1. Some Best practices with medication assisted treatment
Michele Flowers McCarthy, LPCC-S
Director of Program Development
Center for Behavioral Health

2. Special thanks to Michele McCarthy Director of Program Development
Center for Behavioral Health

3. Medication Assisted Treatment (MAT) for Opioid Addiction
Methadone
Buprenorphine
Naltrexone

4. 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 4

5. Methadone Schedule II narcotic
Full mu opioid agonist-binds and activates
Long acting opioid analgesic (6-12 hours)
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 only allowed for MAT, not pain)
Only in OTP setting for addiction, can be used for pain by MDs

6. Methadone benefits Right dose = no euphoric or tranquilizing effects.
Reduces/blocks effects of other opioids.
Tolerance is slow to develop.
Relieves withdrawal and cravings.
Can increase/decrease in small amounts, especially liquid.
Allows the individual to feel “normal”.

7. Methadone benefits
Stabilizes client, can focus on learning recovery skills.
Provides daily observation and more structure than traditional OP-can adjust needs related to compliance, relapse, and long-term recovery.
Improved employment status and family relationships.
Decrease in high risk behaviors= decrease in HIV and Hep. C risk, criminal activities, etc.
Improved physical and mental health and health care.

8. Methadone limitations
Can only be dispensed/administered through a licensed OTP.
Can be expensive.
KY Medicaid and Medicare do not currently cover this LOC.
Only 2 federally funded-Bluegrass and MORE Center
Heavily regulated, lots of rules, can be time consuming.
Heavily stigmatized, especially for pregnant women.

9. Methadone limitations
Abuse liability and diversion
Increased risk when combined with other drugs, especially benzos.
Associated health complications
Torsades de pointe-tachycardia
Detoxification can be difficult, especially if not done correctly or when rushed.

10. Locations of current OTPs
As of June 2017, KY has 16 OTPs and 5 medication stations
OTPs-Paducah, Bowling Green, Elizabethtown, Hopkinsville, Louisville, Frankfort, Lexington, Covington, Ashland, Corbin, Hazard, Paintsville, Pikeville, Owensboro
Med station-Franklin, Georgetown, Carrollton, Maysville, Richmond
2 Federally funded-BGNAP is private, non-profit and MORE Center is run by Louisville Metro Health Dept.
All other OTPs in KY are private for-profit (4 companies)
Treatment locator-

11. Buprenorphine Products
Buprenorphine monotherapy
Subutex*
Generic
Probuphine
Buprenorphine-naloxone combination therapy
Suboxone
Zubsolv
Bunavail

12. Buprenorphine Therapies
Drug Addiction Treatment Act of (DATA 2000)
Schedule III narcotic
Partial mu opioid agonist (ceiling effect)
High affinity for opiate receptors- very “sticky”
Long half-life (24-60 hours)
Administered as sublingual tablet, film, cheek film, implant
Patient limits of 30/100/275

13. Subutex/Buprenorphine monotherapy
Contains buprenorphine only.
Minimally prescribed except with pregnant women or those with adverse reaction to combo med.
Higher rate of diversion, can be injected.
Only generic now RB discontinued distribution and sale of Subutex in September
Probuphine (6 month implant) FDA approved and became available in 2016.

14. Suboxone/Buprenorphine-Naloxone combination therapy
Naloxone added to decrease misuse.
Poor bioavailability sublingually, but use by other routes can precipitate withdrawal.
Reduced abuse potential.
RB launched films October 2010 as effort to decrease diversion and child exposure.
Two generics became available 2013.
Zubsolv available since late 2013.
Bunavail available since late 2014.

15. Buprenorphine formulations

17. Formulations NOT Yet approved for addiction treatment

18. Buprenorphine benefits
Virtually no euphoric or tranquilizing effects.
Blocks effects of other opiates.
Analgesic effect can provide relief for co-occurring chronic pain.
Relieves cravings to use other opiates.
Allows “normal” function.
Lower abuse liability and diversion potential.

19. Buprenorphine benefits
Increased anonymity, less intrusive, less stigma.
Increased treatment options/access to treatment.
Decrease in high-risk behaviors.
“Step down” option after tapering from methadone.
Option if cannot tolerate methadone.
Currently orals covered by all payors, seeing coverage for implant, other components of treatment also covered.

