The Physician’s Role in Combating the Opioid Crisis

Eric Barker, M.D. Medical DirectorDayspring Clinic - Logan

Learning Objectives:

• -Brief overview of how the opioid crisis developed

• -How physicians can help with prevention

• -How physicians can help reduce opioid availability

• -Intermountain’s efforts to reduce opioids

• -MAT (medication assisted treatment) and how physicians can help expand opioid addiction treatment options

Disclaimer: I am not anti-opioid, I am pro-caution

• There are legitimate medical uses for opioids

• We’re starting to see problems with doctors being too afraid to use opioids in instances that they are appropriate

• Also pharmacies refusing to fill, such as the president of the AMA’s meds

• If we use opioids properly, with fear and trembling, we can do it right

Brief overview of how the opioid crisis developed

How the opioid crisis developed

• This is our third or fourth opioid crisis

• Be on the watch for a cocaine and methamphetamine problem coming

I believe in systems issues as the main source of bad outcomes

• Every system is perfectly designed to get the results it gets

• And the system that was in place essentially ran amok

New England Journal of Medicine letter to the editor- 1980

• 11 lines of the proverbial butterfly flapping its wings that would create a devastating hurricane

This somehow became a “landmark study”

• It has been cited over 600 times in other medical articles

• 72% of those cited it as evidence that opioids are not addictive

• 80% of these did not mention at all that these were HOSPITALIZED patients, NOT OUTPATIENTS

Academics also were pushing to use more opioids

• The American Pain Society pushed the idea very hard that pain was the “5th Vital Sign”

• JCAHO signed onto this idea and included it in inspections

• This was a terrible idea: pain is neither vital, nor a sign

If opioids were not addictive, they were underutilized

• It moved from just palliative care and hospice…

• Onto cancer pain…

• Onto acute pain…

• Onto chronic pain…

• Onto regular pain…

• Onto a crisis…

• JCAHO literally made pain control a RIGHT

Industry has come under scrutiny and multiple lawsuits

• "It would be extremely dangerous at this early stage in the life of the product to make physicians think the drug is stronger or equal to morphine….We are well aware of the view held by many physicians that oxycodone [the active ingredient in OxyContin] is weaker than morphine. I do not plan to do anything about that.”

• -Michael Friedman

• "I agree with you. Is there a general agreement, or are there some holdouts?”

• –Richard Sackler

As the problem developed industry fought back

• “We have to hammer on the abusers in every way possible. They are the culprits and the problem. They are reckless criminals.”

• Mr. Sackler, CEO Purdue Pharma, 2001

Interestingly, it wasn’t really such big news initially

• There was shame and stigma about misusing the medications, and individuals and families generally hid it and did not talk about it

• When I arrived in New England in 2013 the 2014 State of the State address by the governor was about one issue: Vermont’s opioid problem

• Once presidential hopefuls started descending upon New Hampshire in 2015, town halls brought the issue of opioids front and center

Severe Opioid Problem in UT• National Comparisons

• 2013 - #5 for overdoses per capita• 22.1 per 100,000

• 2014 - #7 for overdoses per capita• 22.4 per 100,000

• 2015 - #9 for overdoses per capita• 23.4 per 100,000

• We are not better! Others getting worse

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How physicians can help with prevention

Physicians need education

• I attended a top medical school, and got very little addiction training in 2011… but plenty of opioid pain management training

• The state has now mandated opioid training as part of medical education for licensure

• Many institutions and medical specialty boards are requiring safety training on how to prescribe opioids

Physician addiction education must become a priority

• Now medical schools are including this in their curriculum

• However, many practicing physicians don’t know how to deal with a patient who is demonstrating signs of abuse, and just cut them off

• Helping physicians learn about what treatment and recovery look like, and not to panic if a patient is showing addictive behaviors, is key

I believe physicians should risk stratify patients, wisely

• Does the patient have:

• a mental health condition

• a personal history of substance abuse

• a family history of substance abuse

• any trauma in their past

• age less than 25 years old

• any medical issues that could be problematic

• other medications that may interact with opioids

Physicians need to educate patients on use

• People need to be aware that these are the medications are killing tens of thousands of Americans

• Patients should be given Narcan

• Patients should know this is to make pain just tolerable, not zero

• If it’s making someone feel “good” emotionally, watch out

• Patients should know this is for PAIN, not anxiety or sleep or others

• Patients should know this can lead to DUI, and sharing it is illegal

Physicians need to educate patients on storage

• Many patients just share opioids with friends and family unwittingly, and that often leads to abuse and addiction

