Wednesday, January 16, 2013

Medscape - Understanding Opioids: Part 2

Medscape Psychiatry
Understanding Opioids: Part 2

Elinore F. McCance-Katz, MD, PhD, Jeffrey N. Baldwin, PharmD, Ann Marie Schreier, PhD, RN, William T. Kane, DDS, MBA

Jan 16, 2013

Editor's NotePart 1 of Medscape's 2-part Understanding Opioids series brought together a panel of pain specialists to discuss the increasing use of long-term opioid therapy, addressing the resulting risks and how best to prescribe these agents. Part 2 reflects the broad range of medical disciplines in which opioid therapies are used, bringing together a multidisciplinary panel of clinicians to discuss their respective approaches to opioid prescribing.

The widespread use of, and need for clinician education surrounding, opioid analgesic therapies is highlighted by 2 new programs led by the American Academy of Addiction Psychiatry (AAAP) in collaboration with the American Psychiatric Association and the American Osteopathic Academy of Addiction Medicine, and funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). Using online clinical education, the Physician's Clinical Support System-Buprenorphine (PCSS-B) trains clinicians in how to best use buprenorphine to treat opioid-addicted patients, while the Prescriber's Clinical Support System for Opioid Therapies (PCSS-O) is a national initiative led by AAAP in collaboration with the American Dental Association (ADA), American Medical Association, American Psychiatric Association, American Osteopathic Academy of Addiction Medicine, American Society of Pain Management Nursing, and the International Nurses Society on Addictions, helping ensure that clinicians prescribing opioid analgesic therapy are well versed in the nuances of appropriately using these agents, careful not to withhold potentially effective medications from patients who may benefit, and attentive to any potentially abusive and/or addictive behaviors or adverse events.

Elinore F. McCance-Katz, MD, PhD, is an addiction psychiatrist and Professor of Psychiatry at the University of California, San Francisco and serves as Medical Director for both projects. Medscape recently asked Dr. McCance-Katz to moderate Part 2 in this series, herself representing the field of addiction psychiatry, with the remainder of the panel including the following representatives from the PCSS-O Steering Committee: Jeffrey N. Baldwin, PharmD, addiction educator and Professor of Pharmacy Practice and Pediatrics at the University of Nebraska Medical Center; Ann Marie Schreier, PhD, RN, Associate Professor and Director of Alternate Entry MSN at East Carolina University College of Nursing in Greenville, North Carolina; and William T. Kane, DDS, MBA, general practitioner in dentistry in Dexter, Missouri. What follows is their discussion.

The Psychiatrist

Dr. McCance-Katz: Hello everyone, and welcome to this roundtable discussion focusing on how opioids are used by clinicians from different healthcare professions.

A main focus of my work in addiction psychiatry/addiction medicine has been in the treatment of opioid addiction -- including heroin addiction and prescription opioid pain medication addiction. The opioids approved for treatment of opioid addiction are methadone or buprenorphine (but the formulation encouraged by the Center for Substance Abuse Treatment (CSAT)/ SAMHSA for use in opioid addiction treatment is buprenorphine/naloxone). When used for treatment of opioid addiction, methadone can only be dispensed from methadone maintenance programs subject to federal and state regulation. Early in treatment, daily clinic attendance is required. Buprenorphine/naloxone can be prescribed by qualified physicians who have obtained a waiver from the Drug Enforcement Administration to allow them to prescribe this medication from outpatient settings for treatment of opioid addiction. There are several criteria by which physicians can qualify for this waiver, but most physicians will qualify by obtaining the required 8 hours of approved education in the treatment of opioid addiction and clinical use of buprenorphine. (More information is available at the PCSS-B Website.)

When thinking about what medication might be best suited to an individual patient, there are several considerations. These include a discussion of patient preference as well as other factors. For example, the structure provided by a methadone maintenance program may be beneficial to those with serious medical or mental illness because it allows for daily staff contact, which may be needed by some.

Similarly, those with polysubstance abuse or who may have difficulty safely handling opioids as outpatients can benefit from methadone maintenance programs that require daily attendance until there is evidence that progress is occurring in treatment and that opioid abuse has stopped or is substantially diminished. Buprenorphine/naloxone may be more helpful to opioid-dependent people who have concomitant medical or mental illnesses that could be treated by the same physician who is also treating the opioid addiction -- in my case, it is possible for me to offer treatment for mental disorders and opioid dependence.

The ability to treat medical or mental illness in addition to opioid addiction improves the care of those patients by simplifying treatment that can be provided by one clinician in one setting. Those who require medications for concomitant conditions may have fewer drug-drug interactions with buprenorphine than have been observed with methadone. For example, there is a larger number of drug interactions in which methadone concentrations are either increased or decreased with the potential for opioid toxicity or withdrawal, respectively, when administered with certain HIV medications than occurs with these medications and buprenorphine.

Other considerations include the amount of social support available, with those lacking social supports potentially benefitting from the structure of the methadone program. There is evidence that maintenance treatment is more effective than medical withdrawal (detoxification), so I discuss that option as part of a conversation about treatment options for opioid dependence. This is not to say that everyone should receive opioid maintenance therapy; rather, every patient should be evaluated for their needs as well as to obtain their input on which treatment they would like to receive (depending, of course, on what is available in their community).

Continue reading @ Medscape

The Psychiatrist
The Pharmacist
Useful Tips and Resources
The Nurse
Is the Prescription Appropriate?
And, Finally, Dentists

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