Hello and welcome. I'm Dr. Benjamin Druss, Professor and Rosalynn Carter Chair in Mental Health at the Rollins School of Public Health at Emory University and Health Systems Expert for SMI Advisor. I am pleased that you're joining us for today's SMI Advisor webinar, Studying Co-Occurring Opioid Use Disorder in Mental Health Settings. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for 1.0 AMA PRA Category 1 credit for physicians. Content for participating in today's webinar will be available until October 16th, 2021. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Now, I'd like to introduce you to the faculty for today's webinar, Dr. Brian Hurley. Dr. Brian Hurley is an addiction physician and Director of Addiction Medicine for the Los Angeles County Department of Health Services. He's a co-investigator on a number of projects at the RAND Corporation addressing the delivery of pharmacotherapy for alcohol and opioid use disorders in community settings. He's also a senior researcher at the Friends Research Institute and is a primary investigator on a tobacco-related disease prevention program-funded project integrating smoking cessation services into community mental health centers and patient-centered medical homes, and is the lead on the Sierra Health Foundation's MAT Access Point project with LA County's Department of Health Services. He's currently the President-Elect of the American Society of Addiction Medicine and is the Clinical Director of the Addiction Treatment Starts here in Primary Care Program through the Center for Clinical Innovation, focused on increasing the delivery of medications for addiction treatment in California's community health centers. He is a volunteer Assistant Clinical Professor of Addiction Medicine in the Department of Family Medicine at the UCLA David Gavin School of Medicine and serves on the American Board of Psychiatry and Neurology's Addiction Psychiatry Examination Writing Committee. Dr. Hawley, we're so happy to have you here. Thank you for leading today's webinar. Thank you so much, Dr. Dress. I really appreciate being here. I should disclose that I don't have relevant financial relationships with commercial interests, and I'm not going to try to sell you anything today. By the conclusion of this webinar, we should talk about screening and diagnostic assessment tools used to diagnose opioid use disorder among clients served by mental health settings, to compare and contrast the three FDA-approved medications that are indicated for opioid use disorder, discuss the feasibility of these medications within mental health settings, and then talk about integrating medications for opioid use disorder and how those work in mental health programs. But if we're going to talk about opioid use disorder, we should start by talking about opioids. Opioids are a category of medications that activate opioid receptors in the brain. Now, there's a number of opioid receptors in the brain. There's mu, there's kappa, there's delta, and there's others. But the mu opioid receptor is the receptor that seems to be responsible for most of the signs and symptoms of opioid intoxication, including analgesia, pain relief, euphoria, which is feeling activated or high. It's also responsible for what happens with our pupillary response. So our pupils become narrower or constricted when we're on opioids and dilated when we're in withdrawal. The mu opioid receptor is also responsible for many of the constipation, sedation, and effects of opioids, as well as itching and red eyes. It's also responsible for our respiratory depression and potentially respiratory arrest, as well as hypotension or low blood pressure and bradycardia, which is low heart rate. Opioid overdose is the number one cause of death for people in the United States under the age of 50, and the number one cause of death here in Los Angeles County, which is where I'm coming to you from, for people experiencing homelessness, as well as nationally, the number one cause of death for people leaving incarcerated settings and also people leaving addiction treatment settings. So overdose has become a major public health issue, and it can be identified as somebody who is found down and disoriented or unconscious with a decreased breathing rate and constricted pupils. Those three are usually enough to strongly suggest the presence of an opioid overdose. And then if the overdose continues, you'll see lips and fingernails turn blue, choking or gurgling sounds with a face that is pale or clammy, and injection track marks, or what are called legal track marks, are suggestive of somebody that's overdosed. One big push among public health departments, including my own here in Los Angeles County, is to rapidly identify and administer an antidote for opioid overdose, which is naloxone. Now, naloxone could be administered intramuscularly through an injection, but many people who aren't familiar with giving intramuscular injections oftentimes don't. There's a hesitation to put naloxone a mile on a syringe and then use the plunger to administer it intramuscularly. So there's also an intranasal version of naloxone. It's usually you give four milligrams intranasally or two milligrams intramuscularly, if somebody's found down in an overdose. And for synthetic opioids and the opioid overdose crisis in the United States now is mainly driven by synthetic opioids like fentanyl. You oftentimes have to give high dose naloxone in order to reverse those overdoses. So the opioid crisis and the overdose crisis, frankly, in the United States, began in the 1990s, when there was a concerted effort to push physicians and other prescribers to prescribe opioids. And this was mainly opioids for pain control, although what initially may have started as an opioid prescription for pain control, in some cases continued. And we see rates of opioid use disorder approaching 50% in some populations of people prescribed chronic opioids. Let me be clear, not everyone on a prescription opioid necessarily has an opioid use disorder, but there's a significant plurality that do. And when we saw rising rates in the sales of opioid medications, we saw concordant rates of opioid-related death and opioid-related treatment admissions. Interestingly, opioid prescribing has now been on the decrease in the United States since 2011. But opioid overdoses have continued to rise. I alluded to this earlier, but the opioid crisis happens in waves. There's heroin, which is a commonly available street opioid. It's not available for prescription. But the thing with heroin and what makes heroin different than fentanyl is the potency. Very small amounts of fentanyl impact a really big impact. And so we're still seeing overdose rates because of the availability of fentanyl in our system. And then there's fentanyl analogs, things like su-fentanyl, alpha-fentanyl, carfentanyl, which are even more potent than fentanyl itself. So the opioid crisis, again, has happened in waves. Wave one, again, 1990s, was the rise of prescription opioids. Wave two was the rise in heroin overdose deaths, not entirely caused by but contributed to when people are abruptly cut off their opioids, heroin becomes one tool they have available to help alleviate opioid withdrawal. So we saw a conversion off of prescription opioids and on to heroin. But the driver of synthetic opioids, such as fentanyl, is overwhelmingly the