Medication-Assisted Treatment (MAT) – Page 2

AMA Calls On States To Remove Prior Authorization For Opioid Treatment

January 14, 2019

“Following the news that Pennsylvania will remove prior authorization requirements for medication-assisted treatment (MAT) for opioid-use disorder, the president of the American Medical Association (AMA) called on payers in every state to do the same.

“Payers across the nation commonly impose prior-authorization requirements that patients and physicians must meet before medications are available for treatment,” said Barbara McAneny, AMA president, in a statement. “When patients seek help, it is unconscionable to make them wait days or weeks for the right treatment.”

Source: Pharmacist.com – January 7, 2019

Few Patients Receiving Buprenorphine Taper Off; Most of Those Who Do Return to Treatment

December 28, 2018

“Office-based buprenorphine is an effective treatment for opioid use disorder; the current standard of care is to continue it indefinitely. Some patients express a desire to eventually taper off; others experience external pressures to do so. However, data are scant on the frequency and success of tapering off. In this single-site, retrospective cohort study, researchers reviewed 12 years of office-based addiction treatment data including 1308 patients with a median follow-up of 316 days to determine the proportion who tapered off of buprenorphine, describe their characteristics, and determine the proportion that returned.

During the full follow-up period of 2361 days, 48 patients tapered off of buprenorphine. Using Kaplan-Meier proportion estimates, which account for censored participants (those lost to follow-up or at end of the study), 15% tapered off of buprenorphine.
Patients who underwent a supervised taper were engaged in treatment longer (median 774 days versus 433 days), had lower prescribed dosages (45% prescribed <4 mg/day versus 19%), and were more likely to be employed or a student (52% versus 24%), compared with those who underwent an unsupervised taper.
Most of the patients (61%) who tapered off of buprenorphine returned to treatment. Most of them (77%) had undergone an unsupervised taper.

Comments: This study shows that a small proportion of patients receiving buprenorphine taper off and most return to treatment. This supports treating opioid use disorder as a chronic condition and continuing with treatment indefinitely without placing arbitrary time limits or end-points.”

Jarratt Pytell, MD & Darius A. Rastegar, MD

Source: Alcohol, Drugs and Health: Current Evidence – November – December 2018

MATER Center Director, on the Importance of Dr. Finnegan’s Work—Which Continues—and the Need to Treat Mothers for Trauma

December 17, 2018

By Alison Knopf

Loretta Finnegan

Loretta Finnegan, MD, a champion of medication-assisted treatment with methadone, developed her scoring system for newborns more than 40 years ago. The Finnegan Neonatal Abstinence Scoring System (FNASS) assigns a numerical score to 21 clinical signs, and babies are treated accordingly. Developing the test was an important step in making sure that these babies were treated with morphine, if necessary, to manage the symptoms of withdrawal.

But the work of Dr. Finnegan goes far beyond the Finnegan score. When she first started an opioid treatment program (OTP) at Thomas Jefferson University in Philadelphia, 44 years ago, Dr. Finnegan opened a landmark program for pregnant women addicted to opioids. Since then, the program, called Maternal Addiction Treatment Education & Research (MATER), has included intensive outpatient treatment as well as residential treatment.

Diane Abatemarco

Diane Abatemarco, PhD, MSW, director of MATER and associate professor of OB/GYN and Pediatrics at the Sidney Kimmel Medical College at Jefferson, talked with AT Forum about the scope and importance of Dr. Finnegan’s work.

Precipitating Factors

Poverty and childhood trauma are the precipitating factors for almost all women who enter the MATER program, said Dr. Abatemarco. They are also the factors that make it difficult for the women to stay in recovery, she added.

What the MATER program offers is not only the medication—methadone or buprenorphine—and therapy needed to maintain recovery, but the wraparound services, which go farther than those of a typical OTP. Women attend seven days a week and spend at least 10 hours and 30 minutes weekly in group and individual substance use treatment. Their prenatal care is managed at Jefferson. “The fact that Loretta created an OTP here was just remarkable at that time, and housing it in a medical university, offering access to all the other kinds of care that women would need, shows her wisdom and vision,” Dr. Abatemarco said.

