Bob Newman is Retiring, But You Haven’t Heard the Last From Him

April 21, 2013 by Leave a Comment

BobNewmanphotoLegendary methadone treatment advocate Robert G. Newman, MD, is retiring. But, he hastens to add, he is not leaving the field. “What I’m leaving,” he told AT Forum in February, “is the office.”

Dr. Newman announced via a January 26 e-mail that he would be giving up his “formal role” as director of Beth Israel’s Baron Edmond de Rothschild Chemical Dependency Institute. He will continue to work through June, but Hindy Bernstein, his assistant of the past 25 years, will be leaving in April. “Hindy is leaving me for Florida,” he said. Although he will no longer have the financial support of Beth Israel, he will continue advocacy efforts.

An Advocate

“The challenges are at least as great today as they were 40 years ago when I started my advocacy work,” Dr. Newman said. He will continue to be a fly in the ointment, but he does want to see more “noise” from the rest of the opioid treatment program (OTP) community.

His days will continue to begin and end the way they have for years, he told AT Forum. “I go to the Internet, I get the Google alerts, which very often have some particularly horrendous feature that I’m obliged to respond to.”

There is a lot of “bad news” for Dr. Newman to blog, write letters to the editor, and send e-mails about. And he does so very articulately. For example, some states are cutting off methadone treatment arbitrarily, trying to limit it to one or two years. Regulators are confounding addiction and dependence, not recognizing that maintenance medication is treatment, not a “substitute” for heroin. Unbelievable as it is that this non-science is going on today, some 50 years after medication-assisted treatment (MAT) has been proven effective, and in the face of federal officials, Dr. Newman sees it happening. And he isn’t going to be quiet about it.

NIMBY

NIMBY—the “not in my back yard” phenomenon in which even people who claim to support MAT don’t want programs in their neighborhoods—is illegal, violating the Americans with Disabilities Act (ADA). But despite the various ADA wins that OTPs have achieved, they are never “precedent-setting,” and therefore need to be fought over and over again. “This is terribly frustrating to me,” said Dr. Newman.

Dr. Newman said the opioid-treatment field can help with this fight. “There are many reasons for NIMBY, and some of those reasons have to do with the field, how we have allowed our treatment, our patients, our services to be viewed,” he said. “It isn’t just misperception on the part of communities and politicians. Some of the anti-methadone- patient bias reflects the way the field has chosen to isolate itself and adopt and embrace unique practices that make this treatment separate.”

 Office-based Methadone

 Dr. Newman is glad that buprenorphine has been made available to OTPs and to office-based opioid treatment (OBOT) providers, as a treatment tool for caring for opioid dependence. He notes that more than 40 years ago he proposed that private physicians be permitted to offer methadone maintenance, in addition to OTPs. And now that buprenorphine can be utilized in OBOT, why not methadone, he asks rhetorically. Dr. Newman also notes the extremely limited willingness of office-based physicians to become “waivered” to prescribe buprenorphine. “I think some of the practices of programs are so foreign to what is done in every other field of medicine that medical colleagues view this as something that is from Mars and refuse to get involved in any form of opioid-dependence treatment.”

In fact, the requirement that patients go to a clinic every day is a barrier to care. Dr. Newman is skeptical about the effect of the Affordable Care Act (ACA) on OTPs in particular. “I have seen repeated references to the notion that under the ACA, there’s going to be a sudden upsurge of demand for addiction treatment,” he said. “Increased demand, maybe,” he said. “But how is that demand going to be met? You can have all the insurance you want, but an awful lot of people who need treatment will avoid OTPs because of the requirements and the stigma, and there are not that many OBOT providers.”

Nevertheless, he noted that hundreds of thousands of patients do go to OTPs for MAT, which shows how motivated these patients are. “How many people would have the motivation to deal with obesity, smoking, hypertension, or a great many other medical problems if the treatment regimen required many months of daily attendance and a host of other demands? The fact that there are 300,000 people enrolled in MAT is amazing.”

 Methadone Safety and Dosing

With an appropriate dosage schedule, methadone is an extremely safe medication, said Dr. Newman. But he warned that some OTPs give induction increments that are too great. The federal regulations state that the dose on the starting day must not be more than 40 milligrams—the first dose has to be no more than 30, and an additional dose that day can be 10, said Dr. Newman. But after that, there are some programs that raise the dose too quickly. “Some programs have induction protocols of 30, 40, 50, 60, 70,” with the dose going up daily, he said. The rule of thumb—“start low, go slow, aim high”—needs more of an emphasis on “go slow.”

 Federal Exclusions

Finally, Dr. Newman would like to see more support for methadone treatment at the federal level. The insurance plans of the federal Department of Veterans Affairs and the Department of Defense have an exclusion against methadone and buprenorphine maintenance treatment, something Dr. Newman has long railed against. “Tom McLellan (then deputy director of the federal Office of National Drug Control Policy) and other very high-level officials have said the exclusion is bad, and that they were trying to change it,” said Dr. Newman. “But it persists, and that’s inexcusable and shameful. “

What Dr. Newman wants advocates to do is to speak up. “Silence equals death,” he said, citing an oft-used slogan of AIDS activists years ago. And he is not going to be silent. “There are a lot of windmills still out there.”

