Integrat ing Buprenorphine Treatment for Opioid Use Disorder in HIV Pr imar y

Care

Michael MacVeigh, MDKristen Meyers, BS, CADC1

May 10-12, 2017

Por t land

Our Clinic Building

Overview• W elcome Back and Overview of Bup TA t raining

• Site Specific Updates

• Opioid Cr isis: Nat ionwide Overview

• St igma, Shame, and the Power of Language

• Relapse Sensit ive Environments and Retent ion in Care

• Methods to Reduce Diversion

• H igher Level of Care, A lternat ives to OBOT, Taper ing Off Bup

• Mental Health and OUD

• Pain and OUD

Met ro Health Clinic

Bluegrass Care Clinic

Cent ro Ararat Clinic

Opioid Cr isis Nat ionwide

Nationally, opioids were involved in more than61 percent of deaths from overdoses in 2014

By HAEYOUN PARK and MATTHEW BLOCH JAN. 19, 2016, New York Times

The C.D.C. says that 91 people in the United States die every day from opioid overdose.By CHRISTINE HAUSERFEB. 13, 2017, New York Times

2015 Data ComparisonOverdose deaths: 52,404.

Car crashes deaths: 37,757Gun deaths, including homicides and suicides: 36,252

NBC News, Dec 9 2016

N gggg

2016 National Drug Threat Summary

Opiate Cr isis Nat ionwide“Deaths from overdoses are reaching levels

similar to the H.I.V. epidemic at its peak”

Robert Anderson, the C.D.C.’s chief of mortality statistics.

HIV and OUD: ?W ho? W hat? are we t reat ing?

29 year old male

1/18/2017: HIV Viral Load= <20

1/25/2016: Pain MGMT Profile:+Amphetamines+Methamphetamines+Benzodiazepines+Mar ijuana+Opiates+Morphine

HIV and OUD32 year old male

11/15/2016: HIV Viral Load= 26

2/19/2017: Pain MGMT Profile:+Alcohol Metabolit es+Amphetamines+Methamphetamins+Benzodiazepines+Lorazepam+Cocaine+Opiates+Morphine

HIV and OUD36 year old female

02/13/2017: HIV Viral Load= <20

2/14/2017: Pain MGMT Profile:+Alcohol Metabolit es

HIV and OUD50 year old male

12/16/2016: HIV Viral Load= <20

2/14/2017: Pain MGMT Profile:+Mar ijuana Metabolit es

HIV and OUD41 year old male

02/08/2017: HIV Viral Load= <20

01/08/2017: Pain MGMT Profile:+Mar ijuana Metabolit es

HIV and St igmaNASTAD joins public health experts and leaders in affirming that there is now conclusive scientific evidence that a person living with HIV who is on antiretroviral therapy (ART)

and is durably virally suppressed (defined as having a consistent viral load of less than <200 copies/ml) does not sexually transmit HIV. This statement accelerates our longstanding

work to end the dual epidemics of HIV and HIV-related stigma and to dramatically reduce new HIV infections, and is supported by policies and public health practice grounded in

science.

WHY IT’S IMPORTANT

The new evidence will help ameliorate decades of HIV-related st igma and discr im inat ion by confirm ing that t reatment is a power ful prevent ive

intervent ion

© 2017 National Alliance of State and Territorial AIDS Directors

St igma

Stigma is defined as a set of negative beliefs that a group or society holds about a topic or group of people. According to the World Health Organization (WHO), stigma is a major cause of discrimination and exclusion and it contributes to the abuse of human rights. When a person experiences stigma they are seen as less than because of their real or perceived health status.

St igma in Methadone and Buprenorphine Maintenance Treatment Edwin A. Salsit z, M.D., FASAM,

PCSS-MAT MODULES

St igma

In a study across 14 count r ies of 18 of the most st igmat ized issues, including being a cr im inal,

illicit drug addict ion was number 1, and alcohol addict ion number 4.

John Kelly, PhD, Language, Substance Use Disorders, and Policy: They need to reach consensus on an “ Addict ionary” .

Proposed SUD St igma statement• Treatment of substance use disorder leads to reduction in morbidity and mortality in this

population.

• Addiction-related stigma is a major barrier to access to, funding for, and acceptance of such treatment.

• Combating this stigma is critical to support our patients in their recovery and access to care.

