Diagnosis And Treatment Diagnosis And Treatment Of Prescription Opioid Of Prescription Opioid

DependenceDependenceSteven W. Clay, D.O.Steven W. Clay, D.O.

Associate Professor, Department of Family Associate Professor, Department of Family Medicine Medicine

Ohio University Ohio University College of Osteopathic MedicineCollege of Osteopathic Medicine

Athens, OH 45701Athens, OH 45701

OverviewOverview

• 1. Goals of Our Out-Patient Program

• 2. Presenting the Program

• 3. Diagnosis

• 4. Buprenorphine

• 5. Results So Far

1. Goals of Our Out-Patient 1. Goals of Our Out-Patient ProgramProgram

• Turning Lives Around

– Detoxification from Prescription (& Illicit) Opiates

– Involvement in 12 Step / Other Programs

– Treatment of Co-Morbidity

Rural Ohio SettingRural Ohio Setting

• Medicaid or No Insurance

• In-Patient Programs: Not Interested

• Out-Patient Treatment: Maybe Available in Several Weeks to Months

• Drug Screens Only With Cash Up Front

• 20 + Twelve Step Meetings Per Week (Alcohol or Drugs OK)

2. Presenting the Program2. Presenting the Program

• “Our services in Addiction Medicine are limited to those needing help with:– 1. Possible substance abuse or

addiction. – 2. Getting off addictive drugs with as

little discomfort as possible.– 3. Buprenorphine treatment for

narcotic addiction recovery.”•

Weeding OutWeeding Out

• “We are NOT a pain treatment center.”

• “We are NOT an in-patient drug treatment center.”

• “We REQUIRE you to have a personal physician or we will help you find one.”

• “We REQUIRE a signed written treatment contract.”

The RulesThe Rules

• Patients Must follow the rules we set

• Including:

– Attendance at counseling – Attendance at 12 Step meetings”

• Those who break the contract will no longer be seen at our office.

• “If you are NOT prepared to follow the Rules, come back when you are ready!”

Patient EducationPatient Education

• Detox. Only: 97% Relapse By 1 yr.

• Reasons for becoming an addict:

– Genetic, Environmental

– Need to Re-Learn How to Live Without Drugs

• Need for complete treatment:

– 12 Step & Other Support

3. Diagnosis of Addiction 3. Diagnosis of Addiction DisordersDisorders

• Risk Factors

• Interview

• Collateral Information

• Establish Use and Consequences

• Coexisting Physical / Psych Dz.

• DSM-IV / Other Diagnostic List

Addiction DiagnosisAddiction Diagnosis

• Dependence / Addiction: -Preoccupied with

Acquiring / Use -Compulsive use Despite

Adverse Consequences-Chronicity and Relapse

Establish Readiness For ChangeEstablish Readiness For Change

• 1. Pre-Contemplation

• 2. Contemplation

• 3. Preparation

• 4. Action

Prochaska and DiClemente Stages and processes of self-change of Smoking…J of Consult and Clin Psy 1983

Treatment MatchingTreatment Matching

• ASAM Criteria For Treatment Matching:

– Consequences of Use

– Family / Other Support

– Financial Support

– Physical / Psychiatric Co-Morbidity

– Relapse Potential Mee-Lee and Shulman The ASAM Placement Criteria and Matching Patients to Treatment in

Principles of Addiction Medicine 2nd Ed. ASAM 2003

Treatment MatchingTreatment Matching

• Office Follow-Up to In-Patient Treatment Based Upon Illness Severity

• Most Followed as Out-Patients Due to Unavailable:

– Treatment Centers

– Money

– Insurance

Prescription Opiate Addiction Prescription Opiate Addiction Patient PresentationPatient Presentation

• In Contrast to Alcohol / Other Drug Addiction Patients:

– Opiate Addicts Frequently Admit Problem and Ask for Help.

– Friends, Family Refer Patients

– The Word Goes Out in the Addiction Community

4. Buprenorphine4. Buprenorphine

• Subutex:

– Buprenorphine SL

• Suboxone:

– Buprenorphine / Naloxone SL

– 4 / 1 Ratio Buprenorphine Clinical practice Guidelines SAMHSA 2000

BuprenorphineBuprenorphine

• Opioid Partial Agonist

• High Affinity Mu Binding

• Will Displace Many Other Opiates

• Maximum Effect About 30-40 mg Methadone Equivalent

• SL Absorption AcceptableBuprenorphine Clinical practice Guidelines SAMHSA 2000

NaloxoneNaloxone

• Opioid Antagonist

• Will Displace Other Opiates and Initiate Withdrawal

• Poor SL Absorption

• If Taken IV With Buprenorphine, Will Negate Agonist ActionsBuprenorphine Clinical practice Guidelines SAMHSA 2000

