t national judicial college · 6/9/2020 · more people quit smoking vs. nrt…but then more stay...

THE NATIONAL JUDICIAL COLLEGE

Medications for Alcohol and Drug Use Disorders 101: The Science of Medication Treatment

Tuesday, June 9, 2020 9 a.m. in Hawai’i / 12 p.m. Pacific / 1 p.m. Mountain / 2 p.m. Central / 3 p.m. Eastern

Table of Contents: Page

Faculty Biography ...........................................................................................................................1 Webinar Description and Learning Objectives ................................................................................2 Dr. Joshua D. Lee, Medications for Alcohol and Drug Use Disorders 101: The Science of Medication Treatment (Jun. 2020) [NJC/PCSS PowerPoint] ..........................................................3 Upcoming NJC Webinars & NJC On-Demand (For additional resources) ................................ ....21

Brought to you through a generous grant from:

DR. JOSHUA D. LEE, M.D., MSc

Joshua D. Lee MD, MSc is an Associate Professor at the NYU Grossman School of Medicine. He is Co-Director of the Section on Tobacco, Alcohol, and Drug Use in the Department of Population Health and Director of the NYU Addiction Medicine Fellowship. He is an Internal Medicine and Addiction Medicine clinician researcher focused on low threshold addiction pharmacotherapy treatments in primary care and criminal justice settings. He has conducted multiple NIH clinical trials examining the use of naltrexone and buprenorphine opioid and alcohol treatments in community criminal justice involved adults, at release from jail, and within community primary care settings. He treats patients at Bellevue Hospital Center. Dr. Lee joined the faculty of The National Judicial College in 2011.

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Webinar Description: Alcohol and drug abuse are associated with criminal behavior, arrest, and incarceration. Effective treatments are needed to reduce the burden of alcohol and drug abuse on public safety and on the public health. Fortunately, there are three medications (antabuse, acamprosate, and naltrexone) that are FDA-approved for the treatment of alcohol dependence and three medications (methadone, buprenorphine, and naltrexone) that are approved for the treatment of opiate dependence. This presentation will review how these medications work, what the evidence of their effectiveness is, and how they are used in the community. The underutilization of these medications among individuals involved in the criminal justice system presents an exciting opportunity to expand their use and improve alcohol and drug use, public safety and public health outcomes.

Learning Objectives: After participating in this webcast, judges will be able to:

1. Summarize what Medication Assisted Treatment (MAT) is;

2. Describe why MAT is an effective tool, when used with substance abusetherapy, in treating alcohol and drug addiction; and

3. Cite what drugs are used in MAT and how each works.

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Medications for Drug and Alcohol Use Disorders

Joshua D Lee MD MScNYU Grossman School of Medicine

Department of Population HealthJune 10, 2020

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Disclosures

• Grants: NIDA (U01/AS-NCE, R01, U10 (CTN GNYN)) NIAAA (R01-NCE) Laura and John Arnold Foundation (x2) Indivior (ISS)

• Study Drug: Alkermes (Vivitrol), Indivior(Suboxone, Sublocade)

• Consulting (paid and NIH grants): Epiodyne,Nirsum, The Drug Delivery Inc., U.KY, OHSU

Medications for Alcohol and Drug Use Disorders 101: The Science of Medication Treatment Dr. Joshua Lee

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Learning Objectives

After this webcast you will:

1. Summarize what Medication Assisted Treatment(MAT) is;

2. Describe why MAT is an effective tool, whenused with substance abuse therapy, in treatingalcohol and drug addiction;

3. Cite what drugs are used in MAT and how eachworks.

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QUESTION #1(with participant answers)

What type of court do you preside over?

a.) Criminal 29% f.) Treatment 14%

b.) Civil 11% g.) General Jurisdiction 14%

c.) Family 12% h.) Other (Use Chat Tool) 10%

d.) Juvenile 9% i.) N/A, Medical Field 39%

e.) Tribal 2%

• OTHER ANSWERS:

• Worker’s Compensation

• Administrative Law

• Social Security Administration

• Trial Court Administration

• State Intermediate Appellate Court

• Judicial Education

• Medical field and affiliated withlocal/regional drug courts


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Do you currently use Medication Treatment or allow it in your court?

a.) Yes 61%

b.) No 35%

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Today’s Talk on Medications

• Neurobiologic mechanisms of action

How addiction affects the brain

Why medications work

• Alcohol use disorder medications

• Opioid use disorder medications

• Q/A


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Addiction: A Brain Disease

An addicted brain is primarily

responding to impulse, cues, and cravings

Highest concentration of Dopamine receptors

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Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, 1997.

Natural Rewards Elevate Dopamine Levels

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Di Chiara and Imperato, PNAS, 1988

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Drug use triggers a surge in dopamine


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Addiction Treatment: Healing ‘A Brain Disease’

•Do we do something directly to the brain that worksimmediately? Yes, Medications

• Medications for drug use disorders are ‘brain drugs’• Reduce the acute effects of intoxicating substances• Reduce cravings• ‘Time to heal’ and allow for re-learning non-use

•Place/location: CJS, Residential, outpatient•Counseling and social support

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Receptors: proteins on cell surfaces that wait to send a signal downstream

In this example, both buprenorphine and heroin / fentanyl / oxycodone are all opioids and all fit the brain’s mu opioid receptor…but buprenorphine has certain therapeutic actions vs. heroin

Receptor Pharmakodynamics: Buprenorphine fits better… lasts longer…”dominates” other opioids• “binding affinity” – it’s “stickier” and wins the competition for receptor occupancy• Slower “disassociation”…doesn’t go away any time soon (lasts 1-2 days)…not sick and in w/d• Does not fully press the receptor; not the same effects of a full agonist..a ”partial agonist”


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Addiction Medications usually target discreet receptors on the surface of brain cells (neurons)

All of these meds diminish reward effects and a-motivation

SMOKING: Acetylcholine/Nicotine receptors:Mixed agonist (go) / antagonist (no go) varenicline (Chantix)

OPIOIDS:Mu Opioid receptors:Agonist (go) methadoneMixed agonist/antagonist (go/no go) buprenorphine (Suboxone)Antagonist (no go) naltrexone (Vivitrol, oral naltrexone)

ALCOHOL:Glutamate/NMDA, GABA acamprosate

topiramate

STIMULANTSDopamine re-uptake mirtazapine

cocaine vaccine

ALCOHOL:Inhibitors of liver metabolism disulfiram (Antabuse)

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Rates of drug use and related problems in the US

Smoking

Alcohol use disorder

Prescription drug use disorder

310 million, US

Heroin use disorder

Cannabis use

Alcohol use55%

27%

15-20%

10%

3%

0.5%Cocaine, amphetamine, stimulant use 1.0%


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Quitting smoking is all about ‘MAT’

• Smoking is still #1 in terms of lives lost, in US and globally

• Treat w Nicotine and Varenicline (Chantix) or Wellbutrin (Buspar)

Nicotine replacement (NRT): patch, gum, inhalers, lozenges

Varenicline: titrate from 0.5mg to 2mg, x 12-16+ weeks

Wellbutrin: 150mg to 300mg, x7-12+ weeks

Combine: NRT + MEDS >> meds or NRT only

Quitline: 1-866-NY-QUITS

• E-cigs (vaping) to quit: recommended (UK-EU) vs. no (USA)…helpmore people quit smoking vs. NRT…but then more stay on e-cigslong-term…and many of these eventually smoke again (relapse)

• Vaping by teens is clearly bad…unless you are in France!