biggest driver of opioid overdose in the country. And it's only gotten worse during COVID. COVID has only made things worse. There was a period in 2018 where things appeared to stabilize, and starting in 2020, we've only seen rising rates of overdose. Now, you might say, this is fair and good, but I work in a specialty mental health setting. Well, I'll remind you that comfortably a fifth, if not a quarter of patients seen with mental illnesses also have a co-occurring substance use disorder. And half of patients with substance use disorder have a co-occurring mental illness. So there's a non-trivial overlap, somewhere between 20 and 25% of patients with mental illness have a substance use disorder. And when you're looking at serious mental illness systems of care, right, people that treat illnesses like schizophrenia, schizoaffective disorder, bipolar disorder, psychotic features, those serious mental illnesses, we see higher rates up to 30% of patients that have substance use disorder. Now, of the 2 million adults with an opioid use disorder, depression and anxiety are very common. About 27% of people with opioid use disorder meet diagnostic criteria for a bipolar disorder. Now, again, 50% of people with substance use disorders have a co-occurring mental illness, but we see among bipolar and psychotic disorders, you know, any substance use is as high as 50% in very high rates of tobacco use disorder. In a sample of just over 3,000 clients served in where I work, the L.A. County Department of Mental Health, we identified rates of 8% had a probable prescription opioid use disorder. It wasn't full diagnostic criteria, but it was, we used the ASIST, which is a screening tool to look at problem substance use. And 8% of the respondents had an ASIST score that was highly suggestive of the diagnosis of opioid use disorder, and 2% that had a heroin use disorder. And again, the Department of Mental Health offers safety net clinics. So this assumption that many, that I've had going into the study, that many of our patients served at DMH would be using heroin rather than prescription opioids was actually unfounded. Roughly four times the number of people had a prescription opioid use disorder times that what people had with heroin use disorder. And what do we know about the treatment of people with opioid use disorder? Well, treatment is effective, but underutilized for people with co-occurring mental health and opioid use disorder conditions. And the mainstay of opioid use disorder treatment is medications. Medications for opioid use disorder are first line. And this is pretty consistent in the American Society of Addiction Medicine National Practice Guideline in the world, Health Organization Practice Guideline. Medications for opioid use disorder have a significant effect on reducing the rate of overdose and increase treatment retention and health and functioning. But somewhere between 16 and 25% of those with co-occurring opioid use disorder report getting any treatment for both conditions, right? Integrated treatment is, even though we know it's important and not commonly delivered. The lack of co-occurring disorder treatment in mental health settings is oftentimes due to several factors. Many times there's this assumption, if somebody with serious mental illness presents for mental health care, then they should do addiction treatment first and then get whatever mental health symptoms remain taken care of in a specialty mental health system. The attempt to achieve diagnostic clarity or purity by helping somebody not use substances oftentimes has the effect of keeping people out of care. And so there's oftentimes long wait lists for specialty addiction treatment and for high-intensity specialty mental health services. And medications are usually not available. Well, I should say, it says sometimes on the slide, I say usually not available in specialty addiction treatment care. Stigma and logistical barriers are enormous. Parallel care is, again, famously ineffective at treating co-occurring disorders. Integrated treatment is the model. One of the big reasons that parallel care doesn't seem to work is the challenge of navigating multiple service providers, as well as service provider lack of training to work with people with serious mental illness. If the assumption is go to an addiction treatment program and then come back, the addiction treatment program might say, no, we can't take you until your mental health condition is stabilized, and then the patient gets stuck. I'm going to pivot now to talking about how do we identify which of our patients have an opioid use disorder. I put a link in the slide to a tool resource posted on the National Institute of Drug Abuse website. This is a screenshot of that tool resource. So there's a whole number of tools that we can use to identify alcohol use disorder, tobacco use disorder, and other substance use disorders, particularly opioid use disorder. Some are validated for adults. Some are validated for adolescents. Many can be self-administered. Some need to be clinician-administered. I'm going to highlight a few of the ones that I recommend. So the NIDA quick screen is relatively quick. That's the NIDA quick screen. And it asks about alcohol, tobacco, prescription drugs used for non-medical reasons, and illicit drugs. In California, because the legal status of cannabis is evolving, and because cannabis doesn't solidly fit into the illicit category at our state level, even though it remains illicit at the federal level, I add a separate category to the NIDA quick screens we administer here locally because cannabis kind of is in its own category. And that's true for many jurisdictions across the country. So alcohol, tobacco, prescription drugs, illicit drugs. And it really is a question, in the past year, how often have you used the following? For alcohol, how many times did you drink heavily, defined as five or more standard drinks in a day for men, four or more standard drinks in a day for women? Use a tobacco product. Use a prescription drug, such as prescription opioid, for a non-medical reason. And if somebody says, what do you mean for a non-medical reason? I would say, did you use it to get high? Or did you use it in a way that was other than prescribed? And then illicit drugs include all illicit opioids, as well as any other street drugs that somebody might be using. I then recommend, and this is true for primary care, but I would also think that it's equivalently true for especially mental health settings, is to use the tabs to identify who needs a subsequent assessment. So the NIDA quick screen simply identifies who's the group. I'll go back to the NIDA quick screen. The NIDA quick screen simply triages people into a group of people I'm going to ask more questions to, and a group of people that I'm not. That's the purpose of screening. The screening doesn't diagnose anything, in fact, but it identifies who's drinking heavily that I might need to ask more alcohol questions to, who's using a tobacco product that I might want to ask the Fagerstrom on, or frankly, just ask cigarettes per day, in order to assess the degree of their use of tobacco. If somebody indicates using a prescription drug for a non-medical reason, that is not addiction, necessarily, or a substance use disorder, but it implies I should ask more questions. So the more questions are, and