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

Opioid Prevention Programs Could Reduce Deaths from Overdose

hospital sign purchasedshutterstock_33280960“Researchers at the University of Cincinnati  School of Medicine conducted a study that analyzed 19 published studies evaluating the effectiveness of Opioid Overdose Prevention Programs (OOPPs) in terms of recognition, prevention, and risk factors for opioid overdoses. Fourteen of the studies analyzed featured follow-up data on over 9,000 people enrolled in an OOPP, of which half had experienced an overdose and 80% witnessed one.

The research found that eleven of the OOPP studies reported a 100% survival rate when administering naloxone, and the others featured at least an 83% rate. The percentages were determined out of nearly 2,000 naloxone administrations.

However, the researchers believe further studies must be conducted to ensure the strength of knowledge of overdose prevention and risk factors for those who are enrolled in OOPPs. Their findings are promising, but there is limited research and data on OOPPs and that’s really the only way more can be determined about overdose prevention efforts.”

http://www.scienceworldreport.com/articles/15166/20140603/opioid-prevention-programs-reduce-deaths-overdose.htm

The article Development and Implementation of an Opioid Overdose Prevention Program Within a Preexisting Substance Use Disorders Treatment Center which was published in the Journal of Addiction Medicine.

Also see article from Medscape ‘Project Lazarus’ Making Headway on Opioid Overdoses available at: http://www.medscape.com/viewarticle/826865. Free registration required.

Source: ScienceWorldReport.com – June 3, 2014

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

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

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

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

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

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

Methadone-Associated Deaths: Overdoses or Arrhythmias?

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

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

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

 

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

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

 

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

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

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

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

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

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

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

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

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

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

Initiating Methadone Therapy - The panel offers two strong recommendations:

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

Monitoring and Follow-up ECGs

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

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

Adverse Events – Two recommendations:

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

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

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

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

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

Need for Additional Research

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

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

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

Links to Resources Mentioned in This Article                        

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

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

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

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

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

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

Click here to access additional related resources.

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/.

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

Opioid Substitution Therapy Is Linked to Lowered HIV Risk

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

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

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

Source: Aidsmap.com – April 29, 2014

Privacy Being Tightened for Prescription Drug Monitoring Databases

pills“The privacy of information contained in prescription drug monitoring databases is being tightened, The Wall Street Journal reports. Privacy advocates hail the trend, while law enforcement officials say it is hampering their attempts to curb prescription drug abuse.”

“The public and lawmakers are really starting to understand what kinds of threats to privacy come when we start centralizing great quantities of our sensitive personal information in giant electronic databases,” said Nathan Wessler, an attorney with the American Civil Liberties Union. The group represented patients and a doctor who challenged the Drug Enforcement Administration in the Oregon case.”

http://www.drugfree.org/join-together/legal/privacy-being-tightened-for-prescription-drug-monitoring-databases

Source: JoinTogether.org -May 7, 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

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

Jana Burson Blog: More about IRETA’s Guidelines for Benzodiazepines in OTPs

blog1“This is a continuation of my last blog post about the IRETA (Institute for Research, Education & Training in Addictions) guidelines for management of benzodiazepine use in medication-assisted treatment of opioid addiction. You can read all of the guidelines at: http://ireta.org/sites/ireta.org/files/Best%20Practice%20Guidelines%20for%20BZDs%20in%20MAT%202013_0.pdf

Under the section of recommendations regarding addressing benzodiazepine use is found the following statement:

“Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment. People who have a history of benzodiazepine abuse should not be disallowed from receiving previously prescribed benzodiazepines, provided they are monitored carefully and have stopped the earlier abuse.”

The experts, after reviewing the best data, are saying that if a patient has abused benzos in the past, but isn’t abusing prescribed benzos now, it may be OK to continue benzos, with careful monitoring.

I don’t like this statement. It doesn’t conform to my present thoughts on the topic. I fear that the majority of patients with a history of benzodiazepine abuse or addiction will, sooner or later, revert back to problem use of the medication. That’s my anecdotal experience. Anecdotal experience is worth something, but data from clinical trials trumps anecdotal experience, and IRETA’s guidelines are based on both clinical trials and expert opinion.

