Evaluation and Care of Active Duty Service Members (ADSM) and Veterans with Substance Use

Disorders

Anthony Albanese, MD

Anthony Dekker, DO

John D. Hunsaker, MD

November 30, 2018- 8am

Disclosures

Anthony Albanese, MD – Speaker Bureau & Advisory Board • AbbVie Pharmaceuticals, Gilead Sciences, Merck Pharmaceuticals

Anthony Dekker, MD – Nothing to DiscloseJohn D. Hunsaker, MD- Nothing to Disclose

ACE/PESG and AMSUS staff have no interest to disclose.

This continuing education activity is managed and accredited by AffinityCE/Professional Education Services Group in cooperation with AMSUS. ACE/PESG, AMSUS, and all accrediting organizations do not support or endorse any product or service mentioned in this activity.

Learning Objectives

At the conclusion of this activity, the participant will be able to:

1. Screen and diagnose SUD in ADSM/VA members

2. Identify interventions strategies to enhance recovery in SUD ADSM/VA members

3. Initiate Medication Assisted Treatment in ADSM/VA members with OUD

• 42% of Veterans screen positive at some point during their lives for an AUD1

• Veterans with Alcohol Use Disorder2

– Die an average of 15 years earlier

– >2x higher risk for death (non-injury)

– >3x higher risk of death (by injury)

Alcohol Use Disorder (AUD) in Veterans

1 Fuehrlein, B., et. al. Burden of AUD in US Military Veterans: National Health and Resilience in Veterans Study. Addiction. May 2016

2 Fudalej S. et al. Predictors of injury-related and non-injury related mortality among veterans with alcohol use disorders. Addiction. July 2010

Start with Screening

• For Alcohol consider the AUDIT- C (Alcohol Use Disorder Identification Test-Consumption)

– How often do you have a drink containing alcohol? (0-4 – a score of 4 is 4 or more times a week)

– How many standard drinks containing alcohol do you have on a typical day? (0-4)

– How often do you have 6 or more drinks on one occasion? (0-4)

AUDIT C

• Commonly used, validated in Veteran populations

• Maximum score of 12 pts- > 3 in women and > 4 in men indicate risk of AUD

• Validated in studies that include Veteran population.

• Sensitivity men 86%, women 73%

• Specificity men 89%, women 91%

Alcohol Clin Exp Res. 2007 Jul;31(7):1208-17. Epub 2007 Apr 19

Opioids and OUD Risk

• Both dose and duration of opioid therapy have been shown to be important determinants of OUD risk.

0

0.5

1

1.5

2

2.5

3

3.5

Acute use

OR

Low dose Medium dose High dose

0

20

40

60

80

100

120

140

Chronic use

OR

Low dose Medium dose High dose

3x ↑ risk of OUD Up to 122x ↑

risk of OUD

Edlund MF. Clin J Pain 2014;30(7) 557=564. (n=568,640) evaluating the incidence of OUD among those newly prescribed opioids, duration of opioid therapy was more important than dose in determining OUD risk; however the risk amongst those receiving chronic therapy increased dramatically with increasing dose (low dose, acute (OR= 3.03); low dose, chronic (OR= 14.92); medium dose, acute (OR= 2.80); medium dose, chronic (OR= 28.69); high dose, acute (OR= 3.10); high dose, chronic (OR= 122.45). Duration (days of use out of 12 months): Acute= 1-90 days, Chronic= 91+ days; Average daily dose (morphine equivalents): Low= 1-36 mg, medium= 36-120 mg, high= 120+ mg.

Craving or strong desire to use alcohol or opioids or other drugs

Recurrent use resulting in failure to fulfill major role obligations

Recurrent use in hazardous situations

Continued use despite social or interpersonal problems caused or exacerbated by alcohol or opioids

Continued use despite physical or psychological problems

*Tolerance

*Withdrawal

Use in larger amounts or duration than intended

Persistent desire to cut down

Giving up other interests to use substances

Great deal of time spent obtaining, using, or recovering from alcohol or opioids or other drugs

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

Mild SUD: 2-3 CriteriaModerate SUD: 4-5 CriteriaSevere SUD: >6 Criteria*This criterion is not considered to be met for

those individuals taking opioids solely under appropriate medical supervision

Does My Patient Have a Substance Use Disorder?

