AT Forum NEWS NOTES & UPDATES #139
March 2010
Compiled & Edited by Sue Emerson - Publisher
Prior Edition: February 2010
Contents
METHADONE & MEDICATION-ASSISTED TREATMENT
New York State Introduces Bill on OTP Location Restrictions
AATOD Advisory Encourages Voluntary Reporting of OTP Patient Deaths
Overview of OTPs in the U.S. — 2008 N-SSATS Report
Prison-Initiated Methadone Maintenance Improves Postrelease Treatment Outcomes
Methadone Contributes to Bone and Dental Disease: Fact or Fiction?
Black Tar Heroin Spreading Across Middle America
RESEARCH / SURVEYS
Friends and Relatives Provide Nearly All Oxycontin to Abusers
Behind Bars II: Substance Abuse and America's Prison Population
MISCELLANEOUS
Moral Judgment Still Plays a Role in Prescribing Pain Meds
Panel Recommends Amending Federal Privacy Law to Help Integrate Addiction Treatment Records
METHADONE & MEDICATION-ASSISTED TREATMENT (MAT)
New York State Introduces Bill on OTP Location Restrictions
In February, the New York State Assembly and Senate introduced a bill that if enacted into law, would ban new and existing opioid treatment programs (OTPs) from operating within 500 feet of a secondary or elementary school, a day care center, or a house of worship, unless the program is actually operated within a hospital.
The proposed legislation states, "the present existence of methadone treatment centers has distinct consequences upon the community, students, the parents and children of day care centers, and the general public attending their places of worship. Very often the problems of loitering and vandalism accompany the presence of methadone treatment centers. The relocation of these treatment centers would benefit the community in that the negative influences associated with them would not be felt by a vulnerable portion of the public."
The prime sponsor of the bill is Alan Maisel (D), 59th Assembly District, Brooklyn. The Senate sponsor is John Sampson (D), 19th Senate District, Brooklyn.
The proposed legislation can be accessed at:
http://open.nysenate.gov/legislation/api/mobile/bill/A5529 and http://assembly.state.ny.us/leg/?bn=S00094.
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AATOD Advisory Encourages Voluntary Reporting of OTP Patient Deaths
On March 1, the American Association for the Treatment of Opioid Dependence (AATOD) issued an advisory encouraging opioid treatment programs (OTPs) to report all patient deaths during the course of their treatment to the Center for Substance Abuse Treatment (CSAT) using the CSAT form (see link below). This includes deaths due to natural causes such as heart disease, as well as those associated with the ingestion of prescription and illicit drugs.
AATOD President Mark Parrino, MPA, said "in our collective judgment, it makes sense for OTPs to submit such data to CSAT, especially since a significant number of programs already report deaths to their state authorities. While this may add some burden in terms of double reporting, we believe that it is important to have a central repository of such data as a means of further demonstrating that the clear majority of deaths due to the use of methadone lie outside of our treatment system".
The AATOD advisory can be accessed at:
http://www.aatod.org/policystat.html
To submit a mortality report to CSAT, go to http://dpt.samhsa.gov/, click on “Submit an OTP Mortality Report to SAMHSA,” and follow the instructions on the page, which includes links to the form http://dpt.samhsa.gov/pdf/OTPMortalityForm.pdf and the instructions http://dpt.samhsa.gov/pdf/OTPMortalityForm_Instructions.pdf.
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Overview of OTPs in the U.S. — 2008 N-SSATS Special Report
As a follow up to the release of the 2008 National Survey of Substance Abuse Treatment Services (N-SSATS), the Substance Abuse and Mental Health Services Administration Office of Applied Studies issued a short report on opioid treatment programs (OTPs) in late January. Highlights of the report include:
Ancillary Services Offered By OTPs
Research has shown that OTPs offering comprehensive mental and physical health services yield much better patient outcomes. Some clinics have adopted the "one-stop shopping" model, providing all services on-site. Although the principles of comprehensive care are widely accepted, many smaller OTPs lack the resources to implement this type of care.
The following chart summarizes the ancillary services OTPs offered to patients in 2008.
| Ancillary Services Offered by OTPs | % OTPs |
|---|---|
| Substance abuse education | 97% |
| HIV/AIDS education, counseling, support | 85% |
| Case management | 84% |
| Health education other than HIV/AIDS | 76% |
| Assistance with obtaining social services such as Medicaid, WIC, SSI, SSDI | 69% |
| Social skills development | 67% |
| Housing location assistance | 58% |
| Self-help groups such as AA, NA | 46% |
| Employment counseling/training | 44% |
| Mentoring/peer support | 43% |
| Mental health | 42% |
| Family or partner violence | 32% |
| Transportation assistance | 32% |
| Child care | 7% |
Clinical/Therapeutic Approaches Used By OTPs
A variety of clinical or therapeutic approaches are used by OTPs. Each has its strengths, and certain approaches may work best for specific behavioral or addiction problems. The following shows the percentage of OTPs that indicated that they used a specific approach "always or often".
