News & Updates – March 26, 2014; Issue 198

New Resources and Events Available on ATForum.com

Have you visited ATForum.com lately? Over 30 new meetings, conferences, and webinars have been added to the site in addition to key new resources including the following on medication-assisted treatment.

Neonatal Abstinence Syndrome: How States Can Help Advance the Knowledge Base for Primary Prevention and Best Practices of Care
Association of State and Territorial Health Officials – March 2014.

Confronting the Stigma of Opioid Use Disorder—and Its Treatment
Journal of the American Medical Association – February 26, 2014.

Medication-Assisted Treatment With Methadone: Assessing the Evidence
Psychiatric Services – February 1, 2014.

Medication-Assisted Treatment With Buprenorphine: Assessing the Evidence
Psychiatric Services – February 1, 2014.

Medscape Ask the Pharmacist: Methadone or Buprenorphine for Maintenance Therapy of Opioid Addiction: What’s the Right Duration
Medscape – February 3, 2014. Note: A Medscape account is required to view this article. If you do not have a Medscape account you can create one for free.

Advancing Service Integration in Opioid Treatment Programs for the Care and Treatment of Hepatitis C Infection
International Journal of Clinical Medicine – January 2014.

Advancing Access to Addiction Medications Report
American Society of Addiction Medicine (ASAM) – December 2013.

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

Viewpoint: Confronting the Stigma of Opioid Use Disorder—and Its Treatment Published Online in Journal of the American Medical Association

jama-logoIncreasing numbers of overdoses from prescription opioids and a more recent increase in heroin-associated fatalities have caused heartbreak in communities across the country.

Given the severity of this national epidemic, it is time to confront the stigma associated with opioid use disorder and its treatment with medications. By limiting the availability of care and by discouraging people who use opioids from seeking effective services, this stigma is impeding progress in reducing the toll of overdose.

Health care practitioners can counter stigma by adopting accurate, nonjudgmental language to describe this disorder, those it affects, and its therapy with medications. States can promote the provision of comprehensive health services in opioid treatment programs and expand access to effective therapies in the criminal justice system. The public can fight back against the rising threat of overdose by supporting broad access to effective treatment with medications.”

Viewpoint by Yngvild Olsen, MD, MPH; Joshua M. Sharfstein, MD

http://jama.jamanetwork.com/article.aspx?articleID=1838170

Source: The Journal of the American Medical Association – Online February 26, 2014

Heroin Use, and Deaths, Rise – The Death of Philip Seymour Hoffman from an Apparent Heroin Overdose Underscores the Drug’s Resurgence

“The death of actor Philip Seymour Hoffman from an apparent heroin overdose underscores the drug’s resurgence in recent years, fueled by a growing supply from Latin America and a crackdown on prescription narcotics that has pushed addicts to seek old-fashioned alternatives.

The number of heroin users in the U.S. jumped almost 80% to an estimated 669,000 in 2012 from 373,000 in 2007, according to surveys by the Substance Abuse and Mental Health Services Administration, part of the Department of Health and Human Services. Annual overdose deaths attributed to heroin hit 3,094 in 2010, the most recent data available, up 55% from 2000, said the Centers for Disease Control and Prevention.

While heroin is diluted with other substances as it makes its way to the street, retail buyers often get a purer product than in decades past, said James Hunt, special agent in charge of the DEA’s New York division. While a dose of heroin in the 1980s might have been 5% pure, it is not uncommon to find a street bag today that is 50% pure, making it potentially more lethal, he said.

Moreover, heroin is sometimes combined with other dangerous drugs, including the synthetic opiate fentanyl. That combination has been blamed for a spate of deaths in recent months along the East Coast, including 37 in Maryland and 22 in Pennsylvania.”

http://online.wsj.com/news/articles/SB10001424052702304851104579361250012275942

For additional information see February 5 SAMHSA Blog Fentanyl-Laced Heroin Can Kill, But There Are Steps We Can Take to Save:  http://blog.samhsa.gov/2014/02/05/fentanyl-laced-heroin-can-kill-but-there-are-steps-we-can-take-to-save/

Source: Wall Street Journal – February 3, 2014, SAMHSA – February 5, 2014

From NIDA Notes: Medications That Treat Opioid Addiction Do Not Impair Liver Health

A trial that compared buprenorphine/naloxone (Bup/Nx) to methadone produced no evidence that either medication damages the liver. Researchers concluded that Bup/Nx and methadone are equally safe for the liver, and Bup/Nx may be considered a first line alternative to the more established medication for treating opioid addiction.