How do we determine what treatment is needed?

• ASAM Criteria- first published in 1991- last revision 2013.

• Uses 6 Dimensions: withdrawal risk, medical & psychiatric complications, readiness to change, relapse, continued use/problem potential, and recovery environment to determine the intensity of treatment.

• Uses 4 Levels of Treatment ranging from early intervention (0.5) through outpatient (1-2) and residential (3) to full medically managed inpatient Level(4).

Adult Admission Criteria: Crosswalk of Levels 0.5 through 4

Criteria Dimensions

Levels of Service

Level 0.5 Early Intervention

Level 1 OTP Opioid Treatment Program

Level I Outpatient

Services

Level 2.1 Intensive

Outpatient

Level 2.5 Partial

Hospitalization

Level 3.1 Clinically-Managed

Low Intensity

Residential Services

Level 3.3 Clinically-Managed

Pop Specific High

Intensity Residential

Services

Level 3.5 Clinically-Managed

High Intensity

Residential Services

Level 3.7 Medically-Monitored Intensive Inpatient Services

Level 4 Medically-Monitored Intensive Inpatient Services

Dimension 1: Alcohol Intoxication and/or Withdrawal Potential

No withdrawal risk

Withdrawal prevented by OTP

Minimal risk of severe withdrawal Level 1WM

Minimal risk of severe withdrawal Level 2WM

Minimal risk of severe withdrawal Level-2WM

No withdrawal risk

Moderate withdrawal risk (not severe) Level 3.2WM

Moderate withdrawal risk (not severe) Level 3.2WM

Moderate risk of severe withdrawal Level 3.7WM

Severe withdrawal risk Level 4WM

Dimension 2: Biomedical Conditions and Complications

None or stable None or stable

None or stable

None or stable

None or stable None or stable

None or stable

Stable; may need medical monitoring

Medical monitoring required

Needs 24 hour medical care

Dimension 3: Emotional/Behavioral or Cognitive Conditions and Complications

None or stable None or manageable in outpatient structure

None or stable

Mild severity; needs monitoring

Mild to moderate severity; needs monitoring

None or minimal

Mild to moderate severity

Unable to control impulses

Moderate severity

Severe problems needs 24 hour Psychiatric care

Dimension 4: Readiness to Change (insight)

Has insight into use affecting goals

Requires structure therapy to progress

Cooperative, but needs motivation and monitoring

Moderate resistance structure required

Significant resistance; more structure needed

Needs structure to maintain therapeutic gains

Little insight; needs motivating strategies

No insight may not believe treatment is necessary

High resistance and poor impulse control

Not applicable for this level of care

Dimension 5: Relapse/Continued Use or Continued Problem Potential (automaticity)

Need skills to change current use

High relapse risk without OTP

Able to maintain abstinence

Higher automaticity; needs monitoring and support

Significant automaticity; needs more monitoring and support

Understands relapse, but still needs structure

Higher automaticity requiring 24 hour monitoring

Inadequate skills to prevent immediate relapse

Unable to control use with dangerous consequence

Not applicable for this level of care

Dimension 6: Recovery/Living Environment

Good social support

Supportive recovery environment

Supportive recovery environment

Less supportive structure needed to cope

Environment unsupportive; higher structure improves patient coping

Dangerous environment; structure permits success in recovery

Dangerous environment; structure permits success in recovery

Dangerous environment; structure permits success in recovery

Dangerous recovery environment; structure permits success in recovery

Not applicable for this level of care

Adapted from the ASAM Criteria 3rd Ed pp 175-176 (ref 45)

Clinical Institute Withdrawal Assessment for Alcohol Scale-revised (CIWA-Ar)

• 10 item rating system for alcohol withdrawal severity max of 67 points:– 0- no symptoms

– 1- Mild

– 4- Moderate

– 7- Severe

• BP and HR not found to correlate with severity of withdrawal

• Can be given in under 2 minutes

Sullivan,J.T. British Journal of Addiction, 1989; 84: 1353-7.

