ACCREDITATION STATEMENT University of California San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians The University of California San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Creditstrade Physicians should only claim credit commensurate with the extent of their participation in the activity

1

Didactic Series

Office-based Treatment for Substance Abuse Disorder in HIV-infected

Patients Jacqueline Tulsky MD

Pacific AETC June 26 2014

2

Objectives Follow off of Dr Mathewrsquos talk on screening

for SUDs

Review Medication Assisted Treatment for

Opioid ETOH Benzos Methamphetamine dependence

Empower you to treat your patients

3

A patient known to you

30 yo woman with history of HIV disease Hep C endocarditis ETOH crack and street opioid use in remission Admitted for altered mental status UDS from ED -+ morphine cocaine

Seeing you at DC visit

4

Polling Which drugs can you offer MAT for in your practice

1 Opioids 2 ETOH 3 Stimulants 4 Benzodiazepines 5 Combo 6 None

5

ldquo No one is going to save usrdquo

ldquo hellipI was crying not because Superman did not exist but because it meant that there was no one with the power to save ushellip hellipJeffrey Canada ldquoWaiting for Supermanrdquo

Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10

poisoning deaths are caused by drugs

SOURCE CDCNCHS National Vital Statistics System

You Confront Your Patientrsquos SUDs

Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers

Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings

bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs

bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4

bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option

Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53

9

Goals of Medically Assisted Treatment (MAT)

Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug

10

MAT Options for Opioid Dependent Patients

1 Buprenorphinenaloxone (suboxone)

2 Naltrexone (oralinjectable)

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

2

Objectives Follow off of Dr Mathewrsquos talk on screening

for SUDs

Review Medication Assisted Treatment for

Opioid ETOH Benzos Methamphetamine dependence

Empower you to treat your patients

3

A patient known to you

30 yo woman with history of HIV disease Hep C endocarditis ETOH crack and street opioid use in remission Admitted for altered mental status UDS from ED -+ morphine cocaine

Seeing you at DC visit

4

Polling Which drugs can you offer MAT for in your practice

1 Opioids 2 ETOH 3 Stimulants 4 Benzodiazepines 5 Combo 6 None

5

ldquo No one is going to save usrdquo

ldquo hellipI was crying not because Superman did not exist but because it meant that there was no one with the power to save ushellip hellipJeffrey Canada ldquoWaiting for Supermanrdquo

Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10

poisoning deaths are caused by drugs

SOURCE CDCNCHS National Vital Statistics System

You Confront Your Patientrsquos SUDs

Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers

Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings

bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs

bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4

bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option

Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53

9

Goals of Medically Assisted Treatment (MAT)

Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug

10

MAT Options for Opioid Dependent Patients

1 Buprenorphinenaloxone (suboxone)

2 Naltrexone (oralinjectable)

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

3

A patient known to you

30 yo woman with history of HIV disease Hep C endocarditis ETOH crack and street opioid use in remission Admitted for altered mental status UDS from ED -+ morphine cocaine

Seeing you at DC visit

4

Polling Which drugs can you offer MAT for in your practice

1 Opioids 2 ETOH 3 Stimulants 4 Benzodiazepines 5 Combo 6 None

5

ldquo No one is going to save usrdquo

ldquo hellipI was crying not because Superman did not exist but because it meant that there was no one with the power to save ushellip hellipJeffrey Canada ldquoWaiting for Supermanrdquo

Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10

poisoning deaths are caused by drugs

SOURCE CDCNCHS National Vital Statistics System

You Confront Your Patientrsquos SUDs

Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers

Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings

bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs

bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4

bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option

Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53

9

Goals of Medically Assisted Treatment (MAT)

Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug

10

MAT Options for Opioid Dependent Patients

1 Buprenorphinenaloxone (suboxone)

2 Naltrexone (oralinjectable)

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

4

Polling Which drugs can you offer MAT for in your practice

1 Opioids 2 ETOH 3 Stimulants 4 Benzodiazepines 5 Combo 6 None

5

ldquo No one is going to save usrdquo

ldquo hellipI was crying not because Superman did not exist but because it meant that there was no one with the power to save ushellip hellipJeffrey Canada ldquoWaiting for Supermanrdquo

Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10

poisoning deaths are caused by drugs

SOURCE CDCNCHS National Vital Statistics System

You Confront Your Patientrsquos SUDs

Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers

Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings

bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs

bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4

bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option

Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53

9

Goals of Medically Assisted Treatment (MAT)

Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug

10

MAT Options for Opioid Dependent Patients

1 Buprenorphinenaloxone (suboxone)

2 Naltrexone (oralinjectable)

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

5

ldquo No one is going to save usrdquo

ldquo hellipI was crying not because Superman did not exist but because it meant that there was no one with the power to save ushellip hellipJeffrey Canada ldquoWaiting for Supermanrdquo

Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10

poisoning deaths are caused by drugs

SOURCE CDCNCHS National Vital Statistics System

You Confront Your Patientrsquos SUDs

Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers

Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings

bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs

bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4

bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option

Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53

9

Goals of Medically Assisted Treatment (MAT)

Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug

10

MAT Options for Opioid Dependent Patients

1 Buprenorphinenaloxone (suboxone)

2 Naltrexone (oralinjectable)

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

Poisoning is the leading cause of death from injuries in the US and nearly 9 out of 10

poisoning deaths are caused by drugs

SOURCE CDCNCHS National Vital Statistics System

You Confront Your Patientrsquos SUDs

Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers

Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings

bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs

bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4

bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option

Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53

9

Goals of Medically Assisted Treatment (MAT)

Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug

10

MAT Options for Opioid Dependent Patients

1 Buprenorphinenaloxone (suboxone)

2 Naltrexone (oralinjectable)

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

You Confront Your Patientrsquos SUDs

Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers

Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings

bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs

bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4

bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option

Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53

9

Goals of Medically Assisted Treatment (MAT)

Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug

10

MAT Options for Opioid Dependent Patients

1 Buprenorphinenaloxone (suboxone)

2 Naltrexone (oralinjectable)

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

Where to start - Ask Assess In national samples of PLWH only 35 patients reported discussing alcohol use with their HIV providers

Guidelines and policies recommend evidence-based practices for detecting and treating SUDs in primary care settings

bull The US Preventive Services Task Force screening all 18 years + for tobacco and alcohol misuse and provide persons at risk with brief behavioral counseling interventions to prevent more serious SUDs

bull In busy HIV clinics consider using the AUDIT-C with cutoff scores of 3 or 4

bull NM- ASSIST shown by Dr Matthews 2 weeks ago also excellent option

Sources Metsch et al Drug Alcohol Depend 200895(1-2)37-44 Strauss et al J Int Assoc Physicians AIDS Care 20098(6)347-53

9

Goals of Medically Assisted Treatment (MAT)

Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug

10

MAT Options for Opioid Dependent Patients

1 Buprenorphinenaloxone (suboxone)

2 Naltrexone (oralinjectable)

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

9

Goals of Medically Assisted Treatment (MAT)

Eliminate physical withdrawal Eliminate lsquocravingrsquo Balance of ldquocomfortrdquo and function Not over sedated Blocking of euphoria of target drug

10

MAT Options for Opioid Dependent Patients

1 Buprenorphinenaloxone (suboxone)

2 Naltrexone (oralinjectable)

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

10

MAT Options for Opioid Dependent Patients

1 Buprenorphinenaloxone (suboxone)

2 Naltrexone (oralinjectable)

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

11

Polling Questionndash For my patients the access to Suboxone is provided byhellip

1 Me 2 Others in the practice groupclinic 3 Other site in the area 4 Not available 5 I donrsquot know about the access

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

12

Buprenorphinenaloxone (Suboxone) Pharmacology Partial agonistantagonist

Ceiling effect on the mu receptor

Long frac12 life so once a day dosing fine

Similar effect on respiratory drive as benzos

and ETOH Similar idea as methadone but people like it

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

13

Suboxone Maintenance

Studies repeatedly prove efficacy Expensive if not covered but mostly

covered Strongly regulated by federal and state

Special barrier Training and lsquoXrsquo license DEA visitors

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

Typical Suboxone Dosing

Home initiation is used by some mostly we use OBIC based near TAP

Must start opioid NAIumlVE or in withdrawal Use standardized tool ndash COWS to assess Start low 2-4mg with additional doses as

needed Increase q 3-4 days

Target range 16-24 mg max 32mg Stop withdrawal avoid sedationeuphoria

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

15

Naltrexone ndash oralinjectable

Strongest antagonist for opioid receptors Blockade reverses Dose effect so may need to repeat oral in

short order Monthly injectable (Vivitrol) Non selective so will block both pain

opioids illicit substances

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

Naloxone Rescue as first line MAT for opioid addiction The HOW TO MANUAL includes

bull Signs of overdose

bull How to administer naloxone

bull How to provide emergency care

bull Calling 911

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

Who is a good Naltrexone candidate

Canrsquot or donrsquot want agonist maintenance High degree of motivation for abstinence

