A Real Case Substance Use Disorders in 31 yo man presenting to - - PowerPoint PPT Presentation

8/8/2013 1

Substance Use Disorders in Primary Care: Screening, Brief Interventions, Pharmacotherapy

Katherine Julian, M.D.

UCSF Division of General Internal Medicine August 7, 2013

A Real Case…

31 yo man presenting to resident clinic for new

patient appt

Recently hospitalized with new onset atrial

• fibrillation. Resolved with cardioversion. Given

coumadin and presenting to titrate this medication.

Prompted to take an alcohol history→binge

drinking with indications of alcohol dependence

Quiz…Your Clinic Panel

In your clinic panel, what percentage of your current clinic patients would be classified with alcohol abuse or dependence*?

<1% 2-5% 6-9% 10% 20%

0% 14% 27% 35% 24%

• A. <1%
• B. 2-5%
• C. 6-9%
• D. 10%
• E. 20%

Substance Use Issues are Highly Prevalent in Americans

At Risk Drinking* 23% Illicit Drug Use 8% Substance Abuse/Dependence 9% Alcohol 7% Illicit Drugs 3%

SAMHSA, National Survey on Drug Use and Health, 2008 Ages 12+ in the United States

8/8/2013 2

Alcohol Use in Primary Care

3439 primary care

patients

11% had “at risk”

drinking defined as any

• f the following:

> 2 drinks/day > 2 episodes of 5+

drinks/day in 30 days

Drinking and driving Curry SJ, et al. Prev Med 2000;31(5):595-607

Alcohol Use Disorders in Older Adults

3% met full criteria for an alcohol use disorder At-risk drinking was reported in:

17% of men, 11% of women ages 50+ 19% of all respondents ages 50-64 13% of all respondents ages 65+

Binge drinking was reported in:

20% of men, 6% of women ages 50+ 23% of all respondents ages 50-64 15% of all respondents ages 65+

NSDUH, 2009 Blazer D, Wu L. Am J Psychiatry, 2009

Outline

Substance Use Disorders - Definitions SBIRT Screening: quickly assess use and severity of alcohol, illicit drugs, and prescription drug abuse Brief Intervention: a 3-5 minute motivational intervention given to risky or problematic substance users Referral to Treatment Motivational Interviewing ETOH and Opiate Substance Use Pharmacotherapy

Why SBIRT? The Evidence…

Brief interventions can reduce alcohol use for at

least 12 months in patients who are not alcohol dependent.

10-30 % of patients can be expected to change

their drinking behaviors as a result of a brief intervention.

Babor & Higgins-Biddle, 2000; Fleming and Manwell, 1999.

8/8/2013 3

Quiz…

Which of the following is NOT considered to be “at risk” drinking?

4 5 y

• w
• m

a n w h . . . 7 y

• m

a n w h

• .

. . 2 5 y

• w
• m

a n w h . . . 4 y

• m

a n w h

• .

. .

8% 64% 11% 17%

• A. 45 yo woman who drinks 1-2

glasses of wine each night

• B. 70 yo man who drinks 1-2 beers

each night

• C. 25 yo woman who drinks 4-5

drinks once a week when she goes

• ut with friends
• D. 40 yo man who drinks 1-2 glasses
• f wine each night

Definition – At Risk Drinking

Men

• >4 drinks/day or
• >14 drinks/week

Women (and > than 65 yrs)

• >3 drinks/day or
• >7 drinks/week

Increased risk of alcohol-related

problems

Quiz…

Which of the following is NOT

considered to be “at risk” drinking?

• A. 45 yo woman who drinks 1-2

glasses of wine each night

• B. 70 yo man who drinks 1-2 beers

each night

• C. 25 yo woman who drinks 4-5

drinks once a week when she goes

• ut with friends
• D. 40 yo man who drinks 1-2 glasses
• f wine each night

What is a Drink?

A standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid

• unces or 1.2 tablespoons)

8/8/2013 4

New DSM5 - Substance Use Disorder

No longer need to differentiate between

substance abuse and substance dependence

Each substance can be categorized as a disorder Ex: Alcohol use disorder, stimulant use

disorder, etc

Grade Severity: Mild, Moderate, Severe

New DSM5 - Substance Use Disorder

“Maladaptive pattern of substance use leading to

clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:”

Failure to fulfill role obligations Recurrent substance use in situations that are physically

hazardous

Persistent use despite social/interpersonal problems

Criteria for Substance Use Disorder (contd)

Tolerance Withdrawal Using more than originally intended Persistent desire or unsuccessful efforts to cut-down Time spent obtaining/using substance or recovering from side effects Reduction of social/occupational activities Use despite physical/psychological problems Craving

Need 2 criteria for SUD 2-3 criteria =mild 4-5 = moderate >6 = severe

Screening

Some key opportunities include:

As part of a routine examination Before prescribing a medication that interacts with alcohol or other drugs In the emergency department or urgent care center When seeing patients who..

Are pregnant or trying to conceive Have health problems that might be alcohol or drug induced/ related Have a chronic illness not responding to treatment Are likely to drink heavily

NIAAA, 2005. Helping Patients Who Drink Too Much: A Clinician’s Guide (Updated)

8/8/2013 5

How to Screen?

Ask permission: “Would it be ok to spend the next few

minutes talking about alcohol?”

Pre-screen: Do you sometimes drink beer, wine, or

• ther alcoholic beverages?

Single Alcohol Screen Question:

Men: How many times in the past year have you had 5 or

more drinks in one day?

Women (or >65 yo): How many times in the past year

have you had 4 or more drinks in one day?

Positive Screen=1 or more

Smith PC, et al. J Gen Intern Med 2009;24(7); NIAAA Guidelines 2005

How to Screen?

Single Drug Use Screen Question: How many times in the past year have

you used an illegal drug or used a prescription medication for nonmedical reasons?

Positive Screen=1 or more

Smith PC, et al. J Gen Intern Med 2009;24(7); NIAAA Guidelines 2005

Evidence for the Single Screen

Single Question Screen

Sensitivity/specificity: 88%/ 67% for alcohol use d/o Sensitivity/specificity: 82%/79% for unhealthy use

CAGE:

Sensitivity/specificity: 92%/ 48% for alcohol dependence

AUDIT

Sensitivity/specificity: 96%/ 57% for unhealthy use Sensitivity/specificity: 90%/ 61% for alcohol use d/o

Single Drug Screen

Sensitivity/ specificity: 100%/ 74% for drug disorder Sensitivity/specificity: 71%/ 95% for use with consequences

Smith PC, JGIM 2009; Smith PC, Arch Intern Med 2010

A Positive Screen…

1 or more heavy drinking days Any positive drug screen What to do next? Assess…

Determine how many drinks/day in a week Ask which drugs the patient has been using Ask about negative impacts

The follow-up questions are to assess impact and whether

• r not use is serious enough to warrant a

substance use disorder diagnosis.

8/8/2013 6

Criteria for Substance Use Disorder

Failure to fulfill role obligations Recurrent substance use in situations that are physically hazardous Persistent use despite social/interpersonal problems Tolerance Withdrawal Using more than originally intended Persistent desire or unsuccessful efforts to cut-down Time spent obtaining/using substance or recovering from side

effects

Reduction of social/occupational activities Use despite physical/psychological problems Craving

Determining “At Risk” vs. “Substance Use Disorder”

Pts who meet criteria for “at-risk” should get a brief

intervention

Patients who meet substance use disorder criteria

abuse should get a

• Brief intervention

AND

• A referral to specialty care (if they are willing)

AND

• Be considered for pharmacotherapy

What is a Brief Intervention?

Advise and Assist the patient Short, 3-5 minute motivational interviews that

encourage patients to create a plan of action (ex: reduce drinking) that is based on their willingness to change their behavior

Feedback and recommendations are given

respectfully in the form of useful information.

Brief Intervention

Non-judgmental but give direct, honest feedback Provide advice on what a patient should do Negotiate a concrete, realistic plan for behavioral

change

If not ready to change→harm reduction Plan for follow-up

8/8/2013 7

Advise and Assist State your conclusion and recommendation clearly

HOW TO HELP PATIENTS: A CLINICAL APPROACH: NIAAA 2005 Resource for Clinicians

image credit: Comstock

“You are drinking more than is medically safe.”

AT-RISK DRINKING

Advise and Assist State your conclusion and recommendation clearly

HOW TO HELP PATIENTS: A CLINICAL APPROACH

image credit: Comstock

AT-RISK DRINKING

“I strongly recommend that you cut down (or quit) and I’m willing to help.”

