AT Forum Volume 22, #1 – Winter 2012

Denying Medication-Assisted Treatment (MAT) in the Criminal Justice System—Is It Legal?

Denying access to medication-assisted treatment (MAT) for opioid addiction has been a long-standing practice throughout the criminal justice system, with devastating consequences—unnecessary incarceration, increased spread of HIV, hepatitis, and other infectious diseases; drug overdose, sometimes fatal; and recidivism rather than recovery.

Many arrestees and inmates in U.S. facilities are addicted to opioids, yet a December 2011 report from the Legal Action Center says that the vast majority of jails and prisons fail to offer MAT as ongoing maintenance treatment, even when it’s recommended or prescribed by a treating physician. At an estimated cost of about $4,000 per year, MAT successfully reduces addiction and related criminal activity, allowing people to lead productive lives, support families, and pay taxes—rather than costing taxpayers as much as $40,000 annually for imprisonment.

But some probation and parole agencies prohibit MAT, and courts often require detoxification from methadone or buprenorphine before defendants can complete drug court requirements as an alternative to jail or prison.

The Legal Action Center report, Legality of Denying Access to Medication Assisted Treatment in the  Criminal Justice System, (see link) explains why withholding access to MAT at any level of the criminal justice system—correctional facilities, courts, and parole and probation boards—makes no sense, and can violate federal antidiscrimination laws and the United States Constitution.

For example, the Americans with Disabilities Act (ADA) and the Rehabilitation Act of 1973 prohibit discrimination on the basis of disability, and require that each individual’s ability to take part in specific activities be evaluated objectively. Denying access to MAT at any level of the criminal justice system violates these Acts, whether denial is based on a blanket policy or carried out on a case-by-case basis, but without the required objective, individualized evaluation.

Moreover, jails and prisons that force those receiving MAT to detoxify without proper medical supervision and treatment risk violating the Constitution’s EighthAmendment prohibition on cruel and unusual punishment, or the Fourteenth Amendment Due Process clause. Thus, medical best practices continue to elude the vast majority of those who have an opioid use disorder and are unfortunate enough to come up against the criminal justice system. They’re being forced to taper or go to jail.

Access Denied!

Despite advocates’ attempts to work with judges and probation and parole boards, denied access continues. Some examples:

  • Drug court judges who believe in MAT, but rarely refer people for treatment because they feel pressure from district attorneys.
  • District attorneys concerned with what they view as public safety risks in granting outpatient versus residential treatment, and who regard MAT as having the risk of abuse or diversion.
  • Defense attorneys who have little information about what’s appropriate or needed for their clients, or an understanding of best practices in treating opioid addiction, and aren’t prepared to advocate for medication-assisted treatment.
  • Judges and drug court staff who “have a rule: we just don’t let people stay on methadone and graduate from drug court.”
  • The Federal Bureau of Prisons guidelines for treating opioid addiction that call for medically supervised detoxification (including with methadone), cognitive behavioral therapy, and drug abuse education—but do not recommend methadone maintenance treatment, and prohibit treatment with buprenorphine as maintenance therapy.

AT Forum spoke with Sally Friedman, legal director of the Legal Action Center and author of the Center’s report. Written at the request of the American Association for the Treatment of Opioid Dependence (AATOD), the report is being distributed to government and criminal justice agencies, and to consumer groups and advocacy organizations.

Litigation

“The report has focused significant attention on these discriminatory policies, but litigation is another key strategy to bring about the necessary change,” said Ms. Friedman. “Even a few federal court decisions holding criminal justice agencies liable for denying access to MAT could make a big impact.”

“The Legal Action Center is prepared to bring litigation when we find the right case,” said Ms. Friedman—“someone who’s willing to challenge a criminal justice agency and willing to fight to the end of the litigation. We’d welcome hearing from people who’ve been forced off their addiction medications in order to take part in drug courts or other alternative sentencing programs, or by any other part of the criminal justice system.”

Potential cases may be a successful patient in an opioid treatment program (OTP) with a job and family who is picked up on an old warrant and told to taper or face jail; or one where a physician recommends MAT and the judge demurs. “MAT as a treatment option shouldn’t be off the table because of a judge’s misconception that it’s substituting one addiction for another, or because of overblown concerns about diversion,” Ms. Friedman said. “The point of the ADA and the Rehab Act is that the government should make decisions on the basis of objective medical evidence that applies to that individual, and not on the basis of stereotypes or broad generalizations. ADA case law is quite clear that people must be evaluated individually.”

