1. Medication Assisted Treatment for Substance Use Disorders
Courtney Bearden, RN, PMHNP-BC
Director of Nursing and Quality Management
Bluebonnet Trails Community Services

2. Disclosure to Participants
Successful Completion of This Continuing Education Event Requires You to:
Complete registration and sign in sheet
Attend entire event
Participate in education activities
Complete participant evaluation
Commercial Support:
This educational activity received no commercial support.
Disclosure of Conflict of Interest:
The speakers and planning committee for this event have disclosed no financial interests.
Non-Endorsement Statement:
Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, CE Service; Texas Medical Association; or American Nurse Credentialing Center.
Off-Label Use:
The speakers did not disclose the use of products for a purpose other than what it had been approved for by the Food and Drug Administration.
Expiration Date for Awarding Contact Hours:
Complete the attendance sheet and evaluation by the end of the session.
Other Credits Offered:
Professional Development (PD) for Licensed Psychologists
Continuing Education for Licensed Chemical Dependency Counselors (LCDC)
Social Work/LPC/LMFT
Continuing Legal Education (CLE)
Continuing Professional Education for Accounting (CPE)
CEUs for Certified Peer Specialists (CPS) and Certified Family Partners (CFP)

3. Disclosure to Participants
Continuing Medical Education:
The Texas Department of State Health Services, Continuing Education Service is accredited by the Texas Medical Association to provide continuing medical education for physicians.
The Texas Department of State Health Services, Continuing Education Service designates this live activity for a maximum of 16.5 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This course has been designated by The Texas Department of State Health Services, Continuing Education Service for 3 credit(s) of education in medical ethics and/or professional responsibility.
Continuing Nursing Education:
The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
The Texas Department of State Health Services, Continuing Education Service has awarded 16.5 contact hour(s) of Continuing Nursing Education.

5. Outline
Review standardized screening tools for Substance Use Disorders
Review evidence-based treatment options for nicotine, alcohol and opiate use disorders
Provide evidence-based dosing guidelines for medications commonly used in the treatment of Substance Use Disorders

6. Nicotine

7. Nicotine

8. Medications to Treat Nicotine Dependence
First Line (FDA Approved)
Nicotine Replacement Therapy
Bupropion
Varenicline
Second Line (not FDA Approved)
Nortriptyline
Clonidine

9. >6 Month Quit Rates

10. Medications to Treat Nicotine Dependence

11. Alcohol Men: 5 or more in one sitting, 15+ in one week
Women: 4 or more in one sitting, 8+ in one week

13. Alcohol Men: 5 or more in one sitting, 15+ in one week
Women: 4 or more in one sitting, 8+ in one week

14. Alcohol Assessments AUDIT CAGE (cut down, annoyed, guilty, eye opener)
What happens when you google image search “CAGE drinking”

15. Early or full remission
Controlled setting

16. Assessment for Alcohol Withdrawal
CIWA-Ar
<8 Minimal: Drug therapy not usually indicated
8-14 Moderate: Drug therapy indicated
>15 Severe: Drug therapy required, consider inpatient treatment

17. Medications to Treat Alcohol Dependence
Naltrexone (PO and IM)
Acamprosate
Disulfiram
Topiramate

18. Extended-release Injectable Naltrexone
(Depade®, ReVia®)
Extended-release Injectable Naltrexone
(Vivitrol®)
Acamprosate
(Campral®)
Disulfiram
(Antabuse®)
Topiramate
(Topamax®)
Usual adult dosage
Oral dose: 50 mg daily.
IM dose: mg given as a deep intramuscula r gluteal injection, once monthly.
Oral dose: mg (two mg tablets) three times daily; or for patients with moderate renal impairment (CrCl 30 to 50 mL/min), reduce to mg (one tablet) three times daily.
Oral dose: 250 mg daily (range mg to 500 mg).
Oral dose: Initial dose 25 mg at bedtime, increasing the dose by mg daily each week, divided into morning and evening doses. Faster titration is more likely to cause adverse reactions. Target dose is 200 mg per day total dose, but patients unable to tolerate that dose may respond to lower doses

19. Opiates

20. Screening Tools DAST: Drug Abuse Screening Test (free from NIDA)
One question screening: How many times in the past year have you used an illegal drug or a prescription medication for nonmedical reasons? (A positive screen is 1 or more days.)

21. DSM V Opioid Use Disorder
At least two of the following symptoms within a 12 month period:
Taking more opioid drugs than intended.
Wanting or trying to control opioid drug use without success.
Spending a lot of time obtaining, taking, or recovering from the effects of opioid drugs.
Craving opioids.
Failing to carry out important roles at home, work or school because of opioid use.
Continuing to use opioids, despite use of the drug causing relationship or social problems.
Giving up or reducing other activities because of opioid use.
Using opioids even when it is physically unsafe.
Knowing that opioid use is causing a physical or psychological problem, but continuing to take the drug anyway.
Tolerance for opioids.
Withdrawal symptoms when opioids are not taken.