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

Two Kinds of Roles for OTP Peers under the Affordable Care Act

April 21, 2013 by Leave a Comment

flag and stetPeers—patients in medication-assisted treatment (MAT) who are in recovery—are gradually being enlisted into the workforce, thanks to the Affordable Care Act (ACA). Two kinds of roles are surfacing: recovery coaches, and “navigators” who help enroll uninsured people in private insurance through health insurance exchanges. The recovery coaching idea is not new, but the navigator one is—especially at the level of actually enrolling patients.

Community-based organizations in New York City have already signed up to be navigators, and the National Alliance for Medication Assisted Recovery (NAMA) hopes to be a part of this, says Joycelyn Woods, executive director.

Ms. Woods, like many observers, thinks there are going to be many glitches in getting people enrolled, and doubts that everyone who isn’t insured will be by next January. NAMA received a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) for educating patients and training navigators. “What SAMHSA is trying to do is to educate people,” explains Ms. Woods.

Recovery coaches will be a great asset to opioid treatment programs (OTPs), because they will make the programs more like the early ones in which “half the staff were patients,” says Ms. Woods. “They would hire patients and social workers and pair them together. The social worker would teach the patient about the academic part, and the patient would teach the social worker about the other part.” The “other part” is the experience of being a patient, a person with addiction, a person in a program.

Training

Training is based on the Connecticut Community for Addiction Recovery (CCAR) protocol. As it is being used in the FOR-NY Recovery Coach Academy, the training consists of 30 hours. CCAR includes regular follow-up telephone calls—that probably won’t happen with Medicaid, which requires face-to-face contact, says Ms. Woods. But in New York City, which is not rural like Connecticut, it’s likely that face-to-face counseling can be done.

There are also issues with the payment structure for the peers doing coaching, and the state is still working on those.

Some methadone counselors have already participated in training, because they want the recovery coach credential, says Ms. Woods. Although recovery coaching spans all addiction, including alcohol, in New York State anyone doing recovery coaching in a methadone program must also have four hours of training in MAT. This is essential, says Ms. Woods. “Can you imagine people from abstinence-based programs doing recovery coaching in an OTP?”

The NYCB recovery coach credential which requires 60 total hours of training requires 4 hours of MAT training for all coaches wanting the credential, explains Mr. Ginter. The NYCB is the only certification board currently requiring this for their recovery coach credential.

Navigator vs Peercoaching

There’s a subtle difference between what a navigator does, and what the peer acting as a navigator does, says Tom Hill, director of programs at Faces and Voices of Recovery, which has been a major guiding light in the peer recovery coaching movement. “The peer assister or navigator does outreach and pulls people in to walk through the insurance enrollment process,” says Mr. Hill. “There’s one port of entry, and depending on the income, the person would be routed to Medicaid or the exchanges.”

The enrollment process for Medicaid has always been cumbersome, but the Center for Medicare and Medicaid Services (CMS) says it has simplified that process, notes Mr. Hill. “An organization that is able to conduct outreach and get someone to a computer can walk them through the process and get them enrolled.” The Centers for Medicare and Medicaid Services (CMS) is soon to issue a request for applications for navigator grants, says Mr. Hill.

The SAMHSA grants are small: only $25,000 for and there were only eight awarded, says Mr. Hill. “They’re not very detailed because there’s only so much you can do with that amount,” he says. “Some of the grants deal directly with developing enrollment strategies—but others are more generally focused on educating the community,” he says.

There’s a lot of pressure to enroll uninsured people by October 1, says Mr. Hill. “We’ve been pretty clear that the folks we have on the ground in addiction recovery communities are capable of doing the assisting and the navigating,” he says. “Now it’s just a matter of everything falling into place.”

New York City is a good litmus test for the navigator grants, says Mr. Hill, noting that the NAMA grant is good model.

The NAMA contract is to educate MAT patients about the ACA, says Walter Ginter, project director of the Medication Assisted Recovery Support (MARS) project at NAMA. “We’re going to contact all the doctors, and through focus groups and webinars, provide the education about the exchanges,” he says. But he is concerned that the education isn’t going to go far enough, and that actually enrolling people in insurance is a task that has not been well thought out.

“There’s a lot going on at breakneck speed right now,” he says. “It’s exciting and scary and terrifying.”

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

NASADAD Issues Consensus Statement Endorsing Medication-Assisted Treatment

April 21, 2013 by Leave a Comment

health insurance approved1The top state officials in substance abuse treatment approved a consensus statement in December that states that medication-assisted treatment (MAT) should be paid for by public and private health insurance plans. This was the first time that the board of directors of the National Association of State Alcohol and Drug Abuse Directors (NASADAD) approved a statement that endorsed MAT as evidence-based treatment. The statement was released January 15. It focuses on MAT for opioid addiction, and is essentially an anti-stigma document, aimed at supporting single state agencies (SSAs)—the authorities over the Substance Abuse Prevention and Treatment block grant.

