Objectives
OpioidUseIssues:
AllthePlayers
Afterreview,theparticipantwillbeableto:
1)Identifycriteriaforopioidusedisorders
2)Understandthecomplexityoftheopioidissueinourcommunities
AndrewJ.McLean,MD,MPH
MedicalDirector,NDDepartmentofHumanServices
Chair,DepartmentofPsychiatryandBehavioralScience
UNDSchoolofMedicineandHealthSciences
PamSagness,Director
BehavioralHealthDivision
NDDepartmentofHumanServices
Lestweforget
Alcohol
Tobacco
Marijuana
Stimulants/methamphetamine/cocaine
Synthetics
Hallucinogens
Huffing
PsychiatricDisorders-generalrules
Symptoms
Duration
Impactonfunctioning
Notbetterexplainedbysomethingelse…
3)Discusswaysinwhichcommunitiescanreducetheburdenofthis
illness.
Whatareopioids?
Opiates- drugsderivedfromopium.
Opioids- termpreviouslyusedtodescribesyntheticopiates.
Nowitiscommontorefertoallas“opioids.”
OpioidUseDisorders:
1.Opioidsareoftentakeninlargeramountsoroveralongerperiodthanwas
intended.
2.Thereisapersistentdesireorunsuccessfuleffortstocutdownorcontrol
opioiduse.
3.Agreatdealoftimeisspentinactivitiesnecessarytoobtaintheopioid,use
theopioid,orrecover
fromitseffects.
4.Craving,orastrongdesireorurgetouseopioids.
5.Recurrentopioiduseresultinginafailuretofulfillmajorroleobligationsat
work,school,orhome.
6.Continuedopioidusedespitehavingpersistentorrecurrentsocialor
interpersonalproblemscaused
orexacerbatedbytheeffectsofopioids.
7.Importantsocial,occupational,orrecreationalactivitiesaregivenupor
reducedbecauseofopioid
use.
8.Recurrentopioiduseinsituationsinwhichitisphysicallyhazardous.
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OpioidUseDisorders,cont…
9.Continuedopioidusedespiteknowledgeofhavingapersistentor
recurrentphysicalorpsychologicalproblemthatislikelytohavebeen
causedorexacerbatedbythesubstance.
10.Tolerance,asdefinedbyeitherofthefollowing:
a.Aneedformarkedlyincreasedamountsofopioidstoachieve
intoxicationordesiredeffect.
b.Amarkedlydiminishedeffectwithcontinueduseofthesame
amountofanopioid.
Note:Thiscriterionisnotconsideredtobemetforthosetakingopioids
solelyunderappropriatemedicalsupervision.
11.Withdrawal,asmanifestedbyeitherofthefollowing:
a.Thecharacteristicopioidwithdrawalsyndrome
(refertoCriteriaAandBofthecriteriasetforopioidwithdrawal).
b.Opioids(oracloselyrelatedsubstance)aretakentorelieveoravoid
withdrawalsymptoms.
Note:Thiscriterionisnotconsideredtobemetforthoseindividuals
takingopioidssolelyunderappropriatemedicalsupervision.
Whytheneedtoreview:
Howdidwegethere?
Focusonmanagementofnon-cancerpain
OpioidUseDisorders,cont…
Inearlyremission:Afterfullcriteriaforopioidusedisorderwerepreviouslymet,
noneofthecriteriaforopioidusedisorderhavebeenmetforatleast3months
butforlessthan12months(withtheexceptionthatCriterionA4,“Craving,ora
strongdesireorurgetouseopioids,”maybemet).
Insustainedremission:Afterfullcriteriaforopioidusedisorderwerepreviously
met,noneofthecriteriaforopioidusedisorderhavebeenmetatanytimeduring
aperiodof12monthsorlonger(withtheexceptionthatCriterionA4,“Craving,or
astrongdesireorurgetouseopioids,”maybemet).
Specifyif:
Onmaintenancetherapy:Thisadditionalspecifierisusediftheindividualistaking
aprescribedagonistmedicationsuchasmethadoneorbuprenorphineandnone
ofthecriteriaforopioidusedisorderhavebeenmetforthatclassofmedication
(excepttoleranceto,orwithdrawalfrom,theagonist).Thiscategoryalsoappliesto
thoseindividualsbeingmaintainedonapartialagonist,anagonist/antagonist,ora
fullantagonistsuchasoralnaltrexoneordepotnaltrexone.
Inacontrolledenvironment:Thisadditionalspecifierisusediftheindividualisin
anenvironmentwhereaccesstoopioidsisrestricted.
Whytheneedtoreview,continued…
Whatdowecalltheproblem?
ACrisis?“asituationthathasreachedacritical
stage”(Webster’s)
Marketingbypharmaceuticalcompanies
AnEpidemic?(regionalcontagion)
APandemic?(global)
worldhydrocodoneuse
(2010)
Risk-benefitratiobasedoninadequateinformation
Newsupplyanddemand-changebackto“street”
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CDC
Community-TheGiftofTogetherness
MedicalCommunity
§Educationofhealthcarestudentsandprescribers
§CenterforDiseaseControlPrescribingGuidelines
§PrescriptionDrugMonitoringPrograms
§PractitionerBoardrecommendations
§MAT(MedicationAssistedTreatment)
RecentCDCGuidelines
Voluntary
PrimaryCarefocus
ChronicPain(painlastingpast3months,orpast
thetimeofnormaltissuehealing.)
MedicationAssistedTreatment
(MAT)forOpioidUseDisorder
REPLACEMENT
Buprenorphine(sublingual,
buccal,implant)
With/withoutnaloxone
Canbeclinic-basedwith
specialproviderDEAnumber
BLOCKADE
Naltrexone
(dailyoral,ormonthly
injection)
MethadonerequiresanOpioid
TreatmentProgram
environment
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TreatmentandRecovery
Community
PharmacyCommunity
Access
InadditiontotheMedicalCommunitycomments,
Education
MedicationTakeBackPrograms
MATaspartofTreatmentandRecoveryCommunity
Community
Workplace
Education
Safety
Consumerexpectationsforpainmanagement
Recognitionofissues
Reductionofstigma
Support
Housing
SocialDeterminantsofHealth
Corrections/LawEnforcement
OverdoseTreatment
Education/Training
AccesstoNaloxone(opioidreversal):
Treatment
LawEnforcement
AlternativestoIncarceration
Paramedics
DrugCourts
Public
4
Legislature
Messaging
“GoodSamaritan”laws
AccesstoNaloxone
Fundingforeducationandtreatment
HOPE
Questions?Comments?
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