Opioid Maintenance Treatment

(OMT)

What it is………What it is not……

Stacy Seikel, MDBoard Certified Addiction Medicine

Board Certified Anesthesiology

Addiction

Bio-Psych-Social-Disease

Goals of OMT Reduce Cravings & Withdrawal Harm Reduction

HIV, Hep C, Hep B, Endocarditis, Skin abscesses

Decrease Risk of Overdose Prostitution Problems with the law

Goals of OMT (con’t.)

Recovery AA/NA/MA Group & Ind Therapy Life Skills Non Pharmaceutical coping skills

Help People Have Normal Lives

The Center For Drug-Free LivingOMT

Abstinence From All Other Addictive/Mood Altering Substances

Group and Individual Therapy Random UDS Mandatory Classes Encouraged to Attend 12-Step Programs Consult With Patient’s Primary, Specialty,

Pain and Psychiatric Physicians Therapy/Treatment Works!

Common Questions About

Methadone

How Does Methadone Work? Opiate agonist

Mu receptor

Lasts 24-36 hrs.

Common Questions AboutMethadone

Does Methadone make patients “high” or interfere with normal functioning? No, not when used appropriately

No impairment in driving ability

Common Questions AboutMethadone

What is the proper dose of Methadone?

The dose that averts narcotic craving

Common Questions (con’t)

Is Methadone more addictive than Heroin? Addiction is continued use despite

adverse consequences

Dependence is a physiologic phenomena

Common Questions (con’t)

Is Methadone harder to kick than Heroin? Heroin withdrawal-intense and brief

Methadone withdrawal-less acute and longer

Common Questions (con’t)

Does Methadone interfere with good health? Methadone improves health

No effect on immune function, bone density, kidneys or liver

Heroin Use v. Stabilized Methadone Maintenance: A Comparison

Topic Heroin MethadoneEffects on the Body

Onset of Action Seconds 30-90 minutes

Duration of Action 4-6 hours 24-36 hours

Route of Administration Injection, snorting, smoking Oral, in liquid form or

Dissolvable diskettes for medically maintained

patients

Frequency of Administration 4-6x/day 1x every 24 hours

Effective Dose Ever increasing Usually 80-120mg but

individually adjusted.Correctly stabilized patients do not need

adjustment unless medically indicated

Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t)

Topic Heroin MethadoneEffects on Body

Overdose Potential High Very rare at blockage dose

Overall Safety Potentially lethal Non-toxic in opiate tolerant person

Potential for Abuse High Blocking dose prevents “high”

Withdrawal Within 3-4 hours After 24 hours

Physical Reaction Time Impaired Normal

Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t)

Topic Heroin MethadoneEffects on the MindOn Mood Constant mood swings Stable mood if not suffering

other disorders

On Getting High Euphoria for 2 hours High is blocked

On tolerance Increasing tolerance Stabilized

On Cravings Recurring cravings Eliminated

On Intellectual Functioning Impaired Normal

Pain and Emotion Blunted Normal pain and range of emotions

Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t)

Topic Heroin MethadoneEffects on Health

HIV Transmission High rate of transmission Reduced/eliminated withHepatitis C Transmission with needle use and unprotected oral ingestion and treatment

unprotected sex

Immune System for HIV+ Persons Rapid progression to AIDS Progression slowed

Immune/Endocrine System Impaired Normalized during treatmentFor HIV-Persons

Hypothalamus Pituitary Adrenal Axis Suppressed Normalized during treatment

Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t)

Topic Heroin MethadoneEffects on Social Functioning

Criminal Activity High level Reduced/eliminated

Personal Relationships Disrupted

Employment Deteriorating performance Full Functioningloss of employment

Community Relations Destructive impact, high Contributes to publiccrime, high death rate, safety, low mortality,transmission of disease increased health

Sign and Symptoms of Withdrawal

Subjective: Cravings Anxiety Restlessness Irritability Difficulty sleeping

Sign and Symptoms of Withdrawal

“Dose not holding” Thoughts of using Body aches and pains Nausea, sick to stomach Abdominal cramping Muscle cramping

Signs and Symptoms of Withdrawal

Objective: Elevated BP Tachycardia Lacrimation Rhinorhea

Signs and Symptoms of Withdrawal

Piloerection Vomiting Yawning Dilated Pupils

What are the signs of a Methadone overdose?

Nausea and vomiting Constricted (small, pin-point) pupils Drowsiness Cold, clammy, bluish skin Reduced heart rate Reduced body temperature Slow or no breathing

Methadone Maintenance

is notMethadone/Heroin Abuse

ASAM & AAPM & APSConsensus Statement

“Addiction is a primary, chronic, neurologic disease with genetic, psychosocial and environmental factors influencing its

development and manifestations. It is characterized by behaviors that include one or

more of the following; impaired control over drug use, compulsive use, continued use despite

harm, and cravings.

