U.S. Attorney General Holder Urges Use of Drug to Help In Heroin ODs

Attorney General Eric Holder declaring heroin addiction is an “urgent and growing public health crisis,” urged first responders to carry the drug naloxone that helps resuscitate victims from an overdose.

“Addiction to heroin and other opiates — including certain prescription pain-killers — is impacting the lives of Americans in every state, in every region, and from every background and walk of life — and all too often, with deadly results,” Holder said in a video message posted Monday on the Justice Department website.”

http://www.usatoday.com/story/news/politics/2014/03/10/holder-heroin-overdose-help/6247281/

Source: USAToday.com – March 10, 2014

National Institute on Drug Abuse (NIDA) Updated Research Report on Heroin

Wider Use of Antidote Could Lower Overdose Deaths by Nearly 50%

“Distributing naloxone and training people to use it can cut the death rates from overdose nearly in half, according to a new study.

The new study, published in the BMJ, followed the expansion of Overdose Education and Naloxone Distribution (OEND) programs in Massachusetts.  The programs were offered at emergency rooms, primary care centers, rehabilitation centers, support groups for families of addicted people and other places that might attract those at risk.

The study involved 2912 people in 19 different Massachusetts communities — each of which had had at least 5 opioid overdose deaths between 2004 and 2006.  The participants were trained to recognize overdose, call 911 and administer naloxone using a nasal inhaler.  If the naloxone didn’t work, they were instructed to try another dose and perform rescue breathing until help arrived.

During that time, 153 naloxone-based rescues were reported for which there was data on outcomes, and in 98% of those cases, the drug revived the victim.

There are still practical barriers however, to widely distributing naloxone and implementing more OEND type programs. Advocates have argued that the medication should be made available over-the-counter since it has little potential for abuse and is nontoxic. The Centers for Disease Control (CDC), the director of the National Institute on Drug Abuse and even the drug czar’s office support making it more widely available, and unlike the case with needle exchange programs, there has been no organized opposition to OEND. But the Food and Drug Administration (FDA) has no precedent for allowing over-the-counter sales of such a drug: naloxone is a generic medication approved in an injectable form. Without a company to submit an application for its use in the intranasal version, the agency isn’t likely to OK over-the-counter sales.”

http://healthland.time.com/2013/02/05/wider-use-of-antidote-could-lower-overdose-deaths-from-by-nearly-50/

Source: HealthlandTime.com – February 5, 2014

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

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

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

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

Here are two salient points:

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

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

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

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

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

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

AMA Calls on CDC to Help Combat Prescription Drug Abuse

pills 12-20-12“At the American Medical Association (AMA), physicians voted to support a proposal for a more practical approach in preventing death from prescription pain medications.

Specifically, the proposal calls on the Centers for Disease Control and Prevention (CDC) to help provide required information in order to develop appropriate solutions.  The AMA will urge the CDC to promote a standard approach for “documenting and assessing deaths involving controlled substances for pain relief,” stated Patrice Harris, MD, an AMA Board Member.

According to the AMA, the CDC is in a key position to promote a standard approach that can help identify key trends and guide effective preventive measures. A standardized method of data collection and analysis has helped public health officials, law enforcement, and policy makers address other national epidemics.”

Source: American Medical Association – November 19, 2013

National Safety Council Report: Only Three States Adequately Addressing Prescription Drug Abuse

NSCThe National Safety Council (NSC) released its report, Prescription Nation: Addressing America’s prescription drug abuse epidemic showing 47 states must improve existing standards if they are to reduce the number of deaths involving prescription drug overdoses. NSC is calling on states to take immediate action to improve the prescribing, monitoring, treatment and availability of opioid pain relievers.

Prescription drug abuse is a growing public health epidemic. Forty-five people die every day from overdoses of prescription pain relievers, accounting for more deaths than cocaine and heroin combined. Enough pain killers were prescribed in 2010 to medicate every American adult around the clock for one month.

“For the first time since WWII, something other than motor vehicle crashes is the leading cause of unintentional injury deaths for Americans ages 25-64,” said John Ulczycki, vice president of strategic initiatives at NSC. “Countless lives already have been lost. NSC will be working to confront this issue on a national level.”

In the report, NSC examined state efforts in four areas: state leadership and action, prescription drug monitoring programs, responsible painkiller prescribing and overdose education and prevention programs.

Kentucky, Vermont and Washington were the only states that met standards in all four areas.

Fourteen states - Arizona, Delaware, Hawaii, Idaho, Iowa, Kansas, Maine, Missouri, Nebraska, New Hampshire, Pennsylvania, South Carolina, South Dakota and Wyoming – failed to meet standards.

