AT Forum Volume 24, #1 Winter 2014 Newsletter

From the Publisher—Special Issue on Recovery From Opioid Addiction

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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.”

Patients in Methadone Maintenance Treatment Face Obstacles and Stigma When Joining 12-Step Groups

recovery winter 2014 jpegIt’s ironic—and disappointing—that patients in methadone maintenance treatment (MMT) who join mainstream addiction recovery groups face considerable stigma and daunting obstacles from professionals and from other patients, rather than the helping hand they might reasonably hope for and expect.

This became evident in the first in-depth survey detailing the experiences and perceptions of MMT patients in Narcotics Anonymous (NA), Alcoholics Anonymous (AA), and other support groups. Although most of the 323 MMT patients surveyed participated in support groups and found them helpful, patients’ rates of taking part in socializing, speaking at meetings, and other functions were much lower, because of negative experiences.

Key interfering factors include restrictions on MMT patients at 12-step meetings, and obstacles that spring from stigma and professional attitudes.  Yet more MMT patients take part in 12-step programs than might be expected, given the problems encountered.

The OTP Survey

The survey took place at Partners in Drug Abuse Rehabilitation and Counseling (PIDARC), an opioid treatment program (OTP) in Washington, DC. Founded in 1971 as a private, not-for-profit facility, PIDARC today has more than 650 patients and 24 counselors, nurses, physicians, and support personnel. Most patients are poor and African American, and report long-term involvement with the criminal justice system. Many have a history of addiction treatment failures and current medical problems.

The Journal of Groups in Addiction and Recovery published the PIDARC article last November. The lead author is William L. White, MA, a prolific writer and a pioneer in the addiction treatment field. Two of the survey’s coauthors, Howard A. Hoffman, MD, and Brian Crissman, are affiliated with PIDARC.

Enrollees’ Characteristics

Volunteers who were at the OTP at a randomly selected time were enrolled in the survey. Characteristics of the 323:

  • 55% male
  • Average age, 53 years; range, 21 to 79 years
  • Average time in continuous MMT: 2 ¾ years
  • Average percentage of days in the past year abstinent from use of alcohol and non-prescribed drugs: about 70%
  • Primary support affiliation: NA, 68%; other (usually church or PIDARC group), 11%; AA, 7%

Participation in Mainstream Groups

PIDARC doesn’t hold 12-step meetings, but a nonclinical staff person, an NA member, strongly encourages involvement in NA meetings.

Most patients (66 percent) took part in NA/AA programs, and most (about 75 percent) found the programs helpful. Yet most didn’t participate in activities:

Activities of MMT Patients
Who Joined Outside 12-Step Programs

Characteristic  Percent Participating
Have a home group 50
Have a sponsor 26
Sponsor others 13
Attend 12-step social events 23
Take active part in step work 21

 

Patients enjoyed the social aspects of NA and AA. Some liked AA because it “provided more structure and had a stronger spiritual base than NA.” Others identified with NA’s drug-focused fellowship; many never had problems with alcohol.

Problems Encountered

One-fourth of participants encountered a serious problem being an MMT patient within NA or AA. An extreme example: At an NA meeting, a patient who mentioned being in MMT was asked to leave and not return.

Problems MMT Patients Encountered in NA/AA

Problem Approximate Percent
Recipient of negative comments
about methadone use
45
Pressured to stop taking methadone 35
Pressured to reduce their dose 25
Denied the right to speak at a meeting 15
Denied the right to be a sponsor or chair a meeting 10

 

Cautioning against generalizing about patients’ negative experiences, the authors pointed out the considerable variation in “the attitudes of NA and AA groups towards medication-assisted treatment [MAT] of addiction in general and methadone maintenance treatment for opioid addiction in particular.”

Don’t Ask, Don’t Tell

It’s hardly surprising that only 34 percent of patients surveyed disclosed their MMT status at NA or AA meetings, and only about 25 percent did so to their sponsor.

A Lost Opportunity

For patients seeking long-term recovery, “12-Step fellowships and other recovery mutual aid groups may provide a source of critical support,” the authors believe. So lack of support is a squandered opportunity to welcome fellow patients into the recovery circle.

Patients need that support, given their long-term outlook. The common idealized view is that MMT is lifelong therapy, but the fact is that most patients do leave treatment, and they do so without support.

To bring reality home, the authors compiled a list of seven “stark realities” that challenge the idealized views of the optimal time in medication-assisted treatment:

  • 80%-100% of surveyed patients expect to end MMT at some point
  • One-year retention rates in MMT are less than 50%
  • Few patients end treatment in a planned manner (11%, in one study)
  • Post-treatment monitoring, support, and early re-intervention are not standard practices
  • Most discharged patients eventually return to illicit opioid use
  • Patients who end MMT face a significantly increased risk of infectious disease and death
  • Most MMT patients who choose to taper don’t successfully complete the process as planned

The authors note that these realities underscore “the more specific role participation in recovery mutual aid groups could potentially play in long-term recovery from opioid addiction.”

12-step approaches to MMT have a history of encountering obstacles. According to the authors, “The stigma and discrimination MMT patients face when seeking participation within mainstream recovery mutual aid groups are, in part, expressions of the larger professional and cultural stigma attached to MMT in the United States.”

In 1991, MMT patients’ negative experiences in support groups led to the creation of Methadone Anonymous (MA), but, according to the authors, MA “is not widely available in the U.S. at the present time.”

What OTPs Can Do

The authors said that because MMT is a substance-specific treatment, but addiction is not a substance-specific disorder, OTPs and other groups need to address patients’ complex patterns of concurrent and sequential drug use. “Increasing patient participation in recovery mutual aid groups may prove helpful in addressing patterns of multiple drug dependencies.”

