Addictions Panel Workshop  Alison Noice, MA Director of Addiction Medicine Services at CODA, Inc.  William Nunley, MD, MPH Associate Medical Director, CareOregon 2013 Aging and Disability Services Conference 22 May 2013

Workshop Intentions  Overview of Addiction  Principles of Effective Treatment  Community-Based Treatment Options  Additional Discussion

Workshop Primary Reference  Think of one specific person with substance abuse/ addiction with whom you have worked  Jot down a few key facts about them  Admirable traits or experiences  Challenges encountered  Key questions about addiction that may have emerged during your work with them

Two Views of Addiction View 1  Addiction is a medical condition or disease.  As with other medical conditions, has a variable natural history or course.  Treatment requires long-term medical maintenance. View 2  Addiction is caused by weak will or moral failing.  Addiction and treatment are all-or-none states (are or are not an addict/are or are not in recovery).  Treatment is based on criminalization of use and/or spiritual recovery.

Workshop Intentions  Overview of Addiction  Principles of Effective Treatment  Community-Based Treatment Options  Discussion

NIDA Principles of Effective Drug Addiction Treatment  No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each patient's problems and needs is critical.  Treatment needs to be readily available. Treatment applicants can be lost if treatment is not immediately available or readily accessible.  Effective treatment attends to multiple needs of the individual, not just his or her drug use. Treatment must address the individual's drug use and associated medical, psychological, social, vocational, and legal problems.  Treatment needs to be flexible and to provide ongoing assessments of patient needs, which may change during the course of treatment.  Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The time depends on an individual's needs. For most patients, the threshold of significant improvement is reached at about 3 months in treatment. Additional treatment can produce further progress. Programs should include strategies to prevent patients from leaving treatment prematurely.

 Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding nondrug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships.  Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethadol (LAAM) help persons addicted to opiates stabilize their lives and reduce their drug use. Naltrexone is effective for some opiate addicts and some patients with co-occurring alcohol dependence. Nicotine patches or gum, or an oral medication, such as bupropion, can help persons addicted to nicotine.  Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Because these disorders often occur in the same individual, patients presenting for one condition should be assessed and treated for the other.  Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification manages the acute physical symptoms of withdrawal. For some individuals it is a precursor to effective drug addiction treatment. NIDA Principles of Effective Drug Addiction Treatment

 Treatment does not need to be voluntary to be effective. Sanctions or enticements in the family, employment setting, or criminal justice system can significantly increase treatment entry, retention, and success.  Possible drug use during treatment must be monitored continuously. Monitoring a patient's drug and alcohol use during treatment, such as through urinalysis, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that treatment can be adjusted.  Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place them or others at risk of infection. Counseling can help patients avoid high-risk behavior and help people who are already infected manage their illness.  Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Participation in self-help support programs during and following treatment often helps maintain abstinence.

Workshop Intentions  Overview of Addiction  Principles of Effective Treatment  Community-Based Treatment Options  12 Step Overview  Alternate peer-based recoveries  Medication Assisted Treatment  Additional Discussion

12 Step Overview

Community Treatment Options: 12 Step Overview  Three primary components 1. Reorganization of priorities and self-psychology 12 Steps 2. Establishing a pro-social social network Regular attendance of meetings and fellowship 3. Establishing a trusting, collaborative, pro-social relationship with an experienced mentor Sponsorship

12 Steps of Alcoholics Anonymous 1. We admitted we were powerless over alcohol - that our lives had become unmanageable. 2. Came to believe that a power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of god as we understood him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to god, to ourselves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove all these defects of character.

