1. The intersection of medication assisted treatment and mental health
Charles Hilger, MSW, LADC
Vice President MAT Service Line
Meridian Behavioral Health
September 13, 2017

2. Medication Assisted Treatment 101
Presentation Overview
Medication Assisted Treatment 101
ABOUT THE PRESENTER
WHAT DO YOU WANT TO KNOW?
MEDICATION ASSISTED TREATMENT:
MEDICATIONS
GOALS OF MAT
IMPACT OF MAT

3. Medication Assisted Treatment 101
About the Presenter
Medication Assisted Treatment 101
Chuck Hilger, MSW, LADC – Vice President MAT Services, Meridian Behavioral Health – Valhalla Place
20 years working in the field of Substance Use Disorders
13 years in opiate addictions – Medication Assisted Treatment
MARRCH Board Member
Work with National Advocacy Groups on issues of MAT and Harm Reduction
Served on MN State Advisory Boards
Former Adjunct Faculty at Argosy University in the Masters of Clinical Psychology program – Instruct in the area of substance use disorder

4. Medication Assisted Treatment

5. Medication Assisted Treatment 101
Section Objectives
Medication Assisted Treatment 101
Methadone
Buprenorphine/Naloxone (Suboxone)
Naltrexone (Vivitrol, ReVia)
How Opiate Replacement Therapy Works
Impact of Medication Assisted Treatment

6. Medication Assisted Treatment 101
What is Methadone?
Medication Assisted Treatment 101
Methadone is a synthetic opioid – analgesic
Full opioid agonist (schedule II)
Synthesized by Germans in 1938
First used in 1964 to treat heroin/morphine addiction
Effective for persons with low to high tolerance
Considered the gold standard for treating opiate addiction

7. Medication Assisted Treatment 101
What is Methadone? Pharmacology
Medication Assisted Treatment 101
Half life hours
Peak serum blood level 3-5 hours
High affinity for the  receptor site
Moderate dissociation from the receptor site
Risk of over medication and medication interactions
Longer time to stabilize – adequate dose
Safe for prolonged use – nontoxic

8. Medication Assisted Treatment 101
What is Buprenorphine?
Medication Assisted Treatment 101
Buprenorphine is a semi-synthetic opioid – analgesic
Partial opioid agonist (schedule III)
Discovered in 1965 it is an alkaloid of the poppy plant
Approved in 2000 to treat opioid use disorders
Used in “full” treatment or by MD prescription
Effective mostly for persons with low to moderate tolerance
More expensive than methadone
Considered the gold standard for treating opiate use disorders

9. Medication Assisted Treatment 101
What is Buprenorphine? Pharmacology
Medication Assisted Treatment 101
Half life hours
Peak serum blood levels 2-4 hours
High affinity for the  receptor
Slow dissociation from the receptor
Milder withdrawal
Exhibits a “ceiling effect” preventing respiratory depression
Shorter time to stabilize
Safe for prolonged use – nontoxic
Safer medication than Methadone – Ceiling effect

10. Medication Assisted Treatment 101
What is Naltrexone?
Medication Assisted Treatment 101
Naltrexone is an opioid antagonist
Blockade effect
Initiated 7-10 days after last opioid consumption
Monthly intramuscular injection
Half life 5-10 days
Most expensive
(McLellan et al, 1993 and 1994)

11. Medication Assisted Treatment 101
MAT Medications
Medication Assisted Treatment 101
Source: National Institute on Drug Abuse, Pew Charitable Trusts
Credit: Rebecca Hersher and Alyson Hurt/NPR

12. Medication Assisted Treatment 101

13. Medication Assisted Treatment 101
Goals for Medication Assisted Treatment
Medication Assisted Treatment 101
Prevention or reduction of withdrawal symptoms
Prevention or reduction of drug craving
Prevention of relapse to use of addictive drug blockade effect
Restoration to or toward normalcy of any physiological function disrupted by drug abuse
Source: MJ Kreek, Rationale for Maintenance Pharmacotherapy of Opiate Dependence, 1992

