history - Providers` Clinical Support System For Opioid Therapies

Opioid Use Disorders in the American
Indian/Alaska Native Communities
Anthony Dekker, DO
Addiction Technology Transfer Center (ATTC)
Network Coordinating Office
30JUL2015
3:00pmET
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Disclosure Information
Successful Completion:
This course offers 1 contact hour. Upon completion of this course
participants must complete and submit an online evaluation to receive
contact hours. Certificates will be emailed within four weeks.
Commercial Support/Sponsorship:
There is no commercial support for this training.
Non-Endorsement of Products:
The University of Missouri-Kansas City School of Nursing and School
of Medicine and the ANCC do not approve or endorse any commercial
products associated with this activity.
The Addiction Technology Transfer Center Network Coordinating Office has been awarded a sub-contract by the
Providers’ Clinical Support System for Opioid Therapies to conduct portions of programmatic efforts.
Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant
no. 1H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers
and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does
mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government
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Disclosure Information Cont.
Conflict of Interest:
In accordance with continuing education guidelines, the
speaker and planning committee members have disclosed
commercial interests/ financial relationships with companies
whose products or services may be discussed during this
program.
Planning Committee:
Sharon Colbert, Angela Bolen, Susan Garrett, Laurie Krom,
Lisa Paschang, John Foxworth, PharmD, and Joy Fulbright,
MD have nothing to disclose. Jacki Witt is a consultant for
Agile Therapeutics and Watson Pharmaceuticals (Resolved).
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Anthony Dekker DO, Disclosures
• Anthony Dekker, DO has presented numerous
programs on Chronic Pain Management and
Addiction Medicine. The opinions of Dr Dekker are
not necessarily the opinions of the Veteran’s
Administration, the DoD, the US Army, the Indian
Health Service or the USPHS. Dr Dekker has
nothing to disclose. Dr Dekker does not represent
any federal organization.
• Dr Dekker is a clinical professor at the George
Washington University and the ATSU
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Educational Objectives
• At the conclusion of this activity participants should
be able to:
• Appropriately screen substance use disorders in
AI/AN populations
• Identify the signs and symptoms of opioid use
disorders in the AI/AN populations
• Implement medication assisted therapies for opioid
dependence in the AI/AN populations
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Target Audience
•
The overarching goal of PCSS-O is to offer evidence-based
trainings on the safe and effective prescribing of opioid medications
in the treatment of pain and/or opioid addiction.
•
Our focus is to reach providers and/or providers-in-training from
diverse healthcare professions including physicians, nurses,
dentists, physician assistants, pharmacists, and program
administrators.
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Leland Fairbanks MD
Indian Health Service
2015 PCSS-O
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Historical and Sociocultural
Factors
•
•
•
•
Impact of Colonization
Loss of knowledge and traditions
Impact of disease from colonial contact
Forced relocation from the land
Removal of children from the family
9
Demographics-1
•
•
•
•
Over 560 federally recognized tribes
Over 250 distinct languages among tribes
Most American Indians live in Western States
44% live in rural areas
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Demographics-2
• (1997-99) 26% live in poverty
• Life expectancy 63.5 years
• Median age 27.8 years
• (1990 –01) population increased 22.4%
to 2.5
million
11
Epidemiology-1
• 5th leading cause of death chronic liver disease and
cirrhosis
( MMWR,CDC, 1994-96 )
• 20% 12 – 17 yr olds illicit drug use
(SAMSHA Household Survey , 1999)
• Death rates due to alcoholism 7 x greater then
general population
• Suicide 1.5 x national rate
12
Epidemiology-2
• 70% with lifetime alcohol disorder and psychiatric
disorder
(Robin et.al 1997)
• Fetal Alcohol Syndrome rate 3x higher than for all
other groups 2.97 per 1,000 births
(CDC , 1998)
• PTSD prevalence rate 2.75 x higher than general
population
(Kessler et al., 1995)
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Death Rates per 100K-CDC
American
Indian/Alaska
Native
2008 2009 2010
2011
2012
Absolute
%
Heroin
0.9 1.0 0.9
1.2
1.4
0.6
63.9
Opioid Pain
6.2 7.1 6.0
Relievers
6.2
6.2
0.3
4.5
2015 PCSS-O
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Misuse, Overuse and Abuse
15
Concern for Youth
16
Young Adult Use Issues
2015 PCSS-O
17
2015 PCSS-O
18
2015 PCSS-O
19
Factors Contributing to Vulnerability
to Develop a Specific Addiction
use of the drug of abuse essential (100%)
Genetic
(25-50%)
Environmental
(very high)
• DNA
• SNPs
• other
polymorphisms
• prenatal
• postnatal
• contemporary
• cues
• comorbidity
• mRNA levels
• peptides
• proteomics
• neurochemistry
• behaviors
Drug-Induced Effects
(very high)
Kreek et al., 2000
Endogenous Opioids
and Their Receptors
Opioid Classes
Opioid Receptor Types
Endorphins
Mu
Enkephalins
Delta
Dynorphins
Kappa
Endomorphins (?)
