Transcript Suboxone and its Role in Opiate Addiction

SUBOXONE, METHADONE, VIVITROL AND
ITS ROLE IN
OPIATE ADDICTION TREATMENT
• OUTPATIENT DETOXIFICATION
Bradford Health Services
HISTORY OF OPIATE TREATMENT
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Abstinent Model – Treated opiate addicts like
alcoholics and cocaine addicts
Maintenance Model - Initially used to address
Heroin addiction and control undesirable
outcomes of Heroin addiction.
“Harm Reduction” Model – More recent, uses
Suboxone, measures success on reduction of
incidents criteria, tries not to be maintenance,
but it is.
METHADONE
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Developed in Germany in 1937 as a reliable
source of opiate pain reliever for the future.
Introduced in United States in 1947 by Eli Lilly.
Used for managing chronic pain.
Mainly used in treatment of opiate dependence,
shown not to reduce crime, mortality rate and
costs to society of Heroin addiction. Decreases
likelihood Heroin dependent patient will use
Heroin. (Mattick, Courtney, et.al. 2012, Wiley
Online)
Tolerance/dependence develops.
METHADONE CLINICS
States allow 3 to 30 days supply to go home after
a period of observation.
 Methadone Clinics –
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Crime does not increase around a methadone clinic.
(University of Maryland, 2012)
 Communities do not like them.
 Still the most effective treatment for chronic Heroin
addiction but is losing ground rapidly to:
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SUBOXONE
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Buprenorphine and Naloxone combined.
Buprenorphine is a semi synthetic Opioid.
Naloxone is an opiate inverse agonist. It
counters the effect of opiate overdose. Carried by
paramedics to use on OD’s.
The Naloxone is designed to deter the abuse of
the medication by injection.
Still abused by injection and oral use on the
street as the Naloxone is not strong enough to
prevent abuse in non-tolerant
individuals.(Stoller, Bigelow, Strain,
Psychopharmacology, 2001)
SUBOXONE CLINICS
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Just went generic, so costs are going down.
Patients report more functionality over Methadone.
Clinics are in physician practice groups. 100 per
physician, number per physician is changing soon.
Many, many clinics in the Southeast. 500 per month
prescriptions in one pharmacy in Birmingham.
Buprenorphine most often abused by crushing table
and snorting it. So, now there is film.
2007 Sweden confiscated more Buprenorphine than
cocaine, ecstasy and heroin combined.
Reindeerspotting (Finnish Subutex abuse video)
VIVITROL
Extended release formulation of Naltrexone, an
opioid receptor antagonist.
 A shot, once a month.
 Expensive
 Blocks craving and effects of use.
 Pill form Naltrexone has very poor compliance.
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DEATHS FROM OVERDOSE
NEWBORN IN WITHDRAWAL
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Graph Continues to climb….
DEATH RATES BY TYPE AND URBAN
LOCATION
SPECIFIC DRUG EPIDEMICS
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1970 to 2006
ANNUAL NUMBERS (IN MILLIONS) NEW
NON-MEDICAL USERS OF OPIOIDS (12 OR
OLDER)
80’S - 90’S - 00’S - 10’S
TREATMENT FAILURES FOR OPIATE ADDICTION
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Traditional treatment models have a typical recovery
rate between 2 and 5% at one year. (Roman Jovey,
MD, Encounter Books, 2006)
Other studies show 5 to 10%, generally no higher at
one year.
Opiate addicts have a mortality rate 15.8 times higher
than the general public. (Joe and Simpson, Institute of
Behavioral Research, 1990)
Traditional treatment was insight based and did not
address the brain injury. “How do you feel?”
THE OPIATE PATIENT WILL:
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Generally be unable to encode meaningful
insights for retrieval for 90 days.
Be focused on craving until the brain heals from
opiate injury or those cravings are blocked.
(Cigarette craving never goes away.)
Be afraid of being off their “medicine” to the point
of panic.
May be unable to remember treatment
experience at all after a short period. (story)
THE TYPICAL TRADITIONAL TREATMENT
COUNSELING PROFESSIONAL WILL:
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In the first 30 days of treatment:
Believe the patient will have lasting benefit from
GROUP.
Believe the patient will lasting benefit from
INDIVIDUAL.
Believe treatment planning should be based on the
barriers to recovery identified in the P/S.
Not be fully aware that additional medications are
adding to the problem and further complicating the
patients transition to abstinence.
Do not understand and accept the degree of Brain
injury caused by Opiates.
Do 90 in 90 as a discharge plan.
WHAT
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Accept that Methadone Maintenance is the best
way?
 Accept that Suboxone/Subutex Maintenance is
the best way?
 Believe Vivitrol will give the patient time to heal?
 Continue to treat Opiate addicts as we have for
the last 30 years?
 Change our thinking about Opiate treatment.
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ADDICTION PROFESSIONALS
Like predictable things.
 Don’t mind living in a rut, in fact, they carpet
their ruts and move furniture in.
 Often have rigid beliefs.
 Like anyone else, they generally fear change.
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Especially if it involves medication.
HOW TO USE VIVITROL AND SUBOXONE IN
THE ABSTINENT MODEL.
Accept: Extended detox is not maintenance.
 Accept: Individuals who were abusing Suboxone
can be detoxed using Suboxone.
 Accept: Detox for an Opiate addict takes weeks,
at least. Some physicians and institutions
believe detox should last as long as 6 months to a
year or two. (Promotion of additional addiction?)
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THE MODEL
Initial detox at a residential facility to cover other
drugs of abuse. If opiate only, direct to IOP Opiate
detox facility.
 The patient begins a taper on Suboxone or Subutex.
Cravings diminish. The patient is more open to
hearing, maybe not retaining, but hearing.
 Concentrate on acceptance of duration and addiction
as identified barriers to recovery. (Treatment Plans)
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THE MODEL
The patient transitions to a Outpatient licensed
detox facility. Enrolls in the Outpatient program
and the Detox program.
 The patient continues the Suboxone taper. 4 to 8
weeks, while in the outpatient program.
 Treatment planning continues to be focused on
accepting what is required to recovery from
opiates….Duration and Acceptance.
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THE MODEL
The patient either finishes the IOP or ends the
taper.
 The patient is continued in the Outpatient Detox
program, usually one day per week.
 The 7 to 10 day period after the last dose of
Suboxone until Vivitrol can be administered is
the crossroads.
 A meaningful therapeutic relationship where
gains can be maintained is crucial at this and
future moments in treatment.
 Use of something like Clonidine and Trazadone
will help get through the 7 to 10 days and
address the patients need for “medication”
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THE MODEL
The patient gets Vivitrol shot. It’s scary.
 The patient returns to the facility weekly for
group, nurse assessment, individual and
education.
 The patient is encouraged to take the second shot
by staff and other patients who have “been
there”.
 A minimum of 3 and a goal of 12 or more shots.
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THE MODEL
At this point, a sponsor and a home group should be in
place, and are required for outcomes.
 The patient is worked and worked to continue to see
the benefits of the shot, Motivation Interviewing works
well here.
 Family is brought in to sessions to comment on
improvements they have seen.
 Barrier is still acceptance of duration and addiction.
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FINAL THOUGHTS
Typical Addiction Staff will resist this type of
treatment, both referring and program start.
 There are challenging financial implications
 We are in our preliminary outcome data seeing
substantial improvements in recovery rates at
one year for those patients that get at least 3
shots.
 Without a sponsor and home group, most
who discontinue Vivitrol in under 1 year of
use will relapse.
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