PERMEATING BORDERS OVERDOSE PREVENTION Summer Conference 2014 July 24, 2014 ACOPC Allegheny County Overdose Prevention Coalition Presents

Integrating Abstinence-based Recovery with Harm Reduction Neil Capretto, DO, FASAM Medical Director Gateway Rehabilitation Center

INTEGRATING ABSTINENCE-BASED RECOVERY WITH HARM REDUCTION Neil A. Capretto, D.O., F.A.S.A.M. Medical Director Gateway Rehabilitation Center

YearNumber of Overdose Fatalities Average of 58 per year NUMBER OF OVERDOSES BY YEAR - ALLEGHENY COUNTY

Drug overdose deaths increasing in Allegheny County Roberta Lojak holds a high school graduation picture of her daughter Ashley Elder, who died of a heroin overdose in October Lojak is standing in a garden she planted in her daughter's memory. September 27, 2004, Pittsburgh Post-Gazette

To help all affected by addictive diseases to become healthy in body, mind and spirit GATEWAY’S MISSION

Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment National Institute on Drug Abuse Principles of Drug Addiction Treatment REMAINING IN TREATMENT FOR AN ADEQUATE PERIOD OF TIME IS CRITICAL

 May be single most important indicator of medication – assisted outcomes1  Retention permits patients and health care providers to:  Engage in counseling  Stabilize abstinence  Organize chaotic lifestyle  Diagnose and treat co-morbidity  Improve family, social and work relationships 1Center for Substance Abuse Treatment (CSAT) (2005) Medication-assisted treatment for opioid addiction in opioid treatment programs: Treatment Improvement Protocol (TIP) Series #43. DHHS Publication No. (SMA) RETENTION IN TREATMENT ENABLES RECOVERY

Improved life? What aspects? Total abstinence? Some drug use without problems okay? No drug use of any kind Some drugs but not drugs that affect limbic system? What is Recovery?

Total abstinence, belief in a HP but a mean SOB Occasional use, without significant impact on psycho-social functioning Methadone maintenance, good life Recovery Scenarios

What outcomes do we guide people towards? – Drug abstinence – Development of a relationship with God – Able to work – Better health Patient Centered Treatment? - How much choice do you give persons if their higher functioning brain has been co-opted and hijacked by the drugs? Therapist/Physicians Ethical Role

Holy Cow…..!!!!! Resistive to using medications Think “methadone” or “Suboxone” Your Initial Reaction

Medications that benefit the goal of treatment (whatever that is) Not medications versus other treatment strategies, but integration with 12 Step, CBT, and other psychosocial interventions Medication Assisted Defined

Medications used to promote “recovery” from chemical addiction – Stops withdrawal – Reduces the symptoms of post-acute withdrawal – Reduces craving – Blocks the high from abused drugs – Reduces harm Definition: Medication Assisted Recovery

Detoxification medications anti-craving medications (naltrexone, topiramate, acamprosate) blockers (naltrexone, cocaine vaccines) deterrents (Antabuse) maintenance drugs (methadone, buprenorphine) Medication Assisting Drugs

No drugs at all? Psychiatric drugs okay? Anti-craving drugs okay? Blockers okay? Deterrents okay? Opioid Maintenance okay? Big controversy What is Abstinent Based

12 step recovery model often thought of as abstinent based Abstinent based is an active process involving more than just going to meetings Includes psychosocial and spiritual interventions Some medications okay? – Drugs that do not stimulate reward area – Meds to treat co-occurring psychiatric Maintenance drugs like buprenorphine and methadone not usually thought of as acceptable Abstinent Based Conventional View

IS A.A. AGAINST MEDICATION?

Drug misuse can threaten the achievement and maintenance of sobriety Yet some A.A. members must take prescribed medication No A.A. member plays doctor If in doubt, consult a physician with demonstrated experience in the treatment of alcoholism THE A.A. MEMBER – MEDICATIONS AND OTHER DRUGS

Heroin addiction exacts a terrible toll. For many addicts the condition lasts a lifetime – a lifetime shortened by health and social consequences of addiction. NIDA-supported researchers at the University of California, Los Angeles (UCLA), examined the patterns and consequences of heroin addiction over 33 years in nearly 600 heroin-addicted criminal offenders and found that their lives were characterized by repeated cycles of drug abuse and abstinence, along with increased risk of crime or incarceration, health problems, and death. 33-YEAR STUDY FINDS LIFELONG, LETAL CONSEQUENCES OF HEROIN ADDICTION

The death rate among the members of the group is 50 to 100 times the rate among the general population of men in the same age range. “The high mortality rate is evidence of the severe consequences of heroin use,” Dr. Hser says “Even among surviving members of the group, severe consequences such as high levels of health problems, criminal behavior, incarceration, and public assistance were associated with long term heroin use.” 33-YEAR

OPIOID ANTAGONISTS Life Savers – Relapse Reducers

Narcan reversing an overdose

Type date here | Naloxone Pilot Project

As much as we want our patients to “get it” the first time, to leave rehab and abstain from drug use for the rest of their lives, we know, for a significant number of our patients, that isn’t realistic. And that is especially so for those with opiate dependence. One of the most dangerous periods for overdose risk is immediately following discharge from a treatment program. Because the person’s physical tolerance for heroin or other opiate medications has decreased significantly during treatment, going back and using the same amount of the drug as their last dose can be deadly. Of course we want them NOT to use, but we know that some will. We need to educate our patients and their families about the risks of relapse, including overdose, AND give them the tools to protect themselves and/or reverse overdose.

