Medication Assisted Treatment (MAT) and Detoxification Steven Margolies, MD Medical Director and Director of Clinical Se

1. Medication Assisted Treatment (MAT) and Detoxification Steven Margolies, MD Medical Director and Director of Clinical Services Phoenix House New York Region

2. Medication Assisted Treatment (MAT) Medication Assisted Treatment (MAT) is the use of medications in combination with counseling and behavioral therapies The purpose is to provide a whole-patient approach to the treatment of substance use disorders. -SAMHSA

3. Medication Assisted Treatment (MAT): Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is more successful than each alone. Medication Assisted Treatment (MAT) is clinically driven with a focus on individualized patient care. -SAMHSA

4. Medication Assisted Treatment Treating Addiction as a Chronic Disease: Changes to the brain due to chronic exposure to drugs are often long lasting and require a multisystem approach. Medication Assisted Treatment (MAT) allows the patient to focus on behavioral changes while brain functioning stabilizes

5. Medication Assisted Treatment Treating Addiction as a Chronic Disease: Changes to the brain’s functioning include: Abnormal or depleted levels of neurotransmitters such as dopamine. Damage to the pathways that control mood, memory, cognition, concentration, etc.

6. Medication Assisted Treatment Treating Addiction as a Chronic Disease: • These changes take time to adjust and may not always return the brain to pre morbid functioning. • There is no single “one size fits all” treatment and an individualized multifaceted approach is needed. • We should have realistic expectations of treatment and outcomes. • Patients often have significant co occurring mental health disorders.

7. Medication Assisted Treatment Medications are targeted at: Interfering with the reinforcing effect of drugs. Compensating for changes these drugs have caused in the brain.

8. Medication Assisted Treatment Medications that interfere with reinforcing effects may: Reduce response to drugs Decrease drug delivery to the brain Trigger an adverse reaction

9. Medication Assisted Treatment Medicationscompensate for changes drugs have caused in the brain. • Replacement • Treatment of symptoms

10. Medication Assisted Treatment . Medication Assisted Treatment (MAT) is available for the treatment of: • Alcohol • Nicotine • Opiates

11. Medication Assisted Treatment Medications for commonly used for Alcohol include: • Disulifram or Antabuse ® • Naltrexone (oral) or ReVia ® • Naltrexone (long acting injectable) or Vivitrol ® • Acamprosate or Camprail ®

12. Medication Assisted Treatment (MAT) and Alcohol Disulifram or Antabuse ® Is a desensitizing agent. produces adverse effects when taken with alcohol. In 1949 it was the first drug approved by the US FDA in the treatment of alcohol dependence.

13. Medication Assisted Treatment (MAT) and Alcohol Disulifram or Antabuse ® When alcohol is ingested with Antabuse the patient becomes ill and may experience: • Nausea • Warmness of flushing • Vomiting • Sweating • Dizziness • Blurred Vision • Confusion • Palpitations This is called a Disulifram – Ethanol Reaction or DER

14. Medication Assisted Treatment (MAT) and Alcohol Disulifram or Antabuse ® mechanism of action; • Alcohol is metabolized into acetaldehyde then into acetic acid in the body • Acetaldehyde causes the ill effects of alcohol (i.e. “hangovers”) • The enzyme aldehyde dehydrogenase is needed to eliminate Acetaldehyde and turn it into acetic acid • Disulifram inhibits this enzyme

15. Medication Assisted Treatment (MAT) and Alcohol Disulifram or Antabuse Patients cannot have any alcohol while taking this medication Has been shown to reduce alcohol consumption Side effects include neuropathy, hepatoxicity effects and possible exacerbation of psychosis. Compliance can be an issue.

16. Medication Assisted Treatment (MAT) and Alcohol Naltrexone – oral and injectable Is an opioid antagonist which means it blocks the opioid receptor in the brain. Is used for both the treatment of Alcohol and Opioid dependence by blocking the reinforcing effects of the substance. Does not make the patient feel anything intrinsically.

17. Medication Assisted Treatment (MAT) and Alcohol Naltrexone – oral and injectable Is suggested that it works by selectively blocking the endogenous opioid system. This blocks the alcohol “priming effect”. (increased sensitivity to repeated stimuli) Patients do not experience the same euphoric feelings from repeated use and often lose interest in drinking. Patients often comment that they drank but “did not enjoy it”.

18. Medication Assisted Treatment (MAT) and Alcohol Naltrexone – oral and injectable has been shown in multiple studies to: • Decrease cravings and relapse to heavy drinking. • Increase abstinence • Reduce the number of drinking days, relapse events and alcohol related problems. • Has greatest benefit is when it is combined with treatment such as 12 step and CBT.

19. Medication Assisted Treatment (MAT) and Alcohol Naltrexone: • ReVia ® is an oral pill that contains naltrexone and a patient takes daily. • Vivitrol ® is a long acting injection of Naltrexone that lasts for 1 month. Long acting injection does work better. Patients cannot forget to take it and the overall dose is lower with less chance of side effects.

