pcss september 28 intnsa hosted webinarintnsa.org/resources/webinar/2015_sep_28.pdf · target...

1

A Focus on Local, Regional and Global Tools

for Caring for Clients with Opioid Addictions

Dana Murphy-Parker, MS, CRNP, PMHNP-BC, CARN-AP

Carmel Clancy, PhD, RN, BSc (Hons), FPH

The International Nurses Society on Addictions

September 28, 20152

Disclosures

• Dana Murphy-Parker, MS, CRNP, PMHNP-BC, CARN AP

• No Disclosures

• Carmel Clancy

• No Disclosures

3

PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership

with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American

Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of

Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American

Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and

Southeast Consortium for Substance Abuse Training (SECSAT).

For more information visit: www.pcss-o.org

For questions email: [email protected]

Twitter: @PCSSProjects

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) from SAMHSA. The

views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department

of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.4

Target Audience

• The overarching goal of PCSS-O is to offer evidence-based

trainings on the safe and effective prescribing of opioid medications

in the treatment of pain and/or opioid addiction.

• Our focus is to reach providers and/or providers-in-training from

diverse healthcare professions including physicians, nurses,

dentists, physician assistants, pharmacists, and program

administrators.

5

PCSS-O Colleague Support Program

• PCSS-O Colleague Support Program is designed to offer general information to health

professionals seeking guidance in their clinical practice in prescribing opioid

medications.

• PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management.

• Our mentoring approach allows every mentor/mentee relationship to be unique and

catered to the specific needs of both parties.

• The mentoring program is available at no cost to providers.

• Listserv: A resource that provides an “Expert of the Month” who will answer questions

about educational content that has been presented through PCSS-O project. To join email: [email protected].

For more information on requesting or becoming a mentor visit:

www.pcss-o.org/colleague-support

6

Educational Objectives

• At the conclusion of this activity participants should

be able to:

• Incorporate updates of ASAM’s Press Conference and Stakeholder

Summit held in Washington, D.C. on September 24, 2015.

• Discuss ASAM’s National Practice Guideline for the Use of Medications,

pocket guide, mobile phone application, slide deck and future educational

opportunities.

• Increase knowledge of online networking tools, specifically ‘wikis’ and

their role in building international co-operation from diverse cultural

communities in the area of addiction

• Share ‘initial lessons’ from GAaP’s first 6 months of operation: planning

and set up

• Explore with participants the challenges and possibilities particularly

focusing on the impact of such methodology on achieving wider

engagement on a global public health issue and enhancing inter-

professional learning.

7

Definitions: No doubt, this is a Medical Disorder: A

Neurobiological Disorder

• ASAM defines addiction as “a primary, chronic disease of brain reward,

motivation, memory, and related circuitry,” with a “dysfunction in these

circuits” being reflected in “an individual pathologically pursuing reward

and/or relief by substance use and other behaviors.”

• The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

(DSM-5) states Substance Use Disorder is a cluster of cognitive,

behavioral, and physiological symptoms indicating that the individual

continues using the substance despite significant substance-related

problems.

• “Opioid use disorder” (OUD) include.

� Opioid Use Disorder

� Opioid Intoxication

� Opioid Withdrawal

� Other Opioid-Induced Disorders

� Unspecified Opioid-Related Disorders

8

What is this about?

The ASAM National Practice

Guideline for the Use of

Medications in the Treatment of

Addiction Involving Opioid Use

The ASAM National Practice

Guideline is the 1st to include all

FDA-approved medications in

single document

9

Why is this so

important?

12

13

Journal of Addictions Medicine

(2015)

Just published:

Kampman, K. & Jarvis, M. (2015). American Society of

Addiction Medicine (ASAM) National Practice

Guidelines for the Use of Medications in the Treatment

of Addiction Involving Opioid Use. Journal of Addiction

Medicine, 9 (5). September/October 2015.

http://www.asam.org/practice-support/guidelines-and-

consensus-documents/npg

14

Psychosocial Treatment in Conjunction

With Medications for the Treatment of Opioid

Use Disorder

A review of the literature on the efficacy of psychosocial

treatment to be used in conjunction with Medication Assisted

Treatment (MAT) of opioid use disorder was conducted.

