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

Feds Seek Ways to Expand Use of Addiction Drug

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

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

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

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

Source: BostonHerald.com – June 18, 2014

Providing Buprenorphine in an Opioid Treatment Program: Challenges and Opportunities

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

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

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

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

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

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

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

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

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

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

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

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

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

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

New Jersey

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

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

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

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

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

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

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

JSAS gets $120 per month per patient from Medicaid.

 

 

 

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.

Project Lazarus Brings Opioid Treatment Program to Wilkes County Along With Naloxone Kits

kitProject Lazarus, a nonprofit organization based in Moravian Falls, North Carolina, is best known nationally for its work on making the overdose-reversal medication naloxone more available. But the organization, under the guidance of CEO Fred Wells Brason II, was also instrumental in bringing the first opioid treatment program (OTP) to Wilkes County North Carolina. It started as a buprenorphine clinic, which was more palatable to physicians, and then became a full-service OTP including methadone.

The first time Mr. Brason suggested that the county needed an OTP was in 2006, and the response, he recalled, was virulently anti-methadone. “They said, ‘not in our county, and not a drug for a drug.’” But there was no treatment available for people with opioid addiction.

But Mr. Brason, a combination of optimism, determination, and diplomacy, worked out an agreement. First, he got Mountain Health Solutions, an Asheville-based OTP, now owned by CRC Health Group, to set up a satellite clinic in Wilkes County. They would provide only buprenorphine at first—something that was more acceptable by the town. “At least we had something,” he said. Then, he embarked on a two-year education program focusing on methadone. “We talked about addiction, about treatment, and did a lot of myth-busting,” he said. In addition, census in the buprenorphine clinic continued to grow—and Mr. Brason knew that patients needed the comprehensive treatment that is provided in an OTP. “We didn’t want just dispensers, we wanted someone who was an advocate” for the patients, he said.

In addition, buprenorphine is much more expensive than methadone, and since Mountain Health Solutions doesn’t accept Medicaid, it could offer treatment only to people who could afford it, he said. So eventually, what was a buprenorphine clinic became a full-scale OTP in North Wilkesboro.

The doctors in Wilkes County and other counties were among the most vocal opponents of methadone and buprenorphine—at first. In one meeting with them and Jana Burson, MD, from the OTP, one doctor said he didn’t want “those people in the waiting room with Grandma,” Mr. Brason recalled. “I replied, ‘We are meeting right now in a church—and if this were Sunday morning, those people would be here.’” By the time the meeting was over, there was more understanding, at least of buprenorphine, said Mr. Brason, with some of the physicians agreeing to get a waiver so they could provide buprenorphine treatment.

Community Education

Mr. Brason provided education to the community about the importance of medication-assisted treatment during pregnancy, dispelling myths about neonatal abstinence syndrome (facts: NAS is transient and easily treatable, while withdrawing from opioids during pregnancy is harmful to the fetus). “Slowly, after a couple more years, methadone was introduced, and now they are serving more than 400 people a day in our tiny county,” he said. The vast majority are on methadone because they cannot afford buprenorphine.

There are now churches that are financially supporting their members for treatment—paying for the OTP and medications. “The church sees them, that they are going to church, they are going to work, they are supporting their families,” he said.

Mr. Brason is a chaplain, something that gives him credibility in the conservative South—maybe more credibility than a physician or scientist. In addition, he has worked extensively with a hospice in the area. “They know me and who I am,” he said. “That makes a difference.”

It’s still an uphill battle, he said; recently a county commissioner said that methadone clinics are a scam. Brason then sat down with a reporter and got a front page article showing that methadone treatment helps reduce overdose deaths. It was a public relations victory that benefited people who desperately needed help.

“We’ve had a for-profit private detox center all along,” said Mr. Brason. “We were losing people to overdose deaths 24 hours after detox.” That is much better now, because of the presence of the OTP.

Naloxone Kits

Opioid overdose deaths as a problem separate from addiction are also an important focus for Mr. Brason, who was able to introduce naloxone to Wilkes County. Through a grant from Purdue Pharma, the Lazarus Project was able to provide naloxone kits at no charge to the OTP. Originally, when the program started in 2009, this worked by the OTP writing prescriptions for the kits for all new patients—the first weeks on methadone are the riskiest for overdose, not from methadone but from other opioids as the patients are getting used to the doses. Then the patients would go to the pharmacy to pick up their prescription for the $50 kit. However, only 25 percent of the patients were actually getting these prescriptions filled. “They didn’t want to be seen at the pharmacy, they didn’t want the stigma,” he said. So he met with the OTP and agreed on a new system, in which Project Lazarus would pay for half the cost of the kit and the OTP would pay for the other half out of the patient’s enrollment fee. (The grant was over.) The OTP would write the prescription, and then send someone to the pharmacy to pick it up, giving it directly to the patient in the OTP

Spencer Clark, MSW, ACSW, who oversees OTPs for the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services, has been very interested in the naloxone kits, said Mr. Brason. “He wondered if they could do this for every OTP in the state.” So far the OTP has documented four lives saved.

Mr. Brason sends naloxone kits to organizations, including first responders like police departments, across the country. The kits include the nasal atomizers, not the actual naloxone, which must be prescribed. Eventually, he hopes that first responders will be able to use the new auto-injector. “It will be great for them, they don’t have to put it together” like the kits, which come in a box. However, because it does involve a needle, some first responders will be more comfortable with the nasal spray, he said.

