The Opiate Epidemic Across the Life Span: Prevention and Treatment Implications

1. The Opiate Epidemic Across the Life Span: Prevention and Treatment Implications Ted Parran, M.D. FACP Isabel and Carter Wang Chair and Professor in Medical Education CWRU School of Medicine tvp@cwru.edu

2. Opiate Misuse • Use other than directed • For other indications than originally prescribed • Shared with others – but typically for a medical reason • For performance enhancement • For “chemical coping” • Pretty common

3. Opiate Abuse or At Risk Use • Planned use for intoxication/euphoria • Rare adverse consequences • Use remains within peer group norms • “Willful misconduct”

4. Chemical Dependence – opiate as drug of choice • The intermittent inconsistent repetitiveloss of control over use of euphoria producing drug (EPD), causing repetitive adverse consequences • EPD’s: • Opioids • Stimulants • Sedative-hypnotics • Cannabinoids • Other

5. Euphoria or Pleasure Centers in the Brain

7. The Pleasure Centers Affected by Opiates • Opioids act not only on the central structures of the reward circuit (the ventral tegmental area and the nucleus accumbens), but also on other structures that are naturally modulated by endorphins. These structures include the amygdala, the locus coeruleus, the arcuate nucleus, and the periaqueductal grey matter, which also influence dopamine levels, though indirectly. Opiates also affect the thalamus, which would explain their analgesic effect.

8. Opiate Use Related Terms • Tolerance • The development of a need to take increasing doses of a medication to obtain the same effect; tachyphylaxis is the term used when this process happens quickly • Dependence • The development of substance specific symptoms of withdrawal after the abrupt stopping of a medication; these symptoms can be physiological only (ie, absence of psychological or behavioral maladaptive patterns)

9. Terms • Addiction • The development of a maladaptive pattern of medication use that leads to clinically significant impairment or distress in personal or occupational roles. This syndrome also includes a great deal of time used to obtain the medication, use the medication, or recover from its effects; loss of control over medication use; continuation of medication use after medical or psychological adverse effects have occurred.

10. Substance Abuse v. Chemical Dependence USAdult Population Use Abst. SU SA CD Consequences

11. Substance Abuse vs Chemical Dependence Women > 70 yrs old Use SA Abstinent SU CD Consequences

12. Substance Abuse vsChemical Dependence 18–25 yr olds Use CD SU SA Abstinent Consequences

13. Adolescents v. Older Persons:Using Alcohol and Drugs Together

14. Adol Non-medical use of RX opioids: most got from a Friend or Relative

15. Source: SAMHSA, OAS, NSDUH data , July 2007

16. New Drug User Patterns

17. The Prevention – Treatment Spectrum (not either / or) • Primary Prevention – decrease the risk for the whole population • Secondary Prevention – target high risk groups • Tertiary Prevention – treat the disease (hint…this IS Treatment)

18. Morbidity and Mortality from Adol Substance Abuse • 90% of date rapes annually • > 70% of unanticipated teen / young adult pregnancies • > 80% of interpersonal violence on college campuses • > 85% of destruction of property on school campuses • >> 50% of adolescent / young adult drowning incidents • Top 3 leading cause of death for 16-24 year olds (OD’s etc) • ??% of sexually transmitted disease • ??% of shame and humiliation incidents • SO WE NEED PREVENTION!!!

19. IS IT Cool To Be High?Adolescent Substance Misuse and Abuse Prevention

20. The “MYTH” of experimentation • “Experimentation” is no big deal! • “Ever tried smoking” = 35% current smokers • “Ever tried drinking” = 56% current, 35% bingers • “Ever tried MJ” = 55% current users • “Never tried drinking” = 2% smokers, 1% MJ use

21. Early Drinking Initiation Related to Ever Using Illicit Drugs

22. Young Adult:No-use v. Use v. Dependence

23. MYTH: the average age of experimentation is late adolescence • Ever use in 7th / 8th and / 9th grade • Tobacco = 23% / +12% / +13% • Alcohol = 30% / +19% / +22% • MJ = 6% / +8% / +21% • After 9th grade experimentation rates increase by only 2-8% per year

24. Substance abuse prevention: Risks and Resiliency's • PREVETION PRINCIPLE #1 • There are well established risk factors and protective (resiliency) factors for substance abuse. • The job of the family and community is to build protective factors and limit risk factors. • Applications to RX Opiates

25. Substance abuse prevention: environmental factors • PREVENTION PRINCIPLE #2 • Environmental factors such as ease of access, price, advertising, societal norms and values play an extremely important role in encouraging or discouraging substance abuse. • Limit access - minor sales / vending mach. / home • Markedly raise taxes (price) • Eliminate / alter advertising • Provide consistent messages • Applications to RX Opiates

26. Substance abuse prevention: multiple levels of interventions • PREVENTION PRINCIPLE #3 • Prevention messages must be consistent • They must be given over time (longitudinal) • They must be multiple, and involve several different venues: • family / school / religious institutions / sports teams and coaches / clubs / hobbies / environment / media

27. Substance abuse prevention: delay use, eliminate bingeing • PREVENTION PRINCIPLE #4 • Age of onset of experimentation is heavily associated with escalations and high risk use… • SO DELAY EXPERIMENTATION • Binge use is devastating for adolescents and young adults, because judgement is exquisitely soluble in mood altering drugs… • SO ZERO TOLERANCE FOR BINGEING

28. A public health perspective on the disease of opiate addiction

29. Chemical Dependence:a chronic disease!! • High prevalence • Identified risk factors • Hints about etiology • Predictable natural history • Morbidity and mortality • Good treatment efficacy • Potential for prevention

