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

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

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

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

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

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

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

Q & A – Methadone or Buprenorphine for Maintenance Therapy of Opioid Addiction: What’s the Right Duration?

question boxQuestion: How long should patients with opioid addiction be treated with methadone or buprenorphine?

Response from Michael G. O’Neil, PharmD Professor, Department of Pharmacy Practice; Consultant, Drug Diversion and Substance Abuse, South College School of Pharmacy, Knoxville, Tennessee

“Data supporting positive long-term outcomes after definitive discontinuation of methadone or buprenorphine in a predetermined time frame for all patients are lacking. Prudent clinical practice dictates that duration of therapy should be individualized by well-trained addiction specialists, taking into account a disease treatment history that includes such factors as relapse, individual patient characteristics, evidence-based literature, patient adherence, socioeconomic characteristics, and environmental considerations until long-term evidence-based studies prove otherwise.

In summary, the complexities of the disease of opioid addiction have created a frustrating situation for practitioners and patients alike. Basic practice principles for chronic diseases, such as hypertension or schizophrenia, should be applied to patients who are unable to stay in recovery using abstinence programs alone. Strict discontinuance of opioid maintenance therapy solely on the basis of duration of treatment is not clinically justifiable at this time. Individualization of treatment for opioid addiction with methadone or buprenorphine by qualified specialists is necessary for many suffering patients, in conjunction with counseling, community support, or behavioral interventions. Treatment cultures for opioid addiction need to continue to evolve, as does education of the general public.”

The article can be accessed at: http://www.medscape.com/viewarticle/819875

Source: www.Medscape.com - February 3, 2014

Walter Ginter on the Importance of Peers in Recovery With Medication-Assisted Treatment

walterStigma is a common theme among people seeking recovery from the disease of opioid addiction, but it’s particularly poignant for people in medication-assisted treatment (MAT), because stigma can itself prevent recovery from taking place. People who don’t understand MAT—and that’s a big group, including many employers, politicians, and even friends and family members—don’t believe methadone or buprenorphine treatment means being in recovery. But it does. And that’s the message that Walter Ginter, CMA, project director of Medication- Assisted Recovery Services (MARS), and the country’s foremost patient advocate, brings to patients. On December 9, he brought this message to the first White House drug policy conference.

Sponsored by the Office of National Drug Control Policy (ONDCP), the conference included a panel that focused on stigma and drug addiction. Michael Botticelli, deputy director of the ONDCP, and himself in recovery, invited Mr. Ginter to participate. “He called me himself to ask me to be on that panel, and afterwards I got a nice handwritten note from him thanking me for participating,” said Mr. Ginter.  Mr. Botticelli, formerly the official in charge of substance use disorder services for Massachusetts, is a strong supporter of MAT. “This direction and focus that we are seeing from the Obama Administration is encouraging,” continued Mr. Ginter “It would strengthen that effort to see Mr. Botticelli promoted and the recovery community is hopeful that he will fill the opening as director of the ONDCP.”

 Stigma Impedes Recovery

The main stigma patients face in terms of methadone comes from believing what people who know nothing about MAT tell them. They learn to believe the myth that methadone is a substitute drug, and that they aren’t really in recovery. What peer recovery support services can do for patients is to help them eliminate feelings of stigma by helping them understand that they are in treatment with a medication, just like someone with any other disease. “If people come into treatment with the idea that methadone is just substituting one addiction for another,” said Mr. Ginter, “that attitude makes them feel as if recovery isn’t an option, for them. This discouraging prospect sets the stage for a less than optimal outcome. They ask themselves what difference does it make if they use a little benzodiazepines or smoke a little pot, if recovery isn’t an option anyway? That is how stigma stops patients from achieving recovery.”

 Peers Believe Peers

Peers—other people who are in MAT—can help support patients’ recovery in a way that nobody else—not a physician and not other people who are not taking methadone—can. “In the recovery community, you always hear people say they ‘support all pathways to recovery,’” said Mr. Ginter, “but often this is just lip service and not really an endorsement, with too many anti-MAT people weighing in and adding to the stigma. A lot of people support it and understand it’s evidence based practice, but still they don’t accept it as a legitimate pathway.”

At the MARS project, patients learn from peers that methadone and buprenorphine are “not substitute drugs, they’re medications,” said Mr. Ginter. “And suddenly, that person is a candidate for recovery. Before that, they never had a choice.”

When people are given the option of being in recovery, they choose it. Once they realize that taking methadone or buprenorphine is not the same as using, they stop using other drugs and alcohol. Yes, they were in treatment, but neither the opioid treatment program nor the physician could convince them that they were in recovery—it took another person in MAT to do that. “Peers believe things from other peers that they would not believe from anyone else,” said Mr. Ginter.

 Feeling Good

One of the magical things about erasing stigma is this: Once people start to feel good about themselves, the community starts to look at them differently. That’s why one exercise patients can use is to write down three nice things that happen each day.“ At the end of a few weeks, people start to feel better,” said Mr. Ginter. “For us to do well in recovery, we have to feel good about ourselves.”

