Medication Assisted Treatment. Ned Presnall, MSW, LCSW May 17, 2014

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1 Medication Assisted Treatment Ned Presnall, MSW, LCSW May 17, 2014

2 FRONTAL LOBE Consciousness Reasoning Planning Goals Values Sense of Self

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5 I NEED TO USE!!!!!!!!!!! FRONTAL LOBE Consciousness Reasoning Planning Goals Values Sense of Self Host of rationalizations CRAVING

6 I NEED TO USE!!!!!!!!!!! Host of rationalizations CRAVING

7 Rock Bottom Recovery

8 Pharmacological Drive Reduction

9 Four Neurotransmitters affected by chronic alcohol use GABA γ-aminobutryic acid Glutamate Endorphins (opioids) Seratonin

10 Non-addictive medications that aid in treatment of alcohol dependence FDA-approved for alcohol dependence Acamprosate (Campral ) Naltrexone oral and depot (Vivitrol ) Disulfiram (Antabuse ) Depression and Anxiety SSRI s and SNRI s

11 GABA and Glutamate

12 Downregulation of GABA receptors

13 The brain s neurons become insensitive to GABA

14 Upregulation of Glutamate receptors

15 The brain s neurons become hypersensitive to glutamate

16 Some symptoms of alcohol withdrawal Anxiety and Nervousness Irritability Jumpiness or shakiness Tremors Rapid heart rate Sweating Seizures

17 Acamprosate (Campral ) Helps to stabilize the glutamate / GABA imbalance by subtly inhibiting glutamate activity

18 Abstinent at 60 days 80% 70% 67% 60% 50% 50% 40% 30% 20% 10% 0% Acamprosate Placebo Sass H, Soyka M, Mann K, Zieglgansberger W. Relapse Prevention by Acamprosate. Arch Gen Psychiatry. 1996;53:

19 Abstinent at 48 weeks 50% 45% 45% 40% 35% 30% 25% 25% 20% 15% 10% 5% 0% Acamprosate Placebo Sass H, Soyka M, Mann K, Zieglgansberger W. Relapse Prevention by Acamprosate. Arch Gen Psychiatry. 1996;53:

20 Abstinent at 96 weeks 45% 40% 39% Abstinent at 96 weeks 35% 30% 25% 20% 15% 22% who don t need to go to treatment again after 17% 2 years 10% 5% 0% Acamprosate Placebo Sass H, Soyka M, Mann K, Zieglgansberger W. Relapse Prevention by Acamprosate. Arch Gen Psychiatry. 1996;53:

21 Acamprosate A non-addictive medication that costs about $4.50 / day and is covered by most Insurance companies

22 Endorphins (opioids) Alcohol use causes a rush of our endogenous opioids (endorphins), resulting in: Analgesic effects A dopamine high Behavioral reinforcement

23 Genetic differences Persons with family history of alcoholism Lower baseline levels of β-endorphins Greater release of β-endorphins after exposure to alcohol Gianoulakis (1996). Implications of endogenous opioids and dopamine in alcoholism: human and basic science studies. Alcohol and Alcoholism 31:Supp1,

24 Naltrexone Blocks the endorphin rush and the consequent dopamine high Reduces cravings caused by euphoric recall

25 NALTREXONE causes an observable reduction of activity in the midbrain when an alcohol dependent subject is presented visual cues Placebo at 7 days Naltrexone at 7 days VENTRAL STRIATUM Hugh Myrick; Raymond F. Anton; Xingbao Li; Scott Henderson; Patrick K. Randall; Konstantin Voronin. Effect of Naltrexone and Ondansetron on Alcohol Cue-Induced Activation of the Ventral Striatum in Alcohol-Dependent People. Arch Gen Psychiatry. 2008;65(4):

26 NALTREXONE reduces clients subjective craving for alcohol making it easier to stop drinking Volpicelli JR, Alterman AI, Hayashida M, O'Brien CP. Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry Apr;51(4):335-6.

27 By reducing cravings, NALTREXONE contributes significantly to relapse prevention efforts Volpicelli JR, Alterman AI, Hayashida M, O'Brien CP. Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry Apr;51(4):335-6.

28 Alcohol relapse: cumulative abstinence duration (CAD) by Treatment Group. FEENEY G F X et al. Alcohol and Alcoholism 2006;41: The Author Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved

29 Disulfiram By blocking the breakdown of acetaldehyde, alcohol disulfiram causes the symptoms of a hangover, including: Increased heart rate Shortness of breath Nausea and vomiting Throbbing headache

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32 Grams of ethanol per week Acamprosate Naltrexone Disulfiram Baseline Weeks 1-12 Weeks E. LAAKSONEN, A. KOSKI-JANNES, M. SALASPURO, H. AHTINEN, and HANNU ALHO. A RANDOMIZED, MULTICENTRE, OPEN-LABEL, COMPARATIVE TRIAL OF DISULFIRAM, NALTREXONE AND ACAMPROSATE IN THE TREATMENT OF ALCOHOL DEPENDENCE. Alcohol & Alcoholism Vol. 43, No. 1, pp , 2008

33 Medication Assisted Treatment for Opioid Dependence

34 Prior treatment episodes for persons starting treatment for heroin dependence, None or more SAMHSA (2009) Treatment Episodes Data Set.

