Injectable naltrexone (XR-NTX) A RETROSPECTIVE STUDY OF ITS ACCEPTANCE IN A COMMUNITY RECOVERY SETTING BRIANNE FITZGERALD MSN, PMHNP, CARN-AP

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1 Injectable naltrexone (XR-NTX) A RETROSPECTIVE STUDY OF ITS ACCEPTANCE IN A COMMUNITY RECOVERY SETTING BRIANNE FITZGERALD MSN, PMHNP, CARN-AP Overview Gavin Foundation Injectable naltrexone Community report card The project Results Discussion The Gavin Foundation A multiservice organization established in 1962 that provides community based substance abuse prevention, education and treatment. Gavin works from a deep commitment to the community that includes the widespread community of individuals and families in recovery.

2 Injectable naltrexone A prescription medicine used to treat alcohol dependence and to prevent relapse to opioid dependence after opioid detoxification A full mu-opioid receptor antagonist Approved to treat alcohol dependence in 2006 and 2010 for opioid dependence (brand name/new formulation Originally approved in 1984/opioids and 19994/alcohol as naltrexone Blocks the euphoric effects of opioid for approximately 1 month Appeals to those who prefer relapse prevention medication No known abuse or diversion potential Naltrexone Naltrexone is an opioid ANTAGONIST. It works by blocking the opiate receptors in the brain, therefore (theoretically) blocking the effects of heroin and other opiates. People using naltrexone do not achieve the high from using opioids There is no euphoria nor is there any withdrawal when discontinued Pregnancy category C Non scheduled medication Naltrexone Does not cure the craving. Similar to a cast on a broken leg Does not prevent/block the use of other substances Best results come from participation in a comprehensive bio/psych/social and spiritual recovery program Strong recommendations to remain out of environments where drugs are readily available

3 Side effects Any and everything Nightmares/insomnia Nausea/dizziness Headaches/toothaches Anxiety and agitation Adverse effects Vulnerability to opioid OD Precipitation of opioid withdrawal Injection site reactions Hepatotoxicity Depression and suicidality Unintentional/undetermined opioid deaths January 2016-June 2016 vs. injectable naltrexone project 12/15-6/16 Total Male Female Total White Hispanic 67 5 Black 19 4 Asian 4 0 Other 7 1

4 Unintentional/undetermined opioid deaths January 2016-June 2016 vs. injectable naltrexone project 12/14-6/16 total Total The project Identify and assess patient characteristics Length of stay in treatment Recovery oriented behaviors and supports Analyze future trends on how we might best use this underutilized, non addictive, non abusable medication assisted treatment Project (continued) Information on 90 patients admitted between 1/1/15 and 6/30/16 is tallied Including age, race, sex, drug of choice, length of time using, housing situation, prior experiences w treatment and recovery. Issues of overdose, medication adverse effects as well as successes will be described

5 Assessment process Schedule an appointment No waiting to up to 2 weeks) Psych assessment Drug of choice 85/90 use heroin or oral narcotics (93%) and OD s 52/84 (62%) Informed consent Lab orders Insurance information Script for oral naltrexone and naltrexone jewelry Assessment continued Time consuming process No EMR, so hard copy script for labs must include diagnosis This may be a road block for some as getting labs are costly unless you have a PCP willing to accept streamline this process. The entire process when it works well will yield first injection within 7-10 days The oral version is immediately available, unless there is an issue w opioids in system Second visit Patient is advised that pharmacy may be calling them to confirm address. An 800 number NEEDS to be answered An unsupervised urine is expected. Personal belongings remain in the office while this is happening. The medication has been at room temperature at least an hour. Patient is asked if they mind me mixing it in front of them

6 Bend over and relax that butt cheek Goals of treatment This is not harm reduction, we re looking for sustained recovery Decreased opioid use yields decreased overdoses, There is a mandated (though not always adhered to) expectation of skills building. Urines that show up w other drugs may be grounds for discharge We are looking for folks willing to put some skin the game Looking for an improved quality of life 90 intakes

7 A Note on referral sources Persons are self referred or come through the DOC or from detoxes and have already had at least one injection There were 15 referrals from institutions 2 fatal OD after d/c 1 referred for GI review and stopped IN 6 made intake only 2 are doing well w 10 months under their belts (relationship/housing/ work) There were 7 referrals from treatment programs 4/7 were lost to f/u after intake, 2 made it to 2 injections and were then lost to f/u. 1 decided to take oral naltrexone only Planned terminations or never started 18% Elevated LFT s (2) Flushing/sweating/anxiety. No issues w oral (1) Headaches. Using oral (1) Precipitant w/d (1) Eosinophilic pneumonia was ruled out, took oral for awhile(1) Never took an injection, using oral (2) Injections and decided to go without and remain sober (2) in recovery currently Moved to another clinic (6)

8 Some outcomes Vulnerability to opioid OD 4 fatal 2 non fatal Injection site reactions 0 Precipitation of opioid w/d 1 Hepatotoxicity 2 noted before Gavin Foundation Depression and suicidality 1 after 2 injections. Lost to program All over the place OD s (4 fatal, 2 non fatal) Known relapses (12) Still in treatment Lost to follow up unable to reach 3 months after last visit (30) Urines w opioids in them, never came back (2) In therapy, can t make it to injection (3) Outliers (3) One man s story

9 The verdict is NOT in How does the drug work in the real world Who will benefit from this treatment What about the OD risk More beneficial for alcohol users to rein in use Does it diminish your enthusiasm for the drug or is it a stick you know that you can t use Does it blunt the pleasure centers in other areas Compliance issues w the pill No direct evidence comparing it to agonists/partial agonists Lessons learned and implications for practice Of the 2.5 mil who abused or were addicted to opioids in 2012 less than 1 mil received MAT including (bup/meth/in). Less than ½ private sector programs offer MAT and even among those that do only about 1/3 receive it. Both public and private insurance typically limit coverage, caps on dosage and lifetime ceilings, auth. requirements and LIMITED coverage for counseling as well as a fail first criteria that demands that MAT be a last resort. Many TX. Facility managers and staff also prefer an abstinence model, despite (SOME) evidence in favor of MAT including a study of heroin OD s in Baltimore that found that the number of fatal OD s dropped 50% when methadone and buprenorphine treatment became available MAT-Tackling the opioid overdose epidemic Nora D. Volkow et al, NEJM vol 29, No370, May 2014 And my take on this is Addiction is the dis-ease of living elsewhere. The present moment is an awful place to be during active addiction Problem w the culture of prescribing Pain is not the fifth vital sign, it is not a vital sign We have been duped into believing that no one should ever feel any discomfort A crisis of loneliness and isolation, a loss of community and family connection Share the common ground of suffering and imperfection We can t fix everything from chronic pain to body dysmorphia. The culture of the quick fix is a sham