Medication-Assisted Treatment Medication-Assisted Treatment (MAT) (MAT)

for Criminal Justice Populationsfor Criminal Justice Populations

[Insert trainer Name and affiliation [Insert trainer Name and affiliation information here]information here]

Goals of Today’s TrainingGoals of Today’s TrainingAfter this training, you will be familiar with:After this training, you will be familiar with:

AddictionAddiction and how it affects the brainand how it affects the braindopamine and the reward pathwaydopamine and the reward pathway

MedicationsMedications for addiction treatmentfor addiction treatmenthow they work & what they dohow they work & what they do

BenefitsBenefits of addiction treatment to the CJ Systemof addiction treatment to the CJ System

LogisticsLogistics of referring an offenderof referring an offendertypes of clients to look fortypes of clients to look foragencies where MAT is offeredagencies where MAT is offered

• Using medication to treat addiction is a Using medication to treat addiction is a good idea good idea becausebecause......

An Open Conversation about MATAn Open Conversation about MAT

• Using medication in addiction treatment is a Using medication in addiction treatment is a not-so-good idea becausenot-so-good idea because……

• I refer clientsI refer clients to addiction treatment to addiction treatment

becausebecause……

An Open Conversation About MATAn Open Conversation About MATConcerns about MAT?Concerns about MAT?

– The medications?The medications?• Methadone Methadone • Diversion Diversion

– The clinics?The clinics?• ““Bad” methadone clinicsBad” methadone clinics• Attracting dealers and crimeAttracting dealers and crime• Therapeutic communities don’t allow MAT Therapeutic communities don’t allow MAT

MAT Myth Busters: MAT Myth Busters: Myth #1Myth #1““Medication is not a part of treatment.”Medication is not a part of treatment.”

Medication can be an effective part of treatment.Medication can be an effective part of treatment.

Medication is used in the Medication is used in the treatment of many treatment of many diseasesdiseases, including addiction. , including addiction.

Medical decisions must be made by trained and Medical decisions must be made by trained and certified medical providers.certified medical providers.

Decisions about using medications are based on an Decisions about using medications are based on an objective assessment of the individual client’s objective assessment of the individual client’s needs.needs.

““Medicines are drugs, too.”Medicines are drugs, too.”

DrugsDrugs are used to are used to get highget high, but , but medicationsmedications are used to are used to get betterget better. .

MAT Myth Busters:MAT Myth Busters: Myth #2Myth #2

MedicineMedicine (n.) an innovation of the human (n.) an innovation of the human species which has given us a competitive species which has given us a competitive advantage for thousands of years; advantage for thousands of years; innovations in science & medicine have innovations in science & medicine have historically been helpful and progressive.historically been helpful and progressive.

MedicineMedicine (n.) an innovation of the human (n.) an innovation of the human species which has given us a competitive species which has given us a competitive advantage for thousands of years; advantage for thousands of years; innovations in science & medicine have innovations in science & medicine have historically been helpful and progressive.historically been helpful and progressive.

Errors in Language:Errors in Language:

Physical Dependence vs AddictionPhysical Dependence vs Addiction

Errors in Language:Errors in Language:

Physical Dependence vs AddictionPhysical Dependence vs Addiction

““Alcoholics Anonymous (AA) & Narcotics Anonymous Alcoholics Anonymous (AA) & Narcotics Anonymous (NA) do not support the use of medications.”(NA) do not support the use of medications.”

While some specific NA chapters While some specific NA chapters are not tolerant of methadone, are not tolerant of methadone, AA/NA literature and founding AA/NA literature and founding members did not speak or write members did not speak or write against using medications.against using medications.

MAT Myth Busters:MAT Myth Busters: Myth #3Myth #3

The Clinician’s IllusionThe Clinician’s Illusion After After Cohen & Cohen Arch Gen Psych 1984Cohen & Cohen Arch Gen Psych 1984

• MAT medications had to demonstrate the MAT medications had to demonstrate the same level same level of effectivenessof effectiveness as all other types of medications for as all other types of medications for other diseases to get FDA approval.other diseases to get FDA approval.

• We tend to have a biased perceptionWe tend to have a biased perception::– Patients who improve, leave and are forgottenPatients who improve, leave and are forgotten– Patients who do Patients who do notnot improve return frequently and improve return frequently and

are rememberedare remembered• Leads us to think that most patients do not improveLeads us to think that most patients do not improve

……contrary to scientific data.contrary to scientific data.

““MAT is not effective.”MAT is not effective.”

MAT Myth Busters:MAT Myth Busters: Myth #4Myth #4

Reasons include:Reasons include:– peer pressure peer pressure – familial pressurefamilial pressure– tensions of daily lifetensions of daily life– few job opportunitiesfew job opportunities– lack of safe housinglack of safe housing

““Clients who are not using drugs at present Clients who are not using drugs at present do not need MAT.”do not need MAT.”

– isolationisolation– disillusionment & apathydisillusionment & apathy– the stress of complying the stress of complying

with correctional with correctional supervision supervision

More than half of inmates More than half of inmates

will relapse will relapse

within within one monthone month of release. of release.

More than half of inmates More than half of inmates

will relapse will relapse

within within one monthone month of release. of release.

MAT Myth Busters:MAT Myth Busters: Myth #5Myth #5

As you may already know,As you may already know,a client who is abstinent now a client who is abstinent now

may may not remain so forevernot remain so forever..

AddictionAddiction is is notnot a common cold, a common cold,so, so,

itit must notmust not be treated like one. be treated like one.

As you may already know,As you may already know,a client who is abstinent now a client who is abstinent now

may may not remain so forevernot remain so forever..

