Download SUMMARY REPORT MEETING 12 Date: Wednesday, April 25, 2012

SUMMARY REPORT
MEETING 12
Date:
Time:
Hosts:
Topic:
Wednesday, April 25, 2012
11:00AM – 12:00PM
UCLA Integrated Substance Abuse Programs (ISAP) & CA
Dept. of Alcohol and Drug Programs (ADP)
Medication Assisted Treatment for Alcohol and Opioid
Dependence
Presenter: -- Larissa Mooney, MD
Assistant Clinical Professor of Psychiatry, UCLA
Review of ILC Meeting 11
UCLA ISAP
 The eleventh ILC meeting, conducted during CADPAAC on March 28,
2012, involved a presentation by Mady Chalk, PhD entitled A Vision for
the Future: Workforce Investment; Essential Benefits and Parity Update.
Special thanks to our presenter Dr. Chalk for her continued involvement
and support of our learning collaborative. Thank you all for your
participation. A summary from this meeting has been posted on the UCLA
ILC webpage: http://www.uclaisap.org/Affordable-Care-Act/html/learningcollaborative/index.html
Logistics
 Summary and materials discussed from the previous ILC meetings are
available at http://www.uclaisap.org/Affordable-Care-Act/html/learningcollaborative/index.html. Subsequent meeting materials will continue to be
posted on this site.
 The next ILC meeting will be held during CADPAAC on May 23, 2012 from
10:30AM to 12:00PM. UCLA has invited Suzanne Gelber Rinaldo, PhD to
discuss what other states are doing with respect to health care reform and
Medicaid SUD benefits.
 All further meetings are scheduled to be held at 11:00AM (PT) on the 4th
Wednesday of every month, unless otherwise noted.
ILC Meeting 11 Topic:
Medication Assisted Treatment for Alcohol and Opioid Dependence
Topic Introduction – Brandy Oeser, MPH, UCLA ISAP
 The topic for today’s learning collaborative is to hear about Medication
Assisted Treatment for Alcohol and Opioid Dependence. We thank Dr.
Larissa Mooney for presenting on this topic and hope this will be a
learning opportunity for those in the audience but also for the speaker.
Questions and trouble shooting among the group are encouraged.
Larissa Mooney, MD
Assistant Clinical Professor of Psychiatry, UCLA
Summary
 Introduction to addictive disorders
o Addiction is a chronic, relapsing brain disease characterized by
compulsive use despite harmful consequences.
 Pharmacotherapy should be thought of as part of a multi-modal
treatment plan (i.e. medications, therapy, and lifestyle changes).
 Risk Factors include genetics (25-50%), environment (pre/post-natal,
comorbidity, stress-responsivity), drug-induced effects.
o Neurobiology
 Drugs stimulate the dopamine pathway (reward system of the brain):
 Process of addiction causes dysfunctional learning, memory
impairment, maladaptive behavioral patterns, impaired decisionmaking, loss of control, and altered neurobiology.
o Pharmacotherapy in Substance Use Disorders:
 Drugs are used to treat withdrawal (“detox”) symptoms, psychiatric
symptoms or co-occurring disorders, reduce cravings and urges, and
as substitution therapy.
o Alcohol-related Impacts
 3rd leading cause of preventable death, 15-30% of primary care and
hospitalizations, life span reduced by 15 years.
 Cardiovascular consequences include hypertension,
cardiomyopathy, CHD, arrhythmias.
 Hepatic consequences include fatty liver, alcoholic hepatitis,
cirrhosis.
o Neurotransmitters affected by alcohol
 Dopamine: increases feelings of happiness and reward.
 Endogenous Opioids: associated with feelings of euphoria and pain
relief.
 +GABA: main inhibitory neurotransmitter.
 -Glutamate: main excitatory neurotransmitter.
 Medications intervene at different stages in the pathways.
 Medications for Alcohol Dependence
 FDA approved: Disulfiram (Antabuse), PO naltrexone (Revia), IM
naltrexone (Vivitrol), Acamprosate (Campral).


Non-FDA approved: Topiramate (Topamax), Ondansetron (Zofran),
Quetiapine (Seroquel), and Baclofen.
o Disulfiram (Antabuse)
 Mechanisms: inhibits aldehyde dehydrogenase, causing buildup of
acetaldehyde with alcohol ingestion.
 Causes flushing, nausea, vomiting, headache; in severe cases it
can cause arrhythmias, seizures, coma, cardiovascular collapse.
 Reactions may occur 1-2 weeks after dose.
 Most likely to benefit: Highly motivated and directly observed
patients.
o Naltrexone (Revia)
 Mechanisms: µ-opioid antagonist that decreases positive reinforcing
effects and cue/alcohol-related cravings.
 Side effects: nausea, dysphoria, increased LFT’s.
 Results: fewer drinking days, less consumption, decrease cravings.
 Research: in two studies participants treated with Revia had a
greater reduction in relapse during the study than those treated with
placebo.
o IM Naltrexone (Vivitrol)
 Mechanisms: opioid antagonist.
 Enhanced compliance; ideal if drinking is stopped 7 days prior to drug
administration.
 Requires monthly injection and is very expensive.
 Results: decreased heavy drinking days, decreased frequency of
drinking.
o Acamprosate (Campral)
 Mechanisms: NMDA receptor modulation (restores glutamate balance)
 Blocks negative reinforcement.
 Side effects: diarrhea, abdominal discomfort.
 Start post-detox (ideal)
 Results: increased time to relapse, increased total abstinence,
reduced drinking days.
 Research: in all three studies participants treated with Campral
maintained abstinence longer, reduced number of drinking days, and
regained abstinence after relapse more frequently than subjects given
placebo.
Opiates/Opioids
o Public Health Problems
 Disease and Virus exposure (tuberculosis, STDs, HIV/AIDS, HBV,
HCV).
 Needle-related problems include abscess, cellulitis, subacute bacterial
endocarditis, skin conditions, botulism.
o Opioid dependence treatment aims
 Detoxification: opioid and non-opioid based
 Opioid based: methadone and buprenorphine.
 Non-opioid based: clonodine, supportive medications.





