Using Drugs to Treat Drug Addiction How it works and why it makes sense Jeff Baxter, MD University of Massachusetts Medical School May 17, 2011
Objectives Biological basis of addiction Is addiction a chronic disease or just bad choices? Goals of addiction treatment Goals of and options for Medication Assisted Treatment (MAT) Challenges for integrating MAT with drug court proceedings and other treatment modalities
Drug Addiction: Clinical Progression 20 year old female college student Taking oxycontin at parties every other weekend Really likes it. Starts using more and more often Craving drugs. Quits sports, loses motivation for school, spends time only with friends who use Getting sick in the mornings and using daily to avoid symptoms. Tries to stop, but can t tolerate symptoms. Missing school, quits work, moody and irritable. Switches to heroin: can t afford the oxycontin she needs to avoid being sick and to achieve high Fails out of school and arrested for... Violates probation due to ongoing drug use.
Dope Sick
Crossing the line from Abuse to Addiction Loss of Control Compulsive use Use despite Consequences Craving
Why doesn t she just stop using? Our brains affect our behavior, and our behavior affects our brains
Drug Addiction: Biological Progression Predisposed to risk taking and reinforcing effects of drugs through genetics, mental health, youth Drug increases dopamine levels in reward pathway and generates euphoric effects Memory of euphoria, peer influence repeated use, Chronic exposure to drug leads to changes in brain chemistry/structure and conditioned behaviors Altered status becomes the new normal; body and mind expect chemical to be present, unbalanced if it is not Prolonged abstinence required for neural and behavioral restructuring
The Reward Pathway
Addiction : A Disorder of Choice? Drugs not the only things that affect dopamine Spontaneous recovery Responds to positive incentives and motivational enhancement Responds to punishment restrictions and negative reinforcement (although not as well )
Natural History of Substance Use, Abuse and Addiction Addiction loss of control compulsive use use despite negative consequences Natural Recovery Shift of desires and values Changes in social environment and role expectations Improved decision making Decreased risk taking Chronic Disease Long term neuro-chemical changes Relapsing-remitting course Significant health and social consequences Individual Predisposition Environmental factors Treatment to Shorten course Reduce harm
Addiction as a Chronic Disease: Take-Home Messages Not all who use substances are addicted Not all who are addicted require treatment For those who do treatment works, especially while you re actively in treatment Chronic conditions require ongoing care Different treatments or combinations may work better for different people Detoxification is a transition, not treatment Consider where these patients fit into drug court model? How long should this all take?
Goals of Addiction Treatment Reduce and eliminate substance abuse Engage/retain in treatment Facilitate and accelerate behavioral changes Decrease impact on individual Treat/prevent medical co-morbidities Treat/prevent psychiatric co-morbidities Improve productivity Decrease impact on families and society crime, domestic violence/neglect, costs
Goals of Behavioral Treatment Enhance motivation for behavioral change Educated on risks of ongoing use Explore values and goals Improve skills for making change Anticipate triggers and halt cycle of conditioned behaviors Understand thoughts/feelings associated with use and develop safer alternatives Restructure social environment Encourage pro-social activities
Goals of Medication Assisted Treatment Stabilize neurochemical imbalances Relieve symptoms of abstinence syndromes Decrease craving Prevent intoxication and overdose Facilitate neural repair/restructuring Improve engagement and retention in other addiction treatment modalities Effective tools, not definitive cures Designed to be used with other treatment modalities
Imagine your most challenging clients What has worked well? What hasn t worked well? What did you recommend or require? Have your recommendations changed with experience? Do you recommend medication assisted treatment?
What Facilitates or Inhibits Recovery? Most Challenging Mental illness Family history Early initiation, longer duration Few family supports Social environment where drug use is normative Minimal job prospects Most likely to succeed? No mental illness Minimal family hx Late initiation, shorter duration Strong family supports Social environment where drug use unacceptable Solid employment
Medication Assisted Treatment Options Opioids Agonist Treatments Methadone Buprenorphine Detoxification Maintenance Antagonist Treatment Naltrexone Alcohol Aversives Disulfiram Neuromodulators Naltrexone Acamprosate Topiramate Cocaine Vaccine?
What is Methadone? Synthetic opioid agonist Slow onset of action Long half life Dosed for addiction only in licensed addiction treatment centers Detox Maintenance
How does it work? Low doses relieve withdrawal Moderate doses reduce craving High doses block opioid drug effects Average effective maintenance dose 80-120 mg Observed dosing Urine drug screening Monitoring for alcohol use, legal, social problems Mandated behavioral treatment Program structure therapeutic?
Drawbacks to Methadone Limited treatment availability Heavily regulated Daily attendance Transportation Risk of diversion Risk of overdose Risk by association Cost?
Dispelling methadone myths It does not make patients high Methadone patients are not all drugged up and unproductive Patient do not seek out methadone for fun Patients are not trapped in treatment It is not ok to continue to use drugs (opioid or otherwise) while in methadone treatment It is not a substitute addiction physical dependence yes, but all the associate behaviors: no Methadone on the streets that is being abused is RARELY from methadone programs
Buprenorphine (Suboxone ) Opioid partial agonist Low side effect profile Lower overdose risk Mixed with naloxone to prevent IV abuse Flexible, office-based treatment Anonymous Integrated with other forms of medical/psychiatric care Patients control dosing times No take home restrictions Impact on work, family travel Maintenance or detoxification Flexibility of additional treatments, but not required Expanded treatment availability 25
Comparing Methadone to Buprenorphine Methadone More potent, better for bigger habits Very structured Lower cost for medication Medication interactions and cardiac effects may limit use in some Buprenorphine Less potent Lower structure, less monitoring (?) High cost Lower overdose risk Less medication interactions More flexible
Why Opioid Maintenance? 80-90% relapse to drug use without it Increased treatment retention 80% decreases in drug use, crime 70% decrease all cause death rate NIH Consensus Statement JAMA 1998 27
Opioid Treatment Outcomes Summary Kreek MJ 1996, 2001, 2003 Definition: One year retention in treatment Elimination OR significant reduction in illicit opiate use Methadone 50-80% LAAM 50-80% Buprenorphine 40-50% Naltrexone 10-20% Drug free tx 5-20% Detoxification 5-20%
Buprenorphine Maintenance vs. Detox Kakko J et al. Lancet 2003
Naltrexone Opioid Receptor blocker Oral and monthly injectable forms Approved for both opioid and alcohol addiction For alcohol, naltrexone most effective medication available Logistics and cost limiting use of injectable For opioids, naltrexone approved and available, but inferior outcomes to agonist treatment
Summary Consider goals of drug court proceedings, addiction treatment and of your enhanced program. Decrease/eliminate: substance use, criminal activity, criminal justice and medical costs Increase/stabilize: work, medical and mental health conditions, families, community safety Is treatment planning targeting behavioral AND biological aspects of addiction? Would MAT modalities may facilitate meeting goals? Are programs/staff knowledgeable and open to MAT? Are referral agencies utilizing all available evidence-based options?
Thank you! jeff.baxter@umassmed.edu
Drug Dependence, a Chronic Medical Illness McLellan, Lewis, O Brien, Kleber JAMA 2000;284(13) Lifelong condition Genetic heritability Role of personal responsibility Defined patho-physiology Response to treatment Similar rates of treatment failure, nonadherence and dropout to Asthma, DM, HTN
Chronic Disease Cycle Well controlled Out of control Better control