AddictionAddiction is is notnot a common cold, a common cold,so, so,

itit must notmust not be treated like one. be treated like one.

WHY?WHY?WHY?WHY?

Should abstinent clients Should abstinent clients be omitted from MAT? be omitted from MAT?

Should abstinent clients Should abstinent clients be omitted from MAT? be omitted from MAT?

Addiction is…Addiction is…

A CHRONIC DISEASEA CHRONIC DISEASE

The Brain: Hijacked!The Brain: Hijacked!

The Science Behind AddictionThe Science Behind Addiction

CanCan the brain get hijacked? the brain get hijacked?ResearchResearch shows…shows…ResearchResearch shows…shows…

that prolonged drug use canthat prolonged drug use can change brain chemistry.change brain chemistry.that prolonged drug use canthat prolonged drug use can change brain chemistry.change brain chemistry.

Addictive Drugs Can Cause Long-Lasting Changes in the Brain

First, let’s take a look atFirst, let’s take a look at Opioid AddictionOpioid Addiction

Some Examples:Some Examples:– MorphineMorphine– HeroinHeroin– CodeineCodeine

disrupts normal Dopamine functioning.disrupts normal Dopamine functioning.disrupts normal Dopamine functioning.disrupts normal Dopamine functioning.

HowHow can the brain get hijacked can the brain get hijacked by opioids?by opioids?

HowHow can the brain get hijacked can the brain get hijacked by opioids?by opioids?

Opioid use…Opioid use…Opioid use…Opioid use…

Let’s take a look at Let’s take a look at

Dopamine FunctioningDopamine Functioning

Working NormallyWorking Normally, it produces , it produces feelings of feelings of pleasurepleasure and is involved in and is involved in decision decision makingmaking..

Working AbnormallyWorking Abnormally, leads to , leads to cravingscravings, , depressiondepression, , difficulties with decision difficulties with decision makingmaking and and memory problemsmemory problems..

What Is Dopamine?What Is Dopamine?

A hormone A hormone A neurotransmitterA neurotransmitter

What Is Dopamine?What Is Dopamine?

A hormone A hormone A neurotransmitterA neurotransmitter

Abnormal Dopamine FunctioningAbnormal Dopamine FunctioningAbnormal Dopamine FunctioningAbnormal Dopamine Functioning

00100100200200300300400400500500600600700700800800900900

1000100011001100

00 11 22 33 44 5 hr5 hr

Time After AmphetamineTime After Amphetamine

% o

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DADADOPACDOPACHVAHVA

AccumbensAccumbens AMPHETAMINEAMPHETAMINE

00

100100

200200

300300

400400

00 11 22 33 44 5 hr5 hrTime After CocaineTime After Cocaine

% o

f B

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DADADOPACDOPACHVAHVA

AccumbensAccumbensCOCAINECOCAINE

00

100100

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00 11 22 3 hr3 hr

Time After NicotineTime After Nicotine

% o

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% o

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AccumbensAccumbensCaudateCaudate

NICOTINENICOTINE

100100

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00 11 22 33 4hr4hrTime After EthanolTime After Ethanol

% o

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00

Dose (g/kg ip)Dose (g/kg ip)

ALCOHOLALCOHOLALCOHOLALCOHOL

Abnormal Dopamine FunctioningAbnormal Dopamine Functioning

CocaineCocaine

FoodFood

Ac t

i vit

y o

f R

e war

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yst e

m

METHMETH

AlcoholAlcohol

con

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Less

The good news is…The good news is…

OpioidOpioid AddictionAddiction isis

aa treatabletreatable diseasedisease..

Courtesy of Partnership for a Drug Free America.

How can we How can we treattreat opioid addiction? opioid addiction?

The person must learn The person must learn new ways of coping new ways of coping

andand

The brain changes must be addressedThe brain changes must be addressed

We know of We know of 3 ways3 ways::

1. Avoid1. Avoid the drug the drug……using coping using coping

strategiesstrategies

2. Replace2. Replace associations associations …using therapy…using therapy

3. Directly addressing3. Directly addressing the the neural neural effects effects of theof the drug drug

……using using medicationmedication

ThusThus,, MATMAT can can help the person to help the person to

function more normallyfunction more normally

MMedicationedication cancan address many of the changes address many of the changes

caused in the braincaused in the brain..MMedicationedication cancan address many of the changes address many of the changes

caused in the braincaused in the brain..

Facilitating the process ofFacilitating the process ofrecovery.recovery.

Facilitating the process ofFacilitating the process ofrecovery.recovery.

How do medications for How do medications for opioid addiction work?opioid addiction work?

There areThere are three types three types of medications that of medications that can can blockblock the “high”: the “high”:

– AgonistsAgonists- produce opioid effects- produce opioid effects

– Partial AgonistsPartial Agonists- produce moderate opioid effects- produce moderate opioid effects

– AntagonistsAntagonists- block opioid effects- block opioid effects

Dose of Opioid

OpioidEffect

Full Agonist(e.g., methadone)

(e.g. Naloxone)Antagonist

Partial Agonist(e.g. buprenorphine)

How do medications for How do medications for opioid addiction work?opioid addiction work?

