Download Medication Assisted Treatment for Opioid Addiction

THE DISEASE OF OPIOID
ADDICTION AND
MEDICATION ASSISTED
TREATMENT
Michele F. McCarthy, LPCC
Community & Government Liaison
Self Refind
OBJECTIVES
 Learn about the state of opiate addiction today
 Discuss the impact of opiate abuse and addiction
 Identify the currently available medication assisted
treatment options
 Explore the pros and cons of the available treatments
 Discuss special considerations for working with
pregnant patients
 Review rights of patients in medication assisted
treatment
IS IT REALLY AN EPIDEMIC?
Epidemic is defined as:
…attacking or affecting many persons
simultaneously in a community or area…a
widespread occurrence of a disease…a rapid
development, spread, or growth of something,
especially something unpleasant.
KENTUCKY ALL SCHEDULE PRESCRIPTION
ELECTRONIC REPORTING
KASPER QuarterlyTrend Reports for 2011
reflected that opiates accounted for an average
of 57% and benzodiazepines accounted for an
average of 28% of the top controlled
substances that Kentucky doctors wrote
prescriptions for.
SOURCE: KASPER QUARTERLY TREND REPORTS
2011
KASPER DATA 2011
In 2011 alone:
3,093,770 prescriptions were written for
hydrocodone (up from 2,812,878 in 2009).
3,217,535 prescriptions were filled for
hydrocodone.
852,085 prescriptions were written for
oxycodone (up from 646,218 in 2009).
929,525 prescriptions were filled for
oxycodone.
How many more were obtained out of state?
How many more were obtained illegally?
SOURCE: KASPER QUARTERLY TREND REPORTS
2011
OVERDOSE DEATHS ARE ON THE RISE…
 Drugs exceeded motor vehicle accidents as a cause of death in
2009, killing at least 37,485 people nationwide, according to
preliminary data from the U.S. Centers for Disease Control and
Prevention.
 The death toll has doubled in the last decade, now claiming a life
every 14 minutes, making it the number one cause of preventable
deaths.
 Fueling the surge in deaths are prescription pain and anxiety
drugs, which now cause more deaths than heroin and cocaine
combined.
Los Angeles Times, September 2011
KENTUCKY MEDICAL EXAMINER 2011 REPORT
Total cases- 2378
Overdose cases- 684
 Alprazolam (Xanax)-286
 Oxycodone (Percocet)-213
 Hydrocodone (Lortab)-187
 Oxymorphone (opana)-154
 Alcohol-134
 Cocaine-31
 Methamphetamine-21
KENTUCKY HAS MORE TO WORRY ABOUT
KENTUCKY HAS MORE TO WORRY ABOUT
Although we have continued to see an increase in
the prescribing and abuse of prescription opiates,
this is not the only battle we are fighting.
Kentucky House Bill 1- 2012
 Landmark legislation
 But if it does it’s job…
BENEFITS OF TREATMENT
 Total cost of drug use disorders in the US is an est. $180
billion annually
 $100,000 spent on treatment = avoided costs of $487,000
in healthcare and $700,000 in crime
 Every $1 spent on treatment saves criminal justice $7 and
when add in healthcare savings, the savings to cost ratio is
12:1
 Employees treated for substance use have decreased
absenteeism, tardiness, mistakes and on-the-job injuries

SAMHSA CSAT Cost Offset of Treatment Services, April 2009
MEDICATION ASSISTED
TREATMENT OPTIONS
Methadone
Buprenorphine-Suboxone and Subutex
Naltrexone
MEDICATION ASSISTED TREATMENT
 SAMHSA defines MAT as:
“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.”
WORLD HEALTH ORGANIZATION 2009
GUIDELINES
 Efficacy of MAT v. placebo
 Methadone—opiate use,  tx retention, 1/3 mortality
rate,  risk of HIV by 50%
 Buprenorphine—opiate use,  tx retention, 
morphine positive drug screens
 Naltrexone— in opiate use
 Of the treatment options examined, opioid agonist
maintenance treatment, combined with psychosocial
assistance, was found to be the most effective.
