4TH ANNUAL ADDICTION MEDICINE SYMPOSIUM CHRISTIANA MEDICAL CENTER

MEDICATION-ASSISTED TREATMENTS (MAT) FOR OPIOID USE DISORDER

David R Gastfriend MD Scientific Advisor, Treatment Research Institute Chief Architect, CONTINUUM – The ASAM Criteria Decision Engine™ CMO, DynamiCare Health™ Disclosures: Shareholder and former employee of Alkermes, Inc. Royalty recipient, American Society of Addiction Medicine for the licensing of CONTINUUM™ Consultant: Alkermes, BioCorRx, Indivior, Kaleo, Rand Corp.

Oct 2006: Jaclyn Kinkade reports suffering back & neck pain. Dr. Thomas Suits, her employer, prescribes 20 oxycodone pills. “Never taken opioids before,” Jaclyn wrote in her diary. “But…OMG I felt no pain.”

2006

2007 (WSJ 10/5/2012)

Neurobiology of Opioid Use Disorder  Opioids: at substantia nigra & VTA interneurons, rapidly & briefly bind MOP-r,  GABAergic inhibition of DA neurons   Dopaminergic Reward: Initial positive reinforcement; later, regulatory changes via mRNA or protein/peptides  Recurrent withdrawal negatively reinforces recurrent use, via regulatory changes that persist for weeks/months  Negative Reinforcement: mediated via  Upregulation of the KOP-r/dynorphin system (may underlie aversion, dysphoria/anhedonia, and depression-like or anxiety-like states)  Stress-responsive brain areas via the hypothalamo-pituitary-adrenal (HPA) axis (Kreek et al., J Clin Investigation 2012)

Reward & Positive Reinforcement  Pain: brain’s natural signal to protect the body  Proper goal of pain medicine: alleviate but not eliminate pain  Exceeding pain alleviation – risks euphoria  Euphoria = reward  Repeated reward  positive reinforcement  The “Go” System

Withdrawal & Negative Reinforcement  Opioid drugs all wear off after a while  When excessive opioid doses wear off, the brain is in withdrawal  Withdrawal is an uncomfortable, even painful state that is even worse than the pain that preceded taking the medicine  This negative effect  wanting to keep taking the opioid drug, which is known as negative reinforcement  Disrupted ability of inhibitory control damages the “No Go” system

Can Treatment Work?

OUD Behavior: Mediators/Moderators

Maturation, sanctions Support, counseling Opportunity, Outward Bound Contingency Management

Goals of Anti-Opioid Pharmacotherapy  Detoxification: detox without continued meds dominates, but research & experience prove this to be inadequate care  Early recovery protection: period of highest risk for OD  Death rates upon prison release = 12-100x that of general population

 Harm reduction, e.g., from HIV and HEP C transmission

 Anti-craving: stabilize urges/impulses to use long enough to permit counseling effects to take hold  Stress Response Normalization: OUD disrupts ACTH/Cortisol  Extinction: of both positive and negative cue response

 Biological Stabilization: Eating, diurnal cycle, sexual function, capacity for self-care / activities of daily living / treatment retention, general healthcare, relationship bonding  NOT Recovery: Disease acceptance, coping skills, rehab

FDA-Approved Anti-Opioid Agents

Full and Partial Agonists vs. Antagonists antagonist agonist

no effect An antagonist is close enough in shape to bind to the receptor but not An agonist has an close enough to produce active site of similar an effect. It also shape to the takes up receptor space endogenous ligand and so prevents the binding to the receptor endogenous ligand and producing the from binding same effect

effect

Opioid Effect

Full Agonist (Methadone)

Partial Agonist (Buprenorphine) Antagonist (Naloxone)

Log Dose

Specific Binding

Specific Binding

[18F]cyclofoxy (m ligand)

[11C]carfentail (m ligand)

Normal Control

Methadone Maintained Patient

30-35 % receptor occupancy for methadone >80 mg/day Kling et al., JPET 2000

Bup 2mg: 27-47 % occupancy Bup 16 mg: 85-92% occupancy Bup 32 mg: 94-98% occupancy Greenwald, MK et al., Neuropsychoph 2003

Methadone  Full Mu-opioid agonist, slow onset & long duration (23 hrs)  Extensive research shows benefit of treatment initiation  Widely used in harm reduction: Anti-HIV & -HepC  Start at 20-40 mg; titrating up until no craving or illicit use  Average dose 80-100 mg daily  Only in ~1,300 certified programs, per federal law

 Lipophilic, so fat tissue accumulation causes long withdrawal  Must be used as a long-term treatment  Cardiac risk: Prolongs QTc with risk of Torsades de Pointes

MMT: Impact on Treatment & Heroin Use During the 6 Mos. Post-release From Prison ± MMT (N=141)

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

% of 180 days postrelease in treatment

85% % of 180 days postrelease used heroin

64%

(p < 0.001)

46%

11%

C

C+ M

C = Counseling Only (N=70) C+M = Counseling & Methadone Started in Prison (N=71) Gordon, MS et al., Addiction 103:1333-1342, 2008.

