113 -Medication Assisted Therapies: A Primer for Mental Health Clinicians
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Medication-Assisted Therapies for Addiction
Presented by: Dr. Dawn-Elise Snipes, Ph.D, LMHC, LPC-MHSP
Executive Director of AllCEUs.com

An on-demand course based on this product is available for CEUs at https://www.allceus.com/member/cart/index/product/id/16/c/

Objectives
~    Discuss the purpose of long-term pharmacotherapy
~    Identify pharmacotherapies for
~    Smoking
~    Alcohol
~    Opioids
~    Methadone
~    Buprenorphine
~    Cases
Why Medication Assisted Therapy
~    Early Recovery
~    Reduces cravings
~    Provides increased self-efficacy and a greater sense of control
~    Anxiety Reduction due to:
~    May alleviate some of the anxiety/fear about relapsing
~    Pharmacological effects of certain MATs
~    May improve depressive symptoms by
~    Enhancing hope and an sense of empowerment
~    Pharmacological effects of certain MATs

What is our Goal in Early Recovery
~    Reduce Co-Occurring issues
~    Identify and address vulnerabilities
~    Improve overall health
~    Sleep
~    Nutrition
~    Energy (exercise)
~    Maintain abstinence
~    Increase time to relapse
~    Reduce intensity of binge if relapse occurs

Clinical Use of Pharmacotherapy
~    Part of comprehensive plan that addresses the following issues or problems:
~    Emotional
~    Cognitive
~    Physical
~    Social
~    Occupational
~    Environmental
~    Not a substitute for counseling
~    Works best in combination with psychosocial support
Co-Occurring Model of Addiction
~    Co-Occurring Disorders are the Expectation
~    Mood issues must be addressed to prevent relapse
~    Relapse begins when thoughts/urges or behaviors return to “addicted” mindset
~    Addictive behaviors were “learned” as a way to stop distress.
~    Learned behaviors cannot be unlearned.
~    Alternate behaviors and their consequences must be more rewarding than addictive behaviors and the consequences. (LT vs. ST)

Drugs or No Drugs
    No pharmacotherapy for most abused drugs
◦    Stimulants
◦    Hallucinogens (LSD, PCP, Ketamine, Dextromethorphan, Benadryl, Dramamine)
◦    Inhalants
◦    Marijuana
    What is the function of…
◦    Stimulants
◦    Hallucinogens
◦    Psychedelics (5HT2A); “state of empathetic wellbeing”
◦    Dissociatives (reduces glutamate); altered pain perception, depressant; Ketamine, Dextromethorphan
◦    Deliriants (reduces acetylcholine) Benadryl, Dramamine
◦    Inhalants (Depressants)
◦    Marijuana (increases dopamine); generally “relaxing,” pain relieving

Drugs or No Drugs
    Factors to consider
◦    Cost
◦    Availability
◦    Side effects
◦    Barriers
    Workplace drug testing
    Other meds taken
    Incarceration
◦    Motivation

Barriers
~    Stimatization
~    Science vs. dogma
~    Evidence-based treatment vs. “drugs for drug addicts”
~    12-Step groups
~    Becoming more progressive
~    Methadone Anonymous is alternative
~    Counselors
~    Different experiences and biases
~    Payors
~    Most payors require medication assisted therapy be “considered when available.”
What is the endpoint?
~    Duration of most pharmacotherapy is not indefinite
~    Months to years
~    Goal is stabilization
~    Flexibility
~    Individualized
~    Allow for relapse
Smoking Cessation Pharmacotherapy
~    Replacement
~    nicotine patches
~    nicotine gum
~    nicotine lozenges
~    nicotine nasal spray
~    Antidepressant
~    Zyban
~    Partial agonist
~    Varenicline (Chantix)
Nicotine Replacement Therapy (NRT)
~    Always combine with a behavioral therapy program
~    Most available OTC, but all are expensive
~    Many states cover this in Medicaid
~    Look for
~    Reduces harmful effects of tobacco smoking
~    Patients should not smoke while using
Nicotine Patch
~    Highest success rate of available pharmacotherapies
~    Nicoderm, Nicotrol, Habitrol, Prostep
~    Most come in 3 strengths: 21, 14, & 7mg
~    Start with 21mg patch for 6 wks, taper to 14 mg for 2 wks, finally 7 mg for 2 weeks
~    Use new patch in different spot on upper trunk every 24 hrs
Nicotine Gum
~    Nicorette – 2 or 4mg per piece doses
~    Requires correct “chewing technique” — don’t chew like regular chewing gum
~    Chew 1 piece for 30 minutes every 1 to 2 hrs to prevent nicotine W/D
~    Chew regularly for first month, then taper off over 6 months
~    Do not drink coffee or acidic drinks

