Medically assisted treatment MAT Update Medically assisted treatment

Why do we care? The U.S. Department of Health and Human Services has identified opioid use disorder as a national crisis, and in August 2017 a national emergency was declared. Drug overdose is the leading cause of accidental injury among U.S. adults, and rates of opioid-related overdoses increased 200% between 2000 and 2014. Estimates suggest that drug overdose has emerged as the leading cause of death for Americans younger than 50 years.

Drugs of choice Opioids Meth Alcohol Cocaine Others

Sources Provider's Clinical Support System for Opioid Therapies (http://pcssmat.org/education-training) American Society of Addiction Medicine (http://www.asam.org/quality-practice/definition-of-addiction and http://www.asam.org/quality- practice/practice-resources) California Society of Addiction Medicine (http://cme.csam-asam.org)

Models of Buprenorphine-Based MAT for Opioid Use Disorder Some of the current models for addressing the problem. Emergency department initiation of OBOT - Buprenorphine is initiated in the emergency department, then patients are linked with an OBOT provider Hub-and-spoke model - Centralized hub provides initial management; when stabilized, patients are transferred to primary care “spokes” in the community; spoke sites have some psychosocial support, which may include social workers and counseling

More models Inpatient initiation of MAT - Patients identified as having opioid use disorder in the hospital setting are seen by a multidisciplinary addiction consult service; buprenorphine is initiated in the hospital, then patients are linked with primary care clinics for ongoing treatment; psychosocial services are provided on-site in primary care settings OBOT integrated model in which behavioral health, primary care services, and MAT are provided in same setting; six core psychosocial services are required, and some telehealth services are offered

Patient assessment Meeting patients where they are Physically Recovery

Opioid agonist

Mu (μ) receptors stimulated by opioids causing the full range of opioid effects. Adapted from slides at vivitrol.com

Addiction vs dependence Increased tolerance Withdrawal Addiction Craving Loss of control Impairment & distress in important life areas

Heroin, codeine, morphine – 2-4 hours Methadone – 24 hours Half life Heroin, codeine, morphine – 2-4 hours Methadone – 24 hours Buprenorphine – 24-60 hours

Types of medications Agonist Morphine-like effect (e.g., heroin, methadone) Partial Agonist Maximum effect is less than a full agonist (e.g., buprenorphine) Antagonist No effect in absence of an opiate or opiate dependence (e.g., naloxone)

Buprenorphine DATA 2000 greatly increases access Less severe dependency allows for easier transitions between recovery with and without medication Partial agonist is safer with less overdose potential Lower abuse potential People live a normal life free from craving and withdrawal SAVES LIVES

Limitations of Buprenorphine Not a full agonist and does not retain people in treatment as well as full agonist Has diversion potential and may be misused Medication is expensive and access is limited Stigma in the recovery community

Advantages of vivitrol Safe to use, no abuse potential Blocks the effects of opioids Reduces danger of accidental overdose No physical dependence Little or no stigma in the recovery community

Recovery - maybe Detox Inpatient Intensive outpatient Medical access Psych access