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OVERVIEW OF
MEDICATIONS TO
TREAT ADDICTION IN
PRIMARY CARE

Prepared by
CASAColumbia®
February 2014
Outline
• Introduction

• Addiction Involving:
− Tobacco/Nicotine
− Alcohol
− Opioids
− Other Drugs
• Further Consideratio...
INTRODUCTION

© CASAColumbia 2014

3
Addiction
For background
information on addiction
Addiction Medicine:
Closing the Gap
between Science and
Practice1

© CAS...
Addiction
For information on screening,
diagnosis, treatment planning
& management
Overview of Addiction
Medicine for Prim...
Stabilization
• Withdrawal in some cases can be lifethreatening
• Medical management for
stabilization/detoxification may ...
Addiction Treatment
• Treat addiction as a primary disease

• Address tobacco/nicotine, alcohol & other drugs
• Manage co-...
Combined Treatment
• Medications &
psychosocial therapies
• Can increase retention
in treatment

• Can decrease relapse
ra...
Combined Treatment
• To achieve the best results medications should
be combined with psychosocial therapies
• Research stu...
Specialist Referral
Consider for Complex Cases
• Addiction medicine physicians
find a doctor near you
• Addiction psychiat...
ADDICTION INVOLVING
TOBACCO/NICOTINE

© CASAColumbia 2014

11
FDA-Approved Meds
Tobacco/Nicotine
• varenicline (Chantix)
• bupropion (Zyban, Wellbutrin)
• nicotine replacement therapy
...
varenicline
(Chantix)

• 3X higher odds of
smoking cessation7
• Nicotinic acetylcholine
receptor partial
agonist8
• Superi...
varenicline
(Chantix)

• Begin 1wk prior to
target quit date
• Starting dose 0.5mg
QD x 3dy
• Up to 1mg BID x 12wk
extensi...
varenicline
(Chantix)

• Black Box Warning: neuropsychiatric events
• Common Side Effects: headache, insomnia,
nausea, abn...
bupropion
(Zyban, Wellbutrin)

• 2X higher odds of
smoking cessation11

• Inhibits
norepinephrine &
dopamine uptake12

© C...
bupropion
(Zyban, Wellbutrin)

• Begin 1wk prior to
target quit date
• Starting dose 150mg
QD x 3dy
• Up to 150mg BID
x 7-...
bupropion
(Zyban, Wellbutrin)

• Black Box Warning: neuropsychiatric events
• Contraindications: seizure disorder /
predis...
nicotine replacement
(Nicoderm, Nicorette, Commit, Nicotrol)

• 1.5X to 2X higher odds of smoking cessation13
• Nicotine w...
nicotine replacement
(Nicoderm, Nicorette, Commit, Nicotrol)

• Contraindications: severe angina, postmyocardial infarctio...
nicotine replacement
(Nicoderm, Nicorette, Commit, Nicotrol)

Dosing for 1 cigarette

1mg of nicotine

• Patch (OTC): 7/14...
nicotine replacement
(Nicoderm, Nicorette, Commit, Nicotrol)

Delivery method characteristics
• Patch (OTC): only long-act...
ADDICTION INVOLVING
ALCOHOL

© CASAColumbia 2014

23
FDA-Approved Meds
Alcohol
• acamprosate (Campral)
• disulfiram (Antabuse)
• naltrexone (ReVia, Depade,
Vivitrol)
• combine...
acamprosate
(Campral)

• Improves abstinence
& treatment
retention14
• May modulate
glutamate & GABA15

© CASAColumbia 201...
acamprosate
(Campral)

• Begin once abstinent for >24hr if possible
• Dose at 666mg TID x 6mo
• Safe even with severe hepa...
disulfiram
(Antabuse)

• Best efficacy with
routine use in
monitored systems
given high rates of
noncompliance16
• Aldehyd...
disulfiram
(Antabuse)

• Causes diaphoresis,
headache, dyspnea,
hypotension, palpitations,
nausea, vomiting (when
using al...
disulfiram
(Antabuse)

• Starting dose: 250-500mg QD x 1-2wk
• Maintenance dose: 125-500mg QD x 6mo
• Clinicians often sta...
naltrexone
(ReVia, Depade, Vivitrol)

• Decreases drinking by
83% over placebo17
• FDA-approved for
alcohol or opioids
• M...
naltrexone
(ReVia, Depade, Vivitrol)

