beyond medication assisted treatment (mat): chronic care ... · clonazepam (klonopin) 0.5 mg ½ - 1...

Beyond Medication Assisted Treatment (MAT):

Chronic Care of the Opioid Dependent Patient

Craig J. Uthe, MD AAFP ASAMTuesday, August 28, 2018

Beyond MAT: Chronic Care for the Opioid-Dependent Pt

South Dakota Codified Law 36-2A:Health Professionals Assistance Program (HPAP)Passed in 1996


• Review the history and current state of the opioid epidemic and need for MAT programs

• Be able to identify different types of chronic pain drug dependent patients

• Know the three major health components of the chronic pain drug dependent patients

• Differentiate between drug dependence, opioid use disorder & addiction and discern best practice options for treatment and management – including MAT

Objectives:


It's estimated that around 2 percent of infants are now born drug-dependent. In areas gripped by the opioid crisis, the rate is even higher.

Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome, A Systematic Review and Meta-analysis, MacMillan, Kathryn Dee L., et al, JAMA Pediatr. 2018;172(4):345-351


Classification of common “Opioids”

Natural (Opiates):• Morphine• Codeine

Semi-Synthetic (Opioids):• Hydrocodone• Hydromorphone• Oxycodone• Oxymorphone• Buprenorphine• Heroin

Synthetic (Narcotics):• Methadone• Fentanyl• (Tramadol)


• The naïve patient

• High-dose chronic use

• Opioid dependent, seeking within health care

• Opioid dependent, seeking outside of health care

Four General Types of Opioid Use Patients


• Acute Pain: measure opioids in total MMEs per prescription.

[Recommend < 100 MME in total prescription (Rx)]

• Post-op Pain: measure opioids in total MMEs per

prescription based upon a tiered system for severity of pain.

(Example: recommend <100 MME total Rx in Tier 1;

<200 MME total Rx in Tier 2; <300 MME total Rx in Tier 3)

• Chronic Pain: measure opioids in total MMEs per day.(Recommend < 90 MME/day in total Rx)

Opioid Data Analysis: Considerations


• Acute Pain: measure opioids in total MMEs per prescription.

[Recommend < 100 MME in total prescription (Rx)]

Opioid Data Analysis: Considerations

Hydrocodone : Morphine (1:1) Oxycodone : Morphine (1.5:1)(Lorcet, Lortab, Norco, Vicodin, Vicoprofen) (OxyContin, OxyIR, Percodan, Percocet, Roxicet)

Hydrocodone 5 mg (100 mg = 20 pills) Oxycodone 5 mg (<100 mg = 13 pills)

Hydrocodone 7.5 mg (<100 mg = 13 pills) Oxycodone 7.5 mg (<100 mg = 8 pills)

Hydrocodone 10 mg (100 mg = 10 pills) Oxycodone 10 mg (<100 mg = 6 pills)


Chronic Non-Cancer Pain Patient

Pain

Drug Dependence

Mental Health



Pain

Drug Dependence

Mental Health

Chronic Pain is ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury healing, more than 3 to 6 months, and which adversely affects the individual’s well-being. Another definition for chronic or persistent pain is pain that continues when it should not.

American Chronic Pain Association (ACPA) Resource Guide To Chronic Pain Treatment:An Integrated Guide to Physical, Behavioral and Pharmacologic Therapy - 2016 Edition



Pain

Drug Dependence

Mental Health


The appearance of normal, expected pharmacological tolerance and withdrawal during the

course of medical treatment has been known to lead to an erroneous diagnosis of

“addiction,” even when these were the only symptoms present.

Symptoms of tolerance and withdrawal occurring during appropriate medical treatment with

prescribed medications (e.g., opioid analgesics, sedatives, stimulants) are specifically notcounted when diagnosing a substance use disorder.

Individuals whose only symptoms are those that occur as a result of medical treatment (i.e.,

tolerance and withdrawal as part of medical care when the medications are taken as

prescribed) should not receive a diagnosis solely on the basis of these symptoms.

