Treating Opioid Addiction. Opioid Addiction What Every Psychotherapist Needs to Know. To download slides, handouts, forms. Arnold M. Washton, Ph.D.

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1 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Opioid Addictio What Every Psychotherapist Needs to Kow Arold M. Washto, Ph.D. To dowload slides, hadouts, forms Priceto NJ ad New York, NY Private practice of addictio ad cliical psychology Private practice of addictio ad cliical psychology Priceto Mahatta Writte for office-based therapists NY Office: (212) NJ Office: (609) Private practice of addictio ad cliical psychology Priceto Mahatta Treatig Opioid Addictio Focus of today s presetatio Role of Office-Based Therapists Opioid Pharmacology Medicatios Itegrated Approach Assessmet Idividualized Treatmet Plas Gettig Started Relapse Prevetio How to itervee effectively with opioid users i office-based psychotherapy practice What o-medical therapists eed to kow ad do to itervee effectively with opioid users Treatmet of fuctioal adults ot sufferig from severe psychiatric illess The Washto Group- Priceto & Mahatta

2 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Role of Psychotherapists Role of Psychotherapists i Treatig Addictio Alog with PCPs, therapists likely to see more people with SUDS (kowigly or ukowigly) tha most other healthcare professioals Therapists are i a excellet positio to idetify, assess, egage, motivate, treat ad/or refer cliets with SUDs Role of Psychotherapists Role of Psychotherapists Provide private idividualized treatmet as alterative, supplemet, or sequel to stadard oe size fits all programs Establish ad maitai a strog therapeutic alliace Ehace motivatio ad readiess for chage Develop rapport ad therapeutic alliace (egagemet) Assess ature ad extet of substace use Assess related problems ad life cotext Assess desired goals, readiess for chage, supports ad obstacles to chage Explore treatmet optios (office-based, IOP, ipatiet, etc.) Educate about medicatios (pros/cos) Educate ad egage sigificat others Role of Psychotherapists Role of Psychotherapists Lik ad coordiate care with prescribig physicias Support compliace with medicatio regimes Provide CBT, affect regulatio (DBT), midfuless, relapse prevetio, supportive psychotherapy Provide idividual ad/or group therapy Assess ad treat co-occurrig/uderlyig MH problems Provide crisis itervetio ad ogoig support for cliets ad family members Coordiate care with physicias, treatmet programs, ad other providers, whe eeded Educate patiets about potetial beefits/limitatios of medicatio, facilitate likage with medicatio prescribers, ehace compliace with prescribed medicatio regimes, ehace ability to cope with medicatio side effects The Washto Group- Priceto & Mahatta

3 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Role of Psychotherapists Idetify ad address co-occurrig/uderlyig emotioal ad psychological issues (trauma, relatioships, etc.) itertwied with addictio Educate about self-help programs (e.g., NA, AA) ad ecourage givig it a try OPIOID PHARMACOLOGY Classes of Psychoactive Substaces Opioids CNS Depressats (Alcohol & Sedatives) CNS Stimulats Caabioids Hallucioges (Psychedelics) Other Drugs Opium Morphie Heroi Methadoe Opioids ( Narcotics ) Prescriptio Paikillers ØOxycodoe, Hydocodoe, OxyCoti, Codeie, Fetayl, Tramadol All Psychoactive Substaces Cross the blood-brai barrier Alter eurochemical activity i the brai The brai is the target orga of all psychoactive substace use Produce reiforcig effects i humas ad aimals Routes of Admiistratio How to get drugs ito the bloodstream ad brai More rapid routes produce more rapid effects which icrease addictio potetial. From slowest to fastest: Trasdermal (Absorbed thru ski surface) Oral (Igestio, Subligual) Itraasal ( Sortig - Absorbed thru asal mucosa) Itramuscular ijectio (IM) Subcutaeous or itradermal ijectio Itraveous ijectio (IV) Pulmoary Ihalatio (smokig) The Washto Group- Priceto & Mahatta

4 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Half Life v Speed of metabolism v Time it takes for blood level to decrease by 50% from peak value v Usually takes 4 half-lives to fully metabolize v Affects time course & duratio of actio v Affects time course of withdrawal, if ay Tolerace Need for icreasig doses to achieve the same effects ad/or prevet withdrawal Progressive developmet of physiological adaptatio ad immuity to drug effects, startig with the first dose Cross-Tolerace All depedece-producig drugs withi the same pharmacological class or category ca substitute for oe aother, produce similar effects, ad prevet withdrawal Detoxificatio ofte ivolves switchig to a equivalet dose of a loger-actig drug withi the same drug class; for example, Ø Burpreorphie or methadoe for ay other opioids Ø Bezodiazepies (e.g., Valium, Kloopi, Ativa) for alcohol OPIOIDS Poppy Plat Papaver somiferum History Of Opium Amog the the oldest types of drugs i huma history Refereces to opium foud i writigs from 3rd cetury BC Opium use recorded i Chia ad Mesopotamia over 2000 years ago Greeks dedicated the Opium poppy to the Gods of Death (Thaatos), Sleep (Hypos), ad Dreams (Morpheus) 16 th cetury- the first reported use of Opium for aalgesic qualities (pai relief) Preparatios of opium i the form of elixirs became icreasigly popular i the 17 th, 18 th, ad 19 th ceturies By the early 19 th cetury Opium i various forms was cosidered as legitimate as tobacco or tea. The Washto Group- Priceto & Mahatta

