Opioid Maintenance Treatment In Packet


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Opioid Maintenance Treatment In Packet

  1. 1. Opioid Maintenance Treatment (OMT) What it is……… What it is not…… Stacy Seikel, MD Board Certified Addiction Medicine Board Certified Anesthesiology
  2. 2. Addiction <ul><li>Bio-Psych-Social-Disease </li></ul>
  3. 3. Goals of OMT <ul><li>Reduce Cravings & Withdrawal </li></ul><ul><li>Harm Reduction </li></ul><ul><ul><li>HIV, Hep C, Hep B, Endocarditis, Skin abscesses </li></ul></ul><ul><li>Decrease Risk of </li></ul><ul><ul><li>Overdose </li></ul></ul><ul><ul><li>Prostitution </li></ul></ul><ul><ul><li>Problems with the law </li></ul></ul>
  4. 4. Goals of OMT (con’t.) <ul><li>Recovery </li></ul><ul><ul><li>AA/NA/MA </li></ul></ul><ul><ul><li>Group & Ind Therapy </li></ul></ul><ul><ul><li>Life Skills </li></ul></ul><ul><ul><li>Non Pharmaceutical coping skills </li></ul></ul><ul><li>Help People Have Normal Lives </li></ul>
  5. 5. The Center For Drug-Free Living OMT <ul><li>Abstinence From All Other Addictive/Mood Altering Substances </li></ul><ul><li>Group and Individual Therapy </li></ul><ul><li>Random UDS </li></ul><ul><li>Mandatory Classes </li></ul><ul><li>Encouraged to Attend 12-Step Programs </li></ul><ul><li>Consult With Patient’s Primary, Specialty, Pain and Psychiatric Physicians </li></ul><ul><li>Therapy/Treatment Works! </li></ul>
  6. 6. Common Questions About Methadone <ul><li>How Does Methadone Work? </li></ul><ul><ul><li>Opiate agonist </li></ul></ul><ul><ul><li>Mu receptor </li></ul></ul><ul><ul><li>Lasts 24-36 hrs. </li></ul></ul>
  7. 7. Common Questions About Methadone <ul><li>Does Methadone make patients “high” or interfere with normal functioning? </li></ul><ul><ul><li>No, not when used appropriately </li></ul></ul><ul><ul><li>No impairment in driving ability </li></ul></ul>
  8. 8. Common Questions About Methadone <ul><li>What is the proper dose of Methadone? </li></ul><ul><ul><li>The dose that averts narcotic craving </li></ul></ul>
  9. 9. Common Questions (con’t) <ul><li>Is Methadone more addictive than Heroin? </li></ul><ul><ul><li>Addiction is continued use despite adverse consequences </li></ul></ul><ul><ul><li>Dependence is a physiologic phenomena </li></ul></ul>
  10. 10. Common Questions (con’t) <ul><li>Is Methadone harder to kick than Heroin? </li></ul><ul><ul><li>Heroin withdrawal-intense and brief </li></ul></ul><ul><ul><li>Methadone withdrawal-less acute and longer </li></ul></ul>
  11. 11. Common Questions (con’t) <ul><li>Does Methadone interfere with good health? </li></ul><ul><ul><li>Methadone improves health </li></ul></ul><ul><ul><li>No effect on immune function, bone density, kidneys or liver </li></ul></ul>
  12. 12. Heroin Use v. Stabilized Methadone Maintenance: A Comparison Topic Heroin Methadone Effects 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
  13. 13. Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t) Topic Heroin Methadone Effects 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
  14. 14. Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t) Topic Heroin Methadone Effects on the Mind On 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
  15. 15. Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t) Topic Heroin Methadone Effects on Health HIV Transmission High rate of transmission Reduced/eliminated with Hepatitis 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 treatment For HIV-Persons Hypothalamus Pituitary Adrenal Axis Suppressed Normalized during treatment
  16. 16. Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t) Topic Heroin Methadone Effects on Social Functioning Criminal Activity High level Reduced/eliminated Personal Relationships Disrupted Employment Deteriorating performance Full Functioning loss of employment Community Relations Destructive impact, high Contributes to public crime, high death rate, safety, low mortality, transmission of disease increased health
  17. 17. Sign and Symptoms of Withdrawal <ul><li>Subjective: </li></ul><ul><ul><li>Cravings </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Restlessness </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Difficulty sleeping </li></ul></ul>
  18. 18. Sign and Symptoms of Withdrawal <ul><ul><li>“ Dose not holding” </li></ul></ul><ul><ul><li>Thoughts of using </li></ul></ul><ul><ul><li>Body aches and pains </li></ul></ul><ul><ul><li>Nausea, sick to stomach </li></ul></ul><ul><ul><li>Abdominal cramping </li></ul></ul><ul><ul><li>Muscle cramping </li></ul></ul>
  19. 19. Signs and Symptoms of Withdrawal <ul><li>Objective: </li></ul><ul><ul><li>Elevated BP </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Lacrimation </li></ul></ul><ul><ul><li>Rhinorhea </li></ul></ul>
  20. 20. Signs and Symptoms of Withdrawal <ul><ul><li>Piloerection </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Yawning </li></ul></ul><ul><ul><li>Dilated Pupils </li></ul></ul>
  21. 21. What are the signs of a Methadone overdose? <ul><li>Nausea and vomiting </li></ul><ul><li>Constricted (small, pin-point) pupils </li></ul><ul><li>Drowsiness </li></ul><ul><li>Cold, clammy, bluish skin </li></ul><ul><li>Reduced heart rate </li></ul><ul><li>Reduced body temperature </li></ul><ul><li>Slow or no breathing </li></ul>
  22. 22. Methadone Maintenance is not Methadone/Heroin Abuse
  23. 23. ASAM & AAPM & APS Consensus 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.