20. Medication Assisted Treatment (MAT) and Alcohol Naltrexone: Side effects are uncommon but can include anhedonia and elevated liver enzymes. (warning just lifted for Vivitrol® ) Need to be cautious when patients have significant mental illness Naltrexone will block opiates and patients should not take them together. If they need to be treated for acute pain, the doctor needs to be aware to adjust doses.

21. Medication Assisted Treatment (MAT) and Alcohol Acamprosate or Campral® Increases excitatory neurotransmitters in the brain such as Gamma Amino Butyric Acid or GABA which may become unbalanced due to alcohol dependence. Restores the chemical balance in the brain in a person who has recently quit drinking Helps patients continue to remain abstinent from alcohol.

22. Medication Assisted Treatment (MAT) and Alcohol Acamprosate or Campral® Shown to decrease return to drinking once a person has stopped. Should be used together with behavior modification and counseling support. Can cause diarrhea and rash and needs to be used with caution with patients who have kidney disease.

23. Medication Assisted Treatment (MAT) and Nicotine • Nicotine is an addictive drug that causes changes in multiple areas of the brain. • It causes increased feelings of pleasure and has well known withdrawal symptoms. • Medications can be used to replace nicotine through safer delivery systems and that counter some of it’s reinforcing effects. • Medication combined with behavioral treatment results in best outcomes.

24. Medication Assisted Treatment (MAT) and Nicotine Medications commonly used: • Nicotine Replacement Therapy: (NRT) – Nicoderm ® Nicorette ®, etc. • Bupropion SR: Zyban ® or Wellebutrin ® • Varenicline: Chantix®

25. Medication Assisted Treatment (MAT) and Nicotine Nicotine Replacement Therapy (NRT) Patch, Gum, lozenges, e-cigarettes and smokeless cigarettes Has become the mainstay of Nicotine dependence treatment. Harm Reduction – replaces higher risk delivery system of inhaled smoke with safer alternative that can be tapered off Abstinence after first 2 weeks off of taper with patch has been shown to be highly predictive of long term abstinence.

26. Medication Assisted Treatment (MAT) and Nicotine Bupropion SR: Zyban ® or Wellebutrin • Is an oral medication • Also used in the treatment of Depression and Anxiety. • First non-nicotine agent to be approved to treat nicotine dependence.

27. Medication Assisted Treatment (MAT) and Nicotine Bupropion SR: Zyban ® or Wellebutrin • Believed to act on dopamine in the pleasure reward pathway in the brain where it blocks the reinforcing effect of Nicotine. • May also have direct actions on the metabolism of Nicotine as well. • Can start while still smoking up to 1 week prior to stopping. • Can be combined with Nicotine Replacement Treatment (NRT)

28. Medication Assisted Treatment (MAT) and Nicotine Bupropion SR: Zyban ® or Wellebutrin • Treatment is typically 6 to 12 weeks • Caution if there is a history of seizures, mania, head trauma and eating disorders.

29. Medication Assisted Treatment (MAT) and Nicotine Varenicline or Chantix® • Is an oral medication • Blocks nicotine from binding to receptors in the brain that stimulate cravings. • Reduces withdrawal symptoms. • Showed better outcomes than NRT.

30. Medication Assisted Treatment (MAT) and Opioids / Opiates Opiates and Opioids: An opiate is a natural substance derived from the poppy plant Common opiates include opium, morphine and codeine, and are made directly from poppy plants.

31. Medication Assisted Treatment (MAT) and Opioids / Opiates Opiates and Opioids: An opioid is a substance that is synthetic or partly synthetic. Opioids include Oxycodone, Hydrocodone and others.

33. Medication Assisted Treatment (MAT) and Opioids / Opiates Opiates and Opioids: Medication Assisted Treatment (MAT) typically acts directly on Opioid Receptors in the brain by either blocking fully, partially or stimulating them. Used for prescription pain medications and street heroin Focus is on blocking symptoms of withdrawal and stabilizing brain function so behavioral treatment can be initiated. Studies show combined Medication Assisted Treatment (MAT) and behavioral treatment have greater positive outcomes than each alone.

34. Medication Assisted Treatment (MAT) and Opioids / Opiates Medications commonly used to treat Opiate / Opioid Dependence: • Methadone • Buprenorphine / Naloxone – Suboxone ® • Buprenorphine – Subutex ® • Oral Naltrexone - ReVia ® • Long Acting Injectable Naltrexone – Vivitrol ® • Levo Alpha Acetylmethadol – LAAM – no longer used in US

35. Medication Assisted Treatment (MAT) and Opioids / Opiates Methadone: First synthetized in 1939 in Germany to be used as an analgesic. In 1947 it was given the generic name “methadone” by the Council on Pharmacy and Chemistry of the American Medical Association Production was first introduced in 1947 by the US company Eli-Lilly

36. Medication Assisted Treatment (MAT) and Opioids / Opiates Methadone: • After World War II, the number of heroin addicts in large American cities grew rapidly. • Between 1950 and 1961, the death rate of those who were injecting heroin increased drastically. • From 7.2 deaths per 10,000 to 35.8 deaths per 10,000in NYC • In New York City, the average age of death of a heroin injector was 29.

