127 -Treating Opiate Addiction
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Treating Opiate Addiction
Presented by: Dr. Dawn-Elise Snipes
Executive Director, AllCEUs
California Drug and Alcohol Treatment Assessment's Findings
~ Treatment was cost beneficial averaging $7 returned for every dollar invested
~ Patients in MAT showed the greatest reduction in intensity of heroin use
~ Decreased healthcare use
~ Number of days of hospitalization, down  more than half during MAT
Pharmacology
~ 5 Topics
• Receptors
• Function of opioids at receptors
• Consequences of repeated administration and withdrawal of opioids
• The affinity, intrinsic activity and dissociation of opioids from receptors
• General characteristics of abused opioids
Receptors
~ Different types in the brain
~ Mu receptor is most relevant to opioid treatment
~ Activation of the mu receptor allows opioids to exert their analgesic, euphorigenic and addictive effects
Functions of Opioids at Receptors
~ Full Agonists
~ Activate receptors in the brain
~ Bind to receptors and turn them on
~ Increasing doses of full agonists produce increasing effects, until the receptor is fully activated
~ Opioids with the greatest abuse potential are full agonists
~ Examples of full agonists are morphine, heroin, methadone, oxycodone and hydromorphone
Functions of Opioids at Receptors cont…
~ Antagonists
~ Bind to opioid receptors, but instead of activating receptors, they effectively block them
~ Prevent receptors from being activated by agonist compounds
~ Like a key that fits in a lock but does not open it and prevents another key from being inserted
~ Examples of opioid antagonists are naltrexone and naloxone
Functions of Opioids at Receptors cont…
~ Partial Agonists
~ Bind to receptors and activate them but not to the same degree as full agonists
~ Increasing effects of partial agonists reach maximum levels and do not increase further, even if doses continue to rise—the ceiling effect
~ As higher doses are reached, partial agonists can act like antagonists by occupying receptors but not activating them and blocking full agonists from receptors
~ Buprenorphine is an example of a mu opioid partial agonist
Consequences of Repeated Administration and Withdrawal
~ Repeated administration of a mu opioid agonist results in tolerance and dose-dependent physical dependence
~ Spontaneous withdrawal
~ begins 6–12 hours after the last dose
~ peaks in intensity 36–72
~ lasts approximately 5 days
~ Precipitated withdrawal occurs when an individual physically dependent on opioids is administered an opioid antagonist or partial agonist
Characteristics of Abused Drugs
~ Rate of onset of the pharmacological effects of a drug, and its abuse potential, is determined by:
~ the drug's route of administration
~ its half-life
~ Abuse Potential is related to:
~ ease of administration
~ cost of the drug
~ how fast the user experiences the desired results
Naltrexone
~ Antagonist
~ Naltrexone may decrease the likelihood of relapse to drinking (vivtrol)
~ Can precipitate an opioid withdrawal syndrome in buprenorphine-maintained patients
~ Should not  be prescribed for patients being treated with buprenorphine for opioid addiction
Buprenorphine
~ Because it is a partial agonist, higher doses of have fewer adverse effects
~ Slow dissociation rate (long half life)
~ Abuse of buprenorphine primarily via diverting sublingual tablets to the injection route
~ Buprenorphine's partial mu agonist properties make it mildly reinforcing thus encouraging patient compliance with regular administration
~ Suboxone is buprenorphine plus naloxone
~ Naloxone exerts antagonist properties when injected
Comprehensive Care for Recovery
~ Effective treatment addresses:
~ Mental Health
~ Substance Abuse
~ Employment/Finances
~ Housing
~ Social Skills and Support
~ Relationship Skills
~ Parenting Skills
Services
~ Counseling
~ Group and/or individual
~ Strengths-based
~ Motivational approaches
~ Cognitive behavioral approaches
~ Addresses SA and MH concurrently
~ Realizes the interaction between SA, MH and other issues
Services cont…
~ Psychoeducation
~ Fundamentals of addiction
~ Communication skills
~ Coping skills
~ Relapse prevention
~ Employment/interview skills
~ Relationship skills
~ Stinkin’ Thinkin’ (Cognitive distortions and Irrational Thoughts)
Services cont…
~ Medications
~ Mental health
~ Substance abuse (Methadone, Antabuse, Vivitrol)
~ Pain
~ Pro-social Activities
~ To address “down time”
~ Provide support and acceptance from pro-social peers
~ Help people learn how to have fun while sober
Services cont…
~ Wrap-around
~ Child care
~ Transportation
~ Food
~ Medical  and dental care
Risks of Drug Interaction
~ Use of opiates with other drugs can be fatal 1+1=5
~ Other drugs often interact with opioids.
