Todays workshop is sponsored by BSAS The Bureau of Substance - - PowerPoint PPT Presentation

Today’s workshop is sponsored by BSAS

The Bureau of Substance Addiction Services:

• Provides access to addictions services for the uninsured
• Funds and monitors prevention, intervention, treatment and

recovery support services

• Licenses addictions treatment programs and counselors
• Tracks statewide substance use trends
• Develops and implements policies and programs
• Supports the addictions workforce

Helpful Websites: BSAS: www.mass.gov/dph/bsas Helpline: www.helpline-online.com Careers of Substance: www.careersofsubstance.org

Disclosure

The Center for Social Innovation, Praxis and trainers do not receive any financial incentives from programs and providers that provide MAT

• r pharmaceutical companies.

Learning Goals

• 1. Understanding the effects of substance use

disorders on the brain

• 2. Understanding the risks and benefits of

medication-assisted treatment

• 3. Exploring prejudice and myths about MAT
• 4. Helping people with opioid use disorders make

informed decisions about MAT

• 5. Learning how to access MAT resources

The Power of Language

Medication assisted treatment vs. Medication assisted recovery

Opioid Overdose Deaths in Massachusetts

Opioid Overdose Deaths in Massachusetts

Compelling Reasons to Consider M.A.T.

• Most people who have overdosed on opioids have had

treatment experiences that were not effective in bringing them relief from craving, relapse, and compulsive use

• Opioid overdoses are the leading cause of accidental

death in the U.S.

• Research shows that MAT is effective in reducing relapse

when used in combination with other psycho-social treatment and support strategies

• Between 1995-2009, fatal overdoses in Baltimore

decreased by 50% as the availability of MAT increased

(Schwartz et al, 2013)

Outcomes of MAT

• Medication assisted therapy is more effective

than no MAT for opioid use disorder even with high-quality behavioral treatment

– MAT with maintenance produces substantially better outcomes than detoxification1 – 50% abstinent at the end of active treatment vs. 8% when medication is withdrawn

• Sources : 1. Weiss RD, Potter JS, Griffin ML, McHugh RK, Haller D, Jacobs P, Gardin J 2nd, Fischer D, Rosen KD.

Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial Published in final edited form as: Arch Gen Psychiatry. 2011 December; 68(12): 1238–1246.

Opioids

• Heroin
• Hydrocodone
• Hydromorphone
• Oxycodone
• Oxymorphone
• Buprenorphine
• Opium
• Morphine
• Codeine
• Fentanyl
• Methadone
• Tramadol

Semi-Synthetic Opiates Synthetic

The 3 Ways Opioids Are Produced

• 1. Your body makes its own opioids that moderate pain and

produce feelings of pleasure and well being

• Endogenous opioids, such as beta endorphins
• 2. They are derived from the plant-based alkaloids related to

the opium poppy

• Opiates: codeine, morphine, laudanum
• Travel the same pathways as endogenous opioids, but much more potent
• 3. They are partially or completely synthesized in a lab to

produce the opioid response

• Heroin, oxycodone, fentanyl
• More efficiently target and alter brain chemical processes

Opioid Receptors in the Body

Czli

Susan’s Brain

Synapse

Substance Use Disorders Are Conditions of Brain Chemistry

• Addictive drugs seem to “match” the

transmitter system that is deficient

• Substance use disorders tend to be

chronic diseases

• There are mild, moderate, and severe

forms of the condition

• Detoxification is usually the first step in

the total treatment process

Drugs Associated with Neurotransmitters

Why do people have “drugs of choice?”

Dopamine amphetamines, cocaine, alcohol Serotonin LSD, alcohol Endorphins

• pioids, alcohol

GABA benzodiazepines, alcohol Glutamate alcohol Acetylcholine nicotine, alcohol

Opioids: Dependence, Tolerance, and Substance Use Disorders

Savage SR, et al. J Pain Symptom Manage. 2003 Jul;26(1):655-67.

