medical assisted treatment - haymarket center...2009) – greater acceptance in medical community to...
TRANSCRIPT
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Medical Assisted Treatment
Dr. Michael Baldinger Medical Director
Haymarket Center Harborview Recovery Center
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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)
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Sources of Prescription Pain Relievers
76%
19%4%
1%
Friend/Relative
from MD
Dealer
Internet
(SAMHSA, 2008)
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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)
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Annual numbers of new non-medical pain medication users 1965 - 2002
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(New York Times, February 2009)
(AMA News 2009)
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• You are entitled to your own opinions but you are not entitled to your own facts
• Daniel Patrick Moynihan
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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
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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
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Neurotransmitter Effects on Receptors
• Agonist
• Partial Agonist
• Antagonist
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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
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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
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Buprenorphine, Methadone, LAAM: Treatment Retention
(From “An Overview of Opioid Dependence”, Dr. Martin Doot)
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Buprenorphine, Methadone, LAAM Opioid Urine Results
(From “An Overview of Opioid Dependence”, Dr. Martin Doo
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Detoxification vs. Maintenance
(From “An Overview of Opioid Dependence”, Dr. Martin Doot)
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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
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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
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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
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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
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Buprenorphine “Ceiling Effect”
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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
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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
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Considerations regarding Buprenorphine
• Side Effects – Unpleasant Taste – Excessive Sweating – Constipation – Decreased libido – Difficulty urinating – Difficulty with discontinuation
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When to Discontinue Maintenance
• Patient request • Patient unable to comply with Treatment
Contract • Entry into Criminal Justice system • Unacceptable Side Effects
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How to Detox • Methadone
– 3-5 mg per week
• Buprenorphine – 2 mg per week or less – can vary – Interval of 5 days between dose reduction
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Antagonist Therapy • Revia
– 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
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Sedatives and Alcohol
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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
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Sedative Withdrawal Strategies
• Conversion to long acting benzodiazepines • Phenobarbital taper • Anticonvulsants - alone or in combination
with benzodiazepines/phenobarbitol
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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