this comes from the tabs, there's three more questions you might ask, which is, in the past 12 months, how often have you used any drugs, and then you can sort of name them, cannabis, cocaine or crack, heroin, methamphetamine, hallucinogens, ecstasy, MDMA, and then there's a whole variety of others, but that's sort of the major tip. In the past 12 months, how often have you used any prescription medications just for the feeling, more than prescribed, or that were not prescribed for you, and then you can name a whole bunch of opioids, as well as sedatives or stimulants. And then for people that answer anything other than never, then the part two of the tabs is, in the past few months, have you trialed or failed to control, cut down, or stop? In the past few months, has anyone expressed concern? And if the answer is to those, if the answer is yes to either of those, then I think you have enough to actually go through the DSM, Substance Use Disorder Criteria Assessment, actually assess for the diagnosis of opioid use disorder using the DSM. But this process of using a quick screen, asking just a few additional questions for patients that indicate they use substances in the opioid category, and then ask, okay, have you lost control over your use of substances, any difficulty in cutting down or stopping, and has anyone expressed concern? Answers to either of those is yes. Generally, you would want to then proceed to do a full diagnosis assessment. You could also use the ASSIST. I presented the tabs, which is essentially three questions in each substance category. The ASSIST is eight questions in each category, and the ASSIST ends with a substance involvement score split out on this table. So this table currently has the list of various substance categories, and the substance involvement score indicates essentially who is at higher risk of having a use disorder in that substance category. The ASSIST, incidentally, is what the RAND Corporation used when conducting the survey of patients in the waiting room at DMH. Other clues to whether substance use may be present is urine toxicology, and I'm not trying to sell this brand of cup. It's just it has a picture of it that I found useful to put up, but I want to point out that there is a difference between point-of-care immunoassay testing and definitive testing. Just to illustrate, presumptive testing is when you have a patient or a client pee into a cup, and then you read at the bedside or, you know, with the patient in the room. These were the results, and the results are usually determined based on the lines that appear or don't appear on immunoassay strips. These strips are also what labs commonly use in order to identify substances in the urine. These immunoassay strips absolutely have an error rate, and one adaptation to urine drug testing in mental health settings is not every patient served in a mental health setting takes meds, but medications are not uncommonly received by people served by specialty mental health settings. And there's a variety of medications that cause a cross-reactivity with these immunoassay strokes. We can do a whole separate talk on toxicology. There's actually a certification called Medical Review Officer Certification for people that really want to do a deep, deep dive into understanding cross-reactivity and how meds turn different assays positive. But suffice it to say, just because the screen says that something's positive doesn't mean it's assuredly positive. And just because the screen says something is negative doesn't mean it's assuredly negative. And so this is why urine testing should be ordered based on the clinical history. If you get a urine result that's different than expected, that is to say, if you were prescribing a medication and expected something to be there and it wasn't, or you took a clinical history and you really think that somebody is using, but their urine says that they're It's useful to send the sample for definitive testing, because that will actually tell you not simply they were, quote, benzopositive or opioid negative, but it'll tell you which benzodiazepines and which metabolites. So things like clonazepam, aprazolam, lorazepam, they'll tell you what was positive. And famously, lorazepam and clonazepam don't consistently turn the benzoimmunoassay positive. So sending for confirmatory testing to see, do they have clonazepam and lorazepam metabolites in their urine can be really helpful. If I'm prescribing a medication for opioid use disorder, such as buprenorphine, and the presumptive test is absent for buprenorphine, then I'm going to send it for confirmatory testing to see was there an issue with the strip, or was the sample really absent for buprenorphine and norbuprenorphine, and the definitive testing will give me a clue. But if the clinical history matches what's in the presumptive test, you usually don't need to send for definitive testing. The role of definitive testing is when there remains, as a result of the presumptive testing, a question that needs to be answered. So I've talked around addiction, but actually, let me define it. So addiction has a definition. It's a treatable chronic medical disease that involves compulsive interactions, or I'm sorry, complex interactions among the brain, genetics, and the environment, and an individual's life experience. Now, people with addiction use substances or engage in behaviors that become compulsive and oftentimes continue despite harm. And prevention and treatment work as well for addiction as those for other chronic diseases. We see comparable success rates for people with substance use disorders, as compared with conditions like asthma, hypertension, diabetes. So addiction can be correctly conceptualized as a medical illness. One issue with the ASAM definition of addiction, and this is ASAM's definition of addiction, is it's not a diagnostic criteria. In other words, it describes what addiction is, but it doesn't necessarily give guidance on how to diagnose it. So there is a DSM criteria for addiction, and the final common pathway for addiction is dopamine release at the nucleus accumbens. That is, all addiction behavior seems to be driven by alterations in dopamine neurotransmission that project the nucleus accumbens that then have downstream projections into the prefrontal cortex. So what we see functionally is that people with a substance use disorder have a diminished ability to self-regulate their substance use. It is not an absent ability. Some people can't self-regulate their substance use. But then their ability to stop once they've started, their ability to turn down an opportunity, particularly when they're in a situation with drug availability and lots of facilitators of drug use can be difficult. Recovery is possible, but it requires people to make concerted efforts to avoid triggering situations. And oftentimes those behavioral adaptations can be very challenging in the context of withdrawal or significant cravings. We know that dopamine is responsible for addiction in cocaine addiction, methamphetamine use disorder, alcohol use disorder, heroin use disorder, and regardless of the use disorder, we see changes in dopamine neurotransmission. And so these are the 11 DSM-5 criteria. A substance is taken in large amounts over more time than intended, unsuccessful efforts to cut down are present, a great deal of time is spent