medication assisted treatment (mat) issues for women susan f. neshin, md medical director jsas...
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Medication Assisted Treatment (MAT)Issues for Women
Susan F. Neshin, MD
Medical Director
JSAS Healthcare, Inc.
Asbury Park, NJ
E-mail: [email protected]
What is MAT?
• MAT=Medication Assisted Treatment
• EUPHEMISM for opioid maintenance therapy
– Methadone
– Buprenorphine
• Broaden definition
– Naltrexone
– Medication for other drug dependencies
Medications Development Division
• Branch of National Institute on Drug Abuse (NIDA)
• Developing new medications
• Addiction as a brain disease
• Drug craving as a physiologic phenomenon
Rationale for MAT/OMTFor Chronic Opioid Dependence
• Dole’s concept of metabolic derangement
• Current concept of neuronal adaptations to repeated exposures of the drug
• Pre-existing vulnerability and/or consequence of opioid use
• Corrective, not curative
On/Off - Non-Tolerant Drug StatesOn/Off - Non-Tolerant Drug StatesM
oo
d/E
ffe
ct
Sc
ale “ON”
Drug Effect
“OFF”
No Drug Effect;
“Normal”
Overdose
Intoxication
Euphoria
“Normophoria”
Dysphoria
Opioid Maintenance Pharmacotherapy - A Course for Clinicians5
Do
se R
esp
on
se
Time
“Loaded” “High”
Normal Range“Comfort Zone”
“Sick”
Heroin Simulated 24 Hr. Dose/Response
With established heroin tolerance/dependence
0 hrs.
24 hrs.
“Abnormal Normality”
Subjective w/d
Objective w/d
Opioid Maintenance Pharmacotherapy - A Course for Clinicians6
Do
se R
esp
on
se
Time
“Loaded” “High”
Normal Range“Comfort Zone”
“Sick”
Methadone Simulated 24 Hr. Dose/ResponseAt steady-state in tolerant patient
0 hrs.
24 hrs.
“Abnormal Normality”
Subjective w/d
Objective w/d
Opioid Maintenance Pharmacotherapy - A Course for Clinicians
7
Goals for Pharmacotherapy
• Prevention or reduction of withdrawal symptoms
• Prevention or reduction of drug craving
• Prevention of relapse to use of addictive drug
• Restoration to or toward normalcy of any physiological function disrupted by drug addiction
Recent Heroin Use by Current Methadone Dose
0
20
40
60
80
100
120
0 10 20 30 40 50 60 70 80 90 100
Current Methadone Dose mg/day
% H
ero
in U
se
J. C. Ball, November 18, 1988
Retention in Treatment Relative to Dose
0 20 40 60 80 100
80 + mg
60-79 mg
< 60 mg
Adapted from Caplehorn & Bell - The Medical Journal of Australia
Impact of Maintenance Treatment
• Reduction death rates (Grondblah, ‘90)
• Reduction IVDU (Ball & Ross, ‘91)
• Reduction crime days (Ball & Ross)
• Reduction rate of HIV seroconversion
(Bourne, ‘88; Novick ‘90,; Metzger ‘93)
• Reduction relapse to IVDU (Ball & Ross)
• Improved employment, health, & social
function
DEATH RATES IN TREATED AND UNTREATED HEROIN
ADDICTS
0
1
2
3
4
5
6
7
8
MMT VOL DC TX INVOL DC TX UNTREATED
OBSERVEDEXPECTED
Slide data courtesy of Frank Vocci, MD, NIDA - Reference: Grondblah, L. et al.
ACTA PSCHIATR SCAND, P. 223-227, 1990
% A
nn
ua
l De
ath
Rat
es
13
Impact of MMT on IV Drug Use for 388 Male MMT Patients in 6 Programs
PE
RC
EN
T I
V U
SE
RS
0
100
LA
ST
AD
DIC
TIO
N P
ER
IOD
AD
MIS
SIO
N
100%
81.4%
Pre- | 1st Year | 2nd Year | 3rd Year | 4th Year Admission
*
*
63.3%
41.7%
28.9%
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
Crime among 491 patients before and during MMT at 6 programs
0
50
100
150
200
250
300
A B C D E F
Before TX
During TX
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
Cri
me
Day
s P
er Y
ear
HIV CONVERSION IN TREATMENT
0%
5%
10%
15%
20%
25%
In Tx (N=95) Partial Tx(N=45)
No Tx (N=55)
Tx Status
18 month HIV conversion by treatment retentionSource: Metzger, D. et. al. J of AIDS 6:1993. p.1053
OMT as Treatment of Choicefor Chronic Relapsing Opioid
Addict
• Concept of “prolonged abstinence”
– Hyper-reactivity to stress
– Dysphoria/craving increase vulnerability to relapse
Relapse to IV drug use after MMT105 male patients who left treatment
28.9
45.5
57.6
72.2
82.1
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
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
The Medications
• Methadone
– Long-acting full opioid agonist
– Orally effective
– Can be taken once a day
– Prescribed and dispensed at licensed OTPs
The Medications• Buprenorphine
– Approved by FDA in October, 2002– Result of DATA 2000– Long-acting partial opioid agonist– Sublingually effective– Can be taken once a day or less frequently– Prescribed by private practitioner with
waiver
The Medications
• Naltrexone
– Long-acting opioid antagonist
– Orally effective
– Can be taken once a day or less frequently
– Benefits subgroups of opioid addicts
Addiction as a Biopsychosocial Disease
• OMT addresses the biological aspect
• Psychosocial aspects addressed
– Substance abuse counseling
– Mental health treatment
– Support and self-help groups
• Accreditation standards– Should improve treatment– Eliminate “gas and go” model
Women’s Issues
• Higher levels of dual diagnosis than men
• Childcare
• Transportation
• Domestic Violence
• Educational/Vocational
• Financial
• Pregnancy
How to Address Women’s Issues
• Accreditation standards
• Variable levels of resources
• Women’s Set-Aside funds
• One-stop shopping
Dual Diagnosis
• Depression/mood disorders
• Anxiety disorders/PTSD
• Eating disorders
• Symptoms
– Guilt and shame
– Low self esteem
Dual Diagnosis
• Train counseling staff
• Availability of therapist
• Availability of psychiatrist
• Staff with expertise in “survivor” issues