Physical Dependence

Withdrawal symptoms

Tolerance

Physiologic adaptations to

• pioid therapy

Substance use disorders

Compulsive use and maladaptive behaviors

Substance Use Disorders Involve Multiple Factors

Biology/Genes Environment

DRUG

Brain Mechanisms Substance Use Disorders

Risk Factors for Substance Use Disorders

• Heredity / Genetics
• Environment
• Willpower
• Modeling
• Access
• Age of first use
• Education level
• Chronic pain
• Mental health disorders
• Illegal vs. legal substance
• Strength of character
• Childhood trauma
• Intelligence
• Early cigarette smoking

Some people become physically dependent on opioid analgesics while taking them for pain but stop with minor difficulties while others experience intense cravings and compulsive use. What accounts for these different responses?

Risk Factors for Substance Use Disorders

Some people become physically dependent on opioid analgesics while taking them for pain but stop with minor difficulties while others experience intense cravings and compulsive use. What accounts for these different responses?

þ Heredity / Genetics þ Environment

• Willpower

þ Modeling þ Access þ Age of first use

• Education level

þ Chronic pain þ Mental health disorders

• Illegal vs. legal substance
• Strength of character

þ Childhood trauma

• Intelligence

þ Early cigarette smoking

Opioids and Substance Use Disorders

Lasting changes in the brain resulting from regular use: An “endorphin deficiency” that persists… Tolerance

Need for larger and larger amounts to get the desired effects – or, after prolonged use, to feel “normal.” Continued use: the body relies

• n the drug; its own opioid

production shuts down. Reacts if external supply is cut off:

Withdrawal

Opioids and Mood:

What goes up must come down

Prolonged use = deficiencies in the brain’s capacity to regulate mood Pre-existing depression = stronger reinforcing effects = increase risk of a substance use disorder

Prolonged use = deficiencies in the body’s capacity to neutralize pain Opioid use for chronic pain can lead to misuse and a substance use disorder

Opioids and Pain

About 29%-60% of people with opioid use disorders deal with chronic pain

Opioids and Motivation

Most people can’t just walk away even when they want to…

• Manage short periods, despite severe withdrawal
• Long-term recovery = dealing with continuous

craving

• Altered brain chemistry = Long-term distress
• The brain’s motivation mechanisms are affected

Research shows better outcomes require counseling, recovery support and at least 12 month on medication.

General Principles of Pharmacotherapies How each medication works

Partial Agonists Antagonists Agonists

PHARMACODYNAMICS

Directly activate

• pioid receptors

(e.g., morphine, methadone) Unable to fully activate opioid receptors even with very large doses (e.g., buprenorphine) Occupy but do not activate receptors, hence blocking agonist effects (e.g., naloxone)

The Medications: Methadone

• People stabilized on the right dose feel normal, can continue to work and

perform daily tasks, like driving. Can be started at any time.

• Dispensed daily at licensed, registered clinics; long-term patients can be

approved for “take-home” doses

• Recommended for people with histories of intense

cravings and withdrawal; long use; those living with chronic pain or HIV/AIDS

• HIGH RISK of overdose at start of treatment and if

combined with other substances such as alcohol and benzodiazepines

• RISK of serious heart problems & sudden cardiac death

Methadone is a long-acting opioid medication that reduces cravings and withdrawal symptoms

The Ideal Candidates for Opioid Dependency Treatment with Methadone

• Have been objectively diagnosed with an opioid

dependency.

• Recommended for people with higher levels of opioid

dependency, intense cravings and withdrawals.

• A person who is pregnant.
• Not have a significant heart problem.
• Is willing to use this medication as part of a

comprehensive treatment plan and understands that this medication does not take the place of therapy or counseling.

The Medications: Buprenorphine

• Combined with naloxone to prevent misuse (Suboxone)
• A mono-drug formulation has buprenorphine alone.
• Clients stabilized on the right prescribed dose feel normal,

can continue to work and perform tasks like driving.

• Available through doctors with special training and

certification & at OTPs

• Up to a 30-day supply from pharmacies for clients making progress
• Can’t be started until at least 12-24 hours have passed since last opioid use
• RISK of overdose when combined with other substances such as alcohol

and benzodiazepines.

