Matthew A Felgus, MD FASAM · 2017-10-20 · Matthew A Felgus, MD FASAM [email protected]...

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Matthew A Felgus, MD FASAM

[email protected] matthewfelgusmd.com 6333 Odana Rd, Ste 3, Madison WI

53719 (608) 257-1581 Board Certified in Addiction Medicine Board Certified in Psychiatry

Matthew Felgus, MD 10/24/17

MEDICATION

Assisted

Treatment


Medication

Assisted

TREATMENT


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Medical Model

An imprecise and widely used term. Possibly first used by Erving Goffman in Asylums (1961) based on a ‘tinkering services’ model that assumes a technically expert server and an individual client in need of repair.

“medical model." A Dictionary of Sociology. . Encyclopedia.com. 9 Aug. 2017 <http://www.encyclopedia.com


Medical Model

Evidence-based on prior research

We are only as good as the studies that have already come out.

Symptoms are a sign of illness

Focus is on ‘what is wrong (dis-ease)’


Medical Model for MAT

Something is wrong

Your poor opiate-addicted brain

You need medication

You can not stay off opiates without it


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‘Wellness Model’

Integration of physical, mental and spiritual well being (6-8 dimensions)

Conscious and directed by the client

How can I help you heal today?

Does not ignore medication but primary focus is on personal growth Hettler, National Wellness Institute, 1976

SAMHSA.gov, July, 2016


Wellness Model

The patient knows what they need to heal

They may ignore this knowing (i.e. when active in addiction) but in their clear moments, they know

Professionals (MD, counselor) provide guidance


Medication Assisted Treatment…

Saves lives

Ideally equal parts of all of the above

May consist of replacement or blocking agent


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Do Addiction Specialists agree on the ‘best’ method for MAT?


Some MAT Options

Saturate the opioid receptors with a high dose and stay there… forever

Taper as quick as possible (3-6mos)

Taper slowly (4-5 years)

See a counselor for mental health

See an addiction counselor or group


MAT Options

How we offer MAT does matter

Medication is one tool

Medication is the tool

We need to deal with underlying issues for effective treatment


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MAT Recovery is a state of mind, not whether

someone is on opioid replacement

‘There is a right way to work the 12 steps.’ VS

‘I’ve been going through the steps with my sponsor for 23 years. Every time, I go deeper.’

‘Give me something so I don’t feel this anymore.’ VS

‘I am trying to move myself forward.’Matthew Felgus, MD 10/24/17

MAT

Is NOT a wonder pill/film/shot

How we give medication can be more important than what we give

Pill + guided healing makes the medication work better

Telling clients that the medication is but one piece of the puzzle sets expectation

MDs are not trained in healingMatthew Felgus, MD 10/24/17

Patient Case 1

“I’m feeling more stressed. This past month, I’ve gotten in more trouble with the IRS and I don’t know if I’ll be able to pay my mortgage. I’m having more cravings. Can I get an increase so I can feel more comfortable?”


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Medications for Cravings? Yes, but…

Anti-Craving medications do not address the underlying MH ‘driver’

Yes, there is a biochemical change in the brain that may be eased for some people with medication

What exactly is driving a craving?


Dual Diagnosis: Cravings

What exactly is driving a craving?

Neurotransmitters or more?

Anti-Craving medications do not address the underlying MH ‘driver’



Environment (people, places, things)


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Mood state (angry, sad, tired, lonely)





Psychological state (anxiety, bad memories, nightmares)





Psychological state (anxiety, bad memories, nightmares)

Brain wiring/old patterns/path of least resistance

Can we take a pill for this?Matthew Felgus, MD 10/24/17

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Treatment

Helping people to heal what’s inside them or numb out?

We are living in a quick-fix, easy-out culture and our media is reinforcing this

Marijuana as medicine? (Different question from legalization)


The Mental Health ‘Big 4’ for Driving Addiction

Anxiety

Trauma

Depression

Insomnia


Trauma and Substance Abuse

Use Alcohol or drugs to cope

Drink/use not to feel anything

29-59% of women in AODA treatment have trauma. Likely much higher.

Women with PTSD have a 1.4-3.6x higher likelihood of substance abuse. Najavits, et. al, American Journal of Addiction, 1997 6: 273-283.


