Medication Assisted Treatment Karen Drexler, MD National Mental Health Program Director-Substance Use Disorders Department of Veterans Affairs
Disclosures Employed by the Department of Veterans Affairs (VA) No commercial financial conflicts of interest May discuss uses of medications that are not FDA-approved indications. For example: Topiramate and gabapentin for treatment of alcohol use disorder
LEARNING OBJECTIVES The participant will be able to: Understand the rationale for using medications to treat substance use disorders Understand the risks and benefits of different medications for treatment of withdrawal from: Alcohol Opioids Understand the risks and benefits of different medications for treatment of: Alcohol use disorder Opioid use disorder
OVERVIEW Why medications? Specific medications: Alcohol Opioids
WHY MEDICATIONS? SUDs are chronic brain diseases Multifactorial, like other chronic diseases Respond best to comprehensive treatment Require long-term treatment Medications improve treatment outcome over psychosocial interventions alone Facilitate engagement in psychosocial treatment Reduce craving and risk of relapse Protect against opioid overdose
Raising Awareness Since 1999, opioid pain medicine prescriptions quadrupled without any change in Americans report of pain. From 1999 to 2015, the number of opioid-related overdose deaths quadrupled. On average, 91 Americans died of opioid overdose every day.
AS OPIOID SALES INCREASED, SO HAS OPIOID USE DISORDER AND OVERDOSE DEATHS https://www.cdc.gov/mmwr/pr eview/mmwrhtml/mm6043a4. htm July 11, 2017 7
DSM-5 Criteria- Opioid Use Disorder DSM-5 Criteria (2 or more of the following criteria) Craving or strong desire to use opioids Recurrent opioid use in hazardous situations Using more opioids than intended Persistent desire/unable to cut down or control opioid use Great deal of time spent obtaining, using or recovering from the effects Continued opioid use despite persistent opioid-related social problems Continued opioid use despite opioid-related medical or psychological problem Failure to fulfill role obligations in order to use opioids Important activities given up in order to use opioids *Tolerance (requiring at least 50% more to achieve desired effect) *Characteristic withdrawal (e.g. dilated pupils, rhinorrhea, diarrhea, piloerection, muscle cramps, increased pain sensitivity)
SUBSTANCE USE DISORDERS (SUDS) SUDs are chronic brain diseases SUDs respond best to chronic disease management Diabetes/hypertension Diet/exercise for all Medication for most Specialty care for those with complex needs July 11, 2017 9
Opioid Effect Pain/ dysphoria Euphoria OPIOID EFFECT SINGLE DOSE 10
Opioid Effect Pain/ dysphoria Euphoria MULTIPLE DOSES LEAD TO TOLERANCE 11
MAT MECHANISMS OF ACTION Agonist Opiates-opium, morphine, heroin, codeine, oxycodone, hydrocodone Synthetic opioids- methadone, fentanyl Partial agonist Buprenorphine Antagonist Naloxone Naltrexone DATE DOCUMENT TYPE/STATUS 12
Opioid Effect Dysphoria Euphoria SIMPLIFIED MECHANISM OF ACTION Methadone Buprenorphine Heroin Naltrexone 13
EVIDENCE HIERARCHY Metaanalyses of RCTs Randomized Controlled Trials Observational Studies Non Analytical Studies Expert Opinion Recommendations are explicitly linked to the supporting evidence and graded according to the strength of that evidence
PATIENT CENTERED CARE: BEGINS WITH SHARED DECISION MAKING Patient is the expert on his/her life and experience. Elicit preferences and goals Strengths and weaknesses Clinicians are expert on risksbenefits of the full menu of treatment options. Provide easily understandable information for patients to make an informed decision Collaborate to develop treatment goals/objectives/interventions. Assess progress and modify the plan, as indicated.
TREATMENT: OPIOID USE DISORDER Medications We recommend: Buprenorphine/ naloxone (OBOT or OTP) Methadone (in an OTP) If buprenorphine/naloxone or methadone are not acceptable, we recommend: ER-injectable naltrexone Buprenorphine (without naloxone for pregnant patients) Psychosocial Interventions At the start of OBOT, we recommend: Addiction-focused Medical Management Other interventions as indicated In an OTP, we suggest: Individual Drug Counseling and/or Contingency Management For patients for whom OUD medication is unacceptable or unavailable, there is insufficient evidence to recommend for or against any specific psychosocial interventions.
