Treatment and Interventions for Opioid Addictions: Challenges From - - PowerPoint PPT Presentation

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Treatment and Interventions for Opioid Addictions: Challenges From the Medical Director’s Perspective

Dale K. Adair, MD Medical Director/Chief Psychiatric Officer OMHSAS

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Treatment and Interventions for Opioid Addictions: Challenges From the Medical Director’s Perspective

Dale K. Adair, MD Medical Director/Chief Psychiatric Officer OMHSAS

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

None

Conflicts of Interest

Warning Signs

Tom Corbett, Governor Beverly Mackereth, Acting Secretary Dennis Marion, Deputy Secretary OMHSAS

• Diagnosis
• Scope
• Treatment Options
• Challenges

Overview

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Drug Utilization

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Month Illicit Drug Use among Persons Aged 12 or Older: 2012

Heroin Use Statistics

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Month Illicit Drug Use among Persons Aged 12 or Older, by Age: 2011 and 2012

Drug Utilization

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Month Illicit Drug Use among Persons Aged 12 or Older, by Race/Ethnicity: 2002-2012

Drug Utilization

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Month Illicit Drug Use among Persons Aged 18 or Older, by Employment Status: 2011 and 2012

Past Month Drug Use

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Month Illicit Drug Use among Persons Aged 12 or Older, by County Type: 2012

Past Month Drug Use Age 12 and older

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2011-2012

Pain Relievers-Nonmedical Use

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

among Past Year Users Aged 12 or Older: 2011 2012

First Specific Drug Associated with Initiation of Illicit Drug Use among Past Year Illicit Drug Initiates Aged 12 or Older: 2012

Illicit Drug Use Age 12 or older

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Year Initiates of Specific Illicit Drugs among Persons Aged 12 or Older: 2012

Specific Illicit Drugs

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Illicit Drugs-Age Specific

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Mean Age at First Use for Specific Illicit Drugs among Past Year Initiates Aged 12 to 49: 2012

Treatment Locations

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Locations Where Past Year Substance Use Treatment Was Received among Persons Aged 12 or Older: 2012

Most Recent Substance Treatment

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Substances for Which Most Recent Treatment Was Received in the Past Year among Persons Aged 12 or Older: 2012 Past Year among Persons Aged 12 or Older: 2012

Recent Treatment-Pain Relievers

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Received Most Recent Treatment in the Past Year for the Use of Pain Relievers among Persons Aged 12 or Older: 2002-2012

Drug Dependence or Abuse

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Single Day Counts

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Buprenorphine Treatment

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Illicit Drug Dependence or Abuse

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Year Drug Use Treatments

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Overdose Deaths in PA

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Overdose Deaths in Pennsylvania

• In 1990, note for the 64 grey counties, the death rate is too low to be

accurately counted, at less than 3 deaths per 1,000 citizens. The state average is 2.7 deaths per 1,000 citizens, so any colored counties are above average, while grey is below average.

Overdose in PA

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

In 2000, note for the 52 grey counties, the death rate is too low to be accurately counted, at less than 3 deaths per 1,000 citizens. The state average is 7.4 per 1,000 citizens, so the light blue, yellow and orange counties are above average, while grey and dark blue are below average.

Prescription Opioids Use

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Prescription opioids frequently used by adult

enrollees

– 28.3% with any short-acting use in 2012 – 1.8% with any long-acting use

• Most use for short duration

– 40.8% filled single prescription in 2012 – 65.3% had <30 days supply

*Julie Donohue, PhD Associate Prof University of Pittsburgh

Prescription opioids: use

Prescription Opioids

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Prescription opioids: the prescribers

• Primary care, emergency medicine physicians, dentists are top

prescribers – 48% opioid prescribers are PCPs – 22% are EM physicians – 17% are dentists

• These three specialties write 84% of opioid scripts

– PCPs write 65% of scripts – ED physicians write 10% – Dentists write 9%

*Julie Donohue, PhD Associate Prof University of Pittsburgh

Medication Misuse

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Misuse is defined as non-adherence to prescription directions and can be either willful

• r accidental.