The DSM-5 states the following:



Pain

Drug Dependence

Mental Health

Substance Use Disorder

However, prescription medications can be used

inappropriately, & Substance Use Disorder can be correctly diagnosed when there are other

symptoms of compulsive, drug seeking behavior.

- From the DSM-5


A substance use disorder (SUD) can be correctly diagnosed when there are other

symptoms of compulsive, drug seeking behavior. Users (may) substitute one drug for another,

trying to regulate their use by finding a new substance that allows for better control: Xanax

for alcohol, Ritalin for cocaine, methadone for heroin. Multiple

The DSM-5 states the following:

There are 11 criteria for determining SUD with 4 groupings:• 1 – 4. Impaired Control.• 5 – 7. Social Impairment.• 8 – 9. Risky Use.• 10 – 11. Tolerance and Withdrawal.

Severity of Substance Use Disorders:

• Mild: Presence of 2-3 symptoms• Moderate: Presence of 4-5 symptoms• Severe: Presence of 6 or more symptoms


DSM-5 Substance Use Disorder: (11 Criteria)

1. Taking the substance in larger amounts or for longer than you're meant to.2. Wanting to cut down or stop using the substance but not managing to.3. Spending a lot of time getting, using, or recovering from use of the substance.4. Cravings and urges to use the substance.5. Not managing to do what you should at work, home, or school because of substance use.6. Continuing to use, even when it causes problems in relationships.7. Giving up important social, occupational, or recreational activities because of substance use.8. Using substances again and again, even when it puts you in danger.9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.10. Needing more of the substance to get the effect you want (tolerance).11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.



Pain

Drug Dependence

Mental Health


“Addiction”Addiction is defined as a chronic, relapsing brain disease

that is characterized by compulsive drug seeking and use,

despite harmful consequences. It is considered a brain disease because drugs change the brain; they change its structure and how it works. These brain changes can be long lasting and can lead to many harmful, often self-destructive, behaviors.



Pain

Drug Dependence

Mental Health

Patients with chronic pain have a

>50% prevalence rate for a co-

occurring mental health disorder.-Bair MJ, Robinson RL, Katon W, et al. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003;163: 2433–2445. -Sullivan, Mark D. Depression Effects on Long-term Prescription Opioid Use, Abuse, and Addiction. Clin J Pain 2018;34:878–884)



Pain

Drug Dependence

Mental Health

100%

>50%



Pain

Drug Dependence

Mental Health

98+%


OBJECTIVE: BP 132/80 mmHg | Pulse 64 | Temp(Src) 98.2 | Resp 16 | Wt 66.25 kg (146 lb) l BMI 26.28. Pain 4/10. Function 6/10. She is alert, coherent and normal in thought content and speech. She was anxious initially during interview/exam. Some initial tearfulness. The neck is supple w/o adenopathy or masses. Chest is clear. Normal symmetric air entry throughout both lung fields.Heart regular S1 and S2 normal, no murmurs. Abd soft with mild diffuse tenderness but no guarding, no organomegaly. Bowel sounds are scant.Degenerative small joint arthritis deformity noted with stiffness but no active joint swelling. Back with mild kyphosis and sensitivity to touch in general and tenderness to palpation over spinous processes of lumbar L1-L5, lumbar paraspinous muscles extending into bilateral SI region but without sciatic notch tenderness or apprehension. Straight leg raising neg bilat. DTR +2/4 bilat LE. No tremors. No focal neuro abnl. Palp posterior tibial pulses bilaterally.



Pain



Function



Pain



Function


Past medical hx:Hypertension, adult diabetes type 2, chronic pain in female, osteoarthritis, chronic low back pain with hx of radiculopathy, depression, anxiety, GERD, pain medication agreement signed.

Past surgical hx:Vaginal delivery x 2, cholecystectomy, laparoscopy x 2 (endometriosis), vaginal hysterectomy, bilateral salpingo-oopherectomy, cystoscopy, lumbar surgery (laminectomy L4-L5?).