The consensus statement is footnoted and includes the following assertions:

  •  Dependence on alcohol and drugs is a complex but treatable disease that affects brain function and behavior.
  •  No one treatment protocol is appropriate for everyone.
  •  For some individuals, use of medication is recommended as a recovery tool.
  •  Where clinically appropriate, use of medication as a recovery resource should be utilized as an adjunct to other treatment services.

 Medications such as methadone, buprenorphine, and naltrexone (both oral and extended release injection) have been shown to reduce opioid use; and naltrexone, disulfiram, and acamprosate have been shown to be effective in the treatment of alcohol dependence. The appropriate use of these medications allows individuals to experience sustained recovery from opioid and alcohol dependence, including through long-term management using medication maintenance. The medications should be made available to individuals who could benefit from them.

 It is recommended that any medication-assisted treatment be combined with psychosocial and behavioral strategies that are clinically matched to the severity of the individual’s addiction.

 Longitudinal studies show that treatment initiated in the criminal justice system and continued in the community garners lasting reductions in criminal activity and drug abuse. This includes medication-assisted treatment (e.g., methadone, buprenorphine/naloxone, and injectable naltrexone) for some prisoners with opioid dependence.

 “There is still ambivalence around the use of addiction medications,” says Belinda Greenfield, PhD, the State Opioid Treatment Authority (SOTA) for New York. “That’s why NASADAD and the Opioid Treatment Network say MAT is important to be considered as a treatment option.” The SOTAs became part of NASADAD last year when the association formed the Opioid Treatment Network (OTN). Dr. Greenfield, president of the OTN, is also director of the Bureau of Treatment, Addiction Medicine & Self Sufficiency Services of the Office of Alcoholism and Substance Abuse Services (OASAS) in New York State.

 The problem—not accepting MAT—is particularly significant outside of the methadone field, but even in the substance abuse treatment world, a substantial number of providers espouse “drug-free” treatment, says Henrick Harwood, research director for NASADAD. “Many public-sector programs feel on principle that drug-free is the best approach,” he says. . However, he points out that over the last several years, many have been changing their point of view. “There’s been growing support for MAT.”

 Fight Stigma from Within

Dr. Greenfield says that opioid treatment programs (OTPs) themselves could be better advocates for MAT: they need to be vocal about the fact that patients in MAT are in recovery—they should be called “drug-free” because they’re taking a medication, not seeking a drug. “People in MAT are stable and drug-free, and are maintained on an addiction medication.”

Unfortunately, to some degree, Dr. Greenfield says, patients don’t consider themselves part of the recovery community, and that’s something that OTPs should be working to correct, partly by educating staff. “OTPs should be really actively involved in ROSC functions,” she says, referring to Recovery-Oriented Systems of Care.

 It also would help for OTPs to acknowledge that it is not only methadone that constitutes treatment, but buprenorphine, and behavioral therapies as well, says Dr. Greenfield. “We need to consider addiction medications as one of the options. We can’t say we use only methadone. Patients aren’t that cookie-cutter anymore.”

The Medical Mainstream

Stigma relates directly to the mainstreaming of OTPs, says Mr. Harwood. “It’s important to communicate that methadone treatment has moved in the direction of mainstream medication.” Accreditation by the Joint Commission and CARF are helping to promote the fact that OTPs are in the medical mainstream, he says.

Dr. Greenfield also says part of making MAT better accepted means involving patients more—something that is being encouraged in the rest of medicine, as well. “The language around patient-centered care needs to be better integrated in an OTP setting,” she says, noting that patient advisory committees can be helpful in implementing patient-centered care.

Finally, OTP staff need support as well, because they feel stigmatized, says Dr. Greenfield. They should be proud to tell their family and friends that they are working in an OTP, with patients on MAT. “As long as working in an OTP setting doesn’t seem desirable, this is a problem,” she says. “How do we elevate the cachet of working in an OTP and having staff feel proud of the work we do?”

Challenges for SOTAs

In some states, SOTAs themselves have challenges promoting MAT with their own governors and legislature.

“SOTAs are doing everything they can to advocate within their own states,” says Dr. Greenfield. The problem is that despite the scientific literature, methadone isn’t well understood—the fact that it prevents relapse. “Why can’t this rest with the clinicians and physicians?” she asks. Unfortunately, there are places where the legislature and state administrations oppose methadone and OTPs. This hasn’t been a problem in New York. “But the SOTAs and the SSAs in many states have a huge undertaking and a huge task in trying to advocate for methadone.”

One argument that might help sway some MAT opponents is cost-effectiveness. Mr. Harwood notes that the literature documents the cost-effectiveness of methadone and OTPs. “This is something that advocates need to keep in mind,” he says. “It’s not just that MAT is effective. It’s a win-win for society and communities to provide MAT, especially for opioid addiction.”

For the consensus statement, go to http://nasadad.org/wp-content/uploads/2013/01/13-January-15-NASADAD-Statement-on-MAT.pdf

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

Seeking and Getting Substance Abuse Treatment: Barriers Women Face

April 21, 2013 by Leave a Comment

BarrierOur first article in this series, “Becoming Addicted: It’s Different—and Riskier—for Women,” delved into the vulnerabilities that challenge women who have an opioid use disorder (OUD).

