Medication Assisted Therapy for Addiction | Counselor Toolbox Episode 113

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox. Okay, so I'd like to welcome everybody to today's presentation on medication assisted therapies for addiction. And if you are a mental health counselor, you don't typically work with people who are in active addiction. You know, that's cool. If you are working with someone who is in recovery from addiction or on medication assisted therapies, it's helpful to know what meds they might be on and how that might be might be impacting their mood as well as some of the contraindications you might want to be aware of so you know when your patient is getting into a position where they might be in jeopardy of harming themselves. We're going to discuss the purpose of long term pharmacotherapy. And when we talk about long term, it's not necessarily forever and always, but we're really looking at several years as opposed to six months. We'll identify pharmacotherapies for smoking, alcohol and opioids for the most part. We're also going to talk about some of those other drugs that don't have medication assisted therapies identified for them. So why do we use them in early recovery? We want to help people reduce cravings when possible. And medication assisted therapies that are so labeled are designed to assist patients in not having as many cravings. So the medication assisted therapies can help reduce their desire, their compulsion, their obsession to go back out and use in order to feel that feeling again. It provides increased self efficacy and a greater sense of control when clients can go in and say, all right, I'm taking this. It's going to help me not have cravings. Well, we know part of it's going to be placebo effect. That's okay. I don't care where the effects coming from. If it's a positive effect, I'm pretty darn happy. So we want to look at what is this helping the client with. And obviously if you're giving somebody a medication that doesn't do anything at all, or a sugar pill or something, you're probably going to have different results. So I don't want to trick the clients, but I do want to help them see ways that the medications they're taking might help them in early recovery. Medication assisted therapy can help reduce anxiety in a lot of our clients because a lot of clients come in and they've relapsed before and they're trying it again and they're afraid they're going to fail again or they haven't relapsed, but they have. They're going to go to jail if they relapse or they're going to lose their kids. There's a lot at stake on this. So there's a lot of anxiety about if I relapse, how am I going to deal with the feelings and the cravings and the yada, yada, yada, so I don't relapse. And they just focus on all of the what ifs. Medication assisted therapy can help patients have something to focus on, to say, okay, I've got this tool. Now. We're not necessarily talking about a tool forever, but we're talking about a tool to help them climb the mountain. Think about those little poles that people use when they're climbing the mountain. That's kind of what we're thinking about with medication assisted therapy. It's helping people maintain their footing while they're climbing to the apex of recovery, if you will. It also may improve depressive symptoms by enhancing hope and a sense of empowerment. Remember, depression goes with hopelessness and helplessness. So if we can encourage them to focus on the fact, well, this medication assisted therapy may help you not have the cravings. It may make it easier to get through this early recovery period so you can master the skills and tools you need to live a sober lifestyle. That gives me hope when I say it, so I'm hoping it'll give the clients hope when they hear it and it gives them a sense of empowerment because it says you have control over this. We're giving you some tools. We're giving you those little walking poles to help you keep going forward. It's not going to be easy. We're not saying it's going to be easy, but we're going to try to help bolster you along the way. And certain medication assisted therapies have pharmacological effects that will help alleviate depression and anxiety. So that's a nice sort of side effect if you want to look at it that way. If you're using it to reduce cravings, but it also is an antidepressant, well, then bonus, we want to reduce co occurring issues. We know that people who come into detox, if you've worked in a detox facility or even in a crisis stabilization unit, and a little story here that will ring true with a couple of you. The last place I worked, well, a couple places, it was a big facility and we had a crisis stabilization unit and we had a detox unit. Now I was over the detox unit. And we would have clients come in and they would be in crisis. They may be actively psychotic, but they would also be stoned out of their minds. So the crisis unit didn't want them because they're like, well, we can't handle monitoring detox. And we didn't want to take them because we didn't have the staffing to monitor and handle the psychoses. We didn't have a psychiatrist on our facility. So every time one of those clients would come in, we'd end up with this hot potato and they'd be calling the supervisors at home going, who gets them? And really it would end up with an evaluation of what is that person's psychiatric stability and how can we cooperate. Thankfully, we were on the same campus. So if the person had to stay over at the crisis stabilization unit, then our nurse would go over and do the periodic checks to make sure that they were doing okay, do the CWAs, whatever they to do. If the person was stable enough or they could get them to the point where they weren't actively psychotic and a danger to themselves or others, then they could come over to the detox unit where my staff would monitor their detox protocol. So it was. Unfortunately, when you've got people with co occurring issues, it's really a struggle. And most people in early recovery have co occurring issues. Now they may not be floridly psychotic, but they are probably going to have some pretty significant depression or anxiety. I mean, just because of the neurotransmitter imbalance. Remember we've talked before about how when addictive behaviors are used, the brain