Buprenorphine in Primary Care ALLISON FOX, FNP OHSU FAMILY - - PowerPoint PPT Presentation

Buprenorphine in Primary Care

ALLISON FOX, FNP OHSU FAMILY MEDICINE AT RICHMOND CREDIT TO: BRIAN GARVEY, MD, MPH

Disclosures

I have no personal disclosures

Objectives

• Introduction and Summarize the problem
• Basics of buprenorphine
• Overview of bupe office visits and
• Medication Assisted Treatment at OHSU Richmond
• Patient case

Survey

How many prescribe buprenorphine?

• SAMHSA - Substance Abuse and Mental Health Services Administration began certifying PAs

and NPs on February 21, 2017. As of August 28, there were 687 certified PAs nationwide and 2,471 certified NPs. SAMHSA says, "More buprenorphine prescribers are needed to combat the opioid crisis and treat substance use disorders, particularly in rural areas."​

• There are 4,393 NPs in Oregon with active licenses (2,383 Family NPs, 352 Adult NPs)
• In June 2018 only 108 Oregon NPs had their X waiver training to prescribe Buperenorphine

Getting x waiver

Must obtain buprenorphine waiver

• “X number” from DEA, 24 hours of training
• Free online training programs available through PCSS-MAT (Providers Clinical Support System)

In Oregon:

• Less than 1/3 of prescribers with X waiver are ACTUALLY PRESCRIBING buprenorphine in some form

Start your first 4 hours on Saturday from 1-5 pm with my colleauges Nick Gideonse, MD and Amanda Risser, MD

The problem

Deaths in Oregon: 513 in last year (Better than FL 5,516: up 29%, OH 5,231: up 31%)

The Crisis

Don’t forget we (providers) helped to create the problem Providers should help fix it

Source: https://www.medscape.org/viewarticle/465833

Reminder that people with higher ACE scores (Adverse Childhood Experiences) >=4 have a 10x greater risk factor for SUD. Abuse (Emotional, Physical, Sexual); Neglect (Emotional, Physical) Household Challenges (Mother treated violently, household substance abuse, mental illness in househood, parents separate or divorce, criminal household member

Basics of opiate use disorder and buprenorphine

What is Opiate Use Disorder (OUD)?

DSM 5 Criteria:

• Taking the opioid in larger amounts and for longer than intended
• Wanting to cut down or quit but not being able to do it
• Spending a lot of time obtaining the opioid
• Craving or a strong desire to use opioids
• Repeatedly unable to carry out major obligations at work, school, or home due to opioid use
• Continued use despite persistent or recurring social or interpersonal problems caused or made worse by opioid use
• Stopping or reducing important social, occupational, or recreational activities due to opioid use
• Recurrent use of opioids in physically hazardous situations
• Consistent use of opioids despite acknowledgment of persistent or recurrent physical or psychological difficulties

from using opioids

• Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or

markedly diminished effect with continued use of the same amount. (Does not apply for diminished effect when used appropriately under medical supervision)

• *Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal (Does not

apply when used appropriately under medical supervision)

2-3 criteria is required for a mild substance use disorder diagnosis, while 4-5 is moderate, and 6-7 is severe

MAT

3 primary components

• Medication
• Counseling/Behavioral Health Interventions
• Support from Family and Friends

3 primary medication options

• Methadone
• Buprenorphine
• Naltrexone

Source: http://www.addictionoc.com/addressing

• opioid-addiction-medication-

assisted-treatment-mat-fears/

Buprenorphine: How does it work?

Buprenorphine has unique pharmacological properties that help:

• Lower potential misuse
• Diminish the effects of physical dependency to
• pioids, such as withdrawal symptoms and

cravings

• Increase safety in cases of overdose

Buprenoprhine is not a substitute for methadone, it is one more choice on the treatment menu Both should be used in a comprehensive treatment setting

Pharmacology

Buprenorphine has a strong affinity (affinity = strength of a drug to physically bind to receptor) to the

• pioid mu receptor. Meaning: it will displace other opioids from the mu receptor resulting in acute
• pioid withdrawal

Naloxone is added to buprenorphine (Combo = Suboxone) to decrease likelihood of diversion. It is taken as SL tabs, not swallowed due to poor GI bioavailability; naloxone SL has no effect Strong affinity for receptor

• Antagonizes fentanyl-associated respiratory depression

“Ceiling effect”

• Lowers risk of misuse, dependency and side effects

Long-acting

• Mean half-life 37 hours, range 20-70 hours

• Opioid receptor is empty: whenever there is insufficient amount of opioid receptors

activated, the person will feel pain. This happens when someone is going through withdrawal

• Once dependent the body cannot produce enough natural opioids to satisfy the new

receptors formed from large doses of opiates over time

Courtesy of NAABT, nc. (naabt.org) The National Alliance of Advocates for Buprenorphine Treatment

• Opioid receptor is filled with a full-agonist.
• The strong opioid effect of heroin and opiates can cause euphoria and will stop withdrawal

for 4-24 hours.

