Download Two Views of Opioid Dependence

2013 Aging and Disability Services Conference
22 May 2013
Addictions Panel Workshop

Alison Noice, MA
Director of Addiction Medicine Services at CODA, Inc.

William Nunley, MD, MPH
Associate Medical Director, CareOregon
Workshop Intentions
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
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Overview of Addiction
Principles of Effective Treatment
Community-Based Treatment Options
Additional Discussion
Workshop Primary Reference
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Think of one specific person with substance abuse/
addiction with whom you have worked
Jot down a few key facts about them
 Admirable
traits or experiences
 Challenges encountered
 Key questions about addiction that may have emerged
during your work with them
Two Views of Addiction
View 1
 Addiction is a medical
condition or disease.
 As with other medical
conditions, has a variable
natural history or course.
 Treatment requires
long-term medical
maintenance.
View 2
 Addiction is caused by
weak will or moral failing.
 Addiction and treatment
are all-or-none states (are
or are not an addict/are or
are not in recovery).
 Treatment is based on
criminalization of use
and/or spiritual recovery.
Workshop Intentions




Overview of Addiction
Principles of Effective Treatment
Community-Based Treatment Options
Discussion
NIDA Principles of Effective Drug Addiction Treatment
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No single treatment is appropriate for all individuals. Matching treatment settings,
interventions, and services to each patient's problems and needs is critical.
Treatment needs to be readily available. Treatment applicants can be lost if
treatment is not immediately available or readily accessible.
Effective treatment attends to multiple needs of the individual, not just his or her
drug use. Treatment must address the individual's drug use and associated medical,
psychological, social, vocational, and legal problems.
Treatment needs to be flexible and to provide ongoing assessments of patient
needs, which may change during the course of treatment.
Remaining in treatment for an adequate period of time is critical for treatment
effectiveness. The time depends on an individual's needs. For most patients, the
threshold of significant improvement is reached at about 3 months in treatment.
Additional treatment can produce further progress. Programs should include
strategies to prevent patients from leaving treatment prematurely.
NIDA Principles of Effective Drug Addiction Treatment
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Individual and/or group counseling and other behavioral therapies are critical
components of effective treatment for addiction. In therapy, patients address
motivation, build skills to resist drug use, replace drug-using activities with
constructive and rewarding nondrug-using activities, and improve problem-solving
abilities. Behavioral therapy also facilitates interpersonal relationships.
Medications are an important element of treatment for many patients, especially
when combined with counseling and other behavioral therapies. Methadone and
levo-alpha-acetylmethadol (LAAM) help persons addicted to opiates stabilize their
lives and reduce their drug use. Naltrexone is effective for some opiate addicts and
some patients with co-occurring alcohol dependence. Nicotine patches or gum, or an
oral medication, such as bupropion, can help persons addicted to nicotine.
Addicted or drug-abusing individuals with coexisting mental disorders should
have both disorders treated in an integrated way. Because these disorders often
occur in the same individual, patients presenting for one condition should be
assessed and treated for the other.
Medical detoxification is only the first stage of addiction treatment and by itself
does little to change long-term drug use. Medical detoxification manages the acute
physical symptoms of withdrawal. For some individuals it is a precursor to effective
drug addiction treatment.
NIDA Principles of Effective Drug Addiction Treatment
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Treatment does not need to be voluntary to be effective. Sanctions or
enticements in the family, employment setting, or criminal justice system can
significantly increase treatment entry, retention, and success.
Possible drug use during treatment must be monitored continuously.
Monitoring a patient's drug and alcohol use during treatment, such as
through urinalysis, can help the patient withstand urges to use drugs. Such
monitoring also can provide early evidence of drug use so that treatment
can be adjusted.
Treatment programs should provide assessment for HIV/AIDS, hepatitis
B and C, tuberculosis and other infectious diseases, and counseling to
help patients modify or change behaviors that place them or others at risk
of infection. Counseling can help patients avoid high-risk behavior and help
people who are already infected manage their illness.
Recovery from drug addiction can be a long-term process and frequently
requires multiple episodes of treatment. As with other chronic illnesses,
relapses to drug use can occur during or after successful treatment
episodes. Participation in self-help support programs during and following
treatment often helps maintain abstinence.
Workshop Intentions



