Understanding the Overdose Crisis: Science, Stigma, and Solutions - - PowerPoint PPT Presentation

Sarah E. Wakeman, MD, FASAM Medical Director, MGH Substance Use Disorder Initiative Co-chair, MGH Opioid task Force Clinical Co-lead, Partners Healthcare Substance Use Disorder Initiative Director, Addiction Medicine Fellowship Assistant Professor, Harvard Medical School

Understanding the Overdose Crisis: Science, Stigma, and Solutions

Di Disclosu closures res

• Research support funding from OptumLabs

Obj bjec ectives tives

• 1. Describe the evolving landscape of the overdose crisis,

highlighting recent epidemiologic data associated with

• verdose mortality
• 2. Review effective harm reduction and treatment interventions

for those with opioid use disorder

• 3. Compare and contrast systems of care for people with

substance use disorder compared to other medical conditions

Drug overdose now leading cause of death for Americans under 50

In Increase in in Opioid Prescribing Was Corr rrelated wit ith Overdose & Rx OUD

Paulozzi LJ, Jones C, Mack K, Rudd R. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep 2011;60:1487–92.

Ongoing Death Toll ll Due to Heroin/Fentanyl

Hedegaard H. NCHS Data Brief, no 329. 2018.

Ev Evol

• lution

ution

• f
• f the

he Dr Drug ug Ov Over erdose dose Ep Epide demic mic

In 2017, overdose deaths increased by ~10% Opioids involved in over two-thirds of overdose deaths Illicitly manufactured fentanyl drove increase, while heroin and prescription-opioid related deaths remained stable Rates of overdose deaths from cocaine and stimulants increased by 34 % & 33% respectively Largest relative change occurred among black Americans (increase by 25.2%) and largest absolute rate increase was among males aged 25–44 years

Scholl L, et al. MMWR Morb Mortal Wkly Rep 2019;67:1419–1427.

Ov Over erdose dose Do Does es Di Discr criminate iminate

• Those at greatest risk of death
• ften most marginalized
• People experiencing

incarceration, homelessness, serious mental illness have markedly higher rates of

• verdose death
• Treatment models not designed

with these populations in mind

MA DPH. https://www.mass.gov/files/documents/2017/08/31/legislative-report-chapter-55-aug-2017.pdf

“As we have seen repeatedly in the history of medicine, science is one of the strongest allies in resolving public health crises. Ending the opioid [overdose] epidemic will not be any different.”

Stereotypes of f Addiction Im Impact Practice and Polic licy

“For me the most educational experience of the past three decades was to learn that the traditional image of the [person with addiction as having] weak character, hedonistic, unreliable, depraved, and dangerous is totally false. This myth, believed by the majority of the medical profession and the general public, has distorted public policy for seventy years.”

• Dr. Dole

Dole, VP. Drug and Alcohol Review. 1994; 13: pp. 3-4.

Un Understanding erstanding Addictio iction

• “The question is frequently asked:

Why does a man become a [person with addiction]? The answer is that he usually does not intend to. Junk wins by default. I tried it as a matter of

• curiosity. I drifted along taking shots

when I could score. I ended up hooked. You don’t decide to [develop addiction]. One morning you wake up sick and you’re [addicted]. ”

