Restoration of Parenting Ability Through Treatment for Substance Use Disorders

Restoration of Parenting Ability Through Treatment for Substance Use Disorders DEBRA M. BARNETT, MD Board Certified in General Psychiatry, Addiction Psychiatry, Geriatric Psychiatry, and Forensic Psychiatry

OBJECTIVES Participants will better understand what constitutes a substance use disorder. Participants will become more knowledgeable about the treatments for substance use disorders. Participants will be better able to engage persons in treatment with an appreciation for how treatment can produce successful recovery outcomes, including restoration of parenting abilities.

INTRODUCTION A common misperception is that persons with substance use disorders are difficult to treat and that they do not often successfully achieve recovery. Successful recovery is marked by a normalization of all aspects of a person s life, including their ability to parent. This workshop will use a PowerPoint format to examine engagement and treatment outcomes for substance use disorders. Case examples will be included.

WHAT IS A SUD? What defines a substance use disorder? 1. Medical/psychosocial 2. Screening and assessment 3. How a diagnosis is established 4. What is not a substance use disorder

Inebriety Among Women in This Country (Excerpts from JAMA October 29, 1892) This National folly of arresting and sending to jail these poor victims should cease. The practical point for our American physicians is to take up the subject of inebriety and study it as a purely medical topic, and not leave it to police courts and moralists to point out the evil and its remedies. The time is coming when the medical profession will teach the world the causes and remedies for this great and widespread evil of the century.

MEDICAL ASPECT- Biological basis: Acute effects of alcohol/drugs are to produce brain reward and reinforce, but the chronic neuroadaptation: Increases the threshold for reward Produces hedonic dysregulation Repeated use has caused conditioning to occur in related circuits Cues associated with use can activate the reward and withdrawal circuit This can evoke anticipation of the substance or feelings similar to withdrawal that can precipitate relapse in an abstinent person

Prefrontal Cortex Hippocampus Nucleus accumbens Amygdala Ventral tegmental area (VTA) Source: Messing RO. In: Harrison s Principles of Internal Medicine. 2001:2557-2561.

Similarities to Other Chronic Diseases 1-3 Characteristics Drug Dependence Diabetes, Asthma, and Hypertension Well studied Chronic disorder Predictable course Effective treatments Curable NO NO Heritable Requires continued care Requires adherence to treatment Requires ongoing monitoring Influenced by behavior Tends to worsen if untreated 1. McLellan AT et al. Addiction. 2005;100(4):447-458; 2. McLellan AT et al. JAMA. 2000;284(13):1689-1695; 3. McLellan AT. Addiction. 2002;97(3):249-252.

Patients Who Relapse (%) Relapse Rates Are Similar to Other Chronic Diseases 1,2 80 70 60 50 40 30 20 10 0 50% 70% 50% 70% 40% 60% 30% 50% Drug Addiction Type 1 Diabetes Hypertension Asthma 1. McLellan AT et al. JAMA. 2000;284(13):1689-1695; 2. National Institute on Drug Abuse. http://www.nida.nih.gov/scienceofaddiction/sciofaddiction.pdf. Accessed June 30, 2011.

PSYCHOSOCIAL ASPECTS Impact on the individual, family, and community- embedded in the descriptions, definitions, and diagnostic criteria Historically, this was used to distinguish between habit and addiction

PSYCHOSOCIAL ASPECTS Pregnant women, 15 to 44yo, according to NSDUH 2012-2013 average Illicit drug use Current 5.4%; compared to 11.4% for nonpregnant women By trimester 1 st 9%; 2 nd 4.8%; 3 rd 2.4% Alcohol use Current 9.4%; compared to 11.4% for nonpregnant women Binge drinking- 2.3%; Heavy drinking- 0.4% By trimester 1 st 19%; 2 nd 5%; 3 rd 4.4%

PSYCHOSOCIAL ASPECTS AFCARS 2016 Circumstances Associated With Child s Removal Neglect 61% (166,679) Drug Abuse (Parent) 34% (92,107) Caretaker Inability To Cope 14% (37,857) Physical Abuse 12% (33,671) Child Behavior Problem 11% (28,829) Housing 10% (27,871) Parent Incarceration 8% (20,939) Alcohol Abuse (Parent) 6% (15,143) Abandonment 5% (12,889) Sexual Abuse 4% (9,904) Drug Abuse (Child) 2% (6,273) Child Disability 2% (4,554) Relinquishment 1% (2,694) Parent Death 1% (2,212) Alcohol Abuse (Child) 0% (1,242)

DEFINITIONS: World Health Organization- Addiction: Repeated use of psychoactive substance(s), to the extent that the user is periodically or chronically intoxicated shows a compulsion to take the preferred substance(s), has great difficulty in voluntarily ceasing or modifying substance use, and exhibits determination to obtain psychoactive substances by almost any means. Typically, tolerance is prominent and a withdrawal syndrome frequently occurs when substance use is interrupted. The life of the addict may be dominated by substance use to the virtual exclusion of all other activities and responsibilities. DSM-5- Substance Use Disorder: Cluster of cognitive, behavioral, and physiological symptoms underlying change in brain circuits pathological pattern of behaviors

