Medication-Assisted Treatment (MAT) – Page 2

Study: Lack of Nearby OTPs Puts Methadone Patients at Risk of Early Death

October 3, 2018

By Barbara Goodheart, ELS

Under federal law, newly enrolled methadone patients must attend a methadone program six days a week, so caregivers can watch as patients are dosed.

But here’s the problem: Because many new methadone patients don’t have an opioid treatment program (OTP) nearby, this need for daily attendance markedly affects adherence. In fact, 20% to 50% of patients report poor or partial adherence during the most critical time of treatment—the first month, when patients face the highest risk of death.

That’s the subject of a study published this month in Journal of Substance Abuse Treatment.

The study’s authors, most of whom are affiliated with Washington State University, assessed the relationship between spatial access to the only state-funded OTP in Spokane County, Washington, and adherence to treatment during the crucial first month.

Authors’ Hypothesis—Treatment adherence is lower in new patients who live farther from the OTP.

Findings

The 892 patients received their first month’s treatment sometime between February 2015 and December 2017.

Effects of Distance

In the crucial first month of treatment:

Patients living between 5 and 10 miles from the OTP were just as likely to miss doses as those living less than 5 miles away
Patients living more than 10 miles away were more likely to miss methadone doses than patients living within 5 miles
Patients living more than 10 miles away were younger, on average, than those closer; these younger, farther patients were considered possibly at higher risk of not adhering to treatment—and thus at higher risk of death

Other Considerations

Time in Therapy

In the first three months, patients were required to complete 12 sessions of cognitive or behavioral therapy. After three months, take-home doses could be considered for those with good adherence. Also, mandatory attendance for therapy dropped to once monthly.

Age

Median age was 34 years. The older the patient, the less the likelihood of missed doses. For every year of greater patient age, missed doses dropped 2%.

Distance

The authors commented that previous studies suggest that lower income, higher medication costs, and transportation barriers may influence nonadherence, affecting Medicaid patients, such as those in this study.

Day of the Week

Patients were most likely to miss Saturday and Sunday doses. The staff provided Sunday take-home doses only until 2 PM Saturday.

Conclusions

The research team found that during the first month of treatment, “significant positive associations” existed between the number of doses patients missed and the distance patients traveled to the OTP.

The authors stressed the importance of regular attendance, and the need to “improve the spatial availability of OTPs” for patients scattered throughout the area.

Bottom Line

Methadone treatment is known to reduce or eliminate drug use, risky sexual behavior, criminal behavior, and deaths. But many OTP patients lose these benefits early, because no OTP is nearby. Evidence points to the first month as being key.

COMMENT: The authors have provided valuable data showing that the legal need to observe patients’ daily dosing may affect compliance. They’ve also raised important issues for further investigation.

In the meantime, laws have been passed limiting the availability of prescription opioids, and other investigators have suggested different approaches to the opioid problem, described below.

Rosenblum et al. Writing in The Journal of Environmental and Public Health, these authors recommended flexible take-home policies, mobile methadone maintenance services, and methadone medical maintenance—methadone provided by an office-based physician, or a pharmacy. Good ideas, all awaiting implementation. But the awaiting continues: The study was published seven years ago, the opioid crisis continues to surge, and the obstacles remain.

Saitz and Daaleman. Early this year an article in The Annals of Family Medicine urged making methadone treatment part of primary care. The authors said it would be impossible for the country to adequately respond to the current epidemic “without addressing it in primary care and there is no question that the time to do it is now.”

Samet et al. An article in the July issue of New England Journal of Medicine also called for primary care availability—specifically, by asking Congress to update laws. Regulating methadone prescribing in primary care would reduce barriers, the authors said, and would “extend the benefits of a proven, effective medication to people throughout the country.”

Given the variety of approaches to the opioid crisis—restricting opioid prescriptions, constructing more OTPs, allowing primary-care prescribing—what’s the best way to proceed?

The Stanford Approach: Modeling Tools Provide Assessments

A team from Stanford University used sophisticated modeling tools to assess the benefits and harms of various responses to the opioid crisis. They found that policies that expand addiction treatment or mitigate addiction’s harmful effects, such as overdose and infection, are “immediately and uniformly beneficial.” And they lack negative consequences, such as increasing heroin-related deaths. The team published its findings this month in the online edition of The American Journal of Public Health.

