Putting the Pieces Together

1. Putting the Pieces Together Perspectives from an Opioid Addiction Treatment Program

2. 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.

3. 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

4. Theories of Addiction Medical Psychological Environmental Moral

5. Medical Model • Disease • Neurological processes • Other systems affected • Impact on behaviors • Long term neurological implications • Benefits of medication-assisted treatment

6. BASICS OF MEDICATION-ASSISTED THERAPY FOR OPIOID DEPENDENCE

7. GOALS OF TREATMENT: Retention in treatment Reduction in drug use Prevention of relapse Restoration of quality of life 7

8. 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)

9. Impact of Heroin on an IndividualTolerant to Opioids “Loaded” “High” Normal Range“Comfort Zone” Dose Response Subjective withdrawal “Sick” Time 0 hrs. 24 hrs. 9 PAYTE: Opioid Maintenance Pharmacotherapy - A Course for Clinicians

10. 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.

11. Methadone Simulated 24 Hr. Dose/ResponseAt steady-state in tolerant patient “Loaded” “High” Normal Range“Comfort Zone” Dose Response Subjective withdrawal “Sick” Time 0 hrs. 24 hrs. 11 PAYTE: Opioid Maintenance Pharmacotherapy - A Course for Clinicians

12. Common Questions in Methadone Maintenance Treatment How much methadone is enough? Is the medication alone enough to improve treatment outcomes? How long should methadone treatment last? 12

13. 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

14. Methadone Dosing Strain, 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%

15. Methadone Dosing Strain, 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)

16. Impact of Methadone Dosing on Heroin Use Strain, 1999

17. 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

18. 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)

19. Outcome Methadone Methadone + Std. Counseling Methadone + Enhanced Counseling 31% 59% 81% >16 consecutive weeks of (-) urines 0% 28% 55% Methadone Alone is not Sufficient to Achieve Full Benefit: Counseling Matters Retention

20. Time in Treatment • Longer treatment time associated with improved outcomes. • No one right time • “Indefinite” • Limited capacity to predict who is likely to relapse

21. 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.

22. Issues for Opioid Dependent Pregnant Women

23. Methadone Maintenance Treatment is Effective for 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)

24. 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.

25. 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.

26. What about other drugs? • Alcohol abuse and dependency • Cocaine abuse and dependency • Prescription drug misuse

27. 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

28. 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

29. 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.

30. 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?

31. Treatment as prevention of foster care placement • Family Counseling • Parenting Skills classes • Parent Support Groups • Child Care Services • Domestic Violence services • Staff training

32. And in coordination with child welfare and dependency courts: • Facilitation of case resolution • Support for family reunification • Effective intervention

33. What do treatment providers need to accomplish this? • Confidentiality • Collaboration and coordination • Meeting the demands of multiple agencies

34. CASES FOR DISCUSSION

35. Risk of Leaving Treatment Relative to Dose 80 + mg 60-79 mg < 60 mg(Baseline) Adapted from Caplehorn & Bell - The Medical Journal of Australia 35 PAYTE: Opioid Maintenance Pharmacotherapy - A Course for Clinicians