Transcript Document

Methadone
and opioid
use and
misuse.
Monitoring & MOA
Spring Training
2010
Who is speaking?
•
•
•
•
•
•
•
•
•
ACOFP board certified primary care physician
Family Medicine educator (Synergy Medical)
Joint appointment to Dept. of Psychiatry
Credentials in Pain and Addiction
Credentials in Forensics/Deputy Med Examiner
Armed Forces Institute of Pathology
Masters Tox/Pharm U. Missouri at KC/Pharm
Active pain consultant & Hospice Director
Activist, advocate & addictionologist
Conflict of Interest
• Speaker’s Bureau Rickett Benckiser, Inc.
• HealthPlus pays me to speak on mental
health at 1-2 CME events per year.
• Employee at Hospice of Michigan.
Special Consulting: AOAAM consultant at
the White House Office of National Drug
Control Policy (ONDCP) September 2009.
DrMorrone.com





Home
About Me
Medical/Legal
Media Appearances
Contact Us
Home
Welcome to DrMorrone.com. In my world, forensic science, medicine,
teaching, law, criminal justice investigation and toxicology explain mystery
and discover truth. Universal scientific principles often uncover mystery.
What is truth? What is Justice? Sometimes, making complex medical
facts simple honest sound bites, is the only true justice. Teaching and
knowledge are the only weapons against fear and ignorance.
As a practicing physician, teacher, forensic scientist, research scientist,
medical examiner, toxicologist, addictionologist and social advocate, I have
sought simple truth to help, heal or comfort others for 24 years. Over that
period of time, I have watched medical knowledge undergo exponential &
dramatic growth, most recently in areas of drug
development and DNA application. I have attempted
to bring natural justice to every level of “complex
science and medicine” that has been too long-winded
in the past.
This website is to declare my interests as a forensic
scientist, toxicologist, real-world practicing physician,
and medical-legal consultant. I hope to share this with
colleagues and students as well as those who seek
my services to explain, teach and investigate.
Bring me your mystery.
Sincerely,
William R. Morrone, DO, MS, ACOFP, CCD
For Medical/Legal Consulting
For Media Appearances
Dr. William R. Morrone
Belladonna Medical Consultants
Lois Katz Public Relations, LLC
Phone: 609-936-0014
Email: [email protected]
Phone: 989-928-3566
Fax: 989-891-9199
OBJECTIVES
1. Evaluate the REMS epidemiology; opiates for
pain, opiate abuse and unintentional overdose.
2. Opioid "Pharmacokinetics" with antagonism.
3. History/Physical, PMP and urine toxicology.
4. Withdrawal medications in ICU/ambulatory.
5. What about naloxone (Narcan®) ?
6. Methadone for pain vs Methadone clinic?
7. Co-occurring and self-treating in a patient’s
psychopathology…….options?
REMS
• Risk Evaluation and Mitigation Strategies
• Understand the epidemiology and problem.
• Monitor, PMP, Consent and Psych issues.
• Have exit plans and added training.
• FDA has determined certain opioid products
will be required to have REMS to help ensure
that the benefits of the drugs continue to
outweigh the risks of:
• 1) use of certain opioid products in non-opioidtolerant individuals;
• 2) abuse; and
• 3) overdose, both accidental and intentional.
The REMS will include elements to help ensure
that prescribers, dispensers, and patients are
aware of and understand the risks.
•
Pain and Symptom Management for Health Care Professionals
•
Welcome to the portion of the Pain and Symptom Management website devoted to information for
both Michigan health care providers and health policy professionals. This part of the website will
provide health care professionals with state and national guidelines, Michigan legislation,
educational links and various articles and publications related to pain and symptom management.
Health Professionals are also likely to find this website's link to the Advisory Committee
on Pain and Symptom Management of interest.
