Opioids, Methamphetamines, and Alcohol: A tour through

dopamine city

K. Michelle Peavy, PhDPsychologist/Research Consultant

Evergreen Treatment Services – Seattle, WA

Opioid use disorder and its treatment

Why talk about opioids?

• Magnitude of opioid crisis• In 2016, approximately 11.8 million people aged 12 or older misused opioids in the past year; 948,000

people aged 12 or older used heroin in the past year (SAMHSA, 2017)• 2016 saw 63,600 drug poisoning deaths, most of which were opioid related (Hedegaard, 2017).

• > motor vehicle accident deaths in 2016. • > US Soldiers who died during the 20 year span of the Vietnam War.

• Between July 2016-Sep 2017, ED visits for opioid poisonings increased by almost 30% (Vivolo-Kantor, 2018).

PresenterPresentation NotesDeviating a little from my original agenda. Start out with some epidemiological data to underscore the important of why we might want to be talking about this today. Sets the stage for the rest of the material. In terms of national statistics, I was struggling with which completely alarming data to share. I went ahead and chose death as the measuring stick. Assuming that one of theky goals of the provision of health care and mental health care is to avoid death. Very serious problem in the US.Assume that Health care provision is to reduce death2016 more people died of an opioid OD than motor vehicle accidents 2016 20 year span of Vietnam war

CDC Morbidity & Mortality reportJuly 2016-Sep 2107 – ED visits for Ods increased by almost 30%So this is a really big problem in the US.

U.S. Opioid Epidemic

Montana’s heroin use was similar to the

corresponding national annual

average percentage.

(SAMHSA, 2017)

PresenterPresentation NotesThat said, locally Montana appears to be somewhat protected from the opioid epidemic. This graph shows the rate of heroin users in (blue) montana and (red) US. Looks like Heroin rates are similar if not lower in Montana compared to the rest of the country.

Treatment admissions for opioid use disorder in MT• Opioid Treatment Programs

• 2011 80• 2015 489

• Office based buprenorphine patients• 2011 164• 2015 284

511% Increase

73% Increase

(SAMHSA, 2015)

PresenterPresentation NotesAnother way we can tell how drug of abuse are changing in communities is by looking at treatment admissions. Looking at treatment admissions for OUD in MAT programs. (Not IOP/IP/Detox or other settings).

Opioid use disorder (OUD)

EnvironmentPsychological Factors

Drug ExposureVoluntary Choice

1 in 4 people who use heroin develop OUD

Disease of the brain’s reward

system/relapsing medical disorder

Progressive and Chronic…

No OUD

Genetics (34% genetic heritability)Trauma

Similar to: Hypertension (25-50%)Type 2 Diabetes (25-80%)

Addiction is- a chronic, relapsing medical disorder- A disease of the brain’s reward system

PresenterPresentation NotesIn terms of the development of an OUD. Of course – in order to develop an OUD a person has to use that substance in the first place they need to be exposed to the substance. And this is a voluntary choice of course. But the choice is influenced by a number environmental and psychological factors that the person usually doesn’t have any control over. Once a person is exposed to a substance, they may or may not go on to develop a SUD. 1 in 4 people who use heroin go on to develop an SUD and the rest don’t. So there’s this pathway down here. And I think it’s great that a certain proportion of people don’t develop an OUD or spontaneously recover from mild OUD. But I think it’s safe to say that we’re not talking about those people today. Those people certainly aren’t those who show up at ETS, or are those people that you all are concerned about. Many people who use heroin do go on to develop a SUD and we’re not exactly sure why some people do develop OUD and some people don’t. It’s like related to environmental and psyc factors, as well as genetics and trauma hx. What I’ve just described is what the larger medical community labels as a “brain disease”We generally think of OUD as progressive and chronic disease. And, just like other chronic those studying and considering the disease of addiction consider it and label it as a “chronic medical illness”, and it’s actually been compared to and very similar to other chronic medical illness in terms of its etiology, course, and treatment. Speficially, it’s been compared to:Type 2 diabetesHypertentionAsthma.Similar in terms of genetic heritability component, personal choice, and environmental factors involved in the etiology of these disorders. Similar in terms of treatment response.A little bit medicationsA little bit behavioral intervention.

