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Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole and joining me today is Dr. Leah Leisch, she's an assistant professor in the departments of medicine and psychiatry at UAB Medicine. And she's joining me to examine medication assisted treatment for opioid dependency, Dr. Leisch, welcome back. It's such a pleasure to have you join us again. I'd like you to kind of set the table for us about some of the short term and long-term effects of opiates on the body and some of the side effects how they affect the brain and the body? And what do we know now that maybe we didn't know? Only a few short years?

Dr Leah Leisch: Right. Thank you so much for having me, we know so much more about the long term effects of opioids now than we did a few years ago. We now know that over time opioids can actually make the body more sensitive to pain. And so patients on high doses of opioids are using high doses of opioids. Recreationally, can have more pain than they would have if they were off of them sometimes. We also know that long term opioids can be associated with thinning of the bones or osteoporosis, like we normally see in elderly women, as well as in some patients with adrenal insufficiency and immunosuppression.

And so we've, really learned so much about the side effects, unfortunately, because they were medicines that we started people on so long ago, and now we're just sort of catching up and seeing those effects in the short term we know opioids cause constipation, they can cause sedation. They can cause respiratory depression. And that information hasn't changed much in the past few years.

Melanie Cole (Host): So then what had been the parameters or guidelines for prescription of opioids and what's the latest information regarding best practices as of now, and then we're gonna get into addiction and medication assisted treatment for that. But what are the best practices that we know now?

Dr Leah Leisch: Right. So the past few years have seen quite the shift in opioid prescribing guidelines. Most of us recall that in 2016, the CDC released what are now somewhat infamous guidelines about best practices for opioid prescribing, which were fairly restrictive. And while those might be best practices for patients, who've never been on opioids since we know opioids have drastic long-term effects. They really negatively impacted patients who were already on opioids and there was a lot of deprescribing that harmed patients because the effects of withdrawal are so profound.

And so the CDC is actually working on updated guidelines to try and be a bit more patient centered and individualized in how they recommend it. And so at present, there's still a recommendation that we should do our best to avoid initiating long-term opioid therapy and patients who've never been on them. But for those who are already on them, To be more cautious in our tapering attempts and more patient centered in whether we do or do not taper the CDC has also removed, or may remove the guidelines aren't quite out yet some of the specific ONE oral morphine equivalent guidelines.

So previously they had said maybe not prescribe above 200, really think about less than 90. And so now instead, what they're saying is, okay, here are some of the risks of doses above 90. Here are some of the risks of doses above this, and just recommending that you try and do your best to weigh the risks and the benefits.

Melanie Cole (Host): Well, that's a great point you just made because there is still a place for them in patient pain management. But so I'd like you to tell us about. Addiction and dependence really dependence. And what is the medication assisted treatment? What's changed since we spoke the last time?

Dr Leah Leisch: Right. So when we speak specifically about dependence versus addiction versus misuse, it's important that we kind of clarify those terms. And so everyone who's been on everyday opioids will be dependent. What we know from a variety of studies is that somewhere around 20% of patients maintained on long term opioid therapy will develop adamant behaviors, meaning they might have a urine drug screen with unexpected results. They might run out of their medicine early or something like that. But that doesn't mean that 20% of patients develop opioid use disorder or addiction.

And so it might be an isolated episode where there's dependent behavior and not a pattern. So when we speak about substance use disorders or addiction, we differentiate between misuse in a substance use disorder. And a misuse is that sort of isolated event that may happen now may happen six months from now, but isn't happening in a pattern. Substance use disorder is actually a psychiatric diagnosis that you use the DSM five to help diagnose. And there are 11 criteria and patients have to meet two or more of those in the past 12 months to be diagnosed with a substance use disorder.

And then when. Speak about in particular opioids, we clarify that they meet those criteria for opioids. And those 11 criteria I won't really list through them now because you can find them easily online. And they're in the DSM five and they're a bit long to just spit out, but essentially they reflect has the patient developed a lot of craving for opioids? Are they using despite consequences in their life? And has their use of opioids got out of their control, meaning have they tried to cut back or quit? And they can't despite their best efforts.

And you're, looking for the patient to meet at least two. And then depending if they meet two to three it's mild opioid use disorder, four, five it's moderate, and then six or more is severe opioid use disorder. And in regards then if you diagnose your with an opioid use disorder in regards to options for treatment, the most life saving treatment is to get them on a medication for opioid use disorder. I won't speak a ton about counseling today, mostly because the literature is back and forth on whether or not counseling has an impact in more mortality.

That's not to say that there's not benefits of counseling. There are certainly benefits in counseling. that individual studies have shown, but when we take studies as a whole and look at them, trying to decide what impact the counseling had versus medications, patients who receive medications, even without counseling are still far more likely to survive than patients who are not. And so we're really emphatic about getting as many patients as possible on medications for opioid use. So that they can continue to live.

And when we think about options for medications, for opioid use disorder, and you'll notice that the nomenclature has changed, sorry, I didn't even mention that. So we used to call it M A T medication assisted treatment, and now we call it M O U D or mild medications for opioid use disorder. And that's because the majority of addiction specialists don't feel like counseling is per se, it shouldn't be something that prevents people from getting medication. So in the past, if patients couldn't participate in counseling, we would say, well, the medication's just an assistance to your counseling.

