Decisions in Recovery: Treatment for Opioid Use Disorder Handbook This decision support tool was developed with funding from the federal Special thanks to the following organizations for their support and Substance Abuse and Mental Health Services Administration (SAMHSA). contributions: It was prepared by the Center for Social Innovation with Advocates • AIDS Resource Center of Wisconsin, Milwaukee, Wisconsin for Human Potential, Inc. under Bringing Recovery Supports to Scale • American Association for the Treatment of Opioid Dependence Technical Assistance Center Strategy (BRSS TACS); contract number (AATOD) 2012 National Conference, Las Vegas, Nevada HHSS280201100002C, SAMHSA, U.S. Department of Health and Human Services (HHS). Cathy Nugent, Marsha Baker, and Deepa Avula served • Harm Reduction Coalition, Oakland, California as the Contract Officer Representatives. • Casa Segura–The HIV Education and Prevention Project, Alameda County, California Disclaimer • Medication Assisted Recovery Services (MARS) Project, New York, The views, opinions, and content of this decision support tool are those of New York the authors and do not necessarily reflect the views, opinions, or policies • National Alliance for Medication Assisted Recovery (NAMA), New York, of SAMHSA. New York Public Domain Notice • Office-Based Buprenorphine Induction Clinic (OBIC) San Francisco All material in this decision support tool is in the public domain and may General Hospital, San Francisco, California be reproduced or copied without permission from SAMHSA. Citation of • Opioid Treatment Outpatient Program, San Francisco General the source is appreciated. However, this material may not be reproduced Hospital, San Francisco, California or distributed for a fee without the specific written authorization of the • Outside In Medical Clinic, Portland, Oregon Office of Communications, SAMHSA, HHS. • Tom Waddell Health Center, San Francisco, California Electronic Access and Copies of the Material • West End Clinic, Massachusetts General Hospital, Boston, This decision support tool and the accompanying handbook can be Massachusetts accessed electronically on the World Wide Web at http://www.samhsa.gov/brss-tacs/shared-decision-making The following individuals also contributed significantly to the development and content of this decision support tool: Recommended Citation • Gavin Bart, Hennepin County Medical Center, Division of Addiction Substance Abuse and Mental Health Services Administration. (2016). Medicine, Minneapolis, Minnesota Decisions in Recovery: Treatment for Opioid Use Disorder. [Electroni c • Thomas Freese, Pacific Southwest Addiction Technology Transfer Decision Support Tool] (HHS Pub No. SMA-16-4993), 2016. Available Center (ATTC), Los Angeles, California from http://www.samhsa.gov/brss-tacs/shared-decision-making • Walter Ginter, Medication Assisted Recovery Support (MARS) Project, New York, New York Originating Office Division of Pharmacologic Therapies, Center for Substance Abuse • Kurt Kemmling, National Alliance for Medication Assisted Recovery, Norwalk, Connecticut Treatment (CSAT) and the Center for Mental Health Services (CMHS), SAMHSA, 1 Choke Cherry Road, Room 2-1007, Rockville, MD 20850. • Robert Lambert, Connecticut Counseling Centers, Norwalk, Phone: 1-800-789-2647. Website: www.dpt.samhsa.gov. Connecticut • Alan Mathis, Liberation Programs, Bridgeport/Norwalk, Connecticut Contributors • Scott Stokes, Director of Prevention Services, AIDS Resource Center The following organizations and individuals participated in the of Wisconsin, Milwaukee, Wisconsin development, review, and evaluation of this decision support tool. • Matt Tierney, Office-Based Buprenorphine Induction Clinic (OBIC), Prime Contractor San Francisco, California Center for Social Innovation, Inc. (C4) • Nalan Ward, West End Clinic, Massachusetts General Hospital, 200 Reservoir St., Suite 202 Boston, Massachusetts Needham, MA 02494 • William White, Senior Research Consultant, Chestnut Health Systems, http://center4si.com Bloomington, Illinois BRSS TACS Project Director: Livia Davis Finally, special appreciation must go out to people in recovery from opioid Project Director/Developer: Dr. Wayne A. Centrone Subcontracted Project Co-Director/Developer: Laurie Curtis, AHP addiction from across the United States who were willing to share their hope, strength, and experience. Thank you. Content Expert, Lead Writer, Editor: Niki Miller, AHP Subcontractor Advocates for Human Potential, Inc. (AHP) 41 State Street, Suite 500 Albany, NY 12207 http://www.ahpnet.com Center