Recognizing and Managing Substance Use Disorders Katherine Julian, - - PDF document

4/9/15 1

Recognizing and Managing Substance Use Disorders

Katherine Julian, M.D.

UCSF Division of General Internal Medicine April 9, 2015

Disclosures

n None

4/9/15 2

Quiz…Your Clinic Panel

n In your clinic panel, what percentage of your

current clinic patients would be classified with alcohol abuse or dependence*?

• 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

4/9/15 3

Alcohol Use Disorders in Older Adults

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

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

n Binge drinking was reported in:

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

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

Outline

§ Substance Use Disorders - Definitions § SBIRT § Screening § Brief Intervention § Referral to Treatment § ETOH Substance Use Pharmacotherapy § Treatment of Non-Cancer Pain: Balance risks/benefits § Opiate Substance Use Pharmacotherapy

4/9/15 4

Quiz…

n 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

Definition – At Risk Drinking

n Men

• >4 drinks/day or
• >14 drinks/week

n Women (and > than 65 yrs)

• >3 drinks/day or
• >7 drinks/week

n Increased risk of alcohol-related

problems

4/9/15 5

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)

DSM5 - Substance Use Disorder

n No longer need to differentiate between

substance abuse and substance dependence

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

disorder, etc

n Grade Severity: Mild, Moderate, Severe

4/9/15 6

New DSM5 - Substance Use Disorder

n “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:”

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

hazardous

n Persistent use despite social/interpersonal problems

Criteria for Substance Use Disorder (contd)

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

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

4/9/15 7

Screening

U.S Preventive Services Task Force now recommends screening all adult patients for alcohol misuse

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

4/9/15 8

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

4/9/15 9

A Positive Screen…

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

n Determine how many drinks/day in a week n Ask which drugs the patient has been using n 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.

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

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

intervention

n Patients who meet substance use disorder criteria

abuse should get a

n

Brief intervention AND

n

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

n

Be considered for pharmacotherapy

4/9/15 10

What is a Brief Intervention?

n Advise and Assist the patient n 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

n Feedback and recommendations are given

respectfully in the form of useful information.

Brief Intervention

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

change

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

4/9/15 11

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.”

4/9/15 12

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

Stages of Change from Transtheoretical Model

Precontemplation Contemplation Preparation Action Maintenance Lapse

4/9/15 13

Motivational Interviewing

n Specialized skill set designed to help

patients become ready and motivated to change health-related behaviors

n Express empathy, develop

discrepancy, support self-efficacy

MI: Assess Readiness to Change

n Readiness Ruler

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

drinking?”

n “I would say about a 3” n “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?”

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

should stop?”

4/9/15 14

MI: Enhance Motivation

n Listen for “change talk”

n Small verbal cues that the patient has thought about

changing/need to change or health consequences of their behavior

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

think I have a problem.”

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

about this. I can handle it.”

MI: Enhance Motivation

n When you hear “change talk”, use MI skills

(OARS) to respond

n Open-ended questions

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

n Affirmations

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

n Reflections

n “You are really considering whether you should cut

down”

n Summary statements: tie together multiple points

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

people but everyone is making a fuss about your drinking”

4/9/15 15

MI

n Ask Importance/Confidence Questions

n “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)?”

n This will help guide your next steps

n Ask about pros/cons of the behavior

Pharmacotherapy

4/9/15 16

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

n Opioids n Alcohol n Tobacco (nicotine

dependence)

n Cocaine n Methamphetamine n Hallucinogens n Cannabis n Solvents/Inhalants

Substances for which Pharmacotherapy is Not Available

4/9/15 17

Alcohol Use Disorder Pharmacotherapy

Two Phases of Alcohol Use Disorder Treatment:

n

Acute Alcohol Withdrawal

n

Subacute/Chronic Treatment: Maintenance medications to reduce use or prevent relapse to alcohol use (FDA approved)

n

Disulfiram

n

Acamprosate

n

Naltrexone (oral and injectable)

n

Minimum trial of 3 months (risk of relapse high 6-12 months)

Alcohol Relapse Prevention Meds: Disulfiram (Antabuse)

n

Blocks alcohol metabolism (prevents acetaldehyde→acetate); increase in blood acetaldehyde levels

n

Antabuse reaction: flushing, weakness, nausea, tachycardia, hypotension (up to 2 weeks later!)

n

VA Cooperative Study of Disulfuram in 605 men

n

No effect on number of patients maintained abstinence

n

Among non-abstinent, signif fewer drinking days

n

High rate of non-compliance: 80%

n

If adherent, more likely to be abstinent

n

Works better if given in monitored fashion

Fuller RK, et al. JAMA, 1986;256

4/9/15 18

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

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

4/9/15 19

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

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

n May explain reduction of relapse

n Endogenous opioids involved in the reinforcing (pleasure)

effects of alcohol

n May explain reduced craving for alcohol

n Endogenous opioids may be involved in craving alcohol

n 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

4/9/15 20

Naltrexone for Alcohol Use Disorder

n Cochrane Review of NTX (based on 50 RCT)

