17 greico addictionmed - ucsf cme€¦ · •no history of methadone maintenance –interferes with...
TRANSCRIPT
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DangerousFantasyorRisingStar?ReviewofNaltrexoneforopiate,alcohol,and
stimulantusedisorders.
Katherine Grieco, DOChief of Addiction Medicine St. Elizabeth’s Medical CenterAssistant Clinical Professor, Tufts University School of Medicine 12/17
Ihavenothingtodisclose
Outline
• Briefupdateonopioidepidemic– Currentfentanylstatistics– NewNarcan efficacydata
• Emergingnon-narcoticRxdrugsofabuse• Naltrexone
• opiateuse• EtOH use• methamphetamineuse
PresidentTrump’s Commission onCombatingtheOpioidEpidemic
11/1/17
• Drugcourtsinallfederaljudicialdistricts
• Streamlinefederalfundingopportunities
• Changestoreimbursementratessetbyfederaladdictiontreatmentproviders
• AllowmoreEMSresponderstoadministernaloxone
• Tightenrequirementsforprescribers
• Eliminatingpatientpainevaluationsfromsurveys- CMS
• Stepstoensureparity• Betterdataonoverdosedeaths• Bolsteringresearchmoney
Positive feedback from various professional organizations; attacking issue at all angles.
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CDC:Fentanyl Deathsin2016:Up540%in3Years(provisionaldata)
20002015
Increase in deaths from Cocaine & meth use (often involve opiates)
Deaths involving synthetic opioids, mostly fentanyl, jumped from 3,000 to 20,000 in 3 yrs.
ProfitforTraffickers• 1kilogramofFentanylcosts$2,000-$3000
(vs1kgheroin$90,000)
Cutting supply does not stop addiction.
US Customs and Border Protection: Currently seizing pill presses at a rate 19 times higher than in 2011.
Port of Long Beach, California
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Question:Canyouspotthefake??
A. B.
Courtesy of California Poison Control, San Francisco DivisionHydrocodone vs fentanyl/promethazine/cocaine
Fentanyl- California• Overdoses,deathsverylowinCA• 6/10/17:SanYsidroportofentry,U.S.CustomsandBorderProtectionofficialsmadeafentanylseizurethatsetarecordfortheU.S.-Mexicoborder.
• 6/19/17:oneofthenation’slargestfentanylseizuresinLemonGrove,SanDiego
NarcanEfficacyStudy• AmericanCollegeofEmergencyPhysiciansConf,10/30/17
– B&WHospital,S.Weiner• MassachusettsDepartmentofHealth
– ambulance,hospital,anddeathrecords– 12,192peopleadministerednaloxonebyEMS;7/1/13thru12/31/15
• 93%survivedtheoverdose– 6.5%diedthedaytheyreceivedthemedication.
• Ofthosewhosurvived,9.9%diedwithinayear.– Medianagewas54.
• Ofthosewhodied,40%didsooutsideofthehospitalandmorethanhalfpassedawayinthefirstmonth.
• “Youhavea1in10chanceofdyingifwedon’tgetyouintotreatment.”
OtherRxDrugsofAbuse/Cocktails
• Gabapentin– nextslide• Pregabalin
• Controlledsubstance,ScheduleV• Clonidine
– SimilartoBZDhigh• Promethazine
– Oftenusedinconjunctionw/opiatesforeuphoria• Loperamide
– Highdosescancauseeuphoria– Serioussideeffects
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Gabapentin
• Controlledsubstance,scheduleV– Kentuckyisthefirststate– SeveralstatesnowreportonPMP– 9/17:2nd mostcommonlyprescribedpainmedication.
• Gabapentin,opioids,andtheriskofopioid-relateddeath:Apopulation-basednestedcase-controlstudy- TGomesetal,PLoS 10/3/2017
– Canada,1997– 2013– Casesdefinedasopioiduserswhodiedofanopioid-relatedcause
• Concomitantgabapentinandopioidexposure– associatedwitha49%higherriskofdyingfromanopioidoverdose– Seenw/moderate(900- 1,799mgdaily)andhigh(>1,800mgdaily)gabapentindoses
Naltrexone
Question• WhichofthefollowingstatementsisTRUEaboutnaltrexone?a)FDAapprovedforbothalcohol&opioidusedisorders.b)FDAapprovedforalcohol&opioidusedisorder,andmostrecentlystimulantusedisorder(crystalmeth).
c)FDAapprovedforalcoholusedisorder,butnotforopiateusedisorder.
d)Therearerobuststudiesshowingefficacyofnaltrexoneinalcohol,opiates,andcrystalmethuse.
