Embed Size (px)
Citation preview
Medication-Assisted Treatment (MAT) Overview
2014 Opiate Conference: Don’t Get Me Started
Hyatt Regency, Columbus, Ohio
June 30-July 1, 2014
Christina M. Delos Reyes, MD
Medical Consultant,
Center for Evidence-Based Practices at Case1
www.centerforebp.case.edu
Learning Objectives
• Following this presentation, participants will be able to:• Describe the indications, mechanism of action, dosing, and common side
effects related to three medications use to treat opioid use disorders
• Review commonly held myths and attitudes about medication-assisted treatment (MAT)
• Discuss strategies to more fully integrate MAT into existing mental health and addition services
4
5
John R. Kasich, Governor
6
John R. Kasich, Governor
7
8
Treatment Options for Opioid-Addicted Individuals
•Behavioral treatments educate patients about the conditioning process and teach relapse prevention strategies.
•Medications such as methadone and buprenorphine operate on the opioid receptors to relieve craving.
•Combining the two types of treatment enables patients to stop using opioidsand return to more stable and productive lives.
9
Treatment Options for Opioid-Addicted Individuals
• Medically-assisted withdrawal
• Long-term residential treatment
• Outpatient psychosocial treatment
• Behavioral therapies
• Medication-Assisted Treatment (MAT)
10
Medication-Assisted Treatment
•Naltrexone—antagonist• No effect in absence of an opiate or opiate dependence
•Methadone—agonist• Morphine-like effect
•Buprenorphine—partial agonist• Maximum effect is less than a full agonist
11
12
Partial vs. Full Opioid Agonist
Dose of Opiate
OpiateEffect
death
Full Agonist
(e.g., methadone)
Partial Agonist
(e.g. Naloxone)Antagonist
(e.g. buprenorphine)
Naltrexone
• Opiate antagonist to treat opiate dependence
• All effects of opiates are blocked• Must be detoxed and opiate-free or else will cause opiate withdrawal
syndrome
• Blocks opioid receptors that are involved in the rewarding effects of opiates (& alcohol!)
• Risk for hepatotoxicity• Monitor for liver enzymes
13
Naltrexone
• Brand name: Revia (oral tablets)
• Usual dose: 50mg daily
• Efficacy highest in patients who can abstain for 4 to 7 days before initiating treatment
• No negative effect with use
• Some clients notice anxiolytic effect
14
Long- Acting Naltrexone
• Brand name is Vivitrol
• Approved for alcoholism in 2006
• Approved for opiate dependence Oct 2010
• Given monthly, 380 mg appears to have increased efficacy versus 190 mg
15
Naltrexone
• Non-compliance is the main barrier to success
• Most useful for highly motivated patients w/ external circumstances• Impaired professionals, parolees, probationers, etc
16
CAUTION with Naltrexone
• When clients have had opiate receptors blocked for some time, their tolerance is “reset”
• Returning to drug use at the same levels they were previously using [prior to blockade] puts the client at INCREASED RISK for OD/death due to lowered tolerance
• This information needs to be shared with all clients
Methadone
•Opiate agonist to treat opiate dependence
•Well-studied and effective treatment• Normalizes function/return to work, decreases crime/violence, reduces HIV
exposure
•Doses > 70mg/day generally better than low doses
•Enhanced services = improved outcomes• Counseling, medical, social/vocational services,etc
•No contraindication in SMI, though not well studied
18
Methadone
• Usually taken once a day to suppress withdrawal for 24 to 36 hours
• Usually given in liquid form by Opiate Treatment Programs
• Induction phase—no more than 30 to 40 mg on the first day of treatment
• Dosage changes usually occur once a week• More rapid dosage increases can cause overdose
• Maintenance phase—usually 80-120mg daily
19
Methadone
• Common side effects• Sweating, constipation, abnormal libido, sleep abnormalities, mild anorexia,
weight gain, water retention
• Adverse effects• Prologation of QTc (usually seen with very high doses, mean of 350mg daily)
20
Methadone: “Addicting patients to another drug?”
• Difference between PHYSICAL DEPENDENCE vs. ADDICTION (or substance use disorder)
• Pharmacology of methadone prevents highs and lows common with short-acting drugs and normalizes patient functioning
• The patient is PHYSICALLY DEPENDENT on methadone but no longer displaying the behaviors associated with addiction
Methadone
Buprenorphine
Opioid partial agonist risk of overdose and abuse potential
May precipitate opiate withdrawal in dependent individuals
Approved for treatment of opiate dependence• Maintenance dose in the range of 8-16 mg daily
Sublingual route of administration Subutex= Bup only; Suboxone= Bup + Naloxone
23
Direct Buprenorphine Induction from Short-Acting Opioids
•Ask patient to abstain from short-acting opioid (e.g., heroin) for at least 6 hrs. and be in mild withdrawal before administering buprenorphine/naloxone.
