diane p. calello, md, faap, facmt,...
TRANSCRIPT
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Diane P. Calello, MD, FAAP, FACMT, FAACT
NJ AAP Annual Conference and Exhibition
Tuesday, May 22nd, 2018
The Palace at Somerset Park, Somerset NJ
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• Review the scope of the nation’s opioid crisis
• Focus on pediatric population
• Focus on New Jersey
• Discuss the pharmacology underlying abuse and
treatment
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• I have nothing to disclose.
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Prenatal
Exposure
Neonatal
Withdrawal
Opioid Poisoning
Exposures
The Drug-Endangered Child
Adolescent
Addiction,
Mental
Illness
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SOURCE: NCHS, National Vital Statistics System, Mortality
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NJ Advance Media
December 8, 2017
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• 16% rise in opioid deaths last year
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Heroin
U-47700/Furanyl
Fentanyl
Fentanyl
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• Mu opioid receptor agonists:
• Euphoria, analgesia, respiratory depression, miosis
• Other receptors (K, Sigma) effects less an issue
• Heroin (diacetylmorphine)
• Fentanyl
• Novel Synthetic Opioids
• Fentanyl analogues: acetylfentanyl, butyrylfentanyl,
furanylfentanyl, carfentanil, fluoro-fentanyls
• U-47700, 4-ANPP
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Opioid Receptor Agonists/Partial agonists
• Formerly “Opioid Substitution Therapy”
• Methadone, buprenorphine
Opioid Receptor Antagonists
• Naloxone
• Naltrexone
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• Very long-acting full mu opioid receptor agonist
• Variable kinetics, p450 metabolism
• Adverse effects:
• QT prolongation
• Hypoglycemia
• Dispensed in Methadone Treatment Programs
• MMTPs
• Liquid* or tablet formulation
• Approximate doses 30-120 mg daily
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• Partial mu receptor agonist• “Ceiling effect” for respiratory depression
• Can precipitate withdrawal if full agonist on board
• Dispensed in tablet, film form
• With or without naloxone
• Office-based prescribing• X-waiver required
• Seemingly safer in overdose
• Doses 8-32mg BID• TID if concomitant pain
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• Implantable probuphine
• Incision and dermal insertion
• 6 months supply, but only 8mg
• IM depot formulation (Sublocade®)
• 1-4 weeks duration
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Medication Assisted Therapy
• Formerly “Opioid Substitution Therapy”
• Methadone, buprenorphine
Opioid Receptor Antagonists
• Naloxone
• Naltrexone
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• First synthesized in 1960
• “N-allylnoroxymorphone”
• Rapid onset of action
• First line for respiratory depression
• Intranasal, IM, endotracheal
• Increasing programs for bystander,
take-home naloxone
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• Long-acting mu receptor antagonist
• Available in oral, IM depot formulations
• Used for treatment of SUD, not overdose
• Period of abstinence required
• 48-72h
• Longer with methadone, taper to 30mg required
• Useful in alcohol, benzo combined abuse
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• Opioid epidemic has implications at all stages of
development
• Addiction and overdose in adolescence parallels
opioid crisis in overall population
• NJ is far from immune
• Treatment options – pharmacology and beyond
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Adolescent Substance Use:SBIRT and Opioid Use Disorder Treatment
Patricia Cintra Franco Schram MD, DABAMAssistant Professor in Pediatrics
Harvard Medical School
Adolescent Substance use and Addiction Program
Boston Children’s Hospital
May 22, 2018
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Disclosure
• In the last 12 months, neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services related to the content of this CME activity.
• My content will include discussion/reference of commercial products or services.
• I do not intend to discuss an unapproved/investigative use of commercial products/devices.
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Learning Objectives
• To demonstrate screening and assessment
algorithm that aids clinicians in quickly and
accurately assessing substance use and risk
associated with it.
• To demonstrate the use of brief interventions to
prevent, stop or reduce substance use by teens.
• To demonstrate a outpatient clinical model to treat
adolescent who use opioids.
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SCREENING
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Primary Care Provider
• Primary care offices ideal for substance use screening and early intervention:
• Teachable moment
• Confidential relationship
• Health-risk context
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Confidentiality
• Interview adolescent without parents present
• Information can remain confidential unless safety is at risk
• Check state law for guidelines regarding when confidentiality must be broken
• When confidentiality must be broken, discuss first. Try out words to use, avoid revealing small details unless absolutely necessary
Ford CA et al. JAMA. 1997;278(12):1029-1034.
