medication-assistedtreatment 101

MAT Symposium

medication overview & a review of theevidence

Adrienne C. Lindsey, MA, DBHAugust 2014

Part 1

the neuroscience ofaddiction

overview of addictionand the brain

substancesaffect thebrain

chemically

structurally

behaviorally

the reward pathwaydrugs & alcohol acton the rewardpathway, the sameregion activated by:

• eating• sex• drinking• other pleasurable

activities

chemical changes

the role of dopamine• increase in available dopamine

• results in pleasurable feelings

• the behavior is reinforced

• the effect of previouslypleasurable activities is blunted

non-druguser

heavycocaine

user

(National Institute on Drug Abuse, 2010)

smoker

non-smoker

alcoholic

normal normal normal

obese cocaine

(Volkow, 2001)

healthy brain

healthy heart diseased heart

diseased brain/cocaine abuser

Decreased Brain Metabolism in Drug Abuser

Decreased Heart Metabolism inHeart Disease Patient

(National Institute on Drug Abuse, 2010)

glutamate

endogenousopioids

GABA

serotonin

structural changes

(National Institute on Alcohol Abuse & Alcoholism, 2004)

healthyelderlyperson

person withAlzheimer’s

disease

heavydrinker

alcoholicbrain

controlbrain

Oscar-Berman, M., Valmas, M., Sawyer, K.S., Ruiz, S.M., Luhar, R., & Gravitz, Z. (2014). Profiles of impaired, spared, andrecovered neuropsychological processes in alcoholism. In Pfefferbaum, A. & Sullivan, E.V. (Eds.), Handbook of ClinicalNeurology: Alcohol and the Nervous System. Edinburgh: Elsevier (in press).

(National Institute on Alcohol Abuse & Alcoholism, 2004)

control brain alcoholic brain

behavioral changes

classical and operant conditioning

behaviorsthat are

rewardedare likely

to berepeated

positive reinforcement

negative reinforcement

environmental cues

recovery

healthy brain

cocaine abuser (10 days clean)

cocaine abuser (100 days clean)

(National Institute on Drug Abuse, 2007)

leve

l of b

rain

act

ivity

(low

to h

igh)

normal control meth abuser(1 month ofabstinence)

meth abuser(14 months ofabstinence)

(National Institute on Drug Abuse, 2002)

review: substancesaffect the brain…

chemically

structurally

behaviorally

mythbustingPart 2

the facts and fictionof medication-assisted treatment

“…treatment for a substance use

disorder that includes a

pharmacological intervention as part

of a comprehensive substance abuse

treatment plan...”

how MATworks

easeswithdrawal

reducescravings

inducesillness

myth #1: MAT isjust replacing onedrug with another.

MAT vs. illicit drugsprescribed/monitoredby a medical provider

FDA-approved

regulated potency

curbs cravings andwithdrawal symptoms

obtained by illegalmeans

not legally permitted

potency varies

results in euphoriaor a “high”

myth #2: MATdoesn’t work.

to beapproved bythe FDA,medicationsmust beshown to besafe, but alsoeffective

treatmentoutcomes forbuprenorphine(Suboxone)

increasedtreatmentretention

decrease inself-reportedcravings

decreasedillicit opioiduse

treatmentoutcomes formethadone

increased treatmentretention

decreased illicit opioiduse

8-10 fold decrease indrug-related deaths

increase inemployment rates

decrease in criminalactivities

treatmentoutcomesfor alcoholmedications

reduces total numberof drinking days

reduces number ofheavy drinking days

increased likelihoodfor abstinence;reduces the risk ofrelapse

reductions in criminalrecidivism

myth #3: If someoneis clean, they don’tneed MAT.

drug overdose is one ofthe leading causes ofdeath for individualsbeing released from

prison or jail

Reductions in Mortality

Drug overdose was the leading cause of death for

those released from Washington State prisons

between 1999 and 2003 (Binswanger et al., 2007).

Before…

Homicides,

Suicides,

Heart disease, and…

Motor vehicle accidents

myth #4: MAT isn’tsupported by 12-Stepprograms.