•
State and National Guidelines Click here for: state and national guidelines for pain and symptom
management
Palliative Care Click here for: Information about chronic disease and cancer-related palliative care
Links to Pain and Symptom Management Information Click here for: Links to Pain and
Symptom Management Information
•
• Pain & Symptom Management State Legislation Click here for:
information about state legislation pertaining to pain and symptom management
•
•
End of Life Care Click here for: pain management during the final days of life
Publications and Articles Click here for: publications/articles about pain/symptom management
March 30, 2010
«First_Name_Middle_Initial» «Last_Name», «Title»
«Address_Line_1»
«Address_Line_2»
«City», «State» «ZIP_Code»
Dear Dr. «Last_Name»:
In accordance with Rule 338.3132 of the Michigan Board of Pharmacy Administrative Rules, all
physicians who prescribe, administer or dispense controlled substances to drug dependent persons for
the treatment of narcotic addiction in a drug treatment and rehabilitation program are required to obtain
a separate controlled substance license for this practice.
Our records indicate you are currently certified with the U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Services Administration for this practice; however, it
appears you do not hold the required Michigan license. If you currently prescribe, administer or
dispense controlled substances to drug dependent persons in a drug treatment program, please
complete and submit the Controlled Substance License Application-Prescribing Physician for a Drug
Treatment Program application to ensure compliance with Michigan law. This application can be
downloaded from our website at www.michigan.gov/healthlicense by selecting the Pharmacy link and
then Pharmacy Licensing Forms and Applications. Please note that failure to apply for this license
within 30 days after receipt of this correspondence may necessitate review of your professional
license(s).
If you no longer prescribe, administer or dispense controlled substances to drug dependent persons in a
drug treatment program, please complete the certification section below so we may take the
appropriate measures to update your licensing status.
Please contact our office with any questions you may have regarding the above information.
Sincerely,
Michigan Board of Pharmacy
517-373-1737
[email protected]
Please complete the following certification and return in the enclosed postage paid envelope.
I certify that I no longer prescribe, administer or dispense controlled substances for a drug treatment program and give the
Michigan Board of Pharmacy the authority to contact the certifying agency, the U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Services Administration, to inform them of my decision to inactivate my
certification.
Name: ________________________________________ Signature: __________________________________________
Select the single best answer
•
•
•
•
Overdose victims are only new users.
Heroin & opioid deaths always increase together.
Fatal opioid poisonings doubled (1999-2006).
Doctors directly supplied non-Rx use of pain
relievers greater than 70% of the time.
• Hospitalization, detox and incarceration lower
your risk of opioid overdose.
• All of the above.
• None of the above.
Select the single best answer
•
•
•
•
Overdose victims are only new users.
Heroin & opioid deaths always increase together.
Fatal opioid poisonings doubled (1999-2006).
Doctors directly supplied non-Rx use of pain
relievers greater than 70% of the time.
• Hospitalization, detox and incarceration lower
your risk of opioid overdose.
• All of the above.
• None of the above. *
CDC/NCHS Sept 2009:
From 1999 to 2006 fatal poisoning
with opioid analgesics increased
from 4,000 to 13,800
Source Where Pain Relievers Were Obtained for Most
Recent Nonmedical Use among Past Year Users Aged 12
or Older (NSDUH 2006)
Source Where Respondent Obtained
Bought on
Drug Dealer/ Internet
0.1%
Stranger
More than 3.9%
Other 1
4.9%
One Doctor
1.6%
One
Doctor
19.1%
Bought/Took
from Friend/Relative
14.8%
Free from
Friend/Relative
55.7%
Source Where Friend/Relative
Obtained
More than One Doctor
3.3%
Free from
Friend/Relative
7.3%
One
Doctor
80.7%
Bought/Took from
Friend/Relative
4.9%
Drug Dealer/
Stranger
1.6%
Other 1
2.2%
Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown.
1
The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s
Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”
Poisoning Mortality- USA
Unintentional, Drug-Related
Suicide
Undetermined Intent
Source: Paulozzi L, et al. Pharmacoepidemiol Drug Saf. 2006 Sep;15(9):618-27.
