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

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

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

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

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

The Need for Medication Assisted Treatment

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

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

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

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

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

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

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

Buprenorphine Prescribing ‘Disappointingly Low’

Buprenorphine Prescribing ‘Disappointingly Low’

“Few family doctors who complete the required training to prescribe buprenorphine for opioid-addicted patients actually do, new research shows.

A study conducted by researchers at the University of Washington in Seattle showed that following completion of training, fewer than a third of physicians reported prescribing buprenorphine to treat addiction.”

“It’s actually quite frustrating because the problem of opioid addiction has grown enormously in the US over the last 15 years, to the extent that unintentional lethal overdoses from opioids now exceed the number of deaths from car accidents,” study investigator Roger A. Rosenblatt, MD, MPH, of the Department of Family Medicine, University of Washington, told Medscape Medical News.”

A one-time free registration is required to view the article.
http://www.medscape.com/viewarticle/821902

The study was published online March 10 in Annals of Family Medicine.

Source: Medscape.com - March 13, 2014

Prescriptions for Opioids Stabilizing After Fivefold Increase in 10-Year Span

Pg_3_pillsDeath rates from opioids have been soaring in the U.S. since the 1990s. To support the appropriate use of these controlled substances and inform public health interventions to prevent drug abuse, most states have implemented a prescription drug monitoring program (PDMP). In a latest study, researchers at Columbia University’s Mailman School of Public Health evaluated the impact of these state-wide programs and found that after tripling until 2007, annual rates of prescriptions for opioid analgesics have stabilized although the effects of PDMPs on opioid dispensing vary markedly by state. Findings are published in the March/April issue of Public Health Reports.

From 1991 to 2010 the annual number of prescriptions for opioid analgesics in the U.S. almost tripled, from about 76 million to almost 210 million

“We found that PDMPs administered by state health departments appeared to be more effective than those administered by other government agencies, such as the bureau of narcotics and the board of pharmacy, ” said senior author Guohua Li, MD, DrPH, Mailman School of Public Health professor of Epidemiology and director of the Center for Injury Epidemiology and Prevention.”

The press release can be accessed at: http://www.eurekalert.org/pub_releases/2014-03/cums-pfo031014.php

Source: Columbia University’s Mailman School of Public Health – March 10, 2014

U.S. Attorney General Holder Urges Use of Drug to Help In Heroin ODs

Attorney General Eric Holder declaring heroin addiction is an “urgent and growing public health crisis,” urged first responders to carry the drug naloxone that helps resuscitate victims from an overdose.

“Addiction to heroin and other opiates — including certain prescription pain-killers — is impacting the lives of Americans in every state, in every region, and from every background and walk of life — and all too often, with deadly results,” Holder said in a video message posted Monday on the Justice Department website.”

http://www.usatoday.com/story/news/politics/2014/03/10/holder-heroin-overdose-help/6247281/

Source: USAToday.com – March 10, 2014

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

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

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

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

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

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

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

Doctors Urge FDA to Reverse Approval of Zohydro, Controversial New Pain Drug

zoA coalition of addiction experts, physicians and others is urging U.S. health officials to reverse course and block the launch of a powerful painkiller called Zohydro, expected to hit the market next month. The opioid drug, manufactured by Zogenix Inc, contains a potent amount of an active ingredient that could be lethal to new patients and children and is not safer than other current pain drugs, the groups told the Food and Drug Administration.

In December, attorneys general from 28 states also urged the FDA to reconsider its approval of the drug.”

http://www.nydailynews.com/life-style/health/docs-urge-fda-halt-launch-controversial-pain-drug-article-1.1706470

Source: New York Daily News – February 28, 2014

Killing Pain: Fewer Opioid Scripts

prescriiption pad“Doctors and other health providers wrote about 11 million fewer prescriptions for narcotic painkillers in 2013 than in 2012, but some experts expected a bigger drop-off given the brighter spotlight on the nation’s opioid epidemic.

In 2013, there were 230 million prescriptions for opioids such as Vicodin, OxyContin and Percocet, according to data from IMS Health, a drug market research firm. That represents about a 5% drop from a year earlier when 241 million were written.

Opioid prescriptions had grown substantially since the 1990s. At the same time, data show an increase in use of tranquilizers, and weaker opioids such as tramadol, suggesting that Americans are mixing and matching their narcotics and trying unpredictable and dangerous combinations.”

http://www.medpagetoday.com/PainManagement/PainManagement/44499

Source: MedPageToday.com – February 26, 2014

 

Teenagers Treated for Headache Were Prescribed Opioids Almost Half of the Time, According to Study in Journal of Adolescent Health

adolescentClinicians prescribed opioids for almost half of the teenagers they treated for headache when medications, such as aspirin, ibuprofen and naproxen, are recommended as first-line therapies, according to a study today in the Journal of Adolescent Health.

The study was conducted by WellPoint and HealthCore, the outcomes research subsidiary for WellPoint a health benefits company, in conjunction with representatives selected by the American Academy of Pediatrics, American Academy of Family Physicians and American Academy of Neurology. The study included 8,373 adolescents from 13 to 17 years of age with recurring headaches.

“Pediatric and adolescent use of opioids is a concern,” said Dr. Eric Wall, past chair of the American Academy of Family Physicians’ Commission on Science. “The risk of abuse, as well as the potential for redirection, such as sharing with others, is high among adolescents.”

Forty-six percent of those complaining of headache received an opioid prescription. Of those who received a prescription, nearly half – or 48 percent — received only one prescription, while 23 percent received two prescriptions and 29 percent received three or more prescriptions.

Teenagers with visits for headache to the emergency department had twice the rate of opioid prescriptions as those who had not visited the emergency department. And, those who had three or more emergency department visits were four times more likely to have opioid prescriptions.

The study showed much higher rates of opioid prescription than rates of around 12 percent that had been reported previously.

http://www.businesswire.com/news/rxtimes/20140228005350/en/Teenagers-Treated-Headache-Prescribed-Opioids-Time-Study

Source: BusinessWire.com – February 28, 2014

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

Message from AATOD Regarding the Death of Philip Seymour Hoffman

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

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

The AATOD message addresses:

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

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

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

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

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

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

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

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

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

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

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

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

Source: HealthlandTime.com – February 5, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Crime Does Not Increase Around Methadone Clinics in Baltimore

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Source: Jana Burson - February 2, 2014

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