AT Forum Volume 22, #2 Spring 2012 Newsletter

AATOD Conference a Resounding Success

More than 1,350 people attended the American Association for the Treatment of Opioid Dependence (AATOD) meeting held in Las Vegas April 21-25 at the Venetian/Palazzo Hotel. Among the more than 60 attendees from other countries was a large delegation from Vietnam, reporting on that nation’s successful expansion of methadone treatment.

Under the theme “Recovery for Patients, Families, and Communities,” the conference was co-hosted by the Substance Abuse Prevention and Treatment Agency (SAPTA) of the Nevada Department of Health and Human Services/Division of Mental Health and Developmental Services.

Plenary Highlights

The conference opened with Gov. Brian Sandoval endorsing the work of Nevada’s opioid treatment programs (OTPs).  The governor remained to listen to Deborah A. McBride, MBA, SAPTA director, make her opening remarks. There are 11 OTPs in Nevada, and Ms. McBride expressed unwavering support for their valuable contribution in the wake of epidemic prescription-drug abuse in Nevada. AATOD president Mark Parrino, MPA, reported on AATOD’s national work. Gilberto Gerra, MD, director of the Drug Prevention and Health Branch of the United Nations Office on Drugs and Crime, Vienna, Austria, emphasized the international need for medication-assisted treatment (MAT). 

The second plenary session, dedicated to Lisa Mojer-Torres, lawyer, methadone patient, and tireless advocate, who died last year, focused on methadone as a valid pathway to recovery. The session was led by Carol McDaid, co-founder and principal of Capitol Decisions, and William L. White, MA, senior research consultant, Chestnut Health Systems, both in recovery themselves.

“The whole issue of methadone as part of recovery is critical,” remarked Mr. Parrino, noting the negative attitude in many states among legislators and judges who simply don’t think methadone maintenance treatment constitutes recovery.

Timothy P. Condon, PhD, visiting research professor at the Center for Alcoholism, Substance Abuse, and Addictions at the University of New Mexico, did an excellent job of highlighting the science and policy aspects of MAT during the closing plenary. There was also a presentation on MAT as part of health care reform, provided by Paul Samuels of the Legal Action Center.

And during the closing plenary, Justice Michael Cherry, now Chief Justice of the Nevada Supreme Court, expressed strong support for methadone and buprenorphine in the courts and criminal justice system. It is rare to have the highest judge in the state participate throughout an entire AATOD conference, said Mr. Parrino.

Hot Topics

Buprenorphine and Federal Register Notice

Nicholas Reuter, senior public health advisor with the division of pharmacologic therapies at the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), talked with AT Forum about hot topics at the conference, including the pending Federal Register notice allowing OTPs to dispense buprenorphine.

Mr. Reuter said the final rule is now in the Office of Management and Budget (OMB) regulatory review process, where it has been since March 8. The final rule will allow OTPs to prescribe buprenorphine under the same rules as DATA 2000-waived physicians, with some additional requirements.  Now, OTPs can dispense buprenorphine only with the same take-home and treatment rules that apply to methadone in 42 CFR Part 8.

This final rule has taken years to reach this point. The approval may be slowed by the interagency review, speculated Mr. Parrino, with one or two agencies expressing concern about diversion. Ironically, when the proposed rule was first published three years ago, comments expressed concern about OTPs causing buprenorphine diversion. Diversion of buprenorphine is now a major issue, without the final rule. Many OTPs feel that is due to the lack of counseling and other services in the office-based system.

Hepatitis C—A SAMHSA Priority

Robert Lubran, director of the division of pharmacologic therapies at CSAT, talked about the public health implications of hepatitis C virus (HCV) in the U.S., noting that SAMHSA will shift emphasis to screening and treatment for HCV. (See related article in this issue.)

Mr. Reuter added that CSAT has had a focus on HCV at many AATOD conferences: “We emphasize screening and treatment. This is the same situation we had with HIV,” he said. Programs are concerned that if widespread testing is undertaken, funds for treatment must be available.  Most states cover the medical treatment for HCV, but stigma against opioid dependence and OTP patients makes it harder for them to access care.  Mr. Parrino added that AATOD has trained over 700 clinical staff in hepatitis C testing and counseling, but few programs offer on-site treatment.

