OVERVIEW OF MEDICATION ASSISTED
TREATMENT
Sarah Akerman MD
Assistant Professor of Psychiatry Director of Addiction Services
Conflicts of Interest
I do not have any potential conflicts of interest to
Outline
What are opioids and how do they work?
Disease Model of Addiction
Outline
What are opioids and how do they work?
Disease Model of Addiction
Opioids
Opiates - from P. somniferum
Morphine Heroin Codeine Opioids - synthetic
Oxycodone, OxyContin Methadone Buprenorphine Meperidine (Demerol)Opioids
Pharmaceuticals
Swallow
Chew
Intranasal
Intravenous
Heroin
Intranasal
Intravenously
“skin popping”
How do opioids work?
Bind to opioid receptors in the
brain, spinal cord, gastrointestinal
track, other organs
Opioid receptors are molecules on the
surface of cells in the body (μ,δ,κ)
Mu receptor (μ) most relevant to opioid
abuse
Reduce the perception of pain
Reduce the intensity of pain signals to the
brain
Affect brain areas controlling emotion and
reduce effects of a painful stimulus
Other indications: cough,
diarrhea, treatment of addiction
NIDA
Opioids
Intoxication
Drowsiness
Confusion
Decreased temperature
Decreased respiration
Pupils constrict
Gastrointestinal
movement decreases
(nausea, constipation)
No pain
Euphoria
Why do people take drugs?
Drug use starts out because it is pleasurable and/or
helps avoid pain
Drug use is pursued in such a way that negative
consequences follow
Drug use persists in the face of negative
consequences and the desire to quit
Operant Conditioning
Reinforcement increases the frequency of a behavior
Positive reinforcement
Behavior makes a good feeling start
Get “high”
Negative reinforcement
Behavior makes a bad feeling stop
Avoid withdrawal, negative feelings,
Not All Drug Users Become Addicted
% of People Who Try a Drug and go on to Develop a
Substance Use Disorder:
Cocaine: 17-22% (IN)
Heroin: 23%
Cannabis: 9-10%
Alcohol:15%
Cigarettes: 32%
Etiology
Genes
Environment
- Adversity:
- Low socioeconomic status - Unemployed
- Partner/friends who use - Lack of Support
- Temperament Factors - Motivation for Drug - Epigenetics
- Stressful events
- Trauma, maltreatment - Cumulative Stress
Co-Occurring Disorders
OUD
PTSD
Depression Personality Disorders Anxiety Cigarette Smoking Other illicit drug useDSM 5 Substance Use Disorder
Maladaptive pattern of drug use for >12 months
Tolerance Withdrawal
More use than intended (loss of control) Unsuccessful efforts to quit
Significant time spent in procurement, use, recovery Activities (occupational, social etc.) given up
Continued use in the face of adverse health effects Recurrent interpersonal problems from use
Use under dangerous conditions Craving
DSM 5 Substance Use Disorder
2-3- “Mild”
4-5- “Moderate”
≥6- “Severe”
Physiological dependence is neither necessary nor
Outline
What are opioids and how do they work?
Disease Model of Addiction
PFC ACG OFC SCC Hipp NAcc VTA Amyg
REWARD
INHIBITORY
CONTROL
MOTIVATION/
DRIVE
MEMORY/
LEARNING
Brain Centers Involved in Addiction
After Nora Volkow, Director NIDA, 2004 Locus Ceruleus added, after Koob
Disease Model of Addiction
All addictive substances act on specific areas of the
brain
Prolonged use
pervasive change in brain function
Changes persist after drug use stops
The addicted brain is different from the non-addicted
brain:
Brain metabolic activity Receptor availability Gene expression
Disease Model of Addiction
Identifiable symptoms
A predictable course
Treatment that is as successful as that of many
chronic diseases (e.g. diabetes, hypertension,
asthma)
Outline
What are opioids and how do they work?
Disease Model of Addiction
Pl
asma
Co
ncentration
Time
Opioid Agonist Treatment
Euphoria/High
Feeling Normal
Craving/Withdrawal Heroin /short acting
Methadone
Dispensed at Opioid Treatment
Programs
Staffing and practices directed by Federal law (42 CFR Part 8); Schedule II
Can use it in taper and maintenance
Compared to psychosocial interventions
alone
Increased treatment retention Decreased opioid use
Better enables participation in a
Methadone
Works on the same receptor (mu opioid
receptors) as heroin and other abused opioids
Binds to receptor and activates it
Increasing doses produces increasing effects until a maximum effect is achieved (receptor fully activated)
Prevents withdrawal, diminishes drug craving
Long half life
Stops negative reinforcement
Tolerance attenuates the effects of
heroin and other opioids
Prevents positive reinforcement
Buprenorphine (Subutex) and
Buprenorphine/Naloxone (Suboxone)
Available as office based treatment with qualified
providers, Schedule III
Can be used in taper or maintenance treatment
Compared to psychosocial interventions alone:
Improves treatment retention Reduces opioid use
Better enables participation in a
Buprenorphine (Subutex) and
Buprenorphine/Naloxone (Suboxone)
Works on the same receptor (mu opioid receptors) as
heroin and other abused opioids
Partial agonist - binds to the receptor and activate the receptor partially
Increasing the dose does not lead to as great an effect as does increasing the dose of a full agonist- less of a maximal effect is achieved
Binds with high affinity
Prevents positive reinforcement Long half life (20-44 hours)
Buprenorphine (Subutex) and
Buprenorphine/Naloxone (Suboxone)
Pros
Ceiling effect imparts safety
Less respiratory depression compared to full agonists Less risk of overdose than full agonists
Blocks effects of other opioids
Flexibility of office based treatment
Cons
Potential for abuse, diversion
Naloxone/Naltrexone (Vivitrol)
Works on the same receptor (mu opioid
receptors) as heroin and other abused opioids
Antagonist
Binds to the receptor, but doesn’t activate the receptor
Blocks the receptor from being bound by a full agonist or
partial agonist
Like putting gum in a lock
Opioid Use Disorder Treatment
Outcomes
Without opioid agonist therapy
(methadone/buprenorphine)
90-95% relapse within months
Sub-groups with better outcomes (short term use, no IV use, good social support)
With opioid agonist therapy
66% treatment retention at one year
50% of those in treatment with some drug use
Decreased mortality, criminal involvement & healthcare emergencies
Increased employment
Treatment duration (days) Remain ing in tr eat ment (nr) 0 5 10 15 20 0 50 100 150 200 250 300 350 Detox/placebo Buprenorphine
Buprenorphine Maintenance/Detoxification: Retention
Length of Treatment?
Guidance from SAMHSA TIP 43 is “at least 2 years”
Stability in multiple domains of life
Social
Occupational Family
