Transcript Shelly Askew

MEDICATION ASSISTED
TREATMENT for OPIATE
DEPENDENCY
WHAT WORKS?
SHELLEY ASKEW FLOYD, MS
DIRECTOR OF PHARMACOTHERAPY SERVICES
PYRAMID 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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SO WHAT DO WE WANT?
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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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HOW DO YOU CHOOSE?
H
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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
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