OVERVIEW - LPMA · OVERVIEW •ADDICTION IS A SERIOUS, CHRONIC, RELAPSING DISORDER FOR WHICH...
Transcript of OVERVIEW - LPMA · OVERVIEW •ADDICTION IS A SERIOUS, CHRONIC, RELAPSING DISORDER FOR WHICH...
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OVERVIEW
• ADDICTION IS A SERIOUS, CHRONIC, RELAPSING DISORDER FOR WHICH MULTIPLE
EVIDENCE BASED TREATMENTS ARE AVAILABLE
• MEDICATIONS SHOULD BE CONSIDERED AS PART OF A COMPREHENSIVE
TREATMENT PLAN, ADDRESSING BOTH DISORDERED PHYSIOLOGY AND DISRUPTED
LIVES
• MEDICATIONS SHOULD BE CONSIDERED FOR TREATMENT OF: PSYCHIATRIC SX’S,
ADDICTIVE D/O’S, AND CO-OCCURRING D/O’S
• EMERGING LITERATURE SUPPORTS USE OF MEDS IN YOUTH WITH SUDS AND
PSYCHIATRIC COMORBIDITY
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A PRIMER ON THE TREATMENT OF SUBSTANCE USE DISORDERS
PRESENTED BY:
JENNIFER CREEDON, MD ABPN
LSU PSYCHIATRY
SLIDE PRESENTATION PREPARED BY:
ARWEN PODESTA, MD
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ADDICTION IS A BRAIN DISEASE
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ASAM“SHORT” DEFINITION OF ADDICTION
• …A PRIMARY, CHRONIC, RELAPSING DISEASE OF BRAIN REWARD, MOTIVATION, MEMORY AND
RELATED CIRCUITRY. DYSFUNCTION IN THESE CIRCUITS LEADS TO CHARACTERISTIC
BIOLOGICAL, PSYCHOLOGICAL, SOCIAL AND SPIRITUAL MANIFESTATIONS. THIS IS REFLECTED
IN AN INDIVIDUAL PATHOLOGICALLY PURSING REWARD AND/OR RELIEF BY SUBSTANCE USE
AND OTHER BEHAVIORS
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WHY DO WE CARE ABOUT ADDICTION?
• 1 OUT OF 7 INDIVIDUALS WILL HAVE A SERIOUS SUBSTANCE
USE PROBLEM (13.5% LIFETIME PREVALENCE)
• 1 OUT OF 3 AMERICANS ARE DIRECTLY AFFECTED BY
ADDICTION
• UP TO 50% OF ADMISSIONS TO THE ER ARE SUBSTANCE-
RELATED
• ADDICTION IS A COMMON PROBLEM AMONG PHYSICIANS
AND OTHER HEALTH CARE PROVIDERS
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OPIOID ADDICTION
CURRENTLY ABOUT 2.5 MILLION US CITIZENS ACTIVELY ADDICTED TO OPIOIDS
1.9 MILLION TO PRESCRIPTION OPIOIDS (79%)
517,000 TO HEROIN (21%)
OPIOID SOCIETAL COSTS - $55 BILLION A YEAR
OPIOID OD QUADRUPLED SINCE 1999 - 54,404 US OD DEATHS IN 2015 - 33,091 (63%)
INVOLVED OPIATES
INCREASES RISK FOR HIV, VIRAL HEPATITIS, OTHER INFECTIONS, STDS, ETC.
PLUS MULTIPLE SOCIETAL PROBLEMS
ASAM/ NATIONAL SURVEY ON DRUG USE AND HEALTH (NSDUH); US DEPT OF HHS/CDC / MORBIDITY AND
MORTALITY
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PODESTA A. HOOKED: A CONCISE GUIDE TO THE UNDERLYING MECHANICS OF ADDICTION AND TREATMENT FOR PATIENTS, FAMILIES, AND PROVIDERS. INDIANAPOLIS, IN: DOG EAR PUBLISHING; 2016.
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PREVIOUS MEDICAL APPROACHES TO ALCOHOLISM AND DRUG ADDICTION
• BENJAMIN RUSH, MD USED BLEEDING, BLISTERING AND TREATMENT WITH MERCURY LADEN CALOMEL
• DRINK WINE IN WHICH EELS SUFFOCATED
• WATER CURES (HYDROTHERAPY)
• LATER HALF OF 1800S VARIOUS DRUGS: COCAINE, MORPHINE, MJ, HEROIN, ETOH, BROMIDE
• AVERSION THERAPY – 1932 - PRESENT
• ECT, INSULIN SHOCK, PSYCHOSURGERY 1940S – ABOUT 1960S
▪ MID- 1900S DRUG INTERVENTIONS: SEDATIVE, TRANQUILIZERS, AMP/METHAMPHETAMINE, LSD,
HALLUCINOGENS, HORMONES, CO2
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NY STATE INEBRIATE ASYLUM: 1864DEEMED A “COMPLETE FAILURE” IN 1979
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US FEDERAL NARCOTIC FARMS: 1925 -1950CONTINUED INTO 1970S
• FEDERAL NARCOTIC FARMS:
LEXINGTON, KY AND FORT WORTH TEXAS PRIMARY SOURCE OF TREATMENT,
1938 – 1950
• LONG TREATMENT (VOLUNTARY VS INVOLUNTARY)
• LITTLE OR NO FAMILY INVOLVEMENT
• FORCED LABOR
• RELAPSE RATE- VERY HIGH
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Fort Worth Federal Narcotics Farm 1938 - 1971
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Relapse Rate was approximately 95%
Federal “Narcotics Farm” - Lexington, KY 1935-1975
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DOES ABSTINENCE-BASED TREATMENT WORK?
