OPIOID USE DISORDER

1. OPIOID USE DISORDER

2. WORKING WITH COMMUNITIES TO ADDRESS THE OPIOID CRISIS • SAMHSA’s State Targeted Response Technical Assistance (STR-TA) grant created the Opioid Response Network to assist STR grantees, individuals and other organizations by providing the resources and technical assistance they need locally to address the opioid crisis . • Technical assistance is available to support the evidence-based prevention, treatment, and recovery of opioid use disorders.

3. WORKING WITH COMMUNITIES TO ADDRESS THE OPIOID CRISIS • The Opioid Response Network (ORN) provides local, experienced consultants in prevention, treatment, and recovery to communities and organizations to help address this opioid crisis. • The ORN accepts requests for education and training. • Each state/territory has a designated team, led by a regional Technology Transfer Specialist (TTS), who is an expert in implementing evidence-based practices.

4. SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA) Funding for this initiative was made possible (in part) by grant no. 6H79TI080816 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

5. OVERALL MISSION To provide training and technical assistance via local experts to enhance prevention, treatment (especially medication-assisted treatment like buprenorphine, naltrexone, and methadone), and recoveryefforts across the country addressing state and local - specific needs.

6. Approach: To build on existing efforts, enhance, refine, and fill in gaps when needed while avoiding duplication and not “re-creating the wheel.”

7. An Overview of Medication Assisted Treatment and Stigma Beth Tranen, DO, MS, FABAM May 31, 2019

8. SUBSTANCE USE DISORDER • Defined as a primary chronic brain disorder characterized by compulsive substance seeking behavior and use, despite harmful consequences. • Involves cycles of recurrence and remission. • 40-60% genetic contribution

9. OPIOID EPIDEMIC BY THE NUMBERS • US makes up 5% of the world’s population and consumes ~80% of world’s RX opioids. • Rx opioid drugs contribute to 40% of all US opioid overdose deaths. • 2017 data estimate 130+ people died each day from opioid related drug overdoses.

10. OPIOID EPIDEMIC BY THE NUMBERS • 11.4m people misused Rx opioids. • Rx opioid OD rates are highest among people aged 25-54 years • OD rates were higher among non-Hispanic whites and Native Americans/Alaskan natives.

11. TREATMENT-GUIDING PRINCIPLES • Substance use disorders/opioid use disorders (SUD/OUD) are treatable chronic brain disorders best managed using the medical model for managing chronic disorders. • Standard medical practice includes identifying, diagnosing, and treating patients for SUD/OUD using a combination of medications as well as behavioral and psychosocial interventions. • FDA-approved medications are the standard of care and are effective for treating OUD and reducing OD deaths.

12. TREATMENT PRINCIPLES • All patients with OUD should be offered an option of treatment with FDA indicated medications—this includes buprenorphine, XR naltrexone, or methadone. • Evidence based psychosocial interventions used in combination with medication may improve outcomes.

13. OUD: A CHRONIC BRAIN DISORDER Addiction is an acquired bio-behavioral disorder characterized by: • Abnormal mood, cognition and decision-making • Abnormal reactivity to stress and environmental cues • Overwhelming cravings • Impaired insight and the impaired ability for care for oneself • A chronic and relapsing disorder with the highest mortality of all psychiatric disorders.

14. OUD DISEASE COURSE • Risk of symptom recurrence/relapse persists for many years • Periods of symptom remission/exacerbation should be expected • Recognizing the chronicity and the relapsing course of the disorder that may occur even despite treatment should not imply that the treatment is ineffective or useless

15. OUD DISEASE COURSE • One should not expect a “cure” after a one-time treatment episode. • Sustained remission (recovery) can occur (30-40% of patients), despite prior history of relapses.

16. MEDICATION-ASSISTED TREATMENT

17. MAT TREATMENT • Patients presenting for treatment should be thoroughly assessed for medical (dependence on other substances, uncontrolled medical problems) and psychiatric (suicidality, psychosis) conditions. • All patients should be educated about the chronic nature of SUD and be engaged in the process of shared decision making in developing a treatment plan. • Provider should discuss all available treatment options.

18. MAT TREATMENT • Residential programs vs office-based treatment vs OTP. • Risks of treatment without medications. • Explain difference between methadone, buprenorphine, and naltrexone. • Provider should assess the patient’s motivation for MAT, treatment goals, and preferences for any particular medication before a final recommendation is made for first-line treatment.

19. STANDARD MEDICAL MANAGEMENT • Provision of medication induction and/or maintenance medication. • Monitoring of compliance with medication. • Monitoring of patients’ drug use, symptoms, and progress. • Education regarding OUD and medication treatment. • Encouragement for abstinence & treatment adherence.

20. MEDICAL MANAGEMENT • Encouragement for mutual-support groups or self-help/peer support • Brief advice modeled on standard drug counseling • Treatment of medical complications of opioid use • Referrals to specialty services in the community • Use of Case Management services

21. DISEASE COURSE AND LONG TERM MANAGEMENT Long term management rather than repeated episodes of acute treatment should be a primary strategy. • Post-stabilization monitoring, education, and linking with community supports. • Medical, psychosocial, and environmental interventions should be utilized over a lifetime with intensity matching the severity of symptoms.

22. DISEASE COURSE AND LONG TERM MANAGEMENT • Frequent follow ups with the patient to monitor stability/adjust medication. • Focus on treating consequences and monitoring risk factors. • Helping the patient develop self-monitoring/self care, and coping strategies.