• The dramatic increase in overdose and the SUD epidemic demonstrates a need for an approach similar to our success with HIV. The combination of successful therapies and stigma reduction have led to broader acceptance of HIV testing and care.

• Understanding and accepting the value of stigma reduction linked to addiction therapies is critical for both providers and patients.

Michael MacVeigh and Kr isten Meyers

Impact of St igma on Treatment

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), addiction affects approximately 23.5 million Americans every year, and

roughly 11 percent receive treatment.

While there are many factors that contribute to this addiction-treatment gap, stigma is one of the largest.

https://vimeo.com/153845422

St igma and Treatment

Common Myths:

• W hy not taper off? • Subst itut ing one drug/addict ion for another• Methadone (and now Buprenorphine) is harmful • You are not in recovery • You should not get pregnant • You are on methadone; no need for post -op pain meds

St igma in Methadone and Buprenorphine Maintenance Treatment Edwin A. Salsit z, M.D., FASAM,

PCSS-MAT MODULES

Shame“ A power ful, but unquest ioned, convict ion that in some

impor tant way one is flawed and incompetent as a human being… The self condemnat ion and self-loathing that shame precipitates are par t and parcel of a pervasive, persistent , and dest ruct ive set of emot ions that gr ips the sufferers with a cr ippling sense of ter ror and pessim ism, prevent ing them from living harmoniously and confident ly.” (Goldberg, 1991)

The Role of Shame in Opioid Use Disorders Ashley Braun-Gabelman, Ph.D,

PCSS-O MODULES

SHAME

Shame is common among individuals with OUD and associated with use and relapse

W ithin individuals with OUD, par t icular subgroups associated with shame include inject ion heroin users and pregnant women and mothers

Shame should be a focus of OUD t reatmentThe Role of Shame in Opioid Use Disorders

Ashley Braun-Gabelman, Ph.D, PCSS-O MODULES

The Power of Language

W ords are impor tant . If you want to care for something, you call it a flower ; if you want to kill something, you call it a weed. Don Coyhis, Founder of W hite Bison

The power of language

Recovery Brands ht tps://vimeo.com/185592929

Stop Talking Dir t y

In general, person first language is preferable (persons with/suffer ing from..)

substance abuser vs substance use disorder

person is the problem vs person has a problem

Dir t y/Clean UDS vs Posit ive/Negat ive UDS

Relapse Sensit ive Environment

1891-1892 - Keeley League “ Laws must realize a leading fact : Medical not penal t reatment reforms the drunkard.”

W hite, W . (1998) Slaying the Dragon: The History of Addict ion Treatment and Recovery in Amer ica. Bloomington IL: Chestnut Health Systems

Drugs and the Brain

Drugs and pathological gambling behaviors exert their initial effects by acting on the same reward circuitry in the brain that makes food and sex, for example, profoundly reinforcing. 1

Drugs of abuse directly or indirectly target the brain’s reward system by flooding the circuit with dopamine. This reward system is involved in the reinforcement of behaviors and the production of memories. 21 ASAM http://www.asam.org/quality-practice/definition-of-addiction

2 NIH https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain

Neurochemistry of substance use -simplified

How they do it

Caffeine

Cocaine

Methamphetamine

Tobacco

Etoh

Opiates

Marijuana

Blocks reuptake-> incr dopamine

Strongly blocks dopamine reuptake : incr dopamine

Blocks reuptake & increases dopamine release

Nicotinic receptors-> incr dopamine release

Effect on GABA -> incr dopamine release

Effect on GABA -> incr dopamine release

Endocannabinoid binding leads to GABA effect -> incr dopamine release

Neurobiology - Circuitry of addiction/ Reward centerActivation of ventral tegmental area (midbrain) ->

Stimulation of the ventral striatum (espec nucleus accumbens : “pleasure center”)->

Release of dopamine to the entire limbic system, especially:

• Hippocampus: memory formation

• Amygdala : emotion formation

• Ventral striatum: formation of habits (action w/o thought)

Also affects connections to prefrontal cortex and cerebellum.

All these circuits become stronger and more efficient neural pathways as they are activated multiple times

Relapse Sensit ive Environment

W hat is it ?

A systemic philosophy of care with the goal ofmaintaining an individual in addict ion t reatment toenhance the potent ial for sustained recovery.