Nicotine lozenges
~    Commit, generics
~    Suck on & move from side to side until dissolves
~    4 mg or 2 mg doses
~    Flavor
~    Mint, cherry, etc.
~    “warming tingle”
~    No comparison studies with patch or gum
Nicotine Nasal Spray
~    Reduces nicotine craving & mimics pleasurable effects of nicotine
~    1 spray in each nostril, up to 40 times in 24 hours
~    Use for up to 3 months
~    May cause tearing, sneezing, & burning sensation in nose
~    Highest risk for abuse
Bupropion (Zyban)
~    Bupropion 150mg sustained release pills
~    Works on dopamine & norepinephrine receptors in the brain to decrease W/D
~    Start pills 10-14 days before “quit date”
~    Take daily for 3 days, then twice a day
~    Continue pills for 8 – 12 weeks
~    May cause insomnia, anxiety, or seizures
~    Prescription includes behavioral program
Varenicline (Chantix)
~    Nicotine partial agonist
~    Start pills 10 days before quit date
~    Increase dose
~    Take for 12-24 weeks
~    Includes behavioral program
Pharmacotherapy for
Alcohol Dependence
~    Disulfiram (Antabuse)
~    Acamprosate (Campral)
~    Naltrexone (ReVia, Vivitrol)
Disulfiram (Antabuse)
~    Blocks acetaldehyde dehydrogenase
~    Reaction to alcohol
~    Flushing, palpitations, chest tightness
~    Nausea, headache, anxiety
~    Avoid slips or relapses
~    Affects liver, even without alcohol
~    Many drug interactions
~    Motivation is necessary
~    Monitored dosing
Acamprosate (Campral)
~    Alcohol dependence pharmacotherapy
~    Imbalance in GABA and NMDA articular receptors in the brain can lead to alcohol dependency.
~    Normalizes GABA/Glutamate brain activity
~    No drug interactions
~    Minimal side effects
~    Reduces symptoms of protracted                                withdrawal
~    Insomnia
~    Anxiety
~    Restlessness
~    Use caution in suicidal patients

Naltrexone (ReVia)
~    Blocks opioid receptors and pleasurable feelings from alcohol
~    Reduce craving
~    Tablets or implantable pellets
~    Reduces alcohol slips
~    Used for opioids and alcohol

Injectable naltrexone (Vivitrol)
~    Intramuscular injection of depot naltrexone given monthly
~    Recently FDA approved    for alcohol
~    Administer in physician office, not at home
~    Requires patient motivation
Maintenance Pharmacotherapy for Opioids
~    Long-acting medication in controlled setting
~    Counseling
~    Social services
~    Avoid withdrawal & craving
~    Reduce disease & crime
~    Maintenance vs. Detoxification
Methadone
~    Opioid substitution therapy
~    Harm reduction
~    Individual
~    Society
~    Highly regulated
~    Narcotic treatment programs must be licensed
~    Methadone is a mu opioid agonist
~    No withdrawal symptoms
~    No craving
~    Patients are regularly drug tested
~    Treatment programs are required to provide counseling
Phases
~    No take-homes shall be permitted during the first 30 days
~    Eligible for 1 take-home per week from day 31 through day 90, negative drug screens for the preceding 30 days.
~    Eligible for 2 take-homes per week from day 91 through day 180, negative drug screens for the preceding 60 days.
~    Eligible for 3 take-homes per week with no more than a 2-day supply at any one time from day 181 through 1 year, negative drug screens for the preceding 90 days.
~    After 1 year, eligible for 4 take-homes per week with no more than a 2-day supply at any one time; negative drug screens for the preceding 90 days.
~    After 2 years in treatment, eligible for 5 take-homes per week with no more than a 3-day supply at any one time, provided negative drug screens for the preceding 90 days.
~    After 3 years in treatment, the client may be eligible for 6 take-homes per week provided negative drug screens for the past year.

