Integrated Care Collaborative

When the Last Refill was the Last Refill

Brad Anderson, MD Chief, Department of Addiction Medicine

Kaiser Permanente Northwest

Disclosures •  No financial disclosures

•  Cougalgia – chronic pain syndrome due to being a Washington State Cougar fan

–  AKA Pullman-ary hypertension –  Primarily hereditary with some environmental factors. Also transmitted by Leach –  Symptoms include delusions, depression and loss of remote control –  Lab findings: Apple Cup deficiency –  Differential diagnosis: Beavertigo –  Treatments: Bowl therapy and Seahawk substitution therapy show some promise –  Prognosis: Most likely life-long, palliative care probably best

Learning Objectives

•  Recognize addiction and distinguish treatment plans for chronic

pain and non-chronic pain patients. •  Apply taught guidelines and strategies when having conversations

with patients. •  Identify the process for becoming a Suboxone prescriber and

outline workflows in a primary care setting. •  Understand the role of Behavioral Health Consultants within the

model

Opioid Dependence

•  Physical - a physiological state of adaptation to opioids

– Withdrawal syndrome with abstinence – Relief of withdrawal with reintroduction

– As little as two weeks at therapeutic doses

Opioid Addiction A primary, chronic disease with - genetic, - psychosocial and - environmental factors influencing its development and manifestations. It is often progressive, fatal and characterized by - impaired control, - preoccupation with use (craving) and - continued use despite adverse consequences. These symptoms may be continuous or periodic.

The 3 “C”s of Addiction

•  Loss of CONTROL – using month’s meds in a few days or weeks – early refills, obtaining meds from family, friends, Internet, street

•  Adverse CONSEQUENCES – sedation, OD, decrease functioning

•  Preoccupation or COMPULSION (CRAVING) –  reliance on opioids, poor compliance with other treatment modalities

Opioid Dependence

•  Physical dependence does not equal addiction •  Physical dependence usually accompanies addiction

Addiction

•  Latin for “given over” or “awarded to”, from ad - “to” + dicere - “say, pronounce” •  U2 - “lifeless lifeline”, “running to stand still” •  C.S. Lewis - “an ever increasing craving for an ever

diminishing pleasure”.

Diagnosing Addiction

•  Using supply before refills due •  Calling after hours, weekends, ‘Friday at 5:00’ •  Calling when PCP not available •  Multiple ER and UCC visits •  Calling provider at home •  Lost and/or stolen prescriptions •  Meds eaten by dog, fell in toilet, left in Seaside, picked up

by ex-wife, etc...

Diagnosing Addiction

•  Forging or changing scripts •  Borrowing or lending medications •  Obtaining meds from Internet or illegally •  Stockpiling medications •  Family/friends concerned about use •  Reported allergies to other analgesics

Diagnosing Addiction

•  History of addictive disease •  Prior attempts to decrease or stop meds •  Annoyance at other’s comments about use •  Guilt or embarrassment about use •  Use to treat non-targeted symptoms •  Use when no symptoms present •  Unsanctioned dosage increases

The Language of Addiction

Listen to what people say, our language

betrays what we think and feel

•  Patients take lisinopril but the doctor “has them on” oxycodone •  Taking other meds vs “eating” opiates •  Refer to opiates with personal pronoun, “My Vicodin” •  Use slang names for opiates •  Use “supposed to”, “try to”, etc when describing how they take

opiates as opposed to what they actually do

Diagnosing Addiction

• The Big “E”

• Euphoria

• Energy

Diagnosing Addiction •  Opioids have more than just one effect

– analgesia – constipation – miosis “Which of these have you had?” – histamine release –  respiratory depression

•  Euphoria – “What else have you noticed?” – Most patients will describe getting energy – Euphoria, high, rush is too dramatic – Sense of well being, everything is OK

•  The ability to have this neuronal response = addiction

0102030405060708090

100

TIME

DO

SE

Analgesia

Euphoria

Pseudo- addictionEuphoria toAnalgesia

Avoid compassion traps •  “Do you want me to lose my job, do you want me to be on the street?”

–  I want you to have safe and effective pain control and it is my medical opinion that your current medicine won’t give you that.