Michigan Poison Control
• DeVoss Hosp and DMC confirm in MI
approx. 1,000 opioid OD deaths per year.
• Wayne Co. (Detroit) alone (pop 2 million):
• 602 opioid OD deaths – 2006
• 493 opioid OD deaths– 2007
• 530 opioid OD deaths – 2008
• OD deaths: ½ in Detroit and ½ in non-Detroit
Who overdoses?
• Often dependent long
term users; not in
treatment with
5-10 years of
experience
• 17% occur in
new users.
Sporer Ann Emerg Med 2006
Major risk factors
• Opioid Use following a period of abstinence
– Incarceration
– Hospitalization
– Drug treatment/detox
• Mixing classes of drugs
– Primarily other CNS depressants
– Cocaine is involved in nearly 40% of NYC
overdoses
Sporer 2006, Can Acad Emerg Med 2006
Death following incarceration
Post incarceration is major risk factor for
death from OD
– Study of deaths in first 2 weeks post
incarceration among 30,237 released inmates
– 129 times greater likelihood of dying of OD
vs. other WA state residents
– 60% involved opioids
– 74% involved cocaine and other stimulants
Bingswanger NEJM 2007
DEA (2005) 22 states Rx in crime
other
24%
Vicodin
52%
MDMD
8%
Oxy
16%
Allegheny County Trends in Accidental Drug
Overdose Deaths (2000-2006)*
2000-2006*
*Data is from Allegheny County Medical Examiners Annual Reports and includes all overdose deaths where these drugs
were present at time of death, not necessarily cause of death.
Scripts Reported in 2003-2006 by
MDCH on the MAPS
•
•
•
•
•
2003:
2004:
2005:
2006:
2008:
• Hydro/APAP
12,498,338
13,689,728
14,355,989
15,989,785
17,311,431
5,116,486
30 %
Schedule II MAPS methadone info
•
•
•
•
2003: 72,172 scripts
2004: 109,869 increase of 52%
2005: 131,524 increase of 20%
2006: 162,736 increase of 22%
Medicaid requires prior approval for Oxycontin
and not for methadone; there will be a transfer
due to this formulary issue.
Michigan Automated Prescription System
Issue Date
Fill Date Strength
Xxxxxxxxxxxxxxxxxxxxxxxxxx
SAGINAW,MI,486020000
MI,48724
02/27/2008 0697649
02/27/2008
Rx Number Practitioner DEA#
Practitioner Address Dispenser DEA#
Dispenser Address
FALES,THOMAS I PA
WALGREEN CO.
MF0845644
BW7042877
3566 MADISON
APAP/HYDROCODONE BITARTRATE SAGINAW,MI,487061274
101 S JEFFERSON, ADVANCED DIAGNOSTIC IMAG40IN9 GW P GCENESEE AVE, DBA: WALGREENS # 06091
TAB 100.00
750 MG-7.5 MG
Xxxxxxxxxxxxxxxxxxxxxxxxxx
BANGOR,MI,490130000
MI,49013
02/21/2008 4455762
02/21/2008
AL8119299
24TH ST
3973 M-140 BOX 127 211 WEST MONROE
Xxxxxxxxxxxxxxxxxxxxxxxxx
BANGOR,MI,490130000
MI,49013
02/21/2008 4455760
02/21/2008
SYR 120.00
WATERVLIET,MI,490980000
10 MG/5 ML-6.25 MG/5 ML
SWANSTRA PHARMACY
BS9992618
APAP/HYDROCODONE BITARTRATE
TAB 60.00
FALER DRUG STORE
BO6319013
AF6556457
CODEINE/PROMETHAZINE
SYR 180.00
SAGINAW,MI,486020000
10 MG/5 ML-6.25 MG/5 ML
PRINCING'S PHARMACY
QUARTERS,JACK ELWOOD DO
AQ3067825
AK5912402
APAP/HYDROCODONE BITARTRATE
TAB 60.00
SAGINAW,MI,486040000
750 MG-7.5 MG
PRINCING'S PHARMACY
QUARTERS,JACK ELWOOD DO
AQ3067825
3566 MADISON
1438 SCHUST RD 333 S MICHIGAN AVE
