Open Access Journal Article: Advancing Service Integration in Opioid Treatment Programs for the Care and Treatment of Hepatitis C Infection

liverABSTRACT

It is estimated that approximately 200 million people globally are infected with the hepatitis C virus and that roughly half of these people live in Asia. Without treatment, it is estimated that roughly twenty percent of those infected with hepatitis C virus progress to chronic liver disease, then subsequently, end-stage liver disease. Thus, access to hepatitis C testing and subsequent care and treatment of chronic hepatitis C infection are essential to address the global burden of disease.

In the United States, the Center for Disease Control and Prevention estimates that 60% of new cases of hepatitis infection are due to injection drug use. Opioid Treatment Programs (OTP’s) dispense methadone and buprenorphine under specific federal regulations to injection drug users diagnosed with opioid dependence. OTPs are developing comprehensive care and treatment model programs that integrate general medical and infectious disease-related medical care with substance abuse and mental health services. Integrating hepatitis care services and treatment in the substance abuse treatment settings fosters access to care for patients with hepatitis C infection, many who otherwise would not receive needed care and treatment.

This may serve as a national model for highly cost-efficient healthcare that has a measurable outcome of improved public health with reduced hepatitis C prevalence.

http://www.scirp.org/journal/PaperInformation.aspx?PaperID=42589#.Uul-AJtALzZ

Source: International Journal of Clinical Medicine – January 2014

Medicaid Cutbacks in Maine Leave 400 OTP Patients without Coverage

medicaid“In what appears to be insult added to injury, Maine opioid treatment program (OTP) patients not only face having to prove themselves in order to stay in treatment for more than medicaidtwo years, but, due to a cutback in Medicaid, 400 of them will be left with no access to state-paid treatment no matter how well they are doing.”

Alcoholism Drug Abuse Weekly asked John A. Martins, spokesman for the Maine Department of Health and Human Services, in an e-mail what the state’s plans are for those patients.

“Substance use and abuse is not new in Maine or across the nation and occurred long before Maine’s initial expansion of the MaineCare program in 2002 to cover those who are losing coverage,” said Martins. “We remain committed to effective and efficient use of non-MaineCare resources to improve education and successfully prevent addiction and intervene early before addiction occurs.

http://www.alcoholismdrugabuseweekly.com/m-article-detail/medicaid-cutbacks-in-maine-leave-400-otp-patients-without-coverage.aspx

Source: AlcoholismDrugAbuseWeekly.com – January 27, 2014

Experts Challenge Decision That Would Make New Jersey the First State to Effectively Outlaw Methadone Treatment for Pregnant Women

Pg8_law“This week, 76 organizations and experts in maternal, fetal, and child health, addiction treatment, and health advocacy filed an amicus curiae (friend of the court) brief before the New Jersey Supreme Court, urging it to overturn a lower court ruling making the state’s civil child abuse law applicable to women who received medically prescribed methadone treatment while pregnant.

At the center of the case is a woman, identified by the court as Y.N., who had been struggling with a dependency on opioid painkillers. When she found out she was pregnant, she followed medical advice and obtained care that included methadone treatment. She gave birth to a healthy baby who was successfully treated for symptoms of neonatal abstinence syndrome (NAS). NAS is a side effect of methadone treatment and other medications, such as those commonly prescribed to treat depression. Y.N. was reported to the Division of Child Protection and Permanency (DCPP, formerly the Division of Youth and Family Services), and was judged to have abused or neglected her child because she agreed with her physician’s recommendation and followed the prescribed course of methadone treatment while pregnant.

Lawrence S. Lustberg of Gibbons P.C., co-counsel for the amici, explains that “the New Jersey Supreme Court has been a national leader in recognizing that when cases raise scientific, medical, or other technical issues, the evaluation of these issues must be informed by existing scientific knowledge, including expert testimony.” He added, “This case should not be an exception, yet, the decision in the lower court was reached without the input of a single medical expert and without considering the established science addressing the value of methadone treatment to maternal, fetal, and child health, and other key health and social welfare issues in the case.”

Dr. Robert Newman, one of the experts represented in the brief and a nationally and internationally recognized authority on methadone treatment, said, “As a matter of medicine and health care, it is simply nonsensical to regard methadone treatment as a form of child abuse.” He explained, “Decades of research unequivocally demonstrate the benefits of treating a pregnant woman’s addiction to opioids with methadone, an extraordinarily well-studied medication whose benefits to the mother as well as the baby unquestionably outweigh the treatable and transitory side effects that are sometimes seen in the newborns.” He noted that “It is not recommended that women simply stop using opiates during pregnancy” and that “methadone and other related treatments are acknowledged by national and international governmental, academic and clinic authorities to be the best choice for maternal, fetal, and child health, reducing risks of miscarriage, stillbirth, and premature birth.”

The experts’ brief addresses the fact that the lower court did not consider health measures that can be taken after birth to reduce symptoms of NAS, including keeping the new mother and baby together and encouraging breast feeding. The brief also notes that there is nothing in the lower court’s decision that limits its ruling to pregnant women who receive methadone treatment and could be applied to any pregnant woman, including those who experience health conditions such as epilepsy, depression, and blood clots that require medication that have potential adverse effects in the newborn.