\\Guidelines
for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence, World Health Organization, 2009
METHADONE
Dolophine hydrochloride, Methadose
Schedule II narcotic
Long acting opioid analgesic (6-12 hours)
Full mu opioid agonist-binds and activates
MU OPIOID RECEPTOR ACTIVATION
Full agonist
eg, methadone
mu receptor site
Partial agonist
eg, buprenorphine
mu receptor site
Antagonist
Full activation
of mu receptor
site
Partial activation of
mu receptor site
eg, naltrexone
mu receptor
site
Prevents or reverses
activation of mu receptor
site
METHADONE
Long half-life (12-59 hours)- taken once daily or
may be “split-dosed”
Administered orally- 5 and 10 mg tablets, 40 mg
Disket and liquid
40 mg tablets (Disket) only available to treat opioid
addiction (as of January 2008)
METHADONE BENEFITS
Right dose should not cause euphoric or
tranquilizing effects.
Reduces/blocks effects of other opioids.
Tolerance is slow to develop.
Relieves cravings.
Allows the individual to feel “normal”.
METHADONE BENEFITS
Improved employment status and family
relationships.
Decrease in criminal activities.
Decrease in high risk behaviors such as IVDU =
decrease in HIV and Hep. C.
Improved health and health care.
METHADONE LIMITATIONS
Can only be dispensed/administered through an
OTP.
Private can be expensive.
Heavily regulated, lots of rules, can be time
consuming.
Heavily stigmatized
METHADONE LIMITATIONS
Abuse liability and diversion
Increased risk when combined with other
drugs.
Associated health complications*
Detoxification can be difficult
BUPRENORPHINE
Drug Addiction Treatment Act of 2000 (DATA
2000)
In 2002, two forms were FDA approvedSubutex and Suboxone, both made by ReckittBenckiser.
Schedule III narcotic
Opioid analgesic with effects up to 6 hours.
BUPRENORPHINE
Partial mu opioid agonist (ceiling effect) but
high affinity
Long half-life (24-60 hours)
Administered as sublingual tablet* or film
 Subutex- 2 mg or 8 mg buprenorphine
 Suboxone- 2 mg bup + .5 mg naloxone
8 mg bup + 2 mg naloxone
MU OPIOID RECEPTOR ACTIVATION
Full agonist
eg, methadone
mu receptor site
Partial agonist
eg, buprenorphine
mu receptor site
Antagonist
Full activation
of mu receptor
site
Partial activation of
mu receptor site
eg, naltrexone
mu receptor
site
Prevents or reverses
activation of mu receptor
site
SUBUTEX
Contains buprenorphine only.
Historically, minimally used in U.S. except
with pregnant women.
Two generics now available.*
Higher rate of diversion, can be injected.
SUBOXONE
Naloxone added as means to decrease misuse.
Poor bioavailability sublingually, but if dissolved and
injected, will precipitate withdrawal.
Reduced abuse potential.
Film meant to provide added means to combat
diversion.
BUPRENORPHINE BENEFITS
Virtually no euphoric or tranquilizing effects.
Blocks effects of other opiates.
Relieves cravings to use other opiates.
Allows “normal” function.
BUPRENORPHINE BENEFITS
Lower abuse liability and diversion potential.
Increased anonymity, less intrusive, less stigma.
Increased treatment options/access to
treatment.
Here to Help Program
BUPRENORPHINE BENEFITS
Decrease in high-risk behaviors.
Good “step down” option for those tapering
from methadone.
Provides option for those that cannot
tolerate methadone
Is currently covered by Medicaid
BUPRENORPHINE LIMITATIONS
Can be expensive when self pay.
Currently still no generic for Suboxone.
Should not take if opiates still in system.
Counseling may not be available or
affordable in the same area as doctor.
