Methadone Maintenance in the Treatment of Heroin Addiction - PowerPoint PPT Presentation

Loading...

PPT – Methadone Maintenance in the Treatment of Heroin Addiction PowerPoint presentation | free to view - id: 1220c1-NTZiM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Methadone Maintenance in the Treatment of Heroin Addiction

Description:

How important is methadone in treating heroin addiction? What is the rationale? ... Methadone is not teratogenic; children have been followed into adulthood ... – PowerPoint PPT presentation

Number of Views:826
Avg rating:3.0/5.0
Slides: 61
Provided by: joanellen
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Methadone Maintenance in the Treatment of Heroin Addiction


1
Methadone Maintenance in the Treatment of Heroin
Addiction
  • Prop 36 CLAIM Meeting - Oct 2003
  • Joan E. Zweben, Ph.D.
  • Executive Director 14th Street Clinic and EBCRP
  • Clinical Professor of Psychiatry University of
    California, San Francisco

2
Questions Issues
  • How important is methadone in treating heroin
    addiction?
  • What is the rationale?
  • What is the data?
  • How do we decide when/if it can be discontinued?
  • What is included in the psychosocial component of
    treatment?

3
Natural History of Heroin Addiction A 33-Year
Follow-up (1)
  • 581 male heroin addicts, admitted to Calif Civil
    Addicts Program, 1962-1964
  • CAP compulsory drug tx for heroin-dependent
    criminal offenders
  • 284 dead 242 interviewed
  • High rates of disability, hepatitis, excessive
    drinking, cigarette smoking, marijuana use, other
    drug-related problems
  • (Hser et al, 2001)

4
Narcotics Addicts A 33-Year Follow-up (2)
  • Between 1985-1986 to 1996-1997
  • Dead 49
  • Abstinent 20-22
  • Incarcerated 4-7
  • Methadone maintenance 2-6
  • Occasional use 2-3
  • Lost to follow-up 12
  • (Hser et al, 2001)

5
Opiate DependencyHidden Populations
  • Subscribers of Private Insurance Plan
  • Empire Blue Cross/Blue Shield, NYC
  • estimated from opiate dependency diagnosis on
    admission AIDS cases
  • insured 141,000 opiate users between 1982-1992
  • 85,000 among current subscribers (1992)
  • (Eisenhandler Drucker, 1993)

6
Treatment Outcome Data Methadone
  • 8-10 fold reduction in death rate
  • Reduction of drug use
  • Reduction of criminal activity
  • Engagement in socially productive roles improved
    family and social function
  • Increased employment
  • Improved physical and mental health
  • Reduced spread of HIV
  • Excellent retention

7
DEATH RATES IN TREATED AND UNTREATED HEROIN
ADDICTS
Annual Death Rates
Slide data courtesy of Frank Vocci, MD, NIDA -
Reference Grondblah, L. et al. ACTA PSCHIATR
SCAND, P. 223-227, 1990
Opioid Agonist Treatment of Addiction - Payte -
1998
8
Impact of MMT on IV Drug Use for 388 Male MMT
Patients in 6 Programs
100
100
81.4
63.3
41.7
LAST ADDICTION PERIOD
PERCENT IV USERS
ADMISSION
28.9


0
Pre- 1st Year 2nd Year
3rd Year 4th Year Admission
Adapted from Ball Ross - The Effectiveness of
Methadone Maintenance Treatment, 1991
Opioid Agonist Treatment of Addiction - Payte -
1998
9
Relapse to IV drug use after MMT105 male
patients who left treatment
Percent IV Users
Treatment Months Since Stopping Treatment
Adapted from Ball Ross - The Effectiveness of
Methadone Maintenance Treatment, 1991
Opioid Agonist Treatment of Addiction - Payte -
1998
10
Crime among 491 patients before and during MMT at
6 programs
Crime Days Per Year
Adapted from Ball Ross - The Effectiveness of
Methadone Maintenance Treatment, 1991
Opioid Agonist Treatment of Addiction - Payte -
1998
11
  • HIV DISEASE
  • Role of MMTP
  • Education, counseling, and testing --
    prevention
  • Decrease HIV transmission by decreasing
    needle sharing
  • For HIV () patients, provide, refer, and
    coordinate treatment

