1. S UBOXONE, M ETHADONE, V IVITROL AND ITS R OLE IN O PIATE A DDICTION T REATMENT Bradford Health Services OUTPATIENT DETOXIFICATION

2. H ISTORY OF O PIATE T REATMENT Abstinent Model – Treated opiate addicts like alcoholics and cocaine addicts Maintenance Model - Initially used to address Heroin addiction and control undesirable outcomes of Heroin addiction. “Harm Reduction” Model – More recent, uses Suboxone, measures success on reduction of incidents criteria, tries not to be maintenance, but it is.

3. M ETHADONE Developed in Germany in 1937 as a reliable source of opiate pain reliever for the future. Introduced in United States in 1947 by Eli Lilly. Used for managing chronic pain. Mainly used in treatment of opiate dependence, shown not to reduce crime, mortality rate and costs to society of Heroin addiction. Decreases likelihood Heroin dependent patient will use Heroin. (Mattick, Courtney, et.al. 2012, Wiley Online) Tolerance/dependence develops.

4. M ETHADONE C LINICS States allow 3 to 30 days supply to go home after a period of observation. Methadone Clinics – Crime does not increase around a methadone clinic. (University of Maryland, 2012) Communities do not like them. Still the most effective treatment for chronic Heroin addiction but is losing ground rapidly to:

5. S UBOXONE Buprenorphine and Naloxone combined. Buprenorphine is a semi synthetic Opioid. Naloxone is an opiate inverse agonist. It counters the effect of opiate overdose. Carried by paramedics to use on OD’s. The Naloxone is designed to deter the abuse of the medication by injection. Still abused by injection and oral use on the street as the Naloxone is not strong enough to prevent abuse in non-tolerant individuals.(Stoller, Bigelow, Strain, Psychopharmacology, 2001)

6. S UBOXONE C LINICS Just went generic, so costs are going down. Patients report more functionality over Methadone. Clinics are in physician practice groups. 100 per physician, number per physician is changing soon. Many, many clinics in the Southeast. 500 per month prescriptions in one pharmacy in Birmingham. Buprenorphine most often abused by crushing table and snorting it. So, now there is film. 2007 Sweden confiscated more Buprenorphine than cocaine, ecstasy and heroin combined. Reindeerspotting (Finnish Subutex abuse video)

7. V IVITROL Extended release formulation of Naltrexone, an opioid receptor antagonist. A shot, once a month. Expensive Blocks craving and effects of use. Pill form Naltrexone has very poor compliance.

8. D EATHS FROM O VERDOSE

9. N EWBORN IN W ITHDRAWAL Graph Continues to climb….

10. D EATH RATES BY T YPE AND U RBAN L OCATION

11. S PECIFIC D RUG E PIDEMICS 1970 to 2006

12. A NNUAL N UMBERS ( IN M ILLIONS ) N EW N ON - MEDICAL U SERS OF O PIOIDS (12 OR O LDER )

13. 80’ S - 90’ S - 00’ S - 10’ S T REATMENT F AILURES FOR O PIATE A DDICTION Traditional treatment models have a typical recovery rate between 2 and 5% at one year. (Roman Jovey, MD, Encounter Books, 2006) Other studies show 5 to 10%, generally no higher at one year. Opiate addicts have a mortality rate 15.8 times higher than the general public. (Joe and Simpson, Institute of Behavioral Research, 1990) Traditional treatment was insight based and did not address the brain injury. “How do you feel?”

14. T HE O PIATE P ATIENT WILL : Generally be unable to encode meaningful insights for retrieval for 90 days. Be focused on craving until the brain heals from opiate injury or those cravings are blocked. (Cigarette craving never goes away.) Be afraid of being off their “medicine” to the point of panic. May be unable to remember treatment experience at all after a short period. (story)

15. T HE TYPICAL TRADITIONAL TREATMENT COUNSELING PROFESSIONAL WILL : In the first 30 days of treatment: Believe the patient will have lasting benefit from GROUP. Believe the patient will lasting benefit from INDIVIDUAL. Believe treatment planning should be based on the barriers to recovery identified in the P/S. Not be fully aware that additional medications are adding to the problem and further complicating the patients transition to abstinence. Do not understand and accept the degree of Brain injury caused by Opiates. Do 90 in 90 as a discharge plan.

16. W HAT TO D O ? Accept that Methadone Maintenance is the best way? Accept that Suboxone/Subutex Maintenance is the best way? Believe Vivitrol will give the patient time to heal? Continue to treat Opiate addicts as we have for the last 30 years? Change our thinking about Opiate treatment.

17. A DDICTION P ROFESSIONALS Like predictable things. Don’t mind living in a rut, in fact, they carpet their ruts and move furniture in. Often have rigid beliefs. Like anyone else, they generally fear change. Especially if it involves medication.

18. H OW TO USE V IVITROL AND S UBOXONE IN THE A BSTINENT M ODEL. Accept: Extended detox is not maintenance. Accept: Individuals who were abusing Suboxone can be detoxed using Suboxone. Accept: Detox for an Opiate addict takes weeks, at least. Some physicians and institutions believe detox should last as long as 6 months to a year or two. (Promotion of additional addiction?)

19. T HE M ODEL Initial detox at a residential facility to cover other drugs of abuse. If opiate only, direct to IOP Opiate detox facility. The patient begins a taper on Suboxone or Subutex. Cravings diminish. The patient is more open to hearing, maybe not retaining, but hearing. Concentrate on acceptance of duration and addiction as identified barriers to recovery. (Treatment Plans)

20. T HE M ODEL The patient transitions to a Outpatient licensed detox facility. Enrolls in the Outpatient program and the Detox program. The patient continues the Suboxone taper. 4 to 8 weeks, while in the outpatient program. Treatment planning continues to be focused on accepting what is required to recovery from opiates….Duration and Acceptance.

21. T HE M ODEL The patient either finishes the IOP or ends the taper. The patient is continued in the Outpatient Detox program, usually one day per week. The 7 to 10 day period after the last dose of Suboxone until Vivitrol can be administered is the crossroads. A meaningful therapeutic relationship where gains can be maintained is crucial at this and future moments in treatment. Use of something like Clonidine and Trazadone will help get through the 7 to 10 days and address the patients need for “medication”

22. T HE M ODEL The patient gets Vivitrol shot. It’s scary. The patient returns to the facility weekly for group, nurse assessment, individual and education. The patient is encouraged to take the second shot by staff and other patients who have “been there”. A minimum of 3 and a goal of 12 or more shots.

23. T HE M ODEL At this point, a sponsor and a home group should be in place, and are required for outcomes. The patient is worked and worked to continue to see the benefits of the shot, Motivation Interviewing works well here. Family is brought in to sessions to comment on improvements they have seen. Barrier is still acceptance of duration and addiction.

24. F INAL T HOUGHTS Typical Addiction Staff will resist this type of treatment, both referring and program start. There are challenging financial implications We are in our preliminary outcome data seeing substantial improvements in recovery rates at one year for those patients that get at least 3 shots. Without a sponsor and home group, most who discontinue Vivitrol in under 1 year of use will relapse.