BUPRENORPHINE LIMITATIONS
Not enough certified doctors or doctors willing
to treat.
No regulations for OBOTs, only “practice
guidelines”.
Potential for overdose of other opiates due to
ceiling effect.
Abuse and diversion potential still exists.
NALTREXONE
Long half-life (up to 72 hours)
Opioid antagonist-binds, but blocks instead
of activates
Is NOT an opiate
MU OPIOID RECEPTOR ACTIVATION
Full agonist
eg, methadone
mu receptor site
Partial agonist
eg, buprenorphine
mu receptor site
Antagonist
Full activation
of mu receptor
site
Partial activation of
mu receptor site
eg, naltrexone
mu receptor
site
Prevents or reverses
activation of mu receptor
site
NALTREXONE
Historically used primarily for alcohol due to
blocking neurotransmitters believed to be involved
with alcohol dependence.
Oral- ReVia, now generic
Injectable- Vivitrol
Implant- not FDA approved
NALTREXONE TREATMENT
Medication is only one component.
Average length of treatment is 3-9 months.
Works best with highly motivated patients.
Injectable is a great option for compliance
issues or just for convenience.
NALTREXONE BENEFITS
Any physician can prescribe in any setting.
Injectable lasts for 30 days.
Relatively inexpensive (oral) when compared to
Methadone or Bup.
Non-narcotic, non-addictive, does not produce
dependence.
BENEFITS CONT.
More acceptance in abstinence-based programs.
Less stigma than methadone or buprenorphine.
In KY Medicaid covers, but only oral is 1st-tier;
injectable is a 3rd-tier.
Received approval for use for opioid addiction in
last year
NALTREXONE LIMITATIONS
Injection site reactions.
Injectable very expensive for self pay.
Poor compliance with oral version.
Cannot have any opiates in system or will
precipitate withdrawal.
Still not many doctors utilizing.
LIMITATIONS CONT.
Risk of overdose in attempt to break
through blockade.
Not first choice for pregnant patients.
Breastfeeding is not recommended.
Implant is NOT FDA approved.
MAT AND PREGNANCY
MAT AND PREGNANCY
“Cold turkey” detox may trigger miscarriage,
pre-term labor.
Methadone has most research and is still
preferred.
Subutex has shown very positive resultsMOTHER Study.
Several reports of using Suboxone with positive
results.
MAT AND PREGNANCY CONT.
Individualized approach, informed choice
Decreases/ceases cycles of intoxication and
withdrawal
Decrease in high risk behaviors
Opportunity to address other factors-mental
health, social supports, basic needs
MAT AND PREGNANCY STANDARDS
 Federal
 Prenatal care
 Gender-specific services
 Additional state
 Medically able to participate
 Collaborate with OBGYN
 Post-partum care
 Nutrition, parenting, and weekly drug screen
MAT & PREGNANCY STANDARDS
CARF and Joint Commission
 Priority admission
 Counseling for DV, trauma, women’s health
 Appropriate medication dosage
 Educate on MSW- should NOT be initiated
before 14 weeks or after 32 weeks
 Encourage breastfeeding (unless
contraindicated)
KEY POINTS TO REMEMBER
 Opiate addiction is a disease, an epidemic.
 There is no cure, but we do have options and we need
to take advantage of all of them.
 Treatment is not “one size fits all.”
 Just as addiction is lifelong, so is the recovery process
 Chances of maintained recovery significantly increase
when combined with counseling, drug screens,
medication call backs, etc.
KEY POINTS TO REMEMBER
No “perfect” medication that is one size fits all.
Medication is a tool, not a “cure”.
MAT may be appropriate for pregnant women but
must be closely monitored and have informed
consent.
MAT is a legal, valid, and widely researched
evidence-based treatment for addiction.
Individuals receiving MAT are in recovery!
CONTACT INFORMATION
Michele F. McCarthy
Government & Community Liaison
Self Refind
[email protected]
859-605-6387
www.selfrefind.com