Now we examine the potentially daunting barriers women face in seeking and getting substance abuse treatment. Some barriers are largely internal, based on the woman’s attitudes; others are generated by society; still others exist within treatment programs.

As noted in the first article, few women misuse a single substance, so many studies we cite yield data for substance use disorders (SUDs) rather than for OUDs alone.

Finding Treatment

Barriers to treatment confront women from the outset, and it’s no surprise that most women with an SUD are never treated for it. Compared to men with OUDs, women are likely to be at a socioeconomic and educational disadvantage, to be underemployed or unemployed, and to have primary child-care responsibilities. Their OUD comes on more quickly, and they progress more rapidly to serious consequences. Yet women tend to see their substance abuse as stress-related, a temporary crutch that will go away without treatment.

Women are less likely than men to know how and where to get treatment. Typically they refer themselves, sometimes prompted by family or friends, or are referred by the criminal justice system or social service agencies. Men usually are referred by employers, doctors, or the legal system—sources generally considered more knowledgeable about treatment options.

Women may consider private residential clinics too time-consuming, expensive, and tightly regulated to be an option. Television and print media lead many to think that treatment means substance withdrawal, and that methadone is a drug to avoid (see Hearing Bad Things About Methadone Treatment? Thank “Dr. Drew”—Summer 2012 issue).  So it’s no surprise that women account for less than half of treatment admissions for opioid abuse.

Internal (Patient-Related) Barriers

According to Susan M. Gordon, PhD, in addition to misperceptions about programs, internal barriers include low motivation for treatment, denial of problems, psychological problems, internalization of negative social attitudes toward women with SUDs, self-definition, and independent attitudes about help-seeking and self-reliance. Dr. Gordon is director of research at the Caron Foundation Treatment Center in Wernersville, Pennsylvania.

In particular, depression and anxiety may lead women to delay or do without treatment. Studies suggest that high levels of estrogen can enhance the stress response in subcortical regions of the brain, contributing to the higher prevalence of depression and anxiety in women.

Many women with an SUD have a history of sexual, emotional, or physical abuse, as well as suicidal thoughts and attempts. Post-traumatic stress disorder is common, resulting from trauma or abuse. If a woman with an SUD has a history of emotional, physical, or sexual abuse perpetrated by men—and most do—the very idea of a treatment environment that includes men can be distressing.

Women are more likely than their male counterparts to have a drug-using partner supporting her drug use. These women generally receive little encouragement to enter treatment, and may instead encounter resistance.

Health professionals are less likely to identify substance abuse in women than in men; often they refer women to mental health care providers instead of treatment programs. Women themselves are partly responsible; they often choose psychological or psychiatric help rather than substance abuse treatment. Shame and guilt, or lack of awareness of the significance or severity of their addiction, may keep them from sharing their substance history with the mental health provider. So their true problem may go undiagnosed, and they lose the opportunity for treatment for their SUD.

Social Barriers

Society stigmatizes women who abuse substances—especially women who have children or are pregnant. Communities and families often fail to provide the support women need, including child care and encouragement to enter treatment.

“Once a woman has developed an addiction, she deviates more from the female norm, compared with a man with an addiction,” according to Drs. Dorte Hecksher and Morten Hesse, writing in Women’s Issues. She’s viewed by some—and often by the woman herself—as a “fallen woman.” She worries about the disapproval of friends, family, co-workers, and employers, if she enters substance abuse treatment, especially if she is pregnant, or a mother. Her concerns about providing child care and the possibility of losing custody are a heavy burden.

Treatment Program Barriers

Denial. “Breaking the denial is a necessary first step to assisting substance-dependent women to get into treatment,” according to Ozietta D. Taylor, PhD, MEd, LCPC, assistant professor at Coppin State University, Baltimore, Maryland. The Taylor reference below discusses ways of using methods of intervention to help get a woman into treatment.

Socioeconomic barriers. Substance-abusing women are less likely than men to have insurance or full-time jobs, and public funding often means a long wait. Getting to a program is another issue; many don’t have a car or driver’s license, or even money for public transportation.

Therapies and relationships. Men tend to enter treatment with an aggrandized sense of self, according to addictions and trauma expert Claudia Black, PhD, while women are more likely to have a diminished view of themselves, because of their primary role as caregiver. Dr. Black is a senior fellow at The Meadows, a trauma and addiction treatment facility in Wickenburg, Arizona.

Women entering treatment have different needs than men. According to Mary Jeanne Kreek, MD, of The Rockefeller University, “a strong positive correlation exists between troubled relationships, family violence, sexual abuse and poor self-esteem as integral factors in substance abuse among women.” These factors don’t apply to men, and lack of gender-specific services in treatment programs is a definite barrier for women.

Women with SUDs benefit most from supportive therapies and a relationship of mutual respect, empathy, and compassion, according to TIP 51, but “the type of confrontation used in traditional programs tends to be ineffective for women, unless a trusting, therapeutic relationship has been developed.”

The Meadows in Arizona uses a multidisciplinary approach “to address women who present with more complex trauma and addiction issues, and more dual diagnoses,” according to Nancy Bailey, PhD, clinical director, who has commented that many programs still focus on one primary issue.