NAS Babies Grow Up to Become Normal

We first met Dr. Finnegan in Chicago, many years ago, when she and Ira Chasnoff, MD, presented a program on babies whose mothers had been addicted to cocaine. That presentation was crucial to helping erase the awful epithet “crack baby,” implying that the babies would be permanently damaged. These babies were, in fact, normal. And the same applies to babies born with neonatal abstinence syndrome (NAS). “Loretta was a key person in saying that while four in 10 babies exposed to opioids may have NAS, they’re going to be normal, healthy children and adults,” said Dr. Abatemarco.

Dr. Finnegan also strongly believes in the importance of the mother to the child. Great trauma ensues when the two are separated, and this separation often has taken place in the name of protecting the child, when in fact, just the opposite results.

“The problem is the deep misogyny in the United States, where corporations don’t have to cover birth control for their employees,” Dr. Finnegan said. Mothers who are faced with child abuse and neglect charges over opioid use disorders—or babies born with transient NAS, which can also be due to therapeutic methadone or buprenorphine—are victims, as well. “With these moms, it’s just an extension of that; they don’t have the rights over their own children.”

Mom Is the Best Medicine

“As a social worker and a researcher, I know that if you take kids away from their biological parent, and they go into the foster care system, the risk of the non-attachment is a lifelong brain injury,” said Dr. Abatemarco. Even in the worst case scenario—a child scoring “severe” on the Finnegan score—the mom can have rooming in and breastfeed her child, and that score drops exponentially, even without medication, she said. Keeping the mother and baby together from the beginning is a key contribution Dr. Finnegan made to the field.

Dr. Finnegan, who herself had five children in her 20s, continues to stress the importance of the mother-child bond.

“I really do feel if we’re going to battle this epidemic and win, we’re going to need comprehensive therapeutic programming everywhere in the country,” said Dr. Abatemarco. “It cannot be, ‘Just give a woman a prescription for methadone or buprenorphine,’ because that won’t solve the problem.”

Treating Mom, Too

In a study Dr. Abatemarco conducted with MATER patients, funded by a federal grant, she found that each patient had an average of four adverse childhood experiences (ACEs). Based on research, having four ACEs already puts an individual at very high risk for a mental illness or a substance use disorder.

That’s why methadone or buprenorphine alone won’t help them enough. “These women need psychotherapy, housing, they need help with the court system and more,” said Dr. Abatemarco, noting that these services are provided by MATER. “We’re going to have to go back to the social safety net, the way it used to be, and rebuild some programs the way Presidents Kennedy and Johnson developed them,” she said. “Programs need the ability to provide wraparound services.”

In addition, Dr. Abatemarco supports teaching mothers about parenting, “so we can stop the intergenerational trauma.” She has been using “mindfulness” training in her research.

How the Program Works

The MATER residential program has 22 beds for mothers, who can each bring up to three children.

The women come as soon as they know they are pregnant, usually finding their way to the program, which of course also has intensive outpatient and regular outpatient services. Usually the women go to the emergency department. If at Jefferson, they are taken right up to the labor and delivery area, and MATER “navigators” meet them at the bedside.

The women stay in the hospital for from a few days to a week for stabilization on either methadone or buprenorphine during their pregnancy. As soon as they are discharged from the hospital, they come to the MATER program, every day. If, when admitted, the mother was already on methadone, she stays on methadone. If she was already on buprenorphine, she can continue, or switch to methadone. “They make the decision with the doctor,” said Dr. Abatemarco.

Typically, the program used methadone in the past. “That was getting the women to come here 7 days a week,” said Dr. Abatemarco. “And, because we had them coming anyway, we could gently wrap the services around them.” Now, MATER is doing the same thing with buprenorphine, requiring patients to come in every day (the combination product, with naloxone, is not recommended for during pregnancy). As for Vivitrol, Dr. Abatemarco says it should not be used during pregnancy.

Open House

After Dr. Finnegan’s retirement from MATER, the next director was Karol Kaltenbach, PhD, followed by Dr. Abatemarco, who convinced Jefferson to buy a residential treatment facility for the program. Recently an open house reception was held for the opening, and Dr. Finnegan was present.

