Needs
The current opioid epidemic is linked to the increasing supply of prescription opioid medications. As a result, the United States is currently experiencing alarming overdoses related to opiates, and deaths attributed to opioid overdose rose 3-fold in those 15 to 64 years of age between 1999 and 2014 with 33,091 deaths in 2015 involving opioid drug overdoses [1,2]. These severe, lethal, and preventable consequence of opioid misuse and addiction in both adults and adolescents underscore the importance of improving the existing treatment interventions. Medication-assisted treatment (MAT) for opioid use disorder is a proven, effective treatment for individuals with an opioid use disorder. MAT has been shown to increase treatment retention, and to reduce opioid use, opioid overdoses, risk behaviors that transmit HIV and hepatitis C virus, morbidity and mortality [3]. Psychiatrist must have a clinical understanding of these medications, their mechanism of action, and the experience starting and prescribing to provide care to individuals with opioid use disorder.
Objectives
- To identify the FDA-approved medications for the treatment of opioid use disorder.
- Determine the significant risks and benefits to each of these FDA approved drugs.
- Review the role in facilitating behavior change among individuals with substance use disorders.
Resources
1. Treatment Options for Opioid Dependence: A Role for Agonists vs. Antagonists
This resource is an archived webinar that provides an overview of all current treatment (residential and drug-free approaches, agonist maintenance, and antagonist maintenance) of opioid-related conditions. It can be used in totality or broken up, either with an in-person lecture or given to residents for self-directed learning specifically discussing the use of FDA approved medications for treatment and management of OUD. Participants will be able to identify three classes of treatment for opioid dependence and compare rates of relapse in opioid-dependent patients treated post-detoxification with or without medications (agonist or antagonist).
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Marc A. Schuckit, M.D.; Dan L. Longo, M.D., Editor
2. Treatment of Opioid-Use Disorders
This resource is a review article that provides an overview of the current treatment of opioid-related conditions, including both maintenance treatment and management of withdrawal symptoms. It can be used in totality or broken up, either with an in-person lecture or given to residents for self-directed learning specifically discussing the use of FDA approved medications for treatment and management of OUD. This resource is freely accessible via the link provided for both educators and learners and does not require you to create an account and log in to the APA website.
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Judith Martin, M.D.
3. Methadone Maintenance
This resource is a slide set that can be used in totality or broken up, either with an in-person lecture or given to residents for self-directed learning specifically discussing the use of methadone as a maintenance treatment for opioid use disorder. This resource is freely accessible via the link provided for both educators and learners.
Evaluation: Documented completion of this resource can be done through attending supervision suggested in this module.
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Erik Gunderson, M.D., F.A.S.A.M.
4. Models of Buprenorphine Induction
Appropriately dosed buprenorphine is superior to placebo in diminishing illicit opiate use and treatment retention. Physician concerns about induction pose a barrier for treatment adoption. This resource is a slide set that can be used in totality or broken up, either with an in-person lecture or given to residents for self-directed learning specifically discussing the use of buprenorphine induction and its role as a maintenance treatment for opioid use disorder. This resource is freely accessible via the link provided for both educators and learners. Psychiatry residents are encouraged to receive academic training to obtain the DATA 2000 waiver to prescribe buprenorphine and adequate clinical supervision to assure competency in managing patients on buprenorphine maintenance.
APA Resident-Fellow Members have free access to the APA’s waiver-eligible on-line training for buprenorphine. Training is also accessible through the Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT).
Evaluation: This resource includes a posttest which can be used to measure retention of material while meeting ACGME standards.
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Kenneth M. Carpenter, Ph.D Nicole Kosanke, Ph.D.
5. Developing a Behavioral Treatment Protocol in Conjunction with MAT
This module provides an overview of four principles that may play a significant role in facilitating behavior change among substance dependent individuals. The combination of psychosocial and medication assisted treatment protocols can provide an additive benefit to people striving to alter their substance use.
Evaluation: This resource includes a posttest which can be used to measure retention of material while meeting ACGME standards.
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Educator’s Guide
Below is a proposed way for educators to implement resources above.
Applied learning in clinical rotations:
- Residents will complete review resource, “Treatment Options for Opioid Dependence: A Role for Agonists vs. Antagonists” and complete the post-test.
- Residents will then review clinical support materials available through the links provided in resource #2.
- In a second section, participants should discuss the induction and maintenance approaches for methadone and buprenorphine in resources #3 and #4. Residents physicians are encouraged to participate in a didactic training to obtain the DATA 2000 waiver to prescribe buprenorphine in an office setting.
- The resident will apply material learned during their clinical rotations, either on subspecialty substance use rotation, in an outpatient clinic, or on inpatient psychiatry rotation by educating a patient on the three options available and behavior changes approached discussed in resource #5.
- Residents will apply material learned during clinical rotation to at least induce a patient in any of three considered MAT for OUD reviewed and documented the case using resource #3 and #4.
- Attending will examine questions below and record in milestone assessment that resident meets objectives in this module.
- What was the patient’s severity of opioid use disorder?
- What were all the options for FDA approved MAT for OUD discussed?
- What were the elements of the case which led the resident to select the medication they did?
- What are the monitoring requirements for each medication - laboratory values, the frequency of follow-up appointments, symptoms to specifically ask about on the monitoring visits, and the doses for induction, and the maintenance treatment?
Attending will review clinical documentation of the case and provide appropriate feedback as necessary.
References
- United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality ICPSR31921-v4 2011-12-20 2015 Inter-university Consortium for Political and Social Research (ICPSR)
- Johnston, L. D., O'Malley, P. M., Miech, R. A., Bachman, J. G., & Schulenberg, J. E. (2017). Monitoring the Future national survey results on drug use, 1975-2016: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan, 113 pp.
- The Opioid Epidemic: By the Numbers. (Updated June 2016)