Medication Assisted Treatment for Substance Use Disorders Courtney Bearden, RN, PMHNP-BC Director of Nursing and Quality Management Bluebonnet Trails Community Services

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Outline Review standardized screening tools for Substance Use Disorders Review evidence-based treatment options for nicotine, alcohol and opiate use disorders Provide evidence-based dosing guidelines for medications commonly used in the treatment of Substance Use Disorders

Nicotine

Nicotine

Medications to Treat Nicotine Dependence First Line (FDA Approved) Nicotine Replacement Therapy Bupropion Varenicline Second Line (not FDA Approved) Nortriptyline Clonidine

>6 Month Quit Rates

Medications to Treat Nicotine Dependence

Alcohol Men: 5 or more in one sitting, 15+ in one week Women: 4 or more in one sitting, 8+ in one week

Alcohol Men: 5 or more in one sitting, 15+ in one week Women: 4 or more in one sitting, 8+ in one week

Alcohol Assessments AUDIT CAGE (cut down, annoyed, guilty, eye opener) What happens when you google image search “CAGE drinking”

Early or full remission Controlled setting

Assessment for Alcohol Withdrawal CIWA-Ar <8 Minimal: Drug therapy not usually indicated 8-14 Moderate: Drug therapy indicated >15 Severe: Drug therapy required, consider inpatient treatment

Medications to Treat Alcohol Dependence Naltrexone (PO and IM) Acamprosate Disulfiram Topiramate

Extended-release Injectable Naltrexone (Depade®, ReVia®) Extended-release Injectable Naltrexone (Vivitrol®) Acamprosate (Campral®) Disulfiram (Antabuse®) Topiramate (Topamax®) Usual adult dosage Oral dose: 50 mg daily. IM dose: 380 mg given as a deep intramuscula r gluteal injection, once monthly. Oral dose: 666 mg (two 333-mg tablets) three times daily; or for patients with moderate renal impairment (CrCl 30 to 50 mL/min), reduce to 333 mg (one tablet) three times daily. Oral dose: 250 mg daily (range 125 mg to 500 mg). Oral dose: Initial dose 25 mg at bedtime, increasing the dose by 25-50 mg daily each week, divided into morning and evening doses. Faster titration is more likely to cause adverse reactions. Target dose is 200 mg per day total dose, but patients unable to tolerate that dose may respond to lower doses

Opiates

Screening Tools DAST: Drug Abuse Screening Test (free from NIDA) One question screening: How many times in the past year have you used an illegal drug or a prescription medication for nonmedical reasons? (A positive screen is 1 or more days.)

DSM V Opioid Use Disorder At least two of the following symptoms within a 12 month period: Taking more opioid drugs than intended. Wanting or trying to control opioid drug use without success. Spending a lot of time obtaining, taking, or recovering from the effects of opioid drugs. Craving opioids. Failing to carry out important roles at home, work or school because of opioid use. Continuing to use opioids, despite use of the drug causing relationship or social problems. Giving up or reducing other activities because of opioid use. Using opioids even when it is physically unsafe. Knowing that opioid use is causing a physical or psychological problem, but continuing to take the drug anyway. Tolerance for opioids. Withdrawal symptoms when opioids are not taken.

Why agonist treatments?

Medications to Treat Opiate Dependence Naltrexone Methadone Buprenorphine

Selecting the Appropriate Medication Naltrexone Not a controlled substance Less intensive monitoring Low risk of diversion Available in long-acting injectable Patient must be abstinent for 7-10 days before starting naltrexone Monitor liver function

Medication Selection (cont.) Methadone Schedule II controlled substance Can only be prescribed at licensed OTP (Opioid Treatment Program) i.e. “Methadone clinics” or in an inpatient hospital setting Need for daily visits and intensive monitoring- could be a barrier or support depending on patient’s needs May be the best agonist option during pregnancy

Medication Selection (cont.) Buprenorphine Schedule III- prescriber must obtain additional DEA number Limits to number of patients each prescriber can maintain Can be given in OTP or OBOT (Office Based Opioid Treatment) settings Lower risk of abuse or diversion than Methadone, though still some risk Lower risk of overdose May be a better option for patients who cannot attend daily dosing clinic

Naltrexone Precautions Other hepatic disease; renal impairment; history of suicide attempts or depression. If opioid analgesia is needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy Category C. Serious adverse reactions Will precipitate severe withdrawal if the patient is dependent on opioids; hepatotoxicity (although does not appear to be a hepatotoxin at the recommended doses). Common side effects Nausea, vomiting, decreased appetite, headache, dizziness, fatigue, anxiety. Examples of drug interactions Opioid medications (blocks action).

