Blog by Jana Burson on Split Dosing

“Split dosing, when used in reference to the medication-assisted treatment of opioid addiction, means instead of once daily dosing, the total medication dose is divided, or split, into two doses.

Methadone and buprenorphine (Suboxone, Zubsolv, etc.) are long-acting opioids.

When we use these medications for opioid addiction, we prefer to dose once per day.

Before I can order split dosing, I need to get permission from the state and federal authorities, just like I would for extra take homes doses for patient emergencies. In my state, methadone peak and trough levels are usually requested before they grant permission for split dosing. We draw the patient’s blood three hours after their dose, which is the peak. That’s the highest blood level the patient will have on that dose. On the next day, right before they take the next day’s dose, we draw another methadone blood level, called the trough, which is the lowest level the patient ever has on that dose.

Then we compare the peak to the trough. If the peak is more than twice the trough level, the patient is probably a fast metabolizer who will feel better taking part of their dose in the morning and part in the evening.”

http://janaburson.wordpress.com/2014/07/06/split-dosing/ 

Source: JanaBurson.com – July 6, 2014

Blog by William White: The Language of Recovery Advocacy

RecoverySome will question why we as recovery advocates should invest valuable time debating the words used to convey alcohol and other drug (AOD) problems and their solutions when there are suffering individuals and families that need to be engaged, recovery support resources that need to be created, communities that need to be educated, and regressive, discriminatory policies that need to be changed.  We must invest this time because achieving our broader goals depends on our ability to forge a recovery-oriented vocabulary.

Words have immense power to wound or heal.  The wrong words shame people with AOD problems and drive them into the shadows of subterranean cultures.  The wrong words, by conveying that people are not worthy of recovery and not capable of recovery, fuel self-destruction and prevent or postpone help-seeking. The right words serve as catalysts of personal transformation and offer invitations to citizenship and community service.  The right words awaken processes of personal healing, family renewal, and community and cultural revitalization.  The wrong words stigmatize and disempower individuals, families and communities.

It is time people in recovery rejected imposed language and laid claim to words that adequately convey the nature of our experience, strength and hope.  We must forge a new vocabulary that humanizes AOD problems and widens the doorways of entry into recovery.  We must forever banish language that, by objectifying and demonizing addiction, sets the stage for our sequestration and punishment.  We must counter the clinical language that reduces human beings to diagnostic labels that pigeon-hole our pathologies while ignoring our strengths and resiliencies.  We must also reject the disrespectful and demeaning epithets (e.g., “retreads”, “frequent flyers”) professionals sometimes use to castigate those who need repeated treatment episodes.”

http://www.williamwhitepapers.com/blog/2014/06/the-language-of-recovery-advocacy.html

Source: WilliamWhitePapers.com – June 7, 2014

Blog by William White: Volunteerism and Addiction Treatment

blog1“A 1976 national survey of addiction treatment programs in the United States revealed a workforce of nearly 60,000 workers.  The treatment workforce at that time consisted of 31,000 full-time workers and 15,000 part-time paid workers.  The paid professional workforce included 20,000 counselors, 5,000 nurses, 3,000 social workers, 2,500 psychologists, and a small and slowly growing cadre of physicians.  But what is most striking to me in this survey is the reported presence of more than 1,000 full-time volunteers and 13,000 part-time volunteers. As volunteers disappeared from the addiction treatment milieu during the 1980s and 1990s, the story of their role in early addiction treatment and what they meant to people seeking recovery also disappeared.”

http://www.williamwhitepapers.com/blog/2014/06/volunteerism-and-addiction-treatment.html

Source: WilliamWhitePapers.com – June 14, 2014

Blog By Jana Burson: The COWS Score: How Helpful Is It?

“COWS stands for Clinical Opioid Withdrawal Scale, and it’s probably the most commonly used tool to determine the degree of opioid withdrawal experienced by the patient. The scale has eleven items related to opioid withdrawal. Some are subjective, like the question about the degree of anxiety or irritability the patient is feeling. Some items are strictly objective, such as pupil size and pulse rate. And some are sort of a combination of objective and subjective, like the question asking about both nausea and vomiting. The patient may report nausea and score points on the scale, and if the patient vomits, this scores more points.

I think it’s a good tool, but has some drawbacks. I use it during dose induction, particularly on a patient new to medication-assisted treatment. Sometimes patients aren’t sure how they’re “supposed” to feel on replacement medication, and a COWS score gives me a better idea of how much withdrawal they are in.”

The blog can be accessed at: http://janaburson.wordpress.com/2014/05/25/the-cows-score-how-helpful-is-it/

Source: JanaBurson.com – May 25, 2014

Buprenorphine, Methadone and Opiate Replacement Therapy Blog Series from Psychology Today

blog1This three part blog by Joseph Troncale, MD, FASAM, published online on the Psychology Todaywebsite provides a historical overview of opioid addiction and the rise of opioid replacement medication.  The three parts include:

Part 1: Lessons From History – April 30, 2014

Part II: Where the Harrison Act has Brought Us – May 10, 2014

Part III: The Plight of the Opiate Addict from 1914 until Now, and the Rise of Substitution Therapy – May 10, 2014

Dr. Troncale concluded, “There is no perfect drug or therapy, but it is still a certainty that the use of street heroin or synthetic opiates is extremely lethal. I have seen people use NA or AA and get clean, and I have seen people use a combination of buprenorphine or methadone and/or AA and live normal lives. The hope of change is still there. Why people make destructive choices is the question that cannot be explained except by an understanding of the power of the limbic system.”

