opioid maintenance treatment in packet
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Opioid Maintenance Treatment
(OMT)
What it is………What it is not……
Stacy Seikel, MDBoard Certified Addiction Medicine
Board Certified Anesthesiology
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Addiction
Bio-Psych-Social-Disease
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Goals of OMT Reduce Cravings & Withdrawal Harm Reduction
HIV, Hep C, Hep B, Endocarditis, Skin abscesses
Decrease Risk of Overdose Prostitution Problems with the law
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Goals of OMT (con’t.)
Recovery AA/NA/MA Group & Ind Therapy Life Skills Non Pharmaceutical coping skills
Help People Have Normal Lives
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The Center For Drug-Free LivingOMT
Abstinence From All Other Addictive/Mood Altering Substances
Group and Individual Therapy Random UDS Mandatory Classes Encouraged to Attend 12-Step Programs Consult With Patient’s Primary, Specialty,
Pain and Psychiatric Physicians Therapy/Treatment Works!
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Common Questions About
Methadone
How Does Methadone Work? Opiate agonist
Mu receptor
Lasts 24-36 hrs.
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Common Questions AboutMethadone
Does Methadone make patients “high” or interfere with normal functioning? No, not when used appropriately
No impairment in driving ability
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Common Questions AboutMethadone
What is the proper dose of Methadone?
The dose that averts narcotic craving
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Common Questions (con’t)
Is Methadone more addictive than Heroin? Addiction is continued use despite
adverse consequences
Dependence is a physiologic phenomena
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Common Questions (con’t)
Is Methadone harder to kick than Heroin? Heroin withdrawal-intense and brief
Methadone withdrawal-less acute and longer
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Common Questions (con’t)
Does Methadone interfere with good health? Methadone improves health
No effect on immune function, bone density, kidneys or liver
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Heroin Use v. Stabilized Methadone Maintenance: A Comparison
Topic Heroin MethadoneEffects on the Body
Onset of Action Seconds 30-90 minutes
Duration of Action 4-6 hours 24-36 hours
Route of Administration Injection, snorting, smoking Oral, in liquid form or
Dissolvable diskettes for medically maintained
patients
Frequency of Administration 4-6x/day 1x every 24 hours
Effective Dose Ever increasing Usually 80-120mg but
individually adjusted.Correctly stabilized patients do not need
adjustment unless medically indicated
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Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t)
Topic Heroin MethadoneEffects on Body
Overdose Potential High Very rare at blockage dose
Overall Safety Potentially lethal Non-toxic in opiate tolerant person
Potential for Abuse High Blocking dose prevents “high”
Withdrawal Within 3-4 hours After 24 hours
Physical Reaction Time Impaired Normal
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Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t)
Topic Heroin MethadoneEffects on the MindOn Mood Constant mood swings Stable mood if not suffering
other disorders
On Getting High Euphoria for 2 hours High is blocked
On tolerance Increasing tolerance Stabilized
On Cravings Recurring cravings Eliminated
On Intellectual Functioning Impaired Normal
Pain and Emotion Blunted Normal pain and range of emotions
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Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t)
Topic Heroin MethadoneEffects on Health
HIV Transmission High rate of transmission Reduced/eliminated withHepatitis C Transmission with needle use and unprotected oral ingestion and treatment
unprotected sex
Immune System for HIV+ Persons Rapid progression to AIDS Progression slowed
Immune/Endocrine System Impaired Normalized during treatmentFor HIV-Persons
Hypothalamus Pituitary Adrenal Axis Suppressed Normalized during treatment
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Heroin Use v. Stabilized Methadone Maintenance: A Comparison (con’t)
Topic Heroin MethadoneEffects on Social Functioning
Criminal Activity High level Reduced/eliminated
Personal Relationships Disrupted
Employment Deteriorating performance Full Functioningloss of employment
Community Relations Destructive impact, high Contributes to publiccrime, high death rate, safety, low mortality,transmission of disease increased health
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Sign and Symptoms of Withdrawal
Subjective: Cravings Anxiety Restlessness Irritability Difficulty sleeping
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Sign and Symptoms of Withdrawal
“Dose not holding” Thoughts of using Body aches and pains Nausea, sick to stomach Abdominal cramping Muscle cramping
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Signs and Symptoms of Withdrawal
Objective: Elevated BP Tachycardia Lacrimation Rhinorhea
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Signs and Symptoms of Withdrawal
Piloerection Vomiting Yawning Dilated Pupils
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What are the signs of a Methadone overdose?
Nausea and vomiting Constricted (small, pin-point) pupils Drowsiness Cold, clammy, bluish skin Reduced heart rate Reduced body temperature Slow or no breathing
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Methadone Maintenance
is notMethadone/Heroin Abuse
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ASAM & AAPM & APSConsensus Statement
“Addiction is a primary, chronic, neurologic disease with genetic, psychosocial and environmental factors influencing its
development and manifestations. It is characterized by behaviors that include one or
more of the following; impaired control over drug use, compulsive use, continued use despite
harm, and cravings.