NATIONAL TREATMENT OUTCOME RESEARCH DATA ON OPIOID ADDICTION PATIENTS
242 PATIENTS IN RESIDENTIAL TREATMENT
34% RELAPSE WITHIN 3 DAYS 45% RELAPSE WITHIN 7 DAYS
50% RELAPSE WITHIN 14 DAYS 60% RELAPSE WITHIN 90 DAYS
MULTIPLE “STUDIES CONSISTENTLY SHOW 2/3 OF PATIENTS IN ABSTINENCE-BASED
PROGRAMS RELAPSE”. DR BATKI, MD PROF OF PSY, UPSTATE MED CENTER SYRACUSE
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39%
wanted to try opioid drugs
once more
48%
ease of access
to opioids
37%
someone offered
them opioids
62%
mood was bad
62%
cravings were
too much
43%
missed the support
of the treatment
center
Reasons
for
Relapse
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METHADONE TREATMENT FOR HEROIN (OPIOIDS) 1964
Methadone maintenance treatment, started in 1964, ushered in a new era in the
treatment of Opioid Addiction.
Prior to Methadone, the overall relapse rate to heroin use was at least 80%.
APPROVED 1972
JAMA, Aug 23, 1965 – Vol 193, No 8
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ANTABUSE TREATMENT FOR ALCOHOLISM, 1951
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PHARMACOTHERAPY USE IN ADDICTION TREATMENT
• IN 2007, 1 IN 3 PEOPLE WITH OPIOID
DEPENDENCE USED PHARMACOTHERAPY
• IN 2011, 1 IN 4 PEOPLE WITH ALCOHOL
DEPENDENCE USED PHARMACOTHERAPY
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MEDICATION ASSISTED TREATMENT/RECOVERY
• USE SPARINGLY AND ONLY WHEN NEEDED
• TREAT SYMPTOMS TO HELP PATIENT STAY IN RECOVERY AND LEARN TOOLS FOR
LONG TERM WELLNESS
• SOME MEDS MAY BE LONG TERM, BUT MOST WILL BE SHORT TERM WHILE
NEUROGENESIS AND SYNAPTOGENEISS AND NEURAL REPAIR OCCUR, ESPECIALLY
IN THE FIRST 3-6 MONTHS OF RECOVERY.
• MY WHOLE PHILOSOPHY IS STABILIZING UNTIL THE FOUNDATION IS BUILT, THEN
MOVING AWAY FROM MEDICATIONS WHEN POSSIBLE.
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MEDICATION ASSISTED TREATMENT/RECOVERY
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PHARMACOTHERAPY IN SUBSTANCE USE DISORDERS
• TREATMENT OF WITHDRAWAL (DETOX)
• TREATMENT OF PSYCHIATRIC SYMPTOMS OR CO-OCCURRING DISORDERS
• REDUCTION OF CRAVINGS AND URGES
• SUBSTITUTION THERAPY
• PREVENTION
• OVERDOSE REVERSAL
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NEUROTRANSMITTER PATHWAYS AND EFFECT
NATIONAL INSTITUTE ON DRUG ABUSE. 2014.
Dopamine Pathways
Functions
• Reward
• Pleasure, Euphoria
• Motor Function
(fine tuning)
• Compulsion
• Perseveration
• Decision Making
• Mental Focus
• Motivation
• Attachment
Serotonin Pathways
Functions
• Mood
• Mental
• Well-being
• Memory
• Processing
• Sleep
• Cognition
VentralTegmentum
NucleusAccumbens
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BRAIN PATHWAYS
VT
DOPAMINE
STORAGE
NUCLEUS
ACCUMBENSDOPAMINE
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BRAIN PATHWAYS
PODESTA A. HOOKED: A CONCISE GUIDE TO THE UNDERLYING MECHANICS OF ADDICTION AND TREATMENT FOR PATIENTS, FAMILIES, AND PROVIDERS. INDIANAPOLIS, IN: DOG EAR PUBLISHING; 2016.
STAHL SM, ET AL. STAHL’S ILLUSTRATED SUBSTANCE USE AND IMPULSIVE DISORDERS. CAMBRIDGE UNIVERSITY PRESS; 2012.