Methadone: For Whom?  Long history with chaotic lifestyle, psych illness, BZ use

 IV route of drug administration; high tolerance  Needs close, daily supervision  May have difficulty persisting with treatment  High risk for diverting medication  May benefit from take home contingency management

 Wants to continue some subjective sense of opioid dependence  Has chronic pain problems & needs/expects opioids

 Pregnant or planning to become pregnant  Is prepared for long-term or even lifelong dosing

Methadone & Buprenorphine Molecules Methadone

Buprenorphine

Buprenorphine  Partial agonist: ceiling effect, less OD  Opioid activity: ~half of methadone’s  Start patient in mild withdrawal (avoids provoking withdrawal)

 Slow onset, 36 hr-duration: reduces reinforcement  Extensive research shows benefit of treatment initiation  Prescribed daily, weekly or monthly in outpatient care  Has greatly expanded access to care, but more is needed  DEA Schedule C-III, requiring federal waiver, 100 patient limit  Approved for opioid addiction (2002) as Subutex; now used as Suboxone (with naloxone in a 4:1 ratio)  Generics (Zubsolv) & film preparations (Bunavail) approved

Treatment Retention in HIV-Infected Patients Receiving Buprenorphine/Naloxone (n=303)

% Retained

Percent

% Not Retained % Lost to Follow-Up

Fiellin DA et al., JAIDS 2011; 56(Suppl 1) S33-S38.

Agonists: Treatment Retention

Percent Retained

100

Mean retention on BUP: Yser, Addiction 2014: 66 days Baser, AJMC, 2011: 69 days Fishman, CPDD 2011: 9.6 wks (adol/young adults) 92% relapse within 8 wks of taper (Weiss et al., 2011)

80

73% Hi Meth

60

58% Bup 53% LAAM

40

20 20% Lo Meth 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Study Week

Johnson RE, et al (2000)

MMT vs. BUP: Retention (Flexible Dosing)

(Mattick et al., Cochrane 2014)

FAVORS MMT | FAVORS BUP

MMT vs. BUP: Retention  31 RCTs (N=5,430); evidence: mod to high  Flexible dose MMT: better retention vs. BUP doses <16 mg  BUP: when high dose MMT isn’t tolerated  BUP advantages: relative safety, alternate-day administration, convenience & access  No need for more MMT vs. BUP RCTs

(Mattick et al., Cochrane 2014)

MMT vs. BUP: Cognitive Function During Month 1 of Treatment:  Delayed reaction time & verbal memory deficits: Methadone > BUP > CTRLs (Rapeli P et al. ISAM 2006) After Maintenance is Established:   Reaction time: MMT 100 mg vs. CTRLs (Gordon, Psychopharm 1970)

  Working memory: MMT 70 mg (Mintzer & Stitzer. DAD 2002)   Verbal memory: MMT 35 vs. 17.5 mg (Curran et al. Psychopharm 2001)

  Visual memory vs. CTRLs: MMT 66 mg & BUP 9 mg (Pirastu et al. DAD 2006)

 Driving reaction time delay: MMT > BUP (Soyka, et al., J Neuropsych Clin Neurosci 2001; Soyka et al. J Clin Psychopharm 2005)

Buprenorphine: For Whom?  Able to maintain a treatment plan without the daily supportive contacts/structure of a clinic  Has structure in daily life (e.g., employed)  Has a strong sober support system  Has adequate stress management skills  Pregnant women  Patient with cardiac concerns (no QT prolongation)  Wants less of a subjective sense of opioid dependence than with methadone

Probuphine    

6 mo. BUP implant; FDA approved May 2016 Subdermal surgical insertion & removal at 6-months Adverse events: implant-site reactions, BUP reactions Braeburn’s REMS program required, to reduce implant migration, expulsion & nerve damage

6-mo BUP Implant: Retention Number of Patients

120

Buprenorphine

100 80

60

Placebo

40 20 0

0

1

2

3

4

5

6 7

8

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Week

Ling, W. et al. JAMA 2010

N=17 abstinent IV heroin users pre- vs. post- 10–14 days after XR-NTX Results suggest…  limbic cue responses

 capacity for conscious self-regulation

Extended-Release Naltrexone  Month-long mu-opioid competitive antagonism per IM injection

