Post on 24-Dec-2015
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MEDICATION ASSISTED TREATMENT for OPIATE DEPENDENCY
WHAT WORKS?SHELLEY ASKEW FLOYD, MS
DIRECTOR OF PHARMACOTHERAPY SERVICESPYRAMID HEALTHCARE, INC.
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OBJECTIVES:
1. Understanding the importance of medication assistance treatment(MAT) in a LICENSED, CERTIFIED opioid treatment program as a viable strategy to overdose prevention
2. Provide current listing of opioid treatment options available
3. Present challenges and benefits of each
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Pharmacotherapy~
The combined use of medication and psychotherapy in a treatment facility.
Why is this important?- medication complements psychosocial supports/therapy by quieting the brain so counseling can work without the need of the dependent drug…
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Who regulates methadone treatment facilities:
Substance Abuse and Mental Health Services Administration (SAMHSA)
Drug Enforcement Agency
Department of Drug & Alcohol Programs-PA Chapter 715
Accreditation Entities (i.e.CARF, JCAHO)
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History of MAT
Late 19th- Early 20th Century
Public perceptions was that Addiction WAS NOT A DISEASE
Saw increased use in 1950’s and 1960’s (morphine/heroin)
Early 1970’s Addiction IS A DISEASE
Methadone treatment in OTP begins
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Effective medication assisted treatment has the following desired outcomes:
~Prevention of the onset of subjective/objective signs of opioid abstinence syndrome for at least 24 hours (post acute withdrawal)
~Reduction or elimination of drug craving routinely experienced by the patient
~Blockage of the euphoric effects of any illicitly acquired self administered drug without the patient experiencing or observers noticing undesirable effects
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WHAT ARE THE CHOICES?
Traditional agonist therapy medications
Methadone & Buprenorphine
AND
Naltrexone
Antagonist therapy medication
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WHAT IS THE DIFFERENCE?
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Agonist-a chemical that binds to a receptor and activates the receptor in the same way as opioid drugs.
Partial Agonist-activate receptors by stimulating the dopamine reward pathway.
Antagonist-binds to opioid receptors but rather than producing an effect, they block the effects of opioids.
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Methadone (Full opioid agonist)-never formally approved by the FDA but most commonly used for treatment
Buprenorphine (Partial agonist)- Two formulas containing buprenorphine were approved by the FDA for use in the US in Oct 2000. Subutex® (buprenorphine only) and buprenorphine w/naloxone (Suboxone®). Both can be prescribed in a certified physician’s office and now in a LICENSED, CERTIFIED ClINIC
Naltrexone(Antagonist)- Revia® approved in 1984. Vivitrol® was first approved by the FDA for the treatment of alcohol dependence 2006. It received subsequent approval by the FDA for the use of opioid treatment in Oct 2010.
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The first couple of weeks after opioid detox is the most vulnerable period for relapse and overdose.
No 1 shop fits all in the treatment of opioid dependence. The intervention must fit individual need based on:
-Symptoms -Length of dependence
-Medical History & complexities -Setting/location of the program -Individual ability & desire to change
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GUIDELINES FOR CONSIDERATION
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Consider Methadone first when:
History of addiction is severe to moderate > 18-24 months ~Current physiologically dependence and at least one year prior physiologically dependent
~2 documented attempts at short term treatment within 12 months prior to seeking admission
~Pregnant (physiologic dependency requirement waived)-current standard of care
~Inadequate psychosocial or recovery supports, e.g. safe and stable housing, supportive family, employed/in school, etc.