5 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Opioids i U.S. Opium Des Civil War: Opium ad morphie widely used to treat ijured soldiers Morphie addictio: The soldier s disease Late 1800 s: Chiese immigrats ad railroad workers established first opium des i Sa Fracisco ad New York 1870 s: Opium des outlawed, wet udergroud, persisted util WWII Opioid Medicatios for pai relief & cough suppressio Developed by pharmaceutical compaies i U.S. ad Europe Ø Morphie (1804) Ø Codeie (1832) Ø Diacetylmorphie Heroi 1898 Ø Hydrocodoe Vicodi (1920) Ø Hydromorphoe Dilaudid (1924) Ø Oxycodoe Percocet (1927) Ø Methadoe (1937) Heroi Geeric ame: Diacetylmorphie Pateted by Bayer as Heroi i 1898 Marketed as o-addictig, treatmet for morphie addictio 1906: Approved by AMA as replacemet for Morphie 1914: 200,000 heroi addicts i NYC 1914: Harriso Narcotics Act: Outlawed omedical use of Heroi 1924: Heroi outlawed for medical use Bayer Heroi The Washto Group- Priceto & Mahatta

6 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. OPIOIDS Narcotic aalgesics (paikillers) Most potet paikillers kow to ma Morphie is the stadard for all opioid drugs Opioids iclude Ø Natural derivatives from the opium poppy plat (papaver somiferum) kow as opiates Ø Sythetic ad semi-sythetic opioids with morphielike effects 32 Commoly Abused Rx Opioids Fetayl: Diprova, Duragesic Hydromorphoe- Dilaudid Hydrocodoe- Lortab, Vicodi Oxycodoe- OxyCoti, Percocet Kratom Powder & Capsules The Washto Group- Priceto & Mahatta

7 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Kratom Tea Mitragya Speciosa Used i: Malaysia Thailad Ø Idoesia Ø Ø Local ames: Ithag Biak Biak Ø Ketum Ø Kakuam Ø Ø Kratom Olie Ad Kratom Super Powder If you wat the best of the best, as oly the first Kratom supplier i the world ca deliver, our Super Powder Kratom is of urivalled potecy. No eed to shop aroud for blue light specials o garbage quality "kratom." We ca guaratee that our Super Powder Kratom is the highest quality Kratom you ca fid aywhere! Ad at a great price. This powdered M itragya speciosa leaf is high alkaloid like the previous product but has it's ow uique mix of alkaloids. It is superior to the youg, cultivated leaf material which copycat sellers have tried to sell, ad of course to the altogether fake "kratom" which other copycats have tried to offer. Our Kratom Super Powders are very, very fie powder, ot crushed with stem bits as foud elsewhere. Always i stock ad ships to you TODAY! (M-F) You will love this material for your research! 25 grams / $ grams; $ grams / $ Ships SAM E-DAY if ordered by 3 PM cetral! Product ot available to Australia, Demark, Filad, M alaysia, M yamar, New Zealad, Norway, Romaia, Thailad. OPIOID USE IN THE U.S. 5% of world s populatio Cosume 80% of world supply of prescriptio opioids The curret opioid epidemic is a America pheomeo The Washto Group- Priceto & Mahatta

8 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Opioid Overdose Deaths From , more tha 350,000 people died from a overdose ivolvig ay opioid, icludig prescriptio ad illicit opioids. 1 This rise i opioid overdose deaths has occurred i three distict waves. The first wave bega with icreased prescribig of opioids i the 1990s, with overdose deaths ivolvig prescriptio opioids Opioid Overdose Deaths The secod wave bega i 2010, with rapid icreases i overdose deaths ivolvig heroi. The third wave bega i 2013, with sigificat icreases i overdose deaths ivolvig sythetic opioids particularly those ivolvig illicitlymaufactured fetayl which ca be foud i combiatio with heroi, couterfeit pills, ad cocaie. Overdoses DEATHS from heroi or prescriptio opioid pai relievers (OPRs) by age group Opioid ivolvemet i bezodiazepie overdose 10,00 0 9, 000 Tota l Bezodiazepies ad Opioids Bezodiazepies without Opioids 8, 000 7, 000 6, 000 5, 000 4, 000 3, 000 2, 000 1, SOURCE: CDC. Icreases i Heroi Overdose Deaths 45 Source: Natioal Ceter for Health Statistics, CDC Woder OPIOID USE Cotrary to popular belief, most people who use opioids do so without becomig addicted Effective short-term treatmet for pai (e.g., postsurgery or post-ijury) Prologed use for chroic pai poses a high risk of developig both physical ad psychological depedece, especially i vulerable idividuals Physical depedece develops after approximately 4-6 weeks of daily use The Washto Group- Priceto & Mahatta

