Medication Assisted Treatment: A Standard of Care. An interview with Elinore McCance-Katz, MD, PhD, Chief Medical Officer, SAMHSA

Edit-Dr.M-KNote: This interview was issued by SAMHSA’s HRSA Center for Integrated Health Solutions in their February 2014 eSolutions newsletter.

“We have a huge need in our country to treat mental health and substance use concerns, and we have a chronic shortage of specialty care programs with enough capacity to treat everyone with a substance use concern. It is our responsibility to expand access to this care in a way that allows greater choice of where individuals can receive treatment.

With the Affordable Care Act, the treatment of substance use disorders is now an essential benefit. Individuals with multiple complex healthcare needs, including mental health and substance use concerns, can be seen in integrated care settings and health homes.

We are going to see more and more integrated care. All healthcare providers, whether in primary care, mental health, or substance use treatment, will need to learn how to provide treatment for disorders they may not have historically treated. Providers who are not used to treating patients with certain types of problems may not feel confident about providing care. When that happens, the individual is less likely to get the care they need. Primary care providers especially will need to be ready to assess and provide treatment for clients who present with mental health and substance use concerns.

The Need for Medication Assisted Treatment

Medication assisted treatment (MAT) is a standard of care. There are a variety of medications that have been shown to be effective in treating substance use disorders and that can be used safely. Specifically, there are a number of FDA-approved medications for tobacco, alcohol and opioid abuse treatments.

MAT is an effective form of care, when medication is taken as prescribed, used properly, and the individual is engaged with other supports and services. With opioid use disorders, studies show that clients who get medical detoxification only have a greater than 90% relapse rate.

We have to think about how effective the treatment is, what the alternative is if not treated, and where an individual is in their recovery. Individuals with chronic relapsing diseases should have access to MAT. It’s just the standard of care. We cannot diminish the importance of that.

Substance use disorders are not simply treated by taking a medication. In fact, taking medications can be part of the problem. Just giving someone medication is not enough. Psychosocial interventions, counseling, and other services are absolutely necessary and will always be very important.

Integrated care providers are going to have to learn about how to use these medications. Many medications can be used within primary care. We’re going to see a spectrum of severity with clients in primary care. Some may need referral to specialty care and others can be treated at the primary care organization.”

The interview can be accessed at: http://www.atforum.com/addiction-resources/documents/SAMHSA-MAT-A-Standard-of-Care-Feb-2014.pdf

Source: The Substance Abuse Mental Health Services Administration – February 2014

National Institute on Drug Abuse (NIDA) Updated Research Report on Heroin

Message from AATOD Regarding the Death of Philip Seymour Hoffman

AATOD“Philip Seymour Hoffman’s death has attracted national media attention as most celebrity deaths do, especially when they relate to a drug overdose. We have seen this phenomenon shortly after the deaths of Anna Nicole Smith and Michael Jackson. There was an immediate flurry of media attention, and then other stories took center stage.

For many addiction treatment professionals and patient advocates, the issues surrounding celebrity deaths represent the daily struggles that must be confronted by a wary public. A number of issues naturally come to surface during such times about opioid addiction and treatment.”

The AATOD message addresses:

  • Changing Social Attitudes
  • Changing Federal and State Oversight
  • The Opportunity to Educate

“The tragedy of Mr. Hoffman’s death will inevitably be revisited by another celebrity death in the future. We will engage once again in the flurry of media stories which typically have a limited lifespan. Ultimately, we need to work effectively to change America’s perceptions about the safety and danger of prescription opioids, the danger of heroin (which is obviously not an FDA approved drug), and the value of prevention and early intervention in providing access to care. Mr. Hoffman’s death is a stark reminder of the dangers of using heroin. It is not, nor has ever been, a safe drug. The user simply does not know what the drug has been cut with or its potency.

