From the Editor – Maine Continuing to Push for Caps on Medication-Assisted Treatment

April 21, 2013 by Leave a Comment

hour glass1First, Maine imposed two-year caps on methadone and buprenorphine treatment, if paid for by MaineCare, the state’s Medicaid program. The caps were due to take effect January 1, but treatment advocates were able to work out a medical-necessity exemption, which said that as long as patients were doing well, they could stay past the two-year limit.

Never mind that this made no sense—patients who are not doing well should be kicked off treatment—to go where, the streets? In any event, it was better than nothing. But in March, a new bill was introduced that would have eliminated even the medical necessity exemption. Two years on treatment, and that’s it.

Mark Publicker, MD, president of the Northern New England Society of Addiction Medicine, who helped lead the advocates’ battle for the medical necessity exemption, is “back in the saddle”—pressing the state legislature and the regulators for a reasonable approach.

Under the proposed bill, as of January 1, 2015 no patient would be allowed to be on methadone or buprenorphine for more than two years, if paid for by Medicaid.

“It’s outrageous,” he told AT Forum.

Filed Under: Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Spring 2013 Tagged With: , , , , ,

AATOD Guidelines for Guest Medication

March 9, 2013 by 1 Comment

“Absent regulations or published practices for Guest Medication, AATOD is providing these recommended “Guest Medication” guidelines. Guest Medication provides a mechanism for patients who are not eligible for take-home medication to travel from their home clinic for business, pleasure or family emergencies. It also provides an option for patients who need to travel for a period of time that exceeds the amount of  eligible take-home doses to do so within regulatory requirements. While AATOD acknowledges there may be state and program variations, AATOD believes that Guest Medication should be patient centered, respectful, and compassionate.”

http://www.aatod.org/policies/policy-statements/aatod-guidelines-for-guest-medication/

Source: American Association for the Treatment of Opioid Dependence, Inc. – March 6, 2013

Filed Under: 2013-03-11, Medication-Assisted Treatment (MAT), Methadone, News Updates, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs) Tagged With: , , , ,

Pennsylvania – Under the Influence of … Methadone, Others Want More Oversight of Opioid Connected to Fatal Crashes

March 9, 2013 by 1 Comment

“Under a new law that took effect in January, a Methadone Death and Incident Review Team will convene for the first time Monday in Harrisburg to examine the circumstances surrounding methadone-related deaths, including car crashes and overdoses, and will review other problems with the synthetic opioid, the most widely used drug to treat heroin addiction.

Calling methadone “dangerous,” state Sen. Mike Stack, D-Philadelphia supports new regulations that would make methadone clinics partly responsible for crashes involving drivers who leave their facilities. He said he began pushing for methadone reform about two years ago after learning about constituents overdosing.

http://www.mcall.com/news/local/mc-methadone-clinic-crashes-20130302,0,3321816,full.story

Source: The Morning Call – March 2, 2013

Filed Under: 2013-03-11, Medication-Assisted Treatment (MAT), Methadone, News Updates, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs) Tagged With: , , , ,

Fatal Drug Overdoses in U.S. Increase for 11th Consecutive Year

February 28, 2013 by Leave a Comment

hospital sign“Fatal drug overdoses have increased for the 11th consecutive year in the United States, new data show. According to a research letter published Tuesday from the National Center for Health Statistics, 38,329 people died of drug overdoses in the United States in 2010, an uptick from the previous year and the latest sign of a deadly trend involving prescription painkillers.

In 2010, 57% of overdoses, or more than 22,000, involved known prescription drugs. Three-quarters of those involved painkillers like Oxycontin and Percocet while another 9,400 involved some unidentified drug cocktail.”

http://www.latimes.com/health/boostershots/la-heb-drug-overdoses-increase-20130219,0,1564869.story

Source: LATimes.com -February 19, 2013

Filed Under: 2013-03-01, News Updates, Opioid Abuse/Addiction Tagged With: , , , ,

Target ‘Super-spreaders’ to Stop Hepatitis C

February 28, 2013 by Leave a Comment

Each intravenous drug user contracting Hepatitis C is likely to infect around 20 other people with the virus, half of these transmissions occurring in the first two years after the user is first infected, a new study estimates.

