Some Best practices with medication assisted treatment Michele Flowers McCarthy, LPCC-S - PowerPoint Presentation

Some Best practices with medication assisted treatment Michele Flowers McCarthy, LPCC-S Director of Program Development Center for Behavioral Health

Special thanks to Michele McCarthy Director of Program Development Center for Behavioral Health

Medication Assisted Treatment (MAT) for Opioid Addiction Methadone Buprenorphine Naltrexone

Mu Opioid Receptor Activation mu receptor site Full agonist eg , methadone Full activation of mu receptor site eg , buprenorphine Partial agonist Partial activation of mu receptor site mu receptor site mu receptor site eg , naltrexone Antagonist Prevents or reverses activation of mu receptor site

Methadone Schedule II narcotic Full mu opioid agonist-binds and activates Long acting opioid analgesic (6-12 hours) Long half-life (12-59 hours)- taken once daily or may be “split-dosed” Administered orally- 5 and 10 mg tablets, 40 mg Disket and liquid (40 mg only allowed for MAT, not pain)Only in OTP setting for addiction, can be used for pain by MDs

Methadone benefits Right dose = no euphoric or tranquilizing effects. Reduces/blocks effects of other opioids. Tolerance is slow to develop. Relieves withdrawal and cravings. Can increase/decrease in small amounts, especially liquid. Allows the individual to feel “normal”.

Methadone benefits Stabilizes client, can focus on learning recovery skills. Provides daily observation and more structure than traditional OP-can adjust needs related to compliance, relapse, and long-term recovery. Improved employment status and family relationships. Decrease in high risk behaviors= decrease in HIV and Hep. C risk, criminal activities, etc. Improved physical and mental health and health care.

Methadone limitations Can only be dispensed/administered through a licensed OTP. Can be expensive. KY Medicaid and Medicare do not currently cover this LOC. Only 2 federally funded-Bluegrass and MORE Center Heavily regulated, lots of rules, can be time consuming. Heavily stigmatized, especially for pregnant women.

Methadone limitations Abuse liability and diversion Increased risk when combined with other drugs, especially benzos . Associated health complications Torsades de pointe-tachycardia Detoxification can be difficult, especially if not done correctly or when rushed.

Locations of current OTPs As of June 2017, KY has 16 OTPs and 5 medication stations OTPs-Paducah, Bowling Green, Elizabethtown, Hopkinsville, Louisville, Frankfort, Lexington, Covington, Ashland, Corbin, Hazard, Paintsville, Pikeville, Owensboro Med station-Franklin, Georgetown, Carrollton, Maysville, Richmond 2 Federally funded-BGNAP is private, non-profit and MORE Center is run by Louisville Metro Health Dept. All other OTPs in KY are private for-profit (4 companies) Treatment locator- http://dpt2.samhsa.gov/treatment/directory.aspx10

Buprenorphine Products Buprenorphine monotherapy Subutex* Generic Probuphine Buprenorphine-naloxone combination therapy SuboxoneZubsolvBunavailGeneric

Buprenorphine Therapies Drug Addiction Treatment Act of 2000 (DATA 2000) Schedule III narcotic Partial mu opioid agonist (ceiling effect) High affinity for opiate receptors- very “sticky” Long half-life (24-60 hours) Administered as sublingual tablet, film, cheek film, implant Patient limits of 30/100/275

Subutex /Buprenorphine monotherapy Contains buprenorphine only. Minimally prescribed except with pregnant women or those with adverse reaction to combo med. Higher rate of diversion, can be injected. Only generic now RB discontinued distribution and sale of Subutex in September 2011. Probuphine (6 month implant) FDA approved and became available in 2016.

Suboxone /Buprenorphine-Naloxone combination therapy Naloxone added to decrease misuse. Poor bioavailability sublingually, but use by other routes can precipitate withdrawal. Reduced abuse potential. RB launched films October 2010 as effort to decrease diversion and child exposure. Two generics became available 2013. Zubsolv available since late 2013.Bunavail available since late 2014.

Buprenorphine formulations

Formulations NOT Yet approved for addiction treatment

Buprenorphine benefits Virtually no euphoric or tranquilizing effects. Blocks effects of other opiates. Analgesic effect can provide relief for co-occurring chronic pain. Relieves cravings to use other opiates. Allows “normal” function. Lower abuse liability and diversion potential.

Buprenorphine benefits Increased anonymity, less intrusive, less stigma. Increased treatment options/access to treatment. Decrease in high-risk behaviors. “Step down” option after tapering from methadone. Option if cannot tolerate methadone. Currently orals covered by all payors, seeing coverage for implant, other components of treatment also covered.