The review was partially funded by National Institute of Drug

Abuse (NIDA).

Methodology of this review can be found with the ASAM journal

article previously mentioned.

A full article on the literature review will be published in a

subsequent Journal of Addiction Medicine edition.

15

Categories covered in the National

Practice Guidelines

Assessment

Diagnosis

Treatment

16

ASSESSMENT

The first clinical priority should be given to identifying and making appropriate referral for any

urgent or emergent medical or psychiatric problem(s), including drug-related impairment or

overdose.

Completion of the patient’s medical history should include screening for concomitant medical

conditions, including infectious diseases (hepatitis, HIV, and TB), acute trauma, and pregnancy.

(The leading causes of death in people using opioids for nonmedical purposes are overdose and

trauma).

A physical examination should be completed as a component of the comprehensive assessment

process. The prescriber (the clinician authorizing the use of a medication for the treatment of

OUD) may conduct this physical examination him/herself, or, in accordance with the ASAM

Standards1, ensure that a current physical examination is contained within the patient medical

record before a patient is started on a new medication for the treatment of his/her addiction.

Initial laboratory testing should include a complete blood count, liver function tests, and tests for

hepatitis A, B, C and HIV. Testing for TB and sexually transmitted infections should also be

considered. Hepatitis A and B vaccination should be offered, for those who are pregnant and the

general population.

17

Diagnosis

Other clinicians may diagnose OUD, but confirmation of the diagnosis by the provider with

prescribing authority, and who recommends medication use, must be obtained before

pharmacotherapy for OUD commences.

OUD is primarily diagnosed on the basis of the history provided by the patient and a

comprehensive assessment that includes a physical examination.

Validated clinical scales that measure withdrawal symptoms may be used to assist in the evaluation

of patients with OUD: Examples include;

The Objective Opioid Withdrawal Scale (OOWS)a

The Subjective Opioid Withdrawal Scale (SOWS)a

The Clinical Opioid Withdrawal Scale (COWS)a

Visit www. GuidelineCentral.com/OUD for calculators

Urine drug testing during the comprehensive assessment process, and frequently during treatment,

is recommended. 18

Symptoms of Opioid Intoxication

Drooping eyelids

Constricted pupils

Reduced respiratory rate

Scratching (due to histamine release)

Head nodding

19

Withdrawal Signs

OOWS SOWS COWS

Yawning

Rhinorrhea

Piloerection (observe

arm)

Perspiration

Lacrimation

Tremor (hands)

Mydriasis

Hot and cold flushes

Restlessness

Vomiting

Muscle twitches

Abdominal cramps

Anxiety

I feel anxious.

I feel like yawning.

I’m perspiring.

My eyes are tearing.

My nose is running.

I have goose flesh.

I am shaking.

I have hot flashes.

I have cold flashes.

My bones and muscles ache.

I feel restless.

I feel nauseous.

I feel like vomiting.

Pulse

Sweating

Restlessness

Pupil size

Bone or joint aches

Rhinorrhea

Tearing

GI upset

Tremor of outstretched hands

Yawning

Anxiety or irritability

Gooseflesh skin

20

Treatment Setting

Clinicians should consider the patient’s preferences, past treatment history, and

treatment setting when deciding between the use of methadone, buprenorphine, and

naltrexone in the treatment of addiction involving opioid use.

The treatment setting described as Level 1 treatment in the ASAM Criteria may be a

general outpatient location such as a clinician’s practice site.

The setting as described as Level 2 in the ASAM Criteria may be an intensive outpatient

treatment or partial hospitalization program housed in a specialty addiction treatment

facility, a community mental health center, or another setting.