Example of a CJ client who could Example of a CJ client who could benefit from MAT for opioidsbenefit from MAT for opioids

• Male heroin addict, mid-30’sMale heroin addict, mid-30’s• Also does speedballs (heroin and Also does speedballs (heroin and

cocaine) during robberiescocaine) during robberies• Early CJ involvementEarly CJ involvement• Early cigarette and AOD useEarly cigarette and AOD use• Repeated arrests and incarcerationsRepeated arrests and incarcerations• Treatment failuresTreatment failures• Daily criminal activity to support his Daily criminal activity to support his

habithabit

Example of a CJ client who could Example of a CJ client who could benefit from MAT for opioidsbenefit from MAT for opioids

• Female heroin addict, mid-30sFemale heroin addict, mid-30s• Early cigarette and AOD useEarly cigarette and AOD use• Mental health problems & trauma Mental health problems & trauma • Has children in kin foster careHas children in kin foster care• Repeated arrest history mostly related to prostitution and Repeated arrest history mostly related to prostitution and

shop lifting shop lifting • Non-medication treatment failuresNon-medication treatment failures• Extensive involvement with child protective servicesExtensive involvement with child protective services• Recent relapse and incarceration after year of abstinenceRecent relapse and incarceration after year of abstinence• Strong desire to stop using and get kids backStrong desire to stop using and get kids back

• Pregnant womanPregnant woman• Shoots heroin daily Shoots heroin daily • Failed treatmentsFailed treatments• Repeated arrest history mostly related to Repeated arrest history mostly related to

prostitution and shop liftingprostitution and shop lifting

Example of a CJ client who could Example of a CJ client who could benefit from MAT for opioidsbenefit from MAT for opioids

Now, let’s take a look atNow, let’s take a look at Alcohol AddictionAlcohol Addiction

How can the brain get hijacked byHow can the brain get hijacked by Alcohol Addiction?Alcohol Addiction?

dopamine dopamine makes you makes you

happyhappy

glutamate glutamate excitatoryexcitatory

neurotransmitterneurotransmitter…speeds you …speeds you

upup

GABA GABA inhibitoryinhibitory

neurotransmitterneurotransmitter…slows you …slows you

downdown

endogenous endogenous opioidsopioids make you make you

euphoric and euphoric and feel no painfeel no pain

The CastThe CastThe CastThe Cast

Alcohol in the BrainAlcohol in the Brain

First, First, alcoholalcohol is consumed is consumed

Second, Second, endogenous opioidsendogenous opioids are released are released

Third, Third, dopaminedopamine is released is released

The brain remembers the good The brain remembers the good feelings produced by feelings produced by endogenous opioidsendogenous opioids and and dopaminedopamine in the reward pathway, in the reward pathway,

and then desires to repeat and then desires to repeat the the behavior to get the same behavior to get the same good good feelings.feelings.

Thus, Thus, the reward pathwaythe reward pathway is out of is out of balance!balance!

An imbalance in the brain is createdAn imbalance in the brain is created

-as -as GABAGABA is increased is increased

So, the brain slows downSo, the brain slows down

-as -as glutamateglutamate is over- is over-ridden by ridden by GABAGABA

And in response, the brain up-regulates And in response, the brain up-regulates --as the brain tries to as the brain tries to

correct for the correct for the imbalanceimbalance by increasing by increasing sensitivity to sensitivity to glutamateglutamate

An imbalance in the brain is createdAn imbalance in the brain is created

-as -as GABAGABA is increased is increased

So, the brain slows downSo, the brain slows down

-as -as glutamateglutamate is over- is over-ridden by ridden by GABAGABA

And in response, the brain up-regulates And in response, the brain up-regulates --as the brain tries to as the brain tries to

correct for the correct for the imbalanceimbalance by increasing by increasing sensitivity to sensitivity to glutamateglutamate

At the same time…At the same time…

As the brain desired, the up-regulation As the brain desired, the up-regulation works, and the imbalance is corrected. works, and the imbalance is corrected.

Now, if the individual drinks, it takes more Now, if the individual drinks, it takes more alcohol to override the glutamate alcohol to override the glutamate system again and feel the same level system again and feel the same level of intoxication.of intoxication.

This effect is knownThis effect is known asas

Tolerance.Tolerance.

As the brain desired, the up-regulation As the brain desired, the up-regulation works, and the imbalance is corrected. works, and the imbalance is corrected.

Now, if the individual drinks, it takes more Now, if the individual drinks, it takes more alcohol to override the glutamate alcohol to override the glutamate system again and feel the same level system again and feel the same level of intoxication.of intoxication.

This effect is knownThis effect is known asas

Tolerance.Tolerance.

With an unbalanced With an unbalanced reward pathwayreward pathway and an increasingly high and an increasingly high

tolerancetolerance……

The person is The person is developingdeveloping

symptoms of symptoms of

ADDICTIONADDICTION..ADDICTIONADDICTION..

The good news is…The good news is…

AlcoholAlcohol addictionaddiction isis

aa treatabletreatable diseasedisease..

Courtesy of Partnership for a Drug Free America.

How can we treat How can we treat Alcohol Addiction?Alcohol Addiction?

MedicationsMedications for alcoholism can: for alcoholism can:

–ReduceReduce post-acute withdrawal post-acute withdrawal

–Block or easeBlock or ease euphoria from alcohol euphoria from alcohol

–DiscourageDiscourage drinking by creating an drinking by creating an unpleasant association with alcoholunpleasant association with alcohol

Example CJ client who could Example CJ client who could benefit from MAT for alcoholismbenefit from MAT for alcoholism

Male alcoholic, mid-40sMale alcoholic, mid-40sEarly cigarette and alcohol useEarly cigarette and alcohol useHistory of DUIs and violenceHistory of DUIs and violence Intimate partner violenceIntimate partner violenceTreatment failureTreatment failureStrongly desires helpStrongly desires help

Example of a CJ client who could Example of a CJ client who could benefit from MAT for alcoholismbenefit from MAT for alcoholism

• Female, mid-30’sFemale, mid-30’s• Arrested for 4Arrested for 4thth DUI DUI• 3 previous treatment 3 previous treatment

episodes each with about 1 episodes each with about 1 year of abstinence afterwordyear of abstinence afterword

• Has been trying to get Has been trying to get pregnant for about a year.pregnant for about a year.

