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

 

Blog by Jana Burson on Split Dosing

“Split dosing, when used in reference to the medication-assisted treatment of opioid addiction, means instead of once daily dosing, the total medication dose is divided, or split, into two doses.

Methadone and buprenorphine (Suboxone, Zubsolv, etc.) are long-acting opioids.

When we use these medications for opioid addiction, we prefer to dose once per day.

Before I can order split dosing, I need to get permission from the state and federal authorities, just like I would for extra take homes doses for patient emergencies. In my state, methadone peak and trough levels are usually requested before they grant permission for split dosing. We draw the patient’s blood three hours after their dose, which is the peak. That’s the highest blood level the patient will have on that dose. On the next day, right before they take the next day’s dose, we draw another methadone blood level, called the trough, which is the lowest level the patient ever has on that dose.

Then we compare the peak to the trough. If the peak is more than twice the trough level, the patient is probably a fast metabolizer who will feel better taking part of their dose in the morning and part in the evening.”

http://janaburson.wordpress.com/2014/07/06/split-dosing/ 

Source: JanaBurson.com – July 6, 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

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

Pope Francis Opposes Marijuana Legalization, Questions Methadone

Pope Francis said he opposed efforts to legalize marijuana and questioned the use of substitute drugs like methadone to treat heroin addicts.

“Substitute drugs, moreover, aren’t a sufficient therapy, but rather a hidden way to surrender,” Francis said. “I want to emphasize what I’ve said in other occasions. No to every type of drug. Simply no to every type of drug.”

http://www.bloomberg.com/news/2014-06-20/pope-francis-opposes-marijuana-legalization-questions-methadone.html

Source: – Bloomberg News.com – June 20, 2014

News From the States

New Methadone Safety Guidelines Published for Opioid Addiction and Chronic Pain Management

shutterstock_114229831In recent years the safety of methadone has been questioned by data indicating a large rise in the number of methadone-associated overdose deaths occurring at the same time as a marked increase in methadone use to treat chronic pain.

Between 2008 and 2011, several medical groups issued methadone safety guidelines to address the increased mortality. Published in BMJ Supportive & Palliative Care, Annals of Internal Medicine, and Journal of Addictive Diseases, these guidelines focused on preventing cardiac arrhythmias. None addressed other methadone safety issues; nor did they grade the strength of their recommendations or the quality of the evidence.

The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned a 16-member interdisciplinary expert panel to address these shortcomings. The panel’s careful review of the evidence led to specific guidelines for methadone use for treating opioid addiction in licensed opioid treatment programs, and for treating chronic pain in primary care or specialty settings. The Journal of Pain published the guidelines in April.

The new guidelines focus on promoting patient safety and mitigating avoidable harms. They include patient risk assessment, patient education and counseling, selective use of electrocardiography, dose initiation and titration, diligent monitoring and follow-up, and medication interactions.

Zeroing in on the risk of respiratory depression, a major cause of methadone-associated deaths, the panel stressed safety issues—low initial methadone doses, careful titration, and the use of alternative opioids for selected patients. Panelists concluded that the safe use of methadone “requires clinical skills and knowledge to mitigate potential risks, including serious risks related to overdose and cardiac arrhythmias.”

Methadone-Associated Deaths: Overdoses or Arrhythmias?

The panel noted factors that make it difficult to identify the cause of methadone-associated deaths, among them prescribed vs. illicit methadone use, concurrent use of other medications or substances, and uncertainty about links between increased methadone prescribing and a rise in the death rate. In the vast majority of cases, the panel could not determine whether death was due to “respiratory depression related to overdose, or to other factors, such as arrhythmia.”

The characteristics of methadone present special challenges. Methadone has a long and variable half-life, and can interact with many medications. It is difficult to adjust methadone dosages safely when switching patients from a different opioid.  Methadone is associated with a prolonged QTc interval, “which may predispose patients to the ventricular arrhythmia known as torsades de pointes [TdP].” Also, “the proportion of methadone-associated deaths related to arrhythmia is likely to be small relative to the proportion related to accidental overdose,” the panelists found.