The ASAM Criteria describes Level 3 or Level 4 treatment respectively as a residential

addiction treatment facility or hospital.

The venue in which treatment is provided is as important as the specific medication

selected.

21

Treatment Setting, con’t

Opioid Treatment Programs offer daily supervised dosing of methadone, and increasingly of buprenorphine.

Naltrexone can be prescribed in any setting by any clinician with the authority to prescribe any medication.

In accordance with federal law (21 CFR §1306.07), Office-Based Opioid Treatment (OBOT), which provides

medication on a prescribed weekly or monthly basis, is limited to buprenorphine.

Clinicians should consider a patient’s psychosocial situation, co-occurring disorders, and risk of diversion when

determining whether Opioid Treatment Programs (OTP) or OBOT is most appropriate.

•OBOT may not be suitable for patients with active alcohol use disorder or sedative, hypnotic, or anxiolytic

use disorder (or who are in the treatment of addiction involving the use of alcohol or other sedative drugs,

including benzodiazepines or benzodiazepine receptor agonists). It may also be unsuitable for persons who

are regularly using alcohol or other sedatives but do not have addiction or a specific substance use disorder

related to that class of drugs.

� The prescribing of benzodiazepines or other sedative-hypnotics should be used with extreme caution in

patients who are prescribed methadone or buprenorphine for the treatment of an OUD

22

FDA Approved Medications for

Opioid Use Disorder

Methadone

Buprenorphine (In ASAM’s pocket guide, reference to buprenorphine is for the

combination buprenorphine/naloxone formulations. If the single reference is made to

buprenorphine, it is referred to as buprenorphine monoproduct.

Naltrexone, both the oral and the injectable (Vivitrol)

Naloxone

The Guideline Committee recommends the inclusion of clonidine as a practice to support

opioid withdrawal. Clonidine is not FDA-approved for the treatment of opioid withdrawal but it

has been extensively used off-label for this purpose. Clonidine may be used orally or trans-

dermally at doses of 0.1–0.3 mg every 6–8 hours with a maximum dose of 1.2 mg daily to assist in

the management of opioid withdrawal symptoms. Its hypotensive effects often limit the amount

that can be used.

Clonidine can be combined with other non-narcotic medications targeting specific opioid

withdrawal symptoms such as benzodiazepines for anxiety, loperamide for diarrhea,

acetaminophen or nonsteroidal anti-inflammatory medications (NSAIDs) for pain, and ondansetron

or other agents for nausea.

23

Venue for Treatment Setting

Opioid Treatment Programs offer daily supervised dosing of

methadone, and increasingly of buprenorphine.

Naltrexone can be prescribed in any setting by any clinician with

the authority to prescribe any medication.

In accordance with federal law (21 CFR §1306.07), Office-Based

Opioid Treatment (OBOT), which provides medication on a

prescribed weekly or monthly basis, is limited to buprenorphine.

Clinicians should consider a patient’s psychosocial situation, co-

occurring disorders, and risk of diversion when determining

whether Opioid Treatment Programs (OTP) or OBOT is most

appropriate.

24

Current Prescribers for

BuprenorphineTime

Frame

30 patient

certified

% 100 patient

certified

% Total

Past 30

days

Past 60

days

Past 90

days

Last year

Current

314

488

910

3,037

20,722

68.4%

60%

65.6%

67.1%

67.9%

145

325

478

1,489

9,801

31.6%

40.0%

34.4%

32,9%

32.1%

459

813

1,388

4,526

30,523

25

The TREAT ACT

Introduced in July, 2014 by Senator Edward J. Markey (D-Massachusetts) introduced the Recovery

Enhancement for Addiction Treatment (TREAT ACT).

This bill will increase the number of patients that qualified physicians could treat for opioid

dependency and, for the first time, allow certain nurse practitioners and physician assistants to treat

patients by allowing other prescribers to prescribe buprenorphine.

