Transcript Integrating Abstinence-based Recovery with Harm Reduction

ACOPC
Allegheny County Overdose Prevention Coalition
Presents
PERMEATING
BORDERS
OVERDOSE PREVENTION
Summer Conference 2014
July 24, 2014
Integrating
Abstinence-based Recovery
with Harm Reduction
Neil Capretto, DO, FASAM
Medical Director
Gateway Rehabilitation Center
INTEGRATING
ABSTINENCE-BASED
RECOVERY WITH HARM
REDUCTION
Neil A. Capretto, D.O., F.A.S.A.M.
Medical Director
Gateway Rehabilitation Center
NUMBER OF OVERDOSES BY
YEAR - ALLEGHENY COUNTY
Year
Number of Overdose Fatalities
1980-1990
Average of 58 per year
1998
104
2001
180
2005
223
2006
252
2008
236
2012
288
Drug overdose deaths increasing in
Allegheny County
Roberta Lojak holds a high school graduation picture of her daughter Ashley Elder, who
died of a heroin overdose in October 2001. Lojak is standing in a garden she planted in
her daughter's memory.
September 27, 2004, Pittsburgh Post-Gazette
GATEWAY’S MISSION
To help all affected by addictive diseases to
become healthy in body, mind and spirit
REMAINING IN TREATMENT FOR
AN ADEQUATE PERIOD OF TIME IS
CRITICAL
•
Research indicates that most addicted individuals need at least 3
months in treatment to significantly reduce or stop their drug use
and that the best outcomes occur with longer durations of treatment
•
Because individuals often leave treatment prematurely, programs
should include strategies to engage and keep patients in treatment
National Institute on Drug Abuse
Principles of Drug Addiction Treatment
RETENTION IN TREATMENT
ENABLES RECOVERY
May be single most important indicator of medication
– assisted outcomes1
Retention permits patients and health care providers
to:
 Engage in counseling
 Stabilize abstinence
 Organize chaotic lifestyle
 Diagnose and treat co-morbidity
 Improve family, social and work relationships
1Center for Substance Abuse Treatment (CSAT) (2005) Medication-assisted
treatment for opioid addiction in opioid treatment programs: Treatment
Improvement Protocol (TIP) Series #43. DHHS Publication No. (SMA) 05-4048
What is Recovery?
• Improved life? What aspects?
• Total abstinence?
• Some drug use without problems okay?
• No drug use of any kind
• Some drugs but not drugs that affect
limbic system?
Recovery Scenarios
• Total abstinence, belief in a HP
but a mean SOB
• Occasional use, without significant
impact on psycho-social functioning
• Methadone maintenance, good life
Therapist/Physicians Ethical Role
• What outcomes do we guide people towards?
– Drug abstinence
– Development of a relationship with God
– Able to work
– Better health
• Patient Centered Treatment? - How much
choice do you give persons if their higher
functioning brain has been co-opted and
hijacked by the drugs?
Your Initial Reaction
• Holy Cow…..!!!!!
• Resistive to using medications
• Think “methadone” or “Suboxone”
Medication Assisted Defined
• Medications that benefit the goal of treatment
(whatever that is)
• Not medications versus other treatment
strategies, but integration with 12 Step, CBT,
and other psychosocial interventions
Definition: Medication Assisted
Recovery
•
Medications used to promote “recovery” from chemical
addiction
–Stops withdrawal
–Reduces the symptoms of post-acute withdrawal
–Reduces craving
–Blocks the high from abused drugs
–Reduces harm
Medication Assisting Drugs
•Detoxification medications
•anti-craving medications (naltrexone,
topiramate, acamprosate)
•blockers (naltrexone, cocaine vaccines)
•deterrents (Antabuse)
•maintenance drugs (methadone,
buprenorphine)
What is Abstinent Based
•
•
•
•
•
•
No drugs at all?
Psychiatric drugs okay?
Anti-craving drugs okay?
Blockers okay?
Deterrents okay?
Opioid Maintenance okay?