Relapse prevention: agonist maintenance (methadone), partial agonist
maintenance (buprenorphine), agonist maintenance (Naltrexone,
Vivitrol).
 Lifestyle and behavioral changes.
o Opioid Substitution Goals
 Reduce symptoms/signs of withdrawal, reduce/eliminate craving, block
effects of illicit opioids, restore normal physiology, promote
psychosocial rehabilitation and non-drug lifestyle.
o Methadone: Clinical Properties
 Action: CNS depressant / Analgesic.
 Effects last 24 hours; once-daily dosage maintains constant blood
level.
 Prevents withdrawal, reduces cravings and use, facilitates
rehabilitation.
o Buprenorphine
 Mechanisms: Partial µ-agonist, analgesic properties.
 Office-based, expands availability.
 Lower abuse potential, safer in overdose.
o IM Naltrexone (Vivitrol)
 Mechanisms: Opioid antagonist.
 Enhanced compliance.
 Must be opioid free for 7-10 days before injection of dose
 Blocks opioid effects for 4 weeks.
Challenges for Dually Diagnosed
o Patients are more likely to have increased severity of mental illness,
medication noncompliance, worse treatment prognosis, lower income,
worse physical health, increased risk of incarceration.
o Integrated treatment of SUD and MH has shown to be more effective than
separate, sequential, or parallel treatment.
Addiction is a serious, chronic and relapsing disorder, but treatments are
available.
Medications should be considered as part of a comprehensive treatment plan,
addressing both disordered physiology and disrupted lives.
Medications should be considered for treatment of psychiatric symptoms,
addictive disorders, and co-occurring disorders.
Discussion:
Q:
Do you see vivitrol as a means to get off methadone? With vivitrol is
abstinence possible?
A:
I do think that is a possibility. The patient would have to be off methadone
for 10 days before taking vivitrol (which could be risky). This could be possible if
the patient was in an inpatient setting. It really depends on the patient as well,
for some methadone maintenance is the best treatment for them. Every patient
is unique. It is unfortunate that 12-Step programs do not approve of
maintenance medications. I do hope that attitudes will change and we will find
medication friendly meetings and treatment programs.
Q:
Los Angeles is looking at a cost-savings study with vivitrol (it is expensive
to provide but the potential cost savings could be great). For insurance
companies to cover the medication the financial benefit must be clear.
A:
That is very exciting since the cost of vivitrol is a barrier to treatment (it
can cost up to $800 per dose).
Closing Remarks – Valerie Pearce Antonini, UCLA ISAP
 Thanks again to Dr. Mooney for presenting today. It is always helpful to
hear from experts in the field of addiction medicine. Thank you for
volunteering your time and sharing with the group.
 The next ILC Meeting is scheduled on Wednesday, May 23, 2012 at
10:30am during CADPAAC.
 Please remember to reference the website which holds all information and
materials disseminated from the ILC: http://www.uclaisap.org/AffordableCare-Act/html/learning-collaborative/index.html.
APPENDIX 1 – ATTENDEES
COUNTY PARTICIPANTS
MEDIUM
 Solano (Andrew Williamson)
LARGE
 Los Angeles (Yolanda Cordero, John Viernes)
 San Bernardino (Dianne Sceranka)
ORGANIZATION PARTICIPANTS
 AEIGIS (Steve Maulhardt)
ADP PARTICIPANTS
 Trinidad Perez
 John Graham
UCLA PARTICIPANTS
 Darren Urada
 Brandy Oeser
 Valerie Pearce
APPENDIX 2 – AGENDA AND RELEVANT MATERIALS




Overview of Meeting 11
Introductions
 Dr. Larissa Mooney
Topic Discussion – Medication Assisted Treatment for Alcohol and Opioid
Dependence
Q and A
MATERIALS FOR THIS MEETING

PPT Presentation – Larissa Mooney, MD
Copies of materials can be found at UCLA ISAP’s ACA Resources Website:
http://www.uclaisap.org/Affordable-Care-Act/html/learningcollaborative/index.html.