• FDA approved for use in treatment of opioid use disorders in 2002

Buprenorphine is a long-acting opioid medication that reduces cravings and withdrawal symptoms

The Ideal Candidates for Opioid Dependency Treatment with Buprenorphine

• Have been objectively diagnosed with an opioid

dependency

• Are willing to follow safety precautions for the treatment
• Have been cleared of any health conflicts with using

buprenorphine

• Have reviewed other treatment options before agreeing to

buprenorphine treatment

• Is willing to use this medication as part of a

comprehensive treatment plan and understands that this medication does not take the place of therapy or counseling.

The Medications: Buprenorphine

• Buprenorphine’s opioid effects increase

with each dose until at moderate doses they level off, even with further dose

• increases. This “ceiling effect” lowers

the risk of misuse, dependency, and side effects

Buprenorphine Safety

• People should use the following precautions

when taking buprenorphine:

• Do not take other medications without first

consulting your doctor.

• Do not use illegal drugs, drink alcohol, or take

sedatives, tranquilizers, or other drugs that slow

• breathing. Physicians should monitors any liver-

related health issues that they may have.

Pregnant or Breastfeeding Women and Buprenorphine

• Limited information exists on the use of buprenorphine

in women who are pregnant and have an opioid dependency.

• The the few case reports available have not

demonstrated any significant problems resulting from use of buprenorphine during pregnancy.

• The FDA classifies buprenorphine products as

Pregnancy Category C medications, indicating that the risk of adverse effects has not been ruled out.

• Studies indicate that buprenorphine is equally

as effective as moderate doses of methadone.

• Buprenorphine is unlikely to be as effective as

more optimal-dose methadone.

• It may not be the treatment of choice for

patients with high levels of physical dependency. Switching from Methadone to Buprenorphine

Switching from Methadone to Buprenorphine It is best to SLOWLY reduce the therapeutic dose

• f Methadone to 30 mg a day or less for at least a

week, before discontinuing it completely for at least 36 hours before starting Buprenorphine.

Switching from Buprenorphine to Methadone

• Transferring from buprenorphine to methadone

treatment is less complicated than the transition from methadone to buprenorphine.

• Methadone can be commenced 24 hours after

the last dose of buprenorphine

Buprenorphine Misuse Potential

Naloxone is added to buprenorphine to decrease the likelihood of diversion When taken as prescribed, buprenorphine’s

• pioid effects dominate and blocks opioid

withdrawals If sublingual tablets are crushed and injected the naloxone effect dominates and can bring on

• pioid withdrawals

Commencing Naltrexone Following Buprenorphine Maintenance Treatment

• To minimize the risk of withdrawal

symptoms, naltrexone should be delayed for 5-7 days after the last buprenorphine dose.

• Doses of naltrexone taken earlier than this

are likely to induce some withdrawal symptoms depending on the buprenorphine doses in the last few weeks of treatment.

The Medications: Naltrexone

• Vivitrol: monthly long-acting injection
• Naltrexone: available in pill form
• Not a controlled substance; no potential for

diversion; no need to taper.

• Injections through any doctor, P.A. or ARNP – pills – through pharmacies.
• Recommended for people with less intense withdrawal and cravings, highly

motivated for recovery, adolescents and mandated clients.

• Must wait 7-10 days after last opioid use to begin without adverse affects
• HIGH RISK of overdose if people use large amounts override blocking effects or

use after completing a period of treatment due to lowered tolerance.

Naltrexone is an opioid blocker an antogonist – it blocks euphoric and pain relieving effects of opioids; has a similar effect with alcohol

The Ideal Candidates for Opioid Dependency Treatment with Vivitrol

• Have been objectively diagnosed with an opioid

dependency

• Recommended for people with lower levels of opioid

dependency.

• Must be opioid-free for 5-7 days
• Not have a diagnosis of significant liver or kidney

disease.