The panel gave each recommendation a separate grade for the strength of the recommendation and the quality of the evidence. This Addiction Treatment Forum article includes only the strong recommendations. The published guidelines include additional recommendations and practice advice. The table below describes the grading system.

 

Strength of Recommendation Quality of Evidence
Strong: The panel believes that the potential benefits of following the recommendation “clearly outweigh potential harms and burdens” (or vice versa); most clinicians and patients would choose to follow a strong recommendation.
Weak: Benefits outweigh potential harms and burdens (or vice versa), “but the balance of benefits to harms is smaller or evidence is weaker.” Clinical circumstances or patient preferences could affect the decision.
The type, number, size, and quality of studies, strengths of associations, and comparative consistency of results determine the quality of the evidence that supports a recommendation.

High: A low probability exists that new evidence would affect the recommendation.
Low: A high probability exists that new evidence would affect the recommendation.

 

Because of a lack of published evidence-based studies on methadone safety, panelists were obliged to base their recommendations on what they had—evidence they considered to be of generally low quality. Panelists reviewed more than 3,700 abstracts and 168 primary studies, solicited input from more than 20 external peer reviewers, and eliminated the lowest-ranked recommendations. All of the approved recommendations received unanimous or near-unanimous consensus. In contrast, as the authors point out, two of guidelines published earlier “were not fully endorsed by a professional society or government entity, and the third was endorsed by the Substance Abuse and Mental Health Services Administration.”

The following provides highlights of this panel’s recommendations for adult patients.

Patient Assessment and Selection – When considering methadone treatment, perform an individualized medical and behavioral risk-and-benefits evaluation (low-quality evidence).

Patient Education and Counseling - Before prescribing methadone, educate and counsel patients about the indications for treatment, goals of therapy, availability of other therapies, ongoing management, and other factors (low-quality evidence).

Baseline Electrocardiograms - On the controversial key topic of baseline ECGs, the panel has two strong recommendations, both based on low-quality evidence.

  • Obtain an ECG before starting methadone in patients with risk factors for QTc interval prolongation, any previous ECG showing a QTc > 450 ms, or a history suggesting previous ventricular arrhythmia. In patients without new risk factors for QTc interval prolongation, an ECG within the previous 3 months with a QTc < 450 ms can serve as the baseline study.

In contrast, some previous guidelines required a baseline ECG screening for all patients.

  • The panel recommends against methadone use in patients with a baseline QTc interval  > 500 ms.

Some previous guidelines allowed methadone use in selected patients in this category.

Panelists provided a lengthy discussion of ECGs and risk factors for TdP and for QTc interval prolongation.

Initiating Methadone Therapy - The panel offers two strong recommendations:

  • Start with low doses, based on treatment indication and the patient’s previous opioid exposure; titrate slowly; and monitor for sedation (moderate-quality evidence). The panel’s emphasis on low initial dosing and careful titration echoes previous guidelines. It  prioritizes patient safety and takes into consideration methadone’s long, variable half-life—usually assumed to be about one day, but, according to some reports, occasionally as long as 120 hours. The panel stresses the need to withhold the dose temporarily if patients show evidence of sedation, and to restart treatment cautiously.
  • When restarting methadone, consider patients who have not taken opioids for 1 to 2 weeks to be opioid-naïve (low-quality evidence).

Monitoring and Follow-up ECGs

Three strong recommendations for follow-up ECGs, all with low-quality evidence:

  • Base follow-up ECGs on baseline ECG findings, methadone dose changes, and other risk factors for QTc interval prolongation.
  • Switch patients with a QTc interval ≥ 500 ms to a different opioid, or immediately lower the methadone dose; evaluate and correct reversible causes of QTc interval prolongation; repeat the ECG after lowering the methadone dose.
  • In patients with a QTc interval ≥ 450 ms but < 500 ms, consider switching to an alternative opioid or lowering the methadone dose (otherwise, discuss with the patient the potential risks of continuing methadone therapy); evaluate and correct reversible causes of QTc interval prolongation; repeat the ECG after lowering the methadone dose.

