Today s workshop is sponsored by BSAS

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2 Today s workshop is sponsored by BSAS The Bureau of Substance Addiction Services: Provides access to addictions services for the uninsured Funds and monitors prevention, intervention, treatment and recovery support services Licenses addictions treatment programs and counselors Tracks statewide substance use trends Develops and implements policies and programs Supports the addictions workforce Helpful Websites: BSAS: Helpline: Careers of Substance:

3 Disclosure The Center for Social Innovation, Praxis and trainers do not receive any financial incentives from programs and providers that provide MAT or pharmaceutical companies.

4 Learning Goals 1. Understanding the effects of substance use disorders on the brain 2. Understanding the risks and benefits of medication-assisted treatment 3. Exploring prejudice and myths about MAT 4. Helping people with opioid use disorders make informed decisions about MAT 5. Learning how to access MAT resources

5 The Power of Language Medication assisted treatment vs. Medication assisted recovery

6 Opioid Overdose Deaths in Massachusetts

7 Opioid Overdose Deaths in Massachusetts

8 Compelling Reasons to Consider M.A.T. Most people who have overdosed on opioids have had treatment experiences that were not effective in bringing them relief from craving, relapse, and compulsive use Opioid overdoses are the leading cause of accidental death in the U.S. Research shows that MAT is effective in reducing relapse when used in combination with other psycho-social treatment and support strategies Between , fatal overdoses in Baltimore decreased by 50% as the availability of MAT increased (Schwartz et al, 2013)

9 Outcomes of MAT Medication assisted therapy is more effective than no MAT for opioid use disorder even with high-quality behavioral treatment MAT with maintenance produces substantially better outcomes than detoxification1 50% abstinent at the end of active treatment vs. 8% when medication is withdrawn Sources : 1. Weiss RD, Potter JS, Griffin ML, McHugh RK, Haller D, Jacobs P, Gardin J 2nd, Fischer D, Rosen KD. Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial Published in final edited form as: Arch Gen Psychiatry December; 68(12):

10 Opioids Opiates Opium Morphine Codeine Semi-Synthetic Heroin Hydrocodone Hydromorphone Oxycodone Oxymorphone Buprenorphine Synthetic Fentanyl Methadone Tramadol

11 The 3 Ways Opioids Are Produced 1. Your body makes its own opioids that moderate pain and produce feelings of pleasure and well being Endogenous opioids, such as beta endorphins 2. They are derived from the plant-based alkaloids related to the opium poppy Opiates: codeine, morphine, laudanum Travel the same pathways as endogenous opioids, but much more potent 3. They are partially or completely synthesized in a lab to produce the opioid response Heroin, oxycodone, fentanyl More efficiently target and alter brain chemical processes

12 Opioid Receptors in the Body

13 Czli

14 Susan s Brain

15 Synapse

16 Substance Use Disorders Are Conditions of Brain Chemistry Addictive drugs seem to match the transmitter system that is deficient Substance use disorders tend to be chronic diseases There are mild, moderate, and severe forms of the condition Detoxification is usually the first step in the total treatment process

17 Drugs Associated with Neurotransmitters Why do people have drugs of choice? Dopamine Serotonin Endorphins GABA Glutamate Acetylcholine amphetamines, cocaine, alcohol LSD, alcohol opioids, alcohol benzodiazepines, alcohol alcohol nicotine, alcohol

18 Opioids: Dependence, Tolerance, and Substance Use Disorders Physical Dependence Withdrawal symptoms Tolerance Physiologic adaptations to opioid therapy Substance use disorders Compulsive use and maladaptive behaviors Savage SR, et al. J Pain Symptom Manage Jul;26(1):

19 Substance Use Disorders Involve Multiple Factors Biology/Genes Environment DRUG Brain Mechanisms Substance Use Disorders

20 Risk Factors for Substance Use Disorders Some people become physically dependent on opioid analgesics while taking them for pain but stop with minor difficulties while others experience intense cravings and compulsive use. What accounts for these different responses? o Heredity / Genetics o Willpower o Access o Education level o Mental health disorders o Strength of character o Intelligence o Environment o Modeling o Age of first use o Chronic pain o Illegal vs. legal substance o Childhood trauma o Early cigarette smoking

