1. Ambulatory Withdrawal Management Greg Sutmiller MS, LPC, LADC

2. What is it? Ambulatory Detoxification & more SAMHSA: outpatient treatment services providing for safe withdrawal in an ambulatory setting - Managing acute and post-acute withdrawal symptoms in an outpatient setting.

3. Why is it needed? “Opiates are outranked only by alcohol as humanity’s oldest, most widespread, and most persistent drug problem.” Harvard Mental Health Letter, 2004 Dr. Leo Kadehjian

4. Why is it needed? Drug Overdose (OD): 2nd leading cause of unintentional deaths after motor vehicle fatalities CDC, 2010 Opioids: 93% of prescription OD deaths JAMA 2008 Prescription OD deaths increased x4 since 1999 (>heroin + cocaine combined) CDC, 2013 Heroin OD deaths +45% 2006–2010 SAMHSA, 2013 Dr. Leo Kadehjian

5. Why is it needed? United States’ Drug Consumption 4.6% of world population Consumes 2/3 of illicit drug supply Consumes 80% of global opioid supply Consumes 99% of global hydrocodone supply L. Manchikanti and A. Singh, 2008 Dr. Leo Kadehjian

6. Why is it needed? Oxycodone per Capita DEA 2013 Oxycodone Production Quota: 135,000 kg 2011 U.S. Population: 311,591,917 135,000 kg / 311,591,917 persons = 422 mg/person! Dr. Leo Kadehjian

7. Why is it needed? Tolerance builds up significantly and quickly. Tolerated dose can increase 10x in as little as two weeks and up to 35x ultimately. Opiate drugs are becoming more potent. OxyContin Heroin 60%-80% currently vs. 10% or less in 1970’s More people are abusing opiates and becoming opiate dependent. The age of initiation is getting lower. Baby boomers are becoming dependent. Steve Hanson

8. Why is it needed?

9. Lots of people are opiate dependent! Lots of people need to get off opiates! What happens when opiate dependent people come off opiates?

10. Why is it needed?

11. Key Component #4 “Drug courts provide access to a continuum of alcohol, drug, and other related treatment rehabilitation services.” Includes detoxification

12. Why is it needed? NADCP Best Practice Standards Part of the continuum of care Determined by standardized assessment (not phase or professional judgment) ASAM-PPC Participants cannot be sanctioned for substance use if they are at a lower level of care than they need.

13. Why is it needed? ASAM Least Restrictive Level I-D: Ambulatory Detoxification Without Extended Onsite Monitoring Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring Requires specific medical staff: RN/LPN, PA, NP, Physician Requires daily monitoring

14. Who’s it for? Alcohol and Opiates Focus on Opiate Withdrawal Opiate Dependent Mild to Moderate Withdrawal Symptoms COWS ASAM Dimensions Assessment Driven

15. Who’s it for? COWS

16. What’s the goal? Stabilization Manage Withdrawal Symptoms Eliminate Illicit Opiate Use

17. What’s the goal? Get Started Feel better Engage in treatment Manage responsibilities

18. What’s the process? Regular Office Visits Every few days to every day based on need ASAM Level I-D ASAM Level II-D Check in Vital signs Assessment Medication Drug Screens Therapy and/or other psychosocial services

19. What’s the process? Assessment COWS Physical Psychological Case Management

20. What’s the process? Medication Managing Symptoms Clonidine, nausea & diarrhea meds, hypertension meds, etc. Full Agonist Methadone Partial Agonist Buprenorphine (Subutex) Partial Agonist w/ Antagonist Buprenorphine-Naloxone (Suboxone) Full Antagonist Naltrexone (Revia, Depade, Vivitrol)

21. What’s the process? Medically Assisted Treatment (MAT) NADCP Best Practice Standards “Participants are prescribed psychotropic or addiction medications based on medical necessity as determined by a treating physician with expertise in addiction psychiatry, addiction medicine, or a closely related field.” MAT can… Improve outcomes Increase engagement in treatment Reduce illicit drug use Reduce other program violations

22. What’s the process? Buprenorphine and Medically Supervised Withdrawal BUP can be used to cease opiate use or to transition out of agonist (methadone) treatment. Cease opiate use Withdrawal symptoms present 1-2 initial doses on first day Build up dose over next couple days Make sure consumer is compliant and stable Reduction of dose over next few days Some consumers may need to take longer in reduction phase or enter maintenance treatment

23. What’s the process? Drug Screens Screen for the Standards Screen for Specific Opiates Screen for Metabolites

24. What’s the process? Therapy and Other Psychosocial Services VITAL Outpatient (ASAM Level I) Intensive Outpatient (ASAM Level II) Daily if necessary Individual, Group, Case Management, Recovery Support Coordination is key!

25. What does a specialty court need to consider? Coordination Communication Team members Other service providers Adequate Team Representation Medical professional(s) Innovation Creativity Caution

26. References Hallford, J. (2014, July 25). Personal interview. http://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug- addiction/section-iii-action-heroin-morphine/10-addiction-vs-dependence http://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug- addiction/section-iii-action-heroin-morphine/10-addiction-vs-dependence http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_095.htm http://www.nadcp.org/sites/default/files/nadcp/KeyComponents_0.pdf http://www.ncbi.nlm.nih.gov/books/NBK64109/ http://www.ncbi.nlm.nih.gov/books/NBK64158/ http://www.nlm.nih.gov/medlineplus/ency/article/000949.htm http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140220/ http://www.norcen.org/addiction/ambulatory-detoxification http://www.samhsa.gov/data/2k13/TEDS2011/TEDS2011NChp4.htm http://www.windmoor.com/programs/ambulatory-opiate-detox.stml National Association of Drug Court Professionals. Adult Drug Court Best Practice Standards: Volume I. 2013, Alexandria, VA. Substance Abuse and Mental Health Services Administration. TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. 2004, Rockville, MD. Substance Abuse and Mental Health Services Administration. TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. 2005, Rockville, MD.

27. Contact Greg Sutmiller gsutmiller@ctioklahoma.org (918) 384-0002