Source: PsychologyToday.com – April/May 2014

NIDA Blog: Addiction and Free Choice

choices“The recent death of Phillip Seymour Hoffman as a result of drug addiction has provoked many thoughtful, sympathetic responses in the media, from people in recovery who understand how hard it is to wrestle with addiction, as well as from scientifically informed journalists who understand that addiction is a disease. But it has also prompted others to express the age-old notion than drug use is a choice, and that those who die as a consequence of their drug use are just reaping the consequences of their freely chosen actions. It is unfortunate that that view persists in our society, despite the decades of scientific research soundly disproving it.

Choices do not happen without a brain—it is the mechanism of choice. The quality of a person’s choices depends on the health of that mechanism. However much we may wish that a person’s choices were free in all instances, it is simply a fact that an addicted person’s failures in the realm of choice are the product of a brain that has become greatly compromised—it is readily apparent when we scan their brains. Even if taking a drug for the first time is a “free” choice, the progression of brain changes that occurs after that involves the weakening of circuits in the prefrontal cortex and elsewhere that are necessary for exerting self-control and resisting the temptations of drug use. Once addiction takes hold, there is greatly diminished capacity, on one’s own, to stop using. This is why psychiatry recognizes addiction as a disease of the brain, and why professional intervention is needed to treat it in most instances.

Moreover, even the “freely willed” first choice to take a drug cannot be the basis for judgment and stigma against people suffering from addictions. Matters of choice and lifestyle—what you eat, how active you are, where you live—may contribute to the risk for, or even directly cause, a wide range of medical conditions, including chronic diseases like heart disease, type 2 diabetes, and several cancers. We do not withhold or impede treatment of people suffering from those conditions, even if their health may have turned out differently had they made different choices at various points in their lives.

There is no way of precisely predicting which freely chosen adolescent drink, or cigarette, or experimentation with an illegal substance, opened the door to a later loss of free-choice capacity in a person who has become addicted. But once addiction is established, the sufferer from this disease cannot will themselves to be healthy and avoid drugs any more than a person with heart disease can will their heart back to perfect functioning, or a person with diabetes can will their body’s insulin response to return to normal.

Thus, those who say “it was their own choice” after a person dies of an overdose fail to grasp that an addicted person’s brain has a disrupted choice mechanism. And as revealed by Hoffman’s tragic, ultimately fatal relapse into drug taking, the neuronal disruptions in the brain of an addicted person can persist even after decades of sobriety. Speaking of “free choice” is simply not useful when trying to understand an individual’s addiction or its consequences, as addiction is precisely a disease that disrupts the neuronal circuits that enable us to exert free choice.”

http://www.drugabuse.gov/about-nida/noras-blog/2014/02/addiction-free-choice

Source: National Institute on Drug Abuse Dr. Nora Volkow Director – February 18, 2014

AATOD Meeting Highlights: A Banner Meeting for Medication-Assisted Treatment (MAT) Recovery

shutterstock_117405271This year’s meeting of the American Association for the Treatment of Opioid Dependence (AATOD) reflected the continuing evolution of the field, with prescription drug abuse, patient advocacy, and three medications taking top billing. And running throughout the meeting was the theme—recovery.

More than 1,500 attendees were at the conference, held in Center City, Philadelphia at the Downtown Marriott November 9-13.

Key events at this year’s meeting included the admission of Tennessee as a new AATOD member. This was an important addition, with Tennessee’s history as a state where opioid prescription drug abuse first took root a decade ago, with Oxycontin, referred to then as “hillbilly heroin.” Prescription drug abuse, the patient advocacy movement, and the increasing use of the medications Vivitrol and buprenorphine were recurring themes—in conference rooms, in the exhibit hall, and in the earnest conversations between attendees. Centerpiece of the meeting was the awards banquet honoring individuals for extraordinary service in the opioid treatment field.

Prescription Drug Abuse

On November 11, the evening session addressed prescription drug abuse, with the general recognition that this is a major public health crisis that has immediate implications for opioid treatment programs (OTPs) and others who treat opioid dependence. “This is an extremely serious public health issue,” said Mark W. Parrino, AATOD president. “People have all sorts of medicines in their medicine cabinet, and we have to protect those medications from being abused.”

For this reason, AATOD and others in the field support the recent decision of the Food and Drug Administration (FDA) to reschedule hydrocodone from Schedule III to Schedule II, the most restrictive schedule of legal medications on the Controlled Substances Act, said Mr. Parrino.

Doctors should participate in prescription drug monitoring programs (PDMPs), according to Mr. Parrino, who noted that AATOD encourages OTPs to access the databases, but not to provide confidential patient information to them, as per the directive of the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2011.

Patient Advocacy

A growing presence at the conference and at AATOD in general is the OTP patient advocacy movement. Patient advocates like Walter Ginter, project director of Medication Assisted Recovery Services, Zac Talbott, director of the Tennessee chapter of the National Alliance for Medication Assisted Recovery, and Joycelyn Woods, executive director of the National Alliance for Medication Assisted Recovery, are “extremely articulate and forward-thinking,” Mr. Parrino said.