Overcoming Barriers

Programs can do little to overcome barriers generated by the patient and by society, but the opportunities are many once women reach treatment. TIP 51 and the Taylor reference below offer many excellent suggestions.

In particular, women need substance abuse treatment that is multimodal and addresses social services such as vocational rehabilitation.  Comprehensive services can mean the difference between treatment failure and success.

Factors encouraging treatment retention include supportive therapy, a collaborative therapeutic alliance, and onsite child care and children’s services. For women who have lost child custody, comprehensive services can be a powerful motivational tool to stay in therapy. Pregnant women especially need comprehensive services. It’s estimated that as few as four percent of women are pregnant when entering treatment, and the services they sorely need are difficult to come by.

Successful treatment often means walking a fine line. Some women believe they are expected to maintain relationships, even abusive ones, and dependency or economic factors may motivate them to do so. If a woman’s drug use has involved a relationship with a spouse or significant other, OUD treatment may threaten that relationship—and the woman’s physical well-being.

Caregivers need to keep this in mind, and avoid focusing on maintaining relationships while excluding women’s other important needs. Dr. Black has stressed the importance of a woman’s building support and relationships with female peers. The insight of other women in treatment can help her work through a troublesome relationship, and, if necessary, break it off.

According to Dr. Gordon of the Caron Foundation, programs that increase the chances women will complete treatment comprise mixed-gender programs, services for women, and integrated treatment for co-occurring psychological and physical conditions.

Dr. Gordon believes that “internal and social barriers present more daunting obstacles” than treatment program barriers, and she calls for a change in public attitudes, “if women are to reduce their own feelings of shame and sense of denial.”

She maintains that these are not impossible goals. “Public education campaigns have eliminated the stigma from cancer, and have increased dramatically the numbers of people who are screened, diagnosed and successfully treated for this disease. We can achieve the same results for addiction in women.”

*     *     *

Sources

Back SE, Payne RL, Wahlquist MS, et al. Comparative profiles of men and women with opioid dependence: Results from a national multisite effectiveness trial. Am J Drug Alcohol Abuse. 2011;37(5):313-323. doi: 10.3109/00952990.2011.596982.

Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series 51. HHS Publication No. (SMA) 09-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009. http://kap.samhsa.gov/products/manuals/tips/pdf/TIP51.pdf

Goldstein JM, Jerram M, Abbs B, Whitfield-Gabrieli S, Makris N. Sex differences in stress response circuitry activation dependent on female hormonal cycle. J Neurosci. 2010;30(2)431-438.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827936/

Gordon SM. Barriers to treatment for women. Counselor. 2007; 8(3):22-29.

Hecksher D, Hesse M. Women and substance use disorders. Women’s Issues. 2009;7(1):50-62. doi: 10.4103/0973-1229.42585. PMID:21836779.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3151455/

Jamison RN, Butler SF, Budman SH, Edwards RR, Wasan AD. Gender differences in risk factors for aberrant prescription opioid use. J Pain. 2010;11(4):312-320. doi:10.1016/j.pain.2009.07.016.

Kreek MJ, Borg L, Ducat E, Ray B. Pharmacotherapy in the treatment of addiction: Methadone. J Addict Dis. 2010;29(2):200-216. doi:10.1080/10550881003684798. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2885886/

National Abandoned Infants Assistance Resource Center, UC Berkeley. Prenatal Substance Exposure. Fact Sheet. http://aia.berkeley.edu/media/pdf/AIAFactSheet_PrenatalSubExposure_2012.pdf

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2000-2010. National Admissions to Substance Abuse Treatment Services. DASIS Series S-61, HHS Publication No. (SMA) 12-4701. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. http://www.samhsa.gov/data/2k12/TEDS2010N/TEDS2010NWeb.pdf

Filed Under: 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: , , , ,

FDA Approves Amneal’s Generic Suboxone to Treat Opioid Drug Dependence

February 28, 2013 by Leave a Comment

Amneal Pharmaceuticals, LLC, the 7th largest generic drug manufacturer in the U.S. market, has received U.S. FDA approval for one of the first generic versions of Suboxone® sublingual tablets for maintenance treatment of opioid drug dependence. Generic buprenorphine hydrochloride (HCl) and naloxone HCl dihydrate sublingual tablets are now available in 2 mg/0.5 mg and 8 mg/2 mg strengths, both in 30-count bottles. 

http://www.news-medical.net/news/20130225/FDA-approves-Amneale28099s-generic-Suboxone-to-treat-opioid-drug-dependence.aspx

Source: NewsMedical.net – February 25, 2013

Note: On February 26, 2013 the FDA also approved Actavis’ generic Suboxone for treatment of opioid dependence. 

http://www.news-medical.net/news/20130226/FDA-approves-Actavise28099-generic-Suboxone-ANDA-to-treat-opioid-dependence.aspx

Source: NewsMedical.net – February 26, 2013

Filed Under: 2013-03-01, Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), News Updates, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs) Tagged With: , , , ,

Blog – News Outlets Behaving Badly: Appalling Article by Bloomberg

February 28, 2013 by 1 Comment

“I don’t know if any of my readers caught that awful article on bloomberg.com, criticizing methadone clinics and their patients. I’m not going to post a link to it because it doesn’t deserve a link. But I did write to the editor, the writer of the story, and a comment to their post:

I read this disjointed and error-ridden article with sadness. I wish you could spend a day with me, talking to the patients I treat with methadone for their opioid addiction. You’d hear how, for many patients, methadone has been a life-saver. Most of my patients are ordinary people who became addicted before they knew what was happening. A very small number are criminals, and those few get media attention, propagating the myth that all methadone patients are irresponsible criminals. This just isn’t true. My patients are housewives, blue collar workers, secretaries, and schoolteachers. Anyone can become addicted.”