Calling addiction a brain disease—which it is—takes away a lot of guilt, said Mr. Ginter. That internal feeling of guilt is magnified by stigma coming from the outside world.

In some ways, stigma from the outside world isn’t getting any better. “There are these nice dissertations out there about your rights, but if you’re in jail because you got picked up outside your methadone clinic, you can’t tell the cop he’s wrong,” said Mr. Ginter. It would help if drug courts and parole officers saw more patients for whom treatment is working, and not just those for whom it isn’t, he added.

Finally, fear of stigma keeps people from even saying that they are on buprenorphine or methadone. Thousands of people are doing well in treatment—not just the few, like Mr. Ginter, who publicly identify themselves.

As an anecdote illustrating this, Mr. Ginter related that visitors from overseas at the MARS booth at the AATOD conference last fall were amazed that two of the people working at their display booth were patients. “They couldn’t believe that peer recovery support services were provided by ‘real’ methadone patients,” he said.

 Other Participants

The ONDCP half-day meeting also featured panels on public health approaches to drug policy, being “smart on crime” instead of “tough on crime,” with an emphasis on drug courts using MAT, and a screening of The Anonymous People. Mr. Ginter related that the drug court speaker, magistrate Alby Zweig from Denver, was shocked to hear that many of his colleagues require participants to stop using methadone or buprenorphine before they can be admitted.

Note: MARS is a project of the National Alliance of Medication-Assisted (NAMA) Recovery. NAMA chapters are small groups of individuals who organize around advocacy to teach patients about their rights and to support them in their rights. Patient advocates are not the same as peer recovery support.

For more information, go to www.marsproject.org.

Interview: Zac Talbott on Being a Patient and Certified Advocate for Medication-Assisted Treatment

Zac 2-9-14Patients and other individuals who are advocates are a growing force in medication-assisted treatment (MAT) for opioid dependence, providing information and support to patients as well as assistance to opioid treatment programs (OTPs). Advocates also are an essential link between patients and OTPs. They are not as well known as they should be, there aren’t enough of them, and they are in dire need of funding.

In January, Zac Talbott, a patient who is the director of the Tennessee Statewide and Northwestern Georgia chapter of the National Alliance for Medication Assisted Recovery (NAMA Recovery), shared his experiences with addiction, treatment, recovery, and patient advocacy with AT Forum.

 Getting Started in Advocacy: The CMA

Patients and others who want to be advocates need to first have a good knowledge of advocacy and the various issues surrounding MAT. Taking the CMA (Certified Medication Assisted Treatment Advocate) course and obtaining certification gives both patients and health care professionals the basic grounding for advocacy. Certification is essential to being a credible advocate. “There are patients out there who often are well-meaning, who claim to be advocates, but who can do harm,” he said. “A lot of folks without training do not realize that advocates have a code of ethics, and one of the main ethical guidelines is confidentiality. It goes to the heart of our professional credibility. There has never once been a case of a patient’s confidentiality being violated by a CMA working with NAMA-R.”

The second crucial skill that CMAs have is knowing how to communicate with OTPs on behalf of a patient. “You can make things worse for the patient you’re trying to help if you come off like an attack dog. Patients and OTPs agree on more than 90 percent of the issues, and that should always remain the primary focus. It’s also important to remember that the job of a patient advocate is to advocate for what the patient wants. We can’t take off and start a crusade without that patient wanting us to,” he said.

NAMA-R developed the CMA training course with no funding, which was a tremendous challenge. However, the course has been strongly supported by the American Association for the Treatment of Opioid Dependence (AATOD), and the federal Center for Substance Abuse Treatment (CSAT).

 Volunteering and Funding

Some NAMA-R chapters could do significantly more if their expenses were paid. Members are committed people who largely volunteer their time and give of themselves without any compensation.

NAMA Recovery chapters do need funding. NAMA-R is a 501c3 non-profit organization, so donations are tax-deductible. All other industrialized countries fund organizations like NAMA-R, said Mr. Talbott. “The United States is the exception. This leaves NAMA-R dependent on donations from patients, for-profit OTPs, and the pharmaceutical industry.”

In Tennessee—and in many other states—Medicaid won’t currently pay for MAT with methadone. “It’s all cash down here,” he said. The fee for patients is $300 to $400 a month—frequently all the money a patient has.

Mr. Talbott hopes NAMA Recovery can partner with OTPs for funding and support. “We had a wonderful meeting with Chief Operating Officer Jerry Rhodes and the regional managers of CRC Health Group during the AATOD Conference in Philadelphia this past November,” he said. “They recognize that advocacy is extremely important.”

 Insurance and the ACA

Whether the Affordable Care Act (ACA) will help fund MAT is still unclear, said Mr. Talbott. “It’s supposed to, but insurance companies are good at finding loopholes.” Implementation and enforcement are still problematic.

