SOAR – Pitfalls in the Treatment of Opioid Use Disorder – Karen Derefinko

SOAR – Pitfalls in the Treatment of Opioid Use Disorder – Karen Derefinko


– Gonna see if I can do this
completely turned around. Seems like, whoa, that’s a challenge. All right, so today, I
wanna discuss with you the issues surrounding
treatment engagement of individuals with opioid addiction or what we call opioid use disorder and ways that we can
improve treatment adherence. See if I can do this from behind, so you’re gonna see some circles here. I wanted to speak first
about the progression from opioid exposure to overdose. These circles aren’t to scale, but they should give you some idea of the proportion of
individuals in each category so it might surprise you, although not from, now Jerry
has covered some of this, ’bout 2/3 of adults in the United States have been exposed to opioids, either through medical or dental settings. That’s a significant amount. About 4.3 of adult, 4.3% of
adults over the age of 12 report misuse of opioids, and that means using them in ways that doctors are not prescribing. Less than 1% of individuals
actually meet criteria for opioid use disorder, and a smaller portion of
those individuals overdose. About 1.5% of all deaths
in the United States are attributable to opioids. Let’s see if I can do this from behind. Is it working? So we use very different methods to address each of these areas, one more, ranging from prevention
techniques to crisis intervention when we think about overdose, and you hear a lot about
exposure through policy changes, great work in anesthesiology, and you hear a lot, a lot about crisis intervention for overdose. We hear significantly less about the intervention side of things, and that’s what I’m gonna focus on today. So how do we treat individuals
with opioid use disorder? We use two lines. Typically medication-assisted treatment is one of the lines. The most common medicine that we use now for individuals with opioid use disorder is buprenorphine/naloxone, and it’s taken as a tablet or a film that’s gone under the tongue
and it dissolves there. It doesn’t make the individual high. It’s a partial agonist, and because of low abuse potential, it means it can be prescribed
on an outpatient basis. Now the treatment with
buprenorphine/naloxone typically lasts about six months, but it can range to
indefinite periods of time depending on the risk of
relapse for that patient. The second line of treatment
that we use is counseling. Counseling is now required for individuals who are receiving
medication-assisted treatment, which is terrific. We highly approve. The medication-assisted treatment provides support for the cravings, and the counseling helps
individuals make lifestyle changes. Now I often hear the argument, “We’ve heard other speakers
talk about this today, “about buprenorphine/naloxone
or other medications “versus abstinence, “and so, this whole idea of
trying to achieve abstinence “has a very lofty goal. “Aren’t we just trading
one drug for another?” And my response is always, “In the statistics that we receive, “it suggests that
medication-assisted treatment “is actually superior to
trying to get individuals “to be abstinent,” and you’ll see from this graph that in the green is
buprenorphine treatment, and in the yellow is
medication-induced abstinence, and the green suggests that, for individuals who are
on buprenorphine/naloxone, they tend to stay engaged in treatment, and that means taking their medication and showing up to their doctor more often than individuals
who were encouraged to be abstinent, and same thing with relapse. Buprenorphine prevents
relapse at higher rates than abstinence treatment. So if the goal is to get the patient back to daily life functioning, optimal daily life functioning, buprenorphine is superior. We actually have an affiliated clinic in McKenzie, Tennessee. It’s a very rural population, and the director out there,
Dan Sumrok, talks about how, of all of his
buprenorphine/naloxone patients, and he has over a hundred, 100% are employed, and that’s significant when
we think about harm reduction. So when I first started in this area, I wrote a grant for funding to explore barriers to treatment. We all think about this idea of, we know that there are addicts out there, people with opioid use disorder. The challenge must be that
they can’t get to treatment. They’re having issues with transportation. They’re having issue with funding. They don’t know that treatment exists, and certainly, some of
these are absolutely real. They don’t know about treatment. They’ve tried treatment
before with methadone, and they didn’t like it. They have those
difficulties with resources, and some people, especially
at our rural clinics, oddly enough, are really worried, maybe because of the small population, about confidentiality, that other folks knowing that they’re in opioid use disorder treatment is gonna harm their livelihoods, but there have been many system changes that make finding treatment
a little bit easier than it used to be. I’ve listed here the SUPPORT for Patients and Communities Act of 2018, and insurance has expanded
now to allow treatment. So we have more providers than we used to, not a lot more, but we do have more, and we have more availability. People have more resources, but many of us in the field have realized that finding treatment is really only a part of the battle. Even for individuals in treatment, staying engaged is extremely difficult, so practitioners see no-shows,
continued opioid use, use of other drugs and alcohol, and failure to actually use
the buprenorphine/naloxone that they are prescribed. A lot of folks get the
buprenorphine/naloxone prescription, and then, they sell it. So in the research that we’re doing, it supports that idea
that engaging in treatment is difficult. This is something that
we recently published in “Addictive Behaviors”, and I wanted to show a graph
from this recent publication. So this shows you relapse
rates among those in treatment with buprenorphine/naloxone at this rural treatment
facility in Tennessee, and you can see that, so that worked, 54% of patients relapsed
to illicit opioid use within the first five treatment
visits to their provider, and this shows how difficult it is to get engaged in successful treatment. Why do we see such high rates of relapse among individuals receiving treatment? And this is not initiation. This is after they’ve
made that first visit. We’ve talked about some of this, but it’s important to note that opioids are extremely addictive, so long-term use creates a
heightened sense of pain, decreased sense of reward. Many of you have probably heard the phrase chasing the dragon, meaning that individuals who are caught up trying to experience
the highs, essentially, that they felt when they
first started using the drug. Second, buprenorphine/naloxone