using or recovering from use, giving up activities related to substance use, that substance use continues despite medical or psychological consequences, that continued substance use despite social or interpersonal problems, a failure to fulfill related role obligations, and use in situations in which it's physically hazardous, such as driving while intoxicated or injection drug use, and then craving, tolerance, withdrawal, or additional clinical features. These 11 criteria are oftentimes difficult for people that aren't addiction specialists to remember. But you don't have to be an addiction specialist to make this diagnosis. General psychiatrists are fully capable of doing this. Licensed clinicians that have diagnosis in their scope of practice can do this. And so one, it's not a mnemonic, one abbreviated way of remembering is the three Cs. Substance use disorders can be sort of simplified into loss of control, craving, with tolerance and withdrawal, and consequences. And it's interesting, tolerance and withdrawal alone aren't diagnostic of a substance use disorder if the tolerance and the withdrawal are related to a legitimately prescribed substance. So if you're treating a patient with a benzodiazepine, they will have tolerance and go into withdrawal if that benzodiazepine is abruptly withdrawn. That alone is not a substance use disorder. You have to have some element of loss of control and consequences and craving around that substance category for it to count. So the three Cs are kind of for people that may not necessarily be able to conveniently remember all 11 diagnostic criteria are a way of shorthanding. And there's shared vulnerability between addiction and other mental health conditions. For example, we know that opioid receptors, dopamine receptors, and many other intracellular and neurotransmitters are involved in the development of addiction and many other mental health conditions, as well as heritable personality features, such as novelty seeking, harm avoidance, impulsivity, and other heritable psychiatric disorders are all part of the genetic drivers, not just of addiction, but of many other mental health conditions. And then the involvement of parents and siblings and friends. We are now well familiar with the effect of adverse childhood experiences on the health and well-being of our communities, as well as psychiatric disorders and stressors and lack of positive experiences, sources of access to intoxicants, whether by prescription or otherwise family and friends are all drivers of vulnerability to co-occurring disorders. And then we treat co-occurring disorders. Well, I list this as the core components of addiction treatment or wager to say that these are the core components of treatment in general for most of their behavioral health conditions or otherwise, which is medications, counseling, and support. Now we have a whole pharmacopoeia of medications that are available, although the pharmacopoeia or opioid use disorder is much thinner than other mental health conditions. Counseling is counseling, right? Counseling is you help somebody with psychotherapy to help them come to some different state of understanding or acceptance of their life. Is it skill building counseling, where you give somebody skills or strategies or tools to be able to overcome the barriers that they're facing? Do you help somebody with emotional self-regulation, stress tolerance, and trigger identification and activity scheduling? That all is in the realm of counseling. And support, I think, is everything else. It certainly includes people's immediate social circle, whether that's their family or their friends or their church or their self-help recovery group, but support extends well beyond that. Is there people housed? Are they safe? Are they free from being actively traumatized? Are there people that have access to food and transportation? Are they employed? You know, what are the social determinants I also put under support? And addiction treatment has been historically organized to ensure that all three domains of these are organized around the patient at the same time. So we've built an addiction treatment system that exists outside of mental health and exists outside of primary care, where people can get access to all three of these things. But there's a major deficit to that approach, which is that helps the individual patients that will make it. But we have a treatment gap in this country. 90% of people with an opioid use disorder don't get treatment. And comfortably, you know, 70 to 80% of people with a co-occurring disorder don't get access to meds, counseling, support to help with their recovery from opioid use disorder. So I'm hoping that our system will do an even better job of identifying patients and do an even better job of facilitating referrals to specialty substance use disorder is, from my vantage point, a losing proposition. We are much better served by getting components of what can be effective to where our patients already are. So I'm of the opinion that medications for opioid use disorder need to be available in primary care and in the emergency room and in serious mental illness settings, like specialty SUD systems of care, and in our street medicine programs. In other words, these medications should be available horizontally across the spectrum, not just sequestered in specialty addiction treatment. And that also means that patients might receive one component, but not every component. That is, patients might receive medications for opioid use disorder before they start receiving counseling for opioid use disorder. And I would say that that's a strongly evidence-based approach to offer some treatment before somebody is necessarily ready to commit to the full recovery program process. There are three FDA-approved molecules for opioid use disorder, methadone is a molecule, buprenorphine is a molecule, and norexone is a molecule. There are various formulations of methadone, buprenorphine, and norexone that can be identified as individual medications. But these are the three FDA-approved molecules. There's not that many of them. One challenge to methadone is that methadone, compared to the other two, is the most regulated medication used to treat opioid use disorder. You have to go to a methadone clinic, or what we call federally licensed opioid treatment programs, in order to access that molecule. Buprenorphine, on the other hand, can be prescribed by any clinician for the indication of opioid use disorder that has an X waiver, or what's called a drug addiction treatment 2000 waiver. Norexone is not a controlled substance that can be prescribed by anyone that has prescribing authority, where that prescribing authority is either part of a collaborative practice agreement or part of their existing scope of practice. So methadone, again, you have to send a patient to a methadone clinic, buprenorphine can be prescribed as long as the prescriber has an X waiver for the indication of opioid use disorder, and norexone has neither of these regulatory restrictions. Also point out naloxone. Naloxone is a rescue medication. I kind of covered this up front, that there's been a big push to get naloxone as an immunity as a way of helping save people when they're found down in an opioid overdose, but it doesn't treat opioid use disorder, but rescues them in the case of an opioid overdose. Let's