One-quarter of the prescription drugs sold in the United States are used by the elderly, use more meds than any other age group. Older adults are likely to experience more problems with relatively small amounts of medications because of increased medication sensitivity as well as slower metabolism and elimination. Factors associated with prescription medication misuse and abuse by older adults include female sex, social isolation, history of substance use or psychiatric disorder, poly-pharmacy, and chronic medical problems. Commonly prescribed drugs with misuse potential include those for anxiety, pain, and insomnia, such as benzodiazepines, opiate analgesics, and skeletal muscle relaxants.

Risks Populations

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Who is at greatest risk for medication misuse/abuse?

• Factors associated with prescription drug misuse/abuse

in older adults – Female gender – Social isolation – History of a substance abuse – History of or mental health disorder – older adults with prescription drug dependence are more likely than younger adults to have a dual diagnosis – Medical exposure to prescription meds with abuse potential

(Source: Simoni-Wastila, Yang, 2006)

Emergency Department Use

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Emergency Department (ED) Use Related to Misuse/Abuse

• One fifth of ED visits involving prescription medication

misuse/abuse among adults were made by persons aged 70 or

• lder
• Medications involved in ED visits made by older adults:
• Pain relievers (43.5%)
• Medications for anxiety or insomnia (31.8%)
• Antidepressants (8.6%)
• In 2008, there were 256,097 such visits, representing an increase
• f 121.1 percent
• 37.5% were admitted to the hospital

SAMHSA, DAWN Report, 2010

Simple vs Brief Intervention Referral

Intervention Referral

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Attended 1st Appointment Motivational Session 70% Control Group 32%

p = .006

Zanjani F, Oslin D (2005). Telephone Based Referral-Care Management. Grant Supported by Philadelphia Veteran’s Affairs: Mental Illness Research Education and Clinical Center (MIRECC)

Brief Advice

Brief Advice

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Shown to decrease drinking and adverse

health outcomes

• Two components:

– Advice – Link drinking to health

• Recommended by the US Preventative Task

Force

Overdose Deaths in Pennsylvania

Overdose Deaths In Pa

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Age Group Number of Deaths Population Rate per 1,000 0-4 1 723,886 ### 5-9 748,257 ### 10-14 784,882 ### 15-19 40 886,367 4.5 20-24 161 884,157 18.2 25-29 243 796,493 30.5 30-34 252 750,522 33.6 35-39 175 729,924 24 40-44 235 846,199 27.8 45-49 294 926,744 31.7 50-54 239 989,054 24.2 55-59 154 904,747 17 60-64 58 790,089 7.3 65-69 23 564,602 4.1 70-74 8 435,334 ### 75-79 8 357,151 ### 80-84 5 308,139 ### 85+ 13 316,339 4.1

Based on Pennsylvania Department of Health data, overdose deaths in 2011 have the highest rates in age 30-34. These rates decline with age, but increase again after age 85. Rates among

• lder adults are on the rise.

Overdose Deaths in Pennsylvania

Yearly Statistics in Pa

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Drug Overdose Deaths in Pennsylvania

Year Number of Deaths PA Population Rate per 1,000

2011 1,909 12,742,886 15.4 2010 1,550 12,702,379 12.5 2008 1,522 12,448,279 12.6 2006 1,344 12,440,621 11.2 2004 1,278 12,406,292 10.6 2002 895 12,335,091 7.5 2000 896 12,281,054 7.4 1998 628 12,001,451 5.4 1996 630 12,056,112 5.4 1994 596 12,052,410 5.1 1992 449 11,995,405 3.8 1990 333 11,881,643 2.7

• Based on Pennsylvania Department of Health data, overdose deaths have been on the rise over

the last two decades with an increase in the rate of death from 2.7 to 15.4 per thousand Pennsylvanians

Opioid Use Disorder

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• 1. Opioids are often taken in larger

amounts or over a longer period than was intended.

• 2. Persistent desire or unsuccessful efforts

to cut down or control opioid use

• 3. Great deal of time is spent in activities

necessary to obtain the opioid, use the

• pioid, or recover from its effects
• 4. Craving, or a strong desire or urge to

use opioids

• 5. Recurrent opioid use resulting in a

failure to fulfill major role obligations at work, school, or home

• 6. Continued opioid use despite having

persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids

A problematic pattern of opioid use leading to clinically significant impairment or distress is manifested by two or more of the following within a 12-month period:

• 7. Important social, occupational, or

recreational activities are given up or reduced because of opioid use.