Visit nsc.org/rxreport to receive the full report and learn more about solutions to this growing epidemic. Note: Registration is required to access the report. NSC also developed an infographic illustrating the scope of the problem. The infographic can be downloaded at nsc.org/rxnation.

http://www.prnewswire.com/news-releases/nsc-report-only-three-states-adequately-addressing-prescription-drug-abuse-227719161.html

Source: PRNewsWire.com – October 14, 2013

Prescription Drug Abuse: Strategies to Stop the Epidemic

pillsA new report, Prescription Drug Abuse: Strategies to Stop the Epidemic, finds that 28 states and Washington, D.C. scored six or less out of 10 possible indicators of promising strategies to help curb prescription drug abuse. Two states, New Mexico and Vermont, received the highest score receiving all 10 possible indicators, while South Dakota scored the lowest with two out of 10.

According to the report by the Trust for America’s Health (TFAH), prescription drug abuse has quickly become a top public health concern, as the number of drug overdose deaths – a majority of which are from prescription drugs – doubled in 29 states since 1999. The rates quadrupled in four of these states and tripled in 10 more of these states.

Prescription drug related deaths now outnumber those from heroin and cocaine combined, and drug overdose deaths exceed motor vehicle-related deaths in 29 states and Washington, D.C. Misuse and abuse of prescription painkillers alone costs the country an estimated $53.4 billion each year in lost productivity, medical costs and criminal justice costs. Currently only one in 10 Americans with a substance abuse disorder receives treatment.

Some key findings from the report include:

  • Appalachia and Southwest Have the Highest Overdose Death Rates: West Virginia had the highest number of drug overdose deaths, at 28.9 per every 100,000 people – a 605 percent increase from 1999, when the rate was only 4.1 per every 100,000. North Dakota had the lowest rate at 3.4 per every 100,000 people. Rates are lowest in the Midwestern states
  • Rescue Drug Laws: Just over one-third of states (17 and Washington, D.C.) have a law in place to expand access to, and use of naloxone – a prescription drug that can be effective in counteracting an overdose – by lay administrators.
  • Good Samaritan Laws: Just over one-third of states (17 and Washington, D.C.) have laws in place to provide a degree of immunity from criminal charges or mitigation of sentencing for individuals seeking to help themselves or others experiencing an overdose.
  • Medical Provider Education Laws: Fewer than half of states (22) have laws that require or recommend education for doctors and other healthcare providers who prescribe prescription pain medication.
  • Support for Substance Abuse Treatment: Nearly half of states (24 and Washington, D.C.) are participating in Medicaid Expansion – which helps expand coverage of substance abuse services and treatment.
  • ID Requirement: 32 states have a law requiring or permitting a pharmacist to require an ID prior to dispensing a controlled substance.
  • Prescription Drug Monitoring Programs: While nearly every state (49) has a Prescription Drug Monitoring Program (PDMP) to help identify “doctor shoppers,” problem prescribers and individuals in need of treatment, these programs vary dramatically in funding, use and capabilities. For instance, only 16 states require medical providers to use PMDPs.

The report can be accessed at: http://healthyamericans.org/reports/drugabuse2013/

The press release can be accessed at: http://healthyamericans.org/newsroom/releases/?releaseid=291

Source: HealthyAmericans.org – October 7, 2013

Role of Police in Responding to Overdoses Often Unclear: Study

hospital sign“The role of police officers in responding to overdoses is often unclear, according to a new study. Researchers say training officers in administering the overdose antidote naloxone could have a significant impact on the death rate from drug-related fatalities.

The study found that while police officers often serve as medical first responders, it is often unclear what police can or should do at the scene of an overdose, PsychCentral.com reports.

The researchers interviewed 13 law enforcement officials in Connecticut and Rhode Island communities experiencing high rates of drug overdoses. They found officials were supportive of being involved in overdose prevention, but they expressed hesitancy about laypersons administering naloxone. Officers said they were frustrated with their current overdose response options, the lack of accessible drug treatment, the cycle of addiction and the pervasiveness of easily accessible prescription opioid medications in their communities.”

http://www.drugfree.org/join-together/community-related/role-of-police-in-responding-to-overdoses-often-unclear-

Source: JoinTogether.org – September 30, 2013

Naloxone Nasal Spray on Development Fast Track as Emergency Treatment for Opioid Overdose

“AntiOp, Inc., a Kentucky company says its nasal spray could save the lives of thousands of narcotic pain medication and heroin overdose victims and that the Food and Drug Administration (FDA) has specified the final research requirements necessary for approval of the drug. AntiOp, Inc. says, its naloxone nasal spray could be on the market in about 18 months.

