1. The Disease of Opioid Addiction and Medication Assisted Treatment
Michele F. McCarthy, LPCC
Community & Government Liaison
Self Refind

2. Objectives Learn about the state of opiate addiction today
Discuss the impact of opiate abuse and addiction
Identify the currently available medication assisted treatment options
Explore the pros and cons of the available treatments
Discuss special considerations for working with pregnant patients
Review rights of patients in medication assisted treatment

3. Is it really an epidemic?
Epidemic is defined as:
…attacking or affecting many persons simultaneously in a community or area…a widespread occurrence of a disease…a rapid development, spread, or growth of something, especially something unpleasant.

4. KENTUCKY ALL SCHEDULE PRESCRIPTION ELECTRONIC REPORTING
KASPER QuarterlyTrend Reports for reflected that opiates accounted for an average of 57% and benzodiazepines accounted for an average of 28% of the top controlled substances that Kentucky doctors wrote prescriptions for.
Source: KASPER Quarterly Trend Reports 2011

5. KASPER DATA 2011
In 2011 alone:
3,093,770 prescriptions were written for hydrocodone (up from 2,812,878 in 2009).
3,217,535 prescriptions were filled for hydrocodone.
852,085 prescriptions were written for oxycodone (up from 646,218 in 2009).
929,525 prescriptions were filled for oxycodone.
How many more were obtained out of state?
How many more were obtained illegally?
Source: KASPER Quarterly Trend Reports 2011

6. Overdose deaths are on the rise…
Drugs exceeded motor vehicle accidents as a cause of death in 2009, killing at least 37,485 people nationwide, according to preliminary data from the U.S. Centers for Disease Control and Prevention.
The death toll has doubled in the last decade, now claiming a life every 14 minutes, making it the number one cause of preventable deaths.
Fueling the surge in deaths are prescription pain and anxiety drugs, which now cause more deaths than heroin and cocaine combined.
Los Angeles Times, September 2011

7. Kentucky Medical Examiner 2011 REport
Total cases- 2378
Overdose cases- 684
Alprazolam (Xanax)-286
Oxycodone (Percocet)-213
Hydrocodone (Lortab)-187
Oxymorphone (opana)-154
Alcohol-134
Cocaine-31
Methamphetamine-21

8. Kentucky has more to worry about

9. Kentucky has more to worry about
Although we have continued to see an increase in the prescribing and abuse of prescription opiates, this is not the only battle we are fighting.
Kentucky House Bill
Landmark legislation
But if it does it’s job…

10. 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

11. MEDICATION ASSISTED TREATMENT OPTIONS
Methadone
Buprenorphine-Suboxone and Subutex
Naltrexone

12. MEDICATION ASSISTED TREATMENT
SAMHSA defines MAT as:
“The use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful.”

13. WORLD HEALTH ORGANIZATION 2009 GUIDELINES
Efficacy of MAT v. placebo
Methadone—opiate use,  tx retention, 1/3 mortality rate,  risk of HIV by 50%
Buprenorphine—opiate use,  tx retention,  morphine positive drug screens
Naltrexone— in opiate use
Of the treatment options examined, opioid agonist
maintenance treatment, combined with psychosocial
assistance, was found to be the most effective.
\\Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence, World Health Organization, 2009

14. METHADONE Dolophine hydrochloride, Methadose Schedule II narcotic
Long acting opioid analgesic (6-12 hours)
Full mu opioid agonist-binds and activates

15. 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 15

16. METHADONE
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 tablets (Disket) only available to treat opioid addiction (as of January 2008)

17. METHADONE BENEFITS
Right dose should not cause euphoric or tranquilizing effects.
Reduces/blocks effects of other opioids.
Tolerance is slow to develop.
Relieves cravings.
Allows the individual to feel “normal”.

18. METHADONE BENEFITS
Improved employment status and family relationships.
Decrease in criminal activities.
Decrease in high risk behaviors such as IVDU = decrease in HIV and Hep. C.
Improved health and health care.

19. METHADONE LIMITATIONS
Can only be dispensed/administered through an OTP.
Private can be expensive.
Heavily regulated, lots of rules, can be time consuming.
Heavily stigmatized

20. METHADONE LIMITATIONS
Abuse liability and diversion
Increased risk when combined with other drugs.
Associated health complications*
Detoxification can be difficult
*Torsade de pointes

21. BUPRENORPHINE Drug Addiction Treatment Act of 2000 (DATA 2000)
In 2002, two forms were FDA approved- Subutex and Suboxone, both made by Reckitt- Benckiser.
Schedule III narcotic
Opioid analgesic with effects up to 6 hours.