• Wants to stay away from Wants to stay away from alcohol for the baby, but is alcohol for the baby, but is frequently relapsingfrequently relapsing

The MedicationsThe MedicationsFor Opioid Addiction:For Opioid Addiction:

• MethadoneMethadone

• BuprenorphineBuprenorphine

• NaltrexoneNaltrexone

For Alcohol Addiction:For Alcohol Addiction:

• NaltrexoneNaltrexone• AcamprosateAcamprosate• DisulfiramDisulfiram

For Alcohol Addiction:For Alcohol Addiction:

• NaltrexoneNaltrexone• AcamprosateAcamprosate• DisulfiramDisulfiram

The MedicationsThe MedicationsFor Opioid Addiction:For Opioid Addiction:

•MethadoneMethadone•BuprenorphineBuprenorphine

•NaltrexoneNaltrexone

For Alcohol Addiction:For Alcohol Addiction:

•NaltrexoneNaltrexone

•AcamprosateAcamprosate

•DisulfiramDisulfiram

For Alcohol Addiction:For Alcohol Addiction:

•NaltrexoneNaltrexone

•AcamprosateAcamprosate

•DisulfiramDisulfiram

MethadoneMethadoneMethadoneMethadone

MethadoneMethadone-Alleviates withdrawal & blocks euphoria. -Alleviates withdrawal & blocks euphoria.

-Is used for detoxification or maintenance.-Is used for detoxification or maintenance.

-Also known as:-Also known as:-Methadose-Methadose-Dolophine-Dolophine

-Approved: -Approved: 19641964

-Third-Party Payer Acceptance: -Third-Party Payer Acceptance: Covered by most major Covered by most major insurance carriers, Medicare, Medicaid and the VA.insurance carriers, Medicare, Medicaid and the VA.

How does Methadone Work? How does Methadone Work? Full AgonistFull Agonist

Dose of Opioid

OpioidEffect

Full Agonist(e.g., methadone)

(e.g. Naloxone)Antagonist

Partial Agonist(e.g. buprenorphine)

Methadone is the most studied Methadone is the most studied medication for opioid addiction.medication for opioid addiction.– 8-10 fold reduction in death rate8-10 fold reduction in death rate– Reduces opioid useReduces opioid use– Reduces crimeReduces crime– Improves family and social functioningImproves family and social functioning– Increases likelihood of employmentIncreases likelihood of employment– Improves physical and mental healthImproves physical and mental health– Reduces spread of HIVReduces spread of HIV– Low drop-out rate compared to other treatments Low drop-out rate compared to other treatments

What does the research say?What does the research say?

Crime before and during Methadone Crime before and during Methadone Treatment at 6 programsTreatment at 6 programs

0

50

100

150

200

250

300

A B C D E F

Before TX

During TX

Cri

me

Day

s P

er Y

ear

High Rate of Relapse to IV drug use after High Rate of Relapse to IV drug use after drop-out from Methadone Treatmentdrop-out from Methadone Treatment

28.9

45.5

57.6

72.282.1

0

20

40

60

80

100

IN 1 to 3 4 to 6 7 to 9 10 to 12

Pe

rce

nt

IV U

se

rs

Treatment Months Since Stopping Treatment

The MedicationsThe MedicationsFor Opiate Addiction:For Opiate Addiction:

•MethadoneMethadone

•BuprenorphineBuprenorphine•NaltrexoneNaltrexone

For Alcohol Addiction:For Alcohol Addiction:

•NaltrexoneNaltrexone

•AcamprosateAcamprosate

•DisulfiramDisulfiram

For Alcohol Addiction:For Alcohol Addiction:

•NaltrexoneNaltrexone

•AcamprosateAcamprosate

•DisulfiramDisulfiram

BuprenorphineBuprenorphineBuprenorphineBuprenorphine

BuprenorphineBuprenorphine• Available by prescription outside of Methadone Available by prescription outside of Methadone

Treatment ProgramsTreatment Programs• Only physicians with special training and waiver Only physicians with special training and waiver

can prescribecan prescribe• Also known as:Also known as:

– Subutex® Subutex® – Suboxone® (buprenorphine/naloxone) Suboxone® (buprenorphine/naloxone)

• FDA-approved:FDA-approved: 2002 2002

Buprenorphine/Naloxone Buprenorphine/Naloxone “the Combo Tablet”“the Combo Tablet”

Preserves bupe’s effects when taken Preserves bupe’s effects when taken sublingually at optimal ratiosublingually at optimal ratio

Action, safety & efficacy Action, safety & efficacy samesame as bupe alone as bupe alone

– Also contains Naloxone (same as Narcan used to Also contains Naloxone (same as Narcan used to reverse OD) - inert unless injectedreverse OD) - inert unless injected

– Discourages IV use, diversionDiscourages IV use, diversion

– Allows for take-home dosingAllows for take-home dosing

– Dysphoric effects if injected by physically dependent Dysphoric effects if injected by physically dependent personspersons

Partial AgonistPartial Agonist

Dose of Opiate

OpiateEffect

Full Agonist(e.g., methadone)

(e.g. Naloxone)Antagonist

Partial Agonist(e.g. buprenorphine)

How Does Buprenorphine Work?How Does Buprenorphine Work?

How Does Buprenorphine Work?How Does Buprenorphine Work?

