Treatment and Recovery in America National Rx Drug Abuse Summit 4-10-12

1. Treatment and
Recovery in America
April
10-­‐12,
2012
Walt
Disney
World
Swan
Resort

2. Substance Abuse in the
United States:
When and How to Use
Medication Assisted
Treatments
Elinore F. McCance-Katz, MD, PhD
Professor of Psychiatry
University of California San Francisco

3. Accepted Learning Objectives:
1.
Define
when
and
how
medica>on-­‐assisted
treatment
methodologies
for
successful
recovery
of
opioid
addic>on
should
be
used.
2.
Explain
how
to
improve
access
and
quality
of
care
through
strategic
planning
and
community-­‐
wide
coordina>on
with
local
and
state
agencies.
3.
Describe
behavioral
health
issues
faced
by
individuals
within
the
correc>ons
system
and
devise
strategies
to
adequately
address
these
clinical
needs
aHer
incarcera>on.

4. Learning Objectives:
To gain an understanding of:
Recent Advances in Recognition and Treatment of
Substance Use Disorders
SBIRT: What is it and how can it improve medical
care and reduce costs?
Review some of the basics of substance abuse
treatment that can be accomplished in primary
care and other medical settings
– Screening
– Brief intervention/motivational interviewing
– Referral to substance abuse treatment settings when
needed
– Pharmacotherapy for substance use disorders that
can be undertaken in the primary care setting

5. Disclosure Statement
• All presenters for this session, Dr. Elinore
McCance-Katz and Gregory C.
Warren, have disclosed no relevant,
real or apparent personal or
professional financial relationships.

6. Disclosures
Grant Funding from:
National Institutes of Health
National Institute on Drug Abuse
National Institute on Alcohol Abuse and
Alcoholism
Substance Abuse and Mental Health
Services Administration
Center for Substance Abuse Treatment

7. What is SBIRT?
SBIRT is a comprehensive, integrated, public
health approach to the delivery of early
intervention and treatment services for persons
with substance use disorders, as well as those
who are at risk of developing these disorders.
Primary care centers, hospital emergency
rooms, trauma centers, and other community
settings provide opportunities for early
intervention with at-risk substance users before
more severe consequences occur.

8. Why Do We Need SBIRT?
Problem Substance Use is Prevalent in Americans
SAMHSA, National Survey on Drug Use and Health, 2010

9. SBIRT Components
• Screening quickly assesses the severity of
substance use and identifies the appropriate
level of treatment.
• Brief intervention focuses on increasing insight
and awareness regarding substance use and
motivation toward behavioral change.
• Referral to treatment provides those identified as
needing more extensive treatment with access to
speciality care.

10. Is SBIRT Effective?
• SBIRT research has shown that large numbers of
individuals at risk of developing serious alcohol or other
drug problems may be identified through primary care
screening.
• Interventions such as SBIRT have been found to:
– Decrease the frequency and severity of drug and alcohol use,
– Reduce the risk of trauma
– Increase the percentage of patients who enter specialized
substance abuse treatment.
– Be associated with
• fewer hospital days
• fewer emergency department visits
• net-cost savings to the health care system from
these interventions

11. What are the Benefits and Screening
and Brief Intervention?
• Strong evidence for the effectiveness of brief
interventions with alcohol and tobacco use,
growing support for use with other substances.
• Minimal amount of time needed to conduct brief
interventions.
• Low-cost/cost-effective. For each dollar spent, it
has been estimated that $2–$4 (per person)
have been saved in terms of health costs and
costs related to workforce productivity.
Fleming, 2002; Gentilello, et al., 2005

12. How to Rapidly Screen for Alcohol
Problems
Single Question with high sensitivity/specificity:
• In the past year, have you had any times when
you had 5 (for women, 4) or more drinks at one
sitting?
• If yes, explore drinking, offer advice for cutting back or
stopping, if evidence of dependence refer to
substance abuse treatment facility
• Note: a single question does not make a
diagnosis, but indicates a need for
further screening

