Prescription Drug Summit October 29, 2013 RECOGNITION AND ...

Prescription Drug Summit October 29, 2013

Carl Christensen, MD PhD FASAM [email protected] 734 218 5317 1

Carl Christensen, MD, PhD, FASAM, FACOG Clinical Associate Professor, WSU School of Med Interim Medical Director, Mich Health Prof Recovery Program Medical Director, Tolan Medical Research Clinic Past President, Mich Society Addiction Medicine Pain Recovery Solutions Ann Arbor, MI

RECOGNITION AND TREATMENT OF OPIOID DEPENDENCE: What is Addiction and How Do You Treat It?

Disclaimers

n  Consultant, PCSS n  Consultant, DEA/DOJ n  Consultant, BCBS n  Speaker, Reckitt Benckiser

n  Former: ¡  Methadone provider,

WSU ¡  Medical Director, Dawn

Farm ¡  Associate Prof, WSU

What is Addiction? What is Addiction?

n  Physiologic Dependence? n  Lack of willpower? n  An “amoral” condition? n  A brain disease?

Physiology of Addiction 5

Physiologic Dependence: Tolerance and Withdrawal

n  Tolerance: requiring increasing amounts of drug to get the same effect

n  Withdrawal: the opposite effect of the drug when it is removed

n  NEITHER of these imply chemical dependency (addiction)


Lack of Willpower?




An “amoral” condition?


Brain disease?


The Nucleus Accumbens: GO!!!


VTA: the “gas tank”: supplies dopamine to the Nucleus Accumbens


Frontal Cortex: STOP!!!!


What is the problem?

n  Addiction is not a problem of drug WITHDRAWAL…..

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What is the problem?

n  Addiction is not a problem of drug WITHDRAWAL…..

n  It is a problem of: ¡  CRAVING ¡  LOSS OF CONTROL ¡  COMPULSIVE USE ¡  USE DESPITE CONSEQUENCES

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Drug WITHDRAWAL: Gardner 2006


Drug ADDICTION: Gardner 2006


Why Can’t They Stop?????

n  Alcoholics/addicts who finish treatment will often relapse when they re-enter society.

n  They will almost ALWAYS relapse if they undergo quick detox and re-enter society.

n  But: their withdrawal is gone. n  SO: why do they relapse?????



Abnormal response to Ritalin (methylphenidate) is due to abnormal brain chemistry





“I feel like I don’t belong in my own skin….” anonymous alcoholic

n  Decreased Dopamine receptors =decreased Dopamine =

n Decreased Hedonic Tone

n  Salsitz 2006

Grand Rounds Hutzel 4 17 07 24 Physiology of Addiction 25

Can you find the (alleged) future alcoholic?

Stimulants & Blood Flow


High flow

Low flow

Healthy Control Cocaine-dependent

Gottschalk, 2001, Am J Psychiatry

Blood Flow Recovery


Non users

Cocaine users, 10 days sober

Cocaine Users, 100 days sober

High blood flow

Low blood flow

How Long to recover

from Methamphetamine?

[C-11]d-threo-methylphenidate

Volkow et al., J. Neuroscience, 2001.

low

high Normal Control

Methamphetamine Abuser (1 month abstinent)

Methamphetamine Abuser (14 months abstinent)

SAFETY OF OPIOIDS IN CHRONIC PAIN MANAGEMENT

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Are opioids the culprit? Risks factors in opioid deaths in WV HALL et al, JAMA Dec 10 2008; 300; 22: 2613

Risk Factor Percentage involved History of drug abuse 78 Any diverted meds 63 “Nonmedical” route 22 ≥ 5 Providers 21 Alcohol 17 History of previous OD 17 Illicit drug (Coc, H, meth) 16 Currently enrolled in OTP 4 ANY INDICATOR 95 35

Are opioids the culprit? Risks factors in opioid deaths in WV HALL et al, JAMA Dec 10 2008; 300; 22: 2613

Psychotherapeutic Percentage involved ANY PSYCH MED 49 Diazepam 22 Alprazolam (Xanax®) 18 Other benzodiazepine 2 Antidepressant 16 Other psychotherapeutic (AED, ambien)

5

36

4 prescriptions, 4 providers; dead from overdose.

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The real problem?

38

WHY do doctors over prescribe?

n  The Four D’s: ¡  Dishonest ¡  Dated ¡  Disabled ¡  Duped

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Russell Portenoy MD

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Chronic Pain?