Lynn Paltrow, Executive Director of National Advocates for Pregnant Women and co-counsel representing the experts, explained that, “unless the lower court decision is reversed, New Jersey would become the only state in the U.S. to effectively ban pregnant women from receiving methadone treatment.” She added, “DCPP’s position and the lower court’s decision is inexplicable and irrational. They not only fly in the face of the recommendations of the World Health Organization and the U.S. government, but New Jersey itself, which, through collaborations between the New Jersey Department of Mental Health and Addiction Services and DCPP, provides methadone treatment to pregnant women and families in the child welfare system.”

The court is expected to hear oral arguments this term. The group of expert amici included the American College of Obstetricians and Gynecologists, American Psychiatric Association, American Public Health Association, American Society of Addiction Medicine, Medical Society of New Jersey, New Jersey Psychiatric Association, New Jersey Obstetrical and Gynecological Society, National Council on Alcoholism and Drug Dependence, and National Council on Alcoholism and Drug Dependence-NJ. A full list of amici is available here:http://bit.ly/K7vhNo.

In 2013, more than 50 national and international experts published an open letter urging that media coverage of prenatal exposure to opioids be based on science, not stigma and misinformation. This letter is available at: http://bit.ly/1eIdeaz.

http://advocatesforpregnantwomen.org/blog/2014/01/experts_to_new_jersey_supreme.php

Source: National Advocates for Pregnant Women – January 9, 2013

 

 

Proportion of Opioid Treatment Programs Offering On-Site Testing For HIV and STIs Declines

technology“A survey of opioid treatment programs finds that the proportion offering on-site testing for human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) declined substantially between 2000 and 2011, despite guidelines recommending routine opt-out HIV testing in all health care settings, according to a study appearing in the December 25 issue of the Journal of the American Medical Association (JAMA).

From 2000 to 2011, the absolute number of programs offering testing for HIV, STIs, and the Hepatitis C virus (HCV) increased but the percentage offering on-site testing for HIV declined by 18 percent and for STIs by 13 percent. There was no change for HCV testing. More than 75 percent of public programs offered on-site testing for each infection, with no change over time.

Declines were most pronounced in for-profit programs.”

http://medicalxpress.com/news/2013-12-proportion-opioid-treatment-on-site-hiv.html

Source: MedicalExpress.com – December 24, 2013

Blog: For Young People Addicted to Painkillers, the Path Less Taken — Why?

Pill interactions“Many adolescents believe that Rx opioids are safe because they are prescribed by a doctor. But when abused, they can be as potent and as deadly as heroin. In fact, many teens and young adults who abuse Rx opioids move on to heroin abuse.

But Rx opioid or heroin abuse does not have to be lethal. There are behavioral and pharmacological treatments that can save lives and bring even seriously addicted kids into long-term recovery. The problem is that many treatment programs have chosen to either rely on only behavioral treatments or only medications; and most physicians do not have sufficient training in either medication or behavioral therapy to provide effective treatment.

While no one treatment approach is right for every teen, it is clinically sensible — but not easy — to find comprehensive care. We tell families to look for three things: First, the availability of professional counseling; second, medications and regular monitoring for the affected teen; and finally, family therapy to help that teen.

Families can, and should, insist that their treatment providers offer these medications (methadone, buprenorphine, and naltrexone) as part of a treatment plan for teen and young adult patients who are struggling with an Rx opioid addiction. It is possible that medication-assisted treatment will not be necessary, but there should be monitoring and management in place to determine whether or when behavioral treatment alone is not adequate.”

 http://www.huffingtonpost.com/stephen-j-pasierb/teen-addiction_b_4473606.html

Source: HuffingtonPost.com – December 21, 2013

Dr. Jana Burson Blog: Who Should NOT Be in Medication-Assisted Therapy with Either Methadone or Buprenorphine?

“I spend much time and effort explaining how medication-assisted treatment for opioid addiction works for many addicts. It occurred to me that I should explain who isn’t a good candidate for such treatment.

I enthusiastically support medication-assisted treatment (MAT) of opioid addiction, but no treatment works for everyone. MAT doesn’t work for every opioid addict.” Dr. Burson offer ten reasons a patient may not be suitable for MAT including:

  • The patient isn’t addicted to opioids.
  • The patient takes opioids for pain, but has never developed the disease of addiction.
  • The opioid addict presenting for treatment has been physically dependent for less than one year.
  • The opioid addict has the ability to go to a prolonged inpatient residential treatment program for his addiction.

All this is to say that the goal of entering an opioid treatment program isn’t necessarily to
get off the treatment medication.

So if a patient seeks to enter methadone treatment but also expresses a desire to be off buprenorphine or methadone within weeks to months, I tell them their expectations aren’t realistic. These medications don’t work like that. If the patient wants to get off all medications quickly, they need referral to an inpatient program. This way, patients can’t later say they were mislead, and they feel like they have liquid handcuffs, chained forever to methadone, with its many regulations for treatment.’

http://janaburson.wordpress.com/2014/01/05/who-should-not-be-in-medication-assisted-therapy-with-either-methadone-or-buprenorphine/

Source: Jana Burson – MD  – January 5, 2014

New Mexico Jail Methadone Program Shows Mixed Results

jail croppedjailjail cropped
jail cropped“A recent study conducted by the University of New Mexico found that inmates in the methadone maintenance program, which provides a daily dose of methadone to inmates already enrolled in a community-based methadone program, spent almost 40 days longer out of jail than their opiate-addicted counterparts not enrolled in a methadone program. That amounts to per-inmate savings to taxpayers of almost $2,700, according to the study, as taxpayers shell out around $69 to house an inmate per day.

