THE DISEASE OF OPIOID ADDICTION AND MEDICATION ASSISTED TREATMENT Michele F. McCarthy, LPCC Community & Government Liaison Self Refind

THE DISEASE OF OPIOID ADDICTION AND MEDICATION ASSISTED TREATMENT

Michele F. McCarthy, LPCC

Community & Government Liaison

Self Refind

OBJECTIVES

Learn about the state of opiate addiction today Discuss the impact of opiate abuse and

addiction Identify the currently available medication

assisted treatment options Explore the pros and cons of the available

treatments Discuss special considerations for working with

pregnant patients Review rights of patients in medication assisted

treatment

IS IT REALLY AN EPIDEMIC?

Epidemic is defined as:…attacking or affecting many persons simultaneously in a community or area…a widespread occurrence of a disease…a rapid development, spread, or growth of something, especially something unpleasant.

KENTUCKY ALL SCHEDULE PRESCRIPTION ELECTRONIC

REPORTING

KASPER QuarterlyTrend Reports for 2011 reflected that opiates accounted for an average of 57% and benzodiazepines accounted for an average of 28% of the top controlled substances that Kentucky doctors wrote prescriptions for.

SOURCE: KASPER QUARTERLY TREND REPORTS 2011

KASPER DATA 2011 In 2011 alone:

3,093,770 prescriptions were written for hydrocodone (up from 2,812,878 in 2009).

3,217,535 prescriptions were filled for hydrocodone.

852,085 prescriptions were written for oxycodone (up from 646,218 in 2009).

929,525 prescriptions were filled for oxycodone.

How many more were obtained out of state?

How many more were obtained illegally?

SOURCE: KASPER QUARTERLY TREND REPORTS 2011

OVERDOSE DEATHS ARE ON THE RISE… Drugs exceeded motor vehicle accidents as a cause

of death in 2009, killing at least 37,485 people nationwide, according to preliminary data from the U.S. Centers for Disease Control and Prevention.

The death toll has doubled in the last decade, now claiming a life every 14 minutes, making it the number one cause of preventable deaths.

Fueling the surge in deaths are prescription pain and anxiety drugs, which now cause more deaths than heroin and cocaine combined.

Los Angeles Times, September 2011

KENTUCKY MEDICAL EXAMINER 2011 REPORTTotal cases- 2378Overdose cases- 684

Alprazolam (Xanax)-286Oxycodone (Percocet)-213Hydrocodone (Lortab)-187Oxymorphone (opana)-154Alcohol-134Cocaine-31Methamphetamine-21

KENTUCKY HAS MORE TO WORRY ABOUT

KENTUCKY HAS MORE TO WORRY ABOUT

Although we have continued to see an increase in the prescribing and abuse of prescription opiates, this is not the only battle we are fighting.

Kentucky House Bill 1- 2012 Landmark legislation But if it does it’s job…

BENEFITS OF TREATMENT

Total cost of drug use disorders in the US is an est. $180 billion annually

$100,000 spent on treatment = avoided costs of $487,000 in healthcare and $700,000 in crime

Every $1 spent on treatment saves criminal justice $7 and when add in healthcare savings, the savings to cost ratio is 12:1

Employees treated for substance use have decreased absenteeism, tardiness, mistakes and on-the-job injuries

SAMHSA CSAT Cost Offset of Treatment Services, April 2009

MEDICATION ASSISTED TREATMENT OPTIONS

Methadone

Buprenorphine-Suboxone and Subutex

Naltrexone

MEDICATION ASSISTED TREATMENTSAMHSA defines MAT as:

“The use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful.”

WORLD HEALTH ORGANIZATION 2009 GUIDELINES

Efficacy of MAT v. placebo Methadone—opiate use, tx retention, 1/3

mortality rate, risk of HIV by 50% Buprenorphine—opiate use, tx retention,

morphine positive drug screens Naltrexone— in opiate use

Of the treatment options examined, opioid agonistmaintenance treatment, combined with psychosocialassistance, was found to be the most effective.

\\Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence, World Health Organization, 2009

METHADONE

Dolophine hydrochloride, Methadose

Schedule II narcotic

Long acting opioid analgesic (6-12 hours)

Full mu opioid agonist-binds and activates

MU OPIOID RECEPTOR ACTIVATION

mu receptor sitemu receptor site

Full agonistFull agonist eg, methadoneeg, methadone

Full activation Full activation of mu receptor of mu receptor

sitesiteeg, buprenorphineeg, buprenorphinePartial agonistPartial agonist

Partial activation of Partial activation of mu receptor sitemu receptor site


mu receptor mu receptor sitesite

eg, naltrexoneeg, naltrexoneAntagonistAntagonist

Prevents or reverses Prevents or reverses activation of mu receptor activation of mu receptor

sitesite

METHADONE

Long half-life (12-59 hours)- taken once daily or may be “split-dosed”

Administered orally- 5 and 10 mg tablets, 40 mg Disket and liquid

40 mg tablets (Disket) only available to treat opioid addiction (as of January 2008)

METHADONE BENEFITS

Right dose should not cause euphoric or tranquilizing effects.

Reduces/blocks effects of other opioids.Tolerance is slow to develop.Relieves cravings.Allows the individual to feel “normal”.

METHADONE BENEFITS

Improved employment status and family relationships.

Decrease in criminal activities.Decrease in high risk behaviors such

as IVDU = decrease in HIV and Hep. C.Improved health and health care.

METHADONE LIMITATIONS

Can only be dispensed/administered through an OTP.