Big controversy
Abstinent Based Conventional View
•
•
•
•
•
12 step recovery model often thought of as
abstinent based
Abstinent based is an active process involving
more than just going to meetings
Includes psychosocial and spiritual interventions
Some medications okay?
– Drugs that do not stimulate reward area
– Meds to treat co-occurring psychiatric
Maintenance drugs like buprenorphine and
methadone not usually thought of as acceptable
IS A.A. AGAINST
MEDICATION?
THE A.A. MEMBER –
MEDICATIONS AND OTHER
DRUGS
•
Drug misuse can threaten the achievement and
maintenance of sobriety
•
Yet some A.A. members must take prescribed
medication
•
No A.A. member plays doctor
• If in doubt, consult a physician with
demonstrated experience in the treatment of
alcoholism
33-YEAR STUDY FINDS LIFELONG, LETAL
CONSEQUENCES OF HEROIN ADDICTION
Heroin addiction exacts a terrible toll. For many addicts the
condition lasts a lifetime – a lifetime shortened by health and
social consequences of addiction.
NIDA-supported researchers at the University of California, Los
Angeles (UCLA), examined the patterns and consequences of
heroin addiction over 33 years in nearly 600 heroin-addicted
criminal offenders and found that their lives were characterized
by repeated cycles of drug abuse and abstinence, along with
increased risk of crime or incarceration, health problems,
and death.
33-YEAR
The death rate among the members of the group is
50 to 100 times the rate among the general
population of men in the same age range.
“The high mortality rate is evidence of the severe
consequences of heroin use,” Dr. Hser says “Even
among surviving members of the group, severe
consequences such as high levels of health
problems, criminal behavior, incarceration, and
public assistance were associated with long term
heroin use.”
OPIOID ANTAGONISTS
Life Savers – Relapse Reducers
Narcan reversing an overdose
Naloxone Pilot Project
Type date here
800-472-1177 | www.gatewayrehab.org
Naloxone Pilot Project
•
As much as we want our patients to “get it” the first time, to leave rehab and abstain from drug use for the
rest of their lives, we know, for a significant number of our patients, that isn’t realistic. And that is especially
so for those with opiate dependence.
•
One of the most dangerous periods for overdose risk is immediately following discharge from a treatment
program. Because the person’s physical tolerance for heroin or other opiate medications has decreased
significantly during treatment, going back and using the same amount of the drug as their last dose can be
deadly.
•
Of course we want them NOT to use, but we know that some will. We need to educate our patients and their
families about the risks of relapse, including overdose, AND give them the tools to protect themselves and/or
reverse overdose.
Naloxone Pilot Project
Through the Naloxone Pilot Project we propose to:
•
Train GRC staff on ways to address relapse, overdose and prevention
•
Educate patients and families on ways to reduce risk and reverse overdose
•
Distribute intranasal doses of naloxone to patients and/or family members
•
Track patients and families over time to measure:
–
–
–
–
Rates of relapse
Use of naloxone
Rates of overdose
Rates of family anxiety
Naloxone Pilot Project
Ease of Implementation
•
Recruitment: use of long-established family day activities
•
Patient re-engagement: ongoing patient monitoring allows for evaluation and recommendation of
continued treatment after relapse
Training: infrastructure of Ramsey Institute can be used for ongoing training of staff. Outside clinicians
can be included for a fee.
Harm-reduction: implementation can prevent overdose, while education and ongoing monitoring can
reinforce abstinence model
•
•
Naloxone Pilot Project
This is a bold project with the potential to greatly improve patient outcomes, engagement in long-term
treatment and recovery, and position GRC as a leader in overdose prevention.