is flooded with whatever that chemical is and that chemical recedes. If you want to think about ebb and flow, that chemical recedes just as quickly pretty much as it went in, and a little bit different than that, but a lot quicker than the body can catch up. So it goes away. And there's not that counterbalancing chemical in the right levels to help the person feel normal. And you're burning through, if you will, a lot more neurotransmitters. So there's going to be neurotransmitter imbalance. People are going to feel, feel crappy. And when they feel discomfort, and I use that term very generally because the discomfort they're feeling is palpable. I mean, it is really crushing. Sometimes anxiety and depression, they need that to go away. They're like, I cannot survive feeling this way. So what is the response? A lot of times go out and use again. So in early recovery, we really need to help people get to the point where their neurotransmitters are stabilized enough, where they're not feeling like they have to escape, where they're not feeling like they can't breathe because of the anxiety and the depression and they're not craving the drug, which is a whole different ballgame. But this is what we're heading towards. We need to identify and address vulnerabilities and you know, medication assisted therapy, giving them medication or them taking medication, however you want to look at it is one aspect. Just giving them a pill is not going to fix everything. It helps them stabilize so they have the energy and the clear headedness, hopefully to participate in their recovery process. And then we start identifying and addressing their vulnerabilities. If they're homeless, if they're not eating enough, if they've got hepatitis C, if they've got anything else going on that might be contributing to their stress, their pain and their neurotransmitter imbalance. So we help them improve overall health, education, nutrition, energy, help them maintain abstinence. Most of the time, what we're talking about here, most of the drugs, well, the drugs we're talking about, people can abstain from. You're not going to die if you don't have cocaine. It's not like telling somebody they can't ever have food again. So we want to look at this and go, during this period of early recovery, how can we help you maintain abstinence so your body can rest, recover and rebalance? And that's kind of a hot button topic, whether you say you've got to abstain forever or you approach it from during this period of early recovery. I have found, and from a motivational perspective, I have found that in early recovery there's still a little bit of ambivalence. Clients can't imagine going the rest of their life without cocaine, without a drink, without this or that. And if I start talking about forever, it freaks them out. So we talk about how can you maintain abstinence right now because you're here, what are your goals and how can I help you achieve those goals? One of them is to help you reduce the cravings, improve your mood, improve your health, and let's see where you want to go from there. If a relapse occurs, medication assisted therapy often reduces the intensity of the relapse. So that's something to kind of bear in mind. Most drugs, you know, with the exception of Some of the nicotine drugs, which are very dangerous if you smoke while you're using them, will either have a negative effect and make you feel sick, but they're not like life threatening or they've already blocked some of the receptors. So when you use the street drug you don't get the same high and it's just like eh. Whatever. Part of a comprehensive plan that addresses recovery involves us helping people deal with their emotional, cognitive, physical, social, occupational and environmental issues. So we're going to look at that. But remember, people are not going to be able to maintain housing if they're spending all their money on dope. People are not going to maintain a job if they can't get there because they're too hungover or strung out. So medication assisted therapy plays a critical pivotal role in early recovery, helping people start re establishing a new drug free life. It's not a substitute for counseling. We're not saying give them a pill, it's going to make everything better and they can go on their merry way. And that is a misconception a lot of people have about methadone clinics and we'll talk about methadone a lot towards the end of the presentation. But it's important that medication assisted therapy is a tool. You have that person climbing the mountain, okay, they know how to use these walking sticks and there's probably a different word for them, but we'll call them walking sticks. But they need to know how to adjust their breathing when the oxygen starts to get thinner. They need to know how to handle it if all of a sudden a snowstorm comes up. They need to know how to handle it if some other obstacle comes in their way. That's what counseling does. Counseling helps educate people about how to get to the top of the mountain and stay there and thrive instead of falling back down. The co occurring model of addiction Now I want you to just kind of remember this as we're talking says that co occurring disorders are the expectation the person may not have been depressed, anxious, whatever before they started using. They may not have even been symptomatic for bipolar or schizophrenia. But the stress of the addictive behaviors and the stress on their body can trigger the psychosis or the bipolar disorder to kind of show its head. So it's important to understand that people may not have initially started out self medicating. They may have started out using just recreationally and then something happened and they used a little bit more. And as they used more, their brain chemicals got progressively out of whack and then they started Needing to use to feel normal. So by the time they get into active addiction, they've either created a mental health issue, neurotransmitter imbalance, or that one that was still there. They're self medicating either way in early recovery. I haven't ever met anyone who didn't have some level of co occurring issues and that's okay. But they need to understand how that mood issue impacts or plays into the recovery process. Relapse begins when thoughts, urges or behaviors