Opioid Maintenance Pharmacotherapy - A Course for
Clinicians - 1997
12
HIV CONVERSION IN TREATMENT
HIV infection rates by baseline treatment status.
In treatment (IT) n138, not in treatment (OT)
n88Source Metzger, D. et. al. J of AIDS
61993. p.1052
Opioid Maintenance Pharmacotherapy - A Course for
Clinicians - 1997
13
OPIOID MAINTENANCETHERAPY
14
The Addiction ProcessBarriers to Understanding
  • INFLUENCE OF THE STIGMA
  • difficulty understanding the complexity of the
    disorder
  • treatment is denied
  • treatment is diminished
  • treatment is discouraged
  • treatment is conditional

15
I Dont Believe in Methadone
16
Methadone is a medication,not a religion
  • J. Thomas Payte, MD
  • Founding Chair, Methadone Treatment Committee,
    ASAM

17
OverviewOpioid Maintenance Therapy
  • Methadone (MMT) levoacetylmethadol (LAAM),
    buprenorphine (soon)
  • most highly regulated
  • history
  • rationale for replacement therapy
  • political influences
  • diversion

18
OMT, Continued
  • Strong empirical support for safety and efficacy
    (30 years of data)
  • valuable tool in reducing spread of HIV
  • makes the pt accessible to interventions for
    other problems
  • hidden populations of heroin users
  • medical maintenance and office-based practice

19
What is Abstinence?
  • Medication is compatible with 12-step
    participation if appropriately prescribed by
    physician knowledgeable about addiction
  • Pt on methadone is abstinent if not using illicit
    drugs and using legal ones as prescribed
  • Its just another medication. Meds are a tool,
    not a solution

20
Dole Receptor System Dysfunction
  • Endogenous ligand-narcotic receptor system is
    defective hence high relapse rate
  • Stabilize blood level at 150-600 ng/mL
  • This normalizes neurological and endocrine
    functioning
  • This treatment is corrective but not curative
  • Future research identify the specific defect and
    repair it
  • (Dole, JAMA 1988)

21
Genetic Factors
  • Recent studies show distinct genetic
    vulnerability to heroin and other opiates
  • heroin had larger genetic influences unique to
    itself than marijuana, sedatives, stimulants,
    psychedelics (Tsuang et all Merikangas et al
    ARCHIVES 1998)
  • Alcoholism and drug disorders appear to be
    independent
  • Genetic factors impact the transition from drug
    use to abuse/dependence, not use itself

22
Diversion of Medication
  • political hot button
  • key issue in formulating original regs
  • IOM report cannot document significant public
    health or safety problem
  • confusion about DAWN data
  • difficulty of determining cause of death
  • (Rettig 1995)

23
Reasons for Diversion
  • selling take-homes to buy illicit drugs
  • need to supplement income
  • share with or sell to addicted friend/mate
  • unwilling or unable to enter treatment
  • low dose policies of some programs
  • IOM conclusion risks of diverted methadone do
    not outweigh benefits of making MMT more
    available
  • (Rettig 1995)

24
PHARMACOTHERAPY
25
Methadone vs Heroin
  • Can be taken by mouth
  • Slow onset of action
  • No continuing increase in tolerance levels after
    optimal dose is reached relatively constant dose
    over time
  • Pt on stable dose rarely experiences euphoric or
    sedating effects is able to perceive pain and
    have emotional reactions can perform can
    perform daily tasks normally and safely

26
Methadone vs Heroin (2)
  • Long acting prevents withdrawal for 24-36 hours
    (4x-6x as long as heroin), permitting once-a
    day-dosing
  • At sufficient dosage, blocks euphoric effect of
    normal street doses of heroin
  • Medically safe when used on long-term basis (10
    years or more)
  • (Physicians Guide Opioid Agonist Medical
    Maintenance Treatment CSAT 2000)