9 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Opioids: Double-edged sword Corerstoe of pai maagemet Mood alterig properties Stroger, More Dagerous Opioids Drug buyers do t kow what they re buyig Ø Old heroi: Columbia ~10% purity Ø New heroi: Mexica ~40% purity Fetayl: Ø Sythetic opioid made i chemistry labs Ø Smuggled from Mexico ad Chia Ø 80 times more potet heroi Ø Sometimes added to heroi or pills Ø Ukow amouts mixed i heroi or pills cotribute to icreased risk of overdose 49 Opioids Differ Opium Drug Duratio Potecy Methadoe hours **** Asia White Heroi Mexica Brow Heroi Heroi 6-8 hours ***** Oxycoti 3-6 hours ***** Codeie 3-4 hours * Demerol 2-4 hours ** Morphie 3-6 hours *** Fetayl 2-4 hours ********* Lethal Doses of Heroi & Fetayl Fetayl is 80 times more potet tha heroi Naloxoe Naloxoe (Narca) will reverse the effects of opioids, reversig a overdose. Simple asal spray or ijectable No effect other tha blockig the opioids No adverse reactios No potetial for abuse No potetial for overdose The Washto Group- Priceto & Mahatta

10 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Naloxoe (Narca) Reverses opioid overdose Naloxoe A prescriptio medicie that reverses a opioid overdose (may cause withdrawal) Ijectable ad itraasal applicatios Wakes a perso who is overdosig i 3-5 miutes ad lasts miutes Does ot have psychoactive effects does ot make a perso high Narca Nasal Spray SigleStep Auto-ijector Itramuscular Ijectio OPIOID Termiology Opioids Opiates: Nasal with separate atomizer Multi-step Opium Morphie Codeie Semi-Sythetic Heroi Hydrocodoe Hydromorphoe Oxycodoe Oxymorphoe Bupreorphie Sythetic Fetayl Methadoe Tramadol Opioids Natural alkaloids morphie codeie Semisythetics heroi oxycodoe OPIOIDS OPIATES fully or semi-sythetic atural Bid to opioid receptors Morphie-like actio hydrocodoe thebaie bupreorphie aloxoe The Washto Group- Priceto & Mahatta OPIOID DEPENDENCE

11 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Opioid Effects Stimulate opioid (mu) receptors Euphoria Aalgesia Cough suppressio Respiratory depressio (potetially lethal) Pupillary costrictio (meiosis) Costipatio Histamie release (itchig, brochial costrictio) Opioid Effects Stress relief, euphoria Sedatio or activatio Axiolytic Atidepressat Atipsychotic Why Are Opioids So Appealig ad Addictive? Emotioal aesthesia: the prospect of life without psychic pai, egative emotios, bad moods Ehaced motivatio, activatio, relieves boredom Not easily detected: o odor, o stumblig, o slurred speech (except a high doses) Rapid tolerace ad developmet of physical depedece Opioid Tolerace & Physical Depedece Both tolerace ad physical depedece are physiological adaptatios to chroic opioid use Tolerace: v Icreasig doses eeded to produce the same effects Physical Depedece: vwithdrawal sydrome triggered by abrupt dose reductio or cessatio Opioid Withdrawal Sydrome Itesity varies with level & chroicity of use Time course determied by half-life of opioid For short-actig opioids like heroi, withdrawal symptoms peak at hrs, last 5-7 days Protracted symptoms may liger for weeks or moths Ca be stopped or reversed with sufficiet (equipotet) dose of ay opioid agoist Pupillary dilatio Acute Withdrawal Lacrimatio (watery eyes) Rhiorrhea (ruy ose) Muscle spasms, Yawig, Sweatig, Chills, Stomach Cramps, Diarrhea, Vomitig Restlessess, Axiety, Irritability Isomia The Washto Group- Priceto & Mahatta

12 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Protracted Withdrawal Deep muscle aches & pais Isomia Poor appetite Reduced libido, impotece, aorgasmia Depressed mood, ahedoia Drug cravig & obsessio AMSP 69 Opioid Receptors Opioid drugs produce their effects by either stimulatig or blockig eurochemical activatig at opioid receptors Opioid receptors are located mostly i the CNS ad GI tract Opioid Receptors OPIOID RECEPTOR SUBTYPES µ (mu): Activated by morphie: aalgesia Primary actio site of all opioids Ø Distributio: CNS ad GI Ø Liked to abuse/depedece Ø Ø κ (kappa): aalgesia, edocrie chages ad dysphoria δ (delta): for edogeous peptides Mu receptors i Brai Reward Pathways AMSP The Washto Group- Priceto & Mahatta

