1. National Perinatal Association Conference Presented by Sarah Maurer, MA, LPC, CCDP-D, Clinical Director, Center for Life Solutions October 17, 2014

2. Disclosure Information I have no relevant financial relationships to disclose I intend to discuss off-label / investigative uses of the following commercial product: Buprenorphine / Naloxone, Tradename Suboxone, manufactured by Reckitt Benckiser Pharmaceuticals, Inc. 3. What are opioids? Medications that relieve pain Reduce intensity of pain signals reaching the brain Affect brain areas controlling emotion Opioids are synthetic (manufactured in a lab) Examples: hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza), codeine, and related drugs. 4. What are opiates? Drug derived from opium Most common example: Heroin Processed from morphine, a naturally occurring substance extracted from the poppy plant Typically sold as a white or brownish powder (China White) or as a black sticky substance ("black tar) Although purer heroin is becoming more common, most street heroin is "cut" with other drugs or with substances such as sugar, starch, powdered milk, or quinine 5. Opioid Use Disorder Includes signs and symptoms that reflect compulsive, prolonged self-administration of opioid substances that are used for no legitimate medical purpose or, if another medical condition is present that requires opioid treatment, that are used in doses greatly in excess of the amount needed for that medical condition (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, p. 542). 6. What is tolerance? A need for markedly increased amounts of opioids to achieve intoxication or desired effect A markedly diminished effect with continued use of the same amount of an opioid From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, p. 541 7. What is withdrawal? First, there must be cessation or reduction of opioid use that had previously been heavy and prolonged (longer than 3 weeks) OR administration of an opioid antagonist (naloxone or naltraxone) after a period of opioid use AND From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 8. What is withdrawal? Three (or more) of the following symptoms developed within minutes to several days: Dysphoric mood (depression) Nausea or vomiting Muscle aches Watery eyes Runny nose Dilated pupils Excessive sweating Diarrhea Yawning Fever Insomnia Piloerection (goose bumps, goose flesh) 9. Speed & Severity of Withdrawal Heroin, pain pills (short acting) withdrawal symptoms begin within 6-12 hours after last dose; peak within 1-3 days (acute withdrawal) and gradually subside over period of 5-7 days Methadone / Suboxone (long acting) withdrawal symptoms may take 2-4 days to develop Less acute withdrawal symptoms, including anxiety, dysphoria, anhedonia, and insomnia can last for weeks to months 10. Medicated Assisted Treatment Evidence-based practice that combines pharmacological interventions with substance abuse counseling and social support MAT for opioid dependence: Methadone, Suboxone, Naltrexone and Vivitrol 11. How does methadone work? Methadone binds to the same receptor sites as other opioids (opioid agonist) Orally effective Slow onset of action Long duration of action Slow offset of action 12. Treatment Outcome Data: Methadone 8-10 fold reduction in death rate Reduction of drug use Reduction of criminal activity Engagement in socially productive roles- improved family and social function Increased employment Improved physical and mental health Reduced spread of HIV Excellent retention 13. Methadone Treatment Typical intake day Admission Process: Counseling- ASI (Addiction Severity Index) Counseling Assignment & Treatment Plan Medical History & Physical Drug Screen & Blood Work TB Testing Initial Dose Established By Physician Referrals 14. Daily Medication Drink, rinse, speak to nurse prior to stepping away from window Lock Boxes Return take-home bottles with labels intact (reduce diversion) CLS is open 6am to 5:30pm M-F; 7 to 11am on Sat. Closed Sunday (take home medication is provided for Sundays) 15. Drug Testing: Random, every 6 to 8 weeks, can be more often if warranted Oral Fluid Test Urine Screen 16. Counseling All clients are required to attend regular counseling. CLS provides individual counseling, family conferencing, and group education. We have 12 LPCs, LCSWs, Certified Drug & Alcohol Counselors, & counselors-in- training on staff Amount of counseling required depends on treatment level 17. Take Home Medication Must meet criteria Its a privilege, NOT a right Patient must be up-to-date with counseling in order to earn take home medications 18. Medically Supervised Withdrawal Should be attempted when it is desired by a stable patient who has a record of abstinence Should be done within the framework of a support network, counseling, medical care and stable home environment Withdrawal process might take months to years Some will never get off methadone due to medical or psychological issues Average length of methadone treatment is one to three years 19. Buprenorphine Buprenorphine: Subutex Buprenorphine/Naloxone: Suboxone Both approved for the treatment of opiate dependence. Both contain the active ingredient buprenorphine hydrochloride Partial agonist- produces a ceiling effect at higher doses Binds strongly to the opioid receptor and is long-lasting & blocks the effects of other opioids 20. Why did the FDA approve two medications? Subutex contains only buprenorphine The second medication, Suboxone, contains naloxone Subutex is given during the first few days of treatment Suboxone is the formulation