CaseStudy• 28yo malewithHIV,HCV,severeopiateusedisorder,mildalcoholusedisorder.
• Bupe maintenancefor4months(weeklyRxs),relapsed• stoppedtakingonsomedayssohecouldgethigh.
• Nohistoryofmethadonemaintenance– interfereswithwork• Usingheroin/fentanylillicitly,EtOH for2months,occas streetbupetoavoidw/d.Hashad3overdoses,mostrecently10/17.
• Askingaboutnaltrexone,“Iwantthatshot.”– HIVwellcontrolledwithmeds- Dolutegravir plustenofovir/emtricitabine– HCVuntreated,stable– Bipolar,PTSD- Lamictal,prazosin
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MATforOpiateUseDisorder– OptionsBuprenorphine/naloxone– 1st• Partialopioidagonist• Ceilingeffect– resp depression,
sedation• Films/Pills/Injectable• Officebasedtx• Stablepts– nopolydruguse,
supportsysteminplace,psychiatricallystable
• MUSTbeinwithdrawaltostart• Robustdatatosupportefficacy
Methadonemaintenance(MMTP)– 1st• Fullopioidagonist• HigherriskforOD,sedation• Liquidform,dailydosing• FederallyqualifiedOTP(opiatetx
program)• Highlyregulated,structure• Counselingmandated• Ptsinneedofmonitoring,lackof
supportsystem,psychiatricallyunstable,Failedbupe
• Withdrawalnotnecessarytostart• Robustdatatosupportefficacy
Naltrexone– 2nd• Opioidblocker• NOriskforODfromNal;risk
tryingtooverrideblockade• Pillorinjection(Vivitrol)• Officebased• Ptsw/cravings,notexperiencing
withdrawal,notcurrentlyusing• Stablepts- nopolydruguse,
supportsysteminplace,psychiatricallystable(?forptswhohavefailedMMTP/bupe)
• MUSTbeinwithdrawaltostart• Limiteddata
Opiatereplacementtreatmentisassociatedwithreducedmortality,lowerHIVtransmission,improvedsocialfunctioning,andreducedcriminalbehavior.
Naltrexone• Notanewdrug,but–
• increaseinmarketingforOUD:“non-addictivemedication”• gaininginterestfrompatients
• FDAapprovedforOUD,NOT1st line• FDAapprovedforAUD,1st line• NotFDAapprovedforotherSUDs
• FDAapprovedforweightloss:Contrave (nal/buproprion)• Offlabelforself-injuriousbehavior
• Oralformulation– dailydosing• Extendedrelease
– Injection:monthly– Implant:2months(notFDAapproved)
NaltrexoneforOUD• OpiateUseDisorder– approved2010• Mu- opiatereceptorantagonist
– Blocksexogenousopiates;blocksendogenousopiatepeptides– preventtheincreaseddopaminereleaseà pleasurablereinforcingeffectsofdrugs
• Clinically:– Helpwithcravings– Relapseprevention
• Oralformulation(50mgdaily):pooradherence,highdropoutrate,increasedmortality
• InjectableXR(monthly):decentamountofstudieshaveshownefficacyvsplacebo/TAU(HIVandnon-HIVpts)• Incarceration– datasupportinguse;methadone/bupe notoptions
NaltrexoneTrialsforOUD• FDAapprovedbasedonRussianstudy,2011
– Injectable extended-releasenaltrexoneforopioiddependence:adouble-blind,placebo-controlled,multicentre randomised trial.– EKrupitsky,Lancet2011
– Nofollowupdatare:overdoseafterstoppingthemedication
• AustralianStudies,2013– Excessmortalityamongopioid-usingpatientstreatedwithoralnaltrexoneinAustralia.- LDegenhardt,DrugAlcoholRev2013
– Totaloralnaltrexonemortalitywassignificantlygreatervsmethadone• Highmortalityrateposttreatmentcessation.