As for policies that decrease the supply of prescription opioids—they can reduce prescription-related deaths, but could also increase heroin-related deaths, as some people seek heroin as a substitute for prescription opioids. It’s possible, the team believes, that eventually “some such policies may avert enough new addiction to outweigh the harms.”

What, then, is the best policy? It seems there’s no perfect answer. The Stanford team suggested “a portfolio of interventions,” but these would include reducing the prescription opioid supply, probably increasing heroin use temporarily. It would also deprive some patients with chronic pain of a medication they legitimately need.

Opening more OTPs, as the Washington State team recommends, wouldn’t have that disadvantage, and the data indicate it would optimize treatment outcomes.

References

Amiri S, Lutz R, Socias ME, McDonell MG, Roll JM, Amram O. Increased distance was associated with lower daily attendance to an opioid treatment program in Spokane County Washington. J Subst Abuse Treat. 2018;Oct;93:26–30. doi:10.1016/j.jsat.2018.07.006.

Rosenblum A, Cleland CM, Fong C, Kayman DJ, Tempalsky B, Parrino M. Distance traveled and cross-state commuting to opioid treatment programs in the United States. J Environ Public Health. 2011; article ID 2011;948789. Epub 2011;July 6;doi:10.1155/2011/948789.

Saitz R, Daaleman TP. Now is the time to address substance use disorders in primary care. www.annfammed.org/content/15/4/306.full. Ann Fam Med. 2017;(July);15(4):306-308. doi:10.1370/afm.2111.

Samet JH, Botticelli M, Bharel M. Perspective: Methadone in primary care — One small step for Congress, one giant leap for addiction treatment. N Engl J Med. 2018;379:7-8. doi:10.1056/NEJMp1803982.

Pitt AL, Humphreys K, Brandeau ML. Modeling health benefits and harms of public policy responses to the US opioid epidemic. Am J Public Health. Epub ahead of print August 23, 2018:e1-e7. doi:10.2105/AJPH.2018.304590.

Expanding OTP Access In California, Where Waiting Lists Are Not Used

October 3, 2018

By Alison Knopf

California technically doesn’t have waiting lists for opioid treatment programs (OTPs). When a program is full, the operator can ask the state for an increase in slots. If the request is granted—and it usually is—the program then pays for the extra slots in a new license.

This flexibility is very helpful to OTP providers. “We adjust our capacity up or down each year,” said Jason Kletter, PhD, president of BayMark Health Services. “If I only have 200 patients, I’m not going to pay for a license for 500,” said Dr. Kletter, who is also president of California Opioid Maintenance Providers (COMP), a membership organization of OTPs in the state.

“We’ve never had a problem with waiting lists in California,” Dr. Kletter told AT Forum. “BayMark is at only 73% capacity.”

“Narcotic treatment is a Drug Medi-Cal benefit in California ,” said Thomas Renfree, interim executive director of the County Behavioral Health Directors Association. “And because Drug Medi-Cal is an entitlement program, this does not allow for waiting lists for narcotic treatment.” If an OTP has more patients than it can handle in a clinic, new patients are entitled to treatment elsewhere.

Counties in Charge

But that doesn’t mean the transition happens smoothly for everyone. In California, under the terms of the 1115 Waiver for the Drug Medi-Cal Organized Delivery System, said Mr. Renfree, counties act as managed care plans for their residents, which authorizes the county to select the network of providers with whom the county will contract to provide services to its residents. At the same time, each county is responsible to ensure that every eligible beneficiary has timely access to all covered services when medically necessary, including narcotic treatment. Each county is also financially responsible for services provided to its residents, whether in county or out of county.

Under ordinary conditions, if one clinic is at capacity, it asks the county for additional capacity, which refers that request to the state, as indicated above.

Alex Dodd

But Alex Dodd, CEO of Aegis Treatment Centers, said there’s a glitch in this system. “We talk to the county and say the clinic is at capacity, we need your support for additional capacity,” Mr. Dodd told AT Forum. For example, in the Aegis OTP in Modesto, which has historically been full, new patients would historically have been referred to an Aegis clinic across the county border. However, under the Medicaid waiver, counties are not required to pay for treating patients from other counties, because each county gets a set amount for its Medicaid beneficiaries. Stanislaus County and Aegis are working together to open a new clinic in Ceres.

