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Medication-AssistedTreatment (MAT) of Opioid Dependence

Christina M. Delos Reyes, MDChristina M. Delos Reyes, MD

Chief Clinical Officer, ADAMHS Board of Cuyahoga CountyChief Clinical Officer, ADAMHS Board of Cuyahoga County

Medical Consultant, Center for Evidence-Based Practices at CaseMedical Consultant, Center for Evidence-Based Practices at Case

SAMHSA/BJA Opiate Treatment Grant TrainingSAMHSA/BJA Opiate Treatment Grant Training

Cleveland, OhioCleveland, Ohio January 26 & 27, 2012January 26 & 27, 2012

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Learning Objectives

Following this presentation, participants will Following this presentation, participants will be able to:be able to:• List three different types of MAT (medication-List three different types of MAT (medication-

assisted treatment) for opioid dependenceassisted treatment) for opioid dependence• Describe the mechanism of action and the proper Describe the mechanism of action and the proper

dosing for three different types of MAT for opioid dosing for three different types of MAT for opioid dependence.dependence.

• Review common barriers to using MAT in a Review common barriers to using MAT in a variety of treatment settings.variety of treatment settings.

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SOURCE: Naples Daily News, 2001.

Ritual of a Heroin User

“A Fort Myers woman in her 30s prepares a heroin fix at the home of a friend on a recent day. The woman uses a hypodermic needle to inject heroin, which she had heated in a spoonful of water, into a vein in her hand. However, the increased purity of the drug and a fear of contracting HIV from contaminated needles, along with the social stigma associated with needle use, has caused an upsurge in users snorting and smoking heroin. "You first get an adrenaline rush, then a sensation of mellow. You lose sense of time and forget everything,'' the woman said. "Heroin is easy to find...You can get a bag for $10.”

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Opiate/Opioid : What’s the Difference?

OpiateOpiate A term that refers to drugs or medications that are A term that refers to drugs or medications that are

derived from the opium poppyderived from the opium poppy, such as heroin, , such as heroin, morphine, and codeine.morphine, and codeine.

OpioidOpioid A more general term that A more general term that includes opiates as well includes opiates as well

as the synthetic drugs or medicationsas the synthetic drugs or medications, such as , such as buprenorphine, methadone, meperidine buprenorphine, methadone, meperidine (Demerol(Demerol®®), fentanyl—that produce analgesia and ), fentanyl—that produce analgesia and other effects similar to morphine.other effects similar to morphine.

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Basic Opioid Facts

DescriptionDescription: Opium-derived, or synthetics which : Opium-derived, or synthetics which relieve pain, produce morphine-like addiction, relieve pain, produce morphine-like addiction, and relieve withdrawal from opioidsand relieve withdrawal from opioids

Medical UsesMedical Uses: Pain relief, cough suppression, : Pain relief, cough suppression, diarrhea diarrhea

Methods of UseMethods of Use: Intravenously injected, smoked, : Intravenously injected, smoked, snorted, or orally administeredsnorted, or orally administered

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What’s What? Agonists, Partial Agonists,

and Antagonists

AgonistAgonist

Partial AgonistPartial Agonist

AntagonistAntagonist

Morphine-like effect (e.g., heroin)Morphine-like effect (e.g., heroin)

Maximum effect is less than a full Maximum effect is less than a full agonist (e.g., buprenorphine)agonist (e.g., buprenorphine)

No effect in absence of an opiate or No effect in absence of an opiate or opiate dependence (e.g., naloxone)opiate dependence (e.g., naloxone)

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Opioid Agonists

Natural derivatives of opium poppyNatural derivatives of opium poppy

- Opium- Opium

- Morphine- Morphine

- Codeine- Codeine

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Opium

SOURCE: www.streetdrugs.org

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Morphine

SOURCE: www.streetdrugs.org

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Opioid Agonists

Semisynthetics: Derived from chemicals in Semisynthetics: Derived from chemicals in opiumopium