In addition to attending the open house, Dr. Finnegan was present when First Lady Melania Trump visited the program in November, and when President Trump signed the new opioid law this fall. She also attends every AATOD meeting. At last spring’s meeting, she spoke loudly and clearly about the challenges to OTPs and patients. Her awards are many, and keep coming.

For a 2015 news article based on an interview with Dr. Finnegan, go to http://www2.philly.com/philly/health/20151210_Helping_babies_born_to_addicted_moms.html

Also see: http://atforum.com/2018/04/when-mom-is-better-than-morphine-shorten-stay-and-decrease-costs-for-babies-with-methadone-related-nas/

Opportunities for Partnership Between OTPs and Prisons, Jails

December 17, 2018

By Alison Knopf

Although the general attitude toward methadone and buprenorphine is not favorable on the part of many workers in correctional facilities, the trend is changing. This is partly due to the clear evidence that inmates with opioid use disorders (OUDs), once released, have greatly higher risks of overdosing than the general population, and partly due to several recent cases in which people with opioid use disorders died during forced detoxification without medication.

This fall, the National Commission on Correctional Health Care (NCCHC), in partnership with the National Sheriffs’ Association, released guidelines on medication-assisted treatment (MAT) in jails. And Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), made the plenary speech at the annual conference of the NCCHC this fall.

The guide, “Jail-Based Medication-Assisted Treatment: Promising Practices, Guidelines, and Resources for the Field,” is important because jails, as shorter-stay facilities, have been less likely than prisons to offer methadone. For the guide itself, go to https://www.ncchc.org/jail-based-MAT.

Kevin Fiscella

Contributors to the guide are Kevin Fiscella, MD, MPH, an addiction medicine expert who serves on the NCCHC board of directors, and is a professor in the department of family medicine at University of Rochester, New York; Andrew Klein, PhD, of the Advocates for Human Potential, Inc.; and Jennie M. Simpson, PhD, of the Office of Policy, Planning, and Innovation at the federal Substance Abuse and Mental Health Services Administration.

Dr. Fiscella talked with AT Forum about the importance of opioid treatment programs (OTPs) in helping correctional facilities move ahead with instituting MAT.

“There’s a huge opportunity for partnership between OTPs and correctional facilities,” said Dr. Fiscella. This is particularly true for current OTP patients. “When someone gets into jail, if the jail personnel are doing what they should be doing, they should be confirming the dose of methadone, and having at least a minimal relationship with the OTP for coordination of care,” he said. Building on this minimal collaboration to a create genuine partnerships could prove mutually beneficial to OTPs and jails.

Getting Methadone to the Inmate

One of the big logistical problems is getting the methadone into the jail—or taking the inmate to the OTP for it. The Drug Enforcement Administration (DEA) is, it is fair to say, obsessed with the security of the methadone, requiring a specialized pharmacy for it (when used for treatment for addiction, not when used for treatment for pain).

Having an OTP in the jail, much like KEEP at Rikers, or the system in Rhode Island, where the vendor operates in facilities, would be best, but most likely this would be impractical in jails across the country.

However, jails have worked with OTPs on records and dosing of existing patients. “If they could build on that partnership, so the OTP does the dosing, then jails could get around the issue of needing an OTP license,” said Dr. Fiscella, noting that this is unlikely to happen in most small county jails, given the cost and logistics. “Most are probably not going to become OTPs, at least not in my lifetime,” he said.

“Short of that, you’re talking about transporting the person, which requires sheriff deputies taking the patient in custody to the OTP,” said Dr. Fiscella. Preferably, though, it could mean the OTP giving the methadone to the deputy, who then takes it to the jail; or having the OTP transport the methadone to the jail.

Stopping Methadone at the Time of Arrest: “Barbaric”

Early in his career, Dr. Fiscella was medical director of an OTP. “I was struck by the fact that as soon as someone got arrested, their methadone was abruptly stopped,” he said. “It was barbaric. I saw patients who evaded their warrant because they were terrified of jailhouse detox, of withdrawal.”

With an OTP, every drop of methadone has to be accounted for. It’s never clear when someone will be released. There are tracking problems. Methadone stored in jails can be diverted—even by jail staff. Some states, such as Vermont, have overcome these challenges.

