Virginia Opioid Addiction ECHO*

Project ECHO:July 27th

*ECHO: Extension of Community Healthcare Outcomes

Agenda

Agenda

Agenda

VCU Team Clinical Director Mishka Terplan, MD, MPH, FACOG, FASAM

Administrative Medical Director ECHO Hubs and Principal Investigator

Vimal Mishra, MD, MMCi

Clinical Expert

Program Manager

Practice Administrator

IT Support

Lori Keyser-Marcus, PhD

Nanah Fofanah, MPH, CPH

David Collins, MHA

Vladimir Lavrentyev, MBA

Introductions

Fatal drug overdose has been the leading cause of unnatural death in Virginia since 2013

Opioid Epidemic and Virginia

At least 1,420 people died last year due to drug overdose

Project ECHO will likely build capacity and create access to high-quality addiction care at local communities

SAMHSA Buprenorphine Treatment Practitioner Locator Data

Opioid Epidemic and Virginia

Statewide Administrator

Academic hub Academic hub Academic hub

Clinical hub will rotate every 12-16 weeksBi-Weekly 2 hour tele-ECHO Clinics

Every tele ECHO clinic includes a 30-minute talk followed by case discussions

Talks will be developed and delivered by inter-professional experts in substance use disorder

https://www.vcuhealth.org/explore-vcu-health/for-medical-professionals/project-echo

Project ECHO Clinical LeadershipClinical Directors Mishka Terplan, MD, MPH, FACOG, FASAM (VCU)

Richard Lawrence Merkel, MD, PhD (UVA)

Cheri W. Hartman, PhD (Virginia Tech Carilion)

Administrative TeamAdministrative Medical Director ECHO Hub and Principal Investigator

Program Manager

Practice Administrator

IT Support

Vimal Mishra, MD, MMCi

Nanah Fofanah, MPH, CPH

David Collins, MHA

Vladimir Lavrentyev, MBA

Benefits to Participating Clinicians

• Free continuing education credit

• Opportunity to present actual patient cases, in a de-identified format, and receive specialty input

• Addiction treatment training, including management of naloxone/ buprenorphine (e.g. Suboxone)

• Access to a virtual learning community for access to treatment guidelines, tools, and patient resources

• Professional interaction with colleagues with similar interest

• Recording: By participating in this clinic you are consenting to be recorded. If you do not wish to be

recorded, please email ProjectECHO@vcuhealth.org

• Protect Patient Privacy

• Participation and discussion is welcomed

Helpful Reminders

• Rename your ZOOM screen: Please rename your screen with your full name

• All participants are Muted during the call, Please Unmute yourself before speaking. If you have a

question, use the ‘hand-raised’ future in ZOOM or type your question in the Chat box.

• Speak to the Camera, avoid distractions and for ZOOM issues (such as echoing, audio level etc.), use the

chat function to speak with the clinic IT team (Vlad)

Helpful Reminders

What to Expect

I. Overview

II. Introductions

III. Didactic Presentation

IV. Case presentationsI. Case1

I. Case summary II. Clarifying questions III. Recommendations

II. Case 2 I. Case summary II. Clarifying questionsIII. Recommendations

V. Closing and questions

Lets get started!Didactic Presentation

Virginia Opioid Addiction ECHO: Didactic Presentation

Open to all practicing and licensed M.D.s, D.O.s, and Community-based clinicians

Disclosures

Dr. Mishka Terplan and Dr. Lori Keyser-Marcus have no financial conflicts of interest to disclose

There is no commercial or in-kind support for this activity.

Objectives

• Compare and contrast the medications commonly used for treatment of Opioid use disorders including indications, side effects, and regulatory concerns

• Plan strategies to integrate medication for Opioid use disorders into practice

Pharmacotherapy for OUDMedications for the Treatment of OUD

Presenter: Dr. Mishka Terplan

Not everyone who uses drugs becomes addicted

Heroin addiction is a disease – a “metabolic disease” – of the brain with resultant

behaviors of “drug hunger” and drug self-administration, despite negative

consequences to self and others. Heroin addiction in not simply a criminal behavior

or due along to antisocial personality or some other personality disorder

Why do people use opioids?W

ithdr

awal

Nor

mal

Euph

oria

Chronic useAcute use

Tolerance and Physical Dependence

To feel good

To feel better

Maintenance Treatment for Severe Opioid Use DisorderW

ithdr

awal

Nor

mal

Euph

oria

Chronic use Maintenance

Overtime Addiction from Reward Seeking to Relief Seeking

-10 -9 -8 -7 -6 -5 -40

10

20

30

40

50

60

70

80

90

100

% Efficacy

Log Dose of Opioid

Full Agonist(Methadone)

Partial Agonist(Buprenorphine)

Antagonist (Naloxone)

Opioid Efficacy: Full Agonist, Partial Agonist, Antagonist

How does buprenorphine work?

• High affinity, but low activity at the mu opioid receptor

• Low activity is enough activity to TREAT WITHDRAWAL and REDUCE CRAVINGS

• Low activity results in a CEILING EFFECT• Euphoria is unusual• Overdose occurs only with other drugs of

abuse• Opioid dependent patients FEEL NORMAL• High affinity means it is a BLOCKER, more

active opioids can not stimulate the receptor in presence of buprenorphine

SAMHSA/CSAT TIP #40 page13

Withdrawal relief

Pain relief

Euphoria

Respiratory depression

Death

Goals of medication treatment for opioid use disorder

1. Relief of withdrawal symptoms • Low dose methadone (30-40mg), buprenorphine

2. Reduce opioid craving• High dose methadone (>60mg), buprenorphine,

naltrexone

3. Opioid blockade• High dose methadone (>60mg), buprenorphine,

naltrexone

4. Restoration of reward pathway• Long term (>6 months)

• methadone, buprenorphine, naltrexone

Plasma BUP levels for target effects

Target Plasma Concentration

MOR binding

Blocking withdrawal

>1ng/mL > 50%

Opioid blockade > 2-3 ng/mL > 70%

How do buprenorphine + naloxone work?