Treating OUD like the medical disorder it is

“Old skool” SUD Treatment Medical Treatment

“Addiction is a disease.” Views addiction as a “chronic relapsing medical disorder.”

Treatment begins when patient has already made behavior change or “is ready” make behavior change.

Treatment begins at or before the time when symptoms are interfering with patient health and functioning.

Views an increase in symptoms as a sign to withhold treatment.

Views an increase in symptoms as a reason to apply more or different treatment.

Not always 100% effective Not always 100% effective

Blames patient for “failing” in treatment. Blames treatment for failing patient.

Setting MAT(ters)

OTP (highly regulated; medication dispensed)

•Methadone•Buprenorphine

Office based MAT (prescribed;

administered)

•Buprenorphine (“OBOT”)

•Vivitrol

Medications that target OUD

MethadoneFull agonist

Buprenorphine (Suboxone®, Subutex®, Zubsolv®)

Partial agonist Vivitrol extended release naltrexone

Antagonist

4/29/2019 10

PresenterPresentation Notes3 medications used to target OUD are methadone, bup, and vivitrol. I’m not going to be talking about vivitrol today, simply because I only have 20 minutes, and it’s unfortunately not offered as of yet at ETS. We hope that the availability of this medication expands more widely. In the meantime, we’ll discuss the more widely used and ETS offered: methadone and buprenorphine.

Full agonist, activates the opioid receptors in our brains.Partial agonist, partially activates the opioid receptor in a our brains – to a lesser extent; blocks other opioids from binding and exerting their effects. Antagonist, blocks opioids from binding from receptor sites. No opioid effect, blocks other opioids.

Naltrexone

• Oral & extended release injectable (Vivitrol).

• Induction:• 7-10 days no opioid use• Precipitated withdrawal

PresenterPresentation NotesBinds to receptor and block receptor. If someone uses opioids while on naltrexone they will not feel the effects, even if they use opioids repeatedly. They cannot redevelop physiologic dependence or tolerance because the opioid receptors are blocked, and therefore opioids cannot bind to them.

There is an oral formulation that can be taken on a daily basis, but research has shown that people adhere well to the regimen. Because the naltrexone blocks the opioid effect, and if they are seeking an opioid effect they might be inclined to discontinue the medication. There is a long-acting injection (Vivitrol)30 day; IM.

Induction: Because it is a full competitive antagonist, if there is if there are any residual opioids on the receptor when the naltrexone is administered, it can cause precipitated withdrawal. Percipited withdrawal is a very rapid onset of severe withdrawal. To start Nx – need to be completely void of opioids on the receptors. 7-10 days with no opioid use whatsoever. Challenging to achieve opioid free state.

Adverse effects: no physiologic dependenceInjection site reaction (rare)

Medication Assisted Treatment with agonists: Why?

• Addiction is a chronic, medical disorder

• Disease of the brain’s reward system

• Similar to hypertension and diabetes

• Medication helps stabilize the disorder

4/29/2019 12

Goals of Medication Assisted Treatment (Methadone and bup)

• Stabilize physiology; alleviate intoxication/withdrawal cycle

• Alleviate craving

• Engage the patient in recovery• Psychoeducation• Enhance motivation - Motivational Interviewing• CBT for coping skill development & changing thinking patterns

• Duration of treatment is unknown

4/29/2019 13

Life of a an individual with Heroin Addiction

4/29/2019 14

PresenterPresentation NotesAgain as a pictoral. Looks a lot like that other picture I showed of intoxication/withdrawal patternAncient picture. Original research on methadone from the mid-1960s. Research on this form of treatment goes back several decades and there are mountains of evidence supporting the use of methadone for opioid use disorders, by the way.