WATERVLIET,MI,490980000
500 MG-10 MG
ONONUJU,CHIDOZIE JOSHUA DO
3566 MADISON
1438 SCHUST RD 333 S MICHIGAN AVE
Xxxxxxxxxxxxxxxxxxxxxxxxx
SAGINAW,MI,486020000
MI,48724
02/13/2008 0774681
02/13/2008
CODEINE/PROMETHAZINE
AL8119299
3566 MADISON
1320 NORTH MI AVE WENZEL EDWARD GUSTAVE
Xxxxxxxxxxxxxxxxxxxxxxxxx
SAGINAW,MI,486020000
MI,48724
02/13/2008 0774680
02/13/2008
BS9992618
LLANTO,ALFONSO GENERALAO MD
24TH ST
3973 M-140 BOX 127 211 WEST MONROE
Xxxxxxxxxxxxxxxxxxxxxxxxx
SAGINAW,MI,486020000
MI,48724
02/14/2008 0097483
02/14/2008
SWANSTRA PHARMACY
LLANTO,ALFONSO GENERALAO MD
AK5912402
CODEINE/PROMETHAZINE
SYR 240.00
SAGINAW,MI,486040000
10 MG/5 ML-6.25 MG/5 ML
Run Date : 3/19/2008 11:21:19AM Warning : This report contains confidential information,including patient identifiers,and is not a public record. Page
1 of 10
Resources at the State of
Michigan
• Department of Community Health
• Bureau of Health Professions
• www.michigan.gov/healthlicense
Health Investigation Division
• [email protected]
• http://sso.state.mi.us/
What is a good urine drug test?
What is a good urine drug test?
•
•
•
•
•
•
CLIA waivered
Temperature and Specific Gravity
12 panel drug test
10 minute developing (POS)
Closed system
$6.95-$7.95
Only 8 % of primary care
use urine drug toxicology
Call Poison Control Center
•
•
•
•
Identify yourself
Request a Toxicologist
Report patient demographics/data
Record orders in chart
Morphine
Heroin is diacetylmorphine
Physiology of overdose
• Overdose happens over course of
1-3 hours; stereotypic “needle in
the arm” death is only 10-15%
• Opioids depress the urge to breath
and decrease response to carbon
dioxide - leading to respiratory
depression and death
Sporer Ann Emergency Med 2007
Overdoses cannot be cookbook
Heroin
Methadone
•
•
•
•
•
•
•
•
•
•
•
•
•
Active metabolites
6-MAM (short t½)
Morphine
Half-life: 3-4 hours
Often w/ cocaine
Narcan
Inactive metabolites
EDDP
Half-life:12-40 hours
Often w/ benzo’s
Narcan is not enough
Often intubated
You can’t cheat time!
Always make the patient naked.
• Look for fentanyl patches or residual glue.
• Examine tattoos and look for needle marks.
• Rectal exam especially if unconscious and
arrest in the field & also look for cut up
fentanyl patches in the oral cavity (Chiclets).
Progression
Treating the acute
overdose state.
• ABC’s
• Oxygen
• Narcan
• Fluid
• Blood pressure
Treating the detoxed
patient that results
after the overdose.
• Anti-siezure meds
• Nausea
• Panic anxiety
• Pain (myalgia)
• Pysch meds/eval
Naloxone
Pharmacokinetics
Naloxone (Narcan®)
• Opioid antagonist which reverses opioid
related sedation & respiratory depression
and may cause withdrawal.
• Displaces opioids from the receptors, then
occupies the receptor for 30-90 minutes
• No psychoactive effects
• Over the counter in Italy
• Routinely used by EMS
AGONIST
DECREASED
MAXIMAL
EFFECT
PARTIAL
AGONIST
EFFECT
Antagonist
LOG DOSE
Adjuvants
• Adjuvants allow easier opioid withdrawal or
give analgesia in place of low dose opioid.