Naloxone Pilot Project Through the Naloxone Pilot Project we propose to: Train GRC staff on ways to address relapse, overdose and prevention Educate patients and families on ways to reduce risk and reverse overdose Distribute intranasal doses of naloxone to patients and/or family members Track patients and families over time to measure: –Rates of relapse –Use of naloxone –Rates of overdose –Rates of family anxiety

Naloxone Pilot Project Ease of Implementation Recruitment: use of long-established family day activities Patient re-engagement: ongoing patient monitoring allows for evaluation and recommendation of continued treatment after relapse Training: infrastructure of Ramsey Institute can be used for ongoing training of staff. Outside clinicians can be included for a fee. Harm-reduction: implementation can prevent overdose, while education and ongoing monitoring can reinforce abstinence model

Naloxone Pilot Project This is a bold project with the potential to greatly improve patient outcomes, engagement in long-term treatment and recovery, and position GRC as a leader in overdose prevention. Benefits # of lives saved from overdose # of patients re-engaged in treatment after relapse Potential to impact public policy re: HB2090 “Good Sam” law and Standing Order legislation Potential for positive publicity and recognition in the field

NALTREXONE – OPIOID RECEPTOR ANTAGONIST “ Bullet proof vest against opioids” Daily tablet (ReVia) – FDA approved Monthly injection (Vivitrol) – FDA approved Implants – not FDA approved

Naltrexone – Blocks opiate receptors – Compliance impacts effectiveness – Very effective in certain populations – Not addicting, no psychoactive problems NALTREXONE FOR OPIOID DEPENDENCE

There is a broad range of treatment options for heroin addiction, including medications as well as behavioral therapies. Science has taught us that when medication treatment is integrated with other supportive services, patients are often able to stop heroin (or other opiate) use and return to more stable and productive lives. HEROIN TREATMENT

Mortality Prior to the introduction of MMT, annual death rates reported in four American studies varied from 13 per 1,000 to 44 per 1,000, with a median of 21 per 1,000. The most striking evidence of the effectiveness of MMT on death rates are studies directly comparing these rates in opiate addicts, on and off methadone. CONSEQUENCES

Every study showed that death rates were lower in opiate addicts maintained on methadone compared with those who are not. The median death rate for addicts in MMT was 30 percent of the death rate of those not in treatment. A clear consequence of not treating opiate addiction, therefore, is a death rate that is more than three times greater than that experienced by those engaged in MMT. CONSEQUENCES Mortality(cont’d.)

Enter buprenorphine  Effective treatment option for opioid dependence (Ling et al 1998)  Reduces morbidity and mortality (Auriacombe et al 1998)  Improves quality of life (Giacomuzzi, et al 2003, Anisse, 2001)

Partial vs. Full Opioid Agonist Dose of Opiate Opiate Effect death Full Agonist ( e.g., methadone ) Partial Agonist (e.g. Naloxone) Antagonist (e.g. buprenorphine)

Objectives of maintenance treatment To reduce mortality from overdose and infection To reduce opioid and other illicit drug use To reduce transmission of HIV, HBV and HCV To improve the general health and well-being of patients To reduce drug-related crime To improve social functioning and ability to stay in work

Treatment saves lives French population in 1999 = 60,000, Subutex and methadone Year No. of deaths Patients receiving methadone (1998): N= 5,360 Patients receiving buprenorphine (1998): N= 55,000 Auriacombe et al., 2001

ABOUT GATEWAY REHAB’S MAT PROGRAM Gateway Rehabilitation Center is proud to offer rigorous, scientifically supported care, including Medication-Assisted Treatment (MAT) and Twelve-Step facilitation (TSF) therapies. Gateway Rehab’s MAT program focuses on the use of: Suboxone/Zubsolv (sublingual buprenorphine/naloxone) Vivitrol/Revia (Naltexone) While no single approach to recovery is always successful, by offering multiple treatment options, Gateway Rehab endeavors to foster improved results for our patients. To help patients succeed on their journeys to recovery, at Gateway Rehab treatment medications are prescribed in combination with the support of inpatient/outpatient treatment and Twelve-Step support.

Individuals with regular involvement in 12-step programs have a 4.5 times higher rate of stable recovery after 5 years Kaiser-Permanente California Study 2004 ASAM Annual Scientific Meeting

“You have to admit your ignorance in order to come to knowledge because nobody is going to search for knowledge if they think they already have it” Socrates

Addiction is a BIO-PSYCHO-SOCIAL- SPIRITUAL DISEASE Good treatment address all four aspects

ADDICTION BATTERS A THRIVING FAMILY

NEIL A. CAPRETTO, D.O., F.A.S.A.M. MEDICAL DIRECTOR GATEWAY REHABILITATION CENTER 100 MOFFETT RUN ROAD ALIQUIPPA, PA , x1119