Clinical Institute Withdrawal Assessment for Alcohol Scale-

revised (CIWA-Ar)

1. Nausea and vomiting

2. Tremor

3. Paroxysmal sweating

4. Anxiety

5. Agitation

6. Tactile disturbances

7. Visual disturbances

8. Auditory disturbances

9. Headache or fullness

10. Orientation (0-4 points)

Sullivan,J.T. British Journal of Addiction, 1989; 84: 1353-7.

CIWA-Ar

• High scores are predictive of development of seizures and delirium.– <8 = mild symptoms

– 9-15 = moderate symptoms

– > 15 = severe symptoms-high risk

• Scale is currently being used for medication administration at many detoxification centers.

• Using the CIWA-Ar was found to reduce side effects from over-sedation costs by avoiding unnecessary use of medications.

Sample Withdrawal Management Protocols

• Diazepam, Chlordiazepoxide, and Lorazepam most frequently used.

• Carbamazepine- 200mg QID on days 1-3, then 200mg TID day 4, then BID day 5 , then QD day 6.

• Valproate 300mg QID x 3 days, then taper by 300mg/day.

• Gabapentin- 300mg-600mg QID on days 1-3 then 300mg-600mg TID on day 4, 300mg -600mg BID on day 5 and 300mg-600mg HS on day 6. May consider continuing gabapentin- evidence that it helps with post-acute withdrawal.

FDA Approved Options for treatment of alcohol use disorder• Disulfiram

Inhibits aldehyde dehydrogenase- cause nausea, vomiting, flushing, headache with alcohol intake.

Black box warning- safety issues

• Naltrexone - oral and injectable– Reduces reward from alcohol by blocking opioid

receptors- box warning removed.

• Acamprosate – Thought to inhibit action of glutamate on NMDA

receptor and interact with GABA system

Other non-FDA approved options

• Gabapentin – effects on GABA A and glutamate

• Baclofen –GABA B agonist

• Topiramate- Antagonizes glutamate receptors, modulates

cortico-mesolimbic dopamine release and enhances GABA.

• Tricyclic antidepressants (co-morbid depression)

• SSRIs

• Complementary and Alternative Medicine (CAM)- Vitamin/herbal infusions, biofeedback,

acupuncture, animal therapy, yoga. Lack high quality evidence at this time.

Opioids

• Low long-term success rates for detox are poor without medication ~10% remain abstinent after 2 years.

• If detox is considered, it should be pharmaceutically assisted and combined with some form of rehab.

• After detox is complete, consideration should be given to long term naltrexone therapy (380mg monthly injectable demonstrates better results than oral due to compliance).

Suggestions for long-term OUD management

• Buprenorphine and Methadone are considered first line treatments for opioid use disorder. Long term success rates are much higher than with detox, between 60%-80% remain in treatment after 1y.

• Make sure the patient understands the risks and benefits of therapy. Informed consent.

• Make sure the parameters of prescribing are clearly understood by the patient before beginning. –consider a treatment contract.

• Record a good history, physical exam.

Suggestions for long-term opioid management

• Comply with state and federal laws.

• Consider getting your buprenorphine “X” number from the DEA.

**training available**

• Refer to an established clinic for methadone treatment or for buprenorphine if appropriate structure is not available in your practice setting.

Methadone Pharmacokinetics• 6-dimethylamino-4,4-diphenyl-3-heptanone

• Lipophilic base-highly protein bound, well absorbed from GI tract.

• D-isomer (S-methadone)-antagonizes NMDA and inhibits K+ flux at hERG channel prolonging QT

• L-isomer (R-methadone)- strong opiate

• Metabolized (N-demethylated) in liver by CYP 450 system (primarily 3A4- also 2D6 & 1A2) – no active metabolites.

• Biphasic elimination alpha~8-12h (pain relief) beta~30-60h (reduces craving) acidic urine (ph<6) increases excretion 10x.