Courtesy of NAABT, nc. (naabt.org)

• Opioids replaced and blocked by buprenorphine.
• Buprenorphine competes with the full agonist opioids for the receptor. Since it has a

higher affinity (stronger binding ability) it expels existing opioids and blocks others from attaching

• As a partial agonist, the buprenorphine has a limited opioid effect, enough to stop

withdrawal but not enough to cause intense euphoria

Courtesy of NAABT, nc. (naabt.org)

• Over time (24-72 hours) buprenorphine dissipates, but still creates a limited opioid effect

(enough to prevent withdrawal) and continues to block other opioids from attaching to the

• pioid receptors. If someone takes opioids they wouldn’t get high
• At a certain point, the increasing effects of partial agonists reach maximum levels and do not

increase further, even if doses continue to rise- the ceiling effect

• As higher doses are reached, partial agonists can act like antagonists- occupying receptors

but not activating them (or partially activating them) but still blocking full agonists

Courtesy of NAABT, nc. (naabt.org)

Treatment

Who’s a candidate?

• Have been objectively diagnosed with an opioid dependency
• Are willing to follow safety precautions for the treatment
• Have been cleared of any health conflicts with using buprenorphine
• Have reviewed other treatment options before agreeing to buprenorphine treatment

Potential pitfalls

Costs and reimbursement (BH, screening, monitoring labs) False positives and negatives, need for confirmation labs DIVERSION – need random call ins! Lack of engagement – we only want people who want the help

What if someone Messes Up?

Consider having agreements and can refer to them if patient violates agreement Use your own judgement if this is helping the patient or not Refer to more intensive (inpatient) treatment if frequent relapses Switch to a harm reduction model and document as such Don’t prescribe for “side effects” of helping with pain or mood

Indications for declining treatment

• Benzodiazepine dependence
• Alcohol dependence
• Failure to commit to frequent check ins or to abstaining from all substances
• Coming to program for pain or because they want more opiates

○ Concern for using buprenorphine to fund other habits (i.e., meth)

• Refuse to acknowledge addiction
• No documented opiate use disorder history

Treating with Buprenorphine

Buprenorphine treatment happens in three phases:

• The Induction Phase: medically monitored- in your office when a person has abstained from

using opioids for 12-24 hours and is in withdrawal. Bupe can precipitate withdrawal if you jump the gun. Not pretty!

○ Dose too high: lethargy, foggy headed, slow moving, nausea, constricted pupils in low light, unmotivated, dehydration, unjustified feeling of contentment ○ Dose too low: sweating, chills, goose bumps, dilated pupils in normal light, diarrhea, cramps, insomnia, nausea, anxiety, depression, CRAVINGS

• The Stabilization Phase: cravings are gone, patient is experiencing few if any side effects.

Dose may need to be changed, delivery (tabs, film, subutex)

• The Maintenance Phase: when someone is doing well on a steady dose of buprenorphine.

You can decide a time frame for bupe treatment, although some people do need lifetime. Time to engage in treatment for rehabilitation to prevent relapse.

Basics of induction

• Must show withdrawal symptoms – in office or in home (COWS) of at least 8. The higher the

better!

• UDS must be negative for methadone
• Administer 4 mg bupe, no food or drink other than water, should feel relief in 40 minutes.
• If more needed, dose another 4 mg. First day typical dose: 8 mg
• Consider prescribing 2-4 mg to be taken later in the evening if needed
• Assess patients response to first day’s dosing. May stay at 8 mg, or increase dose by 2-4 mg on

day 2

• Titrate up, max of 8mg/d on day one, 16mg day 2, 24mg total*

Induction, cont

• Contact frequently for 3-5 days, then weekly, then q1m
• It takes from 3-7 days for steady-state blood levels to be achieved, wait 3 days to make dose

adjustments

• Aim for suitable maintenance dose within 1-2 weeks
• Higher doses more frequently needed for pain, not necessarily higher use (sometimes true)
• If they experience precipitated withdrawal, push through. Administer an additional 2-4 mg of

bupe hourly until symptoms dissipate

When?