This legislation is supported by:

The American Medical Association

The American Society of Addictions Medicine

The American Association of Nurse Practitioners

The International Nurses Society on Addictions

Rundio, A (2015). Landmark legislation to expand treatment for heroin and

prescription drug addiction. Journal of Addictions Nursing ,26 (3), pp 157-

158.

26

Obama Administration Makes Big Announcement Addressing

Heroin Epidemic

•This past spring, Sen. Edward Markey (D-Mass.) and Sen. Rand Paul (R-Ky.) introduced legislation that would raise the first-year cap from 30 patients to 100 and offer nurse practitioners and physician assistants the ability to prescribe the medication. After one year, doctors could seek to remove the cap entirely.

•http://www.huffingtonpost.com/entry/obama-administration-heroin_55fa058ee4b0fde8b0ccf192

27

Buprenorphine, a Partial Agonist

Opioid-dependent patients should wait until they are experiencing mild to moderate opioid withdrawal before taking the

first dose of buprenorphine to reduce the risk of precipitated withdrawal.

Generally, buprenorphine initiation should occur at least 6–12 hours after the last use of heroin or other short-acting

opioids, or 24–72 hours after their last use of long-acting opioids such as methadone.

Induction of buprenorphine should start with a dose of 2–4 mg.Dosages may be increased in increments of 2–4 mg.

Clinicians should observe patients in their offices during induction. However, home buprenorphine induction may be considered.

Home-based induction is recommended only if the patient or prescribing physician is experienced with the use of buprenorphine.

Buprenorphine doses after induction and titration should be, on average, ≥8 mg per day. However, if patients are

continuing to use opioids, consideration should be given to increasing the dose by4–8 mg (daily doses of 12–16 mg or higher).

The FDA approves dosing to a limit of 24 mg per day, and there is limited evidence regarding the relative efficacy of higher doses. In addition, the use of higher doses may increase the risk of diversion.

28

Buprenorphine, con’t

When considering a switch from buprenorphine to naltrexone,

7–14 days should elapse between the last dose of buprenorphine

and the start of naltrexone to ensure that the patient is not physically dependent

on opioids prior to starting naltrexone.

When considering a switch from buprenorphine to methadone, there is no

required time delay since the addition of a full mu-opioid agonist to a partial

agonist does not typically result in any type of adverse reaction.

Patients who discontinue agonist therapy and resume opioid use should be

made aware of the risks associated with an opioid overdose, and especially the

increased risk of death.

29

Methadone

Methadone is a treatment option recommended for patients who are physiologically dependent on

opioids, able to give informed consent, and who have no specific contraindications for agonist

treatment when it is prescribed in the context of an appropriate plan that includes psychosocial

intervention.

The recommended initial dose ranges for methadone are from 10–30 mg with reassessment in 3–4

hours, and a second dose not to exceed 10 mg on the first day if withdrawal symptoms are

persisting.

The usual daily dosage of methadone ranges from 60–120 mg. Some patients may respond to lower

doses, and some patients may need higher doses.

Dosage increases in 5–10 mg increments applied no more frequently than every 7 days (depending

on clinical response) are necessary to avoid over-sedation, toxicity, or even iatrogenic overdose

deaths.

The administration of methadone should be monitored because unsupervised administration can

lead to misuse and diversion. OTP regulations require monitored medication administration until

the patient’s clinical response and behavior demonstrates that the prescribing of non-monitored

doses is appropriate.30

Methadone, con’t

Switching from methadone to another medication for the treatment of OUD may be appropriate if

the patient experiences intolerable side effects or is not successful in attaining or maintaining

treatment goals through the use of methadone.

Patients switching from methadone to buprenorphine in the treatment of OUD should be on low

doses of methadone prior to switching medications.