Many people who have worked in the addiction treatment community for many years know that heroin has been adulterated with all sorts of dangerous chemicals which can lead to death. We need to continually educate the public about these issues and work with patient advocates and public policy officials to ensure that the message is consistent and sticks.”

http://www.aatod.org/news/message-from-aatod-regarding-the-death-of-philip-seymour-hoffman/

Source: The American Association for the Treatment of Opioid Dependence – February 11, 2014

Wider Use of Antidote Could Lower Overdose Deaths by Nearly 50%

“Distributing naloxone and training people to use it can cut the death rates from overdose nearly in half, according to a new study.

The new study, published in the BMJ, followed the expansion of Overdose Education and Naloxone Distribution (OEND) programs in Massachusetts.  The programs were offered at emergency rooms, primary care centers, rehabilitation centers, support groups for families of addicted people and other places that might attract those at risk.

The study involved 2912 people in 19 different Massachusetts communities — each of which had had at least 5 opioid overdose deaths between 2004 and 2006.  The participants were trained to recognize overdose, call 911 and administer naloxone using a nasal inhaler.  If the naloxone didn’t work, they were instructed to try another dose and perform rescue breathing until help arrived.

During that time, 153 naloxone-based rescues were reported for which there was data on outcomes, and in 98% of those cases, the drug revived the victim.

There are still practical barriers however, to widely distributing naloxone and implementing more OEND type programs. Advocates have argued that the medication should be made available over-the-counter since it has little potential for abuse and is nontoxic. The Centers for Disease Control (CDC), the director of the National Institute on Drug Abuse and even the drug czar’s office support making it more widely available, and unlike the case with needle exchange programs, there has been no organized opposition to OEND. But the Food and Drug Administration (FDA) has no precedent for allowing over-the-counter sales of such a drug: naloxone is a generic medication approved in an injectable form. Without a company to submit an application for its use in the intranasal version, the agency isn’t likely to OK over-the-counter sales.”

http://healthland.time.com/2013/02/05/wider-use-of-antidote-could-lower-overdose-deaths-from-by-nearly-50/

Source: HealthlandTime.com – February 5, 2014

Q & A – Methadone or Buprenorphine for Maintenance Therapy of Opioid Addiction: What’s the Right Duration?

question boxQuestion: How long should patients with opioid addiction be treated with methadone or buprenorphine?

Response from Michael G. O’Neil, PharmD Professor, Department of Pharmacy Practice; Consultant, Drug Diversion and Substance Abuse, South College School of Pharmacy, Knoxville, Tennessee

“Data supporting positive long-term outcomes after definitive discontinuation of methadone or buprenorphine in a predetermined time frame for all patients are lacking. Prudent clinical practice dictates that duration of therapy should be individualized by well-trained addiction specialists, taking into account a disease treatment history that includes such factors as relapse, individual patient characteristics, evidence-based literature, patient adherence, socioeconomic characteristics, and environmental considerations until long-term evidence-based studies prove otherwise.

In summary, the complexities of the disease of opioid addiction have created a frustrating situation for practitioners and patients alike. Basic practice principles for chronic diseases, such as hypertension or schizophrenia, should be applied to patients who are unable to stay in recovery using abstinence programs alone. Strict discontinuance of opioid maintenance therapy solely on the basis of duration of treatment is not clinically justifiable at this time. Individualization of treatment for opioid addiction with methadone or buprenorphine by qualified specialists is necessary for many suffering patients, in conjunction with counseling, community support, or behavioral interventions. Treatment cultures for opioid addiction need to continue to evolve, as does education of the general public.”

The article can be accessed at: http://www.medscape.com/viewarticle/819875

Source: www.Medscape.com - February 3, 2014

Genes Play a Large Role in Opioid Dependence

dna“There is reason to think that opioid dependence is at least 60 percent inherited. Now a genomewide association study appears to have led to the identification of major genes contributing to this risk.

Some major genes that contribute to the risk for opioid dependence appear to have been identified. The genes make proteins that influence calcium signaling or potassium signaling within neurons.