Dr. Andrew Saxon at the Veterans Affairs Puget Sound Health Care System in Seattle, and Dr. Walter Ling at the University of California, Los Angeles Integrated Substance Abuse Program, conducted the trial with colleagues in the NIDA Clinical Trials Network. Dr. Saxon’s team randomly assigned 1,269 new patients in 8 U.S. opioid treatment programs to therapy with either Bup/Nx or methadone. The study findings reflect the experiences of 731 patients who provided blood samples for liver function tests at baseline, completed the 24 weeks of active treatment, and submitted blood for at least 4 of 8 scheduled tests of liver function during treatment. These tests include measuring the levels of two enzymes (alanine aminotransferase and aspartate aminotransferase) that the liver releases when it is injured.

Most trial participants maintained enzyme levels that indicate healthy liver function throughout the study. In 15.5 percent, enzyme levels increased to higher than twice the upper end of the normal range, indicating some ongoing liver injury. A few patients developed extreme elevations to 10 times the upper limit of normal or had other laboratory signs of severe liver injury.

The percentages of Bup/Nx and methadone patients who experienced each outcome were so close as to be statistically equivalent, warranting the conclusion that both medications were similarly safe. Although the researchers could not definitively rule out the possibility that the medications contributed to some of the observed worsening of liver function, their analysis produced no evidence to this effect. Instead, they say the changes most likely resulted from hepatitis, the toxicity of illicit drugs, and impurities in those drugs. Infection with hepatitis B or C doubled a patient’s odds of a significant change in enzyme levels and was the only predictor of worsening liver function. Most extreme increases in enzyme levels occurred when a patient seroconverted to hepatitis B or C, or used illicit drugs during the study.

The researchers note that about 44 percent of those screened for the study did not meet its enrollment criteria, suggesting that the participant group was healthier than many who visit clinics for addiction treatment. The ineligible population was also older, had a higher rate of stimulant use, and was less likely to be white than patients in the enrolled group, suggesting that the evaluable patient group might not be representative of all opioid-dependent patient groups.

Graphs available at: http://www.drugabuse.gov/news-events/nida-notes/2013/12/medications-treat-opioid-addiction-do-not-impair-liver-health

Source: National Institute on Drug Abuse (NIDA) Notes – December 2013

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

Crime Does Not Increase Around Methadone Clinics in Baltimore

crime purchased shutterstock_78337543“Citizens’ concerns that methadone treatment centers (MTCs) might be focal points for serious crime are unwarranted, a recent NIDA-supported study suggests. Dr. Susan Boyd and colleagues at the University of Maryland School of Medicine in Baltimore found that crime rates in the immediate vicinities of that city’s MTCs were level with the rates in the surrounding neighborhoods.

The researchers used Baltimore City Police Department records from 1999‒2001 and global positioning data to plot the distribution of FBI Part I crimes (homicide, forcible rape, robbery, aggravated assault, burglary, larceny theft, motor vehicle theft, and arson) within a 100-meter (328-foot) radius of 15 MTCs. A statistical analysis of the plots showed that the crimes were no more frequent within 25 meters of the MTCs than they were 75 to 100 meters away.

In contrast to the case with MTCs, the likelihood of Part I crimes rose with closer proximity to convenience stores. The researchers suggest that the high volume of foot traffic around these stores provides opportunities for criminals to find victims. Consistent with this surmise, the frequency of crime declined near mid-block residences, where foot traffic is relatively sparse.

The study MTCs included all but one of the 16 centers located in Baltimore. They were situated in diverse communities, including inner-city, working-class, and middle-class neighborhoods, according to Dr. Boyd. The convenience stores and residences were located in neighborhoods that closely resembled those of the MTCs in demographic and social features that influence crime rates.

“There’s no evidence from our study of increased reports of crime around the methadone clinics,” says Dr. Boyd. She and colleagues are now analyzing data on actual arrests around the study sites to see whether drug sales and possession increase with proximity to methadone treatment centers. The researchers hope that demonstrating that MTCs are not hot spots for crime will reduce public resistance to the building of new centers, and thus remove an impediment to making methadone treatment more widely available.”

See graphs available at: http://www.drugabuse.gov/news-events/nida-notes/2012/12/crime-does-not-increase-around-methadone-clinics-in-baltimore

See related blog available from the Institute on Research, Education and Training in Addictions (IRETA) available at: http://iretablog.org/

Source: National Institute on Drug Abuse (NIDA) Notes – January 2014, IRETA – February 13, 2014

Jana Burson Blog: More about IRETA’s Guidelines for Benzodiazepines in OTPs

blog1“This is a continuation of my last blog post about the IRETA (Institute for Research, Education & Training in Addictions) guidelines for management of benzodiazepine use in medication-assisted treatment of opioid addiction. You can read all of the guidelines at: http://ireta.org/sites/ireta.org/files/Best%20Practice%20Guidelines%20for%20BZDs%20in%20MAT%202013_0.pdf

Under the section of recommendations regarding addressing benzodiazepine use is found the following statement:

“Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment. People who have a history of benzodiazepine abuse should not be disallowed from receiving previously prescribed benzodiazepines, provided they are monitored carefully and have stopped the earlier abuse.”