“The FDA has been very encouraging of our approach,” said AntiOp founder and CEO Dr. Daniel Wermeling. “Once we file a new drug application, they plan to complete a priority review of our product, which usually takes about six months.”

Naloxone is already stocked in thousands of emergency rooms, ambulances and post-surgery recovery rooms but in an injectable form. It must be administered intravenously or as a shot into muscle or under the skin. Because many heroin abusers carry hepatitis or the HIV virus, the risk of infection to medical personnel is high. Some emergency responders use atomizers to convert the injectable form of naloxone to a nasal spray. Wermeling and others believe a nasal spray version of naloxone will prove to be effective, safer and easier to administer than the current injection-based approach.”

http://www.fortmilltimes.com/2013/09/20/2970640/naloxone-nasal-spray-on-development.html

Source: FortMillTimes.com – September 20, 2013

New Toolkit Will Combat Opioid Overdose

SAMHSA Opioid Overdose Toolkit

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

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

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

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

Source: SAMHSA – August 28, 2013

New York: New York’s Problem with Prescription Drugs

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

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

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

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

http://digitaljournal.com/article/357369

Source: DigitalJournal.com – September 4, 2013

Prescription Painkiller Overdoses: A Growing Epidemic, Especially Among Women

prescriiption padPrescription drug overdose deaths have skyrocketed in women. Our mothers, wives, sisters and daughters are dying from these overdoses at rates never seen before. 

Consider these numbers: Prescription painkiller overdose deaths increased fivefold among women between 1999 and 2010. While men are more likely to die of a prescription painkiller overdose, since 1999 the percentage increase in deaths was greater among women (400 percent in women compared to 265 percent in men). Prescription painkiller overdoses killed nearly 48,000 women between 1999 and 2010. About 42 women die every day from a drug overdose.

Previous research has shown that women are more likely to have chronic pain, be prescribed prescription painkillers, be given higher doses, and use them for longer time periods than men.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6226a3.htm?s_cid=mm6226a3_w

 http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/index.html

 Source: Centers for Disease Control and Prevention – July 2013

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

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

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

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

Medicaid

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

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

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

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

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

Restrictions by Payers

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

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

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

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

Little Support from Insurance

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

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

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

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

OTPs as Silos

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

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

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

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

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

Philadelphia Releases Benzodiazepine Draft Guidelines for MAT

benzo2benzo 1Important guidelines to help opioid treatment programs (OTPs) determine how to handle benzodiazepine use by their patients have been developed by the Institute for Research, Education and Training in the Addictions (IRETA) for the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS). Roland Lamb, MA, director of the DBHIDS Office of Addiction Services, talked with AT Forum about what the draft guidelines mean to OTPs who are struggling with ways to manage patients who use benzodiazepines while in medication-assisted treatment (MAT).

Although the guidelines were prepared under contract with DBHIDS for use by Philadelphia-area MAT providers, Mr. Lamb said they can be used by anyone—and he hopes they will be, when finalized. “This is a collaboration that went beyond Philadelphia,” he said. Partners were the Community Care Behavioral Health (CCBH) and the University of Pittsburgh in Allegheny County, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Pennsylvania Department of Drug and Alcohol Programs, he said. “We need to make sure the focus is on the disease of addiction and not just on managing medications. Methadone maintenance is so overregulated that it can become medication-focused, as opposed to treating people for their addiction.”

Treating Addiction

And while methadone maintenance is focused on opioid addiction, OTPs and all MAT providers must recognize that they are treating addiction per se, he said. “Once you have stabilized a person on methadone, you still need to pay attention to other issues.” Those other issues could include misuse of alcohol or other drugs, such as benzodiazepines

The concern for OTPs and patients is that benzodiazepines, in combination with methadone, buprenorphine, or any central nervous system (CNS) depressant, could result in respiratory depression and death. “There has been extensive writing about the synergistic effects,” he said.

But it’s not only about risk. Helping patients recover from addiction means counseling and a personal transformation away from seeking relief from drugs and alcohol.

“I believe that OTPs are failing their population if they don’t address addiction,” said Mr. Lamb. “It’s not just benzodiazepines, it’s everything.”

Lower Starting Dose, Inpatient Detox

One of the recommendations is for people on benzodiazepines to be inducted on a lower starting dose of methadone, but another is that all patients need an adequate starting dose. There seems to be a conflict between those two recommendations, but Mr. Lamb said that there isn’t. “What it really means is that you would need a longer lead time to get up to the optimal dose,” he said. “What you don’t want is to continue to follow through to the maximum dosage level, which could be 30 or 40 milligrams, at the onset of treatment,” he said.