30. Chemical Dependence- Treatment data • Natural history studies • >50% who survive ultimately get sober • Brief interventions • decrease in morbidity and mortality after BI’s • Skid row detox’s - >10% one year sobriety • Recovering professionals • 80-85% three year sobriety rates • For Opiates-Pharmacotherapy improves outcomes

31. Opiate Dependence Treatment Options • Medical Withdrawal – detox • 80% have physical dependence and need detox • Pharmacotherapy • Agonist / Partial Agonist / Antagonist • Counseling • Self Help • Social - environmental

32. Treating Addictions as chronic illnesses- the challenge • Study the natural history • Implement screening strategies (CAGE) • Practice presenting the diagnosis (SOAPE) • Assess patient’s readiness for change • Negotiate treatment plans • Develop comfort with pharmacotherapy • Strategies for long-term monitoring

33. HX of Pharmacotherapy of Addiction • History of Pharmacotherapy: • Secobarbital then Librium (valium … ativan … xanax … klonapin … son of klonapin …) • Antabuse • Risks: Addiction / OD / unsafe / distraction from TX • No wonder the recovering community is concerned about pharmacotherapy. • Those who fail to learn from history - repeat it.

34. The Pharmacotherapy of Addiction • “To Prescribe or Not to Prescribe My Dear Watson … That is the Question!” • Two Models: • THE “HARM REDUCTION” MODEL • THE “TREATMENT IMPROVEMENT” or “ADJUNT TO TREATMENT” MODEL

35. “To Prescribe or Not to Prescribe” :The Harm Reduction Approach • Pharmacotherapy first – Addiction TX second • Criteria the must be met: If there is an increase in morbidity in the population without the pharmacotherapy than there is with the pharmacotherapy …then provide the pharmacotherapy! (and gradually introduce additional suggested adjuncts to the pharmacotherapy that might further decrease the morbidity).

36. “To Prescribe or Not to Prescribe” :Adjunct to Treatment Approach • Addiction TX first – Pharma second • Criteria that MUST be met: • SAFE • SOBRIETY / PHYSICALLY • EFFICACIOUS • WELL TOLERATED • INTEGRATED INTO TX PROGRAM • ?? NON-EUPHORIA PRODUCING

37. RX for Addiction: Duration of RX • Methadone maintenance data: • In patient doing well • Duration of two years or longer • Produced improvements in morbidity • AA data: • Lead in Home Group after one year • Sponsor others after two years

38. Longitudinal Monitoring Strategies • Re-assess patient readiness for change q3m (pre-cont. and contemplative stage patients) • Periodic liver function and toxicology tests • Assess adherence with Tx. Prog. (release) • Obtain patient and collateral report of use and Tx. Plan adherence. • Monitor pharmacotherapy-get indicated labs • Document, document, document

39. Opioid Antagonist therapy – transition from detox to rehab • Naloxone (Narcan) available since 1970’s. • Competitive antagonist at the mu receptor. • Short half life, no P.O. bio-availability. • Naltrexone (ReVia, Trexan) available 1985. • Competitive antagonist at the mu receptor, long half life, good P.O. bio-availability. • 25-50mg P.O. qd for six to twelve months as adjunct to comprehensive counseling.

40. Opioid antagonist therapy • Blocks the feeling of a slip • Slip to Relapse is interrupted • Turns relapse into a planned event • Markedly improves IOP retention • So ….. It can really help if patients take it and stay on it!!!

41. OMT – “the highest risk prescribing that is still legal” (hint – OMT = Opioid Maintenance Therapy)

42. Opioid Agonist Maintenance Therapy:Methadone and Suboxone • Intoxication with opioids does not produce significant judgment impairment. • Like nicotine • Unlike alcohol, cocaine / amphetamines • Potential for replacement therapy - • nicotine replacement therapy • opioid maintenance therapy

43. Opioid maintenance data: Outcome • OMT, on balance results in improvement in every domain of life function - • family • health • legal • employment • financial

44. Opioid maintenance data: Duration • Duration of therapy - • When should people get off? • Longer = better. • > 1.5 years better than < 1.5 years. • Need for comprehensive longitudinal gradual approach. • Need ultimate goal of abstinence.

45. Summary – OB-OMT (cont) • Robust monitoring program necessary • Optimize adherence • Increase patient sobriety and quality of life • Minimize diversion • Suboxone diversion: • “therapeutic diversion” per investigators • “substantial financial cost” to insurers • Most is excess medicine due to too high a dose

46. A.A. and Abstinence Based Treatment:Medications in the Self-Help setting? • A.A. Pamphlet entitled “A Letter from Bill W to the Medical Profession” • A.A. pamphlet entitled “For AA Members Who are on Medication”

47. Opioid Dependence: Summary • Use, Abuse, Dependence, or Addiction? • Maintenance v. Detox? • Non-urgent, Urgent, or Emergency? • Inpatient, Residential, or Outpatient? • Which W/D strategy is best / avail? • Post-detox pharmacotherapy!!! • Transition to recovery program!!!!!

48. Treating Addictions as chronic illnesses- the challenge • Study the natural history • Implement screening strategies (CAGE) • Practice presenting the diagnosis (SOAPE) • Assess patient’s readiness for change • Negotiate treatment plans (BI – MI) • Develop comfort with pharmacotherapy • Strategies for long-term monitoring • tvp@cwru.edu

49. Changing the Natural History of Opiate Addiction – PREVENTION AND TREATMENT