1. Monitored Abstinence Martin H. Plawecki MD, PhD Indiana University School of Medicine Department of Psychiatry Alcohol Medical Scholars Program

2. Introduction Many diseases are chronic, relapsing and remitting Controlled, not cured Examples Type I diabetes: 30-50% relapse rate High blood pressure: 50-70% relapse rate Substance use disorders (SUDs): 40-60% relapse rate © Alcohol Medical Scholars Program2

3. Goals of SUD Treatment Harm reduction Abstinence Abstinence monitoring has a role in both © Alcohol Medical Scholars Program3

4. This Lecture Covers Definition/course of Substance Use Disorders (SUDs) Treatments, including with monitored abstinence Methods of monitoring abstinence Efficacy of monitored abstinence © Alcohol Medical Scholars Program4

5. This Lecture Covers Definition/course of Substance Use Disorders (SUDs Definition/course of Substance Use Disorders (SUDs) Treatments, including with monitored abstinence Methods of monitoring abstinence Efficacy of monitored abstinence © Alcohol Medical Scholars Program5

6. Substance Use Disorder In Same Year, ≥2 of: Tolerance Withdrawal Use longer/more Unable to ↓ Lots time use ↓ Activities Use despite probs Craving © Alcohol Medical Scholars Program6 Failed roles Hazardous use Social problems

7. Remission and Relapse Remission Early: no symptoms ≥ 3 months but < 1 year Sustained: no symptoms ≥ 1 year Relapse: back to problematic substance use © Alcohol Medical Scholars Program7

8. Substance Use Disorder © Alcohol Medical Scholars Program8 Abstinence Controlled Use Problems

9. Post Recovery © Alcohol Medical Scholars Program 9 >26 % 7 % Within 3 years

10. This Lecture Covers Definition/course of Substance Use Disorders (SUDs) Treatments, including with monitored abstinence Methods of monitoring abstinence Efficacy of monitored abstinence © Alcohol Medical Scholars Program10

11. Treatment General treatments 12-step programs: Alcoholics Anonymous (“AA”) Cognitive behavioral treatment (CBT) Alcohol Rx meds examples Naltrexone Acamprosate Opioid Rx meds examples Naltrexone Buprenorphine Methadone (to be discussed below) Many treatments include abstinence monitoring © Alcohol Medical Scholars Program11

12. 12 step programs (e.g., Alcoholics Anonymous) Goal: commonly abstinence Self-help recovery group Very common: ~50 meetings/day in Indianapolis Difficult to study given program nature AA keeps people in and accepting of intervention Limited-unequivocal evidence for ↑abstinence © Alcohol Medical Scholars Program12

13. Cognitive Behavioral Therapy: (The Core of Rehab Rx) ↓ Dysfunctional thinking Substitute rational thoughts Relapse prevention Anticipate triggers Learn to cope w/triggers Change behaviors Evidence for ↓drinking/use, ↑abstinence © Alcohol Medical Scholars Program13

14. Alcohol Rx - Naltrexone Goal: reduce drinking Thought to reduce enjoyment of alcohol Daily and long-acting injectable forms Reduces drinking Return to heavy drinking ↓17% Return to any drinking ↓4% → ↑abstinence Drinking days ↓4% © Alcohol Medical Scholars Program14

15. Alcohol Rx - Acamprosate Goal: reduce drinking Thought to reduce withdrawal Oral only (3x/Day) Reduces drinking Return to heavy drinking ↓1% Return to any drinking ↓14% → ↑abstinence Abstinence duration ↑11% © Alcohol Medical Scholars Program15

16. Opioid Rx - Naltrexone Goal: commonly abstinence Blocks all opioid highs Daily and long-acting injectable (LAI) forms Not well accepted by patients → high drop out May be especially useful for docs, nurses, etc Daily – some evidence for ↑abstinence, ↑ Rx LAI - emerging Data for ↓ heroin, ↑abstinence, ↑ Rx © Alcohol Medical Scholars Program16

17. Opioid Rx – Buprenorphine Maintenance Goal: abstinence (harm reduction) Long-acting opioid replaces short-acting heroin Daily medication Increases treatment acceptance - ↑50% Decreases heroin and morphine usage ↓17% vs placebo, ↓11% vs methadone Dose dependent effect (↑dose → ↑results) © Alcohol Medical Scholars Program17

18. Methadone Maintenance Goal: ↓ health risk, ↓ crime, ↑ family/job Replacement: Methadone vs heroin Lasts >24hours → 1x/day dosing Allows work; avoids withdrawal and prevent “high” Cheaper & from clinic → ↓ risky bx, ↓crimes Highly structured and federally regulated Administer methadone daily, usually at clinic Monitor for abstinence – urine drug screens Requires counselling © Alcohol Medical Scholars Program18

19. Court Mandated Rx Goal: ↓ drug use → ↓ crime Links highly structured Rx to legal system Residential and outpatient treatment Random urine drug screens Routine judicial interaction and progress monitoring Success → avoid jail Failure→ ↑ Monitoring frequency/intensity ↑ Punishment up to jail © Alcohol Medical Scholars Program19

20. Physician Health Programs Goal: ↓ patient harm Links highly structured Rx to medical license Residential and outpatient treatment Random urine drug screens +/- Random office visit ≥5 Yr follow-up Success → practice medicine, keep job Failure → Treatment, ↑monitoring frequency/intensity Referral to medical licensing board © Alcohol Medical Scholars Program20