• 8. Recurrent opioid use in situations in

which it is physically hazardous

• 9. Continued opioid use despite

knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

• 10. Tolerance
• 11. Withdrawal

Opioid Treatment

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Medication Assisted Treatment

– Opioid Agonist – Opioid Antagonist

• Drug-free (Medication-free) Treatment

Overview of Medications for Opiate Assisted Treatment

Overview of Medications for Opiate Assisted Treatment

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Methadone Buprenorphine Naltrexone Vivitrol Pro

• Prevents withdrawal

symptoms

• Decreases risky behavior
• Decreases criminality
• Allows counseling
• Promotes access to

medical/psychiatric care

• Promotes rehabilitation
• Cost as low as $5 per week
• Dose: Most patients receive

80-125mg/day but some receive as much as 325mg/day

• Less tightly controlled than

methadone

• Lower potential for abuse and are

less dangerous in an overdose

• Progress in therapy may allow for a

take-home supply of the medication

• Prevents Withdrawal
• Prevents “Craving”
• Does not produce a “High”
• Blocks or reduces the effect of

heroin

• Reduced diversion issues
• Fewer transportation issues
• Better compliance than methadone
• Dosing every 2-3 days
• No opiate effect

“benefits” (i.e. high)

• More limited side

effects

• Helps manage

cravings/ relapse risk

• Benefits found for

multiple addictive behaviors including

• piates, alcohol and

gambling disorders

• Used to treat alcoholism

and heroin addiction

• Monthly injections block

the brain’s ability to get intoxicated or high

• Prospective clients must

be sober for at least 7 days prior to beginning treatment

• Has other side effects

like other medications

• Improved compliance

Con

• Diversion potential
• Abuse Potential
• Does not address the

effects/use of other substances (e.g. alcohol or benzos)

• Daily dosing requirements
• Transportation issues for daily

dose

• Intense withdrawal from

medication

• Higher cost
• Does not address the effects/use of
• ther substances (e.g. alcohol or

benzos)

• Note: Suboxone consists of a

combination of Buprenorphine and Naloxone

• Possible dysphonic

effects

• High non-compliance

rates (self administered, so it is easy to stop)

• Early gastrointestinal

discomfort

• Expensive for those without

insurance coverage ($800- 1200/month avg.)

• High Cost

• 65 free standing clinics and 4

hospital based

• Serving over 14,000 individuals

NTP

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Understanding Older Adults w ith Behavioral Health Needs Pennsylvania Osteopathic Fam ily Physicians Society August 2, 2014

Tom Corbett, Governor Beverly Mackereth, Acting Secretary Dennis Marion, Deputy Secretary OMHSAS

Long Term Care Delivery System Sub-Committee Long Term Care Delivery System Sub Committee

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Understanding Older Adults w ith Behavioral Health Needs Pennsylvania Osteopathic Fam ily Physicians Society August 2, 2014

Methadone Clinics by County

Opioid Agonist

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Methadone

• A meta-analysis of 1969 participants in 11 randomized trials

compared methadone maintenance therapy to placebo or non- medication treatment for opioid dependence (Mattick BP et al, Cochrane Database Sys Rev 2009)

• A 10-year follow up study of 405 patients randomly assigned to

receive either methadone or buprenorphine found an association between the duration of treatment with either medication and lower rates of mortality. (Gibson A., et al, Addiction 2008)

Methadone

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Prescribed by NTP
• Usually 80 – 120 mg daily
• Side effects include constipation, mild

drowsiness, excess sweating, and peripheral edema

• Arrhythmias
• Overdose

Buprenorphine

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Partial Opioid Agonist
• Schedule III
• A meta-analysis that included 4497 participants in

24 randomized trials found that sublingual buprenorphine improved treatment retention and reduced opioid use in patients with opioid dependence compared to placebo treatment

• Most patients will stabilize on 16 to 20 mg/day of

buprenorphine

Buprenorphine Use

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• 37% increase in buprenorphine use in 2 years

