Download Medication Assisted Treatment: An Introduction

Medication Assisted Treatment:
An Introduction
Deborah A. Orr, Ph.D., RN
Remington College
School of Nursing
Why is it difficult to
stop taking some drugs?
What causes the cigarette (non)
smoker to relapse?
How does the unsuccessful treatment
client feel after relapse?
• How does relapse impact the likelihood of
attempting to stop drugs again?
Goal of Medication Assisted Treatment
(MAT)
“MAT is the use of medications, in combination
with counseling and behavioral therapies, to
provide a whole-patient approach to the treatment
of substance use disorders. Research shows that
when treating substance-use disorders, a
combination of medication and behavioral
therapies is most successful. Medication assisted
treatment (MAT) is clinically driven with a focus on
individualized patient care.”
http://www.dpt.samhsa.gov/
Collaborative Treatment Approach
client/family
Medical care
counseling
Community self-help groups
Addiction is a Brain Disease
• Receptor
changes
• Neurotransmitter
changes
Addiction and the Brain
1. Drug attaches to receptors in brain ->
PLEASURE
2. Repeated drug use -> TOLERANCE
3. Absence of drug after prolonged use: ->
WITHDRAWAL
What drugs? Cigarettes, alcohol,
benzodiazepines, opioids
Other drugs target neurotransmitters
Examples: cocaine, crack cocaine,
amphetamines, methamphetamine
Stimulants
alter brain
function by
blocking
reuptake of
dopamine,
so effects of
dopamine
are
intensified.
Can’t you just taper the drugs on your
own?
Withdrawal
• What is the relationship between discomfort
from physical withdrawal symptoms
and
the ability to successfully tolerate
detoxification?
The ability to retain, process, and apply
information?
To benefit from counseling?
Substance: Nicotine
Withdrawal symptoms:
• Irritability
• Restlessness
• Sleep disturbance
• Decreased concentration
• Increased appetite
• Nicotine cravings
• Depression
• Anxiety
Treatment
• Nicotine replacement
medication (patch, gum,
etc.)
• BUPROPION (Zyban):
reduces cravings and may
help with depression
Alcohol
• Chronic, heavy alcohol consumptions depresses
the neurotransmitters GABA and glutamate
• Withdrawal creates a rebound of these
neurotransmitters
brain hyperexcitability
• Withdrawal symptoms: anxiety, irritability,
agitation, tremors, seizures, and DTs
• Alcohol withdrawal can be fatal.
Alcohol Treatment
Detoxification: medically supervised
• Main problems: seizures, hypertension, DTs
• Replacement therapy with a chemically similar
medication (phenobarbital, valium, librium or
ativan) + treatment of withdrawal symptoms
Maintenance: antabuse, vivitrol (naltrexone)
Benzodiazepines
• valium, librium, ativan, xanax
• Withdrawal can be fatal
• Withdrawal symptoms depend on amount,
frequency, duration, and half-life of the
specific drug
Benzodiazepine Withdrawal Symptoms
•
•
•
•
•
•
Severe sleep disturbance
Irritability
Anxiety
Hand tremor
Sweating
Difficulty in concentration, confusion and
cognitive difficulty, memory problems
• Dry retching and nausea, weight loss
• Palpitations, headache
• Hallucinations, seizures, psychosis, and possible
suicide
Benzodiazepine Detoxification
Medications
• Medically managed detoxification
• Usually a benzodiazepine taper + treatment of
withdrawal symptoms
• Anti-seizure medications sometimes used
when there is a history of seizures
Opioids
• Examples: heroin, morphine, dilaudid,
methadone, oxycontin, demerol
• Withdrawal Symptoms: sweating, gooseflesh,
yawning, chills, runny nose, tearing, nausea,
vomiting, diarrhea, and muscle and joint
aches
Medically-Assisted Withdrawal
from Opioids
• Relieves withdrawal symptoms while patients
adjust to a drug-free state
• Can occur in an inpatient or outpatient setting
• Typically occurs under the care of a physician
or medical provider
• Serves as a precursor to behavioral treatment,
because it is designed to treat acute
withdrawal symptoms
SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.
Replacement
Medication:
Methadone
• Must be dispensed from a licensed opioid
treatment center (methadone program).
• Pros + Cons
• Only approved treatment for pregnant opioid
dependent women (prevent fetal withdrawal)
Suboxone (buprenorphine/naloxone)
• Must be prescribed by MD
• May be inpatient or office
based
• May be for detoxification or
maintenance
• Administer the drug
sublingually for a sustained
period at a dosage sufficient
to prevent opioid withdrawal,
block the effect of illicit opiate
use, and decrease opioid
craving
Benefits of Opioid Replacement Medications
for Opioid Addiction
•
•
•
•
Better social functioning
Less risk for illegal behaviors
Less HIV risk behavior
Better able to participate in substance
abuse treatment (the brain works better!)
SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.
Treatment Regimen
• Concomitant behavioral counseling (relapse
prevention, managing triggers, increased
coping skills, etc.)
• Detox versus prolonged detox versus
maintenance
• Vivitrol (naltrexone) once opioid-free to
minimize cravings
Contraindications to Opioid
replacement therapy
• Benzodiazepine use, in particular
• Alcohol dependence
• Serious untreated de-stabilizing psychiatric
disorders
• Inability to safely store or take medication
• Repeated non-adherence to prescribed dosing
regimen
Stimulants
• cocaine, crack cocaine, amphetamines,
methamphetamine
• Chronic use depletes the “reward”
neurotransmitter, dopamine
Stimulant Withdrawal Symptoms
•
•
•
•
•
•
•
Fatigue, but insomnia
Restlessness, irritability
Loss of motivation
Depression
Difficulty concentrating
Sinus problems, headache
Cravings
Stimulants and Other Drugs
• Withdrawal danger: often used with alcohol or
benzodiazepines (which need medically
supervised withdrawal)
• No replacement medication available for
stimulant detoxification
• treatment of withdrawal symptoms
• Monitor for depression and treat as needed
Medical Stabilization Begins Treatment
• MAT makes the person less physically
uncomfortable
• Cognitive impairment caused by withdrawal is
minimized, so counseling can start sooner and
be more effective
• Counselors, client, and medical provider plan
treatment course
• Counselors support medication adherence
behavior by actively exploring barriers.
Counseling
• Initial counseling addresses highest risk
situations for safety, and relapse
• Ongoing counseling addresses triggers, as well
as the residue of addiction in the client’s
current life.
• Counseling addresses psychological issues.
• Counselors alert medical providers to
problems discovered in counseling. TEAM.
Resources
http://store.samhsa.gov/list/series?name=TIPSeries-Treatment-Improvement-Protocols-TIPS
• TIP 45: Detoxification and Substance Abuse
Treatment
• TIP 43: Medication-Assisted Treatment for
Opioid Addiction in Opioid Treatment
Programs
• TIP 42: Substance Abuse Treatment for
Persons With Co-Occurring Disorders
Questions?
Deborah A. Orr, Ph.D., RN
[email protected]
407-562-9083