WETSMAN H. QUESTIONS AND ANSWERS ON ADDICTION. RUSH PRESS; 2007.
VT
DOPAMINE
STORAGE
OPIOID
PEPTIDES
NUCLEUS
ACCUMBENS
ALCOHOL
PCP
OPIATES
OPIATES
ALCOHOL
NICOTINE
NICOTINE
& ALCOHOL
AMPHETAMINES
COCAINE
CANNABINOIDS
MDMA
GABA
SEROTONIN
GLUTAMATE
(FROM CORTEX)
DOPAMINE
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MEDICATION-ASSISTED TREATMENT/RECOVERY
PODESTA A. HOOKED: A CONCISE GUIDE TO THE UNDERLYING MECHANICS OF ADDICTION AND TREATMENT FOR PATIENTS, FAMILIES, AND PROVIDERS. INDIANAPOLIS, IN: DOG EAR PUBLISHING; 2016.
STAHL SM, ET AL. STAHL’S ILLUSTRATED SUBSTANCE USE AND IMPULSIVE DISORDERS. CAMBRIDGE UNIVERSITY PRESS; 2012.
WETSMAN H. QUESTIONS AND ANSWERS ON ADDICTION. RUSH PRESS; 2007.
VT
DOPAMINE
STORAGE
OPIOID
PEPTIDES
NUCLEUS
ACCUMBENS
ALCOHOL
PCP
OPIATES
OPIATES
ALCOHOL
NICOTINE
NICOTINE
& ALCOHOL
AMPHETAMINES
COCAINE
CANNABINOIDS
MDMA
GABA
BUPRENORPHINE
DOPAMINE
BUPROPION
NALTREXONE
SSRI
SEROTONINONDANSETRON
ARIPIPRAZOLE
GLUTAMATE
(FROM CORTEX)
GABAPENTIN
ACAMPROSATE
TOPIRAMATE
BACLOFEN
BUPRENORPHINE
GABAPENTIN
ACAMPROSATE
TOPIRAMATE
BACLOFEN
cb1
AGONIST
VARENICLINE
GLUTAMATE
(FROM CORTEX)
GABAPENTIN
ACAMPROSATE
TOPIRAMATE
BACLOFEN
+ / -
+ / -
+ / -
+
+
+ +
+
+
+
+
-
-
-
-
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MEDICATION ASSISTED TREATMENT/RECOVERY: ALCOHOL DEPENDENCE
FDA-APPROVED:
• DISULFURAM (ANTABUSE)
• PO NALTREXONE (REVIA)
• IM NALTREXONE (VIVITROL)
• ACAMPROSATE (CAMPRAL)
NON-FDA-APPROVED:
• TOPIRAMATE (TOPAMAX)
• ONDANSETRON (ZOFRAN)
• BACLOFEN
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MEDICATIONS FOR OPIOID DEPENDENCE
• DETOXIFICATION
• OPIOID-BASED AGONIST (METHADONE, BUPRENORPHINE)
• NON-OPIOID BASED (CLONIDINE*, SUPPORTIVE MEDICATIONS)
• ANTAGONIST-BASED (NALTREXONE: “RAPID”)
• RELAPSE PREVENTION
• AGONIST MAINTENANCE (METHADONE)
• PARTIAL AGONIST MAINTENANCE (BUPRENORPHINE)
• ANTAGONIST MAINTENANCE (NALTREXONE)
*OFF-LABEL USE.
CAVACUITI C (ED). PRINCIPLES OF ADDICTION MEDICINE: THE ESSENTIALS. PHILADELPHIA, PA: LIPPINCOTT WILLIAMS & WILKINS; 2011.
KNUDSEN HK, ET AL. J ADDICT MED. 2011;5(1):21-27.
MATTICK RP, ET AL. COCHRANE DATABASE SYST REV. 2009;(3):CD002209.
THE AMERICAN SOCIETY OF ADDICTION MEDICINE. ADVANCING ACCESS TO ADDICTION MEDICATIONS. WWW.ASAM.ORG/DOCS/DEFAULT-SOURCE/ADVOCACY/AAAM_IMPLICATIONS-FOR-OPIOID-ADDICTION-TREATMENT_FINAL. ACCESSED JANUARY 30, 2018.
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OPIOID DETOXIFICATION
• MEDICATIONS USED TO ALLEVIATE WITHDRAWAL SYMPTOMS
• OPIOID AGONISTS (METHADONE, BUPRENORPHINE)
• OTHER SUPPORTIVE MEDICATIONS
• CLONIDINE, TIZANIDINE, LOFEXIDINE (ALPHA-2 AGONISTS)*
• CAUTION: HYPOTENSION
• COMFORT MEDICATIONS INCLUDING ANTIDIARRHEALS, ANTIEMETICS,
PAIN MEDICATIONS, MUSCLE RELAXANTS, BENZODIAZEPINES
*OFF-LABEL USE.
