income of less than $20,000 per year was a predictor for higher rates of Co-Occurring Disorders. AMSUS 29 NOV 17

Substance Use Disorders in the Military
Preventive Programs “That Guy”: Alcohol Abuse Prevention Education Campaign Military Pathways Real Warriors Campaign Medical Encounters (Periodic Health Assessment) Military and Civilian Drug Testing program Screening Services Pre Deployment Health Assessment Post Deployment Health Assessment Post Deployment Health Reassessment Program Periodic Health Assessment Diagnosis and Treatment Programs TRICARE Network Providers AMSUS 29 NOV 17

(7) Substance Abuse Treatment Program.
1. NOTIFICATION a. Command notification by healthcare providers will not be required for Service member self and medical referrals for mental health care or substance misuse education. b. Healthcare providers shall notify the commander concerned when a Service member meets the criteria for one of the following mental health and/or substance misuse conditions or related circumstances: (1) Harm to Self.. (2) Harm to Others. The provider believes there is a serious risk of harm to others either as a result of the condition itself or medical treatment of the condition. (3) Harm to Mission (4) Special Personnel. (6) Acute Medical Conditions Interfering With Duty. The Service member is experiencing an acute mental health condition or is engaged in an acute medical treatment regimen that impairs the Service member’s ability to perform assigned duties. (7) Substance Abuse Treatment Program. AMSUS 29 NOV 17

(8) Command-Directed Mental Health Evaluation
(8) Command-Directed Mental Health Evaluation. The mental health services are obtained as a result of a command-directed mental health evaluation consistent with DoD Directive (9) Other Special Circumstances. The notification is based on other special circumstances in which proper execution of the military mission outweighs the interests served by avoiding notification, as determined on a case-by-case basis by a health care provider. (1) The diagnosis; a description of the treatment prescribed or planned; impact on duty or mission; recommended duty restrictions; the prognosis; any applicable duty limitations; and implications for the safety of self or others. (2) Ways the command can support or assist the Service member’s treatment. d. Healthcare providers shall maintain records of disclosure of protected health information . AMSUS 29 NOV 17

COMMANDER DESIGNATION
COMMANDER DESIGNATION. Notification to the commander concerned pursuant to this Instruction shall be to the commander personally or to another person specifically designated in writing by the commander for this purpose. 3. COMMANDERS. Commanders shall protect the privacy of information provided pursuant to this Instruction and DoD Directive (Reference (j)) as they should with any other health information. Information provided shall be restricted to personnel with a specific need to know; that is, access to the information must be necessary for the conduct of official duties. Such personnel shall also be accountable for protecting the information. Commanders must also reduce stigma through positive regard for those who seek mental health assistance to restore and maintain their mission readiness, just as they would view someone seeking treatment for any other medical issue. AMSUS 29 NOV 17

Availability of Care AMSUS 29 NOV 17

Access to Care AMSUS 29 NOV 17

Policy Issues/Concerns DoD and Service-level policies related to substance abuse offenders are consistent with stated mission priorities and goals and allow health care providers and commanders to assist service members with treatment and recovery rather than engaging in disciplinary action. Balance is required when responding to unresolved substance misuse issues, thereby undermining the deterrence benefit of potential disciplinary action. Current TRICARE regulation does not permit SUD treatment delivered by health care providers outside of a TRICARE certified Substance Use Disorder Rehabilitation Facility Current TRICARE regulation does not permit independent practice of licensed mental health counselors in the diagnosis and treatment of SUDs AMSUS 29 NOV 17

COOPH Program Program Overview
Co-Occurring Partial Hospitalization Program or COOPH is a non-command referred intensive outpatient program for service members diagnosed with substance abuse and behavioral health issues. While the primary diagnosis are usually PTSD and substance abuse some patients in need of intensive work may also qualify for this program. Transition: Now that you have a background on the prevalence and treatment of SU/Co-Occurring disorders in the military population, I will now discuss how we treat these conditions at COOPH AMSUS 29 NOV 17

