Download Physician Education Forum - Florida

Opioid Medication-Assisted Treatment Expansion Project
How can you help fight the opioid epidemic?
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The Opioid Epidemic
◦ Medical Burden
◦ Your Patients
◦ Opioid Misuse in your Community
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Addiction 101
Medication Assisted Treatment (MAT)
Buprenorphine
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Efficacy
Unique Features
Debunking the Myths
Barriers to Prescribing
The Physician-friendly Buprenorphine Delivery Model
Discussion: How can you help?
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Urgent public health issue in the U.S.
◦ 78 Americans die every day from an opioid
overdose [1]
◦ Drug overdose is the leading cause of accidental
death in the U.S. Opioid misuse disorders are
driving this epidemic [2]
 40% due to prescription pain killers, 22% due to heroin
 62% overdose deaths due to opiates
◦ Overdose risk increases after leaving a controlled
environment
 E.g. When a patient leaves detox
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Rx Opioids
18,000
Heroin
16,000
Cocaine
Benzodiazepines
14,000
16,235 Rx Opioid Deaths in
2013
Benzodiazepines + Rx Opioids
12,000
Methadone
10,000
8,000
6,000
4,030 opioid
deaths in1999
4,000
2,000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Original Data CDC Matt Gladden, CDC
4
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Effects of opioid misuse [10]:
◦ Respiratory depression
 Decreased oxygen to the brain  brain damage
◦ Evidence that heroin use deteriorates the brain’s
white matter
 Impacts decision making, regulating behavior, and
responses to stress
◦ Overdose death
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90% of heroin users are white, and their mean
age is 22.9 years [8]
Americans aged 50-69 years are the fastest
growing population of opioid addicts [8]
Opioid overdose rates: [9]
◦ Higher for non-Hispanic whites and American
Indian or Alaskan Natives, compared to nonHispanic blacks and Hispanics.
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Substance abuse treatment admissions for
heroin have increased by 90% from 2010201313.
In 201414:
◦ 4.9% of the opioid overdose deaths in the U.S.
occurred in Florida, the 4th highest percentage in
the country.
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How has this public health problem affected
your community or practice?
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Deaths due to drug overdose in Florida
January-June 2015
Source: 2015 Medical Examiners Commision Interim Drug Report
Other
Amphetamines
2%
3%
Cocaine
13%
Benzodiazepines
19%
Alcohol
11%
Opioids (Including
Heroin)
51%
Hallucinogenics
0%
Inhalants
1%
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8
Heroin and Fentanyl Deaths Increasing in
Florida from 2007-201515
Figure 3: Deaths per capita in Florida during first six months of
2015 compared to same period in 2007.
Figure 4: Deaths per million Floridians
in the first six months of 2015.
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Increase in NAS from 20082011 in Florida
NAS rates higher in White
infants than in Black and
Hispanic Infants
10-fold increase in number
of hospital discharges of
newborns with NAS in FL
since 1995
◦ Exceeds national 3-fold
increase
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Brain adjusts to excess dopamine by making
less of it, or reducing ability of cells in the
circuit to respond to it. [4]
◦ Reduces the “high” felt compared to when first
taking the drug.
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Causes people to get less pleasure from
things they used to enjoy, like food or social
activity.
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Opioids attach to opioid receptors in the
brain called µ receptors.
◦ Reduce the perception of pain and produce a sense
or well-being or pleasure [3]
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Induce tolerance with repeated use  need
higher dose to produce the same effect
Opioids desensitize the brain’s own natural
opioid system, making it less responsive over
time [3]
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Addiction is similar to other chronic diseases
◦ Diabetes, heart disease
◦ Involves cycles of relapse and remission
◦ Requires long-term management
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Without treatment, addiction is progressive
and can result in disability and/or premature
death.
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Use of FDA-approved opioid agonists, partial
agonists, and antagonist medications in
combination with counseling and behavioral
health therapies
Huge gaps in MAT Treatment [7]:
◦ 2012: 2.3 million people abuse or are dependent on
opioids.
◦ But, maximum number of people who could access
MAT was 1.4 million.
(U.S. Department of Health & Human Services)
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Has unique properties that help: [5]
◦ Lower potential for misuse
◦ Decrease effects of physical dependency to opioids,
such as withdrawal symptoms and cravings
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Opioid with partial agonist & antagonist
effects:
◦ The lower intrinsic activity gives user a sense of
well-being without full opioid effects
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Buprenorphine is just as effective as
moderate (60 mg per day) doses of
methadone12.
Compared to placebo plus counseling, 75% of
patients receiving buprenorphine plus
counseling continue treatment after one
year12.