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The Connection between Use and Trauma

Never learned to manage feelings in a healthy way (bad modeling)

Drugs are the ‘perfect’ solution to getting rid of memories and unpleasant feelings


Trauma and Substance Use Notice the connections between use and

feelings

Recognize that as use lowers, uncomfortable feelings will increase

As coping increases, feelings will be more manageable (hang in there)

Decrease use if unable to fully stop

Work on both trauma and use togetherMatthew Felgus, MD 10/24/17

Trauma Treatment

DBT

Seeking Safety

EMDR

Brainspotting

“Trauma-informed care”


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Part 2


The Mental Health ‘Big 4’ for Driving Addiction

Anxiety

Trauma

Depression

Insomnia


Other Conditions Leading to Substance Abuse

• Depression

--Still underdiagnosed

--May present as behavior problems in teens

--Alcohol+ Opiates act as short-term numbing agent but worsen mood LT

--Marijuana mimics some symptoms

--Cocaine + Stimulants may mask as well as cause


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Other Conditions Leading to Substance Abuse

• Anxiety

• Can present as panic attacks, social withdrawal, phobias, obsessions and compulsions

• Common for teens and adults to treat anxiety with alcohol, opioids, marijuana and other substances


Opioids and Anxiety

Extremely common presentation

High degree of overlap between withdrawal and anxiety sxs

While anxiety isn’t responsible for the opiate epidemic, it is a major barrier for individuals to stop using


Opioids and Anxiety

Opioids are wonderful numbing agents and individuals with anxiety (and PTSD) want to be numbed

We as treaters need to be more mindful around our messages about anxiety


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Opiate Withdrawal

Increased BP

Increased HR

Sweating/Chills/Hot

flashes

Restlessness

Dilated Pupils

GI

Cramps/Diarrhea

Nausea/Vomiting

Feeling of Dying

Tremor

Yawning

Gooseflesh

Runny nose/Wa

tery eyes

Bone Pain

Muscle Aches


Anxiety

Increased BP

Increased HR

‘Heart attack’feeling/Chest pain

Shortness of Breath/Smothering/

Choking

‘Room closing in’

Fear of going crazy/dying

Out of Body

Depersonalization/Numb

ness

Sweating/Chills/Hot flashes

Restlessness

GI Cramps/Diarrhea

Shaking/Tremor

Inability to Concentrate

Dizzy/Lightheaded/Tingling


Anxiety Vs. Opiate Withdrawal

Inc. BPInc. HR

Sweating/ChillsRestlessness

GI cramps/diarrheaShaking/TremorFeeling of Dying


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OPIOID REPLACEMENT TREATMENT


WHY?

OPIOID USE HAS EXPLODED AND SHOWS NO SIGN OF SLOWING!!!


WHY?

Effective, proven treatment in reducing use


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WHY?


Keeps clients in treatment (carrot)


WHY?



Blocking agent for other opioids


WHY?



Blocking agent for other opioids

Less likely to be abused (but not impossible)


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WHY?

If used properly (lowering doses) clients can be tapered off opioids


WHY?


This is important with a younger population


WHY?


This is important with a younger population

One component of a well-rounded treatment program


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WHY NOT?

Over reliance on medication vs. recovery tools


WHY NOT?


Doses can be too high (clients appear ‘stoned’)


WHY NOT?


Doses can be too high (clients appear ‘stoned’)

Establishing a pattern of dependence on opioid medications at a young age


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WHY NOT?

Less clinical data of success in a younger (teen) population


WHY NOT?


Opioid Replacement for a less severe habit


WHY NOT?


Opioid Replacement for a less severe habit

It is possible to abuse opiate replacement meds (methadone and suboxone)


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Hmmm..

Is there something unique about the opioid dependent brain (vs. cocaine, alcohol, cannabis, etc.)?

Are we reinforcing the ‘terminal uniqueness’ of opioid dependent individuals?

Why don’t we prescribe alcohol or benzodiazepines to alcohol dependent individuals?


Methadone

In use since 1960s

Blocks other opiates and reduces cravings

Can be overdosed

At high doses, individuals can appear to ‘nod out’


Methadone

Yes, you can get high

Are high doses (>150 mg.) necessary to maintain abstinence OR treating sxs of other disorders (dep, anx)? OR BOTH??

Why are we as treaters so avoidant of discomfort of withdrawal solely in this population?


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Buprenorphine

Partial mu agonist with high affinity

Will displace any other mu agonist precipitating withdrawal

Buprenex® - injectable form - only indication is for analgesia

Subutex® – 2 & 8mg sublingual tablets

Suboxone® – Buprenorphine/naloxone combination 2/0.5mg, 4/1mg, 8/2mg & 12/3 mg sublingual films


Buprenorphine/Naloxone

Zubsolv® -- Buprenorphine/naloxone combination 0.7/0.18mg, 1.4/0.36 mg, 2.9/.71mg,5.7/1.4 mg, 8.6/2.1mg

Equivalent to 1, 2, 4, 8, and 12 mg suboxonedosages

Better bioavailability (so lower amt of bup)

Pills tend to crumble when cut



Bunavail® -- Buprenorphine/naloxone combination 2.1/0.3mg,4.2/0.7mg, 6.3/1mg (equal to 4, 8 and 12 mg suboxone)

Sticks to inside of cheek

Better bioavailability?