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Screening Brief Intervention and Referral to Treatment
Ask about past year use
Screen (CRAFFT or NIAAA)
Assess for Acute Risk or AddictionBrief Advice
Brief Intervention
Immediate intervention and/or Refer to TreatmentRe-screen Yearly
Positive Reinforcement
+
+-
+
Ask about riding with impaired
drivers
-
-
-
+
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Ask about past-year use
• In the past 12 months have you . . .
• drank any alcohol (more than a few sips)?
• smoked marijuana?
• Use anything else to get high (like other illegal drugs, prescription or over-the-counter medications, and things that you sniff, huff, or vape ) ?
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Past-year use?
Administer a screen to
determine risk level
YES NO
Ask about riding with an impaired driver
“CAR question”
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CRAFFTC Have you ever ridden in a CAR driven by someone (including yourself) how was
“high” or had been using alcohol /drugs?
R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A Do you ever use alcohol/drugs while you are by yourself, ALONE?
F Do you ever FORGET things you did while using alcohol or drugs?
F Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking ordrug use?
T Have you ever gotten into TROUBLE while you were using alcohol or drugs?
Knight JR. The CRAFFT questions: A brief screening test for adolescent substance abuse. Boston, MA: Copyright Boston Children's Hospital; 1999http://www.ceasar.org/CRAFFT/index.php
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Positive Predictive Value
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
CRAFFT Score
Pro
bab
ility
of
sub
stan
ce
use
dis
ord
er
Knight JR et al. Arch Pediatr Adolesc Med. 2002;156:607-614.
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NIAAA 4-step guide
• Two questions
• Created from national database information
• Screens down to age 9
• Most begin to use alcohol before other drugs
http://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuideOrderForm.htm
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When should we use an alcohol screen?
• With very young patients (ages 9 to 12)
• When time is limited, with patients older than 12 years
• Whenever a patient or parent presents with a specific concern about alcohol
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Ask the 2 questions:
• One about friends drinking
• One about own drinking
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Tips on how to ask:Elementary(age 9-11)
Middle School(age 12-14)
High School(age 15-18)
• Do you have friends who drink?
• Have you everdrank alcohol?
• Do you have friendswho drink?
• In the past year how often did you drink
alcohol?
• In the past year how often did you drink
alcohol?
• How many drinks do your friends usually have
per occasion?
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Determine Risk Level
http://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuideOrderForm.htm
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BRIEF INTERVENTION
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Brief Intervention: Car Safety
• Teens should not drive even after a single drink – often teens don’t notice the early effects of alcohol that can affect driving abilities.
• Think about alternative safe ways of getting home.• get a ride from non-user
• sleep overnight, then go home
• call for a safe ride from parents
• review the CONTRACT FOR LIFE
(http://www.saddonline.com/contract.htm)
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CONTRACT FOR LIFE
SADD. Contract For Life: A Foundation for Trust and
Caring. 2001; http://www.saddonline.com/contract.htm.
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Brief Intervention Goals
1. No use – Positive Feedback to delay the onset of use
2. Lower risk – Brief Advice to quit
3. Moderate risk – Brief Motivational Interviewing to reduce use and to quit
4. Highest risk – Refer to Treatment using motivational interviewing techniques
5. Acute Safety Risk – Immediate Intervention
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No Use
Positive reinforcement
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Lower Risk Use: Brief Advice
1. Advise to stop using alcohol/drugs
2. Provide relevant medical information
“The teen brain and marijuana”
www.ceasar-boston.org
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Moderate risk: Brief Intervention/ Brief Advice
• I recommend for the sake of your health that you stop smoking marijuana altogether.
• Heavy marijuana use affects your concentration. Over time it can impact your mood and affect your performance on the soccer field.
• You are such a good athlete, I would hate to see anything get in the way of your future.
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Neurobiology PowerPoint
The Teen Brain and Marijuanaby Sion Harris
www.ceasar-boston.org
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TREATING ADOLESCENTS WITH OPIOID USE DISORDERS
ADOLESCENT SUBSTANCE USE AND ADDICTION PROGRAM (ASAP)
Boston Children’s Hospital
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Mike
• 16yo, seen for annual physical 6 months ago
• Has been your patient since birth
• Reports that was snorting Oxycontin 30 mg every weekend for a few months
• Today, asked you for help and to prescribe some, because he NEEDS some EVERYDAY and does not have more money
• What would you do?
