Four developments helping address the opioid epidemic

As the opioid epidemic continues across the U.S., new treatment programs and guidelines could help reverse the trend.

That’s according to Christopher M. Jones, PharmD, MPH, director of the division of science policy at HHS. Jones presented the session, “Treating Opioid Use Disorder and Reversing Opioid Overdose,” at the Academy of Managed Care Pharmacy (AMCP) Nexus 2016 in National Harbor, Maryland, on October 4.

Jones

Jones started his presentation by discussing drivers behind the epidemic and top risk factors. He then identified the following programs and developments that could help get things back on track.

1. New CDC guidelines. Until recently there were no national, up-to-date guidelines regarding the risks, benefits, and appropriate use of prescription opioids, said Jones. That changed in March, when the CDC released national guidelines and recommendations.

The recommendations include:

· Non-opioid treatments should be preferred for chronic pain.

· Prescribers and patients should establish treatment goals before starting opioid therapy.

· Prescribers should start with the lowest dose.

· Prescribers should evaluate benefits and harms within one to four weeks; and at least every three months thereafter.

· Prescribers should incorporate risk mitigation strategies and consider naloxone for patients at increased risk for overdose.

· Prescribers should check prescription drug monitoring data when starting treatment and periodically thereafter.

2. Abuse-deterrent properties/FDA labeling. The FDA is encouraging the development of opioid formulations with abuse-deterrent properties to help combat the epidemic. These abuse-deterrent properties make it harder to abuse the medication (such as making it difficult to dissolve it in order to inject it).

Jones cited the following products with FDA abuse-deterrent labeling:

· Oxycodone (OxyContin)

· Oxycodone/naloxone (Targiniq ER)

· Morphine/naltrexone (Embeda)

· Hydrocodone (Hysingla ER)

· Mophine (MorphaBond)

· Oxycondone/naltrexone (Troxyca ER)

Next: Medication-assisted treatment

3. Medication-assisted treatment. Medication-assisted treatment (MAT) is one component of comprehensive treatment of opioid use disorder. To be of maximum benefit, evidence-based behavioral therapy and case management services must also be provided, said Jones. “It’s important to meet every patient where they are with the right product that works for them,” he said.  

Currently, three medications are approved by the FDA for MAT: methadone, buprenorphine, and extended-release injectable naltrexone (approved by the FDA for the prevention of relapse to opioid use after detoxification).  

· Methadone. Methadone can only be dispensed in an opioid treatment program, said Jones, noting that there are about 1,400 programs across the country. “We are now moving toward a universe where all states have them,” he said. Still, he said, many of these programs are in urban areas, which can make it hard for some patients to get treatment.

· Buprenorphine. Buprenorphine has few interactions with HIV or HCV meds, can be used in pregnancy, does not require detoxification, and has generics available, said Jones. It requires a physician prescriber (NP/PA under the Comprehensive Addiction and Recovery Act) with appropriate training.

· Extended-release injectable naltrexone. This is a monthly injection, and patients must be medically detoxed first, said Jones. Naltrexone cannot be used in patients who require opioids for pain. It is relatively expensive but covered by many state Medicaid plans, and it can be prescribed by anyone licensed to prescribe it in their state, he said.

Innovative new programs--such as Vermont’s Care Alliance for Opioid Dependence, the Massachusetts Collaborative Care Model in Community Health Centers, and ED-initiated buprenorphine programs-show promise in helping expand patient access to opioid abuse or misuse treatment, said Jones.

These programs emphasize tactics such as screening and treatment referrals, care coordination, and enhanced communication between primary care physicians and specialists.

4. Naloxone. This opioid antagonist reverses potentially fatal respiratory depression associated with opioid overdose, said Jones. It has no abuse potential and is available in multiple formulation: injection, intranasal, and auto-injector.

Naloxone provides pharmacists the opportunity to engage patients in conversations around opioid safety and risks and to take a more active role in addressing opioid abuse, he said.

Almost all states have naloxone access laws, with most focused on the ability to have standing orders and using pharmacy as the primary distribution for naloxone, said Jones. “State level policy has really been changing on naloxone very quickly.”

Jones said the following patients are good candidates for naloxone:

· Patients with a prior history of overdose;

· Patients receiving medical care for an opioid overdose;

· Patients who inject drugs;

· Patients with opioid use disorder; and

· Patients released from criminal justice system with a history of opioid abuse.