– Lifetime prevalence of drug abuse > 4 times greater in women who report history of sexual assault
• Support/therapy groups
Childcare Issues
• Most women in treatment are of childbearing age
• Children as barrier to treatment
• Services to address
– Children welcome
– On-site child care
– Parenting classes
Domestic Violence
• Train staff
• Facilitate referral to shelter when appropriate
• Support/therapy group
Educational/Vocational Issues
• Most women in treatment are “undereducated” and “underemployed”
• Services to address:
– Train staff about community resources/state-funded programs
– On-site vocational counselor
– Address “sex for drugs” issues
Financial Issues• Treatment is expensive• Proprietary vs. publicly-funded non-profit programs• Services to address patient issues
– Accept Medicaid as payment– Allow for reduced fee/indigency– Counsel on budgeting– Counselor referrals to/interventions with local
service agencies
Pregnancy
Comprehensive OMT with adequate prenatal care can reduce the incidence of obstetrical and fetal complications, in utero growth retardation, and neonatal morbidity and mortality (Finnegan, 1991).
Model Perinatal Program
• On-site prenatal care
• On-site well-baby care
• On-site child care
• Educational groups
– Pregnancy/medical issues
– Methadone and pregnancy
– Effects of drugs of abuse, including alcohol and nicotine, on fetus
Model Perinatal Program
• Educational groups--continued
– Nutrition
– Baby care
– Parenting skills--include fathers
– Contraception/Family Planning
• Counseling on pregnancy termination
Perinatal Addiction
• Withdrawal? - Rarely appropriate during pregnancy (ASAM 1990)– Same recidivism as non-pregnant opioid
addicts (Finnegan, 1990)– Slow withdrawal between 14 and 32 weeks
(Kaltenbach, 1992)
• Dose of methadone should be individually determined and adequate to control craving and prevent withdrawal syndrome
Perinatal Addiction
• MMT patients who become pregnant should be continued at established dose. A mid-trimester reduction may be appropriate in anticipation of 3rd trimester dose increase.
• Altered pharmacokinetics during 3rd trimester often require dose increases and often a split dose to “flatten the curve” and improve maternal and fetal stability.
Perinatal Addiction
• There is no consistent correlation between maternal methadone dose and the severity of neonatal withdrawal syndrome (Stimmel et al., 1982).
• Protocols are available for scoring signs of opioid withdrawal to guide the appropriate use of medications to facilitate a safe and comfortable withdrawal of the passively addicted neonate (Finnegan, 1985).
Perinatal Addiction
• Breast-feeding may be encouraged during MMT - if not otherwise contraindicated (Kaltenbach, 1992).
• Multiple longitudinal studies find that methadone-exposed infants score well within the normal range of development (Kaltenbach, 1992).
Addressing Stigma
• EDUCATE OURSELVES!
– “I don’t believe in methadone!”
– ASAM addressing physician bias• Arizona study -- 96% refusal to treat or
give pain meds• Example of physician opioid addict
Addressing Stigma
• EDUCATE OURSELVES!--continued– Need to educate therapeutic
communities, Minnesota model programs– Need to educate Twelve Step community
• Methadone/buprenorphine as prescribed medications rather than drugs of abuse
• Patients on OMT can work a program of recovery
Addressing Stigma
• Educate service agencies and the general public
– Arizona study -- 66% refused employment or lost job
• Educate patients about the chronic disease concept
– Methadone/buprenorphine as corrective, not curative
• Educate family members
Addressing Stigma
• Publicly funded programs should be mandated to accept patients on OMT
• Private programs should be encouraged to accept patient on OMT
– Great need for residential treatment/halfway houses for women (pregnant or non-pregnant) and their children
Addressing Stigma
• Patients should be encouraged to get involved in advocacy
• Patients need to risk divulging status to treatment providers with support from program staff
Transportation Issues• Lack of transportation as barrier to treatment• Clinics in “out of the way” areas• Services to address
– Use of medical transportation for Medicaid patients– Site program close to public transportation– Give “take-homes” when earned– Van service– Home medication/family member pick-up for
homebound patients
Perinatal Addiction -6
• Obstacle and barriers to MMT must be removed for the pregnant patients.
• More research is needed on innovative models of treatment including medically supervised withdrawal during pregnancy with residential care, intensive relapse prevention and monitoring, high-risk prenatal care. When appropriate hospitals, clinics and individual obstetricians could provide methadone maintenance.
Opioid Maintenance Pharmacotherapy - A Course for Clinicians
Withdrawal during Pregnancy The patient refuses to be placed on
methadone maintenance.
The patient lives in an area where methadone maintenance is not available.
The patient has been stable during treatment & requests withdrawal prior to delivery.
The patient has been so disruptive to the treatment setting that the treatment of other patients is jeopardized, necessitating the removal of the patient from the program.
Opioid Maintenance Pharmacotherapy - A Course for Clinicians
Jarvis & Schnoll,1994