- Diacetylmorphine – Heroin- Diacetylmorphine – Heroin

- Hydromorphone – Dilaudid- Hydromorphone – Dilaudid®®

- Oxycodone – Percodan- Oxycodone – Percodan®®, Percocet, Percocet®®

- Hydrocodone – Vicodin- Hydrocodone – Vicodin®®

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Heroin

SOURCE: www.streetdrugs.org

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Opioid Agonists

SOURCE: www.pdrhealth.com

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Opioid Agonists

SyntheticsSynthetics

- Propoxyphene – Darvon- Propoxyphene – Darvon®®, Darvocet, Darvocet®®

- Meperidine – Demerol- Meperidine – Demerol®®

- Fentanyl citrate – Fentanyl- Fentanyl citrate – Fentanyl®®

- Methadone – Dolophine- Methadone – Dolophine®®

- Levo-alpha-acetylmethadol – ORLAAM- Levo-alpha-acetylmethadol – ORLAAM®®

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Methadone

SOURCE: www.methadoneaddiction.net

DarvocetDarvocet

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Opioid Partial Agonists

Buprenorphine – BuprenexBuprenorphine – Buprenex®®, Suboxone, Suboxone®®, , SubutexSubutex®®

Pentazocine – TalwinPentazocine – Talwin®®

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Buprenorphine/Naloxone combination Buprenorphine/Naloxone combination and Buprenorphine Aloneand Buprenorphine Alone

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Opioid Antagonists

Naloxone – Narcan®Naloxone – Narcan®

Naltrexone Naltrexone – ReVia– ReVia®®, Trexan, Trexan®®

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Opioids and the Brain:

Pharmacology Pharmacology

and Half-Lifeand Half-Life

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SOURCE: National Institute on Drug Abuse, www.nida.nih.gov.

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Terminology

ReceptorReceptor: :

specific cell binding site or molecule: a molecule, specific cell binding site or molecule: a molecule, group, or site that is in a cell or on a cell surface group, or site that is in a cell or on a cell surface and binds with a specific molecule, antigen, and binds with a specific molecule, antigen, hormone, or antibodyhormone, or antibody

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Opioid Agonists: Pharmacology

Stimulate opioid receptors in central nervous Stimulate opioid receptors in central nervous system & gastrointestinal tractsystem & gastrointestinal tract

Analgesia – pain relief (somatic & Analgesia – pain relief (somatic & psychological)psychological)

Antitussive action – cough suppressionAntitussive action – cough suppression

Euphoria, stuperousness, “nodding”Euphoria, stuperousness, “nodding”

Respiratory depressionRespiratory depression

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Opioid Agonists: Pharmacology

Pupillary constriction (miosis)Pupillary constriction (miosis) ConstipationConstipation Histamine release (itching, bronchial Histamine release (itching, bronchial

constriction)constriction) Reduced gonadotropin secretionReduced gonadotropin secretion Tolerance, cross-toleranceTolerance, cross-tolerance Withdrawal: acute & protractedWithdrawal: acute & protracted

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What is the Definition of “Half-Life?”

The time it takes for The time it takes for halfhalf a given amount of a a given amount of a substance such as a drug to be removed from living substance such as a drug to be removed from living

tissue through natural biological activitytissue through natural biological activity

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Duration of Action Two factors determine the duration of action of Two factors determine the duration of action of the medication:the medication:

• Half-life - time it takes to metabolize half the Half-life - time it takes to metabolize half the drug. In general, the longer the half-life, the drug. In general, the longer the half-life, the longer the duration of action.longer the duration of action.

• Receptor affinity or strength of the bond Receptor affinity or strength of the bond between the substance and the receptor - between the substance and the receptor - medications that bind strongly to the receptor medications that bind strongly to the receptor may have very long action even though the may have very long action even though the half-life may be quite short.half-life may be quite short.

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Opioid Antagonist Half-Lives

Naloxone – 15-30 minutesNaloxone – 15-30 minutes

Naltrexone – 24-72 hours Naltrexone – 24-72 hours

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Opioid Agonist Half-Lives

Heroin, codeine, morphine – 2-4 hoursHeroin, codeine, morphine – 2-4 hours

Methadone – 24 hoursMethadone – 24 hours

LAAM – 48-72 hours LAAM – 48-72 hours

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Opioid Partial Agonist Half-Lives

Buprenorphine – 4-6 hours Buprenorphine – 4-6 hours (however, duration of (however, duration of action very long due to high receptor affinity)action very long due to high receptor affinity)

Pentazocine – 2-4 hoursPentazocine – 2-4 hours

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Opioid Addiction and the Brain

Opioids attach to receptors in brain Pleasure

Repeated opioid use Tolerance

Absence of opioids after prolonged use Withdrawal

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What Happens When You Use Opioids?

