Addiction Part 2

1. Addiction Part 2 Focus on Opioid Use Disorder Alëna A. Balasanova, MD, FAPA April 5, 2019

2. Disclosures • I have no relevant financial relationships with commercial interests. • I have no actual or potential conflicts of interest in relation to this presentation

3. Objectives • Summarize SUD epidemiology and general treatment concepts • Define Medication-Assisted Treatment (MAT) and describe its components

4. Scope of the problem

5. The Scope of the Problem: Opioids

6. Overdose Deaths Involving Opioids, United States 2000-2015 Prescription opioid overdose rates leveling off Heroin and synthetic opioid death rates are rising

7. Drugs Involved in U.S. Overdose Deaths1999 to 2017 Among the more than 72,000 drug OD deaths estimated in 2017*, sharpest increase was among deaths related to fentanyl and its analogs (e.g. carfentanil) with nearly 30,000 OD deaths. Source: CDC WONDER

8. The Opioid Epidemic • Every day, more than 130 peoplein the United States die after overdosing on opioids • Since 2001 heroin use has increased 500% BlueCross BlueShield Report: The Health of America 2017

9. The Midwestern region saw opioid overdoses increase 70 percent from July 2016 through September 2017 Quarterly rate of suspected opioid overdose, by US region - Source: Centers for Disease Control and Prevention

10. Sobering statistics • Roughly 21%-29% of patients prescribed opioids for chronic pain misuse them. • Between 8%-12% develop an opioid use disorder. • An estimated 4%-6% who misuse prescription opioids transition to heroin. • About 80%of people who use heroin first misused prescription opioids.

11. The substance use continuum

12. Diagnosing SUD

13. Traditional approach to addiction treatment

14. Treatment: traditional approach Based on historical idea that substance use disorder is an acuteand curable condition • services are time-limited • priority is to remove access to the offending drug • abstinence is the only goal • e.g., 3-5 day inpatient detoxification* and/or 28-day residential programs *withdrawal management by itself isnot an acceptable form of treatment 90-93% return to substance use

15. Redefining the treatment paradigm

16. Today’s standard of care Evidence-based treatment involves a set of services including: • FDA approved medication • counseling and/or behavioral therapy • other supportive services

17. Today’s standard of care: evidence based treatment Services are designed to: • enable an individual to reduce or eliminatealcohol and/or other drug use • address associated physical or mental health problems • restore the patient to maximum functional capacity

18. MAT: an evidence based treatment Medication Assisted Treatment (MAT)is the use of medications in combination with psychosocial or behavioral therapies as part of an individualized approach to treatment of patients with SUDs • No progressive “steps” to complete, not a special “program” requiring referral to an outside facility • Most effective when services available through a regular healthcare provider with whom already have a relationship • Personalized interventions using a spectrum of strategies designed to meet an individual where he or she is at

19. Medication Assisted Treatment

20. MAT components: focus on OUD • Medication management with FDA approved agents • Opioid full agonists  methadone • Opioid partial agonists  buprenorphine • Opioid antagonists  naltrexone • Evidence-based psychosocial treatments • Motivational Interviewing • Manualized therapies (e.g. Seeking Safety) • Harm reduction psychotherapy • Treat co-occurring psychiatric disorders and address comorbid medical illness whenever possible

21. Community self-help groups Alcoholics Anonymous (A.A.) andNarcotics Anonymous (NA) are abstinence-only peer support groups historically believed to be the mainstay of addictions treatment While some individuals may attain and maintain recovery through peer support alone, 12-step groups are not formal treatment but are considered to be an important supplementto formal treatment

22. Peer recovery support Peer support workers can offer role-model recovery and provide support across the continuum of care Self-help groups can offer patients camaraderie within a peer community that is supportive of their recovery

