006- Medication Assisted Treatment for Opiates and Alcohol

 
 
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Medication assisted therapy is becoming a very hotly debated topic.  Some of these medications block cravings or the “high,” while others address the underlying mood and mental health issues that may be maintaining the addiction.  In this episode we will examine the potential benefits and drawbacks of these medications.

 

Show Notes

Medication Assisted Therapy Alcohol and Opiates
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC, NCC
Executive Director, AllCEUs
Objectives
Review some myths about Medication Assisted Treatment
Identify medications used to treat opiate dependence
Identify medications used to treat alcohol dependence
Discuss the mechanisms of action
Evaluate pros and cons of each
Myths
Medications are a crutch
We do what is more rewarding than the alternative
Medications can make sobriety “feel better” by addressing underlying neurochemical imbalances
Medications can remove the rewards from use by
Making it unpleasant (Antabuse)
Removing the “high” (Buprenorphine, Naltrexone)
Both (Suboxone)
Remember recovery is more than just NOT using.
Medications can help ease the transition until the brain has rebalanced and the new lifestyle is in full swing
Myths
Using medication goes against 12-Step Philosophy
Alcoholics Anonymous does not encourage AA participants to not use prescribed medications or to discontinue taking prescribed medications
The Big Book states, “God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such person …Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.”

Pros
Medications Can…
Increase energy and motivation (dopamine and norepinephrine) while the person’s brain and body are recovering
Remove some of the reinforcing effects of the drugs
Prevent relapse by making relapse very unpleasant
Reduce the intensity of co-occurring disorders
Reduce conflict/improve social support
Reduce absenteeism from work
Cons of Medication
Physicians who are educated about addiction treatment and endorse a biopsychosocial model of treatment are difficult to find
Medications can give a false sense of security
Medications may provide false hope
Medications have side effects
There is a stigma associated with the use of medications
Costs money

Opiate Dependence
Neurotransmitters
Mainly dopamine
Patients report feeling
Less pain
Less anxiety
Medications for opiate dependence
Buprenorphine
Methadone
Naltrexone
Naloxone (for opioid overdose)
Buprenorphine & Naloxone (Suboxone)

Buprenorphine
Is as partial opioid agonist (ceiling effect)
Reduces the symptoms of withdrawal from misused opiates
Can be abused
Methadone
Full Mu opiate agonist (suppresses cravings)
Lessens the painful symptoms of opiate withdrawal and blocks the euphoric effects of opiate drugs
Considered relatively safe during pregnancy and breastfeeding
Opiate w/d during pregnancy can trigger contractions and miscarriage

SAMHSA TIP 43 MAT for Opioid Addiction
Naltrexone
Decreases the pleasurable effects of alcohol or opiates by blocking opiate receptors
Alcohol abstinence is not required, but opiate abstinence is
Naltrexone will cause opiate withdrawal in dependent users
Third-Party Payer Acceptance:
Oral is covered by most major insurance carriers, Medicare, Medicaid, and the VA
Vivitrol is not covered in many cases

Naloxone
Blocks opioid receptors
Antagonizes morphine and other opiates.
Prevents or reverses the effects of opioids including respiratory depression, sedation and hypotension.
Neurotransmitters
Alcohol consumption impacts the following neurotransmitters
Dopamine (motivation, pleasure)
Endogenous opioids (pain and euphoria)
Glutamate (Get up and go)
GABA (Relaxation— Produced from Glutamate)
Medications for Alcohol Dependence
Disulfiram (Antabuse)
Naltrexone (ReVia)
Blocks opioid receptors so the reward effects from the endogenous opiates and dopamine are reduced
Vivitrol—Extended Release injectable naltrexone
Acamprosate (Campral)
Newer Medications
Ondansetron
Nalmefene
Gabapentin

Acamprosate
Reduces Post Acute Withdrawal Symptoms
Upregulates (turns on) glutamate receptors reducing depression
Creates an imbalance between Glutamate and GABA
Increasing anxiety, mood lability, insomnia, tremors
There was a noted increase in adverse events of a suicidal nature (suicidal ideation, suicide attempts and/or completed suicides) during the clinical trials.

Acamprosate
Third-Party Payer Acceptance:
Does qualify for the Patient Assistance Program through Forest Laboratories, Inc. Covered by most major insurance carriers, Medicare, Medicaid, and the VA (if naltrexone is contraindicated)

Disulfiram (Antabuse)
Makes patients physically sick if they drink
Third-Party Payer Acceptance:
Covered by most major insurance carriers, Medicare, Medicaid, and the VA
Disulfiram blocks the enzyme acetaldehyde dehydrogenase
alcohol is broken down in the liver to acetaldehyde;
acetaldehyde is converted by the enzyme acetaldehyde dehydrogenase to acetic acid.
This causes acetaldehyde to accumulate in the blood at 5 to 10 times higher than alcohol alone leading to toxcicity

Disulfiram (Antabuse)
The acute toxic reaction lasts about an hour, but will linger while there is alcohol in the blood
Can be triggered by alcohol containing products like cough syrup
Patients taking disulfiram should not be exposed to ethylene dibromide or its vapors, paint fumes, paint thinner, varnish or shellac
Exercise extreme caution when applying aftershave, mouthwash, lotions, colognes and rubbing alcohol
The disulfiram-alcohol reaction can be triggered up to two weeks after the last dose of disulfiram
PATIENT and S.O. EDUCATION IS VITAL

Naltrexone
Decreases the pleasurable effects of alcohol or opiates by blocking opiate receptors
Alcohol abstinence is not required, but opiate abstinence is
Naltrexone will cause opiate withdrawal in dependent users
Third-Party Payer Acceptance:
Oral is covered by most major insurance carriers, Medicare, Medicaid, and the VA
Vivitrol is not covered in many cases

Newer Meds
ONDANSETRON
Sold under the name Zofran, and works through the serotoninergic system especially in regard to the serotonin3 receptor and its effect on dopamine.
In alcoholics, it is possible that there is a heightened sensitivity of the serotonin3 receptor making alcohol more rewarding.
If this receptor could be blocked, there would be a decrease in alcohol-induced dopamine release, resulting in a decrease in alcoholic-drinking behavior.
Newer Medications
NALMEFENE
is an opioid antagonist similar to naltrexone (ReVia) without the risk of liver toxicity, and it is longer acting.
GABAPENTIN (Neurontin)
is being used for pain management, anxiety, & insomnia, problems very common among alcohol-dependent patients.
Comorbid Conditions
Anxiety
SSRIs
Buspar
Insomnia
SSRIs
Gabapentin
Atypical Antipsychotics
Depression
SSRIs
Atypical Antipsychotics
Pain
SSRI/SNRI/Tricyclics
Anticonvulants

Summary
Both opiates and alcohol activate opiate receptors
MAT is used to make sobriety more rewarding and reduce relapse triggers in early recovery
It is essential to address comorbid conditions in addition to the substance
References
http://www.naadac.org/assets/1959/storie_mat_alcohol.pdf
https://www.oasas.ny.gov/AdMed/meds/meds.cfm

More Information and Resources

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