21 Risk Factors for Substance Use Disorders Some people become physically dependent on opioid analgesics while taking them for pain but stop with minor difficulties while others experience intense cravings and compulsive use. What accounts for these different responses? þ Heredity / Genetics o Willpower þ Access o Education level þ Mental health disorders o Strength of character o Intelligence þ Environment þ Modeling þ Age of first use þ Chronic pain o Illegal vs. legal substance þ Childhood trauma þ Early cigarette smoking

22 Opioids and Substance Use Disorders Lasting changes in the brain resulting from regular use: An endorphin deficiency that persists Tolerance Need for larger and larger amounts to get the desired effects or, after prolonged use, to feel normal. Continued use: the body relies on the drug; its own opioid production shuts down. Reacts if external supply is cut off: Withdrawal

23 Opioids and Mood: What goes up must come down Prolonged use = deficiencies in the brain s capacity to regulate mood Pre-existing depression = stronger reinforcing effects = increase risk of a substance use disorder

24 Opioids and Pain About 29%-60% of people with opioid use disorders deal with chronic pain Prolonged use = deficiencies in the body s capacity to neutralize pain Opioid use for chronic pain can lead to misuse and a substance use disorder

25 Opioids and Motivation Most people can t just walk away even when they want to Manage short periods, despite severe withdrawal Long-term recovery = dealing with continuous craving Altered brain chemistry = Long-term distress The brain s motivation mechanisms are affected Research shows better outcomes require counseling, recovery support and at least 12 month on medication.

26 General Principles of Pharmacotherapies How each medication works PHARMACODYNAMICS Agonists Directly activate opioid receptors (e.g., morphine, methadone) Partial Agonists Unable to fully activate opioid receptors even with very large doses (e.g., buprenorphine) Antagonists Occupy but do not activate receptors, hence blocking agonist effects (e.g., naloxone)

27 The Medications: Methadone Methadone is a long-acting opioid medication that reduces cravings and withdrawal symptoms People stabilized on the right dose feel normal, can continue to work and perform daily tasks, like driving. Can be started at any time. Dispensed daily at licensed, registered clinics; long-term patients can be approved for take-home doses Recommended for people with histories of intense cravings and withdrawal; long use; those living with chronic pain or HIV/AIDS HIGH RISK of overdose at start of treatment and if combined with other substances such as alcohol and benzodiazepines RISK of serious heart problems & sudden cardiac death

28 The Ideal Candidates for Opioid Dependency Treatment with Methadone Have been objectively diagnosed with an opioid dependency. Recommended for people with higher levels of opioid dependency, intense cravings and withdrawals. A person who is pregnant. Not have a significant heart problem. Is willing to use this medication as part of a comprehensive treatment plan and understands that this medication does not take the place of therapy or counseling.

29 The Medications: Buprenorphine Buprenorphine is a long-acting opioid medication that reduces cravings and withdrawal symptoms Combined with naloxone to prevent misuse (Suboxone) A mono-drug formulation has buprenorphine alone. Clients stabilized on the right prescribed dose feel normal, can continue to work and perform tasks like driving. Available through doctors with special training and certification & at OTPs Up to a 30-day supply from pharmacies for clients making progress Can t be started until at least hours have passed since last opioid use RISK of overdose when combined with other substances such as alcohol and benzodiazepines. FDA approved for use in treatment of opioid use disorders in 2002

30 The Ideal Candidates for Opioid Dependency Treatment with Buprenorphine Have been objectively diagnosed with an opioid dependency Are willing to follow safety precautions for the treatment Have been cleared of any health conflicts with using buprenorphine Have reviewed other treatment options before agreeing to buprenorphine treatment Is willing to use this medication as part of a comprehensive treatment plan and understands that this medication does not take the place of therapy or counseling.

31 The Medications: Buprenorphine Buprenorphine s opioid effects increase with each dose until at moderate doses they level off, even with further dose increases. This ceiling effect lowers the risk of misuse, dependency, and side effects

32 Buprenorphine Safety People should use the following precautions when taking buprenorphine: Do not take other medications without first consulting your doctor. Do not use illegal drugs, drink alcohol, or take sedatives, tranquilizers, or other drugs that slow breathing. Physicians should monitors any liverrelated health issues that they may have.

33 Pregnant or Breastfeeding Women and Buprenorphine Limited information exists on the use of buprenorphine in women who are pregnant and have an opioid dependency. The the few case reports available have not demonstrated any significant problems resulting from use of buprenorphine during pregnancy. The FDA classifies buprenorphine products as Pregnancy Category C medications, indicating that the risk of adverse effects has not been ruled out.

