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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 “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) 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.