The authors suggested ways for OTPs to help patients establish links with other mutual aid groups:

  • Develop relationships with NA service committees
  • Host NA meetings
  • Coach OTP patients about taking part in NA/AA
  • Establish protocols for linking with mutual aid groups
  • Co-host programs on MAT and recovery with mutual aid groups
  • Encourage development of local MA meetings and other recovery-support meetings for patients in medication-assisted recovery

In closing, the authors emphasize that support groups may be able to reach out to MMT patients if they falter during the crucial period when they face the “stark realities” of life after they leave the OTP “on current doses of methadone without planned tapering and support for the transition to recovery maintenance without medication support.” They note again that “the risk of relapse is great under these circumstances and remains a lifelong risk; 12-Step fellowships and other recovery mutual aid groups may provide a source of critical support for patients seeking stable long-term recovery during and following discharge from OTPs.”

Reference

White WL, Campbell MD, Shea C, Hoffman HA, Crissman B, DuPont RL. Co-participation in 12-Step Mutual Aid Groups and Methadone Maintenance Treatment: A Survey of 322 Patients. J Groups Addict Recovery.  2013;8(4):294-308. Published online Nov. 8, 2013. doi 10.1080/1556035X.2013.836872.

Is Maternal Methadone Treatment Child Abuse and Neglect? New Jersey Supreme Court to Weigh In

pregnant woman jpegOne year after the New Jersey Supreme Court ruled that a pregnant woman did not commit child abuse just because she tested positive for cocaine, the state has brought a similar case to the court: that of a pregnant woman who was in methadone treatment in an opioid treatment program (OTP).

This January, experts in addiction treatment and maternal and fetal health filed a friend of the court brief before the New Jersey Supreme Court, urging it to overturn a lower court ruling in which a pregnant woman in a methadone treatment program was charged with child abuse and found guilty.

In the cocaine case, on February 6, 2013, the New Jersey Supreme Court unanimously held that the state’s child protection laws don’t give child welfare authorities control over pregnant women, and that positive drug test results alone on pregnant women and newborns do not establish neglect. That case involved positive test results for cocaine. The Supreme Court held that those positive test results did not by themselves show maternal neglect.

Here’s the situation now: The state wants to call it child abuse if a woman takes prescribed methadone while pregnant. This is despite the fact that the state has a robust system in which methadone is recommended for pregnant women.

The case involves a woman—YN—who was dependent on opioid pain relievers when she learned she was pregnant. Her medical providers recommended that she obtain methadone treatment and other care, which she did, and she subsequently gave birth to a healthy baby. The baby was successfully treated for neonatal abstinence syndrome (NAS), a predictable treatable and transitory, possible side effect of maternal methadone treatment.

But because of the NAS, YN was reported to the Division of Child Protection and Permanency (DCPP, formerly the Division of Youth and Family Services), and was judged by the lower court to have abused or neglected her child. In effect, the lower court is rewriting the law by applying child abuse statutes to pregnant women and their fetuses, according to the friend of the court brief.

Advocates hope that the Supreme Court will rule, as it did last year, in favor of the mother. Lawrence S. Lustberg, of Gibbons P.C., co-counsel for the amici, said that “the New Jersey Supreme Court has been a national leader in recognizing that when cases raise scientific, medical, or other technical issues, the evaluation of these issues must be informed by existing scientific knowledge, including expert testimony.” He added, “This case should not be an exception, yet, the decision in the lower court was reached without the input of a single medical expert and without considering the established science addressing the value of methadone treatment to maternal, fetal, and child health, and other key health and social welfare issues in the case.”

“As a matter of medicine and health care, it is simply nonsensical to regard methadone treatment as a form of child abuse,” said Robert Newman, MD, one of the experts represented in the brief. “Decades of research unequivocally demonstrate the benefits of treating a pregnant woman’s addiction to opioids with methadone, an extraordinarily well-studied medication whose benefits to the mother as well as the baby unquestionably outweigh the treatable and transitory side effects that are sometimes seen in the newborns.” He noted that “It is not recommended that women simply stop using opiates during pregnancy” and that “methadone and other related treatments are acknowledged by national and international governmental, academic, and clinic authorities to be the best choice for maternal, fetal, and child health, reducing risks of miscarriage, stillbirth, and premature birth.”

The bottom line: YN was in recovery. But unless the lower court’s ruling is reversed, New Jersey will effectively be the first state in the country to ban pregnant women from receiving methadone treatment, said Lynn Paltrow, Executive Director of National Advocates for Pregnant Women (NAPW) and co-counsel representing the experts. Not only do the DCPP’s actions “fly in the face of the recommendations of the World Health Organization and the U.S. government, but New Jersey itself, which, through collaborations between the New Jersey Department of Mental Health and Addiction Services and DCPP, provides methadone treatment to pregnant women and families in the child welfare system.”

The Legal Action Center signed on to the amicus brief and strongly supports the NAPW.  “It is wrong, counterproductive, and dangerous to charge a pregnant woman with child abuse simply because she is in a methadone maintenance program,” Sally Friedman, legal director for the Legal Action Center, told AT Forum. “Singling out pregnant women receiving methadone maintenance treatment also can violate anti-discrimination laws.” Ms. Friedman added that child welfare authorities “need to act on the basis of medical evidence, not myths.” The best way for OTPs to make sure that their patients aren’t reported is to educate, added Ms. Friedman.

The mother, YN, is represented by Clara S. Licata and T. Gary Mitchell.

For the friend of the court brief filed January 9, go to http://advocatesforpregnantwomen.org/briefs/DYFS%20v.%20YN%20-%20Amended%20Supplemental%20Brief%20and%20Appendices.pdf

Guidance Provided for Safe Methadone Induction and Stabilization in OTP Patients By Guest Author Stewart B. Leavitt

doctor and patient jpeg winter 2014Expert opinion from ASAM stresses safety during MMT start-up   

For roughly half a century, methadone dispensed in federally certified opioid treatment programs (OTPs) in the United States has been a well-studied, effective, and relatively safe addiction therapy. Yet, there have been ongoing incidents of methadone-associated overdoses and deaths, largely due to its widespread prescription and frequent misuse as a pain reliever, but also to a lesser extent in patients attending OTPs.