22. BUPRENORPHINE
Partial mu opioid agonist (ceiling effect) but high affinity
Long half-life (24-60 hours)
Administered as sublingual tablet* or film
Subutex- 2 mg or 8 mg buprenorphine
Suboxone- 2 mg bup + .5 mg naloxone
8 mg bup + 2 mg naloxone
*Reckitt announced in September 2012 they will cease production of the tablets

23. 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 23

24. SUBUTEX Contains buprenorphine only.
Historically, minimally used in U.S. except with pregnant women.
Two generics now available.*
Higher rate of diversion, can be injected.
*Reckitt is no longer making Subutex

25. SUBOXONE Naloxone added as means to decrease misuse.
Poor bioavailability sublingually, but if dissolved and injected, will precipitate withdrawal.
Reduced abuse potential.
Film meant to provide added means to combat diversion.

26. BUPRENORPHINE BENEFITS
Virtually no euphoric or tranquilizing effects.
Blocks effects of other opiates.
Relieves cravings to use other opiates.
Allows “normal” function.

27. BUPRENORPHINE BENEFITS
Lower abuse liability and diversion potential.
Increased anonymity, less intrusive, less stigma.
Increased treatment options/access to treatment.
Here to Help Program

28. BUPRENORPHINE BENEFITS
Decrease in high-risk behaviors.
Good “step down” option for those tapering from methadone.
Provides option for those that cannot tolerate methadone
Is currently covered by Medicaid

29. BUPRENORPHINE LIMITATIONS
Can be expensive when self pay.
Currently still no generic for Suboxone.
Should not take if opiates still in system.
Counseling may not be available or affordable in the same area as doctor.

30. BUPRENORPHINE LIMITATIONS
Not enough certified doctors or doctors willing to treat.
No regulations for OBOTs, only “practice guidelines”.
Potential for overdose of other opiates due to ceiling effect.
Abuse and diversion potential still exists.

31. NALTREXONE Long half-life (up to 72 hours)
Opioid antagonist-binds, but blocks instead of activates
Is NOT an opiate

32. 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 32

33. NALTREXONE
Historically used primarily for alcohol due to blocking neurotransmitters believed to be involved with alcohol dependence.
Oral- ReVia, now generic
Injectable- Vivitrol
Implant- not FDA approved

34. NALTREXONE TREATMENT Medication is only one component.
Average length of treatment is 3-9 months.
Works best with highly motivated patients.
Injectable is a great option for compliance issues or just for convenience.

35. NALTREXONE BENEFITS Any physician can prescribe in any setting.
Injectable lasts for 30 days.
Relatively inexpensive (oral) when compared to Methadone or Bup.
Non-narcotic, non-addictive, does not produce dependence.

36. BENEFITS CONT. More acceptance in abstinence-based programs.
Less stigma than methadone or buprenorphine.
In KY Medicaid covers, but only oral is 1st-tier; injectable is a 3rd-tier.
Received approval for use for opioid addiction in last year

37. NALTREXONE LIMITATIONS
Injection site reactions.
Injectable very expensive for self pay.
Poor compliance with oral version.
Cannot have any opiates in system or will precipitate withdrawal.
Still not many doctors utilizing.

38. LIMITATIONS CONT.
Risk of overdose in attempt to break through blockade.
Not first choice for pregnant patients.
Breastfeeding is not recommended.
Implant is NOT FDA approved.

39. MAT and PRegnancy

40. MAT AND PREGNANCY
“Cold turkey” detox may trigger miscarriage, pre-term labor.
Methadone has most research and is still preferred.
Subutex has shown very positive results- MOTHER Study.
Several reports of using Suboxone with positive results.

41. MAT AND PREGNANCY CONT. Individualized approach, informed choice
Decreases/ceases cycles of intoxication and withdrawal
Decrease in high risk behaviors
Opportunity to address other factors-mental health, social supports, basic needs

42. MAT AND PREGNANCY STANDARDS
Federal
Prenatal care
Gender-specific services
Additional state
Medically able to participate
Collaborate with OBGYN
Post-partum care
Nutrition, parenting, and weekly drug screen

43. MAT & PREGNANCY STANDARDS
CARF and Joint Commission
Priority admission
Counseling for DV, trauma, women’s health
Appropriate medication dosage
Educate on MSW- should NOT be initiated before 14 weeks or after 32 weeks
Encourage breastfeeding (unless contraindicated)

44. KEY POINTS TO REMEMBER Opiate addiction is a disease, an epidemic.
There is no cure, but we do have options and we need to take advantage of all of them.
Treatment is not “one size fits all.”
Just as addiction is lifelong, so is the recovery process
Chances of maintained recovery significantly increase when combined with counseling, drug screens, medication call backs, etc.

45. KEY POINTS TO REMEMBER
No “perfect” medication that is one size fits all.
Medication is a tool, not a “cure”.
MAT may be appropriate for pregnant women but must be closely monitored and have informed consent.
MAT is a legal, valid, and widely researched evidence-based treatment for addiction.
Individuals receiving MAT are in recovery!

46. CONTACT INFORMATION
Michele F. McCarthy Government & Community Liaison Self Refind