NBCC, NAADAC, CAADAC, CBBS approved continuing education presentation on treating persons with opiate addiction. Unlimited CEUs available at allceus.com for $69.99 per year.

1. TIPS 40 AND 43: Medication-Assisted
Treatment for Opioid Addiction in Opioid
Treatment Programs (40 HOURS)
 Dr. Dawn-Elise Snipes, PhD, LMHC, CRC, NCC
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2. Methadone Maintenance Facts
 Methadone does not produce euphoric,
tranquilizing, or analgesic effects like morphine
or heroin
 Therapeutic doses of methadone reduce or block
euphoric and tranquilizing effects of all opioid
drugs
 Over time, usually no changes were noted in
tolerance levels for methadone
 Methadone is effective when administered orally
 Methadone relieved opioid craving
 Methadone caused minimal side effects
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3. California Drug and Alcohol Treatment
Assessment's Findings
 Treatment was cost beneficial averaging $7
returned for every dollar invested
 Methadone treatment yields savings of $3 to
$4 for every dollar spent
 Patients in MAT showed the greatest
reduction in intensity of heroin use
 Decreased healthcare use
 Number of days of hospitalization, down
more than half during MAT
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4. Pharmacology
 5 Topics
1) Receptors
2) Function of opioids at receptors
3) Consequences of repeated administration and
withdrawal of opioids
4) The affinity, intrinsic activity and dissociation of
opioids from receptors
5) General characteristics of abused opioids
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5. Receptors
 Different types in the brain
 Mu receptor is most relevant to opioid
treatment
 Activation of the mu receptor allows opioids
to exert their analgesic, euphorigenic and
addictive effects
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6. Functions of Opioids at Receptors
 Full Agonists
 Activate receptors in the brain
 Bind to receptors and turn them
 Increasing doses of full agonists produce increasing
effects, until the receptor is fully activated
 Opioids with the greatest abuse potential are full
agonists
○ Examples of full agonists are morphine, heroin, methadone,
oxycodone and hydromorphone
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7. Functions of Opioids at Receptors cont…
 Antagonists
 Bind to opioid receptors, but instead of activating
receptors, they effectively block them
 Prevent receptors from being activated by agonist
compounds
 Like a key that fits in a lock but does not open it and
prevents another key from being inserted
○ Examples of opioid antagonists are naltrexone and naloxone
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8. Functions of Opioids at Receptors cont…
 Partial Agonists
 Partial agonists possess some of the properties of both
antagonists and full agonists
 Bind to receptors and activate them but not to the same
degree as full agonists
 Increasing effects of partial agonists reach maximum
levels and do not increase further, even if doses continue
to rise—the ceiling effect
 As higher doses are reached, partial agonists can act like
antagonists by occupying receptors but not activating
them and blocking full agonists from receptors
○ Buprenorphine is an example of a mu opioid partial agonist
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9. Consequences of Repeated
Administration and Withdrawal
 Repeated administration of a mu opioid agonist
results in tolerance and dose-dependent
physical dependence
 Withdrawal symptoms are similar to flu
 Spontaneous withdrawal
 begins 6–12 hours after the last dose
 peaks in intensity 36–72
 lasts approximately 5 days
 Precipitated withdrawal occurs when an
individual physically dependent on opioids is
administered an opioid antagonist or partial
agonist
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10. Affinity, Intrinsic Activity, and
Dissociation
 Affinity: strength with which a drug binds to
its receptor
 Intrinsic activity: degree to which a drug
activates its receptors
 Dissociation: measure of the disengagement
of the drug from the receptor
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11. Characteristics of Abused Drugs
 Rate of onset of the pharmacological effects
of a drug, and its abuse potential, is
determined by:
 the drug's route of administration
 its half-life
 its lipophilicity which determines how fast the drug
reaches the brain
 Abuse Potential is related to:
 ease of administration
 cost of the drug
 how fast the user experiences the desired results
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12. Naltrexone
 Antagonist
 Naltrexone may decrease the likelihood of
relapse to drinking
 Can precipitate an opioid withdrawal
syndrome in buprenorphine-maintained
patients
 Should not be prescribed for patients being
treated with buprenorphine for opioid
addiction
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13. Buprenorphine
 Typical analgesic dose of buprenorphine is
0.3–0.6 mg (IM/IV), lasting about 6 hours
 Because it is a partial agonist, higher doses of
have fewer adverse effects