return to that addictive mindset. So again, we need to look at, if somebody starts relapsing, their depression starts increasing again, those depressive thoughts start increasing again, then those thoughts of suicidality and wanting to escape and making it stop are going to come back in and we see an addiction and relapse after that. Addictive behaviors were learned as a way to stop distress and learned behaviors cannot be unlearned. So some people talk about a disease concept. I really talk about learned behaviors. Think about a salesman. A salesman may be great at selling, let's say cars. And then they decide one day, you know what, I don't want to sell cars anymore. This isn't fulfilling. I want to be a plumber. And they learn how to be a plumber and they're good at that. But then all of a sudden something happens and they can't be a plumber anymore. The plumbing is not paying their bills, but they know they can go back and be a good salesman. This is kind of what we're talking about with addictive behaviors. When the good coping skills, when the healthy coping skills, when the sober way of life quits working for some reason. One option, it's not the only option, but one option is to go back to those addictive behaviors that made the pain stop. We want to help people learn alternate behaviors and their consequences which are more rewarding than the addictive behaviors and their consequences. Addictive behaviors may have really awesome short term consequences, makes the pain stop, but in the long term, not so much. It's more punishment than positive reward. Our recovery behaviors in the short term may not feel so great. You know, distress tolerance does not feel near as good as, you know, numbing with opiates or something else. But does it help the person achieve their long term goals? So when do we use drugs? Well, there is no pharmacotherapy for most abused drugs, stimulants, which includes amphetamines and cocaine and Adderall and all those hallucinogens, inhalants and marijuana. So in some of these they talk about Having more psychological addictive behaviors than actual physiological addiction. Either way, if they're addicted, if they have withdrawal symptoms, we're going to have to address it at some point. So what I look at is what are the functions of these different behaviors? Since there's no drug out there that's specifically FDA labeled to address cravings, I say, well, why would the person use it? Let me see if I can get a clue as to their neurotransmitter imbalance. And one of them is start with stimulants and cocaine. The sympramine is actually a tricyclic antidepressant. And it was brought to my attention before this presentation. And it's actually a norepinephrine reuptake inhibitor with very little effect on serotonin. So let's think about this. Cocaine is a stimulant. All right, we got that. Norepinephrine is our get up and go and focus neurochemical, among others, glutamate and stuff. But if we increase the level of norepinephrine, we're increasing the energy level, the availability of focus and motivation, which is a little bit similar to what cocaine does. So and when we look at people who use cocaine, what are they wanting? They're wanting energy, they're wanting to feel good, they're wanting more dopamine. And some drugs, some pharmacological drugs can help them feel a little bit better. They can take the edge off that feeling flat and unfocused and unmotivated. And I just can't do this. There was a study that was done and let me see if I can find it in addiction science and clinical practice in 2003 that showed that disempramine was actually somewhat effective at helping people in the study maintain drug free urines. So that was kind of an interesting. That was Addiction Science and clinical practice in 2003. That is not on your quiz, just point of interest. So when you're dealing with stimulants, we know you're dealing with somebody who was trying to rev themselves up, which means they probably feel bleh. And they either feel bleh unmotivated and depressed or no happiness. And the dopamine is low. So we want to look at, are there pharmacological interventions that a psychiatrist could help them with that might help rebalance some of that or help them address some of those symptoms of apathy or lack of pleasure? Lack of pleasure kind of is part and parcel of depression. So generally your docs are going to look at antidepressants first, antidepressants. And I'm going to go through the big five just because those are the ones that most people think. 5 Zoloft tends to be pretty neutral as far as energy, but it has shown a lot of effects for helping people with compulsive behaviors, especially bulimia and, and compulsive gambling. So Zoloft is out there. When we look at Prozac, Prozac tends to be much more stimulating and can increase anxiety levels. But if you've got someone who's looking for more energy, Prozac might help them, as are some other drugs. I'm just going over the older ones that we're talking about. Paxil on the other hand, tends to slow people way down. It helps with anxiety, so does Zoloft. But Paxil tends to make people sleepier. So a lot of people who take Paxil take it at night. If you're, you've got a patient who's really looking to wake up and get some motivation, obviously it's between them and their doc. But my experience over 20 years has told me that that patient is not going to be very happy on Paxil. So I guess those are the big three that I really wanted to talk about right now. Now, hallucinogens, you don't really think of those as drugs of abuse. You don't have somebody coming in to detox for being addicted to LSD. And but they do, they are out there psychedelics. And there I learned this during this presentation. There are three different types of hallucinogens, psychedelics which act on the 5H2A receptor. If you remember from Tuesday's presentation, 5HT is your serotonin receptor family. And there are I believe, 18 different types of serotonin receptors. 