The intersection of medication assisted treatment and mental health Charles Hilger, MSW, LADC Vice President MAT Service Line Meridian Behavioral Health September 13, 2017

Medication Assisted Treatment 101 Presentation Overview Medication Assisted Treatment 101 ABOUT THE PRESENTER WHAT DO YOU WANT TO KNOW? MEDICATION ASSISTED TREATMENT: MEDICATIONS GOALS OF MAT IMPACT OF MAT

Medication Assisted Treatment 101 About the Presenter Medication Assisted Treatment 101 Chuck Hilger, MSW, LADC – Vice President MAT Services, Meridian Behavioral Health – Valhalla Place 20 years working in the field of Substance Use Disorders 13 years in opiate addictions – Medication Assisted Treatment MARRCH Board Member Work with National Advocacy Groups on issues of MAT and Harm Reduction Served on MN State Advisory Boards Former Adjunct Faculty at Argosy University in the Masters of Clinical Psychology program – Instruct in the area of substance use disorder

Medication Assisted Treatment

Medication Assisted Treatment 101 Section Objectives Medication Assisted Treatment 101 Methadone Buprenorphine/Naloxone (Suboxone) Naltrexone (Vivitrol, ReVia) How Opiate Replacement Therapy Works Impact of Medication Assisted Treatment

Medication Assisted Treatment 101 What is Methadone? Medication Assisted Treatment 101 Methadone is a synthetic opioid – analgesic Full opioid agonist (schedule II) Synthesized by Germans in 1938 First used in 1964 to treat heroin/morphine addiction Effective for persons with low to high tolerance Considered the gold standard for treating opiate addiction

Medication Assisted Treatment 101 What is Methadone? Pharmacology Medication Assisted Treatment 101 Half life 24-36 hours Peak serum blood level 3-5 hours High affinity for the  receptor site Moderate dissociation from the receptor site Risk of over medication and medication interactions Longer time to stabilize – adequate dose Safe for prolonged use – nontoxic

Medication Assisted Treatment 101 What is Buprenorphine? Medication Assisted Treatment 101 Buprenorphine is a semi-synthetic opioid – analgesic Partial opioid agonist (schedule III) Discovered in 1965 it is an alkaloid of the poppy plant Approved in 2000 to treat opioid use disorders Used in “full” treatment or by MD prescription Effective mostly for persons with low to moderate tolerance More expensive than methadone Considered the gold standard for treating opiate use disorders

Medication Assisted Treatment 101 What is Buprenorphine? Pharmacology Medication Assisted Treatment 101 Half life 24-36 hours Peak serum blood levels 2-4 hours High affinity for the  receptor Slow dissociation from the receptor Milder withdrawal Exhibits a “ceiling effect” preventing respiratory depression Shorter time to stabilize Safe for prolonged use – nontoxic Safer medication than Methadone – Ceiling effect

Medication Assisted Treatment 101 What is Naltrexone? Medication Assisted Treatment 101 Naltrexone is an opioid antagonist Blockade effect Initiated 7-10 days after last opioid consumption Monthly intramuscular injection Half life 5-10 days Most expensive (McLellan et al, 1993 and 1994)

Medication Assisted Treatment 101 MAT Medications Medication Assisted Treatment 101 Source: National Institute on Drug Abuse, Pew Charitable Trusts Credit: Rebecca Hersher and Alyson Hurt/NPR

Medication Assisted Treatment 101

Medication Assisted Treatment 101 Goals for Medication Assisted Treatment Medication Assisted Treatment 101 Prevention or reduction of withdrawal symptoms Prevention or reduction of drug craving Prevention of relapse to use of addictive drug blockade effect Restoration to or toward normalcy of any physiological function disrupted by drug abuse Source: MJ Kreek, Rationale for Maintenance Pharmacotherapy of Opiate Dependence, 1992