The experts, after reviewing the best data, are saying that if a patient has abused benzos in the past, but isn’t abusing prescribed benzos now, it may be OK to continue benzos, with careful monitoring.

I don’t like this statement. It doesn’t conform to my present thoughts on the topic. I fear that the majority of patients with a history of benzodiazepine abuse or addiction will, sooner or later, revert back to problem use of the medication. That’s my anecdotal experience. Anecdotal experience is worth something, but data from clinical trials trumps anecdotal experience, and IRETA’s guidelines are based on both clinical trials and expert opinion.

So now I need to challenge my previously held views about benzos in the OTP. It’s unpleasant and uncomfortable to change a long-held view. But isn’t that what I ask of my patients? In the interest of science, I will re-consider my present opinion, but I won’t ignore the last part of the statement, which says careful monitoring needs to be done.”

 http://janaburson.wordpress.com/2014/02/02/more-about-iretas-guidelines-for-benzodiazepines-in-otps/

Source: Jana Burson - February 2, 2014

AT Forum Volume 24, #1 Winter 2014 Newsletter

From the Publisher—Special Issue on Recovery From Opioid Addiction

people-sunlight

For six decades methadone maintenance has been an approved treatment for opioid addiction. People who are taking methadone are no different from those who manage their diabetes by taking insulin: they are in recovery. Yet some policymakers—and even some medical, and yes, some addiction authorities—don’t believe it. Although that may change as more and more professionals buy into the scientific fact that addiction is a brain disease, and therefore it can be treated, and people can recover from it.

The federal government, from the Substance Abuse and Mental Health Services Administration (SAMHSA) to the Office of National Drug Control Policy (ONDCP), states that medication-assisted treatment (MAT) is recovery. In this issue, we write about a comprehensive literature review funded by SAMHSA demonstrating the efficacy of MAT. And we cover an article by William L. White describing the stigma and other obstacles methadone patients face when joining 12-step groups—and the important role these groups could play in helping patients in recovery. We also interview Walter Ginter, peer, patient, and advocate, who spoke before the ONDCP in December on the topic of recovery and MAT. Mr. Ginter, a methadone patient in long-term recovery, is an articulate spokesman for methadone and for patients, helping to guide peer services across the country from his position at MARS, in New York City. We also interview Zac Talbott, based in the less-welcoming South, about his work as an advocate.

Not all of the news is good: In New Jersey, a state that strongly endorses methadone as a treatment for opioid-dependent pregnant women, a woman is facing child abuse and neglect charges simply for being in a methadone program while pregnant. The Supreme Court is due to hear the case, and legal and medical authorities are hopeful that the court will not in effect ban MAT for pregnant women. The woman was in recovery, doing the right thing for herself and her baby, yet was reported, and was held by a lower court to have committed child abuse and neglect by being on methadone while pregnant. On the bright side, the best legal and medical minds who know about MAT have filed a friend of the court brief on the mother’s behalf.

In Philadelphia, where AT Forum attended the AATOD conference last fall, recovery transformation is happening in a solid way, moving from treating addiction as an acute episode to a continuum instead, in which someone enters recovery as a person, not a patient. Roland Lamb discusses efforts to help opioid treatment programs (OTPs) provide what is needed for recovery, with more of a focus on the person than on the dosage and the monitoring. Methadone is a way to recovery—that’s why it was created—but the person taking it is the point of recovery.

Finally, a new evidence-based document from ASAM provides guidance for safe methadone induction and stabilization in OTP patients. This is the first time this vital information has been brought together in one place. Our article by Stewart Leavitt is recommended reading for everyone interested in methadone maintenance treatment.

I hope you enjoy this issue, and we look forward to your comments and feedback.

Sue Emerson
Publisher

MAT With Methadone or Buprenorphine: Assessing the Evidence for Effectiveness

evidenceIt’s not surprising that a thorough review of the efficacy of medication-assisted treatment (MAT) with methadone or buprenorphine reveals  a high level of evidence for the positive impact of MAT in keeping patients in treatment and reducing or eliminating illicit opioid use.

What is surprising is that the stigma against MAT persists—even though evidence suggests that methadone maintenance treatment (MMT) has a positive impact on drug-related HIV risk behaviors and criminal activity—and thus could make clinic neighborhoods safer, rather than less desirable.

The research findings on MMT and buprenorphine or buprenorphine-naloxone maintenance treatment (BMT) were published in November 2013 in two peer-reviewed articles (see References) as part of the Assessing the Evidence Base (AEB) Series sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).

The Assessing the Evidence Base Series

SAMHSA sponsored the AEB Series to help guide providers’ decisions about which behavioral health services public and commercially funded plans should cover. The Affordable Care Act (ACA) greatly expands health care coverage and provides the opportunity “for federal and state agencies to work with private and nonprofit sectors to transform the American health care system” by developing a comprehensive set of community-based, recovery-oriented, and evidence-based services for people with mental and substance use disorders. The ACA doesn’t specify specific treatments, leaving the decision to federal, state, and local agencies, managed care organizations, and commercial and private insurers.