– 12,588 (1.1%) enrollees in 2010 – 17,189 (1.5%) enrollees in 2012

• 75% of buprenorphine users have an OUD

diagnosis recorded in claims

*Julie Donohue, PhD Associate Prof University of Pittsburgh

• Most (77.6%) buprenorphine prescribers are

primary care providers Psychiatrists and emergency medicine physicians account for another 14.4% of prescribers These 3 specialties write 92% of buprenorphine prescriptions

*Julie Donohue, PhD Associate Prof University of Pittsburgh

Buprenorphine: the prescribers

Buprenorphine

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Map of Prescribers

County-level variation

Naltrexone

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Opioid Antagonist
• Effective in patients highly motivated
• A meta-analysis of 1158 participants in 13 randomized

trials compared oral naltrexone maintenance treatment to either placebo or non-medication treatment. No difference was seen between the two groups in sustained abstinence or most other primary outcomes (Minozzi et al, Cochrane Database Sys Rev 2011)

• 50 mg tablet once daily

Long Acting Naltrexone

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• A trial randomly assigned 60 patients with heroin

dependence to receive injectable depot naltrexone (Comer et al, AGP 2006)

• A trial compared a once-monthly, injectable depot

formulation of naltrexone to placebo in 250 patients with

• pioid dependence over 24 weeks (Krupitsky et al,

Lancet 2011)

• A trial in 100 heroin and amphetamine-dependent
• utpatients compared the efficacy of naltrexone

implants to placebo (Tiihonen et al, AJP May 2012)

• A National Institutes of Health

Consensus Conference in the US concluded that “non-pharmacologic supportive services are pivotal to successful treatment” (JAMA 1998)

• Individual and group drug

counseling

• Specific psychosocial interventions
• Drug-free residential programs
• Peer support groups
• Other

Psychosocial Treatments

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Vivitrol Claims

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Increase in opioid related deaths
• Appropriate prescribing practices
• Appropriate use of support services

Challenges/Areas of Concern

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• OMHSAS/DDAP Partnership
• Opioid Workgroups
• Practice Guidelines
• Take Back Programs
• Benzodiazepine Prior Authorization
• Prescription Drug Monitoring

Program Legislation

PA Initiatives to Address Issue

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

None

Conflicts of Interest

Warning Signs

Tom Corbett, Governor Beverly Mackereth, Acting Secretary Dennis Marion, Deputy Secretary OMHSAS

• Diagnosis
• Scope
• Treatment Options
• Challenges

Overview

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Drug Utilization

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Month Illicit Drug Use among Persons Aged 12 or Older: 2012

Heroin Use Statistics

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Month Illicit Drug Use among Persons Aged 12 or Older, by Age: 2011 and 2012

Drug Utilization

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Month Illicit Drug Use among Persons Aged 12 or Older, by Race/Ethnicity: 2002-2012

Drug Utilization

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Month Illicit Drug Use among Persons Aged 18 or Older, by Employment Status: 2011 and 2012

Past Month Drug Use

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Month Illicit Drug Use among Persons Aged 12 or Older, by County Type: 2012

Past Month Drug Use Age 12 and older

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2011-2012

Pain Relievers-Nonmedical Use

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

among Past Year Users Aged 12 or Older: 2011 2012

First Specific Drug Associated with Initiation of Illicit Drug Use among Past Year Illicit Drug Initiates Aged 12 or Older: 2012

Illicit Drug Use Age 12 or older

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Year Initiates of Specific Illicit Drugs among Persons Aged 12 or Older: 2012

Specific Illicit Drugs

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Illicit Drugs-Age Specific

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Mean Age at First Use for Specific Illicit Drugs among Past Year Initiates Aged 12 to 49: 2012

Treatment Locations

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Locations Where Past Year Substance Use Treatment Was Received among Persons Aged 12 or Older: 2012

Most Recent Substance Treatment

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Substances for Which Most Recent Treatment Was Received in the Past Year among Persons Aged 12 or Older: 2012 Past Year among Persons Aged 12 or Older: 2012

Recent Treatment-Pain Relievers

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Received Most Recent Treatment in the Past Year for the Use of Pain Relievers among Persons Aged 12 or Older: 2002-2012

Drug Dependence or Abuse

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Single Day Counts

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Buprenorphine Treatment

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Illicit Drug Dependence or Abuse

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Past Year Drug Use Treatments

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Overdose Deaths in PA

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Overdose Deaths in Pennsylvania

• In 1990, note for the 64 grey counties, the death rate is too low to be

accurately counted, at less than 3 deaths per 1,000 citizens. The state average is 2.7 deaths per 1,000 citizens, so any colored counties are above average, while grey is below average.