Overview of Addiction
Principles of Effective Treatment
Community-Based Treatment Options
 12
Step Overview
 Alternate peer-based recoveries
 Medication Assisted Treatment
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Additional Discussion
12 Step Overview
Community Treatment Options:
12 Step Overview
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Three primary components
1. Reorganization of priorities and self-psychology
 12 Steps
2. Establishing a pro-social social network
 Regular attendance of meetings and fellowship
3. Establishing a trusting, collaborative, pro-social
relationship with an experienced mentor
 Sponsorship
12 Steps of Alcoholics Anonymous
1.
2.
3.
4.
5.
6.
We admitted we were powerless over alcohol - that our lives
had become unmanageable.
Came to believe that a power greater than ourselves could
restore us to sanity.
Made a decision to turn our will and our lives over to the care of
god as we understood him.
Made a searching and fearless moral inventory of ourselves.
Admitted to god, to ourselves, and to another human being the
exact nature of our wrongs.
Were entirely ready to have God remove all these defects of
character.
12 Steps
7.
8.
9.
10.
11.
12.
Humbly asked god to remove our shortcomings.
Made a list of all persons we had harmed, and became willing to
make amends to them all.
Made direct amends to such people wherever possible, except
when to do so would injure them or others.
Continued to take personal inventory, and when we were wrong,
promptly admitted it.
Sought through prayer and meditation to improve our conscious
contact with god as we understood him, praying only for
knowledge of his will for us and the power to carry that out.
Having had a spiritual awakening as the result of these steps, we
tried to carry this message to alcoholics, and to practice these
principles in all our affairs.
Supporting 12 Step Work

Three primary components
1. Reorganization of priorities and self-psychology
 12 Steps
2. Establishing a pro-social social network
 Regular attendance of meetings and fellowship
3. Establishing a trusting, collaborative, pro-social
relationship with an experienced mentor
 Sponsorship
Supporting 12 Step Work

Three primary components
1.
2.
3.
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Reorganization of priorities and self-psychology
 12 Steps
Establishing a pro-social social network
 Regular attendance of meetings and fellowship
A trusting, collaborative, pro-social relationship with an experienced mentor
 Sponsorship
Simple, effective intervention and support