The lead scientist, Joel Gelernter, M.D., a professor of psychiatry, genetics, and neurobiology at Yale University, told Psychiatric News that he was surprised by this finding. He had expected genes that code for opioid receptors to turn out to be major contributors, he said. But that was not the case.

Gelernter and his coworkers conducted a genomewide association study to see whether they could significantly link any gene variants with a risk for opioid dependence. They used a relatively large sample—some 5,700 subjects (over a third with opioid dependence and the rest controls). Afterward they conducted two more studies—one with some 4,000 subjects and the other with some 2,500 ones—to see whether they could replicate their initial findings.

They were able to link variants of a number of genes with a risk for opioid dependence. But the variants that were most strongly associated with opioid dependence risk were those from genes involved in calcium or potassium signaling within neurons.”

http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1820456

Source: Psychiatryonline.org – January 28, 2014

Supreme Court: Heroin Dealer Can’t be Given Longer Sentence Because Client Died

Pg8_law“The U.S. Supreme Court unanimously ruled a heroin dealer cannot be held liable for a client’s death and given a longer sentence if heroin only contributed to the death, and was not necessarily the only cause.

The ruling is likely to result in a shorter sentence for Marcus Burrage, who received 20 extra years in prison because of his client’s death, according to USA Today. The decision is also likely to make it more difficult in the future for prosecutors to extend drug sentences, the article notes.”

Beating the Poppy Seed Defense: New Test Can Distinguish Heroin Use from Seed Ingestion

“Heroin is one of the most widely used illegal drugs in the world, but drug testing has long been challenged by the difficulty in separating results of illicit heroin users from those who have innocently eaten poppy seeds containing a natural opiate. Research in Drug Testing and Analysis explores a new test which may present a solution to this so-called ‘poppy seed defense.’

The team sought to identify an acetylated derivative which is known to be present in street heroin, but would not be found in either poppy seeds or medicines containing opiates. The authors identified a unique glucuronide metabolite (designated ‘ATM4G’) which could be used as a marker of street heroin use. A high frequency for the presence of ATM4G in urine strongly suggests that detection of this metabolite may offer an important advance in workplace drug testing and forensic toxicology, providing a potential solution to the poppy seed defense.

‘This research report addresses a longstanding analytical problem in forensic toxicology and workplace drug testing, by identifying a urinary marker that differentiates street heroin users from those whom have ingested morphine present in poppy seeds’ said Dr. Andrew Kicman, from the Department of Forensic and Analytical Science at King’s College, London.”

http://www.eurekalert.org/pub_releases/2014-01/w-btp010714.php

Source:  Eurekalert.org – January 7, 2014

Monitoring the Future Results Released

In mid-December, The National Institute on Drug Abuse (NIDA) announced the results of its 2013 Monitoring the Future (MTF) survey. The survey, conducted earlier in the year by scientists at the University of Michigan, tracks annual drug abuse trends of eighth, 10th, and 12th-grade students. NIDA is a component of the National Institutes of Health (NIH).

MTF is one of three major survey instruments the Department of Health and Human Services uses to monitor the nation’s substance abuse patterns among teens.

This year’s announcement focused on attitudes about and prevalence of marijuana use, as well as abuse of synthetic drugs, prescription medications, and tobacco.

Prescription Medications – There was mixed news regarding abuse of prescription medications. The survey shows continued abuse of Adderall, commonly used to treat attention deficit hyperactivity disorder, or ADHD, with 7.4 percent of seniors reporting taking it for non-medical reasons in the past year. However, only 2.3 percent of seniors report abuse of Ritalin, another ADHD medication. Abuse of the pain reliever Vicodin has shown a marked decrease in the last 10 years, now measured at 5.3 percent for high school seniors, compared to 10.5 percent in 2003.