• Is willing to use this medication as part of a

comprehensive treatment plan and understands that this medication does not take the place of therapy or counseling.

T

Stages of MAT

Induction: assessment, individualized starting dosages; HIGH RISK for overdose during this stage Stabilization: adjustment to medication, withdrawal and cravings begin to be under control Maintenance: long-term phase of treatment lasting for months / years; periodic reassessment Tapering: medically managed withdrawal through gradually reduced doses over a period of months

Community providers use a four stage process

1 2 3 4

Regulatory Issues

MAT for opioid use disorders is carefully regulated by federal agencies

Research consistently shows treatments less than 90 days are not sufficient for long-term behavioral change Research outcomes for MAT for opioid use disorders are better when treatment continues for 12-24 months

Federal Opioid Treatment Standards (42 CRF 8.12)

Required services:

• General – “OTP shall provide adequate medical,

counseling, vocational, educational and other assessment and treatment services.”

• Medical Assessment
• Special services for pregnant clients
• Initial and periodic assessments
• Counseling-including health and harm reduction

counseling

Essential Services in MAT Programs

• Initial and periodic assessment with goal setting
• Medical assessment and treatment
• Substance use counseling
• Vocational and educational assessment and

counseling

• Health and prevention counseling (HIV, HCV STI)
• Linkage to basic supports
• Drug testing services and monitoring

Legal Issues

+ Driver’s licenses; commercial license

restrictions. + Protected by confidentiality and anti- discrimination laws + Employment protection + Government benefits + Child welfare, drug courts, probation/parole cannot legally require MAT to stop

Opioid Use Disorders: All Available Resources

Chances of success improve we help people use all recovery supports

Professional treatment services; substance abuse counseling Medications Peer recovery support; family support; connections to community Other essential services; mental health, housing, medical care

Person with Opioid Use Disorder

A Real Life Example

What do people need to know to inform choices and make decisions about medication-assisted treatment?

• Outcome research on effectiveness of MAT
• Risks vs. benefits of medication options
• What to expect from MAT
• Providers that offer MAT
• How to talk to others about their decisions
• Sources of peer/community recovery support

Medication-Assisted Treatment: Outcomes

When medications are part of a comprehensive treatment program:

• Decreases illicit opiate use
• Decreases injection drug use
• Decreases hepatitis and HIV infections
• Decreases sexually transmitted infections
• Decreases in overdose fatality rates
• Decreases criminal activity

Why Consider MAT?

When programs incorporate MAT according to practice guidelines some

• f the outcomes include:
• Increases treatment retention
• Improves family stability
• Increases employment
• Cost effective treatment

Essential Question

• Can I or do I want to try MAT?
• Which MAT protocol is best for me?
• What will it take for me to use MAT?

Sequence of Decisions

• 1. Whether MAT is right for them
• 2. Which medication is right
• 3. How to get services that are supportive
• 4. What kinds of support are needed

Weighing the Risks and Benefits of MAT

Medication-assisted Treatment

Benefits MAT Risks MAT Benefits No MAT Risks No MAT

How do you help a person make decisions about MAT?

• 1. Conduct opioid overdose risk assessment
• 2. Explore treatment goals
• 3. Explore beliefs about MAT
• 4. Educate about the benefits of MAT
• 5. Educate about the services and supports

available to people on MAT

• 6. Perform harm reduction interventions

Risks & Benefits of MAT

Benefits Risks

Stabilizes brain functions Long term treatment can reverse some of the damage Allows people to function normally – continue to work Relieves withdrawal symptoms and reduces craving Withdrawal, if stopped abruptly Controlled substances w/abuse potential Medication side effects & interactions Risk of overdose or fatality, especially if taken with benzodiazapines

When do you help a person make decision about MAT?

