1. ACOPC Summer Conference 2016 “Anatomy of Recovery: Peaks and Valleys” July 28, 2016 We have a large number of participants today so please be courteous and fill in seats from the middle and from the front first. #ACOPC2016 @OverdoseFreePA

2. Medication Assisted Treatment in Opioid Addiction Recovery Daniel Garrighan, BS, CADC JADE Wellness Center #ACOPC2016 @OverdoseFreePA

3. Medication Assisted Treatment in Opioid Addiction Recovery Daniel J. Garrighan, CADC

4. Rise in Opioid Abuse Between 1999 and 2006, the number of persons aged 12 and older illicitly using prescription pain relievers doubled from 2.6 to 5.2 million. By 2010, opiate addiction statistics show over 12 million Americans reported using prescription pain medications for non-medical purposes In 2010, an ~ 2 million people reported abusing prescription pain medication for the first time within the previous 12 month period. 2009 admission rate to treatment programs for opiates other than heroin averaged 430% higher than in 1999. 2012 – estimated 13 million IV drug users globally.

5. 2011: Death rates from PDO Across the USA

6. Dept. of Health and Human Services 4 Main Objectives: Educate prescribers on how to identify opioid abuse and to improve prescribing decisions – Increase SUD training for medical clinicians – Increase use of Prescription Monitoring Programs Reduce inappropriate access to opioids – Increase drug take back programs Increase access to effective overdose treatment – Naloxone (Evzio/Narcan) education Increase access to Medication Assisted Treatments – Health and Human Services increased patient limit from 100 to 275 In July of 2016

7. Rates of Relapse In Opioid Dependence are High

8. Relapse rates: Drug addiction and other chronic illnesses

9. Why MAT? Superior Retention rates compared to abstinence treatment Reduction in illicit opioid use/drug seeking Reduction in criminal activity Reduce risk of overdose Improve social functioning Reduction in the transmission of HIV among drug users. Research shows treating SUD, a combination of medication an behavioral therapies is most successful.

10. Medications used in opioid treatment Methadone – Full Agonist Buprenorphine (Suboxone , Subutex  ) – Partial Agonist (low intrinsic activity at Mu receptors Naltrexone (Vivitrol , ReVia  ) – Antagonist Both Methadone and Buprenorphine suppress w/d symptoms and relieve cravings. Naltrexone blocks euphoric effects. Does NOT suppress w/d. High affinity but no intrinsic activity

11. Medications for Opioid Dependence

12. Methadone Maintenance Highly regulated (Federal, state, local agencies) Can only be administered in certified Opioid Treatment Programs (OTP) Strict patient eligibility Highly effective Good treatment retention Gold Standard for opioid – dependence in – pregnancy

13. Methadone Pharmacology Full opioid mu receptor agonist High lipid solubility ½ life ~ 22-24 hours, allowing for Q24hr dosing in most people Peak serum concentration 2-6 hours – Highest level of sedation/analgesia/euphoria

14. Methadone Side Effects: Constipation, GI upset Excessive sweating Drowsiness, fatigue Decreased libido, hypogonadism QTc prolongation (and TdP) – Resulted in LAAM to be removed from market – Increased risk with high dose methadone (>100 mg), hx of cardiac disease or baseline prolonged QTc, and concurrent use of other medications that can affect QTc Respiratory depression Central sleep apnea Death – usually due to respiratory arrest (esp with BZD, EtOH) or fatal arrhythmia

15. Buprenorphine

16. History of Buprenorphine Maintenance Drug and Alcohol Treatment Act (DATA) 2000 – Schedule III, IV, V narcotic medications can be prescribed as treatment for opioid dependence – qualifying physicians can receive a waiver after meeting certified training requirements – Can be office based (vs. OTP) In 2002, FDA approves buprenorphine as a schedule III medication for treatment of opioid dependence. August 5th 2016, HHS Increase eligible providers to increase to treat up to 275 patients.

17. Buprenorphine Properties Partial agonist at mu opioid receptor – Low intrinsic activity – Creates ceiling effect – Reduced side effect profile – Reduced risk for respiratory depression and overdose (due to the partial agonist functionality)

18. Buprenorphine Properties High Receptor Affinity – Can precipitate withdrawal Slow Dissociation (long ½ life) – Long half life: 20-72 hours (mean 37 hours) Low Intrinsic activity (partial agonism)

19. Buprenorphine Side Effects Constipation, GI upset Excessive sweating Drowsiness, fatigue Decreased libido, hypogonadism Respiratory depression, Central sleep apnea, Death (especially with BZD) – Children are vulnerable

20. Buprenorphine Formulations 1 Buccal formulation  Buprenorphine with naloxone (Bunavail  ) Approved by FDA on June 2014 2 sublingual formulations  Buprenorphine (Subutex  ) Preferred formulation in pregnancy Used in detoxes while in controlled environment  Buprenorphine with naloxone (Suboxone , Zubsolv  ) 4:1 buprenorphine to naloxone Naloxone, only active if IV or IM administration – Added to limit diversion