Transfer to BuprenorphineTransfer to Buprenorphine

• Last Week Dose Is What Counts

• From Methadone: Taper By Program:– 5-10 mg Per Week of Daily Dose– Goal 30-40 mg Per Day

• From Oxycodone (etc.): – Many Stop or Taper Before Being Seen– Adjust Daily Dose to PO Equivalent– Snorted (X 0.6), IV (X 1.5)

Transfer to BuprenorphineTransfer to Buprenorphine

• Suboxone Used Initially:

– Less Risk in Office (Theft)

• Half to One 8/2 SL Tablet After:

– 48 Hrs. Without Methadone

– 24 Hrs. Without Oxycodone (Etc.)

• Follow With 8/2 to 16/4 SL Daily

• Information Given and Contract Signed

Follow-up CareFollow-up Care

• 1-2 Weeks Initially

• MUST:

– Go To 12 Step Meetings

– Keep Appointments

– Not Use

• Occasional Dosage Adjustments

• Then Seen Monthly

Non-ComplianceNon-Compliance

• Relapse is Part of the Disease

• Most Admit Mistakes

• I Usually Will Give One Second Chance

• Look For Progress Not Perfection

• Limited Use of Urine Toxicology Screens Due to Cost

Tapering BuprenorphineTapering Buprenorphine

• Decrease By ½ Dose Monthly

• Some Can Rapidly Come Off: 1-2 Weeks

• Some Take Months

• Variation Based on Patient Preference and Involvement in 12 Step Programs

5. Results So Far5. Results So Far

Results So FarResults So Far

• Opiate Addicts Presenting to University Medical Associates Addiction Medicine

• Inclusion Criteria:

– Opiate Use > 20mg / Day Methadone

– Non-Pregnant

– Willing to Follow Rules

• 41 Consecutive Opiate Addicts Placed on Buprenorphine

ResultsResults

• Mean Age 33, Range 18 to 56

• 63% Male -SAMHSA 2002 Drug Use Survey:

Illicit Drug Use 62.1% Male

• Mean Methadone Equivalent Dose Per Day = 88.5 mg

(%) Family History:(%) Family History: Alcohol, Drug & Psych Disorders Alcohol, Drug & Psych Disorders

34

22

10

14

5

10

0

5

0

5

10

15

20

25

30

35

NEG A D AD P AP DP ADP

Psychiatric Diagnosis (%)Psychiatric Diagnosis (%)

53

24

17

7 5

20

0

10

20

30

40

50

60

ANY SMI ANX DYS MDD BIP SAMHSASMI

Drugs/Pain Prior to Opiates (%)Drugs/Pain Prior to Opiates (%)

60

15

20

5

0

10

20

30

40

50

60

POLY PAIN P + P NO PR

Opiate Progression (%)Opiate Progression (%)

73

7 5 15

0

10

20

30

40

50

60

70

80

PRES PR 2 STR STR STR 2 PR

Opiate of Choice (%)Opiate of Choice (%)

58

32

5 2.5 2.5

0

10

20

30

40

50

60

Oxycod Oth pres Heroin Oxy + H Other

Administration Route (%)Administration Route (%)

51

29

127

2.5

0

10

20

30

40

50

60

PO Snrt IV Chew Tea

Detoxed. Before Treatment (%)Detoxed. Before Treatment (%)

75

20

5

00

10

20

30

40

50

60

70

80

NONE METHDONE INPT OUTPT

12 Step Attendance (%)12 Step Attendance (%)

20

44

29

7

0

5

10

15

20

25

30

35

40

45

FREQ OCCAS NONE UNKN

Results (%)Results (%)

53

1015

22

0

10

20

30

40

50

60

TAPER COMPLETE RELAPSE UNKNOWN

O.B.O.T. in S.E. OhioO.B.O.T. in S.E. Ohio

• Mean Age 33

• 63% Male

• Mean Methadone Equiv. 88 mg

• 34% Negative Family History Addiction/Psych Disorders

• 54% Some Mental Illness

O.B.O.T. in S.E. OhioO.B.O.T. in S.E. Ohio

• 80% Common Drug Use Progression

• 90% Prescription Addiction

• 75% No Previous Detoxification

• 64% At Least Tried 12 Step Programs

• 63% Tapering or Completed Program

• 37% Relapsed or Presumed Relapsed