#74: Opioid use disorder, pain, detox, tapers, health policy, and more!

December 22, 2017 | By Carolyn Chan

Combat opioid use disorder and the opioid epidemic as we review common clinical scenarios with addiction medicine specialists, Dr. Stefan Kertesz, University of Alabama at Birmingham School of Medicine and Dr. Ajay Manhapra from the VA Hampton Medical Center in Hampton,Virginia. We need all hands on deck, and that means you! Learn the basics of opioid use disorder treatment as Dr. Manhapra gives us the scoop on “bup, bup, bup” (buphrenophine), and Dr. Kertesz primes us on opioid related health care policy and reminds us that “We can all do something about the opioid crisis”. Plus, Stuart and Paul express some concerns about how to approach these patients. Do not miss this episode filled with clinical pearls, policy, and joy! Special thanks to writers and producers, Dr. Carolyn Chan and Elena Gibson (MD Candidate, MS4), for their hard work on both of our addiction medicine episodes.

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Case from Kashlak Memorial:

A 32 year old male who presents to your clinic today with his wife. He has an active opioid addiction, and uses IV heroin daily. He is ready to quit today and is looking for your help. PMH:  anxiety and PTSD, but he hasn’t followed-up with a doctor in a few years. He is not on any medications.

Clinical Pearls:

1. Risk of death in opioid use disorder (OUD) is high, offer medical treatment early and often. Be familiar with your local treatment options and facilities to refer patients if you are unable to treat them in your office.
2. Counseling patients on treatment options: First, understand your patient’s life context, their living environment, and experience with prior treatment options. Offer contextualized medical therapy and behavioral treatment.
3. OUD detoxification does not have to be done inpatient. Induction therapy for buphrenophine can be initiated in the outpatient setting.
4. OUD medical therapy: Buprenorphine and methadone are evidence based therapies.
5. Buprenorphine-naloxone: Partial mu-opioid agonist. Higher affinity for mu-opioid receptor than full agonists (e.g. heroin, morphine, oxycodone), thus can precipitate withdrawal if taken too soon after patient last used heroin, etc. Typical dose is 4/1 mg to 16/4 mg sublingual taken once daily. Six month implantable version also available. Taper buprenorphine by 2-4 mg per week if stopping to avoid withdrawal (source UpToDate).
6. OUD psychotherapy: All patients who require medical therapy for opioid use disorders should have a psychosocial needs assessment and referrals to psychotherapy or social services if indicated. Not all patients will require formal counseling for their OUD.
7. When determining inpatient residential treatment vs outpatient therapy, consider the life context of the patient before making a recommendation for therapy. Use a shared decision making model.
8. Physicians must compete 8 hours of training to be able to prescribe buprenorphine, and complete a waiver with the DEA to use suboxone (buprenorphine/naloxone) as a tx for addiction.
9. Pain, function and quality of life may improve with opioid dose reduction, in patients  on long-term therapy.
10. Medicaid expansion and opioid epidemic – NYT: Blaming Medicaid for the Opioid Crisis: How the Easy Answer Can Be Wrong
    • Evidence does NOT support theory that medicaid expansion is the cause of the opioid epidemic
11. Opioid Thresholds: Lawmakers are trying to translate healthcare guidelines into policy. This should be done with caution. Op-Ed:  Will strict limits on opioid prescription duration prevent addiction? Advocating for evidence-based policymaking
    • Healthcare guidelines do not always neatly translate into policy
    • This op-ed encourages individuals to advocate for evidence based policy making. – “But the human impulse to show that we are ‘doing something’ absent strong evidence can be harmful.”
12. Op-Ed We can all do something about the opioid crisis

Health care policy: We can all do something about the opioid epidemic.

Goal: Listeners will develop an approach to treating opioid use disorders, and discuss controversies in opioid related health care policy.

Learning objectives:
After listening to this episode listeners will…

1. Counsel patients and their families on addiction treatment options.
2. Describe psychotherapy treatment options for opioid addiction.
3. Describe pharmacological treatment options for opioid addiction
4. Identify controversies in health care policy directed at curtailing opioid addiction.

