RAWATAN METHADON DAN TERAPI
-
Upload
pusat-latihan-aadk -
Category
Documents
-
view
240 -
download
0
Transcript of RAWATAN METHADON DAN TERAPI
-
7/27/2019 RAWATAN METHADON DAN TERAPI
1/54
Methadone MaintenanceTherapy
-
7/27/2019 RAWATAN METHADON DAN TERAPI
2/54
What is methadonemaintenance treatment?
Methadone maintenance treatment(MMT) is a comprehensivetreatment program that involves
the long-term prescribing ofmethadone as an alternative to theopioid on which the client was
dependent.
-
7/27/2019 RAWATAN METHADON DAN TERAPI
3/54
Methadone
Methadone is a long-acting opioidagonist
Only the treatment of opioiddependence.
-
7/27/2019 RAWATAN METHADON DAN TERAPI
4/54
Questions & Issues
How important is methadone in treatingheroin addiction?
What is the rationale?
How do we decide when/if it can bediscontinued?
What is included in the psychosocial
component of treatment?
-
7/27/2019 RAWATAN METHADON DAN TERAPI
5/54
Once the client is stabilized at theright dose, methadone will:
suppress opioid withdrawalsymptoms
reduce cravings for opioids
not induce intoxication (e.g.,sedation or euphoria)
reduce the euphoric effects of
other opioids, such as heroin.
-
7/27/2019 RAWATAN METHADON DAN TERAPI
6/54
-
7/27/2019 RAWATAN METHADON DAN TERAPI
7/54
OPIOIDMAINTENANCE
THERAPY
-
7/27/2019 RAWATAN METHADON DAN TERAPI
8/54
The Addiction Process:Barriers to Understanding
INFLUENCE OF THE STIGMA:
difficulty understanding the complexity ofthe disorder
treatment is denied
treatment is diminished
treatment is discouraged
treatment is conditional
-
7/27/2019 RAWATAN METHADON DAN TERAPI
9/54
I Dont Believe in
Methadone
-
7/27/2019 RAWATAN METHADON DAN TERAPI
10/54
Methadone is a medication,not a religion
J. Thomas Payte, MD
Founding Chair, Methadone TreatmentCommittee, ASAM
O i
-
7/27/2019 RAWATAN METHADON DAN TERAPI
11/54
Overview:Opioid Maintenance Therapy
Methadone (MMT) & levoacetylmethadol(LAAM), buprenorphine (soon)
most highly regulated
history
rationale for replacement therapy
political influences
diversion
-
7/27/2019 RAWATAN METHADON DAN TERAPI
12/54
OMT, Continued
Strong empirical support for safety andefficacy (30 years of data)
valuable tool in reducing spread of HIV
makes the pt accessible to interventionsfor other problems
hidden populations of heroin users
medical maintenance and office-basedpractice
-
7/27/2019 RAWATAN METHADON DAN TERAPI
13/54
What is Abstinence?
