1. Treat Opioid USE DISORDER like the chronic disease it is
Help Curb the Epidemic
Treat Opioid USE DISORDER like the chronic disease it is
Magni Hamso MD MPH FACP Cassi Shelly, RN, NP
Clin Asst Prof, UW-Boise Adult Nurse Practitioner, TRHS
Medical Director, ID Div of Medicaid PMHNP Candidate
@MagniMD

2. Disclosures No financial disclosures.
Will use generic names when possible.
Buprenorphine/naloxone instead of Suboxone. “Bupe” for short.
ER-naltrexone instead of Vivitrol. “Naltrexone” for short.

3. Learning Objectives Review the scope of the opioid overdose epidemic
Define opioids, opioid use disorder (OUD), addiction & recovery – understand OUD as a chronic disease
Review medications for addiction treatment (MAT)
Apply principles of quality chronic disease management to OUD
Review best practices for treatment of OUD in primary care

4. The Scope of the Epidemic

9. Definitions

10. What are Opioids?
Prescription pain medicines such as hydrocodone (Norco), oxycodone, morphine, fentanyl
Illegal drugs such as heroin
Stimulate the opioid receptor in the brain to decrease pain, as side effects make people feel good (euphoria) and slow breathing (overdose risk)

11. What is Addiction?
“a primary, chronic disease of brain reward, motivation, memory, and related circuitry…
…pathologically pursuing reward and/or relief of withdrawal symptoms by substance use…
…Without treatment or engagement in recovery, addiction is progressive and can result in disability and death.”

12. What is Recovery?
“a process of sustained action that addresses the biological, psychological, social and spiritual disturbances…
…aims to improve the quality of life…
…is the consistent pursuit of abstinence.”

13. Slide Credit: Dr. John Giftos, Clinical Director SUD Treatment, Correctional Health Services

14. Slide Credit: Dr. John Giftos, Clinical Director SUD Treatment, Correctional Health Services

15. Slide Credit: Dr. John Giftos, Clinical Director SUD Treatment, Correctional Health Services
I would argue that abstinent when on bupe or methadone. Not drug of choice. Not brought up and down – just kept evening. If stop a BP med, BP will go up. Stop insulin, sugars will go up, may even be hospitalized. No different with bupe or methadone for oud.

16. Opioid Use Disorder Chronic disease of addiction to opioids
Terms abuse and dependence confusing and outdated (but still needed for billing)
Diagnostic criteria* include:
Escalating use & loss of control
Continued use despite negative consequences
Diminished ability to fulfill societal obligations
Tolerance to the effects of the drug
Withdrawal symptoms when the drug is stopped
*11 criteria per DSM V
2-3 mild
4-5 moderate
6-11 severe

17. Who is affected?

18. Who is affected? 70 year-old grandfather, relapsed after 40 years
28 year-old M homeless T1DM
32 year-old pregnant stay-at-home mom on opioids since last c-section
50 year-old M using painkillers after work injury
44 year-old F small business owner

19. OUD is a Chronic Disease
Chronic disease requiring long-term management
28.6 million (10.6% of US population) illicit drug use (NSDUH 2016)
30 million diabetes (NHANES 2015)
2.4 million hepatitis C (CDC 2018)
70,200 overdose deaths 2017 (NIDA)
40,000 breast cancer deaths 2017 (ACS)
this is a primary care issue

20. Medications for Addiction Treatment

21. Role of Medications Medication for Addiction Treatment Harm Reduction
Psychosocial Interventions
Housing, Employment, Mental Healthcare
Recovery Support
Harm Reduction

22. Role of Medications Opioid Agonist Therapy Methadone Buprenorphine
Opioid Antagonist
Extended-release Naltrexone

23. Extended-release Naltrexone
ER Naltrexone
Opioid Antagonist
Once monthly intramuscular injection
Blocks intoxicating/reinforcing effects of opioids
Some interest pre-release
Limited evidence (2 trials compare to standard of care, 25-30% dropped out before first dose)
Increased risk of overdose after antagonist wears off
Extended-release Naltrexone

