Putting the Pieces Together Perspectives from an Opioid Addiction Treatment Program
Dec 15, 2015
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
Medical Model
• Disease
• Neurological processes
• Other systems affected
• Impact on behaviors
• Long term neurological implications
• Benefits of medication-assisted treatment
GOALS OF TREATMENT:
Retention in treatment
Reduction in drug use
Prevention of relapse
Restoration of quality of life
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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
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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)
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.
• 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