Social hx:Married – supportive husband. Two grown daughters – good relationship.Never smoked. Rare alcohol – denies ever being a problem for herself.

Addiction risk factors:Personal hx of psychological disease (depression/anxiety/OCD) and family history of AUD (parents). She denies emotional trauma, PTSD.

Negative PDMP review for aberrant Rx history.


Meds: Hydromorphone (Dilaudid) 4 mg 1-2 q4h prn pain (max: 6/day)Hydrocodone-acetaminophen(Norco)10-325 mg 1-2 q4h prn pain (max:4/d)Lisinopril (Zestril) 20 mg one tab dailyMetformin (Glucophage) 500 mg two tabs dailyDicyclomine (Bentyl) 20 mg tabs one 4 times dailyTemazepam (Restoril) 15 mg 1-2 caps at bedtime prn insomniaClonazepam (KlonoPIN) 0.5 mg ½ - 1 tab bid prn anxietyFluoxetine (Prozac) 20 mg caps, 40 mg once dailyOndansetron (Zofran ODT) 4 mg tab, 1 by mouth q6h prn nauseaOmeprazole (Prilosec) 20 mg po dailyCalcium 1200 mg po dailyVitamin D 600 IU po daily

Allergies: multiple – all “intolerances” without rash, anaphylaxis.


ASSESSMENT:

1. Osteoarthritis of spine with radiculopathy, lumbosacral region

2. Chronic abdominal pain

3. Substance (Opioid) Use Disorder, Severe (7 of 11 criteria)

4. Depression with anxiety

5. Essential hypertension

6. Diabetes mellitus type 2, noninsulin dependent


DSM-5 Substance Use Disorder: (11 Criteria)

1. Taking the substance in larger amounts or for longer than you're meant to.2. Wanting to cut down or stop using the substance but not managing to.3. Spending a lot of time getting, using, or recovering from use of the substance.4. Cravings and urges to use the substance.5. Not managing to do what you should at work, home, or school because of substance use.6. Continuing to use, even when it causes problems in relationships.7. Giving up important social, occupational, or recreational activities because of substance use.8. Using substances again and again, even when it puts you in danger.9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.10. Needing more of the substance to get the effect you want (tolerance).11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.


High-dose Chronic Opioid Use


Morphine Milligram Equivalent (MME)

Higher Dosage, Higher Risk!

Risk is measured with opioid dosages at ≥20 MME/day

Risk doubles (x2) from 20 MME/day to 50 MME/day

Risk increases (x9) from 20 MME/day to 100 MME/day


CONVERSIONFACTOR

Codeine 0.15

Fentanyl transdermal (in mcg/hr)

2.4

Hydrocodone 1

Hydromorphone 4

Methadone

1 – 20 mg/day 4

21 – 40 mg /day 8

41 – 60 mg/day 10

≥ 61 – 80 mg/day 12

Morphine 1

Oxycodone 1.5

Oxymorphone 3

Calculating Total Daily Dose Of Opioids For Safe Dosage

How to calculate Pt’s current daily opioid consumption in MME:

Hydromorphone (Dilaudid) 4 mg 1-2 q4h prn pain (max: 6/day)4 mg 3x/day for pain (max: 3/day)

Hydrocodone-acetaminophen (Norco) 10-325 mg 1-2 q4h prn pain (max:6/d)Hydrocodone-acetaminophen(Norco) 5-325 mg 1-2 pills 4x/day for pain(max:8/d

Hydromorphone:4 mg x 6 tabs = 24 mg/day24 mg/day x 4 (CF) = 96 MME/day

4 mg x 3 tabs = 12 mg/day12 mg/day x 4 (CF) = 48 MME/day

Hydrocodone:5 mg x 8 tabs = 40 mg/day40 mg/day x 1 (CF) = 40 MME/day

Total Hydromorpone + Hydrocodone:96 MME/day + 40 MME/day

48 MME/day + 40 MME/day = 88 MME/dayMME = Morphine Milligrams Equivalent


PLAN: See pt instructions. Will refill her Dilaudid and Hydrocodone at ~ 50% of her dosage reported from last Rx. Warning sx for withdrawal and overdose were reviewed. Will see BHTT to set up follow-up plan and consider L-AC for chem dep eval. She is in agreement to consider this plan and follow-up will depend upon her plan of action for opioid cessation. The Pain Agreement was signed prior to her departure.

