Medication Assisted Treatment

for Opioid and Heroin Epidemic

Dealing with the Opioid & Heroin Epidemic -

A Training Resource

Medications Used to Treat Opioid Addiction

Should medications be used in the treatment of addiction?

• Is this a scientific question?
• Is this a philosophical question?
• Is this a practical question?

Rationale for medication

• Impact the physiology of addiction and dependence
• Improve outcomes including retention and opioiduse
• Protect against lapses, which should be expected
• Reduce high rates of relapse
  • Without medications >80% of heroin addicts relapse within 30 days after detoxification

Medications for the treatment of opioid addiction

1. Methadone – Full Agonist (See Note below) of Opioids
2. Buprenorphine(bupe) - Partial Agonist of Opioids - suboxone, subutex, zubsolv, bunavail
3. Extended release Naltrexone(XRNTX) – Antagonist of Opioids - Vivitrol

For Overdoses

Effectiveness of medications for opioid addiction

Methadone

–Multiple clinical trials and meta-analyses (e.g. Cochrane)

 Below 50% have 6-month abstinence retention

Buprenorphine

–Multiple clinical trials and meta-analyses (e.g.Cochrane)

50% have 6-month abstinence retention

Naltrexone

–Limited effectiveness in pill form

–Long acting injections and implants produce around 50% retention and sustained abstinence (e.g. Krupitskyet al., 2011)

Relapse prevention medications Improve outcomes

Reduced Drug use

Reduced Mortality

Reduced Criminal behavior and recidivism

Reduced HIV and HCV transmission

Reduced Hospitalization

Reduced Homelessness

Reduced Psychiatric symptoms

Increased Employment

Increased Treatment retention

Decreased Downstream costs

Choice of medication: Methadone vs Buprenophine vs XR-NTX (extended release naltrexone)

Patient preference and family preference

Failure of other treatments, try something new

Side effects, anxious anticipation

Long acting duration of XRNTX

Methadone and bupe intrinsically reinforcing

Methadone and bupe relieve withdrawal early

All 3 relieve cravings

More familiarity with methadone and bupe, positive and negative reputation

Partial blockade for bupe, full blockade for XRNTX

Strong opioid effects for methadone, pros and cons

Problems with acceptability of agonists

More tools in the toolbox

Duration of treatment?

Is there an optimal duration?

Evidence so far suggests longer is better, but care should be individualized

Retention under real world conditions is problematic

No reason to suppose pre-imposed limitations helpful

Relapse prevention medication Is the standard of care

But not everyone knows it yet

Persuading patients

Persuading families

Persuading criminal justice system

Persuading SUD providers, especially residential treatment

Persuading payers

Persuading the recovery community

A house divided

Why do we have philosophy in our field?

Big tent, all recovery voices matter

Treatment choice selection bias

Follow up observational bias

The power of language

“Drug-free” treatment

“Abstinence-based” treatment

Medication assisted treatment

Medication assisted recovery

Counseling-assisted medication

“Harm reduction”

Relapse-prevention medications

Anti-addiction medications

Is relapse prevention Medication Prescription just trading one addiction for another?

DSM Criteria for Substance Dependence

A maladaptive pattern of use leading to clinically significant impairment or distress, manifested by 3 or >of the following in a 12-month period:

1.  Tolerance (increased amounts or diminished effects)

2.  Withdrawal (withdrawal syndrome or use to relieve or avoid withdrawal) (Addictive Behaviors –loss of control)

3.  Efforts or desire to cut down or control use

4.  Taken Larger amounts or over a Longer period than intended

5.  Social, recreational or occupational activities given up

6.  Time spent in activities necessary to obtain the substance

7.  Use despite Persistent or recurrent Physical or Psychological problems  

Why medication? Can you be in recovery on medicines

1. Medicines just a crutch or band-aid

–Maybe. Like meetings or groups.

–But if they don’t utilize treatment, it almost doesn’t matter how good it is.

–Actually, they come to psychosocial treatment more.

–Academic if they relapse. Postpone until later when stronger. Remains an open question -maybe need high intensity skill building later in treatment course.

–Real issue, needs to be managed, but not as problematic as scare stories make it out to be.

–Why not both?