Criminal justice agencies and courts who deny access to MAT despite a physician’s recommendation generally haven’t faced legal consequences. “Many courts have found that the ADA prohibits employment and zoning discrimination against people who need or receive MAT,” Ms. Friedman pointed out. “But courts have not yet addressed the question of whether the criminal justice system’s failure to provide or permit MAT violates the ADA or Rehabilitation Act. We think now is the time.”

Suggestions for OTPs

Helpful publications and audiovisual presentations from the Legal Action Center include Educating Courts, Other Government Agencies and Employers About Methadone (2009), a PDF explaining how people in MAT can advocate for their rights so they can get in or stay in treatment, without discrimination; and Know Your Rights: Are You in Recovery from Alcohol or Drug Problems? Rights for Individuals on Medication-Assisted Treatment (see link).

If an OTP patient is forced off of methadone or prohibited from enrolling despite the recommendations of a physician, an OTP Director can contact the Legal Action Center (phone: 212-243-1313 or 1-800-223-4044; fax: 212-675-0286; email: lacinfo@lac.org).

About the Legal Action Center

The only nonprofit law and policy organization in the U.S. whose sole mission is to fight discrimination against people with histories of addiction, HIV/AIDS, or criminal records, the Legal Action Center has for nearly four decades worked to combat stigma and prejudice and to help people reclaim their lives.

Legal Action Center Resources

Legality of Denying Access to Medication Assisted Treatment in the Criminal Justice System.
http://www.lac.org/doc_library/lac/publications/MAT_Report_FINAL_12-1-2011.pdf.
Accessed February 20, 2012.

Know Your Rights: Are You in Recovery from Alcohol or Drug Problems? Rights for Individuals on Medication-Assisted Treatment.
http://www.lac.org/doc_library/lac/publications/Know_Your_Rts_-_MAT_final,_9.28.10.pdf.
Accessed February 20, 2012.

Webinar: Medication-Assisted Treatment: Special Anti-Discrimination Issues.
http://lac.org/index.php/lac/webinar_archive. Accessed February 20, 2012.

Memo on Driving and Psychomotor Studies.
http://www.lac.org/doc_library/lac/publications/mmt-memo_on_driving_and_psychomotor_studies.pdf. Accessed February 20, 2012.

National Association of Criminal Defense Lawyers. http://www.nacdl.org/. Accessed February 20, 2012.

Additional Resources

National Institutes of Health, U.S. Department of Health and Human Services. Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide. Bethesda, MD: National Institute on Drug Abuse. Revised January 2012. NIH Publication No. 06-5316.
http://www.drugabuse.gov/publications/principles-drug-abuse-treatment-criminal-justice-populations. Accessed February 20, 2012.

Whitten L. Prison use of medications for opioid addiction remains low. NIDA Notes, Research Findings. 2011 (July);23(5). http://www.drugabuse.gov/NIDA_notes/NNvol23N5/Prison.html.
Accessed February 20, 2012.

Krantz MJ, Mehler PS. Treating opioid dependence: Growing implications for primary care. Arch Intern Med. 2004;164:277-288. http://archinte.ama-assn.org/cgi/content/abstract/164/3/277.
Accessed February 20, 2012.

SAMHSA Panel: No Mandatory ECG Testing for OTP Patients


 A panel convened by the Substance Abuse and Mental Health Services Administration (SAMHSA) has stopped short of recommending mandatory
electrocardiograms (ECGs) on patients treated with methadone in opioid treatment programs (OTPs). In “QT Interval Screening in Methadone Maintenance Treatment: Report of a SAMHSA Expert Panel,” published November 3 in the Journal of Addictive Diseases, the panel described the process that resulted in the inability to recommend ECG screening for all OTP patients.

The panel, convened initially in 2007, was charged with coming up with recommendations for addressing cardiac risk—specifically, an arrhythmia that can lead
to a dangerous condition known as torsade de pointes (TdP).  An erroneous report by this panel on cardiac effects was published—and later retracted—in the prestigious Annals of Internal Medicine (see related links). Finally, the case has been closed: no required baseline ECGs on OTP patients. There was no consensus
—five panel members voted to recommend baseline ECGs, and four voted against.