And so if you can't afford counseling or you can't access counseling, you shouldn't be on medicine. And what we now know is that even in the absence of counseling, there's some benefit of medicine, in keeping patients alive. And so we've changed it to medications for opioid use disorder. There are still just three FDA approved medicines for opioid use disorder. One is naltrexone. That's a medicine that blocks the muod opioid receptor. It doesn't give any activation or make the person feel high. In fact, it just blocks it completely.

Which means that if they were to use an opioid like heroin or fentanyl, or even a prescribed opioid, they would not feel its effects at all. So patients stop using opioids because it's, just a waste of money and it's not rewarding. Secondly, the second medication for opioid use disorder is, methadone. So methadone has been approved for this since the 1970s. It is an agonist of a muod opioid receptor, meaning it activates that receptor similar to heroin or fentanyl, which have activity at that receptor. However, it's very slow onset, slow acting.

And so it tends not to be misused in the same way that some of the other fast acting opioids. That being said, if you take enough methadone, you can get respiratory suppression and death. And so, because it carries a little bit of risk with it is only dosed through federally registered opioid treatment programs. Locally these are often called methadone clinics. At those clinics, patients have to go once a day, every day. For at least the first three months. If all their drug screenings are consistent and they're participating in counseling, they can sometimes get, take home doses after the first three months.

But it is a therapy that involves a fair amount of work on the patient's part. And unfortunately, locally in Alabama, particularly in Jefferson County access to methadone clinics can be somewhat difficult.. A few months ago, two or three methadone clinics were full and weren't taking any. and so that's something that the state is working on to improve access to because some patients benefit more from methadone than from the others. The third medication for opioid use disorder is buprenorphine. Buprenorphine was the most recently approved. However, even that was approved back in 2000, actually I think it was approved in 1998.

And then the Data 2000 Act allowed providers to prescribe it in an outpatient. so any provider who has an X waiver can prescribe buprenorphine for the treatment of opioid use disorder, buprenorphine is a partial agonist at the mu opioid receptor. Meaning that if you give more of the buprenorphine, you get more activation of the receptor only to a certain extent. Then after higher doses, even the higher doses don't make the receptor anymore activated. And so patients are less likely to have respiratory suppression or death on buprenorphine.

In fact, on therapeutic doses of buprenorphine, there's not reported cases of buprenorphine only fatalities. There's only been some overdoses in the setting of couse of buprenorphine with alcohol or benzodiazepines, other respiratory suppressants. And so if you're using buprenorphine, not prescribed doses, your patient should not have fatal respiratory suppression. Since it is safer, we're allowed to prescribe it through outpatient clinics using our X waivers. One of the major changes in the past year has been physicians used to be required to have eight hours of training in order to get that X waiver.

You no longer have to have those eight hours of training. You simply have to go to the SAMHSA, the Substance Abuse and Mental Health Society of America, S A M H S A, website. And if you, simply Google, SAMHSA, buprenorphine waiver, the website for it will come up and all you need is your DEA, its expiration date and the address it's registered to. And the process of getting that X waiver to treat up to 30 patients takes all of three minutes. And so we're really trying to encourage every provider out there who has a DEA to just go ahead and get that X added that way.

If you ever have a patient walk in your door, you don't have this emergency where you want to get them started on Mo U D, but you don't have the waiver. so that has been the major change that has been helpful.

Melanie Cole (Host): Wow. You are just a wealth of knowledge, Dr. Leisch. That was just such excellent comprehensive answer. And thank you for letting other providers know what's involved in prescribing these medications for opioid use disorder. I'd like you to wrap it up your best advice, which you would like other providers to take away from this updated podcast today. And when you would like them to know that they can refer to the specialists and the experts like yourself at UAB Medicine?

Dr Leah Leisch: I think the big takeaways I would love people to know is that these medicines absolutely save lives. Patients with opioid use disorder, not on medication, have a standardized mortality ratio of about six. When you get them on medication that comes down to just under two. they not only save lives, they've been shown to decrease illicit drug use, decrease criminal activity, improve employment, and many other social measure. And time matters. Patients who are started on medications for opioid use disorder shortly after an overdose are more likely to be on it later than patients who are just referred without being started on medicine.

And so every provider out there needs to be prepared to start a patient on medications for opioid use disorder. At that moment that they first encounter the healthcare system. So I'd like every provider to go ahead and get that X waiver, get knowledgeable about the three FDA approved medicines for opioid use disorders. You can talk to patients about it.. And then if you're not comfortable managing a patient with opioid use disorder long term, it's perfectly fine to refer to addiction care then, it's just important that, that initial care not be delayed. We wouldn't do that for other life threatening conditions, like a heart attack or DKA. And we shouldn't do that for opioid use disorder.

Melanie Cole (Host): What an excellent guest you are. Dr. Leisch thank you so much for joining us today and really sharing your incredible expertise and professional information today. It's such an important area for the country right now. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB- MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.