•  “Do you have pain?” –  I want to use every minute of our time today to talk about your pain management plan.

•  “I wish you could feel my pain.” –  I know you’re suffering and I’m sure that we can work together to reduce pain, so you don’t have to suffer.

Avoid“AllorNothing”Traps

•  “Soyou’regoingtodonothingformethen?”•  “You’recuttingmeoffandIhavetolivewithmypain?”

–  Therearemany,manythingsthatpeoplewithchronicpaincandootherthanopiatestomanagetheirpain.Wouldyouliketohearaboutthem?

•  “I’vetriedallofthatstuff,noneofitworks.”–  Iwanttohearwhatyou’vetriedsowecanfindawayforittobemorehelpfulthistime.

Some Explanatory Models of Addiction

•  Impaired model •  Dry moral model •  Wet moral model •  Self medication hypothesis •  Psychoanalytic model •  Family interaction model •  Old and new medical models •  Bio-psycho-social model

Stay firmly within the medical model •  “Are you accusing me of being an addict?”

–  I have never accused anyone of diabetes but I’ve diagnosed them with it and that is what I am trying to now, diagnose.

•  “Don’t label me as a druggie” –  I have no interest in labels at all, I am interested in helping

people who are struggling with medical problems.

•  “So you’re basically saying that I’m a junkie.” –  I’m saying that addiction is a medical problem that responds to

treatment not a problem of bad morals or behavior.

Avoid the Policing Role

If you become aware of diversion or misuse…

•  Control what you can control – Prescribing

•  Report what you are mandated to report – Child abuse/neglect

•  Don’t take it personally

Managing Threats •  “I heard it’s illegal for you to let me go into withdrawal.”

–  Withdrawal is uncomfortable but not life-threatening, I can prescribe you medicines to help with the withdrawal symptoms.

•  “I’ll just go and use heroin.” –  I certainly hope you don’t because you know that I don’t think any type of

opiate will help your pain.

•  “Don’t bother with any other meds, I’ll just kill myself.” –  I need to ask you some more questions about your thoughts about suicide.

•  “I’m getting a lawyer.” “I’m calling KGW.” –  You do what you feel is right, of course. That’s what I’m doing for you, too.

•  “You have a family, don’t you doc?” – Call the police

Endgame

“Thereisnothingyoucandoorsaythatwillcausemetoprescribe________.Now,howdoyouwanttospendthe

restofourtime?”

DiscussingToxicology•  Speaktowhatyouknowtobetrue,trustyourscience•  “Ididnotusecocaine,areyoucallingmealiar?”

–  Iknowit’sveryhardtotalkaboutdruguse,evenwithyourdoctor,butIwantyoutoknowthatI’mnotheretojudgeyoubuttohelpyou.

–  Iknowit’sembarrassingtochangeyourstorynow…–  Iamconcernedthatyouruseofalcohol(ordrugs)maybecausingsomeofyoursymptomsandactuallymakingyoufeelworse.Iknowthatthiscanbeadifficultsubjecttodiscuss,evenwithyourdoctor,butitisimportanttoconsiderthismedicalconditionsothatwecanworktogethertohelpyoufeelbetter.

– Ahelpfullabtestfordiagnosingthisisaurinetest,whichIamorderingforyou.

GeneralRecommendations

•  Stayinthemedicalexpertrole

•  Emphasizeconcernandcondition

•  Speaktowhatisbehindapatient’scomment,nottothecommentitself•  Speaktowhatyouknowtobetrue,trustyourscience

Chronic Pain & Addiction

•  Addiction - functioning decreases with increasing dose

•  Pseudoaddiction - functioning increases with increasing dose

Diagnosing Addiction

•  Diagnosing addiction can take time •  Frequently requires a trial of medication with close observation •  Treatment plan (“contract”) is essential