The blog can be accessed at: http://janaburson.wordpress.com/2013/02/09/news-outlets-behaving-badly-appalling-article-by-bloomberg/

Source: Janaburson’s Blog – February 9, 2013

Filed Under: 2013-03-01, Medication-Assisted Treatment (MAT), Methadone, News Updates, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs) Tagged With: , , , ,

Addiction Expert: Treatment Providers Can Perpetuate Media Stereotypes of Patients

February 28, 2013 by Leave a Comment

“Stereotypes about addiction, perpetuated by the media, can be unintentionally reinforced by addiction professionals, according to a New York addiction expert.

“When you go to a diabetes clinic, you don’t expect your doctor to have diabetes. But many people treating those who are addicted have themselves been treated for addiction, and tend to use the same lingo as their patients to make them feel more comfortable,” Dr. Edwin A. Salsitz, MD, Medical Director, Office-Based Opioid Therapy at Beth Israel Medical Center, said at a recent meeting, “Solutions to the Addiction Crisis.” “They use terms like ‘dirty’ or ‘clean’ to refer to a urine drug test, instead of the more medical ‘positive’ or ‘negative.’ Using slang in addiction medicine can be confusing and demeaning, and reinforce the stigma attached to addiction.”

http://www.drugfree.org/join-together/addiction/addiction-expert-treatment-providers-can-perpetuate-media-stereotypes-of-patients

Source: JoinTogether.org – February 5, 2013

Filed Under: 2013-03-01, Addiction, Medication-Assisted Treatment (MAT), Methadone, News Updates, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Patient Advocacy Tagged With: , , ,

Ira J. Marion, MAT Legend and Patient Advocate, Passes Away at 68

February 23, 2013 by Leave a Comment

Ira J. Marion, MA, a leader in medication-assisted treatment (MAT) for more than 40 years, died of pancreatic cancer on January 7 at age 68. During his career at the Albert Einstein College of Medicine, Yeshiva University, he turned a pioneering methadone program—one of the first in New York City—into an integrated treatment program offering complete medical and wellness care. Under his guidance, MAT at Einstein expanded from a patient population of 350 in 1970 to what it is today—nine programs treating more than 3,000 patients.

Joyce Lowinson, MD promoted Ira to administrator shortly after he joined the program as a counselor. It turned out that he was an excellent partner to help achieve the goals for the patients, she told AT Forum. He played an important role in introducing the supervised admnistratrion of medication to patients suffering from tuberculosis; the next step was introducing primary care into the clinics.

Empathy for His Patients

When Suzanne Hall-Westcott, Mr. Marion’s companion, first met him, she was working at Phoenix House, a treatment center for substance and alcohol abuse. She recalled that Ira sent her an email after her husband was diagnosed with cancer – the same disease which his wife had died of recently. “He said, ‘This is a terrible time for both of you, in different ways.’” This was the kind of empathy that he had for patients, she said.

Mr. Marion became involved in MAT as a patient. He would often say he was a “product of the system,” as if he was just a patient who got lucky, said Walter Ginter, CMA, project director of the Medication Assisted Recovery Support (MARS) Project of the National Alliance for Medication Assisted (NAMA) Recovery. “Luck had nothing to do with it,” said Mr. Ginter, also a methadone patient. “He started out at the bottom and worked his way up.”

Mr. Marion was known among his colleagues for his wry sense of humor and his colorful way of sharing the stories he loved to tell. But he was better known for his empathy—not only for patients, but for everyone he came into contact with.

As a patient himself, Mr. Marion was able to identify with other patients, but that wasn’t the whole explanation for his skill, said Dr. Lowinson. “He generally showed great empathy for all the people in his life who had difficulties. He always came to the rescue.”

“Ira possessed unique talents among administrators in our treatment community,” said Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD). “He always cared about how patients were being treated, and from the earliest stage was an incredible advocate for giving patients a greater voice in their treatment decisions.”

“Boy, does this guy like to talk!”

Mr. Ginter first met Mr. Marion in 1999, when he was on the methadone advisory group at the New York Office of Alcoholism and Substance Abuse Services (OASAS). “My initial thought was, ‘Boy does this guy like to talk!’” Mr. Ginter recalled. “But as our relationship grew, Ira was the one person I knew in the field who walked the walk,” he said. “We all talk about patient-centered care, but it wasn’t just words with Ira.”

In fact, Mr. Marion never refused to talk to anyone—he always had his iPhone and his iPad with him, and whether it was a patient, a provider, or a reporter on the other end of the line, he would pick up, said Mr. Ginter. “Even at the end, when he was sick, he was happiest when he was sitting in bed with his iPhone in one hand and his iPad in the other.”