Pregnancy Is a Different Situation

If the inmate is pregnant, this relationship is particularly important. Even jails that don’t otherwise offer agonists will often offer them during pregnancy, because of the risk to the fetus in withdrawing from opioids on which the mother is dependent. Typically, workers in jails and prisons who care for inmates (custodial staff) are opposed to agonists, thinking of them as merely prolonging an addiction. But when it comes to the babies, they are more willing to work with OTPs. These partnerships involving pregnant inmates can potentially be expanded to all inmates with OUD.

“Even in the minds of some hardened custodial staff—more sympathy for the fetus than the woman,” said Dr. Fiscella.

“There are jails that will use opioids, including methadone, to treat the pregnant woman, and believing it is legal, because they’re not treating the mom, they’re treating the fetus,” added Dr. Fiscella. A better alternative to meeting the needs of pregnant inmates is provide treatment through partnerships that fully conform with DEA regulations.

How OTPs Can Help

The time has come for OTP leadership to reach out to the local sheriff, for their own current patients, and for any possible new patients who could be admitted via the correction health system, said Dr. Fiscella. “Ask, ‘What can we do to work together better?’ Having those face-to-face meetings is crucial.”

Remember, though, that the biggest problem is that the OTP and the Sheriff are part of two extremely different, siloed institutions. “And now we’re asking them to begin collaborating, when they’re both inherently suspicious of the other.” Overcoming this mistrust takes time and persistence.

What About Buprenorphine and Vivitrol?

As for buprenorphine, there’s already a lot of mistrust because the Suboxone strips have been so easy to smuggle into jails, said Dr. Fiscella. Never mind that the reason that they are being smuggled in is to treat the inmates with OUDs who are sick (i.e., withdrawing). Other forms of buprenorphine might help mitigate these concerns.

Some sheriffs think that a two-week detoxification with buprenorphine is a humane way to treat opioid-dependent new inmates. But maintenance treatment is better. One way to convince the sheriff to work with the OTP is to explain the high risk that people will die of an overdose when they leave the facility. Neither jails nor OTPs want to see anyone die from opioid overdose. This common interest can become the foundation for partnerships.

Finally, Vivitrol, a favorite among many correctional workers because it is not addictive, is going to be difficult to for OTPs to fight. Dr. Fiscella concedes this. In fact, OTPs do treat patients with Vivitrol, and can help supervise the humane detox that can take place in jail, transferring people to Vivitrol when they leave. The challenges with this are, 1) most patients would prefer methadone or buprenorphine, and in this country, patient choice counts; and 2) if the patient doesn’t get repeat Vivitrol shots after discharge, he or she is just as likely to overdose as the patient who is put on abstinence-only treatment after hard detox in jail.

Caught in Chaos—When Pregnant Women With OUD Are Incarcerated; How OTPs Can Help

December 17, 2018

By Barbara Goodheart, ELS

Case Report

This is the story of a young woman with a 15-year history of severe opioid use disorder (OUD), intermittent hospitalization, and incarceration, who becomes pregnant. She has a history of trauma and mental health issues, and few social supports. Her story is the subject of a case report recently published in the Journal of Addiction Medicine.

It’s well known that methadone, in adequate doses, helps to keep pregnant women in treatment and reduces the risks of illicit drug use and overdose. Across the country, some—but not all—corrections facilities will continue pregnant women on opioid agonist treatment. Overall, most correction facilities fail to follow evidence-based treatment guidelines for OUD.

When people with OUD are incarcerated, “methadone is generally stopped immediately—without a taper,” Jessica Gray, MD, lead author on the report, told AT Forum. “Opioid agonists are life-saving treatments that shouldn’t be withheld or limited when people are incarcerated, but outside of Rhode Island and a few other facilities, like Rikers, that’s not the case,” she added. Even jails that do provide methadone treatment for pregnant women generally fail to continue methadone when women return to jail after giving birth, according to Dr. Gray, who works at Massachusetts General Hospital and completed a fellowship in addiction medicine at Boston Medical Center.

The Patient’s Early History

The patient began using illicit medications at age 13 to self-medicate anxiety and depression. She attended a methadone program sporadically. While hospitalized for a benzodiazepine and opioid overdose, she learned that she was pregnant.

