THE DISEASE OF OPIOID ADDICTION AND MEDICATION ASSISTED TREATMENT
Michele F. McCarthy, LPCC
Community & Government Liaison
Self Refind
OBJECTIVES
Learn about the state of opiate addiction today Discuss the impact of opiate abuse and
addiction Identify the currently available medication
assisted treatment options Explore the pros and cons of the available
treatments Discuss special considerations for working with
pregnant patients Review rights of patients in medication assisted
treatment
IS IT REALLY AN EPIDEMIC?
Epidemic is defined as:…attacking or affecting many persons simultaneously in a community or area…a widespread occurrence of a disease…a rapid development, spread, or growth of something, especially something unpleasant.
KENTUCKY ALL SCHEDULE PRESCRIPTION ELECTRONIC
REPORTING
KASPER QuarterlyTrend Reports for 2011 reflected that opiates accounted for an average of 57% and benzodiazepines accounted for an average of 28% of the top controlled substances that Kentucky doctors wrote prescriptions for.
SOURCE: KASPER QUARTERLY TREND REPORTS 2011
KASPER DATA 2011 In 2011 alone:
3,093,770 prescriptions were written for hydrocodone (up from 2,812,878 in 2009).
3,217,535 prescriptions were filled for hydrocodone.
852,085 prescriptions were written for oxycodone (up from 646,218 in 2009).
929,525 prescriptions were filled for oxycodone.
How many more were obtained out of state?
How many more were obtained illegally?
SOURCE: KASPER QUARTERLY TREND REPORTS 2011
OVERDOSE DEATHS ARE ON THE RISE… Drugs exceeded motor vehicle accidents as a cause
of death in 2009, killing at least 37,485 people nationwide, according to preliminary data from the U.S. Centers for Disease Control and Prevention.
The death toll has doubled in the last decade, now claiming a life every 14 minutes, making it the number one cause of preventable deaths.
Fueling the surge in deaths are prescription pain and anxiety drugs, which now cause more deaths than heroin and cocaine combined.
Los Angeles Times, September 2011
KENTUCKY MEDICAL EXAMINER 2011 REPORTTotal cases- 2378Overdose cases- 684
Alprazolam (Xanax)-286Oxycodone (Percocet)-213Hydrocodone (Lortab)-187Oxymorphone (opana)-154Alcohol-134Cocaine-31Methamphetamine-21
KENTUCKY HAS MORE TO WORRY ABOUT
KENTUCKY HAS MORE TO WORRY ABOUT
Although we have continued to see an increase in the prescribing and abuse of prescription opiates, this is not the only battle we are fighting.
Kentucky House Bill 1- 2012 Landmark legislation But if it does it’s job…
BENEFITS OF TREATMENT
Total cost of drug use disorders in the US is an est. $180 billion annually
$100,000 spent on treatment = avoided costs of $487,000 in healthcare and $700,000 in crime
Every $1 spent on treatment saves criminal justice $7 and when add in healthcare savings, the savings to cost ratio is 12:1
Employees treated for substance use have decreased absenteeism, tardiness, mistakes and on-the-job injuries
SAMHSA CSAT Cost Offset of Treatment Services, April 2009
MEDICATION ASSISTED TREATMENT OPTIONS
Methadone
Buprenorphine-Suboxone and Subutex
Naltrexone
MEDICATION ASSISTED TREATMENTSAMHSA defines MAT as:
“The use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful.”
WORLD HEALTH ORGANIZATION 2009 GUIDELINES
Efficacy of MAT v. placebo Methadone—opiate use, tx retention, 1/3
mortality rate, risk of HIV by 50% Buprenorphine—opiate use, tx retention,
morphine positive drug screens Naltrexone— in opiate use
Of the treatment options examined, opioid agonistmaintenance treatment, combined with psychosocialassistance, was found to be the most effective.
\\Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence, World Health Organization, 2009
METHADONE
Dolophine hydrochloride, Methadose
Schedule II narcotic
Long acting opioid analgesic (6-12 hours)
Full mu opioid agonist-binds and activates
MU OPIOID RECEPTOR ACTIVATION
mu receptor sitemu receptor site
Full agonistFull agonist eg, methadoneeg, methadone
Full activation Full activation of mu receptor of mu receptor
sitesiteeg, buprenorphineeg, buprenorphinePartial agonistPartial agonist
Partial activation of Partial activation of mu receptor sitemu receptor site
mu receptor sitemu receptor site
mu receptor mu receptor sitesite
eg, naltrexoneeg, naltrexoneAntagonistAntagonist
Prevents or reverses Prevents or reverses activation of mu receptor activation of mu receptor
sitesite
METHADONE
Long half-life (12-59 hours)- taken once daily or may be “split-dosed”
Administered orally- 5 and 10 mg tablets, 40 mg Disket and liquid
40 mg tablets (Disket) only available to treat opioid addiction (as of January 2008)
METHADONE BENEFITS
Right dose should not cause euphoric or tranquilizing effects.
Reduces/blocks effects of other opioids.Tolerance is slow to develop.Relieves cravings.Allows the individual to feel “normal”.
METHADONE BENEFITS
Improved employment status and family relationships.
Decrease in criminal activities.Decrease in high risk behaviors such
as IVDU = decrease in HIV and Hep. C.Improved health and health care.
METHADONE LIMITATIONS
Can only be dispensed/administered through an OTP.
Private can be expensive.Heavily regulated, lots of rules, can be
time consuming. Heavily stigmatized
METHADONE LIMITATIONS
Abuse liability and diversionIncreased risk when combined with
other drugs.Associated health complications*Detoxification can be difficult
BUPRENORPHINEDrug Addiction Treatment Act of 2000
(DATA 2000)In 2002, two forms were FDA
approved-Subutex and Suboxone, both made by Reckitt-Benckiser.
Schedule III narcoticOpioid analgesic with effects up to 6
hours.
BUPRENORPHINEPartial mu opioid agonist (ceiling effect)
but high affinityLong half-life (24-60 hours)Administered as sublingual tablet* or film
Subutex- 2 mg or 8 mg buprenorphine Suboxone- 2 mg bup + .5 mg naloxone
8 mg bup + 2 mg naloxone
MU OPIOID RECEPTOR ACTIVATION
mu receptor sitemu receptor site
Full agonistFull agonist eg, methadoneeg, methadone
Full activation Full activation of mu receptor of mu receptor
sitesiteeg, buprenorphineeg, buprenorphinePartial agonistPartial agonist
Partial activation of Partial activation of mu receptor sitemu receptor site
mu receptor sitemu receptor site
mu receptor mu receptor sitesite
eg, naltrexoneeg, naltrexoneAntagonistAntagonist
Prevents or reverses Prevents or reverses activation of mu receptor activation of mu receptor
sitesite
SUBUTEX
Contains buprenorphine only.Historically, minimally used in U.S.
except with pregnant women.Two generics now available.*Higher rate of diversion, can be
injected.
SUBOXONE
Naloxone added as means to decrease misuse.
Poor bioavailability sublingually, but if dissolved and injected, will precipitate withdrawal.
Reduced abuse potential.Film meant to provide added means to
combat diversion.
BUPRENORPHINE BENEFITS
Virtually no euphoric or tranquilizing effects.
Blocks effects of other opiates.Relieves cravings to use other
opiates.Allows “normal” function.
BUPRENORPHINE BENEFITS
Lower abuse liability and diversion potential.
Increased anonymity, less intrusive, less stigma.
Increased treatment options/access to treatment.
Here to Help Program
BUPRENORPHINE BENEFITS
Decrease in high-risk behaviors.Good “step down” option for those
tapering from methadone.Provides option for those that
cannot tolerate methadoneIs currently covered by Medicaid
BUPRENORPHINE LIMITATIONS
Can be expensive when self pay.Currently still no generic for Suboxone.Should not take if opiates still in
system.Counseling may not be available or
affordable in the same area as doctor.