Naltrexone Naltrexone (Depade®, ReVia®) Usual adult dosage   Naltrexone (Depade®, ReVia®) Usual adult dosage Oral dose: 50 mg daily. Before prescribing: Patients must be opioid-free for a minimum of 7 to 10 days before starting. If you feel that there’s a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function. Action Blocks opioid receptors, resulting in reduced craving and reduced reward in response to opiates. Contraindications Currently using opioids or in acute opioid withdrawal; anticipated need for opioid analgesics; acute hepatitis or liver failure. Must be opioid free for 7-10 days.

Extended-release Injectable Naltrexone   Extended-release Injectable Naltrexone (Vivitrol®) Usual adult dosage IM dose: 380 mg given as a deep intramuscular gluteal injection, once monthly. Before prescribing: Same as oral naltrexone, plus examine the injection site for adequate muscle mass and skin condition. Action Same as oral naltrexone Contraindications Same as oral naltrexone, plus inadequate muscle mass for deep intramuscular injection; rash or infection at the injection site.

Methadone Methadone Precautions   Methadone Precautions Caution for increased risk of overdose when used in combination with benzodiazepines. Serious adverse reactions Respiratory depression, sedation, prolonged QTc Common side effects Hyperhidrosis, sexual dysfunction, dental problems related to decreased saliva

  Methadone Usual adult dosage Starting dose 30mg, not to exceed 40mg in first day. Usual daily dose 60-120mg. Action Full opioid agonist, reduces cravings and withdrawals Contraindications Hypersensitivity to methadone; patients with respiratory depression; paralytic ileus; high risk for diversion; at risk for prolonged QT interval.

Buprenorphine Buprenorphine Precautions   Buprenorphine Precautions May cause precipitated withdrawal if taken with opiate. Serious adverse reactions Precipitated withdrawal Common side effects Constipation, nausea, hyperhidrosis, dental problems related to decreased saliva

  Buprenorphine Usual adult dosage Must be in mild to moderate withdrawal prior to first dose. Initial dose 2-4mg, increase in increments of 2-4mgs. Usual daily dose 8mg/day, up to 16mg/day. (FDA limit 24mg/day) Action Partial opioid agonist (Suboxone= partial agonist + antagonist) Contraindications Hypersensitivity to buprenorphine or naloxone; severe hepatic impairment.

COWS 5-12: mild 13-24: moderate 25-36: moderately severe >36: severe withdrawal When you google image search COWS opiates

COWS

Opioid Withdrawal

Opioid Overdose Naloxone

Naloxone Intranasal (generic and branded Narcan) Covered by Medicaid without PA Branded Narcan $132.25 cash price Generic naloxone $14-21 cash price Intramuscular (generic) $22.22 per 1mL vial cash price (LifePath) Auto-injector (branded Evzio) Cash price $360 $0 out-of-pocket for commercial insurance (PAP direct delivery service) or Medicaid-eligible Not Medicaid covered (yet)

Sarah 24yo woman, began using prescription opiates at age 16 Progressed to IV heroin use by age 21 BZDs and ETOH on occasion Outpatient treatment – unsuccessful Inpatient detox – remained sober 3 weeks No significant medical history What’s the plan? Trial of naltrexone

Jaime 27yo male, began using opiates at age 21 Began selling drugs and burglarizing homes to support opiate addiction at age 24 Court mandated inpatient treatment x3 Hep C positive, elevated LFTs What’s the plan? Suboxone or methadone?

Felicia 18yo woman, 6 months pregnant with her second child IV heroin user CPS involved after the birth of her first child and has referred her to seek SUD treatment Currently in therapy for past trauma What’s the plan? Methadone- inpatient treatment

Robert 47yo man, started taking Norco 11 years ago after a back injury Now “doctor shopping” to obtain duplicate prescriptions for opiate medications IOP x4 over the past 6 years Professional career, worries he can’t come to daily methadone clinic Continues to struggle with chronic pain Suboxone

Resources PCSSMAT.org SAMHSA ASAM.org https://www.integration.samhsa.gov/clinical-practice/mat/mat-overview ASAM.org