Pregnancy

The months that followed were marked by repeated emergency department visits, hospitalizations, and incarcerations. The patient failed to return for prenatal care, despite follow-up appointments and outreach calls.

Emergency department visits: 6+
Hospitalizations: 3
Incarcerations: 3
Prenatal visit: 1 (while incarcerated)

She had bouts of sedation, probably due to the effects of “methadone treatment combined with illicit benzodiazepines, gabapentin, and clonidine,” the authors of the study believe. She also had pneumonia, a urinary tract infection, a broken arm (from falling), abdominal trauma (after an assault), a potentially life-threatening kidney infection, and a weeklong hospital stay related to abnormalities seen on the baby’s heart monitor. And she was HCV-positive, with a high viral load, indicating an infection that she could pass on to her baby.

According to a study by Kelsey and associates, examining national jail policies in the U.S:

69% of women admitted to local jails meet recognized diagnostic criteria for substance use disorder (previously termed substance abuse or dependence)
About 6% to 10% of women in jails are pregnant
Almost half of all pregnant women with OUD in U.S. jails went through withdrawal without the help of opioid agonists or similar medication

This patient was one of the lucky pregnant women whose methadone treatment was continued per protocol while she was in jail.

Giving Birth

The patient was in jail and at term when labor began. She was taken to the hospital to have her baby. Her shackles were removed, but she was barred from contacting someone to be with her during labor. A corrections officer was posted in the hall outside her hospital room. As distressing as this sounds, Dr. Gray told AT Forum that some institutions still keep women shackled or restrained during labor, with a guard posted inside the room.

Because the woman was incarcerated when she gave birth, the newborn was taken away, and the mother’s custody rights were immediately suspended.

The infant, a son, was healthy and born at term—despite the mother’s lack of prenatal care, and her intermittent use of illicit substances during pregnancy. This was likely thanks in part to her continued treatment with methadone throughout her pregnancy.

Standard care at the woman’s jail is to abruptly stop methadone treatment after a woman gives birth, but the patient’s team—the authors of the study—convinced jail authorities that this would increase the patient’s risks of overdose and relapse post-release. So her methadone treatment continued in jail during the months postpartum, and eventually she was released from incarceration

Jails and OTPs in Alliance

Clearly, a need exists for jails and OTPs to work together to help women like this patient. But how to facilitate it?

According to Kevin Fiscella, MD, MPH, a board member of the National Commission on Correctional Healthcare (NCCHC), some jails have OTP licenses in place, but most need to partner with a community OTP.

Partnering is easier than it sounds, because usually a relationship already exists, Dr. Fiscella told AT Forum. “People come into a jail already taking methadone or buprenorphine, prescribed by an OTP, and the jail personnel need to know the dose.”

Dosing information and the dosing history are especially important for pregnant prisoners. As the pregnancy progresses, women may need higher doses in order to prevent withdrawal. So OTPs want jails to have the dosing information. They, and the jails, want treatment to continue, to protect not only pregnant patients, but all patients from the risks of overdosing once they leave jail.

This collaborative relationship isn’t difficult to establish, but it’s not very common—creating an opportunity for jails to expand their relationships with community OTPs, thus improving care.

The Silo Effect

The situation Dr. Fiscella described works well, but achieving it isn’t always without problems.

Dr. Gray described the treatment system for patients with OUDs as “broken” in some ways, and operating “in silos” that limit interactions. “OTPs are heavily regulated, not part of the mainstream health system or community organizations,” she explained. “Our corrections system is another silo. The more we can get out of these silos and engage our community partners and collaborate as teams the better we can understand complex treatment issues.”

The relationship can be developed either in a crisis, or ahead of time—so people know they can rely on the other entity, the OTP or the hospital, in the future.

“Understanding the safety, logistical, or other concerns and needs of the systems you work with is critical. Working across organizations to address those issues can improve the experience and comfort of all parties, such as in this case providing education and support to nursing staff around methadone in the jail.” You need to support each other, she added, pointing to the current case as a good example of what collaboration can do.

We asked Dr. Gray what OTP personnel can do to help other women facing these challenges. Are counselors—or management—most effective in communicating with jails?

