Comprehensive Medication Assisted Treatment

Presented by: Michael Weaver, MD and Don Hall, LCDC

April 25, 2018

Thomas Durham, PhD

Director of Training

NAADAC, the Association for Addiction Professionals

www.naadac.org

tdurham@naadac.org

Produced By

NAADAC, the Association for Addiction Professionalswww.naadac.org/webinars

www.naadac.org/webinars

www.naadac.org/comprehensive-MAT-webinar

Cost to Watch:

Free

CE Hours

Available:

1.5 CEs

CE Certificate for

NAADAC

Members:

Free

CE Certificate for

Non-members:

$20

To obtain a CE Certificate for the time you spent watching this

webinar:

1. Watch and listen to this entire webinar.

2. Pass the online CE quiz, which is posted at

www.naadac.org/comprehensive-MAT-webinar

3. If applicable, submit payment for CE certificate or join

NAADAC.

4. A CE certificate will be emailed to you within 21 days of

submitting the quiz.

CE Certificate

Using GoToWebinar – (Live Participants Only)

Control Panel

Asking Questions

Audio (phone preferred)

Polling Questions

Webinar PresentersYour

Michael Weaver, MD, DFASAM

Professor & Medical Director,

Center for Neurobehavioral Research on

Addiction

UTHealth McGovern Medical School

Don Hall LCDC, CPT

Adult Rehabilitation Services, SEARCH

Webinar Learning Objectives

LO #1 Recognize

how long-term

pharmacotherapy

fits into the context

of overall addiction

treatment.

LO #2 Describe types

of pharmacotherapy

for smoking cessation,

alcohol dependence,

and opioid addiction.

LO #3 Learn tasks

specific to working with

Medication Assisted

Treatment clients.

1 32

• Nicotine

Replacement

Others (prescription)

• Alcohol

Aversive

Reduce cravings

Reduce fun effects

• Opioids

Antagonist

Agonists

Types of

Medication-Assisted Treatment

• Always combine with a

behavioral therapy

program

• Most available OTC,

but all are expensive

• Reduces harmful

effects of tobacco

smoking

• Patients should not

smoke while using

Nicotine Replacement

Therapy

• There have been many studies

and several meta-analyses of all

products

• Nicotine replacement therapy quit

rates are similar with different

products

Doubles chance of successful

quitting

• Combinations are more effective

than a single product at a time

Efficacy of Tobacco

Cessation Products

• Varenicline

• Higher rate of continuous

tobacco abstinence compared

to bupropion & nicotine patch

• Bupropion

• Quit rates are comparable to

nicotine patch

• Disulfiram (Antabuse) Alcohol antagonist, person will get ill if they drink while it is in their system. Often used as aversion therapy.

• Acamprosate (Campral) prescribed with counseling and therapy. Mechanism is not fully understood.

• Naltrexone (ReVia, Vivitrol) as used in the Sinclair method was shown to reduce levels of abusive drinking by 70 – 80% over time.

Pharmacotherapy for

Alcohol Dependence

There have been many studies and several

meta-analyses of all products

• NaltrexoneInjection: drinking by 25% more

than placebo

Pills: risk of heavy drinking by 17%

more than placebo

Efficacy of AUD

Pharmacotherapy• Acamprosate

• drinking by 14% more than

placebo

• Better for maintenance of

abstinence than initiation if not

abstinent

• Disulfiram

• Longer time to 1st drink

compared to other meds

• Reduced overall drinking

• Only when monitored

• Less benefit when not monitored

Depo-Naltrexone

and Alcohol Use Disorder

Antagonist

maintenance◦Naltrexone

Opioid maintenance◦Methadone

◦Buprenorphine

Opioid Addiction Treatments

Part of comprehensive

plan that addresses

psychological, social, &

spiritual needs

Do not use in place of

counseling

Works best in combination

with psychosocial support

Clinical Use of

Pharmacotherapy

• Medication must be taken

consistently to be effective

• Challenging with long-term

pharmacotherapy for

addiction

Many are not immediately

rewarding

• Requires sustained

motivation

Counselors and advocates help

with this

Adherence

• Enhanced recovery

• Reduced mortality70% reduction

Overdose

Trauma

Homicide

Medical illnesses

• Improved healthMedical

Psychiatric

• Improved psychosocial functioningEmployment

Criminal activity

Family responsibilities

Beneficial Effects

If heroin had a warning label…

• Duration of most long-

term pharmacotherapy is

not indefinite

Months to years

• Goal is stabilization

Flexibility

Individualized

Allow for relapse

What is the Endpoint?