COOPH Program Referral Process
Patients are referred by a medical provider to the program for assessment by our staff. Patients are often referred from inpatient psychiatric care and out patient behavioral health but can come from other medical providers. Once the referral has been received an initial assessment is scheduled for the patient. AMSUS 29 NOV 17

COOPH Program Assessment
Usually three assessments are completed upon the patients initial appointment. Psychosocial assessment by a Psychologist or Social Worker Nursing assessment by our RN Psycho-pharmacological and Psychosocial assessment by our Psychiatrist. The suitability of this patient is determined from these assessments and a start date is established. AMSUS 29 NOV 17

COOPH Program Participation Guidelines
Patients should be able to participate in at least 30 hours a week of programming. Parent commands maintain responsibility for the accountability of their Service Members before and after daily COOPH programming. Patients should be free from other responsibilities while enrolled to ensure maximum effective participation. AMSUS 29 NOV 17

COOPH Program Participation Guidelines (cont)
Abstinence from intoxicants for all participants regardless of diagnosis Proper use of prescribed medications. Patients will wear normal duty dress such as ACU’s, MARPS, except during certain activities where PTs are authorized Patients can refuse treatment, but in doing so will be discharged from the program. All patients must provide command information and a signed letter of consent from the command to start treatment. AMSUS 29 NOV 17

COOPH Program Graduation and Referral
Patients who have successfully completed 4-6 weeks of programming will graduate with a certificate of completion. All patients expecting to graduate will return to referring provider when appropriate, and or another service, or follow up. NO PATIENT LEAVES WITH OUT PROPER FOLLOW UP CARE AND SCHEDULED APPOINTMENTS. AMSUS 29 NOV 17

COOPH Program Programming
Patients attend the program from Monday thru Friday for 4-6 weeks. Patients participate in two 90 minutes process groups and two 60 minute psycho-educational/recreation therapy groups daily. Patients are seen twice weekly by their primary provider for therapy and twice weekly for medication management. AMSUS 29 NOV 17

COOPH Program Relapse Prevention (Substance Use)
Group Therapy Modalities: Relapse Prevention (Substance Use) Early Recovery (Substance Use) Graphic Narrative Processing (PTSD) ACT (Dual Diagnosis/Mood Disorders) DBT (Dual Diagnosis/Mood Disorders) Yoga & Meditation (all patients) Recreation Therapy & Psychoeducational These are the therapies we use at the COOPH. The following slides will go into each of these modalities in greater detail. AMSUS 29 NOV 17

SUBSTANCE ABUSE TREATMENT
For 4-6 weeks patients attend several intensive treatment sessions per week. There are two concurrent curriculum, one for early recovery (8 sessions) and one for relapse prevention (32 sessions). Patients are assessed at intake to determine which group curriculum they will participate in. The AUDIT, CAGE Test and a substance use timeline are used in addition to a brief interview. The patients are familiarized with 12-step programs and other support groups. Patients are taught time management and scheduling skills. Weekly drug/alcohol testing are also conducted. Patients who receive a positive drug/alcohol test while enrolled are staffed to reemphasize the no drug/alcohol use program policy. A more structured relapse prevention plan is completed at this time. AMSUS 29 NOV 17

METHODS OF THERAPEUTIC APPROACH COGNITIVE BEHAVIORAL THERAPY CBT for substance abuse helps clients recognize situations where they are likely to use substances, find ways of avoiding those situations, and learn better ways to cope with feelings and situations that might have, in the past, led to substance use. EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR) Many people struggling with addiction have underlying traumas and use alcohol or drugs to withdraw and numb their memories. EMDR, through eye movements and bilateral stimulation connects the left and ride sides of the brain, allowing the person to look inward and get in touch with his or her innate ability to heal and self-soothe. AMSUS 29 NOV 17

METHODS OF THERAPEUTIC APPROACH (cont) RELAPSE PREVENTION Proposes that relapse is not a random event. The process of relapse follows predictable patterns. Signs of impending relapse can be identified by therapists and their patients. SEEKING SAFETY A significant number of persons with substance use disorders have experienced trauma, often as a result of abuse. Many of them have PTSD. Recent studies have demonstrated strong connections between trauma and addictions, including the role that childhood abuse plays in the development of substance use disorders. This treatment consists of 25 modules divided between cognitive, behavioral and interpersonal topics relevant to substance abuse and PTSD AMSUS 29 NOV 17

METHODS OF THERAPEUTIC APPROACH (cont) EARLY RECOVERY SKILLS Teaches patients a set of skills for establishing abstinence from drugs and alcohol. Patients are taught that they can change their behaviors in ways that will make it easier to stay abstinent. Also that professional treatment can be one source of information and support. SELF-HELP GROUPS(12 Step Programs, e.g. AA, Smart Recovery, Alanon, Double Trouble in Recovery) OTHER METHODS OF PSYCHO-EDUCATION Sleep Hygiene, Medication Education, Anger Management, Boundaries in Relationships, etc. AMSUS 29 NOV 17

GOALS OF EARLY RECOVERY TRACK Provide a structured group for new patients to learn about recovery skills and 12 step and mutual help programs. Introduce patients to the basic tools of recovery and aid patients in stopping drug and alcohol use. Create an expectation of participation in 12-step or mutual-help meetings as a part of treatment. Help patients adjust to participation in a group setting such as relapse prevention, 12-step or social support group. AMSUS 29 NOV 17

GOALS OF RELAPSE PREVENTION TRACK Alert patients to the fact that relapse is not a random event. It is a process. The process of relapse follows predictable patterns. Early and effective intervention for recognition and change of process. Relapse prevention involves an understanding of one’s personal, biological, and social risk factors. Relapse prevention requires a change in lifestyle, not just abstinence. AMSUS 29 NOV 17

Desired Outcome-to change substance use behavior by: Identifying thoughts or feelings that trigger the urge to use, then helping individuals change/manage these thoughts and feelings. Reducing disturbances through teaching methods which individuals can use to help themselves become less irrational and more effective in how they think, feel, and act. Helping individuals to develop effective strategies to cope with those high-risk situations thereby increasing their coping skills so they will not use alcohol and drugs in high-stress situations AMSUS 29 NOV 17

Graphic Narrative Processing for the Treatment of Trauma
Intensive Therapy for the Adverse Effects of Trauma An innovative approach to group and individual therapy in an intensive treatment setting A Pathway to Traumatic Memory Goals of the graphic trauma narrative: To eliminate intrusive and arousal symptoms of PTSD triggered by traumatic memories. Reduce emotional distress typically associated with remembrance of traumatic events Decrease avoidance responses Transforms images from unfinished (seemingly present) experience to past history Major benefit is that it can be conducted in a group setting vs only individual therapy. Was developed out of therapies for rape/sexual trauma Combines Narrative therapy with exposure therapy Soldiers present with many fragmented memories of traumatic experiences because they perseverate of the most traumatic parts of each experience. Graphic Narrative therapy seeks to re-integrate the fragmented memories and provide a cohesive framework from Beginning to Middle to End -Deployment timeline -Pick ONE traumatic event to focus on (usually hour time period) -Patients are instructed to draw out each stage of the event as if creating a comic NEXT SLIDE AMSUS 29 NOV 17

Instinctual Phases of Trauma Response: Structuring the Narrative A before picture The startle The Thwarted intention The Freeze state The state of automatic obedience The altered state The experience of body sensation Self-Repair The after picture to establish endpoint and closure These are the stages that each patient's story can be broken into. AMSUS 29 NOV 17

Instinctual Phases of Trauma Response: Structuring the Narrative 1 2 3 4 5 6 7 8 9 Therapist goes over the story with the patient. Therapist presents the story to the group. (Not patient so that pt can be a witness to his/her own story and engage emotionally without re-experiencing or detaching which is more likely if they tell their own story). Presentation is videotaped. Group provides support/feedback to the patient. Feedback in the group setting provides support and fosters cohesion due to shared experience and can be effective in confronting survivor's guilt. Pt is given the DVD of the presentation which they watch individually and with their therapist. This is the exposure piece. AMSUS 29 NOV 17

Externalized Dialogue of Dissociated Parts: Fighting the War Inside Dissociated parts are acknowledged as belonging to the larger self. Parts gain a conscious and cooperative relationship to the self. Resolution of Victim Mythology: Challenges the assumption that one is a damaged person in a dangerous world. “I used to love life/my wife/family, now I can’t control myself and it makes me so angry I want to end it.” These statements represent three distinct voices existentially born out of the trauma. Pt instructed to write out an externalized dialogue in which the voices talk to each other challenging assumptions, desires, and identity of each part. “What does the Ragger part of you think about the Suicidal part?” AMSUS 29 NOV 17

Acceptance and Commitment Therapy (ACT) for Dual Diagnosis Patients
Model: Cognitive behavioral in nature Switches the focus from CONTROLLING thoughts and feelings to engaging in valued ACTIONS The ACTION focused on is any action that Is based in a deeply held value Related to feelings of satisfaction/meaning Is not based in avoidance Is not an attempt to feel happy or change a feeling AMSUS 29 NOV 17

Hexaflex Model: ACT model uses six interrelated concepts Acceptance/Willingness (to allow for whatever comes up without fighting, controlling it or avoiding it) De-Fusion (getting distance from thoughts so one can decide whether or not to act on them rather than feeling controlled by thoughts and feelings) Mindfulness of the Present Moment (be in the present more often, grounding, all living happens in the present) AMSUS 29 NOV 17

Hexaflex Model (cont): Values (the guiding principles, phrased as actions, that give one’s life meaning – not chosen by others but deeply felt) Committed Action (the actions that are in line with values, acted out even while having unhelpful/un-preferred thoughts/feelings) Self-As-Context (the meta-cognitive part of our self that can step back and look objectively at thoughts deciding if helpful or unhelpful) AMSUS 29 NOV 17

How the model is conveyed: Group setting 3-4 times a week Each week focuses on a limb of the model and its relatedness to specific problems being faced by clients Tolerance of typically avoided emotions (anger/anxiety/sadness/fear) is taught through didactics, psycho-education and experiential exercises such as meditation De-fusion is taught as specific techniques to provide alternatives to the belief: “If I think it , I have to act on it or avoid it” AMSUS 29 NOV 17

Dialectical Behavior Therapy (DBT)
What is DBT: DBT is an Evidenced Based behavioral therapy intervention developed by Marsha M. Linehan DBT is based on concepts from CBT, meditation and the concepts of dialectics as applied to behavioral therapy. DBT is psychosocial skill training to help people effectively cope with overwhelming emotions DBT is highly effective with people who suffers from trauma AMSUS 29 NOV 17

Four components of DBT: Distress-Tolerance: Help individual cope with painful emotions and events to build individuals resiliency by apply new coping strategies (radical acceptance, distractions and relaxation) Mindfulness: Helps individual remain fully in the present moment while focusing on less painful or traumatic events. Mindfulness is the tool to overcome negative judgment about yourself, others or events. AMSUS 29 NOV 17

Four components of DBT (cont): Emotional Regulation Skills: assist individuals with identifying and observing their emotions and assist individuals to modulate their feelings to effectively respond to events, instead of destructive reactions to events. Interpersonal Effectiveness: New tools are established for individuals to express their feelings, beliefs and needs, setting limits and negotiating solutions to problems. Interpersonal effectiveness allows individuals to respectively preserve their relationships with others. AMSUS 29 NOV 17

