Download Dennis H. Smith Medical Center Director

Opioid Addiction
A patient-centered approach.
Sarah Reading, MD
Director, Mental Health Clinical Center
VA Maryland Health Care System
Nurses Organization of Veterans Affairs
June 23, 2016
Disclosures
None
Acknowledgements
♦ Frederick Houts, MD
Deputy Medical Director, Opioid Agonist Treatment
Program (OATP), VAMHCS
♦ Adam Robinson, MD
Director, VAMHCS
Scope
• 21.5 million Americans 12 or older have a
substance use disorder
♦ In 2014, 1.9 million had a substance use disorder
involving prescription pain relievers
♦ 586,000 had a substance use disorder involving
heroin*
• The Veterans Health Administration is home to
the United States’ largest integrated health care
system.
*Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2015
A Vietnam-Era Problem
• 15% of active soldiers were heroin users
• Operation Golden Flow
♦ In June 1971, the U.S. military announced urinalysis of all
returning servicemen. A negative urinalysis was required
before transport home was allowed. The program went into
effect 9/1971, and only 4.5% of the soldiers test positive for
heroin
♦ 5% relapsed within a year of return to the U.S.
♦ 12% relapsed within three years
• These remaining veterans have been the mainstay of our
methadone-maintained patient population.
The Opioid Agonist Treatment
Program at the Baltimore VA
• Established in early 1970s
♦ One of the very first VA Methadone Treatment Programs.
o Modest beginning (fewer than 100 patients; not integrated into other
Baltimore VA addiction programs).
• In the early/mid-1990s, non-methadone substance-use treatment expanded to
several other VA sites in Maryland.
♦ Baltimore VA’s methadone-taking population doubled to well over 250 patients.
♦ Consultation occurred with University of Maryland, NIDA , and VA Central Office.
♦ Perry Point became becoming one of the first VA residential rehab programs to
admit methadone maintenance patients.
♦ Staffing was professionalized to include more master’s-level therapists and
doctorate-level professionals
• Baltimore’s VA was a final site for studies leading to approval of
buprenorphine, after longstanding collaboration with NIDA.
Population vs. Age
A Modern Problem
• Prescription opioid analgesics are the most commonly
abused prescription drugs in the U.S., with the highest
rate of abuse occurring among those ages 18-25.*
• Modern military medicine is unparalleled in its ability to
save Wounded Warriors. Body armor and improved
delivery of battlefield medicine have increased patient
survival from wounds that were fatal in previous
conflicts. This, however, has resulted in pain
management challenges for combat polytrauma
patients. **
President Obama to the
National Governors Assn 2016
• “… in 85 percent of rural counties in America,
there is insufficient or no drug treatment or
mental health treatment available.”
• “… it turns out that it’s a lot cheaper to refill the
prescription with heroin on the street than it is
to try to manage getting more of these pills. And
then folks are off to the races.”
• “… those who are marketing heroin are now
tracking which communities are most
vulnerable.”
Baltimore: Ground Zero of this
US Public Health Crisis
• Baltimore City is home to higher numbers of
heroin addicts and heroin-related crime than
almost any other city in the nation.*
♦ $165 million spent annually on illegal drugs
♦ Population: 621,000 in 2010
• “Opioid pills seem to have a direct relationship
with progression to heroin initiation.”**
Time until treatment
OATP Baltimore VAMC, c. 2020
Public Health Interventions
NALOXONE
Jail Diversion Programs
Needle Exchange Programs
• Goal is to reduce rates of
injection-transmitted infection
• Secondary benefit may include
patients’ willingness to engage
in treatment.
