Dr. Kenneth Saffier's 2013 SLC presentation on Innovative Opioid Abuse Treatments.

1. Opioid Abuse:
How Innovation Can Save Lives
Ken Saffier, MD
Contra Costa Regional Medical Center and
Health Centers
November 2, 2013
AAFP 2013 State Legislative Conference

2. Disclosures
I have nothing to disclose.

3. Overview of this presentation
•
•
•
•
•
Introduction and learning objectives
The current opioid epidemic and access crisis
Buprenorphine “101” for the non-addictionist
Medically assisted therapy for drug addiction
Effective communication strategies – Group
visits and motivational interviewing
• Summary and conclusions

4. Learning Objectives
By the end of this presentation, participants will be
able to:
1. Explain how buprenorphine, a partial opioid
agonist, works and can save lives.
2. Witness and experience the power of patients’
first person perspectives to promote education
and treatment for other patients and
professionals.
3. Define motivational interviewing and explain
why it is particularly well-suited to helping
people with opioid addiction.

5. An Epidemic of Opioid Poisoning and
Overdose Deaths
• 13% of 18-25 yo abused prescription drugs
• In 2010, 3,000 died (18-25) from OD, more than
for heroin and cocaine.
– 8 deaths per day
– 250% increase from 1999
• 10,000 men and 6,600 women in 2010 died
from prescription med OD’s.
• More people die from poisonings than from
MVA’s.

6. * Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment admissions, and crude rates per 10,000 population for kilograms sold.
MMWR - November 4, 2011 / 60(43);1487-1492

7. Lack of Access – A Painful Reality
• Uninsurance associated with 45,000 deaths (1864 yo)in US.
Wilper, AP, et.al. Health Insurance and Mortality in US Adults,
Amer J Pub Health, 2009; 99:2289-2295
• Approximately 10% of those with SUDs receive
specialty care (2.5 of 23.1 million).
• 38% of 1.1 million who felt they needed
treatment had no insurance or funds to pay for
tx.
2012 National Survey on Drug Use and Health, US DHHS

8. Medically Assisted Treatments
• Alcoholism: naltrexone, acamprosate, disulfiram
• Opioid addiction:
– Naltrexone
– Methadone: detox, maintenance
– Buprenorphine

9. Buprenorphine 101 – a brief overview
Agonist
Heroin, hydrocodone, oxycodone, fentanyl
Antagonist
Naloxone, naltrexone
Mixed agonist/antagonist
Pentozacine, butorphanol (Stadol)
Partial agonist
Buprenorphine

10. 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

11. Buprenorphine – a partial agonist
High affinity for the mu opioid receptor
Competes with other opioids and blocks their
effects
Can precipitate withdrawal in highly opioid
dependent individuals
Slow dissociation from the mu receptor
Prolonged therapeutic effect for opioid
dependence treatment
“Ceiling effect” for stimulation of a given
receptor

12. Intrinsic mu Activity: Full Agonist (Methadone), Partial Agonist
(Buprenorphine), Antagonist (Naloxone)
100
90
Full Agonist
(Methadone)
80
70
Intrinsic Activity
60
Partial Agonist
(Buprenorphine))
50
40
30
20
10
Antagonist (Naloxone)
0
-10
-9
-8
-7
Log Dose of Opioid
-6
-5
-4

13. Uses of Buprenorphine
Buprenorphine detox
Buprenorphine maintenance
Short acting opioids
Long acting opioids
Buprenorphine taper
(As an analgesic (transdermal))

14. Buprenorphine vs. Placebo
for Heroin Dependence
Remaining in treatment (nr)
Kakko, Lancet 2003
20
15
4 Subjects in Control Group Died
10
Detoxification
5
Maintenance
0
0
50
100
150
200
250
Treatment duration (days)
300
350

15. Engaging Patients in Treatment
• Access to health care
• Treatment options, including buprenorphine
• Group visits
• Motivational Interviewing

17. Buprenorphine Treatment Groups
•
•
•
•
Began in 2007.
Between 4 – 12 patients/group.
Urine toxicology screening.
Prescriptions written at time of visit or by PCP
after visit.
• Individual visits before and after group appt.
• Other staff: FM resident, Substance abuse
counselor (MFT).

18. AVERAGE PTS/MO/YR
EST. PTS/GROUP
2007
12
3
<1 group/week
2008
21
5.25
1 group/week
2009
32
8.0
1 group/week
2010
48
6.0
2 groups/week
2011
76
6.3
3 groups/week
2012
101 (3 months)
6.3
4 groups/week

19. Additional Tx Components
• Substance abuse counseling, including residential
• Mental health services
• Ongoing regular medical care
• 12 Step programs with sponsors
• Faith-based recovery programs

20. Patient Survey: n=107
• What’s good about buprenorphine?
Selected answers:
– “Saved my life”: 6
– “Allowed me to function”: 20
– “Stay sober and clean”: 22
– “Takes away craving”: 26
– Relief, no withdrawal: 15
– “Miracle drug”: 2
– Blocks other opioids: 4

21. “How long do you plan to take it?”
• Less than 1 year:
15
• More than a year with a stop date:
3
• I don’t know at this time, but I would like
to stop taking it eventually:
53
• I don’t have a desire to stop taking it
at this time:
26

22. Additional Innovations
• Buprenorphine induction clinics
– Integrated Services Model: Office-based
Buprenorphine Induction Clinic, San Francisco
Dept of Public Health
Hersh, D., et.al. J Psychoactive Drugs, 2011, 43: 136-145
• Nurse care managers (NCM) model
– Expansion to 19 FQCHC’s in MA w/ 1 NCM/center
– Average 75 pts/wk
Alford,DP et.al. Arch Intern Med 2011,171:425-431

23. Communication That Really Works –
Motivational Interviewing
“Motivational interviewing is a person-centered
counseling style for addressing the common
problem of ambivalence about change.”
Miller, WR and Rollnick, S. Motivational Interviewing, 3rd ed., 2013
• Individually and in Groups
• Works well with diverse populations
• Collaborative (and fun)

24. Which Style Do You Prefer?
Dancing
Wrestling

25. Four Processes in MI
Miller and Rollnick, 2013
Planning
Evoking
Focusing
Engaging

27. Summary and Conclusions
• Buprenorphine, a partial opioid agonist, saves
lives.
• Access to care and SUD treatment saves lives.
• Group therapy for opioid addiction treatment
with buprenorphine successfully engages
most patients.
• Motivational interviewing helps people
change.

28. Many Thanks
• To Karen, Rodney, Stephen, Susan and our
patients who are our excellent teachers.
• Mary Jean Kreek, MD, Andrew Saxon, MD
• Gary Larson