CAVACUITI C (ED). PRINCIPLES OF ADDICTION MEDICINE: THE ESSENTIALS. PHILADELPHIA, PA: LIPPINCOTT WILLIAMS & WILKINS; 2011.
KNUDSEN HK, ET AL. J ADDICT MED. 2011;5(1):21-27.
MATTICK RP, ET AL. COCHRANE DATABASE SYST REV. 2009;(3):CD002209.
THE AMERICAN SOCIETY OF ADDICTION MEDICINE. ADVANCING ACCESS TO ADDICTION MEDICATIONS. WWW.ASAM.ORG/DOCS/DEFAULT-SOURCE/ADVOCACY/AAAM_IMPLICATIONS-FOR-OPIOID-ADDICTION-TREATMENT_FINAL. ACCESSED JANUARY 30, 2018.
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OPIOID RECEPTOR BLOCKADE: GOALS
• REDUCE SYMPTOMS AND SIGNS OF WITHDRAWAL
• REDUCE OR ELIMINATE CRAVING
• BLOCK EFFECTS OF ILLICIT OPIOIDS
• RESTORE NORMAL PHYSIOLOGY
• PROMOTE PSYCHOSOCIAL REHABILITATION AND NON-DRUG LIFESTYLE
CAVACUITI C (ED). PRINCIPLES OF ADDICTION MEDICINE: THE ESSENTIALS. PHILADELPHIA, PA: LIPPINCOTT WILLIAMS & WILKINS; 2011.
KNUDSEN HK, ET AL. J ADDICT MED. 2011;5(1):21-27.
MATTICK RP, ET AL. COCHRANE DATABASE SYST REV. 2009;(3):CD002209.
THE AMERICAN SOCIETY OF ADDICTION MEDICINE. ADVANCING ACCESS TO ADDICTION MEDICATIONS. WWW.ASAM.ORG/DOCS/DEFAULT-SOURCE/ADVOCACY/AAAM_IMPLICATIONS-FOR-OPIOID-ADDICTION-TREATMENT_FINAL. ACCESSED JANUARY 30, 2018.
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OPIOID RECEPTOR ACTIVATION
CENTER FOR SUBSTANCE ABUSE TREATMENT. CLINICAL GUIDELINES FOR THE USE OF BUPRENORPHINE IN THE TREATMENT OF OPIOID ADDICTION. ROCKVILLE (MD): SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (US); 2004. (TREATMENT
IMPROVEMENT PROTOCOL (TIP) SERIES, NO. 40.)
10
100
0
Rece
pto
r A
ctiv
ation
40
50
30
Log Dose of Opioid
-5-9 -7 -6-8-10
80
-4
90
70
60
20
Full Agonist
(methadone)
Partial Agonist
(buprenorphine)
Antagonist
(naltrexone/naloxone)
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METHADONE
• ORALLY ACTIVE SYNTHETIC Μ-OPIOID FULL AGONIST
• QUICK ABSORPTION, SLOW ELIMINATION, LONG HALF-LIFE
• EFFECTS LAST 24 HOURS; ONCE-DAILY DOSING MAINTAINS CONSTANT BLOOD LEVEL
• PREVENTS WITHDRAWAL, REDUCES CRAVING AND USE
• FACILITATES REHABILITATION
• REQUIRES GOING TO A CLINIC
• LIMITED AVAILABILITY
CAVACUITI C (ED). PRINCIPLES OF ADDICTION MEDICINE: THE ESSENTIALS. PHILADELPHIA, PA: LIPPINCOTT WILLIAMS & WILKINS; 2011.
KNUDSEN HK, ET AL. J ADDICT MED. 2011;5(1):21-27.
MATTICK RP, ET AL. COCHRANE DATABASE SYST REV. 2009;(3):CD002209.
THE AMERICAN SOCIETY OF ADDICTION MEDICINE. ADVANCING ACCESS TO ADDICTION MEDICATIONS. WWW.ASAM.ORG/DOCS/DEFAULT-SOURCE/ADVOCACY/AAAM_IMPLICATIONS-FOR-OPIOID-ADDICTION-TREATMENT_FINAL. ACCESSED JANUARY 30, 2018.
US FOOD AND DRUG ADMINISTRATION. DRUGS@FDA: FDA APPROVED DRUG PRODUCTS. WWW.ACCESSDATA.FDA.GOV/SCRIPTS/CDER/DAF/INDEX.CFM.
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BUPRENORPHINE
• SUBLOCADE™, SUBOXONE®, SUBUTEX®, ZUBSOLV®, BUNAVAIL®
• FDA APPROVED: 2002, AGE 16+ YEARS
• MANDATORY CERTIFICATION FROM DEA (100 PATIENT LIMIT)
• OFFICE-BASED, EXPANDS AVAILABILITY
• ANALGESIC PROPERTIES
• CEILING EFFECT
• MECHANISM: Μ-OPIOID PARTIAL AGONIST
CAVACUITI C (ED). PRINCIPLES OF ADDICTION MEDICINE: THE ESSENTIALS. PHILADELPHIA, PA: LIPPINCOTT WILLIAMS & WILKINS; 2011.