So now I need to challenge my previously held views about benzos in the OTP. It’s unpleasant and uncomfortable to change a long-held view. But isn’t that what I ask of my patients? In the interest of science, I will re-consider my present opinion, but I won’t ignore the last part of the statement, which says careful monitoring needs to be done.”

 http://janaburson.wordpress.com/2014/02/02/more-about-iretas-guidelines-for-benzodiazepines-in-otps/

Source: Jana Burson - February 2, 2014

Guidance Provided for Safe Methadone Induction and Stabilization in OTP Patients By Guest Author Stewart B. Leavitt

doctor and patient jpeg winter 2014Expert opinion from ASAM stresses safety during MMT start-up   

For roughly half a century, methadone dispensed in federally certified opioid treatment programs (OTPs) in the United States has been a well-studied, effective, and relatively safe addiction therapy. Yet, there have been ongoing incidents of methadone-associated overdoses and deaths, largely due to its widespread prescription and frequent misuse as a pain reliever, but also to a lesser extent in patients attending OTPs.

When properly prescribed and used in OTPs, methadone has a favorable safety profile; however, there can be special risks of overdose and death from methadone during start up and early phases of treatment. To address these concerns, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) invited the American Society of Addiction Medicine (ASAM) to convene an expert panel to develop a consensus statement on methadone induction and stabilization, which provides recommendations for reducing risks of overdose or death related to the methadone maintenance treatment (MMT) of addiction.

Methadone Start-Up Takes Time and Caution

A distinguished panel of 10 experts in the MMT field—the “Methadone Action Group,” including Drs. Louis Baxter, Anthony Campbell, Michael DeShields, Petros Levounis, Judith Martin, Laura McNicholas, Tom Payte, Ed Salsitz, and Trusandra Taylor, along with Bonnie Wilford, MS—conducted a comprehensive literature search spanning 1979-2011. The group evaluated the resulting information and collaborated in formulating a best practices consensus document, which was subsequently reviewed and commented on by more than 100 experts in the addiction treatment field.

The final document, published in the November/December edition of ASAM’s Journal of Addiction Medicine [Baxter et al. 2013; PDF here], extensively focuses on safety during the 3 most critical phases of starting MMT: A. methadone induction (weeks 1-2); B. early stabilization (weeks 3-4); C. late stabilization (weeks 5+).

According to the medical literature examined by the expert panel, overdoses and deaths during methadone induction most commonly may occur either because 1) the initial dose is too high, 2) the dose is increased too rapidly, or 3) the prescribed methadone interacts with another drug. Therefore, the panel developed recommendations that help methadone providers avoid or minimize these risks.

When it comes to the initial methadone dosing at MMT start-up, the panel stresses the traditional advice to “start low, go slow.” Acknowledging the difficulties of accurately assessing a new patient’s opioid tolerance—and, therefore, a definitely “safe” methadone dose—the initial dose of methadone should typically range between 10 mg to 30 mg per day. An additional 5-10 mg/day is allowed if necessary to help relieve persistent withdrawal symptoms; however, the standard in the U.S. is that the total daily dose should not exceed 40 mg.

There are a number of high-risk situations to consider that may prompt low initial dosing. These include patient age >60 years, recent use of sedating drugs (e.g., benzodiazepines), alcohol abuse or dependence, concurrent physical disorders (e.g., respiratory or cardiac disease, sleep apnea, central nervous system depression, and others), or taking medications that either increase or decrease methadone metabolism.

It is essential to medically assess patients at intake and closely monitor their response to therapy. It may take several weeks before an optimal methadone dose can be safely achieved, during which time symptoms of withdrawal may persist to some degree, especially late in the day or during the night.

The ASAM panel states that the first day’s methadone dose may be increased “every five or more days in increments of 5 mg or less” [note that this dose increase is at the low end of what previous guidance has recommended]. Because methadone levels accumulate gradually before reaching a steady state, whereby opioid withdrawal is prevented throughout a 24-hour period, patients should be carefully assessed and they often need more time for full effects to be realized rather than more daily methadone during the induction period.

The first 2 weeks of MMT are a critical period from a safety standpoint, and the ASAM expert panel discusses the many subtle factors that may influence a patient’s therapeutic response to methadone and also affect clinical impressions of overmedication. For example, individual patient differences in metabolism may alter the duration of methadone effects; furthermore, in some cases, overmedication may be marked by unexpected feelings of excess energy, with or without euphoria.