This can be expanded to encompass an individual's definit ion of recovery with outcomes based on qualit y oflife and not solely on abst inence.

Relapse Sensit ive Care: Changing Systems of Addict ion Treatment , Stacey C. Conroy LICSW , MPH

PCSS-MAT Online Modules

Key Concepts for building a Relapse Sensit ive Environments (cont )

• Suppor ted by Disease Model • Suppor ted by Neuroscience which provides evidence on

biological reasons for relapse – Treatment engagement, not punitive measures for return of

biological-based symptoms • Suppor ts the SAMHSA definit ion of recovery which

includes, health, wellness, and self determinat ion • Suppor ts Qualit y of Life as an outcome rather than solely

on negat ive ur ine drug screens

Relapse Sensit ive Care: Changing Systems of Addict ion Treatment , Stacey C. Conroy LICSW , MPH

PCSS-MAT Online Modules

Key Concepts for building a Relapse Sensit ive Environments

• The client is not in cont rol of t heir alcohol and/or drug intake or it s consequences

• Increase recovery suppor t s after a relapse and don’t discharge • Explore different measures of t reatment success (like qualit y of

life)• Understanding that relapse is biological • Long-term recovery is best suppor ted by pat ience and suppor t

rather than punishment and abandonment• Treatment for addict ive disorders is not t ypically a “ oneshot ”

t ype of intervent ionRelapse Sensit ive Care: Changing Systems of Addict ion Treatment ,

Stacey C. Conroy LICSW , MPH PCSS-MAT Online Modules

Retent ion in Care

“ All Treatments W ork For Some People/Pat ients”

“ No One Treatment W orks for A ll People/Pat ients” Alan I. Leshner , Ph.D Former Director N IDA

Factors Effect ing Retent ion in CarePatient characteristics, behavior, and other factors unrelated totreatment have been found to contribute relatively little toretention in MAT.

One comprehensive study found that retentionwas determined almost entirely by what happened duringtreatment, not before, although two factors, older age and lessinvolvement with the criminal justice system, predicted longerretention (Magura et al. 1998, 1999). Another factor found toaffect retention was motivation or readiness for treatment (Joe etal. 1998).

SAMHSA Treatment Improvement Protocol (TIP) Series, No. 43.) Chapter 8. Approaches to Providing Comprehensive Care and Maximizing Patient Retention.

Foster ing change In any set t ing, research has shown these four

factors are responsible and needed to effect change:

1. Empathy 2. Posit ive regard 3. Genuineness 4. Feedback

Improving Retent ion, Outcomes and Supervision with PCOMS Presented by George S. Braucht , LPC & CPCS

NAADAC Training Module

Recommended steps to improve pat ient retent ion

Individualize medicat ion dosages. Adequate, individualized medication dosages are probably the most important factor in patient retention (Joseph et al. 2000)

Clar ify program goals and t reatment plans. Treatment providers should explain program goals and treatment plans to every patient. Inconsistent messages adversely affect patient retention, particularly when these messages are about the advisability of…

Simplify the ent ry process. Shortening intake results in better program retention (see chapter 4).

A t tend to pat ients' financial needs. Patients' inability to pay may limit both treatment entry and retention, especially in States where MAT is not covered by Medicaid, State funds, or private insurance.

Approaches to Providing Comprehensive Care and Maximizing Patient Retention.

2005 SAMHSA (Treatment Improvement Protocol (TIP) Series, No. 43.) Chapter 8.

Recommended steps to improve pat ient retent ion (cont .)

Reduce the at tendance burden. Attendance requirements can exert powerful effects on retention. Rhoades and colleagues (1998) found that patients who were required to visit an OTP less frequently were less likely to dropout of treatment and no more likely to use other drugs than patients on a daily attendance schedule.

Provide useful t reatment services as ear ly as possible. Patients were more likely to stay in treatment when they were motivated strongly and engaged earlier in useful activities (Simpson, D.D., et al. 1997b).

Enhance staff-pat ient interact ions. Good staff attitudes and interactions with patients have been associated with higher retention. In one study, patients' frequent contact with staff members and the involvement and visibility of OTP administrators increased patient retention (Magura et al. 1999).

Improve staff knowledge and at t it udes about MAT. OTP staff members should understand MAT and appreciate the wealth of science supporting it, and they should be aware of recommended treatment practices so that they can interact effectively and constructively with patients. Bell (2000)

Approaches to Providing Comprehensive Care and Maximizing Patient Retention.