| Clinical/Therapeutic Approaches Used By OTP | % OTPs |
|---|---|
| Substance abuse counseling | 99% |
| Relapse prevention | 88% |
| Cognitive-behavioral therapy | 46% |
| Motivational interviewing | 43% |
| Brief interventions | 32% |
| Contingency management/motivational incentives | 27% |
| Anger management | 20% |
OTPs provide interventions that are designed to meet a range of needs of their patients as well as to provide medication-assisted therapy for opioid addiction through maintenance or detoxification. By understanding the many facets of care offered by these programs, persons seeking treatment and those professionals who provide referrals to treatment may make informed decisions about the range of services that would help promote and sustain recovery from opioid addiction. Policy makers and funders who are concerned with accessibility to appropriate services may also wish to examine whether or not current funding strategies and facility settings are adequate for the population in need of such therapeutic help.
A PDF file of the 6-page report can be accessed at:
http://oas.samhsa.gov/2k10/222/222USOTP2k10Web.pdf
Source: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (January 28, 2010). The N-SSATS Report: Overview of Opioid Treatment Programs within the United States: 2008. Rockville, MD. Published January 28, 2010
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Prison-Initiated Methadone Maintenance Improves Postrelease Treatment Outcomes
The risk of postrelease relapse is high among inmates who were opioid dependent prior to incarceration. Although research has shown that initiating methadone maintenance treatment (MMT) in prison reduces this risk, the practice has not received widespread acceptance.
In this randomized clinical trial, male inmates (N=204) with preincarceration heroin dependence who were about to be released were assigned to either counseling (advice to seek MMT upon release), counseling plus transfer (directive to report to an MMT facility within 10 days of release), or counseling plus methadone (gradual initiation of MMT in prison and directive to report to an MMT facility within 10 days for continued care).
Mean age of participants was 40 years; 70% were African American, and 71% had received prior substance abuse treatment. The mean duration of incarceration was 605 days. Primary outcomes at 12 months are shown in Table 1.
| Table 1. TREATMENT AND URINE TOXICOLOGY RESULTS | ||||
|---|---|---|---|---|
| Outcome measure | Treatment condition | p | ||
| Counseling only | Counseling + transfer | Counseling + methadone | ||
| Mean days of methadone treatment | 23 | 91 | 166 | <0.01 |
| In methadone treatment for 12 months | 0% | 17% | 37% | -- |
| Opioid-positive urine test | 66% | 49% | 25% | <0.01 |
| Cocaine-positive urine test | 72% | 67% | 43% | <0.05 |
Comments: In this trial, counseling plus prerelease MMT was superior to counseling alone or counseling plus transfer to MMT at engaging patients in treatment and decreasing illicit drug use among inmates with a history of heroin dependence. The primary limitation of the study is that urine toxicology data were not available in 44% of the sample due to reincarceration, hospitalization, or relocation. Nevertheless, this study provides further support for public-health initiatives that improve the transition of substance-use care from the institutional to the community setting.
Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue November/December 2009. Access checked 3/20/10. Jeanette M. Tetrault, MD
Original Source: Kinlock TW, Gordon MS, Schwartz RP, et al. A randomized clinical trial of methadone maintenance for prisoners: results at 12 months post-release. J Subst Abuse Treat. 2009;37(3):277-285.
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Methadone Contributes to Bone and Dental Disease: Fact or Fiction?
Patients receiving or considering methadone maintenance treatment (MMT) for opioid dependence often express concern that methadone causes bone disease and dental decay. Although this has long been considered a misconception, low bone density has been noted in some MMT patients. This cross-sectional study sought to determine the prevalence and risk factors associated with vitamin-D deficiency in patients receiving MMT. Deficiency was defined as a 25-hydroxyvitamin D level less than 20 ng/mL, while insufficiency was defined as a level between 20-30 ng/mL.
Of the 93 patients enrolled in the study, 36% had evidence of vitamin-D deficiency and an additional 16% had evidence of insufficiency.
Vitamin-D deficiency was associated with age over 40 (odds ratio [OR], 3.47) and black or Hispanic race/ethnicity (OR, 3.34).
Longer enrollment in MMT was not associated with vitamin-D deficiency.
Comments: Although causation cannot be inferred and a model adjusting for all independent variables could not be constructed due to limited outcome cases, this small cross-sectional study did demonstrate a high prevalence of vitamin-D deficiency among patients receiving MMT. These findings are important since vitamin-D deficiency can lead to musculoskeletal pain, osteoporosis, and periodontal disease, all of which are common among MMT patients. Further investigation is needed to better understand the association between MMT, other risk factors (e.g., smoking), and vitamin-D deficiency.
Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue November/December 2009. Access checked 3/20/10. Jeanette M. Tetrault, MD
Original Source: Kim TW, Alford DP, Holick MF, et al. Low vitamin D status of patients in methadone maintenance treatment. J Addiction Med. 2009;3(3):134-138.
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Black Tar Heroin Spreading Across Middle America
In mid-February, the Los Angeles Times ran a three part series on a semi-processed form of Mexican heroin known as black tar. Immigrants from Xalisco, Mexico, using convenient delivery by car and aggressive marketing, have moved into cities and small towns across the U.S., often creating demand for heroin where there was little or none.
According to the 2009 U.S. Department of Justice National Drug Threat Assessment report, estimates of Mexican and Colombian heroin production indicate that black tar now accounts for two-thirds or more of the U.S. heroin market.
The articles and an interactive slide show on black tar heroin can be accessed at :
http://www.latimes.com/news/local/la-me-blacktar14-2010feb14,0,4784251,full.story
Source: Los Angeles Times — February 14, 2010
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RESEARCH/SURVEYS
Friends and Relatives Provide Nearly All Oxycontin to Abusers
A startling 97 percent of individuals who misused OxyContin said that they got the drug from a friend or relative with a prescription for the opiate painkiller, HealthDay News reported Feb. 18.
Researchers who surveyed 5,300 adults in Utah found that 85.2 percent of Oxycontin abusers said friends or relatives gave them the drug willingly, while 9.8 percent said they took the drug from friends or relatives without their knowledge. Only 4.1 percent of those surveyed said they had bought the drug.
Study co-author Erin Johnson of the Utah Department of Health urged residents to discard their leftover medication, but acknowledged that many people are unwilling to do so because they paid for the drugs and believe they might need to use them in the future.
The study was published Feb. 19, 2010 in the Center for Disease Control and Prevention's Morbidity and Mortality Weekly Report.
Source: JoinTogether.org — February 25, 2010
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Behind Bars II: Substance Abuse and America's Prison Population
Of the 2.3 million inmates crowding our nations prisons and jails, 1.5 million meet the DSM IV medical criteria for substance abuse or addiction. Another 458,000, while not meeting the strict DSM IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation; or shared some combination of these characteristics, according to Behind Bars II: Substance Abuse and America's Prison Population. Combined these two groups constitute 85 percent of the U.S. prison population.
The new 144-page report released by The National Center on Addiction and Substance Abuse (CASA) at Columbia University also reveals that alcohol and other drugs are significant factors in all crime. In 2006, alcohol and other drugs were involved in these inmate offenses:
- 78 percent of violent crimes;
- 83 percent of property crimes; and
- 77 percent of public order, immigration or weapon offenses; and probation/parole violations.
The CASA report found that only 11 percent of all inmates with substance abuse and addiction disorders receive any treatment during their incarceration. The report found that if all inmates who needed treatment and aftercare received such services, the nation would break even in a year if just over 10 percent remained substance and crime free and employed. Thereafter, for each inmate who remained sober, employed and crime free the nation would reap an economic benefit of $90,953 per year.
"States complain mightily about their rising prison costs; yet they continue to hemorrhage public funds that could be saved if they provided treatment to inmates with alcohol and other drug problems and stepped up use of drug courts and prosecutorial drug treatment alternative programs," said Susan E. Foster, CASA's Vice President and Director of Policy Research and Analysis.
Joseph A. Califano, Jr., CASA's Chairman and President and former U.S. Secretary of Health, Education, and Welfare, called the nation's current prison policies, "Inane and inhuman. Between 1996 and 2006, the U.S. population grew by 12 percent. Over that same period, the number of adults incarcerated grew by 33 percent to 2.3 million inmates and the number of inmates who either met the DSM IV medical criteria for alcohol or other drug abuse and addiction or were otherwise substance involved shot up by 43 percent to 1.9 million inmates. The tragedy is that we know how to sharply reduce the costs of incarceration and the crimes committed by substance-involved offenders."
The report also noted that in 2005, federal, state and local governments spent $74 billion on incarceration, court proceedings, probation and parole for substance-involved adult and juvenile offenders and less than one percent of that amount--$632 million--on prevention and treatment for them.*
The CASA report also found that compared to non-substance involved inmates, substance-involved inmates are not only likelier to be re-incarcerated, begin their criminal careers at an early age, and have more contacts with the criminal justice system, but they are also:
- Four times likelier to receive income through illegal activity;
- Twice as likely to have had at least one parent who abused alcohol or other drugs when they were children;
- 41 percent likelier to have some family criminal history;
- 29 percent less likely to have completed at least high school; and
- 20 percent likelier to be unemployed a month before incarceration.