35 Medications of Opioid Addiction Methadone - agonist Suboxone partial agonist Naltrexone antagonist Vivitrol 28-day injection of naltrexone

36 History of MAT for heroin dependence 1919 The Harrison Act and its interpretation 1929 Congress establishes narcotics hospitals at Lexington and Fort Worth - over 90% relapse rate 1964 Mary Nyswander and Vincent Dole experiment with methadone

37 Primary virtues of Methadone Long-acting so that with a daily dose, a steady state of active opioids can be achieved Eliminates or severely reduces opioid craving At proper doses, it can create an opioid blockade through cross-tolerance People with opioid addiction can focus on the rest of their lives

38 2002 Buprenorphine (Suboxone /Subutex ) Long-acting so that with a daily dose, a steady state of active opioids can be achieved Eliminates or severely reduces opioid craving At proper doses, it can create an opioid blockade through antagonist effect A ceiling effect makes buprenorphine safer than methadone in preventing respiratory depression

39 Heroin Addiction INTOXICATION WITHDRAWAL

40 Buprenorphine or Methadone Maintenance INTOXICATION WITHDRAWAL

41 Isn t using methadone or suboxone just a replacement for using heroin?

42 Cycle of Addiction PANICKED DRUG-SEEKING LYING, CHEATING, STEALING DRUG USE PHYSICAL RELIEF GUILT / SHAME RECALL OF CONSEQUENCES RECALL OF GOOD INTENTIONS FEELING OF HELPLESSNESS LOSS OF CONTROL WITHDRAWAL LOSS OF COGNITIVE CONTROL COMPROMISED VALUES COMPROMISED INTENTIONS AMNESIA RE: CONSEQUENCES RATIONALIZATION OF USE CRAVING DECREASING WELL-BEING INCREASING STRESS MENTAL OBSESSION

43 Methadone Maintenance reduces crime The Effectiveness of Methadone Maintenance Treatment (p. 182), by J. C. Ball and A. Ross, 1991, New York: Springer-Verlag.

44 SUBOXONE facilitates client engagement by reducing cravings and preventing withdrawal Participants completing 28- day treatment Participants transitioning to naltrexone Buprenorphine Clonidine Marsch, L.A., et al. Comparison of pharmacological treatments for opioid-dependent adolescents: A randomized controlled trial. Archives of General Psychiatry 62(10): , 200

45 Naltrexone and Vivitrol 1950 s Abraham Wikler observes the phenomenon of conditioned withdrawal 1960 s Experiments with antagonist therapy - cyclazocine 1971 President Nixon creates the Special Action Office for Drug Abuse Prevention 1972 Congress puts aside money to research nonaddictive anti-craving medications 1984 FDA approves naltrexone for opioid dependence 2010 FDA approves 28-depot naltrexone (Vivitrol ) for opioid dependence

46 Naltrexone and Vivitrol prevent intoxication and reinforcement of opioids without causing physical dependence

47 VIVITROL reduces client cravings, prevents reactivation of addiction and leads to improved treatment retention (All participants received twice weekly relapse prevention therapy) Comer, Sandra D., et al. Injectable, sustained-release naltrexone for the treatment of opioid dependence. Archives of General Psychiatry 63(2): , 2006.

48 % Opioid free weeks in 6 months Evgeny Krupitsky, Edward V Nunes, Walter Ling, Ari Illeperuma, David R Gastfriend, Bernard L Silverman, Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial, The Lancet, Volume 377, Issue 9776, 30 April 6 May 2011, Pages , ISSN , /S (11)

49 Limitations of Vivitrol No natural reward Compliance is based entirely on internal motivation Risk of overdose after medication is discontinued Client must be completely opioid free prior to naltrexone induction

50 Which is the best medication? As with any chronic disease or disorder, the correct medication depends on the characteristics of the patient as well as their stage of recovery

51 Motivation Ongoing Assessment METHADONE - Strongest drug reward - Highest level of accountability SUBOXONE - Moderate drug reward - Moderate level of accountability VIVITROL - No drug reward - Moderate level of accountability Stability

52 Principles of Individualized MAT 1. Educate regarding options. 2. Assess motivation and stability. 3. Provide a clinical opinion. 4. Support client in developing a treatment plan with concrete goals.

53 Ned Presnall, LCSW Clayton Behavioral 9890 Clayton Road St. Louis, MO Videos on recovery with suboxone and methadone can be found at:

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