“Each year, more Americans die from drug overdoses than in traffic accidents, and more than three out of five of these deaths involve an opioid. Since 1999, the number of overdose deaths involving opioids, including prescription opioid pain relievers, heroin, and fentanyl, has nearly quadrupled. “ 2017 Presidential Commission Each year, more Americans die from drug overdoses than in traffic accidents, and more than three out of five of these deaths involve an opioid. Since 1999, the number of overdose deaths involving opioids, including prescription opioid pain relievers, heroin, and fentanyl, has nearly quadrupled. Many people who die from an overdose struggle with an opioid use disorder or other substance use disorder, and unfortunately misconceptions surrounding these disorders have contributed to harmful stigmas that prevent individuals from seeking evidence-based treatment. During Prescription Opioid and Heroin Epidemic Awareness Week, we pause to remember all those we have lost to opioid use disorder, we stand with the courageous individuals in recovery, and we recognize the importance of raising awareness of this epidemic. Opioid use disorder, or addiction to prescription opioids or heroin, is a disease that touches too many of our communities -- big and small, urban and rural -- and devastates families, all while straining the capacity of law enforcement and the health care system. States and localities across our country, in collaboration with Federal and national partners, are working together to address this issue through innovative partnerships between public safety and public health professionals. The Federal Government is bolstering efforts to expand treatment and opioid abuse prevention activities, and we are working alongside law enforcement to help get more people into treatment instead of jail. prescription-opioid-and-heroin-epidemic

Opioid Overdose Epidemic
From 2000 to 2014 nearly half a million people died from drug overdoses. In 2014 alone, 47,055 persons died from drug overdoses – more than in any year on record before. The majority of drug overdose deaths (more than 6 out of 10) involve an opioid. 78 Americans die every day from an opioid overdose (source: CDC) In 2012, 80% of drug overdose deaths in the United States were unintentional. (Drug Overdose in the US: Fact Sheet, 2014) Source: National Vital Statistics System, Mortality file; CDC

Correlation of Opioid Sales with Overdose Deaths and Treatment for Opioid Use Disorder
Rates of prescription painkiller sales, deaths and substance abuse treatment admissions ( ) This chart shows the rates of prescription painkiller sales, deaths, and treatment admissions in the United States. The rate of prescription painkiller sales increased from less than two kilograms per 10,000 people in 1999 to more than seven kilograms per 10,000 people in The rate of prescription painkiller deaths from increased from less than two deaths per 10,000 people in 1999 to more than 4 deaths per 10,000 people in The rate of prescription painkiller treatment admissions increased from less than one treatment admission per 10,000 people in 1999 to more than four treatment admissions in 2009. CDC website accessed 9/3/15 Prescription opioid overdose deaths number more than the deaths from all illegal substances combined SOURCES: National Vital Statistics System, ; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), ; Treatment Episode Data Set, ; ttp://

Opioid Use Disorder (OUD) Epidemic
Anyone who takes prescription opioids can become addicted to them. In 2014, nearly two million Americans either abused or were dependent on prescription opioid pain relievers. 25-41% of patients on prescription opioids meet criteria for opioid use disorder (DSM-5 criteria). The risk of developing OUD increases with the duration and with the prescribed dosage of opioid therapy.

Opioid Use Disorder Epidemic
Among new heroin users, approximately three out of four report abusing prescription opioids prior to using heroin. Heroin-related deaths more than tripled between and 2014. 10,574 heroin deaths in 2014.

Risks of Opioid Therapy
Mortality (of all-causes) Hazard ratio (HR) 1.64 for long acting opioids for non-cancer pain Overdose deaths (unintentional) HR for MED > 100 mg/d Opioid use disorder For patients on long-term opioids (> 90 days) HR 15 for 1-36 mg/d MED HR 29 for mg/d MED HR 122 for > 120 mg/d MED MED=Morphine Equivalent Daily Dose (in mg/d)

Paradigm Shift in Pain Care
There is no completely safe opioid dose threshold below which there are no risks for adverse outcomes. Even a short-term use of low dose opioids may result in addiction. Realization that any initial, short-term functional benefit will likely not be sustained in most patients. Patients on opioids may actually experience a functional decline in the long term, measured by factors like returning to employment. Paradigm shift away from long-term opioid therapy for chronic, non-end-of-life pain management.

