MAT BASICS Peter Mason MD Medical Director Region 1 IDN Opioid Use Disorder OUD Opioid Use Disorder OUD A medical condition characterized by a problematic pattern of opioid use that causes clinically significant impairment or distress ID: 761271
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MAT BASICS Peter Mason MD Medical Director Region 1 IDN
Opioid Use Disorder (OUD) Opioid Use Disorder (OUD): A medical condition characterized by a problematic pattern of opioid use that causes clinically significant impairment or distress. DSM-5 Criteria Maladaptive pattern of drug use for >12 months More use than intended (loss of control) Unsuccessful efforts to quit (not due to emergent pain) Significant time spent in procurement, use, recovery Activities (occupational, social etc.) given up Continued use in the face of adverse health effects Recurrent interpersonal problems from use Use under dangerous conditions Craving Failure to live up to obligations Tolerance* Withdrawal* *Not counted if opioids prescribed OUD Severity Classifications Mild 2-3, Moderate 4-5, Severe >=6
Addiction Addiction: Meets criteria for OUD severe: associated with compulsive or uncontrolled use of one or more substances. Addiction is a primary, chronic brain disease. Dysfunction of circuits in the brain leads to: Characteristic biological, psychological, social and spiritual manifestations Dysfunctional emotional response Problems of behavior (not able to recognize)Progressive disability and premature death resultControl, cravings, compulsion, consequencesThere is potential for both recurrence (relapse) and recovery. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016.
Medication Assisted Treatment “Medication assisted treatment (MAT) combines behavioral therapy and medications to treat substance use disorders.” Source: Substance Abuse and Mental Health Services Administration (SAMHSA), retrieved from: https://www.samhsa.gov/medication-assisted-treatment
Controversy about the name “MAT” Some prefer “psychotherapy assisted medical treatment” Better term, gaining widespread use: “ M edications for Addiction Treatment”
Addiction Treatment Options SUD Treatment Recovery Support Services Mutual Support (12 step, SMART recovery, etc.) Medication Assisted Treatment
Overview of Medications By the Force Opioid Analgesics Share a (relatively) To: «weak" - Hydrocodone, Propoxyphene, Tramadol, Codeine and Drugs Containing A... "Opioid Analgesics : The Opioid Receptors." Opioid Analgesics. Web. 12 Oct. 2016.
Full vs Partial Agonist Source: https://www.naabt.org/education/technical_explanation_buprenorphine.cfm
Normal Opioid Agonist Therapy (OAT) Withdrawal Euphoria Chronic use Acute use Tolerance and Physical Dependence OAT
OPIOID USE DISORDER MEDICATIONS FULL AGONIST: METHADONE (oral liquid) PARTIAL AGONIST: BUPRENORPHINE (sublingual tablets, strips; buccal film; implant and intramuscular injection) In combination with naloxone it is known as Suboxone brand, but there are generic combinations also BLOCKING AGENT: NALTREXONE (IV Vivitrol, oral Revia)RESCUE MEDICATION: NALOXONE (brand name Narcan)
Medication Updates Probuphine – 6-month buprenorphine implant; approved May 26, 2016 Sublocade – Monthly buprenorphine injection; approved November 30, 2017 NNS-2 Bridge – Cranial nerve stimulator to aid with withdrawal symptoms; approved November 15, 2017
MAT Outcomes Reduced risk of HIV and Hepatitis C Decreased risk of opioid overdose Reduction in suicide Lower utilization of non-opioid medical services – Fewer Emergency Department Visits and Hospital Admissions 60% abstinent after one year with medication 50-60% remain in treatment after one yearMore than 80% of patients return to using substances if behavioral interventions are only providedPoor results with detoxification ‘treatment’ (it’s not treatment) 1. Mohlman et al 2016 2. Connery, H. Medication-Assisted Treatment of Opioid Use Disorder: Review of the Evidence and Future Directions. 2015. Harv Rev Psychiatry. 23(2):63-75. 8 The American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use, May 27, 2015. 3. Johan Kakko , Kerstin Dybrandt Svanborg , Mary Jeanne Kreek, Markus Heilig . 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised , placebo-controlled trial The LancetFeb 22, 2003; (361)662-668.
MAT Outcomes Evidence: Psychosocial counseling PLUS Buprenorphine 50-60% of patients still in treatment after 1 year Reduced HIV/Hep C infections Fewer ED and hospital admissions Source: Johan Kakko , Kerstin Dybrandt Svanborg , Mary Jeanne Kreek, Markus Heilig . 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised , placebo-controlled trial The LancetFeb 22, 2003; (361)662-668.
Guidance Document on MAT Best Practices - SECOND EDITION What's New? Current info on prescribing, legislative and medication changes Updated content on treatment planning, drug testing and confidentiality Reference list of current & relevant literatureNew planning tool to assess MAT development and implementationNew section on inducting patients onto buprenorphineUpdated list of resourcesMAT Resources
MAT Resources Community of Practice focused on MAT to promote and support the successful implementation of an integrated MAT approach in healthcare settings.
RESOURCES To access the Guidance Document on Best Practices electronically, visit: www.dhhs.nh.gov/dcbcs/bdas/documents/matguidancedoc.pdf
MAT Resources Tool to assess progress related to MAT program development and implementation of the recommended best practices.
SERVICE DELIVERY AND CLINICAL CONSIDERATIONS PRIMARY CARE CLINIC OR OFFICE-BASED BEHAVIORAL HEALTH/SPECIALTY ADDICTION TREATMENT PROGRAM FREE-STANDING MAT CLINIC OPIOID TREATMENT PROGRAM/METHADONE CLINIC
BARRIERS TO ESTABLISHING A PROGRAM