Mind Matters - Addiction Medications for Relapse Prevention

Estimated read time: 1:20

Summary

The video by Michigan Medicine explores the use of medications in treating addiction and preventing relapse. Dr. Coleman, an addiction medicine physician, explains various treatments for alcohol and opioid use disorders, highlighting FDA-approved medications. The talk emphasizes the chronic nature of substance use disorders and stresses that medications, coupled with therapy, can significantly aid in reducing relapse and promoting recovery. Several medications, their functionalities, and effectiveness in different substance use disorders are detailed, alongside discussing the challenges of discontinuing use and associated controversies.

Highlights

Medications for addiction treatment are crucial as they help manage cravings and facilitate long-term recovery. 🍀
Naltrexone, Acamprosate, and Disulfiram are three FDA-approved medications for treating alcohol addiction. 🍻
Buprenorphine and Methadone are effective in treating opioid addiction by reducing cravings and withdrawal symptoms. 🚑
Patients using these medications see reduced risks of relapse, overdose, and negative health outcomes. ⚕️
Naltrexone can be used for both alcohol and opioid addiction, blocking euphoric effects. 🚫
There are no FDA-approved medications yet for treating stimulant addiction like cocaine or methamphetamine. ⚠️
Nicotine addiction treatments include replacement therapies and medications like Varenicline, showing modest success rates. 🚬

Key Takeaways

Addiction is a chronic, relapsing condition similar to other health conditions. Treating it requires a comprehensive approach. 💡
Medications can be an essential tool for managing substance use disorders by reducing cravings and preventing relapse. 💊
Different medications, like Naltrexone and Buprenorphine, have specific roles and effectiveness based on the substance involved. ⚖️
Stopping medications like Buprenorphine and Methadone needs careful planning due to withdrawal risks. 🚫
There is a notable stigma around using medications for addiction treatment, but they are crucial for effective recovery. 🏥
Access to addiction medications has increased, with primary care providers often able to prescribe them. 🌍
Effective treatment means aligning medication use with patient goals, whether it is complete sobriety or reduced use. 🎯

Overview

In this engaging talk, Dr. Coleman from Michigan Medicine brings to light the role of medications in treating addiction and preventing relapse. Delivered as part of the Mind Matters series, the discussion opens up the complexities of addiction as a chronic, relapsing disorder that needs a treatment approach akin to other chronic medical conditions. With a good sprinkling of personal, research-informed insights, Dr. Coleman brings clarity to an often misunderstood realm of addiction medicine, marrying scientific rigor with compassionate patient care.

Throughout the session, heated issues around the stigma in using medication for addiction treatment are confronted courageously. By breaking down the technical aspects like FDA-approved medications for alcoholism and opioid addiction, the ease of accessibility in current medical practices is also championed. Dr. Coleman gives audiences a refreshing take by elaborating on the strengths and limitations of medications like Naltrexone, Acamprosate, and others crucial in treating varied substance use disorders.

Equally engaging is the exploration of unwarranted biases against medication-assisted treatment, where Dr. Coleman draws comparisons to commonplace medical treatments like insulin dependency for diabetics. The session unfolds a thoughtful dialogue on aligning medication use with patient goals—whether gearing towards full sobriety or moderated use—shedding light on the delicate art of treating addiction beyond the surface-level symptoms.

Chapters

00:00 - 03:00: Introduction and Welcome The chapter serves as an introductory segment where the presenter acknowledges the presence of participants joining the session. There is a brief pause to allow more attendees to connect before beginning the official program. Participants are asked to hold on for a few moments.
03:01 - 03:50: Overview of the Mind Matters Series attended previous lectures in the Mind Matters Series. This series delves into various aspects of cognitive science, exploring how our minds process information, interact with the world, and shape our experiences. In this overview, we'll touch on the key themes and insights from the series, including debates on consciousness, the impact of emotions on decision-making, and the role of technology in cognitive enhancement.
03:51 - 05:30: Introduction of Dr. George Cameron Coleman The chapter introduces Dr. George Cameron Coleman, although the transcript is incomplete, it's indicated that the session or meeting is about to begin, possibly with more introductions or content to follow.
05:31 - 07:30: Understanding Addiction as a Chronic Relapsing Condition This chapter, titled 'Understanding Addiction as a Chronic Relapsing Condition,' explores the nature of addiction and addresses its characteristics as a chronic, relapsing condition. Although the transcript provided is incomplete and only includes a brief segment ('in a minute or two uh once a few more'), it suggests an introduction to the discussion or continuation of a previous topic. In an educational context, this chapter likely aims to deepen understanding about how addiction should be approached, emphasizing the need for long-term strategies and ongoing support for individuals dealing with addiction.
07:31 - 18:00: Medications for Alcohol Addiction The chapter titled 'Medications for Alcohol Addiction' begins with participants logging into the session.
18:01 - 27:00: Medications for Opioid Addiction This chapter discusses medications used in the treatment of opioid addiction. It begins with an emphasis on the importance of respecting time and schedules, perhaps indicating a focus on punctuality and discipline as part of the recovery process. Further details on specific medications or therapeutic approaches were not provided in the excerpt.
27:01 - 30:00: Medications for Cannabis and Stimulant Addiction The chapter 'Medications for Cannabis and Stimulant Addiction' is part of the Mind Matters series, under the Department of Psychiatry's addiction series. It begins by expressing gratitude to participants who have joined the session.
30:01 - 36:00: Medications for Nicotine and Tobacco Addiction Dr. Coleman collaborates with Anne Fernandez, an associate professor and director of clinical programming at UMATS and a clinical psychologist at UMass Clinic, to discuss medications for nicotine and tobacco addiction and relapse prevention. UMATS is part of the Addiction Center in the psychiatry department, located at the Rachel Upton building in Ann Arbor. Their mission focuses on addiction treatment and research.
36:01 - 42:00: UMass Clinic Services and Approach The chapter discusses UMass Clinic's approach to addiction care, emphasizing the integration of research into practical care strategies. It highlights a speaker series designed to disseminate current research on addiction, aiming to provide research-informed guidance and solutions for substance use issues. The focus is on understanding the persistence of substance use problems and strategies to disrupt the cycle of addiction. The series aims to bridge the gap between research and practical care to effectively address substance use challenges.
42:01 - 60:00: Q&A Session This chapter is a Q&A session with Dr. George Cameron Coleman, a clinical assistant professor in the Department of Psychiatry. He specializes in addiction medicine and provides medication management and clinical care to patients with substance use disorders. Dr. Coleman received his MD from the University of Virginia. The focus is on addiction treatment and related aspects.
60:01 - 60:30: Conclusion and Next Session Announcement The chapter introduces Dr. Coleman, discussing his academic and professional background, including his internships, residencies, and fellowship in various medical disciplines, along with his master's degree in Health Informatics from the University of North Carolina. It also touches on his personal interests such as reading nonfiction, hiking, and trail running, especially in the Blue Ridge Mountains.