12 Steps 7. Humbly asked god to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory, and when we were wrong, promptly admitted it. 11. Sought through prayer and meditation to improve our conscious contact with god as we understood him, praying only for knowledge of his will for us and the power to carry that out. 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

Supporting 12 Step Work  Three primary components 1. Reorganization of priorities and self-psychology 12 Steps 2. Establishing a pro-social social network Regular attendance of meetings and fellowship 3. Establishing a trusting, collaborative, pro-social relationship with an experienced mentor Sponsorship

Supporting 12 Step Work  Three primary components 1. Reorganization of priorities and self-psychology 12 Steps 2. Establishing a pro-social social network Regular attendance of meetings and fellowship 3. A trusting, collaborative, pro-social relationship with an experienced mentor Sponsorship  Simple, effective intervention and support  Do you have a sponsor, how often are you attending meetings, what step are you working on currently?

Non-12 Step Peer Recovery

Primary Alternatives to AA  SMART  On-line/meeting based, non-spirituality  Split from Rational Recovery c.1998  Rational Recovery/Rational Recovery Systems, Inc.  Jack Trimpey, LCSW c.1986  addiction as maladaptive behavior (learned, volitional)  Women for Sobriety  Jean Kirkpatrick, sociologist c.1976  Recovery International (Recovery Inc.)  Abraham Low, MD c.1937  Cognitive-behavioral self-help techniques

Primary Alternatives to AA (continued)  Secular Organizations for Sobriety  Dual-Diagnosis Anonymous  Oregon developed EBP  12 Steps + 5 Steps (MI/MH recovery)  Moderation Management  Many, many, many additional

Medication Assisted Treatment

Two Views of Addiction (your client) View 1  Addiction is a medical condition or disease.  As with other medical conditions, has a variable natural history or course.  Treatment requires long-term medical maintenance. View 2  Addiction is caused by weak will or moral failing.  Addiction and treatment are all-or-none states (are or are not an addict/are or are not in recovery).  Treatment is based on criminalization of use and/or spiritual recovery.

Similarities to Other Medical Disorders  Addiction is viewed as medical disorder.  Substance addiction is comparable to asthma, hypertension, and diabetes.  Risk of relapse is highest during first 6 months.  Patients respond best to a combination of pharmacological and behavioral interventions.  Treatment improves outcomes of even severe cases.

Options for use of Addictions Medicines  Medically supervised withdrawal treatment vs.  Medical maintenance treatment  Methadone, buprenorphine, and naltrexone  Pharmacotherapy with assessment, psychosocial intervention, and support services  Detoxification from short-acting opioids

Pharmacotherapy The use of medications to treat a illness (substance abuse/addiction) and positively effect the symptoms and natural course of the illness

Agonist vs Antagonist  Agonist: Binds to the receptor to elicit effect. These drugs mimic the effects of the naturally occurring neurotransmitters with the same or stronger affinity to the receptor  Antagonist: Binds to the receptor but, instead of eliciting response it, it blocks the receptor and prevents activation. In the event the receptor is already activated, the antagonist will replace whatever is already activating the receptor (naltrexone, Narcan)

How Can You Treat Opioid Addiction? Agonist Maintenance Treatment  Usually conducted in outpatient settings  Treatment provided in opioid treatment programs traditionally using methadone, now with buprenorphine, in office-based settings  Patients stabilized on adequate, sustained dosages of these medications can function normally.  Can engage more readily in counseling and other behavioral interventions essential to recovery and rehabilitation  The best, most effective opioid agonist maintenance programs include individual and/or group counseling, as well as provision of, or referral to other needed medical, psychological, and social services. (National Institute on Drug Abuse, 2009)

How Can You Treat Opioid Addiction? Antagonist Maintenance Treatment  Usually conducted in outpatient setting  Initiation of naltrexone often begins after medical detoxification in a residential setting  Repeated lack of desired opioid effects will gradually over time result in breaking the habit of opiate addiction.  Patient noncompliance is a common problem. A favorable treatment outcome requires a positive therapeutic relationship, effective counseling or therapy, and careful monitoring of medication compliance. (National Institute on Drug Abuse, 2009)

Pharmacotherapeutic Medications for Opioid Addiction Treatment  Methadone: Most frequently used, long-acting, has many formulations, decreases pain-killing effects of opioids, available in OTPs  Buprenorphine: Larger doses do not increase effects, has increased margin of safety, administered in doctor’s offices and healthcare settings  Buprenorphine-naloxone: Combination of 2 medications, administered in doctor’s offices and healthcare settings  Naltrexone: Does not have abuse potential; blocks effects of opioids; can cause withdrawal in non-abstinent patients; administered in OTPs and outpatient settings

But aren’t you just trading one addiction for another?