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

placebo (RR 0.83; CI 0.76-0.90)

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

CI 0.92-1.00)

n Estimate…helps 1 out of 9…

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

Pharmacotherapy of Alcohol Dependence: Naltrexone

n Oral Naltrexone Hydrochloride

n DOSE: 50 mg per day

n Extended-Release Injectable Naltrexone (Vivitrol)

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

placebo

n More effective if >7 days abstinence

n Too little data to make conclusion if as effective as PO

form (Cochrane review 2010)

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

Garbutt et al. JAMA, 2005

4/9/15 21

Naltrexone Safety

n Can cause hepatocellular injury in very high doses (eg

5-10 times higher than normal)

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

months, then q 3 months

n Caution about NSAIDS n May have additive hepatic effects

Naltrexone Safety

n Other contraindications

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

n Main adverse effects:

n Gastrointestinal: ab pain, N/V n Headache n Dizziness

4/9/15 22

Summary – Alcohol Use Disorder

n If abstinent:

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

n If still drinking

n Consider naltrexone

n If on opioids

n Consider acamprosate

Quiz…

n Which of the following is the most commonly

misused class of prescription drugs?

• A. Opiates

B.

Stimulants

• C. Benzodiazepines

4/9/15 23

Rates of Prescription Narcotic Abuse

§ Prescription Narcotic Abuse Prevalence: § 12th graders: § 1992: 3.3% 2007: 9.2% § à 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.

Prescription Opioid Abuse

Unintentional US Overdoses 1970-2007

n In 2007, one overdose death

every 19 minutes

n More than heroin and

cocaine combined

National Vital Statistics System. Available at http://www.cdc.gov/nchs/nvss.htm.

4/9/15 24

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%

Case

n 64 yo woman presenting with c/o chronic osteoarthritis

in both knees. X-rays are c/w OA. She has a h/o ulcer approximately 3 years ago. She says she needs something for pain as she is not interested in knee

• replacement. Do you:

n A) Start her on acetaminophen with codeine n B) Refer her to orthopedics anyway n C) Start an NSAID with clear precautions on GI side

effects

n D) Try other treatment modalities (PT, tramadol)

4/9/15 25

Non-Cancer Pain

n Complete hx and PE to evaluate pain n Agree on pain and function goal n Consider non-medication options if appropriate

n Lifestyle changes n Exercise, PT n Therapy, biofeedback n Alternative medicine: mindfulness, massage,

acupuncture, etc

Makris UE, et al. JAMA, 2014

How to Treat Non-Cancer Pain?

n Consider non-opiate meds first

n Tylenol, topical NSAIDS, NSAIDS n Neuropathic pain: gabapentin, TCAs (nortriptyline),

pregabalin, lidocaine patch

n Duloxetine (SNRI) n Muscle relaxants n Tramadol (weak affinity for Mu receptor)

4/9/15 26

How To Balance Treating Pain with Risk*

n ID factors for abuse

n Opioid Risk Tool, Current Opioid Misuse Measure

and others

n Pain Agreement to discuss risks of opioids n Toxicology screening before prescribing and get

• ld records

n Get permission to talk to one family/friend who

is NOT on opiates

*For all patients

Opioids for Non-Cancer Pain

n Good evidence opioids help with acute pain in the short-term

(<6 weeks)

n No good evidence long-term opioids help with chronic (>3 mo)

non-cancer pain

n May cause harm (quality of evidence low) n Increased risk overdose, abuse, addiction, MI, fractures n 9940 patients on opioids >3 months n Risk of annual overdose 3.7X for 50-99mg/d morphine

equivalent (0.7% annual overdose rate)

n 8.9X for > 100mg/d (1.8% annual overdose rate)

Chou R, Ann Intern Med, 2015; Dunn KM, Ann Intern Med, 2010

4/9/15 27

What is a High Dose of an Opioid?

n Cut-off is not exact n MSO4 50 mg is about the same as….

n Codeine 60 mg q4h n Hydrocodone/APAP 10/300 5 times a day n Methadone 5 mg tid n Hydromorphone 4 mg tid n Oxycodone/APAP 10 mg/300 tid n Oxymorphone ER 7.5 mg bid n Fentanyl 25 mcg/hr patch