The story began six years ago when the Food and Drug Administration (FDA) issued an alert relating to methadone and cardiac arrhythmias, followed by a warning label. At higher doses, methadone may prolong the QT interval.

It’s important to note that the presence of QT prolongation does not necessarily lead to TdP, and that TdP can also occur in people who have normal QT intervals. It is also important to know that many medications are related to QT prolongation, alone and in combination with others.

Nobody knows how many OTP patients have suffered methadone-related arrhythmias. “It’s hard to put a finger on it; we really don’t have that much data,” said Anthony Campbell, DO, medical officer with the division of pharmacologic therapies at SAMHSA’s Center for Substance Abuse Treatment (CSAT). “The only way you can capture this is if you have a Holter monitor on the patient at the time of event.”

Panel Recommendations

The recommendations from the panel: Patients with significant risk factors for QT prolongation should have a baseline ECG at admission, and again within 30 days, the panel agreed. These risk factors include a history of cardiac arrhythmia or prolonged QT interval; symptoms suggestive of arrhythmia, such as episodes of syncope, dizzy spells, palpitations, or seizures; medication history; family history of premature death; or any other historical information suggestive of a possible cardiac arrhythmia.

Nothing in the recommendations has the force of law or regulation behind it. These are recommendations only. “Opioid treatment programs and other providers are encouraged to consider these conclusions to the extent that they are practically or financially capable of doing so,” the article concludes. “Nothing in this report is intended to create a legal standard of care for any opioid treatment program or to interfere with clinical judgment in the practice of medicine.”

Not a ‘Major Danger’

OTPs have been divided by this issue. “When we went to the initial meeting the deck was stacked,” said Brian A. McCarroll, DO, of BioMed Behavioral Healthcare in Sterling Heights, Michigan, one of the panel members who voted against requiring ECGs of all patients within 30 days of admission. “It didn’t matter what the clinical evidence was, they wanted something to come out that said this is a major danger with methadone. And it’s not.” Dr. McCarroll is a diplomate of the American Board of Addiction Medicine.

While screening ECGs should not be mandatory for all new OTP patients, complete cardiac histories should be, he said. “If someone has a history of dizzy spells that could be a sign of an arrhythmia, it would be prudent to do an ECG.”

Prevalence of Prolonged QT Interval

The panel concluded that 2 percent of OTP patients have a very prolonged QT interval. If so, of the 250,000 people currently enrolled in OTPs, 5,000 would need “interventions for cardiac risk reduction,” and an additional 40,000 to 60,000 would have a lesser risk but may need an intervention, the article states.

One of the factors the panel considered in coming up with its recommendations was “compelling evidence that the majority of physicians who direct treatment in opioid treatment programs are not fully aware of methadone’s association with adverse cardiac events,” the article stated. In one survey, only 41 percent of 692 physicians in OTPs were aware of methadone’s QT-prolonging properties, and only 24 percent were aware of the possible risk for TdP.

Costs of ECGs

“There were some people who said requiring screening is wrong because OTP patients can’t afford the cost of going to a cardiologist,” said Robert Lubran, MA, MPH, director of CSAT’s Division of Pharmacologic Therapies. “We took the opposing view, which is that it’s
important for patient care and patient safety that the medical staff be aware of this potential problem, and that it’s really incumbent on them to help the patients access needed services.” According to Mr. Lubran, ECGs cost about $100.

If OTPs themselves don’t offer ECGs—and Mr. Lubran acknowledges that many can’t—then it’s “incumbent on the OTP to help the patient find an affordable medical service.” Some OTPs are going to become medical health homes, which means that they will be able to offer affordable ECGs, he said. “And as we’re moving toward health care reform, everybody is supposed to have access to primary medical care. This is another step. We are suggesting that programs understand the consequences of not screening.”

Another argument against requiring ECGs, said Mr. Lubran, was that patients who couldn’t afford them would then be denied treatment. “One side said it was better to get people into treatment, and the other said it was better to get the ECG baseline done at admission.” He has also heard the argument that programs will discharge patients or reduce their dose if they appear to have cardiac risks. “We have never made any recommendation that suggests the answer is discharging patients,” he said. “We don’t want programs to take the easy way out and discharge patients instead of doing a reasonable assessment and treating them as the standard of care provides.”