Consensus Statement (Cont’d)

Physical Dependence

Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal

syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood

level of the drug, and/or administration of an antagonist.

AddictionCompulsive UseLoss of control

Continued use despite adverse consequences

Addiction has nothing to do with what medication one is taking

DemographicsDrug Abuse in US

2.1 million abuse street drugs (heroin, cocaine, crack)

3.9 million abuse Rx drugs (pain meds, sedatives,

stimulants)

Heroin Addiction

>977,000 heroin dependent individuals in the US in 2000

Opioid Treatment Programs (OTP)…

How they are done

Methadone

LAAM

Buprenorphine

Current Inventory of Regulated OTPs

1,000-1,200 Opioid Treatment Programs (OTPs) Certified by SAMHSA/CSAT Registered by DEA Licensed by State

950 Maintenance, 250 Detoxification

Approximately 205,000 Patients in Treatment

Center for Substance Abuse Treatment

Methadone Maintenance Treatment

(MMT)

Most studied drug for the treatment of a disease in the history of the world

Used and effective for over 35 years Relieves sx of withdrawal and

cravings Allows normal functioning

MMT (Cont’d)

Efficacy increased with On site medical support On site psychiatric support Supportive treatment services Urine toxicology

Comorbidities

70% of patients in OMT-HCV positive.

40-50% of patients in OMT have serious depression and anxiety disorders.

Length of Treatment

Research shows 80% relapse rate if MMT withdrawn within the first 12

months.

Pharmacology of Methadone (Cont’d)

Hepatic metabolism (varies with individual)

Renal excretion

Basic, pka=9.2

Metabolized CYP3A4 (inducible)

Pharmacology of Methadone (Cont’d)

Drugs that induce CYP3A4 ( serum methadone levels) rifampicin (Rifampin) carbamazepine (Tegretal) barbituates verapamil amitriptyline (Elavil) alcohol nevirapine

Pharmacology of Methadone (Cont’d)

Drugs that Inhibit Metabolism ( serum methadone levels)

fluoxetine (Prozac) cimetidine (Tagamet) ketoconazole metronidazole (Flagyl) HIV meds

indinavir ritonavir saquinavir

Federal Oversight of Methadone Treatment (OMT)

CSAT and SAMHSA - new accreditation system for MTP

Implemented May 18, 2001

All MTP will be accredited over the next 3 years.

Who Can Offer Treatment?

Physicians employed by a licensed OTP

Physicians in private practice who register separately with DEA as a OTP

MMT Program Phases

Intake Phase 1-30 days No takeouts 2 groups per week 1 individual

Phase I 30-90 days 1 takeout per week 2 groups per week 1 individual per week

MMT Program Phases (Cont’d)

Phase II 91-180 days 2 takeouts per week 2 groups per week 2 individuals per months

Phase III 181-365 days 3 takeouts per week (no more than 2

days supply) if client has neg UDS for preceding 90 days

1 group per week 1 individual per week

MMT Program Phases (Cont’d)

Phase IV > 1 year in treatment 4 takeouts per week (no more than 2

days supply at one time) if negative UDS preceding 90 days

2 groups per month 1 individual per month

Phase V > 2 years in treatment 5 take out (not to exceed 3 at 1 time)

UDS-negative 90 preceding days 1 group per month 1 individual per month

MMT Program Phases (Cont’d)

Phase VI > 3 years in treatment 6 take outs per week - neg UDS for

past year 1 individual per month

Methadone Maintenance at

The Center For Drug-Free Living

Orientation Stage of Recovery State I of Recovery Stage II of Recovery Stage III of Recovery

Orientation Stage

Methadone Education Evaluation & Treatment (MEET) Orientation group HIV education Medication Education Fiscal Responsibility

Orientation Stage (Cont’d)MEET Services

Group therapy training Social Development Treatment compliance Methadone and Your Health

Abstinence model of recovery Side effects of methadone Dosing When to taper? Medical/Surgical issues

Orientation Stage (Cont’d)

Contact medical & psychiatric providers

Approved medication list

Encourage 12 step recovery - NA, MA

Stage I of Recovery(Phase I & II)

Group Therapy- family issues, stress management, lifestyles changes, self esteem, financial stability, anger management, relapse prevention..

Stage II of Recovery (Phase III & IV)

Groups - Relationships, advanced financial management

Support groups stronger - sponsorship, working steps

Relapse prevention

Stage III of Recovery(Phase V & VI)

Self help becomes primary source of support

Consider taper off methadone Aftercare plans Relapse prevention plans

revised and practiced

Continued Drug Abuse ofNon Opiates

Differential Diagnosis Opiate abstinence syndrome

(subclinical) Psychiatric Disorder Pain syndrome Polysubstance Abuse

refer to detox treatment services residential treatment

“Methadone is the most effective method available for healing heroin

addiction.”

National Institute on Drug Abuse

Thank You.