 High affinity prevents displacement
 Slow dissociation rate (half life)
 Daily dosing is not necessarily required
 Abuse of buprenorphine primarily via
diverting sublingual tablets to the injection
route
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14. Buprenorphine cont…
 Lower abuse/overdose potential than full agonists
due to ceiling
 Can precipitate an opioid withdrawal syndrome
 Buprenorphine treatment should not be combined
with opioid antagonists (e.g., naltrexone)
 Buprenorphine is metabolized by the cytochrome
P450 3A4 enzyme system
 Other medications that interact with this enzyme
system should be used with caution
 Plasma concentrations of these drugs increase when
they are administered with newer antidepressants
 Buprenorphine's partial mu agonist properties make
it mildly reinforcing thus encouraging patient
compliance with regular administration
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15. Buprenorphine/Naloxone Combination
 Developed for the U.S. market to decrease the
potential for abuse
 When taken as directed  buprenorphine
effect
 When dissolved and injected  naloxone
(antagonist) effect
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16. MAT Comprehensive Care
 Effective treatment addresses:
 Mental Health
 Substance Abuse
 Employment/Finances
 Housing
 Social Skills and Support
 Relationship Skills
 Parenting Skills
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17. Good Treatment Candidates
 Are interested in treatment for opioid
addiction
 Have no contraindications
 Can be expected to be reasonably compliant
with such treatment
 Understand the benefits and risks
 Are willing to follow safety precautions
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18. Poor Treatment Candidates
 Co-morbid dependence on high doses of
benzodiazepines or other central nervous
system depressants (including alcohol)
 Significant untreated psychiatric co-morbidity
 Active or chronic suicidal or homicidal
ideation/attempts
 Multiple previous treatments for drug abuse
with frequent relapses
 Poor response to previous treatment attempts
with buprenorphine or methadone
 Significant medical complications
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19. Services
 Counseling
 Group and/or individual
 Strengths-based
 Motivational approaches
 Cognitive behavioral approaches
 Addresses SA and MH concurrently
 Realizes the interaction between SA, MH and other
issues
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20. Services cont…
 Psychoeducation
 Fundamentals of addiction
 Communication skills
 Coping skills
 Relapse prevention
 Employment/interview skills
 Relationship skills
 Stinkin’ Thinkin’ (Cognitive distortions and
Irrational Thoughts)
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21. Services cont…
 Medications
 Mental health
 Substance abuse (Methadone, Antabuse)
 Pain
 Pro-social Activities
 To address “down time”
 Provide support and acceptance from pro-social
peers
 Help people learn how to have fun while sober
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22. Services cont…
 Wrap-around
 Child care
 Transportation
 Food
 Medical and dental care
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23. Possible Side Effects of Opioid Agonist
and Partial Agonist Therapy
 Weakness, loss of  Dry mouth
energy (asthenia)  Nausea, vomiting,
 Back pain, chills abdominal pain
 Hot flashes, sweating  Joint and/or muscle
 Flu syndrome and pain (arthralgia)
malaise: cough, rhinitis,  Abnormal dreams
headache  Anxiety, depression
 Weight gain or loss  Sexual side effects
 Constipation  Euphoria
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24. Possible Side Effects of Opioid Agonist
and Partial Agonist Therapy cont…
 Decreased sensitivity  Postural hypotension
to tactile stimulation  Abnormal liver
(hypoesthesia) function tests
 Insomnia  Hyperprolactinemia
 Somnolence  Absence of menstrual
 Yawning periods (amenorrhea)
 Electrocardiogram  Rash
changes, decreased  Blurred vision
heart rate
(bradycardia)
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25. Risks of Drug Interaction
 During any agonist-based pharmacotherapy, abusing
respiratory depressants (e.g., alcohol, other opioid
agonists, benzodiazepines) may be fatal.
 Current or potential cardiovascular risk factors may
be aggravated by opioid agonist pharmacotherapy.
 Other drugs often interact with opioid agonist
medications.
 Patients should know the symptoms of arrhythmia:
 palpitations, dizziness, lightheadedness, syncope or seizures
 seek immediate medical attention
 Maintaining and not exceeding dosage
schedules, amounts and other medication regimens
are important to avoid adverse drug interactions.
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26. *Discussion Forum*
 Think of your experience from working with
patients who are on an opioid agonist or partial
agonist therapy.
 How would you generalize results of the therapy in
relation to side effects, interaction with any other drugs,
effect on co-morbid disorders, and patient’s ability to
successfully avoid substance abuse?
