Integrating Medication- Assisted Treatment (MAT) for Opioid Use Disorders into Behavioral and Physical Healthcare Settings

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1 Integrating Medication- Assisted Treatment (MAT) for Opioid Use Disorders into Behavioral and Physical Healthcare Settings All-Ohio Conference 3/27/2015 Christina M. Delos Reyes, MD Medical Consultant, CASE Center for Evidence-Based Practices 1

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4 Learning Objectives n Following this presentation, participants will be able to: 1. List and describe the clinical considerations in prescribing the three medications used to treat opioid use disorders. 2. Review workforce, insurance, and structural barriers to the integration of MAT into current behavioral and physical healthcare settings 3. Discuss strategies to plan and successfully implement MAT into addiction, mental health, and physical healthcare settings. 4

5 John R. Kasich, Governor 5

6 John R. Kasich, Governor 6

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9 Treatment Options for Opioid-Addicted Individuals n Behavioral treatments educate patients about the conditioning process and teach relapse prevention strategies. n Medications such as methadone and buprenorphine operate on the opioid receptors to relieve craving. n Combining the two types of treatment enables patients to stop using opioids and return to more stable and productive lives. 9

10 Treatment Options for Opioid-Addicted Individuals n Medically-assisted withdrawal n Long-term residential treatment n Outpatient psychosocial treatment n Behavioral therapies n Medication-Assisted Treatment (MAT) 10

11 Medication-Assisted Treatment n Naltrexone antagonist No effect in absence of an opiate or opiate dependence n Methadone agonist Morphine-like effect n Buprenorphine partial agonist Maximum effect is less than a full agonist 11

12 Partial vs. Full Opioid Agonist death Opiate Effect Full Agonist (e.g., methadone) Partial Agonist (e.g. buprenorphine) Dose of Opiate Antagonist (e.g. Naloxone) 12

13 Naltrexone n Opiate antagonist to treat opiate dependence n All effects of opiates are blocked Must be detoxed and opiate-free or else will cause opiate withdrawal syndrome n Blocks opioid receptors that are involved in the rewarding effects of opiates (& alcohol!) n Risk for hepatotoxicity Monitor for liver enzymes 13

14 Naltrexone n Brand name: Revia (oral tablets) n Usual dose: 50mg daily n Efficacy highest in patients who can abstain for 4 to 7 days before initiating treatment n No negative effect with use n Some clients notice anxiolytic effect 14

15 Long- Acting Naltrexone n Brand name is Vivitrol n Approved for alcoholism in 2006 n Approved for opiate dependence Oct 2010 n Given monthly, 380 mg appears to have increased efficacy versus 190 mg 15

16 Naltrexone n Non-compliance is the main barrier to success n Most useful for highly motivated patients w/ external circumstances Impaired professionals, parolees, probationers, etc 16

17 CAUTION with Naltrexone n When clients have had opiate receptors blocked for some time, their tolerance is reset n Returning to drug use at the same levels they were previously using [prior to blockade] puts the client at INCREASED RISK for OD/death due to lowered tolerance n This information needs to be shared with all clients

18 Methadone n Opiate agonist to treat opiate dependence n Well-studied and effective treatment Normalizes function/return to work, decreases crime/violence, reduces HIV exposure n Doses > 70mg/day generally better than low doses n Enhanced services = improved outcomes Counseling, medical, social/vocational services,etc n No contraindication in SMI, though not well studied 18

19 Methadone n Usually taken once a day to suppress withdrawal for 24 to 36 hours n Usually given in liquid form by Opiate Treatment Programs n Induction phase no more than 30 to 40 mg on the first day of treatment n Dosage changes usually occur once a week More rapid dosage increases can cause overdose n Maintenance phase usually mg daily 19

20 Methadone n Common side effects Sweating, constipation, abnormal libido, sleep abnormalities, mild anorexia, weight gain, water retention n Adverse effects Prologation of QTc (usually seen with very high doses, mean of 350mg daily) 20

21 Methadone: Addicting patients to another drug? n Difference between PHYSICAL DEPENDENCE vs. ADDICTION (or substance use disorder) n Pharmacology of methadone prevents highs and lows common with short-acting drugs and normalizes patient functioning n The patient is PHYSICALLY DEPENDENT on methadone but no longer displaying the behaviors associated with addiction

22 Methadone

23 Buprenorphine Opioid partial agonist risk of overdose and abuse potential May precipitate opiate withdrawal in dependent individuals Approved for treatment of opiate dependence Maintenance dose in the range of 8-16 mg daily Sublingual route of administration Subutex= Bup only; Suboxone= Bup + Naloxone 23