Biopsychosocial Model: “Whole Person”
Assess daily function, sleep, psychosocial-spiritual situation, social support, patient’s goals; medical and psychiatric comorbidities, substance use/abuse, suicidal ideation, etc. Include data from urine drug testing, prescription drug monitoring programs, prior records, etc.

The Stepped Care Model for Pain Management, developed by VA, has been implemented within both the Veterans Health Administration (VHA) and Military Health System (MHS) with the aim of providing a continuum of effective, coordinated, and patient-centered treatment to patients with pain. With education, self-care, and whole-health approaches to wellness as the foundation, this model provides progressively more intensive biopsychosocial care within increasingly specialized settings as patients become more complex, have a greater degree of comorbidity, and present higher risk. Psychological, physical, complementary and alternative, and medication therapies are often combined to create a multimodal pain care plan. The goals of the Stepped Care Model for Pain Management include functional rehabilitation, improvement in quality of life, and prevention of the pain becoming chronic and associated deterioration in function

Assessing Pain and Function
Talk to the patient about the pain care plan Set realistic goals for pain and function Several tools are available ● PEG Pain Enjoyment of Life General activity

Setting SMART Goals Specific Identifies a specific action or event that will take place Measurable Should be quantifiable so progress can be tracked Achievable Should be attainable and realistic given resources Relevant Should be personally meaningful Time-bound State the time period for accomplishing the goal ●

Bridging Therapies Safe, short-term therapies that are implemented to help patients transition to more active strategies from less safe, passive strategies. Acupuncture Spinal manipulation (e.g., Osteopathic, chiropractic) Physical modalities (e.g., self-applied electrical stimulation, etc.) Invasive therapies that may be implemented when the benefits of facilitating active treatment strategies outweigh the potential risks of therapy. Trigger point injections Joint injections Nerve blocks Spinal injections

Use Caution When Opioid Therapy is Considered for Acute Pain
Start with a whole person biopsychosocial assessment. Use caution with all opioid prescribing, including for acute pain Even a single opioid prescription may increase risk for developing OUD. Often, opioid therapy for an acute pain condition unintentionally becomes long-term opioid therapy. Avoid opioids for minor injuries (e.g. acute low back pains, sprains). When opioids are required for acute pain, prescribe the lowest effective dose of immediate-release opioids for the shortest therapeutic duration. 3 days or less is often sufficient; more than seven days will rarely be needed. Combine opioids with other pharmacological and non-pharmacological modalities – do NOT use opioids in isolation. Do not use long-acting opioid medication for acute pain, as-need pain or postoperatively. Discuss with the patient benefits, side effects and risks (e.g., sedation, addiction, overdose). Check patient understanding of treatment plan. Counsel patients about safe storage and disposal of unused opioids. Start with a whole person biopsychosocial assessment. Assess: sleep, psychiatric co-morbidities, psychosocial-spiritual situation, patient’s goals, substances, suicidal ideation, UDT, PDMP, prior records. No data for effectiveness outcomes > 16 weeks ● 27% of patients who received new opioid prescription went on to longer term opioid prescribing (21% episodic prescribing pattern and 6% LTOT) ● Hooten, 2015 Mayo Clinic Proceedings

Opioid Risk Assessment and Mitigation: STORM
Stratification Tool for Opioid Risk Monitoring - STORM Leverages VA national data and predictive modeling. States the probability of adverse event within next year (suicide and overdose) and 3 years (suicide and overdose +/- falls and accidents. When considering opioid therapy and for patients on opioids. Key features: Identifies patients at-risk for drug overdose or suicide. Lists risk factors that place patients at-risk. e.g., co-Rx benzodiazepines, previous adverse events, mental health and medical diagnoses, MEDD. Displays risk mitigation strategies, including non-pharmacological treatment options, that have been employed and/or could be considered. Displays upcoming appointments and current treatment providers to facilitate care coordination. Updated nightly.