O O O

N

CH3

H

H COC COC 3 3

diacetyl morphine heroin

O O OH

N

CH3 morphine

H C 3

codeine

O O O

N

CH3

HC 3

codeine

H

hydrocodone

O O O

N

CH3

HC 3

codone hydro oxy

OH

O O O

N

CH3

H

morphine

H

hydromorphone

O O O

N

CH3

H

morphone

OH

hydro oxy

O O O

N

CH

H H

morphine CH=CH2 3 2

OH

naloxone

O O O

N

CH

H

CH=CH2 2

OH

naloxone Narcan

O O O

N

CH

H

CH=CH2 3 2

OH

naloxone naltrexone

O O O

N

CH

H

2

OH

naltrexone Revia, Vivitrol

O O O

N

CH

H H

2

OH

naltrexone

C

CH3

C(CH3)3

OH

3

buprenorphine

O O O

N

CH

H H

2

OH

C

CH3

C(CH3)3

OH

3

buprenorphine •  Subutex

•  Suboxone (with naloxone)

•  Dose: 2 mg, 8 mg

•  Requires a DEA waiver to prescribe

•  30, 100, 275 patient limit

Light switch “ON” – opiate receptor occupied

Activity – how high the drug turns on the light switch

Affinity – how tightly a drug holds on to the light switch

Light switch “OFF” – opiate receptor unoccupied

2 ways to turn off the switch

- stop using the drug

- take a drug with a higher affinity but less activity

Naloxone – no activity

Naltrexone – no activity

Suboxone Puts switch in the halfway position

WITHDRAWAL

RELIEF

Clincal Opiate Withdrawal Scale – C.O.W.S.

Patients are given a score based upon the severity of eleven different withdrawal symptoms.

1.  Pulse 5. Restlessness 9. Muscle/joint/bone aches

2.  GI symptoms 6. Yawning 10. Goosebumps

3.  Sweating 7. Pupil size 11. Runny nose/tearing

4.  Shakes 8. Anxiety

Begin Suboxone when light switch is at least halfway off COWS of 8 to 10

1.  Forshortactingopiates,thisistypicallybetween12-24hoursafterlastuse.2.  Thegoaloftherapyistogettoadosewithnowithdrawalandnocravings.

Thisshouldaonceortwicedailydose,strictlyadheredto.

3.  Thismaintenancedoseisrecommendedforatleast6months.

4.  Physicaldependencedoesdevelopsoithastobetapered,notstoppedabruptly.

5.  Adetoxistypicallydonewithatwoweektaper.6.  Formethadoneitcantakelongertoreachthispoint,so“startlow,goslow”

isrecommendedwiththelastdosebeingatleast48hoursago.Dailydoseshouldideallybeinthe20-30mgrangeinordertoswitchtoSuboxone.

Is Suboxone “Addicting”?

Suboxonedoesn’tcauseaddiction,itTREATSaddiction!

Medication Comparison Suboxone Methadone Naltrexone

Withdrawal management Excellent – inpatient or ambulatory

Good – clinic based only unless done in acute care hospital

No current recommended role unless (has been used to precipitate withdrawal)

Maintenance – office based Yes - preferred Not allowed Yes Maintenance – clinic based Yes Yes – only option No Craving management Excellent Good to very good Low to moderate - indirect Side effects Minimal Minimal to moderate Minimal Respiratory depression Mild with ceiling effect Definite concern with other

sedative-hypnotics None

Street value Moderate to high Moderate to high None Potential for abuse Low High None Withdrawal syndrome Mild Moderate to severe None

0 1 2 3

Pulse (heartbeats per minute) Less than 80 81 to 100 101 to 120

Stomach or intestinal symptoms in the past half an hour

No symptoms Stomach or intestinal cramps Nausea or loose stools Diarrhea and/or vomiting

Sweating No chills or flushing Chills or flushing felt Flushing or sweats observed Beads of sweat on face

Shakes No shakes Shakes felt but not visible Shakes visible

Restlessness Able to sit still without difficulty Difficulty sitting still Frequent shifting in chair or

movements of arms and legs

Yawning No yawning Once or twice in a half hour 3 or more times in a half hour

Pupil size Small or normal Possibly a little larger than normal Larger than normal

Anxiety No anxiety I feel anxious but It's not obvious to others

Others could tell I'm anxious

Muscle, bone or joint aches No aches Mild aches Severe aches of muscles and joints

Goosebumps No goosebumps Can be felt

Runny nose/watery eyes None Stuffy nose or watery eyes Total

Begin Suboxone when you have reached a score of _10__

Suboxone Dosing Instructions

•  When your score is 10, take _____ tablets. You can take an additional ____ to ____ tablets later in the day as needed. You know you will need it if your symptoms begin to increase again.