only curbs cravings, so many patients are pretty
unsatisfied with that feeling, and they relapse to illicit
opioids to get the high, and third, those with opioid addiction have a tendency to seek
immediate gratification. This is something we
call delay discounting in the literature. It makes them very
impulsive decision makers, and interestingly, after
successful treatment, decision making tends to improve, even when we don’t explicitly address it. It’s very peculiar to opioid use disorder. Fourth, behavioral change is challenging. We see this in all kinds
of health-related areas. You see this in obesity research and diabetes research as well. Change simply takes considerable time. Fifth, this is something
that we talked about as well, rural settings, where many individuals with opioid use disorder reside, have very few resources. So part of the reason for this is that there’s very few
substance use clinics in rural areas, and individuals living
in rural populations tend to have very low insurance rates, and so, treatment for many of them is simply unaffordable. Finally, childhood history of trauma, that’s something that was discussed today, seems to harm individuals’
ability to engage in treatment, and we have been some of
the first to document this, and so, we know that
individuals with high ACE scores engage in substance use at higher rates, but we actually were the first to document that they have more trouble
and higher relapse rates when they seek treatment as well. So we believe, from this research, that individuals who’ve been traumatized have fewer resources
available in all likelihood, and they may be relying on opioids to cope with their trauma, so having said all of
those depressing things, there is a silver lining. You may have noticed on this
graph the first time around the dotted trendline. I’ve highlighted it here in red. Even though these issues
create some challenges, there’s reason to believe
that treatment works. What this line is is an average of relapse per visit number to treatment, and what it suggests is that every time you
go to a treatment visit, you are 2% less likely to relapse. So what happens over time is that if you stick with treatment, your risk for relapse will approach zero. So with this information, sorry, in mind, how do we help individuals
who are seeking treatment? And I think this is
the question of the day for those of us who are
engaging in treatment research with opioid use disorder. We show you some of the
work that we’re doing at the University of Tennessee
Health Science Center. I’m gonna talk about three main areas. The first is the use of rewards. Contingency management is
40 to 50 years old now. It’s a little bit controversial because you’re paying
individuals to stay in treatment, but what we know about
contingency management is that it works. So what it typically does, the typical regimen is we give individuals approximately a dollar a day. You see them once a week, they
get a seven to $10 voucher for coming in and having
buprenorphine in their urine, and believe it or not,
this kind of thing works. It’s not always disseminable because if you think about
individuals staying in treatment for years and years, that gets pretty costly, and as we were talking about before, the problem with contingency management is that when you take it away, people have a tendency to relapse if behavioral change hasn’t occurred. The other methods that we are working with at University of Tennessee
Health Science Center are those that use counseling methods, so motivational interviewing, and that is where you’re
enhancing internal motivation of the individual to create
long-term commitment to change. This internal locus of control when you are capitalizing on why the individual
themself wants to change rather than imposing change upon them helps them make long-term changes. In addition, we are also using
substance-free activities. This is a part of behavioral economics. It’s very, very innovative and new. It has not been demonstrated yet to improve adherence to medication, but we think we have a strong shot at it, and this is increasing one’s engagement in activities in daily life that are inconsistent
with their opioid use. So rather than hoping
that they pick up a hobby, we encourage them to do it, and we problem solve
ways for them to do that. Now the drawback for this is that it requires trained
counselors to execute, and that training can
be kind of significant. A lot of settings don’t
have that availability. Now the final area I wanted to talk about is physician training, and I’m talking about
here trauma-informed care, also mentioned today, and physician empathy training. Now trauma-informed care is the creation of a safe and collaborative
environment with your patient rather than blaming them
for the substance use, understanding that they
turned to substances to cope in all likelihood with some form of emotional distress or
trauma in their lives. So creation of that safe environment and recognizing that many substance users have experienced trauma
helps treatment adherence. In addition, physician empathy training, believe it or not, stigma
continues to reside, even in, sorry, even in
addiction medicine settings, and it might surprise you to know that physicians over time, throughout the course of physician, like, sorry, medical school and residency, have decreases in their empathy, and I’ll, there’s probably
physicians in the room, but it’s true. We see it (chuckles) in the literature, and so, there are ways to
improve physician empathy through online training programs. Of course, there is a cost
associated with this as well and the time taken to
train physicians and staff. So I wanted to leave you
with some take home messages from the treatment outcome literature, and that is first, treatment engagement does tend to result in treatment success, encouraging your patients to stick with it because we have evidence that over time, they are going to succeed. In addition, treatment
initiation, it’s important, but engagement in treatment is critical. We found that the first five times that they visit the physician
for buprenorphine/naloxone are very critical to relapse, so helping individuals make it through those first five sessions
is very important. In addition, there are
ways to promote engagement, and we can help you. If you are a treatment setting struggling with a lot of
dropouts in your patient load, we can help you decide on strategies that will work for you. I talked about rewards for attendance and adherence to medication. I talked about counseling techniques that we think are the most
important ones right now and physician and staff training as well. The best method is really
gonna depend on your setting, and my talk was actually really short. Go home, thank you. (audience applauds)

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