20. Buprenorphine limitations
Can be expensive when self pay.
Should not induce if opiates still in system, can precipitate withdrawal, especially long-acting opiates.
Additional treatment components may not be available/affordable.
Not always recommended if using multiple substances, especially benzos.
May not be accessible in other LOCs.

21. Buprenorphine limitations
Many doctors still not willing to treat, those who do at capacity (CARA Act 2016, Section 303)
No federal regulations for OBOTs, only “practice guidelines”.
KBML regulations effective Spring 2015 to help est. minimum standard of care
Potential for overdose of other opiates due to ceiling effect.
Abuse and diversion potential.
Still has stigma and misperception associated.

22. SAMHSA Buprenorphine Physician and Program Locator
The Buprenorphine Physician Locator is a service of the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA).
An on-line resource for locating physicians authorized to prescribe a buprenorphine products for opioid treatment.
Additional resource-

23. Naltrexone
Originally for alcohol due to blocking neurotransmitters believed to be involved with alcohol dependence.
Oral- ReVia, now generic
Injectable- Vivitrol
Implant- not FDA approved

24. Naltrexone Long half-life (up to 72 hours)
Opioid antagonist-binds, but blocks instead of activates
Available as generic tablet* or Vivitrol once monthly injection
Any physician, APRN, PA can prescribe
Can be used for opiates and alcohol
Resource- _mcid=url-vivproviders

25. Naltrexone benefits Non-abusable, no diversion potential.
Good option for compliance issues.
Relatively inexpensive in comparison (oral).
Non-narcotic, non-addictive, does not produce dependence.
More acceptance in abstinence programs, criminal justice, and mutual support groups.
Less stigma than other MAT.
KY MCOs and insurance cover; may require a fail first on the oral.

26. Naltrexone limitations
May not be candidate if poor liver function.
Injectable very expensive for self pay. $ per injection and pt assistance program is only for those with a payor to use toward copay.
Poor compliance with oral version.
Cannot have any opiates in system or will precipitate withdrawal, implementing in OP can be difficult if not detoxed first.

27. Naltrexone limitations
Risk of overdose in attempt to break through blockade.
Still not many doctors utilizing.
Not first choice for pregnant patients.
Breastfeeding is not recommended.
Implant is NOT FDA approved.

28. Naloxone and Overdose
Short-acting antagonist medication, overdose reversal
Injectable and nasal formulations
Approved for 40 years, non-abusable, anyone can be trained
KY now has regulations for prescribing, dispensing, and administering naloxone and includes good Samaritan provision
Overview of SAMHSA’s Opioid Overdose Prevention Toolkit
2016/SMA

29. WHY does treatment not always work?
Individual not in the right level of care
Cookie cutter treatment
Program and individual weren’t a fit-person is not always “being difficult”
Unrealistic expectations for a “cure”
Misunderstanding medication is all they need
Not being able to cope with reality of sobriety
Individual lacks the resources and support to apply program/recovery skills consistently

30. So what’s the right treatment?
Treatment should be individualized
Patients should have a voice in the decision making
Should not only give access based on personal bias
Just because a program works for one doesn’t mean it will work for another.
Should be determined by a qualified addiction professional and the patient.

31. What should it be based on?
Based on assessment of
Co-occurring medical problems or concerns
Severity of the substance use disorder
Co-occurring mental health concerns or disorders
Stability of coping skills, daily living skills, home environment, etc.
Prior treatment, level of motivation

32. Treatment Considerations Related to MAT
Prescription Plans
Drug Testing
Medication Discrepancies
Prescription Monitoring Program
Diversion & Criminal Behaviors
Other services

33. Drug Testing Admission test-what should you test for?
Responding to drug test results
Positive for illicits and unapproved meds
Marijuana
Negative buprenorphine
Falsifying sample
Inability to provide sample
Observed drug testing
Random drug testing

34. Medication Discrepancies
Ever okay for patient to be short meds?
Plan for calling in more? Limitations?
Handling overage
Repeated shortages
Diversion
Needs dose adjustment
Consider higher level of care

35. Diversion and other Criminal Behaviors
Behaviors that are not tolerated must be identified from onset of treatment and defined clearly.
What warrants a discharge? Contacting law enforcement and/or other providers?
Any that would cause the patient to never be allowed to return?