When properly prescribed and used in OTPs, methadone has a favorable safety profile; however, there can be special risks of overdose and death from methadone during start up and early phases of treatment. To address these concerns, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) invited the American Society of Addiction Medicine (ASAM) to convene an expert panel to develop a consensus statement on methadone induction and stabilization, which provides recommendations for reducing risks of overdose or death related to the methadone maintenance treatment (MMT) of addiction.

Methadone Start-Up Takes Time and Caution

A distinguished panel of 10 experts in the MMT field—the “Methadone Action Group,” including Drs. Louis Baxter, Anthony Campbell, Michael DeShields, Petros Levounis, Judith Martin, Laura McNicholas, Tom Payte, Ed Salsitz, and Trusandra Taylor, along with Bonnie Wilford, MS—conducted a comprehensive literature search spanning 1979-2011. The group evaluated the resulting information and collaborated in formulating a best practices consensus document, which was subsequently reviewed and commented on by more than 100 experts in the addiction treatment field.

The final document, published in the November/December edition of ASAM’s Journal of Addiction Medicine [Baxter et al. 2013; PDF here], extensively focuses on safety during the 3 most critical phases of starting MMT: A. methadone induction (weeks 1-2); B. early stabilization (weeks 3-4); C. late stabilization (weeks 5+).

According to the medical literature examined by the expert panel, overdoses and deaths during methadone induction most commonly may occur either because 1) the initial dose is too high, 2) the dose is increased too rapidly, or 3) the prescribed methadone interacts with another drug. Therefore, the panel developed recommendations that help methadone providers avoid or minimize these risks.

When it comes to the initial methadone dosing at MMT start-up, the panel stresses the traditional advice to “start low, go slow.” Acknowledging the difficulties of accurately assessing a new patient’s opioid tolerance—and, therefore, a definitely “safe” methadone dose—the initial dose of methadone should typically range between 10 mg to 30 mg per day. An additional 5-10 mg/day is allowed if necessary to help relieve persistent withdrawal symptoms; however, the standard in the U.S. is that the total daily dose should not exceed 40 mg.

There are a number of high-risk situations to consider that may prompt low initial dosing. These include patient age >60 years, recent use of sedating drugs (e.g., benzodiazepines), alcohol abuse or dependence, concurrent physical disorders (e.g., respiratory or cardiac disease, sleep apnea, central nervous system depression, and others), or taking medications that either increase or decrease methadone metabolism.

It is essential to medically assess patients at intake and closely monitor their response to therapy. It may take several weeks before an optimal methadone dose can be safely achieved, during which time symptoms of withdrawal may persist to some degree, especially late in the day or during the night.

The ASAM panel states that the first day’s methadone dose may be increased “every five or more days in increments of 5 mg or less” [note that this dose increase is at the low end of what previous guidance has recommended]. Because methadone levels accumulate gradually before reaching a steady state, whereby opioid withdrawal is prevented throughout a 24-hour period, patients should be carefully assessed and they often need more time for full effects to be realized rather than more daily methadone during the induction period.

The first 2 weeks of MMT are a critical period from a safety standpoint, and the ASAM expert panel discusses the many subtle factors that may influence a patient’s therapeutic response to methadone and also affect clinical impressions of overmedication. For example, individual patient differences in metabolism may alter the duration of methadone effects; furthermore, in some cases, overmedication may be marked by unexpected feelings of excess energy, with or without euphoria.

Beyond the first 2 weeks—during early and late stabilization—the objective is to achieve a methadone maintenance dose allowing the patient to live a better life free of withdrawal symptoms, drug intoxication or excessive sedation, or troublesome drug craving. Various factors may upset this process—e.g., changes in physical health, psychological distress, continued substance abuse, etc.—so ongoing patient assessments and methadone dose adjustments may be necessary in some cases for an extended period of time. The ASAM expert panel does not comment on what optimal methadone dosing eventually might be, other than to note that “some patients require doses larger than 120 mg/day” for blocking euphoric effects of self-administered (e.g., illicit) opioids.

This new evidence-based document from ASAM is the first time all of this vital information has been so extensively brought together in one place; so, it is recommended and important reading for all persons involved or interested in MMT. At the same time, the principles and best practices described are not entirely new; indeed, this topic was previously discussed, although more briefly, in past AT Forum articles [see Special Report 2003 and ATF fall 2006]. Additionally, in 2007, a methadone induction instruction handout for patients and significant others was made available to AT Forum readers by Tom Payte, MD (who also is one of the Methadone Action Group panel members) [PDF here].

Education and Preparedness Are Essential

Methadone overdose can have a deceptive and slow onset, and the ASAM panel stresses the importance of patient and family education beginning with intake into MMT. Involvement of family [or significant others, and presumably with patient consent] can be a critical safety measure by helping to ensure that they understand the lengthy process of methadone induction and stabilization, as well as the signs/symptoms of overmedication and overdose to watch for along the way. Being able to recognize therapeutic risks and potential problems, and knowing appropriate actions to take if problems do occur, are essential for OTP staff, patients, and patients’ families.

Unfortunately, in the ASAM document there is only a single mention of naloxone, which is an effective and safe antidote for methadone overdose. It states, “Opioid treatment programs should establish protocols for emergency response to and management of patient overdoses, including onsite availability of naloxone and any necessary support and education for families.”

Indeed, there appears to be growing interest in the U.S. (and in other countries) in making naloxone more widely available to patients, their families, and others for helping to reverse opioid overdose in an emergency—whether involving prescribed or illicit opioid agents. For example, Washington State has an aggressive program of naloxone distribution [see StopOverdose.org] and the ASAM expert panel references an “Opioid Overdose Prevention Toolkit” from SAMHSA [PDF here]  that discusses how to identify overdose and the use of lifesaving naloxone. Methadone overdose in MMT—what to know; how to prevent it; what to do if it happens (including naloxone) —was the theme of a past edition of AT Forum [Summer 2007 PDF].