CSAT was to meet in late January to discuss the issue further. Mr. Lubran admitted that there is still controversy about whether QT prolongation contributes to deaths. But there’s enough data to warrant a cardiac risk assessment on each patient. “Whether that includes an ECG or not is up to the OTP,” he said. “Nobody is being required to do this by the federal government.”

Resources:

Krantz MJ, Martin J, Stimmel B, Mehta D, Haigney, MC. QTc interval screening in methadone treatment. Ann Intern Med. 2009;150(6):387-395.
http://www.annals.org/content/150/6/387.full?HITS=10&hits=10&RESULT=&maxtoshow=.
Accessed February 20, 2012.

QTc Interval Screening – AATOD Policy and Guidance Statement. March 30, 2009. American Society for the Treatment of Opioid Dependence, Inc. New York, New York. http://www.aatod.org/qtc.html.  Accessed February 20, 2012.

Mandatory QTc Screening for Methadone Patients – OTPs Respond to Published Guidelines. ATForum. 2009 #2 (Spring); vol 18. http://atforum.com/newsletters/2009spring.php#QTc.
Accessed February 20, 2012.

For a link to the abstract, go to http://www.ncbi.nlm.nih.gov/pubmed/22026519.
Accessed February 20, 2012.

Prospective Employer $37,500 for Not Hiring Methadone Patient

The U.S. Equal Employment Opportunity Commission (EEOC) on January 23 announced that the United Insurance Company of America will pay $37,500 to Craig Burns, whom the company refused to hire because his pre-employment drug test was positive for methadone. Mr. Burns, a patient in an opioid treatment program (OTP) since 2004, was offered a job in North Carolina by the insurance company in January 2010, but the job offer was contingent on his passing a drug test. He gave the company a letter from his OTP explaining why his test was positive for methadone, and said that he was taking a legally prescribed medication. When it got the letter, United Insurance withdrew its employment offer.

This was in violation of the Americans with Disabilities Act (ADA), and the EECO sued United Insurance in August 2011 for discriminating against someone with a disability. “The ADA requires employers to make an individualized assessment of whether an individual can do the job rather than relying on fears or stereotypes,” said Lynette A. Barnes, regional attorney for the EEOC’s Charlotte District, which includes the Raleigh Area Office, where the original charge of discrimination was filed. “We are pleased that, in resolving this case, United Insurance is taking action to ensure that it fulfills its obligations under the ADA.”

In addition to paying Mr. Burns $37,500, United Insurance must perform training that covers the legal requirement to conduct an individualized assessment of disability; the appropriate methods of determining whether the employee poses a direct threat; and the obligation to consider an employee’s or applicant’s request for reasonable accommodation.

Mr. Burns had already found employment elsewhere, so getting rehired wasn’t part of the settlement, Ms. Barnes told AT Forum. So while that $37,500 doesn’t sound adequate for not getting a job in these hard times, at least there is one employer that will no longer be violating federal law by discriminating against OTP patients.

For the press release announcing the resolution, go to
http://www.eeoc.gov/eeoc/newsroom/release/1-23-12.cfm. Accessed February 20, 2012.

Also see
http://atforum.com/news/2011/11/eeoc-sues-employer-for-discriminating-against-methadone-patient/. Accessed February 20, 2012.

For the Consent Decree, go to
http://atforum.com/addiction-resources/documents/2012.01.24ConsentDecree.pdf.
Accessed February 20, 2012.

Vermont to Expand Medication-Assisted Treatment for Opioid Addiction Using a Managed Care Approach

 Vermont is embarking on an ambitious initiative to expand medication-assisted treatment (MAT) in response to the state’s prescription opioid addiction epidemic. The expansion represents the first phase of a larger plan for Vermont to develop an integrated treatment continuum for other substance abuse and co-occurring mental health disorders through a managed care approach.

MAT caseloads are expected to increase by approximately 55 percent during the next two fiscal years. And the vast majority of the expansion will be coming from health homes funding under the Federal Affordable Care Act.

