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Medical Student 8 Hour Buprenorphine Training
Session 1: Overview
Session 1: Overview
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Video Transcription
of the Providers Clinical Support System for Medication Assisted Treatment training course. This training is specifically designed for medical students. Why do you think you're taking this course? Perhaps you said, well, I have no idea. Or maybe you reflected on the opioid crisis and thought, perhaps this course would help me to understand what's happening. If you thought that, then you are on the same wavelength as the school. This course is comprised of seven modules, which, when completed successfully, will result in your receipt of a Data 2000 waiver that will enable you to provide medication-assisted treatment under supervision. So that means we are all working to ensure greater access to medication for opioid use disorders for people that need it. On this first module, we share foundational knowledge that will be expanded on throughout the training. You will see an overview of the opioid crisis in the United States and how it came to be. You will learn about why opioid addiction is such a difficult disease to successfully treat. We will describe the criteria that define opioid use disorder, as well as the history of opioid use and the attempts to counteract its devastation to individuals and society through legislation and treatment modalities. We will also discuss current trends and how the U.S. healthcare industry, with the support of government, is working to address this disease. Finally, we will share data to help you understand the scope of the disease, as well as understand treatment efficacy. The fundamental knowledge we will give you is a holistic view of the challenges we face as medical practitioners, as well as a deeper understanding of the importance of current treatments and their place in bringing about successful outcomes. The Substance Abuse and Mental Health Service Administration has provided funding to establish the Provider Clinical Support System, often referred to as the PCSS. The overarching goal of the PCSS is to train a diverse range of healthcare professionals in the safe and effective prescribing of opioid medications for the treatment of pain, as well as the treatment of substance use disorders, particularly opioid use disorders with medication-assisted treatment. So let's get started. Within the United States, there's a significant number of people that suffer from severe substance use problems. Approximately 20 million people have been diagnosed with a substance use disorder, and about one-third of these individuals have been diagnosed with a comorbid mental health illness. Of the almost 44 million individuals that carry a mental health diagnosis, approximately one-fifth of that population has at least one comorbid substance use disorder. So there's a significant overlay between these two populations. When looking more closely at opioid use and misuse, we see it has risen significantly over the last 30 years. It started in the early 90s and has risen most dramatically over the last 20 years. This was in part due to a concern in the late 80s that pain was undertreated and resulted in undue suffering. Consequently, an authority regulating hospitals in the country, the Joint Commission, JACO, created a screening mandate for pain that was eventually referred to as the, quote, fifth vital sign. This meant that all patients entering a healthcare facility needed to be assessed for pain on a one-to-10 Likert scale. If the patient rated their pain at a four or greater, then the healthcare worker needed to address the pain in their treatment plan. Unfortunately, opioids were marketed as the fastest, most effective way to address pain. Concurrent with this was the introduction of new, powerful, long-acting pain medications like OxyContin and a cascade of overprescribing. The pharmaceutical industry's marketing campaign led physicians to believe that opioid use for pain did not lead to addiction. This resulted in overprescribing opioids in a wide variety of conditions. Overprescribing of opiates led to widespread misuse and diversion of these medications, and in some, moderate to severe opiate use disorders. This was one of the key factors in the creation of the current opioid epidemic. Those with more significant disease started either attempting to obtain their medications from multiple doctors or buying them on the street. They could crush and snort long-acting opioid formulations like OxyContin to get a more rapid, powerful release of the drug. This led to a subset of these individuals, secondary to the mounting expense, to the less expensive illicit opioids such as heroin. Unfortunately, heroin is used most effectively and efficiently through injection, which is associated with significant morbidity and mortality. More recently, we have seen an increase in fentanyl and even more powerful fentanyl analogs as part of the illicit opioid market. They are more easily produced and distributed than heroin. The tragedy is that they are also highly potent and have resulted in an increase in overdose deaths. This graph from the CDC shows the rise of drugs implicated in overdose deaths from 2000 to 2016. You can see the rapid rise of cheaper synthetic opioids primarily driven by fentanyl. This slide shows the very small amount of fentanyl and even smaller amount of carfentanyl equal to 100 milligrams of heroin. The increased deaths can be attributed to this much higher potency of these synthetic opioids over heroin. So if injected unknowingly, it may result in the individuals getting a much higher toxicity of drug than expected resulting in overdose. The National Institute of Drug Abuse defines addiction as a chronic relapsing disease characterized by compulsive drug seeking and use. Despite harmful consequences, it is considered a brain disease because drugs alter brain neurobiology. These PET scans are intended to help you understand that addiction results in tissue changes in the brain. In this case, cocaine. Here it is shown beside a diseased heart, both with significant alterations in tissue function. These are neurobiologic changes that affect how the patient reacts to their environment