Prescrip(on  Pain  Medica(on  Abuse:  The  Importance  of  Treatment    

for  Opioid  Use  Disorders  Elinore F. McCance-Katz, MD, PhD

Chief Medical Officer Substance Abuse and Mental Health Services Administration

Na#onal  RX  Drug  Abuse  Summit  Atlanta,  GA  April  22,  2014  

SAMHSA:  A  PUBLIC  HEALTH  AGENCY  

•  Mission:    To  reduce  the  impact  of  hazardous  substance  use  and  mental  illness  on  America’s  communi#es  

•  Roles:      •  Leadership  and  Voice  –  Influencing  Public  Policy  • Data  and  Surveillance    •  Clinical  Educa>on    •  Public  Educa>on  and  Communica>ons  •  Regula>on  and  Standard  SeAng  •  Prac>ce/Services  Improvement    •  Funding  -­‐  Service  Capacity  

Past  Month  Nonmedical  Use  of  Types  of  Psychotherapeu#c  Drugs  among  Persons  Aged  12  or  Older:  2002-­‐2012  

3

+ Difference between this estimate and the 2012 estimate is statistically significant at the .05 level.

Percent Using in Past Month

Pain Relievers

Tranquilizers

Sedatives

Stimulants

Source: National Survey on Drug Use and Health, SAMHSA, 2013.

More  Fallout  from  Prescrip#on    Pain  Medica#on  Abuse  

Past Month and Past Year Heroin Use among Persons Aged 12 or Older: 2002-2012

Source: National Survey on Drug Use and Health, SAMHSA, 2013.

Morbidity  and  Mortality  with    Prescrip#on  Pain  Medica#on  Abuse  

•  2004-­‐2011:    Increases  in  Emergency  Department  visits  related  to  opioid  analgesic  misuse:  

   Men:  159%                                  Women:  146%  •  2010:  Deaths  related  to  opioid  analgesic  use:  16,651  (313%  

increase  over  past  decade);  most  deaths  involved  opioids  +  other  drugs/alcohol  

•  For  every  death,  there  were:  •  11  treatment  admissions  •  33  Emergency  department  visits  •  880  non-­‐medical  users  

CDC,  2013,  SAMHSA  TEDS,  2001-­‐11,  SAMHSA/DAWN,  2011  

Specific  Illicit  Drug  Dependence  or  Abuse  in  the    Past  Year  among  Persons  Aged  12  or  Older:  2012  

6

Numbers in Thousands

Source: National Survey on Drug Use and Health, SAMHSA, 2013.

SAMHSA’s  Efforts  to  Prevent    Prescrip#on  Drug  Abuse  

•  Partnerships  for  Success  grants  •  Prescrip3on  Drug  Monitoring  

Program  grants  

•  Preven3on  of  Prescrip3on  Abuse  in  the  Workplace  (PPAW)  Technical  Assistance  Center  

•  Promo3on  of  DEA’s  na3onal  take-­‐back  day  (April  26,  2014)  

•  Not  Worth  the  Risk,  Even  If  It’s  Legal  (pamphlet  series)  

SAMHSA’s  Efforts  to  Curb    Prescrip#on  Drug  Abuse  –  Prescriber  Educa#on  

PCSS-O: Focus on Safe Opioid Prescribing www.pcss-o.org

Opioidprescribing.com: focus on CME accredited trainings on safe use of opioids

PCSS-MAT: www.pcssmat.org Focus on Treatment of Opioid Use Disorders

SAMHSA’s  Efforts  to  Prevent    Prescrip#on  Drug  Overdose

•  Opioid Overdose Prevention Toolkit - http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA13-4742

•  Substance Abuse Prevention and Treatment Block Grant: •  Primary prevention funds can be used for

overdose prevention education/training •  Treatment block grant funds can be used

for purchase of naloxone and overdose kits.

Interven#ons  to  Address  Misuse  of  Prescrip#on  Medica#ons  

• Prescrip#on  Drug  Monitoring  Programs  • Intrastate  and  interstate  data  

• Enforcement  efforts  • Community  outreach  and  educa#on  

Treatment  

•  Prescrip#on  pain  medica#ons  and  heroin  are  the  same  types  of  drugs:  opioids  

•  Treatments  are  the  same  

• Medical  Withdrawal  (“Detoxifica#on”)  • >  90%  relapse  rate  in  the  year  following  treatment  

• High  risk  for  overdose  when  relapse  occurs  • Should  not  be  a  stand  alone  treatment

