Supporting Clients on Medication Assisted Therapies

416 -Supporting Clients on Medication Assisted Therapies
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs Counselor Education
Podcast Host: Counselor Toolbox, Case Management Toolbox, NCMHCE Exam Review
CEUs at: https://allceus.com/member/cart/index/product/id/1123/c/

Objectives
– Define MAT
– Explore barriers to treatment
What is Our Goal
– Help people
– Reduce symptoms of depression and anxiety
– Agitation
– Sleep disruption
– Anhedonia
– Fatigue
– Feelings of worthlessness and guilt
– Stay alive (not overdose or commit suicide)
– Be relatively pain free (bidirectional with depression and anxiety)
– Be independent
– Improve interpersonal relationships
– Be financially secure
– Be “productive” members of society to their ability

Goals
– Pain, financial instability, lack of independence, poor relationships, mood disorders, low self-esteem, lack of effective coping skills are common in people addicted to opioids

To Achieve This Goal
– Clients must
– Enter treatment
– Stay in treatment long enough to:
– Get through any PAWS syndromes caused by switching to MAT
– Enable their neurotransmitters to balance out
– Address biopsychosocial issues that trigger or maintain illicit drug use (SPACE)
– Social
– Physical
– Affective
– Cognitive
– Environmental
Question
– Do you have biases towards clients who take antidepressants- Benzodiazepines-
– Methadone is a serotonin re-uptake inhibitor
– Buprenorphine is a partial agonist
– Do you have biases toward clients who take opioids or gabapentin for chronic pain-
– It is possible to develop physical dependence on gabapentin and experience withdrawal effects for up to 45 days
Review of Terms
– Agonists–medications that bind with the brain’s receptors and produce opioid-like effects (Methadone, morphine, fentanyl, heroin)
– Partial agonists-medications that bind with given receptors and only produce limited opioid-like effects.(Buprenorphine)
– Antagonists-medications that block receptors and prohibit opioid-like effects.(Naloxone)
– Street and pain-killer opioids are “short acting”
– MAT is “long acting”

Benefits of MAT
– Methadone does not create a pleasurable or euphoric feeling from mu-receptor activation
– The medications used in MAT reduce cravings, prevent withdrawal and help normalize brain function so that you can focus on developing the healthy thought and behavior patterns that will sustain recovery. (SAMHSA, 2003)
– MAT provides individuals a taper of long-acting opioid medications as a way to wean them off of stronger opioids such as heroin
– A minimum of 12 months is required for methadone maintenance to be effective (NIDA, 2009).

Benefits of MAT
– Reduce overdose risk
– Improve the chance of survival
– Reduce the risk of relapse
– Improve retention in treatment for an adequate period of time to address biopsychosocial issues
– Employment
– Pain
– Other health issues
– Relationship problems
– Mood disorders (The correct SSRI takes up to 2 months to take effect)
– Reduce criminal activities associated with substance use disorders
– Reduce negative health outcomes, including HIV and hepatitis infection
– Improve birth outcomes among addicted pregnant women

Stigma
– Stigma is typically a social process characterized by exclusion, rejection, blame or devaluation that results from an adverse social judgment about a person or group
– The presence of stigma leads to ongoing discrimination and marginalization with detrimental effects for clients, families and communities including decreased self esteem, increased isolation and vulnerability, and a reduced likelihood of service access.
– Associative stigma is the process of being stigmatized due to having a close association with a person who is stigmatized – as if the significant other or clinician was somehow tainted by the relationship. (Halter, 2008)

Questions to Ask
– Why did the person start using opioids-
– What benefit are they getting from opioids-
– Antidepressant
– Antianxiety
– Pain relief
– Improved sleep which reduces anxiety, depression and pain
– “Confidence”
– “Energy”
Depression
– Our endogenous opioid system is important in controlling feelings of pain, stress, anxiety, hopelessness, and pleasure and regulating levels of other neurotransmitters
– Opioids are a system depressant and can increase depression in some people
– Treatment resistant MDD impacts 10-20% of people with depression
– Methadone and buprenorphine serotonin reuptake inhibitors and also acts on the mu-opioid receptor and glutamate receptor
– Like ketamine (which is not an opioid)

Depression
– Ketamine has a lower risk of respiratory depression and lower affinity for mu-opioid receptors than opioids.
– Ketamine is a preferred treatment for a fast-acting antidepressant
– Buprenorphine has shown great potential for use as an antidepressant.
– Heightened clinician awareness of the possibility of serotonin toxicity among patients taking opioids and serotonergic medications is called for.

