X Waiver Online Course – Tom Bertolli, MD Redwood Coast Medical Services Gualala Clinic Marshall Kubota, MD Regional Medical Director Partnership HealthPlan of California June 21, 2016
2 Audio Tips To avoid noise and feedback, we ask that you use the phone instead of your computer microphone for listening/talking during the webinar. Please insert your own voice pin
X Waiver Online Course
3 Conflict of interest All presenters have signed a conflict of interest form and have declared that there is no conflict of interest and nothing to share this presentation.
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4 Objectives The objective of this webinar is to discuss the development of a medical aid program in the primary care setting.
One of our main responsibilities is to heal the pain, but also “do no harm.” In the 1990s, pain was considered the “5th vital sign” along with BP, Pulse, RR and Temperature. Assessment, information and treatment of pain are pushed to the forefront of patient care and pain management is becoming a major decision among patients.
Ironically, the current problems with opioids are the product of efforts to improve patient care. Opium From poppy seeds was first used around 1500 BC to treat pain and insomnia First used in the turn of the 19th century to treat pain and addiction (morphine) Seven decades later , heroin was synthesized from morphine and was sold by Bayer for coughs and respiratory infections because both tuberculosis and pneumonia were major health problems at the time
Non-medical use of prescription opioids, i.e. diversion, decreased between 2003 and 2013 but the proportion of medical use, frequency of use and opioid deaths increased. In 2010, enough opioids were sold in the United States for every adult to receive 5 mg of hydrocodone every four hours for a month. Every day in 2016, 44 people died from an opioid overdose and this number exceeded the number of deaths from car accidents by 50%. However, when used appropriately for serious injuries and trauma, cancer and end if life care, opioids can help people tremendously.
Medication Assisted Treatment: The Who, What, Why, And Where Of Mat
Treatment There are other treatments that are healthy, safe and can reduce pain: Physical therapy Acupuncture Chiropractic care Yoga Massage Meditation Cognitive behavioral therapy Biofeedback Exercise Exercise and diet Medications such as non-steroidal anti-inflammatories, anticonvulsants, gabapentin, naltrexone, buprenorphine-naloxone
Naloxone Methadone Full agonist Long half-life (8-59 hours) No ceiling effect Buprenorphine-Naloxone Half agonist Long half-life (24-60 hours) Ceiling effect
X license since 2011 Manages patients in a community health center as part of a team that includes a nurse practitioner and a counselor drugs and alcohol
What dopamine tells us about opioid addiction. What is normal? The science behind cravings increases dopamine levels
Buprenorphine Treatment For Opioid Use Disorder In Philadelphia
Addiction is a primary, chronic disease of the brain’s reward, motivation, memory and other circuitry. Malfunctions in these circuits lead to biological, psychological, social and spiritual phenomena. This occurs in a person pathologically seeking reward and/or relief through drug use and other behaviors. Addiction results from: Inability to act consistently Lack of control over behavior Craving Diminished awareness of critical issues A negative emotional state
Physical Dependence The body relies on other sources of opioids to prevent withdrawal. Can be solved with a slow taper. In general, endogenous opioids (e.g. endorphins) can be produced to prevent withdrawal but as tolerance increases, the body is able to maintain a balance and the body remains on the outside. Addiction is unusual and classified as a disease. An important situation that arises from the unexpected, the inability to control the use of drugs, drug use and use even to harm oneself or others. No addiction w/o cravings.
The body depends on many substances such as caffeine, nicotine and sugar, can cause physical dependence. Physical dependence to opioids is normal and desirable and is affected by the real problem: addiction is confused because addiction is sometimes called dependence as well as Safety Cravings is rooted in brain transformation. Recovery is the process of reversing, as possible, cells change. Accomplished by correcting and changing healthy behaviors. Addiction is called opioid dependence, drug dependence and opioid use disorder. Just calling it a dependency is confusing.