Rescuing someone from an overdose should mean that person gets access to treatment, said Mr. Brason. First of all, they will—it is hoped—go to the emergency department to get checked out after the rescue. “We approach the link to treatment by tying all the services together. We get our crisis intervention teams to that person within an hour” of the rescue, he said. The crisis counselor interviews the individual to figure out the next steps.

For more information on ordering the kits ($12), go to info@projectlazarus.org. Project Lazarus has covered the shipping charges. For more general information on Project Lazarus, go to http://projectlazarus.org/.

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.

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

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

News From the States

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Source: National Institutes of Health – April 24, 2014

Study Addresses Treatments for Waited-Listed Opioid-Dependent Individuals

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

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

The five components include:

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

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

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

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

Source: MedicalXpress.com – April 10, 2014

Infographic: Benzodiazepine Use and Medication-Assisted Treatment

benzo2The Institute for Research, Education and Training in Addictions (IRETA) has prepared an infographic that addresses immediate consequences, long-term effects, and the relationship between benzodiazepine use and medication-assisted recovery.

The infographic is available for free download at: http://iretablog.org/2014/04/10/infographic-benzodiazepine-use-and-medication-assisted-treatment/

Source: The Institute for Research, Education and Training in Addictions – April 10, 2014

Dr. Jana Burson Blog: Drug Interactions with Methadone

“Recently, medical directors of opioid treatment programs in my state pondered how to handle the risk of medication interactions with methadone. In my area of the country, chart reviews of patients who died while taking methadone revealed many decedents were taking other medications with known interactions with methadone. Obviously, we want to prevent these deaths, and need to protect against drug interactions.

To predict a possible drug interaction, the OTP doctor must know all of the other medications that the patient is taking, both prescription and non-prescription. I assume all doctors at opioid treatment programs ask the patients what medications they are prescribed on the first day, along with what they take over the counter. That’s a good start, but often it’s not sufficient.”

http://janaburson.wordpress.com/2014/03/25/drug-interactions-with-methadone/

Source: Dr. Jana Burson – March 25, 2014

Dr. Jana Burson Blog: Insomnia Medications for Patients in Medication-Assisted Treatment

“In one of my recent blog entries, I talked about some simple measures that can help patients with insomnia, called sleep hygiene. Many times these methods can fix the problem, but other times, patients still can’t sleep well, which interferes with life. In these cases, medications may be of some help.”

The “Z” Medications

“The “Z” group of medications includes zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). These medications, which are not benzodiazepines, have been touted as being safer and less addictive than older benzodiazepines, like temazepam (Restoril), triazolam (Halcion) or clonazepam (Klonopin). However, the “Z” medications stimulate the same brain receptors as benzodiazepines, and are all Schedule IV controlled substances, just like benzodiazepines.

I don’t prescribe the “Z” medications for patients on medication-assisted treatment with methadone or buprenorphine because they can cause overdose deaths in these patients. Also, these medications can give many patients with the disease of addiction the same impulse to misuse their medication. I’ve had patients develop problems with misuse and overuse of these medicines.”

Other Medications

Dr. Burson also discusses clonidine, gabapentin and muscle relaxers.

http://janaburson.wordpress.com/2014/04/12/insomnia-medications-for-patients-in-medication-assisted-treatment/

Source: Dr. Jana Burson – April 12, 2014

New Resources and Events Available on ATForum.com

Have you visited ATForum.com lately? Over 30 new meetings, conferences, and webinars have been added to the site in addition to key new resources including the following on medication-assisted treatment.

Neonatal Abstinence Syndrome: How States Can Help Advance the Knowledge Base for Primary Prevention and Best Practices of Care
Association of State and Territorial Health Officials – March 2014.

Confronting the Stigma of Opioid Use Disorder—and Its Treatment
Journal of the American Medical Association – February 26, 2014.

Medication-Assisted Treatment With Methadone: Assessing the Evidence
Psychiatric Services – February 1, 2014.

Medication-Assisted Treatment With Buprenorphine: Assessing the Evidence
Psychiatric Services – February 1, 2014.

Medscape Ask the Pharmacist: Methadone or Buprenorphine for Maintenance Therapy of Opioid Addiction: What’s the Right Duration
Medscape – February 3, 2014. Note: A Medscape account is required to view this article. If you do not have a Medscape account you can create one for free.

Advancing Service Integration in Opioid Treatment Programs for the Care and Treatment of Hepatitis C Infection
International Journal of Clinical Medicine – January 2014.

Advancing Access to Addiction Medications Report
American Society of Addiction Medicine (ASAM) – December 2013.

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

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

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

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

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

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

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

Fewer Opioid Treatment Programs Offer HIV Testing

“According to a study, fewer opioid treatment programs are offering onsite testing for HIV and sexually transmitted infections (STIs), despite guidelines from the Centers for Disease Control and Prevention (CDC) recommending routine HIV testing in all health care settings.

The absolute number of programs offering testing for HIV, STIs, and HCV increased from 2000 to 2011. However, the percentage of programs offering HIV testing decreased significantly, by 18%, and the percentage of those offering testing for STIs fell by 13% throughout the study. Testing for each infection did not change over time in public programs, but HIV testing dropped by 20% among for-profit programs and 11% in nonprofit programs.

http://www.pharmacytimes.com/publications/issue/2014/February2014/Fewer-Opioid-Treatment-Programs-Offer-HIV-Testing

Source: PharmacyTimes.com - February 19, 2014

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