13 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. 3 Types of Opioids: Actio at Mu Receptor Sites Full agoists morphie oxycodoe Partial (mixed) bupreorphie Atagoists: aloxoe altrexoe 73 Actio of Opioids o Receptors 1. Full agoists: Occupy the receptor ad activate that receptor Icreasig doses of the drug produce icreasig effects util a maximum effect is achieved (receptors are fully activated) Most abused opioids are full agoists Actio of Opioids o Receptors Actio of Opioids o Receptors 2. Partial agoists: Bid to ad activate receptor (like a full agoist) Icreasig dose ot produce as great a effect as does icreasig the dose of a full agoist less of a maximal effect is possible ( ceilig effect ) 3. Atagoists: Bid to receptors but do NOT activate the receptor at all Block the receptor from beig activated by full ad partial agoists Repeated Admiistratio ad Withdrawal Repeated admiistratio of opioids that activate the mu receptor results i dosedepedet physical depedece ad tolerace Physical depedece ad tolerace maifest as characteristic withdrawal sigs ad symptoms upo reductio or cessatio of opioid use (the opioid withdrawal sydrome) Withdrawal Two types of opioid withdrawal associated with mu opioid agoists: Spotaeous withdrawal Precipitated withdrawal The Washto Group- Priceto & Mahatta

14 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Withdrawal Spotaeous Withdrawal Occurs whe a perso physically depedet o mu agoist opioids suddely stops or markedly decreases the amout of use Precipitated Withdrawal Occurs with admiistratio of a opioid atagoist to a perso physically depedet upo mu agoist opioids It ca also occur with the admiistratio of a partial agoist with a greater affiity to receptor Bupreorphie Rapid oset of actio: mi Readily absorbed subligually: 5 10 mi for tablet to dissolve Peak plasma levels at 1 2 h Peak subjective/physiologic effect at 1 4 h Bupreorphie ad µ-opioid receptor availability MRI Bup 0 mg Bup 2 mg Bup 16 mg 0 - Bup 32 mg Zubieta et al, 2000 Partial vs Full Opiate Mu Agoist Mu-Receptor Activity 100 death Full Agoist (e.g. heroi) 70 Opiate Effect Full Agoist (e.g., methadoe) % Mu Receptor Activity Partial Agoist (e.g. bupreorphie) Partial Agoist (e.g. bupreorphie) o drug low dose Full Atagoist (e.g. aloxoe) high dose Dose of Opiate DRUG DOSE The Washto Group- Priceto & Mahatta

15 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. At the receptor level Opioids Compouds such as oxycodoe, hydrocodoe, morphie, fetayl, heroi ad others Fetayl Opioid receptor opioid bupreorphie Opioid receptor opioid altrexoe Opioid aloxoe receptor Opioid OPIOID RECEPTOR Opioids iteract with opioid receptors o erve cells i the brai ad ervous system to produce pleasurable effects ad relieve pai opioid Opioid receptor FULL AGONIST: activates the receptor PARTIAL AGONIST: partially activates, partially blocks ANTAGONIST: No activatio, blocks opioids Activatio of receptor Bupreorphie- Mixed Agoist/Atagoist Naltrexoe (log-actig atagoist) Advatages: Ca be prescribed by certified MDs i office settigs Effective for detox ad maiteace therapy, prevets withdrawal, reduces cravigs, o euphoria, o overdose, excellet log-term results opioid bupreorphie Opioid receptor PARTIAL AGONIST: partial activatio, partial blockade Risks: may iduce withdrawal if other opioids i system, ca lead to overdose aloxoe if combied with bezodiazepies Limitatios: Requires completed withdrawal from opioids (will precipitate withdrawal if take with opioids i the system); requires highly motivated patiet to self-admiister tablets daily Beefits: Prevets opioid itoxicatio bupreorphie ad depedece, reiforces abstiece, efficacy i opioid ad alcohol use, o addictio potetial Oral daily dose vs. log actig ijectio (Vivitrol) Risks: May have icrease risk of death from overdose due to icreased receptor sesitivity ad decreased (depedig upo dose of opioid used i relapse) opioid altrexoe Opioid aloxoe receptor ANTAGONIST: o activatio, blocks opioids Overdose treatmet with pure atagoist Naloxoe short actig medicatio to remove opioid from opioid receptor opioid Opioid receptor aloxoe opioid Desiger Opioids: No-Addictive Psychotropic Medicatios v The curret developmet of more selective Opioids are focused maily o the kappa receptor v Whereas stimulatig the kappa receptor ca iduce dysphoria, blockig it with a selective kappa atagoist appears to produce ati-axiety ad atidepressat effects without euphoria or depedece. v A highly selective kappa atagoist medicatio is soo to be released by Alkermes Pharmaceutical Receptor activated Naloxoe displaces the opioid from the receptor ad ullifies its actio The Washto Group- Priceto & Mahatta