The study published in early December, however, contains another finding that erases the savings: Inmates enrolled in the methadone program tended to stay in jail 36 days longer than other inmates. It’s unclear what causes methadone inmates to stay longer, though the program’s directors and others have a couple guesses – that methadone-receiving inmates are more comfortable in jail than those addicted to heroin, and that inmates getting methadone tend to prefer serving their full sentences and leaving jail without probation.”

http://www.abqjournal.com/331644/news/methadone-program-shows-mixed-results.html

Source:  ABQJournal.com – January 6, 2014

CRC Health Group Announces Acquisition of Nation’s Fourth Largest Opiate Addiction Treatment Network Habit OPCO

“CRC Health Group, the nation’s largest provider of addiction treatment and related behavioral health services, announced the acquisition of Habit OPCO, the nation’s fourth largest provider of opiate addiction treatment clinics. Founded in 1985, Habit OPCO has 22 treatment locations in Massachusetts, Vermont, New Hampshire, New Jersey and Pennsylvania. The acquisition increases CRC Health’s total number of comprehensive treatment centers to 80. The deal is expected to close in the first quarter of 2014.”

http://www.digitaljournal.com/pr/1632400

 Source: DigitalJournal.com – December 10, 2013

 

New Resource: The Partnership at Drugfree.org Launches Innovative Tool to Help Parents Understand Lifesaving Benefits of Medication-Assisted Treatment for Opiate Addiction

The Partnership at Drugfree.org, a national nonprofit working to find evidence-based solutions to adolescent substance use, has launched a  new digital resource that helps parents better understand the potential life-saving benefits of medication-assisted treatment. The online tool is comprised of videos, testimonials and an e-book to help parents make an informed choice when they are looking for treatment options to help a teen or young adult recover from an addiction to prescription pain medications, heroin or other opiates.

http://www.itnewsonline.com/showprnstory.php?storyid=302031

 Source: ITNewsOnline.com – December 12, 2013

Barriers to HCV Care Include Lack of Physical Symptoms, Treatment Side Effects

“Barriers to hepatitis C care for patients enrolled in opioid substitution treatment included the perception of being physically well and concerns about adverse effects associated with interferon-based hepatitis C virus treatment, according to results from the ETHOS study.

“Integrating treatment for hepatitis C within settings that provide treatment for drug dependence minimizes some of the barriers for clients wishing to undertake hepatitis C treatment,” study researcher Carla Treloar, PhD, deputy director of the Centre for Social Research in Health at the University of New South Wales, Australia, told Infectious Disease News. “However, treatment remains an unattractive option for some patients. Providing ways for those without hepatitis C symptoms to be assessed for liver damage may be important to open up alternative conversations about hepatitis C care.”

http://www.healio.com/infectious-disease/hepatitis-resource-center-2013/barriers-to-hcv-care-include-lack-of-physical-symptoms-treatment-side-effects

Source: Healio.com – December 11, 2013

Jana Burson Blog Inspired at AATOD – Supplemental Study of the MOTHER Trial

 

baby“Yesterday at the AATOD conference, I heard a lecture by one of the main authors of the MOTHER (Maternal Opioid Treatment: Human Experimental Research) trial, Dr. Karol Kaltenbach. I’ve posted blogs about this trial (see Dec 16, 2010, March 23, 2013), which randomized opioid-addicted pregnant women to treatment with either methadone or buprenorphine. The goal was to compare outcomes of the babies born to moms maintained on methadone versus buprenorphine.

From the MOTHER study we learned that babies born to moms on buprenorphine have about the same risk of withdrawal, called neonatal abstinence syndrome (NAS), as babies born to moms on methadone. In both groups, fifty percent of the babies had NAS severe enough to need medication to treat opioid withdrawal. The babies were scored on the Finnegan scale, which grades the babies on many signs of withdrawal to indicate when treatment is needed.

Now for the exciting part: a supplemental study of these children is being completed. This data hasn’t yet been published, but Dr. Kaltenbach says it will show that kids of moms on methadone and buprenorphine were compared and assessed at three months, six months, twelve, twenty-four, and thirty-six months. A standardized scoring system for infant development called the Bayley Scale was used to study these children, and the groups were compared to scores for normal children.

Dr. Kaltenbach says there are no differences between the babies born to methadone versus buprenorphine, and better yet – both groups showed scores in the normal ranges on this scale. The scale measured things like language and motor skills, cognitive abilities, and conceptual and social skills.”

http://janaburson.wordpress.com/2013/11/14/inspired-at-aatod/

Source: Jana Burson – November 14, 2013

 

Research: Medication-Assisted Treatment With Methadone: Assessing the Evidence

evidence

Objective - “Detoxification followed by abstinence has shown little success in reducing illicit opioid use. Methadone maintenance treatment (MMT) helps individuals with an opioid use disorder abstain from or decrease use of illegal or nonmedical opiates. This review examined evidence for MMT’s effectiveness.