It’s a Partial Agonist.It’s a Partial Agonist.– Agonist effect Agonist effect helps the patient to feel helps the patient to feel

normal, without craving or withdrawalnormal, without craving or withdrawal

– Binds stronglyBinds strongly to opiate receptor to opiate receptor

– Blocks opiate effectsBlocks opiate effects

– Ceiling effect at higher dosesCeiling effect at higher doses

• Safer than methadone or other full Safer than methadone or other full agonistsagonists

Some Advantages of BuprenorphineSome Advantages of Buprenorphine

• Available through a physician office or non-Available through a physician office or non-methadone clinicmethadone clinic

• Easier to keep job, participate in other Easier to keep job, participate in other activitiesactivities

• Lower level of physical dependenceLower level of physical dependence

• Limited potential for overdoseLimited potential for overdose

• Minimal subjective effects (e.g., sedation)Minimal subjective effects (e.g., sedation)

Some Disadvantages of BuprenorphineSome Disadvantages of Buprenorphine

1.1. Greater medication costGreater medication cost

2.2. Lower level of physical dependenceLower level of physical dependence

-i.e., patients can discontinue treatment-i.e., patients can discontinue treatment

3.3. Not detectable in most urine toxicology Not detectable in most urine toxicology screeningsscreenings

What does the research say?What does the research say?

Over Over 25 years25 years of research and of research and over over 5,000 patients5,000 patients exposed exposed during clinical trials, show thatduring clinical trials, show that

Buprenorphine is a Buprenorphine is a safe safe and effective treatment and effective treatment

for opioid addiction.for opioid addiction.

Buprenorphine is a Buprenorphine is a safe safe and effective treatment and effective treatment

for opioid addiction.for opioid addiction.

What does the research say?What does the research say?

-Buprenorphine is about as effective -Buprenorphine is about as effective as 60 mg daily of methadone.as 60 mg daily of methadone.

-In one study,-In one study, after a year of bupe plus counseling,after a year of bupe plus counseling,

75%75% of patients were retained, of patients were retained, compared to compared to 0%0% in a placebo plus counseling in a placebo plus counseling condition.condition.

The MedicationsThe MedicationsFor Opiate Addiction:For Opiate Addiction:

•MethadoneMethadone

•BuprenorphineBuprenorphine

•NaltrexoneNaltrexone

For Alcohol Addiction:For Alcohol Addiction:

•NaltrexoneNaltrexone•AcamprosateAcamprosate

•DisulfiramDisulfiram

For Alcohol Addiction:For Alcohol Addiction:

•NaltrexoneNaltrexone•AcamprosateAcamprosate

•DisulfiramDisulfiram

NaltrexoneNaltrexoneNaltrexoneNaltrexone

Naltrexone Naltrexone *Used to treat *Used to treat opiateopiate andand alcoholalcohol addiction. addiction.

Trade Names/FormulationsTrade Names/Formulations DepadeDepade oral tablets oral tablets ReViaReVia oral tablets oral tablets VivitrolVivitrol Extended-release naltrexone Extended-release naltrexone

NaltrexoneNaltrexoneAddictive Properties:Addictive Properties: Not addictive and no withdrawal symptoms. Not addictive and no withdrawal symptoms.

Oral formulations:Oral formulations:

Cost:Cost: $110.68 per month, which is around $ $110.68 per month, which is around $3.693.69 a day. a day.6969

Third-Party Payer Acceptance: Third-Party Payer Acceptance: Covered by most major Covered by most major insurance carriers, Medicare, Medicaid, and the VA.insurance carriers, Medicare, Medicaid, and the VA.6868

Long-acting injectable formulation:Long-acting injectable formulation:

Cost: Cost: $866.46 per month, which is around $28.88 per day (injectors $866.46 per month, which is around $28.88 per day (injectors fee not included).fee not included).

Third-Party Payer Acceptance: Third-Party Payer Acceptance: Approximately 90% of patients thus Approximately 90% of patients thus far have received insurance coverage with no restrictions. In far have received insurance coverage with no restrictions. In addition, extended-release naltrexone now has a J code for payors.addition, extended-release naltrexone now has a J code for payors.

How Does Naltrexone Work?How Does Naltrexone Work? AntagonistAntagonist

Dose of Opiate

OpiateEffect

Full Agonist(e.g., methadone)

(e.g. Naloxone)Antagonist

Partial Agonist(e.g. buprenorphine)

NN = naltrexone

It’s an antagonist.It’s an antagonist.

How How DoesDoes Naltrexone Work? Naltrexone Work?

1)1) It blocks opioid It blocks opioid receptors,receptors,

2)2) the reinforcing “reward” the reinforcing “reward” effects from dopamine effects from dopamine are reduced,are reduced,

3)3) drug consumption is thus drug consumption is thus reduced.reduced.

OpioidReceptor

Post-Synaptic Neuron

NNNNNN

NN

NN

NNNN

NN

= opioids

What does the research say?What does the research say?

Naltrexone is effective for opiate and alcohol addiction.Naltrexone is effective for opiate and alcohol addiction.

• Reduces risk of re-imprisonmentReduces risk of re-imprisonment

• Lowers risk of opiate use, with or without Lowers risk of opiate use, with or without psychological support psychological support

• Extended-release naltrexone addresses the Extended-release naltrexone addresses the issue of patient complianceissue of patient compliance

What does the research say?What does the research say?

• Naltrexone for opiates was well tolerated and Naltrexone for opiates was well tolerated and associated with a significant abstinence rate.associated with a significant abstinence rate.

• In a five-year follow up study, naltrexone with In a five-year follow up study, naltrexone with behavioral therapy for opiates saw behavioral therapy for opiates saw improvements in drug use, days of improvements in drug use, days of depressant use, legal status, and psychiatric depressant use, legal status, and psychiatric factor.factor.