Methadone: Stabilizing the Patient

4/29/2019 15

PresenterPresentation NotesMedication Assisted Treatment: Why it works. Blocks the euphoria (the positive reinforcer – what people are seeking)Stops with withdrawal symptoms (the negative reinforcer – what people are avoiding)

This allows people to feel normal.Engage in recovery

But aren’t they still addicted? The Difference Between “Drug” and “Medication”

Drug Medication

Methadone for Opioid Dependence• Six day per week observed dosing with an RN• Monthly random, observed UAs• Mandatory counseling• Regular Prescription Monitoring Program checks• Regular medical provider appointments – ARNPs and

PA-Cs• Once stabilized, may start earning take home dose

privileges• Acupuncture

northwest@attcnetwork.org | http://attcnetwork.org/northwest | phone. 206-685-4419

“M”ountains of evidence supporting “m”ethadone

for OUD• Outcomes: Dole & Nyswander, 1965;

Mattick, et al., 2009

• ↓HIV/AIDS: Ball et al., 1988; Novick et al., 1990; Gowing et al, 2006

• ↓criminal behavior: Mattick et al., 2009; Nurco et al., 1985

• ↓ mortality: Fugelstad et al., 2007; Pierce et al, 2016; Sardo et al., 2017

PresenterPresentation NotesA meta-analysis of 1969 participants in 11 randomized trials compared methadone maintenance therapy with placebo or nonmedication treatment for DSM-IV opioid dependence [6]. Patients receiving methadone were more likely to remain in treatment and to reduce opioid use compared with placebo or nonmedication treatment.As an example, a trial conducted more than 20 years ago randomly assigned 247 participants with opioid dependence to 20 weeks of methadone treatment, the latter 15 weeks of which at stable doses of 50 mg or 20 mg/day of methadone, or placebo [7]. All three groups additionally received individual counseling and group therapy. By treatment week 20, retention was 52.4 percent for the 50 mg group, 41.5 percent for the 20 mg group, and 21 percent for the placebo group. The 50 mg treatment group had a reduced rate of opioid-positive urine samples compared with the 0 mg group (56.4 versus 73.6 percent), while the 20 mg group showed no difference compared with the placebo group. The 20 mg/day dose used in this study is no longer considered to be adequate for most patients based on current knowledge. One-fifth of patients receiving placebo remained in treatment at 20 weeks, illustrating how the non-pharmacologic aspects of methadone treatment can have compelling value to some patients.Fugelstad (2006), using data from a Stockholm methadone program, found that patients discharged from treatment were 20 times as likely to die of unnatural causes, most often heroin overdose.  Sardo, in a 2017 meta-analysis that included 122,885 people treated with methadone, found "The rate of death in treatment was less than a third of the rate out of treatment, with the greatest difference in deaths from overdose."   

Advantages of Buprenorphine

northwest@attcnetwork.org | http://attcnetwork.org/northwest | phone. 206-685-4419

• Can be prescribed by physician

• Long acting (24-36 hours)

• Limited potential for opioid poisoning (ceiling effect)• Minimal subjective effects (e.g., sedation) following a dose

• Lower level of physical dependence

• In combination with naloxone, reduced potential for misuse

PresenterPresentation NotesPreparation- Most Sublinguial preparation; not well absorbed from the GI tract. No oral preparation. - Surgical implantation . Not practical- New formulation just approved by FDA, that is a subcutaneous injection that would last 30 days. We don’t know much about clinically.

Ceiling effect on how much buprenohrphine can activate the receptor. So even when the receptors are activated with bup, it cannot activate c them enough to cause respiratory depression to cause an opioid poisoning. – tremendous safety margin – good treatment. If we Prescribe it from an office andyou give a patient 7-day, 14 day, even 30 day supply – even if the patient took all that at one time – patient would not be able to OD

Most bup is paired with Naloxone (Suboxone). It is there to deter parenteral misuse. (abuse deterrent). If someone were to crush it and inject it, they would also be injecting an antagonist and won’t get much effect from the bup. Doesn’t have a treatment effect when taken properly. an opioid antagonist that has poor sublingual bioavailability

Induction: early mild opioid withdrawal. Abstain 12-24 hours before induction.

Adverse effects of bup: nausea, headache, drowsiness, produces physiologic dependence. Some opioid effects. Will have some withdrawal when getting off. But encourage patients to stay on for a long period of time.

Evidence

Bup vs. Naltrexone

• Study indicated withdrawal hurdle to get on to naltrexone (induction), but once people are inducted the outcomes are quite similar.