 What is your professional stance on furthering the area
of agonist-type therapies (further pharmaceutical
research and availability; increased usage of these
medications)?
 Please take a moment to share your responses in
our professional’s discussion forum. Thank you.
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27. The Consensus Panel Recommends the
Following Goals for Initial Screening
1) Crisis intervention
2) Eligibility verification
3) Clarification of the treatment alliance
4) Explanation of patient and program
responsibilities
5) Education
6) Communication of essential information about
MAT and OTP operations and discussion of the
benefits and drawbacks of MAT
7) Identification of treatment barriers
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28. Behavioral and Circumstantial Indicators
of Suicide Risk
 Talk about committing suicide
 Trouble eating or sleeping
 Drastic changes in behavior
 Withdrawal from friends or social activities
 Loss of interest in hobbies, work, or school
 Preparations for death, such as making a will
or final arrangements
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29. Behavioral and Circumstantial Indicators
of Suicide Risk cont…
 Giving away prized possessions
 History of suicide attempts
 Unnecessary risk taking
 Recent severe losses
 Preoccupation with death and dying
 Loss of interest in personal appearance
 Increased use of alcohol or drugs
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30. Expressed Emotions that May
Indicate Suicide Risk
 Can't stop the pain  Can't make the
 Can't think clearly sadness go away
 Can't make decisions  Can't see a future
 Can’t see any without pain
solutions  Can't see oneself as
 Can't sleep, eat, or worthwhile
work  Can't get someone's
 Can't get out of attention
depression  Can't seem to get
control
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31. Recommended Responses to Indicators
of Suicidality
 Be direct. Talk openly and matter-of-factly
about suicide.
 Be willing to listen.
 Don’t debate whether suicide is right or
wrong.
 Get involved. Become available.
 Don't dare an individual to do it.
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32. Recommended Responses to Indicators
of Suicidality cont…
 Don't act shocked.
 Don't be sworn to secrecy.
 Offer hope but not glib reassurances.
 Take action. Remove means, such as guns or
stockpiled pills.
 Get help from persons or agencies
specializing in crisis intervention and suicide
prevention.
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33. Recommended Procedures for Identifying
and Addressing Domestic Violence
 Look for physical injuries
 Pay attention to other indicators:
 history of relapse or treatment noncompliance
 inconsistent explanations for injuries and
evasiveness
 complications in pregnancy
 possible stress- and anxiety-related illnesses and
conditions
 Fulfill legal obligations to report suspected
abuse
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34. Recommended Procedures for Identifying
and Addressing Domestic Violence cont…
 Get the patient’s permission before
discussing their case
 Understand which types of subpoenas and
warrants require records be turned over to
authorities
 Convey there is no justification for battering
 Contact domestic violence experts when
battery is confirmed
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35. Psychosocial Problems that Decrease
Patient Success
 Lack of stable housing
 Nonexistent or dysfunctional family
relationships
 Poor social skills and lack of a supportive social
network
 Unemployment; lack of employable skills
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36. Working with Elderly Patients
 Monitor the increased risk for drug interactions
 Differentiate between co-occurring disorders and
symptoms and disorders associated with aging
 Differentiate between depression and dementia
 Screen for and treat physical and sexual abuse
 Develop referral sources for elderly patients
 Be sensitive to the elderly patient population
 Provide treatment for age-associated stressors
 Assess and adjust dosage levels of medication for
the slowed metabolism of many elderly patients
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37. 6 Patient-Centered Phases for MAT Services
1) Acute
2) Rehabilitative
3) Supportive-care
4) Medical maintenance
5) Tapering
6) Continuing-care phases
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38. Acute Phase
 Elimination of Illicit Opioids for at Least 24 Hours
 Initially prescribe a medication dosage that
minimizes sedation and negative side effects
 Assess the safety and adequacy of each dose after
administration
 Rapidly but safely increase dosage to suppress
withdrawal symptoms and cravings and
discourage patients from self-medicating
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39. Acute Phase cont…
 Provide or refer clients for services to lessen
the intensity of other biopsychosocial
disorders
 Help patients identify high-risk situations
and develop alternative strategies for coping
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40. Goals of the Acute Phase
1) Elimination of symptoms of
withdrawal, discomfort, or craving for opioids
and stabilization
2) Express feelings of comfort and wellness
throughout the day
3) Abstinence from illicit opioids and abuse of
opioids normally obtained by prescription, as
per drug tests
4) Engagement with treatment staff in assessment
