12/8/18 Is your patient an Uber driver? Why you should ask. I have - PDF document

12/8/18 Is your patient an Uber driver? Why you should ask. I have nothing to disclose A clinical review of substance use disorders: opiates, benzodiazepines, and alcohol Katherine Grieco DO DABAM Medical Director HAVEN – Health Assistance InterVention & Education Network Connecticut NEJM Outline • October 18 th , 2018 • Treatment models • Brief Updates – Opiates – Benzodiazepines – Alcohol

12/8/18 Addiction Treatment Models • Harm reduction – set of practical strategies and ideas aimed at reducing negative consequences associated with drug use – a movement for social justice built on a belief in, and respect for the rights Opiates of people who use drugs – Moderation Management • Abstinence – complete cessation of alcohol and drugs. • Individualized approach – Safety sensitive occupations • Healthcare professionals • Airline pilots • Construction workers – Risk/benefit ratio CDC: Opioid Overdose Deaths As opioid epidemic levels off, stimulant use rises. Age-adjusted drug overdose death rates, by state: United States, 2016 • 2017: 47,944 OD deaths • 2018: 46,655 OD deaths – ~2.8% drop • Opioid overdoses are not declining, rather, are increasing at a slower rate than they have previously.

12/8/18 CDC: Drug Overdose Deaths, 1980-2016 59,000 to 65,000 Drug overdoses are now the leading cause of people died from drug klkl CDC: Fentanyl Deaths in 2016:Up 540% in 3 Years OD in US in 2016 death among Americans under 50. (provisional data) Peak car crash deaths Deaths involving synthetic Worse than HIV 1972 opioids, mostly fentanyl, jumped from Peak HIV deaths 1995 3,000 to 20,000 in 3 yrs. Peak gun deaths 1993 2017: >72,000 deaths Increase in deaths from Cocaine & meth use from drug OD (often involve opiates) WARNING: Crisis has not peaked (?) 2000 2015 Fentanyl Test Strips Overdose Deaths by Opioid, SF Phillip O. Coffin, MD MIA Chris Rowe, MPH San Francisco Dept of Public Health 250 • Detects presence of fentanyl in drug sample not percentage. 200 • Test drug residue • Brown University study Number of Deaths Total 150 Opioids – young adults reduced overdose risk by using less, going slower or Heroin using with someone else present. 100 Rx Opioids (not fent) • SF DOPE Project survey 8/17-1/18, Harm Reduction Coalition Fentanyl – Positive response 50 • Available at syringe-exchanges 26 22 10 11 8 8 5 5 6 6 6 3 Use of rapid fentanyl test strips among young adults who use drugs; Maxwell S Krieger et al. 0 International Journal of Drug Policy, Oct 18, 2018, https://doi.org/10.1016/j.drugpo.2018.09.009 2006 2008 2010 2012 2014 2016

12/8/18 Kratom Kratom • Tropical tree in Southeast Asia • DEA – 2017: Drugs of Concern List – Eat leaves raw, crush or brewed in tea, tablets, • FDA – NOT approved for any capsules, liquid therapeutic use • Acts on opioid receptors • Legal – buy online – Small amounts -> stimulant – Larger amounts -> sedative – Banned in several states, not CA – Users claim it helps with pain & opioid withdrawal – FDA working with DEA to block shipments into USA. • Symptoms (via case report) 44 Kratom-related deaths 2014-2017 – withdrawal • Send-out test in urine – seizures • CDC – link to Salmonella, CA 13 cases (4/17) – psychosis DSM-5 Criteria for ANY Substance Use Disorder 11 Criteria –Presence of at least 2 for OUD • Missing work or school • Using more than intended • Using in hazardous situations • Trying to quit without success Pharmacotherapy for OUD • Increased drug-seeking behavior • Using despite social or personal problems • Interference with important activities • Craving for the drug • Continued use despite health problems • Build up of tolerance • Withdrawals when trying to quit Mild: 2-3; Moderate: 4-5; Severe: 6 or >