Mind Matters - Addiction Medications for Relapse Prevention Transcription

00:00 - 00:30 see a few people um are coming in we'll just wait a few minutes to give folks time to join before we officially start so just sit tight uh for a few minutes thanks
00:30 - 01:00 uh thanks to those of you who have
01:00 - 01:30 already joined we're just going to start
01:30 - 02:00 in a minute or two uh once a few more
02:00 - 02:30 people log in
02:30 - 03:00 hey it's 703 so I want to be respectful
03:00 - 03:30 of everybody's time who's who's logged in and has joined us we thank you so much for joining us for our Series this is the Mind matters series part of the Department of psychiatry's um series on addiction and today
03:30 - 04:00 um Dr Coleman is here to discuss medications for addiction and relapse prevention and I'm Anne Fernandez I'm an associate professor and director of clinical programming at umats I'm also practicing clinical psychologist here at the UMass Clinic uh umatz for those of you who don't know is located at the Rachel Upton building off of Plymouth Road in Ann Arbor and is part of the Addiction Center in the department of psychiatry core part of our mission at umats is to
04:00 - 04:30 deliver care that is directly informed by research and with this speaker series we're hoping to share the latest research on addiction and give research informed information and help and talk about how research and Care can help deal with problems related to substance use when they arrive when they arise what makes substance use problems continue and how to break out of the cycle of problematic substance use we're aiming to deliver the series
04:30 - 05:00 quarterly with each talk focusing on different aspects of addiction and its treatment tonight joining us is Dr George Cam Cameron Coleman and he's a clinical assistant professor in the department of Psychiatry he's a practicing physician in addiction medicine with umats and provides medication management and other clinical care to patients with substance use disorders Dr Coleman received his MD from the University of Virginia he completed his
05:00 - 05:30 internship in Internal Medicine and residency and preventive medicine and his Fellowship in addiction medicine at the University of North Carolina Chapel Hill he also completed a master's degree in Health informatics at the University of North Carolina outside of work Dr Coleman enjoys reading nonfiction hiking and trail running particularly in Blue Ridge Mountains so maybe you haven't gotten to do too much of that lately um well pardon me the cleaners are going
05:30 - 06:00 by uh watching ACC basketball and playing golf so Dr Coleman thank you for joining us and before we begin I wanted to mention that questions can be submitted by clicking on the Q a button at the bottom of the screen you can feel free to put those up during um Dr Pullman's talk to and um we can either uh have them during the talk or we'll can address them after there's an option to submit questions anonymously after Dr Coleman's discussion we'll do our best to answer
06:00 - 06:30 as many questions as possible and um please note you can put general questions you can have questions about clinical care but just refrain from asking questions about specific patients or yourself if you're a patient at umats we just can address those questions in this forum so your clinician if you are a patient or have a loved ones the patient can help with those questions during the clinical care so um and a recording uh will be available and emailed to everyone as soon as
06:30 - 07:00 possible after after um tonight's talk and so now I'll turn it over to Dr Coleman thank you so much thank you Dr Fernandez and welcome everybody let me pull my slides up here as Dr Fernandez said I'm an addiction medicine physician here at umatz and my alma mater University of Virginia was up in town playing Michigan and men's
07:00 - 07:30 basketball a few weeks ago and that was a nail biter but um I'm happy to be with all of you this evening to talk about medications for addiction treatment and relapse prevention and one point that I wanted to make from the get-go here is that medically we really view addiction and substance use disorders as chronic relapsing conditions many of you may have chronic medical problems yourself you have you may have family members that have physical health conditions such as asthma congestive
07:30 - 08:00 heart failure multiple sclerosis all of these conditions are relapsing conditions they're prone to acute flares acute exacerbations from time to time and it's important to recognize that substance use disorders are no different so tonight we will review some of the medications that we have in our Arsenal for addiction treatment to help patients with substance use disorders reduce their risk of relapse for starters some of you may have heard
08:00 - 08:30 this acronym mat which stands for medication assistant assisted treatment this refers to the idea of using medications in combination with counseling for a comprehensive treatment of addiction and substance use disorders you may have seen this online you may have seen mat clinics or you may have seen local clinics that advertise that they do mat now some folks in the addiction treatment Community have pointed out that medications can be treatment in and
08:30 - 09:00 of themselves and should not be viewed as secondary to counseling or therapy or other modalities of treatment so because of this some treatment providers will refer to This Acronym mat as medications for addiction treatment rather than medication assisted treatments let's begin with a review of medications that we have for the treatment of alcohol addiction or alcohol use disorder and really there are three FDA
09:00 - 09:30 approved medications which are Naltrexone acan prosate and disulfurant like all medications we'll review this evening these medications don't provide a cure for the underlying disorder or the underlying addiction itself but they can be a really effective tool for a patient who's participating in a comprehensive treatment program so for starters Naltrexone is really what I consider to be the first line medication for patients with alcohol
09:30 - 10:00 addiction or alcohol use disorder it was FDA approved for this in the 1990s I think 1994. and it's actually an opioid blocker so we'll talk about Naltrexone again later this evening when we talk about treatment options for patients with opioid use disorder but this medication an opioid blocker can actually work in the brain for patients with alcohol addiction by making alcohol less pleasurable so it works by blocking the euphoric effects
10:00 - 10:30 or the rewarding effects the patients experience when they drink alcohol it doesn't block you from becoming intoxicated but it is designed to uncouple that pleasure so many patients will say that they start taking this medication and they sort of lose the taste for alcohol or they don't experience the same Cravings the same urges they're not so preoccupied thinking about drinking what we like about this medication is
10:30 - 11:00 that it's been proven to be effective for patients regardless of whether their goal is to stop drinking altogether and to be sober or whether their goal is to reduce their drinking and drink less in both cases it can be affected by reducing Cravings or urges for alcohol the studies show us that Naltrexone reduces relapse in patients whose goal is sobriety by about a third so it's fairly significantly effective at the