The two recommendations are consistent when looked at together, because the main point is to ultimately get the patient up to the optimal dose. “In induction, they are in limbo, and will be struggling mightily to manage their addiction and perhaps find other means to do that,” he said. Some ways to bring patients up to optimal dosage and minimize the withdrawal symptoms that come with the very early days of induction for some is to provide a split dose during the day, to minimize the valleys, he said.

Another recommendation for patients who are using benzodiazepines is to taper their benzodiazepine use and then induct them into MAT. Sometimes, the best way to do this is inpatient detoxification, the guidelines state.

“It’s problematic that people think MAT is only done in an outpatient methadone program,” said Mr. Lamb. Philadelphia has established MAT across all levels of care. “We have people in residential treatment who receive MAT, as well as people who are in outpatient programs,” he said. “When a person isn’t responding to the outpatient milieu, you need to address the severity of the addiction.” And for OTPs, it may mean assessing the person as needing inpatient treatment. “‘If you didn’t have methadone, what level of care would this person be receiving?’ is a good question to ask,” he said.

Key Recommendations

The key recommendations of the IRETA report clearly state that use of benzodiazepines or other CNS depressants is not a contraindication for methadone or buprenorphine treatment—patients should not automatically be discharged from treatment because they are using benzodiazepines, either by obtaining prescriptions from other physicians or by buying them.

From the Recommendations:

  • CNS depressant use is not an absolute contraindication for the use of either methadone or buprenorphine in MAT, but is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, antidepressants, or alcohol.
  • Individuals who use benzodiazepines, even if used as a part of long-term therapy, should be considered at risk for adverse drug reactions including overdose and death.
  • Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment.
  •  MAT should not generally be discontinued for persistent benzodiazepine abuse, but requires the implementation of risk management strategies.
  • Clinicians should ensure that every step of decision-making is clearly documented.

There wasn’t always unanimous agreement among the participants in the development process for the guidelines, said Mr. Lamb. “We narrowed down the guidelines to what we had consensus around.”

Risk Management vs. Addiction Treatment

At the core of the consensus process was reconciling risk management with treatment of addiction, two goals that can be at odds with one another. But is there really any conflict? If the goal is recovery, then treatment of addiction should include dealing with craving and the problems of patients who are suddenly living without getting high.

There is a desperate need for this information, said Mr. Lamb. “We had a number of providers who were struggling with how to manage the use of benzodiazepines.” That’s the reason for the guidelines, and also the reason for a physician’s town hall sponsored by DBHIDS at the November conference of the American Association for the Treatment of Opioid Dependence (AATOD), to be held in Philadelphia.

“Some people have a legitimate need for an anti-anxiety drug,” said Mr. Lamb. “However, there has to be a limit to how far a provider goes, if there is no cooperation from the patient.”

Some patients start abusing benzodiazepines when they enter MAT because they are no longer able to feel euphoria from opioids, according to Mr. Lamb. “Part of the disease of addiction is the preoccupation with feeling good or feeling better,” he said, referring to euphoria and to minimizing withdrawal symptoms. Others come into treatment managing collateral emotional pain and psychic confusion, he said. “We’ve often found that the need to self-medicate is strong.” That’s why getting a patient stable on methadone is only the first step, he said. “That’s when the hard part begins.”

The early stages of treatment, when patients are no longer experiencing “feeling better” from opioids, are when other drugs, such as cocaine, alcohol, marijuana, or benzodiazepines, get introduced, said Mr. Lamb. “Chemistry is a way of life in our population, always finding new combinations to feel good and to feel better.” A new patient on methadone, once stable, won’t feel any signs of withdrawal, so the need to “feel better” will be gone. “But with this population there is always the need to alter one’s consciousness.” And there may also be depression and anxiety or legitimate mental illnesses, which methadone will not treat, and which require medication. But that doesn’t necessarily mean medications are always the answer.

When opioid-dependent patients begin MAT, they may also be going to other physicians who are prescribing medications for anxiety. “Hopefully the doctors are talking to each other, communicating in the best interest of the patient,” said Mr. Lamb. But the patient may want just the opposite. “Those in care are interested in keeping those two doctors separate, not wanting them to collaborate, because that will interfere with their goals.”

For the draft guidelines, go to: http://ireta.org/sites/ireta.org/files/BZD%20and%20MAT%20FINAL%20REPORT%20Dec%202012%20marked%20draft.pdf

New ASAM Reports Show Increasing Restrictions on Addiction Medications by State Governments and Insurance Companies

ASAM logoState governments and insurance companies are increasingly restricting the use of effective, FDA-approved medications that could help reverse the epidemic of opioid addiction and overdose deaths, according to the most comprehensive reports on opioid addiction medications released June 20 by the American Society of Addiction Medicine (ASAM).

“These reports show that we could be saving lives and effectively treating the disease