Download Ref: SAMHSA - Temple University Sites

Benjamin J. Pariser, DO
RASE Physician
Overview

This presentation will review the option of Medication
Assisted Treatment as part of a comprehensive
recovery program.
Goals

1. Understand the core principles of opioid addiction,
which are central to the rapidly growing epidemic
of opioid abuse, dependence and overdose.
2. Describe classes of medications available for
medication assisted treatment and recovery
3. Explain the role of medications as part of a
comprehensive treatment plan
Opioid Epidemic

Statistics
 Drug overdoses killed 47,000 people in the US in
2014
 130 deaths per day, on average
 29,000, or 80 per day – involved an opioid
Stigma and inadequate access to treatment are the
biggest barriers to overcoming the ongoing crisis.
Ref: A deadly crisis: mapping the spread of America's drug overdose epidemic
By Nadja Popovich; Additional development by Rich Harris.
Source: Centers for Disease Control and Prevention and the National Center for Health Statistics
Overdose Deaths

Opioid Statistics

Opioid Addiction

Medication Assisted Treatments

Medication-Assisted Treatment for Opioid Addiction (MAT):
A type of addiction treatment that involves the following:
 Provided in a certified, licensed opioid treatment program
or a physician’s office
 Provides maintenance pharmacotherapy using an opioid
agonist, a partial agonist, or an antagonist medication
 May be combined with other comprehensive treatment
services, including medical and psychosocial services.
Ref: Substance Abuse and Mental Health Services Administration (SAMHSA)
Medications

 Opioid agonist treatment
 Methadone
 Buprenorphine products
 Buprenorphine/naloxone (Suboxone)
 Buprenorphine (Subutex)
 Opioid antagonist treatment
 Naltrexone for extended- release injectable suspension
(Vivitrol)
 Naloxone (Narcan)
Methadone

 Is the most frequently used medication for opioid addiction
treatment in opioid treatment programs (OTPs)
 Is a synthetic long-acting medication
 Comes in several formulations, including oral solution, liquid
concentrate, tablet/diskette, and powder
 Is a full opioid agonist that decreases the pain-killing and other
effects of opioids
 Was never formally approved by the Food and Drug
Administration (FDA)
 Is a Drug Enforcement Administration (DEA) Schedule II drug
 Is available in outpatient treatment programs.
 Patients typically must go to appointments daily
 Potential for home use (7-30 days)
Ref: SAMHSA
Methadone

 Pros
 Very long half life
 Effective
 Liquid or tablets
 Cons




Overdose potential
Risk of fatal arrhythmias
Drug interactions
Strong Inter-patient variability in absorption,
metabolism, and relative analgesic potency.
Buprenorphine Products

 Does not activate mu receptors fully(partial agonist),
so larger doses of buprenorphine do not produce
greater agonist effects (Ceiling effect)
 Has an increased margin of safety from death by
respiratory depression when increased doses of
buprenorphine are used
 Was approved by the FDA in 2002 Is a DEA
Schedule III drug
 Can be administered in a physician’s office, OTP, or
other medical settings.
Ref: SAMHSA
Buprenorphine Products

Buprenorphine/Naloxone
 Brand names Suboxone and Zubsolv
 Is formulated as a sublingual tablet and film
 Was approved by the FDA in 2002
 Is a DEA Schedule III drug
 Is administered in a physician’s office, an OTP, or
another healthcare setting.
Why is Naloxone in Suboxone?

 Added solely to prevent IV abuse
 Naloxone is a water-soluble molecule that does not
pass through the membranes lining the mouth
 Buprenorphine is a fat soluble molecule that does
pass through the membranes of the mouth
 Neither substance takes effect if swallowed because
it is removed quickly by the liver (first pass effect)
Ref: J.T. Junig, MD, PhD
Buprenorphine

 Pros
 Less clinic attendance
 Can be prescribed in physician office – less stigma
 Ceiling effect
 Cons
 Street value
 Potential for abuse
 Difficult to adhere to the withdrawal protocol
COWS:
Clinical
Opiate
Withdrawal
Scale

Buprenorphine Protocol

Induction




Patient must be in withdrawal to begin induction
Depends on clinic protocol
Seeking dose that relieves withdrawal symptoms
The Induction Phase is the medically monitored startup of
buprenorphine treatment performed in a qualified
physician’s office or certified OTP using approved
buprenorphine products. The medication is administered
when a person with an opioid dependency has abstained
from using opioids for 12 to 24 hours and is in the early
stages of opioid withdrawal. It is important to note that
buprenorphine can bring on acute withdrawal for patents
who are not in the early stages of withdrawal and who have
other opioids in their bloodstream.
Ref: SAMHSA
Buprenorphine Protocol

Stabilization
 The Stabilization Phase begins after a patient has
discontinued or greatly reduced their misuse of the
problem drug, no longer has cravings, and experiences
few, if any, side effects. The buprenorphine dose may
need to be adjusted during this phase. Because of the
long-acting agent of buprenorphine, once patients
have been stabilized, they can sometimes switch to
alternate-day dosing instead of dosing every day.
 Seeking dose that alleviates cravings
Ref: SAMHSA
Buprenorphine Protocol

Maintenance
 The Maintenance Phase occurs when a patient is
doing well on a steady dose of buprenorphine. The
length of time of the maintenance phase is tailored to
each patient and could be indefinite. Once an
individual is stabilized, an alternative approach
would be to go into a medically supervised
withdrawal, which makes the transition from a
physically dependent state smoother. People then
can engage in further rehabilitation—with or
without MAT—to prevent a possible relapse.
Ref: SAMHSA
Buprenorphine Protocol

Medically Supervised Withdrawal
 Individualized withdrawal according to each
patient’s needs
 Ongoing counseling and development of support
network
 No set timeframe/dose reduction
 Depends on clinic philosophy
 Continual monitoring for risk of relapse
Ref: BupPractice
Buprenorphine

Subutex
 Used in pregnancy and nursing
 Risk of abuse
Naltrexone:
Vivitrol

 Is a highly effective opioid antagonist
 Approved by the FDA for maintenance treatment in 1984
 No narcotic effect and produces no withdrawal symptoms when a
patient stops using it
 No abuse potential; tolerance does not develop even after months
of regular use
 Is formulated as an oral tablet and depot injection
 Blocks the effects of heroin, morphine, and methadone
 Displaces buprenorphine to a lesser degree, but in high enough
doses overrides buprenorphine’s activity as well
 Despite its potential advantages, has had little effect on the
treatment of opioid addiction in the United States, primarily
because of poor patient compliance
 Is not on the DEA schedule
 Is available in physicians’ offices, OTPs, and other substance abuse
treatment programs.
Ref: SAMHSA
Tolerance

 Tolerance occurs when the person no longer
responds to the drug in the way that person initially
responded. Stated another way, it takes a higher
dose of the drug to achieve the same level of
response achieved initially.
Ref: National Institute on Drug Abuse (NIDA)
The Faces of Addiction

 Bridget – 26 year old female
 Lynne – 34 year old female
 George – 35 year old male
 Tracey – 23 year old female
 Bob – 24 year old male
Questions
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