~ Benzodiazepines
~ Antihistamines (opiate itch)
~ Muscle relaxants
~ Sleep medications
~ Alcohol
~ Paint fumes
~ Sedating OTC herbs
Psychosocial Problems that Decrease Patient Success
~ Lack of stable housing
~ Nonexistent or dysfunctional family relationships
~ Poor social skills
~ Lack of a supportive social network
~ Unemployment; lack of employable skills
~ http://bonds4jobs.com/about-us
OTP Required Services
~ Comprehensive psychosocial assessment
~ Mental Health
~ Substance Abuse
~ Physical Health
~ Psychosocial Issues
~ Initial and yearly medical assessment
~ Medication dispensing
~ Drug tests
~ Identification of co-occurring disorders
OTP Required Services cont…
~ Treatment planning
~ Case Management
~ Co-Occurring disorders counseling
~ Evaluation of and interventions to address family problems
~ HIV and Hepatitis C virus (HCV) testing, education, counseling, and referral
~ Referral for additional services as needed
Improve Patient Retention
~ Individualize medication dosages
~ Clarify program goals and treatment plans
~ Simplify the entry process
~ Attend to patients' financial needs
~ Reduce the attendance burden
~ Provide useful treatment services as soon as possible
~ Enhance staff-patient interactions
~ Improve staff knowledge and attitudes about MAT
Counseling in MAT
~ Provide support and guidance
~ Monitor other problematic behaviors
~ Help patients comply with OTP rules
~ Identify problems that need extended services and referral
~ Identify and remove barriers to full treatment participation and retention
~ Provide motivational enhancement for positive changes in lifestyle
Patient Goals in Building Relapse Prevention Skills
~ Understand relapse as a process, not an event.
~ Develop new coping skills for high-risk situations and unpleasant emotional and physical states
~ Make lifestyle changes to decrease the need for drugs.
~ Increase participation in healthy activities.
~ Understand and address social pressures to use substances.
~ Develop a supportive relapse prevention network.
Patient Goals in Building Relapse Prevention Skills cont…
~ Learn methods of coping with cognitive distortions.
~ Recognize relapse warning signs and triggers.
~ Combat memories of drug abuse-associated euphoria.
~ Reinforce recollections of negative aspects of drug use and positive aspects of recovery
~ Address “drawbacks” to recovery.
~ Avoid people, places, and things that might trigger drug use.
~ Develop pleasurable and rewarding alternatives to drug use.
Common Drug Combinations and Effects
~ Opiate + alcohol
~ Enhance a high and sedation
~ Opiate + cocaine (“speedball”)
~ Enhance or alter cocaine euphoria
~ Cocaine followed by opiate
~ Reduce cocaine overstimulation (e.g., anxiety, paranoia); modulate the cocaine crash
~ Opiate followed by cocaine
~ Medicate opioid withdrawal
~ Cocaine + alcohol
~ Enhance high; reduce cocaine overstimulation (e.g., anxiety, paranoia)
Objectives
~ Opioids can also be classified according to their effect at opioid receptors. In this manner opioids can be considered as agonists, partial agonists and antagonists. Agonists interact with a receptor to produce a maximal response from that receptor (analgesia following morphine administration is an example). Conversely, antagonists bind to receptors but produce no functional response, while at the same time preventing an agonist from binding to that receptor (naloxone). Partial agonists bind to receptors but elicit only a partial functional response no matter the amount of drug administered (buprenorphine).
~ The human body naturally produces its own opiate-like substances and uses them as neurotransmitters. These substances include endorphins, enkephalins, and dynorphin, often collectively known as endogenous opioids.
~ Endogenous opioids modulate our reactions to painful stimuli. They also regulate vital functions such as hunger and thirst and are involved in mood control, immune response, and other processes.
~ 3 opioid receptors
~ DOP (delta)
~ KOP (kappa)
~ MOP (mu)
~ mu opioid receptor (MOR) – the mu receptor is the main “heroin receptor.” Throughout the body these are the most abundant opioid receptors and they’re directly responsible for heroins’ pleasurable effects, acute pain relief, physical dependence and addiction
~ kappa opioid receptor (KOR) – the kappa receptor is responsible for heroin’s anxiolytic effects, trance-like states, physical dependence, and addiction
~ delta opioid receptor (DOR) – the delta receptor is responsible for heroin’s relief from persistent pain, reduced gastrointestinal motility and modulation of mood
~ By attaching to their mu receptors, exogenous opioids reduce the amount of GABA released (see animation). Normally, GABA reduces the amount of dopamine released in the nucleus accumbens. By inhibiting this inhibitor, the opiates ultimately increase the amount of dopamine produced and the amount of pleasure felt.
~ Dopamine is the precursor to norepinepherine
~ neurotransmitters to make life what it ought to be. These functions are; Serotonin regulates sleep and appetite, Acetylcholine for processing information and memory, GABA acts as your calming neurotransmitter while dopamine is the feel good chemical, plays an important role in mood, energy, attitude, motivation.
~ When you use these drugs of pleasure thy hike the levels of dopamine in the brain beyond the accepted levels. This will force the brain to find a means by which to suppress the production of the neurotransmitter that has been hiked by drug use. naturally, the production of dopamine will be reduced by the brain after sensing that the hike in the levels of dopamine is caused by factors out of the body, therefore when a person who has been using drugs stops using them, the levels of dopamine and serotonin will be too low below the normal levels and this beckons such feelings of depression, anxiety, nervousness and lack of interest in everything.
~ “When ethanol, cannabinoids, opioids, or psychostimulants are taken into the body, serotonin levels in the brain are elevated,” says Parsons. Significantly, he adds, this elevation in serotonin plays a role in the motivation to continue taking drugs.
Medication Assisted Therapy
~ Mu Agonists
~ Partial Agonists
~ Antagonists
~ With continued use of any substance, levels of serotonin and dopamine are altered significantly beyond normal levels. When this “high” wears off, levels of these powerful neurotransmitters, which are now dependent on the drug for production, drop to below normal levels without continued exposure to the substance. When this drop occurs, it can leave a person experiencing the side effects of withdrawal including shakiness, anxiety, depression, and other flu-like symptoms