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Restoration of Parenting Ability
Through Treatment for Substance
Use Disorders
DEBRA M. BARNETT, MD
Board Certified in General Psychiatry, Addiction
Psychiatry, Geriatric Psychiatry, and Forensic
Psychiatry
OBJECTIVES
Participants will better understand what constitutes a substance use disorder.
Participants will become more knowledgeable about the treatments for substance use disorders.
Participants will be better able to engage persons in treatment with an appreciation for how treatment can produce successful recovery outcomes, including restoration of parenting abilities.
INTRODUCTION
A common misperception is that persons with substance use disorders are difficult to treat and that they do not often successfully achieve recovery. Successful recovery is marked by a normalization of all aspects of a person’s life, including their ability to parent. This workshop will use a PowerPoint format to examine engagement and treatment outcomes for substance use disorders. Case examples will be included.
WHAT IS A SUD?
What defines a substance use
disorder?
1. Medical/psychosocial
2. Screening and assessment
3. How a diagnosis is established
4. What is not a substance use
disorder
“Inebriety Among Women in This Country”
(Excerpts from JAMA October 29, 1892)
“This National folly of arresting and sending to jail these poor victims should cease. The practical point for our American physicians is to take up the subject of inebriety and study it as a purely medical topic, and not leave it to police courts and moralists to point out the evil and its remedies. The time is coming when the medical profession will teach the world the causes and remedies for this great and widespread evil of the century.”
MEDICAL ASPECT-
Biological basis:Acute effects of alcohol/drugs are to produce brain “reward” and reinforce, but the chronic neuroadaptation:
➢ Increases the threshold for reward
➢ Produces hedonic dysregulation
➢ Repeated use has caused “conditioning” to occur in related circuits
➢ Cues associated with use can activate the reward and withdrawal circuit
➢ This can evoke anticipation of the substance or feelings similar to withdrawal that can precipitate relapse in an abstinent person
Source: Messing RO. In: Harrison’s Principles of Internal Medicine. 2001:2557-2561.
Ventral tegmental area
(VTA)
Amygdala
Nucleus
accumbens
Prefrontal Cortex
Hippocampus
Similarities to Other Chronic
Diseases1-3
Characteristics Drug Dependence
Diabetes, Asthma,
and Hypertension
Well studied ✓ ✓
Chronic disorder ✓ ✓
Predictable course ✓ ✓
Effective treatments ✓ ✓
Curable NO NO
Heritable ✓ ✓
Requires continued care ✓ ✓
Requires adherence to treatment ✓ ✓
Requires ongoing monitoring ✓ ✓
Influenced by behavior ✓ ✓
Tends to worsen if untreated ✓ ✓
1. McLellan AT et al. Addiction. 2005;100(4):447-458; 2. McLellan AT et al. JAMA. 2000;284(13):1689-1695;
3. McLellan AT. Addiction. 2002;97(3):249-252.
Relapse Rates Are Similar to Other
Chronic Diseases1,2
0
10
20
30
40
50
60
70
80
Drug Addiction Type 1 Diabetes Hypertension Asthma
1. McLellan AT et al. JAMA. 2000;284(13):1689-1695; 2. National Institute on Drug Abuse.
http://www.nida.nih.gov/scienceofaddiction/sciofaddiction.pdf. Accessed June 30, 2011.
