Management of Opiate Dependence in the Outpatient Setting

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1 Management of Opiate Dependence in the Outpatient Setting Abigail Kay, M.D., M.A. Please Note: I have no conflicts of interest Medical Director Narcotic Addiction Rehabilitation Program Department of Psychiatry and Human Behavior Division of Substance Abuse Thomas Jefferson University Hospital

Addiction Rehabilitation Program Department of Psychiatry and Human Behavior

2 I Key Points II Introduction III Opiates: Withdrawal & Overdose IV Methadone Maintenance V Methadone Dosing Issues VI Pain Management Issues

3 If jeans only came in size 2

4 I Key Points

5 If You Only Remember Three Key Points

6 Key Point 1: Addiction Choice

7 Key Point 2: Methadone = Life Saver

8 Key Point 3: Methadone Maintenance WON T help

9 Whoa! Way too much information!

10 Key Question for ALL Patients Do you have any experience with drugs, alcohol or tobacco? There is more to a D&A history than just alcohol and tobacco

11 II Introduction

12 Why did our patient s become addicted to drugs? Don t forget about their trauma history.

13 Physiological Dependence isn t the same as Addiction Any patient given opiates long enough becomes physiologically dependent: Will have withdrawal if medication is stopped May develop tolerance Evidence that the patient = human

physiologically dependent: Will have withdrawal if

14 Addiction Genetic component Can make it easier to become addicted Can make it less easy (but not impossible!) to become addicted Environmental component

15 Key Point 1: Addiction Choice

16 Statistics 980,000+ in the U.S. addicted to heroin & opiates 5,000-10,000 die from O.D./yr Cost of untreated opiate Addiction = $20 billion/yr Heroin addicted pt 6-20x inc in deaths/yr Textbook of Substance Abuse Treament Ch

6-20x inc in deaths/yr Textbook of Substance Abuse Treament Ch. 18 www.cdc.

17 Cost Effectiveness of Treating Addiction (Per NIH) Dec. risk of getting HIV, Hep B&C, endocarditis, TB, Dec criminal activity Improved family stability Save $4 - $13 for each $1 spent on tx ing opiate addiction! State Issue Brief on Methadone Overdose Deaths, June 2007, Marcia Trick National Association of State Alcohol and Drug Abuse Directors Inc.

Save $4 - $13 for each $1 spent on tx ing opiate addiction! www.cdc.gov/idu/facts/methadonefin.

18 Challenge For Opiate Dependent Patients If never try a drug, will never become addicted Patients blamed for their illness Intoxication and withdrawal can make patients difficult to work with Easy population to dislike Often appear to have Axis II dx prior to treatment and remission

and withdrawal can make patients difficult to work with Easy

19 III Opiates: Withdrawal & Overdose (Too Much/Too Little)

20 Opiate Intoxication Constricted pupils Dilation in extreme overdose secondary to anoxia Drowsiness or coma Slurred speech Slow pulse Impairment in attention or memory

21 Opiate Withdrawal Imagine the worst stomach flu you ve had Throwing up Diarrhea Ache all over Now multiply this times 10 Would you take a pill if it would make it go away instantly?

22 Signs of Opioid Withdrawal Vital Signs CNS Eyes Skin Tachycardia Restless/ Irritable Dilated Pupils Piloerection goose bumps HTN Insomnia Lacrimation Fever Craving GI Yawning Nose N/V Rhinorrhea Diarrhea

23 IV Methadone Maintenance

24 History of Heroin and Methadone Bayer Co produced and marketed Heroin. It has limited oral bioavailability Bayer Co s Synthesized an analgesic, Methadone. Useful b/c high oral bioavailability & long half life ASAM Textbook of Addiction Medicine, chapter 4

26 Half Life Issues (T 1/2 ) Drugs with shorter T 1/2 create more of a high more addictive Must use more often to prevent withdrawal Most people addicted to opiates started to get high and keep using to prevent withdrawal

27 Withdrawal Methadone Longer T 1/2 ~36-48 hours after last use (may be less) Peaks in ~4-6 days May last 14+ days Heroin Shorter T 1/2 ~8-12 hours after last use Peaks within 48 hours Subsides in ~5-7 days Substance Abuse A Comprehensive Textbook, 4 th edition, Lowinson, Ruiz, Millman, and Langrod

28 Methadone Maintenance Therapy (MMT) Blocking Dose Suppresses withdrawal x hrs (qday dosing) Blocks opiate cravings Prevents the high if use opiates Note: dose to prevent w/d < blocking dose Key for pain management Methadone Research Web Guide. NIDA International Prgm, 2006

29 Key Point 2: Methadone = Life Saver

30 Key Methadone Point: At correct dose no euphoria, intoxication or sedation Although may see if mixed with other drugs E.g. benzodiazepines Many non-benzos now have street value Clonidine (Catapres) Quetiapine (Seroquel)

31 Methadone Maintenance NOT trading one drug for another Patient doesn t get high from the methadone Pt who appears high is generally using another drug Dosed once a day at a methadone clinic State provides criteria to get take home dose/bottle Allows pt to live a normal life

32 Criteria for MMT Pregnant women: can be maintained during pregnancy Hospitalized patients can be maintained during hospitalization for safety. Admission to Methadone Clinic must have evidence of: Current addiction Addiction > 1 year Massachusetts General Hospital Handbook of General Hospital Psychiatry, 5 th edition, 2004

