Substance Use Disorders - Presentation PDF

Substance Use Disorders MARAH CZAJA, PA-C CLIN ICAL MEDICINE II: SPRING 2025  Objectives Opioids and Pain Summarize core concepts for primary care management of a patient with chronic pain Outline the risks and responsibilities of opioid prescribing Calculate MME (morphine milligr...

Substance Use Disorders MARAH CZAJA, PA-C CLIN ICAL MEDICINE II: SPRING 2025  Objectives Opioids and Pain Summarize core concepts for primary care management of a patient with chronic pain Outline the risks and responsibilities of opioid prescribing Calculate MME (morphine milligram equivalents) and discuss its role in primary care provider during the pharmacologic management of acute and chronic pain Explain how to evaluate risks for opiate-related harms, how to implement a risk reduction strategy, and why avoiding opiates with benzodiazepines is important Opioid Use Disorders Diagnose and manage opioid use disorder List pharmacologic treatment options for opioid use disorder Alcohol and other Substance Use Disorders Diagnose and manage alcohol use disorder noting screening tools, acute intoxication and withdrawal Explain the general principles of psychosocial and pharmacological treatment of alcohol and other non-opiate substance use disorders Harm Reduction Summarize harm reduction strategies of care for people with substance use disorders  Terminology Common Phrases What to use instead Drug user/addict People who use drugs Relapse Return to use Drug test, UA Urine drug screen, oral drug screen Chemical dependency Substance use disorder Sobriety Recovery Abuse Misuse, inappropriate use Urine clean/dirty Negative, positive, substance free, appropriate Habit Substance use disorder Alcoholic Person with alcohol use disorder Drug problem Substance use disorder Clean/sober Actively not using, in recovery Dirty Actively using Former addict Person in recovery Sources: https://www.naabt.org/documents/NAABT_Language.pdf https://www.shatterproof.org/about-addiction/stigma/stigma-reducing-language https://drugfree.org/article/shouldnt-use-word-addict/#  History 1990s-big pharm push for “pain as the fifth vital sign” Drug companies marketed and promoted opioids and minimized risks July 2021-$26 billion multistate settlement agreements Will bring $300 million to Minnesota over next 18 years https://www.ncbi.nlm.nih.gov/books/NBK572085/ Responsible Controlled Substance and Opioid Prescribing. https://www.ag.state.mn.us/opioids/  Epidemiology Rate of opiate prescription misuse among patients receiving treatment for chronic pain is 21%- 29% 2021 National Survey on Drug Use and Health (https://www.samhsa.gov/data/sites/default/files/2 02212/2021NSDUHFFRHighlights092722.pdf) ◦ 40 million people reported using illicit drug (1 in 10) ◦ Prescription pain medication misuse continued to be second only to marijuana for illicit drug use. https://www.ncbi.nlm.nih.gov/books/NBK572085/ Responsible Controlled Substance and Opioid Prescribing. Horn, et al. 2023  2022: CDC Clinical Practice Guidelines for Prescribing Opioids The guideline addresses the following four areas: Determining whether or not to initiate opioids for pain 1) Maximize non-opioid therapy over (Recommendations 1 and 2) opioids first. Discuss risk vs benefit 2) Prefer short acting (IR) >long acting (XR) for Selecting opioids and determining opioid dosages acute pain! Use lowest dose possible. (Recommendations 3, 4 and 5) 3) Shortest duration for pain; When tapering, DO NOT Deciding duration of initial opioid prescription and stop abruptly. Taper by 10% per month or as pt conducting follow-up (Recommendations 6 and 7) tolerates 4) Check PDMP before every Assessing risk and addressing potential harms of opioid use prescription, caution with opioids (Recommendations 8, 9, 10, 11 and 12). and benzos, and discuss treatment options for withdrawal PDMP-Prescription Drug Monitoring Program  Responsibilities of Opioid Prescribing Prescription drug monitoring programs Informed consent Treatment agreements Collaborate with intradisciplinary teams ◦ Pain specialists ◦ Addiction specialists ◦ Mental health ◦ Pharmacists https://www.ncbi.nlm.nih.gov/books/NBK572085/ Responsible Controlled Substance and Opioid Prescribing. Horn, et al. 2023 MMEs-Morphine Milligram Equivalents Effort to standardize dose of opioids prescribed in comparison to a dose of morphine CDC definition: “the amount of milligrams of