Substance Use Disorder Your Role as the Clinical

Substance Use Disorder: Your Role as the Clinical Pharmacist and Overcoming Barriers to Treatment Kimberly Baker MSN, RN, CARN Joan Mapel, Pharm. D

Objectives ● Differentiate between dependence and addiction and recognize the initial symptoms of SUD ● Promote early identification of, and access to, hospital resources for patients with SUD ● Validate the importance of strong community alliances and emphasis on wellness for patients with SUD

Substance Use Disorder (SUD) ● Exact definitions vary depending on source ○ American Psychiatric Association: “A condition is which there is uncontrolled use of a substance despite harmful consequence” ○ DSM-IV*: “A cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems” ○ SAMSHA: “Recurrent use of alcohol and/or drugs causing clinically significant impairment” *Note: DSM-V updated criteria for substance use disorder, but the definition has not been changed from DSM-IV

DSM-5 Criteria for Substance Use Disorder ● Assess symptoms ● 1 point for each symptom ● Add up score

SUD: Dependence vs. Addiction ● Addiction- compulsive drug use despite harmful consequences 1 ○ NOT a preferred term, has fallen out of scientific use ○ Associated with stigma ● Dependence- physical changes relating to continued use of a substance ○ Withdrawal symptoms often seen upon discontinuation

Substance Use Disorder: Who Has It? ● 2019 estimates: 20. 7 million Americans aged 12+2 ○ Alcohol use disorder: 71. 1% ○ Illicit drug use disorder: 40. 1% ○ Both alcohol and drug use disorder: 11. 18% ● Only 1. 5% of people with a substance use disorder received treatment in the past year

Substance Use Disorder and COVID-19 ● COVID-19 caused challenging conditions ○ Social isolation, financial hardships ○ Disrupted access to care or less structured care ● US: September 2019 - August 2020 = 88, 295 predicted deaths 3 ○ 27% more deaths than the previously 12 -month period ○ Monthly deaths from March to May 2020 grew by ~50% ● PA: ~22. 9% increase in overdose deaths from January-August 2019 to January-August 20203

How Stigma Leads to Barriers ● Prevents people from seeking treatment 4 ○ User- fear, embarrassment, belief that treatment is not necessary ○ Healthcare professionals- emotionally challenging, fear for safety ● Recovery is more difficult 5 ○ Insurance coverage/affordability, economic issues, travel concerns ● Biases - both implicit and explicit ○ Avoid words such as clean or addict

Terms to Use and Avoid Instead of this. . . Use this. . . Addict, Junkie, Drunk Patient, person with substance use disorder Former addict Person in recovery Abuse Use, misuse Clean In recovery, not using

Steps to Helping Patients In-patient ● Identify patients that want to make a change ○ Any sort of “change talk” should be supported ● Implement motivational interviewing to determine: ○ Readiness ○ Reservations ○ Driving factors ● Give patients resources that are appropriate for their specific next steps in change

What if Someone Does Not Want to Change? ● Ask the patient why they don’t want to make any changes ○ Denial ○ Minimization ● Ask if you can discuss benefits of behavioral change but be direct ○ Health ○ Personal life ○ Legal concerns

Harm Reduction ● Practical strategies aimed at reducing negative consequences associated with drug use ○ “Meet someone where they are at” ○ Community example- clean needle exchanges, pill test kits ○ Hospital example- naloxone to opioid patients at discharge ● Pittsburgh area resources ○ Prevention Point: https: //www. pppgh. org/ ○ PA Harm Reduction Coalition: https: //www. paharmreduction. org/

But What if They DO Want to Change? ● ● ● Discuss the why Ask them what has worked Ask what their confidence is that they can make these changes Ask about what resources they think would be helpful Ask about other factors that may be contributing to their substance use

The Resources Available ● For patients actively wanting to change consider the following resources: ○ Self-help meetings ○ Family support meetings ○ Out-patient treatment options ● For patients who don’t want to change their substance use behaviors ○ Offer a list of resources available for their future use

Naloxone Saves Lives ● Offer to patients despite where they are in the change process ● Even if patient does not use it, a family member or friend may • FDA Released Statement: “FDA recommends health care professionals discuss naloxone with all patients when prescribing opioid pain relievers or medicines to treat opioid use disorder. Consider 6 prescribing naloxone to those at increased risk of opioid overdose. ”

Clinical Usage of Naltrexone ● Naltrexone is an opioid antagonist used for the treatment of opioid and alcohol use disorder. It is available in a tablet form (Revia®) and as an intramuscular injection (Vivitrol®). ○ Some advantages of using naltrexone over other treatment options: ■ Naltrexone does not have a risk of abuse ■ Naltrexone is not a controlled substance and can be prescribed more easily ○ Some disadvantages of using naltrexone: ■ Patients cannot begin naltrexone until 7 -10 days after their last opioid dose due to severe withdrawal symptoms ■ Patients on naltrexone may become more sensitive to opioids after Naltrexone treatment is discontinued. Patients should be made aware of this increased risk of overdose.