Methods - Three authors reviewed meta-analyses, systematic reviews, and individual studies of MMT from 1995 through 2012. Databases searched were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, and Published International Literature on Traumatic Stress. The authors rated the level of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness and examined maternal and fetal results of MMT for pregnant women.

Results – The review included seven randomized controlled trials and two quasi-experimental studies of MMT, indicating a high level of evidence for the positive impact of MMT on treatment retention and illicit opioid use, particularly at doses greater than 60 mg. Evidence suggests positive impacts on drug-related HIV risk behaviors, mortality, and criminality. Meta-analyses were difficult to perform or yielded non-significant results. Studies found little association between MMT and sex-related HIV risk behaviors. MMT in pregnancy was associated with improved maternal and fetal outcomes, and rates of neonatal abstinence syndrome were similar for mothers receiving different doses. Reports of adverse events were also found.

Conclusions – MMT is associated with improved outcomes for individuals and pregnant women with opioid use disorders. MMT should be a covered service available to all individuals.”

The PDF file of the article was available online as of November 25, 2013 at: http://ps.psychiatryonline.org/data/Journals/PSS/0/appi.ps.201300235.pdf

Source: PsychiatryOnline.org – November 18, 2013

Methadone vs. Buprenorphine: How Do OTPs and Patients Make the Choice?

choicesOpioid treatment programs (OTPs) have always been able to dispense buprenorphine on the same basis as methadone, but now they can dispense take-home buprenorphine more liberally than take-home methadone. This has given rise to many questions about how new patients should be selected for which medication—the appeal of take-homes is clear, but that doesn’t necessarily mean everyone who wants buprenorphine from an OTP should get it. Still, there is very little information available about how to select which patients for which medication. AT Forum talked to top experts in the country about this question.

There aren’t formal selection criteria developed for OTPs, explained Melinda Campopiano, MD, medical officer for the Center for Substance Abuse Treatment (CSAT) at the federal Substance Abuse and Mental Health Services Administration (SAMHSA). Dr. Campopiano said physicians should apply exclusionary criteria for each medication, but aside from that, the decision is “supposed to be made by a physician, based on individual circumstances.”

It’s clear, said Dr. Campopiano, that more is involved than simply patient choice. “How healthy is the patient medically and psychiatrically? How stable is their life? Can they keep take-home medication safely?”

Andrew J. Saxon, MD, professor in the Department of Psychiatry & Behavioral Sciences and director of the Addiction Psychiatry Residency Program at the University of Washington, prefaced his answers to our questions by saying there are no good data that would help predict which patients might do best on which medication. “My responses involve my own opinion,” he said. He is trying to “piece together the data we do have to lead us at least to some reasonably rational decisions.”

Dr. Saxon noted that the situation is no different from any other area of psychiatry—“We have lots of antidepressants and antipsychotics, but no data to tell us which patient will respond best to which” drug.

That said, methadone has the advantage of retaining patients better in treatment, said Dr. Saxon. “This advantage is very important because so many patients drop out of maintenance treatment, and almost all relapse and significantly raise their risk for mortality.”

The advantage of buprenorphine is a better safety profile, allowing the dose to be raised very quickly to therapeutic levels, said Dr. Saxon, who was the source recommended by the National Institute on Drug Abuse for this article.

If what people want is a formula that gives cookie-cutter recommendations for one drug over the other that can apply in all cases—that isn’t going to happen, said Dr. Campopiano. “You can’t use a formula to tell you what medication to give for blood pressure. You might try one, and if that doesn’t work, try another.” It’s important to rely on science, she said.

One of the big challenges with medication-assisted treatment—and all treatment—for addiction is that the field is short on physicians, unlike other medical treatment fields. This creates a struggle when it comes to answering questions about different medications. A choice between buprenorphine and methadone is, after all, a medical decision.  

The decision to treat with buprenorphine or methadone is based on a combination of factors, said Laura Murray, MD, medical director for Addiction Services for NHS Human Services. Dr. Murray oversees medication-assisted treatment with methadone and buprenorphine in multiple OTPs in Philadelphia and surrounding counties. “In our treatment programs, the process begins with a thorough intake assessment to first determine the appropriate level of care, whether that be inpatient treatment or treatment in the OTP setting,” said Dr. Murray. After review and collaboration with the intake specialist, the final decision for the appropriate form of medication is made by the physician, she said.

Patient Preference

A history of patient reliability, patient choice, and a history of response or lack of response to buprenorphine or methadone would guide Peter L. Tenore, MD, medical director of the division of substance abuse at Albert Einstein College of Medicine in New York City. However, patient preference is not as important as the patient’s responsibility in taking medications correctly.

Dr. Tenore stressed that a patient’s desire to have take-homes is not alone a valid criterion for dispensing buprenorphine instead of methadone. Patient responsibility—to take medications correctly and to prevent diversion—and patient history of or a response or nonresponse to buprenorphine—are the important issues, he said.

