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Understanding Medication Assisted Treatment (MAT) for Families Affected by Parental Substance Use The Basics: How It Works

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Understanding Medication Assisted Treatment (MAT) for Families Affected by Parental Substance Use Disorders Medication Assisted Treatment The Basics: How It Works Jason B. Fields MD University of Florida
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Understanding Medication Assisted Treatment (MAT) for Families Affected by Parental Substance Use Disorders Medication Assisted Treatment The Basics: How It Works Jason B. Fields MD University of Florida Fellow in Addiction Medicine Medical Services Manager Linda Mann LCSW, CAP Director of Women s Services DACCO Tampa, Florida 1 2 GOALS FOR PHARMACOTHERAPY Prevention or reduction of withdrawal symptoms Prevention orreduction reduction of drug craving Prevention of relapse to use of addictive drug Restoration to or toward normalcy of any physiological function disrupted by drug abuse Blockade of euphoric effects of illicit self administered opiates PROFILE FOR POTENTIAL PSYCHOTHERAPEUTIC AGENT Effective after oral administration Long biological half life life ( 24 hours) Minimal side effects during chronic administration Safe, no true toxic or serious adverse effects Efficacious for a substantial % of persons with the disorder Source: MJ Kreek, Rationale for Maintenance Pharmacotherapy of Opiate Dependence, Source: MJ Kreek, Rationale for Maintenance Pharmacotherapy of Opiate Dependence, Dose Response e Methadone Simulated 24 Hr. Dose/Response At steady-state in tolerant patient Loaded High Abnormal Normality Normal Range Comfort Zone Subjective w/d Sick Objective w/d Time 0 hrs. 24 hrs. Impact of Maintenance Treatment Reduction death rates (Grondblah, 90) Reduction IVDU and relapse to IVDU (Ball & Ross, 91) Reduction crime days (Ball & Ross) Reduction rate of HIV seroconversion (Bourne, 88; Novick 90,; Metzger 93) Improved employment, health, & social function 5 6 The Statistics TIP 43 from SAMSHA says, risk of relapse during and after tapering is significant and because of the physical and emotional stress of attemptingto to end treatment, its encouraged clients stay in treatment for at least 2 years. The highest risk of relapse is 3 12 months after ending Medication Assisted Treatment. Less than 25% of opiate addicts can be successful in the first yearwhen quitting use cold turkey. Studies show 70% of patients that participate in OTPs for at least 1 year no longer abuse opiates. Nature of the Prescription Drug Crisis 2 Deaths from Opiate Addiction Based on the Medical Examiner s Report (2007) of drug related deaths in Florida, 56% occurred as a result of opioid toxicity (Bohs & Sayed, 2009) Methadone related deaths are connected to pain management clinics and not MAT clinics (Bohs & Sayed, 2009) The Florida Experience In 2007, average of 9 daily lethal overdoses (11 daily as of end of 2008) 3317 of prescription overdose deaths were 70% of total drug deaths in 2007 Over 700,000 Floridians misuse prescription pain meds yearly Top 25 US dispensing practitioners of Oxycodone are all in Florida Florida was one of the largest stateswithout a Prescription Drug Monitoring Program (PDMP), recently implemented Florida has become a major distribution center for opioids and benzodiazepines Source: Broward County Commission on Substance Abuse, United Way, Healers or Dealers? From 2005to 2009, Florida tallied 5, deaths from prescription drugs. That's three times the number of deaths from heroin, cocaine and other illegal drugs combined. Florida is now home to 98 of the top 100 doctors in the United States who dispense Oxycodone right out of their offices. This is one reason Florida is known as the epicenter of the nation's prescription drug abuse crisis. 3 USA Today Prescriptions Now Biggest Cause of Fatal Drug Overdoses Prescription drugs account for most of 26,000 fatal overdoses yearly CDC Prescription Opioids account for 13,800 deaths in 2006 triple the number in ,000 ER visits are due to Opioid Overdoses 2010 Florida Medical Examiners Report In 2009 there were 1,948 oxycodone related deaths and in 2010 there were 2,384 oxycodone deaths, an increase of 22.4%. Also increases from 2009 to 2010 in deaths from other prescription opiates like hydrocodone (10.8%), fentanyl (5.6%), and oxymorphone (109%). Decrease from 2009 to 2010 by 48% in heroin related deaths. 