Opioidcalculator.practicalpainmanagement.com

Using Opiates for Non-Cancer Pain

n Avoid concomitant benzos/sedative-hypnotics

n Check medication list for interactions

n Methadone levels affected by CYP-inducing/inhibitors

n Initiate with short-acting low dose

n Don’t increase more frequently than q2 weeks

n Document pain score and function each visit n Avoid escalating doses above 80-120 mg/d

morphine equivalent doses

4/9/15 28

How To Balance Treating Pain with Opioid Risk?

n Compliance monitoring

n Pill counts, Utox, CURES reports

n Watch for aberrant behaviors

n Unsanctioned use, drug seeking behaviors, rx losses,

etc

n Re-assess function and goals at each visit n Check last dosing (for Utox)

Drug ¡ Window of Detection3 (Days) ¡ Medications that Cause False Positives (Common Examples) ¡ Confirmatory Testing Available for Screening Test? ¡ Amphetamine ¡ 1-3 days ¡ Bupropion, ciprofloxacin, ephedrine, labetalol, melatonin, metoprolol, phenylephrine, pseudoephedrine, ranitidine, sertraline. ¡ Yes ¡ Benzodiazepines* ¡ 1-7 days (2-30 days for diazepam) ¡ Diphenhydramine, gemfibrozil, hydroxyzine, indomethacin, sertraline, trazodone ¡ Yes ¡ Cocaine ¡ 1-3 days ¡

• ¡

No ¡ Methadone ¡ 3-10 days ¡

• ¡

No ¡ Opiates (only codeine, morphine, heroin) ¡ 1-3 days ¡ Fluoroquinolones, quinine, poppy seeds, rifampin ¡ Yes** ¡ Oxycodone ¡ 1-2 days ¡ Codeine, hydrocodone, hydromorphone, oxymorphone ¡ Yes ¡

Urine Toxicology Results

Adapted from UCSF Outpatient Handbook, 2014

4/9/15 29

Urine Toxicology Results

n If concern for tampering, order urine creatinine (should be >20) n ALWAYS cause opiate screen to be positive? n Heroin, morphine, codeine n SOMETIMES cause opiate screen to be positive? n Hydrocodone, hydromorphone, oxycodone, oxymorphone n NEVER cause opiate screen to be positive? n Buprenorphine, fentanyl, meperidine, methadone, tramadol n Check fentanyl immunoassay or methadone screen

Steiger S, Drug Testing FAQ

When to Taper Prescription Opioids (Non-Cancer Pain)?

n When risks > benefits

n Aberrant behaviors

n If multiple agents, convert to morphine equivalents

to calculate total dose

n http://opioidcalculator.practicalpainmanagement.com/ n Reduce long-acting agents first

4/9/15 30

When to Taper Prescription Opioids (Non-Cancer Pain)?

n Slow Taper: reduce dose by 10%/month n Minimizes withdrawal sx n Rapid Taper n Remove 10-15%/week n Indications: substance abuse, loss of control over pill use n Consider referral for substance abuse counseling/

treatment

n Immediate Cessation n Overdose, suicide attempt, rx forgery, diversion, other

threats

Pharmacotherapies for Opiate Dependence

§

Methadone

§

Buprenorphine

§

Naltrexone

4/9/15 31

Opioid Dependence Maintenance Therapy: Methadone

§

Can only be prescribed through a registered “narcotic treatment program”

§

Characteristics

n

Long acting mu agonist

n

Duration of action: 24-36 h

n

30-40 mg will block withdrawal, but not craving

n

Illicit opiate use decreases with increasing methadone dose

n

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

n Prevention of Withdrawal Syndrome n Induction of Tolerance

§ Who is appropriate for methadone therapy?

§ > 18 years

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

§ ECG: methadone prolongs QT in approx 2%

(CSAT 2005)

4/9/15 32

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

4/9/15 33

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

4/9/15 34

Buprenorphine

n How long to treat?

n Small studies: Tapering less effective than ongoing

maintenance

n More illicit opioid use, less abstinence

Fiellin DA, et al. JAMA Intern Med, 2014;174(12)

Opioid Dependence Therapy: Antagonist Treatment (Naltrexone)

n

Prevent impulsive use of drug

n

Relapse rates high (90%) following detoxification with no medication treatment

n

Dose (oral): 50 mg daily, 100 mg every 2 days, 150 mg every third day

n

Dose (IM): 380mg IM q month

n Side effects: hepatotoxicity, monitor liver

function tests every 3 months

n Biggest issue is lack of compliance

4/9/15 35

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

n Prescription opioids high abuse/misuse

potential

n Consider non-opioid treatments for chronic

non-cancer pain

n Ongoing monitoring required for opioid

prescribing

4/9/15 36

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!

n Special thanks to Scott Steiger, MD, UCSF

Division of General Internal Medicine

n Resources

n Local mutual help groups

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

n Substance Abuse Facility Treatment Locator

Website

n http://findtreatment.samhsa.gov/

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