PATIENT INSTRUCTIONS:

Three needs to address:

1) Dependence on your pain pills (opioids):

Take Dilaudid 4 mg 3x/day (lowered from 4 mg 6x/day)

Take Hydrocodone 5/325 1-2 pills 4x/day (lowered from 10/325 4x/day)

*You may take fewer than these a day but not more. No refills will be given

for lost medications. Withdrawal symptoms were reviewed.

An appointment may be set up for you to have an assessment done for your

drug dependence. Follow-up with me in the clinic within two weeks.

2) Chronic Pain:

Work with all your health team members and see your FUNCTION improve, your pain diminish and see your quality of life

improve!

3) Mental Health (Depression/Anxiety):

Will schedule f/u visit with a psychiatrist for re-evaluation of your depression & anxiety

and to re-evaluate your use of Temazepam & Clonazepam.

4) Overdose Risk:

Naloxone (Narcan) 1 mg/mL intranasal sol’n - use in the nose 1 time 1 dose


How to calculate Pt’s current daily opioid consumption in MME:

Hydromorphone (Dilaudid) 4 mg 3x/day for pain (max: 3/day)

Hydrocodone-acetaminophen(Norco)5-325 mg 1-2 pills 4x/day as needed for pain (max:8/d)

Hydromorphone:

4 mg x 3 tabs = 12 mg/day

12 mg/day x 4 (CF) = 48 MME/day



Hydrocodone:



Total Hydromorpone + Hydrocodone:

48 mg/day + 40 mg/day

0 mg/day + 40 mg/day = 40 MME/dayMME = Morphine Milligrams Equivalent



Doctor-Patient Trust Among Chronic Pain Patients on Chronic Opioid Therapy after Opioid Risk Reduction Initiatives: A Survey, Sherman, Karen J. et al, JABFM July–August 2018 Vol. 31 No. 4

Does the patient on chronic opioid therapy trust their physician?

Do you trust your doctor’s judgment in managing your opiate pain medicine?

Clinics who implement opioid risk reduction measures (avg 15 MME/day): 82.2%Clinics without opioid risk reduction measures (avg 120 mg MME/day): 86.3%

Does your doctor trust you in managing your opioid pain medicine?

Clinics implementing opioid risk reduction measures(avg 15 MME/day): 86.2%Clinics without opioid risk reduction measures (avg 120 MME/day): 91.1%


The ultimate goal of MAT is full recovery, including the ability to live a self-directed life. This treatment approach has been shown to:

•Improve patient survival

•Increase retention in treatment

•Decrease illicit opiate use and other criminal activity among people with substance use disorders

•Increase patients’ ability to gain and maintain employment

•Improve birth outcomes among women who have substance use disorders and are pregnant

From the SAMHSA website regarding MAT effectiveness::


Buprenorphine:o Semi-synthetic partial opioid agonisto 2002: Opioid Replacement Therapy for persons

addicted to opioidso Much higher affinity for brain µ receptoro Some signiricant euphoria – first few doseso Some “upper”-like effecto Some addicts take to prevent extremely

uncomfortable symptoms of withdrawalo Will cause “precipitated withdrawal” in person

with notable opioid in system


“The quality of evidence for most functional outcomes was rated low or very low. In sum, weaknesses in the body of evidence prevent strong conclusions about the effects of MAT for opioid use disorder on functional outcomes.Rigorous studies of functional effects would strengthen the body of literature.”



Drug Dependence


“Addiction”

MAT?

MAT?

MAT?

TITLE/HEADING

Questions?

Craig J. Uthe, MDSanford Family Physician

[email protected]

beyond medication assisted treatment (mat): chronic care ... · clonazepam (klonopin) 0.5 mg ½ - 1...

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