“…treatment for a substance use disorder that includes a pharmacological intervention as part of a comprehensive substance use treatment plan...”
(Addiction Technology Transfer Center, 2017)
MAT defined…
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Added narration: “Medication-Assisted Treatment, or MAT, includes the treatment of a substance use disorder with a medication, or medications, as part of a larger substance abuse treatment plan that is also inclusive of more traditional forms of treatment, such as psychotherapy.”
Substance abuse treatment which combines medication with
behavioral therapies has been shown to be more effective than
treatment with behavioral therapies alone.
(Centers for Disease Control & SAMHSA Joint Bulletin, 2014)
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Added narration: “Substance abuse treatment that is inclusive of medications and behavioral therapies, has been shown to be more effective than behavioral therapies alone.”
how MAT works
eases withdrawal symptoms
reduces cravings
induces illness when substance is ingested
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Added narration: “Medications to treat substance use disorders work in one or more of these three ways. Some medications work to ease withdrawal systems, while others assist with cravings, while some medications help to control both withdrawal symptoms and cravings. Some, but fewer medications, work by inducing illness when the substance of choice is ingested.” Take out 3rd bullet ; make specific to Antabuse
improved treatment retention
improved functioning
lower risk of overdose
reduced criminal activity
reduced substance use
increased rates of employment
benefits of MAT
why MAT for problem solving courts?
• MAT is consistent with best-practice for substance use disorder treatment
• MAT has demonstrated reductions in criminal activity
• MAT can result in improved occupational functioning
• Those involved in the criminal justice system often have a more advanced stage condition (e.g. a severe substance use disorder) which may necessitate medication
NADCP – Best Practice Standards
“Medically assisted treatment can significantly improve outcomes for offenders. Buprenorphine or methadone maintenance administered prior to and immediately after release from jail or prison has been shown to significantly increase opiate-addicted inmates’ engagement in treatment; reduce illicit opioid use; reduce arrests, technical parole violations, and reincarceration rates; and reduce mortality and hepatitis C infections.”
National Association of Drug Court Professionals (2013). Adult drug courtbest practice standards (Vol. 1). Alexandria, VA: author.
part 2: myth-bustingclarifying common misconceptions surrounding medication-assisted treatment
Misconceptions regarding MAT has led to underutilization,
depriving those with substance use disorders of medications that may enhance treatment outcomes
and reduce the probability of premature death.
(Knudsen, Abraham, & Roman, 2011; Volkow et al., 2014)
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Additional narration: “There are many misconceptions surrounding MAT, including within the behavioral health field. This often leads to under-utilization, with fewer providers prescribing MAT or making appropriate referrals for MAT. This can deprive patients of critical life-saving medications, particularly those patients at high risk for fatal overdose.” *Yuna, I’m sure there is a better way to present this notion. Currently the slide is very texty. Feel free to reformat.
myth #1: MAT is just replacing one drug with another.
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There are many myths surrounding medication-assisted treatment
bipolar disorder
hypertensionanxiety
schizophrenia
depression
cancer
diabetes post-traumatic stress
medications are used to treat most health and behavioral health conditions
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“Many health and behavioral health conditions occur due to some combination of behavior, life events and genetic susceptibility. The treatment of the below conditions often involve behavioral interventions, education or psychoeducation, therapy and medications. Medications associated with most of these conditions are not stigmatized or as highly stigmatized, compared to medications for substance use disorders.”
MAT vs. illicit drugsprescribed/monitored by a medical provider
FDA-approved
regulated potency
curbs cravings and withdrawal symptoms
obtained by illegal means
not legally permitted
potency varies
results in euphoria or a “high”
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Added narration: “While medication-assisted treatment may activate the same areas of the brain as some illicit drugs, there are stark differences between the two. MAT is prescribed and monitored by a prescriber, while illicit drugs are obtained via illegal, and sometimes dangerous, methods, and are not medically monitored. MAT medications are FDA-approved, meaning they have been shown to be efficacious and the potency of the medication is tightly regulated, while the potency of illicit drugs can vary greatly, and can lead to accidental overdose. Lastly, MAT medications work to diminish cravings and withdrawal symptoms, while illicit drugs result in a high or euphoria. When dosed properly, MAT medications should not result in euphoria.”
addiction vs. dependencecompulsive use
continued use despite consequences
using a substance to get “high”
physiologically reliant on a medication
dependence on medications is common (e.g. insulin, benzodiazepines, antipsychotic medications)
utilize the medication to feel well
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Added narration: “Concerns are often raised regarding MAT, stating patients are merely replacing one drug with another or that one will become “addicted” to their medication. However, the concepts of addition and dependence are often misunderstood. Addiction involves compulsive use and seeking out of a drug or alcohol, continuing to use despite negative consequences, and using a substance to obtain a high or euphoria. Dependence, however, is when one is physiologically dependent on a substance or experiences withdrawal symptoms when attempting to stop the medication. Dependence on medications is common, and can occur with medications for physical health conditions, such as diabetes medications, psychotropic medications, and others. When one is dependent on a medication, they utilize the medication to feel well, rather than to achieve euphoria, like we see with the addiction process.”
