Introduction to Medication Assisted Treatment - PowerPoint Presentation

1. Introduction to Medication Assisted Treatment Michael Dulitz, MPH, NRPOpioid Response Project Coordinator

2. FoundationAddiction is a chronic relapsing brain disease characterized by compulsive use of a substance despite negative consequencesDespite being a chronic disease, addiction is treatable, and individuals can enter remissionAddiction is more common than we see, 10% of adults meet the criteria for a substance use disorder in their lifetime. Only 25% of those that met the criteria for a use disorder ever received care.

3. Addiction is a brain diseaseSubstances that cause addiction primarily work on 2 receptor typesDopaminergicOpioid (primarily the mu receptor)NeurotransmittersDopamineOpioidsEndorphins (endogenous opioids)Exogenous (introduced from outside)EndorphinsOpioidsAlcoholDopamineStimulantsOpioid receptor stimulationReward/Dependence/Loss of ControlSubstance Use Disorder/Addiction

4. Addiction is a brain diseaseWhen we do things that help us survive, we release neurotransmittersThese neurotransmitters create a feeling of wellbeing and create trigger memory creationReceptors for these transmitters are located throughout the body, but substance use disorders affect:Limbic system basic survival instinctsPrefrontal cortex decision making and impulse control

5. Dopamine/Endorphin modelLife affirming activities produce a small spike of dopamine~50% increase with eating~100% increase with sexDopamine levels between 50-100 pg/mL at baselineSubstances spike this dopamine levelMorphine ~300% increaseHeroin ~1,000% increaseMethamphetamine ~900-1,000% increase

6. Dopamine/Endorphin modelWith chronic use, the brain adjusts to the new normal.Decreases baseline dopamine productionCreates more dopamine receptorsResult: brain needs more of the substance to generate the same responseLife affirming activities do not create enough dopamine to trigger proper brain function, impulse control is also lostThe individual will do whatever is needed to obtain the substance

7. Dopamine/Endorphin modelWith chronic use, objective eventually becomes to find enough of the substance to feel normal and avoid withdrawalWhen substance is not present, physical withdrawal occursMemory Loss of memory cuesCharlie Brown Effect

8. Dopamine/Endorphin modelObjectives of Agonist-based Medication Assisted Treatment for Opioid Use DisorderReturn the brain to a normal baseline dopamine levelUse long-acting medication to prevent spikes in dopamineStop cravings for a substanceAllow the addressing of psychosocial needsThree FDA Approved Medications for OUDMethadone – Full agonistBuprenorphine – Partial agonistNaltrexone - Antagonist

9. Dopamine/Endorphin modelHigh dopamine recoveryLow dopamine recoveryIndividuals with strong recovery supportsHighly motivated to enter treatmentPredictable recovery pathMost addiction treatment success data is from these groupsMay do well with abstinence based treatmentUnmet psychological, social, or economic needsUnaddressed ACEs or other traumaUncertain recovery supportsLow treatment retention rates in traditional or abstinence based treatmentBest candidates for medication assisted treatment

10. Dopamine/Endorphin model

11. MethadoneFull opioid receptor activationTreatment goal: Activate the opioid receptors to the point that the individual does not experience opioid cravings, is not in withdrawal, and is not experiencing euphoria.Duration of action: 1-2 daysCan only be provided through Opioid Treatment Programs (OTPs)Closest in Fargo (3-4 people drive daily from Grand Forks)Must dose in person and earn privileges Prevents diversionLiquid form used almost exclusively in OTPs

12. MethadoneOldest and most studied medication for opioid addiction.Ideal candidates:Individuals with exceptionally high opioid use historiesIndividuals with treatment retention difficultiesIndividuals who were unable to tolerate buprenorphine treatmentLarge barriers to treatment in Grand Forks due to a lack of OTPs

13. MethadoneDose Response“Loaded” “High”Normal Range“Comfort Zone”“Sick”“Abnormal Normality”Subjective withdrawalObjective withdrawal 0 hrs.Time24 hrs.

14. BuprenorphinePartial receptor activatorTreatment goal: Activate the opioid receptors to the point that the individual does not experience opioid cravings and is not in withdrawal.Duration of Action: ~24 hoursSublingual tablet, dissolves in 10-20 minutes, onset of action in 30 minutesVery high affinity for receptor sitesWill kick most existing opioids off their receptor -> Precipitated withdrawalCeiling effect – very safe for opioid tolerant individuals

15. BuprenorphineOftentimes combined with naloxone to prevent injection useCommon Forms:Subutex (buprenorphine) sublingual tablet - > Pregnant womenSuboxone (buprenorphine/naloxone) sublingual film - > Most CommonZubsolv (buprenorphine/naloxone) sublingual tablet - > NDMASublocade (buprenorphine) extended release injection - > New to market, $$$$High dose buprenorphine more effective than low dose buprenorphine in maintaining long-term treatment retention

