RAWATAN METHADON DAN TERAPI

7/27/2019 RAWATAN METHADON DAN TERAPI

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Methadone MaintenanceTherapy


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What is methadonemaintenance treatment?

Methadone maintenance treatment(MMT) is a comprehensivetreatment program that involves

the long-term prescribing ofmethadone as an alternative to theopioid on which the client was

dependent.


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Methadone

Methadone is a long-acting opioidagonist

Only the treatment of opioiddependence.


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Questions & Issues

How important is methadone in treatingheroin addiction?

What is the rationale?

How do we decide when/if it can bediscontinued?

What is included in the psychosocial

component of treatment?


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Once the client is stabilized at theright dose, methadone will:

suppress opioid withdrawalsymptoms

reduce cravings for opioids

not induce intoxication (e.g.,sedation or euphoria)

reduce the euphoric effects of

other opioids, such as heroin.


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OPIOIDMAINTENANCE

THERAPY


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The Addiction Process:Barriers to Understanding

INFLUENCE OF THE STIGMA:

difficulty understanding the complexity ofthe disorder

treatment is denied

treatment is diminished

treatment is discouraged

treatment is conditional


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I Dont Believe in

Methadone


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Methadone is a medication,not a religion

J. Thomas Payte, MD

Founding Chair, Methadone TreatmentCommittee, ASAM

O i


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Overview:Opioid Maintenance Therapy

Methadone (MMT) & levoacetylmethadol(LAAM), buprenorphine (soon)

most highly regulated

history

rationale for replacement therapy

political influences

diversion


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OMT, Continued

Strong empirical support for safety andefficacy (30 years of data)

valuable tool in reducing spread of HIV

makes the pt accessible to interventionsfor other problems

hidden populations of heroin users

medical maintenance and office-basedpractice


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What is Abstinence?

Medication is compatible with 12-stepparticipation if appropriately prescribed byphysician knowledgeable about addiction

Pt on methadone is abstinent if not using illicitdrugs and using legal ones as prescribed

Its just another medication. Meds are a tool,

not a solution

D l R S


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Dole: Receptor SystemDysfunction

Endogenous ligand-narcotic receptor system isdefective; hence high relapse rate

Stabilize blood level at 150-600 ng/mL

This normalizes neurological and endocrinefunctioning

This treatment is corrective but not curative

Future research: identify the specific defect and

repair it(Dole, JAMA 1988)


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Genetic Factors

Recent studies show distinct geneticvulnerability to heroin and other opiates:

heroin had larger genetic influences unique to

itself than marijuana, sedatives, stimulants,psychedelics (Tsuang et all; Merikangas et al; ARCHIVES 1998)

Alcoholism and drug disorders appear to beindependent

Genetic factors impact the transition from druguse to abuse/dependence, not use itself


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Diversion of Medication

political hot button

key issue in formulating original regs

IOM report: cannot document significantpublic health or safety problem

confusion about DAWN data

difficulty of determining cause of death(Rettig 1995)


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Reasons for Diversion

selling take-homes to buy illicit drugs

need to supplement income

share with or sell to addicted friend/mate

unwilling or unable to enter treatment

low dose policies of some programs

IOM conclusion: risks of diverted methadone do notoutweigh benefits of making MMT more available

(Rettig 1995)


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PHARMACOTHERAPY


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Methadone vs Heroin

Can be taken by mouth

Slow onset of action

No continuing increase in tolerance levels

after optimal dose is reached; relativelyconstant dose over time

Pt on stable dose rarely experiences euphoricor sedating effects; is able to perceive pain

and have emotional reactions; can perform;can perform daily tasks normally and safely


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Methadone vs Heroin (2)

Long acting; prevents withdrawal for 24-36 hours (4x-6x as long as heroin),permitting once-a day-dosing

At sufficient dosage, blocks euphoriceffect of normal street doses of heroin

Medically safe when used on long-term

basis (10 years or more)(Physicians Guide: Opioid Agonist Medical Maintenance Treatment; CSAT

2000)


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DoseR

esponse

Time

LoadedHigh

Normal Range

Comfort Zone

Sick

Heroin Simulated 24 Hr. Dose/ResponseWith established heroin tolerance/dependence

0 hrs. 24 hrs.

Abnormal Normality

Subjective w/d

Objective w/d

Opioid Agonist Treatment of Addiction - Payte - 1998


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Opioid Agonist Treatment of Addiction - Payte - 1998

GOALS FOR PHARMACOTHERAPY

Prevention or reduction of withdrawal symptoms

Prevention or reduction of drug craving

Prevention of relapse to use of addictive drug Restoration to or toward normalcy of any

physiological function disrupted by drug abuse

Source: MJ Kreek, Rationale for Maintenance Pharmacotherapy of OpiateDependence, 1992

PROFILE FOR POTENTIAL


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PROFILE FOR POTENTIALPSYCHOTHERAPEUTIC AGENT

Effective after oral administration

Long biological half-life (>24 hours)

Minimal side effects during chronic

administration

Safe, no true toxic or serious adverse effects

Efficacious for a substantial % of persons with

the disorder (> 15-20%)


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DoseResponse

Time

LoadedHigh

Normal Range

Comfort Zone

Sick

Methadone Simulated 24 Hr. Dose/Response

At steady-state in tolerant patient

0 hrs. 24 hrs.

Abnormal Normality

Subjective w/d

Objective w/d


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Not Holding Strategies

Cognitive, Behavioral Interventions Increased contact, counseling,

therapy

Alter urinary pH?

Is patient fixing? - Raise dose

Split Dose?