Mr. Ginter was a plenary speaker, on the dais with Mary Jeanne Kreek, MD, vice-president and head of the laboratory of biology of addictive diseases at The Rockefeller University in New York, and H. Westley Clark, MD, director of SAMHSA’s Center for Substance Abuse Treatment.

There were more patient advocates at the conference than ever, which really encourages Mr. Parrino. At the conference, these advocates could walk up to well-tenured administrators, pioneers in the field, and talk with them on their level—a great opportunity for what is the “lifeblood of future patient advocacy” for MAT, he said. It was also very much in keeping with the theme of the conference, which was recovery—these advocates are the spokesmen and spokeswomen for medication-assisted recovery.

Patient advocacy is still at its early stages, but will be increasingly powerful in the future, said Mr. Parrino. “It’s one thing for me to argue about why we should preserve patient confidentiality, but it’s an entirely different thing if patients do it themselves, because they’re talking about their treatment.”

Three Medications

The presence of three medications—buprenorphine, Vivitrol, and methadone—was obvious in the exhibit hall and throughout the presentations. “There are three medications for opioid dependence—we should use them to the benefit of patients,” said Mr. Parrino. While there’s a common belief that most OTP patients do not want Vivitrol, consider this: 80 percent of the patients who taper off methadone or buprenorphine relapse. “Perhaps we could use Vivitrol for the patients who say they no longer want methadone or buprenorphine,” he suggested.

AATOD’s appeal is now broader than ever, encompassing office-based physicians who prescribe buprenorphine under the auspices of DATA 2000, as well as the traditional OTPs that constitute the core of the group’s membership. “We have begun the process of inviting such individual practitioners to join AATOD as individual program members, should they wish to do so,” Mr. Parrino told AT Forum.

At the present time, however, he stressed that the AATOD Board of Directors and its 30 state member associations represent OTPs.

Criminal Justice

Another common theme at this year’s conference was the linkage to criminal justice. One important message referred to the need to better train OTP personnel on how to present the rationale for MAT to criminal justice officials. “It’s a matter of understanding the language of the criminal justice system,” he said. There needs to be funding, possibly through the Addiction Technology Transfer Centers, for training OTPs on how to explain the rationale for gaining access to treatment.

Open Board Meeting

The AATOD open board meeting November 9 included a very impressive presentation by SAMHSA’s Dr. Clark, one of the very few federal officials who have ever run an OTP. Among board members giving presentations: First Vice-President Janice F. Kaufman, RN, on why AATOD developed a guest medication policy (hurricanes, for example), and board member Brian McCarroll, DO, on the development of the naltrexone/Vivitrol guidelines.

Affordable Care Act

The closing plenary featured Paul Samuels, president and director of the Legal Action Center, on the complex implementation of the Affordable Care Act. In the end, this is going to be a state-by-state issue, with some states opting out. “The only solution is real advocacy, having programs unite as a group,” said Mr. Parrino. Also speaking at the plenary: Anne Heron, director of the Division of Regional and National Policy Liaison at SAMHSA, and John O’Brien, senior policy advisor of the Center for Medicare and Medicaid Services at the federal Department of Health and Human Services.

Awards

The centerpiece of the meeting, the awards banquet, honors individuals for extraordinary service in the opioid treatment field. The first recipients were Vincent Dole, MD, and Marie Nyswander, MD, in 1983. Presented by A. Thomas McLellan, PhD, CEO and co-founder of the Treatment Research Institute in Philadelphia, the Nyswander/Dole awards this year went to:

  • Jim B. Graham, Maryland (from 2008-2012, president of the Maryland Association for the Treatment of Opioid Dependence, and Maryland’s representative to the AATOD Board of Directors);
  • Belinda Greenfield, PhD, New York (director of Addiction Medicine & Self Sufficiency Services in the New York Office of Alcoholism and Substance Abuse Services, and the State Opioid Treatment Authority);
  • John Hamilton, Connecticut (CEO of Recovery Network of Programs);
  • Kate Mahoney, Illinois (executive director of Peer Services, Inc.);
  • Joel Millard, Utah (executive director, Project Reality);
  • Luis Duarte Baptista Patricio, MD, Portugal (clinical director, Unidade de Aditologia e Patologia Dual-Casa de Saude de Carnaxide-Portugal);
  • Richard Rawson, PhD, California (associate director at UCLA Integrated Substance Abuse Programs, UCLA Department of Psychiatry and Biobehavioral Sciences in Los Angeles); and
  • Jerome E. Rhodes, Pennsylvania (chief operating officer, CRC Health Group).

The Friend of the Field award, established by AATOD’s board of directors, went to H. Westley Clark, MD, director of the Center for Substance Abuse Treatment at SAMHSA.

The Patient Advocacy Award, named for Richard Lane and Robert Holden, went posthumously to Ira J. Marion, who prior to his death last winter was assistant to the university chairman and director—Government Relations Department of Psychiatry & Behavioral Sciences of the Albert Einstein College of Medicine. Mr. Marion’s work was key to reducing stigma and supporting the rights of patients.

