Putting the Pieces Together

Putting the Pieces Together

Perspectives from an Opioid Addiction Treatment Program

Participants will learn:

• Basic principles of treatment of opioid addiction and polysubstance abuse

• The complexities of treating substance abusing parents

• Strategies for addressing the specific needs of families in substance abuse treatment.

Opioid Addiction Treatment: An

Overview

Theories of Addiction

Treatment of Opioid Dependency

Impact of Opioid Agonist Treatment

Treatment of other drugs of abuse

Pregnancy and Treatment

Theories of Addiction

Medical

Psychological

Environmental

Moral

Medical Model

• Disease

• Neurological processes

• Other systems affected

• Impact on behaviors

• Long term neurological implications

• Benefits of medication-assisted treatment

BASICS OF MEDICATION-ASSISTED THERAPY

FOR OPIOID DEPENDENCE

GOALS OF TREATMENT:

Retention in treatment

Reduction in drug use

Prevention of relapse

Restoration of quality of life

7

Opioid Agonist Therapy

• Most effective treatment for heroin or other opioid dependence

• Targets the major biologic factors perpetuating opioid addiction

• Steady-state opioid maintenance prevents withdrawal and relieves craving for opioids (cross-tolerance)

• Euphoric effects of heroin are blocked or attenuated (narcotic blockade)

Do

se R

esp

on

se

Time

“Loaded” “High”

Normal Range“Comfort Zone”

“Sick”

Impact of Heroin on an IndividualTolerant to Opioids

0 hrs. 24 hrs.

Subjective withdrawal

PAYTE: Opioid Maintenance Pharmacotherapy - A Course for Clinicians9

Methadone: An Effective Treatment for Opioid Dependency

- Reduces heroin use.

- Reduces relapse.

- Reduces rate of HIV

seroconversion.

- Reduces criminal activity.

- Improves employment.

- Improves physical and

mental health.

Do

se R

esp

on

se

Time

“Loaded” “High”

Normal Range“Comfort Zone”

“Sick”

Methadone Simulated 24 Hr. Dose/ResponseAt steady-state in tolerant patient

0 hrs. 24 hrs.

Subjective withdrawal

PAYTE: Opioid Maintenance Pharmacotherapy - A Course for Clinicians

11

12

Common Questions in Methadone Maintenance Treatment

How much methadone is enough?

How long should methadone treatment last?

Is the medication alone enough to improve treatment outcomes?

Methadone: Determining Doses

• Methadone dose affects therapeutic efficacy

• Considerable variability in treatment practices, including doses (D’Aunno, 1992)

• Higher doses have been associated with treatment retention and decreased use of illicit drugs

Methadone DosingStrain, 1993:

• 247 patients entering methadone maintenance

• 20 week randomized clinical trial

– weeks 0-5: all received active methadone

– weeks 6-20: one of three doses

Dose Urine toxicology (+) Retention

0 mg 74% 21%

20 mg 67% 41%

50 mg 56% 52%

Methadone DosingStrain, 1999:

• 40 week randomized clinical trial

• 192 patients entering methadone maintenance

– dose:

• moderate (40-50 mg) vs.

• high (80-100 mg)

– results (opioid-positive urine samples during maintenance):

• moderate: 62%

• high: 53% (p<.05)

Impact of Methadone Dosing on Heroin Use

Strain, 1999

Methadone Dosing Issues• How to decide the correct dose of methadone?

- prevent withdrawal and craving - provide cross-tolerance- reduce drug use- account for medication interactions- consider psychiatric and medical co-morbidity

• Patient preferences affect dosing: - stigma: “I’m not such a bad junkie.”- fears of withdrawal from methadone

Methadone Maintenance: Counseling and Supportive

Services Matter

• McLellan et al., 1993:–6-month randomized clinical trial

–three levels of psychological services• methadone alone

• methadone plus standard counseling services

• methadone plus enhanced services (counseling, medical/psychiatric, employment, and family therapy)

Methadone Alone is not Sufficient to Achieve Full Benefit: Counseling Matters

55%28%0%>16 consecutive

weeks of (-) urines

81%59%31%

Methadone + Enhanced Counseling

Methadone + Std.

CounselingMethadoneOutcome

Retention

Time in Treatment

• Longer treatment time associated with improved outcomes.

• No one right time

• “Indefinite”

• Limited capacity to predict who is likely to relapse

Buprenorphine: Another Option for Treating Opioid Dependence

• Available in primary care settings, not exclusively in drug treatment facilities.

• Partial agonist properties may affect its utility in some patients.

• Appears to have equivalent effectiveness as methadone in many patients.

• Not FDA-approved for treating pregnant women.

Issues for Opioid Dependent Pregnant Women

• Methadone maintenance therapy in combination with counseling, comprehensive services (including prenatal care):

–reduces the incidence of obstetric complications

– reduces neonatal morbidity and mortality (Finnegan, 1991)

Methadone Maintenance Treatment is Effective for Pregnant Women

Methadone Dosing During Pregnancy

• Patients receiving methadone maintenance therapy who become pregnant can be continued at established dose.

• Physiologic change during pregnancy can lead to increased methadone maintenance dose requirements, especially during 3rd trimester.

Implications for Newborns born to Methadone-Maintained Mothers

• Breast-feeding is not contraindicated, unless the mother is using illicit drugs or is infected with HIV.

• Methadone-exposed infants develop comparably to infants born in similar socioeconomic circumstances.

What about other drugs?

• Alcohol abuse and dependency

• Cocaine abuse and dependency

• Prescription drug misuse

Using toxicology reports

• Error rates

• What do the reports mean?

• Patterns of use/abuse

• Other signs

Client progress – ability to keep appointments

Motivation to treatment

Reports from other sources - collaboration

Comprehensive outpatient treatment services includes:

• Substance Abuse Counseling!!!• Primary medical care • Arrangements for concrete service needs (housing, food,

clothing)• Mental health services• Vocational services• Family counseling• Legal services• Interdisciplinary approach• Collaboration

Characteristics of Substance Abusing Families

• Studies of addicted women reveal:– Feelings of low self‑esteem

• Family histories of drug‑using parents reflect:– Disruption – Conflict/domestic violence/incest – Loss of parental figures – Lack of strong affectionate parent‑child bonds.– Addiction

– Post traumatic stress disorder– Anxiety– Depression– Guilt over affects on their children

• The childhood experiences of drug‑abusing women can be characterized by maternal deprivation, lack of supportive family networks, and maltreatment.

Services to families in addiction treatment

• Many approach parenthood with minimal bonding experience, unrealistic expectations and without having learned adequate parenting skills.

• Substance abuse is not only the problem of the individual but must be considered in the context of family.

• What can be done?

Treatment as prevention of foster care placement

• Family Counseling

• Parenting Skills classes

• Parent Support Groups

• Child Care Services

• Domestic Violence services

• Staff training

And in coordination with child welfare and dependency courts:

• Facilitation of case resolution

• Support for family reunification

• Effective intervention

What do treatment providers need to accomplish this?

• Confidentiality

• Collaboration and coordination

• Meeting the demands of multiple agencies

CASES FOR DISCUSSION

Risk of Leaving Treatment Relative to Dose

0 20 40 60 80 100

80 + mg

60-79 mg

< 60 mg(Baseline)

Adapted from Caplehorn & Bell - The Medical Journal of Australia

PAYTE: Opioid Maintenance Pharmacotherapy - A Course for Clinicians

35