• FewstudiescomparingXRtobuprenorphine/naloxoneormethadone(nonespecificallyinHIV)
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XRNaltrexonevsBuprenorphineJAMAPsychiatry10/18/17
Open-label,randomizedclinicaltrialx12wksN=159,(Norway)
PrimaryOutcomes
– Retentioninstudy– #ofUDTsnegativeforillicitopiates– #ofdaysofheroin/illicitopiateuse
SecondaryOutcomes
– #ofdaysofTHC,amphet,cocaine,BZDs,EtOH
– #ofdaysofinjecting– #degreeofopiatecravings– Life/treatmentsatisfaction– Mentalhealth
XRNaltrexonevsBuprenorphine• Noninferior tobuprenorphine/naloxone
– Primaryoutcomeresults:• retentionrate• #negUDTs• #daysofOPIuse
– Secondaryoutcomeresults:• significantlylessheroincraving• significantreductioninBZDuse• significantlyhigherlife/treatmentsatisfaction
• CanweextrapolatethistoUSpopulation?
–Enrollmentfolloweddetox–Avg buprenorphinedose~11mg–Nofollowupdatare:overdoseafterstoppingthemedication
Inthepipeline…XRNaltrexonevsBuprenorphine
• NYUStudy:N=600,6-monthtrial• XRNalvsbuprenorphine/nal• completed1/2017• Resultsnotpublishedyet…
ReturntoCaseStudy• 28yo malewithHIV,HCV,severeopiateusedisorder,mildalcoholusedisorder.
• Bupe maintenancefor4months(weeklyRxs),relapsed• stoppedtakingonsomedayssohecouldgethigh.
• Nohistoryofmethadonemaintenance– interfereswithwork• Usingheroin/fentanylillicitly,EtOH for2months,occas streetbupetoavoidw/d.Hashad3overdoses,mostrecently10/17.
• Askingaboutnaltrexone,“Iwanttheshot.”– HIVwellcontrolledwithmeds- Dolutegravir plustenofovir/emtricitabine– HCVuntreated,stable– Bipolar,PTSD- Lamictal,prazosin
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XRNaltrexoneGuidelines• SAMHSA - ClinicalUseofExtended-ReleaseInjectableNaltrexoneinthetreatmentofOUD:ABriefGuide
• Officebasedaddictiontx– KEY:Comprehensivetxapproach
• Counseling• Psychiatrictreatmentasneeded• Socialsupport:AA,NA,mutual-helpprograms
IdealCandidates• S/popiatedetoxification
– Nowithdrawalsxs– Co-occurringalcoholusedisorder– Shortorlesssevereaddictionhistory– Highlymotivated:
• Professionalsdemonstratesobrietytolicensingboards,criminaljusticeofficials– HCP,attorneys,pilots
• Agonisttherapyforprofessionalsisbannedinsomestates– Unsuccessfultx withbuprenorphineormethadone
• Dependsonreasonforfailure– Successfultx withagonist– butwouldlike‘morefreedom’
NotIdealCandidates
• Unabletocomplete/toleratew/d• PAWS:postacutewithdrawalsyndrome – seenextslide• Unstablepsychiatricsxs• Chronicpainwhichrequiresopioidtx• Advancedliverdisease,impendingliverfailure,acutehep
– ToleratedinstablechronicHBV,HCV,elevatedLFTs
Post-acutewithdrawalsyndrome(PAWS)• 4-8weeksafterdetox;maylast6-12months• Lessphysicalsxs,morepsychologicalsxs
– Insomnia,irritability,anxiety,moodchanges,memoryissues,anhedonia– SeenBZDs,EtOH,OPI,stimulants
• Impairmentinreversallearning“WHENIUSEDRUGSIFEELGOOD”
needstochangeto“WHENIUSEDRUGSBADTHINGSHAPPEN”
– Inabilitytoadapttonewunderstanding– Involvesdopamineandglutamate
• LackofevidencetosupportDSM-5diagnosis
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Contraindications/Warnings• Ptsreceivinglongterm opioidtherapy• Activelytakingbuprenorphineormethadone• Sensitivitytocomponentsofdiluent
– polylactide-co-glycolide,carboxymethylcellulose• BodymassprecludesIMinjectionwith2-inchneedle• ISR– injectionsitereactions• Caution
– activeliverdx,mod-to-severerenalimpairment– Thrombocytopenia,coagulationdisorder– PregnancycategoryC;breastfeeding
Contraindications/Warnings