The conference was co-hosted by the City of Philadelphia Department of Behavioral Health Intellectual disAbility Services (DBHIDS), and the Pennsylvania Department of Drug and Alcohol Programs (DDAP).

Blog: New Forms of Buprenorphine for Opioid Addiction Treatment

“At this year’s American Society of Addiction Medicine conference, researchers talked about innovative ways to dose buprenorphine (formerly known as Suboxone) that may be available in the future.

One of the new products doesn’t yet have a trade name. Researchers call it “CAM 2038.” It’s made by Camurus Pharmaceuticals, a small Swedish company that invented a nanoscale drug delivery system, as they say on their website. This “Fluidcrystal” injection containing buprenorphine comes in preparations of varying doses, and can be dosed once per week or once per month, depending on the preparation.

I like the idea of these depot injections. I’ve decided I don’t want to learn to do the minor surgery required to place Probuphine implants, but I can already do intramuscular and subcutaneous injections. Plus, I’d be seeing the patients once a week or once a month, rather than every six months with the implants. That’s more opportunity to keep track of what is happening with the patient’s addiction treatment counseling, a key component of recovery from addiction.”

http://janaburson.wordpress.com/2013/07/30/new-forms-of-buprenorphine-for-opioid-addiction-treatment/

Source: Jana Burson – July 30, 2013

Blog: Guest Dosing at Opioid Treatment Programs

“Methadone patients have to dose at the facility each day for at least the first ninety days, and after that, if doing well, they can get up to three take homes per week for the next ninety days, then up to four per week after a half of a year, and so on.

What happens if the patient needs to go out of town?

There are three options: leave treatment, the worst option, because of the increased risk of death for patients who leave treatment; special take home doses, often risky if the patient isn’t able to take them as prescribed; and guest dosing.

Guest dosing means a patient of one treatment program can be dosed at another program if that patient travels to another area. All opioid treatment programs send their patients for guest dosing and allow guest dosing for patients of other facilities. It should be a smooth and simple process, under ideal circumstances.

But sometimes circumstances get complicated.”

http://janaburson.wordpress.com/2013/08/09/guest-dosing-at-opioid-treatment-programs/

Source: Jana Burson – August 9, 2013

Blog: The State of Denial (Tennessee) gets Another Chance/Update on the State of Denial: Is the Tide Finally Turning?

“A new opioid treatment program has applied for a certificate of need with Tennessee’s Department of Mental Health and Substance Abuse Services, asking for permission to locate a methadone clinic in Eastern Tennessee. Sources say this is the eleventh attempt to locate an opioid treatment program that prescribes methadone in that part of Tennessee. In 2002, approval was given but then withdrawn due to a technicality.

Even if the certificate of need is approved, this company faces stiff opposition from the modern-day equivalent of villagers with pitchforks, demanding that no treatment center be located near them. This is the ugly face of modern day NIMBYism, and it violates the American with Disabilities Act, a topic of a past blog. (See November 14, 2012) It’s illegal, and past federal court rulings have sent a clear message to towns that violated the ADA in this way, with high six-figure fines.”

http://janaburson.wordpress.com/2013/04/07/the-state-of-denial-tennessee-gets-another-chance/

Source: Jana Burson – April 7, 2013

 Blog: Update on the State of Denial: Is the Tide Finally Turning?

“After my last post, I heard from Steve Kester, the co-owner and manager of the company seeking to open an opioid treatment program in Johnson City, Tennessee. He’s had great news: the certificate of need was approved. In addition, he was invited to write a Sunday editorial in the Johnson City Press, correcting mistaken information and explaining more about how an opioid treatment program works. It’s a great article.

Granted, it’s still posted in the paper as an opinion piece, though every bit of data he describes is science, proven in multiple studies. That’s much more than an opinion. But still, it’s progress for the paper to print this side of the treatment issue.”

Correction from the author, “I misread news about the certificate of need submitted to the state of Tennessee for an opioid treatment program in Johnson City. The certificate of need has been accepted, meaning it is complete. It has not been approved, as I said in this blog entry.”

http://janaburson.wordpress.com/2013/04/11/update-on-the-state-of-denial-is-the-tide-finally-turning/

Source: Jana Burson – April 11, 2013

House Bill Aims to Curb Prescription Drug Abuse

flagA bill introduced in the House of Representatives would ban from circulation certain pharmaceuticals that could be easily abused as recreational drugs. The bill would require the Food and Drug Administration to refuse to approve any new pharmaceuticals that did not use formulas resistant to tampering. For example, pills should not be able to be easily crushed into powders that could be snorted, or melted down into a liquid form that could be taken through injection.

Called the Stop the Tampering of Prescription Pills Act, or STOPP, the law would also apply to generic brands already on the market if their brand-name drugs had adopted  tamper-resistant formulas.

http://abcnews.go.com/blogs/politics/2013/03/house-bill-aims-aims-to-curb-prescription-drug-abuse/

Source: ABCNews.com – March 15, 2013

Blog: Benzos at the Opioid Treatment Program

“Should patients in opioid treatment programs ever be approved to take benzodiazepines? Even addiction medicine doctors hold widely varying opinions on this issue. In my state (North Carolina), all of the doctors who work in opioid treatment programs are invited to participate in a conference call once per month. The people who head the state’s methadone authority and the Governor’s Institute on Substance Abuse are also usually on the call. We discuss difficult issues we’re facing, and discuss difficult cases. Last month, the question was asked pointedly by one of the doctors: “Is zero-tolerance for benzodiazepines now the standard of care for opioid treatment programs in our state?” For the people on this call, the consensus was that the ideal was zero tolerance or at least a restricted policy regarding benzodiazepine use.”