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How to Report…… DISHONEST? n  Allegation Unit n  Bureau of Health Care

Services n  P.O. Box 30454 n  Lansing, 48909 n  (517) 373-9196

DISABLED? n  Michigan Health

Professionals Recovery Program

n  1-800-453-3784 n  WWW.HPRP.ORG

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How do you recognize when you are fueling addiction rather than treating pain? Making the Diagnosis

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ADDICTION ↔ PAIN

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Techniques to Evaluate for signs of addiction in your pain patient

n  Review of Medical Records (refusal?) ◄ n  Physical exam:

¡  Stigmata of addiction: nicotine, opiates, cocaine ¡  Obvious intoxication/withdrawal

n  UDS n  MAPS n  Family interviews n  Multiple visits, evaluate for reliability

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Urine Drug Screens

n  Check for meds that you have been prescribing. (missing meds = malingering)

n  Check for meds that indicate abuse (MJ, cocaine) = addiction

n  Remember your medication may not show up (methadone, fentanyl, suboxone)

n  TELL THE PATIENT YOU ARE TESTING THEM FOR SAFETY’S SAKE

n  TELL THEM YOU PRACTICE UNIVERSAL SCREENING!

Holy Trinity

53



Reliance on Self Report??

n  Of 400 methadone maintained patients tested with saliva screening who denied recent drug use: ¡  30% were positive for cocaine ¡  14% were positive for heroin

¡  Cone, 2011 59 60

How do you make the diagnosis of addiction?

n  Rule out a pure pain diagnosis ¡  You can have both!!!!

n  Rule out malingering (selling) n  Use the DSM IV/V criteria or the 4 C’s:

n  (Craving, Compulsion, loss of Control & use despite Consequences)

n  Keep asking yourself if you made the right diagnosis

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Addiction with Secondary Gain (“Drugstore Cowboy”)

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Addiction with Secondary Gain: Warning Signs

n  Friday afternoon appointments n  Can’t tell you who their referring doc

was n  Just moved from “out of state” n  Vague complaints, normal physical

exam n  Asking for specific narcotics by name n  Most prognostic sign…….

Pregnant?

64 65

“Doctor, am I going to become addicted?”

n  Overall: the incidence of iatrogenic addiction in the chronic pain patient is low.

n  The initial estimate was 1/1000!!! n  BUT:

¡  The incidence of addiction in the chronic pain population is similar to the general population (15%).

n  SO: EXPECT >5% OF YOUR PATIENTS TO SHOW ABERRANT BEHAVIOR

Aronoff, 2000; Heit, 2004; Porter, 1980



What do you do when you realize you are fueling addiction rather than treating pain?

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ADDICTION ↔ PAIN

Do NOT continue to prescribe!

n  “Impression: ¡  Opioid

dependence”. n  Plan:

¡  “Methadone 10 mg tabs, #240, return one month.”

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TREATMENT OF ADDICTION

n  Behavioral: counseling n  Spiritual: 12 step meetings n  Surgical: gastric bypass surgery n  MEDICAL n  The “Gold Standard” of Treatment


Twelve Step Programs


AA involvement in Veterans 1987, 1988 “Dose Response Curve”



Does 12 step help opioid and cocaine dependence?

Drug No mtgs % < 1 week % > 1 week % Odds Ratio Opiates 38 41 81 6.2* Stimulants 28 52 80 2.9 (NS) Alcohol 25 33 65 9.6*

74

% abstinent, *p ≤0.01 Gossop, 2007

TREATMENT OF ADDICTION: Medical

n  Agonists: similar to the “drug” ¡  Suboxone for opiate dependence ¡  Methadone for opiate dependence ¡  Nicotine patches for tobacco dependence ¡  THC for marijuana dependence ¡  Dilaudid for heroin dependence! (Canada)


TREATMENT OF ADDICTION: Medical

n  Antagonists: opposite effect of the drug ¡  Naltrexone for opiate dependence

n  Oral: Rivea n  Injectable: Vivitrol

¡  NOT A NARCOTIC ¡  CANNOT BE DIVERTED


Agonists vs. Antagonists

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Drug Type Analogy Methadone Full Agonist High Octane Buprenorphine Partial Agonist Low Octane Naltrexone/Naloxone Antagonist Water

BOTTOM LINE:

n  In both controlled and retrospective studies, the success rate for most medications is between 40 and 60% (one to two years).

n  When patients come off the medication, they relapse.

n  Relapse may be associated with an increased chance of overdose and death. Physiology of Addiction 78

Benefits of Methadone Salsitz, ASAM, 2012

n  Reduction in death rates (Grondblah, 1990) n  Reduction in IVDU (Ball & Ross, 1991) n  Reduction in # of crime days (Ball & Ross) n  Reduced HIV seroconversion / HCV

conversion n  IMPROVED OUTCOME AFTER

INCARCERATION



Ball 1988: reduction in IVDU

ORT: yes or no??? 80

Ball 1988: reduction in IVDU


Ball 1988: resumption of IVDU!


