MEDICATION ASSISTED ADDICTION TREATMENT:

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MEDICATION ASSISTED ADDICTION TREATMENT
APPROPRIATE USEDAS Quarterly Provider Meeting

• Louis E. Baxter, Sr., M.D., FASAM
• Medical Director-DAS
• President Elect
• American Society Addiction Medicine

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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

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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

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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

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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

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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

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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)

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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

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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)

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MEDICATION ASSISTED THERAPIES

• Medications for detoxification
• Medications for maintenance
• Medications for psychiatric illnesses
• Medical management of pain

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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

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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

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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

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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

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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)

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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

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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

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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)

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TREATMENT ISSUES

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

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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