12/8/18 Tx for Opiate Use Disorder – Options 33 yo male with h/o poor engagement in care/? reliability, using illicit oxycodone pills daily and occasional heroin, unable to stop without significant w/d and cravings. Wants to discuss treatment options. If Buprenorphine/naloxone – 1st Methadone maintenance Naltrexone – 2nd he took time off to enter detox, he fears he would lose his job. • Partial opioid agonist (MMTP) – 1st • Opioid blocker • Ceiling effect – resp depression, • NO risk for OD from Nal; risk • Full opioid agonist sedation trying to override blockade • Higher risk for OD, sedation What is the best tx option for him? • Films/Pills/Injectable • Pill or injection (Vivitrol) • Liquid form, daily dosing • Office based tx – requires federal • Office based • Federally qualified OTP (opiate tx waiver to Rx • Pts w/cravings, not experiencing program) • 1) Buprenorphine/naloxone • Stable pts – no poly drug use, withdrawal, not currently using • Highly regulated, structure support system in place, • Stable pts - no poly drug use, • Counseling mandated • 2) Methadone maintenance psychiatrically stable support system in place, • Pts in need of monitoring, lack of • MUST be in withdrawal to start psychiatrically stable (? for pts support system, psychiatrically • 3) Recommend he use Kratom to help with w/d sxs. • Robust data to support efficacy who have failed MMTP/bupe) unstable, Failed bupe • MUST be in withdrawal to start • 4) Naltrexone • Withdrawal not necessary to start • Limited data • Robust data to support efficacy Opiate replacement treatment is associated with reduced mortality, lower HIV transmission, improved social functioning, and reduced criminal behavior. Injectable Buprenorphine Medication for OUD after opiate overdose • Retrospective cohort study n= 17,568 • Extended-release bupe, subcutaneous abdominal • Methadone, buprenorphine, naltrexone monthly injection • Minority received MOUD, ~12% • Moderate to Severe OUD • Buprenorphine and methadone tx associated with reduced all- • Stabilize on 8-24mg oral bupe for at least 7 days prior to starting cause, opioid-related mortality • Induction dose (first 2 months) followed by maintenance dose • California – MediCal covers as of 10/18 – Only available via REMS certified pharmacies/clinics - Sacramento Larochelle MR ; Bernson D ; Land T; et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Ann Intern Med. 2018; 169: 137-145

12/8/18 Extended-Release Naltrexone Improves Viral XR Naltrexone vs Buprenorphine Suppression in HIV+ Prisoners • 2 Double-blind placebo controlled randomized trials • JAMA Psychiatry 10/18/17 • The Lancet 1/27/18 • Open-label, randomized clinical • Open-label, randomized – AUD, OUD trial x 12 wks controlled trial x 24 wks • Incarcerated PLH released into community • N=159, Norway • N= 570, USA • XR-NTX can improve or maintain HIV viral suppression better • Noninferior to • Both medications equally safe than placebo after release to the community. buprenorphine/naloxone and effective – Enrollment followed detox – Ease of induction remains problematic – Avg buprenorphine dose ~ 11mg for XR Nal – No follow up data re: overdose after – Higher relapse rate upfront – No follow up data re: overdose after stopping the medication Sandra Springer et al, Extended-Release Naltrexone Improves Viral Suppression in HIV+ Prisoners. stopping the medication CROI Abstract Number 96, Boston MA 3/18. XR Naltrexone Guidelines Same case but… • SAMHSA - Clinical Use of Extended-Release Injectable • 33 yo male with active OUD. Wants to discuss treatment options. If he took time off to enter detox, he fears it would Naltrexone in the treatment of OUD: A Brief Guide impact his employment/income. He works as an Uber driver. • Office based addiction tx – Comprehensive tx approach What is the best tx option for him? • Counseling • 1) Buprenorphine/naloxone • Psychiatric treatment as needed • 2) Methadone maintenance • OUD suicide risk: 10% vs 1.3% in the gen population • 3) Recommend he use Kratom to help with w/d sxs. • Social support: AA, NA, mutual-help programs • 4) Strongly recommend detox, followed by naltrexone

12/8/18 BZDs and HIV - Studies • BZD use independent risk factor for HIV seroconversion Benzodiazepine use as an independent risk factor for HIV infection in a Canadian setting; Drug and Alcohol Dependence. Volume 155, Oct 1st 2015 Benzodiazepines • HIV infection itself is significant predictor of BZD & Z-drug use – 76.4% of the HIV pts had BZD or Z-drug Rx; psych illness substantial risk factors – Primarily prescribed by nonpsychiatrists; only 31.1% sought mental health support and received Rx from psychiatrists. Benzodiazepines and Z-Drug Use among HIV-Infected Patients in Taiwan: A 13-Year Nationwide Cohort Study; BioMed Research International, Volume 2015 • BZD use is associated with a low quality of life and high HIV-risk behaviors among patients with SUD. Substance abuse and psychiatric disorders in HIV-positive patients: epidemiology and impact on antiretroviral therapy, Drugs, vol. 66, 2006. BZD Categories/Equivalencies Epidemiology • 80% of pts w/ sedative use disorder use other drugs • 30-50% of pts w/ EtOH use disorder who have presented to detox, use BZDs • 44% IV drug users use BZDs – to offset opiate w/d, common practice – to “come down” from a cocaine high • Ratio of 2:1, women:men • Use increases with age • Most frequently abused Rx drug, 2nd to opioids – Rarely the initial or primary substance of abuse