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Medication-Assisted Treatment (MAT) for Criminal Justice Populations. [Insert trainer Name and affiliation information here]. Goals of Today’s Training. After this training, you will be familiar with: Addiction and how it affects the brain dopamine and the reward pathway Medications

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medication assisted treatment mat for criminal justice populations

Medication-Assisted Treatment (MAT) for Criminal Justice Populations

[Insert trainer Name and affiliation information here]

goals of today s training
Goals of Today’s Training

After this training, you will be familiar with:

  • Addiction
    • and how it affects the brain
    • dopamine and the reward pathway
  • Medications
    • for addiction treatment
    • how they work & what they do
  • Benefits
    • of addiction treatment to the CJ System
  • Logistics
    • of referring an offender
    • types of clients to look for
    • agencies where MAT is offered
an open conversation about mat
An Open Conversation about MAT
  • Using medication to treat addiction is a good idea because...
  • Using medication in addiction treatment is a not-so-good idea because…
  • I refer clients to addiction treatment because…
an open conversation about mat4
An Open Conversation About MAT

Concerns about MAT?

  • The medications?
    • Methadone
    • Diversion
  • The clinics?
    • “Bad” methadone clinics
    • Attracting dealers and crime
    • Therapeutic communities don’t allow MAT
mat myth busters myth 1
MAT Myth Busters: Myth #1

“Medication is not a part of treatment.”

  • Medication can be an effective part of treatment.
  • Medication is used in the treatment of many diseases, including addiction.
  • Medical decisions must be made by trained and certified medical providers.
  • Decisions about using medications are based on an objective assessment of the individual client’s needs.
slide6
MAT Myth Busters:Myth #2

“Medicines are drugs, too.”

Errors in Language:

Physical Dependence vs Addiction

Drugs are used to get high, but medications are used to get better.

Medicine (n.) an innovation of the human species which has given us a competitive advantage for thousands of years; innovations in science & medicine have historically been helpful and progressive.

slide7
MAT Myth Busters:Myth #3

“Alcoholics Anonymous (AA) & Narcotics Anonymous (NA) do not support the use of medications.”

While some specific NA chapters

are not tolerant of methadone,

AA/NA literature and founding members did not speak or write against using medications.

the clinician s illusion after cohen cohen arch gen psych 1984
The Clinician’s IllusionAfter Cohen & Cohen Arch Gen Psych 1984

MAT Myth Busters:Myth #4

“MAT is not effective.”

  • MAT medications had to demonstrate the same level of effectiveness as all other types of medications for other diseases to get FDA approval.
  • We tend to have a biased perception:
    • Patients who improve, leave and are forgotten
    • Patients who do not improve return frequently and are remembered
      • Leads us to think that most patients do not improve

…contrary to scientific data.

slide9
MAT Myth Busters:Myth #5

“Clients who are not using drugs at present do not need MAT.”

Reasons include:

  • peer pressure
  • familial pressure
  • tensions of daily life
  • few job opportunities
  • lack of safe housing

More than half of inmates

will relapse

within one month of release.

  • isolation
  • disillusionment & apathy
  • the stress of complying with correctional supervision
slide10
Should abstinent clients

be omitted from MAT?

As you may already know,

a client who is abstinent now

may not remain so forever.

Addictionis not a common cold,

so,

itmust not be treated like one.

WHY?

addiction is
Addiction is…

A CHRONIC DISEASE

the brain hijacked
The Brain: Hijacked!

The Science Behind Addiction

slide13
Can the brain get hijacked?

Researchshows…

that prolonged drug use can

change brain chemistry.

first let s take a look at opioid addiction
First, let’s take a look atOpioid Addiction

Some Examples:

  • Morphine
  • Heroin
  • Codeine
slide16
How can the brain get hijacked by opioids?

Opioid use…

disrupts normal Dopamine functioning.

slide18
What Is Dopamine?

A hormone

A neurotransmitter

Working Normally, it produces feelings of pleasure and is involved in decision making.