2005 SAMHSA (Treatment Improvement Protocol (TIP) Series, No. 43.) Chapter 8.

Local example of Bup t reatment

Allied Methadone Clinic: •Must at tend daily for 90 days •Build up to 1, 2, then 4 take outs per week. •Build up to weekly take outs •Build up to monthly take outs•Take outs pulled if posit ive UDS •All t ake outs require stable home environment , etc

Helpful Methods to Reduce Diversion• Know your pat ient

– Thorough assessment and history– Risk of other SUD

• Use of cont rolled-substance agreements – Buprenorphine specific

• Thought ful dose management

• Compliance monitor ing – e.g. pill counts and urine screens– regulatory and legal measures

Managing Aberrant Drug-Related Behavior in Primary Care: A Systematic Review Charles E. Argoff, MD Professor of Neurology Albany Medical College

Ur ine Drug Screens• UDT is a test we do for the pat ient ’s care, not to the

pat ient

• UDT result s should increase not decrease communicat ion with the pat ient

• UDT does not diagnose – SUD– Physical dependence – Impairment or Diversion

Pat ient–Centered Ur ine Drug Test ing: Facts you Should Know!Howard A. Heit , M.D., F.A.C.P., F.A.S.A.M

PCSS-MAT Module 4

Ur ine Drug Screens (cont )• Specimen collect ion

• Character ist ics of ur ine – Appearance − Color of a urine specimen is related to the

concentration of its constituents – Temperature − 4 minutes of voiding should fall within the

range of 90ºF to 100ºF with a volume of 30 ml. or more– pH − Range of 4.5 to 8.0 – creatinine concentration: normal human urine has a greater

than 20 mg/dL Pat ient–Centered Ur ine Drug Test ing: Facts you Should Know!

Howard A. Heit , M.D., F.A.C.P., F.A.S.A.MPCSS-MAT Module 4

Ur ine Samples - clues “ Trust , but ver ify”

• UDS-check creat inine levels

• Naloxone levels should be low

• Metabolit e levels should be posit ive meaning that the pat ient is actually taking the medicat ion and it is being metabolized (norbuprenorphine present )

• Specific gravit y - clue to water /watered down sample

• Temp dots - helpful re recent sample.

PDMP

Stateline States Require Opioid Prescr ibers to Check for ‘Doctor Shopping’ Chr ist ine Vesta May 09, 2016

Higher Levels of Care (BUP)

Office Based vs Outpat ient Program (APG)

Inpat ient Treatment while on BUP(KK case)

Case Review APG - OBOT vs OTP

32 yo male with border line personalit y disorder , chronic anxiety, chronic pain, polysubstance use, with mult iple ED/clinic visit s and doc shopping for any and all alter ing substances (benzos, opiates, st imulants and other psychoact ive meds)

Successful HIV suppression and pr ior Hep C cure. Unpredictable clinic at tendance, frequent ED visit s, and confrontat ional behavior . Several hospitalizat ions with dual dx program with ear ly d/c or AMA. Ongoing polysubstance use and provider concern due to benzos.

Case Review APG - OBOT vs OTP

Outside consultation via ECHO led to recs of:Preferred:

• Inpatient tapering of Buprenorphine due to inability to control outpatient management– potentially taper his buprenorphine and initiate naltrexone at Cedar Hills– Depot naltrexone may be a better option for his MAT

Second Option:• Local detox followed by outpatient OTP of depot naltrexone

Third Option:• Outpatient Treatment Program for MAT: to include Bup taper and depot naltrexone

Least desirable option:• Continue with OBOT prescribing: limit duration of the prescriptions to 3-5 days to help reduce risk of

diversion and abuse. the pregabalin should stop since it is likely either being abused or diverted.• Continue aggressive monitoring

Case Review KK - Inpt while on Bup

43 yo male w/longstanding hx of polysubstance abuse with heroin, meth (both IDU), MJ, and interm it tent Etoh. Entered medical care after prolonged ICU stay for severe PCP with unt reated HIV.

Successful HIV therapy once engaged in both HIV and buprenorphine therapies. However , constant st ruggle with meth. He weaned off suboxone per his preference, but then relapsed in m idst of housing cr isis and accelerated meth use. Re-induced on suboxone successfully, but meth use out - of- cont rol.