talk about the pharmacology of these medications briefly. Methadone is what's called a full agonist opioid. It's pretty straightforward. The more methadone you take, the more effect methadone has. If you take too much methadone, you stop breathing. Methadone also causes QT prolongation, so it can be slightly trickier to dose, although I will also say that we routinely dose things in serious mental illness treatments, such as lepidem or valproate, that have comfortably more toxicity, particularly in overdose. Methadone I think could be dosed feasibly in the specialty mental health system of care with appropriate training, but we're not allowed to. The federal rules sequester methadone to federally licensed opiate treatment programs. Buprenorphine is unlike methadone because it does not cause overdose. It has a ceiling effect on respiratory suppression. That is to say, if a patient with an opioid use disorder takes buprenorphine, the buprenorphine helps them feel better. It alleviates withdrawal, but doesn't have the same full opiate effect that methadone would. Because of the ceiling effect, buprenorphine is safe to prescribe well outside of monitored settings because it overwhelmingly reduces the risk of overdose. It doesn't contribute to overdose, it actually reduces the risk of overdose. But there's one other logistic feature that makes buprenorphine unique, which is although buprenorphine is only a partial agonist, it is super high affinity, the opioid receptor. It's a higher affinity than fentanyl is, that is to say it binds the opioid receptor stronger than other opioids, but only causes a partial activation. This is why you have to wait until a patient has metabolized off whatever opioid they might be coming off of before they can take their first dose of buprenorphine. Now let me be clear about this, you only have to have the opioid of choice that somebody might be using metabolize off until they're in mild withdrawal before they start their first dose of buprenorphine. It doesn't have to be fully, fully out of their system, it just needs to be down below the ceiling effect line. So the buprenorphine doesn't precipitate a withdrawal syndrome, that is you wait until the patient's in a little bit of withdrawal and then they take buprenorphine. We used to be so concerned about this that we actually asked patients to come into the office. We would do a cow scale, which is an objective opioid measure scale, and then we would base the buprenorphine doses once our cow score was high enough. Logistically, we rarely do this anymore. Most patients know what withdrawal feels like, withdrawal is not an exceptional thing. When somebody has an opioid use disorder, it happens relatively routinely. And you basically give the patient buprenorphine with the instructions, take this when you're feeling sick, and then they go, okay, I mean, I don't mean like ill, I mean like withdrawal sick is what I'm referring to, and then patients do okay. And there's some good evidence that home initiation of buprenorphine is in no way inferior to in-office initiation of buprenorphine, and frankly, is more accessible to our patients. Naltrexone binds stronger than either of these do. Naltrexone is the strongest binder in terms of receptor affinity of the medications we have available. But one downside to naltrexone is the patient has to be fully, fully off of opioids for at least seven days before they can get, start taking naltrexone. Naltrexone comes in an oral pill or in a monthly injection. The oral pill is famously ineffective at treating opioid use disorder. It doesn't separate from placebo, mostly for adherence reasons. When people are ready to start using opioids again, they just stop taking naltrexone, and it's out of their system by the end of the day. For injectable naltrexone, it's a monthly injection and does seem to have a much stronger response than the oral version for the indication of opioid use disorder. But the big reason why we would give people methadone, buprenorphine, or naltrexone is its effect on reducing the rate of overdose. I've made this point several times of the public health risk that overdose has right now. And unmedicated opioid use disorder has six times the rate of all-cause mortality compared to the general population. Being on a medication for opioid use disorder drops that over fourfold. So what do these medications do? They help keep you alive. They also help with treatment retention. The blue line is who's stuck around treatment. And this is an outpatient primary care sample, and you'll see the treatment retention in this study was close to 57%, and the real world is close to 50%, again, depending on the population you treat. And this compares to roughly 10% treatment retention with unmedicated opioid use disorder treatment as usual using psychosocial support. So medications for opioid use disorder dramatically increase the chance that patient is going to continue to show up and engage in treatment. But not everyone that uses buprenorphine stops using other opioids. Some people use buprenorphine and then return to using other opioids, then go back to buprenorphine. But we see the longer somebody's in treatment, the greater the chance that they are going to stop using any other opioids and just stabilize on buprenorphine. So buprenorphine does a great job of keeping you alive. It does a decent job of helping keep you in treatment and does an okay job of helping reduce opioid use. Up until April of this year, well, let me restate. In order to prescribe buprenorphine for an opioid use disorder, you have to have training. This is the Drug Addiction Treatment Act 2000 X waiver. The training requires that you have a medical license, you hold a DA registration, and you needed eight hours of training for physicians and 24 hours of training for nurse practitioners and physician assistants. But in April of this year, the training requirement was eliminated. So we still need an X waiver to prescribe buprenorphine for the indication of opioid use disorder. But we can now, the federal government will not issue X waivers to people who simply have a valid state medical license and a DA registration and are advanced practice nurses, physician assistants or physicians. Not having the training limits the number of patients you can have treated at any one point in time with buprenorphine. So there's still an advantage to doing the training, but it's no longer a barrier to getting an X waiver. So X waivers are required, but no training is required to obtain one. Here's the link where any physician assistant, a best practice nurse or physician can go to sign up for a day to do that. Buprenorphine is actually relatively easy to prescribe. I'll tell you how to do it. The usual prescription is buprenorphine naloxone eight slash two. There are some practice guidelines that recommend starting at lower doses and certainly starting at lower doses would make sense for patients whose opioid use disorder is relatively mild and who are using low dose opioids. I work in the public sector where people use many grams of heroin or fentanyl or other illicit opioids several times a day. So I tend to gravitate towards higher doses in the populations that I serve. So I prescribe the eight slash two milligram tablets or films, usually prescribe a two week supply, which assuming the patient stabilizes on 16 would be 