Working Abnormally, leads to cravings, depression, difficulties with decision making and memory problems.

slide19
Abnormal Dopamine Functioning

COCAINE

AMPHETAMINE

Accumbens

1100

Accumbens

400

1000

900

DA

800

DA

300

DOPAC

700

DOPAC

% of Basal Release

HVA

HVA

600

% of Basal Release

500

200

400

300

100

200

100

0

0

0

1

2

3

4

5 hr

Time After Amphetamine

Time After Cocaine

250

NICOTINE

ALCOHOL

250

Accumbens

Dose (g/kg ip)

200

Accumbens

200

Caudate

0.25

0.5

150

% of Basal Release

1

2.5

% of Basal Release

150

100

0

2

3 hr

1

0

1

2

3

4

5 hr

100

0

0

0

1

2

3

4hr

Time After Nicotine

Time After Ethanol

slide20
Abnormal Dopamine Functioning

More

Cocaine

Activity of Reward System

METH

controls

treated

Alcohol

Less

Food

slide21
The good news is…

OpioidAddictionisatreatabledisease.

Courtesy of Partnership for a Drug Free America.

how can we treat opioid addiction
How can we treat opioid addiction?

The person must learn new ways of coping

and

The brain changes must be addressed

slide23
We know of 3 ways:

1. Avoid the drug

…using coping strategies

2. Replace associations …using therapy

3. Directly addressingthe neural effects of the drug …using medication

how do medications for opioid addiction work
How do medications for opioid addiction work?

There are three types of medications that can block the “high”:

Agonists

- produce opioid effects

Partial Agonists

- produce moderate opioid effects

Antagonists

- block opioid effects

slide26
Full Agonist

(e.g., methadone)

Partial Agonist

(e.g. buprenorphine)

Antagonist

(e.g. Naloxone)

How do medications for opioid addiction work?

Opioid

Effect

Dose of Opioid

example of a cj client who could benefit from mat for opioids
Example of a CJ client who could benefit from MAT for opioids

Male heroin addict, mid-30’s

Also does speedballs (heroin and cocaine) during robberies

Early CJ involvement

Early cigarette and AOD use

Repeated arrests and incarcerations

Treatment failures

Daily criminal activity to support his habit

example of a cj client who could benefit from mat for opioids28
Example of a CJ client who could benefit from MAT for opioids

Female heroin addict, mid-30s

Early cigarette and AOD use

Mental health problems & trauma

Has children in kin foster care

Repeated arrest history mostly related to prostitution and shop lifting

Non-medication treatment failures

Extensive involvement with child protective services

Recent relapse and incarceration after year of abstinence

Strong desire to stop using and get kids back

example of a cj client who could benefit from mat for opioids29
Pregnant woman

Shoots heroin daily

Failed treatments

Repeated arrest history mostly related to prostitution and shop lifting

Example of a CJ client who could benefit from MAT for opioids
how can the brain get hijacked by alcohol addiction
How can the brain get hijacked byAlcohol Addiction?

endogenous opioids

make you euphoric and feel no pain

glutamate

excitatory neurotransmitter…speeds you up

GABA

inhibitory neurotransmitter…slows you down

dopamine makes you happy

The Cast

alcohol in the brain
Alcohol in the Brain

First, alcohol is consumed

Second, endogenous opioids are released

Third, dopamine is released

slide33
The brain remembers the good feelings produced by endogenous opioids and dopamine in the reward pathway, and then desires to repeat the behavior to get the same good feelings.

Thus, the reward pathway is out of balance!

at the same time
At the same time…

An imbalance in the brain is created

-as GABA is increased

So, the brain slows down

-as glutamate is over-ridden by GABA

And in response, the brain up-regulates

  • -as the brain tries to correct for the imbalanceby increasing sensitivity to glutamate
slide35
As the brain desired, the up-regulation works, and the imbalance is corrected.

Now, if the individual drinks, it takes more alcohol to override the glutamate system again and feel the same level of intoxication.

This effect is knownas

Tolerance.

slide36
With an unbalanced reward pathway

and an increasingly high tolerance…

The person is

developing

symptoms of

ADDICTION.

slide37
The good news is…

Alcoholaddictionisatreatabledisease.