Kreek, 2001
Human Opioid Receptors , , and 



H2N
extracellular fluid
S
S
AA identical in
3 receptors
AA identical in
2 receptors
AA different in
3 receptors
cell membrane
cell interior
HOOC
LaForge, Yuferov and Kreek, 2000
Heroin Addiction: Functional State of a
Typical Addict
Functional State
"High"
"Straight"
"Sick"
AM
PM
AM
PM
AM
(arrows
indicate
times of
injection)
Days
Dole, Nyswander and Kreek, 1966
“On-Off” versus “Steady-State”
Disruption versus Normalization
• levels of gene expression
• receptor mediated events
• physiology
• behaviors
Kreek, 1987; 2001
Allelic Frequencies of the Variant Allele of the A118G
Single Nucleotide Polymorphism of the Human -Opioid
Receptor Gene in Diverse Populations
Ethnicity or
population
Bergen et al.
(1997)
Bond et al.
(1998)
Asian
Japanese
Han Chinese
Chinese
Thai
Malay
Gelernter et al.
(1999)
Szeto et al
(2001)
Tan et al
(2003)
Bart et al
(2003)
0.485 (34)
0.362 (297)
0.351 (208)
0.438 (56)
0.446 (156)
Indian
0.442 (137)
Southwest Native
American
Caucasian
European American
Finnish Caucasian
Swedish Caucasian
0.163 (367)
0.105 (100)
0.122 (324)
0.115 (52)
0.141 (543)
0.107 (187)
Hispanic
0.142 (67)
0.117 (47)
African American
0.016 (31)
0.028 (144)
Other (populations in Israel)
Ethiopian
Bedouin
Ashkenazi
0.170 (49)
0.080 (43)
0.210 (93)
Allele frequency for the variant allele is shown for various study populations. Numbers in parentheses are
the number of subjects whose genotype was ascertained in each study. A study of Han Chinese found the
118G allele at a frequency of 0.321, and no occurrence of the 17T allele in 540 subjects (Li et al., 2000).
LaForge, Yuferov
and Kreek, 2003
Taking the History
• Attitude of the interviewer should be:
 non-judgmental, curious, respectful of cultural beliefs
 To facilitate effective treatment:
 Acknowledge some information is difficult to talk about
 Assure the patient that you are asking because of
concern for his/her health
 Try to avoid using labels or diagnoses
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Taking the History
 Pay attention to the manner in which the
patient responds
 Acknowledge discomfort
 Be persistent
 Always follow-up on “qualified answers”
 Assure confidentiality (as long as no one is
at risk of being harmed)
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Taking the History
• History of drug use:
 Start with first substance used
 Ask about all substances (licit and illicit)
 Determine changes in use over time
(frequency, amount, route)
 Assess recent use (past several weeks)
 Opioid dependence may be addiction to
heroin or to prescription opioids; ask about
history of both
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Taking the History
• Prescription opioids:
 Compulsive use of prescription pain medications
− Unauthorized increases in dose
− Using drug for other than pain relief: anxiety, stress,
insomnia, to get “high”
 Doctor shopping (Indian Health, Tribal, civilian)
 Forging prescriptions
 Frequent visits to the emergency department seeking
opioid medications
 Obtaining medication from family, friends, buying on the
street; selling drugs
 Use of alcohol or other illicit drugs
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Taking the History
• Tolerance, intoxication, withdrawal:
 Explain what is meant by tolerance
 Determine the patient’s tolerance and
withdrawal history
 Ask about complications associated
with intoxication and withdrawal
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Taking the History
• Relapse/attempts to abstain:
 Determine if the patient has tried to
abstain, and what happened
 Longest period of abstinence
 Identify triggers to relapse
31
Taking the History
• Consequences of use:
 Determine current and past levels of functioning
 Identify consequences
– Medical
– Family
– Employment
– Legal
– Psychiatric
– Other traumas
32
Taking the History
• Craving and control:
 Ask about craving and/or a
compulsive need to use
 Determine if patient sees loss of
control over use
• Treatment Episodes
 Response to treatment
 Length of abstinence
33
Taking the History
• Medical history:
 Past and/or present:
− Significant medical illnesses
− Hospitalizations/Operations
− Accidents/injuries
 Drug allergies
 Current medications; evaluate for
abuse of prescription opioids
34
Taking the History
• Psychiatric history
 Symptoms/mental illnesses
 Type of treatment(s) including TIM
 Medication treatment
35
Taking the History
• Family history:
Substance use disorders
Other psychiatric conditions
Other medical disorders
36
Taking the History
• Personal (or social) history:
 Birth and early development
 Trauma
 Education
 Employment and occupations
 Marital status and children
 Living situation
 Legal status
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Evaluating the Patient
Physical
examination:
Look for evidence of addiction
 State PMP
 Needle marks
 Sclerosed veins (track marks)
 Cellulitis/Abscess
 Evidence of hepatitis or HIV
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DoD TBI Occurrence
dvbic.dcoe.mil/dod-worldwide-numbers-tbi
39
Concussion Basics
A concussion:
• is also known as mild traumatic
brain injury (TBI)
• is a change in normal brain
function caused by a blow/jolt
to the head or some other
external force such as a blast
• can occur even without being
knocked out/blacking out
• can temporarily change the way
the brain works
2015 PCSS-O
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Pathology
• Rotational injuries lead to diffuse shearing of small
vessels
• Diffuse axonal injury is underlying lesion
2015 PCSS-O
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Ft. Carson:
Post-Deployment Data (n = 907)
90%
80%
Acute (right after mTBI)
70%
Post-Deployment
60%
50%
40%
30%
20%
10%
0%
Headache Dizziness
2015 PCSS-O
Balance Irritability
Problems
Memory
Terrio et al., JHTR, 2009; 24, 14-23.