• Buprenorphine has good sublingual and IV bioavailabilty but poor GI

bioavailability

• Naloxone (Narcan) has good IV bioavailabilty, but poor GI and sublingual

bioavailability

• The combination results in decreased abuse and diversion for IV use

Medication saves lives. People die when medication stops.

4.3

11.3

9.5

36.1

BUPRENORPHINE METHADONE

ALL CAUSE MORTALITY RATE PER 1000 PERSON YEARS, IN AND OUT OF TREATMENT

In Treatment Out of Treatment

Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, Ferri M, Pastor-Barriuso R. Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. BMJ 2017 Apr 26;357:j1550.

Deaths per 100-person-years

• Pure opioid antagonist • Injectable naltrexone (Vivitrol®)

• Monthly IM injection• FDA approved 2010• Patients must be opioid free for a minimum

of 7-10 days before treatment • Oral naltrexone

• Well tolerated, safe• Duration of action 24-48 hours• FDA approved 1984• 2008 Cochrane Review

• No clear benefit in treatment retention or relapse at follow up over placebo

• Physicians > 80% abstinence at 18 months

Naltrexone

Outcomes NTX placebo

Trial completion 53% 38%

Abstinence at 24 weeks 90% 35%

Change in craving score -10.1 0.7

Krupitsky E, et al. Lancet, 2011

Opioid Detox Outcomes

• Low rate of retention in treatment

• High rates of relapse post treatment

< 50% abstinent at 6 months

< 15% abstinent at 12 months

Increased rates of overdose due to decreased tolerance

O’Connor PG JAMA 2005Mattick RP, Hall WD. Lancet 1996Stimmel B et al. JAMA 1977

So, how long should maintenance treatment last?Long enough

Matching Patients to Pharmacotherapy

• The choice between methadone, buprenorphine or naltrexone depends upon:

• Patient preference - Past experience

• Access to treatment setting

• Ease of withdrawal

• Risk of overdose

• Care = Evidence-Based and Person-Centered

New Formulations

For patients stable on SL bupe for 7+ days

300 mg SQ/ month for 2 months followed by 100mg SQ/month

(Increase monthly dose to 300mg for patients in whom benefits outweigh risks)

SQ Bupe Blockade

Positron Emission Tomography

(PET) study with SUBLOCADE in 2

subjects (one subject receiving 200

mg SC injections and one subject

receiving 300 mg SC injections):

75 to 92% occupancy of the mu-

opioid receptors in the brain was

maintained for 28 days following

the last dose under steady-state

conditions.

SQ Bupe PK

At steady state (generally achieved 4-6 months after starting therapy), average plasma

buprenorphine concentrations with once-monthly Sublocade 100 mg are about 10% higher

than those with 24 mg/day of sublingual buprenorphine tablets.

Efficacy

Cost

Diversion

Relative Risks/Strengths Diverted Opioids

Relative Risks/Strengths Diverted Opioids

OxyContin

Buprenorphine

Methadone

Questions ?

Reference

Mattick RP, Breen C, Kimber J, Davoli M.,Buprenorphine maintenance versus placebo ormethadonemaintenance for opioid dependence.Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD002207.

DOI: 10.1002/14651858.CD002207.pub4.

Case #1

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Case #2

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Scheduled TeleECHO Clinics

Bi-Weekly Fridays 12-2pm

1. May 18: Introduction to Opioid Use Disorder2. June 1: Harm Reduction of Opioids3. June 15: Counselling and Other Support for Treatment of Opioid Use Disorders

4. June 29: Introduction to Motivational Interviewing5. July 13: Identifying Addiction in Primary Care6. July 27: Medications for Treatment of Opioid Use Disorders

How to Access Your Evaluation and Claim Your CME

Shaun McCafferty

Step 1 - Go to https://vcu.cloud-cme.com/aph.aspx and click “Sign In” on the top left

Step 2 – Sign in using the appropriate option for your account.

If you are a VCU Health employee you will sign in using your VCU Health ID and windows password. All others will use your email and password

If you have never logged in with us before and are not a VCU Health employee, your password was set to Password1

Step 3 – Once signed in, click the “My CME” or “My CE” button.

Step 4 – Click on Evaluations and Certificates.

• Evaluations and Certificates – This option allows you to view evaluations that need to be completed for existing activities you have attended and also allows you to view, print or email certificates for activities you have already completed an evaluation for in CloudCME. This is where you will claim credit, fill out evaluations, and download your certificates.

Please contact VCU Health CME directly with any problems or questions at (804) 828-3640 or cmeinfo@vcuhealth.org

Scheduled TeleECHO Clinics

Bi-Weekly Fridays 12-2pm

1. May 18: Introduction to Opioid Use Disorder2. June 1: Harm Reduction of Opioids3. June 15: Counselling and Other Support for Treatment of Opioid Use Disorders

4. June 29: Introduction to Motivational Interviewing5. July 13: Identifying Addiction in Primary Care6. July 27: Medications for Treatment of Opioid Use Disorders

THANK YOU!