Courtesy of Partnership for a Drug Free America.

how can we treat alcohol addiction
How can we treat Alcohol Addiction?

Medications for alcoholism can:

Reduce post-acute withdrawal

Block or ease euphoria from alcohol

Discourage drinking by creating an unpleasant association with alcohol

example cj client who could benefit from mat for alcoholism
Example CJ client who could benefit from MAT for alcoholism

Male alcoholic, mid-40s

Early cigarette and alcohol use

History of DUIs and violence

Intimate partner violence

Treatment failure

Strongly desires help

example of a cj client who could benefit from mat for alcoholism
Example of a CJ client who could benefit from MAT for alcoholism
  • Female, mid-30’s
  • Arrested for 4th DUI
  • 3 previous treatment episodes each with about 1 year of abstinence afterword
  • Has been trying to get pregnant for about a year.
  • Wants to stay away from alcohol for the baby, but is frequently relapsing
the medications

The Medications

For Opioid Addiction:

Methadone

Buprenorphine

Naltrexone

  • For Alcohol Addiction:
  • Naltrexone
  • Acamprosate
  • Disulfiram
the medications42

The Medications

For Opioid Addiction:

Methadone

Buprenorphine

Naltrexone

Methadone

  • For Alcohol Addiction:
  • Naltrexone
  • Acamprosate
  • Disulfiram
methadone
Methadone

-Alleviates withdrawal & blocks euphoria.

-Is used for detoxification or maintenance.

-Also known as:

-Methadose

-Dolophine

-Approved: 1964

-Third-Party Payer Acceptance: Covered by most major insurance carriers, Medicare, Medicaid and the VA.

slide44
Full Agonist

(e.g., methadone)

Partial Agonist

(e.g. buprenorphine)

Antagonist

(e.g. Naloxone)

How does Methadone Work?

Full Agonist

Opioid

Effect

Dose of Opioid

slide45
What does the research say?

Methadone is the most studied

medication for opioid addiction.

  • 8-10 fold reduction in death rate
  • Reduces opioid use
  • Reduces crime
  • Improves family and social functioning
  • Increases likelihood of employment
  • Improves physical and mental health
  • Reduces spread of HIV
  • Low drop-out rate compared to other treatments
high rate of relapse to iv drug use after drop out from methadone treatment
High Rate of Relapse to IV drug use after drop-out from Methadone Treatment

Percent IV Users

Treatment Months Since Stopping Treatment

the medications48

The Medications

For Opiate Addiction:

Methadone

Buprenorphine

Naltrexone

Buprenorphine

  • For Alcohol Addiction:
  • Naltrexone
  • Acamprosate
  • Disulfiram
buprenorphine
Buprenorphine

Available by prescription outside of Methadone Treatment Programs

Only physicians with special training and waiver can prescribe

Also known as:

Subutex®

Suboxone® (buprenorphine/naloxone)

FDA-approved: 2002

buprenorphine naloxone the combo tablet
Buprenorphine/Naloxone “the Combo Tablet”

Preserves bupe’s effects when taken sublingually at optimal ratio

Action, safety & efficacy same as bupe alone

Also contains Naloxone (same as Narcan used to reverse OD) - inert unless injected

Discourages IV use, diversion

Allows for take-home dosing

Dysphoric effects if injected by physically dependent persons

slide51
How Does Buprenorphine Work?

Full Agonist

(e.g., methadone)

Partial Agonist

(e.g. buprenorphine)

Antagonist

(e.g. Naloxone)

Partial Agonist

Opiate

Effect

Dose of Opiate

how does buprenorphine work
How Does Buprenorphine Work?

It’s a Partial Agonist.