Patients on low doses of methadone (30–40 mg per day or less) generally tolerate transition to

buprenorphine with minimal discomfort, whereas patients on higher doses of methadone may

experience significant discomfort in switching medications.

Patients switching from methadone to oral naltrexone or extended-release injectable naltrexone

must be completely withdrawn from methadone and other opioids, before they can receive

naltrexone.

The only exception would apply when an experienced clinician receives consent from the patient to

embark on a plan of naltrexone-facilitated opioid withdrawal management.

Patients who discontinue agonist therapy with methadone or buprenorphine and then resume opioid use should be made aware of the risks

associated with opioid overdose, and especially the increased risk of death.

31

Naltrexone, an Opioid Antagonist

Medication

Naltrexone is a recommended treatment in preventing relapse in OUD.

Oral formula naltrexone may be considered for patients where adherence can be

supervised or enforced. Extended-release injectable naltrexone (Vivitrol) may

be more suitable for patients who have issues with adherence.

Oral naltrexone should be taken daily in 50 mg doses, or 3 times weekly in two

100 mg doses followed by one 150 mg dose.

Extended-release injectable naltrexone should be administered every 4 weeks

by deep intramuscular injection in the gluteal muscle at a set dosage of 380 mg

per injection.

32

Naltrexone, con’t

There is no recommended length of treatment with oral naltrexone or extended-release

injectable naltrexone.

Duration depends on clinical judgment and the patient’s individual circumstances.

Because there is no physical dependence associated with naltrexone, it can be stopped

abruptly without withdrawal symptoms.

Switching from naltrexone to methadone or buprenorphine should be planned,

considered, and monitored.

Switching from an antagonist such as naltrexone to a full agonist (methadone) or a

partial agonist (buprenorphine) is generally less complicated than switching from a full

or partial agonist to an antagonist because there is no physical dependence associated

with antagonist treatment and thus no possibility of precipitated withdrawal.

33

Naloxone, an Opioid Antagonist

Medication

Naloxone should be given in case of opioid overdose.

Naloxone can and should be administered to pregnant women in cases of

overdose in order to save the mother’s life.

The Guideline Committee, based on consensus opinion, recommends that

patients who are being treated for OUD and their family members/significant

others be given prescriptions for naloxone. Patients and family

members/significant others should be trained in the use of naloxone in

overdose.

The Guideline Committee, based on consensus opinion, recommends that first

responders such as emergency medical services personnel, police officers, and

firefighters be trained in and authorized to administer naloxone.

34

Naloxone

Naloxone injection

Evzio® (auto-injector)

0.4 mg/0.4 mL

For emergency treatment of overdose

Narcan®, generic

(various)

Opioid depression, diagnosis

of suspected opioid overdose,

There is not yet an FDA-approved intranasal formulation. There are only kits

made available to deliver the injectable formulation intranasally.

35

WHO - 2009

• The Guidelines review the use of

medicines such as methadone, buprenorphine, naltrexone and

clonidine in combination with psychosocial support in the treatment

of people dependent on heroin or other

opioids. Based on systematic reviews of the literature and using the GRADE

approach to determining evidence quality, the guidelines contain specific

recommendations on the range of

issues faced in organizing treatment systems, managing treatment

programmes and in treating people

dependent on opioids.

36

UK

• 2007 edition

• New guidelines coming

out in early 2016

• Addresses

management of opi

37

Primary Care Setting - UK

38

Australia

39© Middlesex University

GAaP History and Background

• Although established formally in May 2014 the origins and idea for GAaP have been around a long time, primary through ongoing collaboration between Dana Murphy-Parker and Carmel Clancy since 1998