of medical, mental health, and psychosocial
issues
5) Satisfaction of basic needs for food, shelter, and
safety
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41. Transition From the Acute to the
Rehabilitative Phase
 Amelioration of signs of opioid withdrawal
 Decrease in physical drug craving
 Elimination of illicit-opioid use and
reduction in other substance use
 Completion of medical and mental health
assessment
 Development of a treatment plan to address
psychosocial issues
 Satisfaction of basic needs for food, clothing,
shelter, and safety
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42. Eligibility for the Medical Maintenance
Phase of Treatment
 2 years of continuous treatment
 Abstinence from illicit drugs and from abuse
of prescription drugs for the period indicated
by Federal and State regulations
 No alcohol use problem
 Stable living, safe conditions
 Stable and legal source of income
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43. Eligibility for the Medical Maintenance
Phase of Treatment cont…
 Involvement in productive activities
 No criminal or legal involvement for at least
3 years and no current parole or probation
status
 Adequate social support system
 Absence of significant unstabilized co-
occurring disorders
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44. OTP Required Services
 Comprehensive psychosocial assessment
 Mental Health
 Substance Abuse
 Physical Health
 Psychosocial Issues
 Initial and yearly medical assessment
 Medication dispensing
 Drug tests
 Identification of co-occurring disorders
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45. OTP Required Services cont…
 Treatment planning
 Case Management
 Co-Occurring disorders counseling
 Evaluation of and interventions to address
family problems
 HIV and Hepatitis C virus (HCV)
testing, education, counseling, and referral
 Referral for additional services as needed
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46. Improve Patient Retention
 Individualize medication dosages
 Clarify program goals and treatment plans
 Simplify the entry process
 Attend to patients' financial needs
 Reduce the attendance burden
 Provide useful treatment services as soon as
possible
 Enhance staff-patient interactions
 Improve staff knowledge and attitudes about
MAT
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47. Counseling in MAT
 Provide support and guidance
 Monitor other problematic behaviors
 Help patients comply with OTP rules
 Identify problems that need extended
services and referral
 Identify and remove barriers to full
treatment participation and retention
 Provide motivational enhancement for
positive changes in lifestyle
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48. The Standard Components of Substance
Abuse Counseling
 Assistance in locating and joining mutual-help/
peer support
 Education about addiction and the effects of
substances of abuse
 Education about relapse prevention strategies
 Identification of unexpected problems needing
attention
 Assistance in complying with program rules
and regulations
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49. The Standard Components of Substance
Abuse Counseling cont…
 Information about stress- and time-
management techniques
 Assistance in developing a healthy lifestyle
 Assistance in joining socially constructive
groups
 Continuing education on health issues
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50. Format of Individual Counseling
Sessions
 Review how patient feels, coping with cravings, or
changing his or her lifestyle
 Review drug test results and what they mean
 Identify emergencies and decide how to address
them
 Review the treatment plan
 Identify measurable goals and reasonable time
frames
 Review progress in achieving goals, including
abstinence
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51. Format of Individual Counseling
Sessions cont…
 Discuss dosage and take-home medications
 Discuss legal concerns
 Discuss family concerns
 Provide liaison services
 Address routine issues (e.g., transportation,
childcare)
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52. Strategy for Contingency Management in
MAT
 Pick a target behavior that can be measured
easily
 Provide non-monetary incentives for
accomplishing the desired behavior
 such as non-refundable movie passes
 Specify link between the targeted behavior and
the reward
 Put the contract in writing; specify its duration
and any changes over time in contingencies
 shaping
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53. Strategies for Psychotherapy in MAT
 Devote part of each session
 addressing patient’s most recent successes and failures
regarding their substance use
 Adopt a more active therapist role
 Strengthen patient’s resolve to stop substance use
 Teach patient to recognize
 relapse warning signs and develop coping skills
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54. Strategies for Psychotherapy in MAT
cont…
 Assist in rearranging priorities
 reduce preoccupation with substance use
 Assist patient in managing painful affects
 Help patient enhance social functioning and
supports
 Use psychotherapy only after a strong
therapeutic alliance has developed or other
supportive structures are in place
 guard against relapse
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55. Strategies for Psychoeducation
 Psychoeducation serves as an orientation to both
OTP operational and recovery processes.
