Download medication assisted addiction treatment:appropriate use

MEDICATION ASSISTED
ADDICTION TREATMENT:
“APPROPRIATE USE”
DAS Quarterly Provider Meeting
Louis E. Baxter, Sr., M.D., FASAM
Medical Director-DAS
President Elect
American Society Addiction Medicine
GOALS & OBJECTIVES
•
•
•
•
•
•
Review comprehensive evaluation components
DSM-IV-TR diagnosing
Review full treatment planning
Patient Placement – ASAM PPC-2
Treatment of Co-occurring Disorders
Medication Assisted Therapy for detoxification,
maintenance, and pain management
ADDITIONAL RESOURCES
• CSAT TIP # 43 Buprenorphine Therapy
• CSAT TIP # 45 Detoxification and Substance
•
•
Abuse Treatment ***
National Quality Forum – “Evidence Based
Treatment Practices for Substance Use
Disorders”
ASAM’s Monograph – “Achieving Treatment
Success in Alcohol Dependence”
COMPREHENSIVE
EVALUATION COMPONENTS
•
•
•
•
•
•
•
•
•
•
“Chief Complaint” …why are you here?
Alcohol Use History … Screening Tool (CAGE)
Drug Use History … Rx, Illicit, and OTC
Previous Treatment History … include Clergy
Previous Psych History … admissions and OP
Legal History
Past Medical / Surgical History / Medications
Family History … Psychiatric and Substance Use
Marital History
Psychosocial History … Employment / Clubs/ Hobbies
DIAGNOSES
• DSM-IV-TR Criteria for Substance Use
Disorders
– Use disorder; Abuse; Dependence (Addiction)
• DSM-IV-TR Criteria for Psychiatric Disorders
– Depression; Bipolar; Anxiety
• Laboratory Data Documentation of Medical
Disorders
– Chronic pain; Seizure; Migraines; HIV/AIDS; Liver
disease
• National Quality Forum Guidelines (2005)
– Evidence-based Best Practices for SUD
FULL TREATMENT
PLANNING
•
•
•
•
•
•
•
Assessment – Diagnosis
Detoxification – Medical Maintenance
Rehabilitation – Counseling
After / Continuing Care – Twelve Step Program
Co-occurring Illness Care
Pain Management Care
General Medical Care
APPROPRIATE LEVEL OF
CARE
• ASAM Patient Placement Criteria-2
– Only peer reviewed beta tested tool for patient
placement
• Level 0.5 … Brief Intervention (3-6 sessions)
• Level I … Traditional Outpatient (Individual)
• Level II … Intensive Outpatient (group therapy)
•
•
three to five 90 minute sessions weekly
Level III … Residential (Medically supervised)
Level IV … Hospital based (Medically managed)
TREATMENT WORKS
• Full Treatment Experience
(Detoxification; Rehabilitation;
Maintenance)
– General Population recovers @ 77% @
1yr
– Detoxification & Rehab Only @ 33% @ 1yr
– Detoxification Alone @ < 10% @ 1 yr
TREATMENT OUTCOME
COMPARISONS
• Alcoholism … 50-70% abstinent
• Opioid Dependence … 50-80% abstinent
• Cocaine Dependence … 50-60% abstinent
• Nicotine Dependence … 20-40% abstinent
• Diabetes (relapse) … 30-50% stable
• Hypertension (poor control) … 50-60%
• Asthma (multiple ER visits) … 60-80%
(Gaber, Davidson, 1992; McLellan 2002)
MEDICATION ASSISTED
THERAPIES
• Medications for detoxification
• Medications for maintenance
• Medications for psychiatric illnesses
• Medical management of pain
MEDICATIONS FOR
DETOXIFICATION
• Librium … Alcohol and Benzodiazepine detoxification
• Benzodiazepine & Phenobarbital … Benzodiazepine
•
•
•
•
detoxification
Suboxone (Subutex) & Methadone …Opiate
detoxification
Clonidine & Naltrexone … Opiate detoxification
Bromocryptine & Amantadine … Stimulant
detoxification
Wellbutrin … Cannabis detoxification
MEDICATIONS FOR
MAINTENENCE
•
•
•
•
•
•
•
Buprenorphine ….Opiate dependence
Methadone … Opiate dependence
Acamprosate … Alcohol dependence
Naltrexone … Alcohol and Opiate dependence
Vivitrol .......... Alcohol dependence
Disulfram … Alcohol dependence
Nicotine Replacement …Nicotine dependence
STATUS OF ALCOHOL
TREAMENT
• More Treatment Options than ever before
• New medications and psychosocial approaches
• Guidelines for use of medications in “actively using”
•
•
•
alcohol patients and “patients in recovery”
Treatment in outpatient and primary care settings
ASAM Levels I and II
Medications help promote and sustain recovery
Problem … Less than 1/5 of facilities are using new
pharmacotherapy (barriers?)
• Need to engage physicians to move forward in
pace with the new developments in alcohol
treatment
MEDICATIONS FOR ALCOHOL
DEPENDENCE FDA APPROVED
• Disulfiram … aversion therapy
• Oral Naltrexone … reduction in craving
• Injectable Naltrexone … compliance
• Acamprosate … reduction in cravings and
prolonged withdrawal syndromes
DISADVANTAGES OF
MEDICATION THERAPY
• “Use in lieu of” full treatment experience
• Burdensome regimes and side-effects
may undermine commitment to recovery
• Poor medication selection … must meet
patient needs
• Premature discontinuation of
medications (need to match with patient’s
recovery status)
ADJUNCTIVE MEDICATIONS
• SSRIs ………… Affective Depressant Disorders
• Buspar ……… Anxiety Disorders
• Benzodiazepines (Oxazepam, Librium, Klonopin) …
in special psychiatric cases (GAD, Panic Disorder,
Agoraphobia)
• Phenothiazines ... Affective Disorders
(Schizophrenia)
• Lithium ……… Major Depression
• Trazadone … Insomnia
• Other Medications for Medical Problems under
medical supervision
MEDICATIONS FOR PAIN
MANAGEMENT
•
•
•
•
•
•
•
•
•
NSAIDs … at maximum dosages ATC
Methadone … in combination with NSAIDs
Buprenorphine in combination with NSAIDs
Neuroleptics … in combination with other meds
SSRIs … have been shown to be useful
Clonidine … for neuropathic pain
Clonazepam … for lancinating pain
Baclofen …for central nervous system pain
LONG Acting Narcotics …. medical supervision
SPECIFIC PROTOCOLS
• PREGNANT OPIOID DEPENDENT
PATIENTS SHOULD NOT BE
DETOXIFIED
– The treatment of choice is METHADONE
MAINTENANCE
– BUPRENORPHINE … 2,4,6,8 OR 16 MG
FOR Detox and Maintenance (postpartum)
TREATMENT ISSUES
• Mobile Medication Van … multiple
communities
• Needle Exchange Program
• Mobile Methadone and Buprenorphine
• New Drug Protocols … Peer Review-Control
Group Studies
SUMMARY … THE
BEGINNING
• Addiction treatment is growing up
• Pharmacotherapy has arrived
• Pharmacotherapy is not in lieu of
traditional therapy
• Pharmacotherapy is an integral part of a
“full treatment experience”
• Pharmacotherapy is not for everyone
• The need for pharmacotherapy should not
lead to exclusion from treatment programs