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Continuing Education for Health Professionals

WV: Best Practices for Prescribing Controlled Substances and Preventing Drug Diversion, 3 units

Module 10

Treating Opioid Use Disorder (OUD)

Addiction is a chronic, treatable illness. Treating patients with opioid use disorder (OUD) requires continuing care rather than an episodic, acute-care approach. Patients should have access to medical treatment, mental health services, addiction counseling, and other recovery support services. Treatment should be tailored to each patient’s needs and preferences (ASAM, 2015). In fact, there is no single best approach that works for all patients. A comprehensive approach to treatment is part of addressing the problem of drug diversion. Research shows that many people in need of treatment for substance use disorder do not receive treatment:

  • The 2016 National Survey on Drug Use and Health (NSDUH) data indicate that 7.8%, or 21.0 million people, aged 12 or older needed substance use treatment in the past year (SAMHSA, 2017b).
  • In 2016 an estimated 3.8 million people (1.4%) aged 12 or older who needed substance use treatment had received any substance use treatment in the past year (SAMHSA, 2017b).
  • In 2016, an estimated 2.2 million people aged 12 or older received substance use treatment at a specialty facility in the past year. This number represents 10.6 percent of the 21.0 million people who needed treatment (SAMHSA, 2017b). Specialty treatment refers to substance use treatment at a hospital (only as an inpatient), a drug or alcohol rehabilitation facility (as an inpatient or outpatient), or a mental health center.
  • In a single-day count in 2015, 10,099 individuals in West Virginia were enrolled in substance use treatment—a decrease from 10,711 individuals in 2011, but an increase from 9,596 individuals in 2012 and 10,057 individuals in 2013 (SAMHSA, 2017a).
  • In a single-day count in 2015, 3,120 individuals in West Virginia were receiving methadone in opioid treatment programs as part of their substance use treatment—a decrease from 4,699 individuals in 2011 (SAMHSA, 2017a).
  • In a single-day count in 2015, 2,072 individuals in West Virginia were receiving buprenorphine as part of their substance use treatment—an increase from 1,135 individuals in 2011 (SAMHSA, 2017a).

The World Health Organization principles of good care for chronic illness can guide OUD care:

  • Develop a treatment partnership with patients.
  • Focus on patients’ concerns and priorities.
  • Support patients’ self-management of illness.
  • Use the five A’s at every visit (assess, advise, agree, assist, arrange).
  • Organize proactive followup.
  • Link patients to community resources/support.
  • Work as a clinical team.
  • Involve “expert patients,” peer educators, and support staff in the health facility.
  • Ensure continuity of care. (SAMHSA, 2016a)

Medications

The FDA has approved medications to treat OUD and improve patients’ health and wellness. These medications are methadone, naltrexone, and buprenorphine. These medications can reduce or eliminate withdrawal symptoms (methadone, buprenorphine), blunt or block the effects of illicit opioids (methadone, naltrexone, buprenorphine), and reduce or eliminate cravings to use opioids (methadone, naltrexone, and buprenorphine).

 

Source: SAMHSA, 2018.

Comparison of Medications for OUD

Prescribing Consider-
ations

Methadone

Naltrexone

Buprenorphine

Mechanism of action at mu-opioid receptor

Agonist

Antagonist

Antagonist

Phase of treatment

Medically supervised withdrawal, maintenance

Prevention of relapse to opioid dependence, following medically supervised withdrawal

Medically supervised withdrawal, maintenance

Administration route

Oral

Oral, intramuscular extended-release

Sublingual, buccal, subdermal implant, subcutaneous extended release

Possible adverse effects

Constipation, hyperhidrosis, respiratory depression, sedation, QT prolongation, sexual dysfunction, severe hypotension and syncope, misuse potential, neonatal abstinence syndrome

Nausea, anxiety , insomnia, precipitated opioid withdrawal, hepatotoxicity, vulnerability to opioid overdose, depression, suicidality, muscle cramps, dizziness or syncope, somnolence or sedation, anorexia, decreased appetite or other appetite disorders

Intramuscular: Pain, swelling, induration (including some cases requiring surgical intervention)

Constipation, nausea, precipitated opioid withdrawal, excessive sweating, insomnia, pain, peripheral edema, respiratory depression (particularly combined with benzodiazepines or other CNS depressants), misuse potential neonatal abstinence syndrome

Implant: Nerve damage during insertion/removal, accidental overdose or misuse if extruded, local migration or protrusion

Subcutaneous: Injection site itching or pain, death from intravenous injection

Regulations and availability

Schedule II; only available at federally certified Opioid Treatment Programs and the acute inpatient hospital setting for OUD treatment

Not a scheduled medication; not included in OTP regulations; requires prescription; office-based treatment of specialty substance use treatment programs including OTPs

Schedule III; requires waiver to prescribe outside of OTPs.

Implant: Prescribers must be certified in the Probuphine Risk Evaluations and Mitigation Strategy (REMS) Program. Providers who wish to insert/remove implants are required to obtain special training and certification in the REMS Program.

Subcutaneous: Healthcare settings and pharmacies must be certified in the Sublocate REMS Program and only dispense the medication directly to a provider for administration.