• GAaP has been initially supported via small grants via Middlesex University

• 4 founding members of GAaP are drawn from UK, USA, Brazil and New Zealand

Presentation title |

3


Some of the GAaP members…


4


Who is GAaP

|

4

University San Paolo

GAaP Brazil

Middlesex University

GAaP UK

Drexel UniversityGAaP USA

Matua Raki

GAaP New Zealand

NCETA,

GAaP Australia

Potential members coming online

GAaP China

GAaP Israel

GAaP Ireland

GAaP S. KoreaGAaP Japan

Nordland Hospital,

GAaP Norway

Universiteti Planetari I

Tiranes

GAaP Albania


Structure

• Each country has an identified GAaP Co-ordinating Centre – e.g. GAaP USA is Drexel University (contact person Dana Murphy-Parker [email protected])

• The Co-ordinating Centre has a responsibility to set up a GAaP Country Reference Group – these groups must be interdisciplinary, members should have a background in addiction, and be representative of different types of facilities e.g. universities; practice; policy; research etc

• The GAaP co-ordinating centers meet online employing the use of a WIKI platform and Skype


4


Our Vision for GAaP

• Explore addiction issues across countries e.g. policies; service user lived experience; treatment – comparing differences and similarities

• Raise the profile of addiction – including an aspect of ‘activism’

• Establish joint workforce guidelines – standardization of preparation for professionals working in the field of addiction - ‘Getting it into the Water Supply’

• Provide a virtual room for everyone to enter to discuss the issues as outlined above

• Become a knowledge Hub

• Become a vehicle/platform to transfer ‘best practice’ or explore what ‘good looks like’ |

4


• To provide a platform communication tool to raise awareness and explore brief interventions; psychosocial issues; pharmacology

• To be a global online ‘classroom’

• A place to increase curiosity/increasing competencies directly in the field

• A community of practice and a resource tool, which can be sliced in different ways

• An Intersection between policy/clinical/academic communities

• A global knowledge network finding synergies

|

4


Key Strategic Areas

• Practice

• Education

• Research

• Policy

• Workforce Planning

|

4


Methodology for staying connected

& working together

|

4

Wiki (online network

community)

Off line linking e.g. conferences;

staff & student

exchanges

Jointly delivered

on-line courses


It is not without its challenges

• Slow burner

• Techno issues – access issues; variation in level of members expertise

• The world clock – I’m awake, you’re asleep!

• Finding the time

• Funding issues and volunteer syndrome


4


First major project

• MOOC (Massive Open Online Course)

• Falling Down – Older People and Problematic Substance Use

• Course release/ teaching starts on 7th of March until 10 April 2016.


Broad Learning Outcomes for

MOOC

• 1. To explore problematic substances use in relation to older people and their carers through current research, practice and service user and carers perspectives.

• 2. To promote awareness of current challenges when working with problematic substance use in ageing contexts for practitioners working with problematic substance use and for those working in ageing services who may not have a detailed knowledge of this issue.

• 3. To identify the scope of the issue within an international and national context and to identify the need for further knowledge, skills, service development and partnerships as well as future research and guidance in order to meet these challenges

• . 50

References

ASAM (2015). National Practice Guidelines and Associated Products at Press Conference and Stakeholder

Summit on September 24, 2015. Retrieved at Website,

http://www.asam.org/magazine/read/article/2015/09/24/national-practice-guideline-and-associated-products-at-

press-conference-and-stakeholder-summit

Department of Health (England) and the devolved administrations (2007). Drug Misuse and Dependence: UK

Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh

Assembly Government and Northern Ireland Executive.

Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care. Available at

: http://www.skillsconsortium.org.uk/intervention-details.aspx?p=8&d=0&int=52

Rundio, A (2015). Landmark legislation to expand treatment for heroin and prescription drug addiction.

Journal of Addictions Nursing ,26 (3), pp 157-158.

World Health Organization (WHO) (2009). Guidelines for psychosocially assisted pharmacological treatment of

persons dependent on opioids. Retrieved at: http://www.who.int/hiv/pub/idu/opioid/en/

pcss september 28 intnsa hosted webinarintnsa.org/resources/webinar/2015_sep_28.pdf · target...

Documents