Differences in Dosage Forms ● Vivitrol® ○ Advantages: Monthly injection -> better adherence ■ Significantly less first-pass hepatic metabolism compared to oral ■ Side effects are mostly mild Disadvantages: ■ More expensive than oral formulation ■ Injection site reactions are common ■ Must be prepared and administered by a licensed healthcare provider ● Revia® ○ Advantages: ○ Tablet form Affordable Preferred for patients who do not want to take injections ■ No negative adverse effects seen with long term use Disadvantages: ■ Adherence has shown to be lower for oral naltrexone ■ Users reported an increase in suicidal ideation when using Revia® ■ ■ ○

Self-Help Meetings ● AA Meetings ○ National AA Hotline: 1 -212 -870 -3400 ○ Pittsburgh AA: www. pghaa. org/meetings ■ Search for meetings in or around Pittsburgh via zip code ■ 24 -hour Phone: 412 -471 -7472 ○ National website: www. aa. org/pages/en_US ■ Lists AA meetings around the US by zip code

Self-Help Meetings ● NA Meetings ○ National NA Hotline: 1 -818 -773 -9999 ○ National NA Meeting search: www. na. org/meetingssearch/ ■ Search by state or area code ● SMART Recovery ○ www. smartrecoverytest. org/local/ ○ Search by zip code to find an online or in-person meeting

Meetings for Family Support ● Al-Anon: ○ http: //pa-al-anon. org/meetings/ ○ Search by zip code ○ Also offer virtual meetings currently ● Nar-Anon: ○ www. nar-anon. org/find-a-meeting ○ Search by zip code ○ Also offer virtual meetings currently

Website Searches ● Choose website ○ https: //findtreatment. gov ○ https: //findtreatment. samhsa. gov ○ https: //apps. ddap. pa. gov/gethelpnow/Care. Provider. aspx ● Choose search criteria ○ Narrow by treatment type, cost, age, language, special populations, MAT options ○ Search for SUD, mental health treatment, of both

Additional Resources ● Call 1 -800 -662 -HELP (4357) ○ Walks person through treatment options based on what they are looking for *These resources are where practitioners could begin to set-up out-patient treatment for their patients prior to discharge*

Other Resources ● Find naloxone ● https: //www. overdosefreepa. pitt. edu ● Bridge 2 Hope o https: //bridge 2 hope. org/ ● Allegheny County 24 -hour Crisis Line ○ 1 -888 -7 -YOU-CAN (796 -8226)

Patient Case Patient MM, 41 yo male admitted for encephalopathy secondary to recurrent alcohol misuse ● Clear pattern of alcohol misuse ● ○ Prior hospital admissions ○ Chronic cirrhosis of the liver ● Unclear psychiatric history ○ Per mother, no previous mental health diagnoses ○ Presentation in hospital (+) for paranoia, hallucinations, etc.

Inpatient Steps Unclear if this person wants to change their alcohol use ● Begin discussions with patient about positive effects of changing their usage ● Use motivational interviewing to assess patients willingness to change ● Begin to find resources that may be helpful for patient ●

AA Resources ● Patient’s zip code: 15017 ● Print a list for this patient or give him this website https: //www. pghaa. org/meeting

Family Resources ● Patient’s mother is very involved with care and plans to take patient home with her ● Give her this list from Al -Anon for support resources for family members http: //pa-al-anon. org/meetings/

Treatment Resources ● Patient’s zip code: 15017 ● Two closest facilities ● Could further filter based on needs and treatment options https: //findtreatment. gov/results

In Summary… ● ● ● Substance use is a DISORDER, that should be treated like any other health condition a patient is admitted with Take time to talk with your patient about their use and stage of change Let the patient lead conversations and come to change on their own Offer resources both for groups and treatment Offer resources to family members if appropriate

References 1. National Institute on Drug Abuse. Is there a difference between physical dependence and addiction? 2020, Dec 2. https: //www. drugabuse. gov/about-nida/organization/cctn/clinical-trials-network-ctn 2. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP 20 -07 -01 -001, NSDUH Series H-55). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2020. 3. Baumgartner JC, Radley DC. The spike in drug overdose deaths during the COVID-19 pandemic and policy options to move forward. https: //www. commonwealthfund. org/blog/2021/spike-drug-overdosedeaths-during-covid-19 -pandemic-and-policy-options-move-forward. 4. . Rapp et al. Treatment barriers identified by substance abusers assessed at a centralized intake unit. J Subst Abuse Treat. Apr 2006. 30(3). 5. Mojtabi et al. Comparing Barriers to Mental Health Treatment and Substance Use Disorder Treatment among Individuals with Comorbid Major Depression and Substance Use Disorders. J Subst Abuse Treat. Feb 2014. 46(2) 6. U. S. Food and Drug Administration. (2020). Drug Safety Communication (Drug Safety Communication). https: //www. fda. gov/drugs/drug-safety-and-availability/fda-recommends-health-care-professionalsdiscuss-naloxone-all-patients-when-prescribing-opioid-pain.