23. TREATMENT OF OUD Most effective treatment for OUD involves a combination of several approaches: • Medication for Addiction Treatment involves use of medications in combination with intervention to increase adherence. • Psychosocial/behavioral approach focused on helping patients develop skills necessary to maintain abstinence

24. TREATMENT OF OUD • Self Help/Mutual Help support groups form social network supportive of recovery. • Recovery-oriented activities help patients develop satisfying lives.

25. TREATMENT OF OUD SHOULD INVOLVE MEDICATION • Traditional (non-medical) model of psychosocial treatment involves detoxification followed by treatment without medications. • It has a very high failure rate (greater than 90% in 3 months). • Should not be used as a first-line approach. • Detoxification without medications to prevent relapse increases the risk of overdose due to the loss of intolerance.

26. GOALS OF MEDICATION FOR OUD • Reduce mortality – All cause and drug-related • Reduce associated morbidity – Transmission of blood-borne viruses, infectious complications from IV drug use • Reduce opioid use • Increase retention in addiction treatment • Improve general health and well-being • Reduce drug-related crime

27. PURPOSE OF OUD MEDICATION Goal is to allow the re-establishment of the homeostasis of the reward pathways in the brain that have been disrupted by chronic substance exposure. OUD medication can: • Control symptoms of opioid withdrawal • Suppress opioid cravings • Restore emotional responsivity and decision making capacities

28. PURPOSE OF OUD MEDICATION • Decrease reactivity to stress and drug related cues • Block the reinforcing effects of illicit opioids to prevent relapse. • Promote and facilitate patient engagement in therapy and recovery-oriented activities.

29. DISEASE COURSE AND MEDICATIONS • Relapse carries a significant risk of overdose and death due to desensitization • Treatment with agonist medications reduces the risk of death 2-3 fold • Longer length of treatment provides improved benefit from treatment.

30. DISEASE COURSE AND MEDICATIONS • Undetermined duration of treatment with MAT that will prevent a relapse • Risk of relapse should always be considered greatest once medication is stopped • The decision to discontinue medications after a period of successful treatment should only occur after careful discussion of risks between the clinician and the patient.

31. FDA APPROVED MEDICATIONS • Methadone – Full mu-opioid agonist • Buprenorphine – Partial mu-opioid receptor agonist • XR-Naltrexone – Antagonists of mu-opioid receptors

32. AGONIST THERAPY Methadone (Met) and Buprenorphine (Bup): • Constant stimulation of opioid receptors “stabilizes” systems functioning. • Prevents withdrawal, relieves cravings, stabilizes affect, minimizes pathological brain responses, blocks effects of other opioids. • Reducing drug seeking behaviors allow opportunities for the patient to begin behavioral changes and address other problems.

33. AGONIST THERAPY Limitations of Methadone and Buprenorphine include: • Regular oversight needed (less for Bup) • Potential for side effects (Bup has ceiling effect and is safer than Met) • Risk of misuse and diversion

34. ANTAGONIST THERAPY Naltrexone: • Prevents activation of opioid receptors, “stabilizing” system’s functioning. • Blocks effects of exogenous opioids and redevelopment of physical cravings. Limitations: • Can only be administered after opioids are stopped and opioid withdrawal resolves. • If used prior to that time will cause precipitated withdrawal.

35. CO-THERAPIES • Treatment may involve multiple types of therapies. • Cognitive Behavioral Therapy (CBT): • In maladaptive behavioral patterns, learning plays a critical role • Allows patients to identify and correct problematic behaviors by applying learned skills • Allows anticipation of problems and enhances self control by developing coping strategies • Allows exploration of consequences, self monitoring for cravings, and identifying risky situations

36. CO-THERAPIES • Motivational Interviewing: • A guiding style of communication • Allows particular focus on the language of change • Evokes the patient’s own reasons for change • Progressive Vouchers • Community Reinforcement and Family Training

37. STIGMA

38. STIGMA-WHAT IS IT? • Characteristic or condition that is socially discrediting and it is mainly influenced by whether you think someone is to blameand whether they have control over the behavior. • Two main factors influence stigma: cause and controllability • Stigma decreases when: “It’s not his fault” or “She can’t help it”

39. TYPES OF STIGMA IN SUD • Stigma from within • Blame self, feel hopeless • Stigma from recovery community • Medications vs. “abstinence” • Stigma from outside • Choice (moral failing) vs. disease • Stigma from clinicians • Belief that treatment is ineffective

40. STIGMA= PREJUDICE=DISCRIMINATION

41. IMPACT OF STIGMA • Erodes confidence that substance use disorder is a valid and treatable health condition • Creates barriers to jobs, housing, relationships • Deters public from wanting to pay for treatment • Allows insurers to restrict coverage • Stops people from seeking help • Impacts clinical care and treatment decisions

42. STIGMA • Stigma is insidious • Stigma can be a belief, value, or attitude. • Stigma in action leads to prejudice and discrimination. • Language can be a bridge or a barrier for defeating stigma.

43. WHAT CAN YOU DO? • Perform a “language audit” of existing materials for language that may be stigmatizing, then replace with more inclusive language. • Example: Using the search and replace function for electronic documents, search for “addict” and replace with a “person with a substance use disorder”, or search for “abuse” and replace with “use” or “misuse”. • Make sure to review both internal documents (e.g. mission statements, policies) as well as external ones (e.g., brochures, patient forms).

44. CONTACT THE OPIOID RESPONSE NETWORK To ask questions or submit a technical assistance request: • Visit www.OpioidResponseNetwork.org • Email orn@aaap.org • Call 401-270-5900