Beyond the first 2 weeks—during early and late stabilization—the objective is to achieve a methadone maintenance dose allowing the patient to live a better life free of withdrawal symptoms, drug intoxication or excessive sedation, or troublesome drug craving. Various factors may upset this process—e.g., changes in physical health, psychological distress, continued substance abuse, etc.—so ongoing patient assessments and methadone dose adjustments may be necessary in some cases for an extended period of time. The ASAM expert panel does not comment on what optimal methadone dosing eventually might be, other than to note that “some patients require doses larger than 120 mg/day” for blocking euphoric effects of self-administered (e.g., illicit) opioids.

This new evidence-based document from ASAM is the first time all of this vital information has been so extensively brought together in one place; so, it is recommended and important reading for all persons involved or interested in MMT. At the same time, the principles and best practices described are not entirely new; indeed, this topic was previously discussed, although more briefly, in past AT Forum articles [see Special Report 2003 and ATF fall 2006]. Additionally, in 2007, a methadone induction instruction handout for patients and significant others was made available to AT Forum readers by Tom Payte, MD (who also is one of the Methadone Action Group panel members) [PDF here].

Education and Preparedness Are Essential

Methadone overdose can have a deceptive and slow onset, and the ASAM panel stresses the importance of patient and family education beginning with intake into MMT. Involvement of family [or significant others, and presumably with patient consent] can be a critical safety measure by helping to ensure that they understand the lengthy process of methadone induction and stabilization, as well as the signs/symptoms of overmedication and overdose to watch for along the way. Being able to recognize therapeutic risks and potential problems, and knowing appropriate actions to take if problems do occur, are essential for OTP staff, patients, and patients’ families.

Unfortunately, in the ASAM document there is only a single mention of naloxone, which is an effective and safe antidote for methadone overdose. It states, “Opioid treatment programs should establish protocols for emergency response to and management of patient overdoses, including onsite availability of naloxone and any necessary support and education for families.”

Indeed, there appears to be growing interest in the U.S. (and in other countries) in making naloxone more widely available to patients, their families, and others for helping to reverse opioid overdose in an emergency—whether involving prescribed or illicit opioid agents. For example, Washington State has an aggressive program of naloxone distribution [see StopOverdose.org] and the ASAM expert panel references an “Opioid Overdose Prevention Toolkit” from SAMHSA [PDF here]  that discusses how to identify overdose and the use of lifesaving naloxone. Methadone overdose in MMT—what to know; how to prevent it; what to do if it happens (including naloxone) —was the theme of a past edition of AT Forum [Summer 2007 PDF].

In sum, careful management of methadone induction and stabilization, coupled with patient/family education and increased clinical vigilance by staff, can be lifesaving measures during MMT. According to Louis Baxter, MD—ASAM immediate Past-President and chair of the expert panel—in a press release [PDF here], “The use of methadone to treat addiction has saved countless lives in the last 50 years, but it also has an increased risk of toxicity and adverse events for the patient during the medication’s induction and stabilization phases. The protocols designed by the ASAM expert panel could dramatically decrease these negative outcomes if all clinicians prescribing methadone would follow them.”

References

Baxter LE, Campbell A, DeShields M, Levounis P, Martin JA, McNicholas L, Payte JT, Salsitz EA, Taylor T, Wilford BB. Safe Methadone Induction and Stabilization: Report of an Expert Panel. J Addiction Med. 2013(Nov/Dec);7(6):377-386. PDF available at: http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2013/11/26/safe-methadone-induction-and-stabilization. Access checked 1/29/2014.

Leavitt SB. Methadone Dosing & Safety. AT Forum [special report]. 2003 (September). PDF available at: http://www.atforum.com/SiteRoot/pages/addiction_resources/DosingandSafetyWP.pdf. Accessed 1/27/2014.

Methadone Overdose in MMT. AT Forum. 2007(Summer);16(3). PDF available at: http://atforum.com/pdf/Summer07_news.pdf. Access checked 1/29/2014.

Payte JT. Methadone induction instructions to patients and significant others. CMG Induction Handout v7; 2007. PDF available at: http://atforum.com/pdf/PayteSafetyInstructions.pdf. Accessed 1/29/2014.

Safely starting methadone in MMT. AT Forum. 2006(Fall);15(4). PDF available at: http://atforum.com/SiteRoot/pages/current_pastissues/2006Fall.pdf Accessed 1/27/2014.

