Download Medication Assisted Treatment in Adolescents

MAT Overview
NCBH Learning Community
November 23, 2015
Arthur Robin Williams MD MBE
American Academy of Addiction Psychiatry
Division on Substance Abuse
Department of Psychiatry, Columbia University
New York State Psychiatric Institute
SUD Treatment Options
Family
Therapy
Level of Care:
- Outpatient
- Individual
- Program
- Residential
- Inpatient/
Hospital
Other
Psychotherapy
- CRA
- RPT
-TSF
Behavioral
Patient
- CBT
- MI/MET
- CM
- AA/NA
- Self-help
- Smart
Recovery
Medications
(MAT)
SUD Treatment Options
Family
Therapy
Level of Care:
- Outpatient
- Individual
- Program
- Residential
- Inpatient/
Hospital
Other
Psychotherapy
- CRA
- RPT
-TSF
Behavioral
Patient
- CBT
- MI/MET
- CM
- AA/NA
- Self-help
- Smart
Recovery
Medications
(MAT)
- Detoxification
- Aversion
- Anti-Craving
- Substitution
11 Symptoms of Addiction
- Excessive amounts used
- Excessive time spent using/obtaining
- Craving or urges to use
- Unsuccessful attempts
to cut down
- Tolerance
- Withdrawal
- Hazardous use despite
- Health problems
- Missed obligations
- Interference with activities
- Personal problems
Targeting Symptoms
- Excessive amounts used
- Excessive time spent using/obtaining
- Detox taper
(Librium or
Methadone)
- Craving or urges to use
- Unsuccessful attempts
to cut down
Medication
s
(MAT)
- Hazardous use despite
- Health problems
- Missed obligations
- Interference with activities
- Personal problems
- Tolerance
- Withdrawal
(not all substances)
Targeting Symptoms
-Aversion
(Antabuse)
- Anti-Craving
(Naltrexone)
- Excessive amounts used
- Excessive time spent using/obtaining
- Craving or urges to use
- Unsuccessful attempts
to cut down
Medication
s
(MAT)
- Hazardous use despite
- Health problems
- Missed obligations
- Interference with activities
- Personal problems
- Tolerance
- Withdrawal
(not all substances)
Targeting Symptoms
- Excessive amounts used
- Excessive time spent using/obtaining
- Craving or urges to use
- Unsuccessful attempts
to cut down
-Substitution
(methadone or
buprenorphine)
Medication
s
(MAT)
- Hazardous use despite
- Health problems
- Missed obligations
- Interference with activities
- Personal problems
- Tolerance
- Withdrawal
(not all substances)
SUDs and Co-Occurring Disorders:
Assessing Causality
SUD
COD
COD
SUD
SUD
COD
SUDs and COD
 Diagnosis may require collateral from multiple
sources: i.e. timeline for symptom onset
 Worse consequences from SUDs at treatment
intake and poorer long-term outcomes
 Yet most programs (and clinicians) either focus
only on the SUD or the COD !
MAT
• Currently, the FDA has approved medications for
adults for the treatment of addiction to:
– Opioids
– Alcohol
– Nicotine
Evidence-Based Addiction
Psychopharmacology (MAT)
 The FDA approves medications after trials with adults
demonstrate efficacy and safety
 Typically trials exclude subjects under 18 years, dually
diagnosed, pregnant women, hindering
generalizability
 Efficacy v. Effectiveness
 Thus far, none approved for cannabis or stimulants
Background: OUD Neurochemistry
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“Opioids” include synthetic pain pills and heroin
“Opiates” are natural opioids like opium or morphine
Opioids activate mu, delta, kappa receptors
In OUD, receptors are unstable when not activated
Unstable receptors lead to:
 Withdrawal symptoms
 Intense cravings
 Great risk, such as overdose death
 Injection adds infectious disease (HIV, Hepatitis C) and injuries
Background: MAT for OUDs
 Receptors are stabilized with MAT medications
 Patients on MAT experience fewer and less intense
cravings and use drugs at much lower rates
 MAT is the gold standard for OUD treatment:
 Reduces drug use
 Protects against overdoses
 Prevents injection behaviors
MAT: Opioids
 Detoxification
 Is not a treatment on its own (risk factor for OD)
 Should be a mechanism to get someone on MAT
 Maintenance
 Agonist (methadone) or partial agonist (buprenorphine)
 Antagonist Therapy
 Naltrexone pill or xr-naltrexone (Vivitrol) injection
Clinical Opioid Withdrawal Scale
(COWS)
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Increased pulse
Sweating
Restlessness
Pupil dilation
Bone/joint pain
Runny nose/tearing
GI upset
Tremor
Yawning
Anxiety/irritability
Gooseflesh
 Higher score= worse w/d
MAT: Opioids
Detoxification
• Buprenorphine and Methadone better than clonidine
Maintenance for 2+ years
• Use sufficient dose bup >8mg, methadone >100mg
• Buprenorphine more likely to successfully lead to
Naltrexone afterward