morphine an opioid dose is equal to when prescribed” Set arbitrary limits for opioid prescribing TABLE. Morphine milligram equivalent doses for commonly prescribed opioids for pain management Opioid Conversion factor* Codeine 0.15 Fentanyl transdermal (in mcg/hr) 2.4 Hydrocodone 1.0 Hydromorphone 5.0 Methadone 4.7 Morphine 1.0 Oxycodone 1.5 Oxymorphone 3.0 † Tapentadol 0.4 § Tramadol 0.2 https://www.oregonpainguidance.org/opioidmedcalculator/ Opioid Use Disorder What are opioids Pathophysiology Diagnosis Intoxication- Clinical Presentation Withdrawal- Clinical Presentation Treatment: Medications for Opioid Use Disorders  Opioids Vs Opiates Opiates: Derived from Opium (heroin, morphine, codeine) Opioids: Opiates and other synthetic opioids (fentanyl, oxycodone) What are they?? ◦ Fentanyl-most known and dangerous ◦ Prescription Pills-Percocet (Oxycodone/acetaminophen), Vicoden (hydrocodone/acetaminophen), codeine, Dilaudid (hydromorphone), Morphine ◦ Heroin Fentanyl-Available prescribed (patches), IV (surgery), and made synthetically Perc30s The blues Fetty Tranq  Fentanyl How is it used? ◦ Smoking (Straw and foil) ◦ IN ◦ Injection  Opioid Pathophysiology The main opioid receptors that mediate the effects of opioids are mu, kappa, and delta. *Mu receptors mediate analgesia, euphoria, sedation, respiratory depression, gastrointestinal dysmotility, and physical dependence. Mu receptors cause a medullary diminished response to hypercarbia and also a decrease in the respiratory response to hypoxia, resulting in a decreased stimulus to breathe and the development of apnea. Kappa receptors mediate analgesia, diuresis, miosis, and dysphoria. Delta receptors mediate analgesia, inhibition of dopamine release, and cough suppression. Agonist: A drug or substance that binds to a receptor inside a cell or on its surface and causes the same action as the substance that normally binds to the receptor. Antagonist: a substance that blocks or reverses the effects of another substance https://www.ncbi.nlm.nih.gov/books/NBK470415/ Opioid Intoxication Constricted pupils Respiratory Distress Confusion/disorientation Somnolence Constipation  What is opioid withdrawal? Spontaneous withdrawal: occurs when a patient who is physiologically dependent upon opioids reduces or stops opioid use abruptly Precipitated withdrawal: can occur when a patient who is physiologically dependent upon opioids and who has opioids in their system is administered an opioid antagonist (naloxone, naltrexone) or an opioid partial agonist (buprenorphine) Opioid t olerance, dependence, and withdrawal | by Dr. Ming Kao | Within Normal Limits of Reason | Medium Opioid withdrawal in adults: Clinical manifestations, course, assessment, and diagnosis - UpToDate Opioid Withdrawal Opioid Withdrawal https://www.workithealth.com/blog/opiate-withdrawal-timeline/  Case Study CC: Nausea and Body Aces Reviewed screening history done by MA: Denies use of drugs or alcohol. Denies tobacco use. HPI: 21 y/o F presents to the clinic with a CC of nausea, vomiting, and body aches. She states her symptoms have been present for about 2 days and are getting worse. She’s also complaining of sweating, fatigue, and chills. She complains of constantly yawning and feeling quite irritable. She has no sick contacts. General Appearance: You notice the patient is constantly moving and has marked goosebumps on her arms  Case Study-Continued CC: Nausea and Body Aces Reviewed screening history done by MA: Denies use of drugs or alcohol. Denies tobacco use. HPI: 21 y/o F presents to the clinic with a CC of nausea, vomiting, and body aches. She states her symptoms have been present for about 2 days and are getting worse. She’s also complaining of sweating, fatigue, and chills. She complains of constantly yawning and feeling quite irritable. She has no sick contacts. Initially denied substance use when screened by the MA as she feels scared of being judged or having consequences of disclosing her use. However, when asking further about drug use history, she endorses daily use of pressed fentanyl pills, using 5-7 pills per day. She primarily smokes them. She used IV on two occasions with her partner, but is afraid to continue using needles. She started using about one year ago when her partner gave them to her to “help relax”. She has found she has needed to increase the amount she uses just to function and feel “normal”. However, she’s in medical school and doesn’t want to get kicked out when starting clinical rotations and doing a urine drug screen. She tried to stop using, but then started with the above withdrawal symptoms. She never drives while intoxicated, but has occasionally had to use when in class to keep from withdrawal symptoms starting. Her mom is worried that she’s been more withdrawal lately. FH: unremarkable, no hx of SUDs SH: denies use of alcohol or other illicit substances aside from fentanyl. Junior in college, premed. Works part time Opioid (Substance) Use Disorder-DSM V criteria 2-3: mild 4-5: moderate 6+: severe These two alone do NOT equal OUD!  