Pat
ients
Who R
elap
se (
%)
40%–60%
30%–50%
50%–70%50%–70%
PSYCHOSOCIAL ASPECTS
Impact on the individual, family, and
community- embedded in the
descriptions, definitions, and
diagnostic criteria
Historically, this was used to
distinguish between habit and
addiction
PSYCHOSOCIAL ASPECTS
Pregnant women, 15 to 44yo, according to NSDUH 2012-2013 average
Illicit drug use◦ Current 5.4%; compared to 11.4% for non-
pregnant women
◦ By trimester 1st 9%; 2nd 4.8%; 3rd 2.4%
Alcohol use◦ Current 9.4%; compared to 11.4% for non-
pregnant women
◦ Binge drinking- 2.3%; Heavy drinking- 0.4%
◦ By trimester 1st 19%; 2nd 5%; 3rd 4.4%
PSYCHOSOCIAL ASPECTSAFCARS 2016 Circumstances Associated With Child’s Removal
Neglect 61% (166,679)
Drug Abuse (Parent) 34% (92,107)
Caretaker Inability To Cope 14% (37,857)
Physical Abuse 12% (33,671)
Child Behavior Problem 11% (28,829)
Housing 10% (27,871)
Parent Incarceration 8% (20,939)
Alcohol Abuse (Parent) 6% (15,143)
Abandonment 5% (12,889)
Sexual Abuse 4% (9,904)
Drug Abuse (Child) 2% (6,273)
Child Disability 2% (4,554)
Relinquishment 1% (2,694)
Parent Death 1% (2,212)
Alcohol Abuse (Child) 0% (1,242)
DEFINITIONS:
❖ World Health Organization- Addiction: Repeated use of psychoactive substance(s), to the extent that the user is periodically or chronically intoxicated shows a compulsion to take the preferred substance(s), has great difficulty in voluntarily ceasing or modifying substance use, and exhibits determination to obtain psychoactive substances by almost any means. Typically, tolerance is prominent and a withdrawal syndrome frequently occurs when substance use is interrupted. The life of the addict may be dominated by substance use to the virtual exclusion of all other activities and responsibilities.
❖DSM-5- Substance Use Disorder:Cluster of cognitive, behavioral, and physiological symptoms…underlying change in brain circuits…pathological pattern of behaviors
SCREENING INSTRUMENTS
THE DSM-5 DIAGNOSIS
“Substance” Use Disorder
• Problematic pattern of use leading to clinically significant impairment or distress
• At least 2 (of 11 criteria) within a 12-month period
• First 4 reflect impaired control, 5-7 reflect social impairment, 8-9 are risky use, and 10-11 are physiological dependence
• DSM-5 Merged Substance Abuse and Substance Dependence, eliminating use despite legal problems, and added craving/urges
• Specifiers
◦ In early remission- > 3 months but < 12 months
◦ In sustained remission- ≥12 months
◦ Severity
Mild- 2-3 sx
Moderate- 4-5 sx
Severe- ≥6 sx
DSM-51. A/D is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control use of
A/D.
3. A great deal of time is spent in activities necessary to obtain A/D, use it, or recover
from its effects.
4. Craving, or a strong desire or urge to use A/D.
5. Recurrent use of A/D resulting in a failure to fulfill major role obligations at work,
school, or home.
6. Continued use of A/D despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of its use.
7. Important social, occupational, or recreational activities are given up or reduced
because of use of A/D.
8. Recurrent use of A/D in situations in which it is physically hazardous.
9. Use of A/D is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by
A/D.
10. Tolerance, as defined by either of the following: A need for markedly increased
amounts of A/D to achieve intoxication or desired effect; A markedly diminished effect
with continued use of the same amount of A/D.
11. Withdrawal, as manifested by either of the following: The characteristic withdrawal
syndrome for A/D (refer to Criteria A and B of the criteria set for A/D withdrawal); A/D
(or a closely related substance) is taken to relieve or avoid withdrawal symptoms.
WHAT IS NOT A SUBSTANCE USE
DISORDER Tolerance and Withdrawal- “This
criterion is not considered to be met for those individuals taking opioids solely under appropriate (emphasis added) medical supervision.” Pseudoaddiction?
Single use misadventure- including violation of workplace drug policy
Substance misuse which does not meet the criteria for a substance use disorder
BARRIERS TO ENGAGEMENT
Did not feel
they needed
treatment,
16,900,000
Felt they
needed
treatment
and made an
effort to get
it, 351,000
Felt they
needed
treatment
but did not
try, 455,000
2016 National Survey on Drug Use and Health
BARRIERS TO ENGAGEMENT
0 10 20 30 40 50
Not ready to stop
No healthcare coverage and cannot
afford
Did not know where to go to get help
Did not find a program that offered
the desired type of treatment
Might cause neighbors or community
to have negative opinion
Might have negative effect on job
Percent
Percent
ENGAGEMENT TECHNIQUES
An empathetic non-judgmental interview style, reflected in the ease in which you ask relevant questions (think medical model)
Motivational Interviewing
Warm hand-off to a treatment provider
Involuntary?◦ Whether people initiate treatment because of
external motivation or involuntarily, outcomes tend to be the same as if they initiated treatment voluntarily.
