Medical Assisted Treatment Dr. Michael Baldinger Medical Director Haymarket Center Harborview Recovery Center
Current Trends Prescription Drug Abuse/Addiction Non-medical use of prescription pain killers now second most common form of illicit drug use in the U.S. (SAMHSA, 2009) Greater Acceptance in Medical Community to Prescribe for Chronic Pain in past 10 years Development of new more powerful delivery systems for pain medications Ease of Access Non-criminal sources of acquisition (Internet, Physicians Family Medicine Cabinet)
Sources of Prescription Pain Relievers 76% 4% 19% Friend/Relative from MD 1% Dealer Internet (SAMHSA, 2008)
Opiate Use Demographics Estimated 2 million opiate addicts (SAMHSA, 2006) recent increase in heroin addicts in suburban population due to increased purity and movement of criminal gangs into safer suburban settings (Bach & Lantos, 1999) Increased abuse of prescription opiates Prescription opioid misuse increased 140.5% from 1995 to 2005 (CASA, 2005) Approximately 2.1% of US population age 12 and older (5.2 million) report using prescription opioids for non-medical reasons (SAMHSA, 2009) Routes of Administration Prescription Drugs are oral, intranasal or injection Heroin primarily IV, non-injection use of heroin increasing due to purity (NIDA,2005) Conversion of intranasal to IV at 15% per year (Neagus, 1998)
Annual numbers of new non-medical pain medication users 1965-2002
(New York Times, February 2009) (AMA News 2009)
You are entitled to your own opinions but you are not entitled to your own facts Daniel Patrick Moynihan
Methods of Detoxification Using Opioids Methadone Suboxone Tramadol Using Opioid Antagonists AAROD (Anesthesia Assisted Rapid Opiate Detox) Naltrexone/Clonidine Induction Other Clonidine Acupuncture Phytomedicinals Social Detox
Detoxification Effectiveness Methadone and buprenorphine equally effective (dose related) Buprenorphine is safer Greater treatment retention than other methods AAROD is unnecessarily expensive, uncomfortable and potentially life threatening Acupuncture has had mixed results and in general poor study design Without follow up treatment, no method is likely to lead to recovery
Neurotransmitter Effects on Agonist Receptors Partial Agonist Antagonist
Maintenance Methadone and Buprenorphine Rationale for Efficacy Cross-tolerance Prevent Withdrawal Relieve Craving Occupation of Mu Receptor with long-acting opiate Blocks or attenuate euphoric effect of exogenous opioids Restore normal function of opioid neuropathways
Maintenance Evidence for Efficacy Many studies indicate improved medical, psychiatric and employment outcomes in maintenance populations Improved function even in waiting list populations Increased treatment retention Decreased conversion to HIV+, Hepatitis C+ serology Increased mortality in treatment dropout population Overdose, Infectious Disease, Violence and Accidents
Buprenorphine, Methadone, LAAM: Treatment Retention (From An Overview of Opioid Dependence, Dr. Martin Doot)
Buprenorphine, Methadone, LAAM Opioid Urine Results (From An Overview of Opioid Dependence, Dr. Martin Doo
Detoxification vs. Maintenance (From An Overview of Opioid Dependence, Dr. Martin Doot)
Buprenorphine Introduced into clinical practice in the U.S. in 2002 Schedule III narcotic Partial opiate agonist Can be dispensed from outpatient clinic settings with special physician qualifications obtainable after an 8 hour course Greater access to treatment slots than methadone
Pharmacology Suboxone contains buprenorphine and naloxone: Buprenorphine, a partial-opioid agonist, is the primary active ingredient Naloxone, an opioid antagonist, is present to discourage diversion and misuse by people dependent on a full-opioid agonist Suboxone is administered as a sublingual tablet/film and is manufactured in two dosage strengths 2/0.5 mg and 8/2 mg
Sublingual Administration The Buprenorphine in Suboxone enters the bloodstream after dissolving under the tongue Buprenorphine has a very high first-pass absorption rate and is therefore much less effective if swallowed
Buprenorphine Treatment can be done on an inpatient or outpatient basis Induction Make sure patient is in withdrawal (precipitated withdrawal) 2-4 mg of suboxone/subutex as initial dose with onset of opiate withdrawal symptoms (COWS?) Repeat dose every two hours one or two times day 1 (total dose 8 12 mg) Day 2 repeat total dose of day 1 can give up to 8 mg additional Most patients are comfortable at doses 12 16 mg
Buprenorphine Ceiling Effect
Considerations regarding Buprenorphine Dose Dependent Efficacy (12-24 mg) Effective in Combination w/ Psychosocial Treatment High levels of Treatment Retention, fewer side effects than Methadone Access in General Medical Setting Breaks down Barriers to Seeking Tx Expense High Duration of Treatment Variable Detoxification Can be problematic
Considerations regarding Buprenorphine Patient contract essential to clarify expectations Expectations of the physician regarding patient conduct Expectations of patient as to physician s availability and support Need to discuss process of detoxification If patient decides to discontinue maintenance If patient violates contract agreement
Considerations regarding Buprenorphine Side Effects Unpleasant Taste Excessive Sweating Constipation Decreased libido Difficulty urinating Difficulty with discontinuation
When to Discontinue Maintenance Patient request Patient unable to comply with Treatment Contract Entry into Criminal Justice system Unacceptable Side Effects
Methadone 3-5 mg per week How to Detox Buprenorphine 2 mg per week or less can vary Interval of 5 days between dose reduction
Revia Antagonist Therapy Oral dosing leads to greater serum variation with potential for increased side effects. Inexpensive Vivitrol indicated for opiate blockade therapy since October 2011 once a month dosing provides complete irreversible blockade timing of injection tricky avoid precipitated withdrawal
Sedatives and Alcohol
Detoxification Strategies for Alcohol Use of symptom triggered medication dosing leads to shorter detox periods and lower total dose of benzodiazepine used Some studies have indicated good outcomes with anti-seizure medication (Gabapentin/Carbamazepine) with better sleep, less anxiety and post acute withdrawal craving. JAM V5 N4 pp,249, Dec 2011
Sedative Withdrawal Strategies Conversion to long acting benzodiazepines Phenobarbital taper Anticonvulsants - alone or in combination with benzodiazepines/phenobarbitol
Medication Management Anti-craving medication Acamprosate Antabuse Naltrexone Revia Vivitrol Baclofen? Topiramax? Treatment of Post-Acute Withdrawal Sleep (avoid GABA-ergic meds) Mood Disorders Treatment of Pain Narcotics only when necessary controlled amounts, significant others when possible