In sum, careful management of methadone induction and stabilization, coupled with patient/family education and increased clinical vigilance by staff, can be lifesaving measures during MMT. According to Louis Baxter, MD—ASAM immediate Past-President and chair of the expert panel—in a press release [PDF here], “The use of methadone to treat addiction has saved countless lives in the last 50 years, but it also has an increased risk of toxicity and adverse events for the patient during the medication’s induction and stabilization phases. The protocols designed by the ASAM expert panel could dramatically decrease these negative outcomes if all clinicians prescribing methadone would follow them.”

References

Baxter LE, Campbell A, DeShields M, Levounis P, Martin JA, McNicholas L, Payte JT, Salsitz EA, Taylor T, Wilford BB. Safe Methadone Induction and Stabilization: Report of an Expert Panel. J Addiction Med. 2013(Nov/Dec);7(6):377-386. PDF available at: http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2013/11/26/safe-methadone-induction-and-stabilization. Access checked 1/29/2014.

Leavitt SB. Methadone Dosing & Safety. AT Forum [special report]. 2003 (September). PDF available at: http://www.atforum.com/SiteRoot/pages/addiction_resources/DosingandSafetyWP.pdf. Accessed 1/27/2014.

Methadone Overdose in MMT. AT Forum. 2007(Summer);16(3). PDF available at: http://atforum.com/pdf/Summer07_news.pdf. Access checked 1/29/2014.

Payte JT. Methadone induction instructions to patients and significant others. CMG Induction Handout v7; 2007. PDF available at: http://atforum.com/pdf/PayteSafetyInstructions.pdf. Accessed 1/29/2014.

Safely starting methadone in MMT. AT Forum. 2006(Fall);15(4). PDF available at: http://atforum.com/SiteRoot/pages/current_pastissues/2006Fall.pdf Accessed 1/27/2014.

SAMHSA (Substance Abuse and Mental Health Services Administration). Opioid Overdose Prevention Toolkit. Rockville, MD: HHS Publication No. (SMA) 13-4742; 2013. PDF available at: http://store.samhsa.gov/shin/content//SMA13-4742/Overdose_Toolkit_2014_Jan.pdf. Access checked 1/29/2014.

StopOverdose.org. University of Washington Alcohol & Drug Abuse Institute. 2013. Website at: http://www.stopoverdose.org/pharmacy.htm. Access checked 1/29/2014.

————————————————————————————
Stewart B. Leavitt, MA, PhD, is a former editor of Addiction Treatment Forum and most recently was director/editor of Pain Treatment Topics.

Events

eventsNAADAC 2014 Advocacy in Action Conference
March 2-4, 2014
Alexandria, Virginia
Contact: http://naadac.org/advocacyconference

 

American Academy of Pain Medicine (AAPM) 30th Annual Meeting
March 6-9, 2014
Phoenix, Arizona
Contact: http://www.painmed.org/annualmeeting/main.aspx


American Counseling Association (ACA) Annual Conference and Expo
March 27-30, 2014
Honolulu, Hawaii
Contact: http://www.counseling.org/conference/hawaii-aca-2014

 

American Psychiatric Association (APA) 167th Annual Meeting
May 3-7, 2014
New York, New York
Contact: http://annualmeeting.psychiatry.org/

 

National Council for Behavioral Health 43rd National Mental Health and Addictions Conference
May 5-7, 2014
Washington, DC
Contact: http://www.thenationalcouncil.org/cs/conference

 

20th Annual National Treatment Accountability for Safer Communities (TASC) Conference on Drugs Crime and Reentry
May 7-9, 2014
Birmingham, Alabama
Contact: http://www.nationaltasc.org/2013conference/2014-conference1/

 

National Association of Addiction Treatment Providers (NAATP) Annual Conference
May 17-20, 2014
Charlotte, North Carolina
Contact: https://www.naatp.org/

AT Forum Volume 23, #4 Fall 2013 Newsletter

Methadone vs. Buprenorphine: How Do OTPs and Patients Make the Choice?

choicesOpioid treatment programs (OTPs) have always been able to dispense buprenorphine on the same basis as methadone, but now they can dispense take-home buprenorphine more liberally than take-home methadone. This has given rise to many questions about how new patients should be selected for which medication—the appeal of take-homes is clear, but that doesn’t necessarily mean everyone who wants buprenorphine from an OTP should get it. Still, there is very little information available about how to select which patients for which medication. AT Forum talked to top experts in the country about this question.

There aren’t formal selection criteria developed for OTPs, explained Melinda Campopiano, MD, medical officer for the Center for Substance Abuse Treatment (CSAT) at the federal Substance Abuse and Mental Health Services Administration (SAMHSA). Dr. Campopiano said physicians should apply exclusionary criteria for each medication, but aside from that, the decision is “supposed to be made by a physician, based on individual circumstances.”

It’s clear, said Dr. Campopiano, that more is involved than simply patient choice. “How healthy is the patient medically and psychiatrically? How stable is their life? Can they keep take-home medication safely?”

Andrew J. Saxon, MD, professor in the Department of Psychiatry & Behavioral Sciences and director of the Addiction Psychiatry Residency Program at the University of Washington, prefaced his answers to our questions by saying there are no good data that would help predict which patients might do best on which medication. “My responses involve my own opinion,” he said. He is trying to “piece together the data we do have to lead us at least to some reasonably rational decisions.”

Dr. Saxon noted that the situation is no different from any other area of psychiatry—“We have lots of antidepressants and antipsychotics, but no data to tell us which patient will respond best to which” drug.

That said, methadone has the advantage of retaining patients better in treatment, said Dr. Saxon. “This advantage is very important because so many patients drop out of maintenance treatment, and almost all relapse and significantly raise their risk for mortality.”

The advantage of buprenorphine is a better safety profile, allowing the dose to be raised very quickly to therapeutic levels, said Dr. Saxon, who was the source recommended by the National Institute on Drug Abuse for this article.