Acute EffectsAcute Effects: Sedation, euphoria, pupil : Sedation, euphoria, pupil constriction, constipation, itching, and lowered constriction, constipation, itching, and lowered pulse, respiration and blood pressurepulse, respiration and blood pressure

Results of Chronic UseResults of Chronic Use: Tolerance, addiction, : Tolerance, addiction, medical complicationsmedical complications

Withdrawal SymptomsWithdrawal Symptoms: Sweating, gooseflesh, : Sweating, gooseflesh, yawning, chills, runny nose, tearing, nausea, yawning, chills, runny nose, tearing, nausea, vomiting, diarrhea, and muscle and joint achesvomiting, diarrhea, and muscle and joint aches

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Possible Acute Effects of Opioid Use

Surge of pleasurable sensation = “rush”Surge of pleasurable sensation = “rush” Warm flushing of skinWarm flushing of skin Dry mouthDry mouth Heavy feeling in extremitiesHeavy feeling in extremities DrowsinessDrowsiness Clouding of mental functionClouding of mental function Slowing of heart rate and breathingSlowing of heart rate and breathing Nausea, vomiting, and severe itchingNausea, vomiting, and severe itching

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Consequences of Opioid Use Addiction Addiction

OverdoseOverdose

DeathDeath

Use related (e.g., HIV infection, malnutrition)Use related (e.g., HIV infection, malnutrition)

Negative consequences from injection:Negative consequences from injection:• Infectious diseases (e.g., HIV/AIDS, Hepatitis B and C) Infectious diseases (e.g., HIV/AIDS, Hepatitis B and C) • Collapsed veins Collapsed veins • Bacterial infections Bacterial infections • Abscesses Abscesses • Infection of heart lining and valves Infection of heart lining and valves • Arthritis and other rheumatologic problems Arthritis and other rheumatologic problems

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Heroin Withdrawal Syndrome Intensity varies with level & chronicity of useIntensity varies with level & chronicity of use

Cessation of opioids causes a rebound in function Cessation of opioids causes a rebound in function altered by chronic usealtered by chronic use

First signs occur shortly before next scheduled doseFirst signs occur shortly before next scheduled dose

Duration of withdrawal is dependent upon the half-Duration of withdrawal is dependent upon the half-life of the drug used:life of the drug used:

• Peak of withdrawal occurs 36 to 72 hours after last dosePeak of withdrawal occurs 36 to 72 hours after last dose• Acute symptoms subside over 3 to 7 daysAcute symptoms subside over 3 to 7 days• Protracted symptoms may linger for weeks or monthsProtracted symptoms may linger for weeks or months

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Opioid Withdrawal Syndrome

Acute Symptoms Pupillary dilationPupillary dilation

Lacrimation (watery eyes)Lacrimation (watery eyes)

Rhinorrhea (runny nose)Rhinorrhea (runny nose)

Muscle spasms (“kicking”)Muscle spasms (“kicking”)

Yawning, sweating, chills, goosefleshYawning, sweating, chills, gooseflesh

Stomach cramps, diarrhea, vomitingStomach cramps, diarrhea, vomiting

Restlessness, anxiety, irritabilityRestlessness, anxiety, irritability

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Opioid Withdrawal Syndrome

Protracted Symptoms Deep muscle aches and painsDeep muscle aches and pains

Insomnia, disturbed sleepInsomnia, disturbed sleep

Poor appetitePoor appetite

Reduced libido, impotence, anorgasmiaReduced libido, impotence, anorgasmia

Depressed mood, anhedoniaDepressed mood, anhedonia

Drug craving and obsessionDrug craving and obsession

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Treatment Options for Opioid-Addicted

Individuals Behavioral treatments educate patients about the Behavioral treatments educate patients about the

conditioning process and teach relapse prevention conditioning process and teach relapse prevention strategies. strategies.

Medications such as methadone and buprenorphine Medications such as methadone and buprenorphine operate on the opioid receptors to relieve craving.operate on the opioid receptors to relieve craving.

Combining the two types of treatment Combining the two types of treatment enables patients to stop using opioids and enables patients to stop using opioids and return to more stable and productive return to more stable and productive lives.lives.