In Tennessee, for example, the state is making it impossible for new OTPs to open, which means that facilities are opening up across the state border. “Programs in other states are treating the patients that Tennessee isn’t,” said Mr. Talbott. If Tennessee Medicaid were to say that patients had to be treated in a Tennessee facility, that might make it more attractive for programs to open in Tennessee.

Even though his organization is in Tennessee, most of Mr. Talbott’s calls come from outside the state—just because there are so many patients, especially in nearby southern states, who need help. NAMA-R has always had difficulty recruiting individuals willing to make a commitment to advocacy and start a chapter. Stigma, prejudice, and just plain fear have been barriers in southeastern states.

 From Pain Medication to Heroin

Mr. Talbott’s addiction started—as with many people—with a prescription for hydrocodone for a chronic painful condition. Most people feel sick when they take opioids, but Mr. Talbott is part of the 10 percent of the population that is susceptible to addiction. “I loved them,” he said of opioids. His addiction sent him to buying pills from a pill mill and eventually to the street, where he also bought heroin. “This was in the late 90s,” he recalled. “Within eight years I went from a couple of prescribed hydrocodone a day to 25 prescribed 30-milligram doses of oxycodone.” He became an intravenous drug user within four years of initially starting the pills.

“The opposite of the stereotypical drug user,” Mr. Talbott had two college degrees when he first became addicted to opioids, and came from a well-known and well-respected family—“church folks,” he explained.

 Recovery

Then, there was treatment. “I went for all the wrong reasons—I didn’t go because I was seeking recovery,” Mr. Talbott said of his treatment in an OTP. “People who are drug users think that there’s no withdrawal, and that you might even get a little buzz.” But six months after entering the OTP and starting methadone, he found that he was in recovery—by accident. “I had no craving. I stopped using the needle. I was thinking about my life again—by accident. The person I was prior to the addiction quickly started to re-emerge. That’s the beauty of methadone.”

After that, it took Mr. Talbott a year to focus on recovery and life. “There’s so much you need to do, straightening out your credit, fixing everything you did when that disease is active.” When his addiction was at its height, he was in the middle of his masters’ in clinical social work. Ultimately, the addiction took over and he left the program. But even before his addiction, he had always wanted to be in a helping profession—a mental health counselor, an Episcopal priest, or a lawyer. “I wanted to help people,” he said. “Once I was in recovery, that part of me came back quickly.”

He found NAMA Recovery because his counselor recommended it as an alternative to driving to the clinic for four group meetings during his induction period in treatment. “I had to drive more than two hours one way to the OTP because I was so rural. So my counselor said to go to the website—methadone.org—print out, read, and bring in one of the Education Series to discuss ‘and that will count as one of your groups.’” Ultimately, he wrote to the NAMA-R chapter coordinator and said a NAMA Recovery chapter was needed in Tennessee.

NAMA Recovery’s main goal is advocacy, and that is where Mr.Talbott saw his life heading. “It’s a natural fit,” he said. “To be a MAT advocate is to advocate for the patient in treatment, but we’re not patient advocates only or specifically. ‘The patient comes first,’ as Rokki [Roxanne Baker, NAMA-R president] often says.”

 Partnership With OTPs

Patient advocates can have a lot of power, not only on behalf of patients, but on behalf of providers. When onerous restrictions are imposed by states, especially states that don’t have an AATOD chapter, providers call NAMA Recovery. “We are more than just patient advocates, we are MAT advocates,” said Mr. Talbott. “We advocate for the entire modality.”

About a third of the calls he gets—Tennessee joined AATOD just last fall—are from OTPs, said Mr. Talbott. “Sometimes patients and providers don’t have the best relationship. Some OTPs view advocates as whistleblowers and troublemakers, and sometimes the OTPs get defensive as soon as advocates call them. Several of us are trying to stress to OTPs and patients that we’re all on the same team.”

Technically, the provider advocacy organization is AATOD. But when there is an issue that draws both patient and provider complaints, Mr. Talbott reaches out to consult with AATOD president Mark Parrino or the state chapter of AATOD. “We can strategize together,” he said. Sometimes the approach involves filing a complaint with the Department of Justice or SAMHSA’s CSAT, which regulates OTPs. Often, OTPs haven’t even heard of NAMA Recovery, and sometimes haven’t heard of AATOD either, he said.

“The way to go is moving away from patient advocacy specifically and toward MAT advocacy as a modality,” said Mr. Talbott. And patients who are certified advocates can be of immense help to OTPs, whether they are testifying before the legislature or making a complaint to the Department of Justice. Patients and providers aren’t always going to agree, but ultimately they’re fighting the same battles and striving for the same goals.

Recovery Transformation in Philadelphia OTPs: Person-centered, not Patient-centered

RecoveryOver a decade ago, Philadelphia’s public health system moved toward recovery for mental health and addiction services. On the mental health side, there had been a belief that recovery wasn’t possible, especially for people with serious mental illness. On the addiction side, recovery was already in wide parlance, but the system was set up to treat the disorder as if it was acute, with no long-term or continuous follow-up care, resulting in relapses. Now, Philadelphia has taken great steps to bring along its providers in adopting a recovery-based framework. We caught up with Roland Lamb, director of addiction services for the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIdS) to get an update on the recovery transformation as it affects patients in medication-assisted treatment (MAT).