Advise and Assist State your conclusion and recommendation clearly

HOW TO HELP PATIENTS: A CLINICAL APPROACH

Gauge readiness to change

drinking habits

image credit: Comstock

“Are you willing to consider making changes in your drinking?” AT-RISK DRINKING

Advise and Assist

HOW TO HELP PATIENTS: A CLINICAL APPROACH

Is the patient ready to commit to change at this time? NO

Do not be discouraged.

Ambivalence is common. Your advice has

likely prompted a change in your patient’s

• thinking. With continued reinforcement, your

patient may decide to take action. For now, restate your concern about his or her health. AT-RISK DRINKING

8/8/2013 8

Advise and Assist

HOW TO HELP PATIENTS: A CLINICAL APPROACH

Is the patient ready to commit to change at this time? NO

Encourage reflection:

Ask patients to weigh what they like about drinking versus their reasons for cutting down. What are the major barriers to change?

Reaffirm your willingness to help when he or she is ready. Don’t forget FOLLOW-UP

AT-RISK DRINKING

Advise and Assist

HOW TO HELP PATIENTS: A CLINICAL APPROACH

Is the patient ready to commit to change at this time?

YES

Help set a goal to cut down to within maximum limits

• r abstain for a period of time.

Agree on a plan, including—

• What specific steps the patient will take
• How drinking will be tracked
• Who can help
• How to manage high-risk situations

AT-RISK DRINKING

Advise and Assist State your conclusion and recommendation clearly.

Example 2 -- For patients who meet the criteria for

ALCOHOL USE DISORDERS

• Relate to the patient’s concerns

and medical findings, if present.

image credit: Comstock

“I believe that you have an alcohol use

• disorder. You are drinking more than is

medically safe. I’m concerned about your

• health. I strongly recommend that you

quit drinking and I’m willing to help.”

HOW TO HELP PATIENTS: A CLINICAL APPROACH

Advise and Assist Negotiate a drinking goal:

• Abstaining is the safest course for most patients with

AUDs.

• Patients who have milder forms of alcohol abuse or

dependence and are unwilling to abstain may be successful at cutting down.

If needed, refer for additional evaluation by Specialized Substance Abuse Services Consider recommending a mutual help (self-help) group, like AA. For patients with dependence, consider medically managed withdrawal vs. medications

ALCOHOL USE DISORDERS

HOW TO HELP PATIENTS: A CLINICAL APPROACH

8/8/2013 9

Motivational Interviewing

Motivational Interviewing

Specialized skill set designed to help

patients become ready and motivated to change health-related behaviors

Stages of Change from Transtheoretical Model

Precontemplation Contemplation Preparation Action Maintenance Lapse

Mentality of the Stages

8/8/2013 10

Motivational Interviewing Principles

Express empathy Develop discrepancy Roll with resistance – patients aren’t “resistant”

(they just aren’t seeing things the way you do!)

Support self-efficacy

MI: Assess Readiness to Change

Readiness Ruler

“On a scale of 0-10, how ready are you to stop

drinking?”

“I would say about a 3” “So it sounds like you aren’t too interested right now.

But I’m curious why you said ‘3’ rather than ‘0’.” OR “What would it take to move you to a 5?”

“Well, I know I should stop at some point.” “Can you say a bit more about why you think that you

should stop?”

MI: Enhance Motivation

Listen for “change talk”

Small verbal cues that the patient has thought about

changing/need to change or health consequences of their behavior

“I was worried there at first, but I don’t really

think I have a problem.”

“I don’t see why everyone is making such a fuss

about this. I can handle it.”

MI: Enhance Motivation

When you hear “change talk”, use MI skills

(OARS) to respond

Open-ended questions

“Why do you think everyone is making such a fuss?”

Affirmations

“I can see you really care a lot about your health”

Reflections

“You are really considering whether you should cut

down”

Summary statements: tie together multiple points

“I hear you saying that you don’t drink more than most

people but everyone is making a fuss about your drinking”

8/8/2013 11

MI

Ask Importance/Confidence Questions

“On a scale of 1-10, how important is it to you to

stop drinking (or cut back)? On a scale of 1-10, how confident are you that you can stop drinking (or cut back)?”

