MEDICATION ASSISTED MEDICATION ASSISTED ADDICTION ADDICTION

TREATMENT: TREATMENT: “APPROPRIATE USE”“APPROPRIATE USE”

DAS Quarterly Provider DAS Quarterly Provider MeetingMeeting

Louis E. Baxter, Sr., M.D., FASAMLouis E. Baxter, Sr., M.D., FASAMMedical Director-DASMedical Director-DAS

President ElectPresident ElectAmerican Society Addiction American Society Addiction

MedicineMedicine

GOALS & OBJECTIVESGOALS & OBJECTIVES

• Review comprehensive evaluation Review comprehensive evaluation componentscomponents

• DSM-IV-TR diagnosing DSM-IV-TR diagnosing

• Review full treatment planningReview full treatment planning

• Patient Placement – ASAM PPC-2Patient Placement – ASAM PPC-2

• Treatment of Co-occurring DisordersTreatment of Co-occurring Disorders

• Medication Assisted Therapy for Medication Assisted Therapy for detoxification, maintenance, and pain detoxification, maintenance, and pain managementmanagement

ADDITIONAL RESOURCESADDITIONAL RESOURCES

• CSAT TIP # 43 Buprenorphine TherapyCSAT TIP # 43 Buprenorphine Therapy

• CSAT TIP # 45 Detoxification and CSAT TIP # 45 Detoxification and Substance Abuse Treatment ***Substance Abuse Treatment ***

• National Quality Forum – “Evidence Based National Quality Forum – “Evidence Based Treatment Practices for Substance Use Treatment Practices for Substance Use Disorders”Disorders”

• ASAM’s Monograph – “Achieving ASAM’s Monograph – “Achieving Treatment Success in Alcohol Treatment Success in Alcohol Dependence”Dependence”

COMPREHENSIVE COMPREHENSIVE EVALUATION EVALUATION COMPONENTSCOMPONENTS• ““Chief Complaint”Chief Complaint” …why are you here? …why are you here?• Alcohol Use HistoryAlcohol Use History … Screening Tool (CAGE) … Screening Tool (CAGE)• Drug Use HistoryDrug Use History … Rx, Illicit, and OTC … Rx, Illicit, and OTC• Previous Treatment HistoryPrevious Treatment History … include Clergy … include Clergy• Previous Psych HistoryPrevious Psych History … admissions and OP … admissions and OP• Legal HistoryLegal History• Past Medical / Surgical History / MedicationsPast Medical / Surgical History / Medications• Family HistoryFamily History … Psychiatric and Substance Use … Psychiatric and Substance Use• Marital HistoryMarital History• Psychosocial HistoryPsychosocial History … Employment / Clubs/ … Employment / Clubs/

HobbiesHobbies

DIAGNOSESDIAGNOSES

• DSM-IV-TRDSM-IV-TR Criteria for Substance Use Criteria for Substance Use DisordersDisorders– Use disorder; Abuse; Dependence (Addiction)Use disorder; Abuse; Dependence (Addiction)

• DSM-IV-TRDSM-IV-TR Criteria for Psychiatric Disorders Criteria for Psychiatric Disorders– Depression; Bipolar; AnxietyDepression; Bipolar; Anxiety

• Laboratory DataLaboratory Data Documentation of Documentation of Medical DisordersMedical Disorders– Chronic pain; Seizure; Migraines; HIV/AIDS; Liver Chronic pain; Seizure; Migraines; HIV/AIDS; Liver

diseasedisease

• National Quality Forum Guidelines National Quality Forum Guidelines (2005)(2005)– Evidence-based Best Practices for SUDEvidence-based Best Practices for SUD

FULL TREATMENT FULL TREATMENT PLANNINGPLANNING• Assessment – DiagnosisAssessment – Diagnosis

• Detoxification – Medical MaintenanceDetoxification – Medical Maintenance

• Rehabilitation – CounselingRehabilitation – Counseling

• After / Continuing Care – Twelve Step After / Continuing Care – Twelve Step ProgramProgram

• Co-occurring Illness CareCo-occurring Illness Care

• Pain Management CarePain Management Care

• General Medical Care General Medical Care

APPROPRIATE LEVEL OF APPROPRIATE LEVEL OF CARECARE

• ASAM Patient Placement Criteria-2ASAM Patient Placement Criteria-2– Only peer reviewed beta tested tool for patient Only peer reviewed beta tested tool for patient

placementplacement

• Level 0.5 Level 0.5 … Brief Intervention (3-6 sessions)… Brief Intervention (3-6 sessions)

