Substance Use Disorder: The Impact of the Clinical Pharmacy - PowerPoint PPT Presentation

Substance Use Disorder: The Impact of the Clinical Pharmacy Specialist Troy A. Moore, PharmD, MS, BCPP Clinical Pharmacy Specialist- Psychiatry Director, ASHP-Accredited PGY-2 Psychiatric Pharmacy Residency Program South Texas Veterans Health Care System Assistant Professor UT Health San Antonio Dept of Psychiatry- Division of Community Recovery, Research and Training

CPE Information and Disclosures Dr. Troy A. Moore, PharmD, MS, BCPP declare(s) no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

CPE Information  Target Audience: Pharmacists and Pharmacist Technicians  ACPE#: 0202-0000-18-213-L04-P/T  Activity Type: Knowledge-based

Learning Objectives  Explain the role of the CPS in substance use disorder  Review the impact on access and quality  Highlight best practices related to substance abuse disorder

Self-Assessment Questions  The gold standard medication for a pregnant women with OUD is?  The medication associated with reduced ED visits, lower inpatient admission, and reduced healthcare costs for AUD is?  The greatest benefit for smoking cessation is seen with medication, psychotherapy or combination treatment?

Cycles of Addiction Dackis, C., & O'Brien, C. (2005). Neurobiology of Addiction: Treatment and Public Policy Ramifications. Nat Neurosci, Nov;8(11):1431-6.

Substance Use Disorder Terminology Term Definition Usage of a substance for a purpose that is inconsistent with legal or medical guidelines Misuse Maladaptive pattern of use despite knowledge of psychological or physical problems directly Abuse exacerbated by continued drug use Type of behavior a drug misuser or abuser may engage in, such as recurrent requests for early Aberrant prescription refills Behavior Pattern of drug-seeking behavior in pain patients receiving inadequate pain management and mistaken Pseudo- for addiction, portraying an unfortunate interstice of warped emotional salience and undertreated pain Addiction** in the setting of iatrogenic dependence to opioid analgesics. This may be considered an archaic term by some practitioners Decrease in response to a drug dose that occurs with continued use, with both physiological and Tolerance psychological factors contributing to its development Cluster of symptoms with varying degrees of severity that occur upon cessation or reduction of a Withdrawal psychoactive substance Adaptation manifested by production of a withdrawal syndrome inducible upon abrupt cessation, rapid Physical dose reduction, decreasing drug serum concentration, and/or administration of an antagonist Dependence Constellation of emotional reliance for a substance beyond its physical effects, often amplified in the Psychological drug’s absence Dependence

Substance Use Disorder Diagnostic Criteria Hasin et al. Am J Psychiatry 2013; 170:834-851

Epidemiology of Opioid Misuse in Past Year: 2016 2016 NSDUH

Overdose Death Rates Source: CDC WONDER; www.drugabuse.gov

Trends in rates of opioid-related of hospital stays and ED visits, 2008-2015

OUD Risk: Acute and Chronic Center for Substance Abuse Treatment. (2005). Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43.

Diagnostic Criteria: Opioid Use Disorder

Medically Supervised Withdrawal (Detoxification): Scales  Clinical Opiate Withdrawal Scale (COWS)  Clinician scored; 11 questions  Mild (5-12), moderate (13-24), moderately severe (25-36), severe (>36)  Scales without clear categorization of totaled scores  Subjective Opiate Withdrawal Scale (SOWS): patient scored; 16 questions  Objective Opiate Withdrawal Scale (OOWS): clinician scored; 13 questions  Clinical Institute Narcotic Assessment (CINA): clinician scored; 11 questions  Narcotic Withdrawal Scale: clinician assessed physical findings as tool for methadone initiation  Scales for neonatal abstinence syndrome  Modified Finnegan: table-based checklist for CNS, metabolic/vasomotor/respiratory, and gastrointestinal disturbances  Neonatal Abstinence Syndrome Scoring Chart: 10 questions; has modification for premature neonates in sleeping score

Clinical Opiate Withdrawal Scale (COWS) Source: Wesson, D. R., & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoact ive Drugs, 35(2), 253–9.

Medically Supervised Withdrawal (Detoxification): Goals of Treatment  Not necessary to prevent death, in contrast to alcohol withdrawal syndrome  Good opportunity to try and engage patients in treatment  2015 VA/SUD guidelines recommend detoxification with methadone or buprenorphine as first line  Clonidine considered second line  Detoxification without enrollment in treatment has little effect on relapse rate  Adjuvant medications during taper  Anxiety/dysphoria/lacrimation/rhinorrhea: hydroxyzine 25-50mg TID PRN  Myalgia: APAP or NSAIDs  Sleep disturbance: trazodone 50-100mg; gabapentin 300-1800mg  Nausea: antiemetics (no specific preference)  Diarrhea: bismuth subsalicylate or loperamide

Maintenance Treatment after Detoxification  Pharmacotherapy with three FDA-approved medications  Two available agonist medications with the full agonist methadone and partial agonist buprenorphine  Rationale for use include suppression of cravings and withdrawal symptoms via stabilization of neuronal systems, in addition to blocking the acute effects of other opioids in the case of relapse  Appropriate use allows patients to return to a productive lifestyle and address the negative consequences that often arise due to OUD One available antagonist medication with naltrexone   Intended for reinforcement of abstinence (via prevention of opioid intoxication)  Does not directly affect the neuronal systems of OUD and reduce craving Center for Substance Abuse Treatment. (2005). Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. Mattick, R., Breen, C., Kimber, J., & Davoli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev, (3):CD002209

Pharmacotherapies for OUD Methadone (MET) Buprenorphine and Naltrexone Oral (NTX) and Extended- Buprenorphine/Naloxone (BUP) Release Injection (XR-NTX) Oral (liquid/powder/dispersible tablet) Sublingual film or tablets that can be taken Oral tablets to be taken at home or an Route of with consumption that is usually at home or in a physician’s office. 6-month intramuscular injection to be Administration witnessed at an Opioid Treatment implant and monthly IM injection available administered by a healthcare Program (OTP). Take-home doses now professional allowed after meeting regulatory criteria For treating OUD, can only be For treating OUD, prescribers must None; can be filled at any pharmacy Prescribing purchased and dispensed by certified complete limited special training and Restrictions OTPs or hospitals qualify for a DEA prescribing waiver; does not have dispensary restrictions MET has been the gold-standard Since passing of Drug Abuse Treatment Act NTX is best reserved for highly Evidence in OUD treatment since FDA approval in 1960s; in 2000, BUP has been used for office based motivated OUD patients (e.g. Cochrane reviews have demonstrated management of OUD resulting in greater mandated treatment by a professional MET’s favorable treatment retention access and less stigmatized treatment; licensing board), as Cochrane reviews rate compared to placebo treatments Cochrane reviews have noted BUP’s confirm the poor clinical utility of NTX and reduced rates of opioid positive inferiority to MET for treatment retention, due to poor adherence and low urine drug screens but BUP performs equally well in reduction treatment retention; XR-NTX was of opioid positive urine drug screen rates approved in 2010 and has more encouraging data Full mu-opioid receptor agonist; also Partial mu opioid receptor agonist and Full antagonist at mu, delta, and Mechanism of exhibits NMDA antagonism kappa opioid receptor antagonist kappa opioid receptors Action Center for Substance Abuse Treatment. (2005). Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. Kampman, K., & Jarvis, M. (2015). American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addict Med, 9(5):358-367. Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 45; 2 Settings, Levels of Care, and Patient Placement.