The blog is available at: http://janaburson.wordpress.com/2012/11/03/benzos-at-the-opioid-treatment-program/

Source: Janaburson’s Blog – November 3, 2012

Blog: PTSD at the Opioid Treatment Program

“As in other studies, this study shows addiction and post-traumatic stress disorder (PTSD) are related, but we still don’t know which comes first. Does addiction put people in dangerous situations that are likely to become traumatic? Does drug use impair judgment about how to avoid dangerous situations? Or does the PTSD cause addiction, because patients with PTSD have unpleasant feelings, and drugs provide temporary relief from unpleasant feelings?

The blog is available at: http://janaburson.wordpress.com/2012/11/10/ptsd-at-the-opioid-treatment-program/

Source: Janaburson’s Blog – November 10, 2012

Blog: Why Addiction is NOT a Brain Disease

“Attempts to define addiction in concrete scientific terms have been highly controversial and are becoming increasingly politicized. What IS addiction? We as scientists need to know what it is, if we are to have any hope of helping to alleviate it.

There are three main definitional categories for addiction: a disease, a matter of choice, and self-medication. There is some overlap among these meta-models, but each has unique implications for treatment, from the level of government policy to that of available options for individual sufferers.”

http://blogs.plos.org/mindthebrain/2012/11/12/why-addiction-is-not-a-brain-disease/

Source: Plos.org – November 12, 2012

Injecting Someone Who ODs Called a Homicide in Maryland

There’s a difference between a drug overdose and a homicide, even if the drug was heroin and the person who died was injected by a friend. At least, that is the view of Maryland’s chief medical examiner, David R. Fowler, MD, as reported in The Baltimore Sun this spring. But now, Dr. Fowler has done just that: declared a homicide in which a person was injected by someone—a friend, as it turned out—and then died. Amber Brown and her girlfriend drank alcohol and injected each other with heroin in Baltimore one night. Amber Brown fell asleep and didn’t wake up.

Typically, Dr. Fowler calls the hundreds of drug overdoses that occur in his state each year “undetermined,” because he doesn’t believe in labeling a death a homicide—or labeling it with any cause at all—unless there is evidence, notably from witnesses.

In fact, using toxicology records alone to determine cause of death is not scientifically accurate. Someone who is opioid tolerant, for example, might have a high level in the body—enough to kill an opioid-naïve user—but may have died of something else. That’s why chief medical examiners look for other signs related to the death. Was the deceased jogging at the time, and fell over clutching the chest? Perhaps the death was a heart attack. In fact, Ms. Brown had complained of chest pains before she and her friend took alcohol and heroin, according to The Baltimore Sun.

Assuming that drugs caused a death is difficult enough—not to mention assuming that someone else was responsible for administering the drugs.

A few years ago the Substance Abuse and Mental Health Services Administration (SAMHSA) was obsessed with the idea that methadone overdoses were related to methadone diverted from opioid treatment programs. Finally, when all the data were in, the truth was clear: the methadone that was responsible for overdoses was coming from pain prescriptions—and in many cases, the person taking the methadone was opioid naïve, or actually taking it for pain, but unaware that the medication has a very long half-life (is eliminated from the body very slowly, thus additional doses can build up to dangerous levels). Not getting high or feeling pain relief immediately, a person may take another pill.

And in what was a very sad series of unintended consequences over the course of a decade, it was the crackdown on oxycodone (OxyContin), combined with the low cost of methadone, that led to an increased use of methadone for pain, and in turn the entire prescription opioid abuse and overdose crisis has wound up with a crackdown on pain prescribing altogether. Some people who legitimately need pain prescriptions are being denied them, as physicians, wary of being investigated, cut down on their prescribing. At the same time, people who are addicted will need someplace to go for treatment, or will find some other way to avoid withdrawal. They may buy buprenorphine on the street—that buprenorphine/naloxone (Suboxone) is being diverted is already well known—or they may just turn to heroin. Will there be fewer overdoses, or more?

In the case of Amber Brown, whose family has not been located, the autopsy concluded the cause of death was heroin intoxication, and the reason it was easy to call her death a homicide was that the police knew someone else had injected her.

Whether or not there will be criminal charges against the friend, whose name has not been released by police, has not yet been decided. Maryland has one of the nation’s strongest substance abuse treatment programs, especially in medication-assisted treatment for opioid addiction, and there’s a movement in the state to have fewer “undetermined” drug overdose deaths and more identified causes and more people to blame. Kudos to Dr. Fowler for his adherence to medical evidence over the course of his 20 years as the state’s chief medical examiner. Let’s hope he can continue to stand firm as the calls for someone to blame—and punish—for overdoses inevitably mount.

