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POLYSUBSTANCE USE IN THE TREATMENT OF OPIOID USE
DISORDERS WITH BUPRENORPHINE
SESSION 3
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Understand benefits and risks of treating OUD in context of polysubstance use
Understand interventions available for alcohol, benzodiazepine, and stimulant use disorder
Discuss programmatic approaches to ongoing polysubstance use
OBJECTIVES
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35 year old female on Bup‐Nal 6‐1.5mg qd for OUD‐severe (heroin). She has been in treatment for three months and has been making her appointments. She is working occasionally, and is couch surfing.
At the time of enrollment she was taking illicit benzodiazepines and agreed to stop using them. However, she has continued to use them and every urine drug screen is positive. She reports having too much social anxiety without them. Also has irregular cannabis use.
What are your concerns and why?
CASE # 1: Benzodiazepines
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Common in Opioid Use Disorder patients:– Up to 70% lifetime– Cocaine (6‐68%)– Alcohol (25‐49%)– Cannabis (8‐41%)
POLYSUBSTANCE USE IS COMMON
Booth BM et al, 2006; Sumnall HR et al, 2004; Patterson TL et al, 2005; John D et al, 2001; Bovasso G et al, 2001; Williamson A et al, 2015, Hser YI et al, 2016; Savant et al, 2013
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BACKGROUND: 2017 WA STATE SYRINGE EXCHANGE SURVEY
Note: Your local syringe exchange has been provided their specific data. State report to be released in December 2017.
Heroin main drug &
stimulants
Stimulants only
Meth main drug & opioids
Opioids only, 12%
Heroin & meth together
Rx opioids & stimulants Other
Main drug(s)
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• Associated with greater psychopathology• Increased levels of risky behaviors• Poor treatment engagement• Death
WHY WORRY ABOUT POLYSUBSTANCE USE IN PATIENTS BEING TREATED FOR OUD WITH BUPRENORPHINE?
Booth BM et al, 2006; Sumnall HR et al, 2004; Patterson TL et al, 2005; John D et al, 2001; Bovasso G et al, 2001; Williamson A et al, 2015, Hser YI et al, 2016; Savant et al, 2013
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• Cannabis• Cocaine• Benzodiazepines• Alcohol• Methamphetamine
WHICH OF THESE SUBSTANCES HAS BEEN ASSOCIATED WITH OVERDOSE DEATHS IN PATIENTS ON BUPRENORPHINE?
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• 1998 French case series– Six overdose deaths related to bup + benzo’s– IV buprenorphine (Not Bup‐Nal)
• Can occur at therapeutic doses of Buprenorphine in the following contexts:– Related supra‐therapeutic doses of benzodiazepines • Removes ceiling effect
– IV injection of benzos at therapeutic doses– Combined with sedatives
A HISTORY OF BUP‐BENZO RELATED DEATHS
Reynaud M et al, 1998; Schuman‐Olivier Z et al, 2013
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Sample– All Veterans (N=32,422) in 2007 with an Opioid Use Disorder (OUD) Diagnosis
OPIOIDS: PRESCRIBING OPIOIDS AND BENZODIAZEPINES IN PATIENTS WITH OUDS
Watkins, K, et al, 2017
Opioid/Benzo Rx Status
12 month Mortality Rate
24 monthMortality Rate
Prescribed 4.3% 8.3%
Not Prescribed 3.1% 6.2%
% Change 29% 27%
Best practice: Avoid prescribing opioids and benzodiazepines to patients with Opioid Use Disorders
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Sample– Swedish nation‐wide register‐based open cohort from 2005‐2012, N=4501
– OUD Dx and at least one Rx for methadone or buprenorphine
Results– Overdose deaths• Z‐drugs HR 1.98 (CI 1.38‐2.84)• Pregabalin HR 3.22 (CL 2.13‐4.86)
OPIOIDS: Z‐DRUGS AND PREGABALIN
Abrahamsson, T, et al 2017
Best practice: Avoid prescribing z‐drugs and pregabalin to patients with OUDs
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STUDY REVIEW
N=386, Primary Care‐Nurse Care Manager Program, over 12 months
Benzo Misuse vs No Benzo Misuse– No impact on treatment retention– No impact on illicit opioid or cocaine use– Prescribed benzos more ED visits. (OR 3.75 this is high) due to accidental injury – worse in females
– No one died in treatmentTakeaway: Concurrent Benzos lead to more ED visits
Shuman‐Olivier et al, 2013
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Reduced 1 year treatment retention• Benzodiazepine users: 39.9%• Non Benzodiazepine users: 44%
• When > 75% urine positives for benzodiazepines175% more likely to drop out
STUDY REVIEW
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Source: https://www.fda.gov/Drugs/DrugSafety/ucm575307.htm
U.S. FOOD AND DRUG ADMINISTRATION
Implications
Concurrent CNS depressant use is not a contraindication to treating opioid use disorders with buprenorphine despite the increase risk of mortality
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• If patients are admin discharged or not enrolled for BZPs, then they will now likely be doing heroin + BZP
• Out of treatment Not able to help
– Increase risk for IV use, infections, OD, and death
• How do you identify it?