The MedicationsThe MedicationsFor Opiate Addiction:For Opiate Addiction:

•MethadoneMethadone

•BuprenorphineBuprenorphine

•NaltrexoneNaltrexone

For For AlcoholAlcohol Addiction: Addiction:

•NaltrexoneNaltrexone•AcamprosateAcamprosate

•DisulfiramDisulfiram

For For AlcoholAlcohol Addiction: Addiction:

•NaltrexoneNaltrexone•AcamprosateAcamprosate

•DisulfiramDisulfiram

NaltrexoneNaltrexoneNaltrexoneNaltrexone

In two studies, participants treated with naltrexone had a In two studies, participants treated with naltrexone had a greater greater reduction in relapsereduction in relapse during the entire study than those treated with during the entire study than those treated with placebo.placebo.

* statistically significant

23%

54%

0%

10%

20%

30%

40%

50%

60%

Percentage of

Participants Who

Relapsed During the

Study

naltrexone group placebo group

Reduction in Relapse - Volpicelli et al. Study*

What does What does the researchthe research say? say?

Percentage of

participants who

relapsed during the

study

Percentage of

participants who

relapsed during the

study

Participants treated with extended-release naltrexone had a Participants treated with extended-release naltrexone had a greater reduction in the number of heavy drinking daysgreater reduction in the number of heavy drinking days during the entire study than those treated with placebo.during the entire study than those treated with placebo.

19.3

6.0

3.1

0

2

4

6

8

10

12

14

16

18

20

Median Heavy

Drinking Days Per

Month

baseline placebo extended-release

naltrexone

Reduction in Heavy Drinking Days*

* statistically significant

What does What does the researchthe research say? say?

The MedicationsThe MedicationsFor Opiate Addiction:For Opiate Addiction:

•MethadoneMethadone

•BuprenorphineBuprenorphine

•NaltrexoneNaltrexone

For Alcohol Addiction:For Alcohol Addiction:

•NaltrexoneNaltrexone

•AcamprosateAcamprosate•DisulframDisulfram

For Alcohol Addiction:For Alcohol Addiction:

•NaltrexoneNaltrexone

•AcamprosateAcamprosate•DisulframDisulfram

AcamprosateAcamprosateAcamprosateAcamprosate

AcamprosateAcamprosate Reduces post-acute alcohol withdrawal symptoms.Reduces post-acute alcohol withdrawal symptoms.

Is used for maintenance of abstinence from alcohol Is used for maintenance of abstinence from alcohol in patients with alcohol dependence who are in patients with alcohol dependence who are abstinent at treatment initiation.abstinent at treatment initiation.

Addictive Properties:Addictive Properties: Not addictive and no reports of misuse Not addictive and no reports of misuse Also Known As: Also Known As: CampralCampral FDA-Approval: FDA-Approval: 20042004

Cost: Cost: $135.90 per month, which is around $$135.90 per month, which is around $4.534.53 a day. a day.4646

Third-Party Payer Acceptance:Third-Party Payer Acceptance: Patient Assistance Program Patient Assistance Program through Forest Laboratories, Inc.; covered by most major through Forest Laboratories, Inc.; covered by most major insurance carriers; covered by Medicare, Medicaid, and the insurance carriers; covered by Medicare, Medicaid, and the VA (if naltrexone is contraindicated).VA (if naltrexone is contraindicated).

= Glutamate

= acamprosate

glutamate receptors

Post-Synaptic NeuronPre-Synaptic Neuron

Acamprosate modulates the amount of Acamprosate modulates the amount of glutamateglutamate released from the neuron released from the neuron

How Does Acamprosate Work?How Does Acamprosate Work?

What does the research say?What does the research say?

In three studies, participants treated with acamprosate were able to In three studies, participants treated with acamprosate were able to maintain maintain complete abstinencecomplete abstinence more frequently than those treated with placebo more frequently than those treated with placebo

* statistically significant

Study

38%

13%

28%

13%16%

9%

0%

5%

10%

15%

20%

25%

30%

35%

40%

13-WeekStudy (Pelc)*

48-WeekStudy (Sass)*

52-WeekStudy

(Paille)*

Complete Abstinence

acamprosate

placebo

Percentage of participants

who consumed no alcohol during the

entire study

Percentage of participants

who consumed no alcohol during the

entire study

In three studies, participants treated with acamprosate had a greater reduction in the number of drinking days during the entire study than those treated with placebo.

* statistically significant

67%

29%

74%

38%

85%

67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Percentage of days abstinent

13-WeekStudy (Pelc)*

48-WeekStudy (Sass)*

52-WeekStudy

(Paille)*

Reduction in Drinking Days

acamprosate

placebo

What does the research say?What does the research say?

In three studies, participants treated with acamprosate were In three studies, participants treated with acamprosate were able to regain able to regain complete abstinence after one relapsecomplete abstinence after one relapse more frequently than those treated more frequently than those treated with placebo.with placebo.

* statistically significant

Relapse

11%

8%

18%

7%

11%

3%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

13-WeekStudy (Pelc)*

48-WeekStudy(Sass)*

52-WeekStudy

(Paille)*

Regained Complete Abstinence after First Relapse

acamprosate

placebo

What does the research say?What does the research say?

Percentage of participants

who regained complete

abstinence

Percentage of participants

who regained complete

abstinence

The MedicationsThe MedicationsFor Opiate Addiction:For Opiate Addiction:

•MethadoneMethadone

•BuprenorphineBuprenorphine

•NaltrexoneNaltrexone

For Alcohol Addiction:For Alcohol Addiction:

•NaltrexoneNaltrexone

•AcamprosateAcamprosate

•DisulframDisulfram

For Alcohol Addiction:For Alcohol Addiction:

•NaltrexoneNaltrexone

•AcamprosateAcamprosate

•DisulframDisulfram

DisulfiramDisulfiramDisulfiramDisulfiram

DisulfiramDisulfiram Makes the patient physically sick when alcohol is Makes the patient physically sick when alcohol is

consumedconsumed Is used to aid in the management of selected Is used to aid in the management of selected

chronic alcohol patients who want to remain in a chronic alcohol patients who want to remain in a state of enforced sobriety.state of enforced sobriety.

