Introduction to Medication Assisted Treatment Michael Dulitz, MPH,

Introduction to Medication Assisted Treatment Michael Dulitz, MPH,

Introduction to Medication Assisted Treatment Michael Dulitz, MPH, NRP Opioid Response Project Coordinator Foundation Addiction is a chronic relapsing brain disease characterized by compulsive use of a substance despite negative consequences Despite being a chronic disease, addiction is treatable, and individuals Addiction is more common than we see, 10%can of adults the criteria enter meet remission for a substance use disorder in their lifetime. Only 25% of those that

met the criteria for a use disorder ever received care. Addiction is a brain disease Stimulants Opioids Alcohol Dopamine Opioid receptor stimulation Substances that cause addiction primarily work on 2 receptor types Dopaminergic Opioid (primarily the mu receptor) Endorphins Neurotransmitters Reward/Dependence/

Loss of Control Substance Use Disorder/ Addiction Dopamine Opioids Endorphins (endogenous opioids) Exogenous (introduced from outside) Addiction is a brain disease When we do things that help us survive, we release neurotransmitters These neurotransmitters create a feeling of wellbeing and create trigger memory creation Receptors for these transmitters are located throughout the body, but

substance use disorders affect: Limbic system Dopamine/Endorphin model Life affirming activities produce a small spike of dopamine ~50% increase with eating ~100% increase with sex Dopamine levels between 50-100 pg/mL at baseline Substances spike this dopamine level Morphine ~300% increase Heroin ~1,000% increase Methamphetamine ~9001,000% increase Dopamine/Endorphin model

With chronic use, the brain adjusts to the new normal. Decreases baseline dopamine production Creates more dopamine receptors Result: brain needs more of the substance to generate the same response Life affirming activities do not create enough dopamine to trigger proper brain function, impulse control is also lost The individual will do whatever is needed to obtain the substance Dopamine/Endorphin model

With chronic use, objective eventually becomes to find enough of the substance to feel normal and avoid withdrawal When substance is not present, physical withdrawal occurs Memory Loss of memory cues Charlie Brown Effect Dopamine/Endorphin model Objectives of Agonist-based Medication Assisted Treatment for Opioid Use Disorder Return the brain to a normal baseline dopamine level Use long-acting medication to prevent spikes in dopamine Stop cravings for a substance

Allow the addressing of psychosocial needs Three FDA Approved Medications for OUD Methadone Full agonist Buprenorphine Partial agonist Naltrexone - Antagonist Dopamine/Endorphin model High dopamine recovery Individuals with strong recovery supports Highly motivated to enter treatment Predictable recovery path Most addiction treatment success data is from these groups

May do well with abstinence based treatment Low dopamine recovery Unmet psychological, social, or economic needs Unaddressed ACEs or other trauma Uncertain recovery supports Low treatment retention rates in traditional or abstinence based treatment Best candidates for Dopamine/Endorphin model Lack of

dopamine drives common behaviors seen in addiction Augmentation of dopamine is logical in a disease process related to dopamine deficiency We have FDA approved medications to safely increase dopamine

This allows cravings to be stabilized Allowing for behavioral therapy to be effective Methadone Full opioid receptor activation Treatment goal: Activate the opioid receptors to the point that the individual does not experience opioid cravings, is not in withdrawal, and is not experiencing euphoria. Duration of action: 1-2 days Can only be provided through Opioid Treatment Programs (OTPs) Closest in Fargo (3-4 people drive daily from Grand Forks)

Must dose in person and earn privileges Prevents diversion Liquid form used almost exclusively Methadone Oldest and most studied medication for opioid addiction. Ideal candidates: Individuals with exceptionally high opioid use histories Individuals with treatment retention difficulties Individuals who were unable to tolerate buprenorphine treatment Large barriers to treatment in Grand Forks due to a lack of OTPs Dose Response Methadone

Loaded High Abnormal Normality Normal Range Comfort Zone Subjective withdrawal Sick Objective withdrawal 0 hrs. Time 24 hrs. Buprenorphine Partial receptor activator Treatment goal: Activate the opioid receptors to the point that the individual does not experience opioid cravings and is not in

withdrawal. Duration of Action: ~24 hours Sublingual tablet, dissolves in 10-20 minutes, onset of action in 30 minutes Very high affinity for receptor sites Will kick most existing opioids off their receptor -> Precipitated withdrawal Buprenorphine Oftentimes combined with naloxone to prevent injection use Common Forms: Subutex (buprenorphine) sublingual tablet - > Pregnant women Suboxone (buprenorphine/naloxone) sublingual film - > Most Common Zubsolv

