Bruce G. Trigg, MD Duke City Recovery Toolbox Albuquerque, NM

1. Medically Assisted Treatment For Opiate Addiction3rd Annual Alcohol and Substance Abuse Treatment Conference May 13, 2014 Bruce G. Trigg, MD Duke City Recovery Toolbox Albuquerque, NM

2. Faculty Disclosure I am employed as a contractor by a faith-based, for-profit opioid treatment program in Albuquerque, where I prescribe methadone and buprenorphine. I do not receive any funding from pharmaceutical companies

3. Goals of this talk: • What is MAT? • What is the scientific evidence supporting MAT? • What are the barriers keeping millions of people who are addicted to opiates from benefiting from these therapies? • What is harm reduction and how does this fit in with treatment of addiction?

4. What is Medication Assisted Therapy? MAT combines pharmacological intervention with counseling and behavioral therapies to treat addiction.

5. Currently three treatments approved in US • Methadone • Buprenorphine (Suboxone) • Naltrexone

8. Overdose Deaths in New Mexico • Second highest rate in US • In 2012 – 486 deaths • 7% decrease from 2011 • More than half of 2012 deaths were from prescription medications

11. New Mexico Profile 2010

12. Other Public Health Impacts of Opiate Addiction in NM • Estimated 23,000 IV drug users – mostly heroin • 10 to 20% of people living with HIV acquired their infections from injecting drugs • High rates of hepatitis C – more than 32,000 on NM Department of Health registry – at least 60% acquired from injecting drugs

13. Social consequences of drug use in NM • High rates of incarceration and criminal justice sanctions impacting mostly young people of color

14. Public Health Approaches to the Opioid Overdose Epidemic 1-Providing prescribers with the knowledge to improve their prescribing decisions and the ability to identify patients’ problems related to opioid abuse 2-Toreduce inappropriate access to opioids 3- To provide substance abuse treatment to persons addicted to opioids 4- To increase access to effective overdose treatment

15. Less Opioid Prescriptions • NM Depart of Health announced last week a 13% decrease in prescribed opioids from 2010 to 2013 • Impact of media, provider education programs, NM Prescription Monitoring Program, increased vigilance by professional licensing boards and DEA

16. “The key driver of the overdose epidemic is underlying substance abuse disorder.” Medication-Assisted Therapies — Tackling the Opioid- Overdose Epidemic 4/24/14 NEJM

20. Dopamine

21. Picture of opiate addiction: heroin

22. Picture of opiate addiction: pain pills

23. What is addiction? • A term referring to compulsive drug use, psychological dependence, and continuing use despite harm. • Addiction is frequently and incorrectly equated with physical dependence and withdrawal. Physical dependence, not addiction, is an expected result of opioid use.

24. NIH Consensus Statement 1997 • “Whatever conditions may lead to opiate exposure, opiate dependence is a brain-related disorder with the requisite characteristics of a medical illness.” Effective Medical Treatment of Opiate Addiction. NIH Consensus Statement 1997 Nov. 17-19;15(6):4

25. NNI

26. Addiction to heroin is a chronic, relapsing disease with high morbidity and mortality • 33 year follow up of 581 male heroin addicts in Los Angeles found: • Nearly half had died • 20.7% of those living tested positive for heroin • 40% reported using heroin in past year • High rates of disability, hepatitis, mental health disorders, and criminal activity • Fewer than 10% were in methadone maintenance Rx. “Methadone Maintenance and Other Pharmacotherapeutic Interventions in the Treatment of Opioid Addiction.” April 2002, Vol.III, No. 1

27. History of Methadone • Synthesized in Germany during WWII • In 1960s at Rockefeller University in New York City, Drs. Vincent Dole and Marie Nyswander, performed studies showing effectiveness for treatment of heroin addiction • First clinics opened in NYC in mid-1960s

29. Medication Assisted Therapy • The substitution of an opiate-like medication to prevent withdrawal and minimize craving for opiates. • A medical model for the treatment of opiate dependence. Treats opioid dependence as a chronic, relapsing disease. • Effective medications – Methadone or Buprenorphine

30. Medication Assisted Therapy (MAT) The primary goal of MAT is to reduce illegal heroin and other opiate use and the crime, diseases, and deaths associated with opiate addiction and allow patients to live healthy and fulfilling lives.

31. Why is overdose potential low with buprenorphine? Agonist: Methadone, Heroin, etc. Respiratory suppression, death Opioid Effects Partial Agonist: Buprenorphine Antagonist: Naltrexone Log dose

32. Functions of Drugs at mu Receptor Full agonists such as methadone: • Occupy the receptor and activate that receptor • Increasing doses of the drug produce increasing receptor-specific effects until a maximum or toxic effect is achieved • Most abused opioids are full agonists

33. Pharmacologic Properties of Heroin and Methadone

34. What is the abuse potential? • “Methadone’s half-life is approximately 24 hours and leads to a long duration of action and once-a-day dosing. This feature, coupled with its slow onset of action, blunts its euphoric effect, making it unattractive as a principle drug of abuse.” Effective Medical Treatment of Opiate Addiction. NIH Consensus Statement 1997 Nov. 17-19;15(6):14

37. Methadone IS effective • After 1 year, 60% reduction in drug use • After 2 years, 85% • 70% reduction in crime within 4 months • Ball and Ross 1991 • Decreased transmission of blood-borne diseases • Less HIV infection: 5% seroconversion in treated versus 26% non-treatment group • Metzger 1993

40. How should methadone be prescribed? Best outcomes achieved when patients: • are maintained for long periods of time (at least one year) Relapse rate c. 80% in 1 year. • receive high doses (usually 80 to 120 mg daily) • low dose prevents withdrawal symptoms. • higher doses minimize craving for opiates.

41. Exhibit 5-3. Heroin Use in Preceding 30 Days (407 Methadone-Maintained Patients by Current Methadone Dose)Adapted from Ball and Ross, The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and Outcome, Appendix B, p. 248, with permission

42. Methadone Regulation • Can only be dispensed by licensed Opioid Treatment Programs (OTPs) • Must follow federal and state regs • Requires daily dispensing ( six days a week) for first 90 days • By one year can receive up to 2 weeks of take-home doses • Eventually may receive 14 to 30 day supply

44. NIH Consensus Statement 1997 • “Although a drug-free state represents an optimal treatment goal, research has demonstrated that this goal cannot be achieved or sustained by the majority of opiate-dependent people.” Effective Medical Treatment of Opiate Addiction. NIH Consensus Statement 1997 Nov. 17-19;15(6):5

46. Exhibit 5-3. Heroin Use in Preceding 30 Days (407 Methadone-Maintained Patients by Current Methadone Dose)Adapted from Ball and Ross, The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and Outcome, Appendix B, p. 248, with permission

47. Myth #1 Methadone substitutes one addiction for another; a patient on methadone is still a drug “addict”

48. Methadone Reality • A patient on methadone treatment is not a “drug addict” because addiction is compulsive use of drug despite knowing it is causing harm. A methadone patient is being prescribed a medication in a controlled environment for treatment of addiction. • Methadone substitutes a legal, long-acting, safe, prescribed opiate-like medicine for an illegal, dangerous, short-acting opioid.

49. Myth #2 Methadone is more “addictive” and “harder to kick” then heroin

50. Kosten & O’Connor, NEJM 2003