Deciding which services have verified effectiveness isn’t an easy task. To help in the decision-making process, the AEB Series provides a literature evaluation for 14 behavioral health services. For people with substance use disorders, they include, in addition to MMT and BMT, residential treatment, peer-recovery support, and intensive outpatient programs. The goal of the AEB Series is “to provide a framework for decision makers to build a modern addictions and mental health service system for the people who use these services and the people who provide them.”

The Studies

Authors of the MMT and BMT studies searched major databases and other sources to review meta-analyses, reviews, and individual studies from 1995 through 2012.

In brief, the studies found that with adequate dosing, MMT (> 60 mg) and BMT (16 mg-32 mg) caused a similar reduction in illicit opioid use, but MMT was associated with better treatment retention and BMT with a lower risk of adverse events. In pregnancy, MMT and BMT (without naltrexone) showed similar efficacy, but MMT was better than BMT in retaining pregnant women in treatment, and BMT was associated with improved maternal and fetal outcomes, compared to no MAT.

MMT and BMT showed similar occurrence rates of neonatal abstinence syndrome, “but symptoms were less severe for infants whose mothers were treated with BMT.” BMT is associated with a lower risk of adverse events, and has the advantage of greater availability (office facilities improve access and provide earlier care). MMT may be needed for patients who require high doses of opioid agonist treatment, and has the advantage of a possible positive effect on mortality, drug-related HIV risk behaviors, and criminal activity.

The authors advise that MMT “should be a covered service available to all individuals,” and that BMT “should be considered for inclusion as a covered benefit.”

Sprinkled within the two articles are qualifiers such as “possible,” “associated with,” and “suggestive.” That’s because the statistical significance shown in some large, well-designed studies tends to disappear when data from individual studies are merged. Merging changes drug dosages, length of treatment, patient characteristics of the group, and other data; these changes may make reaching statistical significance impossible.

Areas for Future Research

The authors identified several areas where additional data would be helpful. For methadone, these include the impact of MMT on secondary outcomes, the efficacy and safety tradeoffs of doses > 100 mg, and confirmation of results of interim treatment for improved outcome. (In interim treatment, patients receive methadone daily under supervision for up to 120 days, and emergency counseling, while awaiting placement in a program.)  Another research area: the use of MMT in subpopulations—racial and ethnic minority groups, and people who misuse prescription drugs.

For buprenorphine, suggested research areas include the impact of BMT on secondary outcomes, appropriate dosing to enhance outcomes, and confirmation of stepped-care results. (Stepped-care involves gradually increasing buprenorphine doses to 32 mg—higher doses “do not provide additional efficacy;” patients requiring more medication are switched—“stepped-up”—to high-dose methadone.) Other research areas: the use of BMT in subpopulations (described above), and improved induction protocols to minimize retention problems.

A box in each publication summarizes the authors’ findings for each treatment. We reproduce them below, as they appeared in print.

 

Evidence for the effectiveness of MMT: high

Evidence clearly shows that MMT has a positive impacta on:

  • Retention in treatment
  • Illicit opioid use

Evidence is less clear but suggestive that MMT has a positive impact on:

  • Mortality
  • Illicit drug use (non-opioid)
  • Drug-related HIV risk behaviorsb
  • Criminal activity

Evidence suggests that MMT has little impact on:

  • Sex-related HIV risk behaviorsc

 

a Compared with placebo, detoxification, drug-free rehabilitation, or wait-listing
b Sharing injection equipment.
c Having unprotected sexual relations.

 

Evidence for the effectiveness of BMT: high

Evidence clearly shows that BMT has a positive impact compared with placebo on:

  • Retention in treatment
  • Illicit opioid use

Evidence is mixed for its impact on:

  • Non-opioid illicit drug use

 

Regarding retention in treatment and illicit opioid use, BMT had a positive effect compared to placebo, while MMT had a positive effect compared to placebo, detoxification, drug-free protocols, or wait-listing protocols.

Closing Statements

The authors note the importance of MAT, especially considering the poor success rates of abstinence-based treatments, and recognize both MMT and BMT as important treatment options. Below are summaries of their closing statements.

Methadone: The authors point out the need for educating providers, consumers, and family members about the benefits of MMT and ways to avoid the significant adverse events that can occur (referring to respiratory depression and cardiac arrhythmias). They also note the need for education about “appropriate doses to improve efficacy” and “appropriate initiation to minimize adverse events.”

They close with: Because of MMT’s relative efficacy, efforts should be made to increase access to MMT for all individuals who struggle with opioid use disorders. Directors of state mental health and substance abuse agencies and community health organizations should look for methods to increase access to MMT, and purchasers of health care services should cover appropriately monitored MMT.”