If what people want is a formula that gives cookie-cutter recommendations for one drug over the other that can apply in all cases—that isn’t going to happen, said Dr. Campopiano. “You can’t use a formula to tell you what medication to give for blood pressure. You might try one, and if that doesn’t work, try another.” It’s important to rely on science, she said.

One of the big challenges with medication-assisted treatment—and all treatment—for addiction is that the field is short on physicians, unlike other medical treatment fields. This creates a struggle when it comes to answering questions about different medications. A choice between buprenorphine and methadone is, after all, a medical decision.  

The decision to treat with buprenorphine or methadone is based on a combination of factors, said Laura Murray, MD, medical director for Addiction Services for NHS Human Services. Dr. Murray oversees medication-assisted treatment with methadone and buprenorphine in multiple OTPs in Philadelphia and surrounding counties. “In our treatment programs, the process begins with a thorough intake assessment to first determine the appropriate level of care, whether that be inpatient treatment or treatment in the OTP setting,” said Dr. Murray. After review and collaboration with the intake specialist, the final decision for the appropriate form of medication is made by the physician, she said.

Patient Preference

A history of patient reliability, patient choice, and a history of response or lack of response to buprenorphine or methadone would guide Peter L. Tenore, MD, medical director of the division of substance abuse at Albert Einstein College of Medicine in New York City. However, patient preference is not as important as the patient’s responsibility in taking medications correctly.

Dr. Tenore stressed that a patient’s desire to have take-homes is not alone a valid criterion for dispensing buprenorphine instead of methadone. Patient responsibility—to take medications correctly and to prevent diversion—and patient history of or a response or nonresponse to buprenorphine—are the important issues, he said.

“Patient preference guides me a lot,” said Dr. Saxon. “We have a qualitative study showing that patients who prefer methadone but get buprenorphine instead are not well satisfied and don’t stay on it,” he said. “Since we don’t have good data to guide us in making a choice between medications, why not give the patient what the patient wants, unless there are reasons not to?” He added that one reason not to would be that the patient hasn’t done well on that medication before.

Individual preference is a major factor in the decision between methadone and buprenorphine, agreed Dr. Murray. “If an individual presents requesting buprenorphine treatment, we make every attempt to accommodate their preference,” she said. “When a person struggling with addiction has reached the point of accepting the need for help, denying their preferred treatment can be antagonistic and harmful in establishing a therapeutic relationship from the outset.”

However, Dr. Murray noted that the program is “very clear from the beginning that the final decision rests with the program physician after a complete examination and an assessment of appropriateness for treatment,” she said. If patient preference cannot be accommodated, the program works with the patient to help him or her “in a mutual understanding regarding the appropriate treatment and the reasons for the denial.”

Patient preference should be taken into consideration, because patients do better when OTPs “meet them where they’re at,” said Susan F. Neshin, MD, medical director of JSAS Healthcare, an OTP based in Neptune, New Jersey.

Take-homes

If patients’ main reasons for wanting buprenorphine are take-homes, they need to realize that there are more stringent requirements for these privileges.

The more liberal take-home policy for buprenorphine is often attractive for people who are holding down full-time jobs or for mothers with child-care issues, said Dr. Murray. “However, we are very aware of diversion issues and as such we attempt to make an assessment regarding the type of program and the level of structure best suited to the individual, based on their presentation and history.”

 “A patient appropriate for buprenorphine treatment should have relative stability in many important life areas,” said Dr. Neshin, citing employment, housing, relationships, physical and mental health, and support systems. “Patients whose lives are more chaotic need the structure of methadone treatment,” which means coming to the clinic more often.

Array of Services

OTPs offer a broad array of services, and many patients benefit from this. However, many patients are unwilling to commit to the daily attendance and stringent requirements of OTPs. “The stronger their own support systems and commitment to recovery, the less they need the structure of OTPs,” said Dr. Neshin.

It’s not possible to compare office-based treatment with buprenorphine and treatment in the OTP setting (with either buprenorphine or methadone), because of the extra services offered by an OTP. Dr. Tenore demands and arranges for additional services for patients on buprenorphine, as well as for those on methadone.

Treatment in an OTP and office-based treatment are “probably not comparable,” agreed Dr. Saxon, adding that no study has even been done comparing the two settings. “Right now we suspect that patients who make it to office-based treatment are probably different from those who end up in OTPs, with OTP patients being generally sicker and  poorer. But I’m not sure we have adequate data to support that.” And, he stressed, dropout rates from office-based treatment are very high.

In general, patients with a high opioid tolerance and chronicity of use in general should be guided to methadone treatment, said Dr. Neshin. But she added that many patients with apparent high tolerances can comfortably reach an adequate buprenorphine dose.

Previous Failures

For people who have a history of instability on buprenorphine, chances are it won’t be efficacious when tried again, unless there are significant changes in the patient’s circumstances, Dr. Neshin noted.

But clinicians should look beyond a history of failure with either buprenorphine or methadone to the reason for that failure, said Dr. Tenore. Usually, he said, the reason for the failure is that the dose was too low.

Previous failures can make a difference in which medication is chosen, but should never be used alone as a deciding factor, said Dr. Murray. She agreed that the reasons for failure are important. In addition, she said, a past failure with a specific treatment “can lead to a positive outcome in a future attempt, because the individual has learned something from the failed attempt.”

Specific Drug of Abuse

All of our sources agreed that whether patients were addicted to heroin or prescription opioids is not relevant in deciding between methadone and buprenorphine.

But if the patient used opioids intravenously, the structure of an OTP is preferred, regardless of the medication delivered. These patients are more likely to have higher addiction severity scores, noted Dr. Neshin.

Typically, patients with longer addiction histories and longer periods of instability in their lives should be referred for methadone treatment in an OTP, Dr. Neshin said. And while age isn’t an important factor, “immaturity” usually requires the structure of an OTP, she added.