11:00 - 11:30 population level the dosing of this medication is pretty easy and pretty straightforward it's one tablet 50 milligrams once a day there's no need to gradually titrate the dose up or if you decide to discontinue this medication you don't need to titrate the dose down you can just stop it things to remember about Naltrexone are because it is an opioid blocker number one you can't take it if you're
11:30 - 12:00 currently taking opioids number two you can't take it if you've recently taken opioids or been exposed to opioids in the last seven days and number three if you may need opioids in the future say for a surgery a dental procedure or maybe you break your ankle and you wind up in the emergency room and they need to give you a shot of morphine you'll just need to let your doctors know this medication may not be an option for patients with severe Advanced liver
12:00 - 12:30 disease but in almost all patients it can be a safe option in in terms of side effects we typically see that about two out of every 10 patients who start Naltrexone may experience mild side effects that typically include headache nausea reduced appetite fatigue but more often than not those sorts of side effects will resolve in the first week or two you'll see two examples of Naltrexone on the screen here what we use most often
12:30 - 13:00 for patients with alcohol use disorder is the oral tablet the pill down in the bottom right but nitrixon is also available as a shot and an injection that you can get Once in life and that goes by the brand name Vivitrol number two in terms of medications that is FDA approved for the treatment of alcohol addiction is a campusate or the brand name is cambril this is really used for people who have stopped
13:00 - 13:30 drinking and their goal is to avoid returning to drinking so unlike Naltrexone where we can use it even in patients whose goal is just to reduce their drinking a camper site is most effective in patients uh whose goal is or who are ready to commit to Total sobriety it's not an opioid blocker it works a little differently in the brain but it similarly has the effect of reducing cravings and it can also diminish what we refer to as the protracted alcohol withdrawal symptoms they can linger in
13:30 - 14:00 some patients for several weeks after they stop drinking things like depressed mood irritability anxiety and therefore they can help this medication can help patients break the cycle of negative reinforcement if they're inclined to go back to drinking to mitigate some of those protracted withdrawal symptoms the studies show us that this medication has never really been effective in patients whose goal is just to reduce
14:00 - 14:30 their drinking but we know that it works in patients whose goal is total sobriety this medication was initially studied in Europe and it's used more often in Europe than we use it here but some of the initial European studies of this medication showed that about 20 percent of patients were able to remain sober at one year taking this medication as compared to just 10 percent uh who took a placebo some of the U.S studies of a camper site showed mixed results but the studies
14:30 - 15:00 have definitely shown that patients who are really motivated and very clear that their goal is total sobriety this medication may be an effective option for those folks a campus state is a medication that we don't start until you've stopped drinking and you've successfully gone through the the acute detox window so typically we'll start this medication maybe day four day five after you've stopped drinking and in terms of dosing
15:00 - 15:30 it actually is two tablets that you take three times a day so some folks feel that that dosing requirement and having to remember to take two pills three times a day is inconvenient or a headache a camper State tends to have slightly more side effects than the first medication we talked about Naltrexone but typically the side effects include things like lightheadedness dizziness upset stomach uh loss of appetite
15:30 - 16:00 this medication is cleared by the kidneys so it may not be an option for folks with severe kidney disease and it's a reason that we would monitor kidney function for patients who are taking this medication but aside from that it's very safe and it's not a controlled substance the third medication that we have that's FDA approved for the treatment of alcohol addiction is disulforan many of you may be familiar with the brand name for this which is antabuse
16:00 - 16:30 this one's been around since the 1940s and this is the medication that interferes with the way that your body metabolizes or clears alcohol from out of your system so this is the medicine where if you take the medicine and then you drink alcohol it makes you very sick so it is designed to work as a deterrent because of that patients must be very clear that their goal is total sobriety their goal must be to abstain from alcohol altogether and they must have
16:30 - 17:00 already stopped drinking uh we rarely use this medication uh at all these days I think if I have a hundred patients in my clinic who are on medication for alcohol use disorder maybe just one or two are on disulfuran and that's for a couple of reasons uh number one if you do drink alcohol and Trigger the reaction of making yourself violently ill that can make you violently ill and I've seen patients who
17:00 - 17:30 needed to go to the emergency room because of that so we avoid this medication in any patients with underlying liver disease heart disease or lung disease even if you don't drink alcohol and Trigger that reaction this medication has some nastier side effects things like drowsiness reduction in libido headache and even the strange metallic taste that some patients will describe so it can be an option for a small subset of folks whose goal is to reduce
17:30 - 18:00 their drinking but the studies have actually not demonstrated nearly as much Effectiveness in terms of helping people avoid returning to use with alcohol with disulfiram as compared to the first medications that we talked about and typically the studies that did show some benefits were designed where patients would have family members spouses significant others involved in their treatment to help them remain
18:00 - 18:30 accountable and remember to take this medication every day so we'll switch gears here we'll transition from talking about alcohol addiction to opioid addiction and medications for opioid use disorder there are three they are buprenorphine methadone and Naltrexone and these medications are options for the treatment of opioid addiction or opioid use disorder regardless of whether a patient is using heroin or morphine or
18:30 - 19:00 fentanyl or oxycodone or hydrocodone you name it one thing to keep in mind here is that when we talk about Cravings or urges and this is true for all forms of addiction but it's particularly true for patients with opioid use disorder we're not talking about just the fleeting little thought that hey maybe a piece of chocolate would wouldn't be bad right now in patients with addiction but particularly opioid use disorder Cravings are these very intense
19:00 - 19:30 overpowering desires to use a substance to escape to reduce pain to reduce anxiety or to feel pleasure and these the intensity of these Cravings can significantly affect someone's decision making in their judgment the second thing to keep in mind is that patients who have opioid use disorder if they stop using opioids all of a sudden abruptly and they go into what we refer