myth #2: MAT doesn’t work.
to be approved by the FDA, medications must be shown to be safe, but also effective
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Possible narration: “The medications reviewed later in this module are FDA approved to treat substance use disorders. To be FDA approved, medications must be shown to be, not only safe, but also effective, concerning their regarded purpose.”
treatment outcomes for buprenorphine/ naloxone
increased treatment retention
decrease in self-reported cravings
decreased illicit opioid use
(Bart, 2012)
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Added narration: “Patients utilizing buprenorphine/naloxone (or Suboxone) for an opioid use disorder, have been shown to stay in treatment longer, report a decrease in cravings (which is often associated with relapse), and demonstrate reductions in their illicit opioid use.”
24buprenorphine clinical trials
4,500patients with opioid use disorders
buprenorphinewas significantlymore effective at reducingillicit opiate usethan placebo
(Mattick, Kimber, Breen & Davoli, 2008)
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Large meta-analysis of buprenorphine
treatment outcomes for methadone
increased treatment retention
decreased illicit opioid use
8-10 fold decrease in drug-related deaths
increase in employment rates
decrease in criminal activities
(Bart, 2012; Degenhardt et al., 2009; Marsch 1998)
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Is there someway to incorporate this quote from Bart (maybe on a new slide, following this slide)? “Extensive literature and systematic reviews show that maintenance treatment with either methadone or buprenorphine is associated with retention in treatment, reduction in illicit opiate use, decreased craving, and improved social function.” Bart, G. (2012). Maintenance Medication for Opiate Addiction: The Foundation of Recovery. Journal of Addictive Diseases, 31(3), 207–225. http://doi.org/10.1080/10550887.2012.694598
increased likelihood for abstinence; reduced risk of relapse
(Streeton, Whelan, & Streeton, 2001)
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Added narration: “Medications used to treat alcohol use disorders, like medications for opioid use disorders, have been found to reduce consumption.”
myth #3: If someone is abstinent, they don’t need MAT.
drug overdose is one of the leading causes of death for individuals being released from
prison or jail(Binswanger et al., 2007)
those leaving detoxification facilities are at high risk for accidental overdose given reduced tolerance
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Replace with CJ image
myth #4: MAT is too expensive
many MAT medications can be found on state Medicaid/Medicare formularies
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Add local AHCCCS info; check formulary
for those who do not qualify for Medicaid or Medicare many patient assistance programs are available through the medication manufacturers
part 3: the medicationsuses and considerations
currently there are FDA-approved medications for:
-opioid use disorders-alcohol use disorders
There are currently no FDA-approved medications for stimulant use disorders.
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Added narration: “We will review medications to treat alcohol use disorders and opioid use disorders. All medications reviewed in this module are FDA-approved to treat substance use disorders.”
opioid medications
“With opioids there is a small window between euphoria and death.”
--The National Alliance of Advocates for Buprenorphine Treatment
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Added narration: “Medications to treat opioid use disorders are critical given the high risk of accidental overdose from illicit opioids and the misuse of prescription opioids.”
42,249 prescription and illicit opioid-related fatal overdoses in 2016
(Centers for Disease Control, 2017)
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Added narration: “In 2016, there were more than 42,000 opioid-related overdoses, 40% of which involved prescription opioids.”
116 Americans die each day from an opioid overdose
(Centers for Disease Control Mortality & Morbidity Weekly Report, 2016)
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Added narration: “More than one hundred Americans die each day from opioid overdoses.”
nearly half of all opioid overdoses involve a prescription opioid
(Centers for Disease Control, 2017)
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40% - see slide 35
3 out of 4 new heroin users report using
prescription opioids prior to commencing heroin
(Centers for Disease Control, 2017)
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As we’ve made strides in prescription drug misuse prevention, via PDMPs, etc. some have transitioned to heroin. Often easier to obtain and more economical.
medications for opioid use disorders
methadone
buprenorphine
naltrexone
how do opioids work?
dose of opioid
opioideffect
full agonist(e.g., methadone)
(e.g. naloxone)antagonist
partial agonist(e.g. buprenorphine)
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Added narration: “The chart pictured here shows more different medications to treat opioid use disorders work. The x axis represents the dose of the medication, while the y axis represents the opioid effect. Full agonists, such as methadone, act on opioid receptors. Higher doses will result in an increased opioid effect. Partial agonists, act on and block opioid receptors, such as buprenorphine/naloxone. This results in a ceiling effect. While antagonists, like naloxone and naltrexone, block opioid receptors. These medications will be discussed in more detail in a moment. Understanding how a medication works can ensure the patient is prescribed the most useful medication for their past and current pattern of opioid use.”