The full report can be accessed at:
http://www.casacolumbia.org/templates/publications_reports.aspx
Source: The National Center on Addiction and Substance Abuse (CASA) at Columbia University — February 26, 2010
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MISCELLANEOUS
Moral Judgment Still Plays a Role in Prescribing Pain Meds
Few doctors still believe that pain is God's will and that treating it could be a sin, but morality and legality still play a major role in prescribing pain medication, Time magazine reported Feb. 24.
Up to 15 percent of Americans have chronic pain and presumably could benefit from pain medication, but the addictive reputation of opiate-based painkillers makes some doctors reluctant to prescribe the drugs. Other physicians worry about facing prosecution if they prescribe too many painkillers.
However, a review of recent research shows that less than one percent of chronic-pain patients with no past history of addiction became addicted to opiate-based pain medications. Nora Volkow, director of the National Institute on Drug Abuse, suggested that the study findings are not definitive, but estimated that the addiction rate is under 3 percent.
Other research found that the risk of overdosing on these drugs was 0.25 percent.
Experts say few chronic pain patients get the drugs they need, but Volkow cautioned: "There is both overprescribing and underprescribing."
"More people are getting a very little bit of opioids, and that's good," said Siobhan Reynolds, founder the Pain Relief Network. "But those who need high doses are still being put through hell. These drugs are a miracle for the right people: they're not good or bad; they're just what is."
Source: JoinTogether.org — March 1, 2010
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Panel Recommends Amending Federal Privacy Law to Help Integrate Addiction Treatment Records
A new proposal to amend a landmark federal privacy law is butting up against resistance from recovery advocates and others, as the addiction treatment and recovery community struggles to strike a balance between the need for integration with mainstream medicine and privacy concerns about the use of electronic medical records.
Under the federal Confidentiality of Alcohol and Drug Abuse Patient Records Act, enacted in 1972, healthcare professionals are barred from accessing records pertaining to individuals' alcohol and other drug treatment without written authorization, except in emergency situations. Designed to protect people with addictions from stigma and discrimination, the law can sometimes inhibit effective service delivery, such as case management and use of screening and brief intervention programs, some health professionals say.
On Feb. 5, a group calling itself the Patient Protection Coalition released a draft proposal (PDF) that would amend the federal law to allow "very limited disclosures of information about substance-use disorder treatment to healthcare providers and health plans for purposes of treatment, coordination of care, recovery support, quality improvement, disease management and payment."
The proposal would "carve out an exception to the statute that would allow healthcare providers to access a minimal amount of data without getting explicit permission," said Eric Goplerud, Ph.D., head of the Center for Integrated Behavioral Health Policy at the George Washington University Medical Center, who is facilitating and disseminating the coalition's work.
Plan: More Access, Tougher Penalties
Specifically, the proposed amendment to the statute (42 USC 290dd-2) would allow healthcare providers to access demographic information, diagnosis, medications, laboratory results, and identification of past or current treatment providers.
At the same time, the draft statute would explicitly prohibit discrimination on the basis of information in substance-use disorder program records; limit use of patient information in criminal and civil investigations or proceedings; strengthen civil and criminal sanctions against unauthorized disclosures; and give individuals the right to pursue civil remedies against anyone who violates the statute, according to the coalition, led by Richard J. Bonnie, director of the Institute of Law, Psychiatry and Public Policy at the University of Virginia School of Law.
Goplerud noted that the current statute calls for only a $500 fine for those who violate patient privacy, compared to the $1.5 million fines that can be imposed on those who violate the privacy protections of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
"The proposal couples a modest, but necessary, liberalization of treatment-related disclosure with several major amendments designed to strengthen the Act's sanctions and remedies for breaches of confidentiality," the document states.
"Nobody wants to do anything to compromise the basic objectives of the 1972 law, but we do want to see it strengthened," Bonnie told Join Together.
The full article can be accessed at:
http://www.jointogether.org/news/features/2010/panel-recommends-amending.html
Source: JoinTogether.org — February 19, 2010 — By Bob Curley
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All facts and opinions are those of the sources cited. News reports may have been edited for length and/or modified for clarity without altering essential data as originally published.
Addiction Treatment Forum and its associates do not endorse any medications, products, or treatments described, mentioned, or discussed in any of the sources referenced. Nor are any representations made concerning efficacy, appropriateness, or suitability of any such products or treatments. This News Update is made possible by an educational grant from Covidien Mallinckrodt, St. Louis, MO, a manufacturer of methadone and naltrexone.
In view of the possibility of human error or advances in medical knowledge, Addiction Treatment Forum and its associates do not warrant the information contained in the above news updates is in every respect accurate or complete, and they are not responsible nor liable for any errors or omissions that may be found in such information or for results obtained from use of such information.