19:30 - 20:00 as opioid withdrawal they feel miserable physically mentally it is a highly highly unpleasant state to be an acute opioid withdrawal and patients who were in that condition will do almost anything to alleviate the withdrawal and to feel better so keep these ideas in mind cravings and withdrawal because that is what we target with our medication options so the first medication is buprenorphine and buprenorphine is what is called a
20:00 - 20:30 partial opioid or a partial Agonist it binds to the same opioid receptors in the brain just like morphine or oxycodone or heroin but it works a little bit differently and it has what we refer to as a ceiling effect so you can think of the opioid receptor in the brain as the burner on a stove full opioids things like morphine heroin oxycodone they can turn the heat on that burner all the way up to high 10 out of
20:30 - 21:00 10. patients like that because that's what provides the sense of uh pain relief or even Euphoria or intoxication but that's also what can lead potentially to overdose and death when you crank that heat all the way up so unlike those full opioids buprenorphine still turns the heat on the stove it still binds to the opioid receptor but it never goes beyond like low medium heat we're talking maybe three or four or so on the dial
21:00 - 21:30 because of that it still activates the opioid receptors and therefore buprenorphine can eliminate or uh greatly reduce cravings for opioids it can eliminate or greatly reduce withdrawal symptoms without having the dangerous potential of causing sedation causing a sense of high or intoxication or Euphoria or causing uh difficulty breathing or overdose so that is the reason that buprenorphine is designed in
21:30 - 22:00 that manner buprenorphine comes in a number of different formulations the vast majority of patients who take buprenorphine will take the brand formulation which is called Suboxone Suboxone is available as a film or a tablet that dissolves in the mouth under the tongue but buprenorphine is also available in other formulations including a different brand a different pharmaceutical manufacturer called zuppsoft an alternative called Subutex
22:00 - 22:30 as well as a long-acting injection that you can get under the skin once a month or so and that's called sub locate so that may be an option for patients who prefer not to have to take a medication every day or multiple times a day number two is methadone so methadone is a full opioid methadone can turn the burner on the stove all the way up to 10. it's a long-acting opioid so typically it lasts in the body for 24 to
22:30 - 23:00 30 hours and because it is a full opioid it can Target and eliminate opioid cravings and opioid withdrawal it's designed to be administered or to be dosed once a day typically in the morning typically as a liquid but the thing to be aware of with methadone is that I can't write a prescription for my patient with opioid use disorder to go pick up methadone from their Pharmacy I can write a prescription for patients to use low-dose Methadone for pain but
23:00 - 23:30 if I'm treating opioid addiction opioid use disorder typically the doses of methadone that we use are much higher and we can't write prescriptions for that patients who are treated with methadone do so at a methadone Specialty Clinic where the methadone is dispensed typically once a day so access to methadone treatment can be a little trickier for some patients again you have to go in person every day to a clinic to receive your daily dose
23:30 - 24:00 how well do these medications work how effective are they at helping folks avoid relapse well we know without a doubt based on multiple studies that these medications are highly effective that patients with opioid use disorder are treated with these medications are less likely to overdose less likely to die less likely to relapse or return to using less likely to be arrested incarcerated less likely to acquire
24:00 - 24:30 infections related to IV drug use like HIV or Hepatitis C so the list of benefits goes on and on with these medications but what I tell patients is take 10 patients that have opioid addiction or opioid use disorder and they're using either opioid pills heroin fentanyl every day if you take all of those 10 patients you admit them to the hospital or to a rehab facility you treat their withdrawal so
24:30 - 25:00 they stop using and then you discharge them then what we know based on a number of studies is that between 30 and 90 days 9 out of 10 of those patients will return to using opioids we know that that's the nature of opioid addiction relapse rates are about 90 percent in contrast say you take 10 other patients who have the same opioid addiction you admit them to the hospital or rehab facility you treat their withdrawal and then you start them on
25:00 - 25:30 maintenance medication with buprenorphine or methadone then over the same time frame 30 to 90 days what we see is a reduction in the number of folks who will relapse from 9 out of 10 on no treatment down to about four or five out of ten with these medications so that's a significant reduction I mean a 50 percent reduction in the risk of returning to using or relapsing but obviously it's not a silver bullet these medications work because they are
25:30 - 26:00 really effective at managing cravings and withdrawal symptoms which allows patients to get their life back together to feel normal physically and mentally and to devote their energy toward other aspects of recovery and sobriety so we know that if we don't address Cravings if we don't address withdrawal symptoms if we don't treat those things then those are significant risk factors that will increase a patient's likelihood of relapsing
26:00 - 26:30 Naltrexone as we mentioned earlier is an opioid blocker so Naltrexone doesn't turn the burner on the stove on at all in fact it blocks anything else from turning the heat on on the stove so the benefits of Naltrexone are that it's not a controlled substance uh if you decide to stop taking it you're not going to have any withdrawal symptoms from the Naltrexone but the downsides are that because it doesn't turn the stove on it doesn't address cravings and it doesn't address withdrawal nearly as much as
26:30 - 27:00 buprenorphine and methadone now track Zone when we use it for patients with opioid use disorder we use the long-acting injection formulation which is called Vivitrol that's the brand name some of the initial studies when they compare Vivitrol or extended release nitroxone with buprenorphine or methadone suggested that rates of relapse were about the same but newer more recent Studies have shown different
27:00 - 27:30 results especially for more high-risk populations such as patients who are leaving the Criminal Justice System leaving long-term care facilities returning to use or rates of relapse tend to be a little higher with Nitric Zone as compared with buprenorphine or methadone but it still can be a very uh reasonable option for patients who may not have co-occurring pain who may not have had difficulties with relapse in the past
27:30 - 28:00 who may be brand new to treatment so it's an important option that all patients uh learn about we'll switch gears briefly and we'll transition to cannabis addiction or cannabis use disorder so this is patients who might smoke flower cannabis every day or use other THC or CBD products really thus far the most promising medication that we've identified for the treatment of cannabis addiction is uh called in acetylcysteine or neck