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Treatment Options for Opioid-Addicted

Individuals Medically-assisted withdrawalMedically-assisted withdrawal

Long-term residential treatmentLong-term residential treatment

Outpatient psychosocial treatmentOutpatient psychosocial treatment

Behavioral therapiesBehavioral therapies

Medication-Assisted Treatment (MAT)Medication-Assisted Treatment (MAT)

Medication-Assisted Treatment

Naltrexone—antagonist Naltrexone—antagonist Methadone—agonistMethadone—agonist Buprenorphine—partial agonistBuprenorphine—partial agonist

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Naltrexone

Opiate Opiate antagonistantagonist to treat opiate dependence to treat opiate dependence All effects of opiates are blockedAll effects of opiates are blocked

• Must be detoxed and opiate-free or else will cause Must be detoxed and opiate-free or else will cause opiate withdrawal syndromeopiate withdrawal syndrome

Blocks opioid receptors that are involved in Blocks opioid receptors that are involved in the rewarding effects of opiates (& alcohol!)the rewarding effects of opiates (& alcohol!)

Risk for hepatotoxicityRisk for hepatotoxicity• Monitor for liver enzymesMonitor for liver enzymes

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Naltrexone

Brand name: Revia (oral tablets)Brand name: Revia (oral tablets) Usual dose: 50mg dailyUsual dose: 50mg daily Efficacy highest in patients who can abstain Efficacy highest in patients who can abstain

for 4 to 7 days before initiating treatmentfor 4 to 7 days before initiating treatment No negative effect with useNo negative effect with use Some clients notice anxiolytic effectSome clients notice anxiolytic effect

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Long- Acting Naltrexone

Brand name is VivitrolBrand name is Vivitrol Approved for alcoholism in 2006Approved for alcoholism in 2006 Approved for opiate dependence Oct 2010Approved for opiate dependence Oct 2010 Given monthly, 380 mg appears to have Given monthly, 380 mg appears to have

increased efficacy versus 190 mgincreased efficacy versus 190 mg May have increased efficacy for men vs. May have increased efficacy for men vs.

women, and those abstinent when medication women, and those abstinent when medication is initiated vs. those still drinkingis initiated vs. those still drinking

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Long- Acting Naltrexone

Discontinuation rate- 14% in patients on 380 Discontinuation rate- 14% in patients on 380 mg a month, 7% in patients on 190 mg a mg a month, 7% in patients on 190 mg a month and placebo. Most common side month and placebo. Most common side effects: nausea, injection site reaction, effects: nausea, injection site reaction, headache. headache.

LFTs remained stable throughout the LFTs remained stable throughout the medication trialmedication trial

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Naltrexone:Recent Research

2005: Cuts the relapse risk during first 90 days 2005: Cuts the relapse risk during first 90 days by 36% (28% relapse rate on oral naltrexone by 36% (28% relapse rate on oral naltrexone vs. 43% relapse rate on placebo)vs. 43% relapse rate on placebo)

2005: injectable naltrexone resulted in a 25% 2005: injectable naltrexone resulted in a 25% reduction in proportion of heavy drinking days reduction in proportion of heavy drinking days vs. placebovs. placebo

Overall: helps to curb consumption in patients Overall: helps to curb consumption in patients with multiple “slips” but less effective in with multiple “slips” but less effective in maintaining abstinencemaintaining abstinence

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Naltrexone

Non-compliance is the main barrier to successNon-compliance is the main barrier to success Most useful for highly motivated patients w/ Most useful for highly motivated patients w/

external circumstancesexternal circumstances• Impaired professionals, parolees, probationers, etcImpaired professionals, parolees, probationers, etc

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Methadone

Opiate Opiate agonistagonist to treat opiate dependence to treat opiate dependence Well-studied and effective treatmentWell-studied and effective treatment

• Normalizes function/return to work, decreases Normalizes function/return to work, decreases crime/violence, reduces HIV exposurecrime/violence, reduces HIV exposure

Doses > 70mg/day generally better than low dosesDoses > 70mg/day generally better than low doses Enhanced services = improved outcomesEnhanced services = improved outcomes

• Counseling, medical, social/vocational services,etcCounseling, medical, social/vocational services,etc No contraindication in SMI, though not well studiedNo contraindication in SMI, though not well studied

Methadone

Usually taken once a day to suppress withdrawal Usually taken once a day to suppress withdrawal for 24 to 36 hoursfor 24 to 36 hours

Usually given in Usually given in liquidliquid form by Opiate Treatment form by Opiate Treatment ProgramsPrograms

Induction phase—no more than 30 to 40 mg on Induction phase—no more than 30 to 40 mg on the first day of treatmentthe first day of treatment