SCREENING INSTRUMENTS

THE DSM-5 DIAGNOSIS Substance Use Disorder Problematic pattern of use leading to clinically significant impairment or distress At least 2 (of 11 criteria) within a 12-month period First 4 reflect impaired control, 5-7 reflect social impairment, 8-9 are risky use, and 10-11 are physiological dependence DSM-5 Merged Substance Abuse and Substance Dependence, eliminating use despite legal problems, and added craving/urges Specifiers In early remission- > 3 months but < 12 months In sustained remission- 12 months Severity Mild- 2-3 sx Moderate- 4-5 sx Severe- 6 sx

DSM-5 1. A/D is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control use of A/D. 3. A great deal of time is spent in activities necessary to obtain A/D, use it, or recover from its effects. 4. Craving, or a strong desire or urge to use A/D. 5. Recurrent use of A/D resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued use of A/D despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use. 7. Important social, occupational, or recreational activities are given up or reduced because of use of A/D. 8. Recurrent use of A/D in situations in which it is physically hazardous. 9. Use of A/D is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by A/D. 10. Tolerance, as defined by either of the following: A need for markedly increased amounts of A/D to achieve intoxication or desired effect; A markedly diminished effect with continued use of the same amount of A/D. 11. Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for A/D (refer to Criteria A and B of the criteria set for A/D withdrawal); A/D (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

WHAT IS NOT A SUBSTANCE USE DISORDER Tolerance and Withdrawal- This criterion is not considered to be met for those individuals taking opioids solely under appropriate (emphasis added) medical supervision. Pseudoaddiction? Single use misadventure- including violation of workplace drug policy Substance misuse which does not meet the criteria for a substance use disorder

BARRIERS TO ENGAGEMENT Felt they needed treatment and made an effort to get it, 351,000 Felt they needed treatment but did not try, 455,000 Did not feel they needed treatment, 16,900,000 2016 National Survey on Drug Use and Health

BARRIERS TO ENGAGEMENT Might have negative effect on job Might cause neighbors or community to have negative opinion Did not find a program that offered the desired type of treatment Did not know where to go to get help No healthcare coverage and cannot afford Not ready to stop Percent 0 10 20 30 40 50 Percent

ENGAGEMENT TECHNIQUES An empathetic non-judgmental interview style, reflected in the ease in which you ask relevant questions (think medical model) Motivational Interviewing Warm hand-off to a treatment provider Involuntary? Whether people initiate treatment because of external motivation or involuntarily, outcomes tend to be the same as if they initiated treatment voluntarily. Also incorporate a nonjudgmental approach; this is not being done as punishment

TREATMENT Intensity/Level of Care Self-help Outpatient and intensive outpatient Inpatient/residential, partial hospitalization, sober living Psychosocial Therapies Medication Assisted Treatment and Recovery

TREATMENT- ASAM LEVEL OF CARE GUIDELINES

TREATMENT- ASAM LEVEL OF CARE GUIDELINES

MAT and Psychosocial Intervention 1,2 Pharmacotherapy Can control symptoms by normalizing brain chemistry Psychosocial Intervention Essential to change behaviors and responses to environmental and social cues that so significantly impact relapse Both are necessary to normalize brain chemistry, change behavior, and reduce risk for relapse; neither alone may be sufficient 1. McLellan et al. Addiction. 1998;93(10):1489-1499; 2. McLellan et al. JAMA. 1993;269(15):1953-1959.

SUD Management- Pharmacotherapy AKA Medication Assisted Treatment and Recovery (MAT) Practice guidelines state that persons with certain SUDs should be offered medications as part of their treatment Alcohol Use Disorder Opioid Use Disorder

MAT Guidelines National Quality Forum s National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices (p.vii) - recommends that pharmacotherapy should be made available to all adult patients diagnosed with opioid dependence, alcohol dependence, and nicotine dependence, as long as there are not medical contraindications. American Society for Addiction Medicine (ASAM) has an affirmative position on the use of medications for the treatment of alcohol use disorders in their ASAM Patient Placement Criteria: Supplement on Pharmacotherapies for Alcohol Use Disorders. National Institute on Drug Abuse (NIDA)- Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies

MAT Guidelines- APA January 2018 APA recommends (1B) that naltrexone or acamprosate be offered to patients with moderate to severe alcohol use disorder who have a goal of reducing alcohol consumption or achieving abstinence, prefer pharmacotherapy or have not responded to nonpharmacological treatments alone, and have no contraindications to the use of these medications. APA suggests (2C) that disulfiram be offered to patients with moderate to severe alcohol use disorder who have a goal of achieving abstinence, prefer disulfiram or are intolerant to or have not responded to naltrexone and acamprosate, are capable of understanding the risks of alcohol consumption while taking disulfiram, and have no contraindications to the use of this medication.