5H2A is just one of those. But your antidepressants work on different 5ht receptors. So each antidepressant may not work on 5h2a. So if you've got somebody who's using psychedelics and we're talking about your lsd, pcp, they're using them often to get that state of quote empathic well being. They just kind of love everybody and the world is good and we're going to hold hands and sing Kumbaya, which would, I would want to say, what is it when they're not on that? You know, what are they feeling when they're not on that? That they really need a drug to help feel empathy and compassion and love for themselves and other people. I'm hearing anger, maybe anxiety, maybe, maybe some depression. But that would be talking with the client to figure out what's going on. But anyway, 5H2A, we know is a serotonin receptor. So we want to look at a drug that's going to target 5H 2A. Your dissociatives reduce your glutamate level. Now remember, glutamate is the one that's secreted during the fight or flight response. So your dissociatives are probably going to be in people who have higher levels of anxiety. They have altered pain perception, and it's a depressant. You know, it's going to make them slow down, respiration slows down, that sort of thing. But again, you're having somebody slow down instead of speed up. Ketamine, we talked about that on Tuesday. But ketamine is a huge hallucinogen that is used to help people calm down in certain emergency situations. It's actually a horse tranquilizer. But dextromethorphan is a big one that the youth of today are abusing. And dextromethorphan can be bought over the counter. It's a cough syrup. You know, you're probably familiar with it, but if you get it pure and not mixed with guaifenesin or one of those other things, the youth are taking the pure dextromethorphan and using it rectally in order to get high. So being aware that that's an increasing problem, I digress. So if somebody's using a dissociative hallucinogen, I might look at anxiety issues and try to figure out what's going on there. Delirience, Benadryl and Dramamine. Now, delirians are really dangerous because the level between recreational use and lethal is really, really, really small. And it's really easy to kill yourself. So, okay, that's fine, whatever. Warning all over. But the deliriums reduce acetylcholine. And we know that acetylcholine is involved a lot in schizophrenia and powerful dreaming and active mind. And there's a reciprocal relationship between acetylcholine and serotonin. Ah, see, you know, I was gonna get somewhere that made sense. As acetylcholine goes up, serotonin goes down. So if somebody's abusing acetylcholine, we might look and say, hmm, I wonder what's going on. Maybe their levels of serotonin are too high. Maybe they've got some anxiety going on. What is the benefit of this for them? Besides just the Overall feeling. But there are a lot of medications that they can look at. The selective norepinephrine reuptake inhibitors would be kind of tops on my list. But again, that would be between them and their psychiatrist. The take home messages. Hallucinogens can be used recreationally, but if you've got someone who's addicted to them, then there's some other reason, some other thing that is keeping them coming back besides just, you know, a feeling because they're foregoing other activities in their life in order to use this substance. It's almost intolerable to be without it. Your inhalants are depressants. So just like alcohol can be a depressant or is a depressant if somebody's using inhalants or alcohol, I tend to look for high levels of anxiety and see what's going on there where the inhalants actually make them feel better. And interestingly, marijuana increases dopamine, which helps it be relaxing or pain relieving. But I've heard a lot of people who've used marijuana, really potent marijuana or the new resin dots that have come out that have had really, really bad trips. Spice was just new when I was leaving residential or not super new, but it was new ish. And I would regularly have clients go out on work phase and come back in. They'd use Spice and they're like, well, it's not going to show up on a drug test and it's legal, so I can use it because that's the way the addictive mind thinks. And on three occasions I can think of in the course of the year, we had to call the ambulance out because the person's heart rate was it like 200, literally 200. And they were laying on their bed and they felt like they couldn't move. Their arms and legs were so heavy they felt paralyzed. So marijuana is not always. And obviously that was spice. They were using the synthetic thc. But the side effects can differ between people. We want to look at why they're using it. Factors to consider when you're looking at do we consider pharmacotherapy cost. Now my little soapbox here. If a patient needs medication, many places that make the drugs will give out patient assistance programs or give out vouchers through their patient assistance programs. AstraZeneca has a really good patient assistance program, Eli Lilly. So you find the manufacturer of the drug, you go online and you google that company's name plus patient assistance program. It's the easiest way to do it. And then it'll bring you to the page or close to the page for that pharmaceutical company that has the patient assistance program forms on it. The forms are usually one page. The doc fills it out, faxes it in, they make a determination and yada yada. Not every drug is covered on patient assistance programs, but a lot are. There's also a lot of drugs, the generics especially, that are available on formularies, the $4 prescriptions or whatever, through different pharmacies. So in large part for many medications, there is a way to get them affordably, even if your patient doesn't have access to insurance for their prescriptions. Another thing to consider is availability. Can this drug be gotten easily? Methadone is a perfect example of that. Methadone clinics are not on every door, on every street corner. And so if you're going to have your client start a methadone program, they're going to have to go every single day, seven days a week in order to get their meds, because they're not allowed to take home any. So do you want them driving an hour and a half there and an hour and a half back every single morning in order to get dosed? And are they going to do that? Are they going to stay compliant? You want to consider the side effects, you know, if this person takes this medication, what are the side effects and are those acceptable side effects in that person's purview? We want to look at barriers, workplace