1. A Look at Opioid Maintenance Therapy
Nicole Lemieux MLS (ASCP)cm, PA-S

2. Objectives 1. Define opioid maintenance therapy.
2. Recognize limiting factors to opioid maintenance therapy.
3. Discuss the pros and cons of methadone, buprenorphine, and naltrexone.
4. Identify laboratory testing to monitor opioid maintenance therapy.

3. Opioids
Class of medications that reduce the signaling and processing of pain pathways

4. Opioids Prescribed across the board
Primary care #1
For pain after surgery, trauma, or diseases associated with life limiting pain
Common examples: morphine, codeine, fentanyl, hydrocodone, oxycodone
Short term use is beneficial but patients continue to receive the medication for years.
Can also be used for cough medicine, antidiarrheal, difficulty breathing

5. Opioid Misuse The nontherapeutic use of opioids
Taking in amounts not prescribed
Using alternative routes of administration
Obtaining illicitly
Snorting, crushing, injecting

6. Opioid Epidemic 400,000 people a month abuse heroin
4 million people a month abuse prescription opioids
Per CDC, 44 people die each day from overdose
White males seeing the highest increase

7. Opioid Epidemic Risks for misuse Come in early for refills
“Doctor Shop”
Personal or family history of substance abuse
Psychiatric comorbidities
History of sexual abuse as preadolescent
Seen clinically

8. Opioid Epidemic NOT just a street drug epidemic
Users are those that are being prescribed and those that are abusing illegal drugs like heroin or illicitly gained drugs

9. Risks associated with Opioid use
Tolerance – need increased doses to reach the same effects
Next is dependence and withdrawal
Overdose
Death
Respiratory distress
Cardiac events (MI, dysrhythmias, sudden cardiac arrest)
Risks increase with increased doses

10. Opioid Epidemic Trickle down effects Crime Infections diseases
Leading to incarceration
Infections diseases
HIV, Hepatitis C
Increased mortality and morbidity
Trauma, suicide, infectious diseases
Crimes to pay for and obtain drugs
Incarceration burdens our systems, increases costs as their health care needs to be paid for while incarcerated… which leads me to my next point ID – Hep C and HIV treatments are not cheap

11. Treatment Options Detox Medications Opioid Maintenance Therapy
Best when more than one option is employed or coupled together
Inpatient programs work better than outpatient

12. Opioid Maintenance Therapy
AKA: Opioid agonist, agonist replacement therapy
Prescribing a maintenance dose of a legal opioid in lieu of illegal opioid
Two drugs commonly used – Methadone, Buprenorphine
Goal: Avoid illicit drug use, NOT to be drug free
Drugs are given at a steady dose – gets rid of the euphoria that illicit drugs have, but also given at a dose that doesn’t lead to sedation or respiratory distress
Cravings are decreased
Patients can return to their lives – can work, be functional member of society, quit criminal activities
Increases health and decreases mortality

13. Methadone First to be used Opioid Agonist Given orally
Mu receptor agonist
Given orally
Short half – life
Needs daily dosing
Why needs to be monitored

14. Methadone Prescribing
Physicians must have specialized training and certification
Must be at a specialized clinic
Minot – first methadone clinic in North Dakota opened fall of 2016
Severe limitations for patients

15. Pros Cons Methadone Tried and true Relatively cheap
Geographical limitations
Poor Patient Preference
Swapping drugs
Addictive
Worry about discontinuing
Daily dosing, travel, clinics not close

16. Buprenorphine Newer Created to combat methadone’s limitation
Partial agonist/antagonist
Agonist of delta and opioid like receptor 1, partial agonist at mu receptor
Antagonist of kappa receptor
Given sublingually
Dosed 2-3 days or weekly
FDA approved in 2002
Because of partial agonist, has a lower maximum effect than an illicit drug binding at the same site
Binds irreversibly and displaces all other opioids from their receptors – patients are protected from overdosing
Given with narcan

17. Buprenorphine Prescribing
Physicians and Advanced Practice Provider (NP, PA) with certification
In North Dakota – 18 registered certified providers
Physicians 275, Midlevels 30
Likely much higher number as not all providers register

18. Pros Cons Buprenorphine Less geographical limitations Not daily dosage
“Safer” - Ceiling effect
Decreased mortality
Similar efficacy/retention as methadone
Used to discontinue methadone
Provider limitations
Overdose possibilities
Poor patient preference
Higher cost of medication and private clinics
decreased mortality (compared to methadone)
Implantable form – newer – research shows it’s equal in efficacy and retention to sublingual, but has more withdrawal symptoms
Overdose – especially when taken with benzos, antidepressants, other illicit drugs – still an opioid
Patient preference – don’t feel drug free, never get off it,

19. Naltrexone Used to remain opioid free Used for alcohol dependence
Opioid antagonist
Binds to mu receptor and blocks opioid effects
Two forms: Oral (1984) injectable (2010)
Unlike meth and bup who are used to discontinue use
Must be opioid free for a week before beginning – can do a challenge with either narcan (naloxone) or naltrexone and watch for withdrawal symptoms

20. Naltrexone Prescribing – no limitations!
North Dakota – check with your pharmacy
Expensive and pharmacies may not want to stock it

21. Pros Cons Naltrexone No limitations to prescribers
Injectable and implantable forms
Patient preference
Safer?
Used to discontinue methadone or buprenorphine
Not widely known
Expensive
Poor oral compliance and retention
Patient preference – because it is new? No withdrawal when discontinuing like what is possible with bup or meth
Safer – fewer inpatient hospitalizations then bup or meth

22. Drugs of Abuse Testing Urine specimen of choice
Ease of collection
More concentrated than serum
Other specimens: hair, nails, meconium, saliva, breath
Start with screen, move unto confirmatory if needed
Used to check compliance as well as illicit use
Testing for the metabolite of each illicit drug
Screening – certain cut offs for each metabolite

23. Drugs of Abuse Testing Opioids
Can last in urine 2 – 8 days depending on usage
False positives
Antibiotics (Fluoroquinolones, penicillins)
Poppy seeds
Will not be positive with oxycodone, methadone, or buprenorphine
Have separate immunoassays
Naltrexone is not an opioid so not included in typical drug screens
Levaquin, Cipro, amoxicillin
Methadone pos 1-4 days, typically included in drug screen
Oxycodone – typically included in drug screen
Buprenorphine – not typically included
Naltrexone – PCR test available on saliva

24. Drugs of Abuse Testing False Negatives Checking for tampering
Household chemicals
Bleach, vinegar, sodium bicarbonate, Drano, soft drinks, hydrogen peroxide
Diuretics
Lasix, Bumex
Water
Checking for tampering
pH, creatinine, osmolality, odor, color, temperature
Tamper proof collection room
Blue toilet water, no water or soap, monitor patient
Household chemicals – changes the pH
Diuretics increase UO
Didn’t find anything in my research for patients trying to get a false positive methadone result

25. References
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26. Questions?