Maine Plans to Cut OTP Rate, Limit Treatment to Two Years

Included in the massive cuts being proposed for MaineCare, the state’s Medicaid program, are a rate cut from $72 a week to $60 a week per patient in an opioid treatment program (OTP), and a plan to limit medication-assisted treatment (MAT) with methadone or buprenorphine to two years.

The plan has the united support of Gov. Paul LePage, Department of Health and Human Services Commissioner Mary Mayhew, and Director of MaineCare Stefanie Nadeau.

There are some historical points that are important here, all focusing on the fact that for some reason, opioid addiction has been prevalent in this rural state. Kim Johnson, the former Single State Authority for the Substance Abuse Prevention and Treatment Block Grant (SSA), who has since gone to the Network for the Improvement of Addiction Treatment (NIATx), was an ardent supporter of OTP expansion in the state to respond to this demand. Guy Cousins, current SSA for Maine, also is a strong supporter of OTPs. (The SSA in Maine is the director of the Office of Substance Abuse.) But Governor LePage entered office with a different viewpoint.

Maine was one of the first states to note opioid overdoses. In 2006 the Community Epidemiological Work Group meeting heard a presentation about overdoses of methadone and morphine—this was methadone prescribed for pain, because Maine was, like many states, substituting the less-costly methadone for more-costly analgesics in hospital formularies.

With an increase in buprenorphine prescriptions in the state to treat the growing opioid addiction came an increase in buprenorphine abuse. The manufacturer sent researchers to the state who determined that many people abusing buprenorphine were actually using it for something akin to its intended purpose—to stave off withdrawal symptoms. Despite the support of Ms. Johnson and Mr. Cousins, there still was—and still is—a woeful shortage of OTPs in Maine.

It’s ironic that a state with a severe opioid addiction problem, which is the heart of the prescription drug abuse epidemic, would decide to cut back on treatment. The people who should be leading the education of residents are sending the wrong message. This takes us to NIMBY (“not in my backyard”). It took CRC Health Group a year to win a settlement allowing it to open an OTP in Warren, Maine; yet the town is still delaying an administrative review of the proposal.

Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), sent MaineCare Services an eloquent letter on June 14 protesting the two-year limit and the rate reduction, citing the Research Triangle Report findings that quality OTP treatment should cost $143 per patient per week, and that 85 percent of the costs are for labor. “In our judgment the State of Maine has engaged in a disastrous course which will have severely detrimental consequences to the patients in treatment and their families.”

And noting that limiting treatment to a two-year period “goes against all established evidence,” Mr. Parrino also called it a dysfunctional policy. More than 45 years of research have found that more than 75 percent of patients will relapse if their treatment is terminated, he wrote. “Many studies have demonstrated that this high a relapse rate applies to both patients who voluntarily end their treatment and patients who are involuntarily discharged.

“If Maine is of the judgment that it might be saving money by doing such a thing, this is a very risky bit of business since the State will inevitably push patients back into emergency rooms, which are far more expensive,” wrote Mr. Parrino. It would also push people into the criminal justice system, he said.

If Governor LePage asks Maine’s experts in addiction—Mr. Cousins and Marcella Sorg, PhD, of the Margaret Chase Smith Policy Center, come to mind—what they think, we are sure he would obtain good information. It would also help make the state’s population aware that their friends and neighbors are the people who need help. Gov. LePage could also look at the state’s own report on drug use issued in March, which shows that after alcohol, opioids are the second-highest treatment drug named at admission to treatment.

Why don’t governors ask their staff with expertise in addiction before making changes in addiction policy? Could it be because they don’t want to hear the answer?

For the Maine report on drug use trends, go to http://www.maine.gov/dhhs/osa/pubs/data/2012/EpiProfile2012.pdf

We look forward to your comments.

The NAOMI Study: After a Year on Heroin Maintenance, Is it Ethical to Terminate?

A Canadian study that started in 2005 comparing heroin maintenance with methadone maintenance has given rise to a protest from the patients used as guinea pigs.   The patients protesting were actual subjects, clinical trials participants who were injected on a daily basis with heroin for a year. They had already failed methadone maintenance treatment twice. At the end of the year, however, the study was over and after a three-month detox, they were given a choice of methadone or buprenorphine.

Last year, 44 of these subjects formed a group called the North American Opiate Medication Initiative (NAOMI) Patients Association (NPA), and started comparing  notes on how they did after being taken off heroin. In a report released in March full of bittersweet reminiscences of a year on heroin and some scathing comments on how they were treated in the trial (10 minutes to inject, and if they were late, they missed the appointment), and how they survived the years following, NPA members detail their experience, some managing to get clean, some cycling in and out of drug use.

The NAOMI study, published in 2009 in The New England Journal of Medicine, concluded that heroin maintenance was effective. The findings had little effect in the United States since heroin is Schedule I and not used as a treatment medication here.

But the study publication contributed to the formation of the NPA, with patients questioning why the trial would be shut down. In other countries where such trials were done, patients continued to receive heroin. Although NAOMI researchers asked the Canadian government to allow the people who were given heroin to stay on it for compassionate reasons, the government, which runs health care, refused in 2007.

There are some serious questions posed by the NPA about ethics: for example, because people wanted heroin, they signed up for the trial. Under these circumstances, can informed consent really be given? In addition, if something works, can you take it away? One of the participants quoted in the NPA report put it succinctly: “They’re experimenting with a drug for cancer and it starts working. I mean, what are they, what are you going to do? Oh no. You can’t have it anymore.”