Adverse Events – Two recommendations:

  • Monitor patients for common opioid adverse effects and toxicities; consider adverse-effects management to be part of routine therapy (moderate-quality evidence).
  • The panel recommends discussing adverse events with patients—either face-to-face or by phone—within 3 to 5 days after starting methadone and within 3 to 5 days after each dose increase (low-quality evidence).

Urine Drug Testing – Two recommendations, both low-quality evidence:

  • Obtain urine drug screens before starting methadone treatment for opioid addiction and again at regular intervals.
  • Consider urine drug testing in all patients, regardless of risk status, before starting therapy and at regular intervals; the panel recommends such testing for patients who are prescribed methadone for chronic pain and have risk factors for drug abuse (low-quality evidence).

Medication Interactions - Use methadone with care in patients taking other medications that may have additive side effects or pharmacologic interactions with methadone (low-quality evidence).

Methadone Treatment During Pregnancy – Monitor neonates whose mothers received methadone; if neonatal abstinence syndrome occurs, provide appropriate treatment (moderate-quality evidence).

Need for Additional Research

Two related articles appear in the same issue of The Journal of Pain. One discusses in more detail methadone overdose and cardiac arrhythmia potential; the second highlights research gaps related to methadone safety. These gaps include lack of enough evidence to evaluate the comparative mortality associated with of methadone treatment versus treatment with other opioids, and to determine the effectiveness of ECG monitoring and other risk-mitigation steps.

A clear need exists for additional randomized clinical trials and large, well-controlled observational studies to provide additional data. This would allow the expert panel to update the guidelines and provide additional recommendations. The panel plans an update by 2018; earlier, if critical new evidence becomes available.

The article is available online at: http://www.jpain.org/article/S1526-5900(14)00522-7/fulltext

Links to Resources Mentioned in This Article                        

Chou R, Cruciani RA, Fiellin DA, et al. Methadone safety: A clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014;15(4):321-337. http://www.jpain.org/article/S1526-5900(14)00522-7/abstract.  Accessed June 3, 2014.

Chou R, Weimer M, Dana T. Methadone overdose and cardiac arrhythmia potential: Findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline.  J Pain. 2014;15(4):338-365. http://www.ncbi.nlm.nih.gov/pubmed/24685459?dopt=Abstract. Accessed June 3, 2014.

Krantz MJ, Martin J, Stimmel B, Mehta D, Haigney MD. QTc interval screening in methadone treatment. Ann Intern Med. 2009;150(6):387-395. doi:10.7326/0003-4819-150-6-200903170-00103. http://annals.org/article.aspx?articleid=744382. Accessed June 3, 2014.

Martin JA, Campbell A, Killip T, et al. QT interval screening in methadone maintenance treatment: Report of a SAMHSA expert panel. J Addict Dis. 2011; Oct;30(4):283-306. http://www.tandfonline.com/doi/pdf/10.1080/10550887.2011.610710. Accessed June 3, 2014.

Shaiova L, Berger A, Blinderman CD, et al. Consensus guideline on parenteral methadone use in pain and palliative care. Palliat Support Care. 2008;6:165-176. http://journals.cambridge.org/action/displayFulltext?type=1&fid=1885936&jid=PAX&volumeId=6&issueId=02&aid=1885928&bodyId=&membershipNumber=&societyETOCSession=. Accessed June 3, 2014.

Weimer MB, Chou R. Research gaps on methadone harms and comparative harms: Findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline.  J Pain. 2014;15(4):366-376. doi:10.1016/j.jpain.2014.01.496. PMID:24685460. http://www.ncbi.nlm.nih.gov/pubmed/24685460. Accessed June 3, 2014.

Click here to access additional related resources.

Tennessee Law Puts Pregnant Women on Medication-Assisted Treatment for Opioid Addiction in Danger of Arrest

shutterstock_39985291As of July 1, a pregnant woman who gives birth in Tennessee to a baby who has neonatal abstinence syndrome (NAS), a transient and easily treatable condition, could be arrested for assault. Many women in opioid treatment programs (OTPs) are likely to deliver a baby with NAS, so the American Association for the Treatment of Opioid Dependence (AATOD) and the state chapter worked hard to try to convince Gov. Bill Haslam not to sign the bill; however, April 29, he signed it.

