Opiate Substitution Treatment: Opiate Substitution Treatment: An Overview An Overview Ron Jackson, M.S.W. Ron Jackson, M.S.W. Evergreen Treatment Services Evergreen Treatment Services Seattle, WA Seattle, WA
Transcript
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Opiate Substitution Treatment: An Overview Ron Jackson, M.S.W.
Evergreen Treatment Services Seattle, WA
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HEROIN There were 32 heroin-related deaths in the first half of
2001. These represent 37% of all drug deaths. Of the heroin-related
drug deaths: 27 (84.4%) had one or more other drugs in their system
at the time of death. 72% of decedents were male; 94% Caucasian; 3%
African-American; 3% Hispanic.
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HEROIN
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The rate of ED heroin mentions has remained stable since 1998.
Treatment admissions have increased 33% since 1998. ADAM data
showed male arrestees tested positive for opiates at the rate of
9.9% in 2000 and 11.7% in the first quarter of 2001. Heroin prices
seem stable.
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Trends in ED mentions 1988-2000 ( rate per 100,000
population)
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ADDICTION Addiction is a brain disease shaped by behavioral and
social context. Dr. Alan Leshner, Director National Institute on
Drug Abuse Its like Ive got a shotgun in my mouth, my fingers on
the trigger and I like the taste of gun metal. Robert Downey, Jr.
Actor
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Addiction as a Brain Disease lProlonged drug use Pervasive
changes in brain function that 4Persist after drug use stops 4Can
be demonstrated at many levels VMolecular VCellular VStructural
VFunctional
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Drug Dependence: A Chronic Medical Illness Genetic Heritability
twin studies Hypertension 25-50% Diabetes Type 1: 30-55%; Type 2:
80% Asthma 36-70% Nicotine 61% (both sexes) Alcohol 55% (males)
Marijuana 52% (females) Heroin 34% (males) Voluntary Choice shaped
by personality and environment Pathophysiology neurochemical
adaptations Treatment Response Medications effectiveness and
compliance Behavioral interventions McLellan, A.T., et.al., Drug
Dependence, a Chronic Medical Illness Journal of the American
Medical Association 284:1689-1695, 2000.
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581 Male Heroin Addicts Followed for 33 Years Hser et al.,
2001
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Adapted from: JAMA, Dec. 9, 1998, 280 (22), 1936-1943 NIH
Consensus Panel on Effective Medical Treatment of Opiate Addiction
12 member multi-disciplinary panel, Nov. 1997 heard testimony from
25 experts reviewed 941 research reports published over the period
Jan. 1994 - Sept. 1997 Of the various treatments available, MMT,
combined with attention to medical, psychiatric, and socioeconomic
issues, as well as drug counseling, has the highest probability of
being effective.
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Comparing Methadone and Heroin
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LAAM: Levo-Alpha Acetylmethadol A Long-Acting Opiate Agonist
Pharmacological Action Metabolites more active than parent drug
Advantages One dose lasts 48 to 72 hours Fewer trips to the clinic
Better heroin blockage Disadvantage Cardiac complications
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Methadone Dose: How much is enough? Leavitt, SB, et.al., When
Enough is Not Enough. Mt Sinai Journal of Medicine 2000:
67(5&6): 404-411.
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Admission Criteria Adult 16-17 y.o. needs parental/guardian
permission Currently physiologically dependent on an opiate
Exceptions for incarcerated persons and for those who had
previously successfully completed treatment Current dependence on
other drugs doesnt disqualify If in treatment more than 180 days,
patient needs documentation of at least one years history of opiate
dependence.
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Treatment Requirements Attendance for observed dosing 6 days a
week for the first 90 days (methadone); 3 days a week indefinitely
(LAAM) Take-home doses permitted after 90 days but only to those
patients meeting a number of criteria At least once per month
observed urinalysis Some clinics have contingencies; some dont Some
agencies administer alcohol breath tests; some dont Primary
counselor assigned; weekly counseling for at least the first 90
days zAdditional education, i.e., HIV/HCV, family planning
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Opiate Substitution Treatment Goals Primary Goals: Reduction in
of illicit opiate use. Retention in treatment for 1-2 years or
more. Secondary Goals: Reduction in cocaine, alcohol, and other
drug abuse. Reduction in transmission of infectious diseases by
unsterile injection equipment. Reduction in criminal activity.
