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Medication-Assisted Treatment (MAT) for Criminal Justice Populations

Medication-Assisted Treatment (MAT) for Criminal Justice Populations. [Insert trainer Name and affiliation information here]. Goals of Today’s Training. After this training, you will be familiar with: Addiction and how it affects the brain dopamine and the reward pathway Medications

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Medication-Assisted Treatment (MAT) for Criminal Justice Populations

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  1. Medication-Assisted Treatment (MAT) for Criminal Justice Populations [Insert trainer Name and affiliation information here]

  2. Goals of Today’s Training After this training, you will be familiar with: • Addiction • and how it affects the brain • dopamine and the reward pathway • Medications • for addiction treatment • how they work & what they do • Benefits • of addiction treatment to the CJ System • Logistics • of referring an offender • types of clients to look for • agencies where MAT is offered

  3. An Open Conversation about MAT • Using medication to treat addiction is a good idea because... • Using medication in addiction treatment is a not-so-good idea because… • I refer clients to addiction treatment because…

  4. An Open Conversation About MAT Concerns about MAT? • The medications? • Methadone • Diversion • The clinics? • “Bad” methadone clinics • Attracting dealers and crime • Therapeutic communities don’t allow MAT

  5. MAT Myth Busters: Myth #1 “Medication is not a part of treatment.” • Medication can be an effective part of treatment. • Medication is used in the treatment of many diseases, including addiction. • Medical decisions must be made by trained and certified medical providers. • Decisions about using medications are based on an objective assessment of the individual client’s needs.

  6. MAT Myth Busters:Myth #2 “Medicines are drugs, too.” Errors in Language: Physical Dependence vs Addiction Drugs are used to get high, but medications are used to get better. Medicine (n.) an innovation of the human species which has given us a competitive advantage for thousands of years; innovations in science & medicine have historically been helpful and progressive.

  7. MAT Myth Busters:Myth #3 “Alcoholics Anonymous (AA) & Narcotics Anonymous (NA) do not support the use of medications.” While some specific NA chapters are not tolerant of methadone, AA/NA literature and founding members did not speak or write against using medications.

  8. The Clinician’s IllusionAfter Cohen & Cohen Arch Gen Psych 1984 MAT Myth Busters:Myth #4 “MAT is not effective.” • MAT medications had to demonstrate the same level of effectiveness as all other types of medications for other diseases to get FDA approval. • We tend to have a biased perception: • Patients who improve, leave and are forgotten • Patients who do not improve return frequently and are remembered • Leads us to think that most patients do not improve …contrary to scientific data.

  9. MAT Myth Busters:Myth #5 “Clients who are not using drugs at present do not need MAT.” Reasons include: • peer pressure • familial pressure • tensions of daily life • few job opportunities • lack of safe housing More than half of inmates will relapse within one month of release. • isolation • disillusionment & apathy • the stress of complying with correctional supervision

  10. Should abstinent clients be omitted from MAT? As you may already know, a client who is abstinent now may not remain so forever. Addictionis not a common cold, so, itmust not be treated like one. WHY?

  11. Addiction is… A CHRONIC DISEASE

  12. The Brain: Hijacked! The Science Behind Addiction

  13. Can the brain get hijacked? Researchshows… that prolonged drug use can change brain chemistry.

  14. First, let’s take a look atOpioid Addiction Some Examples: • Morphine • Heroin • Codeine

  15. How can the brain get hijacked by opioids? Opioid use… disrupts normal Dopamine functioning.

  16. Let’s take a look at Dopamine Functioning

  17. What Is Dopamine? A hormone A neurotransmitter Working Normally, it produces feelings of pleasure and is involved in decision making. Working Abnormally, leads to cravings, depression, difficulties with decision making and memory problems.

  18. Abnormal Dopamine Functioning COCAINE AMPHETAMINE Accumbens 1100 Accumbens 400 1000 900 DA 800 DA 300 DOPAC 700 DOPAC % of Basal Release HVA HVA 600 % of Basal Release 500 200 400 300 100 200 100 0 0 0 1 2 3 4 5 hr Time After Amphetamine Time After Cocaine 250 NICOTINE ALCOHOL 250 Accumbens Dose (g/kg ip) 200 Accumbens 200 Caudate 0.25 0.5 150 % of Basal Release 1 2.5 % of Basal Release 150 100 0 2 3 hr 1 0 1 2 3 4 5 hr 100 0 0 0 1 2 3 4hr Time After Nicotine Time After Ethanol

  19. Abnormal Dopamine Functioning More Cocaine Activity of Reward System METH controls treated Alcohol Less Food

  20. The good news is… OpioidAddictionisatreatabledisease. Courtesy of Partnership for a Drug Free America.

  21. How can we treat opioid addiction? The person must learn new ways of coping and The brain changes must be addressed

  22. We know of 3 ways: 1. Avoid the drug …using coping strategies 2. Replace associations …using therapy 3. Directly addressingthe neural effects of the drug …using medication

  23. Medicationcanaddress many of the changes caused in the brain. Thus,MAT canhelp the person to function more normally Facilitating the process of recovery.

