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Medication assisted therapies

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  • 1. Presented by: Dr. Dawn-Elise Snipes, Ph.D., LMHC, CRC Executive Director of AllCEUs.com
  • 2.
    • Discuss the purpose of long-term pharmacotherapy
    • Identify pharmacotherapies for
      • Smoking
      • Alcohol
      • Opioids
        • Methadone
        • Buprenorphine
    • Cases
  • 3.
    • Doesn’t cure substance dependence
      • Helps reduce drinking or episodes of use
      • Achieve longer abstinence
    • Works for a proportion of patients
    • Goals
      • Maintain abstinence
      • Increase time to relapse
      • Reduce intensity of binge if relapse occurs
  • 4.
    • Biologic basis
    • Chronic course
      • Relapses and remissions
      • No cure
      • Like other chronic diseases
    • Treatable
      • Individualize therapy
      • Medications may help improve outcomes
  • 5.
    • Part of comprehensive plan that addresses the following issues or problems:
      • Emotional
      • Cognitive
      • Physical
      • Social
      • Occupational
      • Environmental
    • Not a substitute for counseling
    • Works best in combination with psychosocial support
  • 6.
    • Essential component of addiction treatment
    • Multiple modalities available
      • 12-Step
      • Motivational Interviewing
      • Brief, Solution-Focused Therapy
      • Relapse Prevention
      • Contingency Management
  • 7.
    • Whether to add long-term pharmacotherapy
    • No pharmacotherapy for most abused drugs
      • Stimulants
      • Hallucinogens
      • Inhalants
      • Marijuana
    • Factors to consider
      • Cost
      • Availability
      • Side effects
      • Barriers
        • Workplace drug testing
        • Other meds taken
        • Incarceration
      • Motivation
  • 8.
    • Stimatization
      • Science vs. dogma
      • Evidence-based treatment vs. “drugs for drug addicts”
    • 12-Step groups
      • Becoming more progressive
      • Methadone Anonymous is alternative
    • Counselors
      • Different experiences and biases
    • Payors
      • May be easier to justify med than counseling
  • 9.
    • Duration of most pharmacotherapy is not indefinite
      • Months to years
    • Goal is stabilization
      • Flexibility
      • Individualized
      • Allow for relapse
  • 10.
    • Replacement
      • nicotine patches
      • nicotine gum
      • nicotine lozenges
      • nicotine nasal spray
    • Antidepressant
      • Zyban
    • Partial agonist
      • Varenicline (Chantix)
  • 11.
    • Always combine with a behavioral therapy program
    • Most available OTC, but all are expensive
    • Reduces harmful effects of tobacco smoking
    • Patients should not smoke while using
  • 12.
    • Highest success rate of available pharmacotherapies
    • Nicoderm, Nicotrol, Habitrol, Prostep
    • Most come in 3 strengths: 21, 14, & 7mg
    • Start with 21mg patch for 6 wks, taper to 14 mg for 2 wks, finally 7 mg for 2 weeks
    • Use new patch in different spot on upper trunk every 24 hrs
  • 13.
    • Nicorette - 2 or 4mg per piece doses
    • Requires correct “chewing technique” -- don’t chew like regular chewing gum
    • Chew 1 piece for 30 minutes every 1 to 2 hrs to prevent nicotine W/D
    • Chew regularly for first month, then taper off over 6 months
  • 14.
    • Commit, generics
    • Suck on & move from side to side until dissolves
    • 4 mg or 2 mg doses
    • Flavor
      • Mint, cherry, etc.
      • “ warming tingle”
    • No comparison studies with patch or gum
  • 15.
    • Reduces nicotine craving & mimics pleasurable effects of nicotine
    • 1 spray in each nostril, up to 40 times in 24 hours
    • Use for up to 3 months
    • May cause tearing, sneezing, & burning sensation in nose
  • 16.
    • Bupropion 150mg sustained release pills
    • Works on dopamine & norepinephrine receptors in the brain to decrease W/D
    • Start pills 10-14 days before “quit date”
    • Take daily for 3 days, then twice a day
    • Continue pills for 8 - 12 weeks
    • May cause insomnia, anxiety, or seizures
    • Prescription includes behavioral program
  • 17.
    • Nicotine partial agonist
    • Start pills 10 days before quit date
      • Increase dose
      • Take for 12-24 weeks
    • Includes behavioral program
  • 18.
    • Disulfiram (Antabuse)
    • Acamprosate (Campral)
    • Naltrexone (ReVia, Vivitrol)
  • 19.