• Only begin after abstinence from opioids >7dy
• Starting oral dose
25mg QD (Day 1)...
naltrexone
(ReVia, Depade, Vivitrol)

• Black Box Warning: hepatotoxicity
• Contraindications: acute hepatitis, liver fail...
ADDICTION INVOLVING
OPIOIDS

© CASAColumbia 2014

33
FDA-Approved Meds
Opioids

• buprenorphine/naloxone
(Subutex, Suboxone, Zubsolv)
• methadone (Methadose)

• naltrexone (Re...
buprenorphine/naloxone
(Subutex, Suboxone, Zubsolv)

• Reduced use & better treatment retention20
• Partial opioid agonist...
buprenorphine/naloxone
(Subutex, Suboxone, Zubsolv)

• Starting dose
8mg QD (Day 1)
16mg QD (Day 2-3)

• Maintenance dose ...
methadone
(Methadose)

• Reduced use & better
treatment retention21
• Long-acting opioid
agonist
• Distributed only by
lic...
methadone
(Methadose)

• Starting dose 20-40mg QD
• Maintenance dose 80-120mg QD
• Dose may be less depending on baseline ...
methadone
(Methadose)

• Contraindications: respiratory depression,
severe asthma, ileus, hypersensitivity
• Side Effects:...
ADDICTION INVOLVING
OTHER DRUGS

© CASAColumbia 2014

40
FDA-Approved Meds
Other Drugs

• Currently no FDA-approved
medications for addiction
involving other drugs
• Research & de...
FURTHER CONSIDERATIONS

© CASAColumbia 2014

42
For Prescription Drugs
Always consider risks of
addiction if prescribing
• Opioids
• Benzodiazepines

• Stimulants
• Other...
For Adolescent Patients
• Only buprenorphine/naloxone
is FDA-approved for 16 years
& older
• All other medications are
FDA...
For Elderly Patients
• Monitor for drug-drug interactions

• For renal insufficiency adjust dosing of
varenicline, bupropi...
References
1. CASAColumbia. Addiction medicine: closing the gap between science and practice. 2012 Jun.
http://www.casacol...
References
11. Hughes JR, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD0000...
Acknowledgements
• Margot Cohen contributed much of the research
and writing for these materials.
• The following subject-...
Ending Addiction
Changes Everything

www.casacolumbia.org
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Overview of Medications to Treat Addiction in Primary Care

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These materials provide information on prescribing details for FDA-approved medications used to treat addiction in primary care. Visit CASAColumbia.org for more details

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Overview of Medications to Treat Addiction in Primary Care

