New AATOD Policy Statement: Increasing Access to Medication to Treat Opioid Addiction

AATODEarlier this month AATOD issued a policy paper “Increasing Access to Medication to Treat Opioid Addiction – Increasing Access for the Treatment of Opioid Addiction with Medications.” AATOD noted that “this paper raises a number of questions in order to stimulate a thoughtful policy discussion given the urgency of the public health crisis of untreated opioid addiction”.

The statement provides a discussion of: the value of providing comprehensive treatment services to treat a complicated illness, current policy debates on OTPs, DATA 2000 practices, reports of medication diversion, and future policy considerations

http://www.aatod.org/wp-content/uploads/2014/07/MAT-Policy-Paper-FINAL-070214-2.pdf

Source: The American Association of the Treatment of Opioid Dependence – July 2, 2014

 

Treat Patients with Addiction During, After Hospitalization, Researchers Say

hospital sign purchasedshutterstock_33280960The results of a new study demonstrate that starting hospitalized patients who have an opioid (heroin) addiction on buprenorphine treatment in the hospital and seamlessly connecting them with an outpatient office based treatment program can greatly reduce whether they relapse after they are discharged.

Led by researchers at Boston Medical Center (BMC), the study shows the important role that providers play in offering these patients addiction treatment both while in the hospital and after – even if their primary reason for being in the hospital is not for their addiction.

In this study, 139 hospitalized individuals with opioid addiction who were not already in treatment were randomized into two groups. One group received a tapered dose treatment of buprenorphine for withdrawal and referral information about community treatment programs and the other were initiated on buprenorphine, an opioid substitute proven to treat opioid addiction, along with referral to a primary care office-based buprenorphine treatment program.

Of those in the buprenorphine maintenance group, more than one third (37 percent) reported no illicit opioid/drug use for the month after they left the hospital compared to less than one in ten (nine percent) among the control group. These patients also reported, on average, fewer days of illicit drug use and continued to use less over the following six months. This effect was evident despite the fact that these patients did not initially come to the hospital seeking treatment for their addiction.

“Unfortunately, referral to substance abuse treatment after discharge is often a secondary concern of physicians caring for hospitalized patients,” said Jane Liebschutz, MD, MPH, a physician in general internal medicine at BMC and associate professor of medicine at Boston University School of Medicine, who served as the study’s corresponding author. “However, our results show that we can have a marked impact on patient’s addiction by addressing it during their hospitalization.”

This study is published in JAMA Internal Medicine.

http://medicalxpress.com/news/2014-06-patients-addiction-hospitalization.html

Source: Boston Medical University –  June 30, 2014

Online Training Module From PCSS MAT – American Academy of Addiction Psychiatry (AAAP) – Utilizing Innovative Strategies and Community Resources for Methadone Treatment

webThis module is free of charge and provides techniques and strategies that clinicians and program administrators can use to enhance methadone and buprenorphine maintenance treatment.  This affirmative approach aims to improve the experience of both the patients and the staff by encouraging positive interactions between staff and patients and among the patients in an effort to develop a recovery community.  Methadone patients often feel isolated and have limited opportunities for sober social support.  This presentation directly addresses some of the limitations of the modality and provides ideas and options to clinicians to combat the stigma long associated with maintenance treatment by integrating peer services into treatment.

The presenter is Sarah H. Church, PhD, Executive Director, Division of Substance Abuse Albert Einstein College of Medicine.

http://pcssmat.org/event/aaap-online-module-posted-utilizing-innovative-strategies-and-community-resources-for-methadone-treatment/

A listing of upcoming PCSS-MAT webinars is available at: http://pcssmat.org/education-training/webinars/

Source: PCSS – MAT Training – July 1, 2014

Feds Seek Ways to Expand Use of Addiction Drug

White House“The government’s top drug abuse experts are struggling to find ways to expand use of a medicine that is considered the best therapy for treating heroin and painkiller addiction.