“The good news is that we have moved towards more of a person-centered perspective in MAT,” Mr. Lamb said. In other words, providers are learning to look at people as people, not patients.

“We have the richest environment for MAT, with all levels of care,” he told AT Forum. He added that not only is there outpatient methadone, but there is medication-assisted treatment in all levels of care, and there are efforts to reach out to the 144 physicians in the system who are certified to dispense buprenorphine, and to provide access to those they are seeing to all of the treatment resources in Philadelphia.

The Medication ‘Culture’

But, because of the oversight and stigma, it has been a struggle to get providers to focus on the fact that people are people first, and not patients to be “dosed and monitored,” Mr. Lamb said. “The bad news is that we still have to work to overcome the stigma-driven culture of managing the medication, instead of treating addiction and focusing on recovery.”

This medication “culture” isn’t completely the fault of the opioid treatment programs (OTPs), Mr. Lamb noted. “It’s the most regulated form of treatment—in health care—that there is,” he conceded. The preoccupation with regulations, one drug after another, and the diagnosis, is at the cost of focusing on treating the addiction and supporting recovery and other needs. “People lose sight of managing the addiction.” Yes, methadone maintenance is part of recovery, but the medication isn’t the only part of it. “This treatment was created to help people get into recovery, but recovery is more than the medication alone.”

Buprenorphine—the medication—is not on the DBHIDS formulary, said Mr. Lamb. “But we do pay for all the services that surround it—the physical exams, counseling, and the drug screens.”

But whether those in care are taking methadone or buprenorphine, the focus has to be on the individual, said Mr. Lamb. “We are making sure that our providers have what they need—good assessment instruments, evidence-based practices, and psychiatric supports.”

There is a high prevalence of co-occurring mental illness in the MAT population, said Mr. Lamb. “We know a lot of what has happened with those co-occurring illnesses to those in care, who in many cases are self-medicating the very illnesses that they need help with.”

The DHBIdS meets with MAT providers every two months. These include inpatient and outpatient MAT providers, and the state licensing authority and the Drug Enforcement Administration are present as well.

No Involuntary Discharges

One of the key patient-centered initiatives in Philadelphia is this: “We say we don’t want involuntary discharging going on,” said Mr. Lamb, noting that “noncompliance” in addiction treatment is no worse than it is in treatment for high blood pressure or type II diabetes, and that terminating treatment is no solution. The reason for discharge may be violence, or threats of violence, for example, but many times this behavior is a result of untreated mental illness, said Mr. Lamb. Other reasons for discharge are drug dealing on the premises, or, of course, noncompliance with the treatment plan, but aren’t they some of the very reasons treatment is needed?

“We see ourselves as being in a partnership in terms of trying to overcome these issues,” said Mr. Lamb. The person in recovery, the providers, the regulators, and the payers all need to be at the recovery table to make this work.

Another point about person-centered care: OTPs should treat people based upon their need. For example, Pennsylvania requires two and a half hours a month of counseling—but patients should get more if they need it, said Mr. Lamb. “The issue for us is that we want to see counseling based upon the needs of the person.” That’s why the DBHIdS pays based on how much counseling is given. “We track the counseling separately.”

Training in CBT, Other Modalities

“The real challenge for us is to get staff to rethink what they’re doing,” said Mr. Lamb. “We’ve been doing it one staffer at a time.” Staffers are getting training in cognitive behavioral therapy (CBT), dialectal behavioral therapy (DBT), trauma, and the sanctuary model, he said. “All of these are evidence-based practices that we’ve been paying our providers to get trained in.”

There are 11 providers operating 13 OTPs in Philadelphia, treating a total of 5,000 patients a day. “When you think about it, that’s approximately 400 people coming in every day,” said Mr. Lamb. “It would be better if we could have smaller numbers of people in each facility, and more facilities.” He noted that community complaints about traffic would then go down. Of course, for that to happen, there would have to be community cooperation in siting clinics. “There is still so much stigma,” said Mr. Lamb, noting that this comes from the “outside” community and from the drug-addiction treatment community itself.

“Through a recovery focus we have a chance to change the usual ‘down with methadone’ discussion to a discussion about solutions for long-term opioid dependence and long-term recovery,” Mr. Lamb said. This is especially important now, with the burgeoning cohort of people becoming addicted via the non-medical use of prescription opioids, and their conversion to heroin. We need to do a better job of reaching out to, engaging, and retraining this population if we are going to impact the growing number of overdose deaths we are seeing, said Mr. Lamb. “We also need to evolve the recovery focus to one of wellness, and the need for those who are actively recovering to take better care of their health.”

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.