23. Why is addiction seen differently? Both require ongoing care

24. Treatment comparison with other chronic medical conditions Percent of patients who relapse

25. MAT treatment outcomes • Evidence-based treatment using MAT is effective and cost-effective • Medicaid enrollees receiving abstinence-only OUD treatment had 75% higher mortality than those on partial agonist maintenance • Individuals on federal probation receiving opioid antagonist treatment had 50% lower rate of re-incarceration and 70% lower rate of illicit substance use compared to non-treated • Those engaged in outpatient MAT found to have 17%-27% lower odds of getting arrested since starting the treatment episode – even if there is previous criminal justice involvement

26. System impact Every $1 spent on SUD treatment saves $4 in health care expenditures and $7 in criminal justice costs

27. Guiding principles of effective treatment • Standard medical practice includes identifying, diagnosing and treating patients for SUD/OUD. • FDA indicated medications are the standard of care and are effective for treating OUD and saving lives • Evidence based psychosocial interventions in combinations with medication improve outcomes

28. Take-home points • SUD/OUD is a treatable chronic brain disorder • FDA approved medications are the standard of care for treating opioid use disorder • People can and do recover from OUD and other SUDs

29. References Argoff CE, Kahan M, Sellers EM. Preventing and managing aberrant drug-related behavior in primary care: Systemic review of outcomes evidence. J of Opioid Manage. 2014;10(2):119-134. Botticelli MP, Koh HK. Changing the language of addiction. JAMA. 2016;316(13):1361-1362 Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://www.samhsa.gov/data/ Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004. Clark RE, Samnaliev M, Baxter JD et al. The Evidence Doesn’t Justify Steps by State Medicaid Programs to Restrict Opioid Addiction Treatment with Buprenorphine. Health Affairs 2011;30(8):1425-1433 GarnickDW, Horgan CM, Acevedo A et al. Criminal justice outcomes after engagement in outpatient substance abuse treatment. Journal of Substance Abuse Treatment 2014;46: 295-305 Centers for Disease Control: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/how-effective-drug-addiction-treatment http://synergylifestylecenter.com/wp-content/uploads/2016/11/6-synergy-mat.jpg?efcc00 Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999–2015. NCHS data brief, no 273. Hyattsville, MD: National Center for Health Statistics. 2017. McLellan AT, Lewis DC, O’Brien CP et al. Drug Dependence: a Chronic Medical Illness. JAMA 200;284(13):1689-1695. Moran M. Levin Meets with Congressional Leaders About Fate of Affordable Care Act. Psychiatric News 2017;52(6):1-14 Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452. DOI: http://dx.doi.org/10.15585/mmwr.mm655051e1 TkaczJ, Volpicelli J, Un H et al. Releationship between Burprenorphine Adherence and Health Service Utilization and costs among Opioid Dependent Patients. Journal of Substance Abuse Treatment 2014;46:456-462. University of Wisconsin Population Health Institute. County Health Rankings Key Findings 2017. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016. Weinstein ZM, Kim HW, Cheng DM et al. Long-term retention in office based opioid treatment with buprenorphine. J SubstAbus Treat. 2017;74:65-70.

30. Working with communities to address the opioid crisis. • SAMHSA’s State Targeted Response Technical Assistance (STR-TA) Consortium assists STR grantees and other organizations, by providing the resources and technical assistance needed to address the opioid crisis. • Technical assistance is available to support the evidence-based prevention, treatment, and recovery of opioid use disorders. 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.

31. Working with communities to address the opioid crisis. • The STR-TA Consortium provides local, experienced consultants to communities and organizations to help address the opioid public health crisis. • The STR-TA Consortium accepts requests for education and training resources. • Each state/territory has a designated team, led by a regional Technology Transfer Specialist (TTS) who is an expert in implementing evidence-based practices. 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.

32. Contact the STR-TA Consortium • To ask questions or submit a technical assistance request: • Visit www.opioidresponsenetwork.org • Email str-ta@aaap.org • Call 401-270-5900 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.