Medication Assisted Treatment 101 Impact of Maintenance Treatment Medication Assisted Treatment 101 Reduction death rates (Grondblah, ‘90) Reduction IVDU (Ball & Ross, ‘91) Reduction crime days (Ball & Ross) Reduction rate of HIV (Bourne, ‘88; Novick ‘90,; Metzger ‘93) Reduction of relapse to IVDU (Ball & Ross, ‘91) Improved employment, health, & social function

Medication Assisted Treatment 101 Other Benefits of Pharmacotherapy for Opioid Addiction Medication Assisted Treatment 101 Increased Employment Improved Physical and Mental Health Improved Social Function

MAT patients with mental health diagnosis

Medication Assisted Treatment 101 Prevalence and Impact Medication Assisted Treatment 101 Substance use and response to psychiatric treatment in methadone-treated outpatients with comorbid psychiatric disorder No illicit drug use (baseline negative; n = 50), or (2) any illicit drug use (baseline positive; n = 75 Results showed that while both conditions evidenced similar utilization of on-site psychiatric services, baseline negative participants remained in treatment somewhat longer (80.7 vs. 74.8. days, p =.04) and demonstrated greater reductions in GSI scores than baseline positive participants at month 3 (p =.004). These results have implications for interpreting previous studies that have shown inconsistent efficacy of pharmacotherapy and other psychiatric treatments, and for providing clinical care for patients with co-occurring substance use and psychiatric disorders. Substance use and response to psychiatric treatment in methadone-treated outpatients with comorbid psychiatric disorder. / Kidorf, Michael; King, Van L.; Peirce, Jessica; Gandotra, Neeraj; Ghazarian, Sharon; Brooner, Robert K.

Medication Assisted Treatment 101 Prevalence and Impact #2 Medication Assisted Treatment 101 https://m.youtube.com/watch?v=e61g6OlKJQY

Medication Assisted Treatment 101 Prevalence and Impact #3 Medication Assisted Treatment 101 Valhalla Place conducts an average of 80 Diagnostic Assessments per month 60 are appropriate for ongoing services 25% engage in ongoing Mental Health services 15% are already connected to a therapist or engaged in supportive services through private or county agencies 30% chose not to participate Most Common Diagnosis: Anxiety (GAD) 30% Depression (MDD) 35% PTSD 20% Personality Disorders, Schizoaffective, Adjustment 15%

Common Medications and interactions

Medication Assisted Treatment 101 Benzodiazepines Medication Assisted Treatment 101 Benzodiazepines – Tranquilizers Klonopin Ativan (Lorazepam) Xanax Valium 15% of MAT UDS are positive for Benzodiazepines Central Nervous System Depressant Potentiating Effect Benzodiazepines with Methadone is safe if monitored by medical staff and taken as prescribed

Medication Assisted Treatment 101 QTc Prolongation Medication Assisted Treatment 101 QTc Prolongation: Extending the hearts natural rhythm Effects: Syncope and Ventricular Fibrillation and Sudden Cardiac Death (SDC) Certain medications like Methadone and Effexor can contribute to developing prolongation Other factors to consider Family history of heart disease Overall Health

Medication Assisted Treatment 101 Other Medications Medication Assisted Treatment 101 Gabapentin (Neurontin) – Sedation Celexa (antidepressant) – Sedation Soma (muscle relaxant) – Sedation Watch for signs and symptoms at peak methadone levels Medications can be managed so that they do not peak at the same time and increase effects

Coordinating care

Medication Assisted Treatment 101 Multidisciplinary Team Medication Assisted Treatment 101 Communication is key to managing patients with mental health challenges and also in an MAT program! Some patients count on providers not talking Federal confidentiality laws Gaining release of information Sharing treatment goals both ways Care coordination services Professional and patient accountability

Medication Assisted Treatment 101 Thank You Very Much For All Your Help and Participation! Medication Assisted Treatment 101 Chuck Hilger, MSW, LADC Vice President MAT Services Meridian Behavioral Health Chuck.Hilger@meridian programs.com Cell: 612-670-7769