KNUDSEN HK, ET AL. J ADDICT MED. 2011;5(1):21-27.
MATTICK RP, ET AL. COCHRANE DATABASE SYST REV. 2009;(3):CD002209.
THE AMERICAN SOCIETY OF ADDICTION MEDICINE. ADVANCING ACCESS TO ADDICTION MEDICATIONS. WWW.ASAM.ORG/DOCS/DEFAULT-SOURCE/ADVOCACY/AAAM_IMPLICATIONS-FOR-OPIOID-ADDICTION-TREATMENT_FINAL. ACCESSED JANUARY 30, 2018.
US FOOD AND DRUG ADMINISTRATION. DRUGS@FDA: FDA APPROVED DRUG PRODUCTS. WWW.ACCESSDATA.FDA.GOV/SCRIPTS/CDER/DAF/INDEX.CFM.
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BUPRENORPHINE
• CEILING EFFECT
• MECHANISM: Μ-OPIOID PARTIAL AGONIST
• LOWER ABUSE POTENTIAL
• SAFER IN OVERDOSE (BECAUSE OF CEILING EFFECT AND NALOXONE)
CAVACUITI C (ED). PRINCIPLES OF ADDICTION MEDICINE: THE ESSENTIALS. PHILADELPHIA, PA: LIPPINCOTT WILLIAMS & WILKINS; 2011.
KNUDSEN HK, ET AL. J ADDICT MED. 2011;5(1):21-27.
MATTICK RP, ET AL. COCHRANE DATABASE SYST REV. 2009;(3):CD002209.
THE AMERICAN SOCIETY OF ADDICTION MEDICINE. ADVANCING ACCESS TO ADDICTION MEDICATIONS. WWW.ASAM.ORG/DOCS/DEFAULT-SOURCE/ADVOCACY/AAAM_IMPLICATIONS-FOR-OPIOID-ADDICTION-TREATMENT_FINAL. ACCESSED JANUARY 30, 2018.
US FOOD AND DRUG ADMINISTRATION. DRUGS@FDA: FDA APPROVED DRUG PRODUCTS. WWW.ACCESSDATA.FDA.GOV/SCRIPTS/CDER/DAF/INDEX.CFM.
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MEDICATION ASSISTED TREATMENT/RECOVERY: OPIOID DEPENDENCE: DETOX
40 HEROIN ADDICTS RANDOMIZED TO:
• 1 WEEK DETOX FOLLOWED BY PLACEBO AND COUNSELING
• 1 YEAR BUP MAINTENANCE AND COUNSELING
HEROIN USE
• BUPRENORPHINE DETOX, PLACEBO MAINTENANCE = 100% RELAPSED - 4/20 DIED!!
• BUPRENORPHINE MAINTENANCE = 75% (SD 60%) OPIOID NEGATIVE URINE DRUG SCREENS. 0/20
DEATHS
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MAINTENANCE MEDICATION: REDUCE RELAPSE RATES
KAKKO J, ET AL. LANCET. 2003;361(9358):662-668.
• In one study, all patients who were detoxed and counselled
relapsed with about 50 days
• Those receiving maintenance medication with counselling
demonstrated a lower rate of relapse
0
5
10
15
0
20
Rem
ain
ing in
Tre
atm
ent
Treatment Duration (days)
50 100 150 400300250200
Retention: Maintenance vs Detoxification
350
Detoxification
Maintenance
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STUDIES OF MAT WITH SUBOXONE – HOW LONG SHOULD IT BE USED?
MAT WITH SUBOXONE FOR 7 DAYS VS
28 DAYS IN 990 PTS WITH OPIOID SUD
• SIMILAR RELAPSE RATES EITHER WAY ABOUT 87% AT THREE MONTHS (LING 2009)
• MAT C SUBOXONE FOR 3 MO…
60% OPIOID FREE AT 1 YEAR (KATZ 2009/GALANTER 2003)
• MAT C SUBOXONE FOR 6 – 9 MO
90% OPIOID FREE AFTER ONE YEAR (DID NOT LOOK AT OTHER DRUGS) (BADGAIYAN
2015)
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NALTREXONE
• REVIA®
• FDA APPROVED: 1994
• DOSING: 50 MG PO QD (START AT 25 MG QD)
• MECHANISM: Μ-OPIOID ANTAGONIST
• DECREASES POSITIVE REINFORCING EFFECTS
• DECREASES CUE-INDUCED CRAVINGS
• RESULTS: HIGHER RATES OF ABSTINENCE, SIGNIFICANT PERCENTAGE OF OPIOID-FREE WEEKS,
DECREASED CRAVING
CAVACUITI C (ED). PRINCIPLES OF ADDICTION MEDICINE: THE ESSENTIALS. PHILADELPHIA, PA: LIPPINCOTT WILLIAMS & WILKINS; 2011.