mechanism: full agonist (acts on opioid receptors), alleviates withdrawal symptoms & cravings
pros affordable, long half-life allows for once daily dosing, liquid dose prevents diversion, FDA-approved for pregnant womencons risk of overdose when combined with other substances
methadone (Methadose®, Dolophine®)
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This information (below) is not in the slide. Perhaps it can be additional narration or pop-ups *Methadone is one of the most highly regulated medications *A daily liquid dose administered in an Opioid Treatment Program, or OTP, allows for regular contact and observation of the patient *Given its full agonist status, intoxication and overdose is possible with methadone, but take home doses are not common for new patients *Federal panels have found the majority of methadone overdoses occur with pain patients on tablet forms of methadone, not those receiving methadone maintenance in a methadone clinic
mechanism: partial agonist - blocks euphoric effects of opioids, alleviates withdrawal symptoms, assists with cravings
pros better safety profile than methadone, available in a sublingual film, naloxone discourages misuse cons ceiling effect may provide insufficient therapeutic effect for those with longer term opioid use disorders
• once a month injectable buprenorphine• approved by the Food and Drug
Administration in November 2017• for moderate-severe opioid use disorders
pros demonstrates initial promise in reducing illicit opioid use; improved compliance due to injectable formulation; reduced risk for diversion
cons cost ($1,500/month); additional study on long term outcomes needed
buprenorphine extended-release (Sublocade®)
mechanism: full antagonist (blocks opioid receptors)
pros prevents euphoric effects of opioids; non-addictive; extended release injectable availableconsnon-adherence; mood disruptions; extended release injectable very costly; poor to little control of cravings
naltrexone (Depade®, ReVia®, Vivitrol®)
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Vivitrol manufacturers – Alkermes 7-14 abstinence
alcohol medications
medications for alcohol use disorders
naltrexone
acamprosate
disulfiram
mechanism: blocks the pleasurable effects of alcohol; reduces alcohol cravings
pros can be used for alcohol & opioid dependence, non-addictive, reduces drinking episodes & volume, extended release available
cons non-adherence
naltrexone (Depade®, ReVia®, Vivitrol®)
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Added narration: “Because naltrexone is non-addictive/non-habit forming, noncompliance can occur as one can merely stop the medication abruptly without withdrawal symptoms.”
mechanism: assists in post-acute withdrawal symptoms (e.g. irritability, anxiety, agitation)
pros non-addictive, can assist in maintaining abstinence, not easily abused/misused, affordable
cons requires 5 days of abstinence to commence treatment
acamprosate (Campral®)
mechanism: causes physical illness following alcohol consumption
pros non-addictive, affordable ($80/mos), useful with severe alcohol use disorders
cons non-adherence, risk of death for those with certain pre-existing health conditions
disulfiram (Antabuse®)
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Added narration: “Disulfiram, an older medication, is often utilized in community corrections settings, for those with severe alcohol use disorders who have difficulty maintaining abstinence from alcohol on their own. The medication may be administered via watch swallow for increased adherence. The medication works as a deterrent, as patients taking disulfiram become physically ill when ingesting alcohol.”
medications to prevent overdose
mechanism: full antagonist (blocks opioid receptors)
• used to reverse opioid overdose• family members, friends or first responders
can administer• will not cause harm if person is not
experiencing an opioid overdose • nasal & auto-injectors
available
naloxone (Narcan®, Evzio ®)
part 4: MAT referral processidentifying appropriate candidates and locating providers
Consider referrals for medication-assisted treatment (MAT) assessment for defendants with severe substance use disorders or those experiencing physiological dependence.
best practice
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1) Make individuals aware of all tx options at their disposal; 2) make them aware sooner rather than later
those experiencing physiological dependence
those with a severe substance use disorder
unsuccessful with behavioral therapies alone
openness to try MAT
Which specialty court participants are good MAT candidates?
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Speak to this in the context of specialty court candidates
medical professionals will make the ultimate determination around eligibility…
The Substance Abuse and Mental Health Services Administration’s buprenorphine physician locator and Opioid Treatment Program (OTP) locator can be utilized to identify providers in your area.
www.samhsa.gov/medication-assisted-treatment
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Added narration: “Utilize SAMHSA’s opioid treatment program locator and buprenorphine physician locator to identify MAT prescribers in your practice area. These SAMHSA locators allow you to search by city and state, or zipcode.” Yuna, these are the 2 pages within that website we want to drive them to: Opioid Treatment Program locator: http://dpt2.samhsa.gov/treatment/directory.aspx Buprenorphine provider locator: https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator
AZ treatment provider locator: www.substanceabuse.az.gov
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Added narration: “Utilize SAMHSA’s opioid treatment program locator and buprenorphine physician locator to identify MAT prescribers in your practice area. These SAMHSA locators allow you to search by city and state, or zipcode.” Yuna, these are the 2 pages within that website we want to drive them to: Opioid Treatment Program locator: http://dpt2.samhsa.gov/treatment/directory.aspx Buprenorphine provider locator: https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator
Thank you!
Adrienne Lindsey, MA, DBHPrincipal Manager, Interprofessional Training & Curricula