Buprenorphine limitations Can be expensive when self pay. Should not induce if opiates still in system, can precipitate withdrawal, especially long-acting opiates. Additional treatment components may not be available/affordable. Not always recommended if using multiple substances, especially benzos. May not be accessible in other LOCs.

Buprenorphine limitations Many doctors still not willing to treat, those who do at capacity (CARA Act 2016, Section 303) No federal regulations for OBOTs, only “practice guidelines”. KBML regulations effective Spring 2015 to help est. minimum standard of care Potential for overdose of other opiates due to ceiling effect. Abuse and diversion potential. Still has stigma and misperception associated.

SAMHSA Buprenorphine Physician and Program Locator The Buprenorphine Physician Locator is a service of the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA). An on-line resource for locating physicians authorized to prescribe a buprenorphine products for opioid treatment. http://buprenorphine.samhsa.gov/bwns_locator/ Additional resource- http://naabt.org/ 22

Naltrexone Originally for alcohol due to blocking neurotransmitters believed to be involved with alcohol dependence. Oral- ReVia , now generic Injectable- Vivitrol Implant- not FDA approved

Naltrexone Long half-life (up to 72 hours) Opioid antagonist-binds, but blocks instead of activates Available as generic tablet* or Vivitrol once monthly injection Any physician, APRN, PA can prescribe Can be used for opiates and alcohol Resource- http://www.vivitrol.com/getstarted/findadoctor?s_mcid=url-vivproviders

Naltrexone benefits Non-abusable, no diversion potential. Good option for compliance issues. Relatively inexpensive in comparison (oral). Non-narcotic, non-addictive, does not produce dependence. More acceptance in abstinence programs, criminal justice, and mutual support groups. Less stigma than other MAT. KY MCOs and insurance cover; may require a fail first on the oral.

Naltrexone limitations May not be candidate if poor liver function. Injectable very expensive for self pay. $750-1200 per injection and pt assistance program is only for those with a payor to use toward copay. Poor compliance with oral version. Cannot have any opiates in system or will precipitate withdrawal, implementing in OP can be difficult if not detoxed first.

Naltrexone limitations Risk of overdose in attempt to break through blockade. Still not many doctors utilizing. Not first choice for pregnant patients . Breastfeeding is not recommended. Implant is NOT FDA approved.

Naloxone and Overdose Short-acting antagonist medication, overdose reversal Injectable and nasal formulations Approved for 40 years, non- abusable , anyone can be trained KY now has regulations for prescribing, dispensing, and administering naloxone and includes good Samaritan provision Overview of SAMHSA’s Opioid Overdose Prevention Toolkithttp://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit-Updated-2016/SMA16-474228

WHY does treatment not always work? Individual not in the right level of care Cookie cutter treatment Program and individual weren’t a fit-person is not always “being difficult” Unrealistic expectations for a “cure” Misunderstanding medication is all they need Not being able to cope with reality of sobriety Individual lacks the resources and support to apply program/recovery skills consistently

So what’s the right treatment? Treatment should be individualized Patients should have a voice in the decision making Should not only give access based on personal bias Just because a program works for one doesn’t mean it will work for another . Should be determined by a qualified addiction professional and the patient.

What should it be based on? Based on assessment of Co-occurring medical problems or concerns Severity of the substance use disorder Co-occurring mental health concerns or disorders Stability of coping skills, daily living skills, home environment, etc. Prior treatment, level of motivation

Treatment Considerations Related to MAT Prescription Plans Drug Testing Medication Discrepancies Prescription Monitoring Program Diversion & Criminal Behaviors Other services

Drug Testing Admission test-what should you test for? Responding to drug test results Positive for illicits and unapproved meds Marijuana Negative buprenorphineFalsifying sampleInability to provide sampleObserved drug testingRandom drug testing

Medication Discrepancies Ever okay for patient to be short meds? Plan for calling in more? Limitations? Handling overage Repeated shortages Diversion Needs dose adjustment Consider higher level of care

Diversion and other Criminal Behaviors Behaviors that are not tolerated must be identified from onset of treatment and defined clearly. What warrants a discharge? Contacting law enforcement and/or other providers? Any that would cause the patient to never be allowed to return?