 Why?: Oral NTX meta-analysis: 13 RCTs (N=1158) NTX-PO did not reliably  retention or abstinence rates In Canada, NTX-PO associated deaths 3-7x > methadone (Minozzi et al., Cochrane 2011; Gibson AE, Degenhardt LJ, Drug Alc Rev 2007)

 XR-NTX: must be opioid-free 7-10 days (or rapidly detoxed)  Detox causes loss of tolerance, patient must be cautioned  Buttock muscle injection: site reactions; nausea, “NTX flu”  Hepatic safety: even in chronic Hep C+ & HIV+; no black box

 No withdrawal upon treatment completion; self-tapering  Not a controlled substance; no street value  Treatment of choice for opioid + alcohol dependence

XR-NTX RCT: Abstinence, Retention, Craving

Placebo - Median days of treatment=96

XR-NTX - Median days of treatment=168

Krupitsky E et al. Lancet. 2011:1506-13

XR-NTX: For Whom?  Motivated to undergo detox & be opioid-free

 Preparing to leave rehab or jail/prison opioid-free  Monitored by judges, professional boards, employers, schools or sports teams that may not allow agonist treatment  Structure & social supports in place (however, chronicity & severity can be either mild or severe)  Rejects agonist treatment or has failed agonist treatment  Succeeded with agonist treatment & wants to conclude it  Wants shorter-term medication that can be easily concluded

 Late adolescent/emerging adult with shorter duration addiction  Has both opioid and alcohol dependence

Percent of patients with Good Clinical Response (≥ 90% urine-confirmed abstinent weeks) Baseline Predictor Variable

Clinical Global Impression Severity (CGI-S) SF-36 Mental Component EQ-5D Health Craving at Baseline HIV Sero-status

Percent of Patients with Good Clinical Response (> 90% Urine-Confirmed Abstinent Weeks) Lower Severity Higher Severity XR-NTX Placebo XR-NTX Placebo 58.6% (17/29) 39.3% (11/28)

48.5% (47/97)

29.2% (28/96)

48.4% (31/64) 27.4% (17/62)

53.2% (33/62)

35.5% (22/62)

58.0% (29/50) 34.2% (14/41) 42.7% (29/68) 40.0% (22/55)

46.1% (35/76) 60.3% (35/58)

30.1% (25/83) 24.6% (17/69)

HIV Negative 48.7% (36/74) 38.6% (27/70)

HIV Positive 53.9% (28/52) 22.2% (12/54)

Descriptive analysis of baseline predictor-by-treatment interactions, significant at p < 0.15 – ≥ 0.05. Baseline predictor variables that are continuous or count variables are dichotomized at the median split into lower and higher groups. • None of the putative predictor variables yielded significant (p<.05) interactions with treatment.

6-Month Retention on XR-NTX: 3 Studies

Health Prof’ls Study (N=48) 1-Year Safety Study (N=101)

Phase III (N=126)

Retention in Youth, Ages 15-24

# of Weeks Retained in Treatment

Naturalistic treatment data, Baltimore MD (N=92)

2.5

• = p < 0.01 vs. no meds

(Fishman et al., SAMHSA-NIDA, 2016)

Healthcare Costs with OUD Pharmacotherapies    

MMT, direct MMT, overall BUP XR-NTX

= $ 1/day = $10-20/day = $ 4-$30/day = $20-40/day

 6-mo retrospective insurance cost study: all meds + inpt + outpt services (N=10,413) casemix controlled with with instrumental variable analysis $16,752 600

$16,000

561

XR-NTX (N=156)

Oral NTX (N=845) Buprenorphine (N=7596)

400

387

397

Methadone (N=1916) 300

69

84

79

$10,049

$10,000

$8,582

$8,903

$6,000

145 100

$12,000

234 198

101

P-value vs. XR-NTX: ǂ P<0.001

$8,000

249 200

Cost per patient

Admissions per 1000 patients

500

$14,000

$4,000

93 $2,000

0

$0

Detox and/or Rehab

Inpatient Admission: Opioid-Related

Inpatient Admission: NonOpioid-Related

TOTAL COST (Per Patient Over 6 mos)

(Baser O , Chalk M, Fiellin DA, Gastfriend DR. AJMC 17: S235-S246, 2011)

ǂ

Multi-site Open RCT in CJ: Relapse

(N=308)

Week in Study

Lee JD et al. N Engl J Med 2016;374:1232-1242

Lee JD et al. NEJM 2016;374:1232-42

Mortality Upon OUD Re-entry from Prison

Relative Mortality Risk = 12x the general population

Binswanger IA et al. N Engl J Med 2007;356:157-165

Mortality Upon Re-entry from Prison • MMT & BUP  OD & death rates, BUT…rates are increasing XR-NTX has OD/death risk – due to loss of tolerance