Overdose in PA

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

In 2000, note for the 52 grey counties, the death rate is too low to be accurately counted, at less than 3 deaths per 1,000 citizens. The state average is 7.4 per 1,000 citizens, so the light blue, yellow and orange counties are above average, while grey and dark blue are below average.

Prescription Opioids Use

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Prescription opioids frequently used by adult

enrollees

– 28.3% with any short-acting use in 2012 – 1.8% with any long-acting use

• Most use for short duration

– 40.8% filled single prescription in 2012 – 65.3% had <30 days supply

*Julie Donohue, PhD Associate Prof University of Pittsburgh

Prescription opioids: use

Prescription Opioids

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Prescription opioids: the prescribers

• Primary care, emergency medicine physicians, dentists are top

prescribers – 48% opioid prescribers are PCPs – 22% are EM physicians – 17% are dentists

• These three specialties write 84% of opioid scripts

– PCPs write 65% of scripts – ED physicians write 10% – Dentists write 9%

*Julie Donohue, PhD Associate Prof University of Pittsburgh

Medication Misuse

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Misuse is defined as non-adherence to prescription directions and can be either willful

• r accidental.

One-quarter of the prescription drugs sold in the United States are used by the elderly, use more meds than any other age group. Older adults are likely to experience more problems with relatively small amounts of medications because of increased medication sensitivity as well as slower metabolism and elimination. Factors associated with prescription medication misuse and abuse by older adults include female sex, social isolation, history of substance use or psychiatric disorder, poly-pharmacy, and chronic medical problems. Commonly prescribed drugs with misuse potential include those for anxiety, pain, and insomnia, such as benzodiazepines, opiate analgesics, and skeletal muscle relaxants.

Risks Populations

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Who is at greatest risk for medication misuse/abuse?

• Factors associated with prescription drug misuse/abuse

in older adults – Female gender – Social isolation – History of a substance abuse – History of or mental health disorder – older adults with prescription drug dependence are more likely than younger adults to have a dual diagnosis – Medical exposure to prescription meds with abuse potential

(Source: Simoni-Wastila, Yang, 2006)

Emergency Department Use

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Emergency Department (ED) Use Related to Misuse/Abuse

• One fifth of ED visits involving prescription medication

misuse/abuse among adults were made by persons aged 70 or

• lder
• Medications involved in ED visits made by older adults:
• Pain relievers (43.5%)
• Medications for anxiety or insomnia (31.8%)
• Antidepressants (8.6%)
• In 2008, there were 256,097 such visits, representing an increase
• f 121.1 percent
• 37.5% were admitted to the hospital

SAMHSA, DAWN Report, 2010

Simple vs Brief Intervention Referral

Intervention Referral

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Attended 1st Appointment Motivational Session 70% Control Group 32%

p = .006

Zanjani F, Oslin D (2005). Telephone Based Referral-Care Management. Grant Supported by Philadelphia Veteran’s Affairs: Mental Illness Research Education and Clinical Center (MIRECC)

Brief Advice

Brief Advice

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Shown to decrease drinking and adverse

health outcomes

• Two components:

– Advice – Link drinking to health

• Recommended by the US Preventative Task

Force

Overdose Deaths in Pennsylvania

Overdose Deaths In Pa

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Age Group Number of Deaths Population Rate per 1,000 0-4 1 723,886 ### 5-9 748,257 ### 10-14 784,882 ### 15-19 40 886,367 4.5 20-24 161 884,157 18.2 25-29 243 796,493 30.5 30-34 252 750,522 33.6 35-39 175 729,924 24 40-44 235 846,199 27.8 45-49 294 926,744 31.7 50-54 239 989,054 24.2 55-59 154 904,747 17 60-64 58 790,089 7.3 65-69 23 564,602 4.1 70-74 8 435,334 ### 75-79 8 357,151 ### 80-84 5 308,139 ### 85+ 13 316,339 4.1

Based on Pennsylvania Department of Health data, overdose deaths in 2011 have the highest rates in age 30-34. These rates decline with age, but increase again after age 85. Rates among

• lder adults are on the rise.