Who is Eligible for Buprenorphine-Naloxone Chronic pain patients (both moderate and MD’s can not distribute “X” license if pain is Dx) Good DSM V (score of 2 or more) (adherence criteria) Positive DAST for opioids (score of 6 or more) (adherence criteria) SAMHSA (substance abuse and mental health care) the advice: one year history of opioid use before using methadone Clinical basis w/o strict criteria Expected to be effective in 2/3 of patients to whom it is given
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A minimum of 2-3 factors are required for a mild diagnosis, while 4-5 are moderate, and 6-7 are severe {APA. 2013). Opioid Use Disorder is defined instead of drug abuse, if opioids are drugs of abuse. Note: The published analysis is linked below 1. Taking more opioids and longer than expected 2. Want to quit or quit but can’t do it 3. Takes a lot of time to get opioids 4. Craving or having the desire to use opioids Can’t do drugs important work at work, school, or home because of continued opioid use whether continuous or repeated. Social problems or personal disturbances caused or worsened by opioid use 7.Stopping or reducing social, work, or recreational activities due to opioid use Repeated use of opioids in the body is dangerous. .* Tolerance as defined by an increased need to achieve intoxication or need or decrease. d involves continuing to use the same amount. (Not used for reduction when used appropriately under medical supervision) 11.* Withdrawal based on behavior istic syndrome or products used to avoid withdrawal (Not used when used to establish qualified as medical care)
20 DAST-10 Questions I will read you a list of questions about information about your involvement with drugs, excluding alcohol and tobacco, in the past 12 months. When the words “drugs” are used, they mean the use of drugs or over-the-counter/prescription drugs and the use of non-prescription drugs. The various types of drugs include: cannabis (eg, marijuana, hash), solvents, tranquilizers (eg, Valium), barbiturates, cocaine, stimulants (eg, speed), hallucinogens (eg eg, LSD) or narcotics (eg, heroin). Note that the question does not include alcohol or tobacco. If you have a problem with the statement, then choose the answer that is most correct. You can choose to answer or not answer the questions in this section. This question refers to the last 12 months. No Yes 1. Have you used drugs that are not needed for treatment? 1 2. Do you use drugs more than once? 3. Can you stop using drugs when you need to? (If not using drugs, answer “Yes.” 4. Have you ever had “black.outs” or “flashbacks” from using drugs? , choose “No.” 6. Your spouse (or mother father) has ever complained about your involvement with drugs? 7. Have you neglected your family because of your drug use? 9. Have you ever had withdrawal symptoms (feeling sick) when you stopped taking drug?
Interpretation of DAST 10 In this statement, the term “drug abuse” refers to the use of drugs at levels that exceed the guidelines, and/or the use of non-drugs. Patients get 1 point for each “yes” answer as well as question #3, where the “no” answer gets 1 point. DAST-10 Scores Degree of substance use-related problems suggestive of work. DAST-10 Scores Degree of Drug-Related Problems Disagree No Problems Reported None at this time 1-2 Supervisor Low, retest after day 3 -5 Moderate Level Further Analysis 6-8 Advanced Level Analysis 9- 10 Severe Level Skinner, H. A (1982). Drug Use Screening. Add; Behavior 7(4),
Or not… The combination of buprenorphine, a partial μ-opioid agonist shows affinity for and slow dissociation from the μ-opioid receptor and naloxone, an opioid antagonist Buprenorphine: greater affinity for the opioid receptor, better pain med w/0 euphoria; requires mild to moderate elimination or precipitates elimination Naloxone / Naltrexone: antagonists
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• film (2/.5, 4/1, 8/2, 12/3 mg bid); tablets (2/.5, 8/2mg bid); patches (bup only: 5, 7.5, 10, 15, 20 mcg q 7 days); • buccal film (bup only: 75, 150, 300, 450, 600, 750, 900 mcg bid)
Urine drug screening every visit: point of care vs delivery The benefit of the doubt: addiction is a disease Wean descends from drug abuse more when making decisions, choosing dates, writing or having office supplies
Health behavior, cognitive behavior
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