“Hub/Spoke” Initiative

Initially there will be five specialty treatment center “Hubs” for opioid addiction. The Hubs will provide comprehensive assessment and treatment protocols; coordinated referral to ongoing care; methadone treatment and support services; initiation of buprenorphine treatment, and care during the initial stabilization period; coordinated care for clinically complex cases; and specialty consultation and support.

The ongoing-care system, the “Spokes,” will consist of a prescribing physician and other professionals who will monitor the patient’s adherence to treatment; coordinate access to recovery support; and provide counseling, contingency management, and case management services. Spokes will also include providers of outpatient substance abuse treatment, primary care providers, independent psychiatrists, Federally Qualified Health Centers, and other facilities and providers, such as correctional facilities and medical homes.

Shifting the Scale toward Methadone

There are currently 2,800 buprenorphine patients and 614 methadone patients receiving MAT in Vermont, and more patients are being treated with buprenorphine than was expected, said Barbara Cimaglio, deputy director for the department of alcohol and drug abuse programs with the Vermont Department of Health. “If we had better access to methadone treatment, we would see a drop in the number of people seeking buprenorphine treatment,” she told AT Forum. “We want to make sure that both medications are readily available.”

According to Bob Bick, director of mental health and substance abuse services for the Howard Center, which runs the Chittenden Center opioid treatment program (OTP) in Burlington, there are currently 100 to 150 patients on their waiting list. The Chittenden Center has 365 patients working toward a cap of 410. It’s difficult to determine how many there will be after the expansion, because some people put their names on more than one waiting list, but Mr. Bick expects to end up with 700 to 800 patients. “We’ll have to hire new people,” he told AT Forum. “We’re already stretched to the limit.” The Howard Center also has a buprenorphine clinic, with 150 patients.

Integrated Treatment Continuum for Substance Use Dependence “Hub/Spoke” Initiative—Phase 1: Opiate Dependence can be accessed at
http://atforum.com/addiction-resources/documents/HUBSPOKEBriefingDocV122112.pdf. Accessed February 20, 2012.

Patient Advocacy Group Works to Improve Treatment in NY OTPs

 A new group, VOCAL-NY, modeling themselves after some of the aggressive organizations that brought attention to the AIDS crisis in New York,
is focusing their attention on methadone maintenance treatment in opioid treatment programs (OTPs). Last year, a group of VOCAL members went
to the state capitol to get the attention of Gov. Andrew Cuomo about hepatitis C testing and treatment in OTPs. To their surprise, the Office of Alcoholism and Substance Abuse Services (OASAS) was responsive, supporting the need for a more comprehensive hepatitis C program in OTPs, where many patients are infected with the virus. OASAS medical director Steven Kipnis, MD, “got it immediately,” said Sean Barry, a leader of VOCAL, which stands for Voices of Community Advocates and Leaders.

VOCAL has been critical of some OTPs. The organization advocates for improved treatment, transparency, knowledge, and education. In particular, the group says patients should have better testing and treatment for hepatitis C, a major concern for VOCAL-NY members. Treatment should be provided
on site, says Mr. Barry, citing a model used at the Albert Einstein College of Medicine. On-site treatment is important because many patients do not follow through on their own, and patients can benefit from peer and staff support. 

There is some confusion about what is required by the state. According to Vocal-NY, all patients should be screened upon admission to an OTP and at yearly check-ups. Asked what the current OASAS regulations are for OTPs and hepatitis C, an OASAS spokeswoman responded: “OTPs are required to test for Hepatitis C, if clinically indicated.”

But as a result of VOCAL-NY’s efforts, OASAS is in the process of developing additional guidance to assist OTPs in working with patients with hepatitis C, said the OASAS spokeswoman. That guidance was due February 9.

For the report from VOCAL-NY, compiled by surveying OTP patients, see
http://www.vocal-ny.org/publications/beyond-methadone-improving-the-health-of-patients/.

Accessed February 20, 2012.

RESEARCH REPORT: Study Finds No Evidence That Methadone Was Cause of Driving Accidents

A research report from Norway published in the December 11, 2011 issue of Addiction found that men taking methadone for opioid addiction were  more than twice as likely as the general population to be involved in motor vehicle accidents with personal injury. However, there was no evidence that the methadone itself caused the accidents. The study did not even suggest that stable patients on methadone maintenance treatment (MMT)—men or women—
are any more likely to be in motor vehicle accidents than non-MMT patients.