SAMHSA (Substance Abuse and Mental Health Services Administration). Opioid Overdose Prevention Toolkit. Rockville, MD: HHS Publication No. (SMA) 13-4742; 2013. PDF available at: http://store.samhsa.gov/shin/content//SMA13-4742/Overdose_Toolkit_2014_Jan.pdf. Access checked 1/29/2014.

StopOverdose.org. University of Washington Alcohol & Drug Abuse Institute. 2013. Website at: http://www.stopoverdose.org/pharmacy.htm. Access checked 1/29/2014.

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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.

The Joint Commission: Revised Requirements for Opioid Treatment Programs (OTPs)

Joint CommissionOn January 15 the Joint Commission issued for prepublication revised requirements for opioid treatment programs that will become effective March 23. The requirements address four areas:

  • Care, Treatment, and Services
  • Information Management
  • Medication Management
  • Rights and Responsibilities of the Individual

The prepublication requirements can be accessed at:

http://www.jointcommission.org/assets/1/18/Opioid_BHC.pdf

Source: The Joint Commission – January 15, 2014

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

liverABSTRACT

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

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

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

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

Source: International Journal of Clinical Medicine – January 2014

Dr. Westley Clark on Overdose – Prevention of Prescription Drug Abuse Can Start With Education about the Risk of Overdose Death

ClarkOn January 16, the ATTC Network hosted a free webinar, “SAMHSA’s Opioid Overdose Prevention Toolkit & Prescription Drug Abuse,” led by the Director of the Center for Substance Abuse Treatment at SAMHSA, Dr. H. Westley Clark.

In addition to an overview of the toolkit itself, Clark’s presentation included epidemiological details about the current overdose epidemic, federal-level efforts to address overdose, and the importance of access to evidence-based treatment (including medications).

The recorded webinar is available online for on-demand viewing.  You can also download the slides for an overview of the talk.

Here are two salient points:

  • The exchange of prescription pain relievers is happening at a person-to-person level.
  • Prevention of prescription drug abuse can start with education about the risk of overdose death. 

The risk of death from an overdose, said Clark, is a good jumping off place for a larger conversation about substance use.  Not only is pill-popping not harmless, it can actually kill you or someone you love. “We can use overdose as a starting point to get people to be aware of some of the consequences of the misuse of prescription opioids or heroin, for that matter,” he said. “We’ve got friends and relatives who are handing people very powerful drugs with the assumption that if they can take it, then anybody can take it.  And that is not the case.”

Emphasizing the long-term consequences of a behavior–like the possibility of becoming addicted as a result of recreational painkiller use–doesn’t always get through to people.  But the possibility of dying from a drug overdose today or tomorrow?  No kindly neighbor wants to bear responsibility for that.

The Institute for Research, Education & Training in Addictions (IRETA) blog also provides a list of currently available and forthcoming resources to help individuals and communities prevent prescription drug abuse and overdose.

http://iretablog.org/author/iretablog/

Source:  Institute for Research, Education & Training in Addictions – January 27, 2014

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

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

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

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

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

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

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

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

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

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

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

 

 

New Toolkit Will Combat Opioid Overdose

SAMHSA Opioid Overdose Toolkit

“The Substance Abuse and Mental Health Services Administration (SAMHSA) has developed an Opioid Overdose Toolkit to educate first responders, physicians, patients, family members, and community members on ways to prevent opioid overdose, as well as how to use a drug called naloxone to prevent overdose-related deaths.

Inside the toolkit are five separate booklets, each designed for a specific audience:

  • Patients can learn how to minimize the risk of opioid overdose.
  • Prescribers can understand the risks of opioid overdose, as well as clinically sound strategies for prescribing opioids and educating and monitoring patients.
  • First Responders will find five steps to use in responding to an overdose, including how to use naloxone and provide other life-saving assistance.
  • Community Members can view facts about opioid overdose that can help local governments, community organizations and private citizens develop policies and practices to prevent overdoses and deaths.
  • Survivors and Family Members can gain information and support through the information provided in this booklet.”

