SLIDE 1 1
Opioid Addiction Treatment
Thomas R. Kosten, MD Professor of Psychiatry Baylor College of Medicine
SLIDE 2 Continuity of Care: A Critical Goal Re-hospitalization in 296 dependent patients
- Romelsjo et al. Sweden
- All received at least 3 inpatient days
–Group 1: 1 week Inpat. 10 Wks Opt –Group 2: 1 week Inpat. No Opt –Group 3: 8 Weeks Inpat. No Opt
Is shorter cheaper?
SLIDE 3 21% 40% 78% 58%
71% 46%
0% 20% 40% 60% 80%
6 12 24 36
Months After Release 10 Wks Opt 1 Wk Inp 8 Wks Inp
Re-Hospitalization and Initial Time in Tx
Romelsjo et al. – JSAT, 2005
SLIDE 4 Continuity of Care: A Critical Goal
- 1. Treated patients show far more improvements than
non-treated patients.
- 2. Motivation is an important but not critical
ingredient.
- 3. Costs in relapse and re-hospitalization associated
with NOT treating.
- 4. Continuity in outpatient care is critical, cost
effective, and requested by patients!
Who, Why, What Treatment?
SLIDE 5 “Let Me Tell You A Story” WHY? Because a real case will help:
- Illustrate complex pattern of relapse and treatment
reentry typically experienced by opioid-dependent patients.
- Underline importance of screening for illicit drugs.
SLIDE 6 “Let Me Tell You A Story”
- Demonstrate potential of new treatment
paradigms which provide a way to stabilize patients –– in an office setting –– with such
- pioid-based medications as buprenorphine.
- Help us begin to see the cost-savings inherent in
a new treatment paradigm.
WHY? Because a real case will help:
SLIDE 7
Caucasian man, began “chipping” intranasal heroin about 5 years ago. “Let Me Tell You A Story”
SLIDE 8
Caucasian man, began “chipping” intranasal heroin about 5 years ago. “Let Me Tell You A Story”
SLIDE 9
serious auto accident –– due to seizure ––
and ER toxicology screen is positive for cocaine and opioids. “Let Me Tell You A Story”
SLIDE 10 Historic Challenges in Treating
Top reasons physicians ignore substance abuse:
- 426 Primary Care Physicians
1) Don’t know what to do. 69% 2) No effective treatment. 55% 3) Not really a medical problem. 26% 4) No time. 19%
SLIDE 11 Historic Challenges in Treating
Patients reluctant to seek help from traditional methadone clinics:
- In undesirable neighborhoods.
- Inconvenient to reach.
- Requiring daily attendance.
SLIDE 12
The Story of Mr. A, continued
One year after initial treatment, Mr. A returns to ER with heroin overdose sufficient to require naloxone reversal.
SLIDE 13 Opioid Dependence and Other Drug Dependencies as a Chronic, Relapsing Disease State of the art science
(SAMHSA, NIDA, WHO)
now identifies
a chronic disease state.
SLIDE 14 Opioid Dependence as Chronic Disease
We need to:
- Foster the idea of drug dependence as
chronic illness.
- Promote best practices for long-term
management and continuous monitoring models.
SLIDE 15 “Continuum of Care” for Chronic Disease
Opioid dependence and “Mainstream” chronic diseases:
- Striking similarities in onset, course and
re-occurrence.
vs. Striking disparities in policy, treatment availability, treatment evaluation, and insurance coverage.
[www.tresearch.org/add_health/add_health.htm]
SLIDE 16 Opioid Dependence as Chronic Disease
For too long physicians and payors have failed to see drug dependence for what it is, a chronic disease.
Consequently:
- Standard has been to measure
progress by assessing results at some point after patients leave treatment.
SLIDE 17 Opioid Dependence as Chronic Disease
For too long we’ve measured progress by assessing results at some point after patients leave treatment.
Consequently:
value and produce results disappointing to policy makers.
SLIDE 18 Opioid Dependence as Chronic Disease
For too long we’ve failed to see drug dependence as a chronic disease. Moreover:
rejected for other chronically relapsing conditions.
SLIDE 19 Opioid Dependence as Chronic Disease
For too long we’ve failed to see drug dependence for what it is, a chronic disease. In short:
chronic disease model that might work.
SLIDE 20
“Continuum of Care”
When seen as chronic Disease, Opioid Dependence, fits perfectly under the banner “Continuum of Care.”
That’s why we’re here today.
SLIDE 21
“Continuum of Care” for Chronic Disease
Contemporary treatments for opioid dependence must be conceptualized, structured and delivered to meet the differing needs of individuals along a continuum.
SLIDE 22
Opioid Dependence as Chronic Disease OD more responsive to –– and more cost effectively treated –– using chronic disease management model of care.
SLIDE 23
“Continuum of Care” for Chronic Disease
Conflict between new, chronic disease classification and traditional short-term medical management.
Demands a Change. Demands a Shift in Policy.
SLIDE 24 “Continuum of Care” for Chronic Disease
- OD requires time to correct itself.
- Long term maintenance requires
long term reimbursement.
Accept that:
SLIDE 25 “Continuum of Care” for Chronic Disease Versus . . .
revolving door
SLIDE 26
“Continuum of Care” for Chronic Disease
Need to establish parity in care with such chronic diseases as hypertension, diabetes and asthma.
SLIDE 27 “Continuum of Care” for Chronic Disease
Remember Mr. A?
- In spite of extensive intervention
- In spite of good social supports
- In spite of economic opportunity
- In spite of vocational skills
- In spite of multiple detoxifications
- In spite of drug-free outpatient care
Relapse and consumption of extensive health resources.
Why?
SLIDE 28
“Continuum of Care” for Chronic Disease
Because the model for his care was not based on a model for a chronic, relapsing disease.
SLIDE 29
Historic Treatment Options
Traditional goal?
Rehabilitate and Discharge.
SLIDE 30
- 40 – 70% of all addiction treatment
episodes are detox-only
- Cost $1,750 - $2,400 per episode
- Re-detox within a year
– Average = 40% (23 – 78% range) – 28% admitted 3+ times/yr
2000 Inspector General Report
Historic Treatment Options
SLIDE 31 Historic Treatment Options
Relapse rates among diabetics or asthmatics following cessation
- f medication =
- Evidence of effectiveness of medication.
VS. Relapse rates amongst drug or alcohol dependent patients following cessation of treatment =
- Evidence of treatment failure.
SLIDE 32
Treating Opioid Dependence: Changing the Paradigm Patients, like Mr. A, who would have been reluctant to seek help from traditional methadone clinics, will be willing to seek help.
SLIDE 33 Treating Opioid Dependence: Changing the Paradigm
- Make study of addiction part of med school curricula.
- Use medical monitoring strategies (as for other chronic
diseases) to ferret out those most at risk.
- Shift from “rehabilitation” strategy to “chronic care”
strategy.
- Lift insurance limits so that benefits (even incentives)
apply for continued outpatient, medication and behavioral visits –– w/o limit on days or visits.
SLIDE 34
Treating Opioid Dependence: Benefits of a New Paradigm Drug dependence treatments designed to discharge patients upon resolution of acute symptoms have not been effective.
SLIDE 35 Treating Opioid Dependence: Requirements of a New Paradigm Drug dependence should be:
evaluated in the same manner as
illnesses.
SLIDE 36
Case History: How Buprenorphine Made a Difference
Buprenorphine therapy in office practice was successful for Mr. A.
SLIDE 37 Case History: How Suboxone Can Make a Difference For appropriate patients
treatment is an effective and cost effective model for care.
SLIDE 38