Ball 1988: resumption of IVDU!


Problems with methadone

n  Requires initial daily dosing first 90 days. n  Must be “clean” for 2 years before you can

dose monthly! n  Methadone clinics may be a source of “wet

faces and wet places” n  Employers will frequently test for methadone

and not employ methadone users, even if they are negative for other drugs.

Problems with methadone: detox

n  Withdrawal from methadone is long lasting and difficult to handle

n  Clients will frequently take months to over one year to detox off methadone

n  Relapse while detoxing off methadone is common

n  Overdose and death may occur if the addict returns to using during this time



Buprenorphine (“Suboxone®/Zubsolv®”)

�  A partial opiate agonist (less potent) ◦  Less analgesic effect ◦  Less respiratory depression ◦  <100 documented deaths in the U.S.

(Soyka); 4000+ PER YEAR WITH METHADONE

◦  Treats both pain and opiate dependency �  Different formulations are approved

Addiction and Pregnancy 87

Buprenorphine long-term follow up: Fiellin, 2008

Concerns about Suboxone

n  It can be abused (mostly for withdrawal)

n  It is unsafe when combined with sedatives & alcohol.

n  It is an opioid. n  Relapse rates after detox exceed

90%. (Weiss, 2011)

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Vivitrol® (injectable naltrexone) for opioid dependence

Vivitrol: abstinence Vivitrol: craving



Vivitrol: concerns

n  As with methadone and buprenorphine, when the medication is stopped, relapse may lead to death due to lack of tolerance.

n  It is difficult to treat acute pain while on Vivitrol.

The GOLD STANDARD of treatment: 85% success

n  Pilots, Lawyers and Healthcare Prof. n  Continuous monitoring: 3 to 5 years. n  Therapist, Group, 12 step, sponsor n  Immediate intervention for relapse n  Graded response n  Why does it work? IQ?

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The GOLD STANDARD of treatment: 85% success

n  Hawaii's Opportunity Probation with Enforcement (HOPE) ¡  Continuous monitoring ¡  Treatment / 12 step ¡  Rapid consequences ¡  Graded response

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Can you detox?

Doc, when can I get off this sh*t?

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n  101 women underwent detox during pregnancy

n  40 successfully detoxed. n  No adverse fetal effects documented

n  Luty et al, J Sub Abuse Treat 24 (2003); 363 - 367


Maintenance vs. Detox?

n  40 heroin addicts were started on Suboxone.

n  20 were “detoxed” off and offered counseling.

n  20 were kept on Suboxone and offered counseling.

n  A year later…….




102 ORT:

yes or

no???

103 ORT:

yes or

no???

Why Treat Addiction?

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Drug Dependence, a Chronic Medical Illness: McLellan 2000

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n  Only about 40% of patients will be abstinent at one year after treatment.

n  Failure rates may be due to lack of aftercare, often due to insurance difficulties

n  Low economic status, psych comorbidity and lack of family/social supports also predict relapse.

n  Relapse is often viewed as “inevitable” and drug dependence as “hopeless”*

Drug Dependence, a Chronic Medical Illness: McLellan 2000

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n  ONLY 60% OF TYPE I DIABETICS ADHERE TO MEDICATION SCHEDULE

n  LESS THAN 40% OF ASTHMATICS ADHERE TO TREATMENT REGIMEN

n  LESS THAN 40% OF HYPERTENSIVES ADHERE TO THEIR TREATMENT REGIMEN

n  DRUG DEPENDENCE =40 TO 60% ADHERENCE

Addiction: a chronic illness

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n  If you were to stop taking your insulin, and you wound up in a coma in the ICU, your doctor would say:

n  “you need to go back on insulin! You could have died!”

n  If you were to stop your Suboxone/methadone/12 step treatment, and wind up in the ICU, your doctor would say:

n  “You’re an addict. You’re hopeless!!!!!”



Chronic, Treatable but Incurable Diseases

n  Obesity n  Hypertension n  Diabetes n  Asthma n  Addiction


Contact info: Carl Christensen

n  [email protected] n  Cell: 734-‐218-‐5317 n  Patients: 734 448 0226


Prescription Drug Summit October 29, 2013 RECOGNITION AND ...

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