Increase in pro-social activity employment, education, child care,
etc.
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Methadone Maintenance vs. 180 Day Detoxification 12 month study
of 179 opioid dependent patients randomly assigned to: lMethadone
Maintenance 3mean dose=85.3mg 3for 14 months l180 Day Methadone
Detoxification 3mean dose=86.3 mg prior to taper at 120 days
3followed by psychosocial Tx for 8 months K.L. Sees et al., JAMA
2000
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Adapted from: Ball & Ross, 1991. Reduction of Heroin Use By
Length of Stay in Methadone Treatment Pre- treatment Admission:
< 6 months stay Average Stay: 6 to 54 months Long-term: > 54
months
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Adapted from V. Dole (1989) JAMA, 282, p. 1881 Frequency of
Heroin Use & Methadone Dose Level
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Drug Use & Length of Time in Methadone Treatment
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Percentage of Patients with + U/A January December, 2001 Van
service
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Adapted from: Ball & Ross, 1991. The Effects of Methadone
Treatment on Crime Days 70.8% Decline in Crime Days 94% n= 617
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Changes in Illegal Activity Preliminary findings, DASA,
Washington State Outcomes Project, 2002
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Changes in Illegal Activity Preliminary findings, DASA,
Washington State Outcomes Project, 2002
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Comparing Retention Methadone (6 mos.) vs. Drug-free (3 mos.)
Preliminary findings, DASA, Washington State Outcomes Project,
2002
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Comparing 6 month Outcomes Methadone vs. Drug-free Preliminary
findings, DASA, Washington State Outcomes Project, 2002
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Determining the Value of Opiate Substitution Treatment
Washington State DASA, Management Report, December, 2001 1 n=726 2
n=363
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from D. Calsyn, NIDA Grant # R18DA06104 Initial & 18 Month
Self-Report Data From 78 Methadone Patients
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Comparing Retention Methadone (6 mos.) vs. Drug-free (3 mos.)
Preliminary findings, DASA, Washington State Outcomes Project,
2001
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Comparing 6 month Outcomes Methadone vs. Drug-free Preliminary
findings, DASA, Washington State Outcomes Project, 2001
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Methadone and Criminal Justice
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from D. A. Calsyn, NIDA Grant # RA18 DA 06104 Women in
Methadone Treatment: Reduction in Prostitution % of women admitting
to prostitution in previous 6 months 28% 0% 13%
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Adapted from: Marsch, L.A. Addiction 93(4), 515-532, 1998.
Efficacy of Methadone Maintenance: A meta-analysis Estimation of
Results with Intervention* * based on the effect sizes observed in
meta-analysis (# of studies)
Swedish Methadone Study Before Experimental Group (Methadone)
Control Group (No Methadone) Gunne & Gronbladh, 1981
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Swedish Methadone Study After 2 Years Experimental Group
(Methadone) Control Group (No Methadone) Gunne & Gronbladh,
1981 d ab c dd a Sepsis b Sepsis and Endocarditis c Leg Amputation
d In Prison
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Adapted from: Ball & Ross, 1991. Return to I.V. Drug Use
Following Premature Termination of Treatment %IV USERS%IV USERS
Months Since Dropout
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BUPRENORPHINE Partial agonist at Mu-opiate receptor less
subjective high Slowly dissociates from those receptors slow onset
& offset Once-a-day dosing Sublingual administration compounded
with naloxone (BUP/NX) which will precipitate abrupt withdrawal if
injected
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Opiate Antagonists Naloxone (NARCAN ) 3treatment for acute
opiate overdose Naltrexone (ReVia ) 3detoxification from physical
dependence on opiates 3opiate blocker - aid to maintenance of
abstinence from opiates Clonidine (Catapres ) - not an antagonist -
suppresses withdrawal symptoms