“Patient preference guides me a lot,” said Dr. Saxon. “We have a qualitative study showing that patients who prefer methadone but get buprenorphine instead are not well satisfied and don’t stay on it,” he said. “Since we don’t have good data to guide us in making a choice between medications, why not give the patient what the patient wants, unless there are reasons not to?” He added that one reason not to would be that the patient hasn’t done well on that medication before.

Individual preference is a major factor in the decision between methadone and buprenorphine, agreed Dr. Murray. “If an individual presents requesting buprenorphine treatment, we make every attempt to accommodate their preference,” she said. “When a person struggling with addiction has reached the point of accepting the need for help, denying their preferred treatment can be antagonistic and harmful in establishing a therapeutic relationship from the outset.”

However, Dr. Murray noted that the program is “very clear from the beginning that the final decision rests with the program physician after a complete examination and an assessment of appropriateness for treatment,” she said. If patient preference cannot be accommodated, the program works with the patient to help him or her “in a mutual understanding regarding the appropriate treatment and the reasons for the denial.”

Patient preference should be taken into consideration, because patients do better when OTPs “meet them where they’re at,” said Susan F. Neshin, MD, medical director of JSAS Healthcare, an OTP based in Neptune, New Jersey.

Take-homes

If patients’ main reasons for wanting buprenorphine are take-homes, they need to realize that there are more stringent requirements for these privileges.

The more liberal take-home policy for buprenorphine is often attractive for people who are holding down full-time jobs or for mothers with child-care issues, said Dr. Murray. “However, we are very aware of diversion issues and as such we attempt to make an assessment regarding the type of program and the level of structure best suited to the individual, based on their presentation and history.”

 “A patient appropriate for buprenorphine treatment should have relative stability in many important life areas,” said Dr. Neshin, citing employment, housing, relationships, physical and mental health, and support systems. “Patients whose lives are more chaotic need the structure of methadone treatment,” which means coming to the clinic more often.

Array of Services

OTPs offer a broad array of services, and many patients benefit from this. However, many patients are unwilling to commit to the daily attendance and stringent requirements of OTPs. “The stronger their own support systems and commitment to recovery, the less they need the structure of OTPs,” said Dr. Neshin.

It’s not possible to compare office-based treatment with buprenorphine and treatment in the OTP setting (with either buprenorphine or methadone), because of the extra services offered by an OTP. Dr. Tenore demands and arranges for additional services for patients on buprenorphine, as well as for those on methadone.

Treatment in an OTP and office-based treatment are “probably not comparable,” agreed Dr. Saxon, adding that no study has even been done comparing the two settings. “Right now we suspect that patients who make it to office-based treatment are probably different from those who end up in OTPs, with OTP patients being generally sicker and  poorer. But I’m not sure we have adequate data to support that.” And, he stressed, dropout rates from office-based treatment are very high.

In general, patients with a high opioid tolerance and chronicity of use in general should be guided to methadone treatment, said Dr. Neshin. But she added that many patients with apparent high tolerances can comfortably reach an adequate buprenorphine dose.

Previous Failures

For people who have a history of instability on buprenorphine, chances are it won’t be efficacious when tried again, unless there are significant changes in the patient’s circumstances, Dr. Neshin noted.

But clinicians should look beyond a history of failure with either buprenorphine or methadone to the reason for that failure, said Dr. Tenore. Usually, he said, the reason for the failure is that the dose was too low.

Previous failures can make a difference in which medication is chosen, but should never be used alone as a deciding factor, said Dr. Murray. She agreed that the reasons for failure are important. In addition, she said, a past failure with a specific treatment “can lead to a positive outcome in a future attempt, because the individual has learned something from the failed attempt.”

Specific Drug of Abuse

All of our sources agreed that whether patients were addicted to heroin or prescription opioids is not relevant in deciding between methadone and buprenorphine.

But if the patient used opioids intravenously, the structure of an OTP is preferred, regardless of the medication delivered. These patients are more likely to have higher addiction severity scores, noted Dr. Neshin.

Typically, patients with longer addiction histories and longer periods of instability in their lives should be referred for methadone treatment in an OTP, Dr. Neshin said. And while age isn’t an important factor, “immaturity” usually requires the structure of an OTP, she added.

Dr. Murray agreed completely on maturity of the patient playing a role in choice of treatment. While both methadone and buprenorphine patients should be at least 18 years of age, it’s important to determine whether the patient can be compliant with treatment requirements. Younger patients benefit from the more structured environment of methadone maintenance treatment, according to Dr. Murray. “Lifestyle and support systems are important factors in determining the appropriate treatment,” she said, adding again that the more structured environment of methadone maintenance treatment “may be more appropriate for a person without support systems and with an unstable living environment.” 

OTP vs. Office-based

Often, the question of methadone vs. buprenorphine is interpreted as one of OTP vs. office-based treatment. That came up frequently in our interviews, because methadone is still associated with OTPs, and buprenorphine with office-based treatment.

But it’s important to realize that buprenorphine can be given in either setting, and that the fact that patients are allowed buprenorphine take-homes under federal guidelines doesn’t mean that an OTP will make the clinical decision that patients should have take-homes. In other words, methadone always must be dispensed in an OTP (with very rare exceptions), while buprenorphine can be dispensed in an OTP or by an office-based practitioner.