Treatment  

•  Combina#on  of  FDA-­‐approved  medica#on:  • Naltrexone  • Methadone  •  Buprenorphine/naloxone  With  psychosocial  treatments  and  ancillary  treatment  components:    •  Counseling:  Coping  skills/relapse  preven>on  •  Educa>on  •  PDMP  use  •  Toxicology  screening  

Decisions  about  Medica#on    Assisted  Treatment  

•  Naltrexone:    •  Prevents  opioid  effects  including  ‘high’  •  Effec>ve  in  people  with  strong  incen>ves  (legal,  employment)  and  in  those  not  wan>ng  to  use  an  opioid  medica>on    

•  Tablet  and  injectable  (addresses  issues  related  to  adherence)  

•  Can’t  be  used  in  people  needing  treatment  for  pain  

•  Doesn’t  help  craving  

Methadone  and    Buprenorphine/Naloxone  

•  Long  ac#ng,  once  daily  medica#ons  •  NOT  ‘subs#tu#ng  one  drug  for  another’  • Medica#ons  are  #trated  to  a  therapeu#c  dose:  • Withdrawal  blocked  • Craving  reduced  or  stopped  • Tolerance  occurs  so  that  mood-­‐altering  effects  are  diminished  

Methadone    

•  Only  available  through  methadone  maintenance  programs  (MMPs)  

•  Take  home  doses  con#ngent  on  progress  in  treatment  • A`ending  clinic  and  counseling  • Stopping  illicit  drug  use  

•  Large  majority  of  methadone  deaths  are  related  to  methadone  prescribed  for  pain;  not  from  MMPs  

Buprenorphine/naloxone  

•  Opioid  par>al  agonist:  opioid  effects  not  as  strong  as  other  opioids:  oxycodone,  hydrocodone,  methadone,  heroin  

•  Binds  >ghtly  to  opioid  receptors  in  the  brain  so  can  par>ally  block  effects  of  other  opioids  

•  Naloxone  reduces  risk  of  injected  use  in  opioid-­‐dependent  individuals  

•  Available  in  outpa>ent  seAngs  from  qualified  doctors  

Medica#on  Assisted  Treatment  

• Benefits:    • Lifestyle  stabiliza>on    • Improved  health  and  nutri>onal  status    • Decrease  in  criminal  behavior    • Employment    • Decrease  in  injec>on  drug  use/shared  needles:  reduc>ons  in  risk  for  HIV  and  viral  hepa>>s/medical  complica>ons  of  injec>on  drug  use    

Facts  about  Medica#on    Assisted  Treatment  (MAT)  

•  Opioid  dependent,  pregnant  women  are  at  high  risk  for  adverse  outcomes  without  MAT  

•  The  use  of  MAT  by  opioid-­‐dependent  women  with  children  is  an  effec>ve  treatment  that  helps  women  in  paren>ng  their  children  

•  Neonatal  abs>nence  syndrome  (NAS)  occurs  frequently  in  infants  of  mothers  treated  with  MAT;  approximately  50%  will  need  treatment  Buprenorphine  treatment  associated  with  lower  severity  of  NAS  symptoms  and  shorter  hospital  stays    rela>ve  to  methadone  (Jones,  et  al.  2010)  

Myths  about  MAT  

•  ‘Detox’  is  the  best  approach  to  treatment  

•  People  only  need  a  few  weeks/months  of  treatment  • Opioid  use  disorders  are  chronic,  relapsing  condi>ons  

• No  different  than  other  chronic  condi>ons:  diabetes,  high  blood  pressure,  obesity,  depression  

•  Medica#on  doses  should  be  ‘held  low’  There  is  no  medical  basis  for:  •  arbitrary  dosing  limits—use  FDA  and  SAMHSA  guidance  •  for  limi>ng  treatment  dura>on—let  pa>ents  and  their  doctors  decide  these  issues    

Ending  the  Epidemic  

•  Increase  access  to  treatment:  Train  physicians  and  other  clinicians  who  will  provide  treatment  for  opioid  use  disorders    

•  Con>nue  to  train  healthcare  professionals  in  safe  and  appropriate  use  of  opioids  and  alterna>ves  to  use  of  opioids  for  pain  

•  Con>nue  to  educate  the  public  about  the  dangers  of  misuse  of  pain  medica>ons  and  safe  use  when  necessary  including  safe  storage  and  disposal  

•  Use  PDMPs,  treatment  agreements,  and  toxicology  screens  to  increase  safety    

•  Provide  evidence-­‐based  treatment  to  all  who  need  it  for  as  long  as  it  is  clinically  indicated  

Thank  you!  Elinore.McCance-­‐Katz@samhsa.hhs.gov