Opioid Addiction Treatment Thomas R. Kosten, MD Professor of - PowerPoint PPT Presentation

Opioid Addiction Treatment Thomas R. Kosten, MD Professor of Psychiatry Baylor College of Medicine 1

Continuity of Care: A Critical Goal Is shorter cheaper? Re-hospitalization in 296 dependent patients Romelsjo et al. Sweden • • All received at least 3 inpatient days – Group 1: 1 week Inpat. 10 Wks Opt – Group 2: 1 week Inpat. No Opt – Group 3: 8 Weeks Inpat. No Opt

Re-Hospitalization and Initial Time in Tx Romelsjo et al. – JSAT, 2005 10 Wks Opt 1 Wk Inp 8 Wks Inp 78% 80% 71% 58% 60% 46% 40% 40% 21% 20% 0% 6 12 24 36 Months After Release

Continuity of Care: A Critical Goal Who, Why, What Treatment? 1. Treated patients show far more improvements than non-treated patients. 2. Motivation is an important but not critical ingredient. 3. Costs in relapse and re-hospitalization associated with NOT treating. 4. Continuity in outpatient care is critical, cost effective, and requested by patients!

“Let Me Tell You A Story” WHY? Because a real case will help: • Illustrate complex pattern of relapse and treatment reentry typically experienced by opioid-dependent patients. • Underline importance of screening for illicit drugs.

“Let Me Tell You A Story” WHY? Because a real case will help: • Demonstrate potential of new treatment paradigms which provide a way to stabilize patients –– in an office setting –– with such opioid-based medications as buprenorphine. • Help us begin to see the cost-savings inherent in a new treatment paradigm.

“Let Me Tell You A Story” • Mr. A, a 34 year old Caucasian man, began “chipping” intranasal heroin about 5 years ago.

“Let Me Tell You A Story” • Mr. A, a 34 year old Caucasian man, began “chipping” intranasal heroin about 5 years ago.

“Let Me Tell You A Story” • Then, Mr. A had a serious auto accident –– due to seizure –– and ER toxicology screen is positive for cocaine and opioids.

Historic Challenges in Treating Top reasons physicians ignore substance abuse: • 426 Primary Care Physicians 1) Don’t know what to do. 69% 2) No effective treatment. 55% 3) Not really a medical problem. 26% 4) No time. 19%

Historic Challenges in Treating Patients reluctant to seek help from traditional methadone clinics:  In undesirable neighborhoods.  Inconvenient to reach.  Requiring daily attendance.

The Story of Mr. A, continued One year after initial treatment, Mr. A returns to ER with heroin overdose sufficient to require naloxone reversal.

Opioid Dependence and Other Drug Dependencies as a Chronic, Relapsing Disease State of the art science (SAMHSA, NIDA, WHO) now identifies opioid dependence as a chronic disease state.

Opioid Dependence as Chronic Disease We need to:  Foster the idea of drug dependence as chronic illness.  Promote best practices for long-term management and continuous monitoring models .

“ Continuum of Care” for Chronic Disease Opioid dependence and “Mainstream” chronic diseases: • Striking similarities in onset, course and re-occurrence. vs. Striking disparities in policy, treatment availability, treatment evaluation, and insurance coverage . [www.tresearch.org/add_health/add_health.htm]

Opioid Dependence as Chronic Disease For too long physicians and payors have failed to see drug dependence for what it is, a chronic disease. Consequently: • Standard has been to measure progress by assessing results at some point after patients leave treatment.

Opioid Dependence as Chronic Disease For too long we’ve measured progress by assessing results at some point after patients leave treatment. Consequently: • Results have no clinical value and produce results disappointing to policy makers.

Opioid Dependence as Chronic Disease For too long we’ve failed to see drug dependence as a chronic disease. Moreover: • We’ve relied on model rejected for other chronically relapsing conditions.

Opioid Dependence as Chronic Disease For too long we’ve failed to see drug dependence for what it is, a chronic disease. In short: • We’ve failed to adopt chronic disease model that might work.

“Continuum of Care” When seen as chronic Disease, Opioid Dependence, fits perfectly under the banner “Continuum of Care.” That’s why we’re here today.

“Continuum of Care” for Chronic Disease Contemporary treatments for opioid dependence must be conceptualized, structured and delivered to meet the differing needs of individuals along a continuum.

Opioid Dependence as Chronic Disease OD more responsive to –– and more cost effectively treated –– using chronic disease management model of care.

“Continuum of Care” for Chronic Disease Conflict between new, chronic disease classification and traditional short-term medical management. Demands a Change. Demands a Shift in Policy.

“Continuum of Care” for Chronic Disease Accept that: • OD requires time to correct itself. • Long term maintenance requires long term reimbursement.

“Continuum of Care” for Chronic Disease Versus . . . • Mr. A and the revolving door

“Continuum of Care” for Chronic Disease Need to establish parity in care with such chronic diseases as hypertension, diabetes and asthma.

“Continuum of Care” for Chronic Disease Remember Mr. A?  In spite of extensive intervention  In spite of good social supports  In spite of economic opportunity  In spite of vocational skills  In spite of multiple detoxifications  In spite of drug-free outpatient care Relapse and consumption of extensive health resources. Why?

“Continuum of Care” for Chronic Disease Because the model for his care was not based on a model for a chronic, relapsing disease.

Historic Treatment Options Traditional goal? Rehabilitate and Discharge.

Historic Treatment Options • 40 – 70% of all addiction treatment episodes are detox-only • Cost $1,750 - $2,400 per episode • Re-detox within a year – Average = 40% (23 – 78% range) – 28% admitted 3+ times/yr 2000 Inspector General Report

Historic Treatment Options Relapse rates among diabetics or asthmatics following cessation of medication = • Evidence of effectiveness of medication. VS. Relapse rates amongst drug or alcohol dependent patients following cessation of treatment = • Evidence of treatment failure.

Treating Opioid Dependence: Changing the Paradigm Patients, like Mr. A, who would have been reluctant to seek help from traditional methadone clinics, will be willing to seek help.

Treating Opioid Dependence: Changing the Paradigm • Make study of addiction part of med school curricula. • Use medical monitoring strategies (as for other chronic diseases) to ferret out those most at risk. • Shift from “rehabilitation” strategy to “chronic care” strategy. • Lift insurance limits so that benefits (even incentives) apply for continued outpatient, medication and behavioral visits –– w/o limit on days or visits.

Treating Opioid Dependence: Benefits of a New Paradigm Drug dependence treatments designed to discharge patients upon resolution of acute symptoms have not been effective.

Treating Opioid Dependence: Requirements of a New Paradigm Drug dependence should be: • Insured, treated and evaluated in the same manner as other chronic illnesses.

Case History: How Buprenorphine Made a Difference Buprenorphine therapy in office practice was successful for Mr. A.

Case History: How Suboxone Can Make a Difference For appropriate patients office-based BUP treatment is an effective and cost effective model for care.