This will help guide your next steps

Ask about pros/cons of the behavior

MI: Negotiating a Plan

Plan should match the patient’s level of

readiness to change

It is concrete, specific and realistic Patient agrees to it and is able to repeat it back

to you

MI Practice

Continuum of Care for Substance Use Disorders

Self-help (AA, etc) Outpatient – with or without sober housing

• Intensive outpatient - > 3x/wk
• Day treatment
• Usually group-based

Sober Housing (“Halfway House --can be unstaffed) Residential - brief (< 28 da) or extended, non-medical

(“rehab”)

Inpatient hospital for true medical detoxification Aftercare – usually low intensity 1/wk indiv or group

8/8/2013 12

Pharmacotherapy

Decision Making (Counseling) Limbic Drive (Pharmacotherapy) From Pettinati, NIH 2006

Addiction Treatment Model: Treating Limbic Drive and Cortical Thinking Structures

Substances for which Pharmacotherapy is Available

Opioids Alcohol Tobacco (nicotine

dependence)

Cocaine Methamphetamine Hallucinogens Cannabis Solvents/Inhalants

Substances for which Pharmacotherapy is Not Available

Phases of Substance Use as Targets for Pharmacotherapy

Intoxication/overdose Withdrawal/detoxification Abstinence initiation/use reduction Relapse prevention Sequelae (psychosis, agitation, etc.)

8/8/2013 13

Alcohol Use Disorder Pharmacotherapy

Two Phases of Alcohol Use Disoder Treatment:

• Acute Alcohol Withdrawal
• Subacute/Chronic Treatment: Maintenance

medications to reduce use or prevent relapse to alcohol use (FDA approved)

• Disulfiram
• Acamprosate
• Naltrexone (oral and injectable)
• Minimum trial of 3 months (risk of relapse high 6-12

months)

Alcohol Withdrawal

• Most alcohol withdrawal is managed in an inpatient

setting

• Meds typically include:
• Benzodiazepines
• Anticonvulsants
• Adjunctive Medications/supplements
• Avoid outpatient detox; best to refer to specialized

programs with close monitoring

• What’s the role of an outpatient provider?
• Refer for alcohol detox and ongoing substance abuse treatment

Alcohol Relapse Prevention Meds: Disulfiram (Antabuse)

• Blocks alcohol metabolism (prevents acetaldehyde→acetate);

increase in blood acetaldehyde levels

• Antabuse reaction: flushing, weakness, nausea, tachycardia,

hypotension (up to 2 weeks later!)

• VA Cooperative Study of Disulfuram in 605 men
• No effect on number of patients maintained abstinence
• Among non-abstinent, signif fewer drinking days
• High rate of non-compliance: 80%
• If adherent, more likely to be abstinent
• Works better if given in monitored fashion

Fuller RK, et al. JAMA, 1986;256

Alcohol Relapse Prevention Meds: Disulfiram (Antabuse)

• Pt should avoid alcohol containing foods
• Clinical Dose: 250mg daily (range 125-500mg/d)
• SE: metallic taste, sulfur-like odor
• Rare: hepatotoxicity, neuropathy, psychosis
• Check LFTs before, q1mo X 3, then q3 mo
• Contraindications: CAD, hypersen to rubber, varices,

renal disease, severe hepatic dysfunction (LFTs> 3x upper level of nl)

• Encourage patient to attend substance abuse treatment

where disulfiram could be administered by staff/family

8/8/2013 14

Alcohol Relapse Prevention Meds: Acamprosate

Acts on GABA and glutamate neurotransmitter systems Impact is anti-craving, reduced protracted withdrawal Dose: 2 g daily (6 pills/day= TWO 333 mg pills three

times/d)

SE: Diarrhea (up to 16%), nausea, itching (up to 4%) Contraindications: severe renal disease (creat cl < 30

ml/min); dose adjust if CrCl 30-50

Only approved for people who are abstinent

Alcohol Relapse Prevention Meds: Acamprosate

Recommended length of treatment: 1 year Effective in reducing relapse to alcohol use in studies

leading to FDA approval

Meta-analysis of European trials: 36% on acamprosate

abstinent at 6 months vs. 23% on placebo

Not effective in Project COMBINE: 1383 patients

Only naltrexone signif increased % days abstinent and

time to heavy drinking

More severe dependence in European trials (acamprosate

with greater effect in longer h/o dependence)?