for Social Innovation Development Team Nick Garza, Megan Grandin, Corey Grant, Baldwin Martinez, George Payne, Alex Shulman, Erika Simon, Monica Terry, Lisa Carlucci Thomas, Michael Torocsik, Alan Zaitchik Video Production Writer, Producer, Videographer, Editor: Alexander Steacy, Erika Simon, Graphics, Photographer, Colorist: Kristen Nichols Cast: Tarah Johnson Music: M. R. Miller Consultant Lisa Mistler, M.D. Assistant Professor of Psychiatry Geisel School of Medicine; Dartmouth University lisa.a.mistler@dartmouth. edu References/Sources Sources of information used to create this handbook are listed online at http://www.samhsa.gov/brss-tacs/shared-decision-making, under “About This Tool.” Important Information from SAMHSA This handbook is for informational purposes only. The information provided is not intended to diagnose, treat, cure, or prevent any disease or condition, including opioid use disorder. The Substance Abuse and Mental Health Services Administration (SAMHSA) does not approve or endorse any specific treatment. If you have a health condition or concern, contact a health care provider. Decisions about treatment of opioid use disorder are the sole responsibility of you and your treatment providers. Not all the options presented may be appropriate for your situation. Talk with your treatment providers about your situation and the role of medication in your recovery from opioid use disorder. Every effort has been made to ensure the information in this handbook, and on the decision support tool website for which it was developed, is accurate and up-to-date. However, medical information is continually changing and can become quickly outdated. Talk with your providers about the most recent research findings as they relate to your situation. SAMHSA recognizes that widespread use of various medications to support addiction recovery is a new and rapidly changing practice. SAMHSA respects the diverse opinions of the recovery community on its use. SAMHSA acknowledges that this handbook and decision support website do not explore all effective treatment approaches, alternative treatments, or recovery pathways for opioid use disorder. These tools are intended to help make objective, research-based information accessible to individuals and families facing specific decisions about medication for opioid use disorder, rather than to promote any single treatment option. SAMHSA emphasizes that evidence supports that medications are best used in combination with recovery support, lifestyle changes, and professional treatment. 2 Table of Contents Introduction ��������������������������������� 4 Whether Medication Can Support My Recovery ����������������� 5 Thinking About Making a Change? ��������������������������� 5 Tool: My Reasons for Stopping ���������������������������� 7 What Is Medication-Assisted Treatment (MAT)? ��������������������� 9 Tool: Concerns About Treatment �������������������������� 11 Concerns about pregnancy ����������������������������� 13 Tool: Weighing My Gains and Losses ������������������������ 14 Learn More�About the Topics Covered in This Section ���������������� 15 Which Medication Can Support My Recovery? �������������� 22 About Methadone ���������������������������������� 22 About Buprenorphine �������������������������������� 27 About Naltrexone ���������������������������������� 31 Tool: Comparing medications for opioid use disorder ���������������� 35 How Can Medication Support My Recovery? ������������������ 40 Talking with Doctors and Treatment Providers ��������������������� 40 Tool: Talking With a Provider ��������������������������� 42 What to Expect ����������������������������������� 43 Recovery Support���������������������������������� 44 Tool: Who’s In My Corner? ���������������������������� 45 Planning for Success �������������������������������� 46 Tool: Next Steps ��������������������������������� 47 Learn More� About the Topics Covered in This Section ���������������� 48 Appendix ����������������������������������� 57 About This Decision Support Tool �������������������������� 57 Glossary �������������������������������������� 58 Resources ������������������������������������� 63 This handbook is a companion to a website for the electronic decision support tool: Decisions in Recovery: Treatment for Opioid Use Disorder. Visit http://www.samhsa.gov/brss-tacs/shared-decision- making for more information, videos of people talking about their experience with medication-assisted treatment, and links to resources. 