Methadone Mortality Form Becomes Optional

Surprising AATOD, CSAT announced the suspension of their methadone mortality form, introduced only about three years ago.  CSAT will do a “more formal information collection and analysis,” Mr. Lubran told the AATOD Board. “Instead of a voluntary form, we thought we would work with our colleagues in the Center for Behavioral Health Statistics and Quality to do something more official,” he said. “Right now we’re trying to come up with the best analytic procedure, and pursue a pilot. The idea is to do this in a way that is consistent.”  A Dear Colleague letter to the field about the change is dated April 3, but Mr. Parrino wasn’t given it until April 30. (For a copy of the letter, go to http://www.atforum.com/addiction-resources/documents/DearCollegueMethMortalitySuspension-04-2012.pdf).

Benzodiazepine Use in OTP Patients

The use of benzodiazepines in OTP patients was again a hot topic. Ron Jackson, MSW, LICSW, conducted an excellent, well-attended roundtable discussion about how to handle benzodiazepine use in OTP patients. The long-awaited benzodiazepine guidelines are expected to be part of a set of guidelines that cover the use of many different psychoactive substances in an OTP, instead of just benzodiazepines, Mr. Reuter said after the meeting. “We decided to broaden it, to talk about psychoactive medications in general,” confirmed Mr. Parrino. “But it’s really about benzodiazepines.” (See related article in this issue.)

Awards Banquet

Beny J. Primm, MD, executive director, Addiction Research and Treatment Corporation, presented the Nyswander/Dole “Marie” Awards to nine recipients.

Joseph V. Brady, PhD, Maryland

Otto C. Feliu, MS, New York

Hilary Jacobs, MSW, Massachusetts

Edward J. Johnson, MA, South Carolina

Barbara Schlichting, LCSW, New Jersey

Stacy Seikel, MD, Florida

Steve Tapscott, MA, Texas

Stephan Walcher, MD, Germany

William C. Wilson, California

Banquet honorees also included William L. White, MA, who received the prestigious Friend of the Field Award, and Roxanne Baker, CMA, recipient of the Richard Lane/Robert Holden Patient Advocacy Award for her work on behalf of methadone and recovery.

The next AATOD National Conference will convene in November 2013 in Philadelphia.

Some OTPs Discharge, Others Taper for Illicit Benzodiazepine Use

Benzodiazepine use and abuse by patients on methadone is a pressing concern for opioid treatment programs (OTPs) because of potentially dangerous drug interactions, especially during induction, so it was a natural selection for a “hot-topic” meeting at the American Association for the Treatment of Opioid Dependence (AATOD) conference in April. Ron Jackson, MSW, LICSW, moderated the session.

“We decided to have this hot topic because everybody talks about the problems of benzodiazepine use, so we wanted to figure out what treatment providers were doing and why they were doing it,” said Mr. Jackson, who is executive director of Evergreen Treatment Services in Seattle.

Some patients are prescribed benzodiazepines with the knowledge of the OTP.  There was a large degree of difference in program policies about approving such prescriptions as described by participants in the roundtable discussion, ranging from “If it’s being prescribed by a psychiatrist it’s OK” to “Our clinic has a discussion with the prescriber to coordinate care.” But of bigger concern are patients who are taking benzodiazepines but do not have valid prescriptions—they may be doctor-shopping or buying benzodiazepines on the street. For these patients, there is no consensus, at least not one Mr. Jackson detected during the AATOD session. “Program policies are all over the place,” he told AT Forum. Some refuse to admit anyone who says they use benzodiazepines. Some will admit these people but require them to self-taper during the first month—a risk, because the patient could have seizures. One OTP said patients are sent to a local facility for detoxification—but that could be a problem, because they are detoxified from opioids, too.

Some OTPs simply decrease methadone doses for patients whose urine drug tests are positive for benzodiazepines, but Mr. Jackson said there’s no science to support this, as the tests do not measure how much the patient is taking.

In fact, there aren’t many tools for patients who are abusing benzodiazepines, said Mr. Jackson. “I wish there were some sort of benzodiazepine antagonist. Other than cognitive-behavioral therapy to resist cravings, there isn’t anything.”

Evergreen’s PMP Experience

A combination of checking with the prescription monitoring program (PMP) and asking patients what they are taking helps identify which people are on benzodiazepines before they are admitted. The PMP will not tell whether patients have bought them on the street or obtained them in some other way without a prescription, which is why it’s important to also ask them, said Mr. Jackson.