In fact, Stanislaus County, where Modesto is located, has a county-run program, and Aegis refers patients there if its clinic is at capacity, said Mr. Renfree. But what if the county-run program itself is at capacity or the patient wants to be in an Aegis program? “If the client wants to stay with Aegis and doesn’t want to go to the county-run clinic, they may request to receive services in the contracted Aegis facility across the border, he said. Stanislaus County understands that it is not good medical practice to disrupt patient care if the beneficiary has a good relationship with a particular clinic, and it is key to maintain continuity of treatment.

Building New Clinics

Another problem comes from NIMBY (not in my back yard)—not from the behavioral health policy makers, but from local supervisors. “The first thing you try to do is use your existing facility to accommodate the increase in capacity,” said Mr. Dodd. “But sometimes the clinic runs out of physical capacity, in which case you have to build a new clinic somewhere.” Aegis is currently trying to do this in two counties: one is being supportive, and the other is “dragging its feet,” he said.

Why would a county drag its feet about a new OTP during an opioid epidemic, especially when the investment is going to be borne entirely by a private company? “The main reasons we have found historically are stigma-related,” said Mr. Dodd. “If the board of supervisors is not in favor of treatment, they respond to political pressure.”

Public Awareness

California has 19 grants categorized as State Targeted Response to the Opioid Crisis (STR) grants; Aegis is administering six of them. “By and large, this program is well done,” said Mr. Dodd. “But the biggest thing the government could help with next is a public awareness campaign to spread the word about treatment to patients and families. If it were up to me, I’d have a big advertising campaign.”

And Mr. Dodd would like to see more leadership from the governor’s office. When Howard Shumlin, then governor of Vermont, gave his state-of-the-state speech in 2014, “the only thing he talked about was the opioid epidemic,” recalled Mr. Dodd. “Unless there is that political leadership, unless number one says this is a big problem, the public servants are not going to take that direction.”

The big push using STR in California has been on a hub-and-spoke system, in which OTPs are the hubs and office-based opioid treatment (OBOT) prescribers are the spokes And in fact, aside from adding OTP capacity in the north, the biggest focus has been in expanding the spokes, said Dr. Kletter. The same is likely to be true of the new State Opioid Response (SOR) grants.

The STR grants have helped bring visibility and therefore support to the need to expand OTPs, especially north of San Francisco, where Aegis is using STR money to begin setting up programs, and where the relatively small and very rural counties have united. BAART (the predecessor to BayMark) tried to set up an OTP in Humboldt County about 25 years ago, recalled Dr. Kletter, but the county didn’t want it then. “Now, the STR grant gives some money to share with local communities, which garners support from those communities,” he pointed out.

NIMBY Again

The biggest problem facing OTPs is not funding: it is stigma and NIMBYism. There’s a segment of the population that will never be convinced to support a local OTP, said Dr. Kletter, “especially when they think their property values and safety are threatened.”

How to get past that? Community meetings are one way, but this can mean facing groups that are as friendly as “pitchfork mobs,” he said. Maybe the only solution would be to attach strings to funding, in which localities would have to agree to treatment programs to get their Medicaid dollars.

In the meantime, the main actors in OTP expansion are the private for-profit chains, in California as in the rest of the country. If these programs have plans for expanding and want to grow new clinics to meet the demand, they are going to need support, not only in funding, but in public awareness from government leaders. California’s regulatory system is flexible enough to allow new programs, and the law requires treatment on demand for Medicaid patients; advocates hope the momentum from federal STR and SOR grants continues to advance the needs of OTP patients.

Medicare and 42 CFR Part 2: Both Wins in Opioid Package

September 27, 2018

By Alison Knopf

The bipartisan opioid bill was approved by the Senate and House of Representatives conferees, and is now headed for a full vote in the House. There is much good news: Confidentiality under 42 CFR Part 2 is still protected, and Medicare will cover treatment for all in an OTP (opioid treatment program) with methadone as well as with other approved medications.

42 CFR Part 2

Under the House version, 42 CFR Part 2 would have been replaced by HIPAA, severely limiting patients’ rights to control access to their medical records. Last week the American Medical Association wrote lawmakers, urging them to protect 42 CFR Part 2, saying that without it, patients would hesitate to seek treatment (as the American Association for the Treatment of Opioid Dependence, as well as coalitions of patients, and the Legal Action Center, have said repeatedly).