Prescription Drug Monitoring Programs (PDMP)
PDMP is a statewide electronic database that tracks all controlled substance prescriptions. Includes prescription data such dispensed medications and doses. All prescribing providers should register and use the PDMPs regularly. PDMPs improve patient safety by allowing clinicians to: Identify patients who are obtaining opioids from multiple providers. Identify patients who are being prescribed other substances that may increase risk of opioids—such as benzodiazepines. Check PDMP prior to initiation of opioids and at least once every 3 months, consider check prior to every opioid prescription (CDC recommendations). State requirements vary.

Urine Drug Testing Determine compliance with prescribed medications
Random urine drug testing (UDT) needs to be performed prior to and routinely during opioid prescribing Frequency of UDT needs to be based on risk, but at a minimum once every 6 to 12 months for low risk and every 3 months or more frequently for high risk patients Determine compliance with prescribed medications Reveal diversion of prescribed substances Identify use of undisclosed substances Enhance patient motivation to adhere to treatment plan A verbal consent should be obtained and documented in the patient’s medical record by the provider (may be done in advance, at least every 12 months). Before requesting urine, always ask*: • When did you take your last dose? How much? • Have you taken any other pain medicine? Any drugs? *Documentation of this is crucial for interpreting UDT results So what is it that we wish to achieve from urine drug screening? First and foremost, it provides objective evidence to guide treatment and management of patients with chronic pain. It can also indicate compliance with prescribed medication as well as abstinence from drugs of abuse. Not only does it serve as a deterrent but it also demonstrates the clinician’s commitment to preventing misuse of prescribed controlled substances and can even serve as motivation for a patient to adhere to a treatment plan.

Urine Drug Testing Urine Drug Screening (UDS) for OPIOIDS
Source of Opioid Analgesics Natural (from opium) Semisynthetic (derived from opium) Synthetic* (man-made) Codeine Morphine Hydrocodone Hydromorphone Oxycodone Oxymorphone Buprenorphine Fentanyl Methadone Meperidine Tapentadol Tramadol Immunoassay for opiates (UDS) High sensitivity Usually positive Low sensitivity Positive only if taken in high dosage and recently Inability to detect Always negative Detectability of opioids is highly dependent on its source, so whether it is a natural opioid such as codeine and morphine, or if it is semisynthetic or synthetic. Standard opioid immunoassays detect morphine and codeine, but do not reliably detect semisynthetic opioids, such as oxycodone, oxymorphone, buprenorphine, or hydromorphone. The reason is that the side-chain substitutions of the semisynthetic opioids make them poorly reactive with standard immunoassay morphine antibodies which lead to a negative result. It is possible that use of semisynthetic opioids, even at high concentrations, will be inconsistently detected by the immunoassay because of incomplete cross-reactivity. However, there are specific immunoassays for some semisynthetic agents such as oxycodone that are much more sensitive and specific. Hydrocodone is another semisynthetic opioid that may not be detected similarly to oxycodone; however, this opioid has a caveat. 2 of the 8 standard immunoassays are actually hydrocodone-sensitive. However, PRN use of hydrocodone may still be difficult to detect. While opioid immunoassays may or may not detect semisynthetic agents, they do NOT detect synthetic opioids such as methadone at all. But GC/MS can reliably identify most opioids when present. (*) Specific immunoassay tests and GC-MS are necessary Slide Compliments of Lacey J. Miller, Pharm.D Gourlay DL, et al. Connecticut: PharmaCom Group, Inc;2012. Moeller KE, et al. Mayo Clin Proc. 2008;83(1):66-76.

Overdose Education and Naloxone Distribution OEND
Overdose Education (OE) Provide patient education on how to prevent, recognize, and respond to an opioid overdose. Naloxone Distribution (ND) FDA approved as naloxone autoinjector and nasal spray. Dispense and train patient and caregiver/family. Target patient populations: OUD, and prescribed opioids. Offer naloxone when factors that increase risk for opioid overdose are present: h/o overdose, h/o SUD, higher opioid dosages (≥50 MMED), or concurrent benzodiazepine use. OEND provides opportunity to discuss risk; however, naloxone does not eliminate risk or make opioids more effective.