• Patients should know, this can easily kill your children (or dog)

• Patients should know that teenagers or thieves want their meds

• Patients should know to lock the meds, and the dispose the meds

Physicians should watch for warning signs, wisely

• Is the patient using more than prescribed

• Is the patient asking for early refills or higher doses

• Is the patient getting extra from other sources

• Is the patient’s pain extending longer than expected

• Does the patient talk about “it doesn’t hit me fast enough”

• Does the patient say “it’s the only thing that works”

• Does the patient show signs of intoxication or physical withdrawal

• Does the family express concerns

• Are there other substances on urine toxicology

Accountability for medication should be implemented

• For clinics that have patients on chronic opioids, random call backs and drug screens are helpful… and do observed urines

• Bringing all medications to appointments is helpful

• Hospice should not be a buffet of opioid medications, if they “probably won’t need this much”, don’t give them that much

• I find automated pill dispensers useful

• I expect that a new higher technological standard will arise in controlled substance monitoring, and a company based in Utah called Counted is an example

Accountability example for $100

Counted

How physicians can help reduce opioid availability

Prescriptions should be done cautiously

• Physicians should check the controlled substance database

• Prescriptions should be short, not a month long initially

• Prescriptions should not have any initial refills

• Refill dates should be strictly observed

• Yes, this takes some extra time, but a stitch, in time, saves nine

Less Abusable versions of opioids should be sought

• Crush proof

• Tamper proof

• Time delayed release

• Naloxone embedded

• Self-destructing

• Other ideas and ongoing research are in the works

Alternatives to opioids should be considered

• NSAIDs are actually extremely effective

• SNRI’s

• Gabapentinoids

• Physical therapy, AND TALK THERAPY

• Weight loss, capsaicin,

• Massage, TENs, acupuncture, hot and cold

• And much research is ongoing in this area

• And, dare I say it?…

Alternatives to opioids should be considered

• NSAIDs are actually extremely effective

• SNRI’s

• Gabapentinoids

• Physical therapy, AND TALK THERAPY

• Weight loss, capsaicin,

• Massage, TENs, acupuncture, hot and cold

• And much research is ongoing in this area

• And, dare I say it?… CANNABIS (CBD ESPECIALLY)

Living Well with Chronic Pain Course

• Every Monday evening, beginning April 15 from 6 PM to 8:15 PM, for 6 weeks

• FREE!!

• (1) Register Online

• • go to “LivingWell.Utah.gov”

• • scroll down to “Pain Management” and click “Search”

• • find the “Logan Regional Hospital” location

• • select “Register”

• Or (2) Contact - Marilyn Peterson at lwwcc2challenge@gmail.com

• or (435) 720-8108

Intermountain’s efforts to reduce opioids

Current efforts at the medical group

• Increase medication disposal drop boxes (collected 26,000 lbs)

• Distribute naloxone kits… (5,000… I have to ask, why is this so hard?)

• Increase caregiver education

• Increase patient education

• Increase access to MAT, the gold standard treatment (up over 10%)

• Decrease number of tablets prescribed by 40% (down 3.8 Million)

• Decrease number of new prescriptions

Current efforts at insurance group: soft rejections & PAs

• Unless a patient is on hospice or cancer care:

• Multiple long acting opioids – soft reject

• 90 MME dosing – soft reject

• 200 MME dosing – prior authorization

• Concurrent benzo and opioid – soft reject

• Pediatrics – prior authorization

• Pregnant – prior authorization

• Dentist prescribers- can only start with 3 day supply

MAT (medication assisted treatment) and how physicians can help expand opioid addiction treatment options

Fivethirtyeight.com: the best article I have found so far

•What Science Says To Do If Your Loved One Has An Opioid Addiction

• By Maia Szalavitz

• Published Jul. 19, 2016

Treatment Options

• Talk Therapy • Medication

• Reaches Frontal Brain

• Reinforces rational thinking

• Helps prevent relapse

Talk Therapy

• One on one with professional• Group based, professionally led• Peer supported, group based• As an FDA approved therapy app• reSET-O• … and it offers a full program of

CONTINGENCY MANAGEMENT!

Talk Therapy for Addiction is Available in Various Settings

Medications

• Reach midbrain/limbic brain• Regulate brain’s reward system• Normalize system

Isn’t this just trading one addictions directly for another?

• Why would giving someone an opioid medication, treat opioid addiction?

• It’s long acting, not the damaging up and down of street drugs

• The brain re-equilibrates the reward system, metabolism, decisional capacity, and stress response system on the treatment medications.