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Mike
• Evaluate mental health needs
• COWS: Clinical Opiate Withdrawal Scale https://www.drugabuse.gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf
• Comfort meds, depending on the severity/kind of symptoms
• Referral to treatment:
Medication assisted treatment (MAT)
Acute residential treatment (ART)
Detox is NOT treatment
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Outpatient Treatment for Opioid Use Disorder
Meds
• Buprenorphine/naloxone
• Buprenorphine
• Methadone
• Naltrexone XR
• Drug test program
• Counseling for the adolescent
• Address mental health issues
• Parent guidance
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Opioid classification:
Full agonists:•morphine•oxycodone
Partial agonist:•buprenorphine
Antagonists:•naloxone•naltrexone
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How does buprenorphine work?
• Buprenorphine binds to the opioid receptor, but turns the neuron partially on.
• When you take buprenorphine you don’t feel high and you don’t feel bad.
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Buprenorphine blocks other opioids
• Buprenorphine has high affinity for opioid receptors.
• Other opioids cannot bind to the receptor if buprenorphine is there.
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Buprenorphine must be started when you are in withdrawal (or clean)
• Buprenorphine displaces other opioids from the receptor, turning the cell from fully on to partially on. If this happens, you will feel withdrawal symptoms.
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What does Naloxone Do?
• Naloxone also binds to the opioid receptor.
• Naloxone turns the neuron completely off. If you are high from an opioid and take Naloxone you will immediately begin to withdraw.
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Naloxone is a safety feature
• When you take Suboxone under your tongue your body absorbs only the buprenorphine, NOT the naloxone.
• If you injected Suboxone into a vein your body would absorb the buprenorphine and the Naloxone.
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Prescribing Buprenorphine
• 8 hour waiver training (available online) https://www.samhsa.gov/medication-assisted-treatment/training-resources/buprenorphine-physician-training
• Providers Clinical Support System (PCSS)• https://pcssnow.org/about/
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Starting Buprenorphine/Naloxone:
• Opioid use disorder diagnosed, DSM-5
• Social supports available (family and/or friends)
• Medication directly observed by parents
• Frequent medication and counseling visits (weekly in the beginning)
• If no parental involvement, very short prescriptions
• Drug testing
• Counseling for adolescent and parents
• Psychiatric/Psychopharmacologic evaluation, as needed
• Other individualized services as necessary
• Nasal Naloxone prescribed and family trained to use
• PDMP checked frequently
• Recovery meetings (AA and NA) recommended and discussed
• Parents referred to self help, as needed
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Buprenorphine Induction
• 2 hour visit
• No use of opioid, benzo, alcohol for 24-48 h
• No use of buprenorphine or methadone for days
• Pregnancy test
• COWS (Clinical Opiate Withdrawal Scale)
• Parents present preferable
• Drug test collected
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Clinical Opiate Withdrawal Scale (COWS)Time zero 30 minutes 1 hour 2 hours
Pulse –resting (BP)
Sweating
Restlessness *
Pupil size
Bone and joint ache *
Runny nose and tearing
GI upset (last ½ hour) *
Tremor
Yawning
Anxiety or Irritability *
Gooseflesh skin
Score: 5-12 mild13-24 Moderate25-36 Moderately Severe>36 Severe Withdrawal
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Buprenorphine dose, at induction:
• Start with the lowest dose (2 or 4 mg),
according with the COWS
• Repeat in 30 minutes, if no response
• Observe for 2 hours
• Call later and decide evening dose
• Initially it should be BID, until stable
• Adjust dose aiming no cravings and no side effects
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Buprenorphine Side Effects
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Naltrexone Program
• PO for alcohol severe use disorder
• IM for alcohol/opioid severe use disorder
• Program consists of:• Counseling for teen/young adult • Parent guidance• Drug testing• Frequent medication visits• Recovery meetings (AA and NA) recommended and discussed • Other individualized services as necessary
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Random Drug Testing
• Contract
• Random tests, weekly on average
• Drug test results used for monitoring alcohol and substance use, and for medicine compliance
• Medical Review Officer (MRO) visits done with teen and parents
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Psychopharmacology
• In house psychopharmacology program for dually diagnosed adolescents
• Staffed by an addiction psychiatrist with expertise in adolescents
• Substance abuse counseling
• Therapist in the community recommended, as needed
• Coordination of care, as frequently as needed
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Case Management
• To assist with referral to other services or more intensive services for substance use disorders.
