Opioid Maintenance Treatment (OMT)

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Opioid Maintenance Treatment(OMT)

• What it is
• What it is not
• Stacy Seikel, MD
• Board Certified Addiction Medicine
• Board Certified Anesthesiology

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Addiction

• Bio-Psych-Social-Disease

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Goals of OMT

• Reduce Cravings Withdrawal
• Harm Reduction
• HIV, Hep C, Hep B, Endocarditis, Skin abscesses
• Decrease Risk of
• Overdose
• Prostitution
• Problems with the law

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Goals of OMT (cont.)

• Recovery
• AA/NA/MA
• Group Ind Therapy
• Life Skills
• Non Pharmaceutical coping skills
• Help People Have Normal Lives

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The Center For Drug-Free LivingOMT

• Abstinence From All Other Addictive/Mood Altering
  Substances
• Group and Individual Therapy
• Random UDS
• Mandatory Classes
• Encouraged to Attend 12-Step Programs
• Consult With Patients Primary, Specialty, Pain
  and Psychiatric Physicians
• Therapy/Treatment Works!

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Common Questions AboutMethadone

• How Does Methadone Work?
• Opiate agonist
• Mu receptor
• Lasts 24-36 hrs.

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Common Questions AboutMethadone

• Does Methadone make patients high or interfere
  with normal functioning?
• No, not when used appropriately
• No impairment in driving ability

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Common Questions AboutMethadone

• What is the proper dose of Methadone?
• The dose that averts narcotic craving

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Common Questions (cont)

• Is Methadone more addictive than Heroin?
• Addiction is continued use despite adverse
  consequences
• Dependence is a physiologic phenomena

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Common Questions (cont)

• Is Methadone harder to kick than Heroin?
• Heroin withdrawal-intense and brief
• Methadone withdrawal-less acute and longer

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Common Questions (cont)

• Does Methadone interfere with good health?
• Methadone improves health
• No effect on immune function, bone density,
  kidneys or liver

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Heroin Use v. Stabilized Methadone Maintenance
A Comparison
Topic Heroin Methadone Effects on the
Body Onset of Action Seconds 30-90
minutes Duration of Action 4-6 hours 24-36
hours Route of Administration Injection,
snorting, smoking Oral, in liquid form
or Dissolvable diskettes for
medically maintained patients Freq
uency of Administration 4-6x/day 1x every 24
hours Effective Dose Ever increasing Usually
80-120mg but individually
adjusted. Correctly stabilized
patients do not need adjustment
unless medically indicated
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Heroin Use v. Stabilized Methadone Maintenance
A Comparison (cont)
Topic Heroin Methadone Effects on
Body Overdose Potential High Very rare at
blockage dose Overall Safety Potentially
lethal Non-toxic in opiate tolerant
person Potential for Abuse High Block
ing dose prevents high Withdrawal Within 3-4
hours After 24 hours Physical Reaction
Time Impaired Normal
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Heroin Use v. Stabilized Methadone Maintenance
A Comparison (cont)
Topic Heroin Methadone Effects on the
Mind On Mood Constant mood swings Stable mood
if not suffering other disorders On
Getting High Euphoria for 2 hours High is
blocked On tolerance Increasing
tolerance Stabilized On Cravings Recurring
cravings Eliminated On Intellectual
Functioning Impaired Normal Pain and
Emotion Blunted Normal pain and range of
emotions
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Heroin Use v. Stabilized Methadone Maintenance
A Comparison (cont)
Topic Heroin Methadone Effects on Health HIV
Transmission High rate of transmission Reduced/eli
minated with Hepatitis C Transmission with needle
use and unprotected oral ingestion and
treatment unprotected sex Immune System for
HIV Persons Rapid progression to
AIDS Progression slowed Immune/Endocrine
System Impaired Normalized during treatment For
HIV-Persons Hypothalamus Pituitary Adrenal
Axis Suppressed Normalized during treatment
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Heroin Use v. Stabilized Methadone Maintenance
A Comparison (cont)
Topic Heroin Methadone Effects on Social
Functioning Criminal Activity High
level Reduced/eliminated Personal
Relationships Disrupted Employment Deteriora
ting performance Full Functioning loss of
employment Community Relations Destructive
impact, high Contributes to public crime,
high death rate, safety, low mortality, trans
mission of disease increased health
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Sign and Symptoms of Withdrawal

• Subjective
• Cravings
• Anxiety
• Restlessness
• Irritability
• Difficulty sleeping

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Sign and Symptoms of Withdrawal

• Dose not holding
• Thoughts of using
• Body aches and pains
• Nausea, sick to stomach
• Abdominal cramping
• Muscle cramping

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Signs and Symptoms of Withdrawal

• Objective
• Elevated BP
• Tachycardia
• Lacrimation
• Rhinorhea

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Signs and Symptoms of Withdrawal

• Piloerection
• Vomiting
• Yawning
• Dilated Pupils

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What are the signs of a Methadone overdose?