• Intake
• Assessments
• Educational groups
• Counseling sessions
• Family meetings
• Every available opportunity

What do you do if a person decides not to participate in MAT? Harm reduction strategies including:

• Opioid overdose prevention education
• Opioid overdose risk assessment
• Train person and family members to use Narcan
• Provide resources for MAT in case the person

changes his/her mind

• Offer all other services and supports available to

help the person recover

Comparing Medication Options

• Are best treated in doctors’ offices
• Pregnant and post-partum women
• Are getting treatment for HIV/AIDS
• Motivated to try buprenorphine
• Able to adhere to medication treatment
• Benefit from structured programs
• Able to get an approved program
• Pregnant and post-partum women
• Have chronic pain
• People getting treatment for HIV/AIDS
• Able to stop using for 7-10 days
• Mandated by court or employer
• Also benefit from avoiding alcohol
• Motivated to eliminate all opioids now
• Re-entering from prison or jail

Buprenorphine Methadone Naltrexone

Who does well?

When can I start?

• 12-24 hours after last use

How long do I take it?

• Best results when taken 9 months or more
• Safe for long-term maintenance
• Periodic assessment for ongoing treatment

based on individual needs What happens if I stop?

• Withdrawal, less intense, but unpleasant
• Gradual tapering reduces severity

What if I use opioid drugs?

• Moderate to high risk of overdose
• May cancel out effects of other opioids
• Also moderate to high risk of overdose with

alcohol or other substances When can I start?

• Immediately

How long do I take it?

• Best results when for at least 1 year
• Safe for long-term maintenance
• Periodic assessment for ongoing treatment

based on individual needs What happens if I stop?

• Methadone withdrawal symptoms
• Gradual tapering doses reduces severity

What if I use opioid drugs?

• High risk of overdose
• May not have euphoric effict
• Alcohol or other drug use increases risk
• Fatalities reported with benzodiazepines

When can I start?

• After 7-10 days completely opioid-free
• Or risk of bringing on severe withdrawal

symptoms How long do I take it?

• Long-acting injectable lasts 30 days
• Little effect with short-term treatment
• Most studies treat subjects for 5-6 months

What happens if I stop?

• No withdrawal symptoms

What if I use opioid drugs?

• Risk of overdose
• If taken while physicallly dependent on
• pioids, withdrawal can result
• Effects of opioids may be blocked

Starting/Stopping

Information You’ll Want from Your Provider

• What treatment options do you offer for opioid use disorders?
• What medication(s) do you use to treat opioid use disorders?
• How flexible is the program? Will I be able to do this with my

work schedule?

• What are the costs? How do people pay for treatment?
• How soon can I begin treatment?
• What other kinds of help are available?

– Help with transportation – HIV testing – Help with benefits &coverage – Support groups – Childcare – Recovery support services – Counseling – Other: ____________________

Information Your Provider Will Want from You

Gather Your Information:

ü List all your current health conditions and concerns. ü List the medications and supplements you use now. ü List the opioid drugs you have using, how long, and an estimate of how much. ü List any other legal or illicit drugs you use (for example: marijuana, tobacco, valium, alcohol, etc.). ü List dates and details of any past or current treatment for

• pioid use disorders (for example: where, when, and how it

worked out).

MAT for Justice-Involved Clients

Decreased criminal activity & arrests

STUDIES SHOW:

Increased follow up with community treatment upon release; lower recidivism Decreased recurrent drug use Decreased behavioral problems and parole/probati

• n violations

Decreased in HIV risk behavior

Federal Government Set To Crack Down On Drug Courts That Fail Addicts

WASHINGTON — The federal government is cracking down on drug courts that refuse to let opioid addicts access medical treatments such as Suboxone, said Michael Botticelli, acting director of the White House’s Office of National Drug Control Policy, on Thursday. Drug courts that receive federal dollars will no longer be allowed to ban the kinds of medication-assisted treatments that doctors and scientists view as the most effective care for opioid addicts, Botticelli announced in a conference call with reporters… Huffington Post

• Feb. 6, 2015

SAMHSA & BJA Drug Court Grantees

“Under no circumstances may a drug court judge, other judicial official, correctional supervision officer, or any

• ther staff… deny the use of

these medications when made available to the client under the care of a properly authorized physician prescription...”