The work, led by researchers from Oxford University, suggests that early diagnosis and treatment of Hepatitis C in intravenous drug users could prevent many transmissions by limiting the impact of these ‘super-spreaders’ (a highly infectious person who spreads a disease to many other people).

Working out ‘who has infected who’ in fast-spreading diseases such as influenza is often relatively straightforward, but in slow-spreading diseases such as Hepatitis C and HIV, where instances of transmission are spread over months or years, it is extremely difficult. The new approach, developed by a team from Oxford University, University of Athens and Imperial College London, combines epidemiological surveillance and molecular data to describe in detail, for the first time, how Hepatitis C spreads in a population.

http://www.ox.ac.uk/media/news_stories/2013/130201.html

Source: University of Oxford – February 1, 2013

Filed Under: 2013-03-01, Heroin, News Updates Tagged With: , ,

Effective Risk Management Strategies in Outpatient Methadone Treatment – Trainer’s Manual and PowerPoint Slides

February 1, 2013 by 1 Comment

This one-day training program available from The Institute for Research, Education, and Training in Addictions (IRETA)  is designed to increase opioid treatment providers’ (both clinical and administrative staff) knowledge and skills on the most effective ways to conduct risk management strategies for opioid treatment centers.

Training materials include a Trainers Manual and nine PowerPoint presentations, one for each of the nine training modules.

The manual was created as a guide to facilitate the successful delivery of “Effective Risk Management Strategies in Outpatient Methadone Treatment”. It includes suggested scripts and activities for each module to help guide you through the entire training process.

The modules include:

  • Module 1: What’s Going On Out There? (Introduction, Methadone-Associated Mortality, Professional Liability)
  •  Module 2: Managing Risk
  •  Module 3: Risk Management and OTP Practice
  • Module 4: Impairment
  • Module 5: Take-Home Medication
  •  Module 6: Three Case Studies
  • Module 7: Recovery-Oriented Methadone Maintenance (ROMM)
  • Module 8: Pain Management Therapy
  • Module 9: Special Populations and Risk

Modules 1-6 provide information and content for a standalone training of approximately 7 hours – not including breaks and lunch. Modules 7-9 are supportive content to the topic of risk management and can be delivered in approximately three additional hours.

http://ireta.org/riskmanagementcurriculum

Source: The Institute for Research, Education, and Training in Addictions – January 2013

Filed Under: 2013-02-01, Education, Medication-Assisted Treatment (MAT), News Updates Tagged With: , , ,

Reducing Opioid Prescription Painkiller Abuse, New York Mayor Bloomberg Announces New Guidelines

February 1, 2013 by Leave a Comment

“New emergency room guidelines to prevent opioid prescription painkiller abuse have been announced by New York Mayor Bloomberg, Deputy Mayor for Health and Human Services Linda I. Gibbs and Chief Policy Advisor John Feinblatt. The guidelines will be used in all New York City’s public hospitals. He explained that public hospital emergency departments will no longer prescribe long-acting opioid painkillers. Doctors in emergency departments will only prescribe a three-day supply of such medications – all destroyed, lost or stolen prescriptions will not be able to be refilled in emergency departments.”

http://www.medicalnewstoday.com/articles/254893.php

Source: Medical News Today – January 14, 2013

Filed Under: 2013-02-01, News Updates, Opioid Abuse/Addiction, Prescription Drugs Tagged With: ,

Blog: PTSD at the Opioid Treatment Program

November 29, 2012 by Leave a Comment

“As in other studies, this study shows addiction and post-traumatic stress disorder (PTSD) are related, but we still don’t know which comes first. Does addiction put people in dangerous situations that are likely to become traumatic? Does drug use impair judgment about how to avoid dangerous situations? Or does the PTSD cause addiction, because patients with PTSD have unpleasant feelings, and drugs provide temporary relief from unpleasant feelings?

