Treatment Options for Opioid Use Disorder - PowerPoint Presentation

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Treatment OptionsforOpioid Use Disorder

William J. Lorman, JD, PhD, MSN, PMHNP-BC, CARN-APV. P. & Chief Clinical Officer, Livengrin Foundation, Inc.Ass’t Clinical Professor, Doctoral Nursing Dept., Drexel Universitywlorman@livengrin.org

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Medication assisted treatment: an overview

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Goals For PharmacotherapyPrevention or reduction of withdrawal symptomsPrevention or reduction of drug craving

Prevention of relapse to use of addictive drugRestoration to or toward normalcy of any physiological function disrupted by drug abuse3

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Treatments - PharmacologicalShort-Term (Less than 30 days)

Relief of withdrawalWithdrawal Management (Detoxification)Opioid and non-opioidLong-Term (30-180 days)Opioid agonistOpioid antagonist4

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Objectives of Maintenance TreatmentTo reduce mortality from overdose and infectionTo reduce opioid and other illicit drug use

To reduce transmission of HIV, HBV and HCVTo improve the general health and well-being of patientsTo reduce drug-related crimeTo improve social functioning and ability to stay in work5

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Public Expectations of Substance Abuse Treatment InterventionsSafe, complete detoxification

Reduce use of medical servicesEliminate crimeReturn to employment/ self supportEliminate family disruptionNo return to drug use6

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Treatment OptionsPharmacologic treatment options:Methadone

BuprenorphineNaltrexoneAlpha adrenergic agonists (clonidine)Psychosocial support12 step programsCognitive Behavioral Therapy, Motivational Enhancement Therapy, etc.7

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Choosing Maintenance MedicationsNo evidence that certain patients respond better to buprenorphine/methadone

The choice between methadone or buprenorphine depends upon:Overall response to each treatmentMany patients express a clear preferenceAccess to treatment setting (e.g., doctor’s office vs Opioid Treatment Program)Ease of withdrawalPatient (and clinician) expectancy8

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Buprenorphine:Not all patients are suitable

Contraindication for buprenorphine treatment:Hypersensitivity to buprenorphine or naloxoneAge < 16 yearsAccess to specialty treatment services may be required:PregnancyUnstable dual diagnosis/psychiatric co-morbidityUnstable polydrug use (especially benzodiazepines and CNS depressants)

HIV/HCV with acute hepatic dysfunction

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Staying in Treatment Pharmacologic treatment in combination with psychosocial interventions significantly enhances treatment effectiveness:

Retention after 1-year treatment, 75% and 0% in buprenorphine and placebo groups respectively (Kakko et al, 2003)Pharmacotherapy helps patients stay in treatment:Reduces illicit drug use due to decreased cravings and withdrawal symptomsReduces mortality by up to 4-fold (Kreek & Vocci, 2002)10

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Buprenorphine ProductsBuprenorphine MonotherapyBuprenex Injection (not indicated for MAT)

Subutex SL tabletProbuphine Subdermal ImplantButrans Transdermal PatchBuprenorphine/Naloxone Combination TherapySuboxone SL tablet and filmZubsolv SL tabletBunavail Buccal film11

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Other Medications Approved for Treatment of Opioid DependenceAgonist substitution therapies

Methadone179,000 patients receive this type of treatment in the US (American Methadone Treatment Association, 1999)Produces morphine-like agonist effects and cross substitute for heroin.Antagonist therapyNaltrexoneDoes not produce morphine-like subjective effectsDifficult to retain patients in treatment due to a lack of desired positive subjective effectsUsed relatively infrequently compared with agonist therapy

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Dosing of Traditional MedicationsMethadone

The dose is increased until opioid craving, illicit opioid use, and withdrawal symptoms have abated, or, until excessive side-effects (i.e., sedation, constipation, etc.) require a reduction in doseNaltrexoneDosed on a daily or thrice-weekly schedule to produce blockade of illicit opioidsBuprenorphineDosed between 4 and 32 mg/d.13

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NaltrexoneLong-acting opioid antagonistProvides complete blockade of opioid receptors when taken at least three times a week

Total weekly dose of about 350 mg.Treatment retention rates are 20-30% over 6 months.Factors for poor retention:Does not provide narcotic effectCravings may continue during treatment14

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Naltrexone (continued)Initiated following acute withdrawal from opioidsSeven to 10 day opioid free period

Initial dose generally 25 mg (1st day) – GI side effectsThen 50 mg daily or 100mg every other day or 350 mg weekly (in 3 divided doses)Most serious side effect is liver toxicityIf patient uses an opiate while on Naltrexone, it will have no effect.VIVITROL: Monthly injection – 380mgSurgical implant also available15

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NaltrexoneBlockade produced is competitive. Can be overcome by using increasing amounts of the opiate.