16. BuprenorphineOnly DATA 2000 Waivered prescribers can prescribe this medicationTreatment initiationMust be started when in mild withdrawal – generally 8-16 hours from last opioid useInitial dose typically 4-8mg, up to 16mg3-4 day follow up, then titrate dose upOptimal maintenance dose 8-24mgTreatment courseIndividually designed taper – 6 months – lifetimeContinued reassessment, titrate to opioid cravingsLast 2 mg reported to be most difficult

17. NaltrexoneFull receptor antagonist, reverses and caps the opioid receptorStructurally similar to naloxoneTreatment goal: Remove the ability to use a substance by removing the euphoric effects of taking the substanceFDA approved for opioid addiction and alcohol addictionAvailable as a oral tablet and as an extended release injectable (Vivitrol) Oral form is cheap, but has low treatment complianceInjectable form is expensive, but increases treatment compliance (28 days/injection)

18. NaltrexoneIn one major study, extended release naltrexone is similar to buprenorphine or methadone in treatment retentionBUT:Fewer received the first dose of Naltrexone (failed before initiating study)7-10 day opioid free period requiredRelapse more likely in intention to treat analysisMore overdoses, fewer fatal overdoses thoughLess treatment retention after study period

19. NaltrexoneIdeal candidates for extended release naltrexoneIndividuals who are highly motivated and well supported in their recoverySafety netIndividuals who continue to work in professions which prohibit the use of other MAT medicationsAirline pilots/PhysiciansIndividuals who have already gone through a opioid detoxification period and/or are opposed to opioid agonist therapyIndividuals with alcohol use disorder

20. NaltrexoneDopamine and naltrexoneNaltrexone does not assist in returning the body to its baseline dopamine level – “normal feeling”Opioid cravings may persist despite inability to use opioids for euphoriaNaltrexone inhibits endorphins from acting in the body resulting in a dull affectDepressionBottom lineVivitrol has definite value for select clients, but is not the no-brainer it seems at face value, though for some it is the best solutionAlkermes heavily markets Vivitrol to abstinence based providers, jails, drug courts, and governments

21. Nicotine use disorderMedication assisted treatment readily available for nicotine use disorderNicotine replacementProvides a baseline level of nicotine to prevent cravings and withdrawalAllows the individual to address the factors that lead to smoking and reprogram behaviors associated with smokingOther medicationsChantix (varenicline)Wellbutrin (buproprion) Individuals are more successful in recovery when they quit smoking at the same time

22. TreatmentMethadone – Mu Opioid AgonistBuprenorphine –Partial Mu Opioid AgonistSuboxone/Zubsolv (Sublingual)Sublocade (28 day injectable)Naltrexone – Mu Opioid AntagonistVivitrol (28 day injectable)ASAM criteria guide level of careOutpatient (<9 hrs/week)High-Intensity Outpatient (9-20 hrs/week)Partial hospitalization (20-40 hrs/week)Residential Treatment (Clinically or Medically Managed)Intensive Inpatient (24-hour nursing and physician care)Peer SupportMedicationAssistedTreatmentCounselingGroup-based peer support – Treatment philosophies vary!Narcotics Anonymous (NA) /AASMART Recovery – Non 12-stepFaith-centeredRecovery housingAddiction is a complex but treatable disease that affects brain function and behavior. Treatment needs to be readily available and attend to the multiple needs of the individual. No single treatment is appropriate for everyone.Individual-based peer supportEmployer supported – Face It TOGETHERRe-entry programs – Free Through RecoveryProgram supported – Human Service AgenciesPeer to peer

23. How do we properly treat addiction?Assess severity of the substance use disorderControl over substance useHow substance use affects your lifeSymptoms of physical dependenceASAM guidelinesLevel 0.5 – At RiskLevel 1 – Mild SUDLevel 2 – Moderate SUDLevel 3 – Severe SUDSeverity and level helps to dictate the most appropriate treatment

24. How do we properly treat addiction?The more severe the disorder, the more intense level of treatment is neededStart at the level corresponding to needLevel 3 – Residential or inpatientLevel 2 – Intensive outpatientLevel 1 – Outpatient servicesLevel 0.5 – Early interventionMore treatment isn’t better treatment if it doesn’t match the patient’s needMost of this treatment is available locally on an outpatient basis or in-state.

25. TreatmentBuild peer support capacity using their sustainable peer support model$29,000Face It TOGETHERIncrease access to medication assisted treatment$79,000Valley Community Health CentersProvide treatment services to inmates at Grand Forks County Correctional Center$29,000Agassiz AssociatesPeer SupportMedicationAssistedTreatmentCounselingAssist reentry and provide peer support for individuals involved in the criminal justice system$10,000F5 ProjectAddiction is a complex but treatable disease that affects brain function and behavior. Treatment needs to be readily available and attend to the multiple needs of the individual. No single treatment is appropriate for everyone.Opioid Response in Grand ForksEmpowering the Individual | Eliminating Barriers | Enabling Recovery

26. Future concerns

27. Questions?20142015201620172018Opioid Overdoses2227635330Monthly Average – Opioid Overdoses1.82.35.34.42.5Months without a reported Opioid Overdose21001