Proponents of medicinal injectable heroin in Canada think that it’s better at keeping patients in treatment than methadone maintenance, for people who have relapsed from methadone maintenance at least twice before.

There are some flaws to this argument, however. First of all, methadone maintenance in Canada isn’t as regulated as it is in the United States, with counseling requirements. Another flaw is that 75 percent of the NAOMI patients on heroin were unemployed; that is not the case with OTP patients in the United States. In addition, the cost of treatment with heroin in the NAOMI study was $14,891 per patient a year, because of the cost of daily injection, compared to $3,192 for methadone maintenance. And finally, while the heroin maintenance group did have better retention in NAOMI than the methadone group, the dose of the methadone may have been too low; the average dose was 96 milligrams.

Can it happen here? Well, not exactly. But in a large-scale, short-term trial, tapering the buprenorphine dosage of opioid-dependent patients was a self-fulfilling disaster. More than nine out of ten patients relapsed in this trial—more than even the principal investigator had expected. Yes, everyone had expected dismal results. Yet the trial, funded by the National Institute on Drug Abuse, went ahead with that design because that is the way most physicians were using the medication for patients dependent on prescription opioids—as a detox drug. Let’s see if NIDA’s Prescription Opioid Addiction Treatment Study (POATS), as the buprenorphine study was called, leads to its own patient association.

For the NPA report, go to http://drugpolicy.ca/wp-content/uploads/2012/03/NPAreportMarch5-12.pdf

Obituary: PCSS-Methadone

The Physicians’ Clinical Support System for Methadone (PCSS-M) died a quiet and unnoticed death last November when its grant was not renewed. Initially, when the Substance Abuse and Mental Health Services Administration (SAMHSA) launched the PCSS-M project for methadone mentoring, it was intended to bring the expertise of methadone treatment providers to opioid treatment programs (OTPs). The grant for the Physicians’ Clinical Support System for Methadone (PSCC-M) as well as PCSS-B (buprenorphine) went to the American Society of Addiction Medicine (ASAM).

OTPs were able to get telephone or e-mail responses from PCSS-M on issues such as initiating and titrating methadone, converting from other opioids, management of co-occurring conditions, and patient assessment and selection. In addition, physicians using methadone for the treatment of pain were able to access PCSS-M for clinical information and specific questions.

ASAM’s grant for PCSS-M and PCSS-B expired and was not renewed last fall. At the same time, PCSS-M was killed, and replaced by PCSS-Opioids. Both PCSS-B and the PCSS-Opioids went to the American Academy of Addiction Psychiatry (AAAP) and its partners, the American Osteopathic Academy of Addiction Medicine (AOAAM) and the American Psychiatric Association (APA). Now if you want information about methadone, you are supposed to go to http://www.pcss-o.org/. But you’ll find more information about pain. Even SAMHSA didn’t publicize that it had made this change. We found a link to it on the SAMHSA Recovery Month website (http://www.pcssmethadone.org/). The link takes us to the Social Work Leadership Institute.

Not much of a gravestone.

New Study: Methadone Clinics Don’t Bring Crime to Neighborhoods


The NIMBY (“not in my backyard”) people are at it again. But a new study refutes their claims and shows that methadone clinics don’t attract crime.

The Good News

Crime Rates Aren’t Higher Around Methadone Clinics

In a well-designed study published online in Addiction, March 2, 2012 ahead of print, investigators compared data from a computer listing of all FBI reports of serious crimes, such as robbery, homicide, and sexual assault, in specific areas of Baltimore. The areas included 13 methadone treatment centers and three types of control locations: 13 convenience stores, 13 residential points, and 10 general medical hospitals.  The study team found no significant increase in crime around methadone treatment centers (MTCs) or general hospitals. (The study period was January 1, 1999 through December 31, 2001.  After collecting the data, the team spent several years developing the technology and analyzing the data before publishing the article.)

And—here’s something very interesting—investigators did find significantly higher crime counts close to convenience stores. Bottom line: Methadone clinic neighborhoods, unlike those of convenience stores, are not associated with a higher crime rate.

The authors note, ”Our finding that MTCs are not associated with increases in neighborhood crime addresses a major impediment to the establishment of new clinics, and should lead to greater availability of methadone maintenance treatment for the many persons who need it.”

Let’s hope the NIMBYs are paying attention.

Reference: Boyd SJ, Fang LJ, Medoff DR, Dixon LB, Gorelick DA. Use of a “microecologic technique” to study crime incidents around methadone maintenance treatment centers [published online ahead of print March 2, 2012].  Addiction.  doi: 10.1111/j.1360-0443.2012.03872.x. 

But Emotional Protests Persist

From Orange County, Florida: a methadone clinic that opened last month is the latest in a string of establishments “bringing crime to the neighborhood,” some residents complain. Locals told WFTV’s Drew Petrimoulx that pain clinics and pharmacies moving into the area are “attracting the wrong kind of people.” “There’s a lot more vagrancy.” A resident gave WFTV a photo of two people passed out at a bus stop; she said the pair had just left the new methadone clinic.