16 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Pharmacotherapy for Opioid Depedece Goals Alleviate sigs/symptoms of physical withdrawal Opioid receptor blockade Dimiish ad alleviate drug cravig Normalize ad stabilize disrupted brai eurochemistry Types of Medicatios Opioid Atagoist Naltrexoe (full opioid atagoist) Daily pill or mothly ijectio Opioid Agoist (for detox or maiteace) Methadoe (full opioid agoist) Bupreorphie (partial opioid agoist) 3 FDA-Approved Medicatios Bupreorphie (agoist/atagoist) Methadoe (pure agoist) Naltrexoe (pure atagoist) Cliical Uses of Bupreorphie Stabilizatio Detoxificatio (Taperig) Substitutio (Maiteace) Bupreorphie Pharmacology Partial agoist of mu receptor Atagoist at kappa receptor which may cotribute to its ati-depressat ati-axiety effects Poor bio-availability take orally Much more bio-available from subligual mucosa (Peak 2-3 hours followig subligual dose) Bupreorphie (subligual) Bupreorphie Subligual Tablets Suboxoe strips/film (bupreorphie + aloxoe) Zubsolv tablets (bupreorphie + aloxoe) Subutex tablets (bupreorphie oly) The Washto Group- Priceto & Mahatta

17 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Suboxoe Strips/Film Suboxoe Dosages Iitial Stabilizatio o Bupreorphie New 30-Day Bupreorphie Ijectio 1 st dose take approx 24 hours after last opioid use or whe withdrawal sx s emerge Iitial dose depeds o level of opioid depedece, but usually o higher tha 4 mg, with aother 2-4 mg 12 hours later if first does is ot adequate Ofte takes 2-7 days to reach stable, comfortable dose Some patiets coclude prematurely that the medicatio is ot workig for them usually due to iadequate dosig, time eeded to develop stable blood levels, ad sometimes extreme fear of withdrawal SUBCLOCADE 30-Day Subcutaeous Ijectio started after 7+ days stabilizatio o subligual bupreorphie Cliical Advatages of Bupreorphie Ca be Rx by office-based MDs, dispesed at local pharmacies High rate of patiet acceptace Caot overdose ( ceilig effect ) uless combied with high-dose CNS depressats The Washto Group- Priceto & Mahatta

18 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Cliical Advatages of Bupreorphie Cliical Advatages of Bupreorphie Virtually o opioid-iduced high after the first 2-3 doses, if at all Studies documet high treatmet success rates (improved psychosocial fuctioig) ad reduced overdose death rates icludig i adolescets ad youg adults Both relapse rates ad overdose death rates icrease by more tha 50% whe bupreorphie is discotiued prematurely (i.e., less tha 6-12 moths i may cases) Ca be Rx by office-based MDs, dispesed at local pharmacies High rate of patiet acceptace Caot overdose ( ceilig effect ) uless combied with high-dose CNS depressats Virtually o opioid-iduced high after the first 2-3 doses, if at all Has impressive atiaxiety ad atidepressat effects, iduces feeligs of ormality Cliical Limitatios of Bupreorphie Cliical Limitatios of Bupreorphie Expesive, although isurace coverage has bee improvig due to gov t pressures Limited umber of prescribig MDs- mostly psychiatrists ad addictio medicie specialists Requires at least hrs sice last opioid dose to start BUP without precipitatig withdrawal reactio Bias agaist substitutig oe addictive drug for aother Atithetical to orthodox 12-step approach requirig total abstiece from all psychoactive substaces BUP maitais physical depedece but ARRESTS the behavioral sydrome of opioid addictio BUP may ot be potet eough to prevet withdrawal from very high-dose opioid depedece exceedig the equivalet of 30 mg/day methadoe Discotiuig Bupreorphie Methadoe- Advatages vpatiets should cotiue to be followed by provider after discotiuatio vnaltrexoe therapy should be cosidered vpsychotherapy should cotiue vpatiets should be ecouraged to resume bupreorphie treatmet if cravigs, relapses, or dysphoria/mood destabilizatio occur Highly potet, pure opioid agoist Log half-life, approx. 24 hrs Oce per day dosig Ca substitute for high levels of heroi ad other opioid depedece Log-term studies over 50+ years show o adverse medical cosequeces of methadoe maiteace The Washto Group- Priceto & Mahatta