28. And I also will sometimes offer prescriptions to patients or refills to patients when I'm not clear what their followup is. So at the very least, they have some supply back in the pharmacy that they can rely on. So I feel like a two week supply is enough for a patient to get started, particularly if their followup was uncertain, but not so much that they're going to get into trouble. There's more conservative models of this, which is buprenorphine two milligrams to start. And then you only get a week supply as opposed to two weeks supply with more frequent followup, which is, again, totally appropriate if the patient will access the followup and if you have the staffing to do that. Instruct the patients to stop using opioids until they're in mild withdrawal. And then the dosing on day one is take half a strip or a whole strip either way or tablet sublingually about every hour until the withdrawal or cravings are gone. This is faster than most national practice guidelines. But again, from my vantage point, I want patients to stabilize as quickly as possible and always make exceptions and do lower doses or more extended initiation protocols for patients that are more tentative and whose opioid use is at a lower level than what is typical in my practice. Whatever somebody took day one becomes kind of their dose and then they can adjust to go up if they have cravings and go down if they have tolerability issues. Like all medications, buprenorphine has side effects, including headache, dry mouth, and upset stomach, which is opioid side effects. 24 slash 6 is a max dose that a lot of payers have kept. The FDA has evaluated the safety of buprenorphine up to 32 milligrams, which I sort of think of as the functional dose. And in my system of care, this is the handout I give people. We have one in English and Spanish. Because of limited literacy and safety net population, I will oftentimes point at pictures and illustrate how somebody can identify when they're in at least mild withdrawal, which is really simply three OP withdrawal features, which include dilation of the pupils, yawning, tearing, pyloreaction, feeling upset stomach, myalgias, upset stomach. Any three of those will count. This is the illustration. You take either half or a whole of an eight or half or a quarter of a strip based on the instructions that I gave. And then here's the formulations of, the formulations of buprenorphine for opioid use disorder, which is, there's film. The film comes in twos, fours, eights, and twelves. There's a generic tablet, which comes in twos and eights. And then there's a different brand name tablet made by Orexo, called Slobzol, that comes in five different strengths. There is a different brand name film, different than Sploxone film, called Bunavale film, that comes in three different strengths. We also have a generic buprenorphine-only tablet. We co-formulate buprenorphine with naloxone, really as a divergent to injection drug use, not because the naloxone in buprenorphine with naloxone has any therapeutic benefit. So it is still recommended and in my state required to prescribe rescue naloxone to patients treated with buprenorphine, because the naloxone co-formulated in that medication is not a rescue med. We used to have an implantable form of buprenorphine called buprenorphine, but it's off the market. And there is an injectable form of buprenorphine called Sublocade, that's a monthly subcutaneous injection. And as I mentioned before, buprenorphine does not cause respiratory arrest. There are instances of buprenorphine poisoning, but those fatal poisonings almost always involve buprenorphine along with other central nervous system depressants. It's very difficult to overdose on buprenorphine alone. So what do I ask my patients? Because I want to horizontalize the availability of medications for opioid use disorder, I don't spend a lot of time asking people, are you ready to stop using opioids? I mean, if the patient's ready to stop, that's great, but that's not the barrier to entry. The biggest question facing a patient with opioid use disorder in my mind is, are you interested in taking a medication that can help you stay out of withdrawal, use less, and prevent overdose? In other words, patient readiness to accept the medication is the biggest screener that I use. And then, once I know their readiness to engage in medications for opioid use disorder, then I ask them about their readiness to change and put together a more comprehensive treatment plan. But I start with the medications. In other words, I do what's called a medication-first approach, and then build additional counseling and services on top of that. So if somebody's in a mental setting of care, it happens all the time, the number of patients that I treat in a community mental health center in South Los Angeles with buprenorphine, and it's part of their psychotic management, stabilizer management, depressant regimen, anti-anxiety regimen, it's sort of part of what we offer them. But the medications for opioid use disorder, don't hesitate to use them as soon as the patient's ready to participate. Buprenorphine stops cravings, prevents overdose, and stops withdrawal. I still, my patients will work with you to find the right dose. You don't need to feel withdrawal. And if you've tried it before and it didn't work out, try it again with the right dose. And then we'll also ask, what other substances do you use? How much? What's the route? This is kind of part of a typical substance use disorder or intake history. But I don't necessarily need this information in order to start prescribing, although the pharmacy is important for me to know. And the contact number is important for me to know. But this also helps me determine what are the other things patients might need. One question that almost always comes up, okay, if I start buprenorphine, how long do I need to be on it? And my answer to that is not a day longer than necessary. But some patients might need it their whole lives. But we do see fewer ED visits and fewer admissions for patients that stay on buprenorphine. Pivoting off of buprenorphine into naltrexone. Naltrexone comes in an oral pill. It's one strength, 50 milligrams. The dose we use for alcohol use disorder is once a day, but it's ineffective in treating opioid use disorder. Here's a meta-analysis looking at oral naltrexone for opioid use disorder. And it just, it doesn't consistently separate from placebo. Comparing naltrexone to placebo, no statistically significant differences were noted. Naltrexone long-acting injection is a possibility. The only barrier to that is the patient doesn't just have to have stopped opioids. They have to have stopped taking whatever opioids they've been taking and stay stopped for at least a week. So there was this window period between when they stopped using opioids and when they get the injection administered is the biggest factor, but you don't have to have liver function tests measured and you don't have to have an oral lead in naltrexone to administer the injection. The window period is seven days from short of the opioids, 10 days from the contents, extended release opioids like oxycodone or morphine sulfate and 14 days from somebody coming off of buprenorphine or methadone. The reason that I say based on LFTs aren't required is because LFT elevations due to naltrexone are relatively rare. And