Methadone for Opioid Dependence

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Opioid Abuse and Dependence Ingrid Binswanger, MD, MPH Division of General Internal Medicine Division of Substance Dependence UCD School of Medicine Eric Ennis, LCSW, CAC III Director of Adult Outpatient Services Senior Instructor of Psychiatry Addiction Research and Treatment Services (ARTS)


ObjectivesBe familiar with current trends in opioid abuse and dependence, and make accurate diagnoses of opioid and other substance involvement Understand psychosocial and pharmacologic treatment options for patients with substance abuse/dependence Be familiar with services available for opioid dependent patients in the Denver metro area, and how to assist in the coordination of care Initiate a conversation about how we can better manage our patients with opioid abuse/dependence and coordinate care with treatment services


Extent of the Problem3 million have used heroin Opioid dependence related to pharmaceutical agents increasing in prevalence Medical complications of opioid use and dependence are common and serious


Drug Abuse-Related ED Visits Involving Narcotic Analgesics: 1995-2006 1995 1996 1997 1998 1999 2000 2001 2002 2004 2005 2006Source: SAMHSA, The DAWN Report: Narcotic Analgesics, August, 2008.


Unintentional pharmaceutical overdose deaths, West Virginia550% increase in overdose mortality, 1999-2004 295 decedents in 2006 93% associated with opioid analgesics, only 44% were prescribed 63% associated with pharmaceutical diversion 21% associated with doctor shopping


Substance Abuse by DSM CriteriaA maladaptive pattern of substance use leading to clinically significant impairment or distress One (or more) of the following, within a 12-month period: Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home Recurrent substance use in situations in which it is physically hazardous Recurrent substance-related legal problems Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance Symptoms have never met the criteria for substance dependence for this class of substance


Substance Dependence by DSM criteriaA maladaptive pattern of substance use leading to clinically significant impairment or distress Three (or more) of the following, occurring in same 12-month period: Tolerance Withdrawal The substance is taken in larger amounts or over a longer period than was intended Persistent desire or unsuccessful efforts to cut down or control substance use A great deal of time is spent on activities necessary to obtain the substance, use the substance, or recover from its effects Important social, occupational, or recreational activities are given up or reduced The substance use is continued despite knowledge of having a persistent physical or psychological problem likely to have been caused or exacerbated by the substance


Drug Dependence is a Chronic Medical IllnessRequires Screening and prevention Long-term care strategies Medication management Continued monitoring Empathy and patienceMcLellan AT, Lewis DC, O’Brien CP, Kleber HD; Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000


Compliance & ChronicityMcLellan AT, Lewis DC, O’Brien CP, Kleber HD; Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000


Screening for opioid dependenceHistory – Screening tools are available for opioid misuse, e.g. Physician Opioid Therapy Questionnaire Physical exam – signs of intoxication or withdrawal or use Lab tests Urine toxicology screening may be helpful


What should I counsel my opioid-dependent patient about?Opioid dependence is a chronic disease which requires ongoing treatment Overdose risk is substantial Combinations of drugs increase risk Release from jail/prison associated Leaving drug treatment associated HIV and hepatitis risk from sharing needles and paraphernalia


What screening should I perform on my opioid dependent patient?HIV Hepatitis B S Ag Hepatitis C Ab Latent TB infection


What vaccinations should I give my opioid dependent patient?Hepatitis A and B Tetanus


Therapeutic OptionsPsychosocial interventions Contingency management Individual, group and family counseling Motivational interviewing Case management 12-step interventions Pharmacological interventions Methadone (can be used for taper as well) Buprenorphine (can be used for taper as well) Naltrexone (also used for alcohol dependence in oral and injectable forms)


Evidence supports psychosocial interventions in addition to medicationsMaintenance: Cochrane review suggests improvements in number of participants abstinent at follow-up Detoxification: Improvements in opiate use, compliance with treatment, and completion of treatment Amato, 2008


Contingency ManagementRe-arranging the reinforcers in a person’s environment Incentives or rewards to encourage specific behaviors Vouchers, prizes, group acknowledgements, take-home dosing privileges, family privileges


Methadone Maintenance for Opioid Dependence: BenefitsReduced drug use Reduced criminality Improved health (reduced utilization of health care) Improved functioning Public health gains (HIV, Hepatitis,etc.) Overall health care cost savings


Methadone for Opioid Dependence: RisksProlonged QT interval: question of what to do for assessment and treatment Overdose risks: primarily associated with methadone prescribed for pain; treatment decreases risk of overdose from heroin Diversion concerns?


Impact of Short-Acting Heroin versus Long-Acting Methadone on the Functional State of the Patient"High""Straight""Sick"DaysAMPMAMPMAMFunctional State (Methadone)(overdose)"High""Straight""Sick"DaysAMPMAMPMAMFunctional State (Heroin)Dole, Nyswander and Kreek, 1966H


Slow “Build-up” of Constant Dose of Methadone to Steady-StateBlood plasma level of methadoneDays Dose constant at 30 mg to steady-stateOpioid Maintenance Pharmacotherapy - A Course for Clinicians


Induction / Initial DosingAdministered under supervision No signs of sedation or intoxication Manifestation of withdrawal symptoms Single dose of 20-30 mg Methadone, not to exceed 30 mg Same day adjustment, wait 2-4hrs after initial dose (peak effect), 5-10 mg increase Maximum dose first day 40 mgClinical Pharmacology, Chapter 5, (TIP) Treatment Improvement Protocol #43, FDA Public Health Advisory, November 27, 2006


Phases of Methadone DosingPayte and KhuriOpioid Maintenance Pharmacotherapy - A Course for Clinicians


___l-methadone--µ agonist


Source: National Center for Health Statistics.


Methadone MortalityMethadone has been increasingly prescribed for pain over the past 6-8 years (oxycontin, costs) 2004 SAMHSA report Increased prescribing of methadone for pain as the major cause of increased deaths in the United States (700,000 vs. 260,000) Outpatient treatment providers have used this medication as part of our addiction treatment practice for more than 40 years


Methadone Mortality, cont.Sens. Rockefeller and Kennedy have directed the GAO to conduct a study on methadone-associated mortality in the US. The GAO Report has a tentative publication date of March 2009 Report is also likely to focus on the fact that medical examiners and coroners are still not using any standardized methodologies in reporting such methadone-associated mortalities New York Times article 8/17/08

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Last Updated: 8th March 2018

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