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

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John R. Kasich, Governor

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John R. Kasich, Governor

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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.

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Treatment Options for Opioid-Addicted Individuals

• Medically-assisted withdrawal

• Long-term residential treatment

• Outpatient psychosocial treatment

• Behavioral therapies

• Medication-Assisted Treatment (MAT)

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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

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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

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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

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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

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Naltrexone

• Non-compliance is the main barrier to success

• Most useful for highly motivated patients w/ external circumstances• Impaired professionals, parolees, probationers, etc

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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

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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

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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)

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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

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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

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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;

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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

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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”

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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

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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

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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

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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

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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

Christina.DelosReyes@uhhospitals.org