(active in 12 step programs) In professions where agonist treatment is

controversial (HCWs pilots) Successful on agonist but who want to try

abstinence Abstinent but at risk for relapse

Providers Clinical Support System (PCSS) for Medication Assisted Treatment ndash Bisaga A January 2014

17

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

18

ETOH

ETOH dependent and had serious withdrawal ndash residential detox

Everyone else at end of detox or if not so medically at risk can be managed as outpt

After detox patients need maintenance just like opioid use disorder

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

Spectrum and population prevalence of alcohol use in US

Dependence 4

Abuse 5

Risky Use 16

Low Risk Use 30

Abstinence 45

Source Saitz R NEJM 2005352596-607

Unhealthy Use 25

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

Medications for Relapse Prevention bull Three FDA Approved Medications

ndash Naltrexone ndash Disulfiram ndash Acamprosate

bull Promising Medications ndash Topiramate ndash Gabapentin

ETOH Treatment Options Naltrexone 50mg QD

or

Naltrexone ER 380mg IM Q month

wwwniaaanihgovguide

Acamprosate 666 mg TID

or

Disulfiram + Acamprosate

Topiramate 25mg QHS initial then inc 25-50mg BID up to 200mg totalday

Naltrexone (ReViaVivitrol)

bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995

ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006

Naltrexone (ReViaVivitrol)

bull Approved for opioid dependence in 1984 bull Approved for alcohol dependence in 1995

ndash Two formulations available bull Oral tablets (ReVia) bull Depot injection (Vivitrol) approved in 2006

Source wwwniaaanihgovguide

24

Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate

Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going

25

ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds

Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning

per patient or significant other Improvement in LFTs (AST ALT GGT)

27

24 yr got off methamphetamine

hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize

28

Methamphetamine

A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone

Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention

mirtazapine 30mg QHS or placebo 30 minutes counseling weekly

Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)

Colfax et al Arch General Psychiatry 2011681168-75

Mirtazapine for Methamphetamine

Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175

Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention

naltrexone 50mg or placebo counseling 1xwk

Outcome UDS No Meth Naltrexone 65 Placebo 48

Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448

Impact of Findings

Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

24

Gapapentin for ETOH ndash ldquoHow tohelliprdquo Is person is outpatient Rx candidate

Initial Treatment Give Gabapentin 1200mg bid Evaluate next day Is withdrawal present and worsening Rescuehellipor not but then keep it going

25

ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds

Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning

per patient or significant other Improvement in LFTs (AST ALT GGT)

27

24 yr got off methamphetamine

hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize

28

Methamphetamine

A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone

Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention

mirtazapine 30mg QHS or placebo 30 minutes counseling weekly

Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)

Colfax et al Arch General Psychiatry 2011681168-75

Mirtazapine for Methamphetamine

Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175

Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention

naltrexone 50mg or placebo counseling 1xwk

Outcome UDS No Meth Naltrexone 65 Placebo 48

Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448

Impact of Findings

Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

25

ldquoHow Tordquo on ETOH Continued Subsequent Days Evaluate patient can be reached by phone If withdrawal SampS present assess w CIWA Should fade out over 5 days unless other meds Prolonged abstinence supporthellipMEDICATIONS and Social model - NA AA support of all kinds

Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning

per patient or significant other Improvement in LFTs (AST ALT GGT)

27

24 yr got off methamphetamine

hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize

28

Methamphetamine

A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone

Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention

mirtazapine 30mg QHS or placebo 30 minutes counseling weekly

Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)