Rapid Metabolizer High Single and


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Rapid Metabolizer - High Single andSplit Dose Simulation

0

100

200

300

400

500

600

700

0 4 8 12 16 20 24

Single

HighSingle

Split Dose

Minimum

'Normal'Ceiling

High

Normal

Sick

ng

/ml

Hours


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TAPERING

how many remain abstinent?

tapering readiness

tapering strategies

clonidine

handling relapse


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Buprenorphine (1)

1970s - partial opioid agonist useful inopioid dependence treatment

1990s - clinical trials

long duration of action; smooth onset

low physical dependence

mild withdrawal syndrome

good name on the street


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Buprenorphine (2)

DATA 2000 permitted use in MD office

FDA approved Subutex and Suboxone in2002

Physicians must meet trainingrequirements: certified in addictionmedicine, participated in clinical trials, or

took 8 hour course by specifiedorganizations


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Buprenorphine (3)

SUBUTEX & SUBOXONE

Sublingual tablets

Suboxone has naloxone added todiscourage needle use

Partial agonist: ceiling effect

Expensive: $300/month at average dose

Not interchangeable with methadone


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Naltrexone

antagonist; how it works

who does it work for?

accelerated withdrawal protocols

Doles critique

utility with alcoholics


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Methadone in Pregnancy

Comprehensive MMT treatment with prenatalcare improves neonatal outcome

Withdrawal is rarely appropriate during

pregnancy Methadone is not teratogenic; children have

been followed into adulthood

Appropriate dosing is very important

Breast feeding OK if no other drug use


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Opioids and Chronic Pain

Opioid tolerance & physical dependence DONOT equal opioid addiction

Loss of Control Indices:

Continued use despite adverse consequences

Illicit or inappropriate drug seeking behavior

In response to craving or drug hunger

In the absence of pain or withdrawal

Pseudo Addiction


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Pseudo Addiction- in chronic pain patient

Inadequate Treatment of Pain Apparent Drug Seeking Behavior

Effort to achieve adequate analgesia

Early refill, doctor shopping, etc.

Manipulation seen as addictive behavior

May be seen as non-compliance

Cured by adequate treatment of pain


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Chronic Pain Disorder

Opioid Tolerance Opioid Physical Dependence

Absence of illicit or inappropriate drug

seeking behavior No drug hunger in absence of pain

No loss of control

No doctor shopping

Little tendency to escalate dose over time


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PSYCHOSOCIAL

TREATMENT ISSUES


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Population Characteristics

Heterogeneity

Readiness for recovery; motivation

Psychiatric comorbidity

Medical comorbidity

h


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Program Characteristics

Medical component: assessment,dosing, client interactions

Individual counseling Group counseling

Case management

Staff training (ongoing)

Wh t i Ab ti ?


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What is Abstinence?

Medication is compatible with 12-stepparticipation if appropriately prescribed byphysician knowledgeable about addiction

Pt on methadone is abstinent if not using illicitdrugs and using legal ones as prescribed

Its just another medication. Meds are a tool,

not a solution


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Cognitive-Behavioral Therapy

Lends itself to controlled studies; strongsupport for its effectiveness

Especially useful to help establish

abstinence, teach early recovery andrelapse prevention skills

Emphasizes changing behavior and

managing symptoms

Cognitive Behavioral Strategies


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Cognitive Behavioral Strategies(CBT)

MATRIX MODEL - Organizing Principles

Create explicit structure and expectations

Establish positive, collaborative relationship

Teach information and CBT concepts

Positively reinforce behavior change

Provide corrective feedback when necessary

Encourage self-help participation

CBT MATRIX MODEL


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CBT: MATRIX MODEL

Structure is essential: time scheduling, self-help meetings, exercise, work, treatmentactivities

Identify external and internal triggers and

make a plan Tools for managing cravings: thought

stopping, visual imagery, changeenvironment/behavior

TIP #33 has description, patient worksheets(Rawson 1999)


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Clinical Issues


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Is Psychotherapy Useful?

Philadelphia group study, begun 1977

global psychiatric status ratings

elements of drug counseling

models of psychotherapy utilized

benefits to low severity patients

benefits to high severity patients


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Dual Diagnosis Issues

depression

trauma history; PTSD

schizophrenia

medication strategies

PTSD I fl i E l T


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PTSD Influence in Early Tx

Aim: determine tx adherence relative tofrequency of violence and PTSD in MMT pts,male & female

96 pts; over 2/3 exposed to one or more violenttraumatic events

Trauma or PTSD did not predict dropout rates

Those with current PTSD had significantly more

ongoing drug use at 3 months, especiallycocaine

(Hein et al, 2000)

Continued heroin, alcohol,d h d


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and other drug use

patient and provider expectations

enhancing motivation

cocaine use

alcohol use

medical comorbidity; AIDS, chronic pain

controversies about discharge

P h l i l I


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Psychological Issues

AOD use in family of origin

high frequency of childhood physicaland sexual abuse

recognition and appropriate expressionof feelings

issues of self-care, self-soothing

W I


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Womens Issues

remove practical barriers: transportation,child care

intimate relationships as primary hazard

sexual issues

contraceptive practices

F il /C l W k


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Family/Couples Work

engaging family, significant others

education about addiction and MMT

develop existing and new support

structures

couples issues

parenting classes

HIV/AIDS


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HIV/AIDS

impact on MMT staff; providing support

regular assessment of staff attitudes andknowledge

integrating primary care promoting medication compliance

impact of dementia on treatment

MMT d 12 St P


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MMT and 12-Step Programs

benefits and hazards

simulated meetings as a launchingstrategy

meetings in the community Vincent Dole and Bill W.

other types of self-help

advocacy groups

Making Residential Treatment


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Available to Methadone Patients

Some clients need higher level of care

Issues for the methadone program

Issues for the residential program

Security issues

Documentation issues

Funding barriers

Documents

RAWATAN METHADON DAN TERAPI