Elephants, eBay, and Outline Lincolns beard Where are we? - - PDF document

12/9/16 1

Elephants, eBay, and Lincoln’s beard

Clinical Review of the Opioid Epidemic

Katherine Grieco DO 12/16

Outline

• Where are we?
• Statistics
• HIV and opiate epidemics
• New wave of opiates
• MAT and other tx considerations
• Now what?

I have no disclosures.

“Now it’s everybody’s problem, got a nation

• n the verge…”
• https://www.youtube.com/watch?v=fYN14UfO-Uc
• Macklemore – “Drug Dealer”

12/9/16 2

Th The ‘State of the Union’

• 21 million Americans have a substance use disorder
• 40% of those with SUD have mental illness
• Less than ½ receive tx for either
• 90% of those who need tx for SUD do not receive it.
• One in 5 Americans have experienced mental illness in past year
• Suicide rate surges to 30-year high (many involve opiates)
• Overdoses (accidental and intentional) d/t Rx opiate pills and heroin

are skyrocketing

Ho How w did did we e get t her here? e?

• “Providers did this.”
• Pharma
• DEA
• America’s perception

This crisis has not yet peaked

Nu Number o

• f O

Opiate P Prescr criptions Di Dispensed

NIH 2014

12/9/16 3

CDC: US Overdose deaths 2005-2014

• 125 Americans die/day from OD, more

than MVA; one every 12-15 min

• 2014 – most overdose deaths than

any other year on record

• 6 out of 10 involved an opiate
• 1999-2012: overdoses with Vicodin,

Percocet, Oxycontin quadrupled

• 2007-2014: heroin use tripled
• 2010 -2014: heroin deaths tripled

BLUE: 4 deaths per 100,000 RED: 20 deaths per 100,000

Growing Epidemic

• Appalachia
• Work-related injuries – blue collar
• Southwest
• Proximity to Mexico
• Northern California

California

• Mostly rural counties
• Mariposa
• Lake
• Plumas
• Humboldt
• Mendocino

BLUE: 4 deaths per 100,000 RED: 20 deaths per 100,000

CDC – Epidemics, HIV V vs Opiates

• Per CDC, similar to HIV epidemic, 1995.
• HIV deaths rose in shorter time frame, more urban.
• Opiate crisis crosses into rural regions
• TOUGHER TO TREAT - ACCESS
• Increase in HIV, MMWR 4/15
• Indiana – Opana
• Increase in HCV, MMWR 5/15
• Appalachia
• 4-fold increase in HCV infections 2006-2012 in 4 states
• Increase in admissions for opiate tx, & injection use
• “Highly correlated with region’s opioid epidemic abuse”

12/9/16 4

Ba Barri rriers s to care – Insurance, finances

• Unequal coverage between MH/SUD and medical care
• Co-pays
• Number of monthly visits limited
• Refusal to cover inpt rehab without completing outpt program
• Longterm Rehabs denying MAT admissions (medication assisted tx)
• ABC documentary – David Muir
• Vermont – tx waiting list of 500 pts, likely wait a year
• Prior authorizations for MAT
• Cigna
• 10/16: Attorney General NY – Eric Schneiderman

Fe Federal Response

• Mental Health and Substance Use Disorder Parity Task Force
• Created by Obama March 2016
• Guidance for health insurers, state regulators
• Enhance parity compliance and enforcement (audits, penalties)
• Raising limit on Suboxone waivers
• Increasing access to Narcan
• DEA – Cut opioid production by 25%
• Affects Schedule II: oxy, hydrocodone, fentanyl, morphine
• CDC pain guidelines
• Downstream Effect
• Surgeon General’s Report on Alcohol, Drugs, Health 11/16
• Facing Addiction in America

Wh Where’s s the mon money?

$

Law Enforcement

Treatment

$

Law Enforcement

Treatment

Recent Future

12/9/16 5

Changing the Language of Addiction

Psych – “schizophrenic” Med – “diabetic”

• JAMA October 2016
• Case vignette – substance abuser vs person with SUD
• Punitive vs therapeutic measures

“Addict” “Dirty” or “clean” urine “Alcoholic” “Crackhead”

Changing the Language of Addiction

• Office of Drug Control and Policy
• Draft – guidance on how to do this
• Clinical, non stigmatizing language
• First person language
• Less shaming words
• National Press Foundation
• Pts often refer to themselves with these terms
• Teaching opportunity

“Addict” vs person who uses drugs (PWUD) “Alcoholic” vs someone who has alcohol use disorder “Crackhead” vs someone who uses cocaine “Dirty” or “clean” urine vs positive or negative for… “Abuse” vs misuse

Synthetic Opiates

Question

• Where are the majority of synthetic opiates and designer drugs

developed?