21. Chronic Pain Management Goal: control pain, minimize substance misuse Adherence monitoring and risk minimization Explicit behavior agreements Estimate risk Use difficult-to-abuse medications Rx drug monitoring programs Urine drug screens Success → continue in program Failure → lose access to prescription opioids © Alcohol Medical Scholars Program21

22. This Lecture Covers Definition/course of Substance Use Disorders (SUDs) Treatments, including with monitored abstinence Methods of monitoring abstinence Methods of monitoring abstinence Efficacy of monitored abstinence © Alcohol Medical Scholars Program22

23. Monitoring Abstinence - Breath Advantages Easy, non-invasive Cost – reusable device Disadvantages Must be done properly Possibly non-specific © Alcohol Medical Scholars Program23

24. Monitoring Breath Alcohol & Nicotine Breath alcohol concentration Alcohol is water soluble -> appears in the breath Electrochemical detection (burns alcohol) Deep breath is proportional to blood level Detects low alcohol concentration (1 drink in last hour) Nicotine Carbon monoxide (CO) from burning tobacco in breath Electrochemical detection (burns CO) Detected up to 2 days; “smoker” sensitivity < 10 hours © Alcohol Medical Scholars Program24

25. Monitoring Abstinence - Urine Advantages Easy to obtain/non-invasive Detection via specific antibodies Common and inexpensive Disadvantages Positive test → expensive replication Replication takes weeks to get results Specific drugs detected for different time lengths Cheating © Alcohol Medical Scholars Program25

26. Monitoring Abstinence - Urine Urine drug screen Specific antibody screening for substances/byproducts Many substances can be screened in a single test © Alcohol Medical Scholars Program26

27. Times for Useful Urine Monitoring Opioids – 1-3 days Cannabinoids Single use – 3 days Daily – 10-15 days Heavy – >30 days Amphetamines – 2 days Detection Times Cocaine – 2-4 days PCP – 8 days Alcohol – ¼ - ½ day Sedatives Short-acting – 3 days Long-acting – 30 days © Alcohol Medical Scholars Program27

28. A Problem With Urine Monitoring Cheating Adulterants - substances added to urine sample Dilution - intentional fluid over-ingestion Substitution - use of another’s, old, or synthetic urine False attribution - claimed use of one to hide another © Alcohol Medical Scholars Program28

29. Monitoring Abstinence - Blood Advantages Highly specific → confirm other tests Difficult to cheat, low false positives Direct and indirect measurements possible Disadvantages Invasive – requires a blood draw Expensive – includes testing and procedure fees © Alcohol Medical Scholars Program29

30. Monitoring Blood Alcohol and Cannabis Alcohol: Blood Alcohol Concentration Direct detection of alcohol Limited to recent consumption only Alcohol: Carbohydrate deficient transferrin (CDT) Indirect marker - ↑ alcohol > 2 wks → ↑ CDT Timing: abstinence → ↓ CDT in 2-5 weeks Cannabis Direct detection of cannabinoids Acute use: peaks in minutes, ↓ 0 for 1 day Chronic: detectable up to 30 days © Alcohol Medical Scholars Program30

31. Monitoring Abstinence - Electronic Advantages Continuous monitoring Data can be monitored remotely Disadvantages Intrusive and highly visible Expensive Optimized for forensics © Alcohol Medical Scholars Program31

32. Electronic Monitoring - Scram Alcohol → sweat Samples every 30 minutes Automatic alerts Tamper Resistant Cost Lease: $6-8/day lease Purchase: $1,400-1,800 + $5/day © Alcohol Medical Scholars Program32

33. This Lecture Covers Definition/course of Substance Use Disorders (SUDs) Treatments, including with monitored abstinence Methods of monitoring abstinence Efficacy of monitored abstinence Efficacy of monitored abstinence © Alcohol Medical Scholars Program33

34. Efficacy of Monitored Abstinence Methadone clinic 3x ↑ Remain in Rx vs no opiate replacement 2/3x ↓ Positive opioid hair/urine samples 2 ½x ↓ Crime involvement Chronic Pain Management Urine drug testing → ↓ illicit drug usage ↑ Urine drug tests → ↑ prescription adherence ↑ Urine drug tests → ↓ non-prescribed medications © Alcohol Medical Scholars Program34

35. Efficacy of Monitored Abstinence Court mandated Rx 12% ↓ Criminal relapse No clear effect on SUD outcomes Difficult to quantify Highly variable population Different Rx approaches/referral networks Physicians health programs Only ~20% w/ positive UDS at any time during 5 yrs 70-80% Physicians still licensed/employed at 5 yrs © Alcohol Medical Scholars Program35

36. Summary SUDs are chronic relapsing/remitting conditions Interventions can include abstinence monitoring Monitoring - chemical and electronic forms Monitored abstinence → better outcomes © Alcohol Medical Scholars Program36

37. Resources Alcoholics anonymous – www.aa.org Narcotics anonymous – www.na.org Scram Systems – www.scramsystems.com Opioid risk tool - www.opioidrisk.com/node/884 © Alcohol Medical Scholars Program37

38. Questions © Alcohol Medical Scholars Program38