Medically Assisted Treatment

Orman HallSupreme Court of Ohio

NACM Annual ConferenceJuly 12 – 16, 2015

Prescription Opiate and Heroin AddictionIn Ohio

Important Opiate Effects

•Analgesia•Euphoria•Respiratory Depression•Rapid Increase in Tolerance•Rapid Decrease in Tolerance•Overdose

Distribution Rates of Prescription Opioids in Grams per 100,000 population, Ohio, 1997-20111-3

Opioid analgesic grams distributed

Unintentional Drug Overdoses & Distribution Rates of Prescription Opioids in Grams per 100,000 population,

Ohio, 1997-20111-3

Epidemics of Unintentional Drug Overdoses in Ohio, 1979-20121,2,3

Source: 1WONDER (NCHS Compressed Mortality File, 1979-1998 & 1999-2005) 22006-2011 ODH Office of Vital Statistics, 3Change from ICD-9 to ICD-10 coding in 1999 (caution in comparing before and after 1998 and 1999)

Prescription drugs led to a larger overdose epidemic than illicit drugs ever have. Prescription

Pain Medication (Opioids)

Crack Cocaine

Heroin

Heroin & Rx Opioids

Percentage of AoD Clients with an Opiate Diagnosis: SFY 2001 through SFY 2012

Perc

enta

ge

Medication Assisted Treatment

Medications Available for the Treatment of Opiate Addiction

Methadone

Buprenorphine

Naltrexone

MethadoneFull Agonist MedicationLicensed in early 1970’sThe most regulated and researched addiction treatment in history, andThe most misunderstood treatment ever.

What’s a good Methadone Program?Release of information for all providers,Frequent urine or other tox screening,CounselingFlexible treatment plan that embraces harm reduction or abstinenceDiscourage use of other controlled substancesIncreasing intnesity of treatment over time if patient is not compliant

Buprenorphine

Partial Agonist MedicationLicensed in 2002Combined with Naloxone to discourage abuseCeiling Effect Overdose less likely than Methadone

What’s a good Buprenorphine Program?Release of information for all providers,Frequent urine screens,Counseling,Dose <=16mgNo other controlled substances should be allowedIncreasing intensity of treatment over time if non-adherent.Accepts insurance payments for visits.

Naltrexone

Antagonist MedicationAvailable in oral and extended release shot (Vivitrol)Blocks opiate effectsHas no opiate effects

Extended Release AdvantagesApproved for alcohol dependence in 2006 and opiate dependence in 2010Most useful for motivated patients who have undergone detoxification and need support to avoid relapseOnce monthly injection

100

90

80

70

60

50

40

30

20

10

0-10 -9 -8 -7 -6 -5 -4

%Efficacy

Log Dose of Opioid

Full AgonistMorphine, Oxycodone

METHADONE

Partial AgonistBuprenorphine

AntagonistNaloxone, Naltrexone

Opioid Intrinsic Activity

Opioid effect Analgesia Sedation Respiratory

depression

Questions?