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Medications for Alcohol Use Disorders

• #1. Naltrexone (First, Best Option)• Daily pill or monthly extended-release (Vivitrol)• 50mg PO daily, naltrexone• 380mg IM monthly, XR-naltrexone• Opioid antagonist: can’t be on opioids

• Acamprosate (Camparal)• TID dosing, renal clearance, less effective v NT

• Disulfiram (Antabuse)• highly motivated patient, no significant CVD

• Topirimate (Topramax) - non-FDA approved but works OK


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Which medications for alcohol use disorders are currently permitted in your Court?

a.) Naltrexone (Vivitrol, Naltrexone Tablet) 21% f.) All of the above 38%

b.) Acamprosate (Camparal) 4% g.) None of the above 23%

c.) Disulfiram (Antabuse) 7% h.) Other (Use Chat Tool) 8%

e.) Topirimate (Topramax) 4%

Other Answers:

• Don’t have a DWI/Drug court

• Don’t deal with medication issues-administrative hearings only

• Gabapentin

• Methadone and Buprenorphine

• Baclofen

• Ondansetron

• As a health care professional, I hate Antabuse being court ordered

• Permitted is an unusual word in this context for my DTC, the Judge is not the doctor so we do not make a decision about what is permitted or not; we leave the MAT to the doctors to decide

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Naltrexone + alcohol effects

On naltrexone:• Alcohol and drinking is less rewarding in the short term• Drinks don’t taste as good, not as enjoyable, not as fun• NTX does not prevent alcohol intoxication• Reduces cravings – thinking about alcohol when not using

Mu Opioid Receptors OUD1984

AUD1994


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XR‐Naltrexone Alcohol Treatment in Primary Care

LeeJD, Grossman E, GourevitchMN, et al, J Substance Abuse Treatment, 2010

56% of patient stayed in treatment 90 days

• XR-NTX appears feasible as Primary Care Medical Management of alcohol dependence1

0.89

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Baseline Month 1 Month 2 Month 3

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Injection

3rd

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Injection

Daily drinking reductions were robust and seen within the first month

Treatment Retention

Drinking rates in treatment

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Disulfiram (Antabuse): not a brain drug


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Medications for Opiate Dependence

• For maintenance or detox

1. Methadone, full opioid agonist

Once daily, prevents withdrawal sx and craving, cost‐effective1

2. Buprenorphine, partial opiate agonist

Special DEA regulations/training, can be rx’ed in private MD offices

3. Naltrexone, full opioid antagonist

XR‐NTX formulation for opioid dependence

1 O’Brien CP. JAMA 2008.

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QUESTION #4

Which medications for opioid use disorders are currently permitted in your Court?

a.) Methadone 9%b.) Buprenorphine 11%c.) Naltrexone 12%e.) All of the above 50%f.) None of the above 17%g.) Other (Use Chat Tool) 8% (no additional answers from chat tool)


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Heroin use

Detox‐to‐Abstinence

Buprenorphine

Methadone

XR‐Naltrexone

Using Heroin100%

Abstinent0%

Using Heroin80%

Abstinent20%

Using Heroin50%

Abstinent50%

Deaths/year=

1‐2+%

Deaths/year=

0.5‐1.5%

Deaths/year=

0.5‐0.75%

1‐Year Abstinence and Death Rates:No treatment vs. detox‐to‐abstinence vs. medications

About half of persons starting meds are in

treatment and abstinent at 6‐12 months

Mortality is lower among persons on medications

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What is the difference between opioid agonists & antagonists?


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25-30 days

Methadone outcomes, 1965-2015

• Less heroin use• Less IV use• Less HIV transmission• Less overdose death• Less criminal behavior

(harder to show less recidivism)

• Saves taxpayers money• Longer lifespan


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Methadone: Effective, DOT‐only, Stigma

• Federally‐licensed clinics treating opioid dependence only• limited locations• limited number of treatment slots• may only take insurance• daily directly observed therapy (DOT)

• Patients have negative views (sedating, DOT, benzos, ‘rotting’)• Providers have negative views of methadone patients and

clinics

Buprenorphine Office‐based Treatment, US 2002‐present

• Medical office visit• Retail pharmacy• Chronic treatment


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Buprenorphine Products for OUD, 2002‐2020