Buprenorphine: Noting the key advantage of buprenorphine—its availability—and the “limited access to and more restrictive safety profile of MMT,” the authors consider BMT an important treatment for opioid dependence. “Policy makers have reason to promote access to BMT for patients in substance use treatment who may wish to choose BMT as a potentially safer alternative to MMT.

They close with: “Administrators of substance use treatment programs, community health centers, and managed care organizations and other purchasers of health care services, such as Medicare, Medicaid, and commercial insurance carriers, should give careful consideration to BMT as a covered benefit.”

#     #     #

References

Fullerton CA, Kim M, Thomas CP, et al. Medication-assisted treatment with methadone: assessing the evidence. Psychiatric Services in Advance. November 18, 2013; doi: 10.1176/appi.ps.201300235.

Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: Assessing the Evidence. Psychiatric Services in Advance. November 18, 2013; doi: 10.1176/appi.ps.201300256.

Dougherty RH, Lyman DR, George P, Ghose SS, Daniels AS, Delphin-Rittmon ME.

Assessing the Evidence Base for Behavioral Health Services: Introduction to the Series.

Psychiatric Services. 2014; doi: 10.1176/appi.ps.201300214

http://ps.psychiatryonline.org/article.aspx?articleID=1759202

Walter Ginter on the Importance of Peers in Recovery With Medication-Assisted Treatment

walterStigma is a common theme among people seeking recovery from the disease of opioid addiction, but it’s particularly poignant for people in medication-assisted treatment (MAT), because stigma can itself prevent recovery from taking place. People who don’t understand MAT—and that’s a big group, including many employers, politicians, and even friends and family members—don’t believe methadone or buprenorphine treatment means being in recovery. But it does. And that’s the message that Walter Ginter, CMA, project director of Medication- Assisted Recovery Services (MARS), and the country’s foremost patient advocate, brings to patients. On December 9, he brought this message to the first White House drug policy conference.

Sponsored by the Office of National Drug Control Policy (ONDCP), the conference included a panel that focused on stigma and drug addiction. Michael Botticelli, deputy director of the ONDCP, and himself in recovery, invited Mr. Ginter to participate. “He called me himself to ask me to be on that panel, and afterwards I got a nice handwritten note from him thanking me for participating,” said Mr. Ginter.  Mr. Botticelli, formerly the official in charge of substance use disorder services for Massachusetts, is a strong supporter of MAT. “This direction and focus that we are seeing from the Obama Administration is encouraging,” continued Mr. Ginter “It would strengthen that effort to see Mr. Botticelli promoted and the recovery community is hopeful that he will fill the opening as director of the ONDCP.”

 Stigma Impedes Recovery

The main stigma patients face in terms of methadone comes from believing what people who know nothing about MAT tell them. They learn to believe the myth that methadone is a substitute drug, and that they aren’t really in recovery. What peer recovery support services can do for patients is to help them eliminate feelings of stigma by helping them understand that they are in treatment with a medication, just like someone with any other disease. “If people come into treatment with the idea that methadone is just substituting one addiction for another,” said Mr. Ginter, “that attitude makes them feel as if recovery isn’t an option, for them. This discouraging prospect sets the stage for a less than optimal outcome. They ask themselves what difference does it make if they use a little benzodiazepines or smoke a little pot, if recovery isn’t an option anyway? That is how stigma stops patients from achieving recovery.”

 Peers Believe Peers

Peers—other people who are in MAT—can help support patients’ recovery in a way that nobody else—not a physician and not other people who are not taking methadone—can. “In the recovery community, you always hear people say they ‘support all pathways to recovery,’” said Mr. Ginter, “but often this is just lip service and not really an endorsement, with too many anti-MAT people weighing in and adding to the stigma. A lot of people support it and understand it’s evidence based practice, but still they don’t accept it as a legitimate pathway.”

At the MARS project, patients learn from peers that methadone and buprenorphine are “not substitute drugs, they’re medications,” said Mr. Ginter. “And suddenly, that person is a candidate for recovery. Before that, they never had a choice.”

When people are given the option of being in recovery, they choose it. Once they realize that taking methadone or buprenorphine is not the same as using, they stop using other drugs and alcohol. Yes, they were in treatment, but neither the opioid treatment program nor the physician could convince them that they were in recovery—it took another person in MAT to do that. “Peers believe things from other peers that they would not believe from anyone else,” said Mr. Ginter.

 Feeling Good

One of the magical things about erasing stigma is this: Once people start to feel good about themselves, the community starts to look at them differently. That’s why one exercise patients can use is to write down three nice things that happen each day.“ At the end of a few weeks, people start to feel better,” said Mr. Ginter. “For us to do well in recovery, we have to feel good about ourselves.”

Calling addiction a brain disease—which it is—takes away a lot of guilt, said Mr. Ginter. That internal feeling of guilt is magnified by stigma coming from the outside world.