Colfax et al Arch General Psychiatry 2011681168-75

Mirtazapine for Methamphetamine

Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175

Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention

naltrexone 50mg or placebo counseling 1xwk

Outcome UDS No Meth Naltrexone 65 Placebo 48

Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448

Impact of Findings

Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

Monitoring for Response Less binge drinking Fewer drinks per day Abstinence Psychiatric medical and social stability Subjective improvement in functioning

per patient or significant other Improvement in LFTs (AST ALT GGT)

27

24 yr got off methamphetamine

hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize

28

Methamphetamine

A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone

Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention

mirtazapine 30mg QHS or placebo 30 minutes counseling weekly

Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)

Colfax et al Arch General Psychiatry 2011681168-75

Mirtazapine for Methamphetamine

Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175

Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention

naltrexone 50mg or placebo counseling 1xwk

Outcome UDS No Meth Naltrexone 65 Placebo 48

Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448

Impact of Findings

Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

27

24 yr got off methamphetamine

hellip with his HIV diagnosis 8 months ago Me ldquoHow are you doingrdquo Him ldquoI still wake up thinking about using I think about drinking ETOH and smoking meth I canrsquot get it out of my head even though its terrible for merdquo Can you do more than empathize

28

Methamphetamine

A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone

Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention

mirtazapine 30mg QHS or placebo 30 minutes counseling weekly

Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)

Colfax et al Arch General Psychiatry 2011681168-75

Mirtazapine for Methamphetamine

Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175

Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention

naltrexone 50mg or placebo counseling 1xwk

Outcome UDS No Meth Naltrexone 65 Placebo 48

Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448

Impact of Findings

Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

28

Methamphetamine

A glimmer of hope for meth users 1 Mirtazapine 2 Naltrexone

Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention

mirtazapine 30mg QHS or placebo 30 minutes counseling weekly

Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)

Colfax et al Arch General Psychiatry 2011681168-75

Mirtazapine for Methamphetamine

Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175

Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention

naltrexone 50mg or placebo counseling 1xwk

Outcome UDS No Meth Naltrexone 65 Placebo 48

Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448

Impact of Findings

Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

Mirtazapine Design RCT Population N = 60 MSM meth dependent Intervention

mirtazapine 30mg QHS or placebo 30 minutes counseling weekly

Outcome Change +UDS Mirtazapine 73 -gt 44 Placebo 67 -gt 63 (RR 057 95 CI 035ndash093 P = 02)

Colfax et al Arch General Psychiatry 2011681168-75

Mirtazapine for Methamphetamine

Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175

Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention

naltrexone 50mg or placebo counseling 1xwk

Outcome UDS No Meth Naltrexone 65 Placebo 48

Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448

Impact of Findings

Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

Mirtazapine for Methamphetamine

Source Colfax et al Arch Gen Psychiatry 2011 November 68(11) 1168ndash1175

Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention

naltrexone 50mg or placebo counseling 1xwk

Outcome UDS No Meth Naltrexone 65 Placebo 48

Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448

Impact of Findings

Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

Naltrexone Design RCT 12 wks Population N=80 meth dependence Intervention

naltrexone 50mg or placebo counseling 1xwk

Outcome UDS No Meth Naltrexone 65 Placebo 48

Jayaram-Lindstrom et al Am J Psychiatry 20081651442-1448

Impact of Findings

Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

Impact of Findings

Two potential candidates for treatment of methamphetamine dependence particularly when other indications exist Naltrexone ndash comorbid alcohol dependence Mirtazapine- comorbid anxiety or depression

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

Any Time for Your Cases

33

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

References Mirtazapine to reduce methamphetamine use a

randomized controlled trial Arch Gen Psychiatry 20111168-75

Naltrexone for the treatment of amphetamine dependence a randomized placebo-controlled trial Am J Psychiatry 2008 165 1442ndash8

H Myrick R Malcolm P Randall et al TREATMENT OF ALCOHOL WITHDRAWAL A DOUBLE BLIND TRIAL OF GABAPENTIN VS LORAZEPAM IN THE xxx Alcohol Clin Exp Res Sep 2009 33(9) 1582ndash1588

References

Mason B Gabapentin Treatment for Alcohol Dependence JAMA Internal Medicine 2013 DOI 101001jamainternmed201311950

Adams J Gaynes B McGuiness T et al Treating

Depression Within the HIV ldquoMedical Homerdquo A Guided Algorithmn for Antidepressants Management by HIV Clinicians AIDS Patient Care and STDS Vol 26 No 11 2012