Expanding and Improving Treatment

Challenges and Next Steps

Marc Fishman MD

Outline
Limitations of current practice
The general health care connection
The criminal justice system
connection
Youth treatment
Building a better treatment
continuum
Next steps

Relapse prevention medications

The standard of care

These are the standard of care:

Methadone
Buprenorphine
Extended-release naltrexone

If only it were that easy

Limitations to current
practice

Relapse prevention medication

Is the standard of care
But not everyone knows it yet

Persuading patients
Persuading families
Persuading criminal justice system
Persuading SUD providers, especially
residential treatment
Persuading payers
Persuading the recovery community

Linkages from residential/inpatient

treatment
Detox without relapse prevention
medication is unfortunately typical
But inpatient treatment would be an
ideal opportunity for medication
induction

Limitations and unintended

consequences

Medication diversion
Dropout
Substandard practice
Over-promising

Duration of treatment?
Is there an optimal duration?
Evidence so far suggests longer is
better, but care should be
individualized
Retention under real world conditions
is problematic
No reason to suppose pre-imposed
limitations helpful

The criminal justice

connection

XRNTX vs TAU in criminal justice

population

Lee et al. Extended-Release Naltrexone to

Prevent

XRN
TX

TA
U

Median time to
relapse (wks)

10.5

5.0

Opioid neg, 24
wks

74%

56
%

Opioid neg, 78
wks

46%

46
%

Overdose

Fatal overdose 0

Agonist Rx

37

11%

The general healthcare

connection

Hospital initiation of buprenorphine

Well established effectiveness for treatment

seeking pts
What about promotion of treatment upstream
at the motivational moment of medical
80 prevent readmission?
hospitalization to
70
60
50
40
30
20
10
0

Bupe
linkage
72

64
38
12

15

17

Liebschutz et al. JAMA Internal

ED initiation of
buprenorphine
What about promotion of treatment
in the Emergency Dept?
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

Referral
BI+referral
BI+linkage

DOnofrio et al. JAMA. 2015;313(16):1636-

Youth Treatment

Young adults highest prevalence

Non-medical prescription opioids

NSDUH, 2014

Young adults highest prevalence

Heroin

Features of youth opioid

treatment
Family leverage (or not)
Pushback against sense of parental
dependence and restriction
Developmental barriers to treatment
engagement
Invincibility
Immaturity
Salience of burdens of treatment

Prominence of co-morbidity

Retention bup treatment

young adults vs older adults

Family Framework
Treatment often not family friendly,
considerations of confidentiality and
presumed independence
Both families and youth need a recipe
for treatment, with role definitions,
expectations, and responsibilities.
Family mobilization Medicine may
help with the receptors, you still have
to parent this difficult young person

Building a better
treatment continuum

Providing a full continuum of

care
Inpatient detoxification and
stabilization
Short term residential treatment
Long term residential treatment
Day treatment / partial
hospitalization
Assisted living support for outpatient
treatment (IOP plus/ PHP plus)
Recovery housing

Linking patients to medical

care
Embedding medical care in addiction
specialty settings
Embedding opioid treatment for
stable patients in general medical
settings
Medical home models

Linking patients to
psychiatric care
Embedding psychiatric care in opioid
specialty settings
Embedding opioid treatment for
stable patients in mental health
settings
High intensity subspecialty
integrated care models for unstable
patients

Next steps

Next steps
Medication pipeline

Buprenorphine implant Probuphine

Steady, slow release delivery, 6 months
duration

Injectable extended release

buprenorphine
Easier initiation of XR-NTX
More potent antagonists
Prevention of stress related relapse

Next steps
Treatment matching and sequencing
Who should get what and when and
in what order?
What are the important
characteristics for matching?
Responding to trajectory
Relapse
Continuous monitoring for early warning
signs

Additional supports
Responding to struggling patients
Routinely and rapidly

Direct medication administration

7 day services: weekends and evenings
Case management services
Family and peer supports
Housing services
Assertive outreach for extended
engagement
Flexible movement up and down a full
continuum

Young adults
Opioid Negative UDS (absent imputed as pos)

100
90

80

*
*

Percent

70
60
50
40
30

Opioid UDS (NTX)

20

Opioid UDS (SBX)

10
0

*p<.05

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Treatment Weeks

Vo et al. Relapse Prevention

Medications in Community
Treatment for Young Adults with

At a crossroads
A national crisis
A proven set of both old and new tools
But alarmingly poor level of dissemination and
adoption, lack of coherent deployment
A call to action:
Expand access
Integrate care
Combine with other tools in a full continuum
Improve effectiveness and retention under real
world conditions

We have an obligation to do better!

Weve come a long way

But we have a long way to

Contact
Marc Fishman MD
Johns Hopkins University
Maryland Treatment Centers /
Mountain Manor
mjfishman@comcast.net