2. MEDICATION ASSISTED ADDICTION TREATMENT: APPROPRIATE USE DAS Quarterly Provider Meeting Louis E. Baxter, Sr., M.D., FASAM Medical Director-DAS President Elect American Society Addiction Medicine

3. GOALS & OBJECTIVES Review comprehensive evaluation components Review comprehensive evaluation components DSM-IV-TR diagnosing DSM-IV-TR diagnosing Review full treatment planning Review full treatment planning Patient Placement – ASAM PPC-2 Patient Placement – ASAM PPC-2 Treatment of Co-occurring Disorders Treatment of Co-occurring Disorders Medication Assisted Therapy for detoxification, maintenance, and pain management Medication Assisted Therapy for detoxification, maintenance, and pain management

4. ADDITIONAL RESOURCES CSAT TIP # 43 Buprenorphine Therapy CSAT TIP # 43 Buprenorphine Therapy CSAT TIP # 45 Detoxification and Substance Abuse Treatment *** CSAT TIP # 45 Detoxification and Substance Abuse Treatment *** National Quality Forum – Evidence Based Treatment Practices for Substance Use Disorders National Quality Forum – Evidence Based Treatment Practices for Substance Use Disorders ASAMs Monograph – Achieving Treatment Success in Alcohol Dependence ASAMs Monograph – Achieving Treatment Success in Alcohol Dependence

5. COMPREHENSIVE EVALUATION COMPONENTS Chief Complaint …why are you here? Chief Complaint …why are you here? Alcohol Use History … Screening Tool (CAGE) Alcohol Use History … Screening Tool (CAGE) Drug Use History … Rx, Illicit, and OTC Drug Use History … Rx, Illicit, and OTC Previous Treatment History … include Clergy Previous Treatment History … include Clergy Previous Psych History … admissions and OP Previous Psych History … admissions and OP Legal History Legal History Past Medical / Surgical History / Medications Past Medical / Surgical History / Medications Family History … Psychiatric and Substance Use Family History … Psychiatric and Substance Use Marital History Marital History Psychosocial History … Employment / Clubs/ Hobbies Psychosocial History … Employment / Clubs/ Hobbies

6. DIAGNOSES DSM-IV-TR Criteria for Substance Use Disorders DSM-IV-TR Criteria for Substance Use Disorders –Use disorder; Abuse; Dependence (Addiction) DSM-IV-TR Criteria for Psychiatric Disorders DSM-IV-TR Criteria for Psychiatric Disorders –Depression; Bipolar; Anxiety Laboratory Data Documentation of Medical Disorders Laboratory Data Documentation of Medical Disorders –Chronic pain; Seizure; Migraines; HIV/AIDS; Liver disease National Quality Forum Guidelines (2005) National Quality Forum Guidelines (2005) –Evidence-based Best Practices for SUD

7. FULL TREATMENT PLANNING Assessment – Diagnosis Assessment – Diagnosis Detoxification – Medical Maintenance Detoxification – Medical Maintenance Rehabilitation – Counseling Rehabilitation – Counseling After / Continuing Care – Twelve Step Program After / Continuing Care – Twelve Step Program Co-occurring Illness Care Co-occurring Illness Care Pain Management Care Pain Management Care General Medical Care General Medical Care

8. APPROPRIATE LEVEL OF CARE ASAM Patient Placement Criteria-2 ASAM Patient Placement Criteria-2 –Only peer reviewed beta tested tool for patient placement Level 0.5 … Brief Intervention (3-6 sessions) Level 0.5 … Brief Intervention (3-6 sessions) Level I … Traditional Outpatient (Individual) Level I … Traditional Outpatient (Individual) Level II … Intensive Outpatient (group therapy) three to five 90 minute sessions weekly Level II … Intensive Outpatient (group therapy) three to five 90 minute sessions weekly Level III … Residential (Medically supervised) Level III … Residential (Medically supervised) Level IV … Hospital based (Medically managed) Level IV … Hospital based (Medically managed)

9. TREATMENT WORKS Full Treatment Experience (Detoxification; Rehabilitation; Maintenance) Full Treatment Experience (Detoxification; Rehabilitation; Maintenance) –General Population recovers @ 77% @ 1yr –Detoxification & Rehab Only @ 33% @ 1yr –Detoxification Alone @ < 10% @ 1 yr

10. TREATMENT OUTCOME COMPARISONS Alcoholism … 50-70% abstinent Alcoholism … 50-70% abstinent Opioid Dependence … 50-80% abstinent Opioid Dependence … 50-80% abstinent Cocaine Dependence … 50-60% abstinent Cocaine Dependence … 50-60% abstinent Nicotine Dependence … 20-40% abstinent Nicotine Dependence … 20-40% abstinent Diabetes (relapse) … 30-50% stable Diabetes (relapse) … 30-50% stable Hypertension (poor control) … 50-60% Hypertension (poor control) … 50-60% Asthma (multiple ER visits) … 60-80% Asthma (multiple ER visits) … 60-80% (Gaber, Davidson, 1992; McLellan 2002)

11. MEDICATION ASSISTED THERAPIES Medications for detoxification Medications for detoxification Medications for maintenance Medications for maintenance Medications for psychiatric illnesses Medications for psychiatric illnesses Medical management of pain Medical management of pain