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Teens and young adults
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Older adults and the elderly
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Chronic pain patients who misuse opioids
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Pregnant and breastfeeding women who
misuse opioids.
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Figure 1: Kaplan-Meier curve of cumulative retention in treatment - Results from study
comparing 1-year retention rates of patients receiving either buprenorphine or a placebo for
treatment of heroin dependence. [11]
Source: Kakko, Johan et al. “1-year retention and social function after buprenorphineassisted relapse prevention treatment for heroin dependence in Sweden: a randomised,
placebo-controlled trial.” The Lancet. Volume 36:9358. 22 February 2003.
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Buprenorphine Treatment Group: [13]
◦ Neonatal Abstinence Syndrome occurred in 40.4% of the cases.
 Only 14.9% needed withdrawal treatment
◦ Normal birth weights
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Methadone Treatment Group: [13]
◦ 77.8% exhibited Neonatal Abstinence Syndrome
 52.8% needed withdrawal treatment
◦ Had significantly lower birthweights than children born to
buprenorphine subjects.
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Note: Induction is more difficult with buprenorphine for pregnant
women:
◦ Withdrawal symptoms can harm the mother and unborn child
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Buprenorphine-only treatment is recommended for pregnant
women.
◦ No naloxone
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Buprenorphine’s opioid effects increase with each
dose [5]
At moderate doses, the effects level off, even
with further dose increases  “ceiling effect” [5]
◦ Lowers risk of misuse, dependency, and side effects
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Naloxone has been added to reduce the risk of
diversion.
◦ Suboxone
◦ Meant to prevent injection of buprenorphine
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Patient demographic
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Withdrawal symptoms
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Can’t be taken during pregnancy
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Offer only after patient has failed at
abstinence-based treatment
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What barriers do you face to prescribing
buprenorphine?
What are your concerns about prescribing
buprenorphine?
NIATx™ ©2017 University of Wisconsin-Madison www.NIATx.net
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Buprenorphine Prescribing Protocol
◦ Graduated prescribing (also helps with diversion
management)
◦ Managing refills
 Pre-refill counseling with an SUD counselor
 No need to see a doctor unless something is wrong
◦ Induction Protocol (COWS)
 Induction does not have to be performed by a
physician
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Diversion Management Practices
Graduated prescribing
Wrapper Counts
Pill Counts
Random drug tests  add buprenorphine to the
drug screening panel
◦ Patient informed consent
◦ Prescription Drug Monitoring Programs (PDMPs)
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The diversion management practices can be
performed by a nurse, counselor, or other
clinician.
NIATx™ ©2017 University of Wisconsin-Madison www.NIATx.net
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Research shows that a main barrier to
buprenorphine prescribing is a lack of
prescribers.
Need practitioners who are willing to
prescribe to address this public health
problem.
NIATx™ ©2017 University of Wisconsin-Madison www.NIATx.net
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FAQ
◦ How to manage pain for opioid misuse disorder
patients?
◦ How does the provider get paid for buprenorphine?
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Any questions?
NIATx™ ©2017 University of Wisconsin-Madison www.NIATx.net
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https://www.cdc.gov/drugoverdose/epidemic/
http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf
https://www.sciencedaily.com/releases/2016/09/160914105756.htm
https://www.drugabuse.gov/publications/drugfacts/understanding-drug-use-addiction
http://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine
https://www.dhs.wisconsin.gov/publications/p01129.pdf
http://www.hhs.gov/about/news/2015/06/11/opioid-epidemic-medication-assisted-treatment-needsignificantly-exceeds-capacity.html
http://www.medscape.com/viewarticle/831319#vp_2
http://www.cdc.gov/drugoverdose/data/overdose.html
https://www.drugabuse.gov/publications/research-reports/prescription-drugs/opioids/what-are-possibleconsequences-opioid-use-abuse
http://www.sciencedirect.com/science/article/pii/S0140673603126001
https://www.drugabuse.gov/sites/default/files/files/BupTx_Factsheet.pdf
http://www.sciencedirect.com/science/article/pii/S0376871608000677
http://www.floridahealth.gov/statistics-and-data/e-forcse/news-reports/_documents/2015-pdmp-annualreport.pdf
http://kff.org/other/state-indicator/opioid-overdose-deaths-by-type-ofopioid/?dataView=2&currentTimeframe=0&selectedDistributions=synthetic-opioids-other-than-methadone-egfentanyl-tramadol--heroin--total-opioid-overdose-deaths
http://www.miamiherald.com/news/local/article74781717.html
http://www.floridahealth.gov/programs-and-services/womens-health/pregnancy/14_2015-title-v-briefsubstance-exposed-newborns-final-11-06-2014.pdf
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