13. What Can the Primary Care Physician
Use to Treat Substance Use
Disorders?
Pharmacotherapy
Review

14. General Considerations for SUD
Pharmacotherapy
" Tobacco:
Relapse
Preven>on-­‐Yes,
for
office-­‐based/outpa>ent
prac>ce
" Alcohol
 Acute
withdrawal
(usually
done
inpa>ent)
 Relapse
Preven>on-­‐Yes,
for
office-­‐based/outpa>ent
prac>ce
" Opiates
 Acute
withdrawal
(oHen
done
inpa>ent,
but
can
be
outpa>ent
procedure)
 Relapse
Preven>on-­‐Yes,
for
office-­‐based/outpa>ent
prac>ce
" Cocaine/Methamphetamines/S>mulants
 No
FDA
approved
medica>ons
for
withdrawal
symptoms
or
relapse
preven>on

16. Cigare'e
Smoking

17. Cigare'e
Smoking

19. Cigarette Smoking

20. Cigare'e
Smoking

21. Cigare'e
Smoking

22. Cigarette Smoking
Varenicline
 Nico>ne
par>al
agonist
 Decreases
craving
to
smoke
 May
be
useful
in
co-­‐occurring
tobacco
dependence
and
alcohol
abuse
 Twice
daily
oral
medica>on
to
be
started
1
week
before
quit
date
(.5
mg/d
x
3;
.5
BID
x
3;
1
mg
BID)
 Length
of
Treatment:
12
weeks
 Monitor
for
depression/suicidal
thinking
 No
abuse
liability

23. Maintenance Medications To Prevent Relapse To
Alcohol Use (FDA approved)
• Disulfiram
• Naltrexone (oral and injectable)
• Acamprosate

24. Disulfiram
" How
it
Works:
Blocks
alcohol
metabolism
leading
to
increase
in
blood
acetaldehyde
levels;
aims
to
mo>vate
individual
not
to
drink
because
they
know
they
will
become
ill
if
they
do
" Disulfiram/ethanol
reac>on:
flushing,
weakness,
nausea,
tachycardia,
hypotension
 Treatment
of
alcohol/disulfiram
reac>on
is
suppor>ve
(fluids,
oxygen)
" Side
Effects:
 Common:
metallic
taste,
sulfur-­‐like
odor
 Rare:
hepatotoxicity,
neuropathy,
psychosis
" Contraindica>ons:
cardiac
disease,
esophageal
varices,
pregnancy,
impulsivity,
psycho>c
disorders,
severe
cardiovascular,
respiratory,
or
renal
disease,
severe
hepa>c
dysfunc>on:
transaminases
>
3x
upper
level
of
normal
" Avoid
alcohol
and
alcohol
containing
foods
" Clinical
Dose:
250
mg
daily
(range:
125-­‐500
mg/d)
" Adherence:
problem;
but
if
drug
is
taken
it
works
well
(Fuller
et
al.
1994;
Farrell
et
al.
1995);
good
idea
to
start
in
a
substance
abuse
treatment
program

27. Naltrexone
" Potent
inhibitor
of
mu
opioid
receptor
binding
 may
explain
reduc>on
of
relapse
" because
endogenous
opioids
involved
in
the
reinforcing
(pleasure)
effects
of
alcohol
 May
explain
reduced
craving
for
alcohol
" because
endogenous
opioids
may
be
involved
in
craving
alcohol

31. How
to
Select
a
Medica5on
for
Alcohol
Use
Disorders
" Disulfiram: when the patient is
committed to no further drinking; heavy
consequences of relapse
" Naltrexone: for the patient who wants to
cut back or get help for craving
" Acamprosate: naltrexone doesn t work,
patient needs opioid analgesia;
disulfiram not an option

34. Source Where Pain Relievers Were
Obtained for Most Recent Nonmedical Use
among Past Year Users Aged 12 or Older:
NSDUH 2010
Source Where Respondent Obtained
Bought on
Drug Dealer/ Internet
Stranger 0.4% Other 1
More than 4.4% 6.5%
Source Where Friend/Relative Obtained
One Doctor More than One Doctor
1.6% 3.3% Free from
One Doctor Free from Friend/Relative
17.3% Friend/Relative 7.3%
55% One
One Bought/Took
Doctor from
Bought/Took 79.4% Friend/Relative
from Friend/Relative 79.4% 4.9%
14.8%
Drug Dealer/
Stranger
Other 1
1.6%
3.5%
Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown.
1 The Other category includes the sources: Wrote Fake Prescription, Stole from Doctor s Office/Clinic/
Hospital/Pharmacy, and Some Other Way.