• A) US– clandestine labs in the Southwest (ie Breaking Bad)
• B) Mexico – highly organized drug cartel (ie El Chapo)
• C) China – chemists browsing old chemistry journals
• D) Middle East – corrupt pharmaceuticals

12/9/16 6

“Flatline, Drop Dead, Bud Ice”

Fentanyl-laced heroin

• New Haven, CT public health emergency
• 6/23/16: ~20 OD, 3 deaths in 6 hours
• Seeking cocaine
• Cincinatti: 174 OD in 6 days
• Massachusetts: 66% OD deaths in 2016
• Pittsburgh: 22 OD in 10 days
• California: Sacramento County
• 10 deaths, 4/16
• Counterfeit Norco M367
• San Francisco: 75 deaths 7/15, most related to fentanyl

Fentanyl

• Fentanyl – 50-100x more potent than heroin
• Very fast-acting, victims OD w/ needle still in arm
• Colorless, odorless
• Per users:
• Looks concrete/gray (vs powder white)
• Tastes bitter
• Sometimes identified by stamp –ladybug
• Laced blotter paper

Send-out urine test

Carfentanil

• Analog of fentanyl
• 10,000x more potent than morphine
• 100x more potent than fentanyl
• Schedule II narcotic, not intended for human use
• Used to tranquilize elephants and
• ther large mammals – Wildnil
• Lethal amount – 2mg
• Lincoln’s beard on penny

Carfentanil

• Case report of veterinarian splashed in face
• Drowsy within minutes and required narcan
• Transported from China and Mexico
• Confirmed cases in OH, FL
• First responders, law enforcement
• Must wear protective gear
• Require several doses of Narcan

to revive

• No way to test in urine

12/9/16 7

W-18

• University of Alberta in Canada, 1981
• Opiate analgesic, no clinical indication – tested only in mice
• Published in journal at the time
• Potency similar to carfentanil
• Researcher Brent Warren
• 2015 – Calvary
• Law enforcement seized several pills laced with W-18
• First publicized seizure in North America
• 2016 – Florida
• Man arrested for possession of W-18
• Starting to creep into the US.
• China
• Rogue chemists search old journals to find compounds they can

synthesize

No way to test in urine

U-47700

• Opioid, 8x more potent than morphine
• 1970’s - Upjohn Pharmaceuticals
• Alternative to morphine
• Identified in 21 states (CA)
• 46 deaths across the US
• NY, NC
• Schedule 1 as of 11/14/16

Counterfeit Xanax

• Cut with fentanyl
• Emerged end of 2015 – several cases in US including

deaths

• Infant ingested pill found on the floor
• Manufacturures bought Xanax stamp on eBay
• Those seeking Xanax aren’t the same

population seeking opiates

• May not have tolerance to opiates
• Results in overdose

Whack-a-Mole

• Poor detection of Synthetic Opiates
• Difficult to detect in bodily fluids
• Concentrations are incredibly low
• DEA is challenged to keep up with analogs

Lethality is exceeding detectability

Educate your patients

analogs

12/9/16 8 Medication Assisted Treatment and

• ther Tx considerations

MAT: Pharmacotherapy plus counseling and behavioral therapies

Question

• Which of the following are currently approved medications for Opioid

Use Disorder?

• A) Methadone, buprenorphine, naloxone
• B) Methadone, buprenorphine, acamprosate, naltrexone
• C) Methadone, buprenorphine, naltrexone
• D) Methadone, buprenorphine, clonidine

MAT for Opiate Use Disorder – Options

Buprenorphine/naloxone (Suboxone, Bunavail, Zubsolv)

• Partial opioid agonist
• Ceiling effect – resp depression,

sedation

• Films or Pills (buprenorphine –

Subutex)

• Office based tx
• Stable pts – no poly drug use,

support system in place , psychologically stable

• MUST be in withdrawal to start
• Probuphine – next slide

Methadone maintenance (MMTP)

• Full opioid agonist
• Higher risk for OD,

sedation

• Liquid form, daily dosing
• Federally qualified OTP

(opiate tx program)

• Highly regulated, structure
• Counseling mandated
• Pts in need of monitoring,

lack of support system, psychologically unstable, failed Suboxone

• Withdrawal not necessary

to start

Naltrexone

• Opioid blocker
• NO risk for OD
• Pill or injection (Vivitrol)
• Office based
• Pts who are having cravings, not

experiencing any withdrawal, not currently using

• Stable pts - no poly drug use,

support system in place , psychologically stable (not for pts who have failed MMTP and/or Suboxone)

Probuphine

• FDA approved May 2016
• Long acting buprenorphine subdermal implant, 6 months
• Physician-certified, minor procedure – upper arm
• Pre-requisite
• Stable on buprenorphine/suboxone 8/2mg daily for at least 3 months
• Still recommend monthly visits for ongoing counseling and

psychosocial support

12/9/16 9

Le Length of Pharma rmacotherapy??