3 Introduction Are you finding it difficult to stop using? If you’ve thought about cutting down or cutting out narcotics, prescription pain medications, heroin, or other opioid drugs, this tool can help. You can also link to videos intro of real people talking about their lived experiences with many of the topics covered. Is this decision support tool for you? This handbook is for anyone looking for help or information, and for people who care about them, who may be Misusing prescription pain medications, using narcotics, heroin, or other opioid drugs; thinking about seeking help for an opioid problem; or Considering medications that help with recovery from opioid use disorder. If any of the statements below apply, you are probably in the right place. I have been told medications may help me stop using opioids. I just want information. I don’t want to stop using now, but maybe someday I will. I have tried to stop or cut down several times. I am reluctant to use medications because I want to be able to do this on my own. I want a medication to help me through withdrawal. I want to stop using with the help of medication, but I am not sure which one. I am under pressure to stop using. I have chronic pain, and opioids have become a problem. I am pregnant and want to stop using opioids. I am pregnant, and my doctor has recommended I start medication for opioid use disorder. I care about someone who has a problem with opioids. The choice to include medication as part of your recovery is a personal, medical decision. This handbook gives you information about medication options so you can talk through your concerns with a treatment provider and make informed decisions. WARNING: Everyone needs to be aware of the increasing risk of overdose, especially for people taking opioid pain medications, and the steps that can reduce the risk of harm. Learn more at the end of this section: “Overdose prevention” on page 15 4 Whether Medication Can Support My Recovery Thinking About Making a Change? If you have thought about cutting down or stopping your use of narcotics, prescription painkillers, heroin, or any other opioid drug, Do I this tool has information about some of your treatment options and ways to locate a provider who can help. It also has links to online start? videos of people who have been where you are. They found a way to succeed in recovery and reclaim their lives. So can you. Whether it is your first try at stopping or reducing opioid use, or a fresh start after many attempts, give yourself credit for having the courage to change. Although no single pathway to recovery is right for everyone, research has shown people seeking recovery from opioid problems are more successful when they combine a prescribed medication used to treat addiction with professional counseling and a strong support system. Watch videos about making a change: https://www.youtube.com/playlist?list=PLBXgZMI_zqfTGp5CW6NTaljlGUeXGCpxk Why is it so hard to stop? Opioids are synthetic or natural drugs that have certain unique effects on the brain and body. Opioids relieve pain and give a people a sense of well-being or euphoria by changing the body and brain chemistry. The first change many people notice is tolerance, or the need for more of a drug to get the desired effect. Learn more at the end of this section: Opioids and pain “Opioids and pain” on page 15 Over time, the need for the drug becomes a powerful motivator to keep using, even when there is a strong desire to stop. When people need the drug to function normally, they are no longer using to feel good, but rather to avoid withdrawal symptoms and to stop feeling sick. Videos about BRSS TACS Decisions in Recovery: Planning for Success: https://www.youtube.com/playlist?list=PLBXgZMI_zqfS3zQA5XEvDT66vLM_gytdS How do people stop? Recovery begins when you start to think your life might be better without opioids. It is normal to want to stop using one day and then feel unsure or unable to do so the next. Quitting is tough, and change does not happen overnight. Most people need support to become ready, willing, and able to quit. 5 However, even people who are certain they no longer want the daily grind of getting drugs, using drugs, and watching drugs damage their lives and health usually can’t just walk away. They need a plan of action and support. Research shows that when people include a medication prescribed to treat opioid use disorder as part of their recovery plan, their chances of success increase. This doesn’t mean medication is right for everyone. Many people also recover from opioid use disorder without medication. But, it is important information for anyone