American Academy of Addiction Psychiatry Division on Substance Abuse Department of Psychiatry Columbia University New York State Psychiatric Institute MAT Overview NCBH Learning Community SUD Treatment Options ID: 717668
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November 23, 2015Arthur Robin Williams MD MBEAmerican Academy of Addiction PsychiatryDivision on Substance AbuseDepartment of Psychiatry, Columbia UniversityNew York State Psychiatric Institute
MAT OverviewNCBH Learning CommunitySlide2
SUD Treatment OptionsLevel of Care:- Outpatient - Individual - Program- Residential- Inpatient/ HospitalSlide3
SUD Treatment OptionsLevel of Care:- Outpatient - Individual - Program- Residential- Inpatient/ Hospital
- Detoxification
- Aversion
- Anti-Craving
- SubstitutionSlide4
11 Symptoms of AddictionSlide5
Targeting SymptomsMedications (MAT)
- Detox taper
(Librium or
Methadone)Slide6
Targeting SymptomsMedications (MAT)
Aversion (Antabuse)
- Anti-Craving
(
Naltrexone
)Slide7
Targeting SymptomsMedications (MAT)
Substitution(methadone or buprenorphine)Slide8
SUD COD COD SUD SUD COD SUDs and Co-Occurring Disorders:Assessing CausalitySlide9
Diagnosis may require collateral from multiple sources: i.e. timeline for symptom onsetWorse consequences from SUDs at treatment intake and poorer long-term outcomesYet most programs (and clinicians) either focus only on the SUD or the COD !SUDs and CODSlide10
Currently, the FDA has approved medications for adults for the treatment of addiction to:OpioidsAlcoholNicotineMATSlide11
The FDA approves medications after trials with adults demonstrate efficacy and safetyTypically trials exclude subjects under 18 years, dually diagnosed, pregnant women, hindering generalizabilityEfficacy v. EffectivenessThus far, none approved for cannabis or stimulantsEvidence-Based Addiction Psychopharmacology (MAT)Slide12
Background: OUD Neurochemistry“Opioids” include synthetic pain pills and heroin“Opiates” are natural opioids like opium or morphineOpioids activate mu, delta, kappa receptors In OUD, receptors are unstable when not activatedUnstable receptors lead to:Withdrawal symptomsIntense cravingsGreat risk, such as overdose deathInjection adds infectious disease (HIV, Hepatitis C) and injuriesSlide13
Background: MAT for OUDsReceptors are stabilized with MAT medicationsPatients on MAT experience fewer and less intense cravings and use drugs at much lower ratesMAT is the gold standard for OUD treatment:Reduces drug useProtects against overdosesPrevents injection behaviorsSlide14
Detoxification Is not a treatment on its own (risk factor for OD)Should be a mechanism to get someone on MATMaintenanceAgonist (methadone) or partial agonist (buprenorphine) Antagonist TherapyNaltrexone pill or xr-naltrexone (Vivitrol) injectionMAT: OpioidsSlide15
Increased pulseSweatingRestlessnessPupil dilationBone/joint painRunny nose/tearingGI upsetTremorYawningAnxiety/irritabilityGoosefleshHigher score= worse w/dClinical Opioid Withdrawal Scale (COWS)Slide16
DetoxificationBuprenorphine and Methadone better than clonidineMaintenance for 2+ yearsUse sufficient dose bup >8mg, methadone >100mgBuprenorphine more likely to successfully lead to Naltrexone afterwardPregnant women should continue on maintenance given risks of relapse, withdrawal, and overdose following attempted taper
MAT: OpioidsSlide17
Buprenorphine: Pregnancy Lund, et al. 2013Slide18
Antagonist therapyNaltrexone daily pill (low adherence rates) or Vivitrol injection given every 3-4 weeks“Blockers” prevent euphoric/rewarding drug effectsCan satisfy cravingsDoes NOT cause an “aversion reaction”Naloxone (Narcan) reverses overdoses and only lasts 20-40 minutes
MAT: OpioidsSlide19
XR-Naltrexone: Hard to find Krupitsky, et al. 2011Opioid-free weeks (Krupitsky 2012) Slide20
NeuropathologyAnti-glutaminergicPotentiates GABADopamine releaseAlcoholSlide21