14. Medication Assisted Treatment 101
Impact of Maintenance Treatment
Medication Assisted Treatment 101
Reduction death rates (Grondblah, ‘90)
Reduction IVDU (Ball & Ross, ‘91)
Reduction crime days (Ball & Ross)
Reduction rate of HIV (Bourne, ‘88; Novick ‘90,; Metzger ‘93)
Reduction of relapse to IVDU (Ball & Ross, ‘91)
Improved employment, health, & social function

15. Medication Assisted Treatment 101
Other Benefits of Pharmacotherapy for Opioid Addiction
Medication Assisted Treatment 101
Increased Employment
Improved Physical and Mental Health
Improved Social Function

16. MAT patients with mental health diagnosis

17. Medication Assisted Treatment 101
Prevalence and Impact
Medication Assisted Treatment 101
Substance use and response to psychiatric treatment in methadone-treated outpatients with comorbid psychiatric disorder
No illicit drug use (baseline negative; n = 50), or (2) any illicit drug use (baseline positive; n = 75
Results showed that while both conditions evidenced similar utilization of on-site psychiatric services, baseline negative participants remained in treatment somewhat longer (80.7 vs days, p =.04) and demonstrated greater reductions in GSI scores than baseline positive participants at month 3 (p =.004). These results have implications for interpreting previous studies that have shown inconsistent efficacy of pharmacotherapy and other psychiatric treatments, and for providing clinical care for patients with co-occurring substance use and psychiatric disorders.
Substance use and response to psychiatric treatment in methadone-treated outpatients with comorbid psychiatric disorder. / Kidorf, Michael; King, Van L.; Peirce, Jessica; Gandotra, Neeraj; Ghazarian, Sharon; Brooner, Robert K.

18. Medication Assisted Treatment 101
Prevalence and Impact #2
Medication Assisted Treatment 101

19. Medication Assisted Treatment 101
Prevalence and Impact #3
Medication Assisted Treatment 101
Valhalla Place conducts an average of 80 Diagnostic Assessments per month 60 are appropriate for ongoing services
25% engage in ongoing Mental Health services
15% are already connected to a therapist or engaged in supportive services through private or county agencies
30% chose not to participate
Most Common Diagnosis:
Anxiety (GAD) 30%
Depression (MDD) 35%
PTSD 20%
Personality Disorders, Schizoaffective, Adjustment 15%

20. Common Medications and interactions

21. Medication Assisted Treatment 101
Benzodiazepines
Medication Assisted Treatment 101
Benzodiazepines – Tranquilizers
Klonopin Ativan (Lorazepam)
Xanax Valium
15% of MAT UDS are positive for Benzodiazepines
Central Nervous System Depressant
Potentiating Effect
Benzodiazepines with Methadone is safe if monitored by medical staff and taken as prescribed

22. Medication Assisted Treatment 101
QTc Prolongation
Medication Assisted Treatment 101
QTc Prolongation: Extending the hearts natural rhythm
Effects: Syncope and Ventricular Fibrillation and Sudden Cardiac Death (SDC)
Certain medications like Methadone and Effexor can contribute to developing prolongation
Other factors to consider
Family history of heart disease
Overall Health

23. Medication Assisted Treatment 101
Other Medications
Medication Assisted Treatment 101
Gabapentin (Neurontin) – Sedation
Celexa (antidepressant) – Sedation
Soma (muscle relaxant) – Sedation
Watch for signs and symptoms at peak methadone levels
Medications can be managed so that they do not peak at the same time and increase effects

24. Coordinating care

25. Medication Assisted Treatment 101
Multidisciplinary Team
Medication Assisted Treatment 101
Communication is key to managing patients with mental health challenges and also in an MAT program!
Some patients count on providers not talking
Federal confidentiality laws
Gaining release of information
Sharing treatment goals both ways
Care coordination services
Professional and patient accountability

26. Medication Assisted Treatment 101
Thank You Very Much For All Your Help and Participation!
Medication Assisted Treatment 101
Chuck Hilger, MSW, LADC Vice President MAT Services Meridian Behavioral Health programs.com Cell: