Expanding and Improving Treatment

Challenges and Next Steps

Marc Fishman MD
 Outline
• Limitations of current practice
• The general health care connection
• The criminal justice system connection
• Youth treatment
• Next steps
 Relapse prevention medications
The standard of care
These are the standard of care:
– Methadone
– Buprenorphine
– Extended-release naltrexone
• Approx 50% retention at 6 months in
research, compared to 10-20% at 1 month
without meds post-detox
• Naloxone for overdoses
If only it were that easy
Limitations to current practice
 Relapse prevention medication
Is the standard of care
But not everyone knows it yet
• Persuading patients
• Persuading families
• Persuading criminal justice system
• Persuading SUD providers, especially
residential treatment
• Persuading payers
• Persuading the recovery community
 Linkages from residential/inpatient
treatment
• Detox without relapse prevention medication
is unfortunately typical
• But inpatient treatment would be an ideal
opportunity for medication induction
 Limitations and unintended
consequences
• Dropout
• Medication diversion
• Substandard practice
• Over-promising
 Duration of treatment?
• Is there an optimal duration?
• Evidence so far suggests longer is better, but
care should be individualized
• Retention under real world conditions is
problematic
• No reason to suppose pre-imposed limitations
helpful
 XRNTX vs Bup (CTN 51)
Results – relapse free survival
As treated analysis (n=474)

xrntx = 48%

bupe = 44%
 XRNTX vs Bup (CTN 51)
Results – relapse free survival
Intent to treat analysis (n=570)

bupe = 43%

xrntx = 35%
Induction Success (%)
100 94
90
80 72
70
60
50
40
30
20
10
0
XR-NTX BUP-NX
 Incarceration Rand XRNTX x TAU XRNTX
Patients who took study LTR Rand Bup x TAU Bup
medication and continued Recovery N No Meds Relapse
STR OD
TAU after study participation x TAU Methadone
44 yo, CA, M
61 x x x x x N
24 yo, Other, M
59 x x N N N x
57 N x N N 29 yo, CA, F
23 yo, CA, M
55 x x x N N x
39 x x x N x N
Patients

26 yo, AA, M
38 x x x x x x
49 yo, CA, M
58 x x N x x x
20 yo, CA, F
28 x x xx 25 yo, CA, M

23 x x x 38 yo, CA, M
48 yo, AA, M
10 x x x x x x

0 1 2 3 4 5 6 7 8 9 10 11 12
Months in Treatment
 Patients who took study Rx, Incarceration Rand XRNTX x TAU XRNTX
LTR Rand Bup x TAU Bup
dropped out, then re-surfaced Recovery N No Meds Relapse
in TAU STR OD
x TAU Methadone
63 N N N N N N
*
62 24 yo, AA, M
* N N N N N N
60 25 yo, CA, M
* N N N N N N
50 32 yo, AA, M
x N x N x 26 yo, CA, M
49 * N N N x x x
32 N N N 35 yo, CA, M 30 yo, CA, M
Patients

27 N 32 yo, CA, F
N N N N N
26 N N N N N 29 yo, Other, F
26 yo, Hisp, M
18 N x x x x x x x x x

61 N N N 23 yo, CA, F

5 ** N N N 25 yo, CA, M

0 1 2 3 4 5 6 7 8 9 10 11 12
Months in Treatment
 Patients who Rand XRNTX x TAU XRNTX
Incarceration
switched medication LTR Rand Bup x TAU Bup
Recovery N No Meds Relapse
STR OD
x TAU Methadone
43 N N N N N x x x x x 30 yo, AA, M
27 yo, CA, M
35 N x x x x x x x N N
30 yo CA, M
34 N N N N x x x
20 x x x x x x x x x
26 yo CA, F
Patient Number

19 N N N N x x x 48 yo, AA, M
25 yo, CA, F
14 x x x x N N N N x x x x
9 N N N N N x x N N N N
31 yo, CA, M
7 N N N N N N x x x 24 yo, CA, F
4 N N N x x N N N N N
20 yo, CA, M

0 1 2 3 4 5 6 7 8 9 10 11 12
Months in Treatment
The criminal justice connection
 XRNTX vs TAU in criminal justice population

XRNTX TAU
Median time to 10.5 5.0
relapse (wks)
Opioid neg, 24 wks 74% 56
%
Opioid neg, 78 wks 46% 46
%
Overdose 0 7
Fatal overdose 0 3
Lee et al. Extended-Release Naltrexone to Prevent
Opioid Relapse in Criminal Justice Offenders. NEJM. 2016. Agonist Rx (mostly 11% 37
 Diversion and deflection
• Diversion moves criminal justice involved from
corrections system into treatment (eg drug
courts, behind the walls programs etc)
• Deflection moves offenders into treatment
before they enter the corrections systems (eg
STEER, LEAD, etc)
The general healthcare connection
 Hospital initiation of buprenorphine
• Well established effectiveness for treatment seeking pts
• What about promotion of treatment upstream at the
“motivational moment” of medical hospitalization to
prevent readmission?
80
70
60
50 Bupe linkage
40 Detox
72%
30 64d
20 38% 15d 17%
10 12% 7d 9% 4d 3%
0
Initiated Duration No opioid Opioid use Engaged
clinic 6m treatment use per 30d clinic at 6m

Liebschutz et al. JAMA Internal Medicine. 2014

 ED initiation of buprenorphine
• What about promotion of treatment in the
Emergency Dept?
90% Referral
80%
70% BI+referral
60%
BI+linkage
50%
40%
30%
20%
10%
0%
30d tx engagement Reduction days Inpatient tx
opioid use utilization

D’Onofrio et al. JAMA. 2015;313(16):1636-1644

 Hepatitis C
• 60-90% of injection users; 50% of those don’t know
they’re infected
• OUD patients in a large public health system –
– 10.3x mortality compared to general population (other
studies up to 15x)
– HCV doubles risk of all-cause mortality
• We now have curative treatments

Cause of death Proportion

Overdose 17%
Cardiovascular disease 17%
Cancer 17%
Hser et al. J Addict Med. 2017 HCV 12%
Youth Treatment
 Young adults highest prevalence
Non-medical prescription opioids

NSDUH, 2014
Young adults highest prevalence
Heroin
Features of youth opioid treatment
• Family leverage (or not)
• Pushback against sense of parental
dependence and restriction
• Developmental barriers to treatment
engagement
– Invincibility
– Immaturity
– Salience of burdens of treatment
• Prominence of co-morbidity
Retention bup treatment
young adults vs older adults
Next steps
 Next steps
Providing a full continuum of care
• Bed based care
– Short term acute for crisis
– Long term for consolidation and re-entry
• Flexible movement up and down levels of care
• Linkage from in- to out-patient
• Longitudinal care
• Recovery housing supports
• Peer recovery coaching
 Next steps
Linking patients to medical care
• Embedding medical care in addiction specialty
settings
• Embedding opioid treatment for stable
patients in general medical settings
• Medical home models
 Nest steps
Linking patients to psychiatric care
• Embedding psychiatric care in opioid specialty
settings
• Embedding opioid treatment for stable
patients in mental health settings
• High intensity subspecialty integrated care
models for unstable patients
 Next steps
Medications
• Quicker initiation of extended release
naltrexone
• Extended release buprenorphine
• Lofexidine for withdrawal
• Implants
• Stress induced relapse
 Next steps
Treatment matching and sequencing
• Who should get what and when and in what
order?
• What are the important characteristics for
matching?
• Responding to trajectory
– Relapse
– Continuous monitoring for early warning signs
 Next steps
Family Framework
• Treatment often not family friendly,
considerations of confidentiality and presumed
independence
• Both families and youth need a recipe for
treatment, with role definitions, expectations,
and responsibilities.
• Family mobilization – “Medicine may help with
the receptors, you still have to parent this difficult
young person”
• Home delivery?
 At a crossroads
• A national crisis
• A proven set of both old and new tools
• But alarmingly poor level of dissemination and
adoption, lack of coherent deployment
• A call to action:
– Expand access
– Integrate care
– Combine with other tools in a full continuum
– Improve effectiveness and retention under real
world conditions
• We have an obligation to do better!
 We’ve come a long way…

But we have a long way to go.

 Contact

Marc Fishman MD
Johns Hopkins University
Maryland Treatment Centers / Mountain Manor
mjfishman@comcast.net