28:00 - 28:30 this is a supplement it's essentially an amino acid that you can get over the counter and it's been shown to be really effective in animal studies particularly with cannabis addiction the human studies of knack or innocent in acetylcysteine showed that it worked pretty well in adolescence but it worked less well in adults Knack is generally very safe very well tolerated there are essentially no side
28:30 - 29:00 effects the biggest consideration with Knack is really that some pharmacies just don't carry it in stock so even though patients can buy it over the counter sometimes we have to send a prescription and then we need to hunt down a different Pharmacy to to see who has it on their phone today Switching gears again to talk about patients with stimulant addiction or stimulant use disorder this refers to patients who have addiction to cocaine amphetamines or Methamphetamine long
29:00 - 29:30 story short here we don't have any FDA approved medications for the treatment of stimulant addiction a lot of medications have been studied but none of the Studies have shown significant benefit in terms of reducing rates of relapse reducing rates of stimulant use despite a number of different medications that have been tried because of this really the Mainstay of treatment for a stimulant addiction is the kitchen sink a combination of everything else that we have in our tool
29:30 - 30:00 kit so individual therapy family therapy potentially various other sort types of behavioral therapy treatment of co-occurring mental health conditions 12-step programs and other treatment modalities lastly let's talk a little bit about nicotine and tobacco and the treatment options that we'll review here uh are options regardless of what form of nicotine or tobacco a patient is using
30:00 - 30:30 so they may be smoking cigarettes uh using a nicotine Vape using chewing tobacco smoking cigars we know that nicotine is highly addictive and we also know that many patients who use tobacco products really want to quit and we also know that if you take a hundred patients who were using nicotine or tobacco smoking cigarettes every day and they all just try to stop cold turkey the number that will be successful is two or three that doesn't say anything about the
30:30 - 31:00 willpower or the determination of these folks that just tells us that the nature of nicotine addiction is that 97 to 98 percent of folks will will relapse or return to using without some form of treatment so the medications that we use for nicotine or tobacco treatment work in the area of the brain that nicotine is active they work by blocking or reducing the effects of nicotine in the brain and also activating some of the nicotine
31:00 - 31:30 receptors in the brain to Target cravings for nicotine products we have a lot of tools in our toolbox when it comes to Tobacco treatments you're probably all very familiar with the idea of nicotine replacement therapy so these are things like the nicotine patches that you've seen commercials for or you've seen available over-the-counter in CVS or Walgreens uh nicotine patches are long-acting products that deliver some nicotine to your system every day we often use these
31:30 - 32:00 in conjunction with short-acting nicotine replacement whether that's the gum like Nicorette or the lozenge the dosing of nicotine replacement is really critical and I won't get into the weeds here but most people who tell me they've tried the patches tried the gum and it didn't work for them that's because they were using two lower dose we use nicotine replacement often in patients who are hospitalized or maybe recovering from surgery and we know that nicotine replacement is
32:00 - 32:30 much more effective than just stopping cold turkey if you take 100 patients who want to stop smoking or using tobacco then with nicotine replacement we can bump that number from two or three out of a hundred up to 15 or 20 so a modest Improvement other treatment options that we have for nicotine or tobacco include medications prescription medications such as bupropion which goes by the brand name zyban or Wellbutrin as well as
32:30 - 33:00 verenicline which goes by the brand name Chantix so with these we can bump that success rate up even higher with bupropion we typically see 20 or 25 out of 100 patients who are able to be successful and with varenicline or Chantix we see somewhere in the neighborhood of 30 to 40 patients out of 100 who are able to be successful and the numbers that I just gave you that refers to the first time starting any treatment for nicotine or tobacco we often will use
33:00 - 33:30 combinations of these things and it's not uncommon to take or to find patients where it takes them 5 10 15 attempts to quit smoking or to stop showing tobacco before they're able to successfully make that change so patience and persistence is part of treatment and part of what we talk about when we're counseling these medications counseling our patients about these medication options foreign that was a whirlwind tour of the
33:30 - 34:00 medications that we have available for addiction treatments at our Clinic umats University of Michigan addiction treatment services we offer more than just medication but we do specialize in medical evaluation consultation and management for patients whose primary problem is addiction or substance use disorder we're a multi-disciplinary clinic so we have addiction medicine providers like myself we have addiction psychiatrists and other Psychiatry trainees Psychiatry
34:00 - 34:30 residents we have nurses clinical social workers psychologists so we all work as a comprehensive team to develop a treatment plan for our patients we prescribe medications for patients to address the addiction just like the medications we've reviewed tonight as well as other medications for our co-occurring psychiatric illness like depression or anxiety we don't believe that all medications should all patients should be on medication we're not a pill pushing
34:30 - 35:00 Clinic we don't believe that all patients need medications but we believe strongly that all patients should be aware of all the options and we want to work with our patients one-on-one to develop an individualized plan for them for many of our patients medication can be an effective tool in addiction treatment who can come to UMass who can come receive Care at our Clinic we welcome all people who are interested in understanding their substance use maybe
35:00 - 35:30 folks who are interested in changing their substance use maybe folks who know they have addiction they may have tried addiction treatment in the past they may have struggled they may have recently relapsed we welcome all patients we see adolescents all the way up through older adults and we accept most private insurance plans as well as Medicare as I mentioned we prescribe essentially all of the medications if we deem it as appropriate that we've reviewed tonight
35:30 - 36:00 with the exception of methadone for patients with opioid use disorder and as we mentioned methadone is the sort of thing where if that's the option that makes the most sense for a patient with opioid use disorder it can only be dispensed at a methadone clinic or a specialty clinic but we commonly will help patients link to methadone clinics in our area and with regard to the other medications that we talked about people morphine Naltrexone nicotine replacement many of