KNUDSEN HK, ET AL. J ADDICT MED. 2011;5(1):21-27.
MATTICK RP, ET AL. COCHRANE DATABASE SYST REV. 2009;(3):CD002209.
THE AMERICAN SOCIETY OF ADDICTION MEDICINE. ADVANCING ACCESS TO ADDICTION MEDICATIONS. WWW.ASAM.ORG/DOCS/DEFAULT-SOURCE/ADVOCACY/AAAM_IMPLICATIONS-FOR-OPIOID-ADDICTION-TREATMENT_FINAL. ACCESSED JANUARY 30, 2018.
US FOOD AND DRUG ADMINISTRATION. DRUGS@FDA: FDA APPROVED DRUG PRODUCTS. WWW.ACCESSDATA.FDA.GOV/SCRIPTS/CDER/DAF/INDEX.CFM.
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IM NALTREXONE
• VIVITROL™
• FDA APPROVED: 2006
• INTRAMUSCULAR INJECTION ONCE MONTHLY
• NO NEED FOR ORAL LEAD-IN
• MECHANISM: Μ-OPIOID ANTAGONIST
CAVACUITI C (ED). PRINCIPLES OF ADDICTION MEDICINE: THE ESSENTIALS. PHILADELPHIA, PA: LIPPINCOTT WILLIAMS & WILKINS; 2011.
KNUDSEN HK, ET AL. J ADDICT MED. 2011;5(1):21-27.
MATTICK RP, ET AL. COCHRANE DATABASE SYST REV. 2009;(3):CD002209.
THE AMERICAN SOCIETY OF ADDICTION MEDICINE. ADVANCING ACCESS TO ADDICTION MEDICATIONS. WWW.ASAM.ORG/DOCS/DEFAULT-SOURCE/ADVOCACY/AAAM_IMPLICATIONS-FOR-OPIOID-ADDICTION-TREATMENT_FINAL. ACCESSED JANUARY 30, 2018.
US FOOD AND DRUG ADMINISTRATION. DRUGS@FDA: FDA APPROVED DRUG PRODUCTS. WWW.ACCESSDATA.FDA.GOV/SCRIPTS/CDER/DAF/INDEX.CFM.
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COMPARATIVE EFFECTIVENESS OF EXTENDED-RELEASE NALTREXONE VS BUPRENORPHINE-NALOXONE FOR OPIOID RELAPSE PREVENTION (X:BOT):
A MULTICENTER, OPEN-LABEL, RCT
• NIDA FUNDED
• N=570 RANDOMLY ASSIGNED
• 24 WEEKS
• “…IT IS MORE DIFFICULT TO INITIATE PATIENTS TO [EXTENDED-RELEASE NALTREXONE] THAN
[SUBLINGUAL BUPRENORPHINE-NALOXONE], AND THIS NEGATIVELY AFFECTED OVERALL RELAPSE.
HOWEVER, ONCE INITIATED, BOTH MEDICATIONS WERE EQUALLY SAFE AND EFFECTIVE. ”
RCT = RANDOMIZED CONTROLLED TRIAL; NIDA = NATIONAL INSTITUTE ON DRUG ABUSE.
LEE JD, ET AL. LANCET. 2018;391(10118):309-318.
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EXTENDED-RELEASE NALTREXONE VS SUBLINGUAL BUPRENORPHINE-NALOXONE FOR RELAPSE PREVENTION IN OPIOID USE DISORDER
• 12-WEEK MULTICENTER OUTPATIENT OPEN-LABEL RCT, N=159
• 5 URBAN ADDICTION CLINICS IN NORWAY (2012–2015)
• N=80 EXTENDED-RELEASE NALTREXONE AND N=79 BUPRENORPHINE-NALOXONE → N=105 COMPLETED
• BUPRENORPHINE-NALOXONE MEAN DOSE 11.2 MG
• RANDOMIZATION OCCURRED AFTER DETOXIFICATION COMPLETED
• NO SIGNIFICANT DIFFERENCES BETWEEN GROUPS IN
• PROPORTION TOTAL NUMBER OF DAYS OPIOID NEGATIVE URINE TESTS
• RETENTION
• USE OF HEROIN AND OTHER ILLICIT OPIOIDS
• EXTENDED-RELEASE NALTREXONE PATIENTS REPORTED LESS HEROIN CRAVING, MORE
TREATMENT SATISFACTION
TANUM L, ET AL. JAMA PSYCHIATRY. 2017;74(12):1197-1205.
