Opioid Medication Assisted Tx (1) C.L.I.P.S. Taper or replace? Chronic, relapsing illness. Long-term medication tx often needed to prevent relapse. 14 wk RCT. Bup taper vs ongoing MAT. Less +UDOA, more abstinence in MAT grp. 11% taper completed trial vs 66% MAT. Similar results to other trials. JAMA 2014. Patients on opioid agonist tx will have physical dependence. This is not addiction. OUD is fatal disease. MAT is primary prevention for HIV/HCV and death! Available medications Buprenorphine/naloxone (Suboxone). Avg dose 8-16 mg qd. Opioid partial agonist (bup) combined with antagonist (naloxone) Can be prescribed from office after 8 hour training & DEA Waiver (X license) Methadone (MTD). Avg dose 80-120 mg qd. Full opioid agonist Must be prescribed from licensed methadone tx program Legal to rx outpt x3 days while pt is waiting to enter methadone tx program Naltrexone. Dose is 50 mg PO qd. Opioid antagonist. Daily PO or monthly depot injection (Vivitrol). Blocks intoxication and prevents physiologic dependence. Does this stuff actually work? MTD vs placebo or nonmed tx. MTD increased tx retention and reduced heroin use. RR 0.66. Cochrane 2009. Bup/nalox vs MTD or placebo. Bup better than placebo for retention and less +UDOA. MTD better than bup at retention but = at decreasing use. Cochrane 2014. Naltrexone. Better evidence for depot form. Better retention than placebo. Mixed evidence on less +UDOA. Which of these medications are covered by Medi-cal? All of them. Including brand names. Carved out to state Medi-cal. No TAR required for “opioid use disorder” Updated 1/16 K.Greer

Opioid Medication Assisted Tx (2) C.L.I.P.S. Benefits of bup/nalox over methadone Doesn’t appear to share methadone SE (prolonged QT, hyperalgesia, hypogonadism) Much less risk of respiratory depression. Less abuse potential. Patient-centered. Avoid treatment program associated stress, travel, “drug lifestyle.” Engages patients in primary care system Disadvantages of bup/nalox Similar SE to other opioids (constipation, nausea, headache) Less structure for complicated patient Acute pain requires knowledgeable provider (actually not very complex!) How to get your patients into MAT Bup/nalox: Currently at Vista word-of-mouth referral. Formalization forthcoming. Cash pay at SRTP & other private docs in community. Get yourself certified! Methadone: Santa Rosa Treatment Program. DAAC/REAP. Naltrexone: No special prescriber requirements. Rx away! Other considerations Must triage pts. Mild/mod OUD suitable for office tx with bup/nalox or naltrexone. Severe OUD likely needs treatment program oversight. Recommend all patients to engage in some form of behavioral tx Check out SAMHSA-funded Provider Clinical Support System for MAT (PCSS-MAT). Education, training, mentoring, resources, clinical tools. Addiction is NOT a sign of weakness. It is NOT TRUE that all anybody needs to kick addiction is to “be strong.” Recovery takes commitment every day, through treatment and beyond. (SAMHSA friends/family MAT fact sheet 2014) County funded outpt programs? Women’s Recovery Services, DAAC, California Human Development. More @ www.sonoma-county.org/health/services/addictiontreatment.asp