Overdose Deaths in Pennsylvania

Yearly Statistics in Pa

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Drug Overdose Deaths in Pennsylvania

Year Number of Deaths PA Population Rate per 1,000

2011 1,909 12,742,886 15.4 2010 1,550 12,702,379 12.5 2008 1,522 12,448,279 12.6 2006 1,344 12,440,621 11.2 2004 1,278 12,406,292 10.6 2002 895 12,335,091 7.5 2000 896 12,281,054 7.4 1998 628 12,001,451 5.4 1996 630 12,056,112 5.4 1994 596 12,052,410 5.1 1992 449 11,995,405 3.8 1990 333 11,881,643 2.7

• Based on Pennsylvania Department of Health data, overdose deaths have been on the rise over

the last two decades with an increase in the rate of death from 2.7 to 15.4 per thousand Pennsylvanians

Opioid Use Disorder

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• 1. Opioids are often taken in larger

amounts or over a longer period than was intended.

• 2. Persistent desire or unsuccessful efforts

to cut down or control opioid use

• 3. Great deal of time is spent in activities

necessary to obtain the opioid, use the

• pioid, or recover from its effects
• 4. Craving, or a strong desire or urge to

use opioids

• 5. Recurrent opioid use resulting in a

failure to fulfill major role obligations at work, school, or home

• 6. Continued opioid use despite having

persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids

A problematic pattern of opioid use leading to clinically significant impairment or distress is manifested by two or more of the following within a 12-month period:

• 7. Important social, occupational, or

recreational activities are given up or reduced because of opioid use.

• 8. Recurrent opioid use in situations in

which it is physically hazardous

• 9. Continued opioid use despite

knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

• 10. Tolerance
• 11. Withdrawal

Opioid Treatment

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Medication Assisted Treatment

– Opioid Agonist – Opioid Antagonist

• Drug-free (Medication-free) Treatment

Overview of Medications for Opiate Assisted Treatment

Overview of Medications for Opiate Assisted Treatment

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Methadone Buprenorphine Naltrexone Vivitrol Pro

• Prevents withdrawal

symptoms

• Decreases risky behavior
• Decreases criminality
• Allows counseling
• Promotes access to

medical/psychiatric care

• Promotes rehabilitation
• Cost as low as $5 per week
• Dose: Most patients receive

80-125mg/day but some receive as much as 325mg/day

• Less tightly controlled than

methadone

• Lower potential for abuse and are

less dangerous in an overdose

• Progress in therapy may allow for a

take-home supply of the medication

• Prevents Withdrawal
• Prevents “Craving”
• Does not produce a “High”
• Blocks or reduces the effect of

heroin

• Reduced diversion issues
• Fewer transportation issues
• Better compliance than methadone
• Dosing every 2-3 days
• No opiate effect

“benefits” (i.e. high)

• More limited side

effects

• Helps manage

cravings/ relapse risk

• Benefits found for

multiple addictive behaviors including

• piates, alcohol and

gambling disorders

• Used to treat alcoholism

and heroin addiction

• Monthly injections block

the brain’s ability to get intoxicated or high

• Prospective clients must

be sober for at least 7 days prior to beginning treatment

• Has other side effects

like other medications

• Improved compliance

Con

• Diversion potential
• Abuse Potential
• Does not address the

effects/use of other substances (e.g. alcohol or benzos)

• Daily dosing requirements
• Transportation issues for daily

dose

• Intense withdrawal from

medication

• Higher cost
• Does not address the effects/use of
• ther substances (e.g. alcohol or

benzos)

• Note: Suboxone consists of a

combination of Buprenorphine and Naloxone

• Possible dysphonic

effects

• High non-compliance

rates (self administered, so it is easy to stop)

• Early gastrointestinal

discomfort

• Expensive for those without

insurance coverage ($800- 1200/month avg.)