21. Probuphine Steady 6 months dose of Buprenorphine Maintenance treatment in patients who achieved sustained prolonged stability on low to moderate doses of Buprenorphine (no more than 8mg per day)

22. Buprenorphine In Prenatal Period Subutex has been deemed safe in pregnancy – Reduces risk of harms to mother and developing fetus Reduced risk of miscarriage, premature delivery, improves birth weights – Neonatal Opioid Withdrawal occurs less frequently and with less symptoms compared with heroin, short acting opiate pills, or methadone – Women can safely breastfeed while on Subutex

23. Naltrexone Reduces Opiate use: – Blocking positive reinforcing effects of opiates – Reduces craving No tolerance, no physical dependence. Barrier – Must be completely abstinent of opioids to begin Naltrexone treatment; much of the literature suggests 1-2 weeks but depends on the half life of the substance being used.

24. Oral Naltrexone: ReVia – Range 25 mg – 150 mg /day – FDA recommends 50 mg /day – Compliance is a huge barrier to treatment success – Low retention rates (20-30%) over 6 months – Effective for certain populations: When patient is not eligible for agonist or partial agonist therapy When used in monitored and supportive environments When external incentives are in place IM Naltrexone: Vivitrol  – 380 mg dose, Q4weeks – IM in the buttocks – Significantly improves compliance and treatment retention

26. SAMHSA: Focus on MAT, Naloxone MAT needs to be first option therapy for patients with opioid use disorders Improve training for prescribers of MAT Remove barriers for MAT – Expand MAT training to residents, CRNP, other clinicians – Develop a media campaign to address bias against SUD and MAT Increase Education and Access to Naloxone

27. Behavioral Health treatment combined with MAT services Level of care assessment & Psychosocial treatment – PCPC Criteria; guidelines designed to provide clinicians with a basis for determine the appropriate care for individual with SUDS Outpatient, Intensive Outpatient, PHP, Halfway house, Medically Monitored Inpatient Detox, Short Term Residential, Long term Residential.

28. Induction for MAT services On site induction under physician and nurse supervision  SUBOXONE  - Intervals: 15, 15, 30, final 30 minute check. 2-4mg dose until withdrawal symptoms dissipate Weekly Prescriptions until confirmed stability  REVIA  /VIVITROL  – 12.5mg ½ hr 12.5mg ½ hr 380mg Vivitrol  IM

29. MAT in Ambulatory Detoxification Suboxone  detoxification Non-narcotic/Transitional Medication

30. Focus Areas during MAT / Behavioral therapy Behavioral Health Services Community Based recovery supports as mutual aid (12 step programs) Peer Recovery Specialists  Serves as adjunct to professionally directed addiction treatment.  Peer to peer nonclinical assistance to achieve long-term recovery.  Assist with primary, secondary needs; housing, medical, occupational, life skills, support system

31. Continued Focus areas Co-occurring disorder; access to psychiatric care. Physical health needs; coordination of care with PCP, access to PCP, encourage, enable client to care for physical health; dental.

32. Purpose Meaningful daily activities; Job, School, Volunteer, family caretaking, creative endeavors, social interaction, independence, income, resources.

33. Desire What does the PIR Desire? Coming into treatment what are their goals? Preferred treatment options? Treatment Planning Not all individuals seeking treatment are in the same place. – Levels of addiction – Harm Reduction

34. Secondary substance use Presenting for treatment of opioid use disorder; – 23% used marijuana while in treatment during the first 90 days. – Benzo and other central nervous system suppressants including Alcohol

35. Barriers Less than 1/3 of patients in enrolled in D&A are treated with MAT Pain and Addiction Stigma, Funding, transportation, lack of trained prescribers, social support system. Addiction to other CNS depressants (BDZ/EtOh) Lack of MAT in conjunction w/ behavioral therapy

36. 412-380-0100 Dan@myjadewellness.com

37. Resources Supporting Recovery from Opioid Addiction: Community Care Best Practice Guidelines for Buprenorphine and Suboxone  http://www.ct.gov/dmhas/lib/dmhas/publication s/Community_Care_BP_Guidelines_for_Buprenor phine_and_Suboxone.pdf http://www.ct.gov/dmhas/lib/dmhas/publication s/Community_Care_BP_Guidelines_for_Buprenor phine_and_Suboxone.pdf Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction - SAMHSA http://store.samhsa.gov/product/TIP-40-Clinical- Guidelines-for-the-Use-of-Buprenorphine-in-the- Treatment-of-Opioid-Addiction/SMA07-3939 http://store.samhsa.gov/product/TIP-40-Clinical- Guidelines-for-the-Use-of-Buprenorphine-in-the- Treatment-of-Opioid-Addiction/SMA07-3939 Dan@myjadewellness.com

38. Co-Sponsors Thank you!!! Co-Sponsors Pyramid Healthcare, Inc. Greenbriar Treatment Center White Deer Run Treatment Network Summit BHC of PA Community Care Behavioral Health Organization University of Pittsburgh Thank you!!! #ACOPC2016 @OverdoseFreePA