Agonist effect helps the patient to feel normal, without craving or withdrawal

Binds strongly to opiate receptor

Blocks opiate effects

Ceiling effect at higher doses

Safer than methadone or other full agonists

some advantages of buprenorphine
Some Advantages of Buprenorphine

Available through a physician office or non-methadone clinic

Easier to keep job, participate in other activities

Lower level of physical dependence

Limited potential for overdose

Minimal subjective effects (e.g., sedation)

some disadvantages of buprenorphine
Some Disadvantages of Buprenorphine
  • Greater medication cost
  • Lower level of physical dependence
      • -i.e., patients can discontinue treatment
  • Not detectable in most urine toxicology screenings
what does the research say
What does the research say?

Over 25 years of research and over 5,000 patients exposed during clinical trials, show that

Buprenorphine is a safe and effective treatment for opioid addiction.

what does the research say56
What does the research say?

-Buprenorphine is about as effective as 60 mg daily of methadone.

-In one study,after a year of bupe plus counseling,

75% of patients were retained,

compared to 0% in a placebo plus counseling condition.

the medications57

The Medications

For Opiate Addiction:

Methadone

Buprenorphine

Naltrexone

Naltrexone

  • For Alcohol Addiction:
  • Naltrexone
  • Acamprosate
  • Disulfiram
naltrexone
Naltrexone

*Used to treat opiateandalcohol addiction.

Trade Names/Formulations

Depade oral tablets

ReVia oral tablets

Vivitrol Extended-release naltrexone

naltrexone59
Naltrexone

Addictive Properties: Not addictive and no withdrawal symptoms.

Oral formulations:

Cost: $110.68 per month, which is around $3.69 a day.69

Third-Party Payer Acceptance: Covered by most major insurance carriers, Medicare, Medicaid, and the VA.68

Long-acting injectable formulation:

Cost: $866.46 per month, which is around $28.88 per day (injectors fee not included).

Third-Party Payer Acceptance: Approximately 90% of patients thus far have received insurance coverage with no restrictions. In addition, extended-release naltrexone now has a J code for payors.

slide60
Full Agonist

(e.g., methadone)

Partial Agonist

(e.g. buprenorphine)

Antagonist

(e.g. Naloxone)

How Does Naltrexone Work?

Antagonist

Opiate

Effect

Dose of Opiate

how does naltrexone work
How Does Naltrexone Work?

N

= naltrexone

It’s an antagonist.

= opioids

N

  • It blocks opioid receptors,
  • the reinforcing “reward” effects from dopamine are reduced,
  • drug consumption is thus reduced.

N

N

N

Post-Synaptic Neuron

N

Opioid

Receptor

N

N

N

what does the research say62
What does the research say?

Naltrexone is effective for opiate and alcohol addiction.

Reduces risk of re-imprisonment

Lowers risk of opiate use, with or without psychological support

Extended-release naltrexone addresses the issue of patient compliance

what does the research say63
What does the research say?
  • Naltrexone for opiates was well tolerated and associated with a significant abstinence rate.
  • In a five-year follow up study, naltrexone with behavioral therapy for opiates saw improvements in drug use, days of depressant use, legal status, and psychiatric factor.
the medications64

The Medications

For Opiate Addiction:

Methadone

Buprenorphine

Naltrexone

Naltrexone

  • For Alcohol Addiction:
  • Naltrexone
  • Acamprosate
  • Disulfiram
slide65
In two studies, participants treated with naltrexone had a greater reduction in relapse during the entire study than those treated with placebo.

What does the research say?

Reduction in Relapse -

Volpicelli et al. Study*

54%

60%

Percentage

50%

of

40%

23%

Participants

Who

30%

Relapsed

20%

During the

Study

10%

0%

naltrexone group

placebo group

* statistically significant

Percentage of participants who relapsed during the study

slide66
Participants treated with extended-release naltrexone had a greater reduction in the number of heavy drinking daysduring the entire study than those treated with placebo.

What does the research say?

* statistically significant

the medications67

The Medications

For Opiate Addiction:

Methadone

Buprenorphine

Naltrexone

Acamprosate

  • For Alcohol Addiction:
  • Naltrexone
  • Acamprosate
  • Disulfram
acamprosate
Acamprosate

Reduces post-acute alcohol withdrawal symptoms.

Is used for maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation.