KK - inpt on Bup cont inued

• Ut ilizing both case manager , pat ient navigator , weekly and somet imes biweekly visit s, and constant encouragement - he ult imately chose to pursue inpat ient t reatment for his methamphetamine use.

Issues:• Finding a program that would accept his Bup rx and his

insurance• Logist ics of intake, med supply, t rust issues between

staff at facilit y and pat ient , facilit y’s general approach of total cont rol, discomfor t with his medical condit ion

(was off HIV meds at t ime: “ what if..?” )

Alternat ives to BUP

Methadone (RP)

Nalt rexone (data we have and recs)

Switching from Bup to nalt rexone

Taken together , published clinical pract ice recommends induct ion to full dose nalt rexone 5–7 days after buprenorphine discont inuat ion [ 48] .

Buprenorphine-Mediated Transition from Opioid Agonist to Antagonist Treatment: State of the Art and New Perspectives Paolo Mannelli,1,* Kathleen S. Peindl,1 Tong Lee,1 Kamal S. Bhatia,2 and Li-Tzy Wu1

Depot Nalt rexone to BUP swit chCame up in past via emails regarding patients receiving naltrexone in jail upon discharge

and then presenting with interest in buprenorphine.

I would st ill recommend:One would anticipate that naltrexone would block the suboxone and it would be best to wait for the end of a month after naltrexone injection before expecting a response. By then - (if no opiate use) could just start (Bup)If relapse - back to the withdrawal sxs before induction Also - a good place for rapid UDS before starting...

Meanwhile…what our pat ients m ight be doing

I just received my vivitrol shot while having a heroin habit. Obviously went into severe p.w. not my 1st time by the way.. usually 5 days it'd be till I could return to construction work. Sleep a few more days. Anyways this time I tried iv suboxone because I had to be better for work. Did a full day of full blown precipitated withdrawal. Then injected 8mg suboxone. And here's what happened. .. I didn't get high ... and after about 30min started to not feel sick. So it out competes the naltreoxe side and the bupe kicks in…

https://drugs-forum.com/forum/showthread.php?t=255209

Meanwhile…Another patient perspective:

I took 10mg naltrexone 25 hours ago. It sent my into severe PWD so I took a 8mg suboxone 2 hours afterwards

thinking it would overpower the naltrexone. The sub didn't do much at all, presumably because it's binding affinity

is weaker than naltrex so it couldn't break through.

Fast forward to now and I've got some dope. Yesterday, the suboxone was rendered infective because of the

naltrexone I had taken a few hours before. Does that mean I can ignore the bupe's blocking timeframe since it

never had a chance to bind to my receptors (bc of naltrexone)? Or did the bupe slide into my receptors after the

naltrexone came off, despite originally being inactive?

Essentially, I'm trying to understand if I should follow the blockade timeline of 8mg bupe or of 10mg naltrexone to

determine when I can expect this dope to get me high. Cheers!

EDIT: Whoa, now I'm nodding off. Crushed a bundle earlier today. Then another bundle about an hour ago. I guess

I broke through the blockade.

Taper ing off Bup

Can be pat ient or provider init iated

Can be rapid or slow (slow recommended)

Pat ients frequent ly repor t concerns when they are at the lower doses

Planned Taper

ht tp://www.helpmegetoffdrugs.com/taper

Planned Taper

Timeline of w/d

Patients have described the following general timeline for suboxone withdrawal symptoms:

• 72 hours: Physical symptoms at their worst

– Nausea and vomiting– Muscle/body aches– Insomnia or drowsiness– Indigestion– Anxiety, depression, and irritability– Cravings– Fever or chills– Sweating– Headache– Difficulty concentrating

• 1 week: Bodily aches and pains, insomnia, and mood swings

• 2 weeks: Depression

• 1 month: Cravings and depression

MH Tx - is there some magic?

W e were unable to find any data that specific diagnoses are bet ter t reated by specific drugs in the set t ing of OUD or specifically in pat ients on buprenorphine. That being said, t here are lot s of studies document ing higher rates of many MH diagnoses in this populat ion.

The essence of the lit erature is that t reatment of t he psychiat r ic condit ion should proceed as it would without OUD, with tailor ing to the specific pat ient re drug tolerance, effect iveness and preferences. Obviously, t he use of sedat ives would be of greater concern, especially benzos.

