Download MEDICATION ASSISTED TREATMENT* OPTIONS FOR OPIATE

MEDICATION ASSISTED
TREATMENT for OPIATE
DEPENDENCY
WHAT WORKS?
SHELLEY ASKEW FLOYD, MS
DIRECTOR OF PHARMACOTHERAPY SERVICES
PYRAMID HEALTHCARE, INC.
1
OBJECTIVES:
1.
Understanding the importance of
medication assistance treatment(MAT) in a
LICENSED, CERTIFIED opioid treatment
program as a viable strategy to overdose
prevention
2.
Provide current listing of opioid treatment
options available
3.
Present challenges and benefits of each
2
Pharmacotherapy~
The combined use of medication and
psychotherapy in a treatment facility.
Why is this important?- medication
complements psychosocial
supports/therapy by quieting the brain so
counseling can work without the need of
the dependent drug…
3
Who regulates methadone treatment facilities:
Substance Abuse and Mental Health Services
Administration (SAMHSA)
Drug Enforcement Agency
Department of Drug & Alcohol Programs
-PA Chapter 715
Accreditation Entities (i.e.CARF, JCAHO)
4
History of MAT
Late 19th- Early 20th Century
Public perceptions was that Addiction WAS NOT A DISEASE
Saw increased use in 1950’s and 1960’s (morphine/heroin)
Early 1970’s Addiction IS A DISEASE
Methadone treatment in OTP begins
5
SO WHAT DO WE WANT?
6
Effective medication assisted treatment has the
following desired outcomes:
~Prevention of the onset of subjective/objective signs of
opioid abstinence syndrome for at least 24 hours (post acute
withdrawal)
~Reduction or elimination of drug craving routinely
experienced by the patient
~Blockage of the euphoric effects of any illicitly acquired
self administered drug without the patient experiencing or
observers noticing undesirable effects
7
WHAT ARE THE CHOICES?
Traditional agonist therapy medications
Methadone & Buprenorphine
AND
Naltrexone
Antagonist therapy medication
8
WHAT IS THE DIFFERENCE?
9
Agonist-a chemical that binds to a receptor and
activates the receptor in the same way as opioid
drugs.
Partial Agonist-activate receptors by stimulating the
dopamine reward pathway.
Antagonist-binds to opioid receptors but rather than
producing an effect, they block the effects of
opioids.
10
Methadone (Full opioid agonist)-never formally approved by
the FDA but most commonly used for treatment
Buprenorphine (Partial agonist)- Two formulas containing
buprenorphine were approved by the FDA for use in the US in
Oct 2000. Subutex® (buprenorphine only) and buprenorphine
w/naloxone (Suboxone®). Both can be prescribed in a
certified physician’s office and now in a LICENSED,
CERTIFIED ClINIC
Naltrexone(Antagonist)- Revia® approved in 1984.
Vivitrol® was first approved by the FDA for the treatment of
alcohol dependence 2006. It received subsequent approval
by the FDA for the use of opioid treatment in Oct 2010.
11
HOW DO YOU CHOOSE?
H
12
The first couple of weeks after opioid detox is the
most vulnerable period for relapse and overdose.
No 1 shop fits all in the treatment of opioid
dependence. The intervention must fit individual
need based on:
-Symptoms
-Length of dependence
-Medical History & complexities
-Setting/location of the program
-Individual ability & desire to change
13
GUIDELINES FOR CONSIDERATION
14
Consider Methadone first when:
History of addiction is severe to moderate > 18-24 months
~Current physiologically dependence and at least one year
prior physiologically dependent
~2 documented attempts at short term treatment within 12
months prior to seeking admission
~Pregnant (physiologic dependency requirement waived)current standard of care
~Inadequate psychosocial or recovery supports, e.g. safe and
stable housing, supportive family, employed/in school, etc.
15
Methadone Continued:
~Recent documented overdose
~Recently released from prison/jail environment with history
of MAT treatment prior to incarceration
~Not successful in adhering to Buprenorphine treatment
program requirements
~Age 18 years and above
16
Methadone continued:
Benefits:
~Used for the treatment of pain
~Highly regulated in OTP’s
~Daily monitoring with gradual “freedom” (take homes)
Drawbacks:
~Narcotic
~Can be addictive physiologically and/or physically
~Precipitated withdrawal if discontinued abruptly
~Drug interactions
17
Consider Buprenorphine first
History of addiction moderate to mild > 12-18 months
~Unable to access a methadone treatment clinic or
difficulty adhering to scheduled hours for dosing
~Documented severe, uncontrollable adverse effect or true
hypersensitivity to methadone
~Not dependent or abusing Central Nervous System (CNS)
depressants, including benzodiazepines and alcohol
18
Buprenorphine continued:
~Does not have a history of multiple treatment
attempts and relapses, except those with multiple
detox attempts and relapses
~Mental health disorder, if present, is stable, e.g.”