• Active coordination with other providers and/or other levels of coordination.
• Barriers: • Finding individual therapist in the community
• Detox placement
• Residential placement
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Opioid Agonist Treatment
• Associated Stigma, both with the disease of addiction and use of medications
• Low access
• Not enough buprenorphine-waived prescribers
• Low rate of prescribing among waivered physicians
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Opioid Agonist Treatment
• Increase access to Medication Assisted Treatment
• Increase public education
• Increase education among health professionals
• Decrease stigma
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Meier et al. Proceedings of the National Academy of Sciences.
2012 Oct 2;109(40):E2657-64
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The Dunedin Study (New Zealand)(N=1,037)
1 2 3 4 5
Assessment ages
13 yrs(Pre-initiation)
18 yrs 21 yrs 32 yrs 38 yrs
Meier et al. PNAS, 2012
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Change in IQ from 13-38 yrs old
Never used
Mj dependent 2 yrs
Mj dependent 1 yr
Used, never diagnosed
Mj dependent 3+ yrs
IQ change:
•“Never used”
• 99.8 to 100.6
•“Mj dependent 3+ yrs”
• 99.7 to 93.9
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IQ Change by Age when Marijuana Dependence Started
Before
18
Before
18
Before
1818+ 18+18+
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IQ Change by Age when Weekly Use Began,
Among Those No Longer Using at age 38
Before 18 18+
Age weekly use began
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ASAP unpublished data
• Anxiety 32.3%• Anxiety Disorder NOS 22.2%
• PTSD 5.6%
• GAD 4.8%
• OCD 2.7 %
• Panic Disorder 2.7 %
• Social Phobia 1.7%
• Externalizing/ Behavior Disorder 37.3%• ADHD 31.7 %
• ODD 6.6%
• Behavioral Disorder 3.1%
• Conduct Disorder 1.7%
• Depressive Disorders 16.8%• Depression NOS 9.5 %
• MDD 8.1 %
• Dysthymia 1.0%
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2013 Overdose Prevention Act
• Encourages witnesses to and victims of drug
overdoses to seek medical assistance in an
effort to decrease overdose-related fatalities.
• Recognizes that greater availability and
accessibility for the drug naloxone (Narcan),
an opioid antidote, would reduce the number
of opioid overdose deaths.
• Allows prescribers and dispensers to
distribute naloxone (Narcan) without liability
concerns.
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Naloxone (Narcan)
• Works by attaching to the opioid receptors in the
brain, almost immediately causing reversal of
the overdose.
• Police departments, among other groups, are
providing training to individuals and providing
them with access to naloxone to administer
when circumstances warrant it.
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Is It Worth Dying For?
• Approximately 175 people die
EVERY DAY from a drug overdose
in America.
• In 2016, 1,230 people per week died
from a drug overdose (up 22%
from 2015).
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Is It Worth Dying For?
• Drug overdoses caused more
deaths in 2015 (52,404) than
firearms (36,252) or vehicle
crashes (38,300).
• Overdose deaths from opioids
nearly quadrupled from 2000 to
2014 (8,407 to 33,091 annually).
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Epidemic
• Middlesex County NJ had the highest
growth rate for deaths associated with
heroin for 2014 (increased 420% in 4
years).
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What can YOU do?
• Talk to your friends.
• Teach/model healthy coping skills.
• Use prescription medication exactly as prescribed.
• Dispose of expired/unused medication at drop boxes
(see list of area drug drop off boxes).
• Know about resources in your area for help (school
assistance counselors, health care provider,
Middlesex County Office of Health Services, trusted
adult).
• Understand that no one is immune!
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What are WE doing?
• Partnerships are key!
• Schools, hospitals, law enforcement, health departments
and others involved in finding solutions to this public
health crisis.
• Law enforcement gearing towards treatment rather than
punitive measures for addiction.
• Naloxone (Narcan) available over the counter at area
pharmacies and retail stores ($131-$145).
• All area hospitals providing accessibility to opioid
overdose recovery coaches in their Emergency Rooms
and connecting patients to treatment.
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Community Resources
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Time to remember. Time to act!
#EndOverdose
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THANK YOU