• Re-entry in OUD: death rates  12-100X; MMT & BUP  this 3 XR-NTX RCTs in CJ: • Coviello et al., Subst Abuse 2012 (N=61/2 mos.): 0 OD deaths • Lee et al., NEJM 2016 (N=308/18 mos.): XR-NTX=0 ODs vs. TAU=7 • Springer et al., pers. comm. (preliminary N=94/12 mos.): 0 ODs/deaths; decreased HIV Viral Load

• Naloxone nasal spray or auto-injector: immediately reverses OD Should be supplied to ALL opioid users, families & 1st responders But – it is vital to then engage the patient in F/U & counseling

XR-NTX Reports in Opioid Dependence  Alkermes Sponsored/Funded Trials: Alkermes Provided Study Drug for Trials: Studies Conducted Independent of Alkermes:  Total Studies: Total Patients Treated with XR-NTX: Est’d Total XR-NTX Patient x Months:

7 3 5 15 1,683 5,719

 Reported Overdoses on XR-NTX:

4

 Reported Deaths from OD on XR-NTX:

0

Addiction Management & Treatment Most people with addiction are NOT receiving medication-assisted treatment U.S. Addicted Population (millions)

No more than 1 million Receive MAT

At Least 1.5 million Receive no Medications

MAT

Volkow et al. NEJM 2016;370:2063-2066

no Meds

Conclusions: Opioid Dependence  OUD: chronic disease needs long’l rehab, meds + counseling  Goals: save lives, stabilize behavior & build social function  FDA-approved agonists & antagonists: superior to counseling

 Patient choice may be the BEST basis for drug selection  If one agent is unsuccessful, other options should be tried  Inform patients of and offer ALL options  Cost is not a MEDICAL consideration

Myths & Ethical Conundrums  “Gold standard” = health, NOT necessarily abstinence  MAT – “Medication-Assisted Treatment”: stigmatizing perhaps should be “Medication in Addiction Treatment”?  Lifelong “Endorphin Deficiency”: little or no evidence  MMT & OBOT “long term treatment” is not the norm  Reinforcement: Critical & inadequately studied  When MVAs peaked, U.S. mandated airbags, raising car costs by $1,000; OD deaths now surpass MVAs – what can we spend?  Would we license autos that omit seat belts or headlights? Do we accredit hospitals for bypass surgery without cardiology?  If other medical/surgical specialties must report 5-year outcomes, shouldn’t addiction treatment services?  Is it ethical to mandate treatment + pharmacotherapy in CJ? Is it ethical NOT to?

“We find that all of us, as a society, are to blame, but only the defendant is guilty.”

References • Kampman K, Jarvis M (2015). ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addict Med 2015;9: 1–10. http://www.asam.org/quality-practice/guidelines-and-consensusdocuments/npg/complete-guideline • ASAM Criteria. Mee-Lee D, Editor. American Society of Addiction Medicine, 2013 • Baser O, Chalk M, Fiellin DA, Gastfriend DR (2011b). Cost and utilization outcomes of opioid-dependence treatments. Am J Manag Care. 17: S235-S246. • CSAT (2004). Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Treatment Improvement Protocol (TIP) Series 40. HHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration. • CSAT (2008). Medication-assisted treatment for opioid addiction in opioid treatment programs. Treatment Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) 08-4214. Rockville, MD: Substance Abuse and Mental Health Services Administration. • CSAT (2009). Emerging Issues in the Use of Methadone. HHS Publication No. (SMA) 09-4368. Substance Abuse Treatment Advisory, Volume 8, Issue 1. • Dennis BB, Naji L, Bawor M, Bonner A, et al. (2014). The effectiveness of opioid substitution treatments for patients with opioid dependence: a systematic review and multiple treatment comparison protocol. Systematic Reviews 3:105 • Kreek MJ, Levran O, Reed B, Schlussman SD, Zhou Y, Butelman ER (2012). Opiate addiction and cocaine addiction: Underlying molecular neurobiology and genetics. J Clin Invest 122:3387–3393. doi:10.1172/JCI60390. • Kuehn BM. 2005. Office-based treatment for opioid addiction achieving goals. JAMA. 294: 784–6. • Mattick RP, Breen C, Kimber J, Davoli M (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews, 3:CD002209 • NIDA (2012). Principles of Drug Abuse Treatment for Criminal Justice Populations: A research-based guide (NIH No. 11–5316). Rockville MD: National Institute of Health. • SAMHSA (2012). An Introduction to Extended-Release Injectable Naltrexone for the Treatment of People With Opioid Dependence. Advisory, Volume 11, Issue 1. • Weiss RD, Potter JS, Fiellin DA, et al. (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry. 68: 1238-46.