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

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

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

 Source: ITNewsOnline.com – December 12, 2013

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

evidence

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

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

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

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

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

Source: PsychiatryOnline.org – November 18, 2013

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

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

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

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

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

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

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

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

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

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

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

Patient Preference

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

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

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

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

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

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

Take-homes

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

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

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

Array of Services

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

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

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

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

Previous Failures

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

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

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

Specific Drug of Abuse

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

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

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

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

OTP vs. Office-based

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

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

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

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

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

Pregnancy

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

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

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

fundingCost

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

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

Switching Medications

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

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

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

Summing Up

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

NIMBY and Other Problems: Still an Uphill Battle For OTPs, But Hope Seen In Patient Advocacy

advocacyThe NIMBY (Not In My Back Yard) syndrome is one significant challenge for opioid treatment programs (OTPs), which can’t operate if they can’t get approval from municipalities. Methadone maintenance treatment has been proven effective and producing good outcomes for five decades, but that isn’t preventing politicians from pandering to prejudice and discrimination. Still, the field is forging ahead, opening new programs and providing access to treatment to needy patients.

Sally Friedman, legal director with the Legal Action Center, said that local authorities often try to zone out drug and alcohol programs in general, but it’s even more difficult to site a methadone program. “It’s challenging to site any type of facility that serves people who folks don’t want around,” she said. “I’ve seen this from examining case law—there’s NIMBY for everything, the elderly, group homes, communities want to keep out all types of social services.”

But a special place in NIMBY-land is reserved for OTPs. In 1977 the Legal Action Center won a landmark discrimination case in which a federal court prevented White Plains in New York from zoning out alcohol and drug abuse treatment programs—and while it wasn’t specific to OTPs, OTPs are included. “Stereotypes and myths” play a part in the NIMBY decisions, said Ms. Friedman.

The Americans with Disabilities Act (ADA) clearly supports OTPs and their patients, and municipalities and their lawyers can easily lose in federal court since the law is so clear. “But there’s a lot of political calculation,” said Ms. Friedman. Local politicians think they have more to gain politically from keeping the facility out, so they’re willing to risk the lawsuit and let the court tell them what they have to do.

MAT First

One point that the substance abuse treatment field in general needs to make more strongly is that medication is the first-line evidence-supported treatment for opioid addiction. “Myth and misunderstanding continue to plague not just methadone alone but medication-assisted treatment [MAT] in general,” said Michal Botticelli, deputy director of the White House Office of National Drug Control Policy [ONDCP]. For opioid dependence in particular, medication is the “first line in our arsenal,” he said. “We have to make sure people understand that this is the standard of care.”

Mr. Botticelli added that there is an opportunity to create a greater consumer voice in favor of MAT. “People have done exceedingly well on methadone maintenance.” Some people need more than medication—other social supports and the structure of an OTP—but others don’t.

As states continue to express concern about prescription drug abuse and overdoses, mainly surrounding opioids, the ONDCP is increasing its stress on the importance of access to methadone and buprenorphine, as well as social supports provided in an OTP. “If we really want to deal with overdose deaths, we need to make sure that we have adequate access to MAT.”

The same myths and stereotypes that bolster NIMBY apply to the criminal justice system, which routinely denies access to medication-assisted treatment. The biggest myth is the one that methadone and buprenorphine are “substituting one addiction for another,” which couldn’t be farther from the truth. Patients in MAT are not addicted—they are not pursuing drugs, they are in recovery, employed, productive members of society. But proponents of discrimination don’t understand how the medications work.

Lack of Negative Impact

It’s also easy to demonstrate the lack of a negative impact in NIMBY siting cases. Jerry Rhodes, chief operating officer of CRC Health Group, said it’s important to bring out studies that show crime goes down when clinics are deployed. “There is science that shows methadone treatment has good results,” he said. But here’s the problem: the issue is an emotional, not a logical, one.

The studies showing that methadone works have been ignored by many public policy makers. And while OTPs had been hoping to enlist government officials and regulators in support of MAT, that isn’t working either. “We’ve had the rug pulled out from under us,” said Mr. Rhodes. “We’re trying to get a more robust commitment.” 

Support From Patients

One thing OTPs could do better is to involve the support of patients, said Mr. Rhodes. “There are often compelling personal stories around the need for treatment, and the effectiveness of MAT.”

In general, the OTP field has done a poor job of rallying patients. But Mr. Rhodes understands that it’s hard to get patients to come forward. “You could lose your job, your neighbor could say something, there’s a fear of being seen as a patient in a clinic.”

The field is beginning to recognize that OTP patients, like other people in recovery, can be a significant voting bloc. For example, there are 5,000 to 6,000 OTP patients in West Virginia. In a small state like West Virginia, 5,000 votes—in some places, even 1,000 votes—can swing an election. When there is no access to MAT, patients—and prospective patients, who also vote—suffer. “This is a job for the National Alliance for Medication Assisted Recovery  (NAMA),” Mr. Rhodes said.

Collaboration

Another good advocacy tactic involves collaborating with other groups. Mr. Rhodes cited the effectiveness of the autism advocacy movement, which is spearheaded by parents who are fierce advocates for their children. Drug addicts, alcoholics, people with mental illness need the same kind of advocates, but have always been treated as marginal populations, which is what drives the stigma. “We can do a better job of working with other constituents,” he said.

