new medication-assisted treatment for opioid use disorder · 2020. 2. 8. · what is...
TRANSCRIPT
Medication-Assisted Treatment for
Opioid Use Disorder:
From Suboxone to Support Systems
Harm Reduction in the House 2017
Ursula Wagner, LCSWJuleigh Nowinski Konchak, MD MPHCleveland Hester
Setting the Stage:
Opioid Overdose as a Public Health
Crisis
Cook County opioid overdose deaths:
• 2015: 647 deaths • 2016 preliminary >1,000 deaths• Outpacing deaths by gun violence• Heroin in majority of cases
Source: https://www.cityofchicago.org/content/dam/city/depts/cdph/CDPH/Healthy%20Chicago/ChicagoOpioidBrief3_6162017.pdf
What is medication-assisted treatment
(MAT)?
Evidence-based treatment for substance use disorders combining
medication+
psychosocial support
A gold standard: alcohol, opioid, nicotine
Medication can address withdrawal symptoms, urges/cravings, blockade of euphoria
MAT for opioid use disorder (OUD)
Medication / mechanism of
action
How administered /
dosing
Common trade names
Available through
Methadone / full agonist
Liquid, pill, or wafer / daily
Opioid Treatment Program:Regulated by SAMHSA (federal)
Buprenorphine / partial agonist
Sublingual pill or film / daily
Suboxone, Subutex, Zubsolv
Any prescriber (NP, PA, physician) with waiver in
any outpatient setting; special training requiredImplant /
6 months
Naltrexone / antagonist
Oral / daily Vivitrol Any provider with prescribing authority; no special training
requiredExtended-release injectable/ monthly
Source: http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorder
Evidence for MAT for OUD
Research indicates methadone and buprenorphine can:▫ Decrease mortality related to opioid use
▫ Improve treatment retention
▫ Decrease opioid use and criminal activity
▫ Improved ability to obtain and maintain employment
▫ Improve birth outcomes for pregnant women with substance use disorders
▫ Decrease risk for contracting HIV or Hepatitis B, C
▫ Reduce potential for relapse
▫ Enhance social functioning
Research indicates IM naltrexone may:▫ Decrease rates of relapse (over 24 weeks)
▫ Longer median time to relapse
Source: http://www.icjia.state.il.us/articles/an-overview-of-medication-assisted-treatment-for-opioid-use-disorders-for-criminal-justice-involved-individuals
Who is a good candidate for MAT?
• HHO approach: low-threshold induction and maintenance policy▫ Consistent with philosophy of harm reduction▫ Overdose prevention as a goal of program, including naloxone training
• MAT can be combined with higher level of care, if desired
• Responding to the patient’s recovery goals
• Select precautions/contraindications, will vary per clinic
Additional Considerations
Societal and patient biases against MAT:
▫ “a crutch”, not “clean” if taking opiates
True barriers to accessing MAT:
▫ Inadequate # providers of MAT
• Less than ½ with waived providers actually prescribe
▫ Recovery homes
Detox without linkage to care and MAT is NOT treatment
Psychosocial treatment /
Behavioral Therapy
• MAT providers must provide access to behavioral health services▫ Build coping skills and recovery capital▫ Address underlying behavioral health disorders
• Can be provided in clinic by BH staff, plus provider counseling
• Refer patients as indicated and desired by patient to:▫ Meetings: 12-step, NA/AA, Smart recovery▫ Individual or family therapy▫ Higher levels of care: outpatient, intensive outpatient, residential
• Contingency Management built in to clinic schedules for prescription pickups (weekly, bi-weekly, monthly)
Holistic Approach to MAT
• Our team▫ Includes providers, nurses, CADCs & therapists
▫ Situated in a primary care clinic that also provides psych & dental
• Issues addressed in individual & group therapy can include▫ Feelings of isolation, emptiness, boredom
▫ Symptoms that intensify without opiates to numb them
● Depression
● Anxiety
● Traumatic memories
● Hallucinations
● Chronic pain
Participant examples
• KC – has struggled tremendously due to increase in psych symptoms during MAT as he decreased his heroin use
• BL – has been able to get a job, a promotion, and housing due to MAT helping him to decrease his heroin use
• And…introducing our special guest Cleveland!
The Politics of MAT• In US
▫ Drug companies lobbying directly to drug court judges, lawmakers
▫ Deeply ingrained 12-step philosophy leading to● Stigma of agonist therapy
● Popularity of antagonist therapy
• Abroad▫ MAT includes Heroin-Assisted Treatment in Europe, Canada
▫ Could it happen here?
Sources:http://www.npr.org/sections/health-shots/2017/08/03/540029500/to-grow-market-share-a-drugmaker-pitches-its-product-to-judgeshttp://www.npr.org/sections/health-shots/2017/06/12/523774660/a-drugmaker-tries-to-cash-in-on-the-opioid-epidemic-one-state-law-at-a-timehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219559/http://www.citizensopposingprohibition.org/resources/swiss-heroin-assisted-treatment-1994-2009-summary/