• William Burroughs, 1953

Na Natur ural al Hi History tory of

• f Op

Opioi

• id

d Us Use e Di Disord

• rder

er

Euphoric Normal Sick

Addiction

DRUG/ALCOHOL Brain Mechanisms Biology

Genes/Development

Environment

A Disease of Gene-Environment- Development

Slide courtesy of Dr. Compton, NIDA

Ad Addi dicti ction

• n
• Primary, chronic disease

characterized by compulsive drug seeking and use despite harmful consequences

• Involves cycles of recurrence

and remission

• 40-60% genetic

American Society of Addiction Medicine. April 12, 2011. www.asam.org

• NIDA. August, 2010. http://www.drugabuse.gov/publications/science-addiction

Substance Use Disorder is often a Chronic, but Treatable Illness

Healthy Brain

Decreased Brain Metabolism in Substance Use Disorder

Diseased Brain Diseased Heart

Decreased Heart Metabolism in Coronary Artery Disease

Healthy heart

High Low

Slide Courtesy of NIDA

Visualiz ualizing ing Re Recove

• very

ry

Volkow et al. J. Neurosci., December 1, 2001, 21(23):9414–9418

Tr Treatment atment Ou Outcome tcomes s as Go Good

• d as fo

for Ot Other er Chroni ronic c Dis iseases eases

• NIDA. Principles of Drug Addiction Treatment. 2012. McLellan et al., JAMA, 284:1689-1695, 2000 .

Si Simi milar ar to

• Ma

Mana nage geme ment nt of

• f

Di Diab abet etes es or

• r HI

HIV

• No cure
• Goal is to prevent acute and chronic

complications

• Individualized treatment plans and

goals

• Treatment includes:
• Medication
• Lifestyle changes
• Regular monitoring for

complications

• Behavioral support

Le Lear arnin ning g Fr From

• m Ot

Othe her Ep Epide demic mics: s: HI HIV/ V/AI AIDS DS

https://endinghiv.org.nz/

• Early Years: Free Fall

“Recent advances have

• bscured the difficult and
• ften demoralizing character
• f the early years of HIV. As

the 1980s wore on, a hard- boiled fatalism settled in. Although patients and physicians did their best, they were all just playing out the same grim script… The growing sense of despair and frustration opened the door for charlatans.”

Lessons ssons fr from m HIV IV/AI /AIDS DS

Sepkowitz KA. N Engl J Med 2001; 344:1764-1772

• In the 1990s HAART

available; fundamentally altered the epidemic

Lessons ssons fr from m HIV IV/AI /AIDS DS

Sepkowitz KA. N Engl J Med 2001; 344:1764-1772

• In the 1990s HAART

available; fundamentally altered the epidemic

• Sharp & sustained

declines in mortality

• Focus shifted to

adherence, engagement in care

Lessons ssons fr from m HIV IV/AI /AIDS DS

Sepkowitz KA. N Engl J Med 2001; 344:1764-1772

Access & Adh dherence to

• Lifesaving Med

edic icatio ion Can an Fun Fundamentall lly Alter the the Ov Over erdose Ep Epid idemic ic

Carrieri et al. Clinical Infectious Diseases, Volume 43, Issue Supplement_4, 15 December 2006, S197–S215

De Deat aths hs Inc ncreas rease e Wh When en Me Medi dication ation St Stop

• pped

ped

In Treatment Out of Treatment Overdose Mortality 1.4 4.6 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Rate per 1000 person years

Overdose Mortality

N=15 831 people treated with buprenorphine over 1.1-4.5 years (Sordo BMJ. 2017 Apr 26;357:j1550.)

What is is Effective Treatment?

Medication Methadone Buprenorphine Naltrexone Psychosocial Interventions Cognitive behavioral therapy Motivational enhancement therapy Contingency management Recovery Supports Recovery coaching Mutual help organizations

Medication dication Tr Treatment atment Im Improves roves Retention, tention, Abstinence tinence, , Survival vival

Buprenorphine Maintenance

75% retained in treatment 75% abstinent by toxicology

Detoxification + counseling

0% retained in treatment 20% died

Kakko et al. Lancet. 2003 Feb 22;361(9358):662-8

Go Goal al of

• f Me

Medi dicatio ations ns for

• r Ad

Addi diction tion Tr Trea eatme ment nt

Relieve withdrawal symptoms

1

Block effects

• f other
• pioids

2

Reduce cravings

3

Restore normal reward pathway

4

Go Goal al of

• f Me

Medi dicatio ations ns for

• r Ad

Addi diction tion Tr Trea eatme ment nt

Normal

Re Relap apse se Co Comm mmon

• n Af

After er Ta Tape per

Sigmon et al. JAMA Psychiatry. 2013;70(12):1347-1354.

Long Term rm Ou Outc tcomes: s: This is a Go Good Pro rognosis sis Dise sease se

Weiss et al. Drug Alc Depend. 2015;150:112-9.