Medication is compatible with 12-stepparticipation if appropriately prescribed byphysician knowledgeable about addiction
Pt on methadone is abstinent if not using illicitdrugs and using legal ones as prescribed
Its just another medication. Meds are a tool,
not a solution
D l R S
-
7/27/2019 RAWATAN METHADON DAN TERAPI
14/54
Dole: Receptor SystemDysfunction
Endogenous ligand-narcotic receptor system isdefective; hence high relapse rate
Stabilize blood level at 150-600 ng/mL
This normalizes neurological and endocrinefunctioning
This treatment is corrective but not curative
Future research: identify the specific defect and
repair it(Dole, JAMA 1988)
-
7/27/2019 RAWATAN METHADON DAN TERAPI
15/54
Genetic Factors
Recent studies show distinct geneticvulnerability to heroin and other opiates:
heroin had larger genetic influences unique to
itself than marijuana, sedatives, stimulants,psychedelics (Tsuang et all; Merikangas et al; ARCHIVES 1998)
Alcoholism and drug disorders appear to beindependent
Genetic factors impact the transition from druguse to abuse/dependence, not use itself
-
7/27/2019 RAWATAN METHADON DAN TERAPI
16/54
Diversion of Medication
political hot button
key issue in formulating original regs
IOM report: cannot document significantpublic health or safety problem
confusion about DAWN data
difficulty of determining cause of death(Rettig 1995)
-
7/27/2019 RAWATAN METHADON DAN TERAPI
17/54
Reasons for Diversion
selling take-homes to buy illicit drugs
need to supplement income
share with or sell to addicted friend/mate
unwilling or unable to enter treatment
low dose policies of some programs
IOM conclusion: risks of diverted methadone do notoutweigh benefits of making MMT more available
(Rettig 1995)
-
7/27/2019 RAWATAN METHADON DAN TERAPI
18/54
PHARMACOTHERAPY
-
7/27/2019 RAWATAN METHADON DAN TERAPI
19/54
Methadone vs Heroin
Can be taken by mouth
Slow onset of action
No continuing increase in tolerance levels
after optimal dose is reached; relativelyconstant dose over time
Pt on stable dose rarely experiences euphoricor sedating effects; is able to perceive pain
and have emotional reactions; can perform;can perform daily tasks normally and safely
-
7/27/2019 RAWATAN METHADON DAN TERAPI
20/54
Methadone vs Heroin (2)
Long acting; prevents withdrawal for 24-36 hours (4x-6x as long as heroin),permitting once-a day-dosing
At sufficient dosage, blocks euphoriceffect of normal street doses of heroin
Medically safe when used on long-term
basis (10 years or more)(Physicians Guide: Opioid Agonist Medical Maintenance Treatment; CSAT
2000)
-
7/27/2019 RAWATAN METHADON DAN TERAPI
21/54
DoseR
esponse
Time
LoadedHigh
Normal Range
Comfort Zone
Sick
Heroin Simulated 24 Hr. Dose/ResponseWith established heroin tolerance/dependence
0 hrs. 24 hrs.
Abnormal Normality
Subjective w/d
Objective w/d
Opioid Agonist Treatment of Addiction - Payte - 1998
-
7/27/2019 RAWATAN METHADON DAN TERAPI
22/54
Opioid Agonist Treatment of Addiction - Payte - 1998
GOALS FOR PHARMACOTHERAPY
Prevention or reduction of withdrawal symptoms
Prevention or reduction of drug craving
Prevention of relapse to use of addictive drug Restoration to or toward normalcy of any
physiological function disrupted by drug abuse
Source: MJ Kreek, Rationale for Maintenance Pharmacotherapy of OpiateDependence, 1992
PROFILE FOR POTENTIAL
-
7/27/2019 RAWATAN METHADON DAN TERAPI
23/54
PROFILE FOR POTENTIALPSYCHOTHERAPEUTIC AGENT
Effective after oral administration
Long biological half-life (>24 hours)
Minimal side effects during chronic
administration
Safe, no true toxic or serious adverse effects
Efficacious for a substantial % of persons with
the disorder (> 15-20%)
-
7/27/2019 RAWATAN METHADON DAN TERAPI
24/54
DoseResponse
Time
LoadedHigh
Normal Range
Comfort Zone
Sick
Methadone Simulated 24 Hr. Dose/Response
At steady-state in tolerant patient
0 hrs. 24 hrs.
Abnormal Normality
Subjective w/d
Objective w/d
-
7/27/2019 RAWATAN METHADON DAN TERAPI
25/54
Not Holding Strategies
Cognitive, Behavioral Interventions Increased contact, counseling,
therapy
Alter urinary pH?
Is patient fixing? - Raise dose
Split Dose?