Sen. Carl Levin of Michigan on Wednesday pressed officials from the White House, the National Institute of Drug Abuse and other agencies to increase access to buprenorphine, a medication which helps control drug cravings and withdrawal symptoms. It remains underused a decade after its launch.

“As long as we have too few doctors certified to prescribe bupe, we will be missing a major weapon in the fight against the ravages of addiction,” Levin told the forum, which also included patients and non-government medical experts.”

http://bostonherald.com/business/business_markets/2014/06/feds_seek_ways_to_expand_use_of_addiction_drug

Source: BostonHerald.com – June 18, 2014

Drugs for Treating Heroin Users: A New Abuse Problem in the Making?

“Evidence is mounting that certain drugs used to treat heroin users are themselves being sold on the streets – and may even be a ‘gateway’ to heroin or opioid use. As some experts herald their value for treating addiction, others ask if the ‘cure’ is making things worse.

More than a decade ago, the FDA partnered with a British company to develop Suboxone, a new treatment for addiction to opioids. But that effort has had highs and lows, experts say. Lifesaving to some opioid abusers, Suboxone and generic drugs like it have not helped others to whom they have been prescribed – in part, these experts say, because of poor oversight of how the opioids are dispensed and used.

Those drugs have also ended up where the U.S .government hoped they wouldn’t: on the street, where they are sold in the same illicit subculture in which heroin and prescription painkillers are peddled.”

http://www.csmonitor.com/USA/Society/2014/0530/Drugs-for-treating-heroin-users-a-new-abuse-problem-in-the-making

Source: Christian Science Monitor – May 30, 2014

ASAM Article: Twelve Step Recovery and Medication Assisted Therapies

“You’re not clean and sober if you keep taking that medication from your doctor!”

“You’re just substituting one drug for another.”

“You are depressed because you are not grateful enough.”

These and other statements are often made to 12-step members who are legitimately prescribed and taking FDA approved medications to treat their addictions and other co-occurring illnesses. Unfortunately, this so- called “advice” from well-intended but misinformed members is not founded in scientific or 12-step philosophy and violates a long held 12- step policy of ” AA members should not give medical advice to each other.”

http://www.asam.org/magazine/read/article/2014/06/12/twelve-step-recovery-and-medication-assisted-therapies

Source: American Society of Addiction Medicine – June 12, 2014

Providing Buprenorphine in an Opioid Treatment Program: Challenges and Opportunities

shutterstock_3917107When the federal government said in December of 2012 that opioid treatment programs (OTPs) can dispense take-home doses of buprenorphine with fewer restrictions than are placed on take-home doses for methadone—in particular, no waiting period (http://atforum.com/news/2013/02/otps-can-now-dispense-buprenorphine-take-homes-with-no-waiting-periods/), there was an expectation that patients and treatment providers would be interested in buprenorphine. But there was also a concern that the high cost of buprenorphine compared to methadone would be an obstacle. In addition, states have their own rules that may be stricter than the federal government’s.

It turns out that more than a year later, most OTPs are still not dispensing buprenorphine on a widespread basis, and the main reasons are cost and insurance reimbursement. “I just completed a survey among the State Opioid Treatment Authorities, to find out what they think the impediments are to the use of buprenorphine in their state,” Mark Parrino, MPA, President of the American Association for the Treatment of Opioid Dependence (AATOD), told AT Forum in April. “It would seem that the biggest singular impediment is the lack of insurance reimbursement in OTPs.

“California and New York are states with the largest number of certified OTPs; however, California Medicaid does not provide any reimbursement for buprenorphine use in OTPs. At the present time, New York State does not have a current Medicaid reimbursement mechanism for buprenorphine use in their OTPs, although it did have such a reimbursement before the state converted to a new system called APGs [Ambulatory Patient Groups]. I understand that state officials and treatment providers, as organized through COMPA [Committee of Methadone Program Administrators of New York State, Inc.] are working to correct the problem.“

Other states have legislative restrictions for the use of public funds to use buprenorphine in OTPs. Idaho provides a case in point. North Dakota has just released its administrative/licensing regulations for OTPs, and the use of buprenorphine will be required in newly sited OTPs.