27
Heroin Simulated 24 Hr. Dose/ResponseWith
established heroin tolerance/dependence
Loaded High
Abnormal Normality
Normal RangeComfort Zone
Dose Response
Subjective w/d
Sick
Objective w/d
Time
0 hrs.
24 hrs.
Opioid Agonist Treatment of Addiction - Payte -
1998
28
  • GOALS FOR PHARMACOTHERAPY
  • Prevention or reduction of withdrawal symptoms
  • Prevention or reduction of drug craving
  • Prevention of relapse to use of addictive drug
  • Restoration to or toward normalcy of any
    physiological function disrupted by drug abuse

Source MJ Kreek, Rationale for Maintenance
Pharmacotherapy of Opiate Dependence, 1992
Opioid Agonist Treatment of Addiction - Payte -
1998
29
PROFILE FOR POTENTIAL PSYCHOTHERAPEUTIC AGENT
  • Effective after oral administration
  • Long biological half-life (gt24 hours)
  • Minimal side effects during chronic
    administration
  • Safe, no true toxic or serious adverse effects
  • Efficacious for a substantial of persons with
    the disorder (gt 15-20)

Source MJ Kreek, Rationale for Maintenance
Pharmacotherapy of Opiate Dependence, 1992
Opioid Agonist Treatment of Addiction - Payte -
1998
30
Methadone Simulated 24 Hr. Dose/ResponseAt
steady-state in tolerant patient
Loaded High
Abnormal Normality
Normal RangeComfort Zone
Dose Response
Subjective w/d
Sick
Objective w/d
Time
0 hrs.
24 hrs.
Opioid Agonist Treatment of Addiction - Payte -
1998
31
Not Holding Strategies
  • Cognitive, Behavioral Interventions
  • Increased contact, counseling, therapy
  • Alter urinary pH?
  • Is patient fixing? - Raise dose
  • Split Dose?

Payte - Khuri
Opioid Agonist Treatment of Addiction - Payte -
1998
32
Rapid Metabolizer - High Single and Split Dose
Simulation
High
ng / ml
Normal
Sick
Hours
Payte
Opioid Agonist Treatment of Addiction - Payte -
1998
33
TAPERING
  • how many remain abstinent?
  • tapering readiness
  • tapering strategies
  • clonidine
  • handling relapse

34
Buprenorphine (1)
  • 1970s - partial opioid agonist useful in opioid
    dependence treatment
  • 1990s - clinical trials
  • long duration of action smooth onset
  • low physical dependence
  • mild withdrawal syndrome
  • good name on the street

35
Buprenorphine (2)
  • DATA 2000 permitted use in MD office
  • FDA approved Subutex and Suboxone in 2002
  • Physicians must meet training requirements
    certified in addiction medicine, participated in
    clinical trials, or took 8 hour course by
    specified organizations

36
Buprenorphine (3)
  • SUBUTEX SUBOXONE
  • Sublingual tablets
  • Suboxone has naloxone added to discourage needle
    use
  • Partial agonist ceiling effect
  • Expensive 300/month at average dose
  • Not interchangeable with methadone

37
Buprenorphine (4)
  • Poor oral bioavailability
  • Sublingual administration requires longer
    observation
  • Abuse documented in Europe, Australia, and New
    Zealand
  • How much training should be required for
    physicians to use it?

38
Naltrexone
  • antagonist how it works
  • who does it work for?
  • accelerated withdrawal protocols
  • Doles critique
  • utility with alcoholics

39
Methadone in Pregnancy
  • Comprehensive MMT treatment with prenatal care
    improves neonatal outcome
  • Withdrawal is rarely appropriate during pregnancy
  • Methadone is not teratogenic children have been
    followed into adulthood
  • Appropriate dosing is very important
  • Breast feeding OK if no other drug use

40
Opioids and Chronic Pain
  • Opioid tolerance physical dependence DO NOT
    equal opioid addiction
  • Loss of Control Indices
  • Continued use despite adverse consequences
  • Illicit or inappropriate drug seeking behavior
  • In response to craving or drug hunger
  • In the absence of pain or withdrawal

41
Pseudo Addiction- in chronic pain patient
  • Inadequate Treatment of Pain
  • Apparent Drug Seeking Behavior
  • Effort to achieve adequate analgesia
  • Early refill, doctor shopping, etc.
  • Manipulation seen as addictive behavior
  • May be seen as non-compliance
  • Cured by adequate treatment of pain