19 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Methadoe- Limitatios Available oly i licesed programs, ot from officebased physicias or local pharmacies Discourages use of other opioids by mechaism of cross-tolerace, ot receptor blockade No ceilig effect to prevet overdose Effects are additive with other opioids Stigma of methadoe ad methadoe programs historically located i ier-city ghetto eighborhoods Log-term use ca create a high level of opioid depedece ad difficulty with detoxificatio Naltrexoe (Trexa) Pure, very potet opioid atagoist 50 mg tablet completely blocks all opioid effects for at least 24 hours No-addictive, o psychoactive effects Provides peace of mid ad isurace agaist relapse Not a substitute drug, reiforces abstiece, prevets impulsive relapse ot plaed relapse Makes relapse to opioid use virtually impossible Limitatios: compliace with daily dosig ad required 10+ opioid-free days before takig first dose Must wait several days to resume after opioid relapse Naltrexoe Tablets (Trexa) 30-Day Naltrexoe Ijectio (Vivitrol) Vivtrol Ijectio Sigle IM ijectio provides blockade for 30 days Limitatios Expesive, requires special pharmacy order, refrigeratio May MDs are ufamiliar with it ad/or do ot offer Vivitrol ijectios i their practice Ijectio is paiful ad sometimes produces ligerig sores at ijectio site Assessmet The Washto Group- Priceto & Mahatta

20 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Assessmet The startig poit of treatmet ad the workig alliace Sets the stage ad the toe for everythig that follows Motivatioal iterviewig techiques Rogeria cliet-cetered stace ad approach Developig rapport, istillig optimism, safety, ad trust are more importat tha coductig a exhaustive factfidig missio Addicted cliets come to us feel humiliated, afraid, ad cofused They are lookig for re-assurace ad sesible guidace Key Questios Why NOW? What problems is your opioid use causig? What type of help/treatmet do you eed? What would be a first step? How ready are you to take this first step? What are the obstacles to movig ahead? What are you hopig that treatmet ca do for you? Assessmet Gather the relevat facts usig a extesive selfadmiistered questioaire that patiets ca dowload from your website or receive via , fill out by had, ad brig to first appoitmet Go to: for a copy of my New Patiet Questioaire Review the completed form before startig the iterview so you ca focus o what s importat or i eed of further discussio Assessmet Domais Substace Use Profile & Fuctioal Aalysis of Use: Types of opioids, amouts, frequecy, patter, route of admiistratio, cravigs ad urges, precursors ad triggers of use, settigs ad circumstaces of use, source of drug supplies, alcohol ad other drug use Positive Drug Effects: How do opioids curretly help you ad/or how did they help you i the past? Negative Drug Effects: What problems are drugs causig you? Psychosocial ad medical problems/cosequeces, overdose ad ER visits Assessmet Domais Assessmet Domais Tolerace ad Physical Depedece: Progressio of use over time, withdrawal symptoms, curretly addicted?, felt eed for medicatio Life Cotext of Use: Livig situatio, family ad other relatioships, employmet, available supports, etc. Co-Occurrig ad/or Pre-Existig Problems: Psychiatric, Psychological, Other Life Issues Prior Attempts at Treatmet, Self-Guided Chage, AA/NA Ivolvemet: What was helpful/ot helpful Curret Medicatios: For substace use ad/or psychiatric issues Obstacles to Chage, Available Resources to Support Chage: Frieds, family members, etc. The Washto Group- Priceto & Mahatta

21 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Assessmet Domais Behavioral ad Psychological Depedece: degree of impaired cotrol, preoccupatio ad obsessio, iordiate priority, preferred copig strategy, addictio sydrome Motivatio ad Readiess for Chage: exteral pressures, iteral pressures/cocers, ambivalece/coflict about chage, receptivity to suggestios/recommedatios, readiess to take actio Assessmet Domais Behavioral ad Psychological Depedece: degree of impaired cotrol, preoccupatio ad obsessio, iordiate priority, preferred copig strategy, addictio sydrome Motivatio ad Readiess for Chage: exteral pressures, iteral pressures/cocers, ambivalece/coflict about chage, receptivity to suggestios/recommedatios, readiess to take actio Opioid Use Disorder The 4 C s Loss of Cotrol Compulsive use Cotiued use despite harms Cravig DSM V Diagostic Criteria for Substace Use Disorders Impaired Cotrol 1. Usig larger amouts or for loger time tha iteded 2. Persistet desire or usuccessful attempts to cut dow or cotrol use 3. Great deal of time obtaiig, usig, or recoverig 4. Cravig or strog desire or urge to use Substace Use Disorders Social Impairmet 5. Fail to fulfill major roles (work, school, home) 6. Persistet social or iterpersoal problems caused by substace use 7. Importat social, occupatioal, recreatioal activities give up or reduced Substace Use Disorders Risky Use ad/or Despite Cosequeces 8. Use i physically hazardous situatios 9. Use despite physical or psychological problems caused by use The Washto Group- Priceto & Mahatta

