Post on 02-May-2022
ACCREDITATION STATEMENT University of California San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians The University of California San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Creditstrade Physicians should only claim credit commensurate with the extent of their participation in the activity
1
Didactic Series
Office-based Treatment for Substance Abuse Disorder in HIV-infected
Patients Jacqueline Tulsky MD
Pacific AETC June 26 2014
2
Objectives Follow off of Dr Mathewrsquos talk on screening
for SUDs
Review Medication Assisted Treatment for
Opioid ETOH Benzos Methamphetamine dependence
Empower you to treat your patients
3
A patient known to you
30 yo woman with history of HIV disease Hep C endocarditis ETOH crack and street opioid use in remission Admitted for altered mental status UDS from ED -+ morphine cocaine
Seeing you at DC visit
4
Polling Which drugs can you offer MAT for in your practice
1 Opioids 2 ETOH 3 Stimulants 4 Benzodiazepines 5 Combo 6 None
5
ldquo No one is going to save usrdquo
ldquo hellipI was crying not because Superman did not exist but because it meant that there was no one with the power to save ushellip hellipJeffrey Canada ldquoWaiting for Supermanrdquo
Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10
poisoning deaths are caused by drugs
SOURCE CDCNCHS National Vital Statistics System
You Confront Your Patientrsquos SUDs
Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers
Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings
bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs
bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4
bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option
Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53
9
Goals of Medically Assisted Treatment (MAT)
Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug
10
MAT Options for Opioid Dependent Patients
1 Buprenorphinenaloxone (suboxone)
2 Naltrexone (oralinjectable)
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
2
Objectives Follow off of Dr Mathewrsquos talk on screening
for SUDs
Review Medication Assisted Treatment for
Opioid ETOH Benzos Methamphetamine dependence
Empower you to treat your patients
3
A patient known to you
30 yo woman with history of HIV disease Hep C endocarditis ETOH crack and street opioid use in remission Admitted for altered mental status UDS from ED -+ morphine cocaine
Seeing you at DC visit
4
Polling Which drugs can you offer MAT for in your practice
1 Opioids 2 ETOH 3 Stimulants 4 Benzodiazepines 5 Combo 6 None
5
ldquo No one is going to save usrdquo
ldquo hellipI was crying not because Superman did not exist but because it meant that there was no one with the power to save ushellip hellipJeffrey Canada ldquoWaiting for Supermanrdquo
Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10
poisoning deaths are caused by drugs
SOURCE CDCNCHS National Vital Statistics System
You Confront Your Patientrsquos SUDs
Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers
Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings
bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs
bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4
bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option
Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53
9
Goals of Medically Assisted Treatment (MAT)
Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug
10
MAT Options for Opioid Dependent Patients
1 Buprenorphinenaloxone (suboxone)
2 Naltrexone (oralinjectable)
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
3
A patient known to you
30 yo woman with history of HIV disease Hep C endocarditis ETOH crack and street opioid use in remission Admitted for altered mental status UDS from ED -+ morphine cocaine
Seeing you at DC visit
4
Polling Which drugs can you offer MAT for in your practice
1 Opioids 2 ETOH 3 Stimulants 4 Benzodiazepines 5 Combo 6 None
5
ldquo No one is going to save usrdquo
ldquo hellipI was crying not because Superman did not exist but because it meant that there was no one with the power to save ushellip hellipJeffrey Canada ldquoWaiting for Supermanrdquo
Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10
poisoning deaths are caused by drugs
SOURCE CDCNCHS National Vital Statistics System
You Confront Your Patientrsquos SUDs
Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers
Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings
bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs
bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4
bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option
Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53
9
Goals of Medically Assisted Treatment (MAT)
Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug
10
MAT Options for Opioid Dependent Patients
1 Buprenorphinenaloxone (suboxone)
2 Naltrexone (oralinjectable)
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
4
Polling Which drugs can you offer MAT for in your practice
1 Opioids 2 ETOH 3 Stimulants 4 Benzodiazepines 5 Combo 6 None
5
ldquo No one is going to save usrdquo
ldquo hellipI was crying not because Superman did not exist but because it meant that there was no one with the power to save ushellip hellipJeffrey Canada ldquoWaiting for Supermanrdquo
Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10
poisoning deaths are caused by drugs
SOURCE CDCNCHS National Vital Statistics System
You Confront Your Patientrsquos SUDs
Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers
Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings
bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs
bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4
bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option
Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53
9
Goals of Medically Assisted Treatment (MAT)
Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug
10
MAT Options for Opioid Dependent Patients
1 Buprenorphinenaloxone (suboxone)
2 Naltrexone (oralinjectable)
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
5
ldquo No one is going to save usrdquo
ldquo hellipI was crying not because Superman did not exist but because it meant that there was no one with the power to save ushellip hellipJeffrey Canada ldquoWaiting for Supermanrdquo
Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10
poisoning deaths are caused by drugs
SOURCE CDCNCHS National Vital Statistics System
You Confront Your Patientrsquos SUDs
Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers
Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings
bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs
bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4
bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option
Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53
9
Goals of Medically Assisted Treatment (MAT)
Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug
10
MAT Options for Opioid Dependent Patients
1 Buprenorphinenaloxone (suboxone)
2 Naltrexone (oralinjectable)
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10
poisoning deaths are caused by drugs
SOURCE CDCNCHS National Vital Statistics System
You Confront Your Patientrsquos SUDs
Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers
Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings
bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs
bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4
bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option
Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53
9
Goals of Medically Assisted Treatment (MAT)
Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug
10
MAT Options for Opioid Dependent Patients
1 Buprenorphinenaloxone (suboxone)
2 Naltrexone (oralinjectable)
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
You Confront Your Patientrsquos SUDs
Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers
Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings
bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs
bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4
bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option
Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53
9
Goals of Medically Assisted Treatment (MAT)
Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug
10
MAT Options for Opioid Dependent Patients
1 Buprenorphinenaloxone (suboxone)
2 Naltrexone (oralinjectable)
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers
Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings
bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs
bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4
bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option
Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53
9
Goals of Medically Assisted Treatment (MAT)
Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug
10
MAT Options for Opioid Dependent Patients
1 Buprenorphinenaloxone (suboxone)
2 Naltrexone (oralinjectable)
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
9
Goals of Medically Assisted Treatment (MAT)
Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug
10
MAT Options for Opioid Dependent Patients
1 Buprenorphinenaloxone (suboxone)
2 Naltrexone (oralinjectable)
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
10
MAT Options for Opioid Dependent Patients
1 Buprenorphinenaloxone (suboxone)
2 Naltrexone (oralinjectable)
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
11
Polling Questionndash For my patients the access to Suboxone is provided byhellip
1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
12
Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist
Ceiling effect on the mu receptor
Long frac12 life so once a day dosing fine
Similar effect on respiratory drive as benzos
and ETOH Similar idea as methadone but people like it
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
13
Suboxone Maintenance
Studies repeatedly prove efficacy Expensive if not covered but mostly
covered Strongly regulated by federal and state
Special barrier Training and lsquoXrsquo license DEA visitors
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Typical Suboxone Dosing
Home initiation is used by some mostly we use OBIC based near TAP
Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as
needed Increase q 3-4 days
Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
15
Naltrexone ndash oralinjectable
Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in
short order Monthly injectable (Vivitrol) Non selective so will block both pain
opioids illicit substances
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes
bull Signs of overdose
bull How to administer naloxone
bull How to provide emergency care
bull Calling 911
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Who is a good Naltrexone candidate
Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence
(active in 12 step programs) In professions where agonist treatment is
controversial (HCWs pilots) Successful on agonist but who want to try
abstinence Abstinent but at risk for relapse
Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014
17
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
18
ETOH
ETOH dependent and had serious withdrawal ndash residential detox
Everyone else at end of detox or if not so medically at risk can be managed as outpt
After detox patients need maintenance just like opioid use disorder
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Spectrum and population prevalence of alcohol use in US
Dependence 4
Abuse 5
Risky Use 16
Low Risk Use 30
Abstinence 45
Source Saitz R NEJM 2005352596-607
Unhealthy Use 25
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Medications for Relapse Prevention bull Three FDA Approved Medications
ndash Naltrexone ndash Disulfiram ndash Acamprosate
bull Promising Medications ndash Topiramate ndash Gabapentin
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
ETOH Treatment Options Naltrexone 50mg QD
or
Naltrexone ER 380mg IM Q month
wwwniaaanihgovguide
Acamprosate 666 mg TID
or
Disulfiram + Acamprosate
Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Naltrexone (ReViaVivitrol)
bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995
ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Source wwwniaaanihgovguide
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
24
Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate
Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
25
ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning
per patient or significant other Improvement in LFTs (AST ALT GGT)
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
27
24 yr got off methamphetamine
hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
28
Methamphetamine
A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention
mirtazapine 30mg QHS or placebo 30 minutes counseling weekly
Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)
Colfax et al Arch General Psychiatry 2011681168-75
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Mirtazapine for Methamphetamine
Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention
naltrexone 50mg or placebo counseling 1xwk
Outcome UDS No Meth Naltrexone 65 Placebo 48
Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Impact of Findings
Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
Any Time for Your Cases
33
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
References Mirtazapine to reduce methamphetamine use a
randomized controlled trial Arch Gen Psychiatry 20111168-75
Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8
H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012
References
Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950
Adams J Gaynes B McGuiness T et al Treating
Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012