Medications for Substance Use Disorders

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Connecticut Department of Social Services Medical Assistance Program Provider Bulletin 2015-92 www.ctdssmap.com December 2015 TO: Hospitals, Physicians, Advanced Practice Registered Nurses, Behavioral Health Providers RE: Medications for Substance Use Disorders

Naltrexone (Vivitrol) Naltrexone is a non-opioid Medicaid covers a variety of medications for use in medication that is approved for the treatment of the treatment of substance use disorders. The opioid dependence and alcohol dependence. following is a partial list of medications covered Naltrexone is an opioid receptor antagonist; it under the Connecticut Medical Assistance Program binds to opioid receptors effectively blocking (CMAP) and may be prescribed for individuals them. Through this action, it prevents opioid with substance use disorders. These medications receptors from being activated by agonist are used as an adjunct to outpatient or residential compounds, such as heroin or prescription pain treatment for individuals who appear to be good killers, as well as by alcohol, and is reported to candidates and likely to comply with the reduce craving and prevent relapse. As opposed to medication regimens. methadone and buprenorphine, naltrexone can be Buprenorphine (Suboxone) Buprenorphine is a prescribed by any individual who is licensed to partial opioid agonist and can be used for prescribe medicine (e.g., physician, doctor of individuals with an opioid dependence. As such, it osteopathic medicine, physician assistant, and can produce typical opioid agonist effects and side nurse practitioner). Both the oral daily form and effects such as euphoria and respiratory depression. the monthly injectable extended-release form However, its maximal effects are less than those of (Vivitrol®) are FDA approved for treatment of full agonists like heroin and methadone. At low opioid dependence and alcohol dependence. doses, buprenorphine produces sufficient agonist Prescription Restrictions or Limitations: effect to enable opioid-addicted individuals to Naltrexone is currently a preferred drug and does discontinue misuse of opioids without not require prior authorization. Vivitrol is experiencing withdrawal symptoms. currently not a preferred drug and does require Buprenorphine carries a lower risk of abuse, prior authorization. addiction, and side effects compared to full opioid agonists. At high doses and under certain Disulfiram (Antabuse) Disulfiram is used to treat circumstances, buprenorphine may additionally chronic alcoholism. It causes unpleasant effects block the effects of full opioid agonists and can when even small amounts of alcohol are consumed. precipitate withdrawal symptoms if administered These effects include flushing of the face, to an opioid-addicted individual while a full headache, nausea, vomiting, chest pain, weakness, agonist is in the bloodstream. blurred vision, mental confusion, sweating, choking, breathing difficulty, and anxiety. These Formulations for opioid addiction treatment are in effects begin about 10 minutes after alcohol enters the form of sublingual tablets or dissolvable strips. the body and last for 1 hour or more. Disulfiram is Buprenorphine can be prescribed for individuals not a cure for alcoholism, but discourages drinking. with an opioid dependence by a physician with a “DATA” waiver within their private practices. Prescription Restrictions or Limitations: There is a cap of 30 patients for the first year of Disulfiram is not in a class of drugs that is currently prescribing a buprenorphine product, then a cap of subject to the Preferred Drug List (PDL). 100 after the first year. Therefore, there is no prior authorization requirement for coverage of this medication. Prescription Restrictions or Limitations: Suboxone sublingual film is currently a preferred Methadone Methadone is a synthetic agent that drug and does not require prior authorization. works by "occupying" the brain receptor sites Generic buprenorphine tablets are currently non- affected by heroin and other opiates. Compared to preferred and require prior authorization. heroin, morphine and other opioids, methadone has

Questions? Need assistance? Call the Provider Assistance Center Mon. – Fri. 8:00 a.m. – 5:00 p.m. Toll free 1-800-842-8440 or write to Hewlett Packard Enterprise, PO Box 2991, Hartford, CT 06104 Program information is available at www.ctdssmap.com

Provider Bulletin 2015-92 December 2015 page 2

a relatively long half-life. Methadone blocks the and American Society of Addiction Medicine euphoric and sedating effects of opiates; relieves (Sep/Oct 2015), Medication Assisted Treatment is the craving for opiates that is a major factor in recommended for pregnant women who are relapse; relieves symptoms associated with abusing opioids. Coordination between the withdrawal from opiates; does not cause euphoria Obstetrician and licensed chemical dependency or intoxication itself (with stable dosing), thus center or physician accredited to prescribe allowing a person to work and participate normally Buprenorphine is strongly recommended. in society; is excreted slowly so it can be taken only Buprenorphine monotherapy or methadone are once a day. Methadone must be administered in a appropriate treatments during pregnancy. federally “certified” clinic. CT has twenty six Breastfeeding is encouraged for mothers receiving methadone clinics statewide, all of which accept methadone or buprenorphine monotherapy. individuals receiving Medicaid benefits. Buprenorphine with naloxone in combination is Prescription Restrictions or Limitations: For the not recommended for use in pregnancy. purposes of the treatment of opioid addiction, Naltrexone may be continued during pregnancy if Methadone can only be dispensed by a licensed risk of relapse is high. In cases where risk of chemical maintenance facility. Authorization for relapse is low, discontinuation may be appropriate. methadone clinic services is required from Any medication assisted treatment during ValueOptions. pregnancy should only be conducted with Acamprosate (Campral) Acamprosate calcium is appropriate informed consent. FDA-approved for the maintenance of abstinence

from alcohol in patients with alcohol dependence who are abstinent at treatment initiation. Posting Instructions: Provider Bulletins and Prior Acamprosate reduces the physical and emotional Pharmacy Prior Authorization forms can be discomfort (e.g. sweating, anxiety, sleep downloaded from the Hewlett Packard Enterprise disturbances) many people feel in the weeks and Web site at www.ctdssmap.com. months after they've stopped drinking which makes Distribution: This provider bulletin is being it easier for them not to drink after the immediate distributed by Hewlett Packard Enterprise to withdrawal period. providers enrolled in the Connecticut Medical Prescription Restrictions or Limitations: Assistance Program. Acamprosate is not in a class of drugs that is Responsible Unit: DSS, Division of Health currently subject to the PDL so there is no prior Services, William Halsey, (860) 424-5077 authorization requirement for coverage.

Naloxone (Evzio) Naloxone is an opioid antagonist that is used to reverse the effects of opioids, Date Issued: December 2015 including opioid overdose. Naloxone is used to counteract life threatening depression of the central nervous system and respiratory system. Naloxone

has no potential for abuse and has no effect on a person if there are no opioids in the system. Prescription Restrictions or Limitations: Evzio is currently not on the PDL so would require a prior authorization for coverage. Generic naloxone in the syringe and vial form is preferred and does not require prior authorization. Pregnancy: According to The American College of Obstetricians and Gynecologists (May 2012)