In some ways, stigma from the outside world isn’t getting any better. “There are these nice dissertations out there about your rights, but if you’re in jail because you got picked up outside your methadone clinic, you can’t tell the cop he’s wrong,” said Mr. Ginter. It would help if drug courts and parole officers saw more patients for whom treatment is working, and not just those for whom it isn’t, he added.

Finally, fear of stigma keeps people from even saying that they are on buprenorphine or methadone. Thousands of people are doing well in treatment—not just the few, like Mr. Ginter, who publicly identify themselves.

As an anecdote illustrating this, Mr. Ginter related that visitors from overseas at the MARS booth at the AATOD conference last fall were amazed that two of the people working at their display booth were patients. “They couldn’t believe that peer recovery support services were provided by ‘real’ methadone patients,” he said.

 Other Participants

The ONDCP half-day meeting also featured panels on public health approaches to drug policy, being “smart on crime” instead of “tough on crime,” with an emphasis on drug courts using MAT, and a screening of The Anonymous People. Mr. Ginter related that the drug court speaker, magistrate Alby Zweig from Denver, was shocked to hear that many of his colleagues require participants to stop using methadone or buprenorphine before they can be admitted.

Note: MARS is a project of the National Alliance of Medication-Assisted (NAMA) Recovery. NAMA chapters are small groups of individuals who organize around advocacy to teach patients about their rights and to support them in their rights. Patient advocates are not the same as peer recovery support.

For more information, go to www.marsproject.org.

Interview: Zac Talbott on Being a Patient and Certified Advocate for Medication-Assisted Treatment

Zac 2-9-14Patients and other individuals who are advocates are a growing force in medication-assisted treatment (MAT) for opioid dependence, providing information and support to patients as well as assistance to opioid treatment programs (OTPs). Advocates also are an essential link between patients and OTPs. They are not as well known as they should be, there aren’t enough of them, and they are in dire need of funding.

In January, Zac Talbott, a patient who is the director of the Tennessee Statewide and Northwestern Georgia chapter of the National Alliance for Medication Assisted Recovery (NAMA Recovery), shared his experiences with addiction, treatment, recovery, and patient advocacy with AT Forum.

 Getting Started in Advocacy: The CMA

Patients and others who want to be advocates need to first have a good knowledge of advocacy and the various issues surrounding MAT. Taking the CMA (Certified Medication Assisted Treatment Advocate) course and obtaining certification gives both patients and health care professionals the basic grounding for advocacy. Certification is essential to being a credible advocate. “There are patients out there who often are well-meaning, who claim to be advocates, but who can do harm,” he said. “A lot of folks without training do not realize that advocates have a code of ethics, and one of the main ethical guidelines is confidentiality. It goes to the heart of our professional credibility. There has never once been a case of a patient’s confidentiality being violated by a CMA working with NAMA-R.”

The second crucial skill that CMAs have is knowing how to communicate with OTPs on behalf of a patient. “You can make things worse for the patient you’re trying to help if you come off like an attack dog. Patients and OTPs agree on more than 90 percent of the issues, and that should always remain the primary focus. It’s also important to remember that the job of a patient advocate is to advocate for what the patient wants. We can’t take off and start a crusade without that patient wanting us to,” he said.

NAMA-R developed the CMA training course with no funding, which was a tremendous challenge. However, the course has been strongly supported by the American Association for the Treatment of Opioid Dependence (AATOD), and the federal Center for Substance Abuse Treatment (CSAT).

 Volunteering and Funding

Some NAMA-R chapters could do significantly more if their expenses were paid. Members are committed people who largely volunteer their time and give of themselves without any compensation.

NAMA Recovery chapters do need funding. NAMA-R is a 501c3 non-profit organization, so donations are tax-deductible. All other industrialized countries fund organizations like NAMA-R, said Mr. Talbott. “The United States is the exception. This leaves NAMA-R dependent on donations from patients, for-profit OTPs, and the pharmaceutical industry.”

In Tennessee—and in many other states—Medicaid won’t currently pay for MAT with methadone. “It’s all cash down here,” he said. The fee for patients is $300 to $400 a month—frequently all the money a patient has.

Mr. Talbott hopes NAMA Recovery can partner with OTPs for funding and support. “We had a wonderful meeting with Chief Operating Officer Jerry Rhodes and the regional managers of CRC Health Group during the AATOD Conference in Philadelphia this past November,” he said. “They recognize that advocacy is extremely important.”

 Insurance and the ACA

Whether the Affordable Care Act (ACA) will help fund MAT is still unclear, said Mr. Talbott. “It’s supposed to, but insurance companies are good at finding loopholes.” Implementation and enforcement are still problematic.

In Tennessee, for example, the state is making it impossible for new OTPs to open, which means that facilities are opening up across the state border. “Programs in other states are treating the patients that Tennessee isn’t,” said Mr. Talbott. If Tennessee Medicaid were to say that patients had to be treated in a Tennessee facility, that might make it more attractive for programs to open in Tennessee.

