The Disease of Opioid Addiction and Medication Assisted Treatment Michele F. McCarthy, LPCC Community & Government Liaison Self Refind

Objectives Learn about the state of opiate addiction today Discuss the impact of opiate abuse and addiction Identify the currently available medication assisted treatment options Explore the pros and cons of the available treatments Discuss special considerations for working with pregnant patients Review rights of patients in medication assisted treatment

Is it really an epidemic? Epidemic is defined as: …attacking or affecting many persons simultaneously in a community or area…a widespread occurrence of a disease…a rapid development, spread, or growth of something, especially something unpleasant.

KENTUCKY ALL SCHEDULE PRESCRIPTION ELECTRONIC REPORTING KASPER QuarterlyTrend Reports for 2011 reflected that opiates accounted for an average of 57% and benzodiazepines accounted for an average of 28% of the top controlled substances that Kentucky doctors wrote prescriptions for. Source: KASPER Quarterly Trend Reports 2011

KASPER DATA 2011 In 2011 alone: 3,093,770 prescriptions were written for hydrocodone (up from 2,812,878 in 2009). 3,217,535 prescriptions were filled for hydrocodone. 852,085 prescriptions were written for oxycodone (up from 646,218 in 2009). 929,525 prescriptions were filled for oxycodone. How many more were obtained out of state? How many more were obtained illegally? Source: KASPER Quarterly Trend Reports 2011

Overdose deaths are on the rise… Drugs exceeded motor vehicle accidents as a cause of death in 2009, killing at least 37,485 people nationwide, according to preliminary data from the U.S. Centers for Disease Control and Prevention. The death toll has doubled in the last decade, now claiming a life every 14 minutes, making it the number one cause of preventable deaths. Fueling the surge in deaths are prescription pain and anxiety drugs, which now cause more deaths than heroin and cocaine combined. Los Angeles Times, September 2011

Kentucky Medical Examiner 2011 REport Total cases- 2378 Overdose cases- 684 Alprazolam (Xanax)-286 Oxycodone (Percocet)-213 Hydrocodone (Lortab)-187 Oxymorphone (opana)-154 Alcohol-134 Cocaine-31 Methamphetamine-21

Kentucky has more to worry about

Kentucky has more to worry about Although we have continued to see an increase in the prescribing and abuse of prescription opiates, this is not the only battle we are fighting. Kentucky House Bill 1- 2012 Landmark legislation But if it does it’s job…

Benefits of treatment Total cost of drug use disorders in the US is an est. $180 billion annually $100,000 spent on treatment = avoided costs of $487,000 in healthcare and $700,000 in crime Every $1 spent on treatment saves criminal justice $7 and when add in healthcare savings, the savings to cost ratio is 12:1 Employees treated for substance use have decreased absenteeism, tardiness, mistakes and on-the-job injuries SAMHSA CSAT Cost Offset of Treatment Services, April 2009

MEDICATION ASSISTED TREATMENT OPTIONS Methadone Buprenorphine-Suboxone and Subutex Naltrexone

MEDICATION ASSISTED TREATMENT SAMHSA defines MAT as: “The use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful.”

WORLD HEALTH ORGANIZATION 2009 GUIDELINES Efficacy of MAT v. placebo Methadone—opiate use,  tx retention, 1/3 mortality rate,  risk of HIV by 50% Buprenorphine—opiate use,  tx retention,  morphine positive drug screens Naltrexone— in opiate use Of the treatment options examined, opioid agonist maintenance treatment, combined with psychosocial assistance, was found to be the most effective. \\Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence, World Health Organization, 2009

METHADONE Dolophine hydrochloride, Methadose Schedule II narcotic Long acting opioid analgesic (6-12 hours) Full mu opioid agonist-binds and activates

Mu Opioid Receptor Activation mu receptor site Full agonist eg, methadone Full activation of mu receptor site eg, buprenorphine Partial agonist Partial activation of mu receptor site eg, naltrexone Antagonist Prevents or reverses activation of mu receptor site 15

METHADONE Long half-life (12-59 hours)- taken once daily or may be “split-dosed” Administered orally- 5 and 10 mg tablets, 40 mg Disket and liquid 40 mg tablets (Disket) only available to treat opioid addiction (as of January 2008)

METHADONE BENEFITS Right dose should not cause euphoric or tranquilizing effects. Reduces/blocks effects of other opioids. Tolerance is slow to develop. Relieves cravings. Allows the individual to feel “normal”.

METHADONE BENEFITS Improved employment status and family relationships. Decrease in criminal activities. Decrease in high risk behaviors such as IVDU = decrease in HIV and Hep. C. Improved health and health care.

METHADONE LIMITATIONS Can only be dispensed/administered through an OTP. Private can be expensive. Heavily regulated, lots of rules, can be time consuming. Heavily stigmatized

METHADONE LIMITATIONS Abuse liability and diversion Increased risk when combined with other drugs. Associated health complications* Detoxification can be difficult *Torsade de pointes

BUPRENORPHINE Drug Addiction Treatment Act of 2000 (DATA 2000) In 2002, two forms were FDA approved- Subutex and Suboxone, both made by Reckitt- Benckiser. Schedule III narcotic Opioid analgesic with effects up to 6 hours.