Heroin – For cocaine and heroin, while there was no significant change from the 2012 rates, there continues to be a gradual decline in use, with both drugs at historic lows in all three grades. The 2013 rate for high school seniors for past year cocaine use is 2.6 percent, compared to a peak of 6.2 percent in 1999. Similarly, the reported use of heroin by 12th-graders is 0.6 percent this year, compared to a peak of 1.5 percent in 2000.

http://www.drugabuse.gov/related-topics/trends-statistics/monitoring-future

Source: National Institute on Drug Abuse – December 16, 2013

Heroin Addiction Warps Brain’s Ability to Change

brain“In a study of heroin abusers’ post-mortem brains, longer duration of heroin use was associated with changes in the shape and packaging of DNA in the brain in the ventral and dorsal striatum, areas of the brain associated with drug addiction, according to Yasmin Hurd, PhD, of the Icahn School of Medicine at Mount Sinai Hospital in New York, N.Y., and colleagues.

The DNA of these patients’ brains became more “open” to gene expression and overactive, which may mean that a treatment that helps “close” this gap and reduce over activity may help temper addiction, Hurd told MedPage Today during an oral presentation at the Society for Neuroscience meeting.”

http://www.medpagetoday.com/MeetingCoverage/SFN/42901

Source: MedPageToday.com – November 14, 2013

DEA Releases 2013 National Drug Assessment Report

Heroin

According to the report, Heroin availability continued to increase in 2012, most likely due to an increase in Mexican heroin production and Mexican traffickers expanding into the Eastern and Midwest U.S. markets traditionally supplied with white heroin. The amount of heroin seized at the Southwest Border increased significantly between 2008 and 2012 and this, along with other indicators, points to increased smuggling of both Mexican-produced heroin and South American-produced heroin through Mexico.

Heroin-related overdoses and overdose deaths are increasing in certain areas, possibly due to a number of factors, such as high heroin purity, increasing numbers of heroin abusers initiating use at a younger age, and inexperienced abusers switching from prescription opioids to heroin.

Possible reasons for these increases in overdose deaths include:

Availability of high-purity heroin

Law enforcement officials in each of the affected areas reported an increase of high-purity heroin available at the street level.

People are switching from abusing prescription drugs to abusing heroin. 

Law enforcement and treatment officials throughout the country report that many heroin abusers began using the drug after having first abused prescription opioids. These abusers turned to heroin because it was cheaper and/ or more easily obtained than prescription drugs and because heroin provides a high similar to that of prescription opioids. According to treatment providers, many opioid addicts will use whichever drug is cheaper and/or available to them at the time. Several treatment providers report the majority of opioid addicts will eventually end up abusing heroin and will not switch back to another drug because heroin is highly addictive, relatively inexpensive, and more readily available. Those abusers who have recently switched to heroin are at higher risk for accidental overdose. Unlike with prescription drugs, heroin purity and dosage amounts vary, and heroin is often cut with other substances, all of which could cause inexperienced abusers to accidentally overdose.

More people are using heroin, and at a younger age. 

It is possible that increasing overdoses are the result of more people using heroin and using it at a younger age. According to national-level survey data, the number of new heroin users has recently been increasing. NSDUH reports the number of new heroin users increased from 142,000 in 2010 to 178,000 in 2011. Both numbers are a sizeable increase from the average annual estimates of 2002 to 2008 (ranging from 91,000 to 118,000).

Moreover, these new heroin users are considerably younger. In 2011, the average age at first use among heroin abusers aged 12 to 49 was 22.1 years and in 2010 it was 21.4 years, significantly lower than the 2009 estimate of 25.5 years.

Controlled Prescription Drugs

Prescription drug abuse continues to be the nation’s fastest growing drug problem. The abuse of controlled prescription drugs (CPDs) poses a significant drug threat to the United States and places a considerable burden on law enforcement and public health resources. Nationally, 28.1 percent of law enforcement agencies responding to the 2013 National Drug Threat Survey (NDTS) reported CPDs as the greatest drug threat, up from 9.8 percent in 2009. Law enforcement agencies in the Florida/Caribbean, New England, New York/ New Jersey, and Southeast Organized Crime Drug Enforcement Task Force (OCDETF) regions all report that CPDs posed the greatest drug threat at a higher percentage than the national rate.