liver monitoring, I think it was only really required if there's obvious signs of liver disease, such as jaundice or abdominal pain, nausea or vomiting. It's generally good practice to obtain LFTs, but I don't wait for the LFTs to arrive before I'll treat because the logistics that are okay, I would have given you the injection here today during this window period, but I don't have LFTs, so go get your labs and then come back is oftentimes a recipe for the patient never starting. There is one head-to-head, or there's two, one that was done outside of the United States, but the one American study that compared buprenorphine to naltrexone long-acting injection, it's called X-Bot. And the results kind of depend on who you ask because if you do an intention to treat analysis looking at patients that were randomized to naltrexone and compare that to the outcomes of patients randomized to buprenorphine for opioid use disorder, you'll find that buprenorphine did better than naltrexone. But the reason that buprenorphine did better than naltrexone was because it was much easier to get patients started. And you write a prescription, patient starts taking it. Whereas with naltrexone, the patient had to come off of opioids, stay off of opioids, then get the injection administered. And if you took the dropouts out, you abandoned the intention to treat analysis and you simply looked at the protocol analysis, who received naltrexone injection versus who received buprenorphine subliminally, what you would find is actually comparable outcomes in terms of rehab survention, retention and treatment, days of opioid abstinence. One threat to saying that they are comparable though, at least in my view, is by doing a protocol analysis, you're introducing a fair amount of bias because they're not matched samples at that point, right? People who got onto naltrexone might have a less severe form of opioid use disorder or might be more motivated. So the XBOT trial reassured me I could treat patients with naltrexone long-acting injection if they're really motivated to get on it, but it didn't convince me that buprenorphine and naltrexone are equivalent in their clinical effects. I mentioned counseling. Here's a whole list of, and they're really domains of counseling, but various types of evidence-based psychotherapies, including 12-step, CBT, motivation enhancement therapy and so forth. But this is the 2011 Amado review looking at, it's a Cochran review, what's the effect of adding counseling to patients who get medications for opioid use disorder? It was a surprising result, which was we don't really see that counseling makes any difference. It doesn't seem to help that once somebody's stable on a medication for opioid use disorder, they appear to do comparably as well, whether they get counseling or not. Now, I'm of the opinion that counseling might help somebody get onto medications for opioid use disorder, but the medications don't require counseling to be effective. The medications don't require counseling to be effective. So this kind of culminates, and then I'm wrapping up, in the medication-first model, which is even in community mental health centers, people with opioid use disorder should receive medications as quickly as possible prior to lengthy assessments or treatment planning. Medications should be delivered without arbitrary time limits. We always individualize psychoservices, but we don't make pharmacotherapy contingent on psychosocial services, and we only stop medications if it's making the patient worse. Med-first doesn't mean med-only. It just means that we're starting the medication to keep somebody out of withdrawal, to keep their cravings under control, and then gauging what they're ready for in terms of other treatments. Depression and anxiety are really common during opioid use disorder treatment. Fortunately, in community mental health settings or mental health settings in general, I'm pretty comfortable with psychotherapy. SSRI is another first-line antidepressants. I would just say avoid benzodiazepines in general. And then I wouldn't be remiss if I didn't mention the ASAM criteria. Some patients really do need higher levels of care, such as withdrawal management or residential, and you can use the ASAM criteria, multidimensional assessments, to identify what level of care outside of a mental health center somebody might need if they need more support. Because again, 90% of patients with substance use disorder, or sorry, 90% of patients with substance use disorder don't get treatment, and the biggest reason is because people don't think that they need it. So rather than trying to get patients that may not have the insight into the treatment they need, we're better off getting treatment to where the patients are. And the surgeon general agrees with me. Integrating substance use services into mental health and general medical settings results in better outcomes. Here's a tool. This is the RAND, How to Integrate Pharmacotherapy for Substance Use Disorders into Your Mental Health Clinic, focused on alcohol and opioid use disorders. And here's just a few quality metrics you can think about when building a medication for opioid use disorder in mental health settings. Billing remains an issue. You usually have to bill for integrated co-occurring disorder treatment under the primary mental health diagnosis, but this is feasible to do. It's just a bit of a logistic headache to put together a treatment plan. Treating your schizophrenia by treating the opioid use disorder that's interrupting your recovery from schizophrenia, and that's why prescribing buprenorphine can be convoluted, but it's oftentimes necessary to get that data. Okay, I think I went six minutes over where I was supposed to go, but I really appreciate everyone's time and attention. This is my email address, and if you want more, come to the ASAM, CSAM, or AAAP annual meetings. And I'm wondering, Dr. Drost, if you have any questions. Sure. First of all, thank you so much, Dr. Hurley. This was really just a really clear and engaging presentation. So now we're going to shift into Q&A. So for attendees, please feel free to submit your questions by typing them into the question area found in the lower portion of your control panel. But before we shift into Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, to complete mental health rating scales, and even submit questions directly to our team of experts. Download the app now at smiadvisor.org. Download the app now at smiadvisor.org forward slash app. So we have one question that was submitted during the presentation, which is around follow-up after naloxone. Is there a protocol or, you know, what typically happens to people who are given naloxone and typically get some sort of psychological evaluation? They should, but I will tell you, many patients who are administered naloxone find themselves alive but distressed because what naloxone does is block your opiate receptors. So it throws people into immediate opiate withdrawal. So oftentimes what will happen is if somebody's administered naloxone in the field, that depending on, you know, how functional the patient is, the EMTs or paramedics may not even bring them in, right? But you often have the emergency room as the initial point of access. And I've seen a lot of patients leave against medical advice from the ER before they're able to