MAT: AlcoholDetoxification (Youth typically binge drink and rarely require)Use benzodiazepines, phenobarbitalOutpatient v. inpatient modelsAversionAntabuse 250mg or 500mg daily (FDA 1951) Start after all alcohol has clearedC
an dose on site or have observer at homeEffects for up to 2-3 weeks for someConsider as an adjunct to psychosocial therapiesMonitor liver function every 1-3 monthsSlide22
MAT: AlcoholAnti-CravingCampral 666mg TID (FDA 2004) Stabilizes neuroexcitability in protracted withdrawalDosing is problematic (but no side effects)Better choice for patients with liver diseaseNaltrexone 50mg daily (NTX) (FDA 1994)
Reduces number of drinks per drinking day and cravingsSide effects limited (nausea/sedation)LFTs should be followed intermittently (every 3 months)Vivitrol 380mg IM (XR-NTX) (FDA 2006) Long acting monthly injection of naltrexoneSlide23
MAT includes 3 modalities:Methadone (schedule II)Buprenorphine (schedule III)Naltrexone (not controlled)MAT should be provided in addition to intensive psychosocial and behavioral therapyMost patients require MAT for a minimum of 1-2 years of sobriety before attempting to taperSummary: OpioidsSlide24
MAT includesAntabuse (disulfiram) 250mg or 500mg dailyNaltrexone 50mg daily or monthly Vivitrol injectionAcamprosate 666mg PO TIDDosing should be observed by family or programCheck liver function regularly if on naltrexone or AntabuseSummary: AlcoholSlide25
Bekkering, G. E., et al. (2014). "Practitioner review: evidence-based practice guidelines on alcohol and drug misuse among adolescents: a systematic review." J Child Psychol Psychiatry 55(1): 3-21.Bergman, B. G., et al. (2014). "Young adults with co-occurring disorders: substance use disorder treatment response and outcomes." J Subst Abuse Treat 46(4): 420-428.Bush DM, W. D. (2014). "Update: Drug-Related Emergency Department Visits Involving Synthetic
Cannabinoids." Drug Abuse Warning Network. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. October 16, 2014.Friedman P, et al (1994). Retention of patients who entered methadone maintenance via an interim methadone clinic. J Psychoactive Drugs. Apr-Jun; 26(2):217-21. Gray KM, Carpenter MJ, Baker NL, DeSantis SM, Kryway E, Hartwell KJ, McRae-Clark AL, Brady KT. A double-blind randomized controlled trial of Nacetylcysteine in cannabis-dependent adolescents. American Journal of Psychiatry. 2012;169:805–812.
Kaminer
, Y., et al. (2010). "Psychotropic medications and substances of abuse interactions in youth."
Subst
Abus
31
(1): 53-57.
ReferencesSlide26
Krupitsky, et al. (2012). Randomized Trial of Long-Acting Sustained-Release Naltrexone Implant vs Oral Naltrexone or Placebo for Preventing Relapse to Opioid Dependence. Archives General Psychiatry. Sep; 69(9):973-81.Lund IO et al. (2013). A comparison of buprenorphine + naloxone to buprenorphine and methadone in the treatment of opioid dependence during pregnancy: maternal and neonatal outcomes. Subst Abuse 7:61–74, 2013.Moore, S. K., et al. (2011). "Improvement in psychopathology among opioid-dependent adolescents during behavioral-pharmacological treatment." J Addict Med 5(4): 264-271. Niederhofer, H. and W. Staffen (2003). "Acamprosate and its efficacy in treating alcohol dependent adolescents." Eur Child
Adolesc Psychiatry 12(3): 144-148.Niederhofer, H. and W. Staffen (2003). "Comparison of disulfiram and placebo in treatment of alcohol dependence of adolescents." Drug Alcohol Rev 22(3): 295-297.Scherphof, C. S., et al. (2014). "Short-term efficacy of nicotine replacement therapy for smoking cessation in adolescents: a randomized controlled trial." J Subst Abuse Treat
46
(2):
120-127.
Simkin
, D. R. and S. Grenoble (2010). "Pharmacotherapies for adolescent substance use disorders."
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Psychiatr
Clin
N Am
19
(3): 591-608.
References