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Corpus Callosum
2015 PCSS-O
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Potential Clinical Presentation
TBI
PTSD
Flashbacks
Attentional
problems
Headaches
Depression
Nightmares
Insomnia
Dizziness
Irritability
Anxiety
2015 PCSS-O
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PTSD
Physical
Injuries
Substance
Abuse
Anxiety
TBI
Depression
2015 PCSS-O
Pain
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Individualized Care
2015 PCSS-O
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TBI and Co-occurring Conditions
•
•
•
•
•
•
•
PTSD
Pain
Substance Use Disorders
Dual Sensory Impairments
Depression
Anxiety
Suicide
2015 PCSS-O
47
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U.S. Legislation Enabling Office-Based
Treatment of Opioid Dependence
• Drug Addiction Treatment Act of 2000: “Waiver
Authority for Physicians Who Dispense or Prescribe
Certain Narcotic Drugs for Maintenance Treatment or
Detoxification Treatment” (H.R. 4365, Children’s
Health Act of 2000)
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What Can Be Done?
•
•
•
•
•
Listen to the Native Communities
Identify resources in the Community
Educate the Native Leadership
The decision belongs in the community
Use Evidence Based interventions for prevention and
screening
• Use interventions that the community can support
• Provide feedback for the Native Leadership
2015 PCSS-O
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Buprenorphine
• Opioid partial agonist
• Schedule III (vs. methadone: Schedule II)
• Treatment modalities for buprenorphine:
 Office based treatment
− Primary Care
− Specialty (e.g.: Infectious Disease, GI,
Psychiatry, OB-Gyn)
− Substance abuse treatment clinics
 Methadone maintenance programs
50
Buprenorphine Maintenance/Withdrawal:
Retention
Remaining in treatment (nr)
20
15
10
Control
5
Buprenorphine
0
0
50
100
150
(Kakko et al., 2003)
Treatment
200
250
duration (days)
300
350
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Characteristics of Addiction
(Dependence)
• Control (loss of)
• Compulsion to use
• Consequences (continued use
despite negative consequences –
family, occupational/educational,
legal, psychological, medical)
• Craving
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Assess for Other Substance Use
•
•
•
•
•
•
•
•
•
Alcohol
Sedative-hypnotics (especially benzodiazepines)
Cocaine
Methamphetamine
Cannabis
PCP
Nicotine
“Club Drugs” (Ecstasy, ketamine, GHB)
Non-controlled (clonidine, phenergan,
antihistamines, etc.)
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PCSS-O Colleague Support Program
and Listserv
•
PCSS-O Colleague Support Program is designed to offer general information to health
professionals seeking guidance in their clinical practice in prescribing opioid
medications.
•
PCSS-O Mentors comprise a national network of trained providers with expertise in
addiction medicine/psychiatry and pain management.
•
Our mentoring approach allows every mentor/mentee relationship to be unique and
catered to the specific needs of both parties.
•
The mentoring program is available at no cost to providers.
For more information on requesting or becoming a mentor visit:
www.pcss-o.org/colleague-support
•
Listserv: A resource that provides an “Expert of the Month” who will answer questions
about educational content that has been presented through PCSS-O project. To join
email: [email protected].
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PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership
with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American
Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of
Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American
Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American
Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and
Southeast Consortium for Substance Abuse Training (SECSAT).
For more information visit: www.pcss-o.org
For questions email: [email protected]
Twitter: @PCSSProjects
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