36. Other Services Counseling- type and frequency Psychiatric care
Case Management
Medical Care
Other medications
Family involvement

37. Key points to remember
Chances of maintained recovery significantly increase when provided a combination of all the tools.
No treatment or medication is “one size fits all”, needs to be individualized.
The decision to start, change, or end MAT is a medical one and should be made between the treating professional and the patient.
MAT is a legal, valid, and widely researched evidence- based treatment for opioid use disorder.
Just as addiction is lifelong, so is the recovery process.
Individuals receiving MAT are in recovery!

38. Understanding the Disease and the Person
Addendum:
Understanding the Disease and the Person

39. Disease of addiction
Repeated drug use or engagement in addictive behaviors can lead to increased impulsivity, altered judgment, and distorted reward memory.
This results in the individual experiencing craving, drug use replacing healthy coping skills, and trying to reproduce the positive reward memory despite negative consequences.

40. Understanding the person
Rehabilitation vs. habilitation.
Active addiction is a narrow cycle of seeking, obtaining, using, recovering, hiding.
Co-occurring mental and/or physical health disorders impact both use and recovery.
Hyperalgesia
Lack of positive supports
Additional burdens such as felony history, CPS, lack of safe housing, employment

41. Understanding the person
ACEs/trauma
Relapse can be a teachable moment, not failure.
Self-sabotage is not uncommon.
With opiates, less about the high, more about desperation to avoid withdrawal/pain/feeling sick.
Behaviors we may consider as acting out, criminal, manipulative…are survival skills.
Stigma can be a barrier and trigger

43. Opioid Withdrawal Peak between 48 and 72 hours after last dose.
Feels like terrible flu.
Typically subsides after about 1-2 weeks.
Can show persistent withdrawal symptoms for months.
Combined with other factors, can pose greater risks and be fatal.

44. Opioid Withdrawal Symptoms
Abdominal pain
Agitation
Diarrhea
Dilated pupils
Goose flesh
Nausea
Vomiting
Restlessness
Runny nose
Sweating
Involuntary leg movement
Bone and joint pain

45. Post Acute Withdrawal Syndrome (PAWS)
Mood swings
Anxiety
Irritability
Tiredness
Variable energy
Low enthusiasm
Variable concentration
Disturbed sleep

46. PAWS Onset after acute withdrawal symptoms ease
Less physical, more emotional/mental
May come and go in episodes
Can last a few months up to 2 years
Can be relapse trigger
Must be taken into consideration during treatment and aftercare.

47. Impact on Physical Health
Liver and kidney disease
Weakened immune system
Depression of CNS
Physical dependence and addiction
Infections and collapsed veins
Damage to vital organs
Hyperalgesia
HIV and Hepatitis C*
Endocarditis*
Fatal overdose*

48. HIV and Hepatitis C
In 2003 new HIV cases w/o AIDS in KY-109, (KY DPH 2014 HIV/AIDS Surveillance Report).
Scott County Indiana historically 4-5 HIV cases per year, Feb cases, today-217 confirmed.
CDC ranks KY #1 in rate of Hep C rates rising and it is estimated that in general 75% of those with Hep C don’t know it.
In KY the number of people discharged from hospitals with dual dx of Hep and opioid disorder increased from 39 in to 1500 in 2012 (KY ODCP).
Vulnerability assessment of counties most at risk of a rapid HIV spread through IVDU. Of the top 220 counties listed in the report, 54 of them are in Kentucky, with Wolfe county ranked number one. Breathitt, Perry and Clay counties were also in the top five (CDC report 2016).

49. Endocarditis
Symptoms can include: fever, chills, fatigue, aching joints, night sweats, persistent cough, swelling, unexplained weight loss
Clumps of bacteria and cell fragments form in your heart at the site of the infection. These clumps can break loose and travel to your brain, lungs, abdominal organs, kidneys or extremities.
Can cause you to develop abscesses in areas including the brain, kidneys, spleen or liver. An abscess may develop in the heart muscle itself as well. Severe abscesses may require surgery to treat them.

50. Endocarditis
Can damage your heart valves and permanently destroy your heart's inner lining, eventually causing heart failure.
Unfortunately common harm reduction approaches with IVDUs such as needle exchange programs, educating people to not share, to clean their “works” will not protect.
The infection is from bacteria on the skin or sometimes even in the drug itself.
Many don’t seek treatment until later, often ignoring symptoms until they are at a point of needing hospitalization and possible valve replacement.

51. 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