Substance Abuse Mental Health Services Administration

“Applicants must affirm…that the treatment drug court(s) for which funds are sought will not deny any eligible client for the treatment drug court access to the program because of their use of FDA- approved medications for the treatment of substance use disorders…

Bureau of Justice Assistance

Reentry and Drug Overdose

In the first 2 weeks post-release, a former inmate’s risk for death by drug overdose = 129 times the risk for the general population.

Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, Koepsell TD. Release from prison-a high risk of death for former inmates. N Engl J Med. 2007;356(2):157–165.

777 2589 900 614 703 725

1000 2000 3000 Overall 1–2 3–4 5–6 7–8 >9

Deaths per 100,000 Person – Years Weeks After Release

Criminal Justice & Opioid Use Disorders in Massachusetts

Opioid Task Force Recommendations:

• Increase availability of treatment at

designated DOC facilities

• Increase use of injectable naltrexone (Vivitrol)

for people with opioid use disorders returning to community from correctional facilities

MAT during Pregnancy

• If a pregnant woman stops opioids abruptly, withdrawal can

harm the developing fetus

• Methadone is the oldest and best-research course of

treatment; safe for the mother; no damage to fetal development

• Pregnant women treated with methadone are 3x times more

likely to stay in treatment

• Promising studies show buprenorphine (the mono-drug

formula only-Subutex) is also safe

• Complete withdrawal not advised during pregnancy. Should

not be attempted without medical supervision

MAT during Pregnancy

Special challenges include:

• Few social supports, discrimination,

harassment, even when seeking treatment

• Neo-natal abstinence syndrome –

manageable in newborns but may delay baby’s discharge from hospital

• High risk of relapse after delivery,

especially if MAT is discontinued too quickly

MAT for those with Mental Health Conditions

• Research shows that most people who are addicted

to opioids have a mental health disorder (may or may not be diagnosed)

• Methadone-psychiatric medication interactions are a

concern and monitoring and dosage adjustments are necessary

• Collaboration with mental health staff and

community mental health centers is important

• People with mental health condition using MAT may

need additional services and supports

MAT for those with Chronic Pain

• Referral for pain management
• Providers with experience with pain management and MAT
• Chances for relapse increase with inadequate pain relief
• Medication doses of long-acting opioid agonists used in ORT

are often not effective for pain management

• TIP 54: Managing chronic pain in adults with or in recovery

from substance use disorder. (2012) An estimated 29%-60% of people with opioid use disorders deal with chronic pain (CSAT, 2012a).

MAT for those with HIV/AIDS and Viral Hepatitis

• HIV and Hepatitis C risk behaviors decrease significantly

among patients receiving MAT.

• HIV infection rates decrease and adherence to anti-retroviral

medication treatment increases significantly (Springer, Chen, Altice,

2010; Ullman et al., 2010).

• All medications used for MAT have been used safely by

persons with Hepatitis C, even while undergoing treatment.

• Most doctors review liver function tests prior to initiating MAT

to during treatment.

System/Program-Level Issues

• Historically MAT and recovery-oriented

services while sharing the same goals did not share similar methods leading to mutual distrust or suspicion

• Staff from MAT programs and staff from

recovery programs rarely interacted

• Each program has its own models for service

provision.

No wrong door

Part of the Continuum of Care model, No Wrong Door allows clients to access essential services including recover/treatment services (for example housing services, DTA and other support services) from any other state- sponsored agency, as seamlessly as possible.

No wrong door

• Use as many effective tools as are available
• One size does not fit all: as many doors as possible
• A full continuum of care: multiple services with

flexible responses

• Engagement promotes progress
• Expectation of relapsing/remitting course
• Expectation of variable and shifting treatment

readiness

• Recovery as a gradual process, not an overnight

event -- expectation of incremental progress

Additional Resources

• TIP 43: Medication-Assisted Treatment for Opioid Addiction in

Opioid Treatment Programs.

• http://store.samhsa.gov/product/TIP-43-Medication-Assisted-

Treatment-for-Opioid-Addiction-in-Opioid-Treatment- Programs/SMA12-4214