drug testing. If they're working somewhere that prohibits the use of methadone, and then even if they're on prescription methadone, they may, it would show up in a drug test and they may lose their job. There is some argument about whether that's legal, but let's be realistic here. The time it would take to fight that out in court would be not good. What other meds are they taking? There are a lot of medication assisted therapies that don't play nice with other medications. So we have to know that a client cannot be on buprenorphine or methadone and be taking benzos. So, you know, if they're going to continue to take their benzodiazepines, they're going to not be eligible to take some others. And incarceration with methadone, with suboxone, with buprenorphine, with any of these meds. Actually, I found in the criminal justice system, clients generally, in the three states that I've worked, and I'm not going to say this is everywhere, when they go into jail, they are taken off all medication. And the only way they get put back on medication is if they are not manageable in the population. Now I could go off on a whole tangent about that and I will refrain for right now. But that means if they are on medication assisted therapies for addict addictions, the thought is going to be, well, they can't get the substance in here, they don't need these. Cut them off cold turkey. And that can get really ugly if they're on methadone or anything else. And if they're incarcerated, they're not going to be able to get the medications if you happen to work in a jail. And finally, what is their motivation? Are they willing to actually do the work so the medication assisted therapy can be successful because it only does part of it, you know the person. Medication assisted therapy is only the walking sticks. They have to use their own feet to move up the hill. So we need to know, are you willing to do the counseling to address the issues and make behavior and lifestyle changes to address the issues that made you want to use stigmatization? Why people may not want to use medication assisted therapy. There are a lot of places, many 12 step groups, many treatment programs that are very, very opposed to medication assisted therapy, with the exception of, interestingly enough, nicotine replacement therapy. So we want to look at the science versus the dogma. And the science is really supportive of MAT in short to moderate term. And like I said, we're talking six months to maybe five or six years. After that, you know, it gets questionable about whether there's any effect. So we want to look at whether we're using it and we also want to look at whether we're using the medication assisted therapies in an evidence based way or we're just handing it out as a alternative to street drug use. And that's not helpful. That's not medication assisted therapy. That's just peddling. Like I said, 12 step groups are generally pretty against it. Very vehemently against methadone and suboxone, less opposed, but still somewhat opposed to some of the antidepressants and things that are prescribed, whether it's for mental health issues or to reduce cravings. I found a lot of resistance in 12 step programs. Methadone Anonymous is an alternative in some places though. And it's really hard to find an MA group. But if you can, then that's wonderful. Not all counselors are open to medication assisted therapy, so people may have to shop around to find a counselor who can understand the purpose and embrace the use of it. Like I said, there's a lot of counselors out there, especially since you can get Suboxone from your physician, well, from a physician on an outpatient basis. There are a lot of counselors seeing clients for mental health reasons, and those clients are on Suboxone or buprenorphine and maybe even some on methadone. But methadone clinics have their own counseling program. So even as an LMHC or an LPC or a psychologist, it's important to understand what these meds do and why a patient might be on them. Most payors, interestingly, require that medication assisted therapy be considered when available, so that actually shouldn't be on the barrier slide. They're usually pretty open to paying for medication assisted therapy as long as it's FDA approved. For that reason. The hiccup that I found or that I've experienced was when we were trying to get Medicaid to pay for vivitrol injections for alcohol abuse. So you want to check with the insurance company, But a lot of times insurance companies are on board with medication assisted therapy. So what's the end point? Like I said, it's not forever. If you want somebody to stay on methadone forever, you actually have to get a waiver from the state pharmacy board or some state board in order to continue to prescribe. After a certain point, the goal is stabilization. Now, somebody who has mild depression and was abusing drugs for five years may stabilize a lot sooner than somebody who has schizophrenia, bipolar disorder, was using and homeless for 25 years. So this is why we say there's kind of a wide range of what stabilization is. But we want to see them at the point where they're not going to relapse. This treatment is individualized. So, you know, what it could be for. One person is six months. Another person is 26 months. It does allow for relapse. And what do I mean by that? I mean that medication assisted therapy in most cases, sometimes it's up to the psychiatrist, but in most cases, medication assisted therapy says, all right, you were on this and you relapsed. Let's look at your dosage. Let's look at what happened if you come back in and you say, I relapsed. Now, if you relapse and you continue to use or you start using other drugs, now, that's a big no. No. You know, if you drop dirty for cocaine at a methadone program, you're probably going to be discharged. But if you relapse on heroin or fentanyl or whatever your drug of choice was, the doctor is likely Going to look at it and go, okay, let's see what's going on here that would have precipitated this. So on to our meds. Smoking cessation pharmacotherapy comes in patches, gums, lozenges and sprays. The antidepressant Zyban has been effective, has been shown to be effective for smoking cessation and varenicline or Chantix has also been found to be somewhat effective. Now really