Both, Dr. Gray said, for she sees a role for individuals and groups at all OTP levels. Members of a multidisciplinary team can choose the person best suited to present the message to the house of correction, but everyone can impact change. The idea is to create formal and informal partnerships, and make those relationships work—even before a crisis exists.

One Patient Can Make a Difference

“Advocacy can start on an individual level”, said Dr. Gray, “and in this case was used to change the local landscape for women with opioid use disorder who deliver in jail.” The Case Report patient transitioned from being at an incredibly high risk for a bad outcome, to turning her life around.

Dr. Gray later met another pregnant woman in similar circumstances—a woman who wasn’t afraid of what she faced, because of the team’s groundwork with the woman in the Case Report. Dr. Gray was deeply moved to have made such an impact. “The hope is that the precedent you set in providing evidence-based treatment behind bars will positively impact the treatment of future incarcerated patients.”

A Remarkable Change

The new mother discussed earlier in the Case Report underwent a remarkable change after giving birth, Dr. Gray told AT Forum.

There’s no way to know if the change will be permanent, but Dr. Gray is optimistic. “The more that evidence-based treatments (such as opioid agonist medications) are provided, the more likely our patients will survive long enough to be successful.”

# # #

References

Gray J, Saia K, Walley AY. Case Report: 28-year-old woman with opioid use disorder delivers healthy baby while in custody: Addressing Forced Detox. J Addict Med. October 30, 2018. doi:10.1097/ADM.0000000000000468.

Kelsey CM, Medel N, Mullins C, et al. An examination of care practices of pregnant women incarcerated in jail facilities in the United States. Matern Child Health J. 2017;21:1260–1266. doi.org/10.1007/s10995-016-2224-5.

Additional Reading

American Society of Addiction Medicine: The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. KM Kampman. 2015. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf.

DEA’s Foot-Dragging on Mobile Vans Gets Worse

December 17, 2018

By Alison Knopf

More than two years ago, just before Donald Trump was elected president, Demetra Ashley, associate deputy assistant administrator of the office of diversion control with the Drug Enforcement Administration (DEA), told the American Association for the Treatment of Opioid Dependence (AATOD) that new licensing regulations that would provide for more mobile vans to provide methadone and buprenorphine for opioid use disorders were in the works. She told the AATOD board the same thing a few months later, just before the inauguration. A year later, however, the discussion appeared stalled.

It still is.

“I was advised that new regulations can take years to be issued, because they not only have to go through internal DEA review but also interagency review, including both other federal agencies and White House offices, such as the Office of Management and Budget,” said Barbara L. Carreno, DEA spokeswoman, in an email to AT Forum in December. “These new regulations are one of our top priorities, on which we are working diligently,” she said. Her source (at diversion control) “did not know how close to coming out these regulations are,” she added.

Department of Justice Under Extreme Pressure

To be fair, the Department of Justice, DEA’s parent department, has been under extreme pressure lately, to put it mildly. Attorney General Jeff Sessions stepped down—in the face of being fired—on November 7, the day after the midterms. The entire department has been caught up in issues that are not related to methadone or the opioid crisis, but fortunately for patients with opioid use disorder, the Department of Health and Human Services has been giving the subject a lot of attention. The Substance Abuse and Mental Health Services Administration, which is headed by HHS, sent its mobile van recommendations to the DEA years ago. The issue is now in the DEA’s court, where it has been for some time.

The idea was to connect these mobile vans to existing brick-and-mortar opioid treatment programs. To that end, some states are spending federal grant money to purchase the vans, using them for outreach, with the hope that one day, the vans can actually transport medication. In some places of the country, this is already happening. But the federal regulations need to change if mobile vans are to be helpful on a widespread basis.