Fewer abstinence days required to enter COMBINE

Mann K et al. Alcohol Clin Exp Res, 2004 Anton RF et al. JAMA, 2006

Naltrexone for Alcohol Use Disorder

Similar structure to naloxone (Narcan) Potent inhibitor of Mu opioid receptor binding

May explain reduction of relapse

Endogenous opioids involved in the reinforcing (pleasure)

effects of alcohol

May explain reduced craving for alcohol

Endogenous opioids may be involved in craving alcohol

Shown to reduce drinking in those who have cut

down but not abstained (28% naltrexone vs. 43% placebo)

Littleton & Zieglgansberger, (2003) Am J Addict 12[Suppl1]:S3-S11

Naltrexone for Alcohol Use Disorder

Cochrane Review of NTX (based on 50 RCT)

Reduced risk of heavy drinking to 83% of the risk vs.

placebo (RR 0.83; CI 0.76-0.90)

Decreased drinking days by 4% Not significant for return to any drinking (RR 0.96;

CI 0.92-1.00)

Estimate…helps 1 out of 9…

Srisurapanont & Jarusuraisin (2005) Cochrane Database Syst Rev. 2005 Jan 25;(1):CD001867

8/8/2013 15

Pharmacotherapy of Alcohol Dependence: Naltrexone

Oral Naltrexone Hydrochloride

DOSE: 50 mg per day

Extended-Release Injectable Naltrexone (Vivitrol)

380mg IM per month 624 patients 25% decrease in heavy drinking days vs.

placebo

More effective if >7 days abstinence

Too little data to make conclusion if as effective as PO

form (Cochrane review 2010)

Must be opioid-free for 7-10 days before starting

Garbutt et al. JAMA, 2005

Naltrexone Safety

Can cause hepatocellular injury in very high doses (eg

5-10 times higher than normal)

Contraindicated in acute hepatitis or liver failure Check liver function before, q1 month for 3

months, then q 3 months

Caution about NSAIDS May have additive hepatic effects

Naltrexone Safety

Other contraindications

Concomitant opioid analgesics Opioid dependence or withdrawal Medical conditions requiring opioid analgesics Pregnancy (Category C)

Main adverse effects:

Gastrointestinal: ab pain, N/V Headache Dizziness

Summary – Alcohol Use Disorder

If abstinent:

Consider disulfiram as “insurance” (if monitored) Consider naltrexone for relapse prevention Can consider acamprosate

If still drinking

Consider naltrexone

If on opioids

Consider acamprosate

8/8/2013 16

Case Study

A 42 year old man with a 14 year history of alcohol dependence relapsed to alcohol abuse 3 months ago. He currently reports drinking 3-5 drinks 4-5 times/wk, but states that he when he abstains for a day or two

• ccasionally he does not experience alcohol withdrawal
• symptoms. However, his spouse is upset with his drinking

and he now wants medication to help him to abstain. He tried naltrexone in the past, but says it ‘didn’t help much.’ He takes no other medications and has no known allergies.

What of the following would you recommend?

L i v e r f u n c t i

• n

. . . A c a m p r

• s

a t e 6 6 . . . D i s u l f i r a m 2 5 . . .

100% 0% 0%

(from E. McCance-Katz, 2010)

• A. Liver function tests
• B. Acamprosate 666 mg three times daily
• C. Disulfiram 250 mg/d

Case Study: Answer

A and C:

This patient has a long and difficult history of

alcohol dependence.

He has failed naltrexone in the past and

acamprosate is not likely to be helpful (the Combine Study showed it to be inferior to naltrexone).

He has significant consequences of his drinking; is

motivated to quit;

If his liver functions indicate that he does not have

significant impairment; a trial of disulfiram 250 mg daily might help.

(from E. McCance-Katz, 2010)

Quiz…

Which of the following is the most commonly misused class of prescription drugs?

O p i a t e s S t i m u l a n t s B e n z

• d

i a z e p i n e . . .

73% 25% 3%

A.

Opiates

B.

Stimulants

C.

Benzodiazepines

Rates of Prescription Narcotic Abuse

Prescription Narcotic Abuse Prevalence: 12th graders: 1992: 3.3% 2007: 9.2%

• 179% increase over 15 years

OxyContin Vicodin 8th 1.8% 8th 2.7% 10th 3.9% 10th 7.2% 12th 5.2% 12th 9.6% Source: Monitoring the Future, 2007.