It’s much safer for the fetus for a woman to stay on methadone or buprenorphine during her pregnancy than to come off it, medical experts agree. That’s why AATOD and other health care advocates are concerned that out of fear of being arrested, pregnant women will try to avoid or terminate treatment, or if they are not in treatment, avoid medical care altogether.

Although the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS), which regulates OTPs and other treatment programs, has said that it doesn’t want women in treatment in OTPs to be arrested, it has no authority over what individual prosecutors and police officers decide to do.

“It continues to trouble us that the Department of Health and TDMHSAS has no authority over prosecutors,” said a joint press statement signed by AATOD president Mark Parrino, Deb Crowley (chair and president of the Tennessee chapter of AATOD), Joycelyn Woods (executive director of the National Alliance for Medication Assisted Recovery [NAMA-R]), and Zac Talbott (director of NAMA-R of Tennessee). “Under the new law the possibility remains that individual prosecutors could attempt to bring charges against pregnant women enrolled in MAT who deliver babies that show signs of neonatal abstinence syndrome.”

The law has no specific exemption for women in medication-assisted treatment (MAT) who do not test positive for any illicit substance, something that AATOD calls “frightening.” Women in treatment with methadone will be subject to criminal proceedings simply for following the best advice of their physicians.

This is not to say that AATOD thinks any women should be arrested for using drugs—in fact, nobody can be arrested for “using” drugs. What the Tennessee law does is to take another step toward calling a fetus a “person,” and criminalizing the mother for “assault” on the fetus by using drugs.

“This law could leave open the possibility for women to be criminally prosecuted for seeking and obtaining the medical treatment for their disease that is the medically accepted standard of care and most responsible decision they could make for the healthy development of their unborn babies,” concluded AATOD.

Asked whether women in MAT will be protected from arrest, TDMHSAS communications director Michael A. Rabkin said that the law “protects these women from arrest.”  The law says that women who complete a treatment program will not be arrested. What should providers do to protect their patients? “There is nothing specific that providers need to be doing to protect them, since it is the law that protects them from arrest.

Advocates, however, urge that treatment providers can do the best thing for their patients by safeguarding their confidentiality and not reporting them or turning over their records to authorities.

We asked what the TDMHSAS is recommending in terms of whether patients should stay on methadone while pregnant. Mr. Rabkin’s response: “Obstetricians have standards of care that they follow that generally say that pregnant women should stay on methadone, but this decision is an individual decision that must be made by each pregnant woman and her doctor.”

Jack McCarthy, MD, an expert on pregnancy and methadone who is with Bi-Valley Medical Clinic in Sacramento, California, is horrified by the law. “I would call detoxing a pregnant woman ‘fetus abuse,’” he says. “Legally the fetus might be allowed protection from cruel practices such as opioid withdrawal.” McCarthy published a paper on “Intrauterine Abstinence Syndrome” two years ago. Summed up, it says that “You can kill a fetus and you can severely stress a fetus by ‘detoxing’ the mother,’” he said.

The M.A.R.S. Peers Model at Work in Medication-Assisted Treatment for Opioid Addiction

couselingThe M.A.R.S. Project is the only federally funded program that provides peer recovery support to patients in medication-assisted treatment (MAT) for opioid addiction. Funded by the Substance Abuse and Mental Health Services Administration, M.A.R.S. is conducted in collaboration with the substance abuse division of the Albert Einstein College of Medicine in New York City, Yeshiva University, and the National Alliance for Medication-Assisted (NAMA) Recovery.

Walter Ginter, CMA, M.A.R.S. project director, talked with AT Forum recently about how peers can help patients in MAT. First of all, MAT peers can help new patients understand that recovery is a long-term commitment. “All of us come into treatment with the idea that we’re just visiting,” said Mr. Ginter. By the time most patients enter an opioid treatment program (OTP), they have already been through “a couple of detoxes, a therapeutic community,” he said. Patients are usually older than 35, and have already been told that being on methadone means “still using.” Other programs tell people with opioid addiction to go to detoxification and go to meetings, which doesn’t help—at least 80 percent of people who go through detoxification only relapse.