used in the majority of patients 21. How is Suboxone different from Methadone? Subutex and Suboxone are the first narcotic drugs available under the Drug Abuse Treatment Act (DATA) of 2000 for the treatment of opiate dependence that can be prescribed in a doctors office This change will provide more patients the opportunity to access treatment Methadone can only be dispensed in a limited number of clinics that specialize in addiction treatment. There are not enough addiction treatment centers to help all patients seeking treatment 22. How is Suboxone different from Methadone? Less tightly controlled than methadone Lower abuse potential Less dangerous in an overdose Less is known about the long-term effects of Suboxone Newer treatment Less research compared to methadone Suboxone is currently not FDA approved to treat pregnant patients Less research, but could be very promising! 23. Naltrexone Naltrexone is used to help opiate addicts who have stopped taking opiates to stay drug-free Naltrexone is not a narcotic. It works by blocking the effects of opiates, especially the "high'' feeling that makes you want to use them It will not produce any narcotic- like effects or cause mental or physical dependence 24. How is Naltrexone different from Methadone & Suboxone? Naltrexone will cause withdrawal symptoms in people who are physically dependent on opiates Naltrexone treatment is started after you are no longer dependent on opiates Length of time this takes depends on which opiates were taken, the amount used, and how long the individual has been using Very low retention rate NOT approved for pregnant women / Contraindicated 25. Vivitrol Vivitrol is Naltrexone in a monthly injection First approved to treat alcohol dependence. Recently been approved to prevent relapse to opioid dependence after opioid detox You must stop taking opioids before starting VIVITROL. NOT approved for pregnant women / Contraindicated 26. Neo-natal Abstinence Syndrome (NAS) Infants exposed to opioids have higher incidence of NAS Characterized by hyperactivity of CNS & ANS that is reflected in changes in GI tract & respiratory system Withdrawal symptoms begin from minutes to hours after birth to 2 weeks later (most appear within 72 hours) 27. Methadone provides the following advantages: Reduces illegal opioid use as well as use of other drugs Helps to remove the opioid-dependent woman from the drug-seeking environment & eliminates the necessary illegal behavior Prevents fluctuations of the maternal drug level that may occur throughout the day 28. Methadone provides the following advantages (cont): Improves maternal nutrition, increasing the weight of the newborn Improves the woman's ability to participate in prenatal care and other rehabilitation efforts Enhances the woman's ability to prepare for the birth of the infant and begin homemaking Reduces obstetrical complications 29. Priority Population Pregnant women are considered to be a priority population - This means they are assessed & admitted to an appropriate level of care within 48 hours of contact Receive state-funded treatment if no insurance, but will typically be covered under Medicaid CLS currently has 43 pregnant women in treatment (total population = 514). 30. Factors that influence NAS 1. Types of substances used by mothers 2. Timing & dosage of methadone before labor 3. Characteristics of labor 4. Type & amount of anesthesia or analgesic during labor 5. Infant maturity & nutrition 31. Factors that influence NAS (cont) 6. Metabolic rate of infants liver 7. Presence of intrinsic disease in infants With appropriate pharmacotherapy, NAS can be treated satisfactorily without any severe neonatal effects There is no compelling evidence that lowering maternal methadone dosage avoids NAS, in fact lowering a mothers methadone dose may be more harmful 32. Outpatient Treatment St. Louis Area SAMHSA Treatment Locator: http://findtreatment.samhsa.gov/ Bridgeway St. Charles, University City, S. Vandeventer (Suboxone), Town & Country PreferredSt. Charles, Miami St., S. Broadway Provident West County, Chippewa St. Louis Valley Hope- (Suboxone) Olive Blvd. New Beginnings CSTAR- N. Kingshighway Queen of Peace Center- N. Newstead Places for People- Chouteau Salvation Army- Washington Ave. BASIC- Locust St. Alternative Behavioral Care- St. Peters (Suboxone) Gateway- Olive St. 33. Self-Help Groups Narcotics Anonymous Alcoholics Anonymous Al-Anon Family Groups Celebrate Recovery Smart Recovery 34. Community Resources SAMHSA Treatment Locator: http://findtreatment.samhsa.gov/ Department of Behavioral Health Division of Alcohol and Drug Abuse: http://dmh.mo.gov/ada/ Self-Help Communities: Narcotics Anonymous: http://www.na.org/ Alcoholics Anonymous: http://www.aa.org/ Al-Anon Family Groups: http://www.al-anon.org/ Celebrate Recovery: http://www.celebraterecovery.com/ Smart Recovery: http://www.smartrecovery.org/ 35. Questions? Contact Information: Sarah Maurer, LPC, CCDP-D Clinical Director 314-292-6359 sarah@centerforlifesolutions.org Center for Life Solutions, Inc. 637 Dunn Rd., Ste. 180, Hazelwood, MO, 63042 Office: (314)731-0100, Fax: (314)731-0111 36. References: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs, Treatment Improvement Protocol (TIP) Series 43, DHHS Publication No. (SMA) 08-4214. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, reprinted 2006 and 2008. DrugFacts: Prescription Drugs: Abuse and Addiction. (October 2011). Retrieved November 6, 2013, from http://www.drugabuse.gov/publications/research- reports/prescription-drugs/what-prescription-drug-abuse