Saturday, September 28, 2013

A Call for Evidence Based Treatment (in Addiction)

A Call for Evidence Based Treatment

Dr. Bohdan Nosyk

-health economist with a research focus on substance abuse and infectious disease

Presented at the Canadian Society of Addiction Medicine Annual Meeting, Vancouver, BC 2013. These are my rough notes which only give a jist of the wealth of information presented. Dr. Nosyk has contributed to many papers and his slides were excellent often taking graphs from the research he’d published elsewhere. I hope that these notes though will direct someone to where they might find information they are looking for as well as give some idea of the depth and breadth and controversies in this area.

key recommendations
eliminate financial barriers
increase acces to office based
reduce reliance on detox treatment
evaluate integrate new technologies
increase surveillance, evaluation of quality of care

Background Epidemiology
US 2.3 million with opioid dependence 
75-125,000 injection drugs users; 200,000 people with prescription opioid dependence
Opioid overdose second leading cause of accidental death in US - surpassed only by MVA
In ontario deaths related to PO doubled

Treatment Options

Methadone still more effective and less costly than buprenorphine

Nosyk et al, Am J of Epidemiology 2009
Primary finding was that patients with multiple treatment tended over time to stay in treatment and morbidity and mortality
Tends to be a pattern of increasing length of time in treatment

Abstinence durations were longer folllowing sustatined treatemn versu incarceration.  Paitents with multiple abstience episodes tend to go onto abstinence

OST has been deemed highly cost effective if not cost saving
often the cost of tratemnt are more than offset by recuction in acquisitive crime and use of health resourcs realted to transmission of HIV or Hep C

Diacetylmorphine - NAOMI  - trial 
Nosyk et al, CMAJ 2012 
all the benefits were derived from the longer retentions and 85% , when they relapsed the crime went up and health went down

DAM cohorts - NAOMI cost-effectiveness
Nosyk et al CMAJ 2012

If you have ‘retention benefit’ to treatment you will be cost effective

Eliminating financial barriers to treatment
Canada - universal health care - medications covered to varying degrees - relaxing constraints on the availability, length of take-home doses could reduce costs to clients who pay for their own pharmacy services
Other benefits - increase access to clients in rural areas, allow patients who have demonstrated stability greater freedom to participate in family life and employment

Regulations in place to prevent diversion is the primary argument - ‘the argument is moot if it is only provided under direct observation in a pharmacy or clinic”
-given pharmacological properties, methadone is less subject to abuse and less desirable to other readily available opiates

Mortality due to methadone overdoses cited as another barrier - increases in overdose are largely from methadone prescriptions for pain,
Undue restrictions on prescribind medications counter production

Weekend training and methadone certification programs for GPs
Lower mainland, greater toronto - vast increases in access, indications of satisfied demand
but elsewhere - waiting lists from 2 weeks to 12 months , St. John 12 month, Montreal, 6 to 12 months, Manitoba 6-12 months, BC waitlists problems outside lower mainland

Availability of buprenorphine BP-NX and their inclusion in drug formularies - several provinces have allowed coverage under special authority
-good idea to allow as secondary option to Methadone

Opioid Detoxification
  • most people relapse after detoxification
  • alot of tapering and desire to taper
  • longer tapers have higher odds of success - 12 to 52 weeks versus 12 weeks)
  • 4x more likely to succeed
  • tapers taking more than a year 7x more likely

5% for week for tapering is clinical guideline

Best to decrease by stepped every 2 to 4 weeks

Extended vers Short term Buprenorphine - Naloxone for treatment of Opioid Addicted Youth
  • treatment was far better than taper

Mortality among regular or dependent users of heroin and other opioidsL a systematic review 
  • people are more likely to die outside of treatment by 2.8 factor
  • Degenhard - Drug Alcohol Dependence 2009- 
  • Mortality among clients of a state wide opioid pharmacotherapy program over 20 years  and lives saved

Analysis of OST outcomes in publicly funded clinicisn in Calirofornia 1991 to 2011
-total unique individuals 200,000 plus
-every time they reentered detox - likelihood of success decreased
-every contact with methadone maintenance program - tended to stay longer

Current emphasis on detoxification needs to be addressed
-clients desire unlikely to change
-practitioners should obtain and sign release showing they ahve been advised of risk

New developments
 Injectable morphine
injectable heroin

Buprenorphine Implants for Treatment of Opiod dependence
  • Rosenthal et AL, ADDICTION, 2013
  • - promising 

Naltrexone - was done in russia where methadone illegal
-high proportion of confirmed abstinence
-long acting antagonist - what do you do if your client in car accident with legitimate need for opiate

Need for data collection to improve quality of care

BC Pharmanet, Popdata BC - gold standard

6 patterns of dosing noted in research

-difficulty of giving buprenorphine and methadone in aboriginal communities

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