Evergreen’s patients are required to register their prescriptions with the OTP, so the clinicians know about possible drug interactions and are able to coordinate care. Recently Evergreen queried the PMP about all of its patients in the Seattle clinic. It found that 31 percent (350 patients) in the clinic showed up on the PMP. Of these 350 patients, about 20 percent were taking exactly what they had registered they were taking. “I was happy with that,” he said. But of the other 80 percent, 45 percent were prescribed benzodiazepines. Some were taking them but did not inform the OTP, and some were selling them. The number of current benzodiazepine prescriptions per patient ranged from 1 to 19.

Evergreen worked closely with these doctor-shopping patients by trying to get them to quit. “We wanted to continue their OTP treatment while safely tapering them from benzodiazepines,” said Mr. Jackson. “But if patients cannot cooperate, and every drug test is positive for benzodiazepines, and the patient has been to the ER with overdoses, we say, ‘You may need a higher level of care. We can no longer safely give you the medications you need.’”

Many more patients—88 percent of the 350—were getting prescribed opioids, but some were not taking them – this was clear because the medications never appeared in urinalysis tests. Some were selling all of them, which was also true of those receiving prescriptions for benzodiazepines. “One patient said, ‘This is my way of making a living,’” said Mr. Jackson. That patient left treatment. Some were getting prescriptions for Suboxone and selling or giving away the pills.

For patients who had prescriptions for trivial amounts of drugs—for example, a prescription for 6 acetaminophen/ hydrocodone (Vicodin) after a root canal procedure– Evergreen didn’t take any action other than reminding such patients to register their medications. About 25 percent of the patients had prescriptions for these “trivial” amounts.

Seeking a High

The reality is that some people come to methadone treatment but aren’t interested in treatment, according to Mr. Jackson. “They’re interested in the medication. That way they can continue to live the life they want—without craving opioids—and instead can get high from other drugs, like benzodiazepines.” OTPs must face this reality, especially OTPs with limited capacity or waiting lists, noted Mr. Jackson. Patients come to OTPs with a history of seeking euphoria from drugs.  “You end up with this difficult triage decision: who is appropriate, who gets these slots?”

 

Innovative Massachusetts Federally Qualified Health Center Expands OTP Services

For 3 years, Lifeline, an opioid treatment program (OTP) of Stanley Street Treatment and Resources (SSTAR) has been providing methadone treatment at its site in the South End of Fall River, Massachusetts. In 1990 SSTAR became a federally qualified health center (FQHC) providing methadone, primary care, and behavioral health care to their OTP patients. SSTAR was the first OTP in the country by many years to do this—because it couldn’t find any local physicians willing to see OTP patients, according to Lisa Garcia, executive director of the SSTAR OTP.

This spring, SSTAR opened a satellite clinic, South End Services. At the new site there is the large OTP; an outpatient behavioral health program, which includes psychiatry; and the health center with all medical services.  There are no OTP patients on the North End site; all 446 patients are going to South End Services. Before the expansion, the patient census was in the “low 300s,” said Ms. Garcia.

Federal stimulus funds grant of $480,000 provided by the Health Resources and Services Administration (HRSA) enabled SSTAR to renovate and expand the satellite clinic.  SSTAR also contributed $130,000 to complete renovation of the satellite so that all OTP, behavioral health and now medical care services are provided at one location. 

Benefits of Coordinated Care

FQHCs have been funded for 40 years by the federal Health Resources and Services Administration to provide community-run comprehensive primary care services to high-need communities. For an OTP, the benefits of being part of a FQHC are many. Having access to the services of a FQHC makes it easier for the OTP to coordinate health care for its patients.

Having the health center connected to the OTP makes it easy if a methadone patient comes in ill. Each patient has his or her own assigned nurse and physician. The OTP can call and schedule an appointment for the patient. It’s more difficult to get patients to follow through on medical appointments if the appointments are not on site, Ms. Garcia said.

Some patients do come in with their own primary care physicians (PCPs), but they have the option to switch to the health center’s physicians at any time. It’s also beneficial to the patient to have collaboration between the OTP and their PCP, if the patient signs a release so that confidentiality protections are waived. One patient told Ms. Garcia that she liked “being treated as one piece, instead of being treated as tiny pieces.”

“Within the first 90 days after patients are stabilized on methadone, we will talk to the patient about going to a PCP and a dentist,” she said.  In addition, many patients have small children, and the health center will be able to offer pediatric care—another plus for patients.

Welcoming

Patients love the site, reported Ms. Garcia. “I spent a lot of time in the waiting area the first week we opened. I watched the way they came into the building.”