Even as a field, various types of treatment are fragmented—medication, no medication, alcohol, drugs—and OTPs could benefit by these groups working together and bringing OTPs into the tent.

Back to NIMBY

The bottom line is, OTPs need facilities, and that means they need certificates of occupancy. Mr. Rhodes warns clinics against going into a community to develop a clinic and not garnering support first. “You can’t do this and not deal with NIMBY, but you can do a better job of trying to support these efforts.”

Here are some of the things you can expect to hear when you try to site a program. “This isn’t our problem.” That’s pretty easy to refute, because an OTP usually has done research and knows that there is an opioid problem. For example, at one meeting, someone stood up and said, “I don’t want this town becoming a methadone mecca.” A physician who was there then said, “You don’t understand, this town is already a heroin mecca.”

The OD Bandwagon

Despite the many newspaper articles about prescription opioid abuse and overdoses, there are rarely any discussions of the cure—treatment. “People don’t understand how prescription opioid abuse relates to methadone treatment,” said Mr. Rhodes. “We rarely address the cure, we just talk about the magnitude of the problem.”

“Education is key,” agreed Ms. Friedman. “We need to explain how the disease works, how the treatments work, and how we produce successful outcomes.”

Keeping OTP Patients in Treatment Longer: Methadone vs. Buprenorphine

hour glass1Data from the first large randomized U.S. trial comparing treatment retention of methadone and buprenorphine patients confirm what a Cochrane review—generally considered the Gold Standard—and other studies have found: treatment retention is much higher with methadone than with buprenorphine, although  the two are equally effective in suppressing illicit opioid use.

The current study is actually a secondary analysis, using data from a large, multisite, open-label study assessing liver function in individuals treated for opioid dependence. The original study enrolled participants from nine opioid treatment programs (OTPs) between 2006 and 2009, randomized to receive either methadone or buprenorphine (as buprenorphine/naloxone). Buprenorphine patients in that study were more than 50 percent less likely than methadone patients to remain in treatment for 24 weeks.

The data were gathered from 529 methadone and 738 buprenorphine patients. (Investigators changed the original 1:1 ratio to 2:1 because of a higher number of buprenorphine dropouts.) Measurements included patient characteristics at baseline, medication dose and urine drug screens at baseline and weekly, days in treatment, and treatment completion.

The goal of the study was to examine patient and medication characteristics associated with treatment retention and continued illicit opioid use in patients given methadone vs. buprenorphine/naloxone.

Study Group

  • Average age 37 years; two-thirds were male
  • 71% white, 12% Hispanic, 9% African American
  • About 90% smoked cigarettes, 27% used alcohol, 69% had injected drugs during the previous 30 days
  • Positive test results for drugs other than opioids: cocaine, 37%; amphetamine, 9%; marijuana, 24%

Patients were told to abstain from opioids for 12 to 24 hours before study onset, to achieve mild-to-moderate opioid withdrawal.

Key Findings

  • Significantly more buprenorphine patients than methadone patients (25% vs. 8%) dropped out within the first 30 days
  • Significantly more methadone than buprenorphine patients completed treatment (74% vs. 46%)
  • Completion rate was even higher with higher daily doses
    • For methadone: 80% or higher with 60 mg or more; 91% or higher with 120 mg or more
    • For buprenorphine (which showed a linear dose-relationship): 60% with 30 to 32 mg, the study maximum
    • Factors associated with higher dropout rates included being younger, being Hispanic (relative to white), and using heroin, cannabinoids, cocaine, or amphetamine during treatment
    • Higher medication dose was related to lower opiate use, especially in the buprenorphine group

Average maximum daily doses for methadone were 93.1 mg (range, 5 to 397 mg), and for buprenorphine, 22.1 mg (range, 2 to 32 mg).

Investigators noted three important findings about buprenorphine retention:

  • About 25% of buprenorphine patients dropped out during the first 30 days, “suggesting a critical period calling for special efforts in retaining these participants”
  • During the first 9 weeks, positive opiate urine results were significantly lower among those receiving buprenorphine, confirming the drug’s advantage of a much shorter induction time
  • A linear positive relationship between dose and treatment completion rate suggested “the benefit of dosing greater than the common practice of a maximum dose of 16 mg”

Buprenorphine Doses and Treatment Outcomes

Even patients taking 30 to 32 mg buprenorphine daily, the maximum for this study, had a retention rate lower than the methadone group (60 percent vs. 74 percent), and about 30 percent continued opioid use. “These findings suggest that participants may yet fare better with [buprenorphine] doses higher than the 32 mg used in this study,” the authors said. They commented on the generally high safety profile of buprenorphine: “We believe with proper monitoring safety will not be a clinical concern in such an effort.”