Here’s the problem. If buprenorphine is picked up in a pharmacy, the pharmacy benefit covers it. But if it’s dispensed by an OTP, there is no separate reimbursement for the medication—the cost has to come out of the fee the OTP gets for overall treatment. The cost of methadone is far less than the cost of buprenorphine, depending on the formulation.

Private insurance generally doesn’t cover OTP treatment services, in general, so the bulk of the payment falls on Medicaid or on self-pay patients. While there are 49 states that now allow OTPs, only 33 of them allow Medicaid to pay for such treatment, said Mr. Parrino. In the other states, patients have to make out-of-pocket payments. We have also learned that commercial insurance is providing coverage for OTP services but there are a number of restrictions when it comes to paying a claim.

“It’s a state-by-state fight,” he said. “There is no federal fix for this. There are states that have buprenorphine-only OTPs. Ohio provides an illustration where three buprenorphine-only OTPs were approved in 2013. Other states have reported this as well.”

Of course, the federal Centers for Medicare and Medicaid Services (CMS) would not block states that wanted to reimburse OTPs for dispensing buprenorphine, but CMS has historically not intervened if a state refuses to do so.

In some states, there are still regulatory, bureaucratic barriers that need to be fixed. For example, in many states, before the reimbursement issue can even be addressed, language changes are needed that would allow buprenorphine to be dispensed in an OTP.

In self-pay states, adding the cost of buprenorphine to what patients are already paying would be prohibitive, said Mr. Parrino. In spite of this, some treatment systems such as CRC have indicated that 10 percent of their patient population is currently utilizing buprenorphine through their network of OTPs.

When the rule allowing buprenorphine dispensing was published, Mr. Parrino immediately suggested to states that they look into actions that would encourage the use of buprenorphine. However, he doesn’t think there is necessarily great interest in patients switching from methadone to buprenorphine. “I haven’t heard of any groundswell of patients in an OTP saying ‘Please put me on buprenorphine so I can qualify for take-homes,’” he said.

There’s a lot that isn’t known, especially about the physicians who are prescribing buprenorphine from their offices. “We don’t know how many physicians are monitoring and tracking their patients,” said Mr. Parrino, noting that such monitoring and tracking is done by OTPs through federal and state regulations. But intuitively, he said, it makes some sense that a patient would rather go to an office-based treatment—regardless of whether the medication were methadone (which isn’t allowed to be dispensed or prescribed from an office), or buprenorphine—than to an OTP. “If I’m a patient who can pay for care, do I want to go to an OTP where there’s counseling requirements and toxicology testing, or to a physician where there aren’t any treatment requirements?” he asked rhetorically. “On the other hand, I have been informed that some patients do want such services and access such care through OTPs. It is also important to keep in mind that a number of physicians who have DATA 2000 practices are providing excellent care to patients as well as providing a comprehensive array of services at or through their offices. We just do not have credible data to indicate who is doing what.”

There are approximately 325,000 patients in OTPs at the present time. While it’s not clear how many patients are in ongoing treatment with buprenorphine from office-based physicians, AATOD estimates the number to be between 400,000 and 500,000.The number is based on prescriptions being written, but not necessarily unique patients, said Mr. Parrino.

In Vermont, where more OTPs are opening up, there is a current perceived advantage of having patients medicated on site, even with buprenorphine, because of diversion related issues.