(buprenorphine/naloxone) sublingual tablet - > NDMA Sublocade (buprenorphine) extended release injection - > New to market, $$$$ Buprenorphine Only DATA 2000 Waivered prescribers can prescribe this medication Treatment initiation Must be started when in mild withdrawal generally 8-16 hours from last opioid use Initial dose typically 4-8mg, up to 16mg 3-4 day follow up, then titrate dose up Optimal maintenance dose 8-24mg Treatment course Individually designed taper 6

months lifetime Naltrexone Full receptor antagonist, reverses and caps the opioid receptor Structurally similar to naloxone Treatment goal: Remove the ability to use a substance by removing the euphoric effects of taking the substance FDA approved for opioid addiction and alcohol addiction Available as a oral tablet and as an extended release injectable (Vivitrol) Oral form is cheap, but has low treatment compliance Naltrexone In one major study, extended release naltrexone is similar to

buprenorphine or methadone in treatment retention BUT: Fewer received the first dose of Naltrexone (failed before initiating study) 7-10 day opioid free period required Relapse more likely in intention to treat analysis More overdoses, fewer fatal overdoses though Less treatment retention after study period Naltrexone Ideal candidates for extended release naltrexone Individuals who are highly motivated and well supported in their recovery Safety net Individuals who continue to work in professions which prohibit the use of other MAT medications Airline pilots/Physicians

Individuals who have already gone through a opioid detoxification period and/or are opposed to opioid agonist therapy Individuals with alcohol use disorder Naltrexone Dopamine and naltrexone Naltrexone does not assist in returning the body to its baseline dopamine level normal feeling Opioid cravings may persist despite inability to use opioids for euphoria Naltrexone inhibits endorphins from acting in the body resulting in a dull affect Depression Bottom line Vivitrol has definite value for select clients, but is not the nobrainer it seems at face value,

though for some it is the best solution Alkermes heavily markets Vivitrol to abstinence based providers, jails, drug Nicotine use disorder Medication assisted treatment readily available for nicotine use disorder Nicotine replacement Provides a baseline level of nicotine to prevent cravings and withdrawal Allows the individual to address the factors that lead to smoking and reprogram behaviors associated with smoking Other medications Chantix (varenicline) Wellbutrin (buproprion) Individuals are more successful in

recovery when they quit smoking at the same time Treatment Addiction is a complex but treatable disease that affects brain function and behavior. Treatment needs to be readily available and attend to the multiple needs of the individual. No single treatment is appropriate for everyone. Group-based peer support Treatment philosophies vary! Narcotics Anonymous (NA) /AA SMART Recovery Non 12-step Faith-centered Recovery housing Peer Counseling ASAM criteria guide level of care Outpatient (<9 hrs/week) High-Intensity Outpatient (9-20 hrs/week) Partial hospitalization (20-40 hrs/week) Residential Treatment (Clinically or Medically

Managed) Intensive Inpatient (24-hour nursing and physician care) Individual-based peer support Employer supported Face It TOGETHER Re-entry programs Free Through Recovery Program supported Human Service Support Agencies Peer to peer Medication Assisted Treatment Methadone Mu Opioid Agonist Buprenorphine Partial Mu Opioid Agonist Suboxone/Zubsolv (Sublingual)

Sublocade (28 day injectable) Naltrexone Mu Opioid Antagonist Vivitrol (28 day injectable) How do we properly treat addiction? Assess severity of the substance use disorder Control over substance use How substance use affects your life Symptoms of physical dependence ASAM guidelines Level 0.5 At Risk Level 1 Mild SUD Level 2 Moderate SUD Level 3 Severe SUD Severity and level helps to

How do we properly treat addiction? The more severe the disorder, the more intense level of treatment is needed Start at the level corresponding to need Level Level Level Level 3 Residential or inpatient 2 Intensive outpatient 1 Outpatient services 0.5 Early intervention

More treatment isnt better treatment if it doesnt match the patients need Most of this treatment is available Opioid Response in Grand Forks Empowering the Individual | Eliminating Barriers | Enabling Recovery Treatment Addiction is a complex but treatable disease that affects brain function and behavior. Treatment needs to be readily available and attend to the multiple needs of the individual. No single treatment is appropriate for everyone. F5 Project Face It TOGETHER Assist reentry and provide peer support for individuals involved in the

criminal justice system $10,000 Peer Support Counseling Agassiz Associates Provide treatment services to inmates at Grand Forks County Correctional Center $29,000 Build peer support capacity using their sustainable peer support model $29,000 Medication Assisted Treatment

Valley Community Health Centers Increase access to medication assisted treatment $79,000 Future concerns Questions? Opioid Overdoses Monthly Average Opioid Overdoses 2014 22 1.8 2015 27 2.3

2016 63 5.3 2017 53 4.4 2018 30 2.5 Months without a reported Opioid Overdose 2 1 0 0


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