The authors cited a large investigation (Di Petta) linking daily buprenorphine doses as high as 56 mg with a retention rate of over 92 percent at 30 months. They also drew a comparison to the previous long-standing practice of limiting daily methadone doses to 40 mg—later shown to be highly inadequate, with most patients needing 60 to 120 mg or more.

(Although many sources cite a maximum daily dose of 32/8 mg buprenorphine/naloxone, this is not the first clinical study to investigate higher doses. Studies such as this are based on clinical evidence, designed with safety checks in place, and approved by an institutional review board.)

*   *   *

Reference

Hser YI, Saxon AJ, Huang D, et al. Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial. [Epub ahead of print August 20, 2013.]  Addiction. doi: 10.1111/add.12333.

 Resources

Di Petta G, Leonardi C. Buprenorphine high-dose, broad spectrum, long-term treatment: A new clinical approach to opiate alkaloid dependency. Heroin Add & Rel Clin Probl. 2005;7(3):21-26.

Kakko J, Grönbladh L, Dybrandt Svanborg K, et al. A stepped care strategy using buprenorphine and methadone versus conventional methadone maintenance in heroin dependence: a randomized controlled trial. Am J Psychiatry. 2007;164:797-803. doi:10.1176/appi.ajp.164.5.797.

Mattick RP, Kimber J, Breen C, Davoil M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2008;16(2):CD002207. doi: 10.1002/14651858.CD002207.pub3.

Pinto H, Maskrey V, Swift L, Rumball D, Wagle A, Holland R. The SUMMIT trial: a field comparison of buprenorphine versus methadone maintenance treatment. J Subst Abuse Treat. 2010;39(4):340-352. doi: 10.1016/j.jsat.2010.07.009. PMID: 20817384.

Meaning and Methadone: A Model for Promoting Adherence in MMT, Based on Patients’ Perceptions

perceptionThe prevailing dosing model in methadone maintenance treatment (MMT) supports adjusting methadone doses downward, based on signs of opioid intoxication, or upward, based on withdrawal signs or patients’ reports of craving or illicit opioid use. But a recent study, carried out at the Albert Einstein College of Medicine (AECOM) and Montefiore Medical Center, suggests that these guidelines “may not resonate with patients’ understandings, beliefs, or feelings about appropriate doses.” The authors propose an alternative strategy: a model that takes into account patients’ perceptions about methadone doses, and the meanings patients associate with treatment. An underlying but unstated component is increased communication between patients and caregivers. The authors believe their model will improve adherence and enhance MMT success.

Published online June 25 in the Journal of Addiction Medicine, the study found that “perceptions about methadone dosing influence treatment effect at different doses”—the “meaning effect.”  The proposed model is not a protocol for selecting ideal doses, but a way for caregivers to look at factors that influence patients’ ideas of “comfort” and “function,” and the dose ranges patients consider comfortable. The figure below summarizes the concepts behind the model.

perception graphic

Study Group

  • 19 participants recruited from a waiting room at the MMT clinic at the AECOM
  • 10 men, 9 women
  • Most were 40 years or older (range, 29 to 60)
  • Hispanic, 11; white, 5; black, 2; Native American, 1
  • Most had been using heroin for more than 10 years (none were being treated for prescription opioid misuse)
  • 15 were previously in MMT, usually followed by relapse
  • Daily methadone dose: 50 to 280 mg; highest ever: 60 to 290 mg

The authors considered the sample size adequate because late interviews produced no new themes—a situation known as thematic saturation.

Perceptions About Methadone Dosing. Data from transcripts of semistructured interviews reveal that “the perceptions of methadone and MMT formed both before and during treatment shape the dose that an individual patient feels is appropriate and/or comfortable.” Interestingly, participants’ perceived “ideal” methadone dose was 0 to 195 mg—much lower than their current dose.

Participants described ideal dose in terms of their “function” and “comfort,” eg., “I feel normal . . . and that helps me maintain my own activities throughout the day.” “I feel comfortable on 140 mg so I can function.” They said that doses too high or too low compromised their overall function, and viewed high doses as “an obstacle to discontinuing methadone treatment in the future.”

Discussed below are factors that influence the dose range in which patients seem best able to function.

Factors Favoring a Decrease in “Ideal” Dose Range

Factors Directly Related to MMT

  • Lack of taking part/lack of control in treatment
  • Disdain for getting high on methadone
  • Concerns about methadone dependence
  • The idea of doses being “too high”
  • A desire to avoid adverse effects (eg., nodding off)

Some examples:

What participants perceived as their lack of control often made them feel like stopping treatment. They used metaphors of incarceration, such as calling MMT “a life-long sentence.” They saw automatic dose increases triggered by “dirty urines” as unfair—a unilateral control issue. One commented: “they are not asking me why am I still getting high.”

Most participants equated methadone intoxication with intentional misuse. They wanted doses that reflected methadone as a medication rather than a “drug.” Almost all viewed methadone treatment as temporary, so they did not want to become dependent.

Participants expressed “seemingly arbitrary” ideas about dose. More than half felt that their ideal dose was “50% of their current dose or less than that.” They viewed patients who took high doses as “crazy,” “greedy,” or “abusive.”