• Level I Level I … Traditional Outpatient (Individual)… Traditional Outpatient (Individual)

• Level IILevel II … Intensive Outpatient (group therapy) … Intensive Outpatient (group therapy) three to five 90 minute sessions weeklythree to five 90 minute sessions weekly

• Level IIILevel III … Residential (Medically supervised) … Residential (Medically supervised)

• Level IVLevel IV … Hospital based (Medically managed) … Hospital based (Medically managed)

TREATMENT WORKSTREATMENT WORKS

• Full Treatment ExperienceFull Treatment Experience (Detoxification; Rehabilitation; (Detoxification; Rehabilitation; Maintenance) Maintenance) – General Population recovers @ 77% General Population recovers @ 77%

@ 1yr@ 1yr– Detoxification & RehabDetoxification & Rehab Only @ 33% Only @ 33%

@ 1yr@ 1yr– Detoxification AloneDetoxification Alone @ < 10% @ 1 yr @ < 10% @ 1 yr

TREATMENT OUTCOME TREATMENT OUTCOME COMPARISONSCOMPARISONS• Alcoholism … 50-70% abstinentAlcoholism … 50-70% abstinent• Opioid Dependence … 50-80% abstinentOpioid Dependence … 50-80% abstinent• Cocaine Dependence … 50-60% abstinentCocaine Dependence … 50-60% abstinent• Nicotine Dependence … 20-40% abstinentNicotine Dependence … 20-40% abstinent• Diabetes (relapse) … 30-50% stable Diabetes (relapse) … 30-50% stable • Hypertension (poor control) … 50-60%Hypertension (poor control) … 50-60%• Asthma (multiple ER visits) … 60-80%Asthma (multiple ER visits) … 60-80%

(Gaber, Davidson, 1992; McLellan 2002)(Gaber, Davidson, 1992; McLellan 2002)

MEDICATION ASSISTED MEDICATION ASSISTED THERAPIESTHERAPIES• Medications for Medications for detoxificationdetoxification

• Medications for Medications for maintenancemaintenance

• Medications for Medications for psychiatric illnessespsychiatric illnesses

• Medical management of Medical management of painpain

MEDICATIONS FOR MEDICATIONS FOR DETOXIFICATIONDETOXIFICATION• Librium Librium … Alcohol and Benzodiazepine … Alcohol and Benzodiazepine

detoxificationdetoxification

• Benzodiazepine & Phenobarbital Benzodiazepine & Phenobarbital … … Benzodiazepine detoxificationBenzodiazepine detoxification

• Suboxone (Subutex) & MethadoneSuboxone (Subutex) & Methadone …Opiate …Opiate detoxificationdetoxification

• Clonidine & Naltrexone Clonidine & Naltrexone … Opiate detoxification… Opiate detoxification

• Bromocryptine & Amantadine Bromocryptine & Amantadine … Stimulant … Stimulant detoxificationdetoxification

• Wellbutrin Wellbutrin … Cannabis detoxification… Cannabis detoxification

MEDICATIONS FOR MEDICATIONS FOR MAINTENENCEMAINTENENCE• BuprenorphineBuprenorphine ….Opiate dependence ….Opiate dependence

• MethadoneMethadone … Opiate dependence … Opiate dependence

• AcamprosateAcamprosate … Alcohol dependence … Alcohol dependence

• Naltrexone Naltrexone …… Alcohol and Opiate Alcohol and Opiate dependencedependence

• VivitrolVivitrol .......... Alcohol dependence .......... Alcohol dependence

• Disulfram Disulfram … Alcohol dependence… Alcohol dependence

• Nicotine ReplacementNicotine Replacement …Nicotine …Nicotine dependencedependence

STATUS OF ALCOHOL STATUS OF ALCOHOL TREAMENTTREAMENT• More Treatment OptionsMore Treatment Options than ever before than ever before• New medicationsNew medications and psychosocial approaches and psychosocial approaches• Guidelines for use of medications in “Guidelines for use of medications in “actively actively

using”using” alcohol patients andalcohol patients and “patients in “patients in recovery”recovery”

• Treatment in Treatment in outpatientoutpatient and and primary care primary care settingssettings ASAM Levels I and II ASAM Levels I and II

• Medications help Medications help promotepromote and and sustain recoverysustain recovery• Problem … Problem … Less than 1/5 of facilities are using new Less than 1/5 of facilities are using new

pharmacotherapy (barriers?)pharmacotherapy (barriers?)• Need to engage physicians to move forward in Need to engage physicians to move forward in

pace with the new developments in alcohol pace with the new developments in alcohol treatmenttreatment

