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Medication Assisted Recovery

Aaron Newcomb, D.O. April 17 th , 2014. Medication Assisted Recovery. Topic outline. Addiction & Treatment Opiates and Opiate Dependency Opiate Maintenance Treatment Suboxone. Addiction. Epidemiology 10-20% population 30% Harmful Alcohol Use More common than HTN Defining Factors

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Medication Assisted Recovery

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  1. Aaron Newcomb, D.O. April 17th, 2014 Medication Assisted Recovery

  2. Topic outline Addiction & Treatment Opiates and Opiate Dependency Opiate Maintenance Treatment Suboxone

  3. Addiction • Epidemiology • 10-20% population • 30% Harmful Alcohol Use • More common than HTN • Defining Factors • Genetic Factors • Dopamine Reward Mechanism • Compulsive Use • Loss of Control • Drug Obsession • NOT Tolerance or Physical Dependence

  4. Neurobiological Disease • Animal Studies • Selective Breeding • Reproducible Ten Generations • Across Species Lines • Brain Anatomy and Chemistry • Classic Twin Studies • Alcoholism • 4x Risk Biologic Offspring • Regardless of Environment

  5. What Does that Mean? • Chances are likely your life has been affected by addiction. • Science has reproduced a biologic basis of addiction as a disease. • Addiction is not just a simple moral failing. • Solutions to addiction are not simple like, “Pull yourself up by the boot straps and stop using.”

  6. Drugs of Abuse • Percocet • Norco • Xanax • Soma • Adderall • Ritalin Tramadol Robitussin A/C Ambien Dextromethorphan Fioricet

  7. Red Flags • Positive Cannabinoid or other substance • 55% daily or near daily • 7% few times a year • Lost Supply of medication • Escalating Dose Independently • Multiple Providers • No findings on physical exam or MRI • Multiple Drugs of Abuse prescribed • Procuring supply from another source

  8. Addiction Treatment • No longer 28 day Inpatient • AA program • Suboxone and Methadone • Campral and Naltrexone • Wellbutrin & Chantix Addiction Counseling Work Place Monitoring Family Therapy CBT Brief Intervention Detoxification

  9. Treatment success • Positive Predictors • Longer Duration • More Treatment Attempts • Medication Assisted Recovery • Increased Intensity of Treatment • Quit Smoking • 12 Step Meeting within 24 hours of discharge • Negative Predictors • Detoxification Only • Persistent Tobacco Dependency • Treatment Drop Out

  10. Opiates in Brain • Periaqueductal Gray Matter • Analgesia • Locus Coeruleus • Tolerance • Respiratory Depression • Sedation • Analgesic initially only • Reward continuous • Ventral Tegmental Area • Reward

  11. Opioid Dependency • DSM - IV Criterion • No Longer Getting High • Almost 100% Relapse after Detox • Without treatment • Hallmarks • Compulsivity • Lack of Control • Obsession

  12. Things to Know • Opiate surpassed Marijuana in 2008 for Initiation of drug use in 2008 for the Adolescent Group • Almost all procured opiates are obtained from unused medication from friends or family • 59.8% NUPM free from relative • 16.8% One Doctor • <1% internet pharm • 6.5% from drug dealer • Opiate addicted people eventually use to feel normal and avoid withdraw & not to get high

  13. Opiate Maintenance Treatment • Exceptionally Misunderstood • Long acting Opiate = NO REWARD • Prevents Withdraw • Eliminates or Reduces Cravings • Blocks Euphoric Effect of Drug Administration • Not substituting one addicting drug for another • Dramatically improves treatment outcomes • Confidentiality • Long-term Stabilization • Years not Months

  14. Opiate Maintenance Treatment • Methadone • 1960s • 80-120mg • 5-10 yrs, lifetime • Improved • Socially productive activity • Reduction • Mortality, HIV seroconversion, Criminality • Buprenorphine • 2002 • Office Based Therapy • 12-16mg

  15. Suboxone • Buprenorphine + Naloxone • Partial mu agonist • 72 hour half life • Sublingual Administration • Max dose-effect ceiling well below respiratory depression • Schedule III DEA • Must have Waiver to provide out-patient prescription

  16. Suboxone Program • Assessment • Induction • 1-3 Days • Maintenance • Months to ??? • Addiction Counseling • SIRSS & H-Group, Gateway, NA or AA programs • Detoxification • Patient-Physician Decision

  17. Suboxone • Who Is a Good Candidate? • Opiate Addiction • Patient ready for action (sick of being sick) • Resources to obtain medication and transportation • Willingness to Engage in Treatment • Who Is not a Good Candidate? • My wife thinks I have a problem with pain pills. • Adolescent • Non-Opiate Substance Abuse • This has nothing to do with chronic pain management!

  18. Referrals • Jeff Ripperda, M.D. • Murphysboro Health Center • Aaron Newcomb, D.O. • Shawnee Health Services, Carbondale • Donald Bishop, M.D. • Shawnee Women’s Health, Carbondale • There is great need, who else is willing??? • 8 hours CME • Apply for the Waiver • You have resources to help and a program ready!

  19. References • Principles of Addiction Medicine, 4th Ed. 2009 • www.Uptodate.com • SAMHSA • NIDA • NIAAA • Annual Medical and Scientific Conference of the American Society of Addiction Medicine 2010

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