  24. 24. 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.
  25. 25. Addiction Compulsive Use Loss of control Continued use despite adverse consequences Addiction has nothing to do with what medication one is taking
  26. 26. Demographics Drug Abuse in US 2.1 million abuse street drugs (heroin, cocaine, crack) 3.9 million abuse Rx drugs (pain meds, sedatives, stimulants)
  27. 27. Heroin Addiction >977,000 heroin dependent individuals in the US in 2000
  28. 28. Opioid Treatment Programs (OTP)… How they are done <ul><li>Methadone </li></ul><ul><li>LAAM </li></ul><ul><li>Buprenorphine </li></ul>
  29. 29. Current Inventory of Regulated OTPs <ul><li>1,000-1,200 Opioid Treatment Programs (OTPs) </li></ul><ul><ul><li>Certified by SAMHSA/CSAT </li></ul></ul><ul><ul><li>Registered by DEA </li></ul></ul><ul><ul><li>Licensed by State </li></ul></ul><ul><li>950 Maintenance, 250 Detoxification </li></ul><ul><li>Approximately 205,000 Patients in Treatment </li></ul>Center for Substance Abuse Treatment
  30. 30. Methadone Maintenance Treatment (MMT) <ul><li>Most studied drug for the treatment of a disease in the history of the world </li></ul><ul><li>Used and effective for over 35 years </li></ul><ul><li>Relieves sx of withdrawal and cravings </li></ul><ul><li>Allows normal functioning </li></ul>
  31. 31. MMT (Cont’d) <ul><li>Efficacy increased with </li></ul><ul><ul><li>On site medical support </li></ul></ul><ul><ul><li>On site psychiatric support </li></ul></ul><ul><ul><li>Supportive treatment services </li></ul></ul><ul><ul><li>Urine toxicology </li></ul></ul>
  32. 32. Comorbidities <ul><li>70% of patients in OMT-HCV positive. </li></ul><ul><li>40-50% of patients in OMT have serious depression and anxiety disorders. </li></ul>
  33. 33. Length of Treatment Research shows 80% relapse rate if MMT withdrawn within the first 12 months.
  34. 34. Pharmacology of Methadone (Cont’d) <ul><li>Hepatic metabolism (varies with individual) </li></ul><ul><li>Renal excretion </li></ul><ul><li>Basic, pka=9.2 </li></ul><ul><li>Metabolized CYP3A4 (inducible) </li></ul>
  35. 35. Pharmacology of Methadone (Cont’d) <ul><li>Drugs that induce CYP3A4 (  serum methadone levels) </li></ul><ul><ul><li>rifampicin (Rifampin) </li></ul></ul><ul><ul><li>carbamazepine (Tegretal) </li></ul></ul><ul><ul><li>barbituates </li></ul></ul><ul><ul><li>verapamil </li></ul></ul><ul><ul><li>amitriptyline (Elavil) </li></ul></ul><ul><ul><li>alcohol </li></ul></ul><ul><ul><li>nevirapine </li></ul></ul>
  36. 36. Pharmacology of Methadone (Cont’d) <ul><li>Drugs that Inhibit Metabolism (  serum methadone levels) </li></ul><ul><li>fluoxetine (Prozac) </li></ul><ul><li>cimetidine (Tagamet) </li></ul><ul><li>ketoconazole </li></ul><ul><li>metronidazole (Flagyl) </li></ul><ul><li>HIV meds </li></ul><ul><ul><li>indinavir </li></ul></ul><ul><ul><li>ritonavir </li></ul></ul><ul><ul><li>saquinavir </li></ul></ul>
  37. 37. Federal Oversight of Methadone Treatment (OMT) <ul><li>CSAT and SAMHSA - new accreditation system for MTP </li></ul><ul><li>Implemented May 18, 2001 </li></ul><ul><li>All MTP will be accredited over the next 3 years. </li></ul>
  38. 38. Who Can Offer Treatment? <ul><li>Physicians employed by a licensed OTP </li></ul><ul><li>Physicians in private practice who register separately with DEA as a OTP </li></ul>
  39. 39. MMT Program Phases <ul><li>Intake Phase 1-30 days </li></ul><ul><ul><li>No takeouts </li></ul></ul><ul><ul><li>2 groups per week </li></ul></ul><ul><ul><li>1 individual </li></ul></ul><ul><li>Phase I 30-90 days </li></ul><ul><ul><li>1 takeout per week </li></ul></ul><ul><ul><li>2 groups per week </li></ul></ul><ul><ul><li>1 individual per week </li></ul></ul>