◦ Also incorporate a nonjudgmental approach; this is not being done as punishment
TREATMENT
Intensity/Level of Care
◦ Self-help
◦ Outpatient and intensive outpatient
◦ Inpatient/residential, partial hospitalization,
sober living
Psychosocial Therapies
Medication Assisted Treatment and
Recovery
TREATMENT- ASAM LEVEL OF
CARE GUIDELINES
TREATMENT- ASAM LEVEL OF
CARE GUIDELINES
Pharmacotherapy Psychosocial Intervention
MAT and Psychosocial Intervention1,2
Can control symptoms by
normalizing brain chemistry
Essential to change behaviors and
responses to environmental and
social cues that so significantly
impact relapse
1. McLellan et al. Addiction. 1998;93(10):1489-1499; 2. McLellan et al. JAMA. 1993;269(15):1953-1959.
Both are necessary to normalize brain chemistry,
change behavior,
and reduce risk for relapse; neither alone may be sufficient
SUD Management-
Pharmacotherapy AKA
Medication Assisted Treatment and
Recovery (MAT)
Practice guidelines state that persons
with certain SUDs should be offered
medications as part of their
treatment
➢Alcohol Use Disorder
➢Opioid Use Disorder
MAT Guidelines National Quality Forum’s “National Voluntary Consensus
Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices (p.VII)”- recommends that pharmacotherapy should be made available to all adult patients diagnosed with opioid dependence, alcohol dependence, and nicotine dependence, as long as there are not medical contraindications.
American Society for Addiction Medicine (ASAM) has an affirmative position on the use of medications for the treatment of alcohol use disorders in their ASAM Patient Placement Criteria: Supplement on Pharmacotherapies for Alcohol Use Disorders.
National Institute on Drug Abuse (NIDA)- Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies
MAT Guidelines- APA January 2018
APA recommends (1B) that naltrexone or acamprosate be offered to patients with moderate to severe alcohol use disorder who
• have a goal of reducing alcohol consumption or achieving abstinence,
• prefer pharmacotherapy or have not responded to nonpharmacological treatments alone, and
• have no contraindications to the use of these medications.
APA suggests (2C) that disulfiram be offered to patients with moderate to severe alcohol use disorder who
• have a goal of achieving abstinence,
• prefer disulfiram or are intolerant to or have not responded to naltrexone and acamprosate,
• are capable of understanding the risks of alcohol consumption while taking disulfiram, and
• have no contraindications to the use of this medication.
Medication Assisted Treatment
Alcohol Use Disorder
◦ Disulfiram (Antabuse)
◦ Acamprosate (Campral)
◦ Naltrexone oral (ReVia)
◦ Naltrexone IM monthly (Vivitrol)
◦ Probably also Gabapentin and Topirimate
Each has data to support efficacy for various parameters such as duration of complete abstinence, prolonged time to relapse, fewer drinking days, fewer heavy drinking days, and craving
MAT- Alcohol Use Disorder
Treatment
provider
Supplier Action/target
Dosing
Acamprosate Any prescribing
healthcare
provider
Regular pharmacy Glutamate
Orally, three times
a day
Naltrexone
oral
Any prescribing
healthcare
provider
Regular pharmacy Opiate antagonism
Orally, once daily
Naltrexone
IM monthly
Any prescriber
who also either
provides the
injection or refers
Specialty
pharmacy, ships
cold overnight to
prescriber
Opiate antagonism
IM, once a month
Disulfiram Any prescribing
healthcare
provider
Regular pharmacy Inhibits Aldehyde
dehydrogenase
Once daily
MAT- Alcohol Use Disorder
Effect of Vivitrol on Complete Abstinence
MAT- Alcohol Use Dsorder
Effects of Vivitrol on Number of Drinking Days
MAT- Alcohol Use Disorder
Effects of Vivitrol on Heavy Drinking Days
Medication Assisted Treatment
Opioid Use Disorder
◦ Methadone
◦ Naltrexone oral (ReVia)
◦ Naltrexone IM monthly (Vivitrol)
◦ Buprenorphine products (Suboxone, Zubsolv, Bunavail, Sublocade)
Each has data to support efficacy for various parameters such as rates of opioid-free urine testing, treatment retention, and craving