For more coverage on this issue, see

http://atforum.com/2018/09/new-york-str-funds-enhance-treatment/

http://atforum.com/2018/04/aatod-conference-recap-field-has-funding-now-needs-infrastructure/

http://atforum.com/2017/08/mobile-vans-otps-closer-reality/

AATOD Policy Paper Looks at Methadone and Buprenorphine, OTPs and DATA 2000 Practices

December 17, 2018

By Alison Knopf

In a far-reaching policy paper to be published next year, a draft copy of which was obtained by AT Forum, the American Association for the Treatment of Opioid Dependence (AATOD) takes stock of the increasing prevalence of opioid use disorder (OUD). “Medications Used to Treat Opioid Use Disorder: Learning from Past Lessons to Guide Policy,” by Mark Parrino, MPA, AATOD president, discusses the current state of methadone maintenance treatment,

The overdose epidemic started with prescription opioid misuse and transitioned to heroin use; now, illicit fentanyl is the main substance involved in overdoses.

The question is, what can opioid treatment programs (OTPs), the AATOD members, do to help?

The treatment system, including OTPs and DATA 2000 (office-based buprenorphine prescribers) is expanding. The criminal justice system is increasingly involved, and there is a greater interest in treatment of OUDs in prisons and jails.

The policy paper asks key questions, including:

Should we view treating OUD as a public health intervention, with the principal component of care utilizing federally approved medications (methadone, buprenorphine, and Vivitrol/naltrexone)?
Should we devote resources to treating this disorder with medications and additional clinical services?
Should we better-coordinate organized service delivery to treat this illness through a continuum of service delivery components?
Should there be a better connection between DATA 2000 practices and OTPs, to facilitate referrals from one practice to the next?

The Meaning of “Assisted”

The very phrase Medication Assisted Treatment (MAT) suggests that medication alone is not sufficient to treat the complex disorder, the policy paper notes. Indeed, the National Institute on Drug Abuse says this in “Principles of Drug Addiction Treatment,” as does the Substance Abuse and Mental Health Services Administration (SAMHSA), in its “Treatment Improvement Protocol #43: Medication Assisted Treatment for Opioid Addiction in Opioid Treatment Programs.” The AATOD policy paper notes this also.

The policy paper includes a brief description of the early history of the development of methadone maintenance, and a discussion of the value of providing comprehensive treatment services.

History

The policy paper also goes through a history of MAT. One point was made by Vincent Dole, MD, who postulated that “the high rate of relapse of addicts after detoxification from heroin use is due to persistent derangement of the endogenous ligand-narcotic receptor system, and that methadone, in an adequate daily dose, compensates for this defect.” While some patients can do well after treatment is terminated, the majority do not, he wrote. “The treatment, therefore, is corrective but not curative for severely addicted persons.”

OTPs with methadone were developed through a closed panel system following regulation by the Food and Drug Administration (FDA) in 1972. However, the first compendium of clinical guidelines was not published until 1993, through SAMHSA’s first “Treatment Improvement Protocol State Methadone Treatment Guidelines.”

Oversight

Then there was the General Accounting Office Report of 1990: “Methadone Maintenance—Some Treatment Programs Are Not Effective; Greater Federal Oversight Needed.” Although the FDA had regulatory oversight, along with the Drug Enforcement Administration (DEA), the GAO found that the FDA’s oversight was inadequate. After this, regulations became stricter.

The policy paper also cites the findings of John Ball, PhD, that a significant determinant of the effectiveness of methadone maintenance on reducing IV drug use and needle sharing is long-term retention, along with high rates of attendance, and an enduring relationship with staff.

The bottom line point here is that the program characteristics are more important in determining patient outcome than pre-treatment patient characteristics, writes Mr. Parrino.

And a key point is that these findings are equally applicable to DATA 2000 practices—or should be, although there is little research about what DATA 2000 practices are doing, compared to OTPs.

In 2001, SAMHSA took over regulation of OTPs, using accreditation to monitor quality assurance. The National Commission on Correctional Heath Care implemented similar accreditation procedures for treatment in correctional settings.

Diversion

The paper goes on to discuss problems of diversion, noting that the biggest problems occurred when physicians started to prescribe methadone to treat pain. Take-home methadone from OTPs has much greater restrictions than pain medications do.

With the advent of DATA 2000 practices and buprenorphine, however, the value of oversight seemed to be “forgotten,” writes Mr. Parrino.

The decision not to have any federal oversight for DATA 2000 practices was driven by several variables, he writes. The first was the attempt to normalize addiction treatment so that clinical practitioners could treat this illness without the regulatory burden that had been implemented for OTPs.