In deciding between an office-based model and an OTP when giving buprenorphine, IV drug users should be steered toward an OTP unless the office-based practitioner is “conscientious about all the necessary medical testing that needs to be done,” said Dr. Neshin, citing in particular HIV and hepatitis testing.

At NHS, all addiction treatment, whether with methadone or buprenorphine, includes multiple ancillary services, said Dr. Murray. “We believe that for most people, medication-assisted treatment does not work alone.”

Among the ancillary services that should be offered in addition to medication: group and individual therapy, family therapy, case-management services, services for specialized groups such as seniors and pregnant women, enhanced recovery services, peer specialist supports, and on-site psychiatric services—these are all offered by NHS. While some office-based providers give referrals for counseling elsewhere, many are not in a position to provide these ancillary services, said Dr. Murray. And it’s often the OTPs who have to pick up the pieces when the services aren’t provided. “We sometimes treat patients who have failed treatment in an office-based treatment setting because they needed a higher level of care or other services to support their recovery, and these were not made available to them.” 

Pregnancy

Pregnancy status is less relevant as a patient-selection criterion than it used to be, now that enough studies have been done using buprenorphine during pregnancy, said Dr. Neshin. “However, I have had many women who started out on buprenorphine and had to switch to methadone during pregnancy due to inability to reach an adequate buprenorphine dose as the pregnancy progressed,” she said.

There are differences of opinion about this issue, with CSAT’s Dr. Campopiano saying that not enough studies have been done to make clinicians comfortable prescribing buprenorphine during pregnancy, and Dr. Tenore of Albert Einstein saying he would absolutely not prescribe it, citing U.S. Food and Drug Administration (FDA) guidelines.

Dr. Murray conceded that recent studies do suggest positive outcomes with buprenorphine treatment, but she said that methadone maintenance “is still the standard of care, and would be our preferred treatment at this time for a pregnant woman seeking treatment.”

fundingCost

There are huge differences in cost between methadone, which is very inexpensive, and buprenorphine. In New Jersey, for example, if a patient has Medicaid and little money, it is often less expensive to be on office-based buprenorphine than on methadone, Dr. Neshin explained. Many OTPs in New Jersey either do not accept Medicaid or limit the number of Medicaid patients they can treat, and many Medicaid patients have to pay the standard weekly clinic fee. Since Medicaid covers the cost of a buprenorphine prescription, patients may have to pay only a monthly fee to an office-based physician. On the other hand, patients without prescription coverage often cannot afford buprenorphine treatment, as even the cost of generic buprenorphine can be prohibitive.

At NHS, cost is irrelevant, since the only out-of-pocket expense is a “very minimal co-pay for buprenorphine prescriptions,” said Dr. Murray. She explained that patients already in treatment with buprenorphine often are admitted to NHS because they can’t afford the cost of an office visit with their office-based provider.

Switching Medications

Some patients want to “graduate” from methadone to buprenorphine, mainly because they are unable to attend the OTP as frequently as methadone treatment requires, said Dr. Neshin, who has transferred many patients for this and other reasons. Typically, the transfer is done with “minimal discomfort,” and patients usually stabilize within days.

Sometimes the transfer is from buprenorphine to methadone—for example, if a patient isn’t doing well in office-based treatment and continues abusing drugs, a referral to medication-assisted treatment in an OTP—or in some cases, to inpatient treatment—should be made, said Dr. Neshin.

If issues of cost are ignored, said the University of Washington’s Dr. Saxon, “it makes sense to start with buprenorphine with a back-up plan to switch promptly to methadone if the response to buprenorphine is not good.” He added that it’s important for patients to know that it’s “easy to switch from buprenorphine to methadone, but it can be quite challenging to switch from methadone to buprenorphine.”

Summing Up

Overall, the determination to treat with methadone or buprenorphine is multifactorial. Methadone maintenance in an OTP provides greater structure because the individual has to visit every day for dosing, or to attend group sessions and counseling. Patients who want take-home buprenorphine are expected to be reasonably compliant with treatment and safety precautions. Patients who have untreated or unstable psychiatric comorbidities, or are currently abusing or dependent on sedative-hypnotic drugs or alcohol (in addition to opioids) may be recommended for methadone treatment in an OTP instead of treatment with buprenorphine.

Treatment of Opioid Dependence: A Call for an Evidence-Based Approach

evidenceDespite decades of accumulated data on the effectiveness of medication-assisted treatment (MAT), gaps remain between evidence-based standards and current practices. The authors of a recent study attribute these gaps largely to “regulatory constraints and pervasive suboptimal clinical practices.” The study appeared in August in Health Affairs; the authors are affiliated with U.S. or Canadian medical institutions. This article focuses on the findings and recommendations pertaining to the U.S.