Medicare

The House version of the opioid bill would provide for complete coverage by Medicare for patients in OTPs, so they would not have to drop out of treatment─or pay for it on their own─once they turn 65. That is how the final bill reads, as well. The Senate version, however, would have provided for only a five-year pilot project.

Next Steps

On September 25 the House of Representatives Ways and Means Committee conferees released the text of H.R. 6 (https://docs.house.gov/billsthisweek/20180924/HR6.pdf). Next, the full House must vote on the bill, which could take place this week. There could still be changes, at the last minute, if major mistakes are found.

Still, these two measures were watched closely by OTP advocates, as the opioid legislation went through Congress.

“Great news: thanks to our collective efforts, the final negotiated opioid package came out of Congress today, including our Medicare policy!” said Jason Kletter, PhD, AATOD legislative committee chair, in a September 26 statement. “This is great news, as it will not only provide a new funding source for our patients, but will also lead to more commercial insurers covering OTP services, given Medicare is a benchmark plan followed by many private carriers.”

The start date for Medicare coverage is January 1, 2020.

Also see:

http://atforum.com/2018/08/opioid-bills-senate-focus-medicare-otps/

http://atforum.com/2018/06/bills-look-at-expanding-medicare-to-cover-otps/

http://atforum.com/2017/12/medicare-reimbursement-otps-cited-briefing/

HHS Awards Over $1 Billion to Combat the Opioid Crisis

September 27, 2018

“This week, the U.S. Department of Health and Human Services awarded over $1 billion in opioid-specific grants to help combat the crisis ravaging our country. The awards support HHS’s Five-Point Opioid Strategy, which was launched last year and enhanced this week. New data unveiled recently by HHS suggests that efforts are now yielding progress at the national level.

“Addressing the opioid crisis with all the resources possible and the best science we have is a top priority for President Trump and for everyone at HHS,” said Secretary Alex Azar. “The more than $1 billion in additional funding that we provided this week will build on progress we have seen in tackling this epidemic through empowering communities and families on the frontlines.”

“This week, HHS updated its strategic framework for tackling the opioid crisis, which uses science as a foundation for our comprehensive strategy,” said Admiral Brett Giroir, Assistant Secretary for Health and Senior Advisor for Opioid Policy. “With these new funds, states, tribes, and communities across America will be able to advance our strategy and continue making progress against this crisis.”

Source: HHS.Gov – September 19, 2018

HHS Makes a Pitch for Telemedicine in Substance Abuse Treatment

September 27, 2018

“The Health and Human Services Department wants to remind everyone that telemedicine can be an important tool in treating people with addiction and substance abuse issues.

In a blog timed to coincide with Prescription Opioid and Heroin Epidemic Awareness Week, Assistant Health Secretary Adm. Brett P. Giroir, MD, noted that healthcare providers can use connected care platforms to improve Medication Assisted Treatment (MAT) therapy for people struggling with Opioid Use Disorder (OUD).

“HHS is committed to improving access to MAT for OUD and is working on a variety of strategies to improve access to this life saving treatment through increased funding to states and communities, payment policy changes, and education, training and technical assistance,” he wrote. “One such area is to help providers understand how telemedicine can be used, in certain circumstances, to expand access to buprenorphine-based MAT.”

Source: MHealthIntelligence.com – September 18, 2018

HHS Supportive of MAT Prescribing by Nurse Anesthetists, Midwives

September 27, 2018

“Nurse anesthetists can give any drug in the [operating room]; they put you under; and they’re very trained in pain management”… that would seem an obvious category to consider,” Admiral Brett Giroir, MD, assistant secretary for health and senior advisor for opioid policy at HHS, told MedPage Today Thursday at a reporter briefing on the opioid crisis. “Nurse midwives could be another group you might consider; we do support that being considered by Congress to expand those categories.”

Giroir was referring to H.R. 3692, a bill now being considered in Congress — as part of a large appropriations package — that would allow clinical nurse specialists, nurse anesthetists, nurse midwives, and other non-physician clinicians to prescribe buprenorphine and other treatments to opioid use disorder patients. The provision is not included in the Senate version of the appropriations package, and negotiators from both chambers were working Friday to craft a compromise bill, which must be approved by the House and Senate before being sent to the president for his signature. It was unclear at presstime whether the provision would be included in the compromise bill.”