The lead author told Reuters Health, which picked up the study and ran it under a distorted headline (“Drivers on methadone twice as likely to crash”) December 30, that to blame methadone for the crashes would be speculation. “Many different things go into increasing traffic accident risk, like reduced attention, slowed reaction, slowed psychomotor performance, less accurate psychomotor performance, etc.,” said Jorgen G. Bramness, MD, PhD, of the Norwegian Centre for Addiction Research at the University of Oslo.

The Reuters Health article, mainly because of the misleading headline, attracted a lot of attention among opioid treatment programs (OTPs) in the U.S.

The Study

The study was based on records of all Norwegian adults aged 18 to 70, whose prescription data and motor vehicle histories were followed for 2.5 years. Of the 8.1 million “person years” of data generated, 4,626 “person years” involved all methadone prescriptions for the treatment of opioid addiction, and all benzodiazepine prescriptions. About 1,800  people were prescribed methadone, and 26 motor vehicle accidents were reported in this group. Men who were in MMT were twice as likely to be involved in motor vehicle accidents as the rest of the population. This increased risk couldn’t be explained by exposure to benzodiazepines. The authors stated: “We did not know if the methadone was actually taken, or, if it was taken, when and how much.”

Also:

  • Women on MMT were not at increased risk.
  • The study did not look at alcohol or drugs other than methadone and benzodiazepines.
  • The study did not look at whether the methadone patients were in the induction phase of treatment or were stabilized on methadone.

Conclusions

What does this study mean for OTPs? Not much at all. First, the number of accidents in the methadone group—26—was very small. Second, nothing in the report points to any issues related to the ability of stable MMT patients to drive safely. The fact that methadone had no effect on the accident rate among women in the study suggests that a factor other than the medication may have been involved, the authors said.

When patients are not stabilized on their methadone dose, it is inadvisable for them to drive. When they are stable, they can drive, as Norway’s own regulations say.

For an abstract of the Addiction article, go to
http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03745.x/abstract;jsessionid=79474E85DA1DE24B4C5F7C893A20F158.d01t01. Accessed February 20, 2012.

For the Reuters Health article, go to
http://www.reuters.com/article/2011/12/30/us-drivers-methadone-idUSTRE7BT0Z920111230. Accessed February 20, 2012.

For the Legal Action Center’s 2000 memorandum on methadone and driving, go to
http://www.lac.org/doc_library/lac/publications/mmt-memo_on_driving_and_psychomotor_studies.pdf. Accessed February 20, 2012.

PRACTICE POINTERS: How to Effectively Treat Veterans Using Medication-Assisted Treatment

At the end of 2011, veterans from Iraq returned home, many of whom will require treatment for their addiction to prescription opioids. Also at year’s end, the federal government issued a proposal to lift the ban on the military paying for medication-assisted treatment (MAT) with methadone and buprenorphine. In order to help opioid treatment programs (OTPs) prepare for more veterans seeking MAT, AT Forum interviewed three top federal officials—one with the Department of Defense (DoD), one with the Veterans Administration (VA), and one with the Substance Abuse and Mental Health Administration (SAMHSA)—on the effective treatment of veterans.

Military History

The first and most important thing OTPs can do for patients who are veterans is to take a complete “military history,” says Andrew J. Saxon, MD, director of the Addiction Treatment Center in the VA Puget Sound Health Care System in Seattle. OTPs should always ask patients at admission: “Were you in the service? What branch? Where did you do your boot camp or basic training? Where were you stationed? What was your job in the military? What kind of discharge did you get? What happened since you’ve been out?”

Taking the military history lets the veteran know that this is an area of interest, and helps to build a relationship of trust. “Although they don’t necessarily want to talk about their military service, most veterans are proud of it, and they want to have someone acknowledge it,” says Dr. Saxon, who is also professor in the Department of Psychiatry and Behavioral Sciences and director of the Addiction Psychiatry Residency Program at the University of Washington.

“Also, they may divulge something that is troublesome, including posttraumatic stress disorder (PTSD).”

Managing Pain Disorders

Many veterans will be coming home from Iraq and Afghanistan with pain from injuries. OTPs can treat pain, as long as the patient also has an addiction, notes Dr. Saxon. “Some OTPs struggle with how to manage pain,” he says. “Methadone maintenance will not handle all pain issues.” Patients might need other medications, and most people with chronic pain need some form of psychotherapy.