Demand and treatment data indicate that abuse of CPDs, particularly painkillers, is a rapidly growing threat. According to the National Survey on Drug Use and Health (NSDUH), pain relievers are the most common type of CPD taken illicitly and are the CPDs most commonly involved in overdose incidents. Further, CPD-related treatment admissions rose 68 percent between 2007 and 2010 and prescription opiate/opioid-related emergency department visits rose 91.4 percent between 2006 and 2010.

http://www.justice.gov/dea/resource-center/DIR-017-13%20NDTA%20Summary%20final.pdf

Source: Drug Enforcement Administration – November 2013

Treatment of Opioid Dependence: A Call for an Evidence-Based Approach

evidenceDespite decades of accumulated data on the effectiveness of medication-assisted treatment (MAT), gaps remain between evidence-based standards and current practices. The authors of a recent study attribute these gaps largely to “regulatory constraints and pervasive suboptimal clinical practices.” The study appeared in August in Health Affairs; the authors are affiliated with U.S. or Canadian medical institutions. This article focuses on the findings and recommendations pertaining to the U.S.

Based on evidence from many randomized trials, large-scale longitudinal studies, and meta-analyses that show the effectiveness of MAT, the authors recommend four policy changes:

  • Eliminate restrictions on office-based methadone prescribing, and adopt the direct administration and dispensing of methadone in pharmacies. This will require changes in federal and, in some cases, state law.
  • Reduce financial barriers to treatment, such as copayment variations. Provide universal coverage for MAT via public and private insurers.
  • Reduce reliance on opioid detoxification; strong scientific evidence shows that some types are ineffective and possibly harmful.
  • Create and evaluate mechanisms to integrate emerging treatments, such as slow-release buprenorphine implants.

These steps, the authors believe, “can greatly reduce the harms of opioid dependence by maximizing the individual and public health benefits of treatment.”

Following is a discussion of the authors’ specific concerns and recommendations.

Office-based methadone prescribing. The authors note that access to methadone in the U.S. is heavily regulated and “more restricted in the United States than elsewhere in the developed world.” Fewer than 10 percent of all opioid-dependent people in the U.S. currently receive treatment—yet the number of methadone-prescribing facilities has changed little since 2002. Currently only about 8 percent of all substance abuse treatment facilities offer methadone maintenance treatment (MMT).

Treatment in doctors’ offices would offer a less-stigmatizing environment, and would facilitate care of co-occurring conditions, such as HIV and hepatitis C. Moreover, providing methadone under direct observation would virtually eliminate any risk of methadone abuse or diversion.

Experience in Canada shows that office-based MMT could greatly increase patients’ access to treatment. Canada implemented office-based MMT in 1996. In 2012, the number of patients receiving methadone treatment in British Columbia increased from 2,800 to 13,000, and in Ontario it rose from 700 to almost 30,000. These figures suggest that office-based MMT in the U.S. could help meet the increased demand that health reform is expected to produce.

Expanded access would require greater participation by physicians. The authors suggest mandating addiction education in medical schools and increasing the financial incentives for providing treatment, including specifying physician billing codes.

Financial barriers. Evidence clearly shows the economic value of treating drug dependence, yet public and private insurers do not provide widespread coverage of opioid misuse disorders. Moreover, privatization of methadone clinics is increasing, leaving few options for patients who lack insurance and are unable to pay.

Detoxification. The authors come down hard on detoxification leading to planned abstinence, calling it “the most damaging aspect of current treatment of opioid dependence.” They refer specifically to two regimens: detoxification after maintenance treatment, and detoxification (typically 12 weeks) designed to taper the methadone dose to zero. They cite evidence revealing a high risk of relapse into illicit opioid use, and an increased risk of mortality within the month after relapse. 