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Consensus Statement (Cont’d)
Physical Dependence
Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal
syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood
level of the drug, and/or administration of an antagonist.
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AddictionCompulsive UseLoss of control
Continued use despite adverse consequences
Addiction has nothing to do with what medication one is taking
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DemographicsDrug Abuse in US
2.1 million abuse street drugs (heroin, cocaine, crack)
3.9 million abuse Rx drugs (pain meds, sedatives,
stimulants)
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Heroin Addiction
>977,000 heroin dependent individuals in the US in 2000
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Opioid Treatment Programs (OTP)…
How they are done
Methadone
LAAM
Buprenorphine
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Current Inventory of Regulated OTPs
1,000-1,200 Opioid Treatment Programs (OTPs) Certified by SAMHSA/CSAT Registered by DEA Licensed by State
950 Maintenance, 250 Detoxification
Approximately 205,000 Patients in Treatment
Center for Substance Abuse Treatment
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Methadone Maintenance Treatment
(MMT)
Most studied drug for the treatment of a disease in the history of the world
Used and effective for over 35 years Relieves sx of withdrawal and
cravings Allows normal functioning
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MMT (Cont’d)
Efficacy increased with On site medical support On site psychiatric support Supportive treatment services Urine toxicology
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Comorbidities
70% of patients in OMT-HCV positive.
40-50% of patients in OMT have serious depression and anxiety disorders.
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Length of Treatment
Research shows 80% relapse rate if MMT withdrawn within the first 12
months.
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Pharmacology of Methadone (Cont’d)
Hepatic metabolism (varies with individual)
Renal excretion
Basic, pka=9.2
Metabolized CYP3A4 (inducible)
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Pharmacology of Methadone (Cont’d)
Drugs that induce CYP3A4 ( serum methadone levels) rifampicin (Rifampin) carbamazepine (Tegretal) barbituates verapamil amitriptyline (Elavil) alcohol nevirapine
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Pharmacology of Methadone (Cont’d)
Drugs that Inhibit Metabolism ( serum methadone levels)
fluoxetine (Prozac) cimetidine (Tagamet) ketoconazole metronidazole (Flagyl) HIV meds
indinavir ritonavir saquinavir
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Federal Oversight of Methadone Treatment (OMT)
CSAT and SAMHSA - new accreditation system for MTP
Implemented May 18, 2001
All MTP will be accredited over the next 3 years.
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Who Can Offer Treatment?
Physicians employed by a licensed OTP
Physicians in private practice who register separately with DEA as a OTP
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MMT Program Phases
Intake Phase 1-30 days No takeouts 2 groups per week 1 individual
Phase I 30-90 days 1 takeout per week 2 groups per week 1 individual per week
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MMT Program Phases (Cont’d)
Phase II 91-180 days 2 takeouts per week 2 groups per week 2 individuals per months
Phase III 181-365 days 3 takeouts per week (no more than 2
days supply) if client has neg UDS for preceding 90 days
1 group per week 1 individual per week
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MMT Program Phases (Cont’d)
Phase IV > 1 year in treatment 4 takeouts per week (no more than 2
days supply at one time) if negative UDS preceding 90 days
2 groups per month 1 individual per month
Phase V > 2 years in treatment 5 take out (not to exceed 3 at 1 time)
UDS-negative 90 preceding days 1 group per month 1 individual per month
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MMT Program Phases (Cont’d)
Phase VI > 3 years in treatment 6 take outs per week - neg UDS for
past year 1 individual per month
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Methadone Maintenance at
The Center For Drug-Free Living
Orientation Stage of Recovery State I of Recovery Stage II of Recovery Stage III of Recovery
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Orientation Stage
Methadone Education Evaluation & Treatment (MEET) Orientation group HIV education Medication Education Fiscal Responsibility
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Orientation Stage (Cont’d)MEET Services
Group therapy training Social Development Treatment compliance Methadone and Your Health
Abstinence model of recovery Side effects of methadone Dosing When to taper? Medical/Surgical issues
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Orientation Stage (Cont’d)
Contact medical & psychiatric providers
Approved medication list
Encourage 12 step recovery - NA, MA
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Stage I of Recovery(Phase I & II)
Group Therapy- family issues, stress management, lifestyles changes, self esteem, financial stability, anger management, relapse prevention..
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Stage II of Recovery (Phase III & IV)
Groups - Relationships, advanced financial management
Support groups stronger - sponsorship, working steps
Relapse prevention
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Stage III of Recovery(Phase V & VI)
Self help becomes primary source of support
Consider taper off methadone Aftercare plans Relapse prevention plans
revised and practiced
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Continued Drug Abuse ofNon Opiates
Differential Diagnosis Opiate abstinence syndrome
(subclinical) Psychiatric Disorder Pain syndrome Polysubstance Abuse
refer to detox treatment services residential treatment
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“Methadone is the most effective method available for healing heroin
addiction.”
National Institute on Drug Abuse
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Thank You.