Methadone – 30mg or less

• Bupe only until methadone cleared (subutex)
• 36-72 h + after last dose, up to 24 mg bupe on day 1, very close follow up

Heroin – 12 -72 hafter last use – dosing depending on use Long acting (Oxycontin, MS Contin) – 24+h Short acting (oxy, norco, IR) – 12-24h Waiting as long as possible will serve them better

At Each Visit:

❏ UDS at every visit ❏ Ask about any drug use/alcohol use since prior visit ❏ Any cravings? ❏ Home life stable ❏ Work/income stability. Anyone else using at home? ❏ What are they doing to rehabilitate themselves: narcotics anonymous, smart recovery, counseling

Maintenance

Dose stabilization – medication is ASSISTING treatment COUNSELING!!!! At least 6 months, taper when ready, open door to return, risk of relapse even years after

Richmond MAT Program

Richmond MAT: Getting Started

Referrals come from patients, outside and internal providers, drug treatment programs Patient completes application – screened by MAT Patient meets with prescriber (medical risks and diagnoses), nurse/panel manager (treatment plan of program itself) and behavioral health (identifying underlying causes for addiction and motivation for treatment) They MUST have a PCP to keep following for other medical needs to ensure patient engaged in their own health, as well as to address any abnormal labs

Tier System

Tier 1

Intake with entire team, multiple visits to show commitment SHORT prescriptions to increase monitoring More frequent check ins, urine tests, support, behavioral health interventions Minimum 2 weeks to “Graduate” to more leniency Still less intense than methadone programs

• Allows them to focus on TREATMENT (since pill not the treatment, just enables it)

Tier 2 and up

Slowly increase duration of prescriptions to 4 weeks Decrease prescriber visits to 4-8 weeks

• We have not yet done >12 weeks due to provider preference and high risk population

Decrease BH to as needed, always available More visits with ANYONE when requested or needed

• This is why we need YOU

More prescriber visits for changes in doses or other medical needs, if not taken care of by PCP

Taper off?

Overall infrequent, often not a regular conversation until >1 year of treatment High desire to stop, low follow through once patients start feeling withdrawal Slow taper on patient’s schedule, may need to keep them on longer than they wish Open door to return if unable to maintain abstinence on own

• Check if they followed through with the BH support as the actual treatment

The following cases are based on real patients, but some demographics have been changed to protect the patients’ identities.

Patient Example 1

32 yo F Was on chronic opiates (with me) for years for RA, failed to come in for a pill count. When discussing future plan she endorsed while opiates started out being for pain she began to

• veruse. Honest conversation about effort to keep issue under control.

Discussed options, she decided to start bupe She came in looking horrible, in withdrawal. Cows score was over 12. Given 4 mg suboxone, waited 45 minutes-1 hour. She felt a little relief but was still sweaty with an upset stomach. She took another 2 mg. Waited another 30-45 minutes and she took another 2 mg. She walked out smiling and feeling much better.

Success WITH…

Chronic pain, but opiates no longer working

• “I don’t know what could’ve been said to me at the time. I wouldn’t have heard it. I had to hit absolute

rock bottom”

• “I hid my problem from you for years. Part of me was glad when I finally got caught. It was taking over

my life!”

Patient admitted addiction issues

• “You guys are different. I’m used to having to hide or they take away your medication. I didn’t realize

you wanted to help me”

• “I’m SO sorry. You have been so great and I am frustrated with myself for letting you down”
• “Life is so much better – I can play with my kids more”

Thank You

Other Resources

Buppractice.com/resources, including

• New England Journal
• JAMA
• Annals of FM, Annals of IM

Cochrane Review Cantone RE, Fleishman J, Garvey B, Gideonse N. Interdisciplinary Management of Opioid Use Disorder in Primary Care. Ann Fam Med. 2018 Jan;16(1):83. Czerkes M, Blacstone J, Pulvino J. The American College of Obstetricians and Gynecologists: Papers on Current Clinical and Basic Investigation. San Fransisco, US: 2010. Buprenorphine Versus Methadone Treatment for Opiate Addiction in Pregnancy: An Evaluation of Neonatal Outcomes.

Contact me

foxal@ohsu.edu Richmond Clinic: 503-880-9160