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 opioids, 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 opioid mu receptor. Meaning: it will displace other opioids from the mu receptor resulting in acute opioid 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 opioid 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*