22. Why agonist treatments?

23. Medications to Treat Opiate Dependence
Naltrexone
Methadone
Buprenorphine

24. Selecting the Appropriate Medication
Naltrexone
Not a controlled substance
Less intensive monitoring
Low risk of diversion
Available in long-acting injectable
Patient must be abstinent for 7-10 days before starting naltrexone
Monitor liver function

25. Medication Selection (cont.)
Methadone
Schedule II controlled substance
Can only be prescribed at licensed OTP (Opioid Treatment Program) i.e. “Methadone clinics” or in an inpatient hospital setting
Need for daily visits and intensive monitoring- could be a barrier or support depending on patient’s needs
May be the best agonist option during pregnancy

26. Medication Selection (cont.)
Buprenorphine
Schedule III- prescriber must obtain additional DEA number
Limits to number of patients each prescriber can maintain
Can be given in OTP or OBOT (Office Based Opioid Treatment) settings
Lower risk of abuse or diversion than Methadone, though still some risk
Lower risk of overdose
May be a better option for patients who cannot attend daily dosing clinic

27. Naltrexone Precautions
Other hepatic disease; renal impairment; history of suicide attempts or depression. If opioid analgesia is needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy Category C.
Serious adverse reactions
Will precipitate severe withdrawal if the patient is dependent on opioids; hepatotoxicity (although does not appear to be a hepatotoxin at the recommended doses).
Common side effects
Nausea, vomiting, decreased appetite, headache, dizziness, fatigue, anxiety.
Examples of drug interactions
Opioid medications (blocks action).

28. Naltrexone Naltrexone (Depade®, ReVia®) Usual adult dosage
Naltrexone
(Depade®, ReVia®)
Usual adult dosage
Oral dose: 50 mg daily.
Before prescribing: Patients must be opioid-free for a minimum of 7 to 10 days before starting. If you feel that there’s a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function.
Action
Blocks opioid receptors, resulting in reduced craving and reduced reward in response to opiates.
Contraindications
Currently using opioids or in acute opioid withdrawal; anticipated need for opioid analgesics; acute hepatitis or liver failure.
Must be opioid free for 7-10 days.

29. Extended-release Injectable Naltrexone
Extended-release Injectable Naltrexone
(Vivitrol®)
Usual adult dosage
IM dose: 380 mg given as a deep intramuscular gluteal injection, once monthly.
Before prescribing: Same as oral naltrexone, plus examine the injection site for adequate muscle mass and skin condition.
Action
Same as oral naltrexone
Contraindications
Same as oral naltrexone, plus inadequate muscle mass for deep intramuscular injection; rash or infection at the injection site.

30. Methadone Methadone Precautions
Methadone
Precautions
Caution for increased risk of overdose when used in combination with benzodiazepines.
Serious adverse reactions
Respiratory depression, sedation, prolonged QTc
Common side effects
Hyperhidrosis, sexual dysfunction, dental problems related to decreased saliva

31. Methadone
Usual adult dosage
Starting dose 30mg, not to exceed 40mg in first day. Usual daily dose mg.
Action
Full opioid agonist, reduces cravings and withdrawals
Contraindications
Hypersensitivity to methadone; patients with respiratory depression; paralytic ileus; high risk for diversion; at risk for prolonged QT interval.

32. Buprenorphine Buprenorphine Precautions
Buprenorphine
Precautions
May cause precipitated withdrawal if taken with opiate.
Serious adverse reactions
Precipitated withdrawal
Common side effects
Constipation, nausea, hyperhidrosis, dental problems related to decreased saliva

33. Buprenorphine
Usual adult dosage
Must be in mild to moderate withdrawal prior to first dose.
Initial dose 2-4mg, increase in increments of 2-4mgs.
Usual daily dose 8mg/day, up to 16mg/day. (FDA limit 24mg/day)
Action
Partial opioid agonist
(Suboxone= partial agonist + antagonist)
Contraindications
Hypersensitivity to buprenorphine or naloxone; severe hepatic impairment.

34. COWS 5-12: mild 13-24: moderate 25-36: moderately severe
>36: severe withdrawal
When you google image search COWS opiates

35. COWS

36. Opioid Withdrawal

37. Opioid Overdose
Naloxone

38. Naloxone Intranasal (generic and branded Narcan)
Covered by Medicaid without PA
Branded Narcan $ cash price
Generic naloxone $14-21 cash price
Intramuscular (generic)
$22.22 per 1mL vial cash price (LifePath)
Auto-injector (branded Evzio)
Cash price $360
$0 out-of-pocket for commercial insurance (PAP direct delivery service) or Medicaid-eligible
Not Medicaid covered (yet)

40. Sarah 24yo woman, began using prescription opiates at age 16
Progressed to IV heroin use by age 21
BZDs and ETOH on occasion
Outpatient treatment – unsuccessful
Inpatient detox – remained sober 3 weeks
No significant medical history
What’s the plan?
Trial of naltrexone

41. Jaime 27yo male, began using opiates at age 21
Began selling drugs and burglarizing homes to support opiate addiction at age 24
Court mandated inpatient treatment x3
Hep C positive, elevated LFTs
What’s the plan?
Suboxone or methadone?

42. Felicia 18yo woman, 6 months pregnant with her second child
IV heroin user
CPS involved after the birth of her first child and has referred her to seek SUD treatment
Currently in therapy for past trauma
What’s the plan?
Methadone- inpatient treatment

43. Robert 47yo man, started taking Norco 11 years ago after a back injury
Now “doctor shopping” to obtain duplicate prescriptions for opiate medications
IOP x4 over the past 6 years
Professional career, worries he can’t come to daily methadone clinic
Continues to struggle with chronic pain
Suboxone

44. Resources PCSSMAT.org SAMHSA ASAM.org
ASAM.org