22 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Substace Use Disorders Severity ad Specifiers Physical Criteria 10. Tolerace as defied by either of the followig: Need to use a icreasig amout of a substace i order to achieve the desired effect OR Markedly dimiished effect with cotiued use of the same amout of the substace 11. Withdrawal as maifested by either of the followig: The characteristic withdrawal sydrome of the substace OR The substace is take to relieve or avoid withdrawal symptoms Evidece-Based Medicatios (FDA-Approved) Treatmet Bupreorphie Methadoe Naltrexoe Evidece-Based Behavioral Therapies Motivatio-Ehacemet Cogitive-Behavioral (skills traiig) DBT, Midfuless Relapse Prevetio Strategies Modified Psychodyamic Techiques Case Example- Steve 26 y.o. sigle male recetly quit marketig job at isurace compay primarily to avoid cotact with coworkers who were his drug suppliers. Moved back home with his recetly widowed mother who also provided fiacial support. Physically depedet o oxycodoe for past 9 moths. Durig prior year used he oly o weekeds ad o occasios whe he felt extremely stressed out. No prior treatmet history for SA or MH issues The Washto Group- Priceto & Mahatta

23 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Medicatio-Assisted Treatmet (MAT) Case Example- Steve Itegratig evidece-based pharmacological ad psychosocial itervetios Studies show that the combiatio of medicatio ad therapy teds to be more effective tha either aloe Medicatio ad therapy work syergistically They mutually facilitate patiet egagemet, retetio, ad cliical outcomes Steve wated to totally stop usig opioids, but cotiue to moderately use marijuaa ad alcohol, either of which he cosidered a problem. We discussed medicatio optios- BUP ad NAL Steve wated to detox himself at home with othig but sleep meds ad bezos (take from his mother) ad the after 2 weeks get oto altrexoe to prevet relapse. He had heard bad thigs about BUP ad refused to cosider it. Case Example- Steve Case Example- Steve Steve succeeded with his self-detox ad started altrexoe which he took every day for approximately 6 moths while seeig me for weekly idividual ad group therapy. Durig that time, he cut off cotact with dealers/users, ad became ivolved with a ew girlfried who did ot abuse alcohol or drugs I idividual therapy, he idetified grief issues related to his father s recet sudde death ad his ligerig emotioal ad fiacial depedece o his mother. Aroud moth 4 or 5, Steve started to feel depressed about ot fidig aother job ad bega havig trouble copig with his girlfried s demads o his time ad for more meaigful iteractio After stoppig altrexoe, he bega to have fatasies about usig opioids agai, which he kept secret. He did reveal that he had started to bige drik with frieds o weekeds at clubs ad parties, ubekowst to his girlfried. Case Example- Steve Case Example- Steve He agreed to cut back substatially o his drikig (did ot wat to stop completely) ad accept referral to psychiatrist for atidepressat meds. He bega takig Lexapro ad after 3 weeks or so reported feelig somewhat less depressed He routiely talked opely i group ad boded well with other members, but bega to show up less cosistetly to group ad asked to cut back to biweekly idividual sessios claimig that his mother was complaiig about the cost Steve had retured to itermittet ad the daily oxycodoe use which he revealed i a idividual sessio about 6 weeks after becomig re-addicted. He had purchased Suboxoe from a dealer ad was takig 6 mg per day which kept him out of withdrawal ad made him feel ormal. After startig Suboxoe, he completely stopped usig oxycodoe ad his alcohol cosumptio decreased sigificatly. The Washto Group- Priceto & Mahatta

24 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Case Example- Steve Case Example- Steve As of today, he has cotiued o Suboxoe for over a year ad is doig well. He o loger has cravigs for opioids or thoughts about usig. He stopped takig Lexapro, but o loger feels depressed. He regularly atteds idividual ad group sessios, is employed full-time i a iteret-based isurace compay, ad resides with his girlfried. We cotiue to work o affect maagemet issues; separatio-idividuatio (codepedecy) issues regardig his emeshed relatioship with his mother; ad developig greater itimacy with his girlfried. Steve would like to stop takig Suboxoe at some poit, but has deferred makig that decisio for the foreseeable future. Case Example- Richard Case Example- Richard 58 y.o. real estate maager, married for 25 years, two teeage childre, recetly discharged from 7-day ipatiet detox from a combiatio of Percocet (oxycodoe) ad Dilaudid (dihydromorphoe) Had bee obtaiig drugs supplies from MD who freely prescribed them o request Whe the doctor died suddely, Richard paicked ad several weeks later admitted himself to a detox uit I the detox uit, he was give decreasig doses of Suboxoe, but left AMA while still i active withdrawal His determiatio to remai opioid-free led him to seek my help. He stated very clearly that he did ot wat to go to a IOP, to AA meetigs, or to take Suboxoe which he foud distictly upleasat. He started weekly idividual ad group therapy ad somehow maaged to edure the withdrawal symptoms ad complete detox without takig medicatio. Case Example- Richard Case Example- Richard He did agree, however, to take altrexoe startig approximately two weeks after his last dose of Suboxoe to prevet relapse Issues related to his opioid use icluded the death of his 95 y.o. father last year with whom he had a highly coflicted relatioship, alieatio from his wife due largely to his chroic drug use of the past 10 years, ad dissatisfactio with his job i a compay that was havig fiacial problems. Richard had a log history of major depressive disorder that was oly partially alleviated by stadard atidepressats. Opioids provided him with sigificat relief util his escalatig high-dose use resulted i complete tolerace to this beeficial effect. He had a rocky course durig the first six moths of abstiece which icluded two brief episodes of opioid use after temporarily stoppig altrexoe. He is curretly oe year opioid-free a doig well with a combiatio of Zoloft, therapy, ad Naltrexoe. The Washto Group- Priceto & Mahatta