34 Switching from Methadone to Buprenorphine Studies indicate that buprenorphine is equally as effective as moderate doses of methadone. Buprenorphine is unlikely to be as effective as more optimal-dose methadone. It may not be the treatment of choice for patients with high levels of physical dependency.

35 Switching from Methadone to Buprenorphine It is best to SLOWLY reduce the therapeutic dose of Methadone to 30 mg a day or less for at least a week, before discontinuing it completely for at least 36 hours before starting Buprenorphine.

36 Switching from Buprenorphineto Methadone Transferring from buprenorphine to methadone treatment is less complicated than the transition from methadone to buprenorphine. Methadone can be commenced 24 hours after the last dose of buprenorphine

37 Buprenorphine Misuse Potential Naloxone is added to buprenorphine to decrease the likelihood of diversion When taken as prescribed, buprenorphine s opioid effects dominate and blocks opioid withdrawals If sublingual tablets are crushed and injected the naloxone effect dominates and can bring on opioid withdrawals

38 Commencing Naltrexone Following Buprenorphine Maintenance Treatment To minimize the risk of withdrawal symptoms, naltrexone should be delayed for 5-7 days after the last buprenorphine dose. Doses of naltrexone taken earlier than this are likely to induce some withdrawal symptoms depending on the buprenorphine doses in the last few weeks of treatment.

39 The Medications: Naltrexone Naltrexone is an opioid blocker an antogonist it blocks euphoric and pain relieving effects of opioids; has a similar effect with alcohol Vivitrol: monthly long-acting injection Naltrexone: available in pill form Not a controlled substance; no potential for diversion; no need to taper. Injections through any doctor, P.A. or ARNP pills through pharmacies. Recommended for people with less intense withdrawal and cravings, highly motivated for recovery, adolescents and mandated clients. Must wait 7-10 days after last opioid use to begin without adverse affects HIGH RISK of overdose if people use large amounts override blocking effects or use after completing a period of treatment due to lowered tolerance.

40 The Ideal Candidates for Opioid Dependency Treatment with Vivitrol Have been objectively diagnosed with an opioid dependency Recommended for people with lower levels of opioid dependency. T Must be opioid-free for 5-7 days Not have a diagnosis of significant liver or kidney disease. Is willing to use this medication as part of a comprehensive treatment plan and understands that this medication does not take the place of therapy or counseling.

41 Stages of MAT Community providers use a four stage process 1 Induction: assessment, individualized starting dosages; HIGH RISK for overdose during this stage 2 3 Stabilization: adjustment to medication, withdrawal and cravings begin to be under control Maintenance: long-term phase of treatment lasting for months / years; periodic reassessment 4 Tapering: medically managed withdrawal through gradually reduced doses over a period of months

42 Regulatory Issues MAT for opioid use disorders is carefully regulated by federal agencies Research consistently shows treatments less than 90 days are not sufficient for long-term behavioral change Research outcomes for MAT for opioid use disorders are better when treatment continues for months

43 Federal Opioid Treatment Standards Required services: (42 CRF 8.12) General OTP shall provide adequate medical, counseling, vocational, educational and other assessment and treatment services. Medical Assessment Special services for pregnant clients Initial and periodic assessments Counseling-including health and harm reduction counseling

44 Essential Services in MAT Programs Initial and periodic assessment with goal setting Medical assessment and treatment Substance use counseling Vocational and educational assessment and counseling Health and prevention counseling (HIV, HCV STI) Linkage to basic supports Drug testing services and monitoring

45 Legal Issues + Driver s licenses; commercial license restrictions. + Protected by confidentiality and antidiscrimination laws + Employment protection + Government benefits + Child welfare, drug courts, probation/parole cannot legally require MAT to stop

46 Opioid Use Disorders: All Available Resources Chances of success improve we help people use all recovery supports Professional treatment services; substance abuse counseling Medications Person with Opioid Use Disorder Peer recovery support; family support; connections to community Other essential services; mental health, housing, medical care

47 A Real Life Example

48 What do people need to know to inform choices and make decisions about medication-assisted treatment? Outcome research on effectiveness of MAT Risks vs. benefits of medication options What to expect from MAT Providers that offer MAT How to talk to others about their decisions Sources of peer/community recovery support

49 Medication-Assisted Treatment: Outcomes When medications are part of a comprehensive treatment program: Decreases illicit opiate use Decreases injection drug use Decreases hepatitis and HIV infections Decreases sexually transmitted infections Decreases in overdose fatality rates Decreases criminal activity

50 Why Consider MAT? When programs incorporate MAT according to practice guidelines some of the outcomes include: Increases treatment retention Improves family stability Increases employment Cost effective treatment

51 Essential Question Can I or do I want to try MAT? Which MAT protocol is best for me? What will it take for me to use MAT?

52 Sequence of Decisions 1. Whether MAT is right for them 2. Which medication is right 3. How to get services that are supportive 4. What kinds of support are needed

53 Weighing the Risks and Benefits of MAT Benefits MAT Risks MAT Medication-assisted Treatment Benefits No MAT Risks No MAT

54 How do you help a person make decisions about MAT? 1. Conduct opioid overdose risk assessment 2. Explore treatment goals 3. Explore beliefs about MAT 4. Educate about the benefits of MAT 5. Educate about the services and supports available to people on MAT 6. Perform harm reduction interventions

55 Risks & Benefits of MAT Benefits Stabilizes brain functions Long term treatment can reverse some of the damage Allows people to function normally continue to work Relieves withdrawal symptoms and reduces craving Risks Withdrawal, if stopped abruptly Controlled substances w/abuse potential Medication side effects & interactions Risk of overdose or fatality, especially if taken with benzodiazapines

56 When do you help a person make decision about MAT? Intake Assessments Educational groups Counseling sessions Family meetings Every available opportunity

57 What do you do if a person decides not to participate in MAT? Harm reduction strategies including: Opioid overdose prevention education Opioid overdose risk assessment Train person and family members to use Narcan Provide resources for MAT in case the person changes his/her mind Offer all other services and supports available to help the person recover

58 Comparing Medication Options Benefit from structured programs Able to get an approved program Pregnant and post-partum women Have chronic pain People getting treatment for HIV/AIDS When can I start? Immediately Methadone How long do I take it? Best results when for at least 1 year Safe for long-term maintenance Periodic assessment for ongoing treatment based on individual needs What happens if I stop? Methadone withdrawal symptoms Gradual tapering doses reduces severity What if I use opioid drugs? High risk of overdose May not have euphoric effict Alcohol or other drug use increases risk Fatalities reported with benzodiazepines Buprenorphine Who does well? Are best treated in doctors offices Pregnant and post-partum women Are getting treatment for HIV/AIDS Motivated to try buprenorphine Able to adhere to medication treatment Starting/Stopping When can I start? hours after last use How long do I take it? Best results when taken 9 months or more Safe for long-term maintenance Periodic assessment for ongoing treatment based on individual needs What happens if I stop? Withdrawal, less intense, but unpleasant Gradual tapering reduces severity What if I use opioid drugs? Moderate to high risk of overdose May cancel out effects of other opioids Also moderate to high risk of overdose with alcohol or other substances Naltrexone Able to stop using for 7-10 days Mandated by court or employer Also benefit from avoiding alcohol Motivated to eliminate all opioids now Re-entering from prison or jail When can I start? After 7-10 days completely opioid-free Or risk of bringing on severe withdrawal symptoms How long do I take it? Long-acting injectable lasts 30 days Little effect with short-term treatment Most studies treat subjects for 5-6 months What happens if I stop? No withdrawal symptoms What if I use opioid drugs? Risk of overdose If taken while physicallly dependent on opioids, withdrawal can result Effects of opioids may be blocked

59 Information You ll Want from Your Provider What treatment options do you offer for opioid use disorders? What medication(s) do you use to treat opioid use disorders? How flexible is the program? Will I be able to do this with my work schedule? What are the costs? How do people pay for treatment? How soon can I begin treatment? What other kinds of help are available? Help with transportation HIV testing Help with benefits &coverage Support groups Childcare Recovery support services Counseling Other:

60 Information Your Provider Will Want from You Gather Your Information: ü List all your current health conditions and concerns. ü List the medications and supplements you use now. ü List the opioid drugs you have using, how long, and an estimate of how much. ü List any other legal or illicit drugs you use (for example: marijuana, tobacco, valium, alcohol, etc.). ü List dates and details of any past or current treatment for opioid use disorders (for example: where, when, and how it worked out).

61 MAT for Justice-Involved Clients STUDIES SHOW: Decreased recurrent drug use Increased follow up with community treatment upon release; lower recidivism Decreased criminal activity & arrests Decreased behavioral problems and parole/probati on violations Decreased in HIV risk behavior

62 Federal Government Set To Crack Down On Drug Courts That Fail Addicts WASHINGTON The federal government is cracking down on drug courts that refuse to let opioid addicts access medical treatments such as Suboxone, said Michael Botticelli, acting director of the White House s Office of National Drug Control Policy, on Thursday. Drug courts that receive federal dollars will no longer be allowed to ban the kinds of medication-assisted treatments that doctors and scientists view as the most effective care for opioid addicts, Botticelli announced in a conference call with reporters Huffington Post Feb. 6, 2015

63 SAMHSA & BJA Drug Court Grantees Under no circumstances may a drug court judge, other judicial official, correctional supervision officer, or any other staff deny the use of these medications when made available to the client under the care of a properly authorized physician prescription... Substance Abuse Mental Health Services Administration Applicants must affirm that the treatment drug court(s) for which funds are sought will not deny any eligible client for the treatment drug court access to the program because of their use of FDAapproved medications for the treatment of substance use disorders Bureau of Justice Assistance

64 Reentry and Drug Overdose In the first 2 weeks post-release, a former inmate s risk for death by drug overdose = 129 times the risk for the general population. Deaths per 100,000 Person Years Overall >9 Weeks After Release Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, Koepsell TD. Release from prison-a high risk of death for former inmates. N Engl J Med. 2007;356(2):

65 Criminal Justice & Opioid Use Disorders in Massachusetts Opioid Task Force Recommendations: Increase availability of treatment at designated DOC facilities Increase use of injectable naltrexone (Vivitrol) for people with opioid use disorders returning to community from correctional facilities

66 MAT during Pregnancy If a pregnant woman stops opioids abruptly, withdrawal can harm the developing fetus Methadone is the oldest and best-research course of treatment; safe for the mother; no damage to fetal development Pregnant women treated with methadone are 3x times more likely to stay in treatment Promising studies show buprenorphine (the mono-drug formula only-subutex) is also safe Complete withdrawal not advised during pregnancy. Should not be attempted without medical supervision

67 MAT during Pregnancy Special challenges include: Few social supports, discrimination, harassment, even when seeking treatment Neo-natal abstinence syndrome manageable in newborns but may delay baby s discharge from hospital High risk of relapse after delivery, especially if MAT is discontinued too quickly

68 MAT for those with Mental Health Conditions Research shows that most people who are addicted to opioids have a mental health disorder (may or may not be diagnosed) Methadone-psychiatric medication interactions are a concern and monitoring and dosage adjustments are necessary Collaboration with mental health staff and community mental health centers is important People with mental health condition using MAT may need additional services and supports

69 MAT for those with Chronic Pain An estimated 29%-60% of people with opioid use disorders deal with chronic pain (CSAT, 2012a). Referral for pain management Providers with experience with pain management and MAT Chances for relapse increase with inadequate pain relief Medication doses of long-acting opioid agonists used in ORT are often not effective for pain management TIP 54: Managing chronic pain in adults with or in recovery from substance use disorder. (2012)

70 MAT for those with HIV/AIDS and Viral Hepatitis HIV and Hepatitis C risk behaviors decrease significantly among patients receiving MAT. HIV infection rates decrease and adherence to anti-retroviral medication treatment increases significantly (Springer, Chen, Altice, 2010; Ullman et al., 2010). All medications used for MAT have been used safely by persons with Hepatitis C, even while undergoing treatment. Most doctors review liver function tests prior to initiating MAT to during treatment.

71 System/Program-Level Issues Historically MAT and recovery-oriented services while sharing the same goals did not share similar methods leading to mutual distrust or suspicion Staff from MAT programs and staff from recovery programs rarely interacted Each program has its own models for service provision.

72 No wrong door Part of the Continuum of Care model, No Wrong Door allows clients to access essential services including recover/treatment services (for example housing services, DTA and other support services) from any other statesponsored agency, as seamlessly as possible.

73 No wrong door Use as many effective tools as are available One size does not fit all: as many doors as possible A full continuum of care: multiple services with flexible responses Engagement promotes progress Expectation of relapsing/remitting course Expectation of variable and shifting treatment readiness Recovery as a gradual process, not an overnight event -- expectation of incremental progress

74 Additional Resources TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment-for-Opioid-Addiction-in-Opioid-Treatment- Programs/SMA