Rapid Metabolizer High Single and
-
7/27/2019 RAWATAN METHADON DAN TERAPI
26/54
Rapid Metabolizer - High Single andSplit Dose Simulation
0
100
200
300
400
500
600
700
0 4 8 12 16 20 24
Single
HighSingle
Split Dose
Minimum
'Normal'Ceiling
High
Normal
Sick
ng
/ml
Hours
-
7/27/2019 RAWATAN METHADON DAN TERAPI
27/54
TAPERING
how many remain abstinent?
tapering readiness
tapering strategies
clonidine
handling relapse
-
7/27/2019 RAWATAN METHADON DAN TERAPI
28/54
Buprenorphine (1)
1970s - partial opioid agonist useful inopioid dependence treatment
1990s - clinical trials
long duration of action; smooth onset
low physical dependence
mild withdrawal syndrome
good name on the street
-
7/27/2019 RAWATAN METHADON DAN TERAPI
29/54
Buprenorphine (2)
DATA 2000 permitted use in MD office
FDA approved Subutex and Suboxone in2002
Physicians must meet trainingrequirements: certified in addictionmedicine, participated in clinical trials, or
took 8 hour course by specifiedorganizations
-
7/27/2019 RAWATAN METHADON DAN TERAPI
30/54
Buprenorphine (3)
SUBUTEX & SUBOXONE
Sublingual tablets
Suboxone has naloxone added todiscourage needle use
Partial agonist: ceiling effect
Expensive: $300/month at average dose
Not interchangeable with methadone
-
7/27/2019 RAWATAN METHADON DAN TERAPI
31/54
-
7/27/2019 RAWATAN METHADON DAN TERAPI
32/54
Naltrexone
antagonist; how it works
who does it work for?
accelerated withdrawal protocols
Doles critique
utility with alcoholics
-
7/27/2019 RAWATAN METHADON DAN TERAPI
33/54
Methadone in Pregnancy
Comprehensive MMT treatment with prenatalcare improves neonatal outcome
Withdrawal is rarely appropriate during
pregnancy Methadone is not teratogenic; children have
been followed into adulthood
Appropriate dosing is very important
Breast feeding OK if no other drug use
-
7/27/2019 RAWATAN METHADON DAN TERAPI
34/54
Opioids and Chronic Pain
Opioid tolerance & physical dependence DONOT equal opioid addiction
Loss of Control Indices:
Continued use despite adverse consequences
Illicit or inappropriate drug seeking behavior
In response to craving or drug hunger
In the absence of pain or withdrawal
Pseudo Addiction
-
7/27/2019 RAWATAN METHADON DAN TERAPI
35/54
Pseudo Addiction- in chronic pain patient
Inadequate Treatment of Pain Apparent Drug Seeking Behavior
Effort to achieve adequate analgesia
Early refill, doctor shopping, etc.
Manipulation seen as addictive behavior
May be seen as non-compliance
Cured by adequate treatment of pain
-
7/27/2019 RAWATAN METHADON DAN TERAPI
36/54
Chronic Pain Disorder
Opioid Tolerance Opioid Physical Dependence
Absence of illicit or inappropriate drug
seeking behavior No drug hunger in absence of pain
No loss of control
No doctor shopping
Little tendency to escalate dose over time
-
7/27/2019 RAWATAN METHADON DAN TERAPI
37/54
PSYCHOSOCIAL
TREATMENT ISSUES
-
7/27/2019 RAWATAN METHADON DAN TERAPI
38/54
Population Characteristics
Heterogeneity
Readiness for recovery; motivation
Psychiatric comorbidity
Medical comorbidity
h
-
7/27/2019 RAWATAN METHADON DAN TERAPI
39/54
Program Characteristics
Medical component: assessment,dosing, client interactions
Individual counseling Group counseling
Case management
Staff training (ongoing)
Wh t i Ab ti ?
-
7/27/2019 RAWATAN METHADON DAN TERAPI
40/54
What is Abstinence?