Dosage changes usually occur once a weekDosage changes usually occur once a week• More rapid dosage increases can cause overdoseMore rapid dosage increases can cause overdose

Maintenance phase—usually 80-120mg dailyMaintenance phase—usually 80-120mg daily46

Methadone

Common side effectsCommon side effects• Sweating, constipation, abnormal libido, sleep Sweating, constipation, abnormal libido, sleep

abnormalities, mild anorexia, weight gain, water abnormalities, mild anorexia, weight gain, water retentionretention

Adverse effectsAdverse effects• Prologation of QTc (usually seen with very high Prologation of QTc (usually seen with very high

doses, mean of 350mg daily)doses, mean of 350mg daily)

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Buprenorphine

Opioid Opioid partial agonistpartial agonist risk of overdose and risk of overdose and abuse potential abuse potential May precipitate opiate withdrawal in dependent May precipitate opiate withdrawal in dependent

individualsindividuals Approved for treatment of opiate dependenceApproved for treatment of opiate dependence

• Maintenance dose in the range of 8-16 mg dailyMaintenance dose in the range of 8-16 mg daily Sublingual route of administrationSublingual route of administration

Subutex= Bup only; Suboxone= Bup + NaloxoneSubutex= Bup only; Suboxone= Bup + Naloxone

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Buprenorphine

Approved in U.S. (2002) as Approved in U.S. (2002) as office-based office-based treatmenttreatment vs. ‘methadone clinics’ vs. ‘methadone clinics’

Individual doctors may treat up to 30 patients Individual doctors may treat up to 30 patients at a time, using an special DEA #at a time, using an special DEA #• After 1 year, may increase to 100 patientsAfter 1 year, may increase to 100 patients

Must be addiction medicine/addiction Must be addiction medicine/addiction psychiatry certified OR complete 8-hr trainingpsychiatry certified OR complete 8-hr training

Direct Buprenorphine Induction from Short-Acting

Opioids

Ask patient to abstain from short-acting opioid (e.g., Ask patient to abstain from short-acting opioid (e.g., heroin) for at least 6 hrs. and be in mild withdrawal heroin) for at least 6 hrs. and be in mild withdrawal before administering buprenorphine/naloxone.before administering buprenorphine/naloxone.

When transferring from a short-acting opioid, be sure When transferring from a short-acting opioid, be sure the patient provides a methadone-negative urine screen the patient provides a methadone-negative urine screen before 1before 1stst buprenorphine dose. buprenorphine dose.

SOURCE: Amass, et al., 2004, Johnson, et al. 2003.

Buprenorphine

Suboxone= buprenorphine + naloxone in a 4:1 Suboxone= buprenorphine + naloxone in a 4:1 mixturemixture• Available doses: 8/2mg and 2/0.5mg Available doses: 8/2mg and 2/0.5mg • 2 sublingual forms: tablet and Film2 sublingual forms: tablet and Film

Induction phase Day 1: usual dose is 2 mg Induction phase Day 1: usual dose is 2 mg given every 2-3 hours, up to 8 mggiven every 2-3 hours, up to 8 mg

Induction phase Day 2: start with 8mg, can go Induction phase Day 2: start with 8mg, can go up to 16mg depending on patient symptomsup to 16mg depending on patient symptoms

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Buprenorphine

Maintenance phase: usually 8 to 16 mg dailyMaintenance phase: usually 8 to 16 mg daily This may vary in clinical practice, but realize This may vary in clinical practice, but realize

that 16mg dose covers ~95% of opiate that 16mg dose covers ~95% of opiate receptorsreceptors

Adverse side effects: Increased LFTs, cytolytic Adverse side effects: Increased LFTs, cytolytic hepatitishepatitis

Common side effects: generally mildCommon side effects: generally mild• Constipation; dizziness; drowsiness; headache; Constipation; dizziness; drowsiness; headache;

nausea; sweating; vomiting;nausea; sweating; vomiting;52

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Buprenorphine:Recent Research

The SAMHSA Evaluation of the Impact of the DATA Waiver Program• FINAL REPORT in March 2006

Buprenorphine clinically effective and well accepted by patients.

Waiver Program has the availability of medication-assisted treatment for opioid addiction.

Adverse effects, whether involving diversion or adverse clinical events or public health consequences, have been minimal.

The 30-patient limit on individual physician practices and cost / reimbursement issues may be decreasing potential access to treatment.