• (Lee et al., 2017)

PresenterPresentation NotesLee et alETS was a site for this clinical trial. 500-600 participants. -Randomly assigned to Bup or VivitolOutcomes: relapse to illicit opioid use. Retention in tx. Overdose.Intent to treat: slightly better outcomes for bup.Reason for that – more patients were able to get onto the bup, because the time frame to get onto bup (after cessation of opioid use) is much shorter. Secondary analysis: sample of patients who got onto the medications and looked at 6 month outcomes. Findings: Once patients were on medications – no real differences in outcomes.

Evidence: Methadone vs. Bup

Bup less effective than methadone at retaining patients.*

Of the bup patients who are retained, they had lower rates of illicit opioid consumption, suggesting bup may be most useful in highly motivated patients**

*Mattick et al., 2014; **Hser et al., 2014

PresenterPresentation NotesA meta-analysis of 11 randomized trials comparing methadone to buprenorphine in maintenance treatment for DSM-IV opioid dependence concluded that buprenorphine was effective in opioid use disorder but slightly less effective than methadone in its capacity to retain patients in treatment [56].

*While patients might be at low risk for opioid poisoning when naltrexone is in their systems, patients are at elevated risk for opioid poisoning when the medication wears off, in part because tolerance will be low.

Naltrexone Buprenorphine Methadone

Induction difficulty High Moderate Low

Medication adherence Low Moderate High

Risk of opioid poisoning Low* Moderate High(er)

Autonomy High Moderate Low

Diversion risk Low High Moderate

Tapering difficulty Low Moderate High

Counseling required No No Yes

Stigma Low Moderate High

Which medication is right for me?

• Patient preference• Consider previous treatment and OUD severity• We cannot yet predict who will do better on which medication• Successful treatment requires trial and error• We need a full toolbox of options

4/29/2019

23

But what about meth(amphetamine)?

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30319-2/fulltext;

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30319-2/fulltext

Meth & the brain –check it out

• https://www.drugabuse.gov/videos/reward-circuit-how-brain-responds-to-methamphetamine

https://www.drugabuse.gov/videos/reward-circuit-how-brain-responds-to-methamphetamine

Drug Trends

What affects drug trends?

• Markets • Availability

• Of drugs or their ingredients

• E.g., when opioids are hard to find Meth

• Special populations (e.g., MSM)

• “Diseases of despair” • And…trends

People who use drugs, use drugs.

Rates of Methamphetamine use in Montana

• National rates of past year MA use (12+)

• Nationally – 0.56%• Montana – 0.68%

Source: 2017 The NSDUH Report, 2019

PresenterPresentation NotesWA – 0.73%

Treatment for methamphetamine use• No efficacious

medications• Review/network meta-

analysis indicate Contingency Management + Community Reinforcement has the strongest evidence.

De Crescenzo et al., 2018

Let’s notforget Alcohol.• https://www.psychologytoday.com/us/blog/ad

diction-recovery-101/201812/why-alcohol-misuse-may-be-the-forgotten-addiction

• https://www.ncadd.org/index.php/blogs/in-the-news/alcohol-america-s-1-addiction-problem

• https://www.vox.com/policy-and-politics/2017/10/27/16557550/alcohol-tobacco-opioids-epidemic-emergency

• https://opmed.doximity.com/articles/there-s-an-alcohol-epidemic-and-we-aren-t-paying-enough-attention-07489a24-9fb5-42e4-a64f-8792f0a8774d

https://www.psychologytoday.com/us/blog/addiction-recovery-101/201812/why-alcohol-misuse-may-be-the-forgotten-addictionhttps://www.ncadd.org/index.php/blogs/in-the-news/alcohol-america-s-1-addiction-problemhttps://www.vox.com/policy-and-politics/2017/10/27/16557550/alcohol-tobacco-opioids-epidemic-emergencyhttps://opmed.doximity.com/articles/there-s-an-alcohol-epidemic-and-we-aren-t-paying-enough-attention-07489a24-9fb5-42e4-a64f-8792f0a8774d

What are the most harmful drugs?

• The report of the Independent Scientific Committee of Drugs which scored 20 drugs on 16 criteria.