New Jersey

We talked with Ed Higgins, MA, executive director and CEO of JSAS Healthcare Services, an OTP based in Neptune, New Jersey, and the only non-profit OTP in two contiguous counties. The insurance reimbursement problem is a reality, he said. When buprenorphine first came on the market, as Suboxone and Subutex, OTPs made sure it would be covered by Medicaid. And it is—but only as a pharmacy benefit. “I’m not a pharmacy,” said Mr. Higgins. “A Medicaid Rx card won’t work here.” The retail price for a 1-week supply of only 8 milligrams a day of buprenorphine is $50.

So at JSAS, all three physicians are waivered to prescribe buprenorphine. Two of them are American Society of Addiction Medicine (ASAM) physicians. They see patients and write a prescription for buprenorphine, most of which is not reimbursed, said Mr. Higgins. “We can’t bill extra for the induction,” he added. “It’s just a regular Medicaid office visit, and we’re working on 1985 rates.” Only one of our ASAM physicians is currently accepting self-pay patients.

Patients can get buprenorphine from other waived physicians, of course, but Mr. Higgins describes this as the “Wild West,” where patients are charged as much as $350 to $500 for the induction.

Mr. Higgins agrees that the cost of buprenorphine is prohibitive for self-pay patients. And he is curious about the “hundreds of thousands” of patients who enroll in the private-practice model of buprenorphine treatment each year. “This begs for a follow-up study,” he said. “How many of those patients stay in treatment?” There are also questions about dosing: the limit was supposed to be 16 milligrams a day, but there are some patients who require 24 milligrams—although not in his clinic—said Mr. Higgins. “That’s the reality in the private sector.” Some managed care companies are now mandating that patients on buprenorphine be given at least one counseling session a month, he said, while others have no counseling requirement.

Finally, Mr. Higgins said that there are patients who feel better on methadone. But they can’t have the freedom of going to private practitioners, and also be on methadone.

Fewer than 5 percent of the patients at JSAS are on buprenorphine, said Mr. Higgins. “In the world I’d like to live in, we would look at a patient, especially a younger patient, and say, ‘We have some choices for you.’” The OTP could recommend buprenorphine first, and if it doesn’t work, then easily convert to methadone. The problem is that the prices are still too high. There are now five generic forms of buprenorphine, and Mr. Higgins would like to see the manufacturers get together and lower the prices dramatically. “I’m not talking about 10 percent,” he said.

Now, however, the choices just come down to finance. “I can give you 80 milligrams of methadone, and my lowest cost for that is 36 cents. Or you can get a prescription for    16 milligrams of buprenorphine, which is a therapeutic dose, and your weekly cost is going to be approximately $100.”

JSAS gets $120 per month per patient from Medicaid.

 

 

 

Buprenorphine, Methadone and Opiate Replacement Therapy Blog Series from Psychology Today

blog1This three part blog by Joseph Troncale, MD, FASAM, published online on the Psychology Todaywebsite provides a historical overview of opioid addiction and the rise of opioid replacement medication.  The three parts include:

Part 1: Lessons From History – April 30, 2014

Part II: Where the Harrison Act has Brought Us – May 10, 2014

Part III: The Plight of the Opiate Addict from 1914 until Now, and the Rise of Substitution Therapy – May 10, 2014

Dr. Troncale concluded, “There is no perfect drug or therapy, but it is still a certainty that the use of street heroin or synthetic opiates is extremely lethal. I have seen people use NA or AA and get clean, and I have seen people use a combination of buprenorphine or methadone and/or AA and live normal lives. The hope of change is still there. Why people make destructive choices is the question that cannot be explained except by an understanding of the power of the limbic system.”

