Suboxone and Opioid Trends

1. Suboxone and Opioid Trends Joseph Merrill M.D., M.P.H. University of Washington June 16, 2009

2. Suboxone and Opioid Trends • Suboxone treatment for opioid dependence • Limitations of Suboxone in WA State • Development of HMC Suboxone Program • Blending of medication assisted Rx and traditional drug treatment • Trends in prescription opioid use and problems • HMC efforts to improve opioid management

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4. 1-2 Min 3-4 5-6 6-7 7-8 8-9 9-10 10-20 20-30 Your Brain on Drugs Today YELLOW shows places in brain where cocaine goes (striatum) Front of Brain Back of Brain Fowler et al., Synapse, 1989.

5. Addiction as a Brain Disease • Key brain pathways involve motivation, salience, memory, and reward • Prolonged drug use is associated with changes brain function • Changes are pervasive and persist after drug use stops • Brain changes demonstrated at molecular, cellular, structural and functional levels • These studies provide a rationale for medication-assisted treatment of addiction

6. Opioid Dependence Treatment • Methadone Maintenance is best studied • Methadone treatment reduces: • Overall and overdose deaths • Drug use • Criminal behavior • Spread of infectious diseases (HIV, TB) • Methadone may not be used for addiction treatment outside specially licensed programs

7. Methadone Maintenance Treatment • Higher dose treatment improves outcomes • Longer duration of treatment improves outcomes • Psychosocial services improve outcomes • Poor outcomes after discharge from treatment • Maintenance superior to supported detox

8. Methadone Maintenance • Limitations • Highly structured program (6 days/week) • Limited clinical flexibility and medical services • Expansion often opposed, stigma • Ask Methadone Maintenance patients about: • Urine test results, take-home doses • Encourage adequate dose, treatment retention

9. Suboxone for Opioid Addiction • New medication for opioid dependence • Federal legislation (DATA 2000): • Allows trained MDs to prescribe Schedule III-V drugs approved for addiction treatment • Initially limited to 30 patients/group practice, but now each MD can treat up to 100 patients • Safer than methadone • With naloxone, reduced abuse potential

10. Full Agonist vs Partial Agonist 100 90 Full Agonist 80 70 Activity 60 Partial Agonist 50 40 30 20 Antagonist 10 0 -10 -9 -8 -7 -6 -5 -4 Log Dose of Opioid

11. Zubieta et al., 2000

12. Buprenorphine • Superior to psychosocial treatment alone • Longer treatment duration is more effective • Comparable to MMT on most outcomes • Not as good at retaining patients • Medication cost higher than MMT, but total costs hard to compare in different settings • Patients with co-morbid pain and addiction may benefit from physician management

13. Opioid Dependence Treatment • Detoxification alone has low success rates • No clear guidance on choosing between methadone maintenance and buprenorphine • Prescribing buprenorphine requires specific training (8 hours) and a federal waiver • Integration with psychosocial treatment is key • Buprenorphine access limited by availability of MDs, insurance

14. Washington State Suboxone Policy • Limited coverage for CNP, GAU patients • Requires enrolment in state certified addiction program and prior authorization • Limited to 6 months with one 6-month extension possible after clinical review • Maintenance treatment and treatment for pain not covered • Some Medicare Part D plans allow unlimited treatment

15. Suboxone at Harborview • Initial experience: NIDA trial in primary care • Program development with RWJ funding • Piloted in public primary care settings • Public funding with Counseling through ETS • Program limitations • Many steps to enter treatment • Quick access difficult in busy public clinics • Separate counseling challenging

16. Harborview Addictions Program • State certified intensive outpatient program • “Abstinence-based” with 12-step support • Strong co-occurring treatment track • Multiple services (work, child care, housing) • Few patients with opioid addiction • Integrated psychiatric services, so comfortable with medications

17. Blending Treatment Models • Tension between “abstinence” and harm reduction • Limitation in treatment duration favors more intensive approach • Emphasis on group versus individual treatment (no benzos, even prescribed) • Differences in expectations • Program size

18. HMC Suboxone Program Services • Integrated medical and psychatric care • Two 1.5 hour groups per week • Medication dispensing after group • One on one counseling • Regular urine testing • Early review of treatment progress

19. Treatment Continuation Options • Abstinence with sober support (AA/NA) • Methadone maintenance • In-patient treatment with or w/o Suboxone • For patients with pain and addiction, return to primary care opioid management if stable • If insurance allows, transfer to primary care Suboxone treatment

20. Optimal Patient Selection • Short addiction duration or significant recovery without medication assistance • No benzodiazepine problem or use, even prescribed • Not ambivalent about wanting to stop using all drugs and alcohol • Co-morbid medical, psychiatric, pain OK • Drug Court is a good match

21. HMC Suboxone Program • Accepts patients with public funding • Developed within WA State policy limitations • Unique blending of treatment approaches • Best for patients who are working toward recovery without medication assistance • Options for continued medication-assisted treatment are limited