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

Source: Messing RO. In: Harrison’s Principles of Internal Medicine. 2001:2557-2561.

Ventral tegmental area

(VTA)

Amygdala

Nucleus

accumbens

Prefrontal Cortex

Hippocampus

Similarities to Other Chronic

Diseases1-3

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.

Relapse Rates Are Similar to Other

Chronic Diseases1,2

0

10

20

30

40

50

60

70

80

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.

Pat

ients

Who R

elap

se (

%)

40%–60%

30%–50%

50%–70%50%–70%

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 non-

pregnant women

◦ By trimester 1st 9%; 2nd 4.8%; 3rd 2.4%

Alcohol use◦ Current 9.4%; compared to 11.4% for non-

pregnant women

◦ Binge drinking- 2.3%; Heavy drinking- 0.4%

◦ By trimester 1st 19%; 2nd 5%; 3rd 4.4%

PSYCHOSOCIAL ASPECTSAFCARS 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-51. 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

Did not feel

they needed

treatment,

16,900,000

Felt they

needed

treatment

and made an

effort to get

it, 351,000

Felt they

needed

treatment

but did not

try, 455,000

2016 National Survey on Drug Use and Health

BARRIERS TO ENGAGEMENT

0 10 20 30 40 50

Not ready to stop

No healthcare coverage and cannot

afford

Did not know where to go to get help

Did not find a program that offered

the desired type of treatment

Might cause neighbors or community

to have negative opinion

Might have negative effect on job

Percent

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

Pharmacotherapy Psychosocial Intervention

MAT and Psychosocial Intervention1,2

Can control symptoms by

normalizing brain chemistry

Essential to change behaviors and

responses to environmental and

social cues that so significantly

impact relapse

1. McLellan et al. Addiction. 1998;93(10):1489-1499; 2. McLellan et al. JAMA. 1993;269(15):1953-1959.

Both are necessary to normalize brain chemistry,

change behavior,

and reduce risk for relapse; neither alone may be sufficient

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 MattersPrimary 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 opioidwithdrawal, then patients were offered naltrexone treatment; the maintenance group received ongoing BUP therapy.

◦ Taper group: mean percentage of urine samples negative for opioidswas 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

4 Studies of Various Treatment Lengths

• 32% improvement in occupational problems

• 90% improvement in drug-related problems

• 90% improvement in crime-related problems

After 12 Months2

(buprenorphine-only; n=40)

• Heroin use decreased by 81%

• Codeine use decreased by 83%

• Benzodiazepine use decreased by 48%

• Cocaine use decreased by 74%

After 6 Months1

(buprenorphine-only; n=690)

• Less likely to report using any substance or heroin

• More likely to be employed

• Improved on several psychosocial parameters

After 18 Months3

(buprenorphine/naloxone; n=176)

• 91% of urine samples were opioid negative

• 96% of urine samples were cocaine negative

After 2-5 Years4

(buprenorphine/naloxone; n=53)

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