Dr. Murray agreed completely on maturity of the patient playing a role in choice of treatment. While both methadone and buprenorphine patients should be at least 18 years of age, it’s important to determine whether the patient can be compliant with treatment requirements. Younger patients benefit from the more structured environment of methadone maintenance treatment, according to Dr. Murray. “Lifestyle and support systems are important factors in determining the appropriate treatment,” she said, adding again that the more structured environment of methadone maintenance treatment “may be more appropriate for a person without support systems and with an unstable living environment.” 

OTP vs. Office-based

Often, the question of methadone vs. buprenorphine is interpreted as one of OTP vs. office-based treatment. That came up frequently in our interviews, because methadone is still associated with OTPs, and buprenorphine with office-based treatment.

But it’s important to realize that buprenorphine can be given in either setting, and that the fact that patients are allowed buprenorphine take-homes under federal guidelines doesn’t mean that an OTP will make the clinical decision that patients should have take-homes. In other words, methadone always must be dispensed in an OTP (with very rare exceptions), while buprenorphine can be dispensed in an OTP or by an office-based practitioner.

In deciding between an office-based model and an OTP when giving buprenorphine, IV drug users should be steered toward an OTP unless the office-based practitioner is “conscientious about all the necessary medical testing that needs to be done,” said Dr. Neshin, citing in particular HIV and hepatitis testing.

At NHS, all addiction treatment, whether with methadone or buprenorphine, includes multiple ancillary services, said Dr. Murray. “We believe that for most people, medication-assisted treatment does not work alone.”

Among the ancillary services that should be offered in addition to medication: group and individual therapy, family therapy, case-management services, services for specialized groups such as seniors and pregnant women, enhanced recovery services, peer specialist supports, and on-site psychiatric services—these are all offered by NHS. While some office-based providers give referrals for counseling elsewhere, many are not in a position to provide these ancillary services, said Dr. Murray. And it’s often the OTPs who have to pick up the pieces when the services aren’t provided. “We sometimes treat patients who have failed treatment in an office-based treatment setting because they needed a higher level of care or other services to support their recovery, and these were not made available to them.” 

Pregnancy

Pregnancy status is less relevant as a patient-selection criterion than it used to be, now that enough studies have been done using buprenorphine during pregnancy, said Dr. Neshin. “However, I have had many women who started out on buprenorphine and had to switch to methadone during pregnancy due to inability to reach an adequate buprenorphine dose as the pregnancy progressed,” she said.

There are differences of opinion about this issue, with CSAT’s Dr. Campopiano saying that not enough studies have been done to make clinicians comfortable prescribing buprenorphine during pregnancy, and Dr. Tenore of Albert Einstein saying he would absolutely not prescribe it, citing U.S. Food and Drug Administration (FDA) guidelines.

Dr. Murray conceded that recent studies do suggest positive outcomes with buprenorphine treatment, but she said that methadone maintenance “is still the standard of care, and would be our preferred treatment at this time for a pregnant woman seeking treatment.”

fundingCost

There are huge differences in cost between methadone, which is very inexpensive, and buprenorphine. In New Jersey, for example, if a patient has Medicaid and little money, it is often less expensive to be on office-based buprenorphine than on methadone, Dr. Neshin explained. Many OTPs in New Jersey either do not accept Medicaid or limit the number of Medicaid patients they can treat, and many Medicaid patients have to pay the standard weekly clinic fee. Since Medicaid covers the cost of a buprenorphine prescription, patients may have to pay only a monthly fee to an office-based physician. On the other hand, patients without prescription coverage often cannot afford buprenorphine treatment, as even the cost of generic buprenorphine can be prohibitive.

At NHS, cost is irrelevant, since the only out-of-pocket expense is a “very minimal co-pay for buprenorphine prescriptions,” said Dr. Murray. She explained that patients already in treatment with buprenorphine often are admitted to NHS because they can’t afford the cost of an office visit with their office-based provider.

Switching Medications

Some patients want to “graduate” from methadone to buprenorphine, mainly because they are unable to attend the OTP as frequently as methadone treatment requires, said Dr. Neshin, who has transferred many patients for this and other reasons. Typically, the transfer is done with “minimal discomfort,” and patients usually stabilize within days.

Sometimes the transfer is from buprenorphine to methadone—for example, if a patient isn’t doing well in office-based treatment and continues abusing drugs, a referral to medication-assisted treatment in an OTP—or in some cases, to inpatient treatment—should be made, said Dr. Neshin.

If issues of cost are ignored, said the University of Washington’s Dr. Saxon, “it makes sense to start with buprenorphine with a back-up plan to switch promptly to methadone if the response to buprenorphine is not good.” He added that it’s important for patients to know that it’s “easy to switch from buprenorphine to methadone, but it can be quite challenging to switch from methadone to buprenorphine.”

Summing Up

Overall, the determination to treat with methadone or buprenorphine is multifactorial. Methadone maintenance in an OTP provides greater structure because the individual has to visit every day for dosing, or to attend group sessions and counseling. Patients who want take-home buprenorphine are expected to be reasonably compliant with treatment and safety precautions. Patients who have untreated or unstable psychiatric comorbidities, or are currently abusing or dependent on sedative-hypnotic drugs or alcohol (in addition to opioids) may be recommended for methadone treatment in an OTP instead of treatment with buprenorphine.

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.

OTPs as Health Homes: Extra Money for Care Management

healthcare collageSome states are making opioid treatment programs (OTPs) health homes under a federal strategy that is part of the Affordable Care Act (ACA). Under the initiative, which comes from the Centers for Medicare and Medicaid Services (CMS), states can pay OTPs extra money to serve as “health homes” for their patients, meaning that the OTPs will help clients manage both their physical and behavioral health needs, including chronic conditions like obesity and diabetes.

So far, only Maryland, Rhode Island, and Vermont are paying OTPs to be health homes under the ACA. AT Forum talked with health home leaders in the first two states.