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NALTREXONE/VIVITROL
• NALTREXONE SYNTHESIZED IN 1963, APPROVED APPROVED FOR OPIOID ADDICTION IN 1984
• VIVITROL (INJECTABLE NALTREXONE) APPROVED FOR ALCOHOL ADDICTION IN 2006
• DAILY ORAL OR 1X MONTHLY INJECTABLE
• COVERED BY MEDICAID/MEDICARE IN MOST STATES
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Patients treated with VIVITROL and counseling had a
SIGNIFICANTLY HIGHER PERCENTAGE OF OPIOID-FREE
WEEKS
• During weeks 5–24
• VIVITROL IN OPIOID DEPENDENCE: PRIMARY STUDY
ENDPOINT124PLACEBO
90%VIVITROL
35%PLACEBO
P=0.0002
Median placebo patients(with psychosocial support) had 35% cumulative opioid-free weeks
Median VIVITROL patients(with psychosocial support) had 90% cumulative opioid-free weeks
126VIVITROL
Confirmed abstinence = negative urine drug test and no
self-reported opioid use
Reference: 1. Krupitsky E et al. Lancet. 2011;377(9776):1506–1513.
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In the prespecified subset (n=53, 8% of the total study population) patients who abstained
for 7 days prior to the first injection had
92% FEWER HEAVY-DRINKING DAYS
• Median heavy-drinking days
per month
• The same treatment effects were
not evident among the subset of patients (n=571,
92% of the total study population) who were
actively drinking at the time of treatment initiation
• Baseline for both VIVITROL 380 mg and placebo
was 15.2 heavy-drinking days per month
The patients in the VIVITROL 190 mg group are not
included in these results.
17VIVITROL
18PLACEBO
0.2 DaysVIVITROL 380mg
2.5 DaysPLACEBO
P=0.005
Placebo (with psychosocial support) median heavy-drinking days per month
VIVITROL 380 mg (with psychosocial support) median heavy-drinking days per month
Week 2
4W
eek 2
4
0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
References: 1. Garbutt JC et al. JAMA. 2005;293(13):1617–1625. 2. Data on file. Alkermes, Inc. 3. VIVITROL (naltrexone for extended-release injectable suspension) [prescribing information] Waltham, MA: Alkermes, 2015.
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• XBOT
EFFECTIVENESS OF INJECTABLE EXTENDED-RELEASE NALTREXONE VS DAILY BUPRENORPHINE-
NALOXONE FOR OPIOID DEPENDENCE: A RANDOMIZED CLINICAL NONINFERIORITY TRIAL
• CONCLUSIONS AND RELEVANCE: EXTENDED-RELEASE NALTREXONE WAS AS
EFFECTIVE AS BUPRENORPHINE-NALOXONE IN MAINTAINING SHORT-
TERM ABSTINENCE FROM HEROIN AND OTHER ILLICIT SUBSTANCES
AND SHOULD BE CONSIDERED AS A TREATMENT OPTION FOR OPIOID-
DEPENDENT INDIVIDUALS.
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XBOT
Secondary End Points, Cravings
Subjective opioid craving declined rapidly from
baseline in both treatment groups.
Average opioid craving was initially less for the
XR-NTX group (P=0.0012 at week 7) than for
the BUP-NX group, then converged by week
24 (P=0.20)
Craving was self-reported with an opioid-craving VAS, range 0–100.
VAS=visual analog scale
Reference: Lee JD et al. Lancet. 2018;391(10118):309-318.
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HOW TO CHOOSE A MEDICATION
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EVIDENCE-BASED TREATMENTS
• MOTIVATIONAL ENHANCEMENT/CONTINGENCY MANAGEMENT
• MATRIX MODEL
• COGNITIVE-BEHAVIOR THERAPY
• COMMUNITY REINFORCEMENT (PLUS VOUCHERS)
• FAMILY BEHAVIORAL THERAPY
• MUTUAL HELP GROUP
• 12-STEP FACILITATION
• INTENSIVE REFERRAL
• PHARMACOTHERAPY
RIES RK, ET AL (EDS). THE ASAM PRINCIPLES OF ADDICTION MEDICINE. FIFTH EDITION. AMERICAN SOCIETY OF ADDICTION MEDICINE; 2014.
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PODESTA A. HOOKED: A CONCISE GUIDE TO THE UNDERLYING MECHANICS OF ADDICTION AND TREATMENT FOR PATIENTS, FAMILIES, AND PROVIDERS. INDIANAPOLIS, IN: DOG EAR PUBLISHING; 2016.
Biology
Genes
Epigenetics
IEMs
Drugs
Prescribed
Illicit
Stress
Especially
Trauma
Risk of Abuse / Addiction
+ +
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LEVEL OF CARE
• HARM REDUCTION
• COMMUNITY
• OUTPATIENT
• INTENSIVE OUTPATIENT (IOP)
• PARTIAL HOSPITALIZATION (PHP)
• RESIDENTIAL TREATMENT PROGRAM
• AMBULATORY DETOX
• HOSPITAL-BASED TREATMENT PROGRAM
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LEVEL OF CARE
• HARM REDUCTION – “MEET PATIENT WHERE THEY ARE AT”
• COMMUNITY – SBIRT (SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT)
• OUTPATIENT – COUNSELING, THERAPY, MEDICATIONS
• INTENSIVE OUTPATIENT (IOP)
• PARTIAL HOSPITALIZATION (PHP)
• RESIDENTIAL TREATMENT PROGRAM
• AMBULATORY DETOX
• HOSPITAL-BASED TREATMENT PROGRAM
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WHAT YOU NEED TO PROVIDE COMPREHENSIVE ADDICTION TREATMENT:
• X NUMBER, DEA WAIVER (?)