– Ask about it at every visit
–Monitor with Urine Drug Screens
THE BENZODIAZEPINE BIND
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• Has been associated with increased risk for death when combined with buprenorphine
• How do you identify it?– Use AUDIT or AUDIT‐C to screen for risky use and use disorder at the beginning and yearly
– Ask about use at every visit–Monitor with urine drug screens
ALCOHOL AND BUPRENORPHINE
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• Notable in opioid treatment: cocaine– Higher opioid use at baseline – Higher relapse rates–Worse adherence to Buprenorphine
• How do you identify it?– Ask about it at every visit– Urine drug screens
• Methamphetamines– Buprenorphine can reduce methamphetamine cravings
STIMULANTS AND BUPRENORPHINE
Kumari, S, e at 2016; Sullivan L. et al, 2010; Salehi M et al 2015
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• Common: 39‐66%• Mixed impact, but...– Associated with non‐medical opioid/heroin use– Increased risk of drop‐out
• Not a benign substance– Psychiatric issues– Physical Issues
• How do you identify it?– Ask about it– Urine drug screen– Cannabis use disorder?
• Use Cannabis Use Disorder Identification Test‐Revised (CUDIT‐R)
CANNABIS AND OPIOID MAT
Wasserman et al, 1998; Balhara et al, 2014; Roux et al, 2011; Franklin A, et al, 2017
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NEXT STEPS
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CASE # 2: Methamphetamine
41‐year‐old male on Bup‐Nal 12mg‐4mg, who is trying treatment for his opioid use disorder again.
After 6 weeks he has missed one appointment, but called to reschedule later that day. Works and has housing. No psychosocial support. Urine drug screens have remained positive for buprenorphine/ norbuprenorphine, methamphetamines, and cannabis, only.
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• Administrative taper and discharge• Reduce dose of Buprenorphine‐Naloxone • Continue Buprenorphine‐Naloxone dose
WHAT WOULD BE YOUR FIRST STEP?
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CASE # 2: Methamphetamines
41‐year‐old male on Bup‐Nal 12mg‐4mg, who is trying treatment for his opioid use disorder again.
After 6 weeks he has missed 1 appointment, but called to reschedule later that day. Works and has housing. No psychosocial support. Urine drug screens have remained positive for buprenorphine/ norbuprenorphine, methamphetamines, and cannabis, only.
What are some other approaches you would try?
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• Increase frequency of visits
• Increase control of Buprenorphine dispensing
• Increase frequency of urine drug screens
• Consider prescribing of all controlled substances
• If continued use, consider higher level of care –Maximize psychosocial supports
• Others?
GENERAL APPROACH TO POLYSUBSTANCE USE
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• Why are they using it?– Opioid use disorder not adequately treated?– Another substance use disorder?– Psychiatric condition?– Stress management?– Others?
FIRST STEP: EVALUATION
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• Concerning signs?– Intoxication– Positive urine drug screens–Withdrawal symptoms– Cravings– People, places, things
• Potential Specific Treatment Adjustments– Bup Dose Adjustment?–Med change?– Help taking their meds?– Increase/change psychosocial support– AskHow can I best support you?
EVALUATION:OPIOID USE DISORDER NOT ADEQUATELY TREATED?
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• Concerning signs?– Intoxication– Positive urine drug screens–Withdrawal symptoms– Cravings– People, places, things
• Potential Treatment Adjustments?– Additional MAT?– Increase psychosocial support
EVALUATION: ANOTHER SUBSTANCE USE DISORDER?
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1. Medication Assisted Treatment (MAT)– Alcohol MAT options• Acamprosate, Disulfiram, Topiramate, Gabapentin
– Cocaine MAT options• None
–Methamphetamine• Bupropion, Mirtazapine
– Cannabis• Gabapentin (for withdrawal)
ANOTHER SUBSTANCE USE DISORDER?TREATMENT OPTIONS
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Is Substitution Treatment for Stimulant Use Disorders Effective?– Cocaine: mixed results, poor retention–Meth: no
DISCUSSION
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2. Psychosocial Support– Critical for Alcohol Use Disorders• CBT• 12 step groups
– Stimulant Use Disorders• Only consistently effective approach• CBT• Contingency Management
ANOTHER SUBSTANCE USE DISORDER?TREATMENT OPTIONS (CONT’D)
Maude‐Griffin P et al, 1998; Rawson R et al, 2004; Rawson R et al, 2006; Magill M et al, 2009; Ferri et al, 2006
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• Concerning signs?– Appearance–Mood– SI
Potential Treatment Adjustments?– Use screeners– Treat as indicated(will discuss further during next session)
EVALUATION: PSYCHIATRIC DISORDER?
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• Concerning signs?– Homeless– Lots of unstructured time
Potential Treatment Adjustments?– Clonidine augmentation?– Housing support– Vocational support– Legal support– Goals for week
EVALUATION: STRESSORS
Kowalczyk W et al, 2015
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35 year old female on Bup‐Nal 6‐1.5mg qd for OUD‐severe (heroin). She has been in treatment for three months and has been making her appointments. She is working occasionally, and is couch surfing.
At the time of enrollment she was taking illicit benzodiazepines and agreed to stop using them. However, she has continued to use them and every urine drug screen is positive. She reports having too much social anxiety without them. Also has irregular cannabis use.
What would be your next steps for treatment?
CASE # 1: Benzodiazepines
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1. Cut bup dose in half to reduce toxicity2. Treat underlying psych disorder3. Residential Treatment4. Taper
1. Patient2. Clinic administered
TREATMENT OPTIONS BENZODIAZEPINES
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What Are The Benefits To Keeping Patients in Treatment With Ongoing Polysubstance Use?– Keeps people engaged with treatment providers
– Treatment with MAT reduces mortality
DISCUSSION
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What Are The Harms Of Keeping Patients In Treatment With Ongoing Polysubstance Use?– Are you just enabling patients?– Other patients will find it disruptive– Clinic hassle– Risk of overdose
DISCUSSION
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How does your clinic handle polysubstance use?– Are you checking for it and how?– If a person is found to be using other substances, what do you do next?
DISCUSSION
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BIG IDEAS WORKSHEET
Prompt1. Write down any
big ideas from this session.