  24. How do medications for opioid addiction work? There are three types of medications that can block the “high”: Agonists - produce opioid effects Partial Agonists - produce moderate opioid effects Antagonists - block opioid effects

  25. Full Agonist (e.g., methadone) Partial Agonist (e.g. buprenorphine) Antagonist (e.g. Naloxone) How do medications for opioid addiction work? Opioid Effect Dose of Opioid

  26. Example of a CJ client who could benefit from MAT for opioids Male heroin addict, mid-30’s Also does speedballs (heroin and cocaine) during robberies Early CJ involvement Early cigarette and AOD use Repeated arrests and incarcerations Treatment failures Daily criminal activity to support his habit

  27. Example of a CJ client who could benefit from MAT for opioids Female heroin addict, mid-30s Early cigarette and AOD use Mental health problems & trauma Has children in kin foster care Repeated arrest history mostly related to prostitution and shop lifting Non-medication treatment failures Extensive involvement with child protective services Recent relapse and incarceration after year of abstinence Strong desire to stop using and get kids back

  28. Pregnant woman Shoots heroin daily Failed treatments Repeated arrest history mostly related to prostitution and shop lifting Example of a CJ client who could benefit from MAT for opioids

  29. Now, let’s take a look at Alcohol Addiction

  30. How can the brain get hijacked byAlcohol Addiction? endogenous opioids make you euphoric and feel no pain glutamate excitatory neurotransmitter…speeds you up GABA inhibitory neurotransmitter…slows you down dopamine makes you happy The Cast

  31. Alcohol in the Brain First, alcohol is consumed Second, endogenous opioids are released Third, dopamine is released

  32. The brain remembers the good feelings produced by endogenous opioids and dopamine in the reward pathway, and then desires to repeat the behavior to get the same good feelings. Thus, the reward pathway is out of balance!

  33. At the same time… An imbalance in the brain is created -as GABA is increased So, the brain slows down -as glutamate is over-ridden by GABA And in response, the brain up-regulates • -as the brain tries to correct for the imbalanceby increasing sensitivity to glutamate

  34. As the brain desired, the up-regulation works, and the imbalance is corrected. Now, if the individual drinks, it takes more alcohol to override the glutamate system again and feel the same level of intoxication. This effect is knownas Tolerance.

  35. With an unbalanced reward pathway and an increasingly high tolerance… The person is developing symptoms of ADDICTION.

  36. The good news is… Alcoholaddictionisatreatabledisease. Courtesy of Partnership for a Drug Free America.

  37. How can we treat Alcohol Addiction? Medications for alcoholism can: Reduce post-acute withdrawal Block or ease euphoria from alcohol Discourage drinking by creating an unpleasant association with alcohol

  38. Example CJ client who could benefit from MAT for alcoholism Male alcoholic, mid-40s Early cigarette and alcohol use History of DUIs and violence Intimate partner violence Treatment failure Strongly desires help

  39. Example of a CJ client who could benefit from MAT for alcoholism • Female, mid-30’s • Arrested for 4th DUI • 3 previous treatment episodes each with about 1 year of abstinence afterword • Has been trying to get pregnant for about a year. • Wants to stay away from alcohol for the baby, but is frequently relapsing

  40. The Medications For Opioid Addiction: Methadone Buprenorphine Naltrexone • For Alcohol Addiction: • Naltrexone • Acamprosate • Disulfiram

  41. The Medications For Opioid Addiction: Methadone Buprenorphine Naltrexone Methadone • For Alcohol Addiction: • Naltrexone • Acamprosate • Disulfiram

  42. Methadone -Alleviates withdrawal & blocks euphoria. -Is used for detoxification or maintenance. -Also known as: -Methadose -Dolophine -Approved: 1964 -Third-Party Payer Acceptance: Covered by most major insurance carriers, Medicare, Medicaid and the VA.

  43. Full Agonist (e.g., methadone) Partial Agonist (e.g. buprenorphine) Antagonist (e.g. Naloxone) How does Methadone Work? Full Agonist Opioid Effect Dose of Opioid

  44. What does the research say? Methadone is the most studied medication for opioid addiction. • 8-10 fold reduction in death rate • Reduces opioid use • Reduces crime • Improves family and social functioning • Increases likelihood of employment • Improves physical and mental health • Reduces spread of HIV • Low drop-out rate compared to other treatments

  45. Crime before and during Methadone Treatment at 6 programs Crime Days Per Year

  46. High Rate of Relapse to IV drug use after drop-out from Methadone Treatment Percent IV Users Treatment Months Since Stopping Treatment

  47. The Medications For Opiate Addiction: Methadone Buprenorphine Naltrexone Buprenorphine • For Alcohol Addiction: • Naltrexone • Acamprosate • Disulfiram

  48. Buprenorphine Available by prescription outside of Methadone Treatment Programs Only physicians with special training and waiver can prescribe Also known as: Subutex® Suboxone® (buprenorphine/naloxone) FDA-approved: 2002

  49. Buprenorphine/Naloxone “the Combo Tablet” Preserves bupe’s effects when taken sublingually at optimal ratio Action, safety & efficacy same as bupe alone Also contains Naloxone (same as Narcan used to reverse OD) - inert unless injected Discourages IV use, diversion Allows for take-home dosing Dysphoric effects if injected by physically dependent persons

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