Limitations and unintended consequences Medications

Medication diversion

Inconsistency

Non-compliance

Dropout

Substandard practice

Side effects

Over-promising

Other substances

Additional adherence enhancements

Long acting formulations

Increased intensity and frequency of provider monitoring

Increased coordination and communication between medical and counseling staff

Role of concerned other in monitoring of adherence (eg: network therapy)

Supervised administration by caregiver or staff

Prescriptions left for counselor to distribute

Direct med administration up to daily

Integrated treatment: the role of non-medication modalities

One concept: medications synergize counseling and other tools by increasing retention, utilization, time not using

-Evidence mixed for benefit of counseling

-One study: methadone alone < + counseling < + enhanced services (job counseling, family involvement, psychiatry, medical) (McLellanet al. JAMA. 1993;269:1953-1959.)

-One study: no difference methadone with or without counseling (Schwartz et al. 2011.)

Emerging consensus: enhancement value for many but not all, need matching and stepped strategies

Settings and logistics

OTP (opiate treatment program) for methadone

OBOT (office based opioid treatment)

General healthcare vs specialty SUD

SAMHSA waiver for bupe

Nursing staff for XRNTX

Providing a full continuum of care

Inpatient detoxification and stabilization

Short term residential treatment

Long term residential treatment

Day treatment / partial hospitalization

Assisted living support for outpatient treatment (Individual Out Patient IOP “plus” Partial Hospitalization Program PHP “plus”)

Recovery housing

How the Opioid Epidemic affects Women

There is growing recognition that the United States is facing an epidemic due to an increase in opioid misuse, use disorders, and overdose, and that disparities exist between men and women with regard to both prescription opioid and heroin use. Although between 1999 and 2014 men were more likely than women to die of opioid overdoses, the gap in mortality has been closing. Between 1999 and 2010, overdose deaths from prescription pain killers increased more than 400% among women, compared to an increase of 237% among men. Although nonmedical use of prescription opioids among women has generally been decreasing since then, heroin use among women has been increasing, and increasing faster among women than among men. For example, between 2002 and 2013, heroin use among women increased 100% compared to an increase of 50% among men.

The picture of substance use is different for women compared to men. According to the Centers for Disease Control and Prevention (CDC), women are more likely to experience chronic pain and use prescription opioid pain medications for longer periods and in higher doses than men. Women tend to use substances differently than men, sometimes using a smaller amount of drugs for a shorter amount of time before they become dependent. For example, a national multisite effectiveness trial suggests that women who use opioids not only progress to dependence more quickly than men, but also experience more cravings than men. Psychological and emotional distress have also been identified as risk factors for hazardous prescription opioid use among women, but not among men. Many people with a substance use disorder may transition to injection drug use; thereby putting themselves at risk for viral hepatitis and HIV. Notably, new cases of hepatitis C among women increased more than 260% from 2010 to 2014, likely increasing the risk of perinatal hepatitis C transmission to their infants. Finally, women who are caregivers may face additional barriers to treatment for substance use disorders (SUDs), such as lack of childcare.

Treating Special Populations

A. Pregnancy

Unique opportunity and “motivational moment”

Methadone and buprenorphine improve:

–Maternal outcomes

–Fetal outcomes

Neonatal abstinence syndrome (NAS)

–Manageable

–Acceptable side effect

Bupeless NAS, preference for mono product (subutex)

Methadone better retention

B. Co-occurring psychiatric disorders

Very common in patients with SUD

Mood disorders especially common

Outcomes improved with treatment reciprocally

Most psychiatric medications compatible with relapse prevention medications with notable exception of sedative hypnotics

C Initiation of buprenorphine as a pain treatment strategy

At the transition from acute to chronic pain

Longer term strategy for patients with a history of opioid addiction

Possible transitional strategy for others

As part of an overall comprehensive rehabilitative approach

D. Focus on youth

This is a developmental disorder with adolescent onset

Addressing the problem early will maximize impact

Include and empower families to be part of the solution

Developmental barriers to treatment engagement

–Invincibility

–Immaturity

–Salience of burdens of treatment

Variable effectiveness of family leverage (or not) vs family abdication

Pushback against sense of parental dependence and restriction

Prominence of co-morbidity

Bottom line on use of Medications to Treat Opioid Addiction

Relapse prevention medications for opioid addiction should be the standard of care

3 good choices currently, more coming

Tailor medication and delivery and setting to individual patients

Some patients need more intensive support, structure, counseling, accountability; others not so much

Treatment works!!