Medication assisted therapies 2017
Dr. Dawn-Elise Snipes presents a comprehensive overview of medication-assisted therapies for addiction, detailing pharmacotherapies for smoking, alcohol, and opioid addiction. The document emphasizes the role of long-term pharmacotherapy in reducing cravings, improving self-efficacy, and addressing co-occurring disorders, while also highlighting the importance of combining medications with psychosocial support. Key medications discussed include methadone, buprenorphine, and various treatments for smoking cessation and alcohol dependence, illustrating the effectiveness and individualized nature of these therapeutic approaches.
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Medication assisted therapies 2017
- 1. Medication-Assisted Therapies for Addiction Presentedby: Dr. Dawn-Elise Snipes, Ph.D., LMHC, CRC Executive Director of AllCEUs.com
- 2. Objectives Discuss the purposeof long-term pharmacotherapy Identify pharmacotherapies for Smoking Alcohol Opioids Methadone Buprenorphine Cases
- 3. Why Medication AssistedTherapy Early Recovery Reduces cravings Provides increased self-efficacy and a greater sense of control Anxiety Reduction due to: May alleviate some of the anxiety/fear about relapsing Pharmacological effects of certain MATs May improve depressive symptoms by Enhancing hope and an sense of empowerment Pharmacological effects of certain MATs
- 4. What is ourGoal in Early Recovery Reduce Co-Occurring issues Identify and address vulnerabilities Improve overall health Sleep Nutrition Energy (exercise) Maintain abstinence Increase time to relapse Reduce intensity of binge if relapse occurs
- 5. Clinical Use ofPharmacotherapy Part of comprehensive plan that addresses the following issues or problems: Emotional Cognitive Physical Social Occupational Environmental Not a substitute for counseling Works best in combination with psychosocial support
- 6. Co-Occurring Model ofAddiction Co-Occurring Disorders are the Expectation Mood issues must be addressed to prevent relapse Relapse begins when thoughts/urges or behaviors return to “addicted” mindset Addictive behaviors were “learned” as a way to stop distress. Learned behaviors cannot be unlearned. Alternate behaviors and their consequences must be more rewarding than addictive behaviors and the consequences. (LT vs. ST)
- 7. Drugs or NoDrugs No pharmacotherapy for most abused drugs ◦ Stimulants ◦ Hallucinogens (LSD, PCP, Ketamine, Dextromethorphan, Benadryl, Dramamine) ◦ Inhalants ◦ Marijuana What is the function of… ◦ Stimulants ◦ Hallucinogens ◦ Psychedelics (5HT2A); “state of empathetic wellbeing” ◦ Dissociatives (reduces glutamate); altered pain perception, depressant; Ketamine, Dextromethorphan ◦ Deliriants (reduces acetylcholine) Benadryl, Dramamine ◦ Inhalants (Depressants) ◦ Marijuana (increases dopamine); generally “relaxing,” pain relieving
- 8. Drugs or NoDrugs Factors to consider ◦ Cost ◦ Availability ◦ Side effects ◦ Barriers Workplace drug testing Other meds taken Incarceration ◦ Motivation
- 9. Barriers Stimatization Science vs. dogma Evidence-basedtreatment vs. “drugs for drug addicts” 12-Step groups Becoming more progressive Methadone Anonymous is alternative Counselors Different experiences and biases Payors Most payors require medication assisted therapy be “considered when available.”