•
•
•
•
•
•
Gabapentin or Namenda or Amantadine
Valproic Acid / Phenytoin*/ Pregabalin
Amitriptyline/hydroxazine or Benadryl*
Promethazine* or Dextromethorphan
Baclofen* or Ranitidine or Clonidine*
Carbamazepine 200-1600mg per day.
Treat and cover seizures in
polypharmacy withdrawal
• Carbamazepine: suspension 100mg/5mL
given oral or rectal (10mL to 80mL)
• Diastat® (diazepam 2.5, 5mg rectal gel)
• Lorazepam: 2-4mg I.V. push prn seizures
• Phenobarbital: seizure/anxiety/insomnia
Heroin Overdose in France
Source: Carrieri PM, 2006, Clin Infect Dis, 43: S197-215, data from Emmanueli
49
Select the single best answer
•
•
•
•
Methadone treatment increased overdose risk.
Methadone escalation is greater than morphine.
Methadone’s metabolite is more toxic.
Methadone overdose deaths are monotherapy
greater than 74% of the time.
• Methadone has no federal or public guidelines or
web page for methadone use.
• All of the above.
• None of the above.
Select the single best answer
•
•
•
•
Methadone treatment increased overdose risk.
Methadone escalation is greater than morphine.
Methadone’s metabolite is more toxic.
Methadone overdose deaths are monotherapy
greater than 74% of the time.
• Methadone has no federal or public guidelines or
web page for methadone use.
• All of the above.
• None of the above. *
Do not use Methadone unless you
are very comfortable with it.
Document reasons
clearly for using
methadone:
• Hospice
•
•
•
•
Allergies
Formulary
Diagnosis
MMTs /MTPs
Paid for with taxpayer dollars.
• Where do you get your copy?
• Internet
• Print
DHHS publication No. 04-3904
Let us look at
Methadone for pain
clinics and
Methadone for pain
in primary care.
FAQ
• Why do we use methadone?
• Is methadone dangerous?
• How do I learn methadone?
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
What is the Physician Clinical Support System - Methadone? (PCSS-M)
The Physician Clinical Support System for Methadone (PCSS-M) is a free, nationwide program through which health care providers needing information
and mentoring on methadone treatment for opioid addiction and/or pain can connect with experts in the field. PCSS-M MENTORS provide telephone,
email and on-site support. They come from across the country and work in licensed opioid treatment programs, pain clinics, primary care, and other
practice settings. The PCSS-M is coordinated by the American Society of Addiction Medicine (ASAM) in conjunction with other leading medical
societies. PCSS-M offers a national network of trained health care provider mentors with expertise in the clinical pharmacology of methadone and clinical
education. Mentors are supported by NATIONAL EXPERTS in the use of methadone and by a MEDICAL DIRECTOR, C0-MEDICAL DIRECTOR, and
SENIOR ADVISOR.
The PCSS-M MENTORS are members of medical specialty societies and provide mentoring support and educational services based on evidence-based
practice guidelines. The efforts of PCSS-M are coordinated by a STEERING COMMITTEE composed of representatives from the Federal government and
the leading pain and addiction medicine societies, along with primary care and psychiatric organizations that represent the target health care provider
populations.
PCSS-M provides educational services to any and all health care providers treating patients with methadone in an effort to increase the appropriate use and
safety of this efficacious but clinically challenging medication.
The PCSS-M is designed to offer support to clinicians treatment of pain and addiction on a number TOPICS including:
Patient assessment and selection
Initiating and titrating methadone
Conversion from other opioids
Dosing and patient monitoring
Interpreting methadone serum levels
Drug-drug interactions
Methadone and cardiac conduction
Minimizing risk of diversion and overdose
Management of co-occurring conditions
This project is funded by a grant from The Department of Health and Human Services, Substance Abuse and Mental Health Services Administration
(SAMHSA), Center for Substance Abuse Treatment (CSAT); grant#1H79TIO20294-01.