Private can be expensive.Heavily regulated, lots of rules, can be

time consuming. Heavily stigmatized

METHADONE LIMITATIONS

Abuse liability and diversionIncreased risk when combined with

other drugs.Associated health complications*Detoxification can be difficult

BUPRENORPHINEDrug Addiction Treatment Act of 2000

(DATA 2000)In 2002, two forms were FDA

approved-Subutex and Suboxone, both made by Reckitt-Benckiser.

Schedule III narcoticOpioid analgesic with effects up to 6

hours.

BUPRENORPHINEPartial mu opioid agonist (ceiling effect)

but high affinityLong half-life (24-60 hours)Administered as sublingual tablet* or film

Subutex- 2 mg or 8 mg buprenorphine Suboxone- 2 mg bup + .5 mg naloxone

8 mg bup + 2 mg naloxone











sitesite

SUBUTEX

Contains buprenorphine only.Historically, minimally used in U.S.

except with pregnant women.Two generics now available.*Higher rate of diversion, can be

injected.

SUBOXONE

Naloxone added as means to decrease misuse.

Poor bioavailability sublingually, but if dissolved and injected, will precipitate withdrawal.

Reduced abuse potential.Film meant to provide added means to

combat diversion.

BUPRENORPHINE BENEFITS

Virtually no euphoric or tranquilizing effects.

Blocks effects of other opiates.Relieves cravings to use other

opiates.Allows “normal” function.


Lower abuse liability and diversion potential.

Increased anonymity, less intrusive, less stigma.

Increased treatment options/access to treatment.

Here to Help Program


Decrease in high-risk behaviors.Good “step down” option for those

tapering from methadone.Provides option for those that

cannot tolerate methadoneIs currently covered by Medicaid

BUPRENORPHINE LIMITATIONS

Can be expensive when self pay.Currently still no generic for Suboxone.Should not take if opiates still in

system.Counseling may not be available or

affordable in the same area as doctor.

BUPRENORPHINE LIMITATIONS

Not enough certified doctors or doctors willing to treat.

No regulations for OBOTs, only “practice guidelines”.

Potential for overdose of other opiates due to ceiling effect.

Abuse and diversion potential still exists.

NALTREXONE

Long half-life (up to 72 hours)

Opioid antagonist-binds, but blocks instead of activates

Is NOT an opiate











sitesite

NALTREXONE

Historically used primarily for alcohol due to blocking neurotransmitters believed to be involved with alcohol dependence.

Oral- ReVia, now genericInjectable- VivitrolImplant- not FDA approved

NALTREXONE TREATMENT

Medication is only one component.Average length of treatment is 3-9

months.Works best with highly motivated

patients.Injectable is a great option for

compliance issues or just for convenience.

NALTREXONE BENEFITS

Any physician can prescribe in any setting.

Injectable lasts for 30 days.Relatively inexpensive (oral) when

compared to Methadone or Bup.Non-narcotic, non-addictive, does not

produce dependence.

BENEFITS CONT.

More acceptance in abstinence-based programs.

Less stigma than methadone or buprenorphine.

In KY Medicaid covers, but only oral is 1st-tier; injectable is a 3rd-tier.

Received approval for use for opioid addiction in last year

NALTREXONE LIMITATIONS

Injection site reactions.Injectable very expensive for self pay.Poor compliance with oral version.Cannot have any opiates in system or

will precipitate withdrawal.Still not many doctors utilizing.

LIMITATIONS CONT.

Risk of overdose in attempt to break through blockade.

Not first choice for pregnant patients.

Breastfeeding is not recommended.Implant is NOT FDA approved.

MAT AND PREGNANCY

MAT AND PREGNANCY

“Cold turkey” detox may trigger miscarriage, pre-term labor.

Methadone has most research and is still preferred.

Subutex has shown very positive results- MOTHER Study.

Several reports of using Suboxone with positive results.

MAT AND PREGNANCY CONT.

Individualized approach, informed choiceDecreases/ceases cycles of intoxication

and withdrawalDecrease in high risk behaviorsOpportunity to address other factors-

mental health, social supports, basic needs

MAT AND PREGNANCY STANDARDSFederal

Prenatal care Gender-specific services

Additional state Medically able to participate Collaborate with OBGYN Post-partum care Nutrition, parenting, and weekly drug

screen

MAT & PREGNANCY STANDARDSCARF and Joint Commission

Priority admissionCounseling for DV, trauma, women’s

healthAppropriate medication dosageEducate on MSW- should NOT be initiated

before 14 weeks or after 32 weeksEncourage breastfeeding (unless

contraindicated)

KEY POINTS TO REMEMBEROpiate addiction is a disease, an epidemic. There is no cure, but we do have options and

we need to take advantage of all of them.Treatment is not “one size fits all.”Just as addiction is lifelong, so is the recovery

processChances of maintained recovery significantly

increase when combined with counseling, drug screens, medication call backs, etc.

KEY POINTS TO REMEMBER

No “perfect” medication that is one size fits all.

Medication is a tool, not a “cure”.MAT may be appropriate for pregnant

women but must be closely monitored and have informed consent.

MAT is a legal, valid, and widely researched evidence-based treatment for addiction.

Individuals receiving MAT are in recovery!

CONTACT INFORMATION

Michele F. McCarthyGovernment & Community Liaison

Self [email protected]

859-605-6387www.selfrefind.com

Documents

THE DISEASE OF OPIOID ADDICTION AND MEDICATION ASSISTED TREATMENT Michele F. McCarthy, LPCC Community & Government Liaison Self Refind