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Methadone Continued:
~Recent documented overdose
~Recently released from prison/jail environment with history of MAT treatment prior to incarceration
~Not successful in adhering to Buprenorphine treatment program requirements
~Age 18 years and above
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Methadone continued:
Benefits:~Used for the treatment of pain~Highly regulated in OTP’s~Daily monitoring with gradual “freedom” (take homes)
Drawbacks:~Narcotic~Can be addictive physiologically and/or physically~Precipitated withdrawal if discontinued abruptly~Drug interactions
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Consider Buprenorphine first
History of addiction moderate to mild > 12-18 months ~Unable to access a methadone treatment clinic or difficulty adhering to scheduled hours for dosing
~Documented severe, uncontrollable adverse effect or true hypersensitivity to methadone
~Not dependent or abusing Central Nervous System (CNS) depressants, including benzodiazepines and alcohol
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Buprenorphine continued:
~Does not have a history of multiple treatment attempts and relapses, except those with multiple detox attempts and relapses
~Mental health disorder, if present, is stable, e.g.” no emotional, behavioral or cognitive conditions that would complicate treatment
~
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Buprenorphine continued:
~No prior adverse reactions to buprenorphine or naloxone or taking medications that might adversely interact
~Pregnant women may be good candidates (not label indicated)
~Age 16 years and above
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Buprenorphine continued:
Benefits: -More conducive to an engaged lifestyle -Most insurances cover medication and counseling-Counseling requirements Drawbacks:-Diversion issues-Multiple doses-Minimum oversight-Counseling requirements-Payer requirements
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Consider Vivitrol® when:
History of addiction mild or special populations < 12-18 months ~Not interested in methadone or buprenorphine
~Abstinent from opioids 7-10 days prior
~Recovery environment/psychosocial circumstances sufficiently supportive and stable
~Mental health disorder, if present, is stable, e.g.” no emotional, behavioral or cognitive conditions that would complicate treatment
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Vivitrol® continued:
~Exclude acute hepatitis or liver failure
~Not dependent on or abusing Central Nervous System (CNS) depressants, including benzodiazepines and alcohol
~Easier to use in residential settings after detox from opioid
Benefits:~Monthly injection~Non-addictive~Not a narcotic~Will not precipitate withdrawal when discontinued
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Vivitrol® continued:
Draw backs:~Strongest effects are in the first three weeks~Must be opioid free for 7-10 days~Individuals transitioning from buprenorphine or methadone may be vulnerable to precipitated withdrawal up to two weeks~Cost $800-$1000 per monthly injection
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As cute as he may be….he is still there
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Benzodiazepine use in MAT
If an individual is benzodiazepine dependent, consider detoxification first and/or work with prescriber for consideration of alternative medications/ approaches.
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Challenges to MAT:
~Profit motives
~Harm Reduction vs. Drug Free models~Diversion issues~Individual not consistently taking medication~Individual not participating in therapy~Medical complications~Stigma- “drug replacement therapy”~LIFE-no treatment option is guaranteed!
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MAT should continue as long as the patient desires and derives benefit from treatment.
There should be no fixed length of time in treatment.
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…resolution with a final result.
Webster dictionary defines that as completion or in the world of addiction a CURE. We haven’t gotten there yet!
Therefore, an individual may need multiple attempts to get it right as different stressors (or even the same stressors as before treatment) may return.
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WITHOUT TREATMENT WE HAVE ZERO CHANCE AT RECOVERY & PREVENTION!!!
I BELIEVE IT IS SAFE TO SAY-WE HAVE WITNESSED THE ALTERNATIVE!
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PYRAMID HEALTHCARE, INC. offers MAT in the following locations:
Pyramid Pittsburgh Outpatient (Suboxone®/Methadone), Pyramid Pittsburgh Inpatient/Detox (Suboxone®/Methadone)Pyramid Southside Outpatient (Suboxone®/Vivitrol)Foundations Medical Services, LLC (Methadone/Suboxone®*)Pyramid Dolminis (Methadone)Altoona Outpatient (Suboxone®/Vivitrol®**)Duncansville Inpatient/Detox(Suboxone®/Vivitrol®/Methadone)Chambersburg Outpatient (Suboxone®)York Pharmacotherapy Services (Suboxone®/Methadone)Today Inc. Inpatient (Vivitrol®)*-Self pay only**-Must be started in inpatient first
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Coming Soon:Allentown Outpatient (Suboxone®/Vivitrol®)
Hillside (Vivitrol®)
Call 1-888-694-9996 FOR MORE INFORMATION & REFFERAL
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References:
Substance Abuse and Mental Health Services Administration (SAMHSA) website, about medication assisted treatment http://www.dpt.samsha./gov
SAMHSA Treatment Improvement Protocol #43 & #40
Community Care Behavioral Health decision tool algorithm on the use of medication assisted treatment
Alkermes prescribing information packet for Vivitrol®
Federal Guidelines for Opioid Treatment Programs
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THANK YOU
&
QUESTIONS