Medical Assisted Treatment

Dr. Michael Baldinger Medical Director

Haymarket Center Harborview Recovery Center

Current Trends • Prescription Drug Abuse/Addiction

– Non-medical use of prescription pain killers now second most common form of illicit drug use in the U.S. (SAMHSA, 2009)

– Greater Acceptance in Medical Community to Prescribe for

Chronic Pain in past 10 years – Development of new more powerful delivery systems for

pain medications

– Ease of Access • “Non-criminal” sources of acquisition (Internet, Physicians Family Medicine Cabinet)

Sources of Prescription Pain Relievers

76%

19%4%

1%

Friend/Relative

from MD

Dealer

Internet

(SAMHSA, 2008)

Opiate Use Demographics • Estimated 2 million opiate addicts (SAMHSA, 2006)

– recent increase in heroin addicts in suburban population due to increased purity and movement of criminal gangs into “safer” suburban settings (Bach & Lantos, 1999)

– Increased abuse of prescription opiates

• Prescription opioid misuse increased 140.5% from 1995 to 2005 (CASA, 2005)

• Approximately 2.1% of US population age 12 and older (5.2 million) report using prescription opioids for non-medical reasons (SAMHSA, 2009)

– Routes of Administration • Prescription Drugs are oral, intranasal or injection • Heroin primarily IV, non-injection use of heroin increasing due to purity

(NIDA,2005) • Conversion of intranasal to IV at 15% per year (Neagus, 1998)

Annual numbers of new non-medical pain medication users 1965 - 2002

(New York Times, February 2009)

(AMA News 2009)

• You are entitled to your own opinions but you are not entitled to your own facts

• Daniel Patrick Moynihan

Methods of Detoxification • Using Opioids

– Methadone – Suboxone – Tramadol

• Using Opioid Antagonists – AAROD (Anesthesia Assisted Rapid Opiate Detox) – Naltrexone/Clonidine Induction

• Other – Clonidine – Acupuncture – Phytomedicinals – Social Detox

Detoxification • Effectiveness

– Methadone and buprenorphine equally effective (dose related)

– Buprenorphine is safer

– Greater treatment retention than other methods AAROD is unnecessarily expensive, uncomfortable and

potentially life threatening Acupuncture has had mixed results and in general poor study design – Without follow up treatment, no method is likely to lead to

recovery

Neurotransmitter Effects on Receptors

• Agonist

• Partial Agonist

• Antagonist

Maintenance • Methadone and Buprenorphine

–Rationale for Efficacy • Cross-tolerance

– Prevent Withdrawal – Relieve Craving

• Occupation of Mu Receptor with long-acting opiate

– Blocks or attenuate euphoric effect of exogenous opioids – Restore normal function of opioid neuropathways

Maintenance

– Evidence for Efficacy • Many studies indicate improved medical, psychiatric

and employment outcomes in maintenance populations • Improved function even in waiting list populations • Increased treatment retention • Decreased conversion to HIV+, Hepatitis C+ serology • Increased mortality in treatment dropout population

– Overdose, Infectious Disease, Violence and Accidents

Buprenorphine, Methadone, LAAM: Treatment Retention

(From “An Overview of Opioid Dependence”, Dr. Martin Doot)

Buprenorphine, Methadone, LAAM Opioid Urine Results

(From “An Overview of Opioid Dependence”, Dr. Martin Doo

Detoxification vs. Maintenance

(From “An Overview of Opioid Dependence”, Dr. Martin Doot)

Buprenorphine

• Introduced into clinical practice in the U.S. in 2002 • Schedule III narcotic • Partial opiate agonist • Can be dispensed from outpatient clinic settings with

special physician qualifications obtainable after an 8 hour course

• Greater access to treatment slots than methadone

Pharmacology • Suboxone contains buprenorphine and naloxone:

– Buprenorphine, a partial-opioid agonist, is the primary active ingredient

– Naloxone, an opioid antagonist, is present to discourage diversion and misuse by people dependent on a full-opioid agonist

– Suboxone is administered as a sublingual tablet/film and is manufactured in two dosage strengths – 2/0.5 mg and 8/2 mg

Sublingual Administration

• The Buprenorphine in Suboxone enters the bloodstream after dissolving under the tongue

• Buprenorphine has a very high first-pass absorption rate and is therefore much less effective if swallowed

Buprenorphine • Treatment can be done on an inpatient or outpatient

basis • Induction

– Make sure patient is in withdrawal (precipitated withdrawal)

– 2 - 4 mg of suboxone/subutex as initial dose with onset of opiate withdrawal symptoms (COWS?)

– Repeat dose every two hours one or two times day 1 (total dose 8 – 12 mg)

– Day 2 repeat total dose of day 1 – can give up to 8 mg additional

– Most patients are comfortable at doses 12 – 16 mg

Buprenorphine “Ceiling Effect”

Considerations regarding Buprenorphine

• Dose Dependent Efficacy (12-24 mg) • Effective in Combination w/ Psychosocial Treatment

– High levels of Treatment Retention, fewer side effects than Methadone

• Access in General Medical Setting – Breaks down Barriers to Seeking Tx

• Expense – High

• Duration of Treatment – Variable

• Detoxification – Can be problematic

Considerations regarding Buprenorphine

• Patient contract essential to clarify expectations – Expectations of the physician regarding patient

conduct – Expectations of patient as to physician’s

availability and support

– Need to discuss process of detoxification • If patient decides to discontinue maintenance • If patient violates contract agreement

Considerations regarding Buprenorphine

• Side Effects – Unpleasant Taste – Excessive Sweating – Constipation – Decreased libido – Difficulty urinating – Difficulty with discontinuation

When to Discontinue Maintenance

• Patient request • Patient unable to comply with Treatment

Contract • Entry into Criminal Justice system • Unacceptable Side Effects

How to Detox • Methadone

– 3-5 mg per week

• Buprenorphine – 2 mg per week or less – can vary – Interval of 5 days between dose reduction

Antagonist Therapy • Revia

– Oral dosing leads to greater serum variation with potential for increased side effects.

– Inexpensive

Vivitrol – indicated for opiate blockade therapy since

October 2011 – once a month dosing provides complete

irreversible blockade – timing of injection tricky – avoid precipitated

withdrawal

Sedatives and Alcohol

Detoxification Strategies for Alcohol

• Use of symptom triggered medication dosing leads to shorter detox periods and lower total dose of benzodiazepine used

• Some studies have indicated good outcomes with anti-seizure medication (Gabapentin/Carbamazepine) with better sleep, less anxiety and post acute withdrawal craving. –JAM V5 N4 pp,249, Dec 2011

Sedative Withdrawal Strategies

• Conversion to long acting benzodiazepines • Phenobarbital taper • Anticonvulsants - alone or in combination

with benzodiazepines/phenobarbitol

Medication Management • Anti-craving medication

– Acamprosate – Antabuse – Naltrexone

• Revia • Vivitrol

– Baclofen? – Topiramax?

• Treatment of Post-Acute Withdrawal – Sleep (avoid GABA-ergic meds) – Mood Disorders

• Treatment of Pain – Narcotics only when necessary – controlled amounts,

significant others when possible