MAT- Opioid Use Disorder
Treatment
provider
Supplier Action/target
Dosing
Methadone Federally designated
clinics
Daily clinic visits for
several months
Opiate agonist
Naltrexone
oral
Any prescribing
healthcare provider
Regular pharmacy Opiate antagonism
Orally, once daily
Naltrexone IM
monthly
Any prescriber who
also either provides
the injection or
refers
Specialty pharmacy,
ships cold overnight
to prescriber
Opiate antagonism
IM, once a month
Buprenorphine
+/- Naloxone
Waivered prescriber;
Most prescribing
healthcare provider
can qualify
Regular pharmacy
for oral doses;
specialty pharmacy
sends injectable to
prescriber
Partial opiate agonist
Once daily for oral;
once a month for
injection
MAT- Opioid Use Disorder
Benefits of treatment:
Improve patient survival
Increase retention in treatment
Decrease illicit opiate use and other criminal activity among people with substance use disorders
Increase patients’ ability to gain and maintain employment
Improve birth outcomes among women who have substance use disorders and are pregnant
Decreased potential for relapse decreases likelihood of contracting HIV or Hepatitis
(SAMHSA, 2015)
MAT- Opioid Use Disorder
MAT- Opioid Use Disorder
Duration MattersPrimary Care–Based Buprenorphine Taper vs Maintenance Therapy for Prescription Opioid Dependence, A Randomized Clinical Trial; David A. Fiellin, MD, et. al.; JAMA Intern Med. 2014;174(12):1947-1954
◦ 14-week randomized, enrolled 113 patients with prescription opioid dependence from February, 2009, through February, 2013, in a single primary care site. BUP taper was initiated after 6 weeks of stabilization, lasted for 3 weeks, and included medications for opioidwithdrawal, then patients were offered naltrexone treatment; the maintenance group received ongoing BUP therapy.
◦ Taper group: mean percentage of urine samples negative for opioidswas lower; more days per week of illicit opioid use; fewer consecutive wks abstinent; less likely to complete the trial.
Prolonged Medication-Assisted
Treatment Sustains Improvement
4 Studies of Various Treatment Lengths
• 32% improvement in occupational problems
• 90% improvement in drug-related problems
• 90% improvement in crime-related problems
After 12 Months2
(buprenorphine-only; n=40)
• Heroin use decreased by 81%
• Codeine use decreased by 83%
• Benzodiazepine use decreased by 48%
• Cocaine use decreased by 74%
After 6 Months1
(buprenorphine-only; n=690)
• Less likely to report using any substance or heroin
• More likely to be employed
• Improved on several psychosocial parameters
After 18 Months3
(buprenorphine/naloxone; n=176)
• 91% of urine samples were opioid negative
• 96% of urine samples were cocaine negative
After 2-5 Years4
(buprenorphine/naloxone; n=53)
1. Lavignasse P et al. Ann Med Interne (Paris). 2002:153(suppl 3):1S20-1S26; 2. Kakko J. Lancet. 2003;361(9358):662-668; 3. Parran
TV et al. Drug Alcohol Depend. 2010:106(1):56-60; 4. Fiellin DA et al. Am J Addict. 2008;17(2):116-120.
MAT and Parenting Capacity
Medication-Assisted Treatment Improves Child Permanency Outcomes for Opioid-Using Families in the Child Welfare System; Martin Hall, PhD, et.al.; Journal of Substance Abuse Treatment, 2016; 71; 63-67.
“Of the 596 individuals with a history of opioid use in the START program, 55 (9.2%) received MAT. Receipt of MAT services did not differ by gender, age, county of residence, or drug use, though individuals who identified as White were more likely to participate in MAT. In a multiple logistic regression model, additional months of MAT increased the odds of parents retaining custody of their children.”
HOW TO WORK WITH
TREATMENT PROVIDERS
Setting realistic expectations
Understanding initial length of acute
treatment, aftercare, continued
engagement in recovery activities
Understanding the slip/relapse and
defining progress or failure
Arrange for avenues of communication
Acceptance of MAT
Case examples