 Involve family members and selected friends, with
consent
 Adapt educational strategies and materials to the
patient's culture and family
 Discuss methadone and other medications; dispel myths
 Discuss the implications of continuing substance abuse
 Discuss sexual behaviors that may affect relapse
 Discuss the power of triggers with patients and families
 Incorporate special groups to discuss parenting, childcare,
women's issues and coping with HIV/AIDS and HCV
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56. Common Topics in Patient Education
Sessions
 Physical and psychological effects of opioid and
other substance abuse
 Health education information
 Effects of drug use on family and other relations
 Introduction to mutual-help groups such as NA
 Effects and side effects of addiction treatment
medications and interactions with other drugs
 Symptoms of co-occurring disorders
 Compulsive behaviors besides substance abuse
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57. Patient Goals in Building Relapse
Prevention Skills
 Understand relapse as a process, not an event.
 Develop new coping skills for high-risk situations.
 Make lifestyle changes to decrease the need for
drugs.
 Increase participation in healthy activities.
 Understand and address social pressures to use
substances.
 Develop a supportive relapse prevention network.
 Develop methods of coping with negative
emotional states.
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58. Patient Goals in Building Relapse
Prevention Skills cont…
 Learn methods of coping with cognitive
distortions.
 Recognize relapse warning signs and triggers.
 Combat memories of drug abuse-associated
euphoria.
 Reinforce recollections of negative aspects of
drug use.
 Avoid people, places, and things that might
trigger drug use.
 Develop pleasurable and rewarding alternatives
to drug use.
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59. First Responses to a Behavioral Problem
 Identify it
 Review the treatment plan
 Discuss plan with the patient
 Modify or intensify treatment to match the
patient's treatment status
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60. Remedial Approaches
 Reevaluate medication dosage, plasma levels, and
metabolic responses; adjust dosage for adequacy
and patient comfort
 Assess co-occurring disorders; provide
psychotherapy and pharmacotherapy as needed
 Intensify counseling or add ancillary services
 Treat medical or other associated problems
 Consider alternative medications
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61. Remedial Approaches cont…
 Provide inpatient detoxification from
substances of abuse, and continue opioid
pharmacotherapy
 Change counselors if indicated
 Reschedule dosing to times when more staff
are available
 Provide family intervention
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62. Physical Interventions to Managing
Chronic Nonmalignant Pain
 Cold and heat
 Ultrasound
 Counterstimulation
 TENS*
 Massage and manipulation
 Stretching and strengthening
 Orthotics, splints and braces
 Positioning aids
 pillows, supports
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63. Psychological Interventions to Managing
Chronic Nonmalignant Pain
 Deep relaxation
 Biofeedback
 Guided imagery
 Cognitive behavioral therapy
 Mood disorder treatment
 Posttraumatic stress disorder treatment
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64. Summary
 MAT uses a phased approach
 Patients are provided integrated, holistic
treatment
 MAT provides a viable means for many
people to end their addiction to opiate based
drugs.
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65. Common Drug Combinations and Effects
 Heroin + alcohol
 Enhance a high; create euphoria or sedation
 Heroin followed by alcohol
 Medicate opioid withdrawal; medicate cocaine overstimulation
(e.g., anxiety, paranoia)
 Heroin + cocaine (“speedball”)
 Enhance or alter cocaine euphoria
 Heroin followed by cocaine
 Medicate opioid withdrawal
 Cocaine + alcohol
 Enhance high; reduce cocaine overstimulation (e.g., anxiety,
paranoia)
 Cocaine followed by heroin
 Reduce cocaine overstimulation (e.g., anxiety, paranoia);
modulate the cocaine crash
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66. Common Drug Combinations and Effects cont…
 Methadone plus alcohol
 Create a high; sedate
 Methadone plus cocaine
 Reduce cocaine overstimulation (e.g., anxiety, paranoia);
moderate the cocaine “crash”
 Methadone plus benzodiazepines
 Create a high; sedate
 Any opioid plus any nonbenzodiazepine sedative
 Create a high; sedate
 Any opioid followed by any nonbenzodiazepine
sedative
 Medicate opioid withdrawal
 Any opioid plus amphetamine
 Create a high
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67. Drug Descriptions to Know
 Methadone  Buprenorphine
 Oral solution, liquid  Sublingual tablet
concentrate,  Partial mu opioid agonist
tablet/diskette, and  Schedule III
powder
 Full mu opioid agonist  Buprenorphine-
 Never formally approved naloxone
by FDA  Sublingual tablet
 Schedule II  Partial mu opioid
agonist/mu antagonist
 LAAM
 Schedule III
 Oral solution
 Full mu opioid agonist  Naltrexone
 Schedule II  Oral tablet
 Mu opioid antagonist
 Not Scheduled
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CDS Ventures, LLC