Medication Assisted Therapy Alcohol and Opiates
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC, NCCExecutive Director, AllCEUs
Review some myths about Medication Assisted Treatment
Identify medications used to treat opiate dependence
Identify medications used to treat alcohol dependence
Discuss the mechanisms of action Evaluate pros and cons of each
Objectives
Medications are a crutch◦ We do what is more rewarding than the alternative
Medications can make sobriety “feel better” by addressing underlying neurochemical imbalances
Medications can remove the rewards from use by Making it unpleasant (Antabuse) Removing the “high” (Buprenorphine, Naltrexone) Both (Suboxone)
Remember recovery is more than just NOT using. Medications can help ease the transition until the brain
has rebalanced and the new lifestyle is in full swing
Myths
Using medication goes against 12-Step Philosophy◦ Alcoholics Anonymous does not encourage AA participants to not
use prescribed medications or to discontinue taking prescribed medications The Big Book states, “God has abundantly supplied this world with fine
doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such person …Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.”
Myths
Medications Can…◦ Increase energy and motivation (dopamine and
norepinephrine) while the person’s brain and body are recovering
◦ Remove some of the reinforcing effects of the drugs◦ Prevent relapse by making relapse very unpleasant◦ Reduce the intensity of co-occurring disorders◦ Reduce conflict/improve social support◦ Reduce absenteeism from work
Pros
Physicians who are educated about addiction treatment and endorse a biopsychosocial model of treatment are difficult to find
Medications can give a false sense of security Medications may provide false hope Medications have side effects There is a stigma associated with the use of
medications Costs money
Cons of Medication
Neurotransmitters◦ Mainly dopamine
Patients report feeling◦ Less pain◦ Less anxiety
Opiate Dependence
Buprenorphine Methadone Naltrexone Naloxone (for opioid overdose) Buprenorphine & Naloxone (Suboxone)
Medications for opiate dependence
Is as partial opioid agonist (ceiling effect) Reduces the symptoms of withdrawal from
misused opiates Can be abused
Buprenorphine
Full Mu opiate agonist (suppresses cravings) Lessens the painful symptoms of opiate withdrawal and
blocks the euphoric effects of opiate drugs Considered relatively safe during pregnancy and
breastfeeding◦ Opiate w/d during pregnancy can trigger contractions and miscarriage
SAMHSA TIP 43 MAT for Opioid Addiction
Methadone
Decreases the pleasurable effects of alcohol or opiates by blocking opiate receptors
Alcohol abstinence is not required, but opiate abstinence is
Naltrexone will cause opiate withdrawal in dependent users
Third-Party Payer Acceptance:◦ Oral is covered by most major insurance carriers, Medicare,
Medicaid, and the VA◦ Vivitrol is not covered in many cases
Naltrexone
Blocks opioid receptors Antagonizes morphine and other opiates. Prevents or reverses the effects of opioids
including respiratory depression, sedation and hypotension.
Naloxone
Alcohol consumption impacts the following neurotransmitters◦ Dopamine (motivation, pleasure)◦ Endogenous opioids (pain and euphoria)◦ Glutamate (Get up and go)◦ GABA (Relaxation--- Produced from Glutamate)
Neurotransmitters
Disulfiram (Antabuse) Naltrexone (ReVia)
◦ Blocks opioid receptors so the reward effects from the endogenous opiates and dopamine are reduced
◦ Vivitrol—Extended Release injectable naltrexone Acamprosate (Campral) Newer Medications
◦ Ondansetron ◦ Nalmefene◦ Gabapentin
Medications for Alcohol Dependence
Reduces Post Acute Withdrawal Symptoms Upregulates (turns on) glutamate receptors reducing
depression Creates an imbalance between Glutamate and GABA
◦ Increasing anxiety, mood lability, insomnia, tremors There was a noted increase in adverse events of a suicidal
nature (suicidal ideation, suicide attempts and/or completed suicides) during the clinical trials.
Acamprosate
Third-Party Payer Acceptance:◦ Does qualify for the Patient Assistance Program
through Forest Laboratories, Inc. Covered by most major insurance carriers, Medicare, Medicaid, and the VA (if naltrexone is contraindicated)
Acamprosate
Makes patients physically sick if they drink Third-Party Payer Acceptance:
◦ Covered by most major insurance carriers, Medicare, Medicaid, and the VA
Disulfiram blocks the enzyme acetaldehyde dehydrogenase◦ alcohol is broken down in the liver to acetaldehyde; ◦ acetaldehyde is converted by the enzyme acetaldehyde
dehydrogenase to acetic acid. ◦ This causes acetaldehyde to accumulate in the blood at 5 to 10
times higher than alcohol alone leading to toxcicity
Disulfiram (Antabuse)
The acute toxic reaction lasts about an hour, but will linger while there is alcohol in the blood
Can be triggered by alcohol containing products like cough syrup Patients taking disulfiram should not be exposed to ethylene
dibromide or its vapors, paint fumes, paint thinner, varnish or shellac Exercise extreme caution when applying aftershave, mouthwash,
lotions, colognes and rubbing alcohol The disulfiram-alcohol reaction can be triggered up to two weeks
after the last dose of disulfiram PATIENT and S.O. EDUCATION IS VITAL
Disulfiram (Antabuse)
Decreases the pleasurable effects of alcohol or opiates by blocking opiate receptors
Alcohol abstinence is not required, but opiate abstinence is
Naltrexone will cause opiate withdrawal in dependent users
Third-Party Payer Acceptance:◦ Oral is covered by most major insurance carriers, Medicare,
Medicaid, and the VA◦ Vivitrol is not covered in many cases
Naltrexone
ONDANSETRON◦ Sold under the name Zofran, and works through the
serotoninergic system especially in regard to the serotonin3 receptor and its effect on dopamine.
◦ In alcoholics, it is possible that there is a heightened sensitivity of the serotonin3 receptor making alcohol more rewarding.
◦ If this receptor could be blocked, there would be a decrease in alcohol-induced dopamine release, resulting in a decrease in alcoholic-drinking behavior.
Newer Meds
NALMEFENE ◦ is an opioid antagonist similar to naltrexone
(ReVia) without the risk of liver toxicity, and it is longer acting.
GABAPENTIN (Neurontin) ◦ is being used for pain management, anxiety, &
insomnia, problems very common among alcohol-dependent patients.
Newer Medications
Anxiety◦ SSRIs◦ Buspar
Insomnia◦ SSRIs◦ Gabapentin◦ Atypical Antipsychotics
Depression◦ SSRIs◦ Atypical Antipsychotics
Pain◦ SSRI/SNRI/Tricyclics◦ Anticonvulants
Comorbid Conditions
Both opiates and alcohol activate opiate receptors
MAT is used to make sobriety more rewarding and reduce relapse triggers in early recovery
It is essential to address comorbid conditions in addition to the substance
Summary
http://www.naadac.org/assets/1959/storie_mat_alcohol.pdf
https://www.oasas.ny.gov/AdMed/meds/meds.cfm
References
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