Do you have a sponsor, how often are you
attending meetings, what step are you working
on currently?
Non-12 Step Peer Recovery
Primary Alternatives to AA
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SMART
On-line/meeting based, non-spirituality
 Split from Rational Recovery c.1998
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Rational Recovery/Rational Recovery Systems, Inc.
Jack Trimpey, LCSW c.1986
 addiction as maladaptive behavior (learned, volitional)
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Women for Sobriety
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Jean Kirkpatrick, sociologist c.1976
Recovery International (Recovery Inc.)
Abraham Low, MD c.1937
 Cognitive-behavioral self-help techniques
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Primary Alternatives to AA (continued)
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Secular Organizations for Sobriety
Dual-Diagnosis Anonymous
 Oregon
developed EBP
 12 Steps + 5 Steps (MI/MH recovery)
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Moderation Management
Many, many, many additional
Medication Assisted Treatment
Two Views of Addiction (your client)
View 1
 Addiction is a medical
condition or disease.
 As with other medical
conditions, has a variable
natural history or course.
 Treatment requires
long-term medical
maintenance.
View 2
 Addiction is caused by
weak will or moral failing.
 Addiction and treatment
are all-or-none states (are
or are not an addict/are or
are not in recovery).
 Treatment is based on
criminalization of use
and/or spiritual recovery.
Similarities to Other Medical Disorders
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Addiction is viewed as medical disorder.
Substance addiction is comparable to asthma,
hypertension, and diabetes.
Risk of relapse is highest during first 6 months.
Patients respond best to a combination of
pharmacological and behavioral interventions.
Treatment improves outcomes of even severe cases.
Options for use of Addictions Medicines
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Medically supervised withdrawal treatment
vs.
Medical maintenance treatment
 Methadone, buprenorphine, and naltrexone
 Pharmacotherapy with assessment, psychosocial
intervention, and support services
 Detoxification from short-acting opioids
Pharmacotherapy
The use of medications to treat a
illness (substance abuse/addiction)
and positively effect the symptoms
and natural course of the illness
Agonist vs Antagonist
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Agonist: Binds to the receptor to elicit effect. These
drugs mimic the effects of the naturally occurring
neurotransmitters with the same or stronger affinity
to the receptor
Antagonist: Binds to the receptor but, instead of
eliciting response it, it blocks the receptor and
prevents activation. In the event the receptor is
already activated, the antagonist will replace
whatever is already activating the receptor
(naltrexone, Narcan)
How Can You Treat Opioid Addiction?
Agonist Maintenance Treatment
 Usually conducted in outpatient settings
 Treatment provided in opioid treatment programs
traditionally using methadone, now with buprenorphine, in
office-based settings
 Patients stabilized on adequate, sustained dosages of these
medications can function normally.
 Can engage more readily in counseling and other behavioral
interventions essential to recovery and rehabilitation
 The best, most effective opioid agonist maintenance programs
include individual and/or group counseling, as well as
provision of, or referral to other needed medical,
psychological, and social services.
(National Institute on Drug Abuse, 2009)
How Can You Treat Opioid Addiction?
Antagonist Maintenance Treatment
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Usually conducted in outpatient setting
Initiation of naltrexone often begins after medical
detoxification in a residential setting
Repeated lack of desired opioid effects will gradually over
time result in breaking the habit of opiate addiction.
Patient noncompliance is a common problem. A favorable
treatment outcome requires a positive therapeutic relationship,
effective counseling or therapy, and careful monitoring of
medication compliance.
(National Institute on Drug Abuse, 2009)
Pharmacotherapeutic Medications for
Opioid Addiction Treatment
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Methadone: Most frequently used, long-acting, has many
formulations, decreases pain-killing effects of opioids,
available in OTPs
Buprenorphine: Larger doses do not increase effects, has
increased margin of safety, administered in doctor’s offices
and healthcare settings
Buprenorphine-naloxone: Combination of 2 medications,
administered in doctor’s offices and healthcare settings
Naltrexone: Does not have abuse potential; blocks effects of
opioids; can cause withdrawal in non-abstinent patients;
administered in OTPs and outpatient settings
But aren’t you just
trading one addiction
for another?
Promoting Comprehensive Treatment
Effective treatment attends to multiple
needs of individual.
 Counseling and other behavioral
therapies are critical components of
effective treatment.
 Medications, especially combined with
behavioral therapies, are an important
element of treatment for many patients.
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Why Medications for Opioid Dependence?
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Opioids attach to receptors in the brain, causing
pleasure. After repeated opioid use, the brain becomes
altered, leading to tolerance and withdrawal.
Medications operating through the opioid receptors,
such as buprenorphine and methadone, prevent
withdrawal symptoms and help the person function
normally. Medications like naltrexone block the body’s
response to opioids
Behavioral treatment can also address cravings that
arise from environmental cues.
Treatment Recommendations
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Behavioral treatments educate patients about the
conditioning process and teach relapse prevention
strategies.
Medications such operate on the opioid receptors to
relieve craving and inhibit euphoric effects.
Combining the two types of treatment enables
patients to stop using opioids and return to more
stable and productive lives.
Stages of Pharmacotherapy
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Induction: Initial treatment process of adjusting
maintenance medication dosage levels until a
patient attains stabilization
Stabilization: Process of providing immediate
assistance to eliminate withdrawal symptoms and
drug craving
Maintenance: Administering an opioid addiction
medication at stable dosage levels for a period in
excess of 21 days
How long does
someone have to stay
on medications?
Voluntary Tapering and Dose Reduction
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Patients attempt reduction or cessation of
maintenance for many reasons; there is a high
relapse rate.
Withdrawal should be tried when strongly desired
by a stable patient, but sometimes dose tapering is
necessary for administrative reasons.
Many treatment providers can’t improve outcomes
for patients who undertake planned withdrawal, so
withdrawal should be undertaken conservatively.
Voluntary Tapering and Dose Reduction
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Relapse prevention techniques should be
incorporated into treatment both before and during
dosage reduction.
Success rates are likely to be similar for patients
who taper from methadone or buprenorphine, so
similar cautions and monitoring processes should be
in place.
Steps in Patient-Treatment Matching:
Patient Assessment
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Comprehensive assessment should include patient’s:
 Extent,
nature, and duration of substance use
 Treatment history
 Medical, psychiatric, and psychosocial needs
 Functional status
 Gender, culture, ethnicity, and language
 Motivation to comply with treatment
 Recovery support
Steps in Patient-Treatment Matching:
Matching Needs to Settings
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Identify the most appropriate setting or services.
MAT has been offered primarily in dedicated
outpatient OTPs, but more varied programs and
settings have emerged.
Treatment team should collaborate with patients to
determine the most appropriate treatment services.
Patients’ service needs may change. Treatment
matching in some cases can lead to multiple settings.
Steps in Patient-Treatment Matching:
Matching Needs to Settings
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Examples of treatment programs and settings:
 Outpatient
OTPs
 Residential treatment programs
 Mobile treatment units
 Office-based opioid treatment settings
 Criminal justice institutions
 Other treatment settings and specialized programs
Treatment Phases
1
Acute
2
Rehabilitative
3
Supportive Care
4
Medical Maintenance
5
Tapering and MSW
6
Continuing Care
Variations of Phased Treatment
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Types and intensity of services vary throughout treatment.
Most patients need:
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Intensive treatment services at entry
Diversified services during stabilization
Fewer intensive services after recovery benchmarks are met.
Treatment phases are on a dynamic continuum.
Assessment of treatment should be ongoing.
Duration of treatment is a team decision based on data and
medical experience.
Workshop Intentions




Overview of Addiction
Principles of Effective Treatment
Community-Based Treatment Options
Additional Discussion
Thank you for your time and for
your essential service to vulnerable
members of our community.