Based on evidence from many randomized trials, large-scale longitudinal studies, and meta-analyses that show the effectiveness of MAT, the authors recommend four policy changes:

  • Eliminate restrictions on office-based methadone prescribing, and adopt the direct administration and dispensing of methadone in pharmacies. This will require changes in federal and, in some cases, state law.
  • Reduce financial barriers to treatment, such as copayment variations. Provide universal coverage for MAT via public and private insurers.
  • Reduce reliance on opioid detoxification; strong scientific evidence shows that some types are ineffective and possibly harmful.
  • Create and evaluate mechanisms to integrate emerging treatments, such as slow-release buprenorphine implants.

These steps, the authors believe, “can greatly reduce the harms of opioid dependence by maximizing the individual and public health benefits of treatment.”

Following is a discussion of the authors’ specific concerns and recommendations.

Office-based methadone prescribing. The authors note that access to methadone in the U.S. is heavily regulated and “more restricted in the United States than elsewhere in the developed world.” Fewer than 10 percent of all opioid-dependent people in the U.S. currently receive treatment—yet the number of methadone-prescribing facilities has changed little since 2002. Currently only about 8 percent of all substance abuse treatment facilities offer methadone maintenance treatment (MMT).

Treatment in doctors’ offices would offer a less-stigmatizing environment, and would facilitate care of co-occurring conditions, such as HIV and hepatitis C. Moreover, providing methadone under direct observation would virtually eliminate any risk of methadone abuse or diversion.

Experience in Canada shows that office-based MMT could greatly increase patients’ access to treatment. Canada implemented office-based MMT in 1996. In 2012, the number of patients receiving methadone treatment in British Columbia increased from 2,800 to 13,000, and in Ontario it rose from 700 to almost 30,000. These figures suggest that office-based MMT in the U.S. could help meet the increased demand that health reform is expected to produce.

Expanded access would require greater participation by physicians. The authors suggest mandating addiction education in medical schools and increasing the financial incentives for providing treatment, including specifying physician billing codes.

Financial barriers. Evidence clearly shows the economic value of treating drug dependence, yet public and private insurers do not provide widespread coverage of opioid misuse disorders. Moreover, privatization of methadone clinics is increasing, leaving few options for patients who lack insurance and are unable to pay.

Detoxification. The authors come down hard on detoxification leading to planned abstinence, calling it “the most damaging aspect of current treatment of opioid dependence.” They refer specifically to two regimens: detoxification after maintenance treatment, and detoxification (typically 12 weeks) designed to taper the methadone dose to zero. They cite evidence revealing a high risk of relapse into illicit opioid use, and an increased risk of mortality within the month after relapse. 

Potentially useful, however, is detoxification lasting up to one week, designed to treat patients who have overdosed or have severe withdrawal symptoms. Sustained abstinence is not a goal, but subsequent long-term MAT is an option patients have.

Emerging treatments. The past decade has seen several new or potential treatments for opioid dependence. They include slow-release buprenorphine implants, injectable naltrexone, and agents that bind to and activate opioid receptors (eg., injectable diacetylmorphine or heroin maintenance as a second-line treatment for heroin dependence). Although the future status of these emerging treatments is uncertain, the authors stress the benefits of having options available.

The authors note that the Affordable Care Act has the potential to eliminate gaps in treatment coverage, and it “mandates the inclusion of substance abuse and mental health services in the essential benefits that the new state insurance exchanges must offer.”

The authors also emphasize that their recommendations are initial steps, and their list is not exhaustive. “The social and structural reasons behind the low rates of access to this treatment—including stigma and discrimination perpetuated by contradictory social policies that simultaneously treat addiction as a health problem and a crime—must also be addressed.”

Reference

Nosyk B, Anglin MD, Brissette S, Kerr T, et al. A call for evidence-based medical treatment of opioid dependence in the United States and Canada. Health Aff (Millwood). 2013; Aug;32(8):1462-1469. doi: 10.1377/hlthaff.2012.0864.

OTPs as Health Homes: Extra Money for Care Management

healthcare collageSome states are making opioid treatment programs (OTPs) health homes under a federal strategy that is part of the Affordable Care Act (ACA). Under the initiative, which comes from the Centers for Medicare and Medicaid Services (CMS), states can pay OTPs extra money to serve as “health homes” for their patients, meaning that the OTPs will help clients manage both their physical and behavioral health needs, including chronic conditions like obesity and diabetes.

So far, only Maryland, Rhode Island, and Vermont are paying OTPs to be health homes under the ACA. AT Forum talked with health home leaders in the first two states.

“This is a CMS strategy and an endeavor that we support,” said H. Westley Clark, MD, JD, director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA). “From our point of view, we believe the ACA is an important vehicle for behavioral health, and that includes OTPs.”

For OTPs to play an enhanced role under the ACA, states need to apply for approval from CMS to allow the OTPs to serve as health homes, and must use Medicaid money for this purpose.

“The states that have included OTPs in the state plan amendments are doing the field a favor,” said Dr. Clark. He added that this is a critical step, as OTPs try to become participants in the new reimbursement framework.

The state Medicaid dollars that will be going to OTP health homes will initially be matched 90 percent by the federal government.

The logic of selecting OTPs to be health homes, among all substance abuse treatment providers, is that OTPs already have medical staff. OTP patients have a range of conditions that medical staff can address, Dr. Clark said.