12. MEDICATIONS FOR DETOXIFICATION Librium … Alcohol and Benzodiazepine detoxification Librium … Alcohol and Benzodiazepine detoxification Benzodiazepine & Phenobarbital … Benzodiazepine detoxification Benzodiazepine & Phenobarbital … Benzodiazepine detoxification Suboxone (Subutex) & Methadone …Opiate detoxification Suboxone (Subutex) & Methadone …Opiate detoxification Clonidine & Naltrexone … Opiate detoxification Clonidine & Naltrexone … Opiate detoxification Bromocryptine & Amantadine … Stimulant detoxification Bromocryptine & Amantadine … Stimulant detoxification Wellbutrin … Cannabis detoxification Wellbutrin … Cannabis detoxification

13. MEDICATIONS FOR MAINTENENCE Buprenorphine ….Opiate dependence Buprenorphine ….Opiate dependence Methadone … Opiate dependence Methadone … Opiate dependence Acamprosate … Alcohol dependence Acamprosate … Alcohol dependence Naltrexone … Alcohol and Opiate dependence Naltrexone … Alcohol and Opiate dependence Vivitrol.......... Alcohol dependence Vivitrol.......... Alcohol dependence Disulfram … Alcohol dependence Disulfram … Alcohol dependence Nicotine Replacement …Nicotine dependence Nicotine Replacement …Nicotine dependence

14. STATUS OF ALCOHOL TREAMENT More Treatment Options than ever before More Treatment Options than ever before New medications and psychosocial approaches New medications and psychosocial approaches Guidelines for use of medications in actively using alcohol patients and patients in recovery Guidelines for use of medications in actively using alcohol patients and patients in recovery Treatment in outpatient and primary care settings ASAM Levels I and II Treatment in outpatient and primary care settings ASAM Levels I and II Medications help promote and sustain recovery Medications help promote and sustain recovery Problem … Less than 1/5 of facilities are using new pharmacotherapy (barriers?) Problem … Less than 1/5 of facilities are using new pharmacotherapy (barriers?) Need to engage physicians to move forward in pace with the new developments in alcohol treatment Need to engage physicians to move forward in pace with the new developments in alcohol treatment

15. MEDICATIONS FOR ALCOHOL DEPENDENCE FDA APPROVED Disulfiram aversion therapy Disulfiram … aversion therapy Oral Naltrexone … reduction in craving Oral Naltrexone … reduction in craving Injectable Naltrexone … compliance Injectable Naltrexone … compliance Acamprosate … reduction in cravings and prolonged withdrawal syndromes Acamprosate … reduction in cravings and prolonged withdrawal syndromes

16. DISADVANTAGES OF MEDICATION THERAPY Use in lieu of full treatment experience Use in lieu of full treatment experience Burdensome regimes and side-effects may undermine commitment to recovery Burdensome regimes and side-effects may undermine commitment to recovery Poor medication selection … must meet patient needs Poor medication selection … must meet patient needs Premature discontinuation of medications (need to match with patients recovery status) Premature discontinuation of medications (need to match with patients recovery status)

17. ADJUNCTIVE MEDICATIONS SSRIs ………… Affective Depressant Disorders SSRIs ………… Affective Depressant Disorders Buspar ……… Anxiety Disorders Buspar ……… Anxiety Disorders Benzodiazepines (Oxazepam, Librium, Klonopin) … in special psychiatric cases (GAD, Panic Disorder, Agoraphobia) Benzodiazepines (Oxazepam, Librium, Klonopin) … in special psychiatric cases (GAD, Panic Disorder, Agoraphobia) Phenothiazines... Affective Disorders (Schizophrenia) Phenothiazines... Affective Disorders (Schizophrenia) Lithium ……… Major Depression Lithium ……… Major Depression Trazadone … Insomnia Trazadone … Insomnia Other Medications for Medical Problems under medical supervision Other Medications for Medical Problems under medical supervision

18. MEDICATIONS FOR PAIN MANAGEMENT NSAIDs … at maximum dosages ATC NSAIDs … at maximum dosages ATC Methadone … in combination with NSAIDs Methadone … in combination with NSAIDs Buprenorphine in combination with NSAIDs Buprenorphine in combination with NSAIDs Neuroleptics … in combination with other meds Neuroleptics … in combination with other meds SSRIs … have been shown to be useful SSRIs … have been shown to be useful Clonidine … for neuropathic pain Clonidine … for neuropathic pain Clonazepam … for lancinating pain Clonazepam … for lancinating pain Baclofen …for central nervous system pain Baclofen …for central nervous system pain LONG Acting Narcotics …. medical supervision LONG Acting Narcotics …. medical supervision

19. SPECIFIC PROTOCOLS PREGNANT OPIOID DEPENDENT PATIENTS SHOULD NOT BE DETOXIFIED PREGNANT OPIOID DEPENDENT PATIENTS SHOULD NOT BE DETOXIFIED –The treatment of choice is METHADONE MAINTENANCE –BUPRENORPHINE … 2,4,6,8 OR 16 MG FOR Detox and Maintenance (postpartum)

20. TREATMENT ISSUES Mobile Medication Van … multiple communities Mobile Medication Van … multiple communities Needle Exchange Program Needle Exchange Program Mobile Methadone and Buprenorphine Mobile Methadone and Buprenorphine New Drug Protocols … Peer Review-Control Group Studies New Drug Protocols … Peer Review-Control Group Studies

21. SUMMARY … THE BEGINNING Addiction treatment is growing up Addiction treatment is growing up Pharmacotherapy has arrived Pharmacotherapy has arrived Pharmacotherapy is not in lieu of traditional therapy Pharmacotherapy is not in lieu of traditional therapy Pharmacotherapy is an integral part of a full treatment experience Pharmacotherapy is an integral part of a full treatment experience Pharmacotherapy is not for everyone Pharmacotherapy is not for everyone The need for pharmacotherapy should not lead to exclusion from treatment programs The need for pharmacotherapy should not lead to exclusion from treatment programs