• Opioid substitution therapy• Long-acting medication in controlled

settingCounselingSocial services

• Avoid withdrawal & craving

• Harm reductionIndividualSociety

• Single daily dose of the long-acting opioid in a controlled setting

• Highly regulatedNarcotic treatment programs must be licensed

Methadone

Efficacy of Methadone

• There have been many

studies and several meta-

analyses

• Maintenance superior to

detox

• Higher doses (80-100

mg/day) superior to lower

doses (50 mg/d)

• illicit opioid use

• retention in treatment

Buprenorphine

• Alternative to methadone for opioid addiction treatment

• Long-acting opioid agonist-antagonist

• Multiple forms available• Combined with naloxone

(Suboxone, Zubsolv, Bunavail)

• Buprenorphine only (Subutex)

• Detox or maintenance

Efficacy of Buprenorphine• Multiple studies and meta-analyses

• Higher doses (12-16 mg/day) superior to lower doses (6-8 mg/d) to illicit opioid use

• Longer duration of treatment always has superior outcomes to shorter duration

• Few serious adverse events

Methadone or Buprenorphine?

• Treatment efficacy equivalent

• Similar opioid side effects

• Abuse potential• Slightly higher for buprenorphine in opioid non-dependent persons

• Buprenorphine has fewer drug interactions

• Methadone has no ceiling effect

• Buprenorphine more convenient (less restricted)

• Methadone less expensive• Higher cost of buprenorphine, counseling separate cost

• Buprenorphine not age-restricted (can use in teens)

• Individual decision

Methadone or Buprenorphine?

• How “hardcore” a user was the person?

• What is the person’s history with either medication?

• Financial resources

• Time resources

• Buprenorphine is not FDA approved for pregnant women

at this time.

• Person’s attitude toward MAT.

• Family support for MAT.

• Other medical provider’s support for MAT.

MAT Medication Options

For more information, see SAMHSA’s online Decisions in Recovery tool available here:

http://archive.samhsa.gov/MAT-Decisions-in-Recovery/section/whether.aspx

The Efficacy of Opioid Agonist Treatments

Recovery: A process of change through which

individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

Health: Overcoming or managing one’s disease(s)

as well as living in a physically and emotionally healthy way.

Home: A stable and safe place to live.

Purpose: Meaningful daily activities, such as a job,

school, volunteerism, family care taking, or creative endeavors, and the independence, income, and resources to participate in society.

Community: Relationships and social

networks that provide support, friendship, love, and hope.

Medication Assisted Treatment

Medication-assisted treatment is the use of medications,

in combination with

counseling and behavioral

therapies, to provide a whole-patient approach to the treatment of

substance use disorders.

Medication-assisted

treatment for opiate

addiction reflects many

elements of the chronic

care treatment model.

How MAT Fits in

Person in Recovery

An individual can be considered a person in

recovery (PIR) if free from other drugs and non-prescribed medications while participating in MAT (now often referred to as

Medication-Assisted Recovery (MAR).

Recovery Management

• First, recovery management will intensify pre-treatment recovery support services to strengthen the engagement process, enhance motivation for change, and remove environmental obstacles

• Second, recovery management will intensify in-treatment recovery support services to enhance treatment retention and effects.

• Third, recovery management will shift the focus of treatment from acute stabilization to support for long-term recovery maintenance.

Recovery Capital

• Granfield and Cloud (1999) defined recovery capital as “.... the breadth and depth of internal and external resources that can help initiate and sustain recovery from substance use problems”.

• Cloud and Granfield(2009) recently revisited their initial concept and have argued that there are four components to recovery capital:

1 Social capital is defined as the sum of resources that each person has as a result of

their relationships, and includes both support from and obligations to groups to which they belong; thus,

family membership provides supports but will also entail commitments and obligations to the other

family members.

2 Physical capital is defined in terms of tangible assets such as property and money

that may increase recovery options (e.g. being able to move away from existing friends/networks or to

afford an expensive detox service).

3 Human capital includes skills, positive health, aspirations and hopes, and personal

resources that will enable the individual to prosper. Traditionally, high educational attainment and high

intelligence have been regarded as key aspects of human capital, and will help with some of the

problem solving that is required on a recovery journey.

4 Cultural capital includes the values, beliefs and attitudes that link to social

conformity and the ability to fit into dominant social behaviors.

Types of Recovery Capital

Recovery Planning

PIR should be supported in the development of a recovery plan attending to

the four dimensions of wellness and recovery:

- Health: Overcoming or managing one’s disease(s) as well as living

in a physically and emotionally healthy way.

- Home: A stable and safe place to live.

- Purpose: Meaningful daily activities, such as a job, school,

volunteerism, family care taking, or creative endeavors, and the

independence, income, and resources to participate in society.

- Community: Relationships and social networks that provide

support, friendship, love, and hope.

Monitoring for Relapse

• Patient report

• Clinical observation

• Collateral information

• Family

• Other counselors

• Probation officer

• Urine drug screening

• Methadone and to a lesser extent, Buprenorphine

are often stigmatized in many circles.Family

Medical

Police

Work

Support groups

Self

• Methadone and Buprenorphine are protected under

the American with Disabilities Act, and can not be

used as the sole reason for a firing.