AATOD agrees with making standards of care required as a method of guiding clinical care in DATA 2000 practices, based on the history of treating this disorder with medications, writes Mr. Parrino.

Care Coordination

The policy paper also discusses the importance of care coordination, which includes models such as the Vermont Hub and Spoke system, with OTPs as the hubs and DATA 2000 practices as spokes. This model has been very successful.

“There are large states that could certainly benefit from the coordinated models, by breaking them into counties or municipalities,” writes Mr. Parrino. “The point is that coordination of care is critically necessary as first responders save an individual from overdose through the administration of Narcan [naloxone]”, getting the individual to an emergency department, where trained personnel can get the person evaluated and referred to treatment.

Mark Parrino

Finally, the paper focuses on the emerging importance of the criminal justice system, citing positive initiatives in Connecticut and Rhode Island, in particular, where OTPs are operating within prisons and jails. The results from both state experiences is a significant reduction in recidivism: individuals do not return to the correctional system, and there is a dramatic reduction in opioid mortality, writes Mr. Parrino. That’s what happens when inmates are released to community-based practice settings, and smoothly transition into the OTP to continue their treatment, he said. Without question, this kind of intervention should be repeated throughout the United States, so that inmates with OUD can have access to treatment during incarceration, and referred to outpatient treatment facilities upon release.

The policy paper which was released in January 2019 can be accessed at: http://www.aatod.org/wp-content/uploads/2019/01/2019-Policy-Paper-4.pdf

New Resource From SAMHSA: Healthy Pregnancy Healthy Baby Fact Sheets

December 17, 2018

This series of four fact sheets emphasizes the importance of continuing a mother’s treatment for opioid use disorder (OUD) throughout pregnancy. The series includes information on OUD and pregnancy, OUD treatment, neonatal abstinence syndrome, and considerations to address before hospital discharge.

An overview of the fact sheets can be accessed at: https://store.samhsa.gov/product/Opioid-Use-Disorder-and-Pregnancy/sma18-5071

The fact sheets include:

Opioid Use Disorder and Pregnancy | pdf (85.26 KB) Getting the help and support you need from your healthcare professionals

Treating Opioid Use Disorder During Pregnancy | pdf (89.2 KB) Some important things to know about OUD treatment during pregnancy, as well as the Do’s and Don’ts for making sure you receive the best treatment possible.

Treating Babies Who Were Exposed to Opioids Before Birth | pdf (81.65 KB) Some important things to know about what to expect if your baby needs special care after birth, as well as the Do’s and Don’ts for understanding and responding to your baby’s needs.

Good Care While Receiving Opioid Use Disorder Treatment | pdf (83.78 KB) Some important things to know about OUD and caring for your baby, as well as the Do’s and Don’ts for creating a healthy environment for your family.

Source: SAMHSA.gov – August 2018

The Strongest Evidence Yet for a Highly Controversial Addiction Treatment

December 17, 2018

As overdose deaths break records year-after-year in the U.S., a group of researchers has looked around the world for new treatment options to try and landed on a counterintuitive method. A new comprehensive report concludes that it’s time for Americans to earnestly pilot and study “heroin-assisted treatment,” a controversial approach that involves patients who are severely addicted to the drug injecting medical-grade heroin in a supervised setting.

Motivated by the urgency of the country’s overdose crisis that killed more than 70,000 people in 2017, driven mainly by potent fentanyl analogues, researchers at the rand Corporation, a California-based think tank, spent a year studying the medical literature and interviewing stakeholders in six other countries, along with American communities plagued by overdoses. The report also outlines the evidence for supervised-consumption sites, another harm-reduction intervention popular across Canada and Europe.

Studies in countries that use heroin-assisted treatment and supervised consumption sites have found both approaches beneficial for people who have unsuccessfully tried other, less risky approaches to treatment. But the researchers acknowledge that the evidence base for supervised consumption sites could be stronger, and that there are significant legal, political, and cultural barriers standing in the way of heroin-assisted treatment’s implementation in the U.S. America has a history of prioritizing abstinence as the ultimate goal of recovery, and prescribing people addicted to heroin, well, heroin, can be seen as a big leap.”

Source: TheAtlantic.com – December 8, 2018

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