For more information, see For more information, see www.buprenorphine.samhsa.govwww.buprenorphine.samhsa.gov

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Partial vs. Full Opioid Agonist

Dose of Opiate

OpiateEffect

death

Full Agonist(e.g., methadone)

Partial Agonist

(e.g. Naloxone)Antagonist

(e.g. buprenorphine)

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Possible Barriers to using MAT

Potential Fear # 1:Potential Fear # 1:

Medication will Medication will eventually replace eventually replace rehabilitation as the rehabilitation as the treatment of choice for treatment of choice for addictionaddiction “a pill for “a pill for every ill”every ill”

Rationale # 1:Rationale # 1: Medication may be a Medication may be a

useful adjunct to useful adjunct to treatmenttreatment

““Another tool in your Another tool in your toolbox”toolbox”

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Possible Barriers to using MAT

Potential Fear # 2:Potential Fear # 2:Medication will distract Medication will distract

from the difficult work from the difficult work of recovery from of recovery from addictionaddiction

Rationale # 2:Rationale # 2: Medication makes detox Medication makes detox

safer and more humanesafer and more humane Medication may allow Medication may allow

the process of recovery the process of recovery to begin and continueto begin and continue

Medication may make Medication may make recovery possible for recovery possible for those with severe those with severe mental illnessmental illness

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Possible Barriers to using MAT

Potential Fear # 3:Potential Fear # 3:Medication will perpetuate Medication will perpetuate

an existing addictionan existing addiction

Potential Fear # 4:Potential Fear # 4:Medication will cause new Medication will cause new

addictionsaddictions

Rationale # 3:Rationale # 3: Physical dependence to Physical dependence to

medication may occur, medication may occur, but addictive behavior but addictive behavior should decreaseshould decrease

Rationale # 4:Rationale # 4: New addictions to New addictions to

medications are a risk, medications are a risk, but the actual incidence but the actual incidence is quite lowis quite low

Other Barriers to MAT?

FinancialFinancial• MAT may be very expensive and many still do not MAT may be very expensive and many still do not

have insurancehave insurance RegulatoryRegulatory

Until very recently, doctor visits for MAT were not covered by Until very recently, doctor visits for MAT were not covered by ODADASODADAS

LogisticalLogistical• Usual treatment settings may not be set up to provide Usual treatment settings may not be set up to provide

MATMAT Others?Others?

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Medications only work if…

…they are getting “from the bottle to the bloodstream”

How to help clients with the idea of starting meds? • “that will mean I am really sick…” OR “I don’t need a

crutch…” How to help clients with the idea of staying on

meds?• “I feel fine, I don’t need it anymore” OR “if I take

meds, then I am not really sober”

Some Lessons fromMotivational Interviewing

What are the client’s goals? How does medication fit (or not fit) with those

goals? What are the pros and cons of the

medications? Use of reflective listening What is the patient willing to do right now? What are the patient’s fears about medication?

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Hope for Recovery

People with addictive disorders often lack People with addictive disorders often lack experiences of success and have lost hopeexperiences of success and have lost hope

Medications in conjunction with other Medications in conjunction with other interventions can increase hope for a better lifeinterventions can increase hope for a better life• Reduced symptoms of withdrawalReduced symptoms of withdrawal• Reduced symptoms of cravingReduced symptoms of craving• Support for long-term sobrietySupport for long-term sobriety

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Resources ““BUPRENORPHINE TREATMENT: BUPRENORPHINE TREATMENT:

A TRAINING FOR MULTIDISCIPLINARY A TRAINING FOR MULTIDISCIPLINARY ADDICTION PROFESSIONALS”ADDICTION PROFESSIONALS”• http://www.nida.nih.gov/blending/buptreatment.ht

ml NIDA Methadone Research Web Guide NIDA Methadone Research Web Guide

http://international.drugabuse.gov/collaboration/PDFs/MethadoneResearchWebGuide.pdf

Mid-America Addiction Technology Transfer Center. Mid-America Addiction Technology Transfer Center. Psychotherapeutic Medications 2011: What Every Psychotherapeutic Medications 2011: What Every Counselor Should Know.Counselor Should Know. http://www.mattc.org

Contact Information

Christina M. Delos Reyes, MDChief Clinical Officer

ADAMHS Board of Cuyahoga CountyPhone: 216-241-3400 x 728

Fax: 216-241-0805delosreyes@adamhscc.org

Center for Evidence-Based Practices at Case www.centerforebp.case.edu