Case Study-Continued CC: Nausea and Body Aces Reviewed screening history done by MA: Denies use of drugs or alcohol. Denies tobacco use. HPI: 21 y/o F presents to the clinic with a CC of nausea, vomiting, and body aches. She states her symptoms have been present for about 2 days and are getting worse. She’s also complaining of sweating, fatigue, and chills. She complains of constantly yawning and feeling quite irritable. She has no sick contacts. Initially denied substance use when screened by the MA as she feels scared of being judged or having consequences of disclosing her use. However, when asking further about drug use history, she endorses daily use of pressed fentanyl pills, using 5-7 pills per day. She primarily smokes them. She used IV on two occasions with her partner, but is afraid to continue using needles. She started using about one year ago when her partner gave them to her to “help relax”. She has found she has needed to increase the amount she uses just to function and feel “normal”. However, she’s in medical school and doesn’t want to get kicked out when starting clinical rotations and doing a urine drug screen. She tried to stop using, but then started with the above withdrawal symptoms. She never drives while intoxicated, but has occasionally had to use when in class to keep from withdrawal symptoms starting. Her mom is worried that she’s been more withdrawan from the family lately. FH: unremarkable, no hx of SUDs SH: denies use of alcohol or other illicit substances aside from fentanyl. Junior in college, premed. Works part time Case Study Vitals: P 133, BP 122/85, F 99.0, 02 99% HEENT: pupils dilated, 5mm Skin: diaphoretic, piloerection CV: tachycardic, regular rhythm, no murmurs Neuro: bilateral tremors, increased psychomotor activity, restless legs MSE: General appearance with increased psychomotor activity and diaphoretic, speech slow, flat affect and depressed mood, thought content and process normal with no SI/HI, insight and judgement normal. A&Ox3 MOUD: Medications for Opioid Use Disorder Methadone Buprenorphine Naltrexone  Methadone Clinics History Regulations Health Equity Implications  Methadone Pharmacology -Full Opioid Agonist -Long half life (8-59 hours, average 24 hours) -Only dispensed in Methadone clinic OR in hospital settings https://steverummlerhopenetwork.org/recovery/how-medications-work/  Methadone Formulations ◦ Liquid-OUD ◦ Tablets-PAIN Patient Counseling: -No maximum dose (titrate to effect) -No need to wait for withdrawal to start -Need to go to OTP “Methadone Clinic”, starts with daily dosing -pt does NOT need insurance to attend -risk for overdose as it is a full agonist https://findtreatment.gov/locator Buprenorphine Pharmacology Partial Opioid Agonist High Affinity at the Mu Receptor https://steverummlerhopenetwork.org/recovery/how-medications-work/ Buprenorphine Formulations Sublingual ◦ Buprenorphine-naloxone (Suboxone) ◦ Buprenorphine (Subutex) Injectable ◦ Buprenorphine monthly depot (Sublocade) ◦ Buprenorphine weekly or monthly (Brixadi) Patches (PAIN!) ◦ BuTrans Buccal (PAIN!) ◦ Belbuca Buprenorphine vs Buprenorphine- Naloxone Naloxone not activated unless tampered with or misused Deterrent for diversion Street price ◦ Suboxone (bup-nal) (~$2-$3/mg-8mg ~$15-20) ◦ Subutex (bup mono) (~$3-3.50/mg, 8mg ~$25) Buprenorphine Dosages ◦ 2-0.5mg, 4-1mg, 8-2mg, 12-3mg ◦ Typical dose is 8-2mg BID to TID ◦ Ceiling effect at 24mg Case Study How do you want to treat? ◦ -Discuss treatment options with your partner and pros/cons of each treatment option  Case Study How do you want to treat? Methadone Buprenorphine -Would need to refer to -Can start today in clinic methadone clinic -How would you approach induction?  