36:00 - 36:30 these medications can also be prescribed by Primary Care Providers Family Medicine doctors and there have been a number of recent laws that actually made it easier to prescribe evenorphine so that more people have access to people so often we'll help patients who are maybe new to opioid use disorder treatment who are interested in getting stabilized on buprenorphine once we've worked with him for a period of time oftentimes we can transition them back to their primary care doctor who can
36:30 - 37:00 then take over the prescription for suboxone we offer outpatient addiction care as I said for adolescents and adults and in addition to all the medications that we've reviewed tonight this slide details the non-medication treatment modalities that we provide so we do behavioral treatment we do cognitive behavioral therapy we do motivational interviewing we help patients connect with mutual help groups uh in the
37:00 - 37:30 community we offer a number of dedicated group therapy programs through our Clinic that specialize in providing education and helping patients develop relapse prevention plans for themselves we also offer an intensive outpatient program that may be appropriate for patients who are relatively new to sobriety or new to recovery and that involves meeting in our Clinic three days a week for a little bit more intensive treatment we always recommend patients who might
37:30 - 38:00 be interested in learning more about addiction treatment talk it over with a provider that you trust if that's your primary care provider if that's your mental health provider if those providers are able to refer you to our Clinic that's one way to get in the door if you're interested in referring yourself you can find our contact information on our website but we offer a mix of in-person care and visits for patients who are local and would like to
38:00 - 38:30 come work with us one-on-one in clinic we also offer a Telehealth visits and we're able to see patients across the state of Michigan and that's been something that has been a priority for us since covet so that was a whirlwind tour thank you so much for your attention uh I will end the presentation now and we'll be happy to address any questions that you may have may have hey thanks so much Dr Coleman
38:30 - 39:00 um so we'll take questions if people have questions that they want um to put in the Q a feel free to do that as we go we have a few uh to get us started so first off um someone's wondering if there is a risk for Naltrexone if a patient does still binge um on alcohol while on the medication that's a good question so just to clarify is this a question about can you
39:00 - 39:30 get in any trouble if you're prescribed to Naltrexone and then you drink while you take it uh yeah I think they're saying if like the person is taking it so actively taking the medication and then binges like heavy alcohol use while while on the medication yeah great question and the answer is uh very rarely so the one consideration that I didn't mention about Naltrexone is that um it may not be an option for our patients with severe Advanced liver disease because of the way that it's
39:30 - 40:00 cleared from the body by the liver we know that patients who are maybe in the middle of a binge episode can cause some liver inflammation it can damage their liver but the risk of liver toxicity with Naltrexone itself is essentially minimal there used to be a black box warning on Naltrexone many years ago because of concerns for liver damage but that's because they used to prescribe it at much higher doses than we use now adays one tablet 50 milligrams once a
40:00 - 40:30 day um at that dose it's rarely a concern for liver function even if folks sort of have a relapse in return to drinking heavily what we know is that in the long run what's more detrimental to their Liver Health is ongoing chronic heavy alcohol values so we monitor Naltrexone especially in patients who say hey I had a slip I had a lapse I drank a lot sometimes we will monitor liver numbers and for a subset of patients who see a
40:30 - 41:00 liver specialist or a hepatologist we may consider making an adjustment with the Naltrexone lowering the dose but 99 times out of 100 you're not going to cause any extra harm for yourself if you're prescribed Naltrexone and then you drink heavily great thanks so much and I think this is a follow-up question related to Naltrexone is if and it says asking if it can be given I'm assuming prescribed in Canada which I think is yes but that's a good
41:00 - 41:30 question and I don't know the answer to that [Music] um I would I would refer you to your to your local treatment provider there in Canada my assumption is yes it probably is readily available um but I don't have a medical license in Canada so that's actually never something that's come up for me yeah I guess we're right right over the border so um so yeah I I also assume yes but I don't know for sure either um and I'll mention I had one other consideration for now truck Stone so
41:30 - 42:00 it's it's designed to be a once a day medication like all medications your blood pressure pills your antidepressants it's most effective if you take it consistently some patients will take it first thing in the morning other folks will take it before bed some folks like to take it maybe four or five PM right around that happy hour time where there are Cravings or their urges are strongest but we know that Naltrexone may also be beneficial if you just take it as needed so some patients might just keep it
42:00 - 42:30 available uh in case they're going to a wedding or a social function or and if they anticipate that they will be in an environment where alcohol is there and they know they might have stronger Cravings they'd like to have it and just use it as needed we know that it works in that case even if you don't take it every day well I actually did not know that I learned something um so uh so and for candidates for medications
42:30 - 43:00 who are committed to sobriety can Naltrexone be combined with other this person saying option two or three so I think that's the ant abuse um in a conversate for treating alcohol addiction great question um the answer generally is yes we don't see it very often but I have personally had a handful of patients with really severe alcohol use disorder a number of relapses a really tough time maintaining sobriety um and then sometimes in those cases we
43:00 - 43:30 will combine for instance oral Naltrexone with oral a campus eight um so that doesn't happen often and it would have to be a special type of patient but that may be a potential option what I would not recommend would be to use both formulations of nitrixon the oral once a day tablet as well as the injection the patrol once a month you typically don't get any extra Bank from your buck if you're doing that thank you um and how about how difficult is it to
43:30 - 44:00 stop using these medications so I think the answer is probably going to vary by the medication but maybe if you can just speak to um but yeah difficulty in stopping them great question and absolutely it really varies it depends on the medication so for things like Naltrexone uh for instance for alcohol use disorder or a campus eight uh if you are taking those medications for a period of time um you feel like things are better or you no longer need them you no longer