- 10. What is theendpoint? Duration of most pharmacotherapy is not indefinite Months to years Goal is stabilization Flexibility Individualized Allow for relapse
- 11. Smoking Cessation Pharmacotherapy Replacement nicotinepatches nicotine gum nicotine lozenges nicotine nasal spray Antidepressant Zyban Partial agonist Varenicline (Chantix)
- 12. Nicotine Replacement Therapy(NRT) Always combine with a behavioral therapy program Most available OTC, but all are expensive Many states cover this in Medicaid Look for Reduces harmful effects of tobacco smoking Patients should not smoke while using
- 13. Nicotine Patch Highest successrate of available pharmacotherapies Nicoderm, Nicotrol, Habitrol, Prostep Most come in 3 strengths: 21, 14, & 7mg Start with 21mg patch for 6 wks, taper to 14 mg for 2 wks, finally 7 mg for 2 weeks Use new patch in different spot on upper trunk every 24 hrs
- 14. Nicotine Gum Nicorette -2 or 4mg per piece doses Requires correct “chewing technique” -- don’t chew like regular chewing gum Chew 1 piece for 30 minutes every 1 to 2 hrs to prevent nicotine W/D Chew regularly for first month, then taper off over 6 months Do not drink coffee or acidic drinks
- 15. Nicotine lozenges Commit, generics Suckon & move from side to side until dissolves 4 mg or 2 mg doses Flavor Mint, cherry, etc. “warming tingle” No comparison studies with patch or gum
- 16. Nicotine Nasal Spray Reducesnicotine craving & mimics pleasurable effects of nicotine 1 spray in each nostril, up to 40 times in 24 hours Use for up to 3 months May cause tearing, sneezing, & burning sensation in nose Highest risk for abuse
- 17. Bupropion (Zyban) Bupropion 150mgsustained release pills Works on dopamine & norepinephrine receptors in the brain to decrease W/D Start pills 10-14 days before “quit date” Take daily for 3 days, then twice a day Continue pills for 8 - 12 weeks May cause insomnia, anxiety, or seizures Prescription includes behavioral program
- 18. Varenicline (Chantix) Nicotine partial agonist Startpills 10 days before quit date Increase dose Take for 12-24 weeks Includes behavioral program
- 19. Pharmacotherapy for Alcohol Dependence Disulfiram(Antabuse) Acamprosate (Campral) Naltrexone (ReVia, Vivitrol)
- 20. Disulfiram (Antabuse) Blocks acetaldehydedehydrogenase Reaction to alcohol Flushing, palpitations, chest tightness Nausea, headache, anxiety Avoid slips or relapses Affects liver, even without alcohol Many drug interactions Motivation is necessary Monitored dosing
- 21. Acamprosate (Campral) Alcohol dependencepharmacotherapy Imbalance in GABA and NMDA articular receptors in the brain can lead to alcohol dependency. Normalizes GABA/Glutamate brain activity No drug interactions Minimal side effects Reduces symptoms of protracted withdrawal Insomnia Anxiety Restlessness Use caution in suicidal patients
- 22. Naltrexone (ReVia) Blocks opioidreceptors and pleasurable feelings from alcohol Reduce craving Tablets or implantable pellets Reduces alcohol slips Used for opioids and alcohol
- 23. Injectable naltrexone (Vivitrol) Intramuscularinjection of depot naltrexone given monthly Recently FDA approved for alcohol Administer in physician office, not at home Requires patient motivation
- 24. Maintenance Pharmacotherapy forOpioids Long-acting medication in controlled setting Counseling Social services Avoid withdrawal & craving Reduce disease & crime Maintenance vs. Detoxification
- 25. Methadone Opioid substitution therapy Harmreduction Individual Society Highly regulated Narcotic treatment programs must be licensed Methadone is a mu opioid agonist No withdrawal symptoms No craving Patients are regularly drug tested Treatment programs are required to provide counseling
- 26. Phases No take-homesshall be permitted during the first 30 days Eligible for 1 take-home per week from day 31 through day 90, negative drug screens for the preceding 30 days. Eligible for 2 take-homes per week from day 91 through day 180, negative drug screens for the preceding 60 days. Eligible for 3 take-homes per week with no more than a 2-day supply at any one time from day 181 through 1 year, negative drug screens for the preceding 90 days. After 1 year, eligible for 4 take-homes per week with no more than a 2- day supply at any one time; negative drug screens for the preceding 90 days. After 2 years in treatment, eligible for 5 take-homes per week with no more than a 3-day supply at any one time, provided negative drug screens for the preceding 90 days. After 3 years in treatment, the client may be eligible for 6 take-homes per week provided negative drug screens for the past year.
