K A I L E E F R E T L A N D , P H A R M D , B C P S , N C P SC O M M A N D E R U N I T E D S T A T E S P U B L I C H E A L T H S E R V I C E

A C T I N G D I R E C T O R O F P H A R M A C YR E D L A K E H O S P I T A L

Medication Assisted TreatmentNaltrexone (Vivitrol®)

DISCLOSURE

� The speaker has no disclosures or conflicts of interest to disclose.

� Only FDA approved indication will be reviewed

INTEGRATED CARE

“The systematic coordination of general and behavioral healthcare. Integrating mental health,

substance abuse, and primary care services produces the best outcomes and proves the most effective

approach to caring for people with multiple healthcare needs.”

SAMSHA-HRSA Center for Integrated Care

http://www.integration.samhsa.gov/resource/what-is-integrated-care, accessed 11/7/16

INTEGRATED CARE

Medical Team

Mental Health Team

Addiction Support

Social and

Spiritual Support

INTEGRATED CARE

1. Holistic treatment including pharmacologic and non-pharmacologic

2. Meet patients where they are at3. Engagement – allow patient choices, emphasize

long-term

VIVITROL PROGRAM

� In 2016, Red Lake developed Medication Assisted Treatment Protocol¡ Naltrexone (Vivitrol) for Opioid Use Disorder¡ Pharmacy Collaborative Practice Agreement

� Goal: Support Recovery from Opioid Use Disorder� Collaboration between Red Lake Indian Health

Service and Red Lake Chemical Health

Why Naltrexone (Vivitrol®)

� Monthly IM injection indicated for Opioid Use Disorder and Alcohol Use Disorder

� Used to reduce craving and relapse� Fully blocks opioid receptors (antagonist), no

abuse potential and no overdose risk*� Must be fully detoxified off opioids for 7-10 days

or can precipitate acute withdrawal� No prescribing restrictions*considered opioid naïve after Vivitrol, higher risk of overdosing if returning to opioid use

VIVITROL PROGRAM

� Integrated Collaboration¡ Medical Team, Mental Health Team, Addiction Support

� Eligibility¡ Current ASAM assessment¡ Substance Use Disorder diagnosis¡ Detoxed from opioids, no risk of withdrawal (7-10 days since

last use)¡ Willingness to participate in holistic recovery program¡ Not Pregnant (highly recommend contraception planning)

Detox• 7-10 days opioid

free

Clean UDS• Oral Naltrexone

trial dose

Treatment• Vivitrol

Monthly

Chem HealthRule 25Comprehensive integrated program

Medical ExamDiagnosis of OUD

ReferralPharmacy VivitrolBH

VIVITROL PROGRAM

VIVITROL PROGRAM

� Withdrawal¡ Assessment for Withdrawal (COWS, SOWS)

� Laboratory Tests¡ UDS/toxicology screen¡ LFTs, Hep C, HIV¡ Pregnancy

� Informed Consent Form¡ Comprehensive documentation of program responsibilities

and risks¡ Reviewed by provider/pharmacist and patient¡ Signed prior to Vivitrol injection

VIVITROL PROGRAM

� Withdrawal Support¡ Provide withdrawal supportive medications

� Initiation of Vivitrol¡ Ensure 7-10 opioid free¡ UDS to confirm¡ Oral naltrexone 50mg test dose¡ Vivitrol IM injection¡ Observe for acute withdrawal symptoms (up to 1 hour)¡ Give appointment for 28 days

VIVITROL PROGRAM

� Monitoring¡ Routine LFTs, UDS, pregnancy

� Follow-up¡ Weekly follow-up for at initially with provider/pharmacist¡ ASAM recommended outpatient treatment plan¡ Monthly injections in clinic

� Dismissal or Discontinuation¡ If patient isn’t meeting required components – comprehensive

team should meet to reassess level of care¡ If patient chooses to stop Vivitrol – no tapering necessary

MAT Expansion

Expansion� Tribal Medication

Assisted Recovery Program

� Correctional Facility¡ SBIRT, Naltrexone

� Wellness Court� Pharmacy CPA

¡ Expanded to buprenorphine/naloxone and naltrexone

Future� Women’s Health –

perinatal support� OBOT program

¡ 2 Data Waived providers¡ 1 Anticipated

CONCLUSIONS

� Opioid use disorder is a disease that is treatable� Medication Assisted Treatment is effective when

used along with a comprehensive treatment program� Integrated care and multidisciplinary programs offer

supportive and accessible environments for patients to access care.

DISCUSSION

RESOURCES

Indian Health Service Opioid Dependence Management� http://www.ihs.gov/odmSubstance Abuse and Mental Health Services Administration (SAMHSA) � Opioid Overdose Toolkit: http://www.samhsa.gov� Behavioral Health Treatment Locator: https://findtreatment.samhsa.gov to search by address, city, or zip

code � Buprenorphine Treatment Physician Locator: http://www.samhsa.gov/medication-assisted-

treatment/physician-program-data/treatment-physician-locator� State Substance Abuse Agencies: https://findtreatment.samhsa.gov/TreatmentLocator/faces/about.jspxCenters for Disease Control and Prevention (CDC) � http://www.cdc.gov/drugoverdose/epidemic� http://www.cdc.gov/homeandrecreationalsafety/poisoningWhite House Office of National Drug Control Policy (ONDCP) � State and Local Information: http://www.whitehouse.gov/ondcp/state-mapAssociation of State and Territorial Health Officials � (ASTHO) ASTHO 214 Policy Inventory: State Action to Prevent and Treat Prescription Drug Abuse:

http://www.astho.org/rx/profiles/Rx-Survey-HighlightsNational Association of State Alcohol and Drug Abuse Directors (NASADAD)

� Overview of State Legislation to Increase Access to Treatment for Opioid Overdose: � http://nasadad.org/wp-content/uploads/2015/09/Opioid-Overdose-Policy-Brief-2015-Update-FINAL1.pdf American Association for the Treatment of Opioid Dependence (AATOD) � Prevalence of Prescription Opioid Abuse: http://www.aatodPrescribe to Prevent� http://www.prescribetoprevent.org