•  On the morning of the 2nd day, take the total from the first day all at once. You can take an additional ____ to ____ tablets later in the day as needed. You know you will need it if your symptoms begin to increase again.

•  On the morning of the 3rd day, take the total from the 2nd day all at once. You can take an additional ____ to ____ tablets later in the day as needed. You know you will need it if your symptoms begin to increase again.

•  On the morning of the 4th day, take the total from the 3rd day all at once and contact our office.

Suboxone Dosing Instructions •  Take the medicine at the same time every day •  Don’t change the dose without speaking to your provider •  The goal is to have minimal to no cravings with a once a day to twice a day dose. •  The prescription you received on the first day will only be enough to get you

started on the medicine. You will need to call our office to speak with your provider so we can see how you are doing and arrange for your next prescription.

Day 1 2 3 4 5

AM 3 5 6 6

PM 2 1 - -

BED 1 1 1 -

Suboxone is an FDA approved medication for treatment of people with opioid addiction, such as prescription pain medications or heroin. It can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary. All treatment will be individually based, assessed and corroboratively planned. There are 3 components to the treatment: 1. Medical and physical stabilization, including medication. 2. Counseling support. 3. Your commitment to developing a healthy lifestyle. Suboxone can only be obtained from a physician, nurse practitioner or physician assistant who has certification and approval from the DEA. You will not be able to obtain this medicine from your primary care provider, an emergency room or urgent care. Each physician can prescribe for only 100 patients at any given time. Therefore, being prescribed Suboxone at this time is a privilege.

1. I agree to keep and be on time to all of my scheduled appointments with the medical and counseling staff. 2. I agree not to sell, share or give any of my medication to another person. I understand that this is a serious violation of my treatment agreement and will result in the medication being stopped. 3. I agree that the medication I receive is my responsibility and that I will keep it in a safe and secure place. I agree that lost, stolen, or destroyed medications will not be replaced regardless of the reasons for such loss. 4. I agree not to obtain any opiates or benzodiazepines from any other sources while on Suboxone. 5. I agree not to use any other drugs of abuse, including alcohol, marijuana, cocaine, amphetamines, etc., or other opiates while on Suboxone. 6. I agree to provide urine drug screens at the time requested by my treatment providers. 7. I agree to take my medication as the medical staff has instructed and not to change the way I take my medication without first consulting them. 8. I agree not to abruptly stop my medication and I agree to discuss with the medical staff how to comfortably discontinue it if and when appropriate. 9. I agree to actively and positively participate in counseling. Missed appointments may result in the medication being stopped. 10. I agree to have my Suboxone prescriptions filled only at Kaiser Permanente pharmacies. 11. Fees for treatment and services have been explained to me. 12. The fol lowing confidential phone number can be used for voice messaging: ______________________ If I am unable to follow through with the above expectations, I will be offered other treatment options that may be more suitable to my needs.

Paradigm Shift

Sin Repentance Redemption

Crime Punishment Correction

Bad behavior Discipline Good behavior

Symptoms Diagnosis & Treatment Recovery

Suboxone Treatment Benchmarks I: Engagement/Early Treatment 1 to 2 months 1. Medical Induction/Dose Adjustment CMED/ MOD Call 2. Referral/ Treatment Enrollment: CDOP / CDI 3. Establish Counseling Involvement (COVN) 4. 7-14d refill/UDS with refill II. Active Treatment 3 to 6 months 1. Abstinent (negative UDS/patient report ) 2. Taking medication as directed (refill history/pill count) 3. Following treatment plan

a. Program attendance b. Ability to communicate with patient by voicemail or kp.org c. Able to submit to regular drug screens upon request d. Making progress on written Tx plan (follow ASAM Guidelines) e. Recovery/Relapse prevention plan