At SSTAR, the goal is not just “treating” the patient, she said. “We’re trying to get the patient to feel better and to do better.” Even small things can help. Some people’s first reaction when they walk into the well-lit foyer is:  “Glass doors in an OTP?” Ms. Garcia’s response: “We did that to let the sun shine in.” She was speaking about the building, but she was also speaking about the feeling of the program. “We have windows, we have glass doors. That’s part of how the building treats OTP patients with respect.”

Ms. Garcia added, “We spent a lot of time looking at the space and making sure it’s not just white walls—we wanted soothing colors.”

A great source of satisfaction was the parking lot. “For the first time, we have our own parking for patients,” said Ms. Garcia. “One of the things they like best is that they can park without getting frustrated looking for a space.”

Check-in is through the patient’s electronic medical record (EMR), which lets the front desk know whether the patient needs to see a clinician first, or needs to go to the financial department, or can go straight to dosing. This makes patient-flow much easier, according to Ms. Garcia.

At the old site, the OTP was located in the hallway, so patients had to wait in the hallway. At the new site, there are three dosing windows, so the wait isn’t as long, and there is enough space between the windows so patients have privacy. “They feel as if they are going to a real medical office,” said Ms. Garcia. “It’s welcoming to them.”

CODA Credits Its Research Department for Winning SAMHSA Award

 Officials at CODA, one of the three opioid treatment programs (OTPS) to win the 2012 Science and Service Awards sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), firmly believe the program’s commitment to research not only led to the prestigious award, but also is essential to improving outcomes for their patients.   

About 10 years ago CODA started partnering with the National Institute on Drug Abuse (NIDA) to do clinical research, and in 2007 the Portland, Oregon program started its own research department with five people on staff. Grants come from NIDA, from other institutes of the National Institutes of Health, and from various other sources.

 “What is so fantastic about having a research department that is integral to an agency is it creates a tone that carries through to the clinical staff,” said Alison Noice, director of medication-assisted treatment. “It’s not about lip service to evidence-based practices.”

The research department is financially independent, and is not used as a revenue generator for CODA. “We only get the money to pay for our materials” from grants, said Ms. Noice. “We get money for a nurse, for part of a physician, but it isn’t a funding stream,” she said. Having a research department is a “huge boost” to the clinical staff. “It’s something that my staff and my patients can be proud of.”

CODA was the first OTP in Oregon, starting in 1969, and is the only non-profit OTP in the state. “We feel fantastic” about the SAMHSA award, said Ms. Noice. “We’re cutting edge,” because of the research program.

That cutting edge quality owes a lot to the belief that “there is no such thing as a typical opioid-dependent patient,” said Ms. Noice. “CODA is committed to meeting the needs of that wide spectrum.”

Matching Patients to Groups

“The research we do around methadone is primarily on who are the better candidates for what kind of treatment,” said Katarina Weiss, research director. “For example, we were one of the first places to identify that we needed to have groups for younger women.” There has been an increase in young women in OTPs who are prescription opioid abusers, and this group of women “tends to do more sex in exchange for goods and services,” she said. CODA has also added a women’s sexuality group. CODA’s census of 657 is now half female.

Older males tend to drop out of treatment unless they are engaged quickly, said Ms. Weiss. More than 50 percent drop out in the first 90 days. “We’re working on identifying those patients who might be at higher risk of dropping out,” she said. “Why are we losing these people?” The people who are most likely to succeed in treatment are older, less likely to have polydrug abuse, less likely to use benzodiazepines, and ready for treatment, said Ms. Noice. “If we can target them well in the beginning, they will do very well,” she said. “But if we don’t focus on them, they will get lost in this crowd, which is younger and high need.”

Another innovation is massage. Many patients in medication-assisted treatment (MAT) have chronic pain. CODA is using massage therapy to see if that can help. Under a grant from the Massage Therapy Foundation, CODA is conducting research into non-pharmacologic supplementation for people who are in MAT with methadone and who have chronic pain. It’s a randomized controlled trial, with one group receiving treatment as usual, and one receiving treatment and massage.

Rapid HIV Testing

For a project funded by the Mutinomah County health department, CODA is looking at a problem that is plaguing many OTPs—how to get more patients tested for HIV. By implementing rapid HIV testing, more patients are being tested, and the county, which pays for the tests, will save money. Rapid tests, which don’t involve a blood draw, are much less expensive than lab tests.

“The CDC recommends that everyone be tested, but getting patients to go have the test is difficult,” said Ms. Noice, noting that nationally only 24 percent of OTP patients have been tested for HIV. “We found that by offering rapid HIV testing instead of the blood test, which takes two weeks to get results, we have a 95 percent rate of testing.” The sensitivity and specificity of the test is 99.7 percent, she said. “We can do a wonderful intervention and counseling right then,” she added. And that is the appeal—patients are more willing to get the test if they know they can get results and counseling immediately.