24. Methadone Buprenorphine Opioid Agonist Therapy
Reduce withdrawal symptoms & cravings
prevent relapse  allow brain to heal
↓mortality ↓ HIV/HCV ↓ substance use
↓ criminal activity ↑retention in treatment

25. Opioid Agonist Therapy
Methadone
Buprenorphine

26. Opioid Agonist Therapy
Methadone
Buprenorphine

27. Methadonea
Full agonist
Typical dose mg/d
Treatment Program (daily dosing)
Stigma
More risky, especially during induction phase
Better for patients who need more structure, heavier opioid use
Buprenorphine
Partial agonist
Typical dose 16mg/d (max 32)
Office based (prescription)
Managed like any other chronic illness
Protected from overdose (ceiling effect, tight bond)
Bound to naloxone to
prevent diversion
and misuse

28. Office-based Buprenorphine
8 hour training for MD/DO, 24 hour training for NP/PA (free via Project ECHO Idaho, H&W)
30 patients year 1, 100 patients year 2, MD/DO can apply for 275
Basic quality metrics to monitor
Treatment agreement
Regular urine drug screens (every time initially, then ideally random)
Regular PMP reports
Regular follow up
Naloxone
DEA simply requires patient list

29. Office-based Buprenorphine
Day 1: Intake (counselor if available & MD visit, agreement, urine drug screen, PMP, labs)
Day 4: MD visit
Home Induction
Week 1: MD (& counselor if available/interested)
Week 2/3/4: MD (& counselor if available/interested)
Week 6/8: MD (& counselor visit if available/interested)
Regular urine drug screens.
Monthly visits once patient doing well.
Recommend LONG TERM treatment, typically a year or longer;
some need lifelong treatment.
Everyone can take this on in primary care

30. Role of Medications Medication for Addiction Treatment Harm Reduction
Psychosocial Interventions
Housing, Employment, Mental Healthcare
Recovery Support
Harm Reduction

31. Harm Reduction
Practical strategies & ideas aimed at reducing negative consequences of drug use
Meeting users where they are at
Substance use a continuum – from severe use to abstinence
Complete abstinence not always the goal
Empower & give voice to people who use drugs

32. Harm Reduction Safe injection technique Clean needles
HIV, Hepatitis C testing
Hepatitis A & B vaccination
Naloxone (Narcan) for reversal of opioid overdose
Pre-Exposure Prophylaxis for HIV

33. OUD is a Chronic Disease

34. 1. Use person-first language
Treat OUD like the chronic disease it is

35. 1. Use person-first language

36. 2. Normalize medications
Medication for Addiction Treatment
Psychosocial Interventions
Housing, Employment, Mental Healthcare
Recovery Support
Harm Reduction

37. 2. Normalize medications
Encourage patients with OUD to take MAT
Get your x-license and prescribe bupe as part of regular primary care practice
Know the prescribers in your area

38. 3. Emphasize but don’t require behavioral supports
DATA Waiver requires the ability to refer for behavioral health
Many patients do well with medications alone
Many patients engage more in therapy a few weeks to months into medication treatment
If a patient is interested, most data for contingency management & CBT
Allows prioritization of a scarce resource to those who need it most
Fiellin et al. NEJM 2006; Amato et al. Cochrane 2011; Martin et al. Annals 2018; Tetrault et al. J Subst Abuse Treat 2012; TIP 63 SAMHSA

39. 4. Provide patient-centered care
Some patients will want to meet with counselor, some will not
Some will be ready to tackle polysubstance use, some will not
Some will take longer for their first opioid-free urine
Occasional return to use is expected
Treatment is long-term (often life-long)

40. 4. Provide patient-centered care
Some patients with diabetes will want to meet with the nutritionist or pharmacist, some will not
Some will be ready to tackle weight loss and blood pressure, others will not
Some will take longer to get sugars under control
Occasional bumps in sugars are expected
Treatment is long-term (typically life-long)

41. 5. Don’t forget about harm reduction
Many things we can do for patients who are not ready for medications
Ask about clean needles
Offer/refer for HIV & Hepatitis C testing, PrEP
Hepatitis A & B vaccination
Naloxone (Narcan) for reversal of opioid overdose
Pharmacists can dispense without a prescription
Use person first language

42. QUESTIONS?