Few people knew that Mr. Marion was on the NAMA-Recovery board, said Mr. Ginter. “It was a big thing for us to have him on the board—it gave us credibility, and it helped steer and guide us.” For someone whose time was so valuable, Mr. Ginter said, his NAMA-Recovery participation was very generous. “He was a gift to the field. For me that was a blessing.”

Joycelyn Woods, MA, CMA, executive director of NAMA, commended Mr. Marion as an “untiring champion of both patients’ rights and patient-centered care.” He was “courageous in expressing that he was a ‘product of the system,’” said Ms. Woods.

Influence at AATOD

Mr. Parrino first met Mr. Marion briefly in 1975 at a meeting of administrators in the New York State methadone treatment system. “I didn’t know then how our lives would be intertwined,” Mr. Parrino told AT Forum. After they both joined the Board of Directors at COMPA (Committee of Methadone Program Administrators) in 1980, the two worked on a number of projects throughout the 1980s, culminating in a trip to Hong Kong and China on behalf or New York State. “It was a wonderful trip, and I got to know Ira much better, which led to a greater and deeper friendship,” recalled Mr. Parrino.

The China and Hong Kong trip also led to more international travel for Europad and other conferences in Italy, France, Bulgaria, Bratislava, and Russia, to name a few. “Throughout these trips, I was always impressed by Ira’s clear and politically intuitive judgment, and his sense of vision,” said Mr. Parrino.

Mr. Marion had “an enormous influence in the policymaking discussions” of the AATOD Board of Directors, said Mr. Parrino.

Saying Goodbye

One of the hardest things for everyone in the field is Mr. Marion’s absence. “I have come to learn that the mark of an extraordinary human being is not just the legacy of work left behind, but the enormous empty space left in the wake of such a life,” said Mr. Parrino. “Ira can be counted among those individuals—the ones whose whose efforts helped countless patients who will never quite know how much he contributed to their well being.”

Mr. Ginter recalled the day he said goodbye—one week before Mr. Marion’s death in Beth Israel’s hospice. “It was New Year’s morning, and Ira was still on the ball, joking with me,” he said.

The funeral was very private, as Ira had wanted. Instead, Mr. Marion “got what he wanted” for a send-off, said Mr. Ginter. “People honored his request. Everybody went by his house and told ‘Ira stories.’ He wanted people to remember him the way they last saw him, before his battle with cancer,” said Mr. Ginter.

With his late wife, Barbara Housner Marion, to whom he was happily married for 35 years, Mr. Marion had two children. For an online tribute created by his son, go to www.irajmarion.com.

Ms. Hall-Westcott, in an obituary she placed in the New York Times on January 29, called her time with Mr. Marion “our after ever after” life. “We both had lived ‘happily ever after,’ raised our families, and lost our spouses much too soon, to cancer. What happened ‘after ever after’ was to find joy again and dream of growing old together. He will live on in my heart forever.”

Filed Under: 2013-02-21, Medication-Assisted Treatment (MAT), Methadone, News Updates Tagged With: , , ,

MMT Patients Need Physical Activity; Brief Interventions Could Help

February 12, 2013 by 1 Comment

Physical activity is so important for patients in methadone maintenance treatment (MMT). They’re already at increased risk of physical and mental health disorders, including chronic pain and sleep problems. Lack of enough physical activity carries additional risks: cardiovascular disease, various psychiatric disorders, high blood pressure, diabetes, osteoporosis, obesity, and colon cancer.

Given the importance of physical activity to their patients, how can MMT programs help?

A study in the Journal of Substance Abuse Treatment (in press) offers some suggestions. The study assessed the levels of physical activity in 305 MMT patients, cited patients’ perceptions of the benefits of and barriers to exercise, and provided recommendations.

Study Group Characteristics

Participants were recruited between December 2008 and May 2011 at nine MMT sites in New England. All were taking part in a smoking cessation intervention trial, and had been enrolled in MMT for at least four weeks.

Additional characteristics of the group:

  • Average age: 40 years
  • 50% men
  • 243 (80%) non-Hispanic white
  • 113 obese; 103 overweight; 18 refused to be weighed
  • Cigarette use: at least 10 per day (inclusion criterion); average, 19.7
  • Average methadone dose: 109 mg/day

Almost 45 percent considered themselves in fair or poor physical health.

Physical Activity Guidelines

The American Heart Association recommends a healthy adult have at least 30 minutes of moderate-intensity aerobic physical activity five days a week, or at least 20 minutes of vigorous activity three days a week.

Study Results

Only 38 percent of participants met or exceeded recommended guidelines, and almost 25 percent reported no physical activity. In contrast, about 49 percent of adults in the U.S. meet guidelines, and almost 14 percent are inactive (less than 10 minutes of activity of moderate intensity per week).

In general, study participants highly endorsed (rated favorably) the benefits of exercise. More than 75 percent credited exercise with giving a sense of accomplishment, improving health, increasing energy level, feeling stronger, improving cardiovascular fitness, becoming physically fit, increasing confidence to stay clean and sober, and maintaining or losing weight in order to look better. Interestingly, those who met activity guidelines were significantly more likely than the others to report relapse prevention and reduced anxiety as benefits.