While other OTPs might not have wanted to do the work involved in applying for the SAMHSA grant, CODA’s research department is used to writing applications—another benefit of having a research department.

About the Awards

The purpose of the SAMHSA awards is to “promote excellence in the treatment of opioid addiction by recognizing OTPs who use pharmacotherapy as part of their treatment protocol and who have demonstrated implementation of exemplary innovative services, practices, and/or strategies, resulting in improved patient outcomes,” according to SAMHSA’s press release announcing the awards. Programs were judged based on the following criteria:

  • Treatment population(s)/ subpopulation(s) served,
  • Evidence-based practices and treatment,
  • Improved patient outcomes,
  • Innovativeness, and
  • Management and staff capabilities. 

The two other winners were the Addiction Institute of New York at St. Luke’s and Roosevelt Hospitals in New York City, and Connecticut Counseling Centers, Inc. of Norwalk, Connecticut.

The awardees were honored at the awards banquet at the national conference of the American Association for the Treatment of Opioid Addiction held in Las Vegas in April.

Hepatitis C: Good News—and Challenges

“Twelve weeks into treatment they checked my viral count and it was undetectable. I knew I was going to make it through this.” 

— a patient, quoted in Tip 53: Addressing Viral Hepatitis in People With Substance Use Disorders

Tip 53—the new publication from the Substance Abuse and Mental Health Services Administration (SAMHSA)—is full of great information about hepatitis C virus (HCV)—the new rapid diagnostic test, the two new drugs that have advanced the treatment of HCV infection, and everything staffers and patients at opioid treatment programs (OTPs) need to know. (See Resources to find out about a free download or paper copy.)

Why Hepatitis C Is So Important to OTPs

The prevalence of HCV infections in the U.S. is about 3 million to more than 5 million, and at least half are related to injection drug use. Because HCV afflicts between 67 percent and 96 percent of methadone patients, those who aren’t infected need to know how to prevent it, and those who already have it need to know about tests and treatment options, and how to avoid spreading the infection.

Hepatitis C begins as a silent disease. It goes away in about 15 percent to 25 percent of people; otherwise it can persist for decades, without symptoms, until there is severe liver damage that can lead to liver failure or cancer, a liver transplant, or death.

A New Test and New Treatment Options

The new 20-minute screening test can detect HCV antibodies in a blood sample while the patient is waiting. If a patient tests positive on screening and follow-up testing, further workup entails finding out which of six types of HCV—called genotypes—the patient has. Most methadone patients have genotype 1. Workup could also include a liver panel, other blood tests, a viral load test to determine the amount of virus present, and maybe a liver biopsy.

If a caregiver and patient decide treatment is best, two newly approved oral drugs greatly improve the odds for those with genotype 1: telaprevir (Incivek) or boceprevir (Victrelis). When either—never both—is added to the current two-drug therapy—weekly peg-interferon injections, plus daily oral ribavirin, 68 percent to 80 percent of patients respond, vs. 40 percent to 55 percent that responded to the previous two-drug therapy. Treatment time for many patients has been cut in half, to about six months. (The methadone dose may need to be modified, because of interactions with the new drugs.) Patients with genotype 2 or 3 tend to respond well to the earlier two-drug treatment.

When the virus can no longer be detected in the blood for six months, the patient is said to have a “sustained viral response”—an SVR. The virus doesn’t return in up to 99 percent of patients, but reinfection can occur, so preventive steps are important.

In another few years, a new two-drug oral therapy (without peg-interferon injections) may be available. Many oral drugs are in clinical trials, and a regimen now in experimental use in humans has achieved very high cure rates. By then, a hepatitis C vaccine may even be on the horizon.

What OTP Patients Can Do

HCV is highly contagious—much more so than HIV. But it’s a blood-borne disease, rarely spread through sexual contact. Patients need to avoid contact with blood that has been contaminated with the virus. This means not sharing injection needles, or rinse water, even a razor or toothbrush that may harbor invisible traces of blood.

Also, OTP patients should get vaccinated against hepatitis A and B, to help shield the liver from damage caused by those viruses. A damaged liver is less able to withstand hepatitis C infection. OTPs may have these vaccines, or can refer patients elsewhere.

Also important is avoiding alcohol, for it contributes to and often speeds liver damage in people with hepatitis. The same is true of acetaminophen and other drugs that can damage the liver.