BUPRENORPHINE LIMITATIONS
Not enough certified doctors or doctors willing to treat.
No regulations for OBOTs, only “practice guidelines”.
Potential for overdose of other opiates due to ceiling effect.
Abuse and diversion potential still exists.
NALTREXONE
Long half-life (up to 72 hours)
Opioid antagonist-binds, but blocks instead of activates
Is NOT an opiate
MU OPIOID RECEPTOR ACTIVATION
mu receptor sitemu receptor site
Full agonistFull agonist eg, methadoneeg, methadone
Full activation Full activation of mu receptor of mu receptor
sitesiteeg, buprenorphineeg, buprenorphinePartial agonistPartial agonist
Partial activation of Partial activation of mu receptor sitemu receptor site
mu receptor sitemu receptor site
mu receptor mu receptor sitesite
eg, naltrexoneeg, naltrexoneAntagonistAntagonist
Prevents or reverses Prevents or reverses activation of mu receptor activation of mu receptor
sitesite
NALTREXONE
Historically used primarily for alcohol due to blocking neurotransmitters believed to be involved with alcohol dependence.
Oral- ReVia, now genericInjectable- VivitrolImplant- not FDA approved
NALTREXONE TREATMENT
Medication is only one component.Average length of treatment is 3-9
months.Works best with highly motivated
patients.Injectable is a great option for
compliance issues or just for convenience.
NALTREXONE BENEFITS
Any physician can prescribe in any setting.
Injectable lasts for 30 days.Relatively inexpensive (oral) when
compared to Methadone or Bup.Non-narcotic, non-addictive, does not
produce dependence.
BENEFITS CONT.
More acceptance in abstinence-based programs.
Less stigma than methadone or buprenorphine.
In KY Medicaid covers, but only oral is 1st-tier; injectable is a 3rd-tier.
Received approval for use for opioid addiction in last year
NALTREXONE LIMITATIONS
Injection site reactions.Injectable very expensive for self pay.Poor compliance with oral version.Cannot have any opiates in system or
will precipitate withdrawal.Still not many doctors utilizing.
LIMITATIONS CONT.
Risk of overdose in attempt to break through blockade.
Not first choice for pregnant patients.
Breastfeeding is not recommended.Implant is NOT FDA approved.
MAT AND PREGNANCY
MAT AND PREGNANCY
“Cold turkey” detox may trigger miscarriage, pre-term labor.
Methadone has most research and is still preferred.
Subutex has shown very positive results- MOTHER Study.
Several reports of using Suboxone with positive results.
MAT AND PREGNANCY CONT.
Individualized approach, informed choiceDecreases/ceases cycles of intoxication
and withdrawalDecrease in high risk behaviorsOpportunity to address other factors-
mental health, social supports, basic needs
MAT AND PREGNANCY STANDARDSFederal
Prenatal care Gender-specific services
Additional state Medically able to participate Collaborate with OBGYN Post-partum care Nutrition, parenting, and weekly drug
screen
MAT & PREGNANCY STANDARDSCARF and Joint Commission
Priority admissionCounseling for DV, trauma, women’s
healthAppropriate medication dosageEducate on MSW- should NOT be initiated
before 14 weeks or after 32 weeksEncourage breastfeeding (unless
contraindicated)
KEY POINTS TO REMEMBEROpiate addiction is a disease, an epidemic. There is no cure, but we do have options and
we need to take advantage of all of them.Treatment is not “one size fits all.”Just as addiction is lifelong, so is the recovery
processChances of maintained recovery significantly
increase when combined with counseling, drug screens, medication call backs, etc.
KEY POINTS TO REMEMBER
No “perfect” medication that is one size fits all.
Medication is a tool, not a “cure”.MAT may be appropriate for pregnant
women but must be closely monitored and have informed consent.
MAT is a legal, valid, and widely researched evidence-based treatment for addiction.
Individuals receiving MAT are in recovery!
CONTACT INFORMATION
Michele F. McCarthyGovernment & Community Liaison
Self [email protected]
859-605-6387www.selfrefind.com