Opioid Risk Increases with Dosage
Prescription risk factors: No completely safe opioid dose. Risk increases with dose and begins to significantly increase at mg/d MED. Generally avoid increasing above 50 mg/d MED and if > 50 mg/d MED then MUST add additional precautions including more frequent monitoring; Avoid increasing above 90 mg/d MED. Avoid combining with benzodiazepines.

Opioid Risk Increases with Dosage
Washington State - Interagency Guidelines on Prescribing Opioids for Pain

Indications for Opioid Tapering
Source: VA PBM Academic Detailing Service, Opioid Taper Decision Tool, 2016

Tapering/Discontinuation of Opioids
Indications Process Risks outweigh benefits. Treatment goals not met. Opioid use disorder suspected. Unsafe or illegal behaviors. Non-adherence to treatment plan. Severe side effects. Patient preference. Individualize care plan. Optimize whole person care. Psychological, physical, social, spiritual support Gradual taper preferred if safety allows. Can reduce by 5-20% per month. Frequent monitoring by team. Vigilance for unmasked opioid use disorder. Seek specialty consultation for moderate and high risk patients.

Academic Detailing Examples for Opioid Tapering

DSM-5 Criteria for OUD (prescription opioids) (2 or more of the following criteria)
Example behaviors Craving or strong desire to use opioids Describes constantly thinking about opioids Recurrent use in hazardous situations Repeatedly driving under the influence Using more opioids than intended Repeated requests for early refills Persistent desire/unable to cut down or control opioid use Unable to taper opioids despite safety concern or family’s concern Great deal of time spent obtaining, using or recovering from the effects Spending time going to different doctor’s offices and pharmacies to obtain opioids Continued opioid use despite persistent opioid-related social problems Marital/family problems or divorce due to concern about opioid use Continued opioid use despite opioid-related medical/psychological problem Insistence on continuing opioids despite significant sedation Failure to fulfill role obligations Poor job/school performance; declining home/social function Important activities given up No longer active in sports/leisure activities

Opioid Prescribing Recommendations: Summary of 2016 CDC Guidelines

Overview Using the Stages of Change Model
STAGE OF CHANGE Pre-contemplation Contemplation Determination Action Maintenance STRATEGIES Feedback Resolve Ambivalence Define Goals Choose from Menu Relapse as Learning Opportunity

Keys to Successful Treatment
Screen carefully for psychiatric co-morbidity Refer to skilled, empathetic therapists using MET Long-term treatment rather than high-intensity care Integrate self-help programs and family therapy Prompt return to therapy after any relapse External pressure (court, job, family, medical board) can be very helpful

REFERENCES Levounis P, Arnaout B: Handbook of Motivation and Change, Washington, DC, American Psychiatric Publishing, 2010 Najavits LM: Seeking Safety: A Treatment Manual for PTSD and Substance Abuse, New York, The Guilford Press, 2002 Project MATCH series, 1995 Volume 1-Twelve Step Facilitation Therapy Manual, NIH Pub. No Volume 2-Motivational Enhancement Therapy Manual, NIH Pub. No Volume 3-Cognitive-Behavioral Coping Skills Therapy Manual, NIH Pub. No

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Successful Treatment of Opioid Use Disorders in Military and Veteran Populations CAPT Chideha Ohuoha MD MPH, Chief, Addiction Medicine, Fort Belvior Community.

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Successful Treatment of Opioid Use Disorders in Military and Veteran Populations CAPT Chideha Ohuoha MD MPH, Chief, Addiction Medicine, Fort Belvior Community.

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Presentation on theme: "Successful Treatment of Opioid Use Disorders in Military and Veteran Populations CAPT Chideha Ohuoha MD MPH, Chief, Addiction Medicine, Fort Belvior Community."— Presentation transcript:

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