and their need for drug. According to the American Society of Addiction Medicine, addiction is a primary chronic disease the brain rewards system that results in changes to motivation. This system determines what you really want and what your ultimate desires are. These considerations are intimately tied to the reward system of the brain. The neurotransmitter dopamine is the primary driver of motivation. There is a profound release of dopamine associated with illicit drug use. This results in a significant increase in the salience for drugs in the prefrontal cortex. Along with this, there is a significant down regulation of the risk in obtaining or using drugs. Addiction results in a drive to use the drug and an inability to consistently abstain. It results in impairment of behavioral control and creates diminished recognition of problems with one's behavior and interpersonal relationships. It also creates dysfunctional emotional responses. Untreated addiction is often progressive and can result in disability and premature death. Maybe you've learned about the DSM-5. It's the Diagnostic Statistical Manual for Clinicians that contains the signs and symptoms of all mental health disorders classified by the American Psychiatric Association. It was revised in 2013 and no longer uses the terms abuse and dependence in the diagnosis of a drug use disorder. It's important to recognize that substance use problems fall within a continuum. Individuals start along this path in a variety of ways. Patterns of use and degrees of severity differ along the continuum. There are some individuals with increasing drug use and associated risks who will go on to develop significant craving, loss of control, and have significant consequences secondary to their use but continue to use, while others, due to either genetics or their environment, will be able to alter their behavior at this point somewhere along the continuum and prevent the development of the disease of addiction. So the criteria for all substance use disorders are the following and take place within a continuum. They'll have physiologic changes that take place, tolerance and withdrawal, when trying to discontinue or reduce their use. These begin to take place within the first few weeks of regular use. This then can lead to using more drug than intended, which means more time using. There may be the intention to cut back, but the compulsion to use is too strong. Of course, if the person is spending more time getting, using, and recovering from drug, then they are not doing things they had formerly done. They literally begin to be overwhelmed with the thought of using. This is craving. People lose control over their use. At this point, what sets them apart from other less disordered individuals is that they have significant consequences to their use but continue to use. It starts to profoundly affect their lives, and these can be dramatic, negative consequences. These consequences can be job loss, changes in family structure, and or physical problems. If they continue to use on top of these problems, they are in a place of severe illness. So when observing these diagnostic criteria in a patient, one sees a progression of the disease, not unlike many other chronic illnesses. A diagnosis of opiate use disorder can be made on finding at least two of these criteria, or less of these criteria are mild, four or five moderate, and six or greater are severe, all observed within the last 12-month period. Opioids in many forms have been utilized throughout the world for thousands of years. They have been used effectively for a variety of medical conditions. Over the centuries, there have been other periods of problem use. Morphine and heroin were developed in the 1800s and were thought to be breakthroughs in formulating a more potent and easily administered opioid. There have been a variety of milestones of treatment over the last half century. We will be talking about the utility of these medications during this training. Please review the timeline to learn about pivotal milestones in opioid use disorder treatment. The milestone most important to this training is the data 2000. The Drug Addiction Treatment Act was passed in 2000 and allowed physicians who met certain criteria to treat opiate use disorders in their office. Up until that time, a controlled substance for the treatment of opiate use disorder could only be used in an opiate treatment program or OTP, and the only medication was prescribed for the treatment of opioid use disorder. This new law allowed for the use of specific medications scheduled three, four, or five, and approved by the FDA specifically for the treatment of opiate use disorder. So not all formulations of buprenorphine can be used to treat an opiate use disorder. These medications can be used in OTPs, but initially they had to be used the same way as methadone. Data 2000 also specified that Data 2000 also specified the criteria for licensure for the provider of medication-assisted treatment. This is designated by the Drug Enforcement Agency and resulted in the provider having a waiver to the original methadone treatment law. The course you are now taking is the pathway for physicians in training. The criteria to become wavered includes a current DA license, subspecialty training and addictions, or the completion of an eight-hour course like the one you're now taking. When a provider first obtains their waiver, they must adhere to patient panel size limits. In the first year, the provider can only have 30 active patients at one time. After the first year, they may apply to go up to 100, and from there, physicians meeting certain criteria may go to 275. In 2013, accommodations were made to allow treatment in opioid treatment programs similar to office-based practitioners. Prior to this, OTPs could only dispense buprenorphine under the same criteria as methadone with restricted take-home doses. For patients that need greater oversight, OTPs are a good treatment modality. On occasion, we will refer patients to this, quote, higher level of care and not kick them out of treatment. The idea is not to take patients out of treatment just as we wouldn't stop insulin in a patient with diabetes because they're not compliant with their diet and exercise. The Comprehensive