Case Study How do you want to treat? Buprenorphine -Assess COWS Score -If >8, can start buprenorphine -Start 8mg now. If still experiencing -Can start today in clinic withdrawals throughout day, could give -How would you approach additional 8-16mg later in day induction? -follow up in 1-3 days Adjunctive Therapies for Opioid Withdrawal *Clonidine: anxiety and restlessness (one of most effective!) *Hydroxyzine: anxiety *Ondansetron: nausea *Tylenol/ibuprofen: body aches Gabapentin: body aches, anxiety Olanzapine: agitation Lorazepam: severe anxiety/agitation Ask: What else has helped for you in the past? Other Workup Infectious Disease Screening HIV and Hep C Consider STI screening UPT  Efficacy of Methadone and Buprenorphine https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/efficacy-medications-opioid-use-disorder How effective are medications to treat opioid use disorder? NIDA  Naltrexone Opioid antagonist https://steverummlerhopenetwork.org/recovery/how-medications-work/ Naltrexone Formulations ◦ Oral (50mg PO daily) ◦ IM, monthly Medication for Opioid Use Disorder Summary Methadone Buprenorphine Naltrexone Withdrawal effects No concern for precipitated Risk of precipitated withdrawal Will NOT support withdrawal (will withdrawal. Immediately helps with initiation cause withdrawal if given too withdrawal symptoms soon) Initiation Can start at any stage of use Need to wait for withdrawal to Need to wait at least 10 days begin, harder to start since last opioid use-very difficult! Access Limited methadone programs, Easier access in outpatient clinics Easy access in any clinic! access more difficult Cost No insurance needed Can be expensive Cheap! Overdose consideration Higher risk for overdose with Prevents overdose! Completely blocks opioid effect. concurrent use Prevents overdose! Formulation Liquid Tablet, film, shot (bad taste!) Tablet, shot Questions about Opioids?  Alcohol and other substances Diagnose and manage alcohol use disorder noting screening tools, acute intoxication and withdrawal Explain the general principles of psychosocial and pharmacological treatment of alcohol and other non-opiate substance use disorders  Alcohol Use-Epidemiology 2022 National Survey on Drug Use and Health ◦ 29.5 million people ages 12 and older had AUD in past year (10.5% of population!) https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol- use-disorder-aud-united-states-age-groups-and-demographic-characteristics Risk of developing a use disorder Age of first use History of addiction in the family History of adverse childhood experiences Hingson RW et al. Archives of Pediatrics and Adol Medicine 2006 Nescarc, 2001-2002 Screening-recommendations from USPSTF (US Preventative Services Task Force) NIAAA Single Alcohol Screening Question (SASQ) ◦ How many times in the past year have you had (4 for women, 5 for men) or more drinks in a day? ◦ Response of one or more warrants follow-up ◦ Easier to integrate into clinical conversations https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on- alcohol/screen-and-assess-use-quick-effective-methods  Screening-recommendations from USPSTF (US Preventative Services Task Force) Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) ◦ How often did you have a drink containing alcohol in the past year? ◦ How many drinks did you have on a typical day when you were drinking in the past year? ◦ How often did you have six or more drinks on one occasion in the past year? https://www.hepatitis.va.gov/alcohol/treatment/audit-c.asp Alcohol Use Disorders Identification Test Screening Avoid CAGE ◦ Cut down, annoyed, guilty, eye opener ◦ Does not identify all patients who could benefit from brief intervention ◦ Only captures patients already experiencing adverse consequences https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on- alcohol/screen-and-assess-use-quick-effective-methods  If they screen positive, then what??? Ask follow up questions Assess for alcohol use disorder https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/screen-and-assess-use-quick-effective- methods If they do have alcohol use disorder, then what? Assess for risk of withdrawal ◦ Daily alcohol use over past 2-3 weeks? ◦ History of uncomplicated vs complicated withdrawal? ◦ Withdrawal seizures, hallucinations, or DTs?  