Treating chronic pain is a challenge even for VA methadone programs, which have the benefit of being part of a larger health system, says Daniel Kivlahan, PhD, Acting National Mental Health Program Director, Addictive Disorders, Office of Mental Health Services, in the Veterans Health Administration. “For freestanding OTPs, it’s particularly difficult.”

Nicholas Reuter, team leader for the certification and waiver team of the Division of Pharmacologic Therapies at the Center for Substance Abuse Treatment at SAMHSA, noted that for people on active duty, there’s a huge stigma issue with methadone. “Someone might question their suitability for service,” he said. But this would be wrong. “We’ve done what we can to advocate for the ability of a methadone maintenance patient to hold down just about any job.” Mr. Reuter recommends that OTPs emphasize the effectiveness of methadone maintenance treatment when working with veterans. He noted that patients in the Reserves who are called up will need take-home exemptions to allow them to fulfill their Reserve duties, which presents additional difficulty.

Lifting the Ban on MAT

In fact, VA OTPs are in a special—and privileged—position. There are a multitude of services that can be offered, which are paid for without the concerns most non-VA OTPs have about payment or insurance.

Some veterans would prefer to go outside the VA system for substance abuse treatment, Dr. Kivlahan acknowledges. They are fearful that if the VA knows about their addiction, it may hinder their future military career, if they want to be redeployed. Current rules ban people on methadone or buprenorphine from serving in the military.

Finally there is a proposal to change this. The ban on MAT coverage by Tricare, the insurance program run by the DoD for people on active duty, may soon be lifted. The 1986 federal regulation (32 CFR 199.4[e]) applies to methadone and to buprenorphine and allows these drugs to be used only for detoxification or medically supervised withdrawal. Family members and retirees also are banned from accessing Tricare coverage for maintenance treatment with agonist (or partial agonist) opioid medications.

Recently, with troops returning from Iraq and Afghanistan, and the increase in prescription opioid abuse, including among family members of troops in the armed forces, many advocates have urged the DoD to review the evidence and best practice recommendations about OTPs and MAT treatment. The DoD has published a proposed rule in the December 29 Federal Register, citing the “long-term use of pain medications” among troops and the consequent risks of addiction.

The preamble to the proposed rule stated that “in the past, there was not sufficient reliable evidence . . . to establish that the substitution of one addictive drug for another was an effective part of a drug treatment program.” The preamble also says that “medicine is constantly evolving including in the area of drug addiction treatments.” Comments are due by February 27. To read the Federal Register notice, go to http://www.federalregister.gov/articles/2011/12/29/2011-33106/tricare-removal-of-the-prohibition-to-use-addictive-drugs-in-the-maintenance-treatment-of-substance.

About 20 percent of troops return with PTSD, and about 20 percent come back with traumatic brain injury, said Dr. Saxon. The percentage of troops returning with a documented diagnosis of any substance use disorder is 10 percent, said Dr. Kivlahan. However, this is likely the tip of the iceberg, since addiction issues may not surface for weeks or months after troops return home or are discharged from active duty.

Asked whether veterans in OTPs are presenting with prescription opioid addiction or heroin addiction, Dr. Saxon says “We’re seeing both heroin and prescription opioids — I think OTPs need to be prepared for both.”

Additional resources for understanding the special needs of treating veterans:

http://www.va.gov/oaa/pocketcard/
http://www.ptsd.va.gov/
http://www.ptsd.va.gov/professional/ptsd101/course-modules/course-modules.asp
http://www.ptsd.va.gov/professional/ptsd101/course-modules/military_culture.asp
http://www.samhsa.gov/samhsanewsletter/Volume_19_Number_3/fall-2011-volume-19-number-3.pdf
http://www.samhsa.gov/samhsaNewsletter/Volume_19_Number_3/military.aspx
http://www.samhsa.gov/MilitaryFamilies/
(all links accessed February 20, 2012)

Improving Public Health Worldwide Through Medication-Assisted Treatment


Finding ways to improve public health while controlling costs is a major concern in today’s global health care environment. Given the large number of chronic and acute health problems linked with opioid dependence, one effective approach is to provide better access to medication-assisted treatment (MAT).This is according to Thomas F. Kresina, PhD, and Robert Lubran, MA. MPH, authors of “Improving Public Health Through Access to and Utilization of Medication Assisted Treatment,” a review published October 2011 in The International Journal of Environmental Research and Public Health.