The booklets are available for download at:
http://store.samhsa.gov/product/SMA13-4742?utm_source=social&utm_medium=blog&utm_term=OC&utm_campaign=opioid

Source: SAMHSA – August 28, 2013

New York: New York’s Problem with Prescription Drugs

“An analysis, released by the New York City Department of Health in May, reported that between 2005 and 2011 the opioid analgesic overdose fatality rate increased by 65 percent despite the fact that during the same period overall drug overdose deaths decreased by 22 percent. As the drug-of-choice has changed, so too has the image of the traditional drug dealer and addict. Increasingly, those using and abusing these drugs are white middle-class citizens.

According to the same report released by the NYC Department of Health, 56 percent of opioid analgesic overdose fatalities occurred in middle or high income neighborhoods. These are also the neighborhoods where the largest increase in overdose fatality rates were observed. From 2005 to 2011 overdose fatality rates increased in middle income neighborhoods 115 percent while high income neighborhood experienced a 110 percent increase.

The results of the analysis also show that a vast majority of overdose victims are white. The fatality rate for whites was four and a half time higher that the fatality rate for blacks and three times higher than the rate for latinos.

Additionally, contrary to popular belief, the victims of overdose are not just young recreational drug users. In New York City the largest share of overdose fatalities occur in the age range from 45 to 54 years old, accounting for 27 percent of New York City’s opioid overdose fatalities. This is a troubling fact that makes clear the line between prescription misuse and the path to prescription opiate addiction.”

http://digitaljournal.com/article/357369

Source: DigitalJournal.com – September 4, 2013

ASAM: States and Insurance Companies Limit MAT in Face of Opioid Abuse Epidemic and ODs

ASAM logoMedication-assisted treatment (MAT) is being thwarted by state governments and insurance companies, the American Society of Addiction Medicine (ASAM) warned in a scathing report released June 20. The report, which details practices by governments, Medicaid, and insurance companies, shows that by restricting the use of methadone, buprenorphine, and naltrexone, policymakers are doing nothing to stave off the opioid addiction and overdose epidemic. And they may even be adding to it by denying patients MAT, according to the report, which was prepared by the consulting and research firm Avisa Group and the Treatment Research Institute (TRI).

The main point of the report is that the medications work only when used as long-term, maintenance treatment. There is very little evidence that short-term treatment is effective. Yet, short-term, curtailed, or no MAT is what many politicians and insurance companies are calling for

“I wonder how many governors are actively intervening to dictate the nature, amount, and duration of cancer treatment or hypertension medications that are available,” said A. Thomas McLellan, PhD, CEO of TRI, in an interview with AT Forum after the report was released. “I wonder how many state insurance authorities would get away with restricting the amount, duration, and coverage for cancer, pain, asthma, hypertension care.” Treatment of addiction needs to be governed by the same rules of clinical science that govern the rest of medical care, Dr. McLellan said. “At the end of the day this is a medical illness. It is that simple. If you can say a sentence about diabetes treatment and its coverage, and then replace the word diabetes with addiction and have the sentence still make sense, you are probably on the right track.”

Medicaid

medicaidIn 31 states, methadone maintenance treatment in OTPs is covered by fee-for-service (FFS) Medicaid. In some states, additional funding comes from the federal Substance Abuse Prevention and Treatment (SAPT) block grant and state funds. In three states, methadone treatment is funded only through the SAPT block grant or state or county funds, with no Medicaid coverage. Medicaid does not cover methadone maintenance at all in 17 states. States having no public funding for methadone maintenance, according to the report, are:

    • Arkansas
    • Colorado
    • Idaho
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Mississippi
    • Montana
    • North Dakota
    • Oklahoma
    • South Carolina
    • South Dakota
    • Tennessee
    • West Virginia

Although addiction is a chronic disease, with opioid addiction best treated with medications and behavioral interventions, not only are the medications underutilized, but their use is deliberately being foiled for reasons related to cost and stigma.

“These reports show that we could be saving lives and effectively treating the disease of addiction if state governments and insurance companies remove roadblocks to the use of these medications,” said Stuart Gitlow, MD, president of ASAM. “Treatment professionals need every evidence-based tool available to end suffering from this chronic disease.

The report on effectiveness of opioid medications looked at 642 different studies evaluating the three medications—the only medications approved by the Food and Drug Administration for the treatment of opioid addiction. The report also shows that the medications are cost-effective, roughly comparable to diabetes medications.