Medication is compatible with 12-stepparticipation if appropriately prescribed byphysician knowledgeable about addiction
Pt on methadone is abstinent if not using illicitdrugs and using legal ones as prescribed
Its just another medication. Meds are a tool,
not a solution
-
7/27/2019 RAWATAN METHADON DAN TERAPI
41/54
Cognitive-Behavioral Therapy
Lends itself to controlled studies; strongsupport for its effectiveness
Especially useful to help establish
abstinence, teach early recovery andrelapse prevention skills
Emphasizes changing behavior and
managing symptoms
Cognitive Behavioral Strategies
-
7/27/2019 RAWATAN METHADON DAN TERAPI
42/54
Cognitive Behavioral Strategies(CBT)
MATRIX MODEL - Organizing Principles
Create explicit structure and expectations
Establish positive, collaborative relationship
Teach information and CBT concepts
Positively reinforce behavior change
Provide corrective feedback when necessary
Encourage self-help participation
CBT MATRIX MODEL
-
7/27/2019 RAWATAN METHADON DAN TERAPI
43/54
CBT: MATRIX MODEL
Structure is essential: time scheduling, self-help meetings, exercise, work, treatmentactivities
Identify external and internal triggers and
make a plan Tools for managing cravings: thought
stopping, visual imagery, changeenvironment/behavior
TIP #33 has description, patient worksheets(Rawson 1999)
-
7/27/2019 RAWATAN METHADON DAN TERAPI
44/54
Clinical Issues
-
7/27/2019 RAWATAN METHADON DAN TERAPI
45/54
Is Psychotherapy Useful?
Philadelphia group study, begun 1977
global psychiatric status ratings
elements of drug counseling
models of psychotherapy utilized
benefits to low severity patients
benefits to high severity patients
-
7/27/2019 RAWATAN METHADON DAN TERAPI
46/54
Dual Diagnosis Issues
depression
trauma history; PTSD
schizophrenia
medication strategies
PTSD I fl i E l T
-
7/27/2019 RAWATAN METHADON DAN TERAPI
47/54
PTSD Influence in Early Tx
Aim: determine tx adherence relative tofrequency of violence and PTSD in MMT pts,male & female
96 pts; over 2/3 exposed to one or more violenttraumatic events
Trauma or PTSD did not predict dropout rates
Those with current PTSD had significantly more
ongoing drug use at 3 months, especiallycocaine
(Hein et al, 2000)
Continued heroin, alcohol,d h d
-
7/27/2019 RAWATAN METHADON DAN TERAPI
48/54
and other drug use
patient and provider expectations
enhancing motivation
cocaine use
alcohol use
medical comorbidity; AIDS, chronic pain
controversies about discharge
P h l i l I
-
7/27/2019 RAWATAN METHADON DAN TERAPI
49/54
Psychological Issues
AOD use in family of origin
high frequency of childhood physicaland sexual abuse
recognition and appropriate expressionof feelings
issues of self-care, self-soothing
W I
-
7/27/2019 RAWATAN METHADON DAN TERAPI
50/54
Womens Issues
remove practical barriers: transportation,child care
intimate relationships as primary hazard
sexual issues
contraceptive practices
F il /C l W k
-
7/27/2019 RAWATAN METHADON DAN TERAPI
51/54
Family/Couples Work
engaging family, significant others
education about addiction and MMT
develop existing and new support
structures
couples issues
parenting classes
HIV/AIDS
-
7/27/2019 RAWATAN METHADON DAN TERAPI
52/54
HIV/AIDS
impact on MMT staff; providing support
regular assessment of staff attitudes andknowledge
integrating primary care promoting medication compliance
impact of dementia on treatment
MMT d 12 St P
-
7/27/2019 RAWATAN METHADON DAN TERAPI
53/54
MMT and 12-Step Programs
benefits and hazards
simulated meetings as a launchingstrategy
meetings in the community Vincent Dole and Bill W.
other types of self-help
advocacy groups
Making Residential Treatment
-
7/27/2019 RAWATAN METHADON DAN TERAPI
54/54
Available to Methadone Patients
Some clients need higher level of care
Issues for the methadone program
Issues for the residential program
Security issues
Documentation issues
Funding barriers