The blog is available at: http://janaburson.wordpress.com/2012/11/10/ptsd-at-the-opioid-treatment-program/

Source: Janaburson’s Blog – November 10, 2012

Filed Under: 2012-11-29, Addiction, Blog, Medication-Assisted Treatment (MAT), News Updates, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs) Tagged With: , , , , ,

Perspective: Docs Feel Pressure to Give Addicts Opioids

November 29, 2012 by Leave a Comment

doctors“A push to treat chronic pain and financial disincentives for treating addiction may pressure clinicians into prescribing opioids for patients who are already addicted, a researcher suggested.

Over the past decade, there’s been a perfect storm of changing clinician attitudes toward pain treatment and patient attitudes towards suffering, combined with a lack of compensation for time-consuming clinic visits such as addiction counseling, Anna Lembke, MD, of Stanford University, wrote in a perspective in the New England Journal of Medicine.”

http://www.medpagetoday.com/Psychiatry/Addictions/35539

The full perspective can be accessed at: http://www.nejm.org/doi/full/10.1056/NEJMp1208498

Source: MedPageToday.com – October 24, 2012

Filed Under: 2012-11-29, Addiction, Medication-Assisted Treatment (MAT), News Updates, Opioid Abuse/Addiction Tagged With: , , ,

AATOD Issues Prescription Monitoring Program Guidelines for OTPs

October 11, 2012 by Leave a Comment

The American Association for the Treatment of Opioid Dependence (AATOD), issued guidance this June to opioid treatment programs (OTPs) encouraging them to “utilize prescription monitoring programs (PMPs) as an additional resource to maximize safety in patient care pursuant to applicable state guidelines.”

When OTPs do access state PMP data bases, they should do so for therapeutic reasons, not for the purpose of restricting access to treatment, according to AATOD. “OTPs are discouraged from using such data for the sole purpose of restricting treatment access or for responding in a punitive fashion to the needs of patients in treatment.”

OTPs Should Not Report Confidential Data

OTPs, because of confidentiality law applying specifically to treatment for addiction, should not report anything that could identify their patients to PMPs, said AATOD, citing guidance from the Substance Abuse and Mental Health Services Administration (SAMHSA). Under 42 CFR Part 2, the federal regulation protecting the confidentiality of substance abuse treatment records, treatment programs may not divulge patient-identifying information without the patient’s written, specific consent. That was the point SAMHSA’s H. Westley Clark, MD, JD, was making in his September 27, 2011 Dear Colleague letter (See AT Forum Fall, 2011). SAMHSA administers 42 CFR Part 2.

However, no patient consent is required for the OTP—or anyone else—to request information from the PMP about a patient. Under 42 CFR Part 2, making such a request does not constitute disclosing a patient’s status as a substance abuse treatment patient.

But AATOD does recommend that OTPs notify a patient when they are accessing a PMP database, even though SAMHSA says this isn’t necessary. “The OTP should inform patients that they are accessing PMP databases by posting information or by distributing information to patients, explaining what a PMP does and why the program is requesting the data,” according to AATOD.

SAMHSA is expected to issue additional guidance on PMPs to OTPs.

According to AATOD, there are concerns that some people want to weaken 42 CFR Part 2 to make it possible for other physicians to access information about OTP patients. “As I understand it, someone from the Centers for Disease Control and Prevention may have recommended this idea about one year ago,” Mark W. Parrino, MPA, AATOD president, told AT Forum in an e-mail. “I also know that a number of physicians who work in emergency rooms have made similar recommendations.”

If a PMP re-discloses identifying data to interested parties about a patient, individuals could be discouraged from accessing medication-assisted treatment, according to AATOD.

So far, 49 of the 50 states either have active PMPs or legislation approving the use of PMPs.

The AATOD Guidance document can be accessed at: http://aatod.org/guidance_to_otps.html

Filed Under: Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Treatment Programs (OTPs), Prescription Drugs, Summer 2012 Tagged With: , , ,

New Drug Abuse Warning Network (Dawn) Report Issued on Drug-Related Emergency Department Visits

August 10, 2012 by Leave a Comment

The Substance Abuse Mental Health Services Administration (SAMHSA) issued a report July 2 on drug-related emergency room (ER) visits in 2010. There were 4.0 million drug-related ED visits made by patients aged 21 or older in 2010. Of these visits, 1.9 million, 47.2 percent, involved drug misuse or abuse.