Buprenorphine• Mu partial agonist, kappa & delta antagonist- less issues

with sedation and respiratory depression

• Approved in sublingual form with or without naloxone for treatment of opioid addiction

• Has good pain relieving properties at low/intermediate doses (8mg-16mg/day)- but possible ceiling effect at high doses (>24mg/day)

• Viable option for patients with addiction and pain who are willing to participate in the addiction treatment program.

• Should be started when patient is in moderate withdrawal to prevent “precipitated withdrawal”

Clinical Opioid Withdrawal Scale (COWS)

• 11 items including: – Resting pulse Sweating Restlessness

– Pupil size Bone/Joint aches Runny nose/tearing

– GI upset Tremor Yawning

– Anxiety or Irritability Gooseflesh

• Score:

– 5-12 = Mild Withdrawal

– 13-24 = Moderate

– 25-36 = Moderately Severe

– >36 = Severe Withdrawal

Safety Measures for Patients on Chronic Opioid Therapy

• Give controlled substance use agreement

• Check morphine equivalents (doses > 100 are high risk, over 180 are very high risk for overdose. (CDC guideline uses 50/90)*

• Avoid concomitant benzo use when possible.

• Check Prescription Drug Monitoring Program (PDMP).

• Check urine toxicology

• Check depression screen

• Give Naloxone prescriptionhttps://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf

Non-Pharmacologic Treatment • 12 Step meetings (support not treatment)

AA/ Celebrate Recovery

• SMART recovery, LifeRing, Moderation Management, Women for Sobriety, Secular Organizations for Sobriety, other secular groups

• Insight oriented “process” groups

• Cognitive or Dialectic Behavioral Therapy

• Motivational Enhancement

• Coping Skill Enhancement

• No group has a significantly better outcome than the others- given the same length of treatment. (ITT)

Contact Information

Anthony Albanese MD, FACP, DFASAManthony.albanese@va.gov916-825-4015

Anthony Dekker, DO anthony.dekker@va.gov623-551-5212

John D. Hunsaker, MD john.d.hunsaker4.mil@mail.mil571-231-2368

Chideha Ohuoha, MDchideha.Ohuoha@samhsa.hhs.govph:

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Medication Assisted Therapy and Active Duty Military Service

John Hunsaker, MDMAJ, MC

30 Nov 2018

AR 600-85 and Medication Assisted Therapies (MAT)

• Section 8-20: a. Methadone maintenance will not be used.

b. Use of Disulfiram will not be mandatory.

• Buprenorphine and naltrexone are not mentioned.

• Army SUDCC operations manual (2016) does not address MAT.

DODI 1010.4 (5)j

• (1) In addition to the psychosocial treatments provided in SUD treatment, all personnel should be evaluated for appropriate adjunctive pharmacotherapy as part of a comprehensive treatment plan.

• (2) Long-term drug replacement therapies may be made available. Service members requiring long-term drug replacement therapies (greater than 6 months) must have their adherence to Service retention standards assessed by authorized medical personnel.

Adherence to Service retention standards

• Some cases are more clear than others.– Combat wounds that persist and will result in eventual

medical separation.– Preexisting drug use for which MAT is being used to

control.

• Others more difficult to align with service standards.– Iatrogenic opiate dependence, with primary medical

concern resolved or found fit for duty.

Chapter 9 Separation (AR 635-200)

• Commander determines that further rehabilitation efforts are not practical.

• This is not an appropriate avenue for iatrogenic dependence using MAT.

Memorandum from Under Secretary of Defense (Feb 14 2018)

• Service members who have been non-deployable for more than 12 consecutive months, for any reason, will be processed for administrative separation in accordance with Department of Defense instruction,… or will be referred into the Disability Evaluation System…

The Way Ahead

• MAT used to treat opiate use disorders secondary to illicit substance use can follow existing guidance as discussed (Chapter 9 after SUDCC failure or 12 months of continued non-deployability)

• Those treated for iatrogenic causes follow an unknown path. – Discussions on creating another category for medical

separation (Chapter 5-17).