• High Cost

• 65 free standing clinics and 4

hospital based

• Serving over 14,000 individuals

NTP

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Understanding Older Adults w ith Behavioral Health Needs Pennsylvania Osteopathic Fam ily Physicians Society August 2, 2014

Tom Corbett, Governor Beverly Mackereth, Acting Secretary Dennis Marion, Deputy Secretary OMHSAS

Long Term Care Delivery System Sub-Committee Long Term Care Delivery System Sub Committee

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Understanding Older Adults w ith Behavioral Health Needs Pennsylvania Osteopathic Fam ily Physicians Society August 2, 2014

Methadone Clinics by County

Opioid Agonist

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Methadone

• A meta-analysis of 1969 participants in 11 randomized trials

compared methadone maintenance therapy to placebo or non- medication treatment for opioid dependence (Mattick BP et al, Cochrane Database Sys Rev 2009)

• A 10-year follow up study of 405 patients randomly assigned to

receive either methadone or buprenorphine found an association between the duration of treatment with either medication and lower rates of mortality. (Gibson A., et al, Addiction 2008)

Methadone

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Prescribed by NTP
• Usually 80 – 120 mg daily
• Side effects include constipation, mild

drowsiness, excess sweating, and peripheral edema

• Arrhythmias
• Overdose

Buprenorphine

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Partial Opioid Agonist
• Schedule III
• A meta-analysis that included 4497 participants in

24 randomized trials found that sublingual buprenorphine improved treatment retention and reduced opioid use in patients with opioid dependence compared to placebo treatment

• Most patients will stabilize on 16 to 20 mg/day of

buprenorphine

Buprenorphine Use

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• 37% increase in buprenorphine use in 2 years

– 12,588 (1.1%) enrollees in 2010 – 17,189 (1.5%) enrollees in 2012

• 75% of buprenorphine users have an OUD

diagnosis recorded in claims

*Julie Donohue, PhD Associate Prof University of Pittsburgh

• Most (77.6%) buprenorphine prescribers are

primary care providers Psychiatrists and emergency medicine physicians account for another 14.4% of prescribers These 3 specialties write 92% of buprenorphine prescriptions

*Julie Donohue, PhD Associate Prof University of Pittsburgh

Buprenorphine: the prescribers

Buprenorphine

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Naltrexone

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Opioid Antagonist
• Effective in patients highly motivated
• A meta-analysis of 1158 participants in 13 randomized

trials compared oral naltrexone maintenance treatment to either placebo or non-medication treatment. No difference was seen between the two groups in sustained abstinence or most other primary outcomes (Minozzi et al, Cochrane Database Sys Rev 2011)

• 50 mg tablet once daily

Long Acting Naltrexone

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• A trial randomly assigned 60 patients with heroin

dependence to receive injectable depot naltrexone (Comer et al, AGP 2006)

• A trial compared a once-monthly, injectable depot

formulation of naltrexone to placebo in 250 patients with

• pioid dependence over 24 weeks (Krupitsky et al,

Lancet 2011)

• A trial in 100 heroin and amphetamine-dependent
• utpatients compared the efficacy of naltrexone

implants to placebo (Tiihonen et al, AJP May 2012)

• A National Institutes of Health

Consensus Conference in the US concluded that “non-pharmacologic supportive services are pivotal to successful treatment” (JAMA 1998)

• Individual and group drug

counseling

• Specific psychosocial interventions
• Drug-free residential programs
• Peer support groups
• Other

Psychosocial Treatments

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

Vivitrol Claims

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• Increase in opioid related deaths
• Appropriate prescribing practices
• Appropriate use of support services

Challenges/Areas of Concern

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS

• OMHSAS/DDAP Partnership
• Opioid Workgroups
• Practice Guidelines
• Take Back Programs
• Benzodiazepine Prior Authorization
• Prescription Drug Monitoring

Program Legislation

PA Initiatives to Address Issue

Tom Corbett, Governor Beverly Mackereth, Secretary Dennis Marion, Deputy Secretary OMHSAS