Alcohol Withdrawal-Pathophysiology GABA Glutamate ◦ Inhibitory neurotransmitter “stop” o Excitatory amino acid “go” ◦ Alcohol enhances GABA o Alcohol inhibits reabsorption of Glutamate  Chronic alcohol use → Constant presence of ethanol preserves homeostasis between these two  Abrupt cessation unmasks adaptive response, resulting in overactivity of CNS  Alcohol Withdrawal-Manifestations Mild Withdrawal ◦ Insomnia, tremors, anxiety, nausea/vomiting, anorexia, headache, diaphoresis, palpitations Can start as soon as 6 hours after cessation. Usually peaks 12-48 hours and resolves within 48-72 hours Alcohol Withdrawal-Manifestations Severe Complications Withdrawal Seizures ◦ 12-48 hours after last drink ◦ Typically in folks with heavy, chronic use ◦ More common if hx of seizures Alcoholic hallucinosis ◦ Hallucinations 12-24 hours after last drink ◦ Usually visual, can be auditory and tactile ◦ Patients typically aware they are happening Alcohol Withdrawal-Manifestations Severe Complications Delirium Tremens ◦ Up to 5% experiencing withdrawal ◦ Hallucinations, disorientation, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis ◦ 48-96 hours after last drink ◦ Other complications ◦ Hypovolemia, metabolic acidosis, hypokalemia, hypomagnesemia, hypophosphatemia  Alcohol Withdrawal-Management Benzodiazepines ◦ Typically diazepam ◦ Lorazepam if liver dysfunction Barbiturates: Phenobarbitol Dose based on CIWA Scale https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5597013/  Alcohol Use Disorder-Pharmacotherapy Naltrexone: 50mg PO, first line ◦ Opioid antagonists-works downstream on dopamine ◦ Blunts “reward” of drinking Acamprosate: 666mg TID ◦ MOA largely unknown, Works at glutamate/NMDA receptors and CCBs ◦ Only beneficial if already abstinent Disulfiram: (rarely use) ◦ Blocks conversion of acetaldehyde to acetic acide, resulting in upsurge of acetaldehyde ◦ Makes you sick (flushing, nausea, vomiting, etc) *Gabapentin: 300mg BID and 600mg qHS ◦ Inhibition of alpha-2 unit of CCBs, decreasing abnormal excitement of brain https://www.grepmed.com/images/7943/medications-mechanismofaction-treatment-druginformation- pharmacology Other Substances and Harm Reduction  Stimulants Cocaine Meth Prescribed Amphetamines -Adderall, etc Stimulants Intoxication Hyperfocus Rapid speech Anorexia Anxiety Paranoia Palpitations Hypertension Cardiac events Psychosis Stimulants Withdrawal Meth-often referred to as “meth washout” Hunger/increased appetite Depression Fatigue Difficulty concentrating Anxiety Irritability Suicidal ideation Stimulants-Treatments Cognitive Behavioral Therapy Contingency Management Social supports ◦ Access to food, stable housing, etc Pharmacotherapy-Limited ◦ Access Study-Potential utilization of high dose bupropion and naltrexone for meth  Other substances? Psychedelics: “shrooms” psilocybin Kratom: low dose like stimulant, high dose like opioid Phenibut: GabaB (similar effect to benzo) GHB: (“date rape drug”, chemsex drug) LSD: acid, hallucinogenic PCP: pixie dust, hallucinogenic  Harm Reduction Fentanyl test strips Clean supplies (needles, pipes) IN→ smoking→ injection Clean needles Narcan  Naloxone: Narcan https://www.nhcgov.com/FAQ.aspx?QID=582 Naloxone: Narcan https://www.drugfreenorthernmichigan.net/recovery/naloxone-saves-lives.html Naloxone: Narcan References Horn DB, Vu L, Porter BR, et al. Responsible Controlled Substance and Opioid Prescribing. [Updated 2023 Oct 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572085/ Fighting the Opioid Epidemic in Minnesota. The Office of MN Attorney General Keith Ellison. https://www.ag.state.mn.us/opioids/ Opiate Withdrawal Timeline: What to Expect. Kali Lux, Jan 19, 2023 https://www.workithealth.com/blog/opiate-withdrawal-timeline/ https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w https://www.grepmed.com/images/7943/medications-mechanismofaction-treatment-druginformation-pharmacology Naloxone Saves Lives. Drug Free Northern Michigan Coalition Alliance. https://www.drugfreenorthernmichigan.net/recovery/naloxone-saves-lives.html New Hanover County. Signs and Symptoms of Opioid overdose https://www.nhcgov.com/FAQ.aspx?QID=582 https://steverummlerhopenetwork.org/recovery/how-medications-work/ https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/efficacy-medications-opioid-use-disorder NIDA How effective are medications to treat opioid use disorder? https://www.naabt.org/documents/NAABT_Language.pdf https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5597013/ https://www.shatterproof.org/about-addiction/stigma/stigma-reducing-language https://drugfree.org/article/shouldnt-use-word-addict/#