Alternatives to Buprenorphine

Transcription

1 Alternatives to Buprenorphine Charles Morgan, MD, FASAM, FAAFP Medical Director Bridgeton, NJ Westfield, PA New York, NY Cherry Hill, NJ Northfield, NJ 1

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3 Heroin Purity increasing Pharmaceuticals Expense Availability The Fifth Vital Sign Opioids Can Now Be Drugs of Entry 3

4 Ventral Tegmental Area Locus Coeruleus Nucleus Accumbens Limbic System 4

5 Endorphins Mu Receptor Delta Receptor 5

6 Evolutionary Biology Instincts Pain relief Endurance Orgasm 6

7 Prefrontal Cortex Stop Midbrain Go 7

8 Endocannabinoids GABA Dopamine Glutamate Others 8

9 AA 1935 Akron, Ohio Bill Wilson & Bob Smith NA 1953 Sun Valley, California More than 58,000 meetings in 131 countries by nd Largest 12 Step Movement Jimmy Kinnon 9

10 #Big Book Distributed 21, 234, From historical lists & GSO data Library of Congress AA Big Book One of the top 88 most influential books in the United States

11 Since Mid 1960 s Nyswander & Dole JAMA, 1976 Criteria for Admission to Program Restrictions 11

12 Synthesized 1963 Drug Abuse Office and Treatment Act 1972 (called for long lasting, non-addictive, antagonists to treat opioid dependence) Naltrexone 50mg Approved by FDA 1984 Vivitrol (Alkermes) Approved

13 Late 1970 s Anesthesia and Pain Late 1990 s Off Label Detoxification DATA 2000 Approved

14 22 Year Old with Opioid Dependence Age of 1 st Opioid = 15 Years Old = 7 years = 2005 Buprenorphine available in

15 Cost Restrictive X Numbers Caps Geography Physical Dependence Bias Risk of Loss Diversion Scrutiny Not Universally Accepted by Boards, Legal System & Others Double Edge Sword 15

16 Definition The preparation for treatment Relieve Suffering Safety Establish Relationships and Trust Medical Work Up 16

17 Myalgia Cravings Irritability Piloerection Diaphoresis Rhinorrhea Lacrimation Mood Swings Kicking Restlessness 17

18 Tremor Leaving Treatment Arthralgia Mydriasis Spontaneous Ejaculation Nausea Vomiting Abdominal Cramps Diarrhea Motor Agitation 18

19 Buprenorphine Methadone 19

20 Phenobarbital Clonidine Muscle Relaxants Anti-Emetics Anti-Inflammatory Anti-Diarrhea Anti-Spasmodics 20

21 Phenobarbital Tramadol Muscle Relaxants Anti-Emetics Anti-Inflammatory Anti-Diarrhea Anti-Spasmodics 21

22 Phenobarbital Reversal with naloxone followed by Naltrexone 22

23 Reversal Under Anesthesia 23

24 Staff Environment Comfort measures Hydrotherapy Massage Acupuncture Introduction of Ongoing Care 12 Step Involvement Sleep 24

25 Continuing Withdrawal PAWS Poly Substance Dependence 25

26 Brain Regrowth Synaptic Pruning Mindfulness Studies Fake it until you make it Stick with the Winners Avoid People, Places & Things 26

27 PTSD Substance Induced Mood Disorder Adjustment Disorders Borderline, Antisocial, or Cluster B characteristics 27

28 Hepatitis C HIV Heart Disease Peripheral Vascular Problems Malnutrition Renal Disease 28

29 Full Antagonist Lock & Key Dose 50 mg per Day or 50mg Every Other Day Monitor Liver Functions Initial Side Effects Accommodation Like a Salve 29

30 Legal System Health Care Professionals Others at Risk 30

31 Oral Parenteral Once per month Better outcomes Better compliance 31

32 Gabapentin Melatonin Relaxing Tea Avoid Valerian & Kava Kava Ibuprofen 32

33 Family EAP Programs Employers Legal System Sponsors and 12 step members 33

34 Group Support Supervision of Milieu 34

35 There will come a time when nothing stands between us and a drink except our Higher Power. We have a daily reprieve contingent upon the maintenance of our spiritual condition. 35

36 Trust Hope Acceptance 36

37 Contingency Management Mindfulness Dialectic Behavior Therapy Cognitive Behavioral Therapy Meditation 37

38 Think it Through A Day at a Time 38

39 Reliance on the strength they already have Get to know your patient Compassion Love 39

40 Boredom Tolerance of Discomfort Tolerance of Pleasure Change Vocabulary: Getting High 40

41 There will come a time when nothing stands between us and a drink except our Higher Power. We have a daily reprieve contingent upon the maintenance of our spiritual condition. 41