Disclosures: Dr. Kertesz owns stock in Merck & Co. and Abbott Laboratories, amounting to less than 3% of assets, but has no other income, honoraria, consultancies or grants related to the health industry. Dr Manhapra reports no relevant financial disclosures.

Time Stamps

• 00:00 Intro
• 01:35 Guest Bios
• 03:10 Picks of the week
• 06:22 Case from Kashlak Memorial
• 07:20 Controversy: Is opioid addiction a real disease?
• 10:16: Vietnam Heroin Study (4)
• 12:52 Counseling patients on treatment options for opioid use disorder
• 17:32 Detox and initiation of medical treatment
• 18:50 Psychosocial needs and treatment (5)
• 20:50 How effective is Narcotic Anonymous?
• 21:36 80/20 rule
• 25:50 Inpatient vs outpatient treatment, complex discharge planning
• 27:03 Shared decision making for treatment options
• 31:50 Medical treatment is strongly recommend for OUD
• 32:17 Viewpoint: harms reduction in residential programs with polysubstance use
• 32:29 Taper, abstinence, and long-term treatment with buprenorphine
• 34:50 How to prescribe buprenorphine – Take the leap!
• 39:30 Medical education and the opioid epidemic
• 42:02 1980 NEJM article (6)
• 43:00 Complex persistent dependence patients (7)
• 46:40 Post-op pain and risk of addiction
• 51:34 Approach to increasing pain medications
• 54:50 Health Policy Intro
• 54:59 Opioid thresholds for patients and policy
• 61:39 Medicaid expansion and opioid epidemic (10)
• 66:25 Take home points
• 69:50 Round Table
• 73:56 Outro

Links from the show:

1. Stefan’s book pick:The Storm Light Archive by Brandon Sanderson
2. Ajay’s music pick: Bob Dylan’s New Album
3. Paul’s book pick: Deadeye Dick by Kurt Vonnegut
4. “Vietnam Study” – Robins, L. N. (1993). Vietnam veterans rapid recovery from heroin addiction: a fluke or normal expectation? Addiction, 88(8), 1041-1054. doi:10.1111/j.1360-0443.1993.tb02123.x
5. American Academy of Addiction Guidelines for the use of medications in the treatment of addiction involving opioid use.
6. NEJM letter-  Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med
7. Complex persistence dependence patients – Manhapra, A., Arias, A. J., & Ballantyne, J. C. (2017). The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary. Substance Abuse, 1-10. doi:10.1080/08897077.2017.138166
8. Dose reduction in opioids and pain improvement – Frank, J. W., Lovejoy, T. I., Becker, W. C., Morasco, B. J., Koenig, C. J., Hoffecker, L., . . . Krebs, E. E. (2017). Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy. Annals of Internal Medicine, 167(3), 181. doi:10.7326/m17-0598
9. NPR Article with Dr. K.-  Is There A Way To Keep Using Opioid Painkillers And Reduce Risk?
10. Medicaid expansion and opioid epidemic – NYT: Blaming Medicaid for the Opioid Crisis: How the Easy Answer Can Be Wrong

Recommended Reading:
Opioid Treatment

1. AAFP: Managing Opioid Addiction with Buprenorphine
2. Annals IM: Beyond The Guidelines How Would You Manage Opioid Use in These Three Patients?
3. Manhapra, A et al. The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary. Substance Abuse 2017.

Health Policy

1. Op-Ed We can all do something about the opioid crisis
2. NPR : What Vietnam Taught us About Breaking Bad Habits
3. Blog Post – Opioid Prescribing: Dosage Threshold or Ceiling?
4. Podcast: Zachary Siegel: Where Are The Opioid Recovery Activists?
5. Mundkur, M, Kertesz, S, Gordon A. Will strict limits on opioid prescription duration prevent addiction? Advocating for evidence-based policymaking. Substance Abuse 2017.