“No A.A. member should ‘playdoctor;’ all medical advice andtreatment should come from aqualified physician.”

--A.A. General Service Office(Member Medications & Other Drugs brochure)

“…just as it is wrong to enable orsupport any alcoholic to becomereaddicted to any drug, it’s equallywrong to deprive any alcoholic ofmedication, which can alleviate orcontrol other disabling physicaland/or emotional problems.”

--A.A. General Service Office(Member Medications & Other Drugs brochure)

“NA as a whole has no opinion on outsideissues, including prescribed medications.Use of psychiatric medication and othermedically indicated drugs prescribed bya physician and takenunder medicalsupervision isnot seen ascompromising aperson’s recovery inNA.”

myth #5: MAT is tooexpensive

many MAT medicationscan be found onstate Medicaid/Medicareformularies

RBHAformulary

buprenorphine/naloxone

buprenorphine

disulfiram

acamprosate

naltrexone

for thosepatients whodo not qualifyfor Medicaid or Medicaremany patient assistanceprograms are availablethrough the drugmanufacturers

grant funding

private insurance

prescription discountcards

tribal funds

additional MAT funding sources

Part 3

the medicationsuses and considerations

medicationsfor alcohol

naltrexone

acamprosate

disulfiram

mechanism: blocks the pleasurableeffects of alcohol; reduces alcoholcravings

pros can be used for alcohol & opioiddependence, non-addictive,reduces drinking episodes& volume, extended releaseavailablecons non-compliance

naltrexone (Depade®, ReVia®, Vivitrol®)

mechanism: assists in post-acutewithdrawal symptoms (e.g. irritability,anxiety, agitation)

pros non-addictive, can assist patient inmaintaining abstinence,not easily abused/misused, affordablecons patient must beabstinent to begintreatment

acamprosate (Campral®)

mechanism: makes patient physicallyill when ingesting alcohol

pros non-addictive, affordable ($60/mos),useful with chronic alcoholismcons non-compliance,risk of death for thosewith existing healthconditions, may not beappropriate for SMI px’s

disulfiram (Antabuse®)

medicationsfor opioids

methadone

buprenorphine

naltrexone

how do opioidswork?

dose of opioid

opioideffect

full agonist(e.g.,methadone)

(e.g. naloxone)antagonist

partial agonist(e.g. buprenorphine)

mechanism: full agonist (acts on opioidreceptors), alleviates withdrawalsymptoms & cravings

pros affordable (usually gov’t subsidized),convenient dosing (1x/day), demonstratedsafety for pregnant womencons intoxicationwith too high a dose,risk of overdose

methadone (Methadose®, Dolophine®)

mechanism: partial agonist - blockseuphoric effects of opioids, alleviateswithdrawal, assists with cravings

pros easier to taper than methadone,less risk of OD than methadone,available in a sublingualfilm, naloxonediscourages abusecons costly $$$

buprenorphine (Subutex®)buprenorphine/naloxone (Suboxone®)

new FDA-approved buprenorphine/naloxone generic sublingual film

expected release: Oct. 2014

manufacturer claims 2xthe bioavailability

-allows for lower dose(arguably less risk forabuse)

buprenorphine/naloxone (Bunavail®)

injectable buprenorphine; once amonth dosing

buprenorphine implant,good for 6 months

more to come….

upcoming products

mechanism: full antagonist (blocksopioid receptors)

pros prevents euphoric effects ofopioids; non-addictive;extended releaseavailable

consnon-compliance

naltrexone (Depade®, ReVia®, Vivitrol®)

building a case for MATPart 4

a review of the evidenceand patient benefits

substance abusetreatment is effective andcost-neutral…

…but half ofconsumers will

be lost toattrition

improved treatment retention

improvedfunctioning

lower risk ofoverdose

reduced criminal activity

reducedsubstance use

employment

benefits of MAT

improved treatmentretention

counselingonly

23 days incommunity treatment

0offenders remained in

treatment at 1 year

counseling +methadone

166 days in communitytreatment

1/3of offenders remained in

treatment at 1 year

(Kinlock, Gordon, Schwartz, Fitzgerald & Grady, 2009)

n=204; randomly assigned

reductions insubstance use

204prison inmates received counseling or counseling and

methadone treatment services (Kinlock et al., 2009)