• Nausea and vomiting
• Constricted (small, pin-point) pupils
• Drowsiness
• Cold, clammy, bluish skin
• Reduced heart rate
• Reduced body temperature
• Slow or no breathing

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Methadone Maintenance

• is not
• Methadone/Heroin Abuse

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ASAM AAPM APSConsensus Statement
Addiction is a primary, chronic, neurologic
disease with genetic, psychosocial and
environmental factors influencing its development
and manifestations. It is characterized by
behaviors that include one or more of the
following impaired control over drug use,
compulsive use, continued use despite harm, and
cravings.
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Consensus Statement (Contd)
Physical Dependence Physical dependence is a
state of adaptation that is manifested by a drug
class specific withdrawal syndrome that can be
produced by abrupt cessation, rapid dose
reduction, decreasing blood level of the drug,
and/or administration of an antagonist.
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Addiction Compulsive Use Loss of
control Continued use despite adverse
consequences Addiction has nothing to do with
what medication one is taking
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DemographicsDrug Abuse in US
2.1 million abuse street drugs (heroin,
cocaine, crack) 3.9 million abuse Rx drugs
(pain meds, sedatives, stimulants)
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Heroin Addiction
gt977,000 heroin dependent individuals in the US
in 2000
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Opioid Treatment Programs (OTP)How they are
done

• Methadone
• LAAM
• Buprenorphine

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Current Inventory of Regulated OTPs

• 1,000-1,200 Opioid Treatment Programs (OTPs)
• Certified by SAMHSA/CSAT
• Registered by DEA
• Licensed by State
• 950 Maintenance, 250 Detoxification
• Approximately 205,000 Patients in Treatment

Center for Substance Abuse Treatment
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Methadone Maintenance Treatment(MMT)

• Most studied drug for the treatment of a disease
  in the history of the world
• Used and effective for over 35 years
• Relieves sx of withdrawal and cravings
• Allows normal functioning

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MMT (Contd)

• Efficacy increased with
• On site medical support
• On site psychiatric support
• Supportive treatment services
• Urine toxicology

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Comorbidities

• 70 of patients in OMT-HCV positive.
• 40-50 of patients in OMT have serious depression
  and anxiety disorders.

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Length of Treatment
Research shows 80 relapse rate if MMT withdrawn
within the first 12 months.
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Pharmacology of Methadone (Contd)

• Hepatic metabolism (varies with individual)
• Renal excretion
• Basic, pka9.2
• Metabolized CYP3A4 (inducible)

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Pharmacology of Methadone (Contd)

• Drugs that induce CYP3A4 (? serum methadone
  levels)
• rifampicin (Rifampin)
• carbamazepine (Tegretal)
• barbituates
• verapamil
• amitriptyline (Elavil)
• alcohol
• nevirapine

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Pharmacology of Methadone (Contd)

• Drugs that Inhibit Metabolism (? serum methadone
  levels)
• fluoxetine (Prozac)
• cimetidine (Tagamet)
• ketoconazole
• metronidazole (Flagyl)
• HIV meds
• indinavir
• ritonavir
• saquinavir

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Federal Oversight of Methadone Treatment (OMT)

• CSAT and SAMHSA - new accreditation system for
  MTP
• Implemented May 18, 2001
• All MTP will be accredited over the next 3 years.

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Who Can Offer Treatment?

• Physicians employed by a licensed OTP
• Physicians in private practice who register
  separately with DEA as a OTP

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MMT Program Phases

• Intake Phase 1-30 days
• No takeouts
• 2 groups per week
• 1 individual
• Phase I 30-90 days
• 1 takeout per week
• 2 groups per week
• 1 individual per week

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MMT Program Phases (Contd)

• Phase II 91-180 days
• 2 takeouts per week
• 2 groups per week
• 2 individuals per months
• Phase III 181-365 days
• 3 takeouts per week (no more than 2 days supply)
  if client has neg UDS for preceding 90 days
• 1 group per week
• 1 individual per week

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MMT Program Phases (Contd)

• Phase IV gt 1 year in treatment
• 4 takeouts per week (no more than 2 days supply
  at one time) if negative UDS preceding 90 days
• 2 groups per month
• 1 individual per month
• Phase V gt 2 years in treatment
• 5 take out (not to exceed 3 at 1 time)
  UDS-negative 90 preceding days
• 1 group per month
• 1 individual per month

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MMT Program Phases (Contd)

• Phase VI gt 3 years in treatment
• 6 take outs per week - neg UDS for past year
• 1 individual per month

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Methadone Maintenance at The Center For
Drug-Free Living

• Orientation Stage of Recovery
• State I of Recovery
• Stage II of Recovery
• Stage III of Recovery

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Orientation Stage

• Methadone Education Evaluation Treatment (MEET)
• Orientation group
• HIV education
• Medication Education
• Fiscal Responsibility

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Orientation Stage (Contd)MEET Services

• Group therapy training
• Social Development
• Treatment compliance
• Methadone and Your Health
• Abstinence model of recovery
• Side effects of methadone
• Dosing
• When to taper?
• Medical/Surgical issues

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Orientation Stage (Contd)

• Contact medical psychiatric providers
• Approved medication list
• Encourage 12 step recovery - NA, MA

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Stage I of Recovery(Phase I II)

• Group Therapy- family issues, stress management,
  lifestyles changes, self esteem, financial
  stability, anger management, relapse prevention..

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Stage II of Recovery (Phase III IV)

• Groups - Relationships, advanced financial
  management
• Support groups stronger - sponsorship, working
  steps
• Relapse prevention

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Stage III of Recovery(Phase V VI)

• Self help becomes primary source of support
• Consider taper off methadone
• Aftercare plans
• Relapse prevention plans revised and practiced

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Continued Drug Abuse ofNon Opiates

• Differential Diagnosis
• Opiate abstinence syndrome (subclinical)
• Psychiatric Disorder
• Pain syndrome
• Polysubstance Abuse
• refer to detox
• ? treatment services
• residential treatment

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Methadone is the most effective method available
for healing heroin addiction.
National Institute on Drug Abuse
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• Thank You.