• Hypersensitivityreactions• Hepatotoxicity• Depression/suicidality– relative• Precipitatedopioidwithdrawal
– Moreseverethannaturalwithdrawal
• Overdosemayresultfromtryingtoovercometheopiateblockade
Warning:OpioidOverdose
• Nocomprehensivemortalitydatayetavailableforinjectable• Casesoffatalopioidoverdosehavebeenreportedinptswho:
– Usedopioidsatorneartheendofthe1-monthdosinginterval.– Usedopioidsaftermissingadose– Attemptedtoovercometheopioidblockade– Upregulationofopioidreceptorsincreasessensitivitytoopiateeffects
• 1/3ofptswill“test”blockade,within1-2daysafter1st injection• Veryfewpatientstrytointentionally“overridetheblockade”
Sideeffects• 2%:LFTabnormalities• 4-7%:nausea,vomiting,headache,fatigue,andmusclecramps• 5%:Psych- depression,suicidalthoughtsand/orbehavior
• OUDsuiciderisk:10%vs1.3%inthegenpopulation• OralNal:10%suicidality
• Injectionsitepainandinduration– Asepticabscess,obesity– subcutaneousfat
• Seriousallergicreactions:skinrash,facialortongueswelling• Rarecasesofsevereallergicpneumonia(eosinophilic)
• Majorityofsideeffectswerereportedas“mildtomoderate”.• NosignificantinteractionswithHIVmeds
• Liver
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SafetyProfile:NaltrexoneinHIV• HepaticsafetyandantiretroviraleffectivenessinHIV-infectedpatientsreceivingnaltrexone– JTetrault,etal.2/2012,Alcoholism,Clinical&ExperimentalResearch.– Oralformulation– proventobesafeinHIV,HIVRNAdecreased
• AnevaluationofhepaticenzymeelevationsamongHIV-infectedreleasedprisonersenrolledintworandomizedplacebo-controlledtrialsofextendedreleasenaltrexone– PVagenas,7/2014,JSubstanceAbuseTx– XRformulation– nodifferenceinLFTelevationvsplacebo– 50%ofpts+HCV– 33%onpsychiatricmedication
SafetyProfile:NaltrexoneHIV,HCV
• Hepaticsafetyofinjectableextended-releasenaltrexoneinpatientswithchronichepatitisCandHIVinfection.- MCMitchell,11/2012,JStudAlcoholDrugs.
– 88%HIV+,42%HCV+– Safetouse
• Feasibilityandsafetyofextended-releasenaltrexonetreatmentofopioidandalcoholusedisorderinHIVclinics:apilot/feasibilityrandomizedtrial.– PTKorthuis,PLum etal,6/2017Addiction.– Non-blindedrandomizedtrialofXR-NTXvspharmacotherapyTAU,N=51– Ptsw/OUD:HIVsuppressionimprovedfrom67to80%forXR-NTX– feasible&safe
Plasmaconcentrationsonadailybasisx1month
– XRNal remainsrelativelystablebythefifthdayofthemonth– concentrationoforalnal peaksonadailybasis.
• overaperiodof24hours,oralnal peakswithinthefirsthourofdosingandfallsbelowtherapeuticlevelswithin8hours.
RedLine:XRNalYellowLine:oralnal
XRNaltrexone
• 380mgIMinjection• Glutealmuscleevery28-30days• 2peaklevelsfollowinginjection
– 2hoursafter– 2-3dayslater
• After14days,bloodlevelslowlydeclinesinlinearfashion• Reachsteadystateattheendofthefirstdosinginterval
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HowtoPrescribe(sameforOUD&AUD)
• Opiatefreefor7-10days– 2weeksforbupe ormethadone
• Screen– LFTS,renalfunctionthenQ6-12mos
• RecCheck3-4months• LFTsincreasemildandself-limiting,resolveswith
continuation– UDSw/ethylglucuronide,HCG
• ThenrandomUDS• CheckPMP
• Tolerancetest-POnaltrexonefor2wks– Someinsurancedictates30daytrialwith
compliancefailure• Challengetest(NAforAUD)
– Narcandoseand/orpo challengetest:25mgnaltrexone,wait1hour
• Injection:upperouterquadofglutealregion,alternatesidemonthly– Physician,Nurse,orPAcanadminister
• Housekeepingitems– Orderedviaspecialtypharmacy
– Deliveredtoclinic– Storedinfridge– F/umedicationmonitoringcanbe
billed/performedbyanRN.