BUPRENORPHINE Partial mu opioid agonist (ceiling effect) but high affinity Long half-life (24-60 hours) Administered as sublingual tablet* or film Subutex- 2 mg or 8 mg buprenorphine Suboxone- 2 mg bup + .5 mg naloxone 8 mg bup + 2 mg naloxone *Reckitt announced in September 2012 they will cease production of the tablets

Mu Opioid Receptor Activation mu receptor site Full agonist eg, methadone Full activation of mu receptor site eg, buprenorphine Partial agonist Partial activation of mu receptor site eg, naltrexone Antagonist Prevents or reverses activation of mu receptor site 23

SUBUTEX Contains buprenorphine only. Historically, minimally used in U.S. except with pregnant women. Two generics now available.* Higher rate of diversion, can be injected. *Reckitt is no longer making Subutex

SUBOXONE Naloxone added as means to decrease misuse. Poor bioavailability sublingually, but if dissolved and injected, will precipitate withdrawal. Reduced abuse potential. Film meant to provide added means to combat diversion.

BUPRENORPHINE BENEFITS Virtually no euphoric or tranquilizing effects. Blocks effects of other opiates. Relieves cravings to use other opiates. Allows “normal” function.

BUPRENORPHINE BENEFITS Lower abuse liability and diversion potential. Increased anonymity, less intrusive, less stigma. Increased treatment options/access to treatment. Here to Help Program

BUPRENORPHINE BENEFITS Decrease in high-risk behaviors. Good “step down” option for those tapering from methadone. Provides option for those that cannot tolerate methadone Is currently covered by Medicaid

BUPRENORPHINE LIMITATIONS Can be expensive when self pay. Currently still no generic for Suboxone. Should not take if opiates still in system. Counseling may not be available or affordable in the same area as doctor.

BUPRENORPHINE LIMITATIONS Not enough certified doctors or doctors willing to treat. No regulations for OBOTs, only “practice guidelines”. Potential for overdose of other opiates due to ceiling effect. Abuse and diversion potential still exists.

NALTREXONE Long half-life (up to 72 hours) Opioid antagonist-binds, but blocks instead of activates Is NOT an opiate

Mu Opioid Receptor Activation mu receptor site Full agonist eg, methadone Full activation of mu receptor site eg, buprenorphine Partial agonist Partial activation of mu receptor site eg, naltrexone Antagonist Prevents or reverses activation of mu receptor site 32

NALTREXONE Historically used primarily for alcohol due to blocking neurotransmitters believed to be involved with alcohol dependence. Oral- ReVia, now generic Injectable- Vivitrol Implant- not FDA approved

NALTREXONE TREATMENT Medication is only one component. Average length of treatment is 3-9 months. Works best with highly motivated patients. Injectable is a great option for compliance issues or just for convenience.

NALTREXONE BENEFITS Any physician can prescribe in any setting. Injectable lasts for 30 days. Relatively inexpensive (oral) when compared to Methadone or Bup. Non-narcotic, non-addictive, does not produce dependence.

BENEFITS CONT. More acceptance in abstinence-based programs. Less stigma than methadone or buprenorphine. In KY Medicaid covers, but only oral is 1st-tier; injectable is a 3rd-tier. Received approval for use for opioid addiction in last year

NALTREXONE LIMITATIONS Injection site reactions. Injectable very expensive for self pay. Poor compliance with oral version. Cannot have any opiates in system or will precipitate withdrawal. Still not many doctors utilizing.

LIMITATIONS CONT. Risk of overdose in attempt to break through blockade. Not first choice for pregnant patients. Breastfeeding is not recommended. Implant is NOT FDA approved.

MAT and PRegnancy

MAT AND PREGNANCY “Cold turkey” detox may trigger miscarriage, pre-term labor. Methadone has most research and is still preferred. Subutex has shown very positive results- MOTHER Study. Several reports of using Suboxone with positive results.

MAT AND PREGNANCY CONT. Individualized approach, informed choice Decreases/ceases cycles of intoxication and withdrawal Decrease in high risk behaviors Opportunity to address other factors-mental health, social supports, basic needs

MAT AND PREGNANCY STANDARDS Federal Prenatal care Gender-specific services Additional state Medically able to participate Collaborate with OBGYN Post-partum care Nutrition, parenting, and weekly drug screen

MAT & PREGNANCY STANDARDS CARF and Joint Commission Priority admission Counseling for DV, trauma, women’s health Appropriate medication dosage Educate on MSW- should NOT be initiated before 14 weeks or after 32 weeks Encourage breastfeeding (unless contraindicated)

KEY POINTS TO REMEMBER Opiate addiction is a disease, an epidemic. There is no cure, but we do have options and we need to take advantage of all of them. Treatment is not “one size fits all.” Just as addiction is lifelong, so is the recovery process Chances of maintained recovery significantly increase when combined with counseling, drug screens, medication call backs, etc.

KEY POINTS TO REMEMBER No “perfect” medication that is one size fits all. Medication is a tool, not a “cure”. MAT may be appropriate for pregnant women but must be closely monitored and have informed consent. MAT is a legal, valid, and widely researched evidence-based treatment for addiction. Individuals receiving MAT are in recovery!

CONTACT INFORMATION Michele F. McCarthy Government & Community Liaison Self Refind mmccarthy@selfrefind.com 859-605-6387 www.selfrefind.com