8/8/2013 17 Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2006

Bought/Took from Friend/Relative 14.8% Drug Dealer/ Stranger 3.9% Bought on Internet 0.1% Other 1 4.9% Free from Friend/Relative 7.3% Bought/Took from Friend/Relative 4.9% One Doctor 80.7% Drug Dealer/ Stranger 1.6% Other 1 2.2%

Source Where Respondent Obtained Source Where Friend/Relative Obtained

One Doctor 19.1% More than One Doctor 1.6% Free from Friend/Relative 55.7% More than One Doctor 3.3%

Pharmacotherapies for Opiate Dependence

• Methadone
• Buprenorphine
• Naltrexone

Opioid Dependence Maintenance Therapy: Methadone

• Can only be prescribed through a registered

“narcotic treatment program”

• Characteristics
• Long acting mu agonist
• Duration of action: 24-36 h
• 30-40 mg will block withdrawal, but not craving
• Illicit opiate use decreases with increasing methadone

dose

• 80-100 mg is more effective at reducing opioid use than

lower doses (e.g.: 40-50 mg/d)

Strain EC, et al. JAMA, 1999

Opioid Dependence Therapy: Methadone

• Agonist therapy

Prevention of Withdrawal Syndrome Induction of Tolerance

• Who is appropriate for methadone therapy?

> 18 years

Greater than 1 year of opioid dependence Medical compromise Infectious disease Pregnancy*

ECG: methadone prolongs QT in approx 2%

(CSAT 2005)

8/8/2013 18

Opioid Dependence Maintenance Therapy: Methadone

• Can interact with many commonly used

medications

• Decreased methadone concentrations:
• Pentazocine
• Phenytoin
• Carbamazepine
• Rifampin
• Many HIV meds
• Increased methadone concentrations:
• Ciprofloxacin
• Fluvoxamine
• Discontinuation of inducing drug

McCance-Katz et al. 2009

Opioid Dependence Maintenance Therapy: Buprenorphine

• Mu Opioid receptor, high affinity, partial agonist
• Binds opioid receptors; slow to dissociate
• If recent opioids, may withdraw
• OD can’t be reversed with standard dosing of naloxone
• Dosing may be daily, every other day or three

times weekly

• Average dose 8-16 mg daily
• Little effect on respiration or cardiovascular

responses at high doses

McNicholas, 2004

Opioid Dependence Maintenance Therapy: Buprenorphine

• To reduce diversion, combined with naloxone in

4:1 ratio

• Cheaper price than buprenorphine alone!
• Occas increase in LFTs
• SE: N/V (?if due to withdrawal)
• Equivalent to lower dose of methadone in reducing

illicit opioid use (though 80mg methadone better)

• Primary care physicians may be providers of this

treatment as well as addiction specialists

Opioid Dependence Maintenance Therapy: Buprenorphine

• Metabolized by cytochrome P450
• Drug Interactions: Atazanavir/ritonavir: increases

buprenorphine concentrations; rifampin: decreases buprenorphine concentrations; opiate withdrawal possible

• Buprenorphine DEA certification required to

prescribe (8 hrs of training)

• Can treat up to 100 patients

8/8/2013 19

Opioid Dependence Therapy: Antagonist Treatment (Naltrexone)

• Prevent impulsive use of drug
• Relapse rates high (90%) following

detoxification with no medication treatment

• Dose (oral): 50 mg daily, 100 mg every 2 days,

150 mg every third day

Side effects: hepatotoxicity, monitor liver function

tests every 3 months

Biggest issue is lack of compliance

• Injectable naltrexone not currently approved

for opioid dependence, but likely to also be effective

Take Home Points

Ask, Assist, Advise, Refer: At-risk and substance

use disorders common

Three medications FDA-approved for the

maintenance treatment of alcoholism Disulfiram: for those already abstaining Naltrexone (oral daily or injectable once monthly):

To reduce use in those still drinking

Acamprosate: for those who can’t take Naltrexone

Take Home Points

Three medications FDA-approved for treatment of

• pioid dependence

Methadone (must be given through a licensed

narcotic treatment program)

Buprenorphine/naloxone (Suboxone) available by

prescription from qualified providers)

Naltrexone: an opioid antagonist best for highly

motivated patients

Thank You!

Resources

Local mutual help groups

www.ncadi.samhsa.gov (resources) www.aa.org

Substance Abuse Facility Treatment Locator

Website

http://findtreatment.samhsa.gov/

http://www.niaaa.nih.gov/Pages/default.aspx