1. Medication Assisted Treatment: An Introduction Deborah A. Orr, Ph.D., RN Remington College School of Nursing

2. Why is it difficult to stop taking some drugs?

3. What causes the cigarette (non) smoker to relapse?

4. How does the unsuccessful treatment client feel after relapse? How does relapse impact the likelihood of attempting to stop drugs again?

5. Goal of Medication Assisted Treatment (MAT) “MAT is 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. Medication assisted treatment (MAT) is clinically driven with a focus on individualized patient care.” http://www.dpt.samhsa.gov/

6. Collaborative Treatment Approach client/family Medical care counseling Community self-help groups

7. Addiction is a Brain Disease Receptor changes Neurotransmitter changes

9. Addiction and the Brain 1.Drug attaches to receptors in brain -> PLEASURE 2.Repeated drug use -> TOLERANCE 3.Absence of drug after prolonged use: -> WITHDRAWAL What drugs? Cigarettes, alcohol, benzodiazepines, opioids

10. Other drugs target neurotransmitters Examples: cocaine, crack cocaine, amphetamines, methamphetamine

11. Stimulants alter brain function by blocking reuptake of dopamine, so effects of dopamine are intensified.

12. Can’t you just taper the drugs on your own?

13. Withdrawal What is the relationship between discomfort from physical withdrawal symptoms and the ability to successfully tolerate detoxification? The ability to retain, process, and apply information? To benefit from counseling?

14. Substance: Nicotine Withdrawal symptoms: Irritability Restlessness Sleep disturbance Decreased concentration Increased appetite Nicotine cravings Depression Anxiety Treatment Nicotine replacement medication (patch, gum, etc.) BUPROPION (Zyban): reduces cravings and may help with depression

15. Alcohol Chronic, heavy alcohol consumptions depresses the neurotransmitters GABA and glutamate Withdrawal creates a rebound of these neurotransmitters brain hyperexcitability Withdrawal symptoms: anxiety, irritability, agitation, tremors, seizures, and DTs Alcohol withdrawal can be fatal.

16. Alcohol Treatment Detoxification: medically supervised Main problems: seizures, hypertension, DTs Replacement therapy with a chemically similar medication (phenobarbital, valium, librium or ativan) + treatment of withdrawal symptoms Maintenance: antabuse, vivitrol (naltrexone)

17. Benzodiazepines valium, librium, ativan, xanax Withdrawal can be fatal Withdrawal symptoms depend on amount, frequency, duration, and half-life of the specific drug

18. Benzodiazepine Withdrawal Symptoms Severe sleep disturbance Irritability Anxiety Hand tremor Sweating Difficulty in concentration, confusion and cognitive difficulty, memory problems Dry retching and nausea, weight loss Palpitations, headache Hallucinations, seizures, psychosis, and possible suicide

19. Benzodiazepine Detoxification Medications Medically managed detoxification Usually a benzodiazepine taper + treatment of withdrawal symptoms Anti-seizure medications sometimes used when there is a history of seizures

20. Opioids Examples: heroin, morphine, dilaudid, methadone, oxycontin, demerol Withdrawal Symptoms: sweating, gooseflesh, yawning, chills, runny nose, tearing, nausea, vomiting, diarrhea, and muscle and joint aches

21. Medically-Assisted Withdrawal from Opioids Relieves withdrawal symptoms while patients adjust to a drug-free state Can occur in an inpatient or outpatient setting Typically occurs under the care of a physician or medical provider Serves as a precursor to behavioral treatment, because it is designed to treat acute withdrawal symptoms SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.

22. Replacement Medication: Methadone Must be dispensed from a licensed opioid treatment center (methadone program). Pros + Cons Only approved treatment for pregnant opioid dependent women (prevent fetal withdrawal)

23. Suboxone (buprenorphine/naloxone) Must be prescribed by MD May be inpatient or office based May be for detoxification or maintenance Administer the drug sublingually for a sustained period at a dosage sufficient to prevent opioid withdrawal, block the effect of illicit opiate use, and decrease opioid craving

24. Better social functioning Less risk for illegal behaviors Less HIV risk behavior Better able to participate in substance abuse treatment (the brain works better!) Benefits of Opioid Replacement Medications for Opioid Addiction SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.

25. Treatment Regimen Concomitant behavioral counseling (relapse prevention, managing triggers, increased coping skills, etc.) Detox versus prolonged detox versus maintenance Vivitrol (naltrexone) once opioid-free to minimize cravings

26. Contraindications to Opioid replacement therapy Benzodiazepine use, in particular Alcohol dependence Serious untreated de-stabilizing psychiatric disorders Inability to safely store or take medication Repeated non-adherence to prescribed dosing regimen

27. Stimulants cocaine, crack cocaine, amphetamines, methamphetamine Chronic use depletes the “reward” neurotransmitter, dopamine

28. Stimulant Withdrawal Symptoms Fatigue, but insomnia Restlessness, irritability Loss of motivation Depression Difficulty concentrating Sinus problems, headache Cravings

29. Stimulants and Other Drugs Withdrawal danger: often used with alcohol or benzodiazepines (which need medically supervised withdrawal) No replacement medication available for stimulant detoxification treatment of withdrawal symptoms Monitor for depression and treat as needed

30. Medical Stabilization Begins Treatment MAT makes the person less physically uncomfortable Cognitive impairment caused by withdrawal is minimized, so counseling can start sooner and be more effective Counselors, client, and medical provider plan treatment course Counselors support medication adherence behavior by actively exploring barriers.

31. Counseling Initial counseling addresses highest risk situations for safety, and relapse Ongoing counseling addresses triggers, as well as the residue of addiction in the client’s current life. Counseling addresses psychological issues. Counselors alert medical providers to problems discovered in counseling. TEAM.

32. Resources http://store.samhsa.gov/list/series?name=TIP- Series-Treatment-Improvement-Protocols-TIPS TIP 45: Detoxification and Substance Abuse Treatment TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders

33. Questions? Deborah A. Orr, Ph.D., RN Debbie.orr@remingtoncollege.edu 407-562-9083