Engagement in agonist therapy associated with abstinence at Month 42: Patients still on agonist therapy: 79.6% abstinent Not on agonist therapy: 50.8% abstinent

Hser et al. Addiction. 2016 Apr;111(4):695-705.

Early Use Duri ring Treatment Should be Expected

Among

• ng Th

Those se at t Hig ighest hest Ris isk k of Death, ath, Tr Treat eatment ment Retention tention Low

• In 12 months after nonfatal overdose, 11% received MMT for median
• f 5 months, 17% bupe for median of 4 months, and 6% NTX for

median of 1 month

• Despite short duration of treatment, there was a reduction in all-

cause mortality with MMT (AHR 0.47) and bupe (AHR 0.63). For NTX, there was no mortality benefit (AHR 1.44)

Larochelle MR. Ann Intern Med. 2018 Aug 7;169(3):137-145.

Tr Treatment atment Retention tention Has s Benefit nefit Ir Irrespective espective of To f Toxicology icology Results sults

• Treatment retention

strongly associated with quality of life

• Toxicology results not

associated with QoL, however patient self- report of substance use was inversely related with QoL

Mitchell SG. J Psychoactive Drugs. 2015 Apr-Jun;47(2):149-57

St Struc uctur ture e & & De Delivery very of

• f Ca

Care e Cr Cruc ucial ial for

• r

Re Retent ention ion

• Patients fall out of care when they are

not welcomed back:

• “You could only miss 14 days in a

row…to stay on it. And I came back like the 15th day. So they told me I was no longer eligible.”

• Patients report staff who “worked with”

them and were “nice,” “caring,” & “respectful” offered support and encouragement were important factors in sticking with treatment:

• “They showed me that there’s a

light at the end of that tunnel. There’s hope. You hear that? There’s hope!”

Teruya C. J Psychoactive Drugs. 2014 Nov-Dec;46(5):412-26.

Hi High gh Th Thres eshold hold vs Lo Low w Th Thres eshold hold Ca Care

• PWUD face numerous barriers to

engage in services:

• Registration threshold

(accessing care and staff)

• Competence threshold (ability to

communicate needs)

• Efficiency threshold (“What

about those who need 1000 cups of coffee before they start to speak about their needs?”)

• TRUST
• Low-threshold care aims to reduce

barriers (‘thresholds’) through less stringent eligibility criteria to broaden potential reach

Edland-Gryt M. Int J Drug Policy. 2013 May;24(3):257-64.; Mofizul Islam M. Int J Drug Policy. 2013 May;24(3):220-2.

Tr Trea eatme ment nt Se Selec ection: tion: Be Belief ef ver ersus sus Sc Scienc ence

“We as a society… think [people with addiction] should just get off drugs and by strenuously hauling up on their own bootstraps should stay off no matter what. Policymakers and some clinicians continue to promote detoxification as ‘treatment,’ even though detoxification does nothing to help people stay off drugs.”

Ling W. J Neuroimmune Pharmacol (2016) 11:394–400

Des espite pite Scien entific tific Adv dvan ances, ces, Hug uge e Gap aps in n Car are

“[The] profound gap between the science of addiction and current practice… is a result of decades of marginalizing addiction as a social problem rather than treating it as a medical condition. Much of what passes for “treatment” of addiction bears little resemblance to the treatment of other health conditions.”

Addiction Medicine: Closing the Gap between Science and Practice www.casacolumbia.org

Th The Scien ience ce is is Cl Clear: ar: Medications dications fo for Addicti diction

• n

Tr Treatment atment Wo Work

Gr Grea eate ter r Ac Access ess Ne Need eded ed

Th The Ne e Need ed for

• r

Ch Chan ange ge

“For nearly a century, physicians were indoctrinated with the societal attitude that [people with addiction] brought upon themselves the suffering they deserve. Even after we began to regard [people with addiction] as having a disease, our policies continued to reflect our attitude: [people with addiction] are sick, they need help, but they also sin, so do not help them too much. Until the correct mindset is restored in the physician, the mere availability of an effective medication will not make a

• difference. To put it another way, for

buprenorphine to succeed clinically, physicians themselves must first change before they can help patients change their lives.”