• Pregnant women should continue on maintenance
given risks of relapse, withdrawal, and overdose
following attempted taper
Buprenorphine: Pregnancy
Lund, et al. 2013
MAT: Opioids
Antagonist therapy
• Naltrexone daily pill (low adherence rates) or Vivitrol
injection given every 3-4 weeks
• “Blockers” prevent euphoric/rewarding drug effects
• Can satisfy cravings
• Does NOT cause an “aversion reaction”
• Naloxone (Narcan) reverses overdoses and only lasts
20-40 minutes
XR-Naltrexone: Hard to find
Krupitsky, et al. 2011
 Opioid-free weeks (Krupitsky 2012)
Alcohol
 Neuropathology
 Anti-glutaminergic
 Potentiates GABA
 Dopamine release
MAT: Alcohol
Detoxification (Youth typically binge drink and rarely require)
• Use benzodiazepines, phenobarbital
• Outpatient v. inpatient models
Aversion
• Antabuse 250mg or 500mg daily (FDA 1951)
• Start after all alcohol has cleared
• Can dose on site or have observer at home
• Effects for up to 2-3 weeks for some
• Consider as an adjunct to psychosocial therapies
• Monitor liver function every 1-3 months
MAT: Alcohol
Anti-Craving
• Campral 666mg TID (FDA 2004)
– Stabilizes neuroexcitability in protracted withdrawal
– Dosing is problematic (but no side effects)
– Better choice for patients with liver disease
• Naltrexone 50mg daily (NTX) (FDA 1994)
– Reduces number of drinks per drinking day and cravings
– Side effects limited (nausea/sedation)
– LFTs should be followed intermittently (every 3 months)
• Vivitrol 380mg IM (XR-NTX) (FDA 2006)
– Long acting monthly injection of naltrexone
Summary: Opioids
 MAT includes 3 modalities:
 Methadone (schedule II)
 Buprenorphine (schedule III)
 Naltrexone (not controlled)
 MAT should be provided in addition to intensive
psychosocial and behavioral therapy
 Most patients require MAT for a minimum of 1-2 years
of sobriety before attempting to taper
Summary: Alcohol
 MAT includes
 Antabuse (disulfiram) 250mg or 500mg daily
 Naltrexone 50mg daily or monthly Vivitrol injection
 Acamprosate 666mg PO TID
 Dosing should be observed by family or program
 Check liver function regularly if on naltrexone or
Antabuse
References
 Bekkering, G. E., et al. (2014). "Practitioner review: evidence-based practice guidelines
on alcohol and drug misuse among adolescents: a systematic review." J Child Psychol
Psychiatry 55(1): 3-21.
 Bergman, B. G., et al. (2014). "Young adults with co-occurring disorders: substance use
disorder treatment response and outcomes." J Subst Abuse Treat 46(4): 420-428.
 Bush DM, W. D. (2014). "Update: Drug-Related Emergency Department Visits Involving
Synthetic Cannabinoids." Drug Abuse Warning Network. Substance Abuse and Mental
Health Services Administration, Center for Behavioral Health Statistics and Quality.
October 16, 2014.
 Friedman P, et al (1994). Retention of patients who entered methadone maintenance
via an interim methadone clinic. J Psychoactive Drugs. Apr-Jun; 26(2):217-21.
 Gray KM, Carpenter MJ, Baker NL, DeSantis SM, Kryway E, Hartwell KJ, McRae-Clark AL,
Brady KT. A double-blind randomized controlled trial of Nacetylcysteine in cannabisdependent adolescents. American Journal of Psychiatry. 2012;169:805–812.
 Kaminer, Y., et al. (2010). "Psychotropic medications and substances of abuse
interactions in youth." Subst Abus 31(1): 53-57.
References
 Krupitsky, et al. (2012). Randomized Trial of Long-Acting Sustained-Release
Naltrexone Implant vs Oral Naltrexone or Placebo for Preventing Relapse to
Opioid Dependence. Archives General Psychiatry. Sep; 69(9):973-81.
 Lund IO et al. (2013). A comparison of buprenorphine + naloxone to
buprenorphine and methadone in the treatment of opioid dependence during
pregnancy: maternal and neonatal outcomes. Subst Abuse 7:61–74, 2013.
 Moore, S. K., et al. (2011). "Improvement in psychopathology among opioid-dependent
adolescents during behavioral-pharmacological treatment." J Addict Med 5(4): 264-271.
 Niederhofer, H. and W. Staffen (2003). "Acamprosate and its efficacy in treating
alcohol dependent adolescents." Eur Child Adolesc Psychiatry 12(3): 144-148.
 Niederhofer, H. and W. Staffen (2003). "Comparison of disulfiram and placebo in
treatment of alcohol dependence of adolescents." Drug Alcohol Rev 22(3): 295-297.
 Scherphof, C. S., et al. (2014). "Short-term efficacy of nicotine replacement therapy for
smoking cessation in adolescents: a randomized controlled trial." J Subst Abuse Treat
46(2): 120-127.
 Simkin, D. R. and S. Grenoble (2010). "Pharmacotherapies for adolescent substance use
disorders." Child Adolesc Psychiatr Clin N Am 19(3): 591-608.