Potentially useful, however, is detoxification lasting up to one week, designed to treat patients who have overdosed or have severe withdrawal symptoms. Sustained abstinence is not a goal, but subsequent long-term MAT is an option patients have.

Emerging treatments. The past decade has seen several new or potential treatments for opioid dependence. They include slow-release buprenorphine implants, injectable naltrexone, and agents that bind to and activate opioid receptors (eg., injectable diacetylmorphine or heroin maintenance as a second-line treatment for heroin dependence). Although the future status of these emerging treatments is uncertain, the authors stress the benefits of having options available.

The authors note that the Affordable Care Act has the potential to eliminate gaps in treatment coverage, and it “mandates the inclusion of substance abuse and mental health services in the essential benefits that the new state insurance exchanges must offer.”

The authors also emphasize that their recommendations are initial steps, and their list is not exhaustive. “The social and structural reasons behind the low rates of access to this treatment—including stigma and discrimination perpetuated by contradictory social policies that simultaneously treat addiction as a health problem and a crime—must also be addressed.”

Reference

Nosyk B, Anglin MD, Brissette S, Kerr T, et al. A call for evidence-based medical treatment of opioid dependence in the United States and Canada. Health Aff (Millwood). 2013; Aug;32(8):1462-1469. doi: 10.1377/hlthaff.2012.0864.

Almost Half of Hospitalized Heroin Users Self-Report Good Health

hospital sign purchasedshutterstock_33280960“Nearly half of heroin users who are hospitalized for medical or surgical treatment perceive themselves to be in good, very good, or excellent health, “underlining a disconnect between addiction and perceived health status,” according to a study of 112 patients.

The apparent disparity between self-reported health and disease burden suggests that “perceptions of health status may not actually reflect physical health but a different construct altogether,” Lidia Z. Meshesa and her colleagues wrote.

The investigators enrolled 112 non–treatment-seeking hospitalized heroin users in the study. The average age of the participants was 40 years, and 72% were male, reported Ms. Meshesa, of the Clinical Research and Education (CARE) Unit at Boston Medical Center, and her coauthors (Addict. Behav. 2013;38:2884-7). None was currently in treatment for substance abuse. All the participants completed a standard questionnaire on health-related quality of life and were asked detailed questions about their drug use and mental and physical health histories.”

http://www.clinicalpsychiatrynews.com/news/neurology/single-article/almost-half-of-hospitalized-heroin-users-self-report-good-health/572f62cb339ce00cb34f0fd033eb9228.html

Source: ClinicalPsychiatryNews.com – October 21, 2013

Drug Addiction Relapse Infographic: The Revolving Door

relapse-the-revolving-door_0“One of the persistent challenges of fighting addiction is the risk of relapse, or the full return to an addictive lifestyle after an attempt to quit.”

This new infographic visually shows:

  • Rates of Drug Addiction Relapse vs. Chronic Illness
  • What Triggers a Relapse?
  • Relapse Rates by Drug
  • Factors Most Likely to Trigger Relapse
  • Demographics of Substance Abuse Treatment Admissions

http://healthworkscollective.com/107146/relapse-revolving-door

Source: HealthWorksCollective.com – June 8, 2013

Study: Many Arrested Men Use Illegal Drugs But Don’t Receive Treatment

jail“More than 60% of men arrested in five U.S. cities used at least one illegal drug, but fewer than 15% received drug treatment, a government report found.

Data from the Bureau of Justice Statistics indicate that 68% of jail inmates, 53% of state prison inmates and 46% of federal prison inmates abuse or are addicted to drugs and alcohol.”

http://www.usatoday.com/story/news/nation/2013/05/23/half-of-men-arrested-used-drugs/2356033/

Source: USAToday.com – May 23, 2013

Site last updated March 28, 2014 @ 7:50 am