Patients’ Views

Focus groups of OTP patients interviewed in Beyond Methadone (see Resources) called for at least one onsite OTP specialist for hepatitis C—but that’s a difficult goal for a small OTP, and trained staff can fill many roles. The survey noted that about one-fourth of OTP patients didn’t know their HCV status, and didn’t recall ever being offered a test. The survey also found that more than half who tested positive said they weren’t referred for follow-up tests or medical care, nor were they aware of any support groups or educational materials at their program. Based on these focus findings, OTPs can provide more HCV education, testing, support, and treatment, either onsite or by referral. 

How OTP Staff Can Help

OTPs are being called upon to help patients deal with a deadly illness. According to the Centers for Disease Control and Prevention (CDC), more people in the U.S. now die each year from hepatitis C than from AIDS—almost 5 per 100,000 from hepatitis C, vs. about 4 per 100,000 from AIDS. Clearly, early diagnosis, treatment, and support services would save much suffering and many lives. This is a great opportunity for OTPs to make a difference in the lives of their patients.

VOCAL-NY and other patient advocacy groups have long urged OTPs to provide better intervention and care for patients with HCV.  Many OTPs—67 percent, according to the National Survey of Substance Abuse Treatment Services—already test patients for HCV infection, and that’s very encouraging, but it leaves a sizeable percentage untested, therefore untreated. Some OTPs that test haven’t the resources to provide follow-up care for patients who test positive—additional tests, education, counseling, and medical care. Those OTPs will need a strong referral system to send patients elsewhere, and to make sure they follow up.

Sometimes the side effects of HCV therapy may feel similar to withdrawal symptoms. Staff can encourage peers and patients in treatment to share experiences, support each other, and help each other access care and adhere to treatment.

Many OTPs offer testing only, but staff can still help immensely by being supportive of patients and providing information about HCV in a nonjudgmental, compassionate way, referring patients to outside sources, and making sure they follow up. VOCAL-NY recommends that OTPs with limited services “establish a concrete referral system for HCV patients, and enter into memoranda of understanding (MOUs) with medical providers for follow-up care.”

Among the many wonderful resources for OTP staff in Tip 53 are leads for patients seeking financial help. Treating hepatitis C is costly and can take many months. Yearly medical expenses can easily top $60,000—and that’s before a liver transplant, which can add $100,000 to $250,000 for the procedure alone.

Hepatitis is inflammation of the liver. It can be caused by viruses, substance or alcohol use, certain diseases, or exposure to toxins. The term viral hepatitis refers to liver inflammation caused by any of several viruses; A, B, and C are the most common in the U.S. Acute hepatitis lasts six months. If acute hepatitis doesn’t go away—through treatment, or on its own—it becomes chronic hepatitis, and can last indefinitely, whether treated or not.

Resources

Substance Abuse and Mental Health Services Administration. Addressing Viral Hepatitis in People With Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 53. HHS Publication No. (SMA)11-4546. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.  http://store.samhsa.gov/shin/content//SMA11-4656/SMA11-4656.pdf

Beyond Methadone: Improving Health and Empowering Patients in Opioid Treatment Programs. VOCAL-NY and Community Development Project of the Urban Justice Center (CDP). ebook. By Alexa Kasdan, Phil Marotta, Alison Hamburg, VOCAL New York; and the Urban Justice Center. Brooklyn, NY. VOCAL New York, New York, N.Y. October 6, 2011. http://www.vocal-ny.org/wp-content/uploads/2011/10/Methadone-Report-Cover1.jpg

 

A Call for OTPs to Step up Rapid HIV Testing

The Substance Abuse and Mental Health Services Administration (SAMHSA) and their Addiction Technology Transfer Center (ATTC) network, along with the National Institute on Drug Abuse (NIDA), are urging substance abuse treatment programs to step up rapid testing for HIV during the time patients are in treatment programs. Patients in substance abuse treatment are at high risk of HIV infection because they may engage in injection drug use and unsafe sex.

The need for rapid HIV testing is compelling, with new HIV cases in the U.S. appearing at a steady rate of about 50,000 per year. About one person in five who is HIV positive is unaware of it—and those are the people, according to SAMHSA, who transmit most new cases of HIV. Identifying them and getting them into treatment could impact the spread of HIV.