Restrictions by Payers

A major part of the report is a survey of state Medicaid and other insurer restrictions.  “We really learned something there,” said Dr. McLellan. “I thought there were frank restrictions on MAT, but that is not the case.” Instead of explicit, written restrictions, there are non-quantitative treatment limitations, to use the language of the parity law. Insurance companies make it very difficult for patients to get the right amount of medication, and to access MAT in general.

The report found that insurance company representatives did not want to discuss opioid treatment medications, and that while every state covers at least one opioid addiction medication on the Medicaid formulary, restrictions vary and often amount to a complete denial of access, with coverage limits and onerous utilization review common by states. The situation is similar for private insurance companies, which have utilization management techniques that can be contradictory and arbitrary, and often limit quantities and dosages.

The situation is similar for private insurance companies. They have utilization management techniques, which can be contradictory and arbitrary, and often limit quantities and dosages.

These limitations are in direct opposition to recommendations by medical associations and the Substance Abuse and Mental Health Services Administration (SAMHSA), according to ASAM. Not only do these limitations have no therapeutic goal, but they can risk patient safety and lead to suffering and death.

Little Support from Insurance

Mady Chalk, PhD, of TRI, conducted the survey of commercial insurance plans for the report. “I was surprised at the extent of the comments that we got,” Dr. Chalk told AT Forum. “One was ‘How did you get my name and my email address?’ Another was ‘I sent this up the chain, and my CEO says I can’t respond.’” Most of the data for the commercial report was culled from secondary sources.

Public insurance—Medicaid—officials also did not want to discuss the restrictions on MAT. The National Association of Medicaid Directors refused to write a letter of support for the survey (which would have encouraged state Medicaid directors to respond), said Dr. Chalk. “They said they couldn’t support it because it would mean that the Medicaid directors would have to change their practices, and ‘we can’t put them in that position.’” Dr. Chalk was surprised at the extent of the resistance to even examining policies related to MAT. “Of course it might mean you would have to change some practices,” she said.

A number of insurance companies use “step therapy,” also known as “fail-first,” in which patients have to fail on a certain dose before it can be increased. “They can have a requirement that you have to start with 8 milligrams of buprenorphine, and if that doesn’t work then you can move up to 16,” said Dr. Chalk. One state said that in order for Medicaid to pay for Vivitrol, the patient would have to fail first at two attempts of residential treatment and fail two attempts at buprenorphine, she said.

Another general practice of many insurance companies is to allow patients to have a prescription for buprenorphine, for example, for six months, and then require a renewal of the prior authorization, said Dr. Chalk. But there’s a catch—“they say if you’re not at the moment in “active treatment”—which they don’t define—then no renewal.”

OTPs as Silos

Ironically, the price objections by payers to buprenorphine and extended-release naltrexone are not there for methadone, which is very inexpensive as a medication. But since it can only be given in OTPs, they don’t know how to deal with the modality.

Addiction treatment is often criticized as being a separate “silo” from medical care, but OTPs are like silos within silos, according to the report. Even though the report treats methadone, buprenorphine, and naltrexone equally, methadone is unique. Methadone tablets cannot be prescribed for opioid dependence on an outpatient basis; they can only be provided in OTPs, which have their own accreditation and licensing systems. Anyone closely involved with regulation and reimbursement of OTPs is unlikely to be familiar with other reimbursement systems, the report noted. In many cases, OTPs are not familiar with Medicaid, even when Medicaid covers some of the costs of treatment. Likewise, Medicaid staff who are not involved with OTPs or methadone know little about that system—even if their agency pays for treatment.

“We found virtually no commercial insurance coverage for methadone in OTPs,” said Dr. Chalk. Many insurance companies don’t want to reveal publicly that they cover addiction treatment because they are worried about “adverse selection,” a phenomenon in which people with a certain disease sign up for the insurance company that covers its treatment. However, if all of the insurance companies had coverage and benefits for addiction treatment, adverse selection would not be such an issue, said Dr. Chalk. Because of adverse selection concerns, access to medications is likely to continue to be a problem, even when health care reform is implemented.

“It is essential that there be greater transparency on the part of commercial plans and Medicaid agencies, so that consumers and treatment programs and clinicians are able to understand what their access is to medications,” said Dr. Chalk.

For the full report, go to: http://www.asam.org/docs/advocacy/Implications-for-Opioid-Addiction-Treatment

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