Medication Assisted Treatment: Changing the Trajectory of the Opioid Epidemic Complexities in the Compassionate Management of Patients with Substance Use Disorder Melinda Campopiano, MD CSAT/SAMHSA Melinda.campopiano@samhsa.hhs.gov

The Epidemic

Truthpharm.org/remembering-loved-ones

Death Rates by Region

The Trajectory http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit-Updated-2016/SMA16-4742 http://prescribetoprevent.org/

Changing the Trajectory

Medication Assisted Treatment (MAT) The use of pharmacotherapy to support recovery from opioid use disorder. To be of maximum benefit evidence based behavioral therapy and case management services must also be provided

Benefits of MAT Reduces all cause mortality Reduces HIV risk Improves adherence to medical treatment Improves social function Decreases criminal behaviors Decreases drug use Schwartz R Opioid Agonist Treatments and Heroin Overdose Deaths in Baltimore, Maryland, 1995-2009. American Journal of Public Health May2013, Vol 103, No. 5.pp. 917-922 Soyka M. et al. Criminal Behavior in Opioid-Dependent Patients Before and During Maintenance Therapy: 6-year Follow-Up of a Nationally Representative Cohort Sample J Forensic Sci, November 2012, Vol. 57, No. 6 Fullerton, C. Assessing the Evidence: MAT with Methadone. Psychiatric Services in Advance, November 18, 2013; doi: 10.1176/appi.ps.201300235 Modesto-Lowe et al.: Methadone Deaths in Pain and Addiction Populations. JGIM 2012 Apr; 25(4): 305-9 Gibson A. Exposure to Opioid Maintenance Treatment Reduces Long-term Mortality. Addiction, 103, 462–468 Bell J, Zador D; A Risk-benefit analysis of methadone maintenance treatment. Drug Safety 2000 Mar; 22 (3): 179-190 Springer S Retention on Buprenorphine is Associated with High Levels of Maximal Viral Suppression among HIV-Infected Opioid Dependent Released Prisoners. PloS ONE May 2012 Volm 7 No. 5 Scharz R Retention on buprenorphine treatment reduces emergency department utilization, but not hospitalization, among treatment-seeking patients with opioid dependence. Journal of Substance Abuse Treatment 43(2012) 451-457. Mattick RP, Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence (Review) Copyright © 2014 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd. Marsch L, The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis. Addiction (1998) 93(4), 515± 532

Reduction of Mortality Reduces all cause mortality by half Critical to connect overdose survivors and persons with OUD and comorbid psychiatric or medical problems to recovery engagement services Screening, Brief Intervention and Referral to Treatment is a useful strategy to accomplish this.

Reduce HIV Risk Not as well studied but likely also reduces Viral Hepatitis risk MAT programs can be a venue for not just screening/testing but for delivery and monitoring of HIV and Hep C treatment, observed medication, specialist follow up, and Pre-exposure Prophylaxis (PrEP).

Improves Social Function Return to work Fulfill family and social roles Break the intergenerational cycle of substance use Decreases criminal behavior Improves compliance with medical treatment of other conditions

Decrease Drug Use Decrease misuse of prescription opioids, decreases supply of opioids in circulation. Opioids provided for MAT more controlled and monitored, and less abusable. Increasing capacity for treatment will decrease diversion of buprenorphine.

Medications Methadone and buprenorphine are approved by the FDA to treat opioid use disorder Both are opioid agonists Extended-release injectable naltrexone is approved by the FDA for the prevention of relapse to opioid use after detoxification An opioid antagonist There are multiple medications that can control or alter the course of opioid use disorder. Just like patients with high blood pressure people with substance use disorder need to be put on the medication that will work best for them. This selection of medication should be made based on the needs of that person, their other medical or psychiatric problems, their ability to manage their medication, and their life circumstances. When you think about the pros and cons of these medications remember to ask yourself: “If I had high blood pressure would I expect to receive the medicine that is best for me or the one that someone decided to allow me to have based beliefs about my condition or the medicine used to treat it?”

Methadone Requires certification as an opioid treatment program and program DEA registration samhsa.gov/medication-assisted-treatment Methadone must be administered and dispensed at the program

Buprenorphine Formulated with or without naloxone buprenorphine monoproduct (without naloxone) is only for pregnancy Few interactions with HIV or HCV meds Can be used in pregnancy Does not require detoxification to begin Generics available http://store.samhsa.gov/shin/content//SMA16-4938/SMA16-4938.pdf

Extended Release Injectable Naltrexone Monthly injection or daily oral medication Patient must be medically detoxed first. Optimal approach is for patients to receive first dose prior to leaving detox/rehab Cannot be used by patients who require opioids for pain Also indicated for alcohol use disorder http://store.samhsa.gov/shin/content/SMA14-4892/SMA14-4892.pdf

NEW Free MAT APP Information on medications A buprenorphine prescribing guide, which includes information on the waiver process and patient limits Clinical support tools such as treatment guidelines, ICD-10 coding, and more Access to critical helplines and SAMHSA's treatment locators http://store.samhsa.gov/apps/mat/

MAT Decisions in Recovery

Samhsa.gov/medication-assisted-treatment

Pcssmat.org