So when they finally get to an OTP, they’re desperate, he said. But they still don’t think they should stay, because being on methadone isn’t “real recovery.” Peers—other patients on methadone—can communicate the facts: They can say, “’I’m not using, I’m taking a medication for a brain disorder,’” and model the appropriate recovery response. This was an unexpected bonus for M.A.R.S., he said.

Trusting Peers More Than Counselors

Why do you need peers? Of course, counselors can say the same thing—that methadone is a medication for a brain disease, and does mean being in recovery. “But when they hear that from the counselor, they wonder about the motivation, because the counselor is paid to say it,” said Mr. Ginter.  The real problem is that patients haven’t learned to trust their counselors, not that counselors are giving misinformation. The same phenomenon occurs in other conditions; for example, patients who are overweight can get better nutrition support from peer groups than from doctors, who they may feel patronized by and disconnected from.

Support is key. Recovery in general has been based on mutual support, he said. “Why do people go to 12-step meetings—for support.”

Mental health peers are part of community mental health centers, and are much more allied with treatment than MAT peers, he said. Insurance companies are starting to reimburse some peers in substance use disorders, but not in MAT. At a recent meeting of mental health peers, Mr. Ginter got the clear impression that insurance companies don’t like the idea of maintenance medication. “They’re concerned about paying for methadone treatment for the rest of someone’s life,” he said.

Mr. Ginter’s M.A.R.S. program is the only one like it in the country, but some other peers have been trained there. Cheryl Blankenship Kupras, a Licensed Clinical Social Worker, worked for an OTP for 12 years in Santa Clara County, California. The OTP, a Beyond M.A.R.S. grantee, sent Ms. Blankenship Kupras, a manager, to peer training, along with two long-standing patients.

‘By the Patients and For the Patients’

It’s essential that any peer group be “by the patients and for the patients,” said Ms. Blankenship Kupras. “It can’t be an arm of the clinic,” because then patients don’t trust the peers.”

The peer who was most involved in the program “really wanted to break down the us-versus-them mentality,” she said. “Whatever was said in M.A.R.S. stayed in M.A.R.S.”

The clinic does control medication, but beyond that, the peers make sure that patients have a place to go for support that is different than mandated counseling, said Ms. Blankenship Kupras. This is particularly important because many OTP patients don’t feel welcome at 12-step meetings. “Just having another option for support is important,” she said. It’s important for the OTP to give the peers a place to meet in the building, as well.

Peer groups can also provide education to dispel myths. “Everybody was hearing rumors,” Ms. Blankenship Kupras said. “So they asked a physician from the program to come in and make a presentation.” Originally, the doctor was reluctant to do this, because she was afraid patients would ask questions about their personal treatment. As it turned out, that didn’t happen. She saw the patients in a different light, and more importantly, they saw her in a different light as well. “The presentation helped them to make a connection with the doctor in a way they hadn’t before,” she said.

Study Suggests Chronic Pain is Widespread and Undertreated in MMT Programs By Guest Author Stewart B. Leavitt

shutterstock_119720380Pain is a worldwide epidemic and more than a third of all adults, or 100 million persons, in the U. S. alone suffer from chronic pain conditions of some sort, as estimated by the U.S. Institute of Medicine (IOM 2011). Even more troubling, newly published research suggests that the prevalence of clinically significant, persistent pain among patients in methadone maintenance treatment (MMT) programs is nearly twice that  of  the general population—and most of that chronic pain is going untreated.

Survey Provides Bleak Picture of Pain in MMT

Writing recently in the journal Pain Medicine, Kelly E. Dunn, PhD, and colleagues reported on a survey of MMT patients at the Johns Hopkins Bayview Medical Center in Baltimore, Maryland (Dunn et al. 2014). Approximately 80 percent of all patients at the clinic responded to a self-report questionnaire widely used in the pain field—the Brief Pain Inventory (BPI)—which assesses severity of pain and its interference with daily activities. Additional data were gathered on patient demographics, pain location, drug use, and current treatments for pain and addiction.