“This is a CMS strategy and an endeavor that we support,” said H. Westley Clark, MD, JD, director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA). “From our point of view, we believe the ACA is an important vehicle for behavioral health, and that includes OTPs.”

For OTPs to play an enhanced role under the ACA, states need to apply for approval from CMS to allow the OTPs to serve as health homes, and must use Medicaid money for this purpose.

“The states that have included OTPs in the state plan amendments are doing the field a favor,” said Dr. Clark. He added that this is a critical step, as OTPs try to become participants in the new reimbursement framework.

The state Medicaid dollars that will be going to OTP health homes will initially be matched 90 percent by the federal government.

The logic of selecting OTPs to be health homes, among all substance abuse treatment providers, is that OTPs already have medical staff. OTP patients have a range of conditions that medical staff can address, Dr. Clark said.

SAMHSA has strongly promoted the need for OTPs to have electronic health records, qualified service organization agreements, and health homes, “so OTPs can play a stronger role” under the ACA. CMS is the lead agency on the ACA, with SAMHSA on the periphery, Dr. Clark explained. “Since this is a nascent activity, our role has not been robust. But we are talking to the American Association for the Treatment of Opioid Dependence (AATOD) and to OTPs about the ACA and our hope that OTPs will play a larger role in the delivery of services.”

There’s a big difference between a “patient-centered medical home,” which is a very broad term, and a “health home,” which is codified in the ACA. A health home is for individuals with a chronic condition; importantly, a substance use disorder (SUD) is included in the definition of a chronic condition. A patient-centered medical home is a primary care approach in which there is a home base for both healthy and unhealthy people.

 To participate in a behavioral health care health home under the ACA, and to qualify for the 90-percent federal match, the patient must either have a serious and persistent mental illness and two chronic conditions, or have one chronic condition and be at risk for another. In other words, patients with an SUD and at risk for another chronic condition would be eligible, and this constitutes almost all patients in OTPs.

Rhode Island

Rhode Island was still waiting to hear back from CMS on its state plan amendment, which created health homes in OTPs, when AT Forum interviewed Rebecca L. Boss, administrator of behavioral health services in the state’s Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals. But because the CMS decision can be retroactive—and approval of the proposal was expected—the state is going ahead with implementing health homes at five of the state’s six OTPs.

Ms. Boss, who is also the State Opioid Treatment Authority (SOTA) for Rhode Island, said having OTPs be health homes is a “passion” for her. “Having worked in an OTP, I know first-hand that patients in opioid treatment who have chronic conditions have had difficulty accessing quality medical care,” she told AT Forum. “What better place, in my mind, than an OTP where patients have relationships with medical staff, where they’re comfortable, and where they show up on a regular basis.”

Barriers to health care for OTP patients have included stigma, transportation problems, and lack of insurance, noted Ms. Boss, who added that some patients just need help following up on treatment plans, such as taking medication for diabetes.

A small state, Rhode Island has 3,800 OTP patients receiving methadone maintenance treatment on any given day. About 2,000 are current Medicaid clients—a number that will grow on January 1 when Medicaid expands.

$87 per Patient per Week

There will be 125 patients in each OTP “health home” team, with at least 10 teams statewide, Ms. Boss said. OTPs will get about $87 per week for each patient in a health home team. This rate is separate and apart from what OTPs receive for treatment and an important part of rate setting was teasing out which services covered under treatment would be considered health home activities. Ms. Boss added that the federal government pays 90 percent of the health home service part for the first two years.

Factors such as tobacco use, obesity, and increased age can count as risk for development of a second chronic condition, in addition to SUDs, according to Ms. Boss. “It would be rare that clients in an OTP not meet the criteria” for being in a health home.

One of the biggest challenges will be recruiting patients for health homes. Enrollment has to be voluntary. In Rhode Island, individuals have been auto-enrolled, but have the right to opt out, Ms. Boss explained.

Something New?

OTPs don’t need to provide health care services to be health homes, but they do need to make sure patients have access to such services. In Rhode Island, there will be a nurse dedicated to following 125 patients, coordinating their care. “Patients don’t have to go to just any nurse at a dosing window, they have their own nurse who will help them,” said Ms. Boss.

In many cases, OTPs have already been helping patients who have health issues. “This is the opportunity to reimburse them for some services they have been doing all along,” according to Ms. Boss. “They haven’t had a lot of case managers, but counselors have been doing yeoman’s work in terms of case management.” She added that the health home fees will also pay for part of a physician’s time, the services of case managers, the coordinating services of a masters-level team, and a pharmacist to coordinate medications.

Maryland

Maryland has identified three provider types to be health homes—two are mental health, and one is an OTP. To be eligible as a health home, an OTP must be enrolled with Maryland Medicaid, be accredited by CARF International or the Joint Commission (or pursuing such accreditation), and submit an application to the state. As of November 4, eight OTPs have submitted applications and three have been approved.

According to Lisa Hadley, MD, clinical director of the state’s Alcohol and Drug Abuse Administration and Mental Hygiene Administration, participants must have an SUD, be in methadone treatment, and be at risk for another chronic condition—similar to the Rhode Island health home initiative. For the three OTPs approved so far, there are almost 1,000 patients—410 in one OTP, 281 in another, and 285 in the third.

Almost $99 per Patient per Month

Maryland health home OTPs will be paid an additional $98.87 a month for each patient in the health home, said Dr. Hadley, who is also the SOTA for Maryland. The OTPs will be responsible for providing six different services: comprehensive care management, care coordination, health promotion, individual and family support, and referrals for community support. “Through all their treatment, whether they’re in the hospital or in the community, the health home is responsible for helping to link the patient to what they need.” According to Dr. Hadley, Maryland Medicaid will pay the additional fee, with the federal government paying 90 percent for the first two years, after which the match goes down to the standard 50 percent.

The state will also help the OTPs by providing data on hospital encounters and pharmacy alerts, she said. The program started in October, and is expected to grow in January. “We hope to be getting more applications” from OTPs. “We’re very excited to be able to help OTP patients.”