Benefits
• # of lives saved from overdose
• # of patients re-engaged in treatment after relapse
• Potential to impact public policy re: HB2090 “Good Sam” law and Standing Order legislation
• Potential for positive publicity and recognition in the field
NALTREXONE – OPIOID
RECEPTOR ANTAGONIST
“Bullet proof vest against opioids”
• Daily tablet (ReVia) – FDA approved
• Monthly injection (Vivitrol) – FDA approved
• Implants – not FDA approved
NALTREXONE FOR
OPIOID DEPENDENCE
Naltrexone
– Blocks opiate receptors
– Compliance impacts effectiveness
– Very effective in certain populations
– Not addicting, no psychoactive problems
HEROIN
TREATMENT
There is a broad range of treatment options for
heroin addiction, including medications as well as
behavioral therapies.
Science has taught us that when medication
treatment is integrated with other supportive
services, patients are often able to stop heroin (or
other opiate) use and return to more stable and
productive lives.
CONSEQUENCES
Mortality
Prior to the introduction of MMT, annual death rates
reported in four American studies varied from 13 per
1,000 to 44 per 1,000, with a median of 21 per 1,000.
The most striking evidence of the effectiveness of MMT
on death rates are studies directly comparing these
rates in opiate addicts, on and off methadone.
CONSEQUENCES
Mortality(cont’d.)
Every study showed that death rates were lower in opiate
addicts maintained on methadone compared with those who
are not.
The median death rate for addicts in MMT was 30 percent
of the death rate of those not in treatment.
A clear consequence of not treating opiate addiction,
therefore, is a death rate that is more than three times
greater than that experienced by those engaged in MMT.
Enter buprenorphine

Effective treatment option for opioid
dependence (Ling et al 1998)

Reduces morbidity and mortality (Auriacombe et al
1998)

Improves quality of life (Giacomuzzi, et al 2003, Anisse, 2001)
Partial vs. Full Opioid Agonist
death
Opiate
Effect
Full Agonist
(e.g., methadone)
Partial Agonist
(e.g. buprenorphine)
Antagonist
(e.g. Naloxone)
Dose of Opiate
Objectives of maintenance
treatment
• To reduce mortality from overdose and infection
• To reduce opioid and other illicit drug use
• To reduce transmission of HIV, HBV and HCV
• To improve the general health and well-being of patients
• To reduce drug-related crime
• To improve social functioning and ability to stay in work
Treatment saves lives
1996 Subutex and methadone
600
No. of deaths
500
French population in
1999 = 60,000,000
400
300
Patients receiving buprenorphine
(1998): N= 55,000
200
100
Patients receiving methadone
(1998): N= 5,360
0
1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999
Year
Auriacombe et al., 2001
ABOUT GATEWAY REHAB’S MAT
PROGRAM
Gateway Rehabilitation Center is proud to offer rigorous, scientifically
supported care, including Medication-Assisted Treatment (MAT) and
Twelve-Step facilitation (TSF) therapies.
Gateway Rehab’s MAT program focuses on the use of:
• Suboxone/Zubsolv (sublingual buprenorphine/naloxone)
• Vivitrol/Revia (Naltexone)
While no single approach to recovery is always successful, by offering
multiple treatment options, Gateway Rehab endeavors to foster
improved results for our patients. To help patients succeed on their
journeys to recovery, at Gateway Rehab treatment medications are
prescribed in combination with the support of inpatient/outpatient
treatment and Twelve-Step support.
Individuals with regular
involvement in 12-step
programs have a 4.5 times
higher rate of stable
recovery after 5 years
Kaiser-Permanente California
Study 2004 ASAM Annual Scientific
Meeting
“You have to admit your
ignorance in order to come to
knowledge because nobody
is going to search for
knowledge if they think they
already have it”
Socrates
Addiction is a
BIO-PSYCHO-SOCIALSPIRITUAL DISEASE
Good treatment address
all four aspects
ADDICTION BATTERS A THRIVING
FAMILY
NEIL A. CAPRETTO, D.O., F.A.S.A.M.
MEDICAL DIRECTOR
GATEWAY REHABILITATION CENTER
100 MOFFETT RUN ROAD
ALIQUIPPA, PA 15001
1-800-472-1177, x1119
[email protected]
www.gatewayrehab.org