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MEDICATION ASSISTED ADDICTION TREATMENT: “APPROPRIATE USE” DAS Quarterly Provider Meeting

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. GOALS & OBJECTIVES. Review comprehensive evaluation components DSM-IV-TR diagnosing

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MEDICATION ASSISTED ADDICTION TREATMENT: “APPROPRIATE USE” DAS Quarterly Provider Meeting

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  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” • ASAM’s 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 @ 77% @ 1yr • Detoxification & Rehab Only @ 33% @ 1yr • Detoxification Alone @ < 10% @ 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 patient’s 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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