44:00 - 44:30 have the Cravings or if you don't feel like they help you you can just stop them you don't have to gradually taper down your dose the most problematic medications or the ones where we have to put the most thought into it in terms of discontinuation would be buprenorphine and methadone and that's because buprenorphine is a partial opioid methadone is a full opioid so your body will develop a dependence to those and if you were to stop those abruptly you would experience the same opioid
44:30 - 45:00 withdrawal as if you were experienced as if you were using heroin or morphine patients will say that the the withdrawal may feel a little bit different but that still is a risk because of that for buprenorphine and methadone if a patient really wants to stop or has a reason to stop then we we like to have as much time as possible to gradually taper the dose down but for the remainder of the the medications with the exception of bupropion which is an antidepressant and
45:00 - 45:30 can can cause some mild withdrawal symptoms um most of the others that we talked about uh can just be stopped obviously I would not recommend making the decision for yourself to stop your medications I would always encourage you to discuss with your treatment provider but there is no safety risk and abruptly stopping something like um uh Chantix for instance one other caveat though would be
45:30 - 46:00 patients who have opioid use disorder and are on Vivitrol attracts on the opioid block or the injection Vivitrol um what we know is that because that's an opioid block or if patients are not actively using opioids their tolerance will go down and we see sometimes patients who have come into the clinic every month they're getting their Vivitrol injections and then if we stop hearing from them if they stop showing up if they stop receiving their medications and then all of a sudden
46:00 - 46:30 they relapse and return to using with opioids because their tolerance is so much lower they are at much higher risk of Overdose and death with returning to use with opioids so that is a special consideration for patients who are thinking about stopping the vitron thank you um so I one thought I just had around Naltrexone that I think you touched on it now for example but also buprenorphine is the increased
46:30 - 47:00 accessibility in the United States um and maybe in Canada as well um but how some of the laws have changed such that accessing some of these medications you can do through your primary care provider so I think sometimes it's hard for people like sometimes it's easier to see Primary Care to begin a conversation than try to get into a specialty clinic which also sometimes have a wait list sure um so I think that that was something that was just coming to mind to stress um that there are a lot of Pathways to
47:00 - 47:30 find out more information there are a lot of Pathways that's a great Point um Suboxone or buprenorphine Primary Care Providers can prescribe it if they've done special training so you need a special waiver on your license to prescribe it but as I mentioned there are a lot of legal changes that have been made and that have been proposed um to to reduce those barriers for prescribers so if you're interested in starting a
47:30 - 48:00 medication like Suboxone check with your primary care to see whether they prescribe it oftentimes there might be one or two folks one or two providers in a clinic that prescribes it but if not there are a number of websites where you can find providers in your community and um a tangential thought along the idea of expanding access to this treatment is that was one of the the priorities for the Affordable Care Act is that it did
48:00 - 48:30 make substance use disorder treatment a covered expense and so patients who are on federal health insurance like Medicare um or uh and oftentimes many Private health plans as well um will cover and and must cover these medications Knack the cannabis
48:30 - 49:00 supplement that can help with cannabis use they're saying that they got some at Whole Foods that's 500 milligrams wondering about quitting cannabis and if you need a pharmaceutical grade or if like something through a grocery store kind of um chain would be sufficient sure sure that's a great question so whether you buy the The Knack from Whole Foods or you get it from CVS over the counter or whether I send a prescription for it it's the same typically it's the same supplements the dose matters so the
49:00 - 49:30 studies that showed some benefits um with this medication again and we saw the most benefit in younger populations adolescents the dose is 1200 milligrams twice a day so typically it's two 600 milligram tablets or capsules twice a day that might be a little bit tricky to get to if you have 500 milligram capsules from Whole Foods but the dose does matter all right thank you
49:30 - 50:00 um and then someone's wondering if there's a medication to reduce cocaine Cravings yeah yeah great question I wish there was unfortunately no there have been some studies that showed potential benefit with some medications in patients with stimulant addiction more so methamphetamine than cocaine but those are highly specialized sub populations and we we don't really generalize those results to to the
50:00 - 50:30 public um a lot of medications have been tried for patients with cocaine addiction even the stimulants things like Adderall with the idea being could you substitute one stimulant for another would that lower uh cravings and the answers no uh the answer is unfortunately none of this the studies showed any benefits and that's something that that our Neuroscience colleagues are working hard on if they could develop a medication that that was proven to be effective for cocaine or
50:30 - 51:00 methamphetamine addiction that would be a game changer for that population because right now we just don't have medications for those folks unfortunately thank you um and uh how about for mat how long you should take it for is it a lifetime um something you take for your whole life or is it period of time yeah great question this comes up often in patients particularly folks who are receiving buprenorphine for opioids
51:00 - 51:30 um so I'll Target uh I'll Freight my answer to that population than if patient or if participants have another question then please ask to clarify but long story short in terms of how we how long should we continue medication like buprenorphine for opioid addiction the answer is we don't really know because we don't have long-term studies that have compared patients who stop medication or taper down on their medication versus stay on it for life the general consensus is that opioid
51:30 - 52:00 addiction like all substance use disorders are chronic relapsing illnesses so if patients have achieved some degree of stability with medication like buprenorphine if it ain't broke don't fix it continue on it for as long as it is working I personally have had patients with opioid addiction who have been on Suboxone for 20 years um I've had patients who have been on it that long and intend to stay on it the rest of their life patients who have been on it 5 10 15 20