Anxiety
– Deficiencies in the opioid system can also contribute to anxiety and reduced serotonin.
– Opioid receptors and opioids themselves play a role in stress and anxiety.
– Our endogenous opioid system boosts the effects of benzodiazepines
– Taking opioids and benzodiazepines concurrently is life threatening
– Some parts of this opioid system actually increase anxiety
– Anxiety is one of the symptoms of opioid withdrawal, which is one of the reasons for relapse

OCD
– Buprenorphine augmentation improved symptoms of OCD, compared to placebo
Pain
– Long-term use of opioids, including methadone, either illicitly or for therapeutic purposes, has profound effects on the perception of pain
– Gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are the first-line agents for treating neuropathic pain.
– Tramadol and other opioids are recommended as second-line agents
– Cannabinoids are newly recommended as third-line agents.
– Other anticonvulsants, methadone, and botulinum toxin are recommended as fourth-line agents.
– Methadone blocks the euphorigenic effects of short acting opioids. This blockade can be overcome when higher than normal doses of short-acting agonists are used or increases in methadone dosing
– Methadone is relatively ineffective with neuropathic pain
PTSD
– Up to half of patients with PTSD and up to 95% of people suffering TBI develop chronic pain.
– PTSD is strongly associated with opioid use and abuse.
– PTSD and TBI often co-occur and amplify overlapping symptoms.
– The use of opioids can help provide temporary relief from PTSD symptoms
– Reduces arousal
– Increases serotonin
– Increases in dopamine
– Decrease respiration via binding with opioid receptors in the brain stem

– 2012 was the height of the VA’s prescribing of opioid painkillers, and it had the highest rate of veteran suicide
Supporting Patients on MAT
– Federal law requires patients who receive treatment in an OTP to receive medical, counseling, vocational, educational, and other assessment and treatment services, in addition to prescribed medication.
– 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, we must explore innovative strategies for enhancing retention in buprenorphine treatment.
– Access difficulty
– Unsupportive living environments
– Lack of attention to co-occurring disorders
– Expense for repeated doctor visits and dosing with no insurance
– Time required for clinic visits

Side Effects of MAT
– Common
– Mood changes
– Immediately after switching to MAT
– 3-6 months after starting MAT
– 6+ Months after
– Headache
– Dizziness and blurred vision due to alterations in neurotransmitters
– Assess impairments caused by dizziness (driving, stairs, exercising, carrying an infant)
– Have clients monitor their blood pressure and heart rate

Side Effects of MAT
– Common
– Drowsiness
– Due to alterations in neurotransmitters, reductions in cortisol, sleep changes or inadequate respiration
– Assess sleep quality and quantity
– Encourage deep breathing throughout the day
– Sexual impotence/decreased libido (30-40%) due to lowered sex hormones, especially testosterone
– Naltrexone (for alcohol or opiates) can produce anhedonia and reduced libido, decreased lubrication and anorgasmia
– Consider alterations to birth control
– Osteoporosis due to endorcrinopathy

Side Effects of MAT
– Common
– Dry mouth
– Carry a water bottle
– Use a dry-mouth rinse
– Sleep disruption
– Sleep hygiene
– Constipation
– Healthy diet & hydration
– Exercise

Side Effects of MAT
– Common
– Difficulty concentrating
– Take notes/ Plan ahead
– Reduce distractions
– Take frequent breaks
– Practice good time management
– Stay organized

Side Effects of MAT
– Less common
– Suicidal ideation
– Hallucinations
– Paranoia
– Delusions

Other Issues
– Family judgement
– Work judgement
– The Americans with Disabilities Act (ADA) and many state protections come into play
– Asking an employee or prospective employee about legal drug use and/or prescription medications is prohibited unless special conditions are met
– A safety-sensitive position is one in which even a momentary lapse of attention can have disastrous consequences. (DOT, Law Enforcement, Fire-Rescue etc…)
– Employers may only ask about and/or test for prescription medications when such inquiry is job related and consistent with business necessity.
Summary
– Methadone has higher treatment retention rates than buprenorphine-naloxone does, while buprenorphine-naloxone has a lower risk of overdose. For all patient groups, physicians should recommend methadone or buprenorphine-naloxone treatment over abstinence-based treatment