Factors Indirectly Related to MMT

  • Stigma around and shame about MMT; some didn’t feel “clean” when taking methadone
  • Some felt ashamed about being on what they considered a high dose

Factors Favoring an Increase in “Ideal” Dose Range

Directly related to MMT: Some participants expressed concerns about possible withdrawal symptoms (“dope sickness”). Indirectly related: Some saw certain co-administered medications, chronic pain, pregnancy, or stress as reasons for needing higher methadone doses.

Clearly, factors favoring a decrease in dose range far outnumbered those favoring an increase. This was in line with participants’ perceptions that their current dose was much higher than their ideal dose.

Factors Exerting Mixed Pressures Over “Ideal” Dose Ranges

  • Family and friends were likely to make participants feel they should be on a lower dose, or even off methadone. Alternatively, they could have a stabilizing effect by motivating patients to stay in treatment.
  • Methadone formulations drew mixed responses. Many considered “orange pills” the strongest. Some saw “white pills” as relatively strong; others considered them weaker (“I was still feeling urges.”). The liquid methadone dispensed at the clinic drew comments such as “hits you quicker” and “holds much longer.”

Authors’ Conclusions

The authors suggest that their MMT model will add nuance to understanding “the acceptability (and, perhaps also, the effectiveness) of certain doses,” and help lead to a more patient-centered understanding of undermedication and overmedication. This would enhance clinicians’ “sensitivity to the patient experience and foster greater adherence to and success in MMT.”

Justin J. Sanders, MD, MSc, formerly a chief resident in family and social medicine at Montefiore Medical Center, is now a palliative care fellow at Harvard Medical School. Dr. Sanders received a Chairman’s Award for Research as a result of the work that led to this publication.

Reference

Sanders JJ, Roose RJ, Lubrano MC, Lucan SC. Meaning and methadone: Patient perceptions of methadone dose and a model to promote adherence to maintenance treatment. [Epub ahead of print June 25, 2013.] J Addict Med. doi:10.1097/ADM.0b013e31829702le.

MARS™ Thought-Leadership Helps Raise Profile of Peer Recovery Support Services: Ginter Joins Plenary, Will Showcase Innovative Trainings at 2013 AATOD Conference

Medication-Assisted Recovery Services (MARS™), part of a leading national nonprofit organization that provides peer support services and training to address the needs of the medication-assisted recovery community, announced its Project Director has been invited to deliver a plenary presentation at the upcoming 2013 AATOD Conference in Philadelphia. Walter Ginter will join other prominent treatment and recovery leaders during the middle plenary session to talk about “Keeping Recovery the Focus”.

In his plenary session, Mr. Ginter will focus specifically on how methadone became the pathway for him to reach his full potential and how he has taken that experience to create the MARS™ Project, a structured program of education and peer support that is helping many others across the country who are in medication-assisted treatment to strengthen their recovery. He will also share his work as an advocate for medication-assisted recovery, helping overcome the barriers and stigma that can fight against recovery efforts.

Mr. Ginter will participate in the plenary session entitled “Keeping Recovery the Focus”, which hones in on a new era that will require programs to adapt to the ongoing implementation of health care reform. Emphasis will be on the 50-year evolution of methadone treatment and where the field is today as an accredited, science-based modality.

The press release can be accessed at: http://www.prweb.com/releases/2013/10/prweb11226954.htm

Source: PRWeb.com – October 14, 2013

Another View: Healthy Moms on Methadone Can Safely Breast-Feed By John McCarthy

“I am responding to The Sacramento Bee’s article on how Sacramento Child Protective Services handled the case of a baby who died of a drug overdose (“CPS lapse cited in death,” The Public Eye, Sept. 1). This report seems to imply that routine breastfeeding by mothers on steady and controlled doses of methadone might expose their babies to the possibility of an overdose. It is physiologically impossible for a baby nursed from birth by a mother on stable daily doses of methadone to overdose.”

http://www.sacbee.com/2013/09/14/5734760/another-view-healthy-moms-on-methadone.html

Source: The Sacramento Bee – September 14, 2013

Blog: Guest Dosing at Opioid Treatment Programs

“Methadone patients have to dose at the facility each day for at least the first ninety days, and after that, if doing well, they can get up to three take homes per week for the next ninety days, then up to four per week after a half of a year, and so on.

What happens if the patient needs to go out of town?

There are three options: leave treatment, the worst option, because of the increased risk of death for patients who leave treatment; special take home doses, often risky if the patient isn’t able to take them as prescribed; and guest dosing.

Guest dosing means a patient of one treatment program can be dosed at another program if that patient travels to another area. All opioid treatment programs send their patients for guest dosing and allow guest dosing for patients of other facilities. It should be a smooth and simple process, under ideal circumstances.

But sometimes circumstances get complicated.”

http://janaburson.wordpress.com/2013/08/09/guest-dosing-at-opioid-treatment-programs/

Source: Jana Burson – August 9, 2013

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