4 Benefits of MAT to the Community 5 Why MAT as a solution? Not addressing the addiction leaves the individual ill and no closer to recovering and gaining pro social behaviors, proactive instead of reactive. Chasing answers to the adverse events associated with opiate addiction such as ER expenses does not get to the solution. Treatment adapted from the biopsychosocial model of addiction which shows opiate addicts do recover. Over 35 years of research justifying MAT as the standard of practice in the medical community for the opiate dependent individual. Benefits of MAT to the Individual and Community Reduces Deaths Reduces Crime Promotes healthier lifestyle Reduces economic impact Allows client to return to normal activities of daily living including parenting Promotes pro social behaviors Reduced Crime Criminal activities are decreased as individuals are being treated for their addiction and do not have to rob, steal or sell drugs to maintain their habit. A nationwide study showed 82% of clients in MAT were arrested at least once before starting treatment and this arrest rate decreased to 19% after one year of treatment (O Connor & Carillo, 2006). Three to five years post treatment treatment arrests were still down 50% (O Connor & Carillo, 2006). A study by NIDA found that methadone treatment reduced illicit opiate use by 70%, criminal activity by 57% (O Connor & Carillo). Promotes Healthier Lifestyle Research shows long term MMT is medically safe, over 35 years of research Long term treatment causes no negative effects to the heart, lungs, liver, kidneys, bones, blood, brain, or other vital organs Reduction rate of HIV seroconversion (Bourne, 88; Novick 90,; Metzger 93). Reduction of intravenous drug use and its complications. Participants can maintain a relationship with primary care provider with continuity of care and address mental health concerns. 6 Reduced Economic Impact Bohs and Sayed (2009) analyzed economic costs of drug use in Florida and reported $22,867,843,781was spent on adverse events due to drug use, Billions spent on reactive measures. The same study showed about 3% of Florida s GDP is spent on consequences of drug use. Out of every $100 it was reported $96.80 is spent on burden public programs (i.e. criminal justice) with only 0.2% of costs spent on treatment programs with zero dollars spent on research to enhance proactive efforts on these economic issues. Reduced Economic Impact Prescription diversion is costly. Bohys & Sayed (2009) stated $266,510 was spent every hour on drug related crimes. Clients must dose with Methadone in MAT daily, promoting diversion control. In viewing the economic costs spent in Florida on drug issues, 23 billion spent overall and 2.3 billion on crime alone. For every $1 spent on methadone allows $4 to be saved in social and health costs (O Connor & Carillo, 2006). Return to Normal Activities of Daily Living Individual can focus on daily activities with attention to short and long term goals Methadone does not produce euphoria as the medicine fills opiate receptors in the brain eliminating physical withdrawal (O Connor & Carillo, 2006). While on the medication the brain returns to normal physiological functioning, no negative effects on mental function (O Connor & Carillo, 2006). A NIDA study found increased full time employment by 24% (O Connor & Carillo, 2006). Participants may again participate in their family and return to parenting. Research Demonstrates Three Major Messages Opioid addiction is a brain disease. Supervised treatment works when tailored to the individual. When patients are effectively treated society benefits From the publication Countering Opioid Stigma for AATOD, Opioid Addiction is a Brain Disease Use of drugs starts off as voluntary behavior, but once continued, use of an addictive drug brings about structural and functional changes in the brain that cause compulsive drug seeking and use (Leshner 1997) The addicted brain is distinctly different from the non addicted brain, as manifested by changes in brain activity, receptor availability, gene expression and responsiveness to environmental cues (Leshner 1997). Research shows that long term drug use results in significant changes in brain function that persist long after the individual stops using drugs. The drug induced changes in brain function have behavioral consequences, including the compulsion to use drugs despite adverse consequences the defining characteristic of addiction (NIDA 1999). Supervised Treatment Works Well When Individualized MMT is not substituting one drug for another (COMPA 1997) Opiate euphoria is absent and opiate withdrawal symptoms are eliminated Cravings for opiates is effectively diminished The ability to focus on daily life activities and goals is restored. Methadone blocks the effects of heroin and other opiate drugs, rendering ineffective attempts to take them to achieve euphoria Dependence is a medical disorder that can be treated effectively. Of the various treatments available, MMT combined with individual attention to medical, psychiatric and socioeconomic issues, as well as drug counseling, has the highest probability of being effective (NIH Consensus Statement 1997). Similar to other diseases of the brain (depression) and other diseases of the body (hypertension, diabetes) opioid addiction is a chronic, relapsing disease. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The appropriate amount of time depends on the individual s problems and needs (NIDA). When Patients Are Treated Effectively Society Benefits Methadone therapy.is one of the longest established, most thoroughly evaluated forms of drug treatment Methadone therapy helps keep more than 100,000 addicts off heroin, off welfare, and on the tax rolls as law abiding, productive citizens (National Drug Control Strategy, 1999). The financial cost of untreated opiate dependence to the individual, the family, and society are estimated to be approximately $20 billion/year (NIH Consensus Statement, 1997) Methadone and Pregnancy A three city field study of methadone treatment patients in NYC, Baltimore and Philadelphia found significant reductions in criminality across 14 types of crimes, most categories declining over 80% (NIDA 1999). Lifetime arrest rates of 151 male patients in Baltimore demonstrated a substantial reduction after admission to methadone treatment an 85% decrease in the annual arrest rate in comparison to the addiction years (Ball et al. 1994) 8 Opioid misuse during pregnancy is a serious and growing concern: High rates of infection Premature delivery Low birth weight, which is an important risk factor for later developmental delay. Comprehensive methadone maintenance treatment that includes prenatal care reduces the risk of obstetrical and fetal complications, in utero growth retardation, and neonatal morbidity and mortality. Obstetrical Complications Opiate Abuse Remember the polysubstance abuse is the norm.. Increased spontaneous Abortion, especially first trimester Increased 3 rd trimester premature delivery, premature rupture of membranes Intrauterine Growth Retardation Amnionitis Placental Insufficiency Postpartum Hemorrhage Pre eclampsia eclampsia and Eclampsia Septic thrombophlebitis Acceptance as the Standard of Care Methadone has been accepted since the late 1970s to treat opioid addiction during pregnancy In 1998, a National Institutes of Health consensus panel recommended methadone maintenance as the standard of care for pregnant women with opioid addiction Recent literature supports Buprenorphine as another option for safe medication assisted assisted treatment for opioid addiction (MAT) in pregnant patients. Standard of Care Methadone maintenance has been the recommended standard of care over no treatment or Medication Assisted Withdrawal (MAW) based on: Longer durations of maternal drug abstinence Better obstetrical care compliance Avoidance of associated risk behaviors Reductions Rd in ftlilli fetal illicit it drug exposure Enhanced neonatal outcomes heavier birth weight (Kaltenbach 1998). 9 Standard of Care Methadone is the oldest, most widely used medication prescribed during pregnancy, and in comparison to infants born to heroin abusing mothers, infants from methadone treated mothers have: Increased fetal growth Reduced fetal mortality Decreased risk of HIV infection Decreased risk of pre eclampsiaeclampsia Less fetal exposure to rapid and unpredictable cycles of heroin induced highs and withdrawal Increased likelihood of the infants being discharged to their parents (Finnegan 1991). Pregnancy Specific Benefits of Opioid Maintenance Therapy Methadone Maintenance Therapy (MMT) is regarded as an established treatment with birth outcomes comparable to a general obstetrical population lti (KreekMJ, 2000) Fewer Pre term Births Less Intrauterine Growth Restriction Fewer Low Birth Weight Infants Less Maternal Drug Use Greaterreduction reduction with higher dose ofmethadone Improved Prenatal Care Compliance (Burns L, 2004; Goler NC, 2008) There appears to be no differential effect of either treatment (methadone or Buprenorphine) it was exposure to stable treatment that was important (Gibson 2008). Common Medical Complications Among Pregnant Women Who Are Opiate Addicted (many of these from intravenous drug use) Common Obstetrical Complications Among Women Addicted to Opioids (The fetus is at risk for morbidity and mortality because of episodes of maternal withdrawal compounded by a lack of prenatal care) Anemia Bacteremia/septicemia Cardiac disease, especially endocarditis Cellulitis Depression and other mental disorders Edema Gestational Diabetes Hepatitis A, B, and C Hypertension/tachycardia Phlebitis Pneumonia Poor dental hygiene STDs Chlamydia Condyloma acuminatum Gonorrhea Herpes HIV/AIDS Syphilis Tetanus Tuberculosis UTIs Cystitis Pyelonephritis Urethritis Abruptio placentae Chorioamnionitis Intrauterine death IUGR Intrauterine passage of meconium Low Apgar Scores Placental insufficiency Amnionitis Postpartum hemorrhage Preeclampsia Premature labor/delivery PROM Septic thrombophlebitis Spontaneous abortion, especially first trimester 10 Methadone and Pregnancy Neonatal Abstinence Syndrome METHADONE AND BUPRENORPHINE: PRESENTATION AND MANAGEMENT There is no evidence that higher doses are harmful to the ft fetus. The neonate has a high probability of having NAS (Neonatal Abstinence Syndrome) Delivery should be arranged for a hospital where the neonate can be appropriately managed for NAS, if necessary. Dosages relative to Neonatal Abstinence Syndrome Historically, treatment providers have based dosing decisions on the need to avoid or reduce the incidence of NAS (Kaltenbach et al. 1998). This low dose approach emerged from several 1970s studies (Harper et al. 1977) and has been contradicted by more