Even though his organization is in Tennessee, most of Mr. Talbott’s calls come from outside the state—just because there are so many patients, especially in nearby southern states, who need help. NAMA-R has always had difficulty recruiting individuals willing to make a commitment to advocacy and start a chapter. Stigma, prejudice, and just plain fear have been barriers in southeastern states.

 From Pain Medication to Heroin

Mr. Talbott’s addiction started—as with many people—with a prescription for hydrocodone for a chronic painful condition. Most people feel sick when they take opioids, but Mr. Talbott is part of the 10 percent of the population that is susceptible to addiction. “I loved them,” he said of opioids. His addiction sent him to buying pills from a pill mill and eventually to the street, where he also bought heroin. “This was in the late 90s,” he recalled. “Within eight years I went from a couple of prescribed hydrocodone a day to 25 prescribed 30-milligram doses of oxycodone.” He became an intravenous drug user within four years of initially starting the pills.

“The opposite of the stereotypical drug user,” Mr. Talbott had two college degrees when he first became addicted to opioids, and came from a well-known and well-respected family—“church folks,” he explained.

 Recovery

Then, there was treatment. “I went for all the wrong reasons—I didn’t go because I was seeking recovery,” Mr. Talbott said of his treatment in an OTP. “People who are drug users think that there’s no withdrawal, and that you might even get a little buzz.” But six months after entering the OTP and starting methadone, he found that he was in recovery—by accident. “I had no craving. I stopped using the needle. I was thinking about my life again—by accident. The person I was prior to the addiction quickly started to re-emerge. That’s the beauty of methadone.”

After that, it took Mr. Talbott a year to focus on recovery and life. “There’s so much you need to do, straightening out your credit, fixing everything you did when that disease is active.” When his addiction was at its height, he was in the middle of his masters’ in clinical social work. Ultimately, the addiction took over and he left the program. But even before his addiction, he had always wanted to be in a helping profession—a mental health counselor, an Episcopal priest, or a lawyer. “I wanted to help people,” he said. “Once I was in recovery, that part of me came back quickly.”

He found NAMA Recovery because his counselor recommended it as an alternative to driving to the clinic for four group meetings during his induction period in treatment. “I had to drive more than two hours one way to the OTP because I was so rural. So my counselor said to go to the website—methadone.org—print out, read, and bring in one of the Education Series to discuss ‘and that will count as one of your groups.’” Ultimately, he wrote to the NAMA-R chapter coordinator and said a NAMA Recovery chapter was needed in Tennessee.

NAMA Recovery’s main goal is advocacy, and that is where Mr.Talbott saw his life heading. “It’s a natural fit,” he said. “To be a MAT advocate is to advocate for the patient in treatment, but we’re not patient advocates only or specifically. ‘The patient comes first,’ as Rokki [Roxanne Baker, NAMA-R president] often says.”

 Partnership With OTPs

Patient advocates can have a lot of power, not only on behalf of patients, but on behalf of providers. When onerous restrictions are imposed by states, especially states that don’t have an AATOD chapter, providers call NAMA Recovery. “We are more than just patient advocates, we are MAT advocates,” said Mr. Talbott. “We advocate for the entire modality.”

About a third of the calls he gets—Tennessee joined AATOD just last fall—are from OTPs, said Mr. Talbott. “Sometimes patients and providers don’t have the best relationship. Some OTPs view advocates as whistleblowers and troublemakers, and sometimes the OTPs get defensive as soon as advocates call them. Several of us are trying to stress to OTPs and patients that we’re all on the same team.”

Technically, the provider advocacy organization is AATOD. But when there is an issue that draws both patient and provider complaints, Mr. Talbott reaches out to consult with AATOD president Mark Parrino or the state chapter of AATOD. “We can strategize together,” he said. Sometimes the approach involves filing a complaint with the Department of Justice or SAMHSA’s CSAT, which regulates OTPs. Often, OTPs haven’t even heard of NAMA Recovery, and sometimes haven’t heard of AATOD either, he said.

“The way to go is moving away from patient advocacy specifically and toward MAT advocacy as a modality,” said Mr. Talbott. And patients who are certified advocates can be of immense help to OTPs, whether they are testifying before the legislature or making a complaint to the Department of Justice. Patients and providers aren’t always going to agree, but ultimately they’re fighting the same battles and striving for the same goals.

Recovery Transformation in Philadelphia OTPs: Person-centered, not Patient-centered

RecoveryOver a decade ago, Philadelphia’s public health system moved toward recovery for mental health and addiction services. On the mental health side, there had been a belief that recovery wasn’t possible, especially for people with serious mental illness. On the addiction side, recovery was already in wide parlance, but the system was set up to treat the disorder as if it was acute, with no long-term or continuous follow-up care, resulting in relapses. Now, Philadelphia has taken great steps to bring along its providers in adopting a recovery-based framework. We caught up with Roland Lamb, director of addiction services for the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIdS) to get an update on the recovery transformation as it affects patients in medication-assisted treatment (MAT).

