for Addiction Bias and Burnout Kevin Carl MD What is Medication Assisted Treatment MAT The use of medications in combination with counseling and behavioral therapies for the treatment ID: 713459
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Medication Assisted Treatment for Addiction: Bias and Burnout
Kevin Carl, MDSlide2
What is Medication Assisted Treatment (MAT)?
The use of
medications
in combination with counseling and behavioral therapies for the
treatment
of substance use disorders.
Why the special term?Slide3
Historical Addiction TreatmentAddiction as moral failing, weakness.
Was and still is largely “Self-Help” - Few official treatment options
Physical detoxification
Has often been paternalistic and oversimplifiedSlide4
What is Medication Assisted Treatment (MAT)?
The use of medications in combination with counseling and behavioral therapies for the treatment of substance use disorders.
Pharmaceutical tools that assist the person with a substance use disorder to achieve meaningful recovery.
Recovery vs. SobrietySlide5
BiasAddiction is about choices and willpower. Just don’t pick up!
MAT is a crutch - you need to learn to walk on your own.Slide6
More Bias Some of the strongest opposition to MAT comes from treatment providers and people in recovery!
What worked for me should work for you.Slide7
Side NoteWe will focus on MAT in general, and MAT for Opioid Addiction.
Nicotine - NRT Gum, Lozenge, Spray, Bupropion (Wellbutrin/Zyban), Chantix
Alcohol - Disulfram (Antabuse), Acamprosate (Campral), Naltrexone (ReVia)
Cocaine - ?Topamax, ?Vaccine
Marijuana - NoneSlide8
MAT for Opioid Use Disorders
3 effective options:
Methadone -
Opiate
Naltrexone (Revia pills, Vivitrol shots) -
NON
-Opiate
Buprenorphine (Suboxone, Subutex, Zubsolv) -
Opiate (special properties)
Naloxone (Narcan)Slide9
EffectivenessMAT for Opioid Addiction: ~25-50% reduced risk
Risk without?
After a heart attack: Aspirin reduces further events from 8.2% to 6.7% (1.5% reduction/yr)
After a heart attack: Aspirin reduces risk of death from 4.1% to 3.7% (0.4% reduction/yr)
Taking Aspirin just to prevent a first heart attack: reduces risk from 0.57% to 0.51% (0.06% reduction/yr)Slide10
MethadoneMethadone is the oldest and most effective treatment for opioid use disorder.
It activates opioid receptors in the brain
This reduces or eliminates cravings, prevents withdrawal, and makes people feel NORMAL.
People remain
dependent
but not necessarily
addicted
to methadone.
It is risky when mixed with benzodiazepines and alcohol - can be abused.
Must be dosed once a day at a specialized methadone clinic (because it is riskier without supervision), and it can be started before you go into withdrawal.
Reduces
many
metrics of personal and public health.Slide11
Naltrexone (Revia pills, Vivitrol shots)Naltrexone blocks the opioid receptors in the brain. Any opioids given should have no effect. It often reduces cravings for opioids.
You must be opioid-free to start, otherwise it will bring on withdrawal symptoms.
It comes in a once-daily pill form (ReVia), or a monthly injection that a nurse can administer (Vivitrol).
Most people don’t feel different (aside from less cravings).
Some small risk that people will try to overpower the blockade and OD.Slide12
BuprenorphineBuprenorphine partially activates opioid receptors in the brain.
For many people, this will reduce or eliminate cravings, prevent withdrawal, and make people feel normal (generally not high).
Can be used short term for withdrawal, or as maintenance.
People remain
dependent
on buprenorphine (if you stop it abruptly, you will have withdrawal), but this is different than
addiction
(which involves a loss of control, cravings, acting against your values, unmanageability, etc). Slide13
BuprenorphineBuprenorphine alone is usually very safe, though if mixed with benzodiazepines (Xanax, Klonopin, others) or alcohol it can be dangerous. It must be kept away from children.
You must be in moderate withdrawal (12-24 hours from last opioid use) to start buprenorphine, or it can throw you into a bad withdrawal.
Doctors must have a special license to be able to prescribe buprenorphine.
Studies show buprenorphine effectively reduces or eliminates illegal opioid use, reduces the spread of Hep C and HIV, stabilizes life function, keeps people in counseling treatment, and likely reduces deaths. Slide14
MAT Bias
“People just want to get high on something legal.”
“You’re just trading one addiction for another.”
“People are selling/diverting it, and it is getting into the wrong hands.”
“Methadone clinics and Buprenorphine pill-mills are just full of junkies.”Slide15
Burnout
Selection bias in the emergency response field.
If you work with people with active SUD’s (you do), balance the frustration and burnout by learning from people in recovery. Slide16
Final ThoughtsDO:
Be Kind
Be Humble
Be Patient
DON’T:
Alienate / Demean
Judge
Assume