Medication assisted therapy for alcohol and opiates

Medication Assisted Therapy Alcohol and Opiates

Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC, NCCExecutive Director, AllCEUs

Review some myths about Medication Assisted Treatment

Identify medications used to treat opiate dependence

Identify medications used to treat alcohol dependence

Discuss the mechanisms of action Evaluate pros and cons of each

Objectives

Medications are a crutch◦ We do what is more rewarding than the alternative

Medications can make sobriety “feel better” by addressing underlying neurochemical imbalances

Medications can remove the rewards from use by Making it unpleasant (Antabuse) Removing the “high” (Buprenorphine, Naltrexone) Both (Suboxone)

Remember recovery is more than just NOT using. Medications can help ease the transition until the brain

has rebalanced and the new lifestyle is in full swing

Myths

Using medication goes against 12-Step Philosophy◦ Alcoholics Anonymous does not encourage AA participants to not

use prescribed medications or to discontinue taking prescribed medications The Big Book states, “God has abundantly supplied this world with fine

doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such person …Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.”

Myths

Medications Can…◦ Increase energy and motivation (dopamine and

norepinephrine) while the person’s brain and body are recovering

◦ Remove some of the reinforcing effects of the drugs◦ Prevent relapse by making relapse very unpleasant◦ Reduce the intensity of co-occurring disorders◦ Reduce conflict/improve social support◦ Reduce absenteeism from work

Pros

Physicians who are educated about addiction treatment and endorse a biopsychosocial model of treatment are difficult to find

Medications can give a false sense of security Medications may provide false hope Medications have side effects There is a stigma associated with the use of

medications Costs money

Cons of Medication

Neurotransmitters◦ Mainly dopamine

Patients report feeling◦ Less pain◦ Less anxiety

Opiate Dependence

Buprenorphine Methadone Naltrexone Naloxone (for opioid overdose) Buprenorphine & Naloxone (Suboxone)

Medications for opiate dependence

Is as partial opioid agonist (ceiling effect) Reduces the symptoms of withdrawal from

misused opiates Can be abused

Buprenorphine

Full Mu opiate agonist (suppresses cravings) Lessens the painful symptoms of opiate withdrawal and

blocks the euphoric effects of opiate drugs Considered relatively safe during pregnancy and

breastfeeding◦ Opiate w/d during pregnancy can trigger contractions and miscarriage

SAMHSA TIP 43 MAT for Opioid Addiction

Methadone

Decreases the pleasurable effects of alcohol or opiates by blocking opiate receptors

Alcohol abstinence is not required, but opiate abstinence is

Naltrexone will cause opiate withdrawal in dependent users

Third-Party Payer Acceptance:◦ Oral is covered by most major insurance carriers, Medicare,

Medicaid, and the VA◦ Vivitrol is not covered in many cases

Naltrexone

Blocks opioid receptors Antagonizes morphine and other opiates. Prevents or reverses the effects of opioids

including respiratory depression, sedation and hypotension.

Naloxone

Alcohol consumption impacts the following neurotransmitters◦ Dopamine (motivation, pleasure)◦ Endogenous opioids (pain and euphoria)◦ Glutamate (Get up and go)◦ GABA (Relaxation--- Produced from Glutamate)

Neurotransmitters

Disulfiram (Antabuse) Naltrexone (ReVia)

◦ Blocks opioid receptors so the reward effects from the endogenous opiates and dopamine are reduced

◦ Vivitrol—Extended Release injectable naltrexone Acamprosate (Campral) Newer Medications

◦ Ondansetron ◦ Nalmefene◦ Gabapentin

Medications for Alcohol Dependence

Reduces Post Acute Withdrawal Symptoms Upregulates (turns on) glutamate receptors reducing

depression Creates an imbalance between Glutamate and GABA

◦ Increasing anxiety, mood lability, insomnia, tremors There was a noted increase in adverse events of a suicidal

nature (suicidal ideation, suicide attempts and/or completed suicides) during the clinical trials.

Acamprosate

Third-Party Payer Acceptance:◦ Does qualify for the Patient Assistance Program

through Forest Laboratories, Inc. Covered by most major insurance carriers, Medicare, Medicaid, and the VA (if naltrexone is contraindicated)

Acamprosate

Makes patients physically sick if they drink Third-Party Payer Acceptance:

◦ Covered by most major insurance carriers, Medicare, Medicaid, and the VA

Disulfiram blocks the enzyme acetaldehyde dehydrogenase◦ alcohol is broken down in the liver to acetaldehyde; ◦ acetaldehyde is converted by the enzyme acetaldehyde

dehydrogenase to acetic acid. ◦ This causes acetaldehyde to accumulate in the blood at 5 to 10

times higher than alcohol alone leading to toxcicity

Disulfiram (Antabuse)

The acute toxic reaction lasts about an hour, but will linger while there is alcohol in the blood

Can be triggered by alcohol containing products like cough syrup Patients taking disulfiram should not be exposed to ethylene

dibromide or its vapors, paint fumes, paint thinner, varnish or shellac Exercise extreme caution when applying aftershave, mouthwash,

lotions, colognes and rubbing alcohol The disulfiram-alcohol reaction can be triggered up to two weeks

after the last dose of disulfiram PATIENT and S.O. EDUCATION IS VITAL

Disulfiram (Antabuse)

Decreases the pleasurable effects of alcohol or opiates by blocking opiate receptors

Alcohol abstinence is not required, but opiate abstinence is

Naltrexone will cause opiate withdrawal in dependent users

Third-Party Payer Acceptance:◦ Oral is covered by most major insurance carriers, Medicare,

Medicaid, and the VA◦ Vivitrol is not covered in many cases

Naltrexone

ONDANSETRON◦ Sold under the name Zofran, and works through the

serotoninergic system especially in regard to the serotonin3 receptor and its effect on dopamine.

◦ In alcoholics, it is possible that there is a heightened sensitivity of the serotonin3 receptor making alcohol more rewarding.

◦ If this receptor could be blocked, there would be a decrease in alcohol-induced dopamine release, resulting in a decrease in alcoholic-drinking behavior.

Newer Meds

NALMEFENE ◦ is an opioid antagonist similar to naltrexone

(ReVia) without the risk of liver toxicity, and it is longer acting.

GABAPENTIN (Neurontin) ◦ is being used for pain management, anxiety, &

insomnia, problems very common among alcohol-dependent patients.

Newer Medications

Anxiety◦ SSRIs◦ Buspar

Insomnia◦ SSRIs◦ Gabapentin◦ Atypical Antipsychotics

Depression◦ SSRIs◦ Atypical Antipsychotics

Pain◦ SSRI/SNRI/Tricyclics◦ Anticonvulants

Comorbid Conditions

Both opiates and alcohol activate opiate receptors

MAT is used to make sobriety more rewarding and reduce relapse triggers in early recovery

It is essential to address comorbid conditions in addition to the substance

Summary

http://www.naadac.org/assets/1959/storie_mat_alcohol.pdf

https://www.oasas.ny.gov/AdMed/meds/meds.cfm

References