  1. 1. OVERVIEW OF MEDICATIONS TO TREAT ADDICTION IN PRIMARY CARE Prepared by CASAColumbia® February 2014
  2. 2. Outline • Introduction • Addiction Involving: − Tobacco/Nicotine − Alcohol − Opioids − Other Drugs • Further Considerations © CASAColumbia 2014 2
  3. 3. INTRODUCTION © CASAColumbia 2014 3
  4. 4. Addiction For background information on addiction Addiction Medicine: Closing the Gap between Science and Practice1 © CASAColumbia 2014 4
  5. 5. Addiction For information on screening, diagnosis, treatment planning & management Overview of Addiction Medicine for Primary Care2 (62 Slides) Overview of Addiction Medicine for Primary Care: Supplement3 (30 Pages) © CASAColumbia 2014 5
  6. 6. Stabilization • Withdrawal in some cases can be lifethreatening • Medical management for stabilization/detoxification may be required • Details for these topics can be found on Pages 88-92 of the CASAColumbia® report Addiction Medicine: Closing the Gap between Science and Practice1 © CASAColumbia 2014 6
  7. 7. Addiction Treatment • Treat addiction as a primary disease • Address tobacco/nicotine, alcohol & other drugs • Manage co-occurring disorders dopamine transporters © CASAColumbia 2014 7
  8. 8. Combined Treatment • Medications & psychosocial therapies • Can increase retention in treatment • Can decrease relapse rates © CASAColumbia 2014 8
  9. 9. Combined Treatment • To achieve the best results medications should be combined with psychosocial therapies • Research studies illustrate the effectiveness of various combinations of treatment4-6 • Details for psychosocial therapies can be found on Pages 102-106 of the CASAColumbia® report Addiction Medicine: Closing the Gap between Science and Practice1 © CASAColumbia 2014 9
  10. 10. Specialist Referral Consider for Complex Cases • Addiction medicine physicians find a doctor near you • Addiction psychiatrists find a doctor near you Addiction medicine physician: http://www.abam.net/find-a-doctor Addiction psychiatrist: https://application.abpn.com/verifycert/verifyCert.asp?a=4 © CASAColumbia 2014 10
  11. 11. ADDICTION INVOLVING TOBACCO/NICOTINE © CASAColumbia 2014 11
  12. 12. FDA-Approved Meds Tobacco/Nicotine • varenicline (Chantix) • bupropion (Zyban, Wellbutrin) • nicotine replacement therapy (e.g., patch, gum, lozenge, inhaler, nasal spray) • combinations • combine with psychosocial therapies © CASAColumbia 2014 12
  13. 13. varenicline (Chantix) • 3X higher odds of smoking cessation7 • Nicotinic acetylcholine receptor partial agonist8 • Superior to bupropion & single-form nicotine replacement therapy9 © CASAColumbia 2014 13
  14. 14. varenicline (Chantix) • Begin 1wk prior to target quit date • Starting dose 0.5mg QD x 3dy • Up to 1mg BID x 12wk extension of 12wk © CASAColumbia 2014 14
  15. 15. varenicline (Chantix) • Black Box Warning: neuropsychiatric events • Common Side Effects: headache, insomnia, nausea, abnormal dreams • FDA Warning: increased risk of CV events in patients with known CVD • Meta-analyses show no increased risk of neuropsychiatric events9 or cardiac events9-10 © CASAColumbia 2014 15
  16. 16. bupropion (Zyban, Wellbutrin) • 2X higher odds of smoking cessation11 • Inhibits norepinephrine & dopamine uptake12 © CASAColumbia 2014 16
  17. 17. bupropion (Zyban, Wellbutrin) • Begin 1wk prior to target quit date • Starting dose 150mg QD x 3dy • Up to 150mg BID x 7-12wk extension of 12wk © CASAColumbia 2014 17
  18. 18. bupropion (Zyban, Wellbutrin) • Black Box Warning: neuropsychiatric events • Contraindications: seizure disorder / predisposition; abrupt cessation of alcohol / sedatives; risky use / addiction involving alcohol • Common Side Effects: insomnia, tachycardia, weight loss, headache, lower seizure threshold • Meta-analysis shows no increased risk of neuropsychiatric events9 © CASAColumbia 2014 18
  19. 19. nicotine replacement (Nicoderm, Nicorette, Commit, Nicotrol) • 1.5X to 2X higher odds of smoking cessation13 • Nicotine without exposure to other toxins © CASAColumbia 2014 19
  20. 20. nicotine replacement (Nicoderm, Nicorette, Commit, Nicotrol) • Contraindications: severe angina, postmyocardial infarction, pregnancy, hypersensitivity • Side Effects: minimal except nasal spray (local irritation, cough, headache, dyspepsia) • Combination long-acting (e.g., patch) & shortacting (e.g., gum) better than single form13 © CASAColumbia 2014 20