Toleratingthe7-10dayopiate-freegap• Comfortmedications• Naltrexonedrivenwithdrawal
– Anesthesia-assistedrapidopioiddetoxNOTrecommendedperCDC• Naltrexoneplusgeneralanesthesia,BZDsover4-6hrs• Riskofpersistentw/dsxs,andriskofdeath
– Crosstaperofagonistwithnaltrexoneover7-10days,seenextslide
• TheBridgeDevice
TransitionfromdetoxtoXRNal
• Long-ActingInjectableNaltrexoneInduction:ARandomizedTrialofOutpatientOpioidDetoxificationWithNaltrexoneVersusBuprenorphine.MSullivan,etal.AmJPsychiatry5/17
– Bupetaperfollowedby7daysofopiatefreeperiod– Versusbupedosexone,thenascendingdosesofnaltrexoneandclonidinex7days
– NaldetoxgroupwasmorelikelytoreachinductionofXRnal
TheNeurostimSystem-2Bridge
• FDAapproved11/15/17foropiatew/dsymptoms– Approved2014foracupuncture
• Battery-operateddevice,attachestotheear• Transmitselectricalpulsesthroughfourpoints• Wearfor5days,reducessxs ofopiatew/d
• Singlearmclinicalstudy,n=73– COWSscoredecreasedinallptsby31%,30minafterplacement– 88%ofptstransitionedtoMAT“successfully”after5daysofusingdevice
• Contraindicated:hemophilia,cardiacpacemakers,psoriasisvulgaris• Rxonly• Nocontrolledclinicaltrial
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SpecialConsiderations• Acuteinjury/pain
– Non-opiateanalgesics– Acetaminophen/NSAIDs,NMDAantagonists(ex.Ketamine),Alpha-2agonists(ex.Clonidine),Antispasmotics (ex.Baclofen),Antineuropathic agents(ex.Gabapentin)
– Non-pharmacologictherapies:peripheralandneuraxial nerveblocks,localanesthesia
• Emergencysurgery:– regionalanesthesia,benzodiazepines,non-opiateanalgesics,ketamine– Opiateblockadecanbeoverridden– hospitalsetting
• Electivesurgery:– Oralnaltrexone:d/cuse72hoursprior;½life14hours(5half-lives)– XRNaltrexone:lastinjection4-6wks prior;½life5days– OR- transition
tooraltherapywithdiscontinuation3dayspreoperatively.
• Medicalalertbracelet
XRNaltrexoneinProfessionals
• Studiesshowsuccessinanesthesiologists• XRNal inHCPs,JournalofAddictionMedicine,6/2017
– Nurses,doctors,pharmacists– N=38,2years– Longesttx durationofanystudyofXRNal– 1st studyinHCPsofXRNal foropiateusedisorder– increasedmentalhealthfunctioning,increaseinemploymentrate,decreaseinopiatecravings
ReturntoCaseStudy• 28yo malewithHIV,HCV,severeopiateusedisorder,mildalcoholusedisorder.
• Bupe maintenancefor4months(weeklyRxs),relapsed• stoppedtakingonsomedayssohecouldgethigh.
• Nohistoryofmethadonemaintenance– interfereswithwork• Usingheroin/fentanylillicitly,EtOH for2months,occas streetbupetoavoidw/d.Hashad3overdoses,mostrecently10/17.
• Askingaboutnaltrexone,“Iwanttheshot.”– HIVwellcontrolledwithmeds- Dolutegravir plustenofovir/emtricitabine– HCVuntreated,stable– Bipolar,PTSD- Lamictal,prazosin
Question• Isourpatientagoodcandidateforinjectablenaltrexone?
• YES
• NO
• NOTSURE
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YesorNo?• Yes
– WouldhelpwithcravingsforbothOPIandEtOH– Longacting– notableto‘stop’inordertogethigh– Wouldassistinmaintainingemployment– Decliningtoconsiderbupe/methadone– Willengagept – ifhefails,canswitchto1st lineoptions
• No– Lackofstructurewithmonthlyinjection– RelapsedonanagonistwithweeklyRxs– Activelyusing– needstodetoxtostartNal (↑riskofoverdose)– Concernforworseningpsychsxs– Lackofevidence– NOT firstlinetreatment,considermethadone(1st line)
Summary– XRNalforOUD• XRNaltrexoneisstillconsidered2nd lineforOUDtx.• Morestudiesneededcomparingto1st lineofbupeandMMTP.
– It’sbetterthanplacebo– thisisallweknow.
