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A Look at Opioid Maintenance Therapy Nicole Lemieux MLS (ASCP)cm, PA-S 1 Objectives • 1. Define opioid maintenance therapy. • 2. Recognize limiting factors to opioid maintenance therapy. • 3. Discuss the pros and cons of methadone, buprenorphine, and naltrexone. • 4. Identify laboratory testing to monitor opioid maintenance therapy. 2 Opioids 3 • Class of medications that reduce the signaling and processing of pain pathways http://www.pharmacytimes.com/publications/issue/2011/june2011/an-overview-of-opioids Opioids • Prescribed across the board • Primary care #1 • For pain after surgery, trauma, or diseases associated with life limiting pain • Common examples: morphine, codeine, fentanyl, hydrocodone, oxycodone 4 Opioid Misuse • The nontherapeutic use of opioids • Taking in amounts not prescribed • Using alternative routes of administration • Obtaining illicitly 5 Opioid Epidemic • 400,000 people a month abuse heroin • 4 million people a month abuse prescription opioids • Per CDC, 44 people die each day from overdose 6 Opioid Epidemic • Risks for misuse • • • • • Come in early for refills “Doctor Shop” Personal or family history of substance abuse Psychiatric comorbidities History of sexual abuse as preadolescent 7 Opioid Epidemic • NOT just a street drug epidemic 8 Risks associated with Opioid use • • • • Tolerance – need increased doses to reach the same effects Next is dependence and withdrawal Overdose Death • Respiratory distress • Cardiac events (MI, dysrhythmias, sudden cardiac arrest) • Risks increase with increased doses 9 Opioid Epidemic • Trickle down effects • Crime • Leading to incarceration • Infections diseases • HIV, Hepatitis C • Increased mortality and morbidity • Trauma, suicide, infectious diseases 10 Treatment Options • Detox • Medications • Opioid Maintenance Therapy 11 Opioid Maintenance Therapy • AKA: Opioid agonist, agonist replacement therapy • Prescribing a maintenance dose of a legal opioid in lieu of illegal opioid • Two drugs commonly used – Methadone, Buprenorphine • Goal: Avoid illicit drug use, NOT to be drug free 12 Methadone 13 • First to be used • Opioid Agonist • Mu receptor agonist • Given orally • Short half – life • Needs daily dosing http://www.methadoneaddiction.com/side-effects-of-methadone-use/ Methadone • Prescribing • Physicians must have specialized training and certification • Must be at a specialized clinic • Minot – first methadone clinic in North Dakota opened fall of 2016 14 Methadone Pros 15 Cons • Tried and true • Geographical limitations • Relatively cheap • Poor Patient Preference • Swapping drugs • Addictive • Worry about discontinuing Buprenorphine • Newer • Created to combat methadone’s limitation • Partial agonist/antagonist • Agonist of delta and opioid like receptor 1, partial agonist at mu receptor • Antagonist of kappa receptor • Given sublingually • Dosed 2-3 days or weekly 16 https://www.opiates.com/blog/buprenorphine-opiate-used-treat-addiction/ Buprenorphine • Prescribing • Physicians and Advanced Practice Provider (NP, PA) with certification • In North Dakota – 18 registered certified providers 17 Buprenorphine Pros 18 Cons • Less geographical limitations • Provider limitations • Not daily dosage • Overdose possibilities • “Safer” - Ceiling effect • Poor patient preference • Decreased mortality • Higher cost of medication and private clinics • Similar efficacy/retention as methadone • Used to discontinue methadone Naltrexone 19 • Used to remain opioid free • Used for alcohol dependence • Opioid antagonist • Binds to mu receptor and blocks opioid effects • Two forms: Oral (1984) injectable (2010) http://theinfluence.org/pushing-naltrexone-as-the-answer-to-our-heroin-problems-is-unscientific-and-unethical/ Naltrexone • Prescribing – no limitations! • North Dakota – check with your pharmacy 20 Naltrexone Pros 21 Cons • No limitations to prescribers • Not widely known • Injectable and implantable forms • Expensive • Patient preference • Poor oral compliance and retention • Safer? • Used to discontinue methadone or buprenorphine Drugs of Abuse Testing • Urine specimen of choice • Ease of collection • More concentrated than serum • Other specimens: hair, nails, meconium, saliva, breath • Start with screen, move unto confirmatory if needed • Used to check compliance as well as illicit use 22 Drugs of Abuse Testing • Opioids • Can last in urine 2 – 8 days depending on usage • False positives • Antibiotics (Fluoroquinolones, penicillins) • Poppy seeds • Will not be positive with oxycodone, methadone, or buprenorphine • Have separate immunoassays • Naltrexone is not an opioid so not included in typical drug screens 23 Drugs of Abuse Testing • False Negatives • Household chemicals • Bleach, vinegar, sodium bicarbonate, Drano, soft drinks, hydrogen peroxide • Diuretics • Lasix, Bumex • Water • Checking for tampering • pH, creatinine, osmolality, odor, color, temperature • Tamper proof collection room • Blue toilet water, no water or soap, monitor patient 24 References 25 • American Psychiatric Association. (2013). Substance-Related and Addictive Disorder. In Diagnostic and Statistical Manual of • Dakwar, E., & Kleber, H. D. (2015). Naltrexone-facilitated buprenorphine discontinuation: A • Dowell, D., Haegerich, T.M., & Chou, D. (2016). CDC Guidleine for Prescribing Opioids for Chronic Pain – United States. MMWR Recomm Rep 2016(65), 1-49. doi:http://dx.doi.org/10.15585/mmwr,rr6501e1(http://dx.doi.org/10.15585/mmwr.rr6501e 1) • Gerra, G., Fantoma, A., & Zaimovic, A. (2006). Naltrexone and buprenorphine combination in the treatment of opioid dependence.Journal Of Psychopharmacology, 20(6), 806-814. doi:10.1177/0269881106060835 • Jacobs, P., Ang, A., Hillhouse, M. P., Saxon, A. J., Nielsen, S., Wakim, P. G., . . . Blaine, J. D. (2015). Treatment outcomes in opioid dependent patients with different induction dosing patterns and trajectories. The American Journal on Addictions, 24(7), 667-675. doi:10.1111/ajad.12288 • Krupitsky, E., Zvartau, E., Blokhina, E., Verbitskaya, E., Wahlgren, V., Tsoy-Podosenin, M., . . . patients stabilized on oral naltrexone or an extended release naltrexone implant. The doi:10.1080/00952990.2016.1197231 • Laposata, M. (2014). Laboratory medicine: the diagnosis of disease in the clinical laboratory. New York: McGraw-Hill Education. • Lembke, A., MD, Humphreys, K., PhD, & Newmark, J., MD. (2016). Weighing the Risks and 2016, from Pubmed. • Lobmaier, P., Gossop, M., Waal, H., & Bramness, J. (2010). The pharmacological treatment of 66(6), 537-545. doi:10.1007/s00228-010-0793-6 opioid addiction—a clinical perspective. European Journal of Clinical Pharmacology, • Nielsen, S., Larance, B., Degenhardt, L., Gowing, L., Kehler, C., & Lintzeris, N. (2016). Opioid Systematic Reviews . doi:10.1002/14651858.cd011117.pub2 agonist treatment for pharmaceutical opioid dependent people. Cochrane Database of • Nunes, E. V., Krupitsky, E., Ling, W., Zummo, J., Memisoglu, A., Silverman, B. L., & Gastfriend, D. R. (2015). Treating opioid dependence with injectable extended-release Who will respond?. Journal Of Addiction Medicine, 9(3), 238243. doi:10.1097/ADM.0000000000000125 • Pagana, K. D., & Pagana, T. J. (2014). Mosby's manual of diagnostic and laboratory tests. St. Louis, MO: Mosby Elsevier. • Prescription Prices, Coupons & Pharmacy Information - GoodRx. (n.d.). Retrieved January 07, 2017, from https://www.goodrx.com/ • Rosenthal, R. N., Ling, W., Casadonte, P., Vocci, F., Bailey, G. L., Kampman, K., … Beebe, K. L. (2013). Buprenorphine Implants for Treatment of Opioid Dependence: Randomized and Sublingual Buprenorphine/Naloxone. Addiction (Abingdon, England), 108(12), 2141–2149. http://doi.org.ezproxy.undmedlibrary.org/10.1111/add.12315 • Substance Abuse and Medical Health Services Administration. (2016). Retrieved January 7, • Schukit, M. A., M.D. (2016, July 2). Treatment of Opioid-Use Disorders. The New England • Uebelacker, L. A., Bailey, G., Herman, D., Anderson, B., & Stein, M. (2016). Patients' Beliefs About Medications are Associated with Stated Preference for Methadone, Assisted Therapy Following Inpatient Opioid Detoxification. Journal of Substance Abuse Treatment, 66, 48-53. doi:10.1016/j.jsat.2016.02.009 Mental Disorders (5th ed.). doi: 10.1176/appi.books.9780890425596.dsm16 feasibility trial. Journal Of Substance Abuse Treatment, 5360-63. doi:10.1016/j.jsat.2015.01.004 buprenorphine/naloxone Woody, G. (2016). Anhedonia, depression, anxiety, and craving in opiate dependent American Journal of Drug and Alcohol Abuse, 42(5), 614-620. Benefits of Chronic Opioid Therapy. American Family Physician, 93(12), 982-990. Retrieved September 26, naltrexone (XR-NTX): Comparison to Placebo 2017, from https://www.samhsa.gov/ Journal of Medicine, 375(4), 357-368. Retrieved September 26, 2016, from Pubmed. Buprenorphine, Naltrexone, or no Medication- Questions? 26