- 27. Effectiveness Controlled trials andmeta-analyses comparing medication and placebo show the superiority of agonist pharmacotherapy Improved treatment retention Reduces and often eliminates use of nonprescribed opioids Decreases criminal activity Reduces spread of HIV Results similar to long-term therapy of most chronic diseases
- 28. Beneficial effects Enhanced recovery Reducedmortality 70% reduction Overdose Trauma Homicide Medical illnesses Improved health Medical Psychiatric Improved psychosocial functioning Employment Criminal activity Family responsibilities
- 29. Does methadone getyou high? Because of its longer half-life, methadone suppresses withdrawal and drug craving for 24 to 36 hours No real euphoria at prescription doses Does cause sedation Can be reassuring Confused with “high” DEADLY if mixed with other drugs Benzodiazepines Alcohol
- 30. Impairment on Methadone Cognitiveimpairment may occur: During induction Change in dose Combination with other drugs/medications On a stable dose patient can Drive safely Complex tasks Care for others
- 31. Methadone forever? Nofederal limit for time on methadone Some states restrict time ◦ Virginia: evaluate every 2 years to see if can come off Individual variability ◦ Time required to stabilize (use, housing, family, job) ◦ Long-term clients (decades) Initial: can’t imagine life without something Stable: able to consider coming off ◦ Taper off comfortably over months/years
- 32. Buprenorphine Alternative to methadonefor opioid addiction treatment Long-acting opioid agonist-antagonist Multiple forms available Combined with naloxone (Suboxone): most common Buprenorphine only (Subutex) Used for treatment ofacute pain (Buprenex) Detox or maintenance
- 33. Buprenorphine Binds to opioidreceptors in body Only activates receptor around 40%, not 100% like other opioids (heroin, methadone) If already in withdrawal, 40% is pretty good If not in withdrawal, dropping from 100% to 40% receptor activation causes withdrawal Very low risk of overdose Can OD when combined with benzos
- 34. Office-based opioid therapy Buprenorphineis less restricted than methadone (Schedule III) Get prescription from pharmacy with refills (up to 6 months) Outpatient physician visits for medication checks as needed Addiction counseling is separate, patient may be referred to another provider for this service
- 35. Taking Buprenorphine Sublingual tablet Dissolveunder tongue Takes around 5 min. to dissolve Won’t be active if swallowed Comes in 2mg and 8mg tablets Typical dose is 12-16 mg once daily Can take 3 times a week https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment- physician-locator
- 36. Methadone or Buprenorphine? Treatmentefficacy equivalent Similar opioid side effects Abuse potential Slightly higher for buprenorphine Buprenorphine has fewer drug interactions Buprenorphine more convenient (less restricted) Buprenorphine not age-restricted (can use in teens) Methadone less expensive Methadone has no ceiling effect
- 37. Suboxone Combination of Buprenorphineand Naloxone Do not confuse with Subutex which is buprenorphine only The short-term, desirable effects of Suboxone include: A pain relieving effect that is between 20 and 30 times more powerful than morphine. A mild euphoria that can lasts for around 8 hours with general effects of the substance lasting for 24 - 72 hours. A sense of calm and inflated well-being. A perception of fewer worries and lower stress. Increased relaxation.
- 38. Suboxone Suboxone may beabused by individuals addicted to a short-acting opioid drug like heroin, by using it in between doses to keep withdrawal symptoms from occurring The Naloxone only “kicks in” if the suboxone is altered and injected or snorted. Suboxone is dosed such that the prescribe is getting enough to avoid withdrawal symptoms In a person who is not already tolerant to opiates, the effect of Suboxone can cause a “mellow high” Exposure to Naloxone is lower with sublingual vs. buccal (cheek)administration
- 39. Final Thoughts onOpiates Like any other opioid, tolerance develops quickly, and goes away quickly. There is a danger of overdose in patients who have tapered or stopped using opiate agonists who relapse. Note: Narcan (Opiate Reversal) is Naloxone By the end of the year, Walgreens will make naloxone available without a prescription at its pharmacies in the following states: Alabama, Arkansas, California, Colorado, Connecticut, District of Columbia, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Wisconsin
- 40. Urine Drug Screening Useas deterrent, not to ‘catch in the act’ Random Minimum of 8 samples/year on maintenance therapy Verify presence of methadone, buprenorphine, etc. Look for Illicit substances Unauthorized prescriptions Opioids Benzodiazepines
- 41. Summary Long-term pharmacotherapy isavailable and effective for several addictions Medication + counseling = recovery Smoking cessation Nicotine replacement is available over-the-counter Bupropion and varenicline are available by prescription for smoking cessation Multiple medications are available by prescription for alcohol dependence
- 42. Summary Methadone/buprenorphine maintenance proven toreduce mortality, crime, & spread of infection Substitution therapy to eliminate withdrawal, cravings, & heroin effects Individualized dose