AdaptCompass Behavioral Health SouthRiver Community Health Center Douglas County Pain Summit March 21 2017 Best Practices in Medication Assisted Treatment for Opioid Use Disorder Objectives ID: 720591
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Gregory S. Brigham, Ph.D., CEO
Adapt|Compass Behavioral Health | SouthRiver Community Health CenterDouglas County Pain Summit, March 21, 2017
Best Practices in
Medication Assisted Treatment
for Opioid Use DisorderSlide2
Objectives
Provide overview of opioid use disorderReview 3 types of FDA-approved medications for opioid use disorder
Review best practices for integrated MAT and behavioral interventionsSlide3
Opioid AgonistsSlide4
Mu
(μ) receptors stimulated by opioids causing the full range of opioid effects.
Adapted from slides at vivitrol.comSlide5
Death
Coma
Nod
Euphoria
Relax
Pain
Progressive CNS Depression
Opioids
Action
DoseSlide6
6
Dependence vs. AddictionDependence
Increased toleranceWithdrawal
Addiction
Craving
Loss of control
Impairment & distress in important life areasSlide7
7
Differing Strengths & Durations of Action
Opioid Agonist Half-Lives
Heroin, codeine, morphine – 2-4 hours
Methadone – 24 hours
Buprenorphine – 24-60 hours
Adapted from NIDA/ATTC Blending ProductSlide8
8
Acute Opioid Withdrawal Symptoms
Pupillary dilationWatery eyes
Runny nose
Muscle spasms (“kicking”)
Yawning, sweating, chills, gooseflesh
Stomach cramps, diarrhea, vomiting
Restlessness, anxiety, irritability
Usually result in further use to quiet symptomsSlide9
Three Types of Medication for Opioid Use Disorder
Agonist
Morphine-like effect (e.g., heroin, methadone)
Partial
Agonist
Maximum effect is less than a full agonist (e.g., buprenorphine)
Antagonist
No effect in absence of an opiate or opiate dependence (e.g., naloxone)Slide10
Death
Coma
Nod
Euphoria
Relax
Pain
Progressive CNS Depression
Methadone
Action
DoseSlide11
Methadone: A Full Agonist
www.methadoneaddiction.net/m-pictures.htm Slide12
Authoritative review of 11 randomized clinical trials with 1,969 patients
Conclusion methadone is superior to placebo in: Retaining patients in treatment
Reducing illicit opioid useSlide13
Advantages of Methadone
70% or more treatment retention at 1 yearTreats craving
Blocks illicit opioid useOver 40 years of research and treatment experience demonstrating effectiveness
Significantly reduces risk for addiction related death and health problems
Medication cost is minimalSlide14
Limitations of Methadone
Full agonist with abuse potentialPotential for dangerous interactions with other drugs when misused
Highly regulated resulting in limited access to careStrong physical dependence results in difficult withdrawal
Significant stigma in the community
Heavy burden on patients for compliance Slide15
Partial Agonist
Buprenorphine
Opioid Effect
DoseSlide16
Buprenorphine: A Partial AgonistSlide17
Review of 24 randomized clinical trials with 4,497 patients
Conclusion buprenorphine is superior to placebo and to moderate dose methadone:Retaining patients in treatment
Reducing illicit opioid useSlide18
BUP/NX Office-Based Practice
DATA 2000 physicians office-based prescription BUP for opioid use disorderCARA 2016 (7/22/16): increase patient # limits; NP & PA to prescribe
Retention rates ≈48% at 6 months.
Requires ability to refer for behavioral treatment
Diversion and other problems are common and require close monitoring & interventionSlide19
Advantages of Buprenorphine
DATA 2000 greatly increases accessLess severe dependency allows for easier transitions between recovery with and without medication
Partial agonist is safer with less overdose potential
Lower abuse potential
People live a normal life free from craving and withdrawal
SAVES LIVESSlide20
Limitations of Buprenorphine
Not a full agonist and does not retain people in treatment as well as full agonistHas diversion potential and may be misused
Medication is expensive and access is limitedStigma in the recovery community Slide21
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Strang, J., McCambridge, J., Best, D., Beswick, T. Bearn, J., Rees, S., & Gossop, M. (2003). Loss of tolerance and overdose mortality after inpatient opiate detoxification.
British Medical Journal. May 2003; 959-960. About 4% 12-month mortality risk positively correlated with longer abstinence. Slide22
Antagonist, e.g., naloxone
Opioid Antagonist
Opioid Effect
DoseSlide23
Opioid Antagonist
Adapted from slides at vivitrol.com
Receptor blocked by antagonistSlide24
Gluteal Intramuscular Injection
of Vivitrol24
Adapted from slides at vivitrol.comSlide25
Advantages of Vivitrol
Safe to use, no abuse potentialBlocks the effects of opioids
Reduces danger of accidental overdose No physical dependence
Little or no stigma in the recovery community Slide26
Limitations of Vivitrol
Less research and clinical experienceNo reinforcing effects to support retention in treatment
No withdrawal symptoms to prevent treatment drop-outHigh cost limits access
May not control cravings
Must be opioid free for induction, indication is for relapse preventionSlide27
No One Treatment is
Right for Everyone3 FDA-approved medications to support recovery
Numerous ways to integrate pharmacotherapies & behavioral interventions3 MAT approaches available in Douglas CountySlide28
MAT for Opioid Use Disorder
Available in Douglas County BUP Taper followed by Vivitrol for Relapse Prevention
Office-based Buprenorphine at SRCHC and URMCBUP + Motivational Stepped CareOpioid Treatment Program (eff. 3/15/17)
Methadone or Buprenorphine
Motivational Stepped CareSlide29
Acknowledgements
Umpqua Health for grant support to develop the OTP, as well as ongoing support for ongoing servicesOHA & SAMHSA for grant support to establish the Opioid Treatment Program