NO. There is no magic.

Depression• Pharmacotherapy: Select ive serotonin reuptake inhibitors (SSRIs): (e.g. fluoxet ine, ser t raline) o “ First line” due to safety profile, generally well t olerated, affect the hepat ic P450 system thus pay at tent ion to potent ial for drug-drug interact ions. Serotonin and norepinephr ine reuptake inhibitors (SNRIs) (e.g. venlafaxine, duloxet ine): Monitor blood pressure, par t icular ly with venlafaxine Tr icyclic ant idepressants (TCAs): Cont raindicated in those with cardiac conduct ion delays, fatal in overdose. o Some posit ive evidence for t reat ing depression in those on methadone maintenance (Nunes et al 1998; W oody et al 1975; T it ievksy 1982) Monoamine oxidase inhibitors (MAO-I):Required dietary rest r ict ions, wash out per iod required when swit ching from ir reversible MAO-I to another ant idepressant Other : bupropion (norepineprhine and dopamine reuptake inhibitor ), m ir tazapine (alpha 2 adrenergic blocker ), t razodone/nefazodone (5HT2 antagonists)

• Psychotherapy: Evidence-based psychotherapies for depression include: Cognit ive Behavioral Therapy (CBT) and Interpersonal Psychotherapy (ITP) (But ler AC 2006; Van Hees ML 2013)

PTSD• Psychotherapy: Evidence-based psychotherapies for PTSD include Cognit ive

Behavioral Therapy (CBT), including exposure-based CBT. CBT for PTSD involves a combinat ion of psychoeducat ion, relaxat ion and anxiety management techniques, cognit ive techniques, imagined and in vivo exposure to t rauma-related st imuli, and relapse prevent ion (Gabbard et al. 2007).

• Pharmacotherapy: Meta-analyses and several randomized cont rolled t r ials published generally suppor t t he

super ior it y of SSRIs and serotonin-norepinephr ine reuptake inhibit ors (SNRIs) over placebo for non-combat -related PTSD. The data for SSRIs and combat -related PTSD is more m ixed; t he most recent (2004) APA guidelines recommended SSRIs as first -line. Tr icyclic ant idepressants and monoamine oxidase inhibit ors showed improvement in int rusive and depressive symptoms, but SSRIs are considered first -line in par t due to safety profiles.

Mir tazapine and nefazodone have also be shown to be super ior t o placebo in t reat ing PTSD. Prazosin has been found to be effect ive for PTSD-related nightmares and sleep disturbance. Other medicat ions with some indicat ion, often in uncont rolled repor t s, include: carbamazepine, beta-blockers, lit hium, clonidine, benzodiazepines, t o name a few.

Adjunct ive t reatment with a second-generat ion ant ipsychot ics in pat ients who have par t ially responded to an SSRI or an SNRI have also be shown to be effect ive (Gabbard et al. 2007; Brady et al. in Nunes et al. 2010)

ADHD

• Nonpharmacological intervent ions which encompass a wide-range of intervent ions including behavior therapy, academic intervent ions, family therapy, care coordinat ion have been well studied in children but not adult s (Murphy 2005)

• Pharmacologic intervent ions can be broken down into st imulants and non-st imulants:

• St imulants have demonst rated efficacy in numerous double-blind, placebo cont rolled t r ials. Considered first -line t reatments. Examples include: methylphenidate and related compounds: dexmethylphenidate, and longer -act ing methylphenidate agents (e.g. Concer ta, Metadate CD, Ritalin LA) and dext roamphetamine and mixed amphetamine salt s and longer act ing related compounds (e.g. Vyvanse, Adderall X R)

• Non-st imulants: atomoxet ine (St rat tera) is the first /only non-st imulant medicat ion FDA approved for t reatment of ADHD in adult s. Other medicat ions demonst rat ing some efficacy include: bupropion, alpha agonists (guanfacine, clonidine—both FDA approved for t reatment of ADHD in children and adolescents), modafanil, TCAs, MAOIs

ADHD cont inuedNo data in ADHD-OUD to guide t reatment

however , based on studies with ADHD-SUD:

• Atomoxet ine: First -line t reatment , par t icular ly shown helpful for abst inent alcohol-dependent individuals, t hose with t ic disorder . H igh drop-out rate when given to cocaine abusers with ADHD (Levin et al. 2009)

• Bupropion (“ Off-Label” – not FDA approved for ADHD) Efficacy in smoking cessat ion Useful in comorbid mood disorders Open studies show improved ADHD/SUD/Mood outcome

• Guanfacine, modafinil, t r icyclic ant idepressants (Off-label) W ilens 2004; Riggs 1998; Schubiner 2005; W ilson and Levin 2005; Mar iani and Levin 2007.

