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MEDICATION ASSISTED ADDICTION TREATMENT:

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MEDICATION ASSISTED ADDICTION TREATMENT: APPROPRIATE USE DAS Quarterly Provider Meeting Louis E. Baxter, Sr., M.D., FASAM Medical Director-DAS – PowerPoint PPT presentation

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Title: MEDICATION ASSISTED ADDICTION TREATMENT:


1
MEDICATION ASSISTED ADDICTION TREATMENT
APPROPRIATE USE DAS Quarterly Provider Meeting
  • Louis E. Baxter, Sr., M.D., FASAM
  • Medical Director-DAS
  • President Elect
  • American Society Addiction Medicine

2
GOALS OBJECTIVES
  • Review comprehensive evaluation components
  • DSM-IV-TR diagnosing
  • Review full treatment planning
  • Patient Placement ASAM PPC-2
  • Treatment of Co-occurring Disorders
  • Medication Assisted Therapy for detoxification,
    maintenance, and pain management

3
ADDITIONAL RESOURCES
  • CSAT TIP 43 Buprenorphine Therapy
  • CSAT TIP 45 Detoxification and Substance Abuse
    Treatment
  • National Quality Forum Evidence Based
    Treatment Practices for Substance Use Disorders
  • ASAMs Monograph Achieving Treatment Success
    in Alcohol Dependence

4
COMPREHENSIVE EVALUATION COMPONENTS
  • Chief Complaint why are you here?
  • Alcohol Use History Screening Tool (CAGE)
  • Drug Use History Rx, Illicit, and OTC
  • Previous Treatment History include Clergy
  • Previous Psych History admissions and OP
  • Legal History
  • Past Medical / Surgical History / Medications
  • Family History Psychiatric and Substance Use
  • Marital History
  • Psychosocial History Employment / Clubs/
    Hobbies

5
DIAGNOSES
  • DSM-IV-TR Criteria for Substance Use Disorders
  • Use disorder Abuse Dependence (Addiction)
  • DSM-IV-TR Criteria for Psychiatric Disorders
  • Depression Bipolar Anxiety
  • Laboratory Data Documentation of Medical
    Disorders
  • Chronic pain Seizure Migraines HIV/AIDS Liver
    disease
  • National Quality Forum Guidelines (2005)
  • Evidence-based Best Practices for SUD

6
FULL TREATMENT PLANNING
  • Assessment Diagnosis
  • Detoxification Medical Maintenance
  • Rehabilitation Counseling
  • After / Continuing Care Twelve Step Program
  • Co-occurring Illness Care
  • Pain Management Care
  • General Medical Care

7
APPROPRIATE LEVEL OF CARE
  • ASAM Patient Placement Criteria-2
  • Only peer reviewed beta tested tool for patient
    placement
  • Level 0.5 Brief Intervention (3-6 sessions)
  • Level I Traditional Outpatient (Individual)
  • Level II Intensive Outpatient (group therapy)
    three to five 90 minute sessions weekly
  • Level III Residential (Medically supervised)
  • Level IV Hospital based (Medically managed)

8
TREATMENT WORKS
  • Full Treatment Experience (Detoxification
    Rehabilitation Maintenance)
  • General Population recovers _at_ 77 _at_ 1yr
  • Detoxification Rehab Only _at_ 33 _at_ 1yr
  • Detoxification Alone _at_ lt 10 _at_ 1 yr

9
TREATMENT OUTCOME COMPARISONS
  • Alcoholism 50-70 abstinent
  • Opioid Dependence 50-80 abstinent
  • Cocaine Dependence 50-60 abstinent
  • Nicotine Dependence 20-40 abstinent
  • Diabetes (relapse) 30-50 stable
  • Hypertension (poor control) 50-60
  • Asthma (multiple ER visits) 60-80
  • (Gaber, Davidson, 1992 McLellan 2002)