  40. 40. MMT Program Phases (Cont’d) <ul><li>Phase II 91-180 days </li></ul><ul><ul><li>2 takeouts per week </li></ul></ul><ul><ul><li>2 groups per week </li></ul></ul><ul><ul><li>2 individuals per months </li></ul></ul><ul><li>Phase III 181-365 days </li></ul><ul><ul><li>3 takeouts per week (no more than 2 days supply) if client has neg UDS for preceding 90 days </li></ul></ul><ul><ul><li>1 group per week </li></ul></ul><ul><ul><li>1 individual per week </li></ul></ul>
  41. 41. MMT Program Phases (Cont’d) <ul><li>Phase IV > 1 year in treatment </li></ul><ul><ul><li>4 takeouts per week (no more than 2 days supply at one time) if negative UDS preceding 90 days </li></ul></ul><ul><ul><li>2 groups per month </li></ul></ul><ul><ul><li>1 individual per month </li></ul></ul><ul><li>Phase V > 2 years in treatment </li></ul><ul><ul><li>5 take out (not to exceed 3 at 1 time) UDS-negative 90 preceding days </li></ul></ul><ul><ul><li>1 group per month </li></ul></ul><ul><ul><li>1 individual per month </li></ul></ul>
  42. 42. MMT Program Phases (Cont’d) <ul><li>Phase VI > 3 years in treatment </li></ul><ul><ul><li>6 take outs per week - neg UDS for past year </li></ul></ul><ul><ul><li>1 individual per month </li></ul></ul>
  43. 43. Methadone Maintenance at The Center For Drug-Free Living <ul><li>Orientation Stage of Recovery </li></ul><ul><li>State I of Recovery </li></ul><ul><li>Stage II of Recovery </li></ul><ul><li>Stage III of Recovery </li></ul>
  44. 44. Orientation Stage <ul><li>Methadone Education Evaluation & Treatment (MEET) </li></ul><ul><ul><li>Orientation group </li></ul></ul><ul><ul><li>HIV education </li></ul></ul><ul><ul><li>Medication Education </li></ul></ul><ul><ul><li>Fiscal Responsibility </li></ul></ul>
  45. 45. Orientation Stage (Cont’d) MEET Services <ul><ul><li>Group therapy training </li></ul></ul><ul><ul><li>Social Development </li></ul></ul><ul><ul><li>Treatment compliance </li></ul></ul><ul><ul><li>Methadone and Your Health </li></ul></ul><ul><ul><ul><li>Abstinence model of recovery </li></ul></ul></ul><ul><ul><ul><li>Side effects of methadone </li></ul></ul></ul><ul><ul><ul><li>Dosing </li></ul></ul></ul><ul><ul><ul><li>When to taper? </li></ul></ul></ul><ul><ul><ul><li>Medical/Surgical issues </li></ul></ul></ul>
  46. 46. Orientation Stage (Cont’d) <ul><li>Contact medical & psychiatric providers </li></ul><ul><li>Approved medication list </li></ul><ul><li>Encourage 12 step recovery - NA, MA </li></ul>
  47. 47. Stage I of Recovery (Phase I & II) <ul><li>Group Therapy- family issues, stress management, lifestyles changes, self esteem, financial stability, anger management, relapse prevention.. </li></ul>
  48. 48. Stage II of Recovery (Phase III & IV) <ul><li>Groups - Relationships, advanced financial management </li></ul><ul><li>Support groups stronger - sponsorship, working steps </li></ul><ul><li>Relapse prevention </li></ul>
  49. 49. Stage III of Recovery (Phase V & VI) <ul><li>Self help becomes primary source of support </li></ul><ul><li>Consider taper off methadone </li></ul><ul><li>Aftercare plans </li></ul><ul><li>Relapse prevention plans revised and practiced </li></ul>
  50. 50. Continued Drug Abuse of Non Opiates <ul><li>Differential Diagnosis </li></ul><ul><ul><li>Opiate abstinence syndrome (subclinical) </li></ul></ul><ul><ul><li>Psychiatric Disorder </li></ul></ul><ul><ul><li>Pain syndrome </li></ul></ul><ul><ul><li>Polysubstance Abuse </li></ul></ul><ul><ul><ul><li>refer to detox </li></ul></ul></ul><ul><ul><ul><li> treatment services </li></ul></ul></ul><ul><ul><ul><li>residential treatment </li></ul></ul></ul>
  51. 51. “ Methadone is the most effective method available for healing heroin addiction.” National Institute on Drug Abuse
  52. 52. <ul><li>Thank You. </li></ul>