quickly, agonists are those drugs that they take that have roughly the same effect as the street drug they were taking or the nicotine. Partial agonists are ones that drugs that they can take or medication assisted therapies they can take that activate those same neurons that in this case the nicotine does, but only activates it a little bit more than halfway, about 60%. So instead of getting a wahoo, they're getting a okay. But it helps take the edge off so they're not feeling whatever this was down here. They're up at a level where it's tolerable. So partial agonists have been shown to be very effective. NRTs should always be combined with a behavioral therapy program. They've shown in the research over and over and over again that just replacing it is simply switching the method of access. In many cases we need to look at two things with nicotine. One, why were they using, you know, let's address those neurotransmitter imbalances and the stressors, physical, cognitive, emotional that were causing those neurotransmitter imbalances. But also we need to address the habit because when people use, especially cigarettes, there's a lot of habitual, there's a lot of ritual to it. My mother was a multiple pack a day smoker. She would get up in the morning, roll out of bed before she even had her feet on the ground. She was lighting up her first cigarette and she chain smoked throughout the day. It wasn't a do I need a cigarette right now? It was, I'm conscious, I need to be smoking. And for her, as she went through and stopped smoking, part of it was to start addressing some of those habits. Now, now she's on nicotine nicotine replacement therapy. But I see that in many cases there's still a lot of habit to it, you know, harm reduction here, I'm okay with it, she's okay with it. So you know, whatever. But behavior therapy addresses the habits and helps people break that. Either the hand to mouth habit or the I'm driving in the car, so I have to have a cigarette habit helps them learn distress tolerance, surfing urges, all that kind of stuff. Nicotine replacement therapy is expensive, and expensive depends on the person. But even the generics, it's like 16 bucks for a box of the gum. So it's not inexpensive. Many states cover this through the Medicaid program. So if somebody's on Medicaid, they might be covered. I didn't finish my thought there. You also want to look for smoking cessation programs in your state. Many state smoking cessation programs have free access or significantly discounted access to the NRS. Many state government employees also qualify for free or extremely low cost NRTs. NRTs reduce the harmful effects of tobacco smoking. They haven't been shown to be anywhere near as useful with people who dip. And patients should not smoke while using. It actually could precipitate a heart attack, so let's not do it. The nicotine patch has the highest success rate of available pharmacotherapies, partly in my opinion, because it scares the snot out of them if they know that if they smoke, they. They might have a heart attack. I've worked with clients before in other situations, in other settings. I have one client that I remember distinctly, bless his heart. He was very low cognitive functioning, schizophrenic, but just the sweetheart. And he relapsed on cocaine. And I remember sitting in the nurse's office and I was talking to him, and I'm like, you know, John, I'm really worried about you, because the medications you're on, if you used, when you're using cocaine, that could really be really dangerous. He goes, oh, don't worry, Ms. Dawn. I stopped using my medications about three days before I went out and used because I didn't want to die. Okay. You know, I'm glad he didn't want to die, and I'm glad he had that kind of forethought. But so the addictive mind will work in mysterious ways with the patch. You know, if it's on there, it's kind of on there. Granted, it's helping. It's transdermal, it's kind of steady state, whatever. But I think there's also a certain amount of fear that goes along with that. The gums require a correct chewing technique. You're not supposed to chew it like regular gum. And they tell you to chew regularly for the first month and then taper off over six months. They found that people who chew a piece of gum every two to four hours, and I don't remember what the number was instead of waiting till there was a craving, had a higher success rate than those people who waited for a craving and the drink. Drinking coffee or acidic drinks while you're chewing the gum reduces the absorption of the nicotine. So there's a lot of things to consider. With the gum, are you able to not drink coffee? I know that would be a big deal for me. And you know, is this going to work for you? With the gum, it's easy to kind of forego it and go, you know what, I'll have a cigarette instead. So they have to be super motivated. Lozenges suck on, move it to the side till it dissolves. There's no comparison studies of the effectiveness of lozenges versus the patch or the gum. But some people prefer that. If they've got like I do tmj, I can't chew gum. So the lozenge might be effective, but the nasal spray also might be. It mimics the pleasurable effects of nicotine and has the highest risk for abuse. If you're working with someone, and I do want you to consider this, if you're working with somebody who used to or continues to self administer other kinds of illicit drugs through inhalation, nasal spray is probably not a good way to go because that can be an easy, easy trigger for relapse for other things. The spray can only be used for up to three months. So there are options for people if they're motivated to try to get off nicotine. And part of it is what they believe is going to work for them and won't, what won't trigger other problems. Zyban is again an antidepressant. It works on the dopamine and norepinephrine receptors to decrease withdrawal symptoms. They say this needs to be started about two weeks before the quit date and then you kind of taper down to, you take it daily for three days. You can continue the pills for eight to 12 weeks. So you're not going to be taking it forever. Side effects, it could cause insomnia, not so bad, anxiety, not so great, or seizures. Gives me pause, but depends on the person, if they've, if they're not