Overall, the 227 survey participants were 45 years old, had been in MMT for 4.5 years on average, and roughly half were male (47%) and Caucasian (49%). Sixty percent of respondents (N=137) indicated on the BPI that they had chronic pain. Also, there were some statistically significant differences in this group compared with MMT patients not reporting such pain: Patients with chronic pain were older (mean age 46 vs. 42 years, respectively), had higher average daily methadone doses (86 mg/d vs. 71 mg/d), and had a higher rate of benzodiazepine-positive urine samples in the past 90 days (7% vs. 3%).

Chronic pain was reported in multiple body areas by roughly a third (36%) of patients with pain, but the most common locations were the back (51%) and lower extremities (59%). Average pain during the past 24 hours on a 0-to-10 scale was reported as 5.8, with worst pain averaging 7.2. Also, using a 10-point scale to rate how pain affected daily life, interference with sleep was ranked highest (6.0 on average), followed by interference with general activity, normal work, and enjoyment of life. Interference in relationships with other people was least affected by chronic pain (rated 4.1 on average).

Merely 13 percent (N=18) of study participants with chronic pain reported receiving pain management treatment, and these patients were significantly more likely to be female, report less income from employment, and have a lower rate of benzodiazepine use. MMT patients being treated for pain most commonly reported back pain, and the majority of those being treated (89%) were prescribed medications; half received short-acting opioids and a third received nonopioid medications (eg., NSAIDs, gabapentin). Only 28 percent received nonpharmacologic therapies for their pain, such as physical therapy. Overall, those treatments were effective; study participants indicated that pain management provided, on average, 51 percent relief from their pain (range 0%-90%).

In sum, this study found that a substantial proportion of patients in a large MMT program reported clinically significant and persistent pain, for which only a relative handful were receiving pain management therapy. Dunn and her coauthors state, “Overall these data suggest that pain was not being adequately evaluated or treated in the majority of this sample. These findings are remarkable . . . and they illustrate what little progress has been made in the past 10 years regarding the concurrent treatment of pain and opioid use disorders.

Better and More Research is Needed

Similar to Dunn et al., in 2008, Cruciani and colleagues reported a study that found 61 percent of 390 MMT patients had experienced persistent pain for more than 6 months, and greater than a third of those patients (37%) had severe chronic pain (Cruciani et al. 2008). In an Addiction Treatment Forum interview article last year (see AT Forum, Winter 2013), it was noted that pain in patients attending MMT programs is commonplace, and a recent study of 489 patients had found that 237 (48.5%) had clinically significant chronic pain. Generally, past research surveys have reported high but varying prevalences of chronic pain among MMT patients, ranging from approximately 27 percent to 80 percent, with relatively few receiving pain care (references in Dunn et al. 2014).

While the newly reported study by Dunn and colleagues is consistent with most of the past research, it also exhibits many of the limitations in this area of scientific inquiry:

  • Dunn et al. gathered data for their study between December 2006 and January 2007, but were just reporting on results now in 2014; so, the outcomes may or may not reflect current circumstances. Unfortunately, it is not unusual in the pain research literature or government surveys for the reporting of data to come long after its collection.
  • Chronic pain was defined in the Dunn et al. study as answering “yes” to the BPI question, “Have you had pain other than everyday kinds of pain today?” And, even though locations of pain also were reported by patients and recorded by the investigators, this was a somewhat vague definition of chronic pain.This is a common problem encountered in most surveys of chronic pain, since there usually are no readily observable clinical signs or imaging evidence (eg., on X-ray, MRI) of pathology to confirm the presence, severity, or duration of pain. Pain most often is what the patient says it is, without sufficient clinical confirmation; so, it is understandable that there are wide variations in the prevalence of pain reported in different studies of pain in MMT patients, as well as in the general population.
  • There was a small, but significant, increase in benzodiazepine use among patients with pain (small differences between groups in illicit opioid and cocaine use were not statistically significant). However, considering that sleep disturbance was ranked high in persons with pain, this might account for their greater use of sedatives like benzodiazepines; additionally, Dunn et al. did not distinguish between prescribed vs. illicit use of these medications.
  • There was no assessment by Dunn et al. of which came first, pain or addiction, patients’ histories of pain or its treatment, and how MMT might have affected chronic pain. For example, although patients with pain were receiving higher average methadone doses (86 mg/day), the researchers acknowledge that persistent symptoms of opioid withdrawal in some persons were likely confused with chronic pain. Dunn and coauthors also note that some patients might have been receiving certain treatments in the MMT clinic—eg., antidepressants, cognitive behavioral therapy, biofeedback—that were intended for pain management, but not identified as such.
  • In general, the study by Dunn and colleagues surveyed a relatively small sampling of MMT patients in a single clinic setting, which cannot be assumed to represent the larger MMT population. While they present statistical data on those patients receiving pain care during MMT, their numbers were so small (N=18) that the validity of results in this group need confirmation in a larger sampling. For example, the findings that patients receiving pain care were more likely to be women, making less money from employment, and less likely to be using benzodiazepines should be cautiously considered in view of such small numbers.

Dunn et al. do not speculate as to why there is such a high prevalence of chronic pain among MMT patients, or why so few patients receive pain management for those conditions. Clearly, more and better research is needed to understand these problems and to develop strategies for providing effective pain management in the presence of the disease of addiction. At the least, there is a need for prospective studies examining large numbers of patients upon entry to MMT—or buprenorphine therapy—for addiction and during long-term follow-up to determine the progress of those with clinically diagnosed pain conditions.

Challenges and Opportunities

As Dunn and colleagues point out, patients with opioid addiction are likely being “systematically undertreated for pain.” And, while surveys have found that MMT clinic staff are interested in receiving education on treating pain in persons with substance-use disorders, there could be important barriers for MMT patients when it comes to receiving adequate pain care.

Opioid analgesics have been demonstrated as effective for relieving most types of moderate to severe pain, although their long-term use for chronic pain needs further investigation. Dunn and colleagues found that half of their respondents being treated for pain (N=9) were administered short-acting opioids, and Cruciani et al. similarly had noted that 47 percent of MMT patients with pain in their survey were receiving opioid pain relievers. Methadone itself is an excellent analgesic; however, to be effective for pain, it requires more frequent administration than the once-daily (or even split-dose) regimen provided during MMT for addiction. At the same time, many staff in MMT programs are uneducated in, or uncomfortable with, the concurrent administration of methadone and other opioids.

Often multiple types of pain treatment are necessary—spanning the medication and nondrug spectrums—which can be costly and required for extended periods of time. Yet, Dunn and her coauthors note, patients in addiction treatment have historically had limited access to insurance or other financial resources for such care. Furthermore, the pain-care field is highly fragmented, with the various specialists—eg., rheumatologists, orthopedists, neurologists, physiatrists—in high demand and short supply in most communities.

Dunn et al. conclude that their study should illustrate to health care professionals in both the substance abuse treatment and pain management fields that “patients with both disorders are not necessarily intractable hopeless cases and that they deserve the same level of attention and clinical care as chronic pain patients in the general population.” However, unless the many challenges are overcome, the plights of persons with chronic pain in methadone or buprenorphine maintenance treatment are unlikely to improve. There is an important opportunity here for the addiction treatment and pain care fields to forge alliances that can serve the mutual goal of achieving better care for patients with co-occurring pain and opioid use disorders.

References

Cruciani RA, Esteban S, Seewald RM, et al. MMTP patients with chronic pain switching to pain management clinics. A problem or an acceptable practice? Pain Med. 2008;9(3):359-364. doi: 10.1111/j.1526-4637.2006.00224.x. http://www.ncbi.nlm.nih.gov/pubmed/18366514

Dunn KE, Brooner RK, Clark MR. Severity and interference of chronic pain in methadone-maintained outpatients [Epub ahead of print April 7, 2014]. Pain Med. doi:10.1111/pme.12430. http://www.ncbi.nlm.nih.gov/pubmed/24703517

IOM (U.S. Institute of Medicine). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. June 2011. http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx.