be administered any sort of evaluation. My own opinion is if you've administered naloxone to somebody in the field, you get them into buprenorphine treatment as fast as possible. So there's been a big push in California, but also across the country, in places like Yale and Boston, to very quickly start patients in the ER on medications for opioid use disorder. Once those medications have helped somebody no longer feel an acute opiate withdrawal, they're probably gonna be in a much better place to do a more significant sexual social assessment for what's going on. There is a theory, but it's hard to prove, that a non-trivial number of these drug overdoses that are a huge public health threat are in fact suicides. But it's hard to know if you can't get a mental health assessment. And you can't get a mental health assessment if a patient's busy running out of a setting of care to go alleviate their opiate withdrawal. That's why the medication-first approach is so important in any setting of care, is it can help stabilize the patient to actually get the assessment you need in order to be able to help build the critically important services that somebody needs, whether it's counseling or support or whatever else they need in order to be able to achieve recovery. Great, thanks. We have another question, which is about people who, clients who are prescribed Suboxone and then purchase more off the street. So what's your understanding of what's going on there and why they would be using more Suboxone? Probably because the dose they're being prescribed isn't high enough, right? If I have a patient on buprenorphine who is purchasing buprenorphine on the street, I would ask them, is it working, right? Like, are you finding 16 isn't enough? Do you need 20? Is 20 not enough? Do you need 24? There's no, because of the safety profile of buprenorphine, they don't worry so much about treating with high dose buprenorphine if there's a good clinical history. But Dr. Drost, there's another part of that. There's a converse to that question that I wanna bring up, which is what about the patient who's prescribed buprenorphine that's selling it on the street, right? They might be taking some of it for themselves, but selling it. And this is where, you know, those are instances where you might not want to continue somebody in buprenorphine treatment if they can't safely manage it. The initial conversation I'll have if I think a patient's diverting it is to who are you diverting it to and can you get them to come into treatment? But if it's really just a second income source for the patient, oftentimes I will at that point say, you know, you need more monitored. This is where kind of the ASAM level of care comes in. You need more monitoring to safely be treated with your medications than I can provide. Let me refer you to an opioid treatment program where they'll just administer you the medications every day so you don't have to worry that much about your going off and diverting them. Now, diverting buprenorphine is not necessarily a total deal breaker. I've had patients divert buprenorphine and I'll continue to treat them if, you know, there's a really good reason and it's sort of as a, I'm trying to think of, you know, patients whose family members ran out of their buprenorphine and so they lent some of their buprenorphine to their family member. Like, those are sort of understandable reasons that aren't sort of treatment agreement deal breakers, you know, in my view. But if a patient is buying more buprenorphine on the street than what I'm prescribing, it sort of implies that they might need a higher dose and I would explore that with them. Great answer. Thanks, thanks so much. I'm curious, you know, a lot of, there are a lot of practical kind of recommendations here about how prescribers can do more for prescribing buprenorphine. Is that generally something that they can just do without kind of authorization by their clinic or is that something that requires kind of buy-in at the clinic or organization level? So I'm an ex-waivered psychiatrist myself. I have absolutely gone rogue and prescribed buprenorphine without telling anybody because the truth is, for the clinic, from the clinic's perspective, the patient is leaving the clinic and going and picking up their medications as usual. So the clinic isn't necessarily, you know, involved, but that is never effective at actually getting the clinic to be effective at treating opioid use disorder. And there's a whole strategy on the RAND toolkit that I mentioned around integrating medications for alcohol and opioid use disorder into the clinic that talks about the importance of leadership support, workflow development, and an awful lot of time spent with organizational development, where you talk to people and you talk to them again and you talk to them again and you get everyone on the same page so that it's not a mystery what someone's doing. So certainly there are instances of, you know, a clinician going in and prescribing medications without anyone knowing, but frankly, that might, you know, have a very modest impact on that clinician's panel of patients, but it misses a greater opportunity to get the entire clinic on board and ready. So if you're a clinician working in a clinic and you're like, I don't know if I have permission, do the work of actually being the clinical champion for this and getting senior leadership on board and aware and educated. And there's an entire set of tool resources that, again, I keep highlighting it because I'm one of the co-authors, but the RAND Corporation developed to assist with exactly that kind of advocacy. Great, great, wonderful. Well, that's gonna be it for questions. Just wanna let folks know that if you have any follow-up questions about this or any other topic related to evidence-based care for SMI, our clinical experts are available for online consultations. Any mental health clinicians can submit a question and receive a response from one of our SMI experts, and these are free and confidential. Coming up, SMI Advisor is proud to partner with the American Psychiatric Association on the Mental Health Services Conference, which will be taking place October 14th to 15th. The keynote address at this conference will be delivered by Dr. Miriam Delfin-Rittman, who's the newly appointed Assistant Secretary of Mental Health and Substance Use for HHS and the Administrator of SAMHSA. There'll be a number of exciting topics on the agenda, including climate change and mental health, structural racism, and mental health in rural and indigenous populations. I encourage you to learn more and register now at psychiatry.org forward slash MHSC. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. This may take up to five minutes. You'll then be able to select Next to advance and complete the program evaluation before completing your credit. Please join us next week on September 24th, 2021, as Dr. Kim Bullock presents Extended Reality, XR Technology Treatment for Serious Mental Illnesses. Again, this free webinar will be September 24th, from 12 to one Eastern time. Thank you for joining us. Until next time, take care.

co-occurring opioid use disorder

mental health settings

evidence-based care

buprenorphine

overdose reduction

treatment retention

substance use services

medication-based treatment

counseling support

integrating services