Now a thought experiment

• Imagine that you have not eaten in 2 days.

• You have been working hard and burning calories. Your stomach is growling, you are starving.

• Now think about a piece of pie and ice-cream. You crave it, it would taste so good, it would be so enjoyable.

• Now envision you just finished Thanksgiving Dinner

• So full – you can’t move• Food receptors – fully saturated • Pie and ice cream – Sound repulsive• You don’t want any more food. If you ate

it, it would not be enjoyable.

• Patients have a hunger for the drug

• Giving patients methadone or buprenorphine oConsistently full of opioids

oOpioid receptors = saturated• No Cravings

• Using = No reward

• This is why medications work

Satiating Addiction Cravings

Non-medication treatments are good for many addictions, BUT…

“For opioid addiction itself, however, the best treatment is indefinite, possibly lifelong maintenance with either methadone or

buprenorphine. That is the conclusion of every expert panel and systematic review that has considered the question — including the World Health Organization, the Institute of Medicine, the National Institute on Drug Abuse, and the Office of National Drug Control Policy.”

• Maia Szalavitz, award winning journal and author on the issue of addiction

Gavin Bart, MD, Director Division of Addiction Medicine, University of Minnesota

• “…When used alone [non-pharmacological interventions for opiate addiction] should be considered to lie outside the domain of first-line evidence based treatment. Historical data indicate poor outcome in patients provided only psychosocial interventions. Whether compelled or voluntary, return to opiate use approaches 80% within two years of intensive residential treatment.”

• HAZELDEN HAS ADOPTED MAT FOR OPIOID USE DISORDER!

There are three FDA approved medications for Opioid Addiction

• Long acting injectable naltrexone, buprenorphine, and methadone

Buprenorphine:

• Decreased overdoses 80% in France

• Kakko et al: 1 year 75% retention versus 0%, 0% deaths versus 20%

• Decreased all cause mortality more than 2 fold (120,000)

• Increases retention in treatment about 2 fold (1,000)

• Medication taper only has same high rates of treatment failure as non-medication treatment, over 90%

• Maintenance treatment is the key, not less than a year

Methadone- Only available in special programs

• Decreases all cause mortality more than three fold (120,000)

• Compared to psychological treatment only, methadone treatment reduced rates of death by 50% (150,000)

• Increases retention in treatment by 3.5 fold

• Medication taper only has same high rates of treatment failure as non-medication treatment, over 90%... EVEN 6 MONTH TAPER

Cochrane and other reviews show medication treatment matters

• Reduces HIV and Hep C rates

• Reduces overdose rates

• Reduces overdose deaths by 50%

• Reduces crime and recidivism

• Reduces illicit opioid use

• Increases retention in treatment by three-fold

• They consider it a settled question and say that we don’t need any more studies; that’s how strong the evidence is.”

• Dr. Mark Willenbring, former director of treatment research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA)

• Opioids – MOST lethal addiction

• MAT – Reduces deaths by over 50%

• Strong science and evidence• MAT is gold standard

• Can’t help dead people

• Dr. Mark Willenbring –

• The question is settled

Medication TherapySAVES LIVES!

The best thing physicians can do in my opinion

• Get trained and X-waivered to become a buprenorphine prescriber

• Get patients addicted to opioids onto Sublocade

“The data on opioid substitution is that they produce an 80

percent decrease in drug overdose death, period. Imagine it’s

1995, at the peak of the HIV/AIDS epidemic, and we have a cure

that works in 80-plus percent of people and we’re debating

whether we want to give it to people.”

-Atul Gawande, MD

Atul Gawande, MD

• We are opening a full Opioid Treatment Program in Logan, UT

• Accepting transfer patients March 25, 2019

• Accepting new patients April 8, 2019

Intermountain Dayspring Clinic• Opioid Treatment Program

• Intermountain Healthcare's First full OTP• On Logan Region Hospital’s Campus• Full Range MAT opioid treatment options• Therapy and counseling• Additional services

• Logan is the largest metro area in Utah without easy access to a full opioid treatment program

• Opioid treatment programs are the most economical way to treat opioid addiction

What is an Opioid Treatment Program• A comprehensive treatment program addressing medication,

counseling, medical issues, and social services• The program includes:

• medical evaluation• laboratory testing (HIV, TB, Hep C, STDs)• group counseling (various group structures: trauma,

men’s, women’s, etc.)• random drug testing• individual counseling• dispensing medication (methadone, buprenorphine)• psychosocial support services (housing, educational,

vocational)

Questions?

• Thank you

Call 435 -716 -1320 to schedule patient intakes