The total number of drug-related ED visits increased 94 percent from 2004 (2.5 million visits) to 2010 (4.9 million visits).

  • ED visits involving misuse or abuse of pharmaceuticals increased 115 percent between 2004 and 2010.
  • ED visits involving misuse or abuse of narcotic pain relievers increased 156 percent between 2004 and 2010.
  • ED visits involving misuse or abuse of oxycodone products increased 255 percent between 2004 and 2010.
  • ED visits involving misuse or abuse of benzodiazepines increased 139 percent between 2004 and 2010.
DAWN Report: Misused or Abused Drugs Most Commonly Involved in Emergency Department (ED) Visits:
2004 to 2010
Drug 2004 Number of ED Visits 2010 Number of ED Visits % Change, 2004 to 2010 2010 ED Visits per 100,000 Population 

 
Alcohol – In Combination with Other Drugs NA 564,796 NA 182.5
Alcohol – Underage Drinking** NA 189,060 NA 215.4
Illicit Drugs 991,640 1,171,024 NC 378.5
Cocaine NA 488,101 NA 157.8
Heroin NA 224,706 NA 72.6
Marijuana 281,619 461,028 64 149.0
Pharmaceuticals 626,472 1,345,645 115 434.9
Anti-anxiety and Insomnia Drugs 210,711 472,769 124 152.8
Benzodiazepines 170,471 408,021 139 131.9
Antidepressants NA 105,229 NA 34.0
Pain Relievers 282.275 659, 969 134 213.3
Narcotic Pain Relievers 166,338 425,247 156 137.4
Hydrocodone Products 46,536 115,739 149 37.4
Oxycodone Products 51,418 182,748 255 59.1

 
* Because a visit may involve multiple drugs, the sum of visits by drug will be greater than the total.
**Underage drinking includes both use of alcohol in combination with other drugs and use of alcohol only for patients aged 20 or younger.

The 8-page report can be accessed at: http://www.samhsa.gov/data/2k12/DAWN096/SR096EDHighlights2010.pdf

Source: 2010 SAMHSA Drug Abuse Warning Network (DAWN) – July 2, 2012

Filed Under: 2012-08-10, Addiction, News Updates, Opioid Abuse/Addiction, Other Drugs of Abuse, Prescription Drugs Tagged With: , , ,

Some OTPs Discharge, Others Taper for Illicit Benzodiazepine Use

May 29, 2012 by 3 Comments

Benzodiazepine use and abuse by patients on methadone is a pressing concern for opioid treatment programs (OTPs) because of potentially dangerous drug interactions, especially during induction, so it was a natural selection for a “hot-topic” meeting at the American Association for the Treatment of Opioid Dependence (AATOD) conference in April. Ron Jackson, MSW, LICSW, moderated the session.

“We decided to have this hot topic because everybody talks about the problems of benzodiazepine use, so we wanted to figure out what treatment providers were doing and why they were doing it,” said Mr. Jackson, who is executive director of Evergreen Treatment Services in Seattle.

Some patients are prescribed benzodiazepines with the knowledge of the OTP.  There was a large degree of difference in program policies about approving such prescriptions as described by participants in the roundtable discussion, ranging from “If it’s being prescribed by a psychiatrist it’s OK” to “Our clinic has a discussion with the prescriber to coordinate care.” But of bigger concern are patients who are taking benzodiazepines but do not have valid prescriptions—they may be doctor-shopping or buying benzodiazepines on the street. For these patients, there is no consensus, at least not one Mr. Jackson detected during the AATOD session. “Program policies are all over the place,” he told AT Forum. Some refuse to admit anyone who says they use benzodiazepines. Some will admit these people but require them to self-taper during the first month—a risk, because the patient could have seizures. One OTP said patients are sent to a local facility for detoxification—but that could be a problem, because they are detoxified from opioids, too.