Not recommended to cut in order to taper


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Suboxone®

• Dosage Range: not agreed upon

• Research shows receptors saturated at 16mg

although some prescribers go MUCH higher

• Manufacturer does NOT recommend >24

• Quick detox vs. slow (1+yr.) detox

vs. maintenance

• Is it possible to taper off without relapse?Matthew Felgus, MD 10/24/17


Half-life is 22-40 hours (average 35 hrs.) so only needed once daily

Safer in OD since less respiratory depression than other opioids

Best if used as past of a treatment program


Buprenorphine/ Naloxone

Yes, you can get high….if not opioid dependent

Diversion of prescription

Party drug for those without an opioid habit

Prevention of opioid withdrawal in those using

Self detox for those trying to quit


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MDs take an 8 hour class to prescribe

Not enough prescribers for demand in rural areas

No addiction training needed

NPs take a 24 hour class to prescribe



100 Patient Cap Removed 8/2016

MDs can not treat up to 275 pts

Better access vs. increase in ‘buprenorphine mills’?



MDs over-rely on medical model

“Everyone with chronic pain should be on Suboxone.”

Safer than other opioids, yes…but

Are opioids truly the best treatment for chronic pain?


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Patient Case 2

“Doc, I need more Suboxone®. Since I went down, I’m having more back pain. That’s always my sign that I’m in withdrawal.”

No other withdrawal symptoms by questioning and exam.


Patient Case 2

On further discussion, he had a back injury at work over 10 years ago. He had forgotten, so did not disclose this at the initial evaluation. The injury was never evaluated or treated. He was taking illicit opiates from prior to the injury until starting buprenorphine 2 years ago.


Patient Case 2

This step down on buprenorphine allowed him to feel the chronic discomfort of his old injury.

Do I increase his opiate replacement?


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Case Study 3

Jack is a 26 year old computer programmer who presents for evaluation as a transfer from another buprenorphineprovider. He has been prescribed Suboxone® 36 mg. per day for the past 10 months. He reports he isn’t sure that medication is working.


Case Study 3

Jack reports that for the first several weeks of treatment, he had been given 16 mg. He used no other opiates during this time. However, 4-5 hours after taking his dose, he would experience shortness of breath, increased heart rate, sweating, edginess.


Case Study 3

His MD increased his buprenorphine to 20 mg for 2 days, then 24 mg. per day in a divided dose. He reported good effect, but after 1 week, all of his “withdrawal” symptoms returned, this time 4 hours after each dose. He had no use of other opiates but admitted thinking about it, only to relieve sxs.


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Case Study 3

Suboxone® increased to 32 mg, then with continuing complaints ofwithdrawal up to 36 mg. (16mg in the morning, 20 mg in the evening.) After one month, he did try to decrease to 32 mg. but began to worry that his symptoms would come back so his MD increased and kept him at 36 mg.


Case Study 3 Diagnosed with Generalized Anxiety

Disorder

Started on citalopram and gabapentin. Later added propranolol

Started individual CBT and group therapy. Over past year, Brainspotting.

After 3 months of above, did decrease buprenorphine to 28 mg. Five years later, dose is 0.5 mg. per day.Matthew Felgus, MD 10/24/17

Opiate Receptor Blockade

Naltrexone

OralDaily

Vivitrol

Injection of naltrexoneLasts 4 weeks


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WHY?

It’s not an opiate


WHY?


It can not be abused (no high)


WHY?



No street value


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WHY?



No street value

It saves lives


WHY?



No street value

It saves lives –

Injection as leaving incarceration or rehab does help prevent overdose


WHY NOT?

Injection is expensive ($800-1200/vial)


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WHY NOT?


Not an opiate and does not numb (still can have cravings)


WHY NOT?


Not an opiate and does not numb (still can have cravings that are driven by ‘big 4’)

May be done under duress (family, legal system may require)


WHY NOT?


Not an opiate and does not numb (still can have cravings that are driven by ‘big 4’)

May be done under duress (family, legal system may require)

Patients may try to overcome block as injection wears off and overdose


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Naltrexone (oral)

Approved in 1994 for treatment of alcohol dependence

Decreases alcohol consumption by likely blocking positive reinforcing effects

Blocks opiate receptors

Biggest challenge is compliance (continuing medication)


Naltrexone

Side Effects

Nausea SleepinessAbnormal rise in liver enzymesMood blunting or depression/lack of

‘runner’s high’ type of feeling possible (less likely with injection)


Vivitrol

Opioid users may attempt to overcome the block (OD as shot is waning at end of month)

Pain medication will not be as effective (accident or emergent surgery)

HOWEVER, benefits> drawbacks in most


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Final Thoughts

Addiction is a condition of body, mind and soul

Nearly all individuals who become addicted are trying to numb something, and need our help to learn to feel again

Medication alone will not solve the issue of substance abuse and addiction but may be one piece of the puzzle


Final, Final thoughts…

Healing should be our goal. But it is a s-l-o-w process and relapse is the rule rather than the exception

The medical profession has a lot to learn about the above, and the majority of MDs are not trained in treating addictions


THANK YOU


Matthew A Felgus, MD FASAM · 2017-10-20 · Matthew A Felgus, MD FASAM [email protected]...

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