    • Blocks acetaldehyde dehydrogenase
    • Reaction to alcohol
      • Flushing, palpitations, chest tightness
      • Nausea, headache, anxiety
    • Avoid slips or relapses
    • Affects liver, even without alcohol
    • Motivation is necessary
      • Monitored dosing
  • 20.
    • Alcohol dependence pharmacotherapy
    • No drug interactions
    • Minimal side effects
      • Diarrhea
    • Reduces symptoms of protracted abstinence
      • Insomnia
      • Anxiety
      • Restlessness
    • Use caution in suicidal patients
  • 21.
    • Begin as soon as possible after the acute withdrawal period
      • Does not treat withdrawal symptoms
    • Dose: two 333 mg tablets 3 times daily
      • with or without food
      • Takes 5-7 days to reach effective level
    • Treat for 12 months
      • Effect sustained for at least 12 months more
  • 22.
    • Blocks opioid receptors
    • Reduce craving
    • Tablets or implantable pellets
    • Reduces alcohol slips
    • Used for opioids and alcohol
  • 23.
    • Intramuscular injection of depot naltrexone given monthly
    • Recently FDA approved for alcohol
    • Administer in physician office, not at home
    • Requires patient motivation
  • 24.
    • Oral naltrexone compounded by pharmacy into pellet
      • Inserted subcutaneously (minor surgery)
      • Lasts for 1-3 months, may be replaced
    • Antagonist maintenance
      • Similar to oral/intramuscular naltrexone therapy
    • Requires detoxification from opioids first
    • Not approved by FDA
  • 25.
    • Abstinence-based
      • Narcotics Anonymous
      • Residential (with or after detox)
    • Antagonist maintenance
      • Naltrexone
    • Opioid maintenance
      • Methadone
      • Buprenorphine
      • Heroin
  • 26.
    • Long-acting medication in controlled setting
      • Counseling
      • Social services
    • Avoid withdrawal & craving
    • Reduce disease & crime
    • Maintenance vs. detoxification
  • 27.
    • Opioid substitution therapy
    • Harm reduction
      • Individual
      • Society
    • Highly regulated
      • Narcotic treatment programs must be licensed
    • Very effective
    • Methadone is a mu opioid agonist
      • No withdrawal symptoms
      • No craving
  • 28.
    • Methadone given for <180 days
    • Stabilization of withdrawal symptoms and behavior over weeks/months
    • Taper over a few months
    • Option for those who don’t meet criteria for maintenance
    • Risk of overdose after tapering off
  • 29.
    • Single daily dose of the long-acting opioid in a controlled setting
    • Use of methadone for >180 days (6 mo.)
    • Counseling and social services
    • Referral for primary medical services
  • 30.
    • Controlled trials and meta-analyses comparing medication and placebo show the superiority of agonist pharmacotherapy
    • Improved treatment retention
    • Reduces and often eliminates use of nonprescribed opioids
    • Decreases criminal activity
    • Reduces spread of HIV
    • Results similar to long-term therapy of most chronic diseases
  • 31.
    • 18 years old or older
    • Physical dependence
      • At least 1 year of use
        • Continuous
        • Intermittent
      • Withdrawal signs
    • Chronic use
      • Needle tracks on skin
    • Exceptions
      • Younger than 18 if
        • Physical dependence
        • Failed 2 other treatments
        • Parental consent
      • Not physically dependent if just released from
        • Incarceration
        • Hospital
      • Pregnant
  • 32.
    • Majority of opioid receptors are blocked by methadone
      • No withdrawal symptoms or cravings
      • Can’t “feel” heroin effects
    • Different for each patient
      • Usually 60-100mg daily
      • May be higher for some patients
  • 33.
    • Individually determined
      • Based on tolerance, withdrawal
      • Other medications, physical activity level
    • Induction
      • Start at 30mg and rapidly titrate up to 60mg or more
    • Stabilization
      • Client feedback, slow titration
    • Haven’t had adequate trial of MM if hasn’t been on >60mg for several months
  • 34.
    • Enhanced recovery
    • Reduced mortality
      • 70% reduction
        • Overdose
        • Trauma
        • Homicide
        • Medical illnesses
    • Improved health
      • Medical
      • Psychiatric
    • Improved psychosocial functioning
      • Employment
      • Criminal activity
      • Family responsibilities
  • 35.
    • Sedation
    • Constipation
    • Sweating
    • Lower testosterone levels
    • Arrhythmia
    • Hyperalgesia
  • 36.