NIMBY and Other Problems: Still an Uphill Battle For OTPs, But Hope Seen In Patient Advocacy

advocacyThe NIMBY (Not In My Back Yard) syndrome is one significant challenge for opioid treatment programs (OTPs), which can’t operate if they can’t get approval from municipalities. Methadone maintenance treatment has been proven effective and producing good outcomes for five decades, but that isn’t preventing politicians from pandering to prejudice and discrimination. Still, the field is forging ahead, opening new programs and providing access to treatment to needy patients.

Sally Friedman, legal director with the Legal Action Center, said that local authorities often try to zone out drug and alcohol programs in general, but it’s even more difficult to site a methadone program. “It’s challenging to site any type of facility that serves people who folks don’t want around,” she said. “I’ve seen this from examining case law—there’s NIMBY for everything, the elderly, group homes, communities want to keep out all types of social services.”

But a special place in NIMBY-land is reserved for OTPs. In 1977 the Legal Action Center won a landmark discrimination case in which a federal court prevented White Plains in New York from zoning out alcohol and drug abuse treatment programs—and while it wasn’t specific to OTPs, OTPs are included. “Stereotypes and myths” play a part in the NIMBY decisions, said Ms. Friedman.

The Americans with Disabilities Act (ADA) clearly supports OTPs and their patients, and municipalities and their lawyers can easily lose in federal court since the law is so clear. “But there’s a lot of political calculation,” said Ms. Friedman. Local politicians think they have more to gain politically from keeping the facility out, so they’re willing to risk the lawsuit and let the court tell them what they have to do.

MAT First

One point that the substance abuse treatment field in general needs to make more strongly is that medication is the first-line evidence-supported treatment for opioid addiction. “Myth and misunderstanding continue to plague not just methadone alone but medication-assisted treatment [MAT] in general,” said Michal Botticelli, deputy director of the White House Office of National Drug Control Policy [ONDCP]. For opioid dependence in particular, medication is the “first line in our arsenal,” he said. “We have to make sure people understand that this is the standard of care.”

Mr. Botticelli added that there is an opportunity to create a greater consumer voice in favor of MAT. “People have done exceedingly well on methadone maintenance.” Some people need more than medication—other social supports and the structure of an OTP—but others don’t.

As states continue to express concern about prescription drug abuse and overdoses, mainly surrounding opioids, the ONDCP is increasing its stress on the importance of access to methadone and buprenorphine, as well as social supports provided in an OTP. “If we really want to deal with overdose deaths, we need to make sure that we have adequate access to MAT.”

The same myths and stereotypes that bolster NIMBY apply to the criminal justice system, which routinely denies access to medication-assisted treatment. The biggest myth is the one that methadone and buprenorphine are “substituting one addiction for another,” which couldn’t be farther from the truth. Patients in MAT are not addicted—they are not pursuing drugs, they are in recovery, employed, productive members of society. But proponents of discrimination don’t understand how the medications work.

Lack of Negative Impact

It’s also easy to demonstrate the lack of a negative impact in NIMBY siting cases. Jerry Rhodes, chief operating officer of CRC Health Group, said it’s important to bring out studies that show crime goes down when clinics are deployed. “There is science that shows methadone treatment has good results,” he said. But here’s the problem: the issue is an emotional, not a logical, one.

The studies showing that methadone works have been ignored by many public policy makers. And while OTPs had been hoping to enlist government officials and regulators in support of MAT, that isn’t working either. “We’ve had the rug pulled out from under us,” said Mr. Rhodes. “We’re trying to get a more robust commitment.” 

Support From Patients

One thing OTPs could do better is to involve the support of patients, said Mr. Rhodes. “There are often compelling personal stories around the need for treatment, and the effectiveness of MAT.”

In general, the OTP field has done a poor job of rallying patients. But Mr. Rhodes understands that it’s hard to get patients to come forward. “You could lose your job, your neighbor could say something, there’s a fear of being seen as a patient in a clinic.”

The field is beginning to recognize that OTP patients, like other people in recovery, can be a significant voting bloc. For example, there are 5,000 to 6,000 OTP patients in West Virginia. In a small state like West Virginia, 5,000 votes—in some places, even 1,000 votes—can swing an election. When there is no access to MAT, patients—and prospective patients, who also vote—suffer. “This is a job for the National Alliance for Medication Assisted Recovery  (NAMA),” Mr. Rhodes said.

Collaboration

Another good advocacy tactic involves collaborating with other groups. Mr. Rhodes cited the effectiveness of the autism advocacy movement, which is spearheaded by parents who are fierce advocates for their children. Drug addicts, alcoholics, people with mental illness need the same kind of advocates, but have always been treated as marginal populations, which is what drives the stigma. “We can do a better job of working with other constituents,” he said.

Even as a field, various types of treatment are fragmented—medication, no medication, alcohol, drugs—and OTPs could benefit by these groups working together and bringing OTPs into the tent.

Back to NIMBY

The bottom line is, OTPs need facilities, and that means they need certificates of occupancy. Mr. Rhodes warns clinics against going into a community to develop a clinic and not garnering support first. “You can’t do this and not deal with NIMBY, but you can do a better job of trying to support these efforts.”

Here are some of the things you can expect to hear when you try to site a program. “This isn’t our problem.” That’s pretty easy to refute, because an OTP usually has done research and knows that there is an opioid problem. For example, at one meeting, someone stood up and said, “I don’t want this town becoming a methadone mecca.” A physician who was there then said, “You don’t understand, this town is already a heroin mecca.”

The OD Bandwagon

Despite the many newspaper articles about prescription opioid abuse and overdoses, there are rarely any discussions of the cure—treatment. “People don’t understand how prescription opioid abuse relates to methadone treatment,” said Mr. Rhodes. “We rarely address the cure, we just talk about the magnitude of the problem.”

“Education is key,” agreed Ms. Friedman. “We need to explain how the disease works, how the treatments work, and how we produce successful outcomes.”

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