looking at treatment options. Learn more at the end of this section: “How do people stop?” on page 16 6 Tool: My Reasons for Stopping People stop using opioids or cut down for very good reasons. This worksheet lists some of them. Directions: For each statement, select the choice that best describes how much it matters to you. Skip any statements that do not apply. Then make note of your three most important reasons for quitting. Use the space at the bottom to add any other reasons. Share this worksheet with people in your support network when you talk over treatment options and what matters most to you. Make a copy for yourself to remember the reasons you decided to get help. Refer to it when you are tempted to use. This matters to me: For myself a lot some a little • • • 1. I am worried about my health. • • • 2. I do not want to go to jail/prison. • • • 3. I want the law off my back. • • • 4. I want to keep or get a job. • • • 5. I do not want to feel sick all the time. • • • 6. I want to go to or stay in school. • • • 7. I cannot afford my drug use. • • • 8. I am tired of the hassle. • • • 9. I do not like being around other users. • • • 10. Getting and using drugs takes all my time. 7 This matters to me: For the people I love a lot some a little • • • 11. I am or want to get pregnant. • • • 12. I want to set a better example for my children. • • • 13. I want to see my children more. • • • 14. I want better relationships with my family/partner. This matters to me: For my quality of life a lot some a little • • • 15. I want to feel more in control of my life. • • • 16. I want to do other things with my life. • • • 17. I can do better than this. • • • 18. Things seem to be getting worse. • • • 19. I want to respect myself. • • • 20. I want to live like other people. Note any other reasons: 8 What Is Medication-Assisted Treatment (MAT)? Medication-assisted treatment (MAT) for opioid use disorder combines counseling and other recovery supports with prescribed medications. These medications help reduce cravings and withdrawal symptoms that come from stopping opioid use. The medications approved for MAT are methadone, buprenorphine, and naltrexone. Watch videos that describe MAT: https://www.youtube.com/playlist?list=PLBXgZMI_zqfTYEmi25ZxGlJ1It_r20B9X More about medication-assisted treatment There are two key ways medications work to help reduce opioid use: 1. Methadone and buprenorphine are long-acting medications that reduce craving and control withdrawal symptoms by satisfying areas of the brain affected by opioid use disorder. This allows people to continue to work and function normally. 2. Naltrexone blocks the pain-relieving effects of opioids and their ability to induce euphoria. These rewarding aspects of opioid use lead to the desire for more. Research shows the extended release injectable form of naltrexone reduces cravings, helps people remain in treatment longer, and helps them abstain from opioid use. Three medications are currently approved for treating opioid problems: Methadone is a long-acting opioid medication that reduces cravings and withdrawal symptoms. It is usually taken by mouth in liquid form. It is dispensed to addiction treatment clients daily in single doses and only at certified opioid treatment programs. Methadone is highly effective for treating opioid use disorder, especially in people with extensive histories of drug use. Side effects of methadone include constipation, sexual problems, swelling, and sweating. It can also can cause heart problems or make them worse. Buprenorphine is usually taken daily and must be dissolved under the tongue or in the mouth. It comes in tablet form and as a film. Doctors who complete a training and certification process can prescribe buprenorphine for office-based treatment or at treatment programs. Patients making satisfactory progress may receive a prescription for buprenorphine to take at home. It has proven to be very effective, although not more effective than methadone. For some people it may offer advantages. Risk of overdose is lower and withdrawal from buprenorphine may be milder. Buprenorphine is widely available in a formula that contains added naloxone, which discourages abusing or injecting it. Access to buprenorphine has helped many individuals seek treatment who otherwise might not have. Some common side effects are headache, nausea, and constipation. Naltrexone blocks the ability of opioids to eliminate pain and induce euphoria. This removes the rewarding aspects of opioid use that result in a desire for more. Reduced cravings make it easier 9