Rapid tests for onsite use are inexpensive and widely available to Opioid Treatment Programs (OTPs) and other programs through the local health department and the State Authority. Positive rapid test results must be confirmed by traditional blood tests. Rapid test results take one to 20 minutes, so patients can learn their HIV status in a single visit. Despite this, and despite the well-known link between substance misuse and HIV infection, fewer than half of U.S. drug treatment programs offer HIV testing onsite. OTPs do better than most programs; 69 percent of OTPs offer onsite HIV testing.

How Effective Are Onsite Testing and Counseling?

To find out, SAMHSA-ATTC /NIDA carried out a multisite HIV Rapid Testing and Counseling Study, enrolling adults from four types of programs—outpatient medication-assisted treatment, outpatient psychosocial, intensive outpatient, and residential. Participants were either HIV-negative or of unknown HIV status, and had not been HIV-tested during the previous 12 months. They were divided randomly into three HIV testing groups:

  • Onsite, with brief risk-reduction counseling
  • Onsite, with verbal information about testing only
  • Referred for offsite testing

Results

More than 80 percent of those tested onsite received their test results, compared to only 18 percent who followed through when referred offsite. The results support routine rapid HIV testing and providing patients with information about testing, but not risk-reduction counseling for those who tested HIV–.  Patients were glad to have test results so quickly, and said they “felt safe,” and were “so happy” about being able to be tested in their own program, rather than being referred elsewhere, according to Louise Haynes, MSW. Onsite testing was a real asset to the program.

The HIV Rapid Testing Initiative 

The HIV Rapid Testing in Substance Abuse Treatment Program is a joint effort by the SAMHSA-ATTC /NIDA Blending Initiative to put the results of medical research—such as new rapid diagnostic tests—into the hands of treatment providers as quickly as possible. Spurred by an Institute of Medicine report of a 17-year gap between the publication of research results and their practical impact on patient care, the Blending Initiative speeds the dissemination of findings from research-based drug abuse treatment into community-based practice.  Its website offers a Fact Sheet, Resource Guide, Marketing Materials, Training Information, State-Specific Testing Laws, and other resources, including a Budget Worksheet to help OTPs set up an HIV Rapid Testing Program.

http://www.attcnetwork.org/explore/priorityareas/science/blendinginitiative/rapidtesting/hivrapidtest.asp

http://www.cdc.gov/hiv/topics/testing/rapid/#Main

http://www.drugabuse.gov/publications/nidasamhsa-blending-initiative

Prisoners Taking Effective Methadone Doses Report to Methadone Treatment Programs After Release

“To be effective, [opioid addiction] treatment must begin in prison and be sustained after release through participation in community treatment programs.”—Nora D. Volkow, MD, Director, National Institute on Drug Abuse (NIDA)a

A simple goal, but rarely achieved. So it’s refreshing to hear of a detention system that actually views incarceration as “an opportunity for prevention and treatment, including initiating methadone treatment prior to release”—a system where inmates’ doses are titrated to effective levels, and inmates report to methadone treatment programs (MTPs) after release.

That system is the Rikers Island Key Extended Entry Program (KEEP), offering methadone treatment to opioid-dependent inmates of New York City’s jails. The KEEP program began in 1986; today its goal remains to relieve or prevent opioid-dependent inmates’ withdrawal symptoms, and to engage inmates in long-term, effective methadone maintenance treatment (MMT).

The Effective-Dose Effort

In July 2007, in response to a trend toward low-dose methadone prescribing, KEEP initiated an evidence-based, dose-adjustment, quality-improvement (QI) protocol to maximize the therapeutic effects of methadone, and to improve inmates’ reporting rate to MTPs after release. They trained counselors, physicians, and pharmacists in the QI guidelines, which call for gradual titration to methadone doses of 70 mg per day or higher, as necessary, at increases of 5 to 10 mg per day.

About 650 opioid-dependent prisoners were enrolled in the QI study. Roughly half were in MTPs at the time of arrest. The group was fairly representative of the Rikers’ population—average age, 40 years, 72 percent men, 40 percent African American, 41 percent Hispanic, and 19 percent Caucasian/other.  Data were collected in July and November, 2007.

Results

The methadone dose at the time of discharge ranged from 15 to an exceptionally high 1,140 mg/day, with a median of 50 mg/day. The proportion of patients reaching effective doses increased significantly among those incarcerated at least 21 days, allowing time for titration. At discharge, significantly fewer patients (34 percent vs. 72 percent) were within the lowest methadone dosage range—15 to 30 mg/day—than those discharged before the QI program began.