no emotional, behavioral or cognitive conditions
that would complicate treatment
~
19
Buprenorphine continued:
~No prior adverse reactions to buprenorphine or
naloxone or taking medications that might adversely
interact
~Pregnant women may be good candidates (not label indicated)
~Age 16 years and above
20
Buprenorphine continued:
Benefits:
-More conducive to an engaged lifestyle
-Most insurances cover medication and counseling
-Counseling requirements
Drawbacks:
-Diversion issues
-Multiple doses
-Minimum oversight
-Counseling requirements
-Payer requirements
21
Consider Vivitrol® when:
History of addiction mild or special populations < 12-18
months
~Not interested in methadone or buprenorphine
~Abstinent from opioids 7-10 days prior
~Recovery environment/psychosocial circumstances
sufficiently supportive and stable
~Mental health disorder, if present, is stable, e.g.” no
emotional, behavioral or cognitive conditions that would
complicate treatment
22
Vivitrol® continued:
~Exclude acute hepatitis or liver failure
~Not dependent on or abusing Central Nervous System (CNS)
depressants, including benzodiazepines and alcohol
~Easier to use in residential settings after detox from opioid
Benefits:
~Monthly injection
~Non-addictive
~Not a narcotic
~Will not precipitate withdrawal when
discontinued
23
Vivitrol® continued:
Draw backs:
~Strongest effects are in the first three weeks
~Must be opioid free for 7-10 days
~Individuals transitioning from buprenorphine or
methadone may be vulnerable to precipitated
withdrawal up to two weeks
~Cost $800-$1000 per monthly injection
24
As cute as he may be….he is still there
25
Benzodiazepine use in MAT
If an individual is benzodiazepine dependent,
consider detoxification first and/or work with
prescriber for consideration of alternative
medications/ approaches.
26
Challenges to MAT:
~Profit motives
~Harm Reduction vs. Drug Free models
~Diversion issues
~Individual not consistently taking medication
~Individual not participating in therapy
~Medical complications
~Stigma- “drug replacement therapy”
~LIFE-no treatment option is guaranteed!
27
MAT should continue as long as the patient
desires and derives benefit from treatment.
There should be no fixed length of time in
treatment.
28
…resolution with a final result.
Webster dictionary defines that as completion or in
the world of addiction a CURE. We haven’t gotten
there yet!
Therefore, an individual may need multiple
attempts to get it right as different stressors (or
even the same stressors as before treatment) may
return.
29
WITHOUT TREATMENT WE HAVE ZERO
CHANCE AT RECOVERY &
PREVENTION!!!
I BELIEVE IT IS SAFE TO SAY-WE HAVE
WITNESSED THE ALTERNATIVE!
30
PYRAMID HEALTHCARE, INC. offers MAT in the
following locations:
Pyramid Pittsburgh Outpatient (Suboxone®/Methadone),
Pyramid Pittsburgh Inpatient/Detox (Suboxone®/Methadone)
Pyramid Southside Outpatient (Suboxone®/Vivitrol)
Foundations Medical Services, LLC (Methadone/Suboxone®*)
Pyramid Dolminis (Methadone)
Altoona Outpatient (Suboxone®/Vivitrol®**)
Duncansville Inpatient/Detox(Suboxone®/Vivitrol®/Methadone)
Chambersburg Outpatient (Suboxone®)
York Pharmacotherapy Services (Suboxone®/Methadone)
Today Inc. Inpatient (Vivitrol®)
*-Self pay only
**-Must be started in inpatient first
31
Coming Soon:
Allentown Outpatient (Suboxone®/Vivitrol®)
Hillside (Vivitrol®)
Call 1-888-694-9996 FOR MORE
INFORMATION & REFFERAL
32
References:
Substance Abuse and Mental Health Services Administration
(SAMHSA) website, about medication assisted treatment
http://www.dpt.samsha./gov
SAMHSA Treatment Improvement Protocol #43 & #40
Community Care Behavioral Health decision tool algorithm
on the use of medication assisted treatment
Alkermes prescribing information packet for Vivitrol®
Federal Guidelines for Opioid Treatment Programs
33
THANK YOU
&
QUESTIONS
34