Addictive Properties:Addictive Properties: No abuse or withdrawal No abuse or withdrawal Also Known As:Also Known As: AntabuseAntabuse

FDA-Approval:FDA-Approval: 19511951 Cost: Cost: $57.59 per month, which is around $1.92 a day.$57.59 per month, which is around $1.92 a day.6262

Third-Party Payer Acceptance: Third-Party Payer Acceptance: Covered by most major Covered by most major insurance carriers, Medicare, Medicaid, and the VA.insurance carriers, Medicare, Medicaid, and the VA.6161

Best for supervised and/or highly motivated patients: Best for supervised and/or highly motivated patients: eg. Family member willing to observe dosing.eg. Family member willing to observe dosing.

How Does Disulfiram Work?How Does Disulfiram Work?IfIf alcohol is consumed alcohol is consumed,, Acetaldehyde Acetaldehyde accumulates in the accumulates in the blood 5 to 10 times blood 5 to 10 times higher than higher than normal. normal. This produces theThis produces the

Disulfiram-Alcohol Reaction:Disulfiram-Alcohol Reaction:

IfIf alcohol is consumed alcohol is consumed,, Acetaldehyde Acetaldehyde accumulates in the accumulates in the blood 5 to 10 times blood 5 to 10 times higher than higher than normal. normal. This produces theThis produces the

Disulfiram-Alcohol Reaction:Disulfiram-Alcohol Reaction: confusion respiratory depression cardiovascular collapse myocardial infarction congestive heart failure unconsciousness convulsions death

sweating thirst weakness chest pain dizziness palpitation hyperventilation rapid heartbeat blurred vision

throbbing in head/neck brief loss of consciousness throbbing headache lowered blood pressure difficulty breathing marked uneasiness copious vomiting nausea flushing

What does the research say?What does the research say?

Participants treated with disulfiram had a greater Participants treated with disulfiram had a greater reduction in the number of drinking daysreduction in the number of drinking days during the during the entire study than those treated with placebo.entire study than those treated with placebo.

* statistically significant

Study

49.0

75.4

86.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

Average Total

Drinking Days

During the Entire Study

250mg ofdisulfiram

1mg ofdisulfiram

placebo

Reduction in Drinking Days - Fuller et al. Study*

What does MAT offer to the What does MAT offer to the Criminal Justice System?Criminal Justice System?

Benefits to the CJ System Include:Benefits to the CJ System Include:

public safety public safety

public healthpublic health

effectiveness effectiveness of Probation & of Probation &

ParoleParole

rate of opiate rate of opiate overdoseoverdose

recidivismrecidivism

public and DOC public and DOC CostsCosts

rate of opiate rate of opiate overdoseoverdose

recidivismrecidivism

public and DOC public and DOC CostsCosts

Increased Public SafetyIncreased Public SafetySubstance-Related ViolenceSubstance-Related Violence

• Alcohol use associated with violence Alcohol use associated with violence – Men drinking in 45% of cases Men drinking in 45% of cases – Women drinking in 20% of casesWomen drinking in 20% of cases– Two-thirds of victims of intimate partner violence Two-thirds of victims of intimate partner violence

reported that alcohol involved in the incidentreported that alcohol involved in the incident

• Alcohol intoxication is strongly related to Alcohol intoxication is strongly related to offenses that involve personal confrontationoffenses that involve personal confrontation– Homicide, physical assault, sexual assault, and robberyHomicide, physical assault, sexual assault, and robbery

• Alcohol availability related to violent assaultAlcohol availability related to violent assault– Communities and neighborhoods that have more bars Communities and neighborhoods that have more bars

and liquor stores per capita experience more assaultsand liquor stores per capita experience more assaults

• Drug-related violence is a major cause of death Drug-related violence is a major cause of death among ex-offendersamong ex-offenders

Mean C

rim

e-D

ays

per

yr.

Longer Time in MAT Decreases Crime-DaysLonger Time in MAT Decreases Crime-Days

Increased Public SafetyIncreased Public SafetyIncreased Public SafetyIncreased Public Safety

An additional tool for repeat offendersAn additional tool for repeat offenders

• Increased retention and effectiveness of Increased retention and effectiveness of community addiction treatmentcommunity addiction treatment

• Decreased recurrent drug useDecreased recurrent drug use

• Decreased behavioral problems and crimeDecreased behavioral problems and crime

• Decreased violations and arrestsDecreased violations and arrests

• Decreased P&P workload & hasslesDecreased P&P workload & hassles

Effect of MAT on Parole & ProbationEffect of MAT on Parole & ProbationEffect of MAT on Parole & ProbationEffect of MAT on Parole & Probation

Increased Public HealthIncreased Public Health

Drug abuse treatment is Drug abuse treatment is HIV and HCV prevention!HIV and HCV prevention!

• Drug injectors who do not enter treatment are up toDrug injectors who do not enter treatment are up to 6x 6x more likely to become infected with HIV more likely to become infected with HIV than injectors than injectors who enter and remain in treatment who enter and remain in treatment

• Treatment Treatment reduces associated risk behaviorsreduces associated risk behaviors such as such as sharing injection equipment and unprotected sexsharing injection equipment and unprotected sex

• Treatment Treatment provides opportunities for screening, provides opportunities for screening, counseling, and referral to additional servicescounseling, and referral to additional services, , including early HIV treatmentincluding early HIV treatment

Drug abuse treatment is Drug abuse treatment is HIV and HCV prevention!HIV and HCV prevention!