• THERAPISTS/COUNSELORS
• TREATMENT PROGRAMS TO REFER TO AND FROM
• FACILITATED REFERRAL BEST
• COMMUNITY-BASED SUPPORT PROGRAMS
• 12 STEP, INCLUDES REFUGE RECOVERY, SELF-MANAGEMENT AND RECOVERY
TRAINING (SMART), ALCOHOLICS ANONYMOUS (AA), ETC.
• PEER SUPPORT
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CLINICAL MANAGEMENT OF COMORBID DISORDERS
• INDIVIDUALIZE AND INTEGRATE TREATMENT FOR COMORBID DISORDERS WHENEVER POSSIBLE
• CONSIDER DEVELOPMENTAL NEEDS AND STAGES
• CONSIDER RANDOM DRUG TESTING
• CONSIDER NEED FOR HIGHER LEVEL OF CARE
• CONSULT ADDICTION MEDICINE SPECIALIST IF NECESSARY
MINKOFF K. PSYCHIATR SERV. 2001;52(5):597-599.
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MEDICATION MANAGEMENT IN COMORBID DISORDERS
• AMBIVALENCE IS COMMON
• WHEN DO WE USE MEDICATIONS IN PATIENTS WITH OUD?
• WHEN TO INITIATE PHARMACOTHERAPY WHEN DIAGNOSIS IS UNCLEAR?
• WITH PSYCHOSIS, MODERATE TO SEVERE DEPRESSION, OR MANIA, TREAT SOONER
• STRATEGIES INCLUDE
• COMMUNICATE FREQUENTLY WITH CAREGIVERS
• VERBALIZE CLEAR EXPECTATIONS (RE: MEDICATION OUTCOMES, CONFIDENTIALITY)
• EXPECT POSSIBILITY OF MISUSE AND DRUG INTERACTIONS
• SCHEDULE FREQUENT FOLLOW-UPS
MINKOFF K. PSYCHIATR SERV. 2001;52(5):597-599.
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IF YOU’RE GOING TO FLY THE PLANE…
• MY GOAL
• LOWEST AMOUNT OF MEDICATION
• SAFEST CHOICE OF MEDICATION
• MOST EFFECTIVE MEDICATION
• DECREASE/STOP MEDICATIONS WHEN CAN
• EG, BUPRENORPHINE UNTIL READY TO STOP, THEN USE THE PODESTA PROTOCOL TO TAKE THEM
OFF COMFORTABLY
• COMPARE TO DIABETES
• LIFESTYLE CHANGE
• HABIT CHANGE
• DIET CHANGE
• TIME FRAME
• VERY SHORT-TERM
• MEDIUM TIME (3 MONTHS TO 2 YEARS)
• LONG-TERM
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CURRENT OPIOID MAT CONTROVERSIES/QUESTIONS
• WHICH PATIENTS SHOULD BE OFFERED MAT AND WHEN IN THEIR TREATMENT COURSE SHOULD
THEY BE OFFERED IT?
• HOW LONG DO YOU CONTINUE MAT?
• MAT VS ABSTINENCE AND IS THERE A HAPPY MEDIUM?
• LONG-TERM SIDE EFFECTS?
• IS A PATIENT WHO USES MEDICATION TO MAINTAIN SOBRIETY IN “REAL RECOVERY” (AND
DOES IT MATTER)?
• NO FDA APPROVED MEDICATIONS FOR ADDICTIONS OTHER THAN OPIOID AND ALCOHOL
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COST EFFECTIVENESS OF TREATMENT
• COST TO SOCIETY OF DRUG ABUSE IS $200 BILLION/YEAR
• TREATMENT IS LESS EXPENSIVE THAN INCARCERATION
• METHADONE MAINTENANCE = $4700/YEAR
• IMPRISONMENT = $18400/YEAR
• OTHER STUDIES SHOW THAT EVERY $1 INVESTED IN TREATMENT CAN YIELD UP TO $7 IN
SAVINGS
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IN CONCLUSION
• ADDICTION IS A SERIOUS, CHRONIC, AND RELAPSING DISORDER; USE
MULTIPLE EVIDENCE-BASED TREATMENTS
• MEDICATIONS SHOULD BE CONSIDERED AS PART OF A COMPREHENSIVE
TREATMENT PLAN, ADDRESSING BOTH DISORDERED PHYSIOLOGY AND
DISRUPTED LIVES
• MEDICATIONS SHOULD BE CONSIDERED FOR TREATMENT OF
PSYCHIATRIC SYMPTOMS, ADDICTIVE DISORDERS, AND COMORBID
DISORDERS