Download Diagnosis And Treatment Of Prescription Opioid Dependence

Diagnosis And Treatment
Of Prescription Opioid
Dependence
Steven W. Clay, D.O.
Associate Professor, Department of Family
Medicine
Ohio University
College of Osteopathic Medicine
Athens, OH 45701
Overview
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1. Goals of Our Out-Patient Program
2. Presenting the Program
3. Diagnosis
4. Buprenorphine
5. Results So Far
1. Goals of Our Out-Patient
Program
• Turning Lives Around
– Detoxification from Prescription
(& Illicit) Opiates
– Involvement in 12 Step / Other
Programs
– Treatment of Co-Morbidity
Rural Ohio Setting
• Medicaid or No Insurance
• In-Patient Programs: Not Interested
• Out-Patient Treatment: Maybe Available
in Several Weeks to Months
• Drug Screens Only With Cash Up Front
• 20 + Twelve Step Meetings Per Week
(Alcohol or Drugs OK)
2. Presenting the Program
• “Our services in Addiction Medicine are
limited to those needing help with:
– 1. Possible substance abuse or
addiction.
– 2. Getting off addictive drugs with as
little discomfort as possible.
– 3. Buprenorphine treatment for
narcotic addiction recovery.”
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Weeding Out
• “We are NOT a pain treatment center.”
• “We are NOT an in-patient drug
treatment center.”
• “We REQUIRE you to have a personal
physician or we will help you find one.”
• “We REQUIRE a signed written
treatment contract.”
The Rules
• Patients Must follow the rules we set
• Including:
– Attendance at counseling
– Attendance at 12 Step meetings”
• Those who break the contract will no
longer be seen at our office.
• “If you are NOT prepared to follow the
Rules, come back when you are ready!”
Patient Education
• Detox. Only: 97% Relapse By 1 yr.
• Reasons for becoming an addict:
– Genetic, Environmental
– Need to Re-Learn How to Live
Without Drugs
• Need for complete treatment:
– 12 Step & Other Support
3. Diagnosis of Addiction
Disorders
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Risk Factors
Interview
Collateral Information
Establish Use and Consequences
Coexisting Physical / Psych Dz.
DSM-IV / Other Diagnostic List
Addiction Diagnosis
• Dependence / Addiction:
-Preoccupied with
Acquiring / Use
-Compulsive use Despite
Adverse Consequences
-Chronicity and Relapse
Establish Readiness For Change
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1. Pre-Contemplation
2. Contemplation
3. Preparation
4. Action
Prochaska and DiClemente Stages and processes of self-change of Smoking…J of Consult and
Clin Psy 1983
Treatment Matching
• ASAM Criteria For Treatment Matching:
– Consequences of Use
– Family / Other Support
– Financial Support
– Physical / Psychiatric Co-Morbidity
– Relapse Potential
Mee-Lee and Shulman The ASAM Placement Criteria and Matching Patients to Treatment in
Principles of Addiction Medicine 2nd Ed. ASAM 2003
Treatment Matching
• Office Follow-Up to In-Patient
Treatment Based Upon Illness Severity
• Most Followed as Out-Patients Due to
Unavailable:
– Treatment Centers
– Money
– Insurance
Prescription Opiate Addiction
Patient Presentation
• In Contrast to Alcohol / Other Drug
Addiction Patients:
– Opiate Addicts Frequently Admit
Problem and Ask for Help.