24 Direct Buprenorphine Induction from Short-Acting Opioids n Ask patient to abstain from short-acting opioid (e.g., heroin) for at least 6 hrs. and be in mild withdrawal before administering buprenorphine/naloxone. n When transferring from a short-acting opioid, be sure the patient provides a methadone-negative urine screen before 1 st buprenorphine dose. SOURCE: Amass, et al., 2004, Johnson, et al

25 Buprenorphine n Suboxone= buprenorphine + naloxone in a 4:1 mixture Available doses: 8/2mg and 2/0.5mg 2 sublingual forms: tablet and Film n Induction phase Day 1: usual dose is 2 mg given every 2-3 hours, up to 8 mg n Induction phase Day 2: start with 8mg, can go up to 16mg depending on patient symptoms 25

26 Buprenorphine n Maintenance phase: usually 8 to 16 mg daily n This may vary in clinical practice, but realize that 16mg dose covers ~95% of opiate receptors n Adverse side effects: Increased LFTs, cytolytic hepatitis n Common side effects: generally mild Constipation; dizziness; drowsiness; headache; nausea; sweating; vomiting; 26

27 Buprenorphine n Approved in U.S. (2002) as office-based treatment vs. methadone clinics n Individual doctors may treat up to 30 patients at a time, using an special DEA # After 1 year, may increase to 100 patients n Must be addiction medicine/addiction psychiatry certified OR complete 8-hr training 27

28 Partial vs. Full Opioid Agonist death Opiate Effect Full Agonist (e.g., methadone) Partial Agonist (e.g. buprenorphine) Dose of Opiate Antagonist (e.g. Naloxone) 28

29 Possible Barriers to using MAT Potential Fear # 1: Medication will eventually replace rehabilitation as the treatment of choice for addictionà a pill for every ill n Rationale # 1: n Medication may be a useful adjunct to treatment n Another tool in your toolbox 29

30 Possible Barriers to using MAT Potential Fear # 2: Medication will distract from the difficult work of recovery from addiction n Rationale # 2: n Medication makes detox safer and more humane n Medication may allow the process of recovery to begin and continue n Medication may make recovery possible for those with severe mental illness 30

31 Possible Barriers to using MAT Potential Fear # 3: Medication will perpetuate an existing addiction Potential Fear # 4: Medication will cause new addictions n Rationale # 3: n Physical dependence to medication may occur, but addictive behavior should decrease n Rationale # 4: n New addictions to medications are a risk, but the actual incidence is quite low 31

32 Other Barriers to MAT? n Financial MAT may be very expensive and many still do not have insurance n Regulatory Until very recently, doctor visits for MAT were not covered by state funding n Logistical Not enough methadone clinics; not enough slots Usual treatment settings may not be set up to provide MAT 32

33 Medications only work if n they are getting from the bottle to the bloodstream n How to help clients with the idea of starting meds? that will mean I am really sick OR I don t need a crutch n How to help clients with the idea of staying on meds? I feel fine, I don t need it anymore OR if I take meds, then I am not really sober

34 Some Lessons from Motivational Interviewing n What are the client s goals? n How does medication fit (or not fit) with those goals? n What are the pros and cons of the medications? n Use of reflective listening n What is the patient willing to do right now? n What are the patient s fears about medication?

35 Discussion n What strategies can your setting use to more fully integrate all three types of MAT? Inpatient vs. Outpatient AOD vs. MH Physical vs. Behavioral health n Can you think of short-term goals (3 to 6 months) and long-term goals (12 to 24 months) which would improve integration? n How might the CEBP assist you in meeting goals?

36 Summary n MAT is an important part of the toolkit for treating opioid use disorders n Despite internal and external barriers, MAT can be successfully implemented n Set short- and long-term goals in order to more fully integrate MAT into your setting

37 Resources n BUPRENORPHINE TREATMENT: A TRAINING FOR MULTIDISCIPLINARY ADDICTION PROFESSIONALS buptreatment.html n NIDA Methadone Research Web Guide PDFs/MethadoneResearchWebGuide.pdf n Mid-America Addiction Technology Transfer Center. Psychotherapeutic Medications 2011: What Every Counselor Should Know. 37

38 Christina M. Delos Reyes, MD Medical Consultant Center for Evidence-Based Practices Case Western Reserve University Euclid Avenue Cleveland, Ohio

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