25 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Itegrated Approach Itegrated Approach Trastheoretical Cliet-cetered, idividualized Oe size does ot fit all Stages of Chage Cetrality of the therapeutic relatioship Self-medicatio model (fuctioal role of drug use) Disease model of addictio Self-help programs (NA, AA, etc) Opioids are pharmacologically compellig The addictio ad supportig behaviors must be addressed directly at the outset of treatmet Motivatioal techiques Cogitive-behavioral techiques (skills traiig) Affect maagemet techiques (DBT, midfuless) Itegrated Approach Gettig Started Relapse prevetio strategies Supportive psychotherapy Psychodyamic (relatioal) techiques Establish iitial abstiece Self-taperig Medicatio-assisted detox (BUP, Methadoe) Prevet relapse Idividual ad/or group therapy oly Medicatio-assisted therapy with altrexoe or bupreorphie Treatmet Decisios Treatmet Decisios Decisios are patiet-drive, ot diagosis-drive Collaborative process Refer for medical detox? Ipatiet or outpatiet? Refer to MD for bupreorphie stabilizatio, defer decisio about detox vs. maiteace Refer to MD for altrexoe to help with relapse prevetio if patiet is already abstiet Refer to itesive outpatiet program (IOP)? Refer to ipatiet rehab? Cotiue to work with you idividually either aloe, i cojuctio with IOP, ad/or i cojuctio with medicatio prescribers? How you ca help: Provide ogoig support, guidace, holdig eviromet Facilitate likages with other providers The Washto Group- Priceto & Mahatta

26 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Treatmet Decisios Coordiate care, cotai crises Ehace medicatio compliace ad copig with side effects Ogoig idividual ad/or group therapy to improve copig skills, address co-existig ad uderlyig issues Ivolve sigificat others, whe appropriate Issues to be a addressed Use of alcohol, marijuaa, bezodiazepies Avoidig cotact with dealers ad other users Avoidig ad copig with high risk situatios Is the real problem physical addictio, uderlyig psychological issues, mood dysregulatio ad other psychiatric disorders? Role of psychotropic medicatio Respodig to Resumed Use Respodig to Resumed Use Laguage makes a differece- resumed use or episode of use rather tha relapse or screw up Progress is ofte either smooth or liear Setbacks are commo, ot catastrophic evets Not a sig of persoal failure Not a sig that treatmet has failed or is ot workig properly Debriefig- What happeed? How did it happe? How ca it be preveted it from happeig agai? What uaddressed ad possibly ew (as yet udefied) issues did it reveal? Was the use plaed, coscious, deliberate or seemigly accidetal ad out of the blue What were the apparetly irrelevat decisios ad silet setups leadig up to the use Respodig to Resumed Use Maagig Cravigs Did it produce the desired effects or was it disappoitig? Was it worth it? What made the drug use look attractive agai? What were the thoughts ad feeligs i the aftermath of usig? What s ext, what is eeded? Need to revise ay aspect of treatmet pla ad/or devote more cocetrated time to certai issues? Cravigs are commo ad expectable durig recovery They are strogest i the early phase of abstiece Cravigs are a result of drug-iduced chages i brai chemistry ad behavioral coditioig factors Cravigs are ot a idicatio of failure, poor motivatio, or uavoidable relapse The Washto Group- Priceto & Mahatta

27 Treatig Opioid Addictio- GSAPP Arold M. Washto, Ph.D. Maagig Cravigs Maagig Cravigs Cravigs do ot have to lead ievitably to drug use The fear is they will build i itesity util they become ubearable ad usig is the oly way to get rid of them Thik beyod the high. Play the tape to the ed. Leave or avoid situatios that evoke cravigs Distract yourself with alterative activities Detach from the cravig (midfuless) Delay ay decisio to use Cravigs are temporary, like waves that peak ad the drop off. The goal is to surf the cravig util it subsides Givig i to cravigs stregthes them; ridig them out weakes them (reiforcemet vs. extictio) The Washto Group- Priceto & Mahatta