MEDICATIONS FOR MEDICATIONS FOR ALCOHOL DEPENDENCE ALCOHOL DEPENDENCE FDA APPROVEDFDA APPROVED• DisulfiramDisulfiram … aversion therapyaversion therapy

• Oral NaltrexoneOral Naltrexone … reduction in craving … reduction in craving

• Injectable NaltrexoneInjectable Naltrexone … compliance … compliance

• AcamprosateAcamprosate … reduction in cravings … reduction in cravings and prolonged withdrawal syndromesand prolonged withdrawal syndromes

DISADVANTAGES OF DISADVANTAGES OF MEDICATION THERAPYMEDICATION THERAPY• ““Use in lieu of”Use in lieu of” full treatment full treatment

experienceexperience• Burdensome Burdensome regimesregimes and and side-effectsside-effects

may undermine commitment to recoverymay undermine commitment to recovery• Poor Poor medication selectionmedication selection … must … must

meet patient needsmeet patient needs• Premature discontinuationPremature discontinuation of of

medications (need to match with medications (need to match with patient’s recovery status)patient’s recovery status)

ADJUNCTIVE ADJUNCTIVE MEDICATIONSMEDICATIONS• SSRIsSSRIs ………… Affective Depressant Disorders ………… Affective Depressant Disorders• BusparBuspar ……… Anxiety Disorders ……… Anxiety Disorders• Benzodiazepines Benzodiazepines (Oxazepam, Librium, (Oxazepam, Librium,

Klonopin) … in Klonopin) … in special psychiatric cases special psychiatric cases (GAD, (GAD, Panic Disorder, Agoraphobia)Panic Disorder, Agoraphobia)

• PhenothiazinesPhenothiazines ... Affective Disorders ... Affective Disorders (Schizophrenia)(Schizophrenia)

• LithiumLithium ……… Major Depression ……… Major Depression• TrazadoneTrazadone … Insomnia … Insomnia• Other Medications for Medical Problems Other Medications for Medical Problems

under medical supervisionunder medical supervision

MEDICATIONS FOR PAIN MEDICATIONS FOR PAIN MANAGEMENTMANAGEMENT• NSAIDsNSAIDs … at maximum dosages ATC … at maximum dosages ATC

• MethadoneMethadone … in combination with NSAIDs … in combination with NSAIDs

• BuprenorphineBuprenorphine in combination with NSAIDs in combination with NSAIDs

• NeurolepticsNeuroleptics … in combination with other meds … in combination with other meds

• SSRIsSSRIs … have been shown to be useful … have been shown to be useful

• ClonidineClonidine … for neuropathic pain … for neuropathic pain

• ClonazepamClonazepam … for lancinating pain … for lancinating pain

• BaclofenBaclofen …for central nervous system pain …for central nervous system pain

• LONG Acting Narcotics …. medical supervisionLONG Acting Narcotics …. medical supervision

SPECIFIC PROTOCOLSSPECIFIC PROTOCOLS

•PREGNANT OPIOID PREGNANT OPIOID DEPENDENT PATIENTS DEPENDENT PATIENTS SHOULD NOT BE DETOXIFIEDSHOULD NOT BE DETOXIFIED– The treatment of choice is The treatment of choice is

METHADONE MAINTENANCEMETHADONE MAINTENANCE– BUPRENORPHINE … 2,4,6,8 OR 16 BUPRENORPHINE … 2,4,6,8 OR 16

MG FOR Detox and Maintenance MG FOR Detox and Maintenance (postpartum)(postpartum)

TREATMENT ISSUESTREATMENT ISSUES

• Mobile Medication VanMobile Medication Van … multiple … multiple communitiescommunities

• Needle Exchange ProgramNeedle Exchange Program

• Mobile Methadone and BuprenorphineMobile Methadone and Buprenorphine

• New Drug ProtocolsNew Drug Protocols … Peer Review- … Peer Review-Control Group Studies Control Group Studies

SUMMARY … THE SUMMARY … THE BEGINNINGBEGINNING

• Addiction treatment Addiction treatment is growing upis growing up• Pharmacotherapy Pharmacotherapy has arrivedhas arrived• Pharmacotherapy is not in lieu of Pharmacotherapy is not in lieu of

traditional therapytraditional therapy• Pharmacotherapy Pharmacotherapy is anis an integral part integral part of of

aa “full treatment experience”“full treatment experience”• PharmacotherapyPharmacotherapy is not is not for everyonefor everyone• The need for pharmacotherapy should The need for pharmacotherapy should

not lead to exclusion from treatment not lead to exclusion from treatment programsprograms