1. Benjamin J. Pariser, DO RASE Physician

2.  This presentation will review the option of Medication Assisted Treatment as part of a comprehensive recovery program. Overview

3.  1.Understand the core principles of opioid addiction, which are central to the rapidly growing epidemic of opioid abuse, dependence and overdose. 2.Describe classes of medications available for medication assisted treatment and recovery 3.Explain the role of medications as part of a comprehensive treatment plan Goals

4.  Statistics  Drug overdoses killed 47,000 people in the US in 2014  130 deaths per day, on average  29,000, or 80 per day – involved an opioid Stigma and inadequate access to treatment are the biggest barriers to overcoming the ongoing crisis. Opioid Epidemic Ref: A deadly crisis: mapping the spread of America's drug overdose epidemic By Nadja Popovich; Additional development by Rich Harris. Source: Centers for Disease Control and Prevention and the National Center for Health Statistics

5.  Overdose Deaths

6.  Opioid Statistics

7.  Opioid Addiction

8.  Medication-Assisted Treatment for Opioid Addiction (MAT): A type of addiction treatment that involves the following:  Provided in a certified, licensed opioid treatment program or a physician’s office  Provides maintenance pharmacotherapy using an opioid agonist, a partial agonist, or an antagonist medication  May be combined with other comprehensive treatment services, including medical and psychosocial services. Ref: Substance Abuse and Mental Health Services Administration (SAMHSA) Medication Assisted Treatments

9.   Opioid agonist treatment  Methadone  Buprenorphine products  Buprenorphine/naloxone (Suboxone)  Buprenorphine (Subutex)  Opioid antagonist treatment  Naltrexone for extended- release injectable suspension (Vivitrol)  Naloxone (Narcan) Medications

10.   Is the most frequently used medication for opioid addiction treatment in opioid treatment programs (OTPs)  Is a synthetic long-acting medication  Comes in several formulations, including oral solution, liquid concentrate, tablet/diskette, and powder  Is a full opioid agonist that decreases the pain-killing and other effects of opioids  Was never formally approved by the Food and Drug Administration (FDA)  Is a Drug Enforcement Administration (DEA) Schedule II drug  Is available in outpatient treatment programs.  Patients typically must go to appointments daily  Potential for home use (7-30 days) Methadone Ref: SAMHSA

11.   Pros  Very long half life  Effective  Liquid or tablets  Cons  Overdose potential  Risk of fatal arrhythmias  Drug interactions  Strong Inter-patient variability in absorption, metabolism, and relative analgesic potency. Methadone

12.   Does not activate mu receptors fully(partial agonist), so larger doses of buprenorphine do not produce greater agonist effects (Ceiling effect)  Has an increased margin of safety from death by respiratory depression when increased doses of buprenorphine are used  Was approved by the FDA in 2002 Is a DEA Schedule III drug  Can be administered in a physician’s office, OTP, or other medical settings. Buprenorphine Products Ref: SAMHSA

13.  Buprenorphine/Naloxone  Brand names Suboxone and Zubsolv  Is formulated as a sublingual tablet and film  Was approved by the FDA in 2002  Is a DEA Schedule III drug  Is administered in a physician’s office, an OTP, or another healthcare setting. Buprenorphine Products

14.   Added solely to prevent IV abuse  Naloxone is a water-soluble molecule that does not pass through the membranes lining the mouth  Buprenorphine is a fat soluble molecule that does pass through the membranes of the mouth  Neither substance takes effect if swallowed because it is removed quickly by the liver (first pass effect) Why is Naloxone in Suboxone? Ref: J.T. Junig, MD, PhD J.T. Junig, MD, PhD

15.   Pros  Less clinic attendance  Can be prescribed in physician office – less stigma  Ceiling effect  Cons  Street value  Potential for abuse  Difficult to adhere to the withdrawal protocol Buprenorphine

16.  COWS: Clinical Opiate Withdrawal Scale

17.  Induction  Patient must be in withdrawal to begin induction  Depends on clinic protocol  Seeking dose that relieves withdrawal symptoms  The Induction Phase is the medically monitored startup of buprenorphine treatment performed in a qualified physician’s office or certified OTP using approved buprenorphine products. The medication is administered when a person with an opioid dependency has abstained from using opioids for 12 to 24 hours and is in the early stages of opioid withdrawal. It is important to note that buprenorphine can bring on acute withdrawal for patents who are not in the early stages of withdrawal and who have other opioids in their bloodstream. Buprenorphine Protocol Ref: SAMHSA

18.  Stabilization  The Stabilization Phase begins after a patient has discontinued or greatly reduced their misuse of the problem drug, no longer has cravings, and experiences few, if any, side effects. The buprenorphine dose may need to be adjusted during this phase. Because of the long-acting agent of buprenorphine, once patients have been stabilized, they can sometimes switch to alternate-day dosing instead of dosing every day.  Seeking dose that alleviates cravings Buprenorphine Protocol Ref: SAMHSA

19.  Maintenance  The Maintenance Phase occurs when a patient is doing well on a steady dose of buprenorphine. The length of time of the maintenance phase is tailored to each patient and could be indefinite. Once an individual is stabilized, an alternative approach would be to go into a medically supervised withdrawal, which makes the transition from a physically dependent state smoother. People then can engage in further rehabilitation—with or without MAT—to prevent a possible relapse. Buprenorphine Protocol Ref: SAMHSA

20.  Medically Supervised Withdrawal  Individualized withdrawal according to each patient’s needs  Ongoing counseling and development of support network  No set timeframe/dose reduction  Depends on clinic philosophy  Continual monitoring for risk of relapse Buprenorphine Protocol Ref: BupPractice

21.  Subutex  Used in pregnancy and nursing  Risk of abuse Buprenorphine

22.  Naltrexone :  Is a highly effective opioid antagonist  Approved by the FDA for maintenance treatment in 1984  No narcotic effect and produces no withdrawal symptoms when a patient stops using it  No abuse potential; tolerance does not develop even after months of regular use  Is formulated as an oral tablet and depot injection  Blocks the effects of heroin, morphine, and methadone  Displaces buprenorphine to a lesser degree, but in high enough doses overrides buprenorphine’s activity as well  Despite its potential advantages, has had little effect on the treatment of opioid addiction in the United States, primarily because of poor patient compliance  Is not on the DEA schedule  Is available in physicians’ offices, OTPs, and other substance abuse treatment programs. Vivitrol Ref: SAMHSA

23.   Tolerance occurs when the person no longer responds to the drug in the way that person initially responded. Stated another way, it takes a higher dose of the drug to achieve the same level of response achieved initially. Ref: National Institute on Drug Abuse (NIDA) Tolerance

24.   Bridget – 26 year old female  Lynne – 34 year old female  George – 35 year old male  Tracey – 23 year old female  Bob – 24 year old male The Faces of Addiction

25.  Questions