•
•
•
OPIOID TREATMENT PROGRAM
Mentor Name Specialty Location
Gavin Bart, MD OTP Minneapolis, MN Mark Jorrisch, MD OTP Louisville, KY Mark Kraus, MD, FASAM OTP Waterbury, CT
Edwin Salsitz, MD OTP New York, NY Laurene Spencer, MD OTP Hillsborough, CA Trusandra Taylor, MD OTP Philadelphia,
PA Alex Walley, MD, MSc OTP Boston, MA Charles Walton, MD OTP Highland, UT Susan Whitley, MD OTP New York City,
NY George Woody, MD OTP Philadelphia, PA
•
•
•
•
•
•
•
•
PAIN TREATMENT
Mentor Name Specialty Location
Howard Heit, MD, FACP, FASAM Pain Treatment Fairfax, VA
Brian McCarroll, DO, MS Pain Treatment Clinton Township, MI
Mary McMasters, MD Pain Treatment Fishersville, VA
William Morrone, DO, MS, ASAM, ACOFP, DAAPM Pain Treatment Bay City, MI
Randy Seewald, MD Pain Treatment New York City, NY
William Yarborough, MD Pain Treatment Tulsa, OK
•
•
•
•
•
•
•
•
•
•
•
PRIMARY CARE
Mentor Name Specialty Location
Jeff Baxter, MD Primary Care Worcester, MA
John Brooklyn, MD Primary Care Jericho, VT
Anthony Dekker, DO Primary Care Phoenix, AZ
Ramsey Farah, MD, MPH, FAAP Primary Care Hagerstown, MD
James Finch, MD Primary Care Durham, NC
Michael Fingerhood, MD Primary Care Baltimore, MD
Adam Gordon, MD, MPH, FACP Primary Care Pittsburgh, PA
John Hopper, MD, FAAP, FACP Primary Care Ypsilanti, MI
Joe Merrill, MD, MPH Primary Care Seattle, WA
How do you get that web page?
http://www.pcssmethadone.org/pcss/index.php
A free nationwide program (PCSS-M) that
healthcare providers needing information and
mentoring can connect to methadone experts in
addiction and pain management. A similar web
resource exists for buprenorphine (PCSS-B).
Pharmacology
• Efficacy greater than
morphine
• Full Mu-opioid agonist
• Inhibits reuptake of
5HT and NE.
• NMDA antagonist
resulting in additional
analgesia
Analgesia similar to morphine
•
•
•
•
•
•
Once daily for opioid addiction (MMT only)
Liquid used mostly for addiction and HOSPICE
15 mg morphine equal to 5 to 10 mg methadone
150 mg morphine equal to 30 mg methadone
Suitable for pain when there is morphine allergy
Slow onset helps avoid establishing
reward behaviors that can occur
with fast acting short duration
opioids
Less dose escalation with
methadone?
• N=40, advanced cancer
• methadone vs morphine
• Doses of both drugs were minimized and titrated to acceptable
analgesia with minimal adverse effects.
• Pain control and side effects were similar
• Pill counts.
• Opioid escalation was significantly less with methadone
• More stable analgesia over time was seen in patients treated with
methadone.
– Mercadante S et al. J Clin Oncol 1998;16:3656-3661.
Methadone Pharmacokinetics
• Metabolized in liver NO active
metabolites (EDDP).
• Elimination half life of about 22
hours but varies in each person.
• Duration 8-12 hours with
repeated dosing.
• Minimal renal excretion
primarily fecal excretion.