at risk for seizures and if they've got concurrent depression, this might be helpful for them. The prescription includes a behavioral program to go with it. Chantix is a nicotine partial agonist. So Chantix is one of those that goes in and stimulates those receptors enough, but not all the way again. This is one you start before the quit date, you increase your dose and it can be taken for 12 to 24 weeks and includes a behavioral program. One thing they found with smoking is that people who are in recovery from abuse of other substances are at a much greater risk of relapse if they continue smoking. One theory is because they are using a drug to moderate their moods through the nicotine, and it serves as sort of a gateway drug. But pharmacotherapy for alcohol dependence, Antabuse, Camprol and Vivitrol. Ant abuse blocks acetyl Hyde dehydrogenase. Basically, it keeps enough alcohol in the system that you actually start suffering alcohol poisoning and it makes you vomit. The reaction is flushing, palpitations, chest tightness, nausea, anxiety and headache. If you drink while you're on this, it does help people avoid slips or relapses. But. But I do know addicts who've taken it, who have taken it. And just to see how bad the effect would be, when they got it, they intentionally went out and started drinking just to see how much they could drink and how bad it would be if they actually relapsed again. So we want to look for somebody who's motivated. It will affect the liver even without alcohol and has a ton of drug interactions. So motivation is really necessary for a patient on ant abuse. Campral or acamprosate helps address the GABA and NMDA receptors in the brain, which can lead to alcohol dependency. Remember, alcohol, GABA is your natural anti anxiety. And NMDA is responsible for learning and a lot of other things. It's also involved in the stress, fight or flight response. So Camprol normalizes gaba and glutamate in the brain keeps that bath warm. Because GABA is made from glutamate, it doesn't have any drug interactions to note minimal side effects. And it can reduce the symptoms of protracted withdrawal. So after somebody gets off detox, they may have some ongoing foggy head post acute withdrawal symptoms. Kamprol has been shown to help with that, but you want to use caution with it in suicidal patients. And Revia blocks opioid receptors and pleasurable feelings from alcohol. This is naltrexone, and we're going to talk about it on the next slide. As vivitrol reduces craving, it comes in tablets or implantable pellets, reduces alcohol slips, and can be used for opioids and alcohol. Now it's blocking those opioid receptors. So when somebody drinks, they drink, and they're just like, what was that? Which can be okay. Vivitrol is an intramuscular injection of naltrexone which is given monthly. The nice thing is it has to be done in a doctor's office but it's only once a month dosing. It was recently approved for alcohol and but also requires patient motivation. Maintenance therapy for opioids and long acting medication in a controlled setting is what we're looking at because we know that we want to make sure that people don't relapse because relapse on opioids is way deadlier in many cases than relapse on pretty much any other drug. Helps avoid withdrawal and craving, reduces disease and crime and we and or we want to look at it in terms of maintenance or detoxification. So are we looking at it for an 18 month step down so they don't have withdrawal symptoms from the heroin or are they going to be on it for a couple of years while they learn other skills? And yeah, 18 months step down from heroin is not unheard of. 18 months step down from methadone is also not unheard of. Methadone is a full agonist. It's opioid substitution therapy, highly regulated. It has to be licensed, has to be in a specific program. You can't just get it at your doctor's office. Patients are regularly drug tested and treatment programs are required to provide counseling. Now these are going out pretty quickly. I don't know if they're going to come back so I'm not going to spend a lot of time on them. But just so you know and you can go back and look at this a little bit more closely later if you're interested. But there are phases in opioid treatment, methadone treatment. Initially they have to come in seven days a week to get their meds. Over the period of a year they start getting to the point where they can get up to three take home doses per week. So they're still having to come in four days a week. After three years in treatment they may be eligible for six take homes per week. So they have to come in once a week provided that all of their negative, their drug screens for the past year have been negative. So there's a lot of drug testing, a lot of counseling. But in order to make it available and reduced aversion and everything, all of these regulations have to be in place. Controlled trials comparing medication and placebo show the superiority of agonist that full scale methadone pharmacotherapy improve treatment retention, eliminates the use of non prescribed opioids because they're feeling, they're not feeling the cravings. Decreased criminal activity, reduced spread of HIV with pretty good results. Reduced mortality, improved health and improved psychosocial functioning. But can you get all of these from other drugs? Do we have to do a full opioid agonist? Not necessarily, but methadone does not get you high because of its longer half life. Methadone suppresses withdrawal and drug drug cravings for 24 to 36 hours at prescription doses. Now if you take three doses of methadone, yeah, you're probably gonna feel pretty darn good or die. But there's no real, real euphoria for people who are on methadone. Maintenance once they get used to causes, sedation, but not so much that they can't work or drive safely. Once they've kind of developed a tolerance and they're on a good, good dose. It is deadly if it's mixed with any kind of depressant, including benzos and alcohol. Cognitive impairment may occur during induction or a change in dose or in combination with other drugs or medications, including over the counter. But like I said, once they get used to it, it's totally safe. Some states restrict the amount of time people can be on methadone. They need to be