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

Methadone Programs Can be Key in Educating, Treating Hepatitis C Patients

liver“People who inject drugs and are enrolled in a drug treatment program are receptive to education about, and treatment for, hepatitis C virus, according to a study by researchers at several institutions, including the University at Buffalo.

That finding, published online this week in the Journal of Addiction Medicine will be welcome news to health care providers. “One of the most important findings of this work is that people who inject drugs do want to be educated about the disease and that education is associated with willingness to be treated,” says senior author Andrew H. Talal, MD, professor of medicine in the Division of Gastroenterology, Hepatology and Nutrition at UB and adjunct associate professor of medicine at Weill Cornell Medical College. research assistant professor of medicine at UB.”

http://www.sciencedaily.com/releases/2014/05/140516203359.htm

Source: ScienceDaily.com -May 16, 2014

Blog By Jana Burson: The COWS Score: How Helpful Is It?

“COWS stands for Clinical Opioid Withdrawal Scale, and it’s probably the most commonly used tool to determine the degree of opioid withdrawal experienced by the patient. The scale has eleven items related to opioid withdrawal. Some are subjective, like the question about the degree of anxiety or irritability the patient is feeling. Some items are strictly objective, such as pupil size and pulse rate. And some are sort of a combination of objective and subjective, like the question asking about both nausea and vomiting. The patient may report nausea and score points on the scale, and if the patient vomits, this scores more points.

I think it’s a good tool, but has some drawbacks. I use it during dose induction, particularly on a patient new to medication-assisted treatment. Sometimes patients aren’t sure how they’re “supposed” to feel on replacement medication, and a COWS score gives me a better idea of how much withdrawal they are in.”

The blog can be accessed at: http://janaburson.wordpress.com/2014/05/25/the-cows-score-how-helpful-is-it/

Source: JanaBurson.com – May 25, 2014

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

NYC: National Development and Research Institutes, Inc. (NDRI) Honors Dr. Beny J. Primm for Lifetime Contribution to the Fields of Addiction and Its Related Diseases

Primm“Dr. Beny J. Primm was recently honored by the National Development and Research Institutes, Inc. (NDRI) and presented with the Lifetime Contribution Award by Dr. H. Westley Clark, MD, and Mr. Joseph Lunievicz at The Masonic Temple on at 71 West 23rd Street, NY, NY.

Dr. Primm is the co-founder of Addiction Research Treatment Corporation (Now known as SMART) served as its Executive Director for more than 40 years, and as President of the Urban Resource Institute since its creation in 1980. Selected by four U.S. Presidents to serve as a consultant on a variety of substance abuse and public health issues, he was appointed to the Commission on AIDS by President Ronald Reagan, selected as the first Director of the Center for Substance Abuse Treatment of the US Department of Health and Human Services by President George Bush, and named U.S. Representative on issues of drug addiction and AIDS to the World Health Organization in Geneva.”

http://wcalvinanderson.wordpress.com/tag/american-association-for-the-treatment-of-opioid-dependence/

Source: Calvin Anderson – April 28, 2014

E-mail Communication from AATOD President Mark Parrino on MAT for Opioid Addiction in the Criminal Justice System

AATOD“I am providing a link to an important letter to Attorney General Eric Holder, dated April 10, 2014, which was signed by sixteen US Senators. The Senators are urging the Attorney General to work with all of the branches in the Department of Justice to utilize the federally approved medications to treat opioid addiction “in combination with counseling”. “Specifically, the Department should initiate a multi-state program utilizing anti-addiction medications to support successful reentry into society of opioid addicted offenders from various correctional settings.” I know that you will join me in supporting this approach and clearly the sixteen Senators understand the benefit of providing access to Medication Assisted Treatment for opioid addiction in the Criminal Justice setting.”

The AATOD letter can be accessed at: http://www.aatod.org/wp-content/uploads/2014/04/Letter-to-AG-Holder-on-Prescription-opioid-and-heroin-addiction.pdf

Source: American Association for the Treatment of Opioid Dependence – April 28, 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

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