– Friends, Family Refer Patients
– The Word Goes Out in the
Addiction Community
4. Buprenorphine
• Subutex:
– Buprenorphine SL
• Suboxone:
– Buprenorphine / Naloxone SL
– 4 / 1 Ratio
Buprenorphine Clinical practice Guidelines SAMHSA 2000
Buprenorphine
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Opioid Partial Agonist
High Affinity Mu Binding
Will Displace Many Other Opiates
Maximum Effect About 30-40 mg
Methadone Equivalent
• SL Absorption Acceptable
Buprenorphine Clinical practice Guidelines SAMHSA 2000
Naloxone
• Opioid Antagonist
• Will Displace Other Opiates and Initiate
Withdrawal
• Poor SL Absorption
• If Taken IV With Buprenorphine, Will
Negate Agonist Actions
Buprenorphine Clinical practice Guidelines SAMHSA 2000
Transfer to Buprenorphine
• Last Week Dose Is What Counts
• From Methadone: Taper By Program:
– 5-10 mg Per Week of Daily Dose
– Goal 30-40 mg Per Day
• From Oxycodone (etc.):
– Many Stop or Taper Before Being Seen
– Adjust Daily Dose to PO Equivalent
– Snorted (X 0.6), IV (X 1.5)
Transfer to Buprenorphine
• Suboxone Used Initially:
– Less Risk in Office (Theft)
• Half to One 8/2 SL Tablet After:
– 48 Hrs. Without Methadone
– 24 Hrs. Without Oxycodone (Etc.)
• Follow With 8/2 to 16/4 SL Daily
• Information Given and Contract Signed
Follow-up Care
• 1-2 Weeks Initially
• MUST:
– Go To 12 Step Meetings
– Keep Appointments
– Not Use
• Occasional Dosage Adjustments
• Then Seen Monthly
Non-Compliance
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Relapse is Part of the Disease
Most Admit Mistakes
I Usually Will Give One Second Chance
Look For Progress Not Perfection
Limited Use of Urine Toxicology
Screens Due to Cost
Tapering Buprenorphine
• Decrease By ½ Dose Monthly
• Some Can Rapidly Come Off:
1-2 Weeks
• Some Take Months
• Variation Based on Patient Preference
and Involvement in 12 Step Programs
5. Results So Far
Results So Far
• Opiate Addicts Presenting to University
Medical Associates Addiction Medicine
• Inclusion Criteria:
– Opiate Use > 20mg / Day Methadone
– Non-Pregnant
– Willing to Follow Rules
• 41 Consecutive Opiate Addicts Placed
on Buprenorphine
Results
• Mean Age 33, Range 18 to 56
• 63% Male
-SAMHSA 2002 Drug Use Survey:
Illicit Drug Use 62.1% Male
• Mean Methadone Equivalent Dose Per
Day = 88.5 mg
(%) Family History:
Alcohol, Drug & Psych Disorders
35
34
30
25
22
20
14
15
10
10
10
5
5
5
0
0
NEG
A
D
AD
P
AP
DP
ADP
Psychiatric Diagnosis (%)
60
53
50
40
24
30
20
17
20
7
10
5
0
ANY SMI
ANX
DYS
MDD
BIP
SAMHSA
SMI
Drugs/Pain Prior to Opiates (%)
60
60
50
40
30
20
20
15
10
5
0
POLY
PAIN
P+P
NO PR
Opiate Progression (%)
80
70
73
60
50
40
30
20
7
5
15
10
0
PRES
PR 2 STR
STR
STR 2 PR
Opiate of Choice (%)
60
58
50
40
32
30
20
10
5
2.5
2.5
Oxy + H
Other
0
Oxycod
Oth pres
Heroin
Administration Route (%)
60
51
50
40
29
30
20
12
7
10
2.5
0
PO
Snrt
IV
Chew
Tea
Detoxed. Before Treatment (%)
80
75
70
60
50
40
30
20
20
5
10
0
0
NONE
METHDONE
INPT
OUTPT
12 Step Attendance (%)
45
44
40
35
30
25
29
20
20
15
10
7
5
0
FREQ
OCCAS
NONE
UNKN
Results (%)
60
53
50
40
30
22
20
15
10
10
0
TAPER
COMPLETE
RELAPSE
UNKNOWN
O.B.O.T. in S.E. Ohio
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Mean Age 33
63% Male
Mean Methadone Equiv. 88 mg
34% Negative Family History
Addiction/Psych Disorders
• 54% Some Mental Illness
O.B.O.T. in S.E. Ohio
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80% Common Drug Use Progression
90% Prescription Addiction
75% No Previous Detoxification
64% At Least Tried 12 Step Programs
63% Tapering or Completed Program
37% Relapsed or Presumed Relapsed