Relatively fine line between the amount of opiate it takes to overcome the blockade and the lethal dose.Usage has been most successful in populations who are highly motivated and are not likely to try to overcome the blockade (individuals with a good support system, professionals, etc.).16

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METHADONEMay only be prescribed in the community for opiate addiction treatment by physicians’ affiliated with an CSAT accredited Methadone Maintenance Treatment Program. Federal and State regulations govern its utilization within these programs.

Specific criteria must be met in order to be admitted to a program.17

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METHADONERationale for long-term methadone maintenance:

Ability to relieve protracted abstinence syndromeBlock heroin euphoriaPsychosocial stabilizationReduced criminal activityNo serious side effectsMainly constipation, sweating, drowsiness, decreased sexual interest/performanceSafe during pregnancy

Today’s high-purity street heroin has required even higher methadone doses to achieve cross-tolerance

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Methadone-BenefitsProduces tolerance to other opiates.

Can be given in a single daily dose (24 hour half life).Reduces opiate cravings.Prevents emergence of opiate physical withdrawal symptoms.Requires patient to be involved in ongoing formal treatment.Results in increased employment, improved physical and mental health, and improved social functioning.Pt’s involved in MM programs have a significantly reduced rate of seroconversion to HIV disease.No long term physical or mental complications have been identified. 19

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Methadone-IssuesPatients need to go to MM clinic daily to get their medication. May limit social activities.

Patients remain physically dependent on Methadone.MM patients are often discriminated against in housing and other social programs.Patients are often not welcomed at community self-help support groups (i.e. NA) due to their use of Methadone.Side Effects: Most common problems are chronic constipation and excessive sweating.Duration of treatment: Felt to be long term in most cases.20

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Some Principles of Substitution Management21

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Select Appropriate PatientsMinimum age of 18 years (generally)At least one year of physiologic dependence on a narcotic

Meets criteria for opioid dependence22

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Prevent RelapseEducate patient and family about potential for relapseEncourage involvement in Narcotics Anonymous and Nar-Anon

Monitor patient for symptoms of opioid intoxication or drug-seeking behaviorAdjust dosage according to needs23

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Evaluate & Treat Medical ConditionsInfectious DiseaseReduce risk of contracting and transmitting disease

Educate family and involve them in preventive effortsPain ManagementConsider non-narcotic agents firstEvaluate cross-tolerance in narcotic analgesiaAvoid narcotics that induce withdrawal24

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Drugs That Interact with MethadoneInduction

RifampinPehnytoinEthyl AlcoholBarbituratesCarbamazepineSt. John’s WartInhibitionFluconazole

Cimetidine

Erythromycin

Fluvoxamine

Fluoxetine

Ketoconazole

Nefazadone

Ritonavir

Clomipramine

Haloperidol

Paroxetine

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Psychosocial services26

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Cycle of Opiate Addiction27

Drug Use

Physical dependence

Withdrawal symptoms

Need for drugs

Obtain money for drugs

Obtain drugs

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Planning CareDeveloped through collaboration among the addictions nurse, the multidisciplinary treatment team, the patient and significant others.The plan of care:

Addresses priorities firstIncorporates principles of appropriate treatmentIncludes specific interventions that reflect current science and evidence of effectivenessIncludes health educationDesignates a discharge planIncludes strategies for health promotion and restoration of health28

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Implementation of CareInterventions are based on problem identificationInterventions include:Detoxification as needed

Appropriate administration of pharmacologic therapiesDevelopment of a therapeutic relationshipMaintain safetyHealth teachingInvolvement of patient in goal settingAttention to family issuesReferral for ongoing support29

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Evaluating CareDocument the patient’s responses to interventionsExamine the patient’s progress toward attainment of outcomesUse ongoing assessment data to revise plan of care as needed.

Involve the patient, significant others, and other healthcare providers in the evaluation of care.Ensure that evaluation is an ongoing process.30

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Strategies toImproveTreatment Adherence31

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Psychosocial Support for PatientsEducate the patient about his or her addiction and help him or her make appropriate behavioral and lifestyle changes

Refer to 12-step alcohol or narcotics abuse programsRequire SUD-IOP at a minimumEmpathize with the patient’s emotional discomfort during the treatment process32

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Focus on Behavior ChangeScheduling time to participate in new activitiesParticipating in regular physical activity

Making positive nutritional or dietary changesParticipating in 12-step alcohol or narcotics abuse programsGradually increasing responsibilities33

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Patient EducationBehavior change is essential to recovery. The patient should also understand the following facts about buprenorphine use:

How it works to treat opioid dependenceThe risk of overdose when buprenorphine is combined with alcohol or other drugs, such as diazepamWhile taking buprenorphine, the effects of heroin and other opioids will be somewhat blocked, and trying to overcome the blockade by using more heroine may result in a lethal overdoseAfter buprenorphine use is discontinued tolerance to opioid is likely to decrease and a heroin overdose may occur if heroin is used34

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