Some OTPs simply decrease methadone doses for patients whose urine drug tests are positive for benzodiazepines, but Mr. Jackson said there’s no science to support this, as the tests do not measure how much the patient is taking.

In fact, there aren’t many tools for patients who are abusing benzodiazepines, said Mr. Jackson. “I wish there were some sort of benzodiazepine antagonist. Other than cognitive-behavioral therapy to resist cravings, there isn’t anything.”

Evergreen’s PMP Experience

A combination of checking with the prescription monitoring program (PMP) and asking patients what they are taking helps identify which people are on benzodiazepines before they are admitted. The PMP will not tell whether patients have bought them on the street or obtained them in some other way without a prescription, which is why it’s important to also ask them, said Mr. Jackson.

Evergreen’s patients are required to register their prescriptions with the OTP, so the clinicians know about possible drug interactions and are able to coordinate care. Recently Evergreen queried the PMP about all of its patients in the Seattle clinic. It found that 31 percent (350 patients) in the clinic showed up on the PMP. Of these 350 patients, about 20 percent were taking exactly what they had registered they were taking. “I was happy with that,” he said. But of the other 80 percent, 45 percent were prescribed benzodiazepines. Some were taking them but did not inform the OTP, and some were selling them. The number of current benzodiazepine prescriptions per patient ranged from 1 to 19.

Evergreen worked closely with these doctor-shopping patients by trying to get them to quit. “We wanted to continue their OTP treatment while safely tapering them from benzodiazepines,” said Mr. Jackson. “But if patients cannot cooperate, and every drug test is positive for benzodiazepines, and the patient has been to the ER with overdoses, we say, ‘You may need a higher level of care. We can no longer safely give you the medications you need.’”

Many more patients—88 percent of the 350—were getting prescribed opioids, but some were not taking them – this was clear because the medications never appeared in urinalysis tests. Some were selling all of them, which was also true of those receiving prescriptions for benzodiazepines. “One patient said, ‘This is my way of making a living,’” said Mr. Jackson. That patient left treatment. Some were getting prescriptions for Suboxone and selling or giving away the pills.

For patients who had prescriptions for trivial amounts of drugs—for example, a prescription for 6 acetaminophen/ hydrocodone (Vicodin) after a root canal procedure– Evergreen didn’t take any action other than reminding such patients to register their medications. About 25 percent of the patients had prescriptions for these “trivial” amounts.

Seeking a High

The reality is that some people come to methadone treatment but aren’t interested in treatment, according to Mr. Jackson. “They’re interested in the medication. That way they can continue to live the life they want—without craving opioids—and instead can get high from other drugs, like benzodiazepines.” OTPs must face this reality, especially OTPs with limited capacity or waiting lists, noted Mr. Jackson. Patients come to OTPs with a history of seeking euphoria from drugs.  “You end up with this difficult triage decision: who is appropriate, who gets these slots?”

 

Filed Under: Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Treatment Programs (OTPs), Prescription Drugs, Spring 2012 Tagged With: , , , , ,

A Call for OTPs to Step up Rapid HIV Testing

May 29, 2012 by Leave a Comment

The Substance Abuse and Mental Health Services Administration (SAMHSA) and their Addiction Technology Transfer Center (ATTC) network, along with the National Institute on Drug Abuse (NIDA), are urging substance abuse treatment programs to step up rapid testing for HIV during the time patients are in treatment programs. Patients in substance abuse treatment are at high risk of HIV infection because they may engage in injection drug use and unsafe sex.

The need for rapid HIV testing is compelling, with new HIV cases in the U.S. appearing at a steady rate of about 50,000 per year. About one person in five who is HIV positive is unaware of it—and those are the people, according to SAMHSA, who transmit most new cases of HIV. Identifying them and getting them into treatment could impact the spread of HIV.

Rapid tests for onsite use are inexpensive and widely available to Opioid Treatment Programs (OTPs) and other programs through the local health department and the State Authority. Positive rapid test results must be confirmed by traditional blood tests. Rapid test results take one to 20 minutes, so patients can learn their HIV status in a single visit. Despite this, and despite the well-known link between substance misuse and HIV infection, fewer than half of U.S. drug treatment programs offer HIV testing onsite. OTPs do better than most programs; 69 percent of OTPs offer onsite HIV testing.