    • No real euphoria
    • Does cause sedation
      • This is one of the typical opioid effects
      • Can be reassuring
      • Confused with “high”
    • DEADLY if mixed with other drugs
      • Benzodiazepines
      • Alcohol
  • 37.
    • Cognitive impairment may occur:
      • During induction
      • Change in dose
      • Combination with other drugs/medications
    • On a stable dose patient can
      • Drive safely
      • Complex tasks
      • Care for others
  • 38.
    • Dose set by physician
      • Feedback from client
    • Dispensed by nurse or pharmacist
      • Liquid or tablets
    • Specific procedure required
      • Observed dosing
      • Reduce diversion
    • Take-out doses
  • 39.
    • Methadone is diverted to black market
    • Dosing procedure at window to reduce diversion
    • High security at MM clinics
    • Most methadone sold on street is from prescriptions for pain management, not from MM clinics
  • 40.
    • Alarm system
    • Storage safe
    • Surveillance
    • Security guards
    • Local police
    • Required by DEA
  • 41.
    • Required component
    • Formats
      • Groups
      • Individual
      • 12-Step
    • Relapse prevention
    • Coping skills
    • Case management
  • 42.
    • No federal limit for time on methadone
    • Some states restrict time
      • Virginia: evaluate every 2 years to see if can come off
    • Individual variability
      • Time required to stabilize (use, housing, family, job)
      • Long-term clients (decades)
    • Initial: can’t imagine life without something
    • Stable: able to consider coming off
      • Taper off comfortably over months/years
  • 43.
    • Alternative to methadone for opioid addiction treatment
    • Long-acting opioid agonist-antagonist
    • Multiple forms available
      • Combined with naloxone (Suboxone): most common
      • Buprenorphine only (Subutex)
      • Used for treatment of acute pain (Buprenex)
    • Detox or maintenance
  • 44.
    • Binds to opioid receptors in body
    • Only activates receptor around 40%, not 100% like other opioids (heroin, methadone)
      • If already in withdrawal, 40% is pretty good
      • If not in withdrawal, dropping from 100% to 40% receptor activation causes withdrawal
    • Very low risk of overdose
      • Can OD when combined with benzos
  • 45.
    • Buprenorphine is less restricted than methadone (Schedule III)
      • Get prescription from pharmacy with refills (up to 6 months)
      • Outpatient physician visits for medication checks as needed
    • Addiction counseling is separate, patient may be referred to another provider for this service
  • 46.
    • Sublingual tablet
      • Dissolve under tongue
      • Takes around 5 min. to dissolve
      • Won’t be active if swallowed
    • Comes in 2mg and 8mg tablets
    • Typical dose is 12-16 mg once daily
    • Can take 3 times a week
  • 47.
    • Treatment efficacy equivalent
    • Similar opioid side effects
    • Abuse potential
      • Slightly higher for buprenorphine in opioid non-dependent persons
    • Buprenorphine has fewer drug interactions
    • Methadone has no ceiling effect
    • Buprenorphine more convenient (less restricted)
    • Methadone less expensive
      • Higher cost of buprenorphine, counseling separate cost
    • Buprenorphine not age-restricted (can use in teens)
    • Individual decision
  • 48.
    • In general, all drug use is reduced on MM & bup
    • May escalate other drug use when heroin not effective
      • Cocaine
      • Alcohol
      • Sedatives (benzos)
    • Intensify counseling, reaffirm goals for all drug abstinence
  • 49.
    • Patient report
    • Clinical observation
    • Collateral information
      • Family
      • Other counselors
      • Probation officer
    • Urine drug screening
  • 50.
    • Use as deterrent, not to ‘catch in the act’
    • Random
      • Minimum of 8 samples/year on maintenance therapy
    • Verify presence of methadone, buprenorphine, etc.
    • Look for
      • Illicit substances
      • Unauthorized prescriptions
        • Opioids
        • Benzodiazepines
  • 51.
    • Long-term pharmacotherapy is available and effective for several addictions
      • Medication + counseling = recovery
    • Smoking cessation
      • Nicotine replacement is available over-the-counter
      • Bupropion and varenicline are available by prescription for smoking cessation
    • Multiple medications are available by prescription for alcohol dependence
  • 52.
    • Methadone/buprenorphine maintenance proven to reduce mortality, crime, & spread of infection
      • Substitution therapy to eliminate withdrawal, cravings, & heroin effects
      • Individualized dose and time on maintenance
      • Effective for more than just opioid addiction