The article aroused AT Forum’s curiosity, so we spoke with the authors about their work. Both authors are affiliated with the Substance Abuse and Mental Health Services Administration (SAMHSA) and are helping other nations address opioid addiction and HIV/AIDS. We learned some of the ways health care is changing—through linked services, onsite services with linkages where needed, vans, electronic record systems with interoperability—and how opioid treatment programs (OTPs) are adapting to these changes and using new practices to help nations with HIV problems related to opioid misuse.

Dr. Kresina and Mr. Lubran stressed that in addition to keeping patients in treatment, MAT can improve public health by integrating its services with primary medical care and with the comprehensive social, psychological, and community services that address all of an individual’s needs. This is true worldwide as well as here in the U.S.

Providing MAT and Primary Medical Care

Some evolving changes in health care delivery systems in the U.S. are spreading to countries that have major HIV and opioid issues. An example is coordinated care, where the OTP is part of a care system that comprises case managers, care coordinators, and recovery coaches. These team members make sure that patients with multiple medical and mental health problems obtain treatment from a mental health worker, or diabetes doctor, or a doctor at the HIV clinic, then return to the OTP for follow-up care.

Another example is the “one-stop shopping” OTP that has most services onsite and needs only a few referral resources, such as cardiology, diabetes, or ob-gyne. Used increasingly in the U.S. and migrating abroad is a system of electronic record-keeping that integrates the OTP record with the primary-care clinic record. Each linked caregiver can see how others are looking after the patient so they can prescribe appropriate treatment and contact other providers if they have questions.

A Global Health Care Effort

Dr. Kresina is part of the one-U.S. Government approach to foreign assistance where all U.S. agencies contribute to efforts of the State Department. He provides technical assistance on substance abuse treatment and pharmacologic therapy as part of the President’s Emergency Plan for AIDS Relief (PEPFAR)—a highly effective initiative to expand access to HIV/AIDS prevention, care, and treatment worldwide. Depending on the culture and willingness of each nation, PEPFAR helps those impacted by the global increase in opioid abuse by establishing MAT as a way of counteracting the HIV/AIDS epidemic. Dr. Kresina provides technical assistance to establish models of care that use best practices learned here, and has been successful in promoting evidence-based treatment paradigms in Vietnam, Russia, Ukraine, China, and Africa.

Dr. Kresina described the authors’ vision of helping other countries improve their public health—as is happening here in the U.S.—by providing access to MAT and comprehensive services, “so that mainstream medicine can incorporate issues like integrated care into the primary care services they provide—and extend that to include substance abuse treatment, mental health services, and medication-assisted treatment. In other words, not just treating HIV/AIDS, but incorporating a comprehensive approach into the existing health structure,” benefiting not only the patient, but the community, and, ultimately, worldwide health.

Kresina TF, Lubran R. Improving public health through access to and utilization of medication assisted treatment. Int J Environ Res Public Health. 2011;8:4102-4117. doi:10.3390/ijerph8104102.

Free access to the article is available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3210600/?tool=pubmed. Accessed February 20, 2012.

Events to Note

Addiction Medicine 2012
March 30-31, 2012
Asheville, North Carolina
Contact: www.sa4docs.org

National Rx Drug Abuse Summit
April 10-12, 2012
Orlando, Florida
Contact: www.nationalrxdrugabusesummit.org

American Society of Addiction Medicine (ASAM) 43rd Annual Medical-Scientific Conference
April 19-22, 2012
Atlanta, Georgia
Contact: www.asam.org

American Association for the Treatment Opioid Dependence, Inc. National Conference
April 21-25, 2012
Las Vegas, Nevada
Contact: www.AATOD.org

Midwestern Psychological Association (MPA) Annual Meeting
May 3-5, 2012
Chicago, Illinois
Contact: www.midwesternpsych.org

American Psychiatric Association (APA) 165th Annual Meeting
May 5-9, 2012
Philadelphia, Pennsylvania
Contact: www.midwesternpsych.org

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