Medication Assisted Treatment Alcohol Use Disorder Disulfiram (Antabuse) Acamprosate (Campral) Naltrexone oral (ReVia) Naltrexone IM monthly (Vivitrol) Probably also Gabapentin and Topirimate Each has data to support efficacy for various parameters such as duration of complete abstinence, prolonged time to relapse, fewer drinking days, fewer heavy drinking days, and craving

MAT- Alcohol Use Disorder Treatment provider Supplier Action/target Dosing Acamprosate Any prescribing healthcare provider Regular pharmacy Glutamate Orally, three times a day Naltrexone oral Any prescribing healthcare provider Regular pharmacy Opiate antagonism Orally, once daily Naltrexone IM monthly Any prescriber who also either provides the injection or refers Specialty pharmacy, ships cold overnight to prescriber Opiate antagonism IM, once a month Disulfiram Any prescribing healthcare provider Regular pharmacy Inhibits Aldehyde dehydrogenase Once daily

MAT- Alcohol Use Disorder Effect of Vivitrol on Complete Abstinence

MAT- Alcohol Use Dsorder Effects of Vivitrol on Number of Drinking Days

MAT- Alcohol Use Disorder Effects of Vivitrol on Heavy Drinking Days

Medication Assisted Treatment Opioid Use Disorder Methadone Naltrexone oral (ReVia) Naltrexone IM monthly (Vivitrol) Buprenorphine products (Suboxone, Zubsolv, Bunavail, Sublocade) Each has data to support efficacy for various parameters such as rates of opioid-free urine testing, treatment retention, and craving

MAT- Opioid Use Disorder Treatment provider Supplier Action/target Dosing Methadone Federally designated clinics Daily clinic visits for several months Opiate agonist Naltrexone oral Any prescribing healthcare provider Regular pharmacy Opiate antagonism Orally, once daily Naltrexone IM monthly Any prescriber who also either provides the injection or refers Specialty pharmacy, ships cold overnight to prescriber Opiate antagonism IM, once a month Buprenorphine +/- Naloxone Waivered prescriber; Most prescribing healthcare provider can qualify Regular pharmacy for oral doses; specialty pharmacy sends injectable to prescriber Partial opiate agonist Once daily for oral; once a month for injection

MAT- Opioid Use Disorder Benefits of treatment: Improve patient survival Increase retention in treatment Decrease illicit opiate use and other criminal activity among people with substance use disorders Increase patients ability to gain and maintain employment Improve birth outcomes among women who have substance use disorders and are pregnant Decreased potential for relapse decreases likelihood of contracting HIV or Hepatitis (SAMHSA, 2015)

MAT- Opioid Use Disorder

MAT- Opioid Use Disorder Duration Matters Primary Care Based Buprenorphine Taper vs Maintenance Therapy for Prescription Opioid Dependence, A Randomized Clinical Trial; David A. Fiellin, MD, et. al.; JAMA Intern Med. 2014;174(12):1947-1954 14-week randomized, enrolled 113 patients with prescription opioid dependence from February, 2009, through February, 2013, in a single primary care site. BUP taper was initiated after 6 weeks of stabilization, lasted for 3 weeks, and included medications for opioid withdrawal, then patients were offered naltrexone treatment; the maintenance group received ongoing BUP therapy. Taper group: mean percentage of urine samples negative for opioids was lower; more days per week of illicit opioid use; fewer consecutive wks abstinent; less likely to complete the trial.

Prolonged Medication-Assisted Treatment Sustains Improvement After 6 Months 1 (buprenorphine-only; n=690) Heroin use decreased by 81% Codeine use decreased by 83% Benzodiazepine use decreased by 48% Cocaine use decreased by 74% After 18 Months 3 (buprenorphine/naloxone; n=176) After 12 Months 2 (buprenorphine-only; n=40) 32% improvement in occupational problems 90% improvement in drug-related problems 90% improvement in crime-related problems After 2-5 Years 4 (buprenorphine/naloxone; n=53) Less likely to report using any substance or heroin More likely to be employed Improved on several psychosocial parameters 91% of urine samples were opioid negative 96% of urine samples were cocaine negative 4 Studies of Various Treatment Lengths 1. Lavignasse P et al. Ann Med Interne (Paris). 2002:153(suppl 3):1S20-1S26; 2. Kakko J. Lancet. 2003;361(9358):662-668; 3. Parran TV et al. Drug Alcohol Depend. 2010:106(1):56-60; 4. Fiellin DA et al. Am J Addict. 2008;17(2):116-120.

MAT and Parenting Capacity Medication-Assisted Treatment Improves Child Permanency Outcomes for Opioid-Using Families in the Child Welfare System; Martin Hall, PhD, et.al.; Journal of Substance Abuse Treatment, 2016; 71; 63-67. Of the 596 individuals with a history of opioid use in the START program, 55 (9.2%) received MAT. Receipt of MAT services did not differ by gender, age, county of residence, or drug use, though individuals who identified as White were more likely to participate in MAT. In a multiple logistic regression model, additional months of MAT increased the odds of parents retaining custody of their children.

HOW TO WORK WITH TREATMENT PROVIDERS Setting realistic expectations Understanding initial length of acute treatment, aftercare, continued engagement in recovery activities Understanding the slip/relapse and defining progress or failure Arrange for avenues of communication Acceptance of MAT

Case examples