Source: MedPageToday.com – September 21, 2018

American Medical Association: How Medicaid Programs Can Help End The Opioid Epidemic

September 27, 2018

Medicaid makes sense as an effective, efficient and ultimately life-saving resource for patients living with opioid-use disorder (OUD), yet in many states the program represents deadly missed opportunities.

“The AMA is working at the federal and state levels to advocate changes to promote recovery among what research indicates is a population of roughly 2 million adults with OUD. Opioid overdose deaths grew by 10 percent last year, according to the Centers for Disease Control and Prevention.

“We know what works,” said Patrice A. Harris, MD, chair of the AMA Opioid Task Force. “The research shows that medication-assisted treatment [MAT] helps people stay in recovery longer and saves lives.”

The new, provisional figures from the CDC “yet again underscore that this epidemic will not be reversed until we deal with access issues and stigma associated with opioid misuse,” Dr. Harris added.

The AMA has urged all health insurance companies and other payers to remove administrative and other barriers to high-quality, evidence-based treatment for patients with pain and those with opioid use disorder.

Improving Medicaid OUD treatment is essential to turning the tide. Medicaid expansion under the Affordable Care Act, which requires at least some OUD provisions, and has helped add many thousands of OUD patients to gain coverage for their treatment.

Adequately serving Medicaid OUD patients requires a multipronged approach, but the common thread among solutions from the AMA and the states leading the way is to increase access to high quality, evidence-based care.”

Source: American Medical Association – September 19, 2018

The GOP Says Expanding Medicaid Fueled The Opioid Crisis. This Study Shows Otherwise.

September 17, 2018

“Contradicting a popular conservative talking point, new research shows that Medicaid expansion under the Affordable Care Act helped states treat residents with addiction and didn’t change prescription painkiller fill rates.

“This supports the idea that Medicaid expansion has been beneficial in increasing the number of people receiving an important addiction treatment,” said Brendan Saloner, assistant professor at the Johns Hopkins Bloomberg School of Public Health and lead author of the study, which was published this month in the journal JAMA Network Open.

The researchers compared California, Maryland and Washington, where Medicaid was expanded under the ACA, to Florida and Georgia, where it wasn’t, and found that prescription fills for the addiction medication buprenorphine combined with the overdose reversal antidote naloxone increased significantly in expansion counties. In comparison, prescription fills for opioid painkillers remained about the same after Medicaid expansion, although more patients paid for those prescriptions using Medicaid.”

Source: HuffingtonPost.com – August 23, 2018

There Are Solutions To The Opioid Epidemic. Here’s How You Convince People To Support Them.

September 17, 2018

A new study looks at different messages for strategies to combat the opioid epidemic. Some work better than others.

“There are plenty of evidence-based ideas that could help end the opioid epidemic, from more access to addiction treatment to harm reduction efforts. But the policy proposals to enact such ideas often have trouble getting off the ground — largely thanks to resistance from the general public and politicians, even in the midst of what amounts to the deadliest drug overdose crisis in US history.

A new survey of more than 5,500 Americans by Civis Analytics provides some hints for advocates looking to build public support for policy responses to the opioid crisis. The survey gauged public support for medications used to treat opioid addiction and needle exchanges, both of which have decades of evidence to support them. The analysis then compared how different messages affect levels of support among the general public.”

Source: Vox.com – September 13, 2018

Young People With Opioid Addiction Not Getting Proper Treatment

September 17, 2018

“The vast majority of young people struggling with addiction to opioids are not receiving medications that have been recommended to treat their disease, a new study shows.

Only one in four received one of the medications approved by the U.S. Food and Drug Administration – methadone, buprenorphine or naltrexone – within three months of their diagnosis, according to the report in JAMA Pediatrics.

The situation was even worse for the younger people with addiction, researchers found. Just one in 21 adolescents under age 18 received one of the guideline-recommended medications, researchers found.

“This study shows that the great majority of youth are not receiving treatment recommended in evidence-based guidelines,” said the study’s lead author, Dr. Scott Hadland, a pediatrician and addiction specialist at the Grayken Center for Addiction at the Boston Medical Center. “That’s really concerning because the data suggest that when people do receive medication they are much more likely to remain in treatment.”

Source: WHBL.com – September 10, 2018

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