Medication assisted therapies

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Medication assisted therapies

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

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