• Travel can be a problem. http://www.indro-online.de/travel.htm

Discussion of Stigma and Laws

Summary

• Long-term pharmacotherapy is available and

effective for several Substance Use Disorders

• Medication + counseling = recovery

• Smoking cessation: Replacement Therapy,

Bupropion, Varenicline

• Alcohol Dependence: Disulfiram, Acamprosate,

Naltrexone

• Opiate Dependence: Methadone,

Buprenorphine,Naltrexone

Summary

Medication Assisted Recovery is a practical,

accurate, and non-stigmatizing way to describe a pathway

to recovery made possible by physician-prescribed and

monitored medications, along with other recovery supports,

e.g., counseling and peer support.

Cases for Group Discussion

Case 1

• 45 y/o Black male

• Injecting $200 of heroin daily for 18 mo.

• Began snorting at age 22, injecting for past 20 years

• Multiple detox, residential 5 yrs ago

• Longest clean time was 3 years in prison, relapsed weeks after release

• Occasional cocaine and Vicodin pills bought on the street

Case 2

• 29 y/o White male

• On MM for 4 years, clean for over 3.5 yrs, on take-out

doses for over 2 years

• Off probation, has steady job in landscaping, supporting

wife & son

• Stable on medication for depression, followed by local

psychiatrist

• Wants to come off methadone

Case 3

• 36 y/o Hispanic woman

• Smokes tobacco cigarettes since age 16

• Currently smokes 1½ packs per day

• Tried light cigarettes, just smoked more of them each day

• Occasional use of an electronic cigarette

• Wants help to quit smoking now

Case 4

• 56 y/o White male

• Binges with beer and more mixed drinks on weekends

• Went through detox 3 years ago, but relapsed after a

month

• Occasionally goes to an Alcoholics Anonymous meeting

• Has cravings for alcohol during the week

• Wants to quit drinking because he is worried about liver

damage

Case Resolutions

• 1. Long-term user: suitable for maintenance

• 2. Doing well, wants to come off: taper slowly

• 3. Mult tx approp: NRT, pills; can use nic gum or

lozenge for cravings PRN; e-cig is not for

cessation

• 4. Binge drinker: acamprosate (esp. w/ liver

damage) or NTX appropriate

Questions?

Thank You!

YourMichael Weaver, MD, DFASAM

Professor & Medical Director,

Center for Neurobehavioral Research on

Addiction

UTHealth McGovern Medical School

Don Hall LCDC, CPT

Adult Rehabilitation Services, SEARCH

www.naadac.org/comprehensive-MAT-webinar

Cost to Watch:

Free

CE Hours Available:

1.5 CEs

CE Certificate for

NAADAC Members:

Free

CE Certificate for Non-

members:

$20

To obtain a CE Certificate for the time you spent watching this

webinar:

1. Watch and listen to this entire webinar.

2. Pass the online CE quiz, which is posted at

www.naadac.org/comprehensive-MAT-webinar

3. If applicable, submit payment for CE certificate or join

NAADAC.

4. A CE certificate will be emailed to you within 21 days of

submitting the quiz.

CE Certificate

May 8, 2018 June 13, 2018

May 23, 2018June 27, 2018

Upcoming Webinars

www.naadac.org/webinars

Intergenerational Trauma and the Healing Forest

Model

By J. Carlos Rivera, CADCIII

Ensuring Fidelity to Motivational Interviewing

among Frontline Service Providers

By Ben Callaway, LMSW and Nicole Chisolm,

MPH

Therapeutic Considerations of

Psychopharmacology for Opioid Use

Disorders

By Linda Shaffer, MA, ED.S, LCAS

Picking up the Pieces for Wholeness and

Recovery

By Dana DeDolf, MA, LPC, CADCIII, MAC

www.naadac.org/webinars

Over 145 CEs of free educational

webinars are available. Education

credits are FREE for NAADAC

members.

WEBINAR SERIES

In each issue of Advances in

Addiction & Recovery, NAADAC's

magazine, one article is eligible for

CEs.

MAGAZINE ARTICLES

NAADAC offers face-to-face

seminars of varying lengths in the

U.S. and abroad.

FACE-TO-FACE SEMINARS

Earn CEs at home and at your own

pace (includes study guide and

online examination).

INDEPENDENT STUDY COURSES

NAADAC Annual Conference, October 6-8

2018, Houston, TX

www.naadac.org/2018annualconference

CONFERENCES

Demonstrate advanced education in diverse

topics with the NAADAC Certificate Programs:

• Recovery to Practice

• Conflict Resolution in Recovery

• National Certificate in Tobacco Treatment

Practice

CERTIFICATE PROGRAMS

www.naadac.org/education

Thank you for joining!

NAADAC

44 Canal Center Plaza, Suite 301

Alexandria, VA 22314

phone: 703.741.7686 / 800.548.0497

fax: 703.741.7698 / 800.377.1136

naadac@naadac.org

www.naadac.org

NAADACorg

Naadac

NAADAC