37. Medication Assisted Treatment (MAT) and Opioids / Opiates Methadone: • Methadone is a slow-acting opioid that is taken orally. • it reaches the brain slowly, dampening the high or euphoria that occurs with other routes of administration while preventing withdrawal symptoms. • Long half life diminishes the lows or withdrawal and allows for a steady state.

38. Medication Assisted Treatment (MAT) and Opioids / Opiates

39. Medication Assisted Treatment (MAT) and Opioids / Opiates Methadone: Is used for Maintenance and Detoxification form short acting opioid and opiate dependence. Patients are maintained in a state where they are comfortable but not high or low. Typically administered in an Opioid Treatment Program (OTP) where doses are monitored and dispensed by medical staff including physicians and nurses and where therapeutic interventions are provided. Therapy is typically evidence based and provided by trained counseling staff.

40. Medication Assisted Treatment (MAT) and Opioids / Opiates Methadone: Allows for therapeutic intervention during all phases of treatment. Studies show that medication combined with therapeutic interventions have significantly greater outcomes than either alone. Decreases relapse and risks associated with IV Drug Abuse such as HIV, Hepatitis, Endocarditis, etc. Is often a valuable tool in decreasing use of heroin and access to treatment. Shown to improve retention in treatment

42. Medication Assisted Treatment (MAT) and Opioids / Opiates Buprenorphine: Buprenorphine, is a long-acting partial agonist that acts on the opiate / opioid receptors as heroin and morphine. Relieves drug cravings without producing the same intense "high" or dangerous side effects. Both blocks and stimulates the opiate receptor but if the patient has used and is dependent on opiates, it will displace them and cause withdrawal. Has a greater affinity for the opiate receptor than other opiates. Can only be started or induced when a patient is in active withdrawal or will cause precipitated withdrawal.

43. Medication Assisted Treatment (MAT) and Opioids / Opiates Buprenorphine: Suboxone® is Buprenorphine with naloxone which prevents overdose if injected or abused. Can be prescribed in a doctor’s office for outpatient treatment by a waivered physician only. Has been shown to improve retention in treatment compared To placebo plus counseling. Is as effective as methadone.

44. Medication Assisted Treatment (MAT) and Opioids / Opiates Buprenorphine: Suboxone is available in a film which is taken under the tongue and rapidly dissolves. Film is individually wrapped to prevent tampering and numbered. Compared to Methadone has less anxiolytic effects and significantly higher costs. Buprenorphine alone (Subutex) is available for pregnancy and if there is any other contraindication to naloxone.

45. Medication Assisted Treatment (MAT) and Opioids / Opiates Naltrexone – oral and injectable Is an opioid antagonist which means it blocks the opioid receptor in the brain. Is used for both the treatment of Alcohol and Opioid dependence by blocking the reinforcing effects of the substance. No intrinsic psycho active effects

46. Medication Assisted Treatment (MAT) and Opioids / Opiates Naltrexone – oral and injectable Selectively blocks the endogenous opioid system and reinforcement. Patients do not experience euphoric feelings when using opiates as receptors are blocked and they do not get high. Patients often comment that they used but did not feel anything. Risk is when trying to override the blockade with increasing amounts of opiates.

47. Medication Assisted Treatment (MAT) and Opioids / Opiates Naltrexone – oral and injectable has been shown in multiple studies to: Decrease cravings and relapse Increase abstinence Has greatest benefit is when it is combined with treatment such as 12 step and CBT.

48. Medication Assisted Treatment (MAT) and Opioids / Opiates Naltrexone: • ReVia ® is an oral pill that contains naltrexone and a patient takes daily. • Vivitrol ® is a long acting injection of Naltrexone that lasts 1 month. Long acting injection does work better. Patients cannot forget to take it and the overall dose is lower with less chance of side effects.

49. Medication Assisted Treatment (MAT) and Opioids / Opiates Naltrexone: Side effects are uncommon but can include injection site reactions, anhedonia and elevated liver enzymes. (warning just lifted for Vivitrol ® ) Need to be cautious when patients have significant mental illness Naltrexone will block opiates and patients should not take them together. If they need to be treated for acute pain, the doctor needs to be aware to adjust doses.

50. Medication Assisted Treatment (MAT) and Opioids / Opiates Pregnancy: Methadone and Buprenorphine: If a patient is opiate dependent and pregnant there is a high risk associated with withdrawal that includes fetal demise. Methadone has been treatment of choice to maintain throughout pregnancy then treat baby post partum. Buprenorphine has shown good results but risk is during induction and precipitated withdrawal. Naltrexone is contraindicated in pregnancy.