“The good news is that we have moved towards more of a person-centered perspective in MAT,” Mr. Lamb said. In other words, providers are learning to look at people as people, not patients.

“We have the richest environment for MAT, with all levels of care,” he told AT Forum. He added that not only is there outpatient methadone, but there is medication-assisted treatment in all levels of care, and there are efforts to reach out to the 144 physicians in the system who are certified to dispense buprenorphine, and to provide access to those they are seeing to all of the treatment resources in Philadelphia.

The Medication ‘Culture’

But, because of the oversight and stigma, it has been a struggle to get providers to focus on the fact that people are people first, and not patients to be “dosed and monitored,” Mr. Lamb said. “The bad news is that we still have to work to overcome the stigma-driven culture of managing the medication, instead of treating addiction and focusing on recovery.”

This medication “culture” isn’t completely the fault of the opioid treatment programs (OTPs), Mr. Lamb noted. “It’s the most regulated form of treatment—in health care—that there is,” he conceded. The preoccupation with regulations, one drug after another, and the diagnosis, is at the cost of focusing on treating the addiction and supporting recovery and other needs. “People lose sight of managing the addiction.” Yes, methadone maintenance is part of recovery, but the medication isn’t the only part of it. “This treatment was created to help people get into recovery, but recovery is more than the medication alone.”

Buprenorphine—the medication—is not on the DBHIDS formulary, said Mr. Lamb. “But we do pay for all the services that surround it—the physical exams, counseling, and the drug screens.”

But whether those in care are taking methadone or buprenorphine, the focus has to be on the individual, said Mr. Lamb. “We are making sure that our providers have what they need—good assessment instruments, evidence-based practices, and psychiatric supports.”

There is a high prevalence of co-occurring mental illness in the MAT population, said Mr. Lamb. “We know a lot of what has happened with those co-occurring illnesses to those in care, who in many cases are self-medicating the very illnesses that they need help with.”

The DHBIdS meets with MAT providers every two months. These include inpatient and outpatient MAT providers, and the state licensing authority and the Drug Enforcement Administration are present as well.

No Involuntary Discharges

One of the key patient-centered initiatives in Philadelphia is this: “We say we don’t want involuntary discharging going on,” said Mr. Lamb, noting that “noncompliance” in addiction treatment is no worse than it is in treatment for high blood pressure or type II diabetes, and that terminating treatment is no solution. The reason for discharge may be violence, or threats of violence, for example, but many times this behavior is a result of untreated mental illness, said Mr. Lamb. Other reasons for discharge are drug dealing on the premises, or, of course, noncompliance with the treatment plan, but aren’t they some of the very reasons treatment is needed?

“We see ourselves as being in a partnership in terms of trying to overcome these issues,” said Mr. Lamb. The person in recovery, the providers, the regulators, and the payers all need to be at the recovery table to make this work.

Another point about person-centered care: OTPs should treat people based upon their need. For example, Pennsylvania requires two and a half hours a month of counseling—but patients should get more if they need it, said Mr. Lamb. “The issue for us is that we want to see counseling based upon the needs of the person.” That’s why the DBHIdS pays based on how much counseling is given. “We track the counseling separately.”

Training in CBT, Other Modalities

“The real challenge for us is to get staff to rethink what they’re doing,” said Mr. Lamb. “We’ve been doing it one staffer at a time.” Staffers are getting training in cognitive behavioral therapy (CBT), dialectal behavioral therapy (DBT), trauma, and the sanctuary model, he said. “All of these are evidence-based practices that we’ve been paying our providers to get trained in.”

There are 11 providers operating 13 OTPs in Philadelphia, treating a total of 5,000 patients a day. “When you think about it, that’s approximately 400 people coming in every day,” said Mr. Lamb. “It would be better if we could have smaller numbers of people in each facility, and more facilities.” He noted that community complaints about traffic would then go down. Of course, for that to happen, there would have to be community cooperation in siting clinics. “There is still so much stigma,” said Mr. Lamb, noting that this comes from the “outside” community and from the drug-addiction treatment community itself.

“Through a recovery focus we have a chance to change the usual ‘down with methadone’ discussion to a discussion about solutions for long-term opioid dependence and long-term recovery,” Mr. Lamb said. This is especially important now, with the burgeoning cohort of people becoming addicted via the non-medical use of prescription opioids, and their conversion to heroin. We need to do a better job of reaching out to, engaging, and retraining this population if we are going to impact the growing number of overdose deaths we are seeing, said Mr. Lamb. “We also need to evolve the recovery focus to one of wellness, and the need for those who are actively recovering to take better care of their health.”

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