expanding and improving treatment: challenges and next steps

8/18/2019 Expanding and Improving Treatment: Challenges and Next Steps

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Expanding and Improving Treatment

Challenges and Next Steps

Marc Fishman MD


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Outline

• Limitations of current practice

• The general health care connection

•

The criminal ustice s!stemconnection

• "outh treatment

•

#uilding a $etter treatmentcontinuum

• Next steps


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%elapse prevention medications The standard of care

These are the standard of care:

–Methadone

–

#uprenorphine –Extended&release naltrexone


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If onl! it 'ere that eas!


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Limitations to current

practice


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%elapse prevention medicationIs the standard of care

#ut not ever!one (no's it !et

• )ersuading patients

• )ersuading families• )ersuading criminal ustice s!stem

• )ersuading S*D providers+ especiall!

residential treatment• )ersuading pa!ers

• )ersuading the recover! communit!


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Lin(ages from residential,inpatienttreatment

• Detox 'ithout relapse preventionmedication is unfortunatel! t!pical

• #ut inpatient treatment 'ould $e anideal opportunit! for medicationinduction


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Limitations and unintended

conse-uences

• Medication diversion

• Dropout

•

Su$standard practice• Over&promising


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Duration of treatment.

• Is there an optimal duration.

• Evidence so far suggests longer is$etter+ $ut care should $eindividuali/ed

• %etention under real 'orld conditionsis pro$lematic

• No reason to suppose pre&imposedlimitations helpful


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The criminal ustice

connection


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0%NT0 vs T1* in criminal usticepopulation

XRNTX

TAU

Median time torelapse 2'(s3

4567 765

Opioid neg+ 89'(s

:9; 7<;

Opioid neg+ :='(s

9:

Lee et al6 Extended&%elease Naltrexone to)revent


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The general healthcare

connection


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Aospital initiation of $uprenorphine

• Bell esta$lished e@ectiveness for treatment

seeking pts• Bhat a$out promotion of treatment upstream

at the motivational moment of medical

hospitali/ation to prevent readmission.

545

85

>5

95

75

#upelin(age

Lie$schut/ et al6 ?1M1 Internal


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"outh Treatment


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"oung adults highest prevalenceNon&medical prescription opioids

NSD*A+ 8549


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Features of !outh opioidtreatment

• Famil! leverage 2or not3

• )ush$ac( against sense of parentaldependence and restriction

• Developmental $arriers to treatmentengagement – Invinci$ilit!

– Immaturit! – Salience of $urdens of treatment

• )rominence of co&mor$idit!


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Retention bup treatment

young adults vs older adults


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Famil! Frame'or(

• Treatment often not famil! friendl!+considerations of conJdentialit! andpresumed independence

• #oth families and !outh need a recipefor treatment+ 'ith role deJnitions+expectations+ and responsi$ilities6

• Famil! mo$ili/ation K Medicine ma!help 'ith the receptors+ !ou still haveto parent this dicult !oung person


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#uilding a $etter

treatment continuum


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)roviding a full continuum ofcare

• Inpatient detoxiJcation andsta$ili/ation

• Short term residential treatment

• Long term residential treatment

• Da! treatment , partialhospitali/ation

• 1ssisted living support for outpatienttreatment 2IO) plus, )A) plus3

• %ecover! housing


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Lin(ing patients to medicalcare

• Em$edding medical care in addictionspecialt! settings

• Em$edding opioid treatment forsta$le patients in general medicalsettings

• Medical home models


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Next steps


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Next stepsMedication pipeline

• #uprenorphine implant K )ro$uphine – Stead!+ slo' release deliver!+ < months

duration

• Inecta$le extended release$uprenorphine

• Easier initiation of 0%&NT0

• More potent antagonists

• )revention of stress related relapse


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Next steps Treatment matching and se-uencing

• Bho should get 'hat and 'hen andin 'hat order.

• Bhat are the importantcharacteristics for matching.

• %esponding to traector! – %elapse

– Continuous monitoring for earl! 'arningsigns

1dditional supports


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1dditional supports%esponding to struggling patients

%outinel! and rapidl!• Direct medication administration

• : da! services 'ee(ends and evenings

• Case management services• Famil! and peer supports

• Aousing services

• 1ssertive outreach for extendedengagement

• Flexi$le movement up and do'n a fullcontinuum


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Young adultsOpioid Negative UDS (absent iputed as pos!

" e r # e n t

Treatent $ee%s

4 8 > 9 7 < : = E 45 44 48 4> 49 47 4< 4: 4= 4E 85 84 88 8> 895

45

85

>5

95

75


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1t a crossroads

• 1 national crisis• 1 proven set of $oth old and ne' tools

• #ut alarmingl! poor level of dissemination andadoption+ lac( of coherent deplo!ment

• 1 call to action – Expand access

– Integrate care

– Com$ine 'ith other tools in a full continuum

– Improve e@ectiveness and retention under real'orld conditions

• Be have an o$ligation to do $etterP


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BeGve come a long 'a!Q

#ut 'e have a long 'a! to


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Contact

Marc Fishman MD

?ohns Aop(ins *niversit!Mar!land Treatment Centers ,

Mountain Manor

mJshmanRcomcast6net

expanding and improving treatment: challenges and next steps

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