4. 14-28d refill/random UDS, per counselor III. Maintenance / Monitoring Treatment Support 6 to 12 months 1. Update and revise treatment plan (follow ASAM guidelines) 2. Taking medication as directed (refill history/pill count) 3. Regular Counseling Attendance to be determined by treatment plan 4. Ongoing monitoring of abstinence via urine drug screens/patient report 5. Monitor and revise recovery and relapse plan as needed 6. If appropriate, support during tapering 7. 28d refill/random UDS, per counselor IV. Annuals - 12 month or longer 1. Needs to be seen in person by case management counselor yearly. 2. 28d refill/random UDS

Suboxone Treatment Benchmarks I: Engagement/Early Treatment 1 to 2 months II. Active Treatment 3 to 6 months III. Maintenance / Monitoring Treatment Support 6 to 12 months IV. Annuals - 12 month or longer

Whichofthesethreechoiceslookbesttoyou?

ONE

Not make a change

TWO

Make a change

THREE

Take a break

The results of your questionnaire show that you are at risk of problems due to alcohol

Whichofthesethreechoiceslookbesttoyou?

ONE

Not make a change

TWO

Make a change

THREE

Take a break

Alcohol

Marriage

Children

Health

Work

Legal Friends

Finances

School

Parents

“Howhasyourdrinkingbothered youorcausedproblemsforyou?”

ONE – Not Make a Change

Decisions regarding a change are yours to make.

As your clinician, I recommend that you consider making a change.

We have a lot of options to help you, should you decide to make a change.

I know that change can be difficult.

I am confident that if you decide to change you will be able to do so.

TWO – Make a Change

What change do you want to make?

Let’s set a specific goal

TWO – Make a Change

What questions do you have?

Can I have alcohol in my life and have it not

cause problems?

What’s wrong with having a drink now and

then?

Can I control my use of alcohol?

Can’t I just have a glass of wine

with dinner?

What is considered a

healthy amount to drink?

How much is “too much”?

TWO – Make a Change

“Can I have alcohol in my life and have it not cause problems?” “Can I control my use of alcohol?”

What questions do you have?

Men under 65 – no more than 14 drinks per week no more than 4 drinks per occasion Women – no more than 7 drinks per week no more than 3 drinks per occasion

Low risk drinking trial for 30 days Trial of controlled drinking for 30 days Recommended: Men – 1 to 2 drinks per day, no more, no less Women – 1 drink per day, no more, no less

Keep a journal – follow up in 30 days One drink = 12 oz. beer / 5 oz. wine / 1.5 oz. liquor (one shot)

Three – Take a Break

A A

Smart Recovery

Addiction Medicine Primary

Care

BehavioralHealth

Consultant

Church Group

Rational Recovery

Decisional Balance

Exploring ambivalence by looking at pros and cons of the behavior and change

•  Advantages/disadvantages •  Like/dislike •  Reasons to change/reasons to keep things the way they

are

Scaling

ready “On a scale of 0-10, how willing are you to change?” able Straight question: “Why did you pick a __?” Backward question: “Why didn’t you pick a (lower number)?” Forward question: “What would need to be different for you to move up to a __?” Future question: “Let’s suppose you change. A year from now, what would your life look like?”

life

Our mission is to provide an environment of safety, access to tools, and connection to a community

we are the Department of Addiction Medicine

References&Resources•  AmericanSocietyofAddictionMedicinepositionpaper2004

–  Office-BasedOpioidAgonistTreatment(OBOT)–  https://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/

2011/12/15/office-based-opioid-agonist-treatment-(obot)

•  AmericanSocietyofAddictionMedicine–  Suboxonewaivertraining–  https://elearning.asam.org/products/treatment-of-opioid-use-disorder-waiver-qualifying-8-hours-online

•  NationalInstituteonAlcoholAbuseandAlcoholism–2005–  HelpingPatientsWhoDrinkTooMuch-ACLINICIAN’SGUIDE–  https://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/guide.pdf

•  WHO/UNODC/UNAIDSpositionpaper,2004–  SubstitutionmaintenancetherapyinthemanagementofopioiddependenceandHIV/AIDS

prevention–  http://www.who.int/substance_abuse/publications/en/PositionPaper_English.pdf?ua=1