2xas many inmates in the counseling only group

screened positive for opioids at 1 year post-release

interim methadone treatment

(Schwartz, Jaffe, Grady, Das, Highfield, & Wilson, 2009)

762patients

24buprenorphine clinical trials

4,500opioid-addicted patients

buprenorphinewas significantlymore effective at reducingillicit opiate usethan placebo

(Mattick, Kimber, Breen & Davoli, 2008)

naltrexone v placebo

fewer slips

fewer significant relapses

fewer total drinking days

(O’Brien, Volpicelli, &Volpicelli, 1996)

naltrexone vplacebo

reduced consumption

fewer relapses

cont’d abstinence

(O’Malley et al., 1992)

reduced mortality

8-10fold reduction in deaths for opiate dependent individuals usingmethadone

13xhigher mortality rate for opiate users than non opiate users

death rates in treated &untreated heroin addicts

MAT has also beenfound to reduce…

risky behaviors-IV drug use-unprotected sex

reducing…-HIV-Hepatitis C

reductions incriminal activity

MAT can reducecriminal activity

and reincarceration

Reductions in Recidivism

annu

al c

rime

days

Annual Crime Days Before Methadone Treatment and During MethadoneTreatment (amongst 6 programs) (Ball & Ross, 1991)

Reductions in Recidivism

• 342 inmates with opioiddependence

• methadone maintenance whileincarcerated; referral formethadone clinic upon release

• reincarceration rates werereduced by 70% whileparticipants were enrolled intreatment(Dolan et al., 2004)

Reductions in Arrests

• 300+ opiate dependent clients

• interim methadone treatmentvs. no treatment/waiting list

• significantly fewerarrests at 6 months(Schwartz, Jaffe, O’Grady,Kinlock, Gordon, Kelly,Wilson & Ahmed, 2009)

improvements inemployment status

↑ functioning↑ employment outcomes

cost savings

$27,802average annual cost per offender for incarceration in

Pima County jail

$11,442average cost per offender for one year of out-of-

pocket MAT services and standard probation

$7,354if an offender pays 40% of his or her treatment costs, the cost of

one year of standard probation and MAT services drops to

$16,360annual savings per year, per offender, when providing MAT servicesto an offender on community supervision, as opposed to incarceratingthat individual for one year

$72.5 billionannual healthcare costs related to prescription opioid misuse/abuse

MAT cost-savings

improved healthoutcomes

improvedproductivity/reducedabsenteeism &presenteeism

reduced criminalactivity

reducedrecidivism/reincarceration

MAT referralprocess simplified

Part 5

identifying appropriate candidatesand locating providers

identifying MATcandidates

appropriate MATcandidates

history of use

previous failedtreatmentattempts

openness to tryMAT

activepsychosis

serioushealthconditions

dependenton multiplesubstancesinappropriate

MAT candidates

medical professionals will makethe ultimate determinationaround eligibility…

locating an MATprovider

The Substance Abuse and Mental Health ServicesAdministration’s buprenorphine physician locator canidentify those providers in your area who are certifiedto prescribe buprenorphine

buprenorphine.samhsa.gov

the Single-State Agency (SSA) for substance abusetreatment providers for your state can point you to MATproviders in your area…

other MAT providerresourcesin-house treatmentcoordinators/liaisons

existing contractedproviders

requesting MAT ofexisting providers

help us help you…-name of agency-contact info.-forms of MAT-forms ofpayment

OR…

names of providersyou’re referring to

funding MAT

financing

Medicare/Medicaid

private insurance

patient-assistanceprograms

prescriptiondiscount cards

grant funding

tribal funds

changes in agerestrictions

substance abusetreatment parity

health exchanges

employermandates

Medicaid expansion

healthcare reformimplications

strengtheningrelationships with

MAT providers

strengtheningrelationships

cross-trainings

liaisons

contractualarrangements