10
MEDICATION ASSISTED THERAPIES
  • Medications for detoxification
  • Medications for maintenance
  • Medications for psychiatric illnesses
  • Medical management of pain

11
MEDICATIONS FOR DETOXIFICATION
  • Librium Alcohol and Benzodiazepine
    detoxification
  • Benzodiazepine Phenobarbital Benzodiazepine
    detoxification
  • Suboxone (Subutex) Methadone Opiate
    detoxification
  • Clonidine Naltrexone Opiate detoxification
  • Bromocryptine Amantadine Stimulant
    detoxification
  • Wellbutrin Cannabis detoxification

12
MEDICATIONS FOR MAINTENENCE
  • Buprenorphine .Opiate dependence
  • Methadone Opiate dependence
  • Acamprosate Alcohol dependence
  • Naltrexone Alcohol and Opiate dependence
  • Vivitrol .......... Alcohol dependence
  • Disulfram Alcohol dependence
  • Nicotine Replacement Nicotine dependence

13
STATUS OF ALCOHOL TREAMENT
  • More Treatment Options than ever before
  • New medications and psychosocial approaches
  • Guidelines for use of medications in actively
    using alcohol patients and patients in
    recovery
  • Treatment in outpatient and primary care settings
    ASAM Levels I and II
  • Medications help promote and sustain recovery
  • Problem Less than 1/5 of facilities are using
    new pharmacotherapy (barriers?)
  • Need to engage physicians to move forward in pace
    with the new developments in alcohol treatment

14
MEDICATIONS FOR ALCOHOL DEPENDENCE FDA APPROVED
  • Disulfiram aversion therapy
  • Oral Naltrexone reduction in craving
  • Injectable Naltrexone compliance
  • Acamprosate reduction in cravings and prolonged
    withdrawal syndromes

15
DISADVANTAGES OF MEDICATION THERAPY
  • Use in lieu of full treatment experience
  • Burdensome regimes and side-effects may
    undermine commitment to recovery
  • Poor medication selection must meet patient
    needs
  • Premature discontinuation of medications (need to
    match with patients recovery status)

16
ADJUNCTIVE MEDICATIONS
  • SSRIs Affective Depressant Disorders
  • Buspar Anxiety Disorders
  • Benzodiazepines (Oxazepam, Librium, Klonopin)
    in special psychiatric cases (GAD, Panic
    Disorder, Agoraphobia)
  • Phenothiazines ... Affective Disorders
    (Schizophrenia)
  • Lithium Major Depression
  • Trazadone Insomnia
  • Other Medications for Medical Problems under
    medical supervision

17
MEDICATIONS FOR PAIN MANAGEMENT
  • NSAIDs at maximum dosages ATC
  • Methadone in combination with NSAIDs
  • Buprenorphine in combination with NSAIDs
  • Neuroleptics in combination with other meds
  • SSRIs have been shown to be useful
  • Clonidine for neuropathic pain
  • Clonazepam for lancinating pain
  • Baclofen for central nervous system pain
  • LONG Acting Narcotics . medical supervision

18
SPECIFIC PROTOCOLS
  • PREGNANT OPIOID DEPENDENT PATIENTS SHOULD NOT BE
    DETOXIFIED
  • The treatment of choice is METHADONE MAINTENANCE
  • BUPRENORPHINE 2,4,6,8 OR 16 MG FOR Detox and
    Maintenance (postpartum)

19
TREATMENT ISSUES
  • Mobile Medication Van multiple communities
  • Needle Exchange Program
  • Mobile Methadone and Buprenorphine
  • New Drug Protocols Peer Review-Control Group
    Studies

20
SUMMARY THE BEGINNING
  • Addiction treatment is growing up
  • Pharmacotherapy has arrived
  • Pharmacotherapy is not in lieu of traditional
    therapy
  • Pharmacotherapy is an integral part of a full
    treatment experience
  • Pharmacotherapy is not for everyone
  • The need for pharmacotherapy should not lead to
    exclusion from treatment programs
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