  21. 21. nicotine replacement (Nicoderm, Nicorette, Commit, Nicotrol) Dosing for 1 cigarette 1mg of nicotine • Patch (OTC): 7/14/21mg, q12-24hr, 8wk taper • Gum (OTC): 2/4mg, q1-2hr, 3mo taper • Lozenge (OTC): 2/4mg, q1-2hr, 3mo taper • Inhaler (Rx): 6-16 cartridges, q24hr, 3-6mo taper • Nasal Spray (Rx): 1-2 sprays, q1hr, 3-6mo taper © CASAColumbia 2014 21
  22. 22. nicotine replacement (Nicoderm, Nicorette, Commit, Nicotrol) Delivery method characteristics • Patch (OTC): only long-acting method • Gum (OTC): “chew & park” technique crucial; should not be used with acidic food or liquids • Inhaler (Rx): beneficial for behavioral rituals • Nasal Spray (Rx): fastest absorption, most side effects © CASAColumbia 2014 22
  23. 23. ADDICTION INVOLVING ALCOHOL © CASAColumbia 2014 23
  24. 24. FDA-Approved Meds Alcohol • acamprosate (Campral) • disulfiram (Antabuse) • naltrexone (ReVia, Depade, Vivitrol) • combine with psychosocial therapies © CASAColumbia 2014 24
  25. 25. acamprosate (Campral) • Improves abstinence & treatment retention14 • May modulate glutamate & GABA15 © CASAColumbia 2014 25
  26. 26. acamprosate (Campral) • Begin once abstinent for >24hr if possible • Dose at 666mg TID x 6mo • Safe even with severe hepatic disease • Contraindication: severe renal disease • Common Side Effects: diarrhea, fatigue © CASAColumbia 2014 26
  27. 27. disulfiram (Antabuse) • Best efficacy with routine use in monitored systems given high rates of noncompliance16 • Aldehyde dehydrogenase inhibitor © CASAColumbia 2014 27
  28. 28. disulfiram (Antabuse) • Causes diaphoresis, headache, dyspnea, hypotension, palpitations, nausea, vomiting (when using alcohol) • Monitoring by spouse, supervisor, etc. is highly recommended © CASAColumbia 2014 28
  29. 29. disulfiram (Antabuse) • Starting dose: 250-500mg QD x 1-2wk • Maintenance dose: 125-500mg QD x 6mo • Clinicians often start & maintain at 250mg QD • Remains active 14 days after discontinuation • Contraindications: severe myocardial occlusive disease, psychosis, hypersensitivity • Side Effects: hepatitis, psychosis © CASAColumbia 2014 29
  30. 30. naltrexone (ReVia, Depade, Vivitrol) • Decreases drinking by 83% over placebo17 • FDA-approved for alcohol or opioids • Mu opioid receptor inhibitor • Genetic factors affect efficacy © CASAColumbia 2014 30
  31. 31. naltrexone (ReVia, Depade, Vivitrol) • Only begin after abstinence from opioids >7dy • Starting oral dose 25mg QD (Day 1), 50mg QD (Day 2) • Maintenance oral dose 50mg QD x 6mo • Depot dose 380mg IM q4wk: better compliance • Trial of at least 3mo recommended © CASAColumbia 2014 31
  32. 32. naltrexone (ReVia, Depade, Vivitrol) • Black Box Warning: hepatotoxicity • Contraindications: acute hepatitis, liver failure, prescribed opioids • Side Effects: headache, GI distress, syncope, LFT elevation • Literature review suggests no increased risk for causing or worsening hepatic disease18-19 © CASAColumbia 2014 32
  33. 33. ADDICTION INVOLVING OPIOIDS © CASAColumbia 2014 33
  34. 34. FDA-Approved Meds Opioids • buprenorphine/naloxone (Subutex, Suboxone, Zubsolv) • methadone (Methadose) • naltrexone (ReVia, Depade, Vivitrol)* • combine with psychosocial therapies * details for naltrexone included on previous slides for addiction involving alcohol © CASAColumbia 2014 34
  35. 35. buprenorphine/naloxone (Subutex, Suboxone, Zubsolv) • Reduced use & better treatment retention20 • Partial opioid agonist + opioid antagonist • Exercise caution in quantities prescribed per visit due to potential for misuse • Special training required in order to prescribe • See details under section “For Physicians” at buprenorphine.samhsa.gov © CASAColumbia 2014 35
  36. 36. buprenorphine/naloxone (Subutex, Suboxone, Zubsolv) • Starting dose 8mg QD (Day 1) 16mg QD (Day 2-3) • Maintenance dose 12-16mg QD • Contraindication: hypersensitivity • Side Effects: respiratory depression, headache, pain, insomnia, GI symptoms © CASAColumbia 2014 36
  37. 37. methadone (Methadose) • Reduced use & better treatment retention21 • Long-acting opioid agonist • Distributed only by licensed facilities © CASAColumbia 2014 37
  38. 38. methadone (Methadose) • Starting dose 20-40mg QD • Maintenance dose 80-120mg QD • Dose may be less depending on baseline opioid use • Must follow licensed facility protocol, e.g., EKGs © CASAColumbia 2014 38
  39. 39. methadone (Methadose) • Contraindications: respiratory depression, severe asthma, ileus, hypersensitivity • Side Effects: QT prolongation, respiratory depression © CASAColumbia 2014 39
  40. 40. ADDICTION INVOLVING OTHER DRUGS © CASAColumbia 2014 40