Addictive Properties: Not addictive and no reports of misuse

Also Known As: Campral

FDA-Approval: 2004

Cost: $135.90 per month, which is around $4.53 a day.46

Third-Party Payer Acceptance: Patient Assistance Program through Forest Laboratories, Inc.; covered by most major insurance carriers; covered by Medicare, Medicaid, and the VA (if naltrexone is contraindicated).

how does acamprosate work
How Does Acamprosate Work?

Acamprosate modulates the amount of glutamate released from the neuron

Pre-Synaptic Neuron

Post-Synaptic Neuron

= Glutamate

glutamate

receptors

= acamprosate

what does the research say70
What does the research say?

In three studies, participants treated with acamprosate were able to maintain complete abstinence more frequently than those treated with placebo

Complete Abstinence

38%

40%

35%

Percentage of participants who consumed no alcohol during the entire study

28%

30%

25%

16%

20%

acamprosate

13%

13%

15%

placebo

9%

10%

Study

5%

0%

13-Week

48-Week

52-Week

* statistically significant

Study (Pelc)*

Study (Sass)*

Study

(Paille)*

slide71
In three studies, participants treated with acamprosate had a greater reduction in the number of drinking days during the entire study than those treated with placebo.

What does the research say?

Reduction in Drinking Days

85%

90%

74%

80%

67%

67%

70%

60%

50%

Percentage of days abstinent

38%

acamprosate

40%

29%

placebo

30%

20%

10%

0%

13-Week

48-Week

52-Week

* statistically significant

Study (Pelc)*

Study (Sass)*

Study

(Paille)*

slide72
In three studies, participants treated with acamprosate were able to regain complete abstinence after one relapse more frequently than those treated with placebo.

What does the research say?

Regained Complete Abstinence

after First Relapse

18%

18%

16%

Percentage of participants who regained complete abstinence

14%

11%

11%

12%

8%

10%

7%

8%

acamprosate

placebo

6%

3%

4%

Relapse

2%

0%

13-Week

48-Week

52-Week

* statistically significant

Study (Pelc)*

Study

Study

(Sass)*

(Paille)*

the medications73

The Medications

For Opiate Addiction:

Methadone

Buprenorphine

Naltrexone

Disulfiram

  • For Alcohol Addiction:
  • Naltrexone
  • Acamprosate
  • Disulfram
disulfiram
Disulfiram

Makes the patient physically sick when alcohol is consumed

Is used to aid in the management of selected chronic alcohol patients who want to remain in a state of enforced sobriety.

Addictive Properties: No abuse or withdrawal

Also Known As:Antabuse

FDA-Approval:1951

Cost: $57.59 per month, which is around $1.92 a day.62

Third-Party Payer Acceptance: Covered by most major insurance carriers, Medicare, Medicaid, and the VA.61

Best for supervised and/or highly motivated patients:

eg. Family member willing to observe dosing.

how does disulfiram work
How Does Disulfiram Work?
  • If alcohol is consumed,Acetaldehyde accumulates in the blood 5 to 10 times higher than normal. This produces the
  • Disulfiram-Alcohol Reaction:
  • throbbing in head/neck
  • brief loss of consciousness
  • throbbing headache
  • lowered blood pressure
  • difficulty breathing
  • marked uneasiness
  • copious vomiting
  • nausea
  • flushing
  • sweating
  • thirst
  • weakness
  • chest pain
  • dizziness
  • palpitation
  • hyperventilation
  • rapid heartbeat
  • blurred vision
  • confusion
  • respiratory depression
  • cardiovascular collapse
  • myocardial infarction
  • congestive heart failure
  • unconsciousness
  • convulsions
  • death
what does the research say76
What does the research say?

Participants treated with disulfiram had a greater reduction in the number of drinking days during the entire study than those treated with placebo.