• Highest risk of relapse follows detox – first 90 days
• Beyond 90 days
• Very individualized
• Safe to stay on indefinitely
• Side effects of MAT fairly minimal
• Pts request to stop
• Stable
• Buprenorphine/methadone
• Slow taper recommended

Longterm treatment results in higher rates of recovery

Be Behavioral Treatme ment

• Counseling
• With referral to psych provider as needed
• Coping skills/support
• Inpatient
• Longterm rehab, 30-60 days
• Outpatient
• IOP: intensive outpatient program, 3-4 days per wk x 4-6 wks
• Step-down: 1-2x per week
• AA/NA: voluntary, several groups offered per day

Ty Typical Road to Recovery

• STEP 1: Enter detox (3-5 days)
• Treated with bupe or methadone
• Transfer to bupe maintenance or methadone maintenance
• STEP 2: Inpatient rehab, 30-90 days –OR- IOP
• STEP 3: Sober house, 30-60 days
• STEP 4: Independent housing
• Start Suboxone outpatient without the above.

Resources-SAMHSA

12/9/16 10

Naloxone (Narcan)

• Opiate antagonist – reverses opiate overdoses
• Nasal spray
• Intramuscular injection – auto injector
• Nasal atomizer
• Takes effect within 2-5 min, lasts 45-90 minutes. Rare side effects

Narcan

• Controversy - More Narcan, more overdoses??
• Gov of Maine, Paul LePage
• Vetoed bill to allow OTC access to Narcan 4/16
• 'Naloxone does not truly save lives; it merely extends them until the next overdose.'
• Studies show no clear evidence for increase in heroin use
• Potential lawsuits for NOT prescribing potentially live-saving

medication

Acudetox

• Evidence
• reduce: cravings for alcohol, drugs, nicotine, sugar, withdrawal

symptoms, relapse episodes, anxiety, insomnia, and agitation.

• Auricular points
• 5 points in the ear
• Needles vs seeds
• Vaccaria plant
• Very effective!
• NADA

5 Points -Ear

• ShenMen (Heavenly Gate) –calms the spirit, helps

decrease anxiety, insomnia and pain.

• Sympathetic – balances the sympathetic nervous system,

calms the fight/flight response.

• Kidney – addresses the emotion of fear.
• Liver – detoxifies and unblocks stuck energy (both

emotional and physical), addresses the emotion of anger.

• Lung – “let go,” associated with the emotions of grief and sadness.

12/9/16 11

Before acudetox…

• A typical detox pt

After acudetox…

Ap Apps

• A-CHESS
• GPS – if pt is near a trigger spot, phone will ring – FaceTime with a counselor
• recoveryBox
• Sober Grid

Now what?

12/9/16 12

Ou Our Resp sponse se (as providers/educators)

• Self -educate on SUD
• Online training programs/CME
• Utilize MAT
• Buprenorphine waiver
• Addiction Medicine/Psych Fellowships
• Popping up all over
• Board Certification – ABAM, AAAP
• Medical/nursing schools
• Primary care providers – “it’s my responsibility”
• Buprenorphine training/refer

Ca Call to Ac Action – SAMHSA, ASAM

• Treatment Gap
• Amer Journal of Public Health, 2015
• Almost every state has OUD rates which exceed their buprenorphine

treatment capacity

• Primary care providers
• Don’t want to see “those patients”
• Tx not effective

Ca Call to Ac Action – SAMHSA, ASAM

• Consider…
• You are already seeing those pts
• After 6-12 months in tx:
• 50-80% pts stop using opiates

Compared to…

• DM, 40-70% pts have disease under control, ½ adherent
• HTN, 30-50% pts have BP under control, <30% adherent

PCSS-O website

• Providers’ Clinical Support System for Opioid Therapies
• ‘National training and mentoring project developed in response to

the prescription opioid overdose epidemic.’

• FREE CME: webinars and archived modules
• FREE Buprenorphine Waiver training
• Fulfill state CME requirements for addiction/opiate Rx training
• Free mentoring/support
• PCSS-O.org

12/9/16 13

Re Resources

• ASAM - American Society of Addiction Medicine
• AAAP – American Academy of Addiction Psychiatry
• SAMHSA – Substance Abuse Mental Health Services Administration
• NIDA – NDEWS (National Drug Early Warning System)
• Opioidprescribing.org – Boston University SOM
• PrescribeToPrevent.org
• UCSF Clinician Consultation Center, Substance Use Warmline
• 855-300-3595

Thank you!

Opioid Overdose Prevention Awareness