SAMHSA has strongly promoted the need for OTPs to have electronic health records, qualified service organization agreements, and health homes, “so OTPs can play a stronger role” under the ACA. CMS is the lead agency on the ACA, with SAMHSA on the periphery, Dr. Clark explained. “Since this is a nascent activity, our role has not been robust. But we are talking to the American Association for the Treatment of Opioid Dependence (AATOD) and to OTPs about the ACA and our hope that OTPs will play a larger role in the delivery of services.”

There’s a big difference between a “patient-centered medical home,” which is a very broad term, and a “health home,” which is codified in the ACA. A health home is for individuals with a chronic condition; importantly, a substance use disorder (SUD) is included in the definition of a chronic condition. A patient-centered medical home is a primary care approach in which there is a home base for both healthy and unhealthy people.

 To participate in a behavioral health care health home under the ACA, and to qualify for the 90-percent federal match, the patient must either have a serious and persistent mental illness and two chronic conditions, or have one chronic condition and be at risk for another. In other words, patients with an SUD and at risk for another chronic condition would be eligible, and this constitutes almost all patients in OTPs.

Rhode Island

Rhode Island was still waiting to hear back from CMS on its state plan amendment, which created health homes in OTPs, when AT Forum interviewed Rebecca L. Boss, administrator of behavioral health services in the state’s Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals. But because the CMS decision can be retroactive—and approval of the proposal was expected—the state is going ahead with implementing health homes at five of the state’s six OTPs.

Ms. Boss, who is also the State Opioid Treatment Authority (SOTA) for Rhode Island, said having OTPs be health homes is a “passion” for her. “Having worked in an OTP, I know first-hand that patients in opioid treatment who have chronic conditions have had difficulty accessing quality medical care,” she told AT Forum. “What better place, in my mind, than an OTP where patients have relationships with medical staff, where they’re comfortable, and where they show up on a regular basis.”

Barriers to health care for OTP patients have included stigma, transportation problems, and lack of insurance, noted Ms. Boss, who added that some patients just need help following up on treatment plans, such as taking medication for diabetes.

A small state, Rhode Island has 3,800 OTP patients receiving methadone maintenance treatment on any given day. About 2,000 are current Medicaid clients—a number that will grow on January 1 when Medicaid expands.

$87 per Patient per Week

There will be 125 patients in each OTP “health home” team, with at least 10 teams statewide, Ms. Boss said. OTPs will get about $87 per week for each patient in a health home team. This rate is separate and apart from what OTPs receive for treatment and an important part of rate setting was teasing out which services covered under treatment would be considered health home activities. Ms. Boss added that the federal government pays 90 percent of the health home service part for the first two years.

Factors such as tobacco use, obesity, and increased age can count as risk for development of a second chronic condition, in addition to SUDs, according to Ms. Boss. “It would be rare that clients in an OTP not meet the criteria” for being in a health home.

One of the biggest challenges will be recruiting patients for health homes. Enrollment has to be voluntary. In Rhode Island, individuals have been auto-enrolled, but have the right to opt out, Ms. Boss explained.

Something New?

OTPs don’t need to provide health care services to be health homes, but they do need to make sure patients have access to such services. In Rhode Island, there will be a nurse dedicated to following 125 patients, coordinating their care. “Patients don’t have to go to just any nurse at a dosing window, they have their own nurse who will help them,” said Ms. Boss.

In many cases, OTPs have already been helping patients who have health issues. “This is the opportunity to reimburse them for some services they have been doing all along,” according to Ms. Boss. “They haven’t had a lot of case managers, but counselors have been doing yeoman’s work in terms of case management.” She added that the health home fees will also pay for part of a physician’s time, the services of case managers, the coordinating services of a masters-level team, and a pharmacist to coordinate medications.

Maryland

Maryland has identified three provider types to be health homes—two are mental health, and one is an OTP. To be eligible as a health home, an OTP must be enrolled with Maryland Medicaid, be accredited by CARF International or the Joint Commission (or pursuing such accreditation), and submit an application to the state. As of November 4, eight OTPs have submitted applications and three have been approved.

According to Lisa Hadley, MD, clinical director of the state’s Alcohol and Drug Abuse Administration and Mental Hygiene Administration, participants must have an SUD, be in methadone treatment, and be at risk for another chronic condition—similar to the Rhode Island health home initiative. For the three OTPs approved so far, there are almost 1,000 patients—410 in one OTP, 281 in another, and 285 in the third.

Almost $99 per Patient per Month

Maryland health home OTPs will be paid an additional $98.87 a month for each patient in the health home, said Dr. Hadley, who is also the SOTA for Maryland. The OTPs will be responsible for providing six different services: comprehensive care management, care coordination, health promotion, individual and family support, and referrals for community support. “Through all their treatment, whether they’re in the hospital or in the community, the health home is responsible for helping to link the patient to what they need.” According to Dr. Hadley, Maryland Medicaid will pay the additional fee, with the federal government paying 90 percent for the first two years, after which the match goes down to the standard 50 percent.

The state will also help the OTPs by providing data on hospital encounters and pharmacy alerts, she said. The program started in October, and is expected to grow in January. “We hope to be getting more applications” from OTPs. “We’re very excited to be able to help OTP patients.”

Site last updated March 28, 2014 @ 7:50 am