• IfptfailedMMTPand/orbupe,bemorecautiousw/naltrexone.• Inthemidstofanopiatecrisis,consider:
– Engagement- meetingpatientswheretheyare– propereducationre:MAToptions,risksofOD– Weighingrisks/benefits
PROS
CONS
NaltrexoneforAlcoholUseDisorder
• SeveralRCTs:strongevidenceNalsignificantlyreduces– alcoholrelapses– frequencyandquantityofalcoholconsumptioninthosewhododrink– alcoholcravings
• Ptsshouldnotbeactivelydrinkingattimeofadministration– Considerdetoxfirst(dependsonseverityofusedisorder)
• DoesnotreactadverselywithEtOHintake• Sameprescribinginformation/processasforOUD
MATforAlcoholUseDisorder– OptionsDisulfiram(Antabuse)
–NegativeReinforcement,doesnotcontrolcravings–Ethanol-->Acetaldehyde-->Acetate–BuildupofAcetaldehyde
•Flushing,nausea•Headache/dizzy•Palpitations
•Dose:250mgdaily->500mgdaily•DrugInteractions
–Warfarin–Anti-convulsants/seizuremeds–HIVmeds– Ritonavir(oralsolution)
•SideEffects:hepatotoxicity,neuropathy•Contraindications
–Pregnancy–RecentEtOH use(LFTs,rxn)–CognitiveImpairment
Acamprosate (Campral)• Mitigates/modulateseffectsof
alcoholinthebrain• Efficacy??
-Reviewof7trials-Abstinentatoneyear:
Acamprosate:23%Placebo:15%
-COMBINEStudy:nosignificanteffectondrinkingvsplacebo
• 333mgtablets:2tablets3x/dayStartafterperiodofabstinenceDose666mgTID
• SE:bloating,diarrhea• Contraindications
- Renaldisease- Pregnancy
Naltrexone• Opioidantagonist• Pillorinjection(Vivitrol)• Officebased• Efficacy
–19publishedstudieshaveshownefficacyvsplacebo
• Dosage:–Oralform:50mgdaily–Injectableform:monthly
• SE:Nausea,headache,fatigue• Contraindications:
– Acuteliverdisease–Takingopioids
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MethamphetamineUse
MAUse
• HIVInSiteUCSF/Ward86PracticeRecommendations• Behavioraltherapies– THE onlyevidence-basedtreatment
– MatrixModel:CBT,recovery/relapse-preventiongroups,drugscreening
– StonewallProject:InSF
• NoFDAapprovedmedicationsfortreatment• Studies– naltrexone,psychostimulants
– Smallsize,highdropoutrate– Promisingbutnotcompelling
MA– 1st USNaltrexonestudy
• Neuropsychopharmacology,5/15– UCLA,LRayetal.
• N:30,OralNaltrexonevsPlacebo• Significantlyreducedrewardingeffectsofmeth
– Significantlyreducedcravings– Lessarousedbymeth
• N:25(subsetofabovestudy)• fMRIs:resultsnotpublishedyet
OralNaltrexoneinMA&EtOH• Feasibility,acceptability,andtolerabilityoftargetednaltrexonefornondependentmethamphetamine-usingandbinge-drinkingmenwhohavesexwithmen.JAcquir ImmuneDefic Syndr.2016,SantosGM,etal.
• 30non-dependentMA-use,binge-drinkingMSM• Nal vsplacebox8weeks• Targeteduse– craving,anticipatinguse• RESULTS
• Feasible,acceptable,andwelltolerated• Associatedw/significantsexualriskreductions• Forsome,associatedw/methandbinge-drinkingreductions.
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Incontrast…XRNalinMAuse
• Extended–releasenaltrexoneformethamphetaminedependenceamongmenwhohavesexwithmen:arandomizedplacebo-controlledtrial.POCoffinetal,Addiction2017.– Double-blind,placebo-controlled,randomizedtrialofXRNALversusplaceboover12 weeksfrom2012to2015.
– Extended-release naltrexone doesnotappeartoreduce methamphetamine useorsexualriskbehaviorsamongmethamphetamine-dependentMSMcomparedwithplacebo.
MA• MolecularPsychiatry,3/17;TheScrippsResearchInstitute• Rats:Ceasingmethtriggeredneurogenesisinthedentategyrus
– Strengtheneddrug-associatedmemories– Dentategyrusformsnewmemories
• Ratslearnedtoassociateaparticularlocationwithmethuse.
• Returningtothislocationservedasatriggeringcue.– intheory,promptingapt torelapse.
MA
• SyntheticmoleculeIsx-9(isoxazole-9) blocksneurogenesis– Ratslesslikelytorelapse– Needclinicaltrials
Summary
• Naltrexone– 1st lineforAUD– 2nd lineforOUD– needmoredata;usewithcaution– NotFDAapprovedforMA– needmoredata
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ThankYou
International OverdoseAwareness Day