• Drug injectors who do not enter treatment are up toDrug injectors who do not enter treatment are up to 6x 6x more likely to become infected with HIV more likely to become infected with HIV than injectors than injectors who enter and remain in treatment who enter and remain in treatment

• Treatment Treatment reduces associated risk behaviorsreduces associated risk behaviors such as such as sharing injection equipment and unprotected sexsharing injection equipment and unprotected sex

• Treatment Treatment provides opportunities for screening, provides opportunities for screening, counseling, and referral to additional servicescounseling, and referral to additional services, , including early HIV treatmentincluding early HIV treatment

Binswanger IA et al. N Engl J Med 2007;356:157-165

RR=12

RR=4 RR=3.2

Lower rates of opiate OverdoseLower rates of opiate Overdose““Sentenced to death…Sentenced to death…afterafter releaserelease!”!”

“RR”= Risk Ratio“RR”= Risk Ratio

Binswanger IA et al. N Engl J Med 2007;356:157-165

Causes of Death among ReleaseesCauses of Death among ReleaseesAdjusted for Age, Sex, and RaceAdjusted for Age, Sex, and Race

0

2

4

6

8

10

12

Overd

ose

Homicide

Live

r Dise

ase

MVA

Suici

deCV

D

Canc

er

Rela

tive R

isk o

f D

eath

Prison detox• decreased tolerance • increased risk of

overdose

Decreased RecidivismDecreased Recidivism

Recurrent substance abuse contributes Recurrent substance abuse contributes to high recidivism rates.to high recidivism rates.

As mentioned earlier:As mentioned earlier:

>50% will relapse…>50% will relapse…within one month of release.within one month of release.

Recurrent substance abuse contributes Recurrent substance abuse contributes to high recidivism rates.to high recidivism rates.

As mentioned earlier:As mentioned earlier:

>50% will relapse…>50% will relapse…within one month of release.within one month of release.

Decreased Public CostsDecreased Public Costs

• Every $1 spent on addiction treatment saves $4 to $7 Every $1 spent on addiction treatment saves $4 to $7 from reduced costs of drugs, crime & punishmentfrom reduced costs of drugs, crime & punishment– For some outpatient programs, For some outpatient programs, savings exceed costs by 12:1.savings exceed costs by 12:1.

Reduced costs include:Reduced costs include:

• lost child supportlost child support• foster care and welfare foster care and welfare

costscosts• reduced productivityreduced productivity• unemploymentunemployment• victimizationvictimization

• violent and property violent and property crimescrimes

• prison expensesprison expenses• court and criminal costscourt and criminal costs• emergency room visitsemergency room visits• child abuse and neglectchild abuse and neglect

The National Institutes of Health (1997) estimated the The National Institutes of Health (1997) estimated the cost of opiate dependence tocost of opiate dependence to individuals, families, and individuals, families, and

society to be approximatelysociety to be approximately $20 billion per year$20 billion per year..

The National Institutes of Health (1997) estimated the The National Institutes of Health (1997) estimated the cost of opiate dependence tocost of opiate dependence to individuals, families, and individuals, families, and

society to be approximatelysociety to be approximately $20 billion per year$20 billion per year..

• Increases retention and effectiveness of community Increases retention and effectiveness of community addiction treatmentaddiction treatment

• Decreases recurrent drug useDecreases recurrent drug use• Decreases drug-related crimeDecreases drug-related crime• Decreases addicted persons violated or arrestedDecreases addicted persons violated or arrested• Increases community time between relapsesIncreases community time between relapses• Decreases incarceration costsDecreases incarceration costs

Effect of MAT on DOC BudgetEffect of MAT on DOC BudgetReduces number of addicts Reduces number of addicts

going through repeated going through repeated arrest-incarceration-release cyclesarrest-incarceration-release cycles

Effect of MAT on DOC BudgetEffect of MAT on DOC BudgetReduces number of addicts Reduces number of addicts

going through repeated going through repeated arrest-incarceration-release cyclesarrest-incarceration-release cycles

MATMAT strengthens the efficacy of the strengthens the efficacy of the Criminal Justice System.Criminal Justice System.

HowHow?? By enriching theBy enriching the CJ System CJ System with with

an evidence-based practicean evidence-based practice

that that addresses one of addresses one of its root problemsits root problems,,

AddictionAddiction..

So, what does MAT offer to the So, what does MAT offer to the Criminal Justice System?Criminal Justice System?

GoodGood treatmenttreatment isis holistic, integrated holistic, integrated andand multifaceted, multifaceted, taking into account thetaking into account the individual’sindividual’s

physicalphysical, , behavioralbehavioral, , andand spiritual spiritual well-beingwell-being..

MedicationMedication::--should be used should be used inin combinationcombination with with behavioralbehavioral treatment, treatment, as stated on FDA labelingas stated on FDA labeling..

--can help with braincan help with brain chemistrychemistry……the rest is up tothe rest is up to usus..

*Note*Note*Note*Note

You might be wondering…You might be wondering…

-WHO is a good candidate to refer?-WHO is a good candidate to refer?

Consider:Consider:

• History of substance abuseHistory of substance abuse

• Willingness to consider MATWillingness to consider MAT

-WHERE -WHERE is is MAT MAT typicallytypically offered? offered?• Which local agencies?Which local agencies?

• What happens after you make What happens after you make a referral?a referral?

For more information, contact:For more information, contact:

[Insert trainer Name here][Insert trainer Name here][Insert trainer email and/or [Insert trainer email and/or

phone number here]phone number here]

[Insert trainer website here][Insert trainer website here]