Reduction in Drinking Days -

Fuller et al. Study*

86.5

90.0

75.4

80.0

70.0

Average

49.0

60.0

Total

Drinking

50.0

Days

40.0

During the

30.0

Entire Study

20.0

10.0

0.0

250mg of

1mg of

placebo

disulfiram

disulfiram

Study

* statistically significant

benefits to the cj system include
Benefits to the CJ System Include:

public safety

public health

effectiveness

of Probation & Parole

rate of opiate overdose

recidivism

public and DOC Costs

increased public safety substance related v iolence
Increased Public SafetySubstance-Related Violence

Alcohol use associated with violence

Men drinking in 45% of cases

Women drinking in 20% of cases

Two-thirds of victims of intimate partner violence reported that alcohol involved in the incident

Alcohol intoxication is strongly related to offenses that involve personal confrontation

Homicide, physical assault, sexual assault, and robbery

Alcohol availability related to violent assault

Communities and neighborhoods that have more bars and liquor stores per capita experience more assaults

Drug-related violence is a major cause of death among ex-offenders

longer time in mat decreases crime days
Longer Time in MAT Decreases Crime-Days

Increased Public Safety

Mean Crime-Days per yr.

slide81
Effect of MAT on Parole & Probation

An additional tool for repeat offenders

  • Increased retention and effectiveness of community addiction treatment
  • Decreased recurrent drug use
  • Decreased behavioral problems and crime
  • Decreased violations and arrests
  • Decreased P&P workload & hassles
increased public health
Drug abuse treatment is
  • HIV and HCV prevention!
    • Drug injectors who do not enter treatment are up to 6x more likely to become infected with HIV than injectors who enter and remain in treatment
    • Treatment reduces associated risk behaviors such as sharing injection equipment and unprotected sex
    • Treatment provides opportunities for screening, counseling, and referral to additional services, including early HIV treatment

Increased Public Health

slide83
Lower rates of opiate Overdose

“Sentenced to death…afterrelease!”

“RR”= Risk Ratio

RR=12

RR=4

RR=3.2

Binswanger IA et al. N Engl J Med 2007;356:157-165

slide84
Causes of Death among Releasees

Adjusted for Age, Sex, and Race

Prison detox

  • decreased tolerance
  • increased risk of overdose

Binswanger IA et al. N Engl J Med 2007;356:157-165

decreased recidivism

Decreased Recidivism

Recurrent substance abuse contributes to high recidivism rates.

As mentioned earlier:

>50% will relapse…

within one month of release.

decreased public costs
Every $1 spent on addiction treatment saves $4 to $7 from reduced costs of drugs, crime & punishment

For some outpatient programs, savings exceed costs by 12:1.

Reduced costs include:

Decreased Public Costs

The National Institutes of Health (1997) estimated the cost of opiate dependence to individuals, families, and society to be approximately$20 billion per year.

  • violent and property crimes
  • prison expenses
  • court and criminal costs
  • emergency room visits
  • child abuse and neglect
  • lost child support
  • foster care and welfare costs
  • reduced productivity
  • unemployment
  • victimization
slide87
Effect of MAT on DOC Budget

Reduces number of addicts going through repeated arrest-incarceration-release cycles

  • Increases retention and effectiveness of community addiction treatment
  • Decreases recurrent drug use
  • Decreases drug-related crime
  • Decreases addicted persons violated or arrested
  • Increases community time between relapses
  • Decreases incarceration costs
slide88
So, what does MAT offer to the Criminal Justice System?

MAT strengthens the efficacy of the Criminal Justice System.How?By enriching the CJ System with an evidence-based practice that addresses one of its root problems,Addiction.

slide89
Goodtreatmentis holistic, integrated and multifaceted, taking into account theindividual’s

physical, behavioral, andspiritual well-being.

Medication:

-should be used incombination withbehavioraltreatment, as stated on FDA labeling.

-can help with brainchemistry…

the rest is up tous.

*Note

you might be wondering who is a good candidate to refer

You might be wondering…-WHO is a good candidate to refer?

Consider:

History of substance abuse

Willingness to consider MAT

-WHERE is MAT typically offered?

  • Which local agencies?
  • What happens after you make a referral?
slide91
For more information, contact:

[Insert trainer Name here]

[Insert trainer email and/or phone number here]

[Insert trainer website here]

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