Other Services Counseling- type and frequency Psychiatric care Case Management Medical Care Other medications Family involvement

Key points to remember Chances of maintained recovery significantly increase when provided a combination of all the tools. No treatment or medication is “one size fits all”, needs to be individualized. The decision to start, change, or end MAT is a medical one and should be made between the treating professional and the patient. MAT is a legal, valid, and widely researched evidence-based treatment for opioid use disorder. Just as addiction is lifelong, so is the recovery process. Individuals receiving MAT are in recovery!

Addendum: Understanding the Disease and the Person

Disease of addiction Repeated drug use or engagement in addictive behaviors can lead to increased impulsivity, altered judgment, and distorted reward memory. This results in the individual experiencing craving, drug use replacing healthy coping skills, and trying to reproduce the positive reward memory despite negative consequences. http://www.asam.org/for-the-public/definition-of-addiction

Understanding the person Rehabilitation vs. habilitation. Active addiction is a narrow cycle of seeking, obtaining, using, recovering, hiding. Co-occurring mental and/or physical health disorders impact both use and recovery. Hyperalgesia Lack of positive supports Additional burdens such as felony history, CPS, lack of safe housing, employment

Understanding the person ACEs/trauma Relapse can be a teachable moment, not failure. Self-sabotage is not uncommon. With opiates, less about the high, more about desperation to avoid withdrawal/pain/feeling sick. Behaviors we may consider as acting out, criminal, manipulative…are survival skills. Stigma can be a barrier and trigger

Opioid Withdrawal Peak between 48 and 72 hours after last dose. Feels like terrible flu. Typically subsides after about 1-2 weeks. Can show persistent withdrawal symptoms for months. Combined with other factors, can pose greater risks and be fatal.

Opioid Withdrawal Symptoms Abdominal pain Agitation Diarrhea Dilated pupils Goose flesh Nausea VomitingRestlessnessRunny nose Sweating Involuntary leg movementBone and joint pain

Post Acute Withdrawal Syndrome (PAWS) Mood swings Anxiety Irritability Tiredness Variable energy Low enthusiasm Variable concentrationDisturbed sleep

PAWS Onset after acute withdrawal symptoms ease Less physical, more emotional/mental May come and go in episodes Can last a few months up to 2 years Can be relapse trigger Must be taken into consideration during treatment and aftercare.

Impact on Physical Health Liver and kidney disease Weakened immune system Depression of CNS Physical dependence and addiction Infections and collapsed veins Damage to vital organs HyperalgesiaHIV and Hepatitis C*Endocarditis*Fatal overdose*

HIV and Hepatitis C In 2003 new HIV cases w/o AIDS in KY-109, 2013-268 (KY DPH 2014 HIV/AIDS Surveillance Report). Scott County Indiana historically 4-5 HIV cases per year, Feb 2015-26 cases, today-217 confirmed. CDC ranks KY #1 in rate of Hep C rates rising and it is estimated that in general 75% of those with Hep C don’t know it.In KY the number of people discharged from hospitals with dual dx of Hep and opioid disorder increased from 39 in 2000 to 1500 in 2012 (KY ODCP).Vulnerability assessment of counties most at risk of a rapid HIV spread through IVDU. Of the top 220 counties listed in the report, 54 of them are in Kentucky, with Wolfe county ranked number one. Breathitt, Perry and Clay counties were also in the top five (CDC report 2016).

Endocarditis Symptoms can include: fever, chills, fatigue, aching joints, night sweats, persistent cough, swelling, unexplained weight loss Clumps of bacteria and cell fragments form in your heart at the site of the infection. These clumps can break loose and travel to your brain, lungs, abdominal organs, kidneys or extremities. Can cause you to develop abscesses in areas including the brain, kidneys, spleen or liver. An abscess may develop in the heart muscle itself as well. Severe abscesses may require surgery to treat them.

Endocarditis Can damage your heart valves and permanently destroy your heart's inner lining, eventually causing heart failure. Unfortunately common harm reduction approaches with IVDUs such as needle exchange programs, educating people to not share, to clean their “works” will not protect. The infection is from bacteria on the skin or sometimes even in the drug itself. Many don’t seek treatment until later, often ignoring symptoms until they are at a point of needing hospitalization and possible valve replacement.

Benefits of treatment Total cost of drug use disorders in the US is an est. $180 billion annually $100,000 spent on treatment = avoided costs of $487,000 in healthcare and $700,000 in crime Every $1 spent on treatment saves criminal justice $7 and when add in healthcare savings, the savings to cost ratio is 12:1 Employees treated for substance use have decreased absenteeism, tardiness, mistakes and on-the-job injuries SAMHSA CSAT Cost Offset of Treatment Services, April 2009