Nutt et al., 2010

National & MT Rates of AUD

MT = 3.7MT = 13.9

MT = 7.1

Source: 2017 The NSDUH Report, 2019

PresenterPresentation NotesAUD rates down nationally (2017)

Treatment options for AUD

4/29/2019

Despite what we may hear, see and believe…most people with substance use disorders do NOT want to be using drugs and alcohol in a harmful way

• Levels of clinical care• Outpatient• Intensive outpatient • Partial hospitalization• Residential • Detox• Inpatient

• Medication Assisted Treatment (MAT) for alcohol• Naltrexone• Disulfuram • Acamprosate• Topiramate

• Non-clinical pathways • Peer support (e.g., 12-step meetings)• Self-help resources• Faith-based recovery

• No treatment or recovery services

36

PresenterPresentation NotesOutpatient Services A professionally delivered treatment modality that provides daily to weekly attendance at a clinic or facility, typically less than 9 hours of service/week for adults, or less than 6 hours a week for adolescents, allowing the patient to return home or to other living arrangements during non-treatment hours.

Intensive Outpatient & Partial Hospitalization A professionally delivered treatment modality that provides daily to weekly attendance at a clinic or facility, typically requiring 9 to 20 or more hours of service/week, allowing the patient to return home or to other living arrangements during non-treatment hours.

Clinically Managed Low to High Intensity Residential Services A professionally delivered treatment modality that provides 24 hour living support and programmatic structure with available trained personnel. clinical and co-occurring disorder services, and stabilization for patients in imminent danger

Medically Managed Intensive Inpatient Services A professionally delivered treatment modality that provides 24-hour nursing care and medical staff, with daily physician care and counseling available for patients suffering from severe instability and imminent danger.

What informs my treatment recommendations?• Your ASAM*-informed assessment (using ASAM Dimensions) • Severity of AUD

• Need for medical detox?• Stage of change• Previous treatment• Client/Patient preference

*American Society of Addiction Medicine

Alcohol Use Disorder?

No

Heavy drinking?

No

Ongoing assessment

Yes

SBIRT*/MI/ongoing assessment

Yes

Mild

Interested in change?

Yes

CBT/TSF/Other EBP/Mutual help

group

No

SBIRT*/MI/ongoing assessment

Moderate

Interested in change?

No

MI/Contingency Management

Yes

Interested in medication?

Yes

MAT + Psychosocial txor MAT alone

No

Collaboratively determine

LOC/intervention

Severe

Withdrawal sx?

Yes

Need for detox?

Yes

Start with medical detox; then there

could be a whole other flow chart

No

Recommendation for MAT/med assessment

+ other tx services; collaborative tx

planning

No

Recommendation for MAT/med assessment

+ other tx services; collaborative tx

planning

MI and/or CM to address ambivalence

and/or lack of engagement

SBIRT (Screening, Brief Intervention, and Referral to Treatment)

AUD is often chronic. Treatment recommendations and trajectory may change over time.

Thank you for your interest in serving individuals with a substance use disorder!

• Stay in touch!https://www.evergreentx.org/

peavy@evergreentx.org

https://www.evergreentx.org/mailto:peavy@evergreentx.org

ReferencesBall, J. C., Lange, W. R., Myers, C. P., & Friedman, S. R. (1988). Reducing the risk of AIDS through methadone maintenance treatment. Journal Of Health and social behavior, 214-226.

De Crescenzo, F., Ciabattini, M., D’Alò, G. L., De Giorgi, R., Del Giovane, C., Cassar, C., ... & Cipriani, A. (2018). Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis. PLoSmedicine, 15(12), e1002715.

Dole, V. P., & Nyswander, M. (1965). A medical treatment for diacetylmorphine (heroin) addiction: a clinical trial with methadone hydrochloride. Jama, 193(8), 646-650.

Fugelstad, A., Stenbacka, M., Leifman, A., Nylander, M., & Thiblin, I. (2007). Methadone maintenance treatment: the balance between life-saving treatment and fatal poisonings. Addiction, 102(3), 406-412.

Gowing, L. R., Farrell, M., Bornemann, R., Sullivan, L. E., & Ali, R. L. (2006). Brief report: Methadone treatment of injecting opioid users for prevention of HIV infection. Journal of general internal medicine, 21(2), 193-195.