33 Urine = Your Friend

34 Urine Drug Screen Methadone You need a special test for methadone If you only test for opiates and they are only taking methadone it will come back NEGATIVE If it comes back positive for opiates using non-methadone opiate

35 QTc Issues Can get prolonged QTc interval from Methadone and other medications Can get torsades de pointes This can be lethal If pt has prolonged QTc consult cardiology May have to d/c methadone and re-challenge to r/o as cause Avoid other QTc prolonging agents

36 I ve thrown in some prescription drugs that don t interact well.

37 Methadone Drug Interactions P450 3A4 Principles of Addiction Medicine Third ed., pg 736 & Substance Abuse, a Comprehensive Text Fourth ed., pg 184 P450 Inducers Rifampin Phenytoin Ethyl alcohol Barbiturates Carbamazepine Amprenavir Efavirenz Nevirapine Phenobarbital Spironolactone P450 Inhibitors Cimetidine Ketoconazole Erythromycin Fluvoxamine Fluconazole Cipro

38 V Methadone Dosing Issues

39 US Federal Guidelines: 30mg = max 1 st dose methadone Someone ask me Why?

40 Lethality 40mg methadone can be lethal in patients without tolerance 5-10mg can be lethal in children Textbook of Substance Abuse Treatment Many deaths that occur with first week of methadone maintenance are due to too rapid inc in dose

41 Actual Dose vs. Blood Level Dose Day Actual Dose Given Equivalent Blood Dose 1 30mg 30mg 2 40mg 55mg 3 50mg 77.5mg 4 60mg 98.75mg 5 65mg

42 Dosing Guide 5 half lives (T ½ ) to reach steady state T ½ for Methadone = 24 36hrs 5 days for steady state May not feel benefit/side effects of dose As an outpt, or inpt, must be careful otherwise will overshoot correct dose & overdose pt. XS dosing may not be apparent in the first day or so Can inc dose more quickly inpt but MUST take extreme care

43 Clinical Opiate Withdrawal Scale COWS 11 Question subjective/objective rating scale for opiate withdrawal

44 Tapering of Methadone/Detoxification Gradual taper of agent Inpatient : 5-10% dec q1-7 days Outpatient: decrease slowly and stop detox if pt has s/sx withdrawal Methadone taper Initial dose 10mg and have 5mg PRN until no sx of withdrawal. Decrease 5-10mg/day Supportive only treatment PRN medications Rapid Detoxification Use Naltrexone to ppt withdrawal while patient is under anesthesia (DON T DO THIS!)

45 When Tapering Methadone Remember Ideally we will work with the patient to listen to what their body is telling them Each patient will require their own unique dose of methadone It may be 0mg It may be 5mg It may be 64mg It may be 217 mg

46 But.. < 15% of patients are successful in tapering off of methadone Compare to HTN or DM medications No patient wants to be on methadone Offer Buprenorphine as alternative

47 Tx of Opiate Toxicity - Cautions Naloxone has short half life & MMT has half life pt who OD s on Methadone may respond initially BUT then re-overdosed after Naloxone cleared. May need to re-dose patient with Naloxone at later time Substance Abuse A Comprehensive Textbook, 4 th edition, Lowinson, Ruiz, Millman, and Langrod

48 VI Pain Management Issues

49 Opiate dependent patient not on MMT or not on blocking dose of MMT

50 Pain Sensitivity Evidence that pt s on MMT (or opiate dependence) are MORE sensitive to pain Methadone at maintenance dose provides NO analgesia for acute pain management Eg post surgical patient Pt s with opiate dependence may require HIGHER doses of opiates for pain management because of tolerance Scimeca, M et al, Treatment of Pain in Methadone-Maintained Patients. The Mount Sinai Journal of Medicine Vol 67, Nos 5&6 Oct/Nov 2000

51 H&P Get excellent, detailed H&P Tx any comorbid psych/med d/o If on MMT check dose = adequate Determine type of pain Neuropathic Nociceptive Scimeca, M et al, Treatment of Pain in Methadone-Maintained Patients. The Mount Sinai Journal of Medicine Vol 67, Nos 5&6 Oct/Nov 2000

52 Key Point 3: Methadone WON T help

53 Pearls Preventing pain takes less meds than treating each pain episode Sometimes opiates are the drug of choice Sometimes non-opiates are the drugs of choice High dose NSAIDs can be very effective Help team members understand your patients issues Coordinate with the methadone treatment team

54 Plan Ahead! (When Possible)

55 Key Point 1: Addiction Choice

56 Key Point 2: Methadone = Life Saver

57 Key Point 3: Methadone WON T help

58 And the most important point of all

59 Treatment needs to be customized to fit the patient, not vice versa.

60 Key Papers & Links _07.htm Federal MMT regs Boyer EW. Management of Opioid Analgesic Overdose. NEJM 367:2 July 12,

61 Questions?

One example: Chapman and Huygens, 1988, British Journal of Addiction

One example: Chapman and Huygens, 1988, British Journal of Addiction This is a fact in the treatment of alcohol and drug abuse: Patients who do well in treatment do well in any treatment and patients who do badly in treatment do badly in any treatment. One example: Chapman