Methadone Dosing
• Package insert advised dosage of 2.5 to 10mg every 3-4
hours as needed
• 40-50 mg/day can be deadly for new patient
• FDA black box warning
• 18 deaths - Kent county, 11 deaths - Bay
County (2006)
• 2003 DAWN data from ME’s in Detroit identified 64
deaths from methadone
• Benzos found in 74% of deaths related to methadone
• Marked drowsiness (side effect) add methylphenidate
• Duration of analgesia about 8 hours (6 to 10 hours)
•
•
•
•
•
2 Vicodin q 4-6 hours
800 mg IBU q 8
Valium 5 q 8
Percocet 5 q HS
Restoril 30 q HS
Hospice White
Male end stage
liver chirrosis,
type2 NIDDM,
HCV, tibial
ulcer & LE
DNP
• 5mg methadone
po q 8 to 12
• One Vicodin q 24 prn
• 250mg (bed time only)
carisoprodol q HS
• 600mg gabapentin q 8
• 25mg nortriptyline q HS
• 10mg baclofen q 8
Hospice White
Male end
stage liver
chirrosis,
type2 NIDDM,
HCV, tibial
ulcer & LE
DNP
Honest talk about addictions.
People Treated for Opiate Use in Vermont by Fiscal Year
1800
1600
People
1400
1200
Heroin
1000
800
Other Opiates/
Synthetics
Non-prescription
Methadone
600
400
200
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
State Fiscal Year
Substance
Heroin
Other Opiates/ Synthetics
Non-prescription Methadone
2000
2001
2002
2003
2004
2005
2006
2007
2008
256
140
3
439
156
4
546
219
2
693
340
8
671
513
15
710
719
26
722
1139
36
631
1425
57
617
1602
53
Data Source: Vermont Substance Abuse Treatment Information System (SATIS)
This reflects only people receiving treatment at state-funded treatment facilities.
Methadone and mortality
• Prospective study of opioid dependent
patients applying for methadone treatment
in Norway
• 3,789 subjects followed for up to 7 years
• Clausen Drug Alc Dep 2008
Results
Pre-treatment
In treatment
Post-treatment
Total mortality
Odds ratio
1
0.5
1.43
Total overdose
Odds ratio
1
0.20
1.40
Percent
of deaths due to
overdose
79%
27%
61%
Clausen 2008
Send recovered patients to
treatment CBT/individual/group
Maintenance therapy prevents
overdose
Since the institution of buprenorphine and methadone
maintenance in 1996 in France heroin overdose dropped 79%
French population in
1999 = 60,000,000
600
No. of deaths
500
400
Patients receiving buprenorphine
(1998): N= 55,000
300
200
Patients receiving methadone
(1998): N= 5,360
100
0
1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999
Year
Auriacombe et al., 2001
Selecting treatment modalities
Consider:
 Patient expectations of treatment
 Patient goals (detox vs maintence)
 Stages of change
 Current circumstances
 Available resources
 Past history of treatment outcome
 Evidence regarding safety, efficacy
and effectiveness
 Need for pain management
Outpatient and Inpatient
• Victory Clinical Services: 989.752.7867
• Recovery Pathways, LLC: 989.928.3566
• Michigan Behavioral Health Institute:
Dr. Douglas Foster: 989.894.3000
• Detroit, Flint or Mt. Pleasant methadone clinic
• White Pine / HealthSource (inpatient)
• Bay Regional Medical Center (inpatient)
“End Game” examples
• Opioid overdose w/ pain management
should change to buprenorhine/naloxone or
methadone clinic and therapy.”
• Heroin overdose should go to methadone
clinic for structure and therapy.
• Street opioid overdose should go to
methadone clinic for structure and therapy.
• Opioid overdose with multiple outpatient
failures go to methadone clinic.
BIG TAKE HOME POINT
• Do not try to be a methadone clinic in your
office.
• Dependence must be separated from pain.
• Keep methadone pain management
patients and make your charts absolutely
100% unambiguous with supporting
documentation with reassessment .
Naltrexone
Core
Slide Acknowledgements
• Alice Bell
• Melinda Campopiano, MD
• Sharon Stancliff, MD
Call any time.
 Director of Hospice and Palliative Care:
Hospice of Michigan - 989.790.7352.
 Assistant Director Family Medicine:
Synergy Medical Alliance - 989.583.6800.
24 hour Answering Service:
989.891.8979
Any question. Any medicine.
[email protected]