52:00 - 52:30 years and may want to gradually taper down and we take an individualized approach to that we talk about the potential risks and benefits if we do taper we go slowly many patients find that they may be able to gradually reduce their dose of something like Suboxone some patients are able to come all the way off and they feel good other patients reduce their dose and they don't feel so good they feel those cravings re-emerge and that scares them um I will say that for some of our
52:30 - 53:00 sickest patients with opioid use disorder folks who have bad medical complications for instance from injection drug use who have bad skin and soft tissue infections infections in the heart valves and the lining of their heart maybe folks that have need one or more surgeries to uh to treat those infections we recommend staying on medications like buprenorphine or methadone really for life because the relapse could could be life-threatening in that case especially for folks that
53:00 - 53:30 we see at the hospital who have had multiple heart valve replacement surgeries so yeah the answer really is it depends uh talk with your doctor there are risks and benefits and if you really are interested in trying to taper off we encourage you to do so when the rest of your house is in order so to speak you've got a good recovery environment you've got a strong support system you've had a long period of stability and go go slow take her slowly
53:30 - 54:00 um and there's a follow-up clarifying question about Knack the how you had mentioned 1200 milligrams per day to clarify if you you had said two times a day or once a day I think you said two times but yes 1200 milligrams twice a day that's that's the the dosing of that medication that they used in the studies so that's why we use it um individual patients may feel like it works for them if they take it once a
54:00 - 54:30 day but but we recommend 1200 milligrams twice a day for for cannabis okay and then um why is so Matt I I've said Matt but um that stands for medication assisted treatment and as Dr Coleman said sometimes people say medications for opioid use disorder or medications for alcohol use disorder um so sometimes we say all these different terms I just wanted to make sure I was being clear but um why is the why are these medications so controversial in um the recovery
54:30 - 55:00 Community yeah that's a great question so um buprenorphine is not nearly as old of a treatment as something like antabuse for instance buprenorphine has only been around since late 90s early 2000s or thereabouts and so there's quite a bit of stigma from older individuals in the recovery Community who don't understand it or maybe folks who think that you're using a partial opioid or in the case of methadone you're using a full opioid why how is that not just
55:00 - 55:30 substituting one drug for another and the answer is these are treatments that have been studied that are prescribed and overseen by a physician and we know how they work in the same way that if your relative has diabetes and her pancreas stops producing insulin we give her insulin replacement I mean we treat the diabetes with insulin so we know that these medications are effective treatments
55:30 - 56:00 even though it is a common perception that you're just substituting one thing for another um the proof is in the pudding though I mean what we know is that these medications greatly reduce the risk of Overlook overdose death they greatly reduce the risk of relapse um and they are more effective than willpower alone no medication um so there are some schools of thought that say the only way you can do this is
56:00 - 56:30 by yourself you need to overcome this and what we know is that if you ADD medication you're much more likely to be successful yeah I think maybe you can speak to this but for certain certain addictions that's more true than others like my you know the opioid use opioid use disorders in particular when they've studied Psychotherapy um versus medication Psychotherapy alone isn't actually super effective without
56:30 - 57:00 medications to supplement well with alcohol use disorder I think the evidence is shows that both are good but Psychotherapy can be as effective as medications and that's one of the really rewarding aspects of working in addiction treatment we've got medications and treatments that work really well and they can they can change the trajectory of a patient's life I mean it's I've seen patients who have felt like they've been at Rock Bottom they're in total despair they're using relapse after relapse maybe they're homeless maybe they have recently uh
57:00 - 57:30 gotten divorced or lost their job and if you start them on medication their life can dramatically change in a short period I mean several months uh and and so we know that that effect is possible another thing that I will say if I'm counseling patients who are maybe considering buprenorphine is that we tend to recommend you you commit to staying on this medication for at least as many years as you were using whatever it was you were using so if you've been using heroin every day for four years or
57:30 - 58:00 in pills before that then just commit to staying on buprenorphine for at least that long because it can take that long for some of the chronic changes in the brain to rewire we know that chronic substance use particularly chronic opioid use causes a lot of changes in the brain and so that's the reason that we don't recommend using a medication like Suboxone for a month or six weeks or six months because treatment when extended is more likely
58:00 - 58:30 to be successful and one last question and then we'll wrap up um someone is wondering about using Naltrexone to reduce drinking but um using cocaine when you're on Naltrexone and if there's risk for them yeah so that's a good question I will say number one um nowadays I see so many patients who think they're using cocaine that's laced with fentanyl so if you think you're using cocaine um I would strongly encourage you to find a program in your community that has fentanyl test strips
58:30 - 59:00 because you may be exposing yourself to Fentanyl unknowingly um now trekzone has been studied for cocaine addiction and it just didn't work unfortunately now strike zone is not going to block the high that you might get from from cocaine use but it could block if there's any opioids such as fentanyl in your cocaine it could block that um so now trexon is not going to make it any less likely to uh that you reduce
59:00 - 59:30 your cocaine use um and we also know that patients who are mixing cocaine and alcohol um are more at risk of Adverse Events more at risk of of overdose so um so that's sort of that would be my response to that yeah so it sounds like taking Naltrexone and having cocaine in your system isn't dangerous like if you have Naltrexone and then you great well thank you everyone for your
59:30 - 60:00 attendance and to Dr Coleman for um your excellent talk and overview and answers to all these questions um we hope everybody found the information from today's session very helpful and we did provide some links in the chat including our research Resource page and clinic and information on our next session we have on January 11th uh 2023 which will be the same time at seven o'clock and it's focused on how to
60:00 - 60:30 help a loved one battling addiction and I would like to just point out that the educational series was made possible by the Patrick Gibbons memorial fund which honors the memory of Dr Gibbons a passionate Doctor Who helped many people in pursuit of recovery from addiction so thank you again to Dr Coleman and thank you for everyone for attending foreign