Medically Assisted Treatment
(MAT)
Methadone
Suboxone
• Methadose®, Dolophine®
• Suboxone®
(buprenorphine with naloxone)
– Common since 1974
– Must be dispensed from a
federally regulated clinic
– No intrinsic, protective
overdose properties
– Has abuse liability
• Particularly when
combined with
benzodiazepines
– Inexpensive
– Approved by FDA in 2002
– May be prescribed by
outpatient primary care
providers
– Limited overdose risk
(ceiling effect---and
combined with naloxone,
a.k.a. Narcan™)
– Low abuse liability
Methadone ≠ Treatment
Diabetes (type 1) v. Addiction
Paradigmatic Disease (loss
of beta cell function; no
insulin; broken pancreas)
Genetic predisposition
Possible (albeit rare) to
manage through sheer
force of will or
environmental changes.
Medications: essential
Medications help.
No medication particularly
helpful for cocaine,
cannabis, benzodiazepine,
or alcohol addiction.
Education typically enough.
Rescripting needed to
make better choices.
Often requires lifelong
groups.
Associated (and causal) to
cardiac disease, stroke,
kidney failure, neuropathy
Complex management
One addiction predisposes
to other addictions,
associated with comorbid
illness (e.g., HCV, HIV).
Don’t Medications Help
Everyone?
Medication: The First Step
Medication: The First Step
What patient-centered
treatment looks like
Brain
Reward
Center
What is a clinician to do?
Patient-Centered Care
Public Health
Should not condone drug
use
Keep patients engaged in
treatment for as long as
possible.
Goal of patient and
treating clinicians should
eventually match and
include cessation of all
alcohol and illegal drug use
Decrease population rates of
self-injection and overdose
without necessarily decreasing
problematic behavior
The work of recovery
• Acute
♦ Goal is elimination of opioid withdrawal, decreased
alcohol use, and appropriate medical intervention
• (Re)habilitative
♦ Behavioral contracts; return to acute phase for
ongoing drug use
• Supportive Care
♦ Goal: Discontinue Alcohol and all illegal drugs
• Medical MaintenancePossible Tapering
RECOVERY
• Employment
• (Re)habilitation
• Treatment of comorbid medical and
psychiatric illnesses
• Cessation of alcohol and other drug use
• Modeling of Behavior
• Rescripting
TRIGGERS
•
•
•
•
Cocaine
Cannabis
Alcohol
Etc.
BIOLOGICAL DRIVE TO USE MORE OPIOIDS
Therapeutic Optimism
• Ingredients for patient success:
♦ Keeping outpatient appointments
o Patients who show up get better!
♦ Decreasing drive toward self-injection
♦ Treatment of comorbid illness
♦ Relationship with community and care givers
♦ Rescripting
♦ Replacing problematic behavior with productive
behavior
Resources vs. Scale
• The Opioid-Agonist Treatment Program (OATP) is
the only one within the entire VA Maryland
Health Care System that has a waitlist.
• Despite increasing numbers of primary care
providers with buprenorphine-prescribing
waivers, many patients are not yet stable enough
for weekly or biweekly visits.
• Counselors within the OATP must have fewer
than 50 patients each.
Comprehensive Care is
Demanding
Doctor/Care Provider
Patient
• Take a thorough history.
• Evaluate for comorbid
illnesses.
• Manage comorbid illnesses.
• Advocate for the patient.
• Work past immediate
feelings to sabotage
treatment.
• Take medications as
prescribed.
• Avoid benzodiazepines,
cocaine, alcohol, and
criminal activity.
• Change people, places, and
things.
Make the first bite of the apple
count
• Improved early engagement means improved treatment
retention.
• Longer retention yields better outcomes.
• Retention times decrease with each readmission.
“The need of securing success at the outset is
imperative. Failure at first is apt to dampen the
energy of all future attempts, whereas past
experience of success nerves one to further
vigor.”
—William James’ The Principles of Psychology, vol. 1
(Chapter entitled “Habit” and published in 1890; emphasis on outset his.)
What Does Recovery Look Like?
• Independent Dynamic Factors Affecting
Employment:
♦ Treatment of Substance Use
♦ Treatment of Mental Illness
♦ Treatment of Chronic Diseases
♦ Education
One patient at a time…