evaluated periodically to see if they can come off. One of the benefits of methadone is for people who either are refusing to get off heroin or street opiates the hard way, they want a kinder, gentler detox or they can't imagine living without something. So this kind of helps them, but so do buprenorphine and suboxone. Buprenorphine is an alternative to methadone. It's a long acting opioid agonist antagonist. It has a ceiling. It's only going to get you so far and then not so much so again, like the other partial agonist, it gets you from to okay, but not all the way up to woohoo, multiple forms. It can be combined with naloxone which is called suboxone. Buprenorphine only is called Subutex and when it's used for treatment of acute pain it can be called buprinex. It binds to opioid receptors in the body and only activates them about 40%. If somebody's already in withdrawal from opioids, then activating those receptors 40% is pretty good. It's going to take them from feeling like they've got a really bad case of the flu to okay, I can survive the day. If they're not in withdrawal, then dropping from 100% to 40% is going to make them feel pretty crappy. So it's up to the doctor and the patient how they transition. Buprenorphine is less restricted than methadone. You can get it from a pharmacy with refills for up to six months. But outpatient physician visits for medication checks are needed. Addiction counseling is separate and the patient may be referred to another provider for this service. Again, because it's an outpatient thing like Suboxone. So we're going to skip over that and move on to Suboxone in the interest of time. Combination buprenorphine and naloxone, they put those two together so that if somebody decides to either to try to inhale it or inject it, the naloxone kicks in and it triggers an opiate withdrawal right away. So you're not going to use, you're not going to do that. The short term desirable effects of Suboxone are a pain relieving effect that's between 20 and 30 times more powerful than morphine and a mild euphoria that lasts for around eight hours. A sense of calm and inflated well being. A perception of fewer worries and lower stress, increased relaxation. It can be abused by individuals addicted to short acting opioids like heroin because they'll use it between doses to keep withdrawal symptoms from occurring. It can also be abused by other people who are doubling up, you know, taking two or three Suboxone at a time. The naloxone only kicks in if the Suboxone is altered and injected or snorted. If a person who is not already tolerant to opiates uses Suboxone, the effect produces a mellow high, but it's evidently a pretty pleasant feeling. Final thoughts. Like any other, opioid tolerance develops quickly and goes away quickly. There's a danger of overdose in patients who've tapered or stopped using opiate agonists who relapse because they often relapse expecting to be able to use as much as they were using before they stopped. And that's not the case because of that. Narcan, which is the opiate reversal, is available in 35 states at Walgreens and some other pharmacies, but is available without a prescription. And yes, Suboxone can be put on stamps. It can be put on anything that can be licked. So it is the preferred drug in many correctional institutions. Urine drug screening needs to be incorporated into all medication assisted therapy in order to help people stay safe. Make sure that the medication assisted therapy is doing its job and help us figure out what else we need to do if the person is relapsing. Obviously we're missing something and we don't want to just put them in a situation where they're still in danger, they're still suffering. Long term pharmacotherapy is available and effective for several addictive substances. Medication plus counseling equals recovery. Medication alone won't do it. And for some patients, that period of time until their neurotransmitters stabilize and they can see colors again and they can feel feelings is so oppressive that without some sort of stabilizing pharmacotherapy, counseling alone may not be enough. So we need to consider the client. Nicotine replacement is available over the counter. Bupropion and Veronics are available by prescription for smoking cessation. Multiple medications are available by prescription for alcohol dependence, including Antabuse and Vivitrol Methadone. Buprenorphine maintenance has been proven to reduce mortality, cross crime and the spread of infection. Substitution therapy to eliminate withdrawal cravings and heroin effects. So we're really using either a full or a partial opiate agonist in order to help people feel some of the benefits. To address some of the reasons, if you will, that they started using the illicit substance in the first place. All of these require an individualized dose because people are going to have different tolerances to opiates. We are so excited to announce the launch of DocSnights.com and its associated podcast, Happiness Isn't Brain Surgery. These resources are designed to provide practical tools and information to help people start living happier. Docsnights.com contains solution focused goal sheets, what we often call treatment plans, videos, informational texts, workbooks, and a variety of other resources that clients can use to enhance their counseling experience. Unlike other sites that just provide the worksheets, Docsnipes.com provides text and video resources to walk people through using the tools. The resources are ready made for you, saving you, the clinician loads of time and freeing you up to do the actual counseling work. During the first half of 2017, we're offering introductory memberships for $5 per month. Lock in your rate now. Annual memberships are also available at a discounted rate for organizations. If you would like to use our resources with your CL but don't want to have them subscribe individually, contact supportocsnipes.com for pricing. Go to docsnipes.com to learn more and join us each week for the Facebook live broadcast and recording of the podcast@docsnipes.com Facebook if you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing@Allce.com Counselortoolbox this episode has been brought to you in part by allce.com providing 24.7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month.