Hedegaard, H., Warner, M., & Miniño, A.M. (2017). Drug overdose deaths in the United States, 1999–2016. NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics.

Hser, Y. I., Saxon, A. J., Huang, D., Hasson, A., Thomas, C., Hillhouse, M., ... & Cohen, A. (2014). Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial. Addiction, 109(1), 79-87.

Lee, J. D., Nunes Jr, E. V., Novo, P., Bachrach, K., Bailey, G. L., Bhatt, S., ... & King, J. (2017). Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X: BOT): a multicentre, open-label, randomised controlled trial. The Lancet.

McLellan, A.T., et.al., Drug Dependence, a Chronic Medical Illness Journal of the American Medical Association 284:1689-1695, 2000.

Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev, 3(3).

References (cont.)Mattick, R. P., Kimber, J., Breen, C., & Davoli, M. (2008). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev, 2(2).

Novick, D. M., Joseph, H., Croxson, T. S., Salsitz, E. A., Wang, G., Richman, B. L., ... & Whimbey, E. (1990). Absence of antibody to human immunodeficiency virus in long-term, socially rehabilitated methadone maintenance patients. Archives of Internal Medicine, 150(1), 97-99.

Nurco, D. N., Ball, J. C., Shaffer, J. W., & Hanlon, T. E. (1985). The criminality of narcotic addicts. Journal of Nervous and Mental Disease.

Nutt, D. J., King, L. A., & Phillips, L. D. (2010). Drug harms in the UK: a multicriteria decision analysis. The Lancet, 376(9752), 1558-1565.

The NSDUH report. (2019) Rockville, Md. :Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Dept. of Health & Human Services.

Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health(HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/

Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: Montana, Volume 4: Indicators as measured through the 2015 National Survey on Drug Use and Health, the National Survey of Substance Abuse Treatment Services, and the Uniform Reporting System. HHS Publication No. SMA–17–Baro– 16–States–MT. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017.

Pierce, M., Bird, S. M., Hickman, M., Marsden, J., Dunn, G., Jones, A., & Millar, T. (2016). Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England. Addiction, 111(2), 298-308.

Sordo, L., Barrio, G., Bravo, M. J., Indave, B. I., Degenhardt, L., Wiessing, L., ... & Pastor-Barriuso, R. (2017). Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. bmj, 357, j1550.

Vivolo-Kantor, A. M., Seth, P., Gladden, R. M., Mattson, C. L., Baldwin, G. T., Kite-Powell, A., & Coletta, M. A. (2018). Vital signs: trends in emergency department visits for suspected opioid overdoses—United States, July 2016–September 2017. Morbidity and Mortality Weekly Report, 67(9), 279.

https://www.samhsa.gov/data/

Opioids, Methamphetamines, and Alcohol: A tour through dopamine cityOpioid use disorder and its treatmentWhy talk about opioids? U.S. Opioid EpidemicMontana’s heroin use was similar to the corresponding national annual average percentage.Treatment admissions for opioid use disorder in MTOpioid use disorder (OUD)Treating OUD like the medical disorder it isSetting MAT(ters)Medications that target OUDNaltrexoneMedication Assisted Treatment with agonists: Why?Goals of Medication Assisted Treatment (Methadone and bup)Life of a an individual with Heroin AddictionMethadone: Stabilizing the PatientBut aren’t they still addicted? The Difference Between “Drug” and “Medication”Methadone for Opioid Dependence“M”ountains of evidence supporting “m”ethadone for OUDSlide Number 19Evidence��Bup vs. NaltrexoneEvidence: Methadone vs. Bup *While patients might be at low risk for opioid poisoning when naltrexone is in their systems, patients are at elevated risk for opioid poisoning when the medication wears off, in part because tolerance will be low.Which medication is right for me?�But what about meth(amphetamine)? �Meth & the brain – check it outDrug TrendsWhat affects drug trends?People who use drugs, use drugs.Rates of Methamphetamine use in MontanaTreatment for methamphetamine useLet’s not�forget Alcohol.What are the most harmful drugs?Slide Number 33National & MT Rates of AUDTreatment options for AUDWhat informs my treatment recommendations?Slide Number 38Thank you for your interest in serving individuals with a substance use disorder!ReferencesReferences (cont.)