Opioid Agonist Treatment: “Trading one substance for another? ” Joseph Sakai, M. D. Copyright Alcohol Medical Scholars Program 1
Objectives: • • Opioids and opioid dependence Natural course Methadone Other agonist treatments Copyright Alcohol Medical Scholars Program 2
Opioids, Opioid Dependence: • Define opioids – Opiates – Semi-synthetic – Synthetic Copyright Alcohol Medical Scholars Program 3
Opioids, Opioid Dependence: • Endogenous opioid system – Receptors • Mu • Delta • Kappa – Endorphins • Beta-endorphins • Enkephalins • Dynorphins Copyright Alcohol Medical Scholars Program 4
Opioids, Opioid Dependence: • Opioid dependence: Tolerance Withdrawal Use more than intended Unable to cut down Increased time using Give up other activities Use despite consequences Copyright Alcohol Medical Scholars Program 5
Opioids, Opioid Dependence: • Epidemiology – Lifetime use • 1. 8% of 10 th graders used heroin (lifetime) • 3. 6 million Americans have used heroin – Dependence • 1: 4 heroin users with lifetime dependence • 1: 1000 in US with opioid dependence in 2002 Copyright Alcohol Medical Scholars Program 6
Natural Course: • Detox alone high relapse • 20 yr after detox – 10% stable abstinence at 5 yrs – 35% stable abstinence at 18 year • 24 yr f/u – ~20% no heroin use: last 10 yrs of the study Copyright Alcohol Medical Scholars Program 7
Natural Course: • Medical risks: – Abscesses – Sepsis – Osteomyelitis – Thrombophlebitis – Endocarditis Copyright Alcohol Medical Scholars Program 8
Natural Course: • Medical risks: – HCV • 70% IV users • 65% after 1 yr needle use; ~85% at 5 yrs – HIV • IV users ~75% of new HIV infections • HIV ~20% Copyright Alcohol Medical Scholars Program 9
Natural Course: • Death – Overdose 1. 5%/yr – 24 yr study – 28% sample deceased – Not in tx; 63 x expected mortality rate • Low employment: – – 36. 4% active users employed Heroin dosed Q 6 hours Need time to recover But need money to buy the drug Copyright Alcohol Medical Scholars Program 10
Natural Course: • Crime: – Most commit crimes – F/u 10 years ~18% incarcerated – One study n=573 12 month period: • >80, 000 crimes reported • Costs: – Medical costs: $1. 2 billion per yr – Total cost estimate: $20 billion per yr Copyright Alcohol Medical Scholars Program 11
Natural Course: Summary • • • Unlikely to remit with detox alone Medical risks High mortality Low employment Crime High cost to society Copyright Alcohol Medical Scholars Program 12
Treatment: Goals • • Complete abstinence Reduce use of heroin Reduce harm Increase employment Reduce crime Engage in treatment Be cost effective Copyright Alcohol Medical Scholars Program 13
Treatment: Modalities • Rehabilitation – Engage patient – Support abstinence – Prevent relapse – Life management skills – Coping skills Copyright Alcohol Medical Scholars Program 14
Treatment: • Rehabilitation – Individual – Groups – Urines – Psychosocial treatments – Medications Copyright Alcohol Medical Scholars Program 15
Treatment: • Antagonists – Naltrexone • • • Pure antagonist Absorbed orally 50 -150 mg/dose Dosed daily or 3 x/wk Retention poor Copyright Alcohol Medical Scholars Program 16
Treatment: • Agonists – Theory • Pre-existing dysphoria • Pre-existing receptor dysfunction • Induced receptor dysfunction Copyright Alcohol Medical Scholars Program 17
Treatment: Methadone • • Mu agonist Half life 22 -48 hours Dosing (slowly ↑ to 80 mg +) Needs specialized clinics Copyright Alcohol Medical Scholars Program 18
Treatment: Methadone • • ↓ Heroin use by 50% ↓ HIV 4 fold ↑ Employment 24% ↓ 50% criminal activity Copyright Alcohol Medical Scholars Program 19
Treatment: Methadone • ↑ Retention in rehabilitation 28 times • ↑ Retention in HCV treatment • ↑ Health outcomes (HCV, HIV) Copyright Alcohol Medical Scholars Program 20
Treatment: Methadone • ↓ Mortality 50% – Before and after methadone – In vs out of treatment • Cost effective – <$13/day – 4: 1 cost benefit ratio Copyright Alcohol Medical Scholars Program 21
Methadone: Summary Yes • • Complete abstinence Reduce use of heroin Reduce harm Increase employment Reduce crime Engage in treatment Save lives Be cost effective Copyright Alcohol Medical Scholars Program No X X X X 22
Treatment: Barriers • • • Out of medical mainstream Stigma of specialized clinics Location of clinics Daily dosing Federal regulations Copyright Alcohol Medical Scholars Program 23
Treatment: Methadone • Barriers to use of methadone • Misconceptions – Methadone dependence – Trading one substance for another? – Methadone must be taken for life Copyright Alcohol Medical Scholars Program 24
Treatment: LAAM (levo-alpha acetyl methadol) • LAAM – Mu agonist – Orally dosed – Effects: 72 hours – Dose (20 -100 mg three times per week) – Licensed clinics Copyright Alcohol Medical Scholars Program 25
Treatment: LAAM • Retention ↓(39% vs. 60% LAAM vs. methadone) • Same reduction in heroin use (55% vs. 46% LAAM vs. methadone) • Safety concerns – Cardiac abnormalities (QT prolongation) – LAAM (ORLAAM) sale and distribution discontinued Copyright Alcohol Medical Scholars Program 26
Treatment: Buprenorphine • Buprenorphine – Agonist/antagonist – Half life 37 hrs – Dosing 8 -32 mg/d – Can precipitate withdrawal – Absorption (poor oral) Copyright Alcohol Medical Scholars Program 27
Treatment: Buprenorphine • Office based – Increased access • 20% of heroin dependent persons can get methadone • Methadone not available in some states – Any physician can be trained • Safer in overdose • Risk for diversion – Can combine with Naloxone to ↓injection Copyright Alcohol Medical Scholars Program 28
Treatment: Buprenorphine • Outcome – Retention in treatment • Slightly lower than methadone • 50% vs. 59%(buprenorphine vs. methadone) – Heroin use • Slightly worse than methadone (low dose) • 38% vs. 40. 5% (buprenorphine vs. methadone) Copyright Alcohol Medical Scholars Program 29
Conclusions: • Opioid dependence is destructive • Methadone maintenance is effective • Other agonist treatments are available A challenge to you… Copyright Alcohol Medical Scholars Program 30
Скачать презентацию Opioid Agonist Treatment Trading one substance for another
acb3fdd8072c60eac8ca13ad9901b5da.ppt