In addition to providing the best results, effective doses yielded the best rates of reporting to MTPs upon reentry. In fact, all prisoners who reached 55 mg/day or higher—even those not in the QI study—reported to an MTP post-release.
The authors note some shortcomings in their study, published January 2012 in Substance Abuse. Gradually increasing a prisoner’s methadone dose requires several weeks, so the short length of stay of many jail prisoners made it difficult to reach an optimum dose before their release. The authors also said it would be helpful to add more data to the study, especially on dosage, and to follow up with prisoners after reentry, to see if they remained in treatment.

Here’s some evidence from follow-up data from NIDA: a graph showing that prisoners started on methadone one month before release are more likely to be in treatment and heroin-free six months later than those who receive counseling alone. Dr. Volkow, who presented this slide at a Blending Conference in April 2010, called for implementation of this evidence-based treatment nationwide, calling it a “win-win scenario.”

 

Dr. Volkow’s initial premise doesn’t seem so difficult to carry out. So why aren’t other jails and prisons doing what KEEP has done?  We look forward to hearing your comments on your experiences with medication-assisted treatment in your probation, parole, jail, or prison system.

References

aNational Institute on Drug Abuse. Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-based Guide. National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD. NIH Publication No. 06-5316. Published September 2006, Revised January 2012.
http://www.drugabuse.gov/publications/principles-drug-abuse-treatment-criminal-justice-populations

bHarris A, Selling D, Luther C, et al. Rate of community methadone treatment reporting at jail reentry following a methadone increased dose quality improvement. Subst Abus 2012;33(1):70-75.

Stop Stigma Now: Small Organization Rises to Raise Funds for Methadone Treatment PR Campaign

 Stop Stigma Now, a small group of retired opioid treatment program (OTP) providers has a big—and honorable—goal: eradicating stigma against the methadone treatment field. It began about five years ago with the closure of the Mount Sinai Narcotics Rehabilitation Center in New York City, recalls Joycelyn Woods, project coordinator with the National Alliance for Medication Assisted Recovery (NAMA Recovery).

The physician and administrator who led that program got together and started talking about the fact that the stigma situation isn’t any better than it was in 2007. “It’s worse,” said Ms. Woods. “Nobody is going to do anything about it unless we do something about it ourselves. I had hoped for a long time that the federal government would do it—they have the money and the resources.”

Sy Demsky, the former administrator at Mount Sinai (he retired shortly before the closure), and Philip Paris, MD, the physician, helped organize the Stop Stigma Now group. “Their idea is to raise money from new sources and create a huge PR campaign,” said Ms. Woods. One suggested way of raising money was to ask OTP patients—each of whom would contribute one dollar. “The programs have to decide whether to cooperate. This could be impossible to manage,” she said.

This leaves Stop Stigma Now in a difficult position—doing something very important, without adequate funding to make it happen.  With prescription opioid abuse rampant, OTPs and state substance abuse agencies seeking to address this are faced with new zoning restrictions or outright prohibition based on prejudice or unfounded fears.

“We wish to let the public see our patients as the successes so many of them are,” Dr. Paris told AT Forum in an e-mail. “Our patients are dependent on their medication, not addicted,” he said. “They are not substituting methadone for their street drug. Instead, methadone helps to correct the illness induced by years of using heroin or abusing pain medications.”

Stop Stigma Now attended the AATOD conference in Las Vegas, prominently passing out buttons and letting the addiction treatment field know about their work. “We were received warmly with a show of support by many of the leaders in the field,” said Dr. Paris. “We received many pledges for future financial support. That is very important if we are to be able to widen our anti-stigma message.”

To find out more about Stop Stigma Now, and to make a donation, go to http://www.methadone.org/stopstigmanow/.

Link accessed May 27, 2012

Events

The Virginia Summer Institute for Addiction Studies
July 16-17, 2012
Williamsburg, Virginia
Contact: http://www.vsias.org/

SAMHSA 5th National Conference on Behavioral Health for Women and Girls
July 17-19, 2012
San Diego, California
Contact: http://samhsawomensconference.org/

American Mental Health Counselors Association (AMHCA) Annual Conference
July 19-21, 2012
Orlando, Florida
Contact: http://www.amhca.org/

International AIDS Conference
July 22-27, 2012
Washington, DC
Contact: http://www.aids2012.org/

American Psychological Association 120th Annual Convention
August 2-5, 2012
Orlando, Florida
Contact: http://www.apa.org

American Sociological Association
August 17-20, 2012
Denver, Colorado
Contact: http://www.asanet.org/AM2012/index.cfm

Links accessed on May 27, 2012

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