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Ridgeview and the Ridgeview Continuing Medical Education Program are proud to present the Ridgeview Podcast: CME Series. Quality, portable and on-demand continuing medical education, featuring a variety of our exceptional physicians, providers and other staff from Ridgeview and it's affiliates. Hosting the program are Fred Demeuse, PA-C and Jason Hicks, PA-C. Thanks for tuning-in, downloading and listening! 

 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview & Ridgeview Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Nov 1, 2019

In this podcast, Dr. Greg Peterson, a emergency medicine physician with Ridgeview Medical Center, discusses opioid use disorder, treatments for opioid withdrawal, and the use of medical assisted therapy (MAT) for the ongoing opioid crisis.

Enjoy the podcast!

Objectives:  
  Upon completion of this podcast, participants should be able to:

  • State at least 3 facts of where we (the United States) are at with the opioid epidemic today.
  • Describe the components of medical assisted therapy (MAT).
  • Assess the potential expansion of using medical assisted therapy (MAT) into the emergency department.

CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org.

To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.

 CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.”

  

FACULTY DISCLOSURE ANNOUNCEMENT 

It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

SHOW NOTES:

In this podcast, we are discussing opioid use disorder, treatment of opioid withdrawal, and medical assisted therapy for the current opioid crisis that is ongoing.

CHAPTER 1:

The CDC noted that in 2016, a little over 2 million Americans suffer with OUD (opioid use disorder). In that same year there are around 42,000 deaths related to the opioid misuse. Interestingly, about 135,000 new heroin users after misusing mediations in 2015. Essentially, over 100 deaths daily are related to this epidemic. The stats are staggering and unfortunate.

The direct medical costs in 2016 were $12.2 billion. Indirect societal costs $9.2 billion. Total societal costs area somewhere around $80 billion.

Interestingly, less than 5% of morphine equivalents come from the ED. 

MAT is a longer-term strategy for treating patients along with counseling and psychosocial support to assist those for the propensity of misuse.  Withdrawal is treatment of acute phase sxs (n/v/d/piloerection) along with some of the more prolonged phase sxs of withdrawal include: anhedonia, depression, insomnia, decreased appetite which can last months or longer.

COWS or Common Opioid Withdrawal Symptoms is a scoring tool that allows the clinician to better assess where the patient is within their withdrawal state. The scoring system is based on 0-4/5. 4 and 5 obviously being more concerning for severe withdrawal sxs. Common sxs include: HR, dilated pupils, diaphoresis, anxiety/irritability, restlessness, joint or bone pain, GI upset, tremors, runny nose, yawning, and gooseflesh skin. Usually less than 5 - no withdrawal.  5-12 your are starting to withdrawal; 13-24 moderate withdrawal; over 24 - badness.

CHAPTER 2:

The options for treatment of pt with withdrawal can include: opioid agonist - such as methadone or buprenorphine or non-opioid medications such as: alpha-adrenergic medications - including: clonidine, antiemetics (like Zofran). Studies show these treatment options are effective for treating the withdrawal.

The medications for typical MAT use and withdrawal are the opioid agonist Methadone and Buprenorphine.  Buprenorphine is partial mu agonist and is thought of as a safer medical treatment option for withdrawal and MAT. The literature notes that their is "ceiling effect" for euphoria with the use of Buprenorphine. Typically dispensed as a tablet, sublingual film, depot injection, subcutaneous (sc patches) along with implantable. 

Buprenorphrine is compounded with Naloxone (trade name Suboxone) with is thought to be safer and less prone to abuse. If given, a person is till using opioids Suboxone can precipitate withdrawal sxs.  Withdrawal sxs are based on shorter vs longer acting opioids. Norco or Percocet are shorter time periods to withdrawal in comparison to Methadone which can take several weeks before pts experience sxs.

The Drug Addiction Treatment Act of 2000, or DATA 2000, requires clinicians to have a valid license, DEA#, and complete an 8-hour training course covering Buprenorphine and OUD treatment management.

"Warm Hand Off" is generally the PCP or ED physician and addiction specialist having a discussion directly with the patient about the next steps in their care management.

"Cold Hand Off" is streamlined referral system where social work is assisting the patient by providing resources or helping with the setup of next appointment.

CHAPTER 3:

Vivitrol comes in a 380mg dose of naltrexone that is given as an IM depot injection monthly for opioid medical assisted therapy.

The literature seems to report that MAT combined with psychosocial management is more effective than just the psychosocial therapy.  The psychosocial model by itself has a low success rate, in comparison to combined therapy.  Some studies have included that therapy + Suboxone vs solo therapy with Suboxone did not show a difference in the rates of success.

Dr. Peterson notes that proposing MAT to a medical group or hospital is complex. It requires close collaboration with addiction specialists, therapy, and social work for the continued coordination of care. Optimally, the thought is short follow-up 24-48 hrs after discharge from the clinic or Ed to addiction specialist.

CITED LITERATURE:

  1. Cisewksi, DH, Santos, S, Koyfman, A, & Long, B. (2019 Jan). Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting. Am J Emerg Med,37(1). pp. 143-150. doi: 10.1016/j.ajem.2018.10.013. Epub 2018 Oct 11.
  2. Duber HC, Barata, IA, Cloe-Ena, E, Liang SY, Ketcham, E, Macias-Konstantopoulos, W, Ryan, SA, Stavros, M, & Whiteside, LK. (2018, Oct.). Identification, management, and transition of care for patients with opioid use disorder in the emergency department. Ann Emerg Med, 72(4). pp. 420-431. doi: 10.1016/j.annemergmed.2018.04.007. Epub 2018 Jun 5.
  3. D'Onofrio G, O'Connor, PG, Pantalon, MV, Chawarski, MC, Busch, SH, Owens, PH, Bernstein, SL & Fiellin, DA. (2015, Apr 28). Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA, 313(16). pp. 1636-44. doi: 10.1001/jama.2015.3474. 
  4. Schuckit MA (2016, July 28).  Treatment of opioid-use disorders. N Eng J Med, 375 pp.357-368.  doi: 10.1056/NEJMra1604339.
  5. Sigmon SC, Bisaga, A, Nunes EV, O'Conner PG, Kosten T & Woody G. (2012, May). Opioid detoxification and naltrexone induction strategies: Recommendations for clinical practice. Am J Drug Alcohol Abuse, 38(3). pp.187-99. doi:10.3109/00952990.2011.653426. Epub 2012 Mar 12.
  6. Samuels EA, D'Onofrio, GD, Huntley K, Levin S, Schuur JD, Bart G, Hawk K, Tai B, Campbell CI & Venkatesh AK. (2019, Mar). A quality framework for emergency department treatment of opioid use disorder. Ann Emerg Med, 73(3). pp.237-247. doi:10.1016/j.annemergmed.2018.08.439. Epub 2018 Oct 11.