Motivation: The Key for MMT Patients

The most frequently perceived barrier to exercise was lack of motivation (103 participants). This is consistent with findings from previous studies in substance users. The authors cite an earier study showing that, “encouragingly, motivation to exercise was the best predictor of physical activity.” Among other barriers cited were not having enough energy, having an injury or disability, and health problems.

Noting that brief interventions or counseling sessions have helped increase physical activity in a variety of populations, the authors suggest this approach for MMT patients. Measures could include “brief, counselor administered physical activity or exercise intervention” based on adaptations of the widely used five A’s for smoking cessation intervention—ask, advise, assess, assist, arrange—to provide “a standardized framework for a clinic based brief intervention.” They add that the potential benefits in mental health and relapse prevention, highly endorsed by participants, should be covered during the “advise” part of the exercise.

“Another potentially cost-effective intervention,” according to the authors, “could involve peer led exercise promotion groups run through methadone clinic programs.” Moreover, it would be useful to have a brief discussion of exercise and physical activity during monthly counseling sessions or doctors’ visits, the authors said. “Developing efficacious and low-cost physical activity adjuncts to this population at high risk for lifestyle-induced medical conditions may have important benefits for health and drug treatment outcomes.”

*     *     *

Caviness CM, Bird JL, Anderson BJ, et al. Minimum recommended physical activity, and perceived barriers and benefits of exercise in methadone maintained persons. J Subst Abuse Treat. 2012. http://dx.doi.org/10.1016/j.jsat.2012.10.002.

Link to the five As of smoking cessation: http://www.ahrq.gov/clinic/tobacco/tobaqrg.pdf

_________

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

Blog: Benzos at the Opioid Treatment Program

November 29, 2012 by 1 Comment

“Should patients in opioid treatment programs ever be approved to take benzodiazepines? Even addiction medicine doctors hold widely varying opinions on this issue. In my state (North Carolina), all of the doctors who work in opioid treatment programs are invited to participate in a conference call once per month. The people who head the state’s methadone authority and the Governor’s Institute on Substance Abuse are also usually on the call. We discuss difficult issues we’re facing, and discuss difficult cases. Last month, the question was asked pointedly by one of the doctors: “Is zero-tolerance for benzodiazepines now the standard of care for opioid treatment programs in our state?” For the people on this call, the consensus was that the ideal was zero tolerance or at least a restricted policy regarding benzodiazepine use.”

The blog is available at: http://janaburson.wordpress.com/2012/11/03/benzos-at-the-opioid-treatment-program/

Source: Janaburson’s Blog – November 3, 2012

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

Medical Consensus or Child Abuse? Moms on Methadone Caught in the Middle

September 28, 2012 by Leave a Comment



 “Cases like Rebecca’s have become increasingly common in recent years, according to maternal-health and drug-treatment advocates, who say they are seeing more parents charged with child abuse for undergoing methadone maintenance, despite scientific evidence showing that it is the best way to wean addicts off opiates. The treatment may even save a fetus’s life, since going cold turkey can bring on premature birth or in some cases a miscarriage.”

“But because methadone is an opiate, like the drugs it is prescribed to treat, there is confusion among some doctors, child welfare workers and judges that using it is just substituting one drug for another, said Jocelyn Woods of the National Alliance for Medication Assisted Recovery.”

Mothers get caught in the middle. “Judges and caseworkers are practicing medicine without a license, even against medical advice,” said Emma Ketteringham of National Advocates for Pregnant Women, who worked on Rebecca’s case.

http://www.thedailybeast.com/articles/2012/09/02/medical-consensus-or-child-abuse-moms-on-methadone-caught-in-the-middle.html

Source: The DailyBeast.com – September 2, 2012

Filed Under: 2012-09-28, Addiction, Medication-Assisted Treatment (MAT), Methadone, News Updates, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs) Tagged With: , , , ,

September 2012 Issue of Heroin Addiction and Related Clinical Problems is Now Available Online

September 28, 2012 by Leave a Comment

Heroin Addiction and Related Clinical Problems, the official journal of EUROPAD (European Opiate Addiction Treatment Association), is a peer-reviewed publication for professionals wanting to stay informed of research and opinion on opioid misuse treatment in Europe and around the world. A particular emphasis is on medication-assisted treatments for opioid addiction. Articles in this issue include:

  •  Assessing the current state of opioid-dependence treatment across Europe: methodology of the European Quality Audit of Opioid Treatment (EQUATOR) project
  • Is substance use disorder with comorbid adult attention deficit hyperactivity disorder and bipolar disorder a distinct clinical phenotype?
  • Economic evaluation of opioid substitution treatment in Greece
  •  The journey into injecting heroin use
  • Cognitive behavioural coping skills therapy in cocaine using methadone maintained patients: a pilot randomised controlled trial

The September issue can be accessed at: Heroin Addiction and Related Clinical Problems September 2012 (2.12 MB, 116pp)

Filed Under: 2012-09-28, Addiction, Heroin, Medication-Assisted Treatment (MAT), Methadone, News Updates, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs) Tagged With: , , , , ,
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