35. Why Are Such Large Numbers of Opioid
Medications Being Prescribed?

36. Prescribers have a mandate to relieve pain
• But may not receive enough training on
the various approaches to treatment of
pain
Prescribers have a mandate not to prescribe
to those with addiction
• But may not receive enough training on
recognition and treatment of substance
use disorders

37. Opioids
for
Pain
Management
 Chronic opioids for non-malignant pain
presents potential problems:
 Lack of evidence for efficacy, particularly with
high dose opioid therapy over long periods
 Syndrome of rebound pain/hyperalgesic
states produced by opioid use
 Withdrawal syndromes masquerading as
pain
Balantyne et al., 2003

39. What s the Best Path?

44. Naltrexone

50. Why is All of This Important?
• Drug and alcohol use disorders affect approximately
10% of Americans
• Screening and early intervention= prevention!
• Substance use disorders are chronic, relapsing diseases
that are likely to recur once diagnosed
• Effective pharmacotherapies are available and can be
implemented in primary care
• Substance abuse can negatively impact other illnesses
present in the patient (e.g.: alcoholic cardiomyopathy,
COPD, HIV/AIDS, HCV, other ID) and/or can
masquerade as an illness that the patient does not have
(e.g.: HTN, seizure d/o, mental disorders)
• Can contribute to non-adherence to prescribed
regimens, toxicities due to drug interactions

51. Clinical Support Systems
Sponsored by Center for Substance Abuse Treatment/SAMHSA

52. References
• Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for
problem drinkers: long-term efficacy and benefit-cost analysis. Alcoholism: Clinical and Experimental
Research 2002; 26: 36-43.
• Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol
drinkers. JAMA 1997; 277:1039-45.
• SAMHSA, Results from the 2010 National Survey on Drug Use and Health: Summary of National
Findings, NSDUH Series H-41, HHS Publication # SMA 11-4658, Rockville, MD Substance Abuse and
Mental Health Services Administration, 2011.
• Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol interventions for trauma
patients treatment in emergency departments and hospitals: a cost benefit analysis. Annals of
Surgery 2005, 241:541-550.
• Edwards et al. 2003
• Fuller RK, et al.: Veterans Administration cooperative study of disulfiram in the treatment of
alcoholism: study design and methodological considerations. Control Clin Trials. 1984 Sep;5(3):
263-73
• O’Farrell TJ, et al.: Disulfiram (antabuse) contracts in treatment of alcoholism. NIDA Res Monogr.,
150:65-91, 1995.
• Garbutt JC, Kranzler HR, O Malley SS, Gastfriend DR, Pettinati HM, Silverman BL, Loewy JW, Ehrich
EW: Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a
randomized controlled trial. JAMA 2005; 293: 1617-1625.
• VA/DoD CPG SUDs, www.oqp.med.va.gov/cpg/SUD/SUD_Vase.htm
• Donovan DM, et al.: Combined pharmacotherapies and behavioral interventions for alcohol
dependence (The COMBINE Study): Examination of posttreatment drinking outcomes. J Stud Alcohol
Drugs 2008 69: 5-13.
• Anton RF, et al.: Combined pharmacotherapies and behavioral interventions for alcohol dependence:
the COMBINE study: a randomized, controlled trial. JAMA 2006 295 (17): 2003-2017.
• McNicholas, L. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction: A
treatment improvement protocol (TIP 40). Rockville, MD: US Department of Health and Human
Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse
Treatment, 2004.
• U.S. Public Health Service: A clinical practice guideline for treating tobacco use and
• dependence: A US public health service report. JAMA 2000; 283:3244–3254.