It’s not as if this was an elite section of Orange County to begin with. In fact, one resident asked why the neighborhood was picked for a new methadone clinic when the area already had so many problems. 

Readers responding on the WFTV website echoed that opinion:

“Don’t make me laugh. That area has been horrible for a decade or more.”

“That area has been called heroin run for many years.”

“ . . . one is a fool to go near there.”

(http://www.wftv.com/news/news/neighbors-say-methadone-clinic-bringing-crime/nLPyN/).

Another From Somers Point, New Jersey: Fear gripped residents when an 89-year-old woman was attacked and sexually assaulted in her home. A suspect was arrested, and the incident apparently is totally unrelated to the local methadone clinic that has been operating for 10 years. But that hasn’t calmed people. They’re upset and angry about the clinic. Staff writer Christopher Ramirez said residents are “fed up with problems in their neighborhood and are placing blame for recurring issues on a methadone clinic directly across from their homes.”

The City Council got creative and found a novel way to spur the methadone clinic to move: it introduced an ordinance to prohibit parking on the street bordering the clinic.

(http://www.pressofatlanticcity.com/news/top_three/article_68980e70-bee0-11df-be4a-001cc4c03286.html.)

And lastly from Salem, Florida: the Zoning Board of Appeals last month unanimously rejected a permit request for a methadone clinic. SalemPatch.com says Community Substance Abuse Centers (CSAC) plans to appeal, raising alarm among residents.

The ZBA’s stated reasons for rejection: traffic concerns and the residential character of the area, which includes Witchcraft Heights. [The Salem name is linked with a rumored ghost population; some say Salem is “bursting with struggling spirits just waiting to spook you.” Maybe that’s part of the problem. www.ghostsofamerica.com.]

Any evidence of a rise in crime around existing clinics? Not that Salem Police Chief Paul Tucker is aware of. He should know, and he supports having a methadone clinic in Salem.

http://salem.patch.com/articles/area-police-chiefs-meth-clinics-dont-up-crime

Sometimes Good Sense Prevails

As reported on the AT Forum website last November, a Warren, Maine methadone clinic won a NIMBY battle after a yearlong fight. Education, mediation, and lawsuit considerations triumphed over a classic NIMBY response based on emotions, and the community finally granted permits for an opioid treatment program.

http://atforum.com/news/2011/11/methadone-clinic-wins-nimby-battle/OTP Patients

(All sites accessed March 30, 2012.)

 Tell us about your OTP NIMBY experiences and how you overcame them. You
 can post your comments by clicking the comment link at the top of this page.

 

15-Minute Methadone in Baltimore – Police and Public Health vs. the Regulators

Baltimore is on the verge of a showdown over methadone. It’s not the usual NIMBY battle – Baltimore has embraced medication-assisted treatment for opioid addiction since the days of the well-informed and visionary Mayor Kurt Schmoke. Instead, it’s about something called “open-access” methadone, in which someone can come in for a quick assessment and get the medication within 15 minutes.

Waiting lists for treatment in Baltimore, where heroin addiction is a long-time problem, mean that many people are turned away for treatment when they most need it and are most likely to benefit. What are they supposed to do for a month while they are waiting to be admitted? Most go back to their dealers.

Now, one program is vowing to tackle the regulatory apparatus preventing methadone treatment from expanding and is just going to do it – at least that’s what the operator says.  In late June, Rev. Milton Williams, pastor of the New Life Evangelical Baptist Church in Northeast Baltimore, who already operates a traditional opioid treatment program “Turning Point”, said he would start offering “open access” methadone – treatment within 15 minutes – on July 5.

No, it’s not endorsed by the Maryland Alcohol and Drug Abuse Administration or the state’s health department, which has not given approval for the scheme. But Williams said his church is going to go forward with it anyway, adding that he would be able to treat 100-150 more patients a day.

And Williams has a well-placed and powerful supporter: the Baltimore Police Department. Even the police department is in favor of Williams’ plan.

The Baltimore Sun published stark statements from the police department saying that arresting addicts was not going to happen anymore. Detective Donny Moses, spokesman for the department, said he “had a change of heart” about arresting addicts after five years in the narcotics division. “I must have arrested a million and one people addicted to heroin, and I thought there had to be a better way,” he said. “I was thinking this was someone’s daughter or son and someone was praying for you.” Moses added: “The Police Department is no longer interested in locking up all the addicts.”

And Lt. Col. Ross Buzzuro from the police commissioner’s office said: “We can’t arrest ourselves out of this problem.”

Some critics rightly point out that counseling and other services are important, as well as methadone, to treatment. But in the absence of any funding for extra treatment, giving out the medication will at least give patients a safe option to street use of heroin or other drugs.

Like so many people who are passionate about treatment, Williams has personal reasons for being involved. His daughter was shot in a drug deal in 2002. She left three children behind.

On one side a pastor who is a zealous advocate, a community which is infested with drug deals, a police department that knows what drugs are doing to the neighborhood, and a drug that has been the single most successful treatment for opioid addiction for more than half a decade – and on the other bureaucrats who may not step far outside their well-appointed offices and who see no problem with waiting lists lasting a month, not to mention rulemakings lasting years – and it’s not hard to decide which side has the moral imperative in this showdown.

Which will win is another story.

Site last updated July 17, 2014 @ 5:55 pm