recent studies (Brown et al. 1998). There is no compelling evidence supporting reduced methadone dosages to avoid NAS. On the contrary, higher doses of Methadone have been associated with: Increased weight gain Decreased illegal drug use Improved compliance with prenatal care by pregnant women in MAT Increased birth weight Increased head circumference Prolonged gestation Improvedgrowthofinfantsborntowomenin of to women MAT (De Petrillo and Rice 1995) ***Reduced methadone dosages may result in continued substance use and increased risks to both expectant mothers and their fetuses*** 11 Initial Neonatal Work up First urine-will only detect very recent substance use First meconium-will ill detect t substances used after 20 weeks gestation Standardized NAS scoring should begin within 2 to 4 hours of birth and repeated every 2 hours Finnegan Scores Easy to learn/administer Promotes standardization/consistent management Assess for other diagnoses as indicated particularly for persistent diarrhea Substance Exposed Infants May be full term and look healthy Symptoms occur 60% of time and to varying degrees within a few days of birth and include: Tensed Muscles Frequent Diarrhea High Respiratory Rates Loss of Appetite Vomiting Marble like appearance Increased risk of SIDS Long hospital stays which can cause clashes with families Infant Withdrawal Opioids (heroin, codeine, morphine, Oxycodone) Withdrawal occurs in 42 94% exposed infants Occurs 24 hours after birth and as long as 6 days after birth Methadone (synthetic opiod) Best medical option for opioid addicted pregnant women does not cause birth defects blocks the euphoric and sedating effects of other opioids decreases illicit behaviors, improves prenatal care and outcomes prevents acute maternal withdrawal that is associated with fetal death Withdrawal usually occurs within 1 4 weeks. Treatment for Babies Withdrawal can last weeks or months No universal standard for pharmacologically treating babies Finnegan scale helps determine treatment Tiny doses of morphine, methadone, phenobarbital or clonidine used to relieve symptoms and wean newborns of addiction Doctor mayattempt attempt to treat baby without drugs Long term effects remain unknown 12 Discharge Planning Integrate the mother/family into the treatment team Establish and maintain communication with other providers methadone hd or Buprenorphine providers, early intervention, i visiting iii nurses, child protective services, pediatric care, school programs, community support programs regarding treatment plans for the child, the mother and the family Confirm follow up appointments and activities and review with mother/family, provide written instructions Monitorstatus of followup onthe plans developed with providers and document this in file Reduce the barriers to treatment transportation, child care, attitudes and behaviors, resources Developmental Sequelae Research findings on developmental sequelae associated with in utero methadone exposure are diverse but most studies suggest that infants through2 year olds function well within the normal developmental range. They do not differ in cognitive function from a population that was not drug exposed and was of comparable socioeconomic and racial background (Kaltenbach 1996). Other data have suggested that maternal drug use is not the most important factor in how opioid exposed p infants and children develop but that family characteristics and functioning play a significant role (Johnson et al. 1987). Developmental Sequelae One long term follow up study of 27 children who had been exposed to methadone in utero found no cognitive impairment in preschool years (Kaltenbach et al. 1998). Overall, prenatal exposure to methadone provided as part of comprehensive treatment does not appear to be associated with developmental or cognitive impairments (Kaltenbach 1996). Buprenorphine There have been 31 published reports of Buprenorphine, a partial mu muopioid agonist, exposure during pregnancy that were reviewed and summarized (Jones et al. 2008). Overall, the studies report approximately 522 neonates prenatally exposed to Buprenorphine, with a wide range of therapeutic doses from 0.4 to 24 mg sublingual tablets/day. Generally, the pregnancies were uneventful, without physical teratogenic effects, and with low rates of prematurity, suggesting that Buprenorphine is relatively safe and effective for this population. 13 Methadone vs. Buprenorphine Opioid maintained patients who become pregnant should be maintained on the current agent Suboxone can be changed directly to Subutex Even though it is a category C drug, Buprenorphine may be used with pregnant patients in the US under certain circumstances Buprenorphine should only be initiated when Patient cannot tolerate methadone Methadone program is not accessible Patient is adamant about avoiding methadone Patient is capable of informed consent New Study! Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure, Jones et. Al 2010, New England Journal of Medicine. A double blind, double dummy,
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