Promoting Comprehensive Treatment  Effective treatment attends to multiple needs of individual.  Counseling and other behavioral therapies are critical components of effective treatment.  Medications, especially combined with behavioral therapies, are an important element of treatment for many patients.

Why Medications for Opioid Dependence?  Opioids attach to receptors in the brain, causing pleasure. After repeated opioid use, the brain becomes altered, leading to tolerance and withdrawal.  Medications operating through the opioid receptors, such as buprenorphine and methadone, prevent withdrawal symptoms and help the person function normally. Medications like naltrexone block the body’s response to opioids  Behavioral treatment can also address cravings that arise from environmental cues.

Treatment Recommendations  Behavioral treatments educate patients about the conditioning process and teach relapse prevention strategies.  Medications such operate on the opioid receptors to relieve craving and inhibit euphoric effects.  Combining the two types of treatment enables patients to stop using opioids and return to more stable and productive lives.

Stages of Pharmacotherapy  Induction: Initial treatment process of adjusting maintenance medication dosage levels until a patient attains stabilization  Stabilization: Process of providing immediate assistance to eliminate withdrawal symptoms and drug craving  Maintenance: Administering an opioid addiction medication at stable dosage levels for a period in excess of 21 days

How long does someone have to stay on medications?

Voluntary Tapering and Dose ReductionVoluntary Tapering and Dose Reduction  Patients attempt reduction or cessation of maintenance for many reasons; there is a high relapse rate.  Withdrawal should be tried when strongly desired by a stable patient, but sometimes dose tapering is necessary for administrative reasons.  Many treatment providers can’t improve outcomes for patients who undertake planned withdrawal, so withdrawal should be undertaken conservatively.

Voluntary Tapering and Dose ReductionVoluntary Tapering and Dose Reduction  Relapse prevention techniques should be incorporated into treatment both before and during dosage reduction.  Success rates are likely to be similar for patients who taper from methadone or buprenorphine, so similar cautions and monitoring processes should be in place.

Steps in Patient-Treatment Matching: Patient Assessment  Comprehensive assessment should include patient’s:  Extent, nature, and duration of substance use  Treatment history  Medical, psychiatric, and psychosocial needs  Functional status  Gender, culture, ethnicity, and language  Motivation to comply with treatment  Recovery support

Steps in Patient-Treatment Matching: Matching Needs to Settings  Identify the most appropriate setting or services.  MAT has been offered primarily in dedicated outpatient OTPs, but more varied programs and settings have emerged.  Treatment team should collaborate with patients to determine the most appropriate treatment services.  Patients’ service needs may change. Treatment matching in some cases can lead to multiple settings.

Steps in Patient-Treatment Matching: Matching Needs to Settings  Examples of treatment programs and settings:  Outpatient OTPs  Residential treatment programs  Mobile treatment units  Office-based opioid treatment settings  Criminal justice institutions  Other treatment settings and specialized programs

Treatment Phases Acute Rehabilitative Supportive Care Medical Maintenance Tapering and MSW Continuing Care

Variations of Phased Treatment  Types and intensity of services vary throughout treatment.  Most patients need:  Intensive treatment services at entry  Diversified services during stabilization  Fewer intensive services after recovery benchmarks are met.  Treatment phases are on a dynamic continuum.  Assessment of treatment should be ongoing.  Duration of treatment is a team decision based on data and medical experience.

Workshop Intentions  Overview of Addiction  Principles of Effective Treatment  Community-Based Treatment Options  Additional Discussion

Thank you for your time and for your essential service to vulnerable members of our community.