• Ling. J Neuroimmune Pharmacol (2016) 11:394–400

Systems stems Fa Failures, lures, Not

• t Pat

atient ent Fa Failure lures

• Patient admitted to the hospital with heart

attack…

• Told it’s her fault because of diet, high

stress job, and history of tobacco use

• Advised to call a list of cardiologists/cath

labs

• Told she can’t get aspirin or cholesterol

medication until she sees a nutritionist first

• Sent home with a stern reminder to not

have another heart attack

Systems stems Fa Failures, lures, Not

• t Pat

atient ent Fa Failure lures

• Patient admitted to the hospital with

endocarditis…

• Told it’s her fault because of her

substance use disorder

• Advised to call a list of treatment

programs

• Told she can’t get addiction medication

until she sees a counselor first

• Sent home with a stern reminder to not

use drugs

Wh What t Does s Care re Look

• k

Like ke Currentl rently? y?

What t Could uld Pe Person son-Cen Centered tered Care e Look k Like ke fo for Opioid ioid Use e Disor sorder? der?

Li Like e Ca Care fo e for An Any Ot Othe her Illness ness

Hospitalization

Using ing Hos

• spita

pitali lizati tion n as a Reachable achable Mome

• ment

nt

• Initiating methadone in hospital:
• 82% present for follow-up addiction care
• Initiating buprenorphine vs detox:
• Bupe: 72.2% enter into treatment after discharge
• Detox : 11.9% enter treatment after discharge

J Gen Intern Med. Aug 2010; 25(8): 803–808; JAMA Intern Med 2014 Aug;174(8):1369-76.)

Tr Trea eatme ment nt in th n the e ED ED

• 78% vs 37% engaged

in buprenorphine treatment

• Fewer days of self-

reported opioid use

D'Onofrio et al. JAMA 2015 Apr 28;313(16):1636-44

Treatment in in Primary ry Care

No difference in opioid use, study completion, or cocaine use between the 2 groups

Fiellin DA et al. Am J Med 126:1 2013

Buprenorphine Myths and Realities

Words Matter

Pa Patient ent-Cente Centered red Ca Care

• Includes the following dimensions :
• recognition of bio-psychosocial influences on health
• acknowledgement of subjective health needs and

experiences

• shared power and decision-making between patients

and health care providers

• promotion of patient-provider communication and

relationships based on mutual trust

Caring ring fo for Patients tients Wh Who Use se Substan bstances: ces: Key Qu Questions stions

• Would I respond this

way to a patient with another medical condition?

• Are there ways in which
• ur approaches/policies

may actually cause harm?

• How can I identify,

acknowledge, and support this patient’s most pressing needs?

Pati tient-Centered Care Checkli list

• Respect dignity, humanity, and autonomy of

individual

• Care guided by science, delivered with

compassion

• Person-first, accurate language
• Involvement of affected individuals

Ev Eviden dence ce Ba Based ed Tr Trea eatme ment nt Ch Chec ecklis klist

• Immediate access to all types of

medication for OUD treatment

• Treatment based on clinical need &

patient preference/experience (i.e. not a one-size-fits-all approach)

• Focus is on retaining patients in care

Sy Systems tems Ba Based ed Ch Chec ecklis klist

Prevention

• Judicious
• pioid

prescribing

• Address risk

factors for development

• f OUD

Treatment

• Immediate

access to medication for OUD in all settings

• Reduce

stigma Harm Reduction

• Naloxone
• Syringe

exchange

• Safe

consumption sites

Outpatient Addiction Champion Teams Urgent “Bridge” Clinic Recovery Coaches Inpatient Addiction Consult Team The MGH Substance Use Disorder Initiative

Embracing a New Model l of Care for Substance Use Dis isorder

ED Buprenorphine #GetWaivered HOPE Clinic for Pregnant & Parenting Women and Families

Th Than ank you

• u!

swakeman@partners.org @DrSarahWakeman