  41. 41. FDA-Approved Meds Other Drugs • Currently no FDA-approved medications for addiction involving other drugs • Research & development ongoing for marijuana, cocaine, others • Combine with psychosocial therapies © CASAColumbia 2014 41
  42. 42. FURTHER CONSIDERATIONS © CASAColumbia 2014 42
  43. 43. For Prescription Drugs Always consider risks of addiction if prescribing • Opioids • Benzodiazepines • Stimulants • Other addictive prescription drugs © CASAColumbia 2014 43
  44. 44. For Adolescent Patients • Only buprenorphine/naloxone is FDA-approved for 16 years & older • All other medications are FDA-approved for 18 years & older • Adolescent treatment should focus more on psychosocial therapies © CASAColumbia 2014 44
  45. 45. For Elderly Patients • Monitor for drug-drug interactions • For renal insufficiency adjust dosing of varenicline, bupropion, acamprosate, methadone • For hepatic insufficiency adjust dosing of bupropion, buprenorphine/naloxone, methadone, naltrexone (contraindication if severe) © CASAColumbia 2014 45
  46. 46. References 1. CASAColumbia. Addiction medicine: closing the gap between science and practice. 2012 Jun. http://www.casacolumbia.org/addiction-research/reports/addiction-medicine 2. CASAColumbia. Addiction medicine: primary care clinical guide. 2013 Aug. http://www.casacolumbia.org/health-careproviders/guide 3. CASAColumbia. Addiction medicine: primary care clinical guide supplement. 2013 Aug. http://www.casacolumbia.org/health-careproviders/guide-supplement 4. Amato L, et al. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD005031. 5. Anton RF, et al. Naltrexone combined with either cognitive behavioral or motivational enhancement therapy for alcohol dependence. J Clin Psychopharmacol. 2005 Aug;25(4):349-57. 6. Feeney GF, et al. Cognitive behavioural therapy combined with the relapse-prevention medication acamprosate: are short-term treatment outcomes for alcohol dependence improved? Aust N Z J Psychiatry. 2002 Oct;36(5):622-8. 7. Fiore MC, et al. Clinical practice guideline. Treating tobacco use and dependence: 2008 update. U.S. Department of Health and Human Services, 2008 May. 8. U.S. Food and Drug Administration. Highlights of prescribing information for Chantix (varenicline). 2013 Feb. http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/021928s030lbl.pdf 9. Cahill K, et al. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013 May 31;5:CD009329. 10. Prochaska JJ, et al. Risk of cardiovascular serious adverse events associated with varenicline use for tobacco cessation: systematic review and meta-analysis. BMJ 2012; 344:e2856. © CASAColumbia 2014 46
  47. 47. References 11. Hughes JR, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD000031. 12. U.S. Food and Drug Administration. Prescribing information: Zyban (bupropion hydrochloride). 2012 Jan. http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020711s036lbl.pdf 13. Stead LF, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2012 Nov 14;11:CD000146. 14. Rösner S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD004332. 15. U.S. Food and Drug Administration. Highlights of prescribing information for Campral (acamprosate calcium). 2012 Jan. http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021431s015lbl.pdf 16. Laaksonen E, et al. A randomized, multicentre, open-label, comparative trial of disulfiram, naltrexone and acamprosate in the treatment of alcohol dependence. Alcohol Alcohol. 2008 Jan-Feb;43(1):53-61. 17. Rösner S, et al. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD001867. 18. Brewer C, et al. Naltrexone: report of lack of hepatotoxicity in acute viral hepatitis, with a review of the literature. Addict Biol. 2004 Mar;9(1):81-7. 19. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. Naltrexone: LiverTox Clinical and Research Information on Drug-Induced Liver Injury. http://livertox.nih.gov/Naltrexone.htm 20. Mattick RP, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD002207. 21. Mattick RP, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD002209. © CASAColumbia 2014 47
  48. 48. Acknowledgements • Margot Cohen contributed much of the research and writing for these materials. • The following subject-matter experts served as external reviewers for these materials: Kevin Kunz, M.D., M.P.H., Frances Levin, M.D., Charles O’Brien, M.D., Ph.D. • Funding was provided by The Joseph A. Califano, Jr. Institute for Applied Policy. © CASAColumbia 2014 48
  49. 49. Ending Addiction Changes Everything www.casacolumbia.org

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