Effectiveness
~    Controlled trials and meta-analyses comparing medication and placebo show the superiority of agonist pharmacotherapy
~    Improved treatment retention
~    Reduces and often eliminates use of nonprescribed opioids
~    Decreases criminal activity
~    Reduces spread of HIV
~    Results similar to long-term therapy of most chronic diseases
Beneficial effects
~    Enhanced recovery
~    Reduced mortality
~    70% reduction
~    Overdose
~    Trauma
~    Homicide
~    Medical illnesses
~    Improved health
~    Medical
~    Psychiatric
~    Improved psychosocial functioning
~    Employment
~    Criminal activity
~    Family responsibilities
Does methadone get you high?
~    Because of its longer half-life, methadone suppresses withdrawal and drug craving for 24 to 36 hours
~    No real euphoria at prescription doses
~    Does cause sedation
~    Can be reassuring
~    Confused with “high”
~    DEADLY if mixed with other drugs
~    Benzodiazepines
~    Alcohol
Impairment on Methadone
~    Cognitive impairment may occur:
~    During induction
~    Change in dose
~    Combination with other drugs/medications
~    On a stable dose patient can
~    Drive safely
~    Complex tasks
~    Care for others
Methadone forever?
    No federal limit for time on methadone
    Some states restrict time
◦    Virginia: evaluate every 2 years to see if can come off
    Individual variability
◦    Time required to stabilize (use, housing, family, job)
◦    Long-term clients (decades)
    Initial: can’t imagine life without something
    Stable: able to consider coming off
◦    Taper off comfortably over months/years
Buprenorphine
~    Alternative to methadone for opioid addiction treatment
~    Long-acting opioid agonist-antagonist
~    Multiple forms available
~    Combined with naloxone (Suboxone): most common
~    Buprenorphine only (Subutex)
~    Used for treatment of    acute pain (Buprenex)
~    Detox or maintenance
Buprenorphine
~    Binds to opioid receptors in body
~    Only activates receptor around 40%, not 100% like other opioids (heroin, methadone)
~    If already in withdrawal, 40% is pretty good
~    If not in withdrawal, dropping from 100% to 40% receptor activation causes withdrawal
~    Very low risk of overdose
~    Can OD when combined with benzos
Office-based opioid therapy
~    Buprenorphine is less restricted than methadone (Schedule III)
~    Get prescription from pharmacy with refills (up to 6 months)
~    Outpatient physician visits for medication checks as needed
~    Addiction counseling is separate, patient may be referred to another provider for this service
Taking Buprenorphine
~    Sublingual tablet
~    Dissolve under tongue
~    Takes around 5 min. to dissolve
~    Won’t be active if swallowed
~    Comes in 2mg and 8mg tablets
~    Typical dose is 12-16 mg once daily
~    Can take 3 times a week

https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator
Methadone or Buprenorphine?
~    Treatment efficacy equivalent
~    Similar opioid side effects
~    Abuse potential
~    Slightly higher for buprenorphine
~    Buprenorphine has fewer drug interactions
~    Buprenorphine more convenient (less restricted)
~    Buprenorphine not age-restricted (can use in teens)
~    Methadone less expensive
~    Methadone has no ceiling effect
Suboxone
~    Combination of Buprenorphine and Naloxone
~    Do not confuse with Subutex which is buprenorphine only
~    The short-term, desirable effects of Suboxone include:
~    A pain relieving effect that is between 20 and 30 times more powerful than morphine.
~    A mild euphoria that can lasts for around 8 hours with general effects of the substance lasting for 24 – 72 hours.
~    A sense of calm and inflated well-being.
~    A perception of fewer worries and lower stress.
~    Increased relaxation.

Suboxone
~    Suboxone may be abused by individuals addicted to a short-acting opioid drug like heroin, by using it in between doses to keep withdrawal symptoms from occurring
~    The Naloxone only “kicks in” if the suboxone is altered and injected or snorted.
~    Suboxone is dosed such that the prescribe is getting enough to avoid withdrawal symptoms
~    In a person who is not already tolerant to opiates, the effect of Suboxone can cause a “mellow high”
~    Exposure to Naloxone is lower with sublingual vs. buccal (cheek)administration
Final Thoughts on Opiates
~    Like any other opioid, tolerance develops quickly, and goes away quickly.
~    There is a danger of overdose in patients who have tapered or stopped using opiate agonists who relapse.
~    Note: Narcan (Opiate Reversal) is Naloxone
~    By the end of the year, Walgreens will make naloxone available without a prescription at its pharmacies in the following states:
~    Alabama, Arkansas, California, Colorado, Connecticut, District of Columbia, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Wisconsin

Urine Drug Screening
~    Use as deterrent, not to ‘catch in the act’
~    Random
~    Minimum of 8 samples/year on maintenance therapy
~    Verify presence of methadone, buprenorphine, etc.
~    Look for
~    Illicit substances
~    Unauthorized prescriptions
~    Opioids
~    Benzodiazepines
Summary
~    Long-term pharmacotherapy is available and effective for several addictions
~    Medication + counseling = recovery
~    Smoking cessation
~    Nicotine replacement is available over-the-counter
~    Bupropion and varenicline are available by prescription for smoking cessation
~    Multiple medications are available by prescription for alcohol dependence
Summary
~    Methadone/buprenorphine maintenance proven to reduce mortality, crime, & spread of infection
~    Substitution therapy to eliminate withdrawal, cravings, & heroin effects
~    Individualized dose