Zubsolv

Generic BUP-NX

Sublocade 2019

Probuphine Implant 2016

Suboxone Tablets2002

2010

2009

Bunavail*daily tablets and film are mostly bup-naloxone combinations

Buprenorphine‐naloxone (Suboxone) maintenance produces better opioid treatment outcomes vs. detox and counseling only

Detox Relapse

In this outpatient study, relapse after brief detox w buprenorphine was 90%

WeissRD et al, Arch Gen Psyche, 2011


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Bellevue Primary Care Buprenorphine Clinic,2006-2013 (N=485)

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Transfers InductionsAll Patients

Retention in treatment

Extended‐Release Naltrexone (Vivitrol): the opioid antagonist approach

• Monthly intramuscularinjection

• Given by nurse, PA, MD,pharmacist

• Non‐narcotic, not a controlledsubstance

• Must detox off opioids first!!

• Jail, prison, detox, rehab,other

• Not for use if:

• Pregnancy

• Chronic pain requiring opioids


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Less heroin relapse among parolees and probationers: XR-NTX vs. Treatment as Usual, N=308 across 5 US Sites

LeeJD et al, 2016, NEJM

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XR-NTX leaving jail, the next 6 months and risk of relapse

NIDA U01 Trial (LeeJD), manuscript pending


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Summary

• All MAT for opioid use disorder has good data onfeasibility and effectiveness in CJS populations

• The neurobiologic basis for medication’s actionsand effects are well understood

• Approach to medication treatments for OUD andAUD are similar to smoking cessation and otherchronic diseases

• On medication treatments, patients tend to do better

• All can be combined w counseling, services, work,housing supports, etc.

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QUESTIONS??

THANK YOU

@DrJoshuaDLee


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The National Judicial College (NJC), through a generous grant from SAMHSA/PCSS, invites you to attend these one-hour, live webinars:

Practical Use of Medication Treatment for Judges: A Discussion Tuesday, June 30, 2020 at 11:00 a.m. PST / 12:00 p.m. MST / 1:00 p.m. CST / 2:00 p.m. EST

This webinar, through a panel discussion, features judges from around the country who will discuss their experience with medication treatment (MAT) for alcohol and opiate addicted defendants and participants. These national experts will focus on the legal, ethical, and practical issues surrounding the use of MAT. This webinar builds on the information from the June 9th Webinar with Dr. Joshua Lee, Medications for Alcohol and Drug Use Disorders 101: The Science of Medication Treatment, which while helpful, is not required to attend this webinar.

Visit https://www.judges.org/courses/ to view all of NJC’s courses.

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http://www.judges.org

https://pcssnow.org/

https://pcssnow.org/

https://www.judges.org/evrplus_registration/?action=evrplusegister&event_id=147

https://www.judges.org/courses/

https://sunnywithachanceofarmageddon.wordpress.com/2012/11/19/when-medications-go-wrong/

https://creativecommons.org/licenses/by-nc-nd/3.0/

FREE TRAFFIC WEBINARS FOR JUDGES DUI in Indian Country

Tuesday, June 23, 2020 at 10 a.m. PST / 11a.m. MST / 12 p.m. CST / 1 p.m. EST This webcast will address various aspects of handling Tribal Court DUI cases in order to build and enhance competency and skills of Tribal Judges. Topics to be covered include complaint filing procedures, discovery and pretrial procedures, setting the case for trial, evidentiary issues, and sentencing options.

These webinars are brought to you through generous funding from the National Highway Traffic Safety Administration [NHTSA].

Access to Justice in Impaired Driving Cases: The Costs of Pre-Trial Conditions

Wednesday, August 19, 2020 at 9 a.m. PST / 10 a.m. MST / 11 a.m. CST / 12 p.m. EST Access to justice has increasingly become the focus in courts across the country. This webcast will focus on the delicate balancing act of imposing pre-trial conditions on impaired drivers in traffic courts and the obstacles they often face in complying. This course will explore innovative and creative approaches to these cases while in the pre-trial stage and ways to avoid often crippling legal financial obligations and cost prohibitive conditions before final adjudication. This course will also address some of the practical challenges presented in imposing some conditions.

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