Source: PsychologyToday.com – April/May 2014

Opioid Substitution Therapy Is Linked to Lowered HIV Risk

“Methadone maintenance therapy and treatment with buprenorphine-naloxone are equally effective at reducing HIV injecting risk behaviours among people who inject drugs, investigators from the United States report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

Both treatments were associated with significant reductions in injecting practices linked to a risk of HIV transmission. Sexual risk behaviour also decreased in women taking both therapies. However, drop-out rates were higher among people treated with buprenorphine-naloxone and men taking this therapy reported significantly higher rates of sexual risk-taking.”

http://www.aidsmap.com/Methadone-and-buprenorphine-naloxone-both-associated-with-reduced-HIV-risk-among-people-who-inject-drugs/page/2849368/

Source: Aidsmap.com – April 29, 2014

Blog by Jana Burson Methadone and Buprenorphine During Incarceration

jail-cropped“As a health care provider, of course I’m opposed to any refusal to treatment a patient while incarcerated. I think it’s a violation of the 8th Amendment about cruel and unusual punishment, but since I’m no legal scholar, I’ve searched the internet for more information about this situation. I found a great article co-authored by a doctor and a lawyer. They make the point that opioid addiction is a complex illness, and forced withdrawal causes severe physical and psychological suffering. Also, because opioid withdrawal makes people especially vulnerable, they may be coerced into giving testimony that incriminates themselves. They are less able to make decisions.

Prisons are charged to provide as much care as is available to prisoners as general population, yet opioid addicts are denied access to medication-assisted treatments for addiction. These treatments are, as you probably know if you’re a regular reader of this blog, one of the most evidenced-based medical treatments in all of medicine.”

http://janaburson.wordpress.com/2014/05/11/methadone-and-buprenorphine-during-incarceration/

Source: JanaBurson.com – May 11, 2014

SAMHSA Blog: Recovery Includes Medical Treatment

samhsa“Within the health domain, clinical treatment plays a critical role in recovery.  Access to safe and effective medications is a vital tool on the path to recovery for many people with mental and/or substance use disorders.  We can think of recovery as a process by which people learn to manage their conditions and lead productive lives.  It is facilitated by working with providers via medications, counseling, rehabilitative services, stress and relapse management, and other services and supports.  Just as with other health conditions, medication is often a key part in achieving positive outcomes. However, medication is not effective for everyone or for every mental health condition, so there needs to be individualized approaches to care and treatment.  The recovery model incorporates all of these variables and provides new hope to many individuals with serious mental illnesses.

To optimize the use of medications to assist recovery, consumers/peers, families, and providers need to be fully informed, engaged, and involved.  SAMHSA has developed evidence-based approaches in areas such as shared decision-making, family psychoeducation, medication treatment, evaluation, and management, and provider training and clinical decision support.”

http://blog.samhsa.gov/2014/05/01/recovery-includes-medical-treatment/#.U3Z6YptALzZ

Source: Substance Abuse and Mental Health Services Administration -May 1, 2014

Other National News of Interest

News From the States

National Institutes of Health Press Release: HHS Leaders Call For Expanded Use of Medications to Combat Opioid Overdose Epidemic

New England Journal of Medicine commentary describes that vital medications are currently underutilized in addiction treatment services and discusses ongoing efforts by major public health agencies to encourage their use

A national response to the epidemic of prescription opioid overdose deaths was outlined in the New England Journal of Medicine by leaders of agencies in the U.S. Department of Health and Human Services (HHS). The commentary calls upon health care providers to expand their use of medications to treat opioid addiction and reduce overdose deaths, and describes a number of misperceptions that have limited access to these potentially life-saving medications. The commentary also discusses how medications can be used in combination with behavior therapies to help drug users recover and remain drug-free, and use of data-driven tracking to monitor program progress.

The commentary was authored by leaders of the National Institute on Drug Abuse (NIDA) within the National Institutes of Health, the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Centers for Medicare and Medicaid Services (CMS).

“When prescribed and monitored properly, medications such as methadone, buprenorphine, or naltrexone are safe and cost-effective components of opioid addiction treatment,” said lead author and NIDA Director Nora D. Volkow, M.D. “These medications can improve lives and reduce the risk of overdose, yet medication-assisted therapies are markedly underutilized.”