Opioid Agonist Treatment of Addiction - Payte -
1998
42
Chronic Pain Disorder
  • Opioid Tolerance
  • Opioid Physical Dependence
  • Absence of illicit or inappropriate drug seeking
    behavior
  • No drug hunger in absence of pain
  • No loss of control
  • No doctor shopping
  • Little tendency to escalate dose over time

Opioid Agonist Treatment of Addiction - Payte -
1998
43
PSYCHOSOCIAL TREATMENT ISSUES
44
Population Characteristics
  • Heterogeneity
  • Readiness for recovery motivation
  • Psychiatric comorbidity
  • Medical comorbidity

45
Program Characteristics
  • Medical component assessment, dosing, client
    interactions
  • Individual counseling
  • Group counseling
  • Case management
  • Staff training (ongoing)

46
What is Abstinence?
  • Medication is compatible with 12-step
    participation if appropriately prescribed by
    physician knowledgeable about addiction
  • Pt on methadone is abstinent if not using illicit
    drugs and using legal ones as prescribed
  • Its just another medication. Meds are a tool,
    not a solution

47
Cognitive-Behavioral Therapy
  • Lends itself to controlled studies strong
    support for its effectiveness
  • Especially useful to help establish abstinence,
    teach early recovery and relapse prevention
    skills
  • Emphasizes changing behavior and managing symptoms

48
Cognitive Behavioral Strategies (CBT)
  • MATRIX MODEL - Organizing Principles
  • Create explicit structure and expectations
  • Establish positive, collaborative relationship
  • Teach information and CBT concepts
  • Positively reinforce behavior change
  • Provide corrective feedback when necessary
  • Encourage self-help participation

49
CBT MATRIX MODEL
  • Structure is essential time scheduling,
    self-help meetings, exercise, work, treatment
    activities
  • Identify external and internal triggers and make
    a plan
  • Tools for managing cravings thought stopping,
    visual imagery, change environment/behavior
  • TIP 33 has description, patient worksheets
  • (Rawson 1999)

50
Clinical Issues
51
Is Psychotherapy Useful?
  • Philadelphia group study, begun 1977
  • global psychiatric status ratings
  • elements of drug counseling
  • models of psychotherapy utilized
  • benefits to low severity patients
  • benefits to high severity patients

52
Dual Diagnosis Issues
  • depression
  • trauma history PTSD
  • schizophrenia
  • medication strategies

53
PTSD Influence in Early Tx
  • Aim determine tx adherence relative to frequency
    of violence and PTSD in MMT pts, male female
  • 96 pts over 2/3 exposed to one or more violent
    traumatic events
  • Trauma or PTSD did not predict dropout rates
  • Those with current PTSD had significantly more
    ongoing drug use at 3 months, especially cocaine
  • (Hein et al, 2000)

54
Continued heroin, alcohol, and other drug use
  • patient and provider expectations
  • enhancing motivation
  • cocaine use
  • alcohol use
  • medical comorbidity AIDS, chronic pain
  • controversies about discharge

55
Psychological Issues
  • AOD use in family of origin
  • high frequency of childhood physical and sexual
    abuse
  • recognition and appropriate expression of
    feelings
  • issues of self-care, self-soothing

56
Womens Issues
  • remove practical barriers transportation, child
    care
  • intimate relationships as primary hazard
  • sexual issues
  • contraceptive practices

57
Family/Couples Work
  • engaging family, significant others
  • education about addiction and MMT
  • develop existing and new support structures
  • couples issues
  • parenting classes

58
HIV/AIDS
  • impact on MMT staff providing support
  • regular assessment of staff attitudes and
    knowledge
  • integrating primary care
  • promoting medication compliance
  • impact of dementia on treatment

59
MMT and 12-Step Programs
  • benefits and hazards
  • simulated meetings as a launching strategy
  • meetings in the community
  • Vincent Dole and Bill W.
  • other types of self-help
  • advocacy groups

60
Making Residential Treatment Available to
Methadone Patients
  • Some clients need higher level of care
  • Issues for the methadone program
  • Issues for the residential program
  • Security issues
  • Documentation issues
  • Funding barriers
About PowerShow.com