Buprenorphine Therapy in Addiction Treatment Ken Roy, MD, FASAM Addiction Recovery Resources, Inc. River Oaks Hospital Tulane Department of Psychiatry www.arrno.org
Like Minded Doc
What is MAT? Definition = MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. MAT can be viewed as a transitional term for counselors and clinicians who have been less familiar with OR accepting of the use of medication in addiction treatment. Medication should be viewed as just one of multiple clinical interventions for any illness, neither more important nor less important than other evidence-based strategies. MAT COULD ALSO BE CALLED PHARMACOLOGICAL THERAPY OF ADDICTION.
Bup Mills I am not here in any way to argue for or to condone the prescription of any drug, including buprenorphine, instead of psychosocial treatment for addiction Buprenorphine is not effective alone, in the absence of psychosocial therapies, for the treatment of addiction I especially abhor the concurrent prescription of benzodiazepines and buprenorphine as antithetical to the treatment of addiction
The Case for MAT FDA Approved Medications for the Treatment of Opiate Dependence: Literature Reviews on Effectiveness and Cost-Effectiveness Report developed for the American Society of Addiction Medicine by the Treatment Research Institute, 2013 Methadone, Buprenorphine and Vivitrol are cost effective for the treatment of addiction to opiates All three are underutilized
Hard Science Several other studies have shown that relative to outpatient, abstinence-oriented drug abuse treatment, office-based outpatient treatment (OBOT) with buprenorphine improves six-month treatment engagement (50-60% retention at six months vs. 25 to 40%); significantly reduces cravings, illicit opioid use and mortality (Fiellin et al, 2006; Fiellin et al, 2008; Fudula et al, 2003; Mattick et al, 2008; Gundersen & Fiellin, 2008; Gibson et al, 2008; Amass et el, 2012; Parran et al, 2010; Fareed et al, 2011) ; and improves psychosocial outcomes (Parran et al, 2010; Ponizovsky et al, 2010). From TRI Review
Residential Treatment No one has scientifically studied relative retention or quality of recovery in residential settings of 28 90 days Problems with how to set up the study How do you randomize Problems with perceived impact on treatment milieu What program is willing to participate in the study Lloyd Gordon MD at CoPac has done an internal study & abandoned Suboxone
Why MAT for Opiate Addicts Post Acute Withdrawal Syndrome (PAWS) What I learned with naltrexone induced detoxification Physical detox followed by Anergy, anhedonia, anorexia Anger, self-centeredness, external locus of control Always happens Lasts months to years without naltrexone induction Predicts relapse Impairs spiritual growth and ability to connect Looks like a Personality Disorder Gets people kicked out of treatment
Methadone The Different Drugs Pure opiate receptor agonist at mu, kappa & delta receptors Buprenorphine Partial Agonist at the mu receptor, antagonist at the kappa receptor Naltrexone Pure antagonist at the mu & kappa receptors Injectable form = Vivitrol
Buprenorphine Partial agonist at the mu receptor Difficult to OD Liking does not increase with dose above 12mg 32mg Highly competitive at the mu receptor Blocks opiate effects once it is on the receptor Induces detox if given too early after last use Antagonist at the kappa receptor Possible effect on hyperalgesia Reversal of opiate induced kappa effects Depression, anergy, dysphoria
Should all Opiate Addicts Have MAT No! And all diabetics shouldn t have insulin Treatment should be individualized Treatment should be flexible And, treatment should be patient centered The place for ideology in treatment should be tempered by science Treatment evolved, in part, to protect patients from doctors We have done very well working with a section of the bellshaped curve, but only that section
The Bell-Shaped Curve
Individualize MAT Possible candidates for methadone Multiple failed buprenorphine Severe Personality Disorder Antisocial, criminal justice history Possible candidates for buprenorphine Failed abstinence based treatment Poor psychosocial skills/support Adolescent onset using lifestyle Possible candidates for Vivitrol Late onset of use Addiction following surgery in patient without using lifestyle Availability of long term residential treatment
The Most Important Thing The decision for MAT is independent of the decision for treatment If a patient is a candidate for IOP he/she should go there If a patient is a candidate for RTP he/she should go there If a patient is a candidate for drug court same Etc. The experience at Addiction Recovery Resources Patient peers on buprenorphine, no drug or Vivitrol No observed difference in adherence, step work Long term recovery in all groups