•When transferring from a short-acting opioid, be sure the patient provides a methadone-negative urine screen before 1st buprenorphine dose.
SOURCE: Amass, et al., 2004, Johnson, et al. 2003.
Buprenorphine
• Suboxone= buprenorphine + naloxone in a 4:1 mixture• Available doses: 8/2mg and 2/0.5mg
• 2 sublingual forms: tablet and Film
• Induction phase Day 1: usual dose is 2 mg given every 2-3 hours, up to 8 mg
• Induction phase Day 2: start with 8mg, can go up to 16mg depending on patient symptoms
25
Buprenorphine
• Maintenance phase: usually 8 to 16 mg daily
• This may vary in clinical practice, but realize that 16mg dose covers ~95% of opiate receptors
• Adverse side effects: Increased LFTs, cytolytic hepatitis
• Common side effects: generally mild• Constipation; dizziness; drowsiness; headache; nausea; sweating; vomiting;
26
Buprenorphine
• Approved in U.S. (2002) as office-based treatment vs. ‘methadone clinics’
• Individual doctors may treat up to 30 patients at a time, using an special DEA #• After 1 year, may increase to 100 patients
• Must be addiction medicine/addiction psychiatry certified OR complete 8-hr training
27
28
Partial vs. Full Opioid Agonist
Dose of Opiate
OpiateEffect
death
Full Agonist
(e.g., methadone)
Partial Agonist
(e.g. Naloxone)Antagonist
(e.g. buprenorphine)
Possible Barriers to using MAT
Potential Fear # 1:
Medication will eventually replace rehabilitation as the treatment of choice for addiction “a pill for every ill”
• Rationale # 1:
• Medication may be a useful adjunct to treatment
• “Another tool in your toolbox”
29
Possible Barriers to using MAT
Potential Fear # 2:
Medication will distract from the difficult work of recovery from addiction
• Rationale # 2:
• Medication makes detox safer and more humane
• Medication may allow the process of recovery to begin and continue
• Medication may make recovery possible for those with severe mental illness
30
Possible Barriers to using MAT
Potential Fear # 3:
Medication will perpetuate an existing addiction
Potential Fear # 4:
Medication will cause new addictions
• Rationale # 3:
• Physical dependence to medication may occur, but addictive behavior should decrease
• Rationale # 4:
• New addictions to medications are a risk, but the actual incidence is quite low
31
Other Barriers to MAT?
• Financial• MAT may be very expensive and many still do not have insurance
• Regulatory• Until very recently, doctor visits for MAT were not covered by state funding
• Logistical• Not enough methadone clinics; not enough slots
• Usual treatment settings may not be set up to provide MAT
32
Medications only work if…
• …they are getting “from the bottle to the bloodstream”
• How to help clients with the idea of starting meds? • “that will mean I am really sick…” OR “I don’t need a crutch…”
• How to help clients with the idea of staying on meds?• “I feel fine, I don’t need it anymore” OR “if I take meds, then I am not really
sober”
Some Lessons fromMotivational Interviewing
• What are the client’s goals?
• How does medication fit (or not fit) with those goals?
• What are the pros and cons of the medications?
• Use of reflective listening
• What is the patient willing to do right now?
• What are the patient’s fears about medication?
Discussion
• What strategies can your setting use to more fully integrate all three types of MAT?• Inpatient vs. Outpatient
• AOD vs. MH
• Physical vs. Behavioral health
• Can you think of short-term goals (3 to 6 months) and long-term goals (12 to 24 months) which would improve integration?
• How might the CEBP assist you in meeting goals?
Summary
• MAT is an important part of the toolkit for treating opioid use disorders
• Despite internal and external barriers, MAT can be successfully implemented
• Set short- and long-term goals in order to more fully integrate MAT into your setting
Resources
• “BUPRENORPHINE TREATMENT: A TRAINING FOR MULTIDISCIPLINARY ADDICTION PROFESSIONALS”• http://www.nida.nih.gov/blending/buptreatment.html
•NIDA Methadone Research Web Guide http://international.drugabuse.gov/collaboratio
n/PDFs/MethadoneResearchWebGuide.pdf•Mid-America Addiction Technology Transfer Center.
Psychotherapeutic Medications 2011: What Every Counselor Should Know. http://www.mattc.org
37
www.centerforebp.case.edu
Christina M. Delos Reyes, MD
Medical Consultant
Center for Evidence-Based Practices
Case Western Reserve University
10900 Euclid Avenue
Cleveland, Ohio 44106-7169
216-368-0808