Research has led to several medications that can be used to help treat opioid addiction, including methadone, usually administered in clinics; buprenorphine, which can be given by qualifying doctors; and naltrexone, now available in a once-a-month injectable, long-acting form. The authors stress the value of these medications and describe reasons why treatment services have been slow to utilize them. The reasons include inadequate provider education and misunderstandings about addiction medications by the public, health care providers, insurers, and patients. For example, one common, long-held misperception is that medication-assisted therapies merely replace one addiction for another – an attitude that is not backed by the science. The authors also discuss the importance of naloxone, a potentially life-saving medication that blocks the effects of opioids as a person first shows symptoms of an overdose.

The article describes how HHS agencies are collaborating with public and private stakeholders to expand access to and improve utilization of medication-assisted therapies, in tandem with other targeted approaches to reducing opioid overdoses.  For example, NIDA is funding research to improve access to medication-assisted therapies, develop new medications for opioid addiction, and expand access to naloxone by exploring more user-friendly delivery systems (for example, nasal sprays). CDC is working with states to implement comprehensive strategies for overdose prevention that include medication-assisted therapies, as well as enhanced surveillance of prescriptions and clinical practices. CDC is also establishing statewide norms to provide better tools for the medical community in making prescription decisions.

Charged with providing access to treatment programs, SAMHSA is encouraging medication-assisted therapy through the Substance Abuse Prevention and Treatment Block Grant as well as regulatory oversight of medications used to treat opioid addiction. SAMHSA has also developed an Opioid Overdose Toolkit  to educate first responders in the use of naloxone to prevent overdose deaths. The toolkit includes easy-to-understand information about recognizing and responding appropriately to overdose, specific drug-use behaviors to avoid, and the role of naloxone in preventing fatal overdose.

“SAMHSA’s Opioid Overdose Toolkit is the first federal resource to provide safety and prevention information for those at risk for overdose and for their loved ones,” said co-author and SAMHSA Administrator Pamela S. Hyde, J.D. “It also gives local governments the information they need to develop policies and practices to help prevent and respond appropriately to opioid-related overdose.”

CMS is working to enhance access to medication-assisted therapies through a more comprehensive benefit design, as well as a more robust application of the Mental Health Parity and Addiction Equity Act.

“Appropriate access to medication-assisted therapies under Medicaid is a key piece of the strategy to address the rising rate of death from overdoses of prescription opioids,” said co-author Stephen Cha, M.D., M.H.S., chief medical officer for the Center for Medicaid and CHIP [Children’s Health Insurance Program] Services at CMS. “CMS is collaborating closely with partners across the country, inside and outside government, to improve care to address this widespread problem.”

However, the authors point out that success of these strategies requires engagement and participation of the medical community.

The growing availability of prescription opioids has increased risks for people undergoing treatment for pain and created an environment and marketplace of diversion, where people who are not seeking these medications for medical reasons abuse and sell the drugs because they can produce a high.

The press release can be accessed at: http://www.nih.gov/news/health/apr2014/nida-24.htm

The New England Journal of Medicine article can be accessed at: http://www.nejm.org/doi/full/10.1056/NEJMp1402780?query=featured_home

Source: National Institutes of Health – April 24, 2014

Study Addresses Treatments for Waited-Listed Opioid-Dependent Individuals

waiting line“Addiction to heroin and prescription painkillers – has reached epidemic levels across the country, with treatment waitlists also at an all-time high. However, ensuring timely access to effective treatment – particularly in rural states like Vermont – has become a substantial problem. University of Vermont (UVM) Associate Professor of Psychiatry Stacey Sigmon, Ph.D., has taken a stand to address this issue and has a new grant to support her campaign.

Sigmon’s latest project, funded by a National Institute on Drug Abuse (NIDA) award, will develop a novel Interim Buprenorphine Treatment (IBT) to help opioid-dependent Vermonters bridge challenging waitlist delays. She’s proposed a treatment “package” of five key components designed to maximize patient access to evidence-based medication for opioid dependence while minimizing common barriers to treatment success, including risks of medication non-adherence, abuse and diversion.”