How Effective Are Onsite Testing and Counseling?

To find out, SAMHSA-ATTC /NIDA carried out a multisite HIV Rapid Testing and Counseling Study, enrolling adults from four types of programs—outpatient medication-assisted treatment, outpatient psychosocial, intensive outpatient, and residential. Participants were either HIV-negative or of unknown HIV status, and had not been HIV-tested during the previous 12 months. They were divided randomly into three HIV testing groups:

  • Onsite, with brief risk-reduction counseling
  • Onsite, with verbal information about testing only
  • Referred for offsite testing

Results

More than 80 percent of those tested onsite received their test results, compared to only 18 percent who followed through when referred offsite. The results support routine rapid HIV testing and providing patients with information about testing, but not risk-reduction counseling for those who tested HIV–.  Patients were glad to have test results so quickly, and said they “felt safe,” and were “so happy” about being able to be tested in their own program, rather than being referred elsewhere, according to Louise Haynes, MSW. Onsite testing was a real asset to the program.

The HIV Rapid Testing Initiative 

The HIV Rapid Testing in Substance Abuse Treatment Program is a joint effort by the SAMHSA-ATTC /NIDA Blending Initiative to put the results of medical research—such as new rapid diagnostic tests—into the hands of treatment providers as quickly as possible. Spurred by an Institute of Medicine report of a 17-year gap between the publication of research results and their practical impact on patient care, the Blending Initiative speeds the dissemination of findings from research-based drug abuse treatment into community-based practice.  Its website offers a Fact Sheet, Resource Guide, Marketing Materials, Training Information, State-Specific Testing Laws, and other resources, including a Budget Worksheet to help OTPs set up an HIV Rapid Testing Program.

http://www.attcnetwork.org/explore/priorityareas/science/blendinginitiative/rapidtesting/hivrapidtest.asp

http://www.cdc.gov/hiv/topics/testing/rapid/#Main

http://www.drugabuse.gov/publications/nidasamhsa-blending-initiative

Filed Under: Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Spring 2012 Tagged With: , , , , ,

SAMHSA Panel: No Mandatory ECG Testing for OTP Patients

March 8, 2012 by 1 Comment


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

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

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

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

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

Panel Recommendations

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

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

Not a ‘Major Danger’

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

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

Prevalence of Prolonged QT Interval

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

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

Costs of ECGs

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

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

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

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

Resources:

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

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

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

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

Filed Under: Newsletter, Opioid Treatment Programs (OTPs), Winter 2012 Tagged With: , , , ,

CSAT: Accessing Prescription Drug Data to Maximize OTP Patient Safety

November 28, 2011 by Leave a Comment

Prescription drug monitoring programs (PDMPs), electronic databases of prescriptions submitted by dispensers (pharmacies and practitioners
who dis­pense out of their office) and run by state agencies, are useful to help coordinate care, prevent doctor-shopping, deter prescription
drug abuse, and assist law enforcement authorities in preventing diversion. As of September 2011, 36 states have operational PDMPs, and an additional 12 states and 1 territory have enacted legislation to implement a program. Most PDMPs collect data on schedules II to IV controlled substances.

This fall, a “Dear Colleague” letter from H. Westley Clark, MD, director of the Center for Substance Abuse Treatment (CSAT), encouraged opioid treat­ment programs (OTPs) to participate in PDMPs. The letter, released September 27, says that physicians, physician assistants, nurse practitioners, pharma­cists, and other OTP staff should utilize state PDMPs “to maximize safety of patient care.” PDMPs can assist the OTP prescriber to revise their treatment plans, possibly preventing serious adverse events.

Medical Director Case Study

The letter from Dr. Clark cites a case study in which an OTP medical director found that 23 percent of patients in the OTP were prescribed significant amounts of benzodiazepines, opioids, and other controlled sub­stances, unknown to clinic staff and revealed only by a search of the PDMP database.

