Medication Assisted Treatment Ned Presnall, MSW, LCSW May 17, 2014
FRONTAL LOBE Consciousness Reasoning Planning Goals Values Sense of Self
I NEED TO USE!!!!!!!!!!! FRONTAL LOBE Consciousness Reasoning Planning Goals Values Sense of Self Host of rationalizations CRAVING
I NEED TO USE!!!!!!!!!!! Host of rationalizations CRAVING
Rock Bottom Recovery
Pharmacological Drive Reduction
Four Neurotransmitters affected by chronic alcohol use GABA γ-aminobutryic acid Glutamate Endorphins (opioids) Seratonin
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
GABA and Glutamate
Downregulation of GABA receptors
The brain s neurons become insensitive to GABA
Upregulation of Glutamate receptors
The brain s neurons become hypersensitive to glutamate
Some symptoms of alcohol withdrawal Anxiety and Nervousness Irritability Jumpiness or shakiness Tremors Rapid heart rate Sweating Seizures
Acamprosate (Campral ) Helps to stabilize the glutamate / GABA imbalance by subtly inhibiting glutamate activity
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;53:673-680
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;53:673-680
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;53:673-680
Acamprosate A non-addictive medication that costs about $4.50 / day and is covered by most Insurance companies
Endorphins (opioids) Alcohol use causes a rush of our endogenous opioids (endorphins), resulting in: Analgesic effects A dopamine high Behavioral reinforcement
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, 33-42.
Naltrexone Blocks the endorphin rush and the consequent dopamine high Reduces cravings caused by euphoric recall
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):466-475.
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. 1994 Apr;51(4):335-6.
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. 1994 Apr;51(4):335-6.
Alcohol relapse: cumulative abstinence duration (CAD) by Treatment Group. FEENEY G F X et al. Alcohol and Alcoholism 2006;41:321-327 The Author 2006. Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved
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
Grams of ethanol per week 700 600 500 400 300 Acamprosate Naltrexone Disulfiram 200 100 0 Baseline Weeks 1-12 Weeks 13-52 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. 53 61, 2008
Medication Assisted Treatment for Opioid Dependence
Prior treatment episodes for persons starting treatment for heroin dependence, 2009 30 25 20 15 10 5 0 None 1 2 3 4 5 or more SAMHSA (2009) Treatment Episodes Data Set.
Medications of Opioid Addiction Methadone - agonist Suboxone partial agonist Naltrexone antagonist Vivitrol 28-day injection of naltrexone
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
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
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
Heroin Addiction INTOXICATION WITHDRAWAL
Buprenorphine or Methadone Maintenance INTOXICATION WITHDRAWAL
Isn t using methadone or suboxone just a replacement for using heroin?
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
Methadone Maintenance reduces crime The Effectiveness of Methadone Maintenance Treatment (p. 182), by J. C. Ball and A. Ross, 1991, New York: Springer-Verlag.
SUBOXONE facilitates client engagement by reducing cravings and preventing withdrawal 80 70 60 50 40 30 Participants completing 28- day treatment Participants transitioning to naltrexone 20 10 0 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):1157-1164, 200
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
Naltrexone and Vivitrol prevent intoxication and reinforcement of opioids without causing physical dependence
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):210-218, 2006.
% 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 1506-1513, ISSN 0140-6736, 10.1016/S0140-6736(11)60358-9.
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
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
Motivation Ongoing Assessment 12 10 8 6 4 2 0 METHADONE - Strongest drug reward - Highest level of accountability SUBOXONE - Moderate drug reward - Moderate level of accountability VIVITROL - No drug reward - Moderate level of accountability 1 2 3 4 5 6 7 8 9 10 Stability
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.
Ned Presnall, LCSW Clayton Behavioral 9890 Clayton Road St. Louis, MO 63127 ned@claytonbehavioral.com 314-222-5896 www.claytonprograms.com Videos on recovery with suboxone and methadone can be found at: www.claytonprograms.com/category/medications