ADHD - addit ional concernsSt imulants Use in substance-abusing pat ients is complex and cont roversial

• Use extended-release formulat ions of st imulants (e.g., OROS MPH, d-MPH X R, MAS X R, of MPH SR)

• Monitor closely - both ADHD symptoms and pat tern of alcohol/drug use• If severe SUD may refer for intensive intervent ion pr ior to star t ing

medicat ion – May need to avoid stimulants if they have current abuse/ dependence on

prescription stimulants or high risk of diversion of medication (i.e., sold medication in past)

• Non-pharmacologic approaches adjunct ively For SUD: Group and individual psychotherapy (e.g. cognit ive-behavioral t herapy); Self-help; Family therapy for adolescents and young adult s For ADHD: Cognit ive-behavioral t herapy, organizat ional coaches

Pain issues and Buprenorphine

2 fair ly different set t ings:

1.Pat ients with chronic pain issues and on t reatment with buprenorphine for OUD

1.Pat ients on buprenorphine for OUD and in need of acute pain management (especially post -surgical/t rauma)

Buprenorphine as analgesic

Sublingual Bup and Chronic Pain• Systemat ic review • 10 t r ials involving 1,190 pat ients • Due to

heterogeneit y of studies, pooling result s and metaanalysis not possible• A ll studies repor ted effect iveness in t reat ing chronic pain • Major it y of studies were observat ional and low qualit y

• Current evidence insufficient to determ ine effect iveness of SL buprenorphine for t reatment of chronic pain

Cotes J, Montgomery L. Pain Medicine 2014

Recall - buprenorphine is available in a t ransdermal formulat ion specifically for the t reatment of chronic pain and that formulat ion does NOT require a waiver . BUT - it CANNOT be used to t reat OUD ( per licensure).

Buprenorphine maintenance theoret ical concerns for acute pain

Buprenorphine (a par t ial mu agonist ) may • antagonize the effects of previously administered opioids or • block the effects of subsequent administered opioids• However…Exper imental mouse and rat pain models:

Combinat ion of buprenorphine and full opioid agonists (morphine, oxycodone, hydromorphone, fentanyl, et c) resulted in addit ive or synergist ic effects

• Receptor occupancy by buprenorphine does not appear to cause impairment of mu-opioid receptor accessibilit y

Acute Pain Buprenorphine Maintenance Treatment Theoret ical Concern Kogel B, et al. European J of Pain. 2005 Englberger W et al. European J of Pharm. 2006

Acute Pain Management Opt ions1. Cont inue buprenorphine(? Lower dose) and t it rate shor t -act ing opioid

analgesic 2. D/C buprenorphine, use opioid analgesic, t hen re-induce 3. Divide buprenorphine to every 6-8 hours 4. Use supplemental doses of buprenorphine* 5. If inpat ient some are using # 1 (above) or :• d/c buprenorphine • star t methadone 20-40mg (or other extended-release, long-act ing opioid)• use shor t -act ing, immediate-release opioid analgesics • t hen re-induce w/ buprenorphine when acute pain resolves

Alford DP. Handbook of Office-Based Buprenorphine Treatment of Opioid Dependence. 2010 A lford DP, Compton P, Samet JH. Ann Intern Med 2006 * Book SW , Myr ick H, Malcolm R, St rain EC. Am J Psychiat ry 2007

Looking Forward• NP, PA Can Prescr ibe-CARA Act• Addict ion Medicine Officially Recognized as a Medical Subspecialt y• Probuphine: Injectable, Long-Act ing Bup, once a month, clinical t r ial

under way!• ECHO (Extension for Community Healthcare Outcomes)

• MAT BH Consultant posit ions• Peer Recovery Mentors• Hospital based addict ion medicine consultat ion• Other clinic based groups (art therapy, harm reduction groups)

• Coordinat ion with outside agencies (12-step, housing, Bup friendly tx programs)

• Other Ideas?

Resources