The case study, a first-person account, is appended to the Dear Colleague letter and shows clearly the patient safety issues these other substances raise when OTP staff is unaware they are being prescribed. Methadone is a powerful, long-acting opioid and “can be fatal when mixed with other drugs or medications,” the OTP medical director’s account says. “Benzodiazepines, combined with methadone or other opioids, have caused many overdose deaths in our state . . . Opioids can cause overdose deaths even if not mixed with other drugs. For this reason, it’s critical to know whether or not the patient is getting another opioid in addition to the methadone we are prescribing.”

The medical director recalled that at least eight of these patients were filling prescriptions for metha­done, in addition to their methadone doses prescribed by the OTP. “About half of them said they were selling or giving the methadone pills prescribed by community doctors to friends or family. The other half claimed to be taking the extra methadone themselves, with no good explanation about why they hadn’t asked for dose increases at our treatment program.”

Some patients said they had been taking prescriptions for benzodiazepines (mostly alprazolam, diazepam, or clonazepam), and “found methods to avoid detection on observed urine drug screens, some said they were giving them to friends of family members, and some admitted to selling them.” The community-based physicians prescribing these medicines didn’t know that the patients were being treated at an OTP, the medical director said. And, no one at the OTP was aware that these patients were see­ing other doctors or being prescribed benzodiazepines or opioids.

The OTP medical director noted that many patients ultimately appreci­ated the program’s efforts to address this problem, adding that there was less drug dealing going on in the nearby parking lot. “The majority of patients were dedicated to their recovery and found the drug dealing to be a temptation and a vexation.” Also, counselors and nurses said patients who were discovered through the PDMP became compliant with treatment and indicated that the PDMP system helped with their recovery.

The case study concluded that initial and ongoing monitoring of a patient’s prescription history using PMDP data can play an important role in safe and effective addictions treatment.

confidentialOTP Patient Confidentiality Concerns

OTPs cannot provide information about their patients to PDMPs because of 42 CFR Part 2, the federal confidentiality law, and are not required to participate, the Dear Colleague letter notes. PDMPs are not bound by the confidentiality law, and could disclose identifying information about patients in OTPs, if the OTPs provided information to the PDMPs, the letter further notes. Therefore, CSAT advises OTPs not to provide information to PDMPs regarding their patients.

Chris Baumgartner, program coordinator with Alliance of States with Prescription Monitoring Programs (ASPMP), which provides technical assistance under a Bureau of Justice Assistance contract to BJA-fund­ed PDMPs, said that if the patient got a prescription from the OTP and took it to a pharmacy, the pharmacy will input that data. But OTPs cannot participate by providing dose or dispensing information, he said.

CSAT notes OTPs should consider notifying patients about the existence of PDMPs. This also can serve to facilitate open communication with patients about their prescriptions and help coordinate care between the OTP and other medical providers.

Will Accessing PDMPs be a Barrier to Entering Medication-Assisted Treatment?

“From my perspective, I do not see a con to having programs access PDMP databases in terms of getting information,” said Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), which has been working with the ASPMP. “If there is a con, it’s basically going to be that some patients may not want to enter an OTP—word will eventually get out that programs will be accessing this data,” he said. “But frankly, I do not see this as a con.”

Mr. Baumgartner agreed that knowing that the OTP is participating in accessing information may be a barrier to treatment. “The patient may say, ‘If you’re going to monitor me, I don’t want that.’”

For Additional Reading:

http://atforum.com/addiction-resources/documents/dearColl-pmp2011.pdf (Dr. Clark’s letter). Accessed November 10, 2011.

http://www.maine.gov/dhhs/osa/data/pmp/treatment.htm (how Maine tells OTPs to use PDMPs). Accessed November 10, 2011.

www.pmpalliance.org (Alliance of States with Prescription Monitoring Programs). Accessed November 10, 2011.

For more on the federal confidentiality regulations and OTPs, go to http://s1052832.instanturl.net/newsletters/2010fall.php#otpconfidentiality Accessed November 10, 2011.

Filed Under: Fall 2011, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Prescription Drugs Tagged With: , ,
«Older Posts

Site last updated May 13, 2013 @ 4:22 pm