The five components include:

  • Three months of maintenance therapy using buprenorphine.
  • A, computerized portable device manufactured in Finland called a Med-O-Wheel, which dispenses each day’s dose at a predetermined time, after which all medication is locked away and inaccessible.
  • Clinical support will come from a mobile health platform that uses technology to deliver patient monitoring and support beyond the confines of the medical office.
  • The fourth component involves an automated call-back procedure during which participants are contacted at randomly-determined intervals and directed to visit the clinic for a pill count and urinalysis.
  • Development and provision of an HIV and hepatitis educational intervention delivered via a portable iPad platform.

“These technologies are particularly compatible with rural settings, says Sigmon, where there are multiple burdens – including long distances and transportation barriers – that can make it hard for a patient to come to a treatment center on a daily basis.

Once developed, these treatment components also don’t need to be limited to people on wait lists. In fact, they can also be used to support the physicians with patients already enrolled in a methadone, office-based buprenorphine or pain management clinics,” says Sigmon.”

http://medicalxpress.com/news/2014-04-treatments-waited-listed-opioid-dependent-individuals.html

Source: MedicalXpress.com – April 10, 2014

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

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

SAMHSA’s New Report Tracks the Behavioral Health of America

 

samhsa“A new report from the Substance Abuse and Mental Health Services Administration (SAMHSA) illuminates important trends – many positive — in Americans’ behavioral health, both nationally and on a state-by-state basis.

SAMHSA’s new report, the “National Behavioral Health Barometer” (Barometer), provides data about key indicators of behavioral health problems including rates of serious mental illness, suicidal thoughts, substance abuse, underage drinking, and the percentages of those who seek treatment for these disorders. The Barometer shows this data at the national level, and for each of the 50 states and the District of Columbia.

The Barometer indicates that the behavioral health of our nation is improving in some areas. For example, the rate of prescription pain reliever abuse has fallen for both children ages 12-17 and adults ages 18-25 from 2007 to 2011 (9.2 percent to 8.7 percent and 12.0 percent to 9.8 percent respectively).

In the United States, only 14.8% of persons aged 12 or older with illicit drug dependence or abuse (an estimated 1.1 million individuals) in 2012 received treatment for their illicit drug use within the year prior to being surveyed.

The Barometer also shows more people are getting the help they need in some crucial areas. A case in point is that the number of people getting buprenorphine treatment for a heroin addiction has jumped 400 percent from 2006 to 2010. In 2012 the number of people who received buprenorphine as part of their substance abuse treatment was 39, 223. The number of people who received methadone as part of their substance abuse treatment was 311,718 in 2012.

The data in the Barometer is drawn from various federal surveys and provides both a snapshot of the current status of behavioral health nationally and by state, and trend data on some of these key behavioral health issues over time. The findings will be enormously helpful to decision makers at all levels who are seeking to reduce the impact of substance abuse and mental illness on America’s communities.

“The Barometer is a dynamic new tool providing important insight into the “real world’ implications of behavioral health issues in communities across our nation,” said SAMHSA’s Administrator, Pamela S. Hyde.”Unlike many behavioral health reports, its focus is not only on what is going wrong in terms of behavioral health, but what is improving and how communities might build on that progress.”

The Barometer also provides analyses by gender, age group and race/ethnicity, where possible, to further help public health authorities more effectively identify and address behavioral health issues occurring within their communities, and to serve as a basis for tracking and addressing behavioral health disparities.”

To view and download copies of the national or any state Behavioral Health Barometer, please visit the SAMHSA web site at http://store.samhsa.gov/product/SMA13-4796?from=carousel&position=1&date=0130214

http://www.samhsa.gov/newsroom/advisories/1401301041.aspx

Source: – Substance Abuse and Mental Health Services Administration – 1/31/14

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