 

OUD medications reduce illicit opioid use, retain people in treatment, and reduce risk of opioid overdose better than treatment with placebo or no medication. Medication can be taken on a short-term or long-term basis. Patients taking medication for OUD are considered to be in recovery.

  • The science demonstrating the effectiveness of medication for OUD is strong.
  • This doesn’t mean that remission and recover occur only through medication; some people achieve remission without OUD medication.
  • Medication for OUD should be successfully integrated with outpatient and residential treatment.
  • Patients treated with OUD medications can benefit from individualized psychosocial supports.
  • Expanding access to FDA-approved medications is an important public health strategy.
  • Improving access is crucial to closing the wide gap between the need for treatment with OUD medications and the availability of such treatment. (SAMHSA, 2018)

People with OUD can benefit from medications for varying lengths of time, including lifetime treatment. Treatment with OUD medication is linked to better outcomes and retention than treatment without medications. Further, studies show that medication as part of treatment of OUD is cost effective.

The best results occur when a patient receives medication for as long as it provides a benefit. This is called maintenance treatment. OUD medications give patients time to make the life changes that are associated with long-term remission and recovery. Maintenance treatment minimizes cravings and withdrawal symptoms.

After time, patients may wish to stop opioid agonist therapy for OUD through gradually tapering doses of the medications. Outcomes depend on the length of their treatment, abstinence from illicit drugs, financial and social stability, and motivation to discontinue the medication (SAMHSA, 2018).

Healthcare providers need special training and certification to prescribe medications to treat OUD. A patient taking FDA-approved medication for OUD can be considered to be in recovery. Clinicians should also be aware that diversion of medications for treating OUD do occur (ASAM, 2015; SAMHSA, 2018).

Preventing Opioid Overdose-Related Deaths: Naloxone

Opioid overdose-related deaths can be prevented when naloxone is administered in a timely manner. As a narcotic antagonist, naloxone displaces opiates from receptor sites in the brain and reverses respiratory depression that usually is the cause of overdose deaths. Naloxone may cause dizziness, drowsiness, or fainting. These effects may be worse if it is taken with alcohol or certain medicines (SAMHSA, 2016a). In 2015 the FDA approved the first naloxone nasal spray—NARCAN−developed as a result of NIDA-funded research. Naloxone is also available as an autoinjector—EVZIO—that provides verbal step-by-step instructions for use. Increasing access to naloxone is a priority for the U.S. Department of Health and Human Services, and research funded by NIDA is developing strategies to identify people at risk and ensure they have access to naloxone in the event of an overdose.

SAMHSA’s Opioid Overdose Toolkit (2016a) recommends five strategies for preventing overdose deaths.

  • Encourage providers, persons at high risk, family members, and others to learn how to prevent and manage opioid overdose.
  • Ensure access to treatment for individuals who are misusing or addicted to opioids or who have other substance use disorders.
  • Ensure ready access to naloxone.
  • Encourage the public to call 911.
  • Encourage prescribers to use state Prescription Drug Monitoring Programs. (SAMHSA, 2016a)

In the worst-case scenario put forth by STAT’s expert panel, that toll could spike to 250 deaths a day, if potent synthetic opioids like fentanyl and carfentanil continue to spread rapidly and the waits for treatment continue to stretch weeks in hard-hit states like West Virginia and New Hampshire. If that prediction proves accurate, the death toll over the next decade could top 650,000.

 

Max Blau, 2017

Barriers to Treatment

The primary problem with the opioid epidemic is simple: It is easier to get high than it is to get help. People who need substance use treatment sometimes do not have access to treatment. Stigma surrounding substance use disorders remains high.

A video series issued by SAMHSA called “Prevention Conversations” stresses the importance of breaking the stigma around drug use. SUD is a disease and not a moral failing.

SAMHSA suggests the following strategies for reducing stigma:

  • Do away with labels. Avoid stigmatizing labels such as “addict,” “junkie,” or “drug user” when referring to patients. Using the term “clean” for someone who is not currently using drugs implies that someone who is actively using is “unclean” or “dirty.”
  • Use “person first” language. Using person first language, such as “a person who uses drugs,” demonstrates that you aren’t defining a person by their drug use.
  • Understand that drug use falls along a continuum. This continuum of substance use ranges from abstinence/low-risk use to chronic dependence and encompasses all stages in between. People may move back and forth along this continuum for a variety of reasons.
  • Embrace positive change. Treatment for substance use disorders has historically been viewed as binary, with addiction and abstinence as a person’s only two options.
  • Beware of unintentional bias. People initiate and continue to use drugs for a variety of reasons. Without intending to, we may make value judgments about those reasons—deeming them “good” or “bad,” “necessary” or “unnecessary,” or even considering people “weak” or “strong” based on their substance use behaviors.
  • Reflect on your own experiences. Many of us have lived experience of substance misuse—either our own or through a family member, loved one, co-worker, or neighbor. These experiences may be difficult, but they remind us that people who use drugs are first and foremost people—with strengths, passions, interests, and goals.
  • Understand that substance misuse is often linked to trauma. Trauma is a risk factor for almost all behavioral health and substance use disorders. Understanding the relationship of trauma to substance misuse and knowing how to engage with people who use drugs in ways that prevent re-traumatization, will help you create a safe and supportive environment where everyone is encouraged to hear and be heard without judgment. (SAMHSA CAPT, 2018)
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