Addiction Recovery Act, called CARA, became law in 2016. It expanded medication-assisted treatment prescribing privileges to nurse practitioners and physician assistants. It is currently in a five-year trial period. These providers are required to complete a 24-hour training to be eligible for the waiver. Even though we have the opportunity to treat people with this effective medication now in the outpatient setting, we are significantly deficient in the availability of treatment access. About 22 million individuals in the country have a substance use disorder. However, there are roughly 2.5 million treatment slots available. Though not all 20 million people are seeking treatment, we currently are unable to have treatment available at the time the patient is motivated to enter treatment. CARA was an attempt to decrease this gap, hence the training for you as medical students. There are a whole range of treatment goals that can be established. This ranges from a reduction in harm to sustained recovery. Those individuals fully engaged in treatment will continue their drug use and often move forward in multiple domains, including the biopsychosocial and physical. The treatment options, methadone, a full agonist, buprenorphine, a partial agonist, and naltrexone, an antagonist. There are also behavioral treatments that can be used concurrent with these medications. The use of behavioral treatment alone is not recommended due to the poor long-term efficacy. The ultimate goal is to maintain long-term recovery with or without medication. How long the patient is on medication is patient-specific. Treatment should be patient-oriented. There have been many studies identifying the value of medication in the treatment of addictive diseases. This one was done many years ago in 1971, 45 years ago. This was prior to the use of medication-assisted treatment and followed those who had successfully completed a program. It found that most people treated for heroin relapsed within the first three months. About 90% of people will relapse without medication. The use of buprenorphine promotes retention in treatment. We know that if we keep people in treatment, they do better. Those who remain in treatment become more likely over time to abstain from other opioids. Offering embedded behavioral counseling modalities can improve recovery for many. Unfortunately, those patients in medication-assisted treatment still have a death rate approximately twice that of the general population. It's not a cure-all. This is a lethal disease. But no treatment following acute withdrawal increases the death rate six times compared to the general population. There is a significant reduction in mortality for those in medication-assisted treatment. Keiko did a study back in the early 2000s where there were 20 individuals that had been started on maintenance dose of buprenorphine and another 20 entered into a withdrawal program using buprenorphine. All subjects had access to behavioral treatments, but none of the individuals that went through the withdrawal stayed in treatment, whereas a significant number of those on medication in treatment did well. Regrettably, at the end of one year, four of the patients in the withdrawal cohort died of a drug overdose. That's 20%. What has been your major takeaway from this module? Here is what we hope you take away. The rates of overdose deaths from opioids are at an all-time high and have continued to increase, partly because of the introduction of fentanyl. As we discussed earlier, the Diagnostic Statistical Manual 5 defines substance use disorders by having two or more symptoms that highlight a physiologic effect, loss of control, and harmful consequences. When a person meets these criteria, they clearly have an opioid use disorder and would benefit from treatment. A number of legislative initiatives have been passed to improve access to treatment for these individuals. Medication-assisted treatment for opioid use disorders has several benefits, including improved retention in treatment and social functioning, and a decrease in the number of fatal overdoses. In a nutshell, these people get their lives back.
Video Summary
The video transcript summarizes the first module of the Providers Clinical Support System for Medication Assisted Treatment training course, which is designed for medical students. The module provides foundational knowledge on the opioid crisis in the United States and explains why opioid addiction is difficult to treat. It also discusses the criteria for opioid use disorder diagnosis, the history of opioid use and treatment, current trends, and efforts by the U.S. healthcare industry to address the crisis. The video emphasizes the need for greater access to medication-assisted treatment for individuals with opioid use disorders. It mentions the Substance Abuse and Mental Health Service Administration's funding of the Provider Clinical Support System (PCSS) to train healthcare professionals in safe and effective prescribing of opioid medications. The video highlights the importance of understanding the scope of the disease and treatment efficacy. It also provides information on the treatment options available, such as methadone, buprenorphine, and naltrexone, and the value of medication-assisted treatment in reducing mortality rates. The ultimate goal is to maintain long-term recovery with or without medication, but the video acknowledges that treatment should be patient-oriented and individualized. Legislative initiatives have been implemented to improve access to treatment for individuals with opioid use disorders. The video concludes by emphasizing the benefits of medication-assisted treatment, including improved retention in treatment, social functioning, and a decrease in fatal overdoses.
Keywords
Medication Assisted Treatment
opioid crisis
opioid use disorder
treatment options
legislative initiatives
The content on this site is intended solely to inform and educate medical professionals. This site shall not be used for medical advice and is not a substitute for the advice or treatment of a qualified medical professional.
Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 and grant no. 1H79TI085588 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
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