MEDICATION FOR OPIOID USE DISORDER (OUD)
BUPRENORPHINE VERSUS METHADONE Buprenorphine/naloxone Methadone Treatment setting? Any Specially licensed OTP Mechanism of action Partial opioid agonist Full opioid agonist FDA approved for OUD? Yes Yes Reduces opioid craving? Yes Yes Improves treatment retention? Yes Yes, better than buprenorphine Reduces mortality? Yes Yes, but first month carries higher risk than maintenance phase Recommended for OUD candidates with anticipated need for opioid pain medicine? No Yes, with caution
EXTENDED RELEASE INJECTABLE NALTREXONE
ADDICTION-FOCUSED MEDICAL MANAGEMENT
Close Monitoring & Brief Counseling May Be Sufficient 24-wk RCT in Primary Care (n=141) Physician Management (PM) is 15 min structured counseling by MD x 24 wks. Weekly tapering to monthly CBT-SUD is weekly individual therapy PM +/- CBT-SUD associated @ 12- weeks with: Almost 80% retention 4-5 weeks of consecutive abstinence Fiellin et al: Am J Medicine 2013 2013-Fiellin et al- Am J Medicine 22
BUPRENORPHINE MAINTENANCE IMPROVES ODDS OF SUCCESSFUL RECOVERY 10-FOLD Phase 2 Time Point Observed, No./Total No. (%) [95% Confidence Interval (CI)] End of treatment 177/360 (49.2) [43.9-54.5] 8-week posttreatment follow-up 31/360 (8.6) [5.9-12.0] Odds Ratio (95% CI) P Value 10.6 (7.2-15.6) <0.001 Weiss R et al: 2011;Arch Gen Psych 23
TREATMENT: ALCOHOL USE DISORDER Medications We recommend: Acamprosate Disulfiram Naltrexone- oral or injectable Topiramate If first-line medication is unacceptable, we suggest: Gabapentin Psychosocial Interventions We recommend: Behavioral Couples Therapy for alcohol use disorder Cognitive Behavioral Therapy for substance use disorders Community Reinforcement Approach Motivational Enhancement Therapy 12-Step Facilitation For patients in early recovery, we recommend promoting active involvement in group mutual help: Peer linkage Network support 12-step facilitation
Medication Assisted Treatment (MAT) Reduces Mortality for Those with OUD Retention in methadone and buprenorphine treatment is associated with reduced overdose and all-cause mortality. The first 4 weeks of methadone induction and the first month after discontinuing either medication is associated with higher mortality. 2017-Sordo et al-bmj Open 25
Oral Naltrexone for Alcohol Use Disorder Volpicelli et al: 1992 Arch Gen Psych 49(11):876-80
Oral Naltrexone Reduces Relapse to Heavy Drinking 27
XR-Naltrexone Injection Associated with Reduced Mortality and Hospital Readmissions Outcome measure 1 year mortality Odds Ratio for NTX-XR/control 0.30 (p < 0.001) In subset with detox in prior year Subsequent detox episodes 1 year mortality 0.80 (p < 0.001) 0.78 (p < 0.001) Case-Control design 387 veterans with AUD received extended-release injectable naltrexone (NTX-XR) 3759 controls Propensity score weighted, mixed-effects logistic regression model for 1-year mortality. For subset with at least one detox episode in previous year, # detox episodes in following year. Harris et al- 2015-Alcohol Clin Exp Res-39:79 83 28
Efficacy of Disulfiram in Blinded versus Open-Label Trials 2014-Skinner et al-plos One 2014 g= 0.70
Efficacy of Supervised versus Unsupervised Disulfiram 2014-Skinner et al-plos One 2014 g = 0.82
Acamprosate Supports Abstinence in Alcohol Use Disorder Jonas et al: 31
Alcohol Care Management (ACM) Behavioral Health Lab 26 week randomized trial of ACM (medication and psychosocial support) in primary care clinic versus referral to SUD specialty care. Behavioral Health Provider (BHP) on Primary Care team delivers personalized, measurement-based SUD care. Motivational interviewing Patient education Action planning 32
CONCLUSIONS Substance use disorders are preventable and treatable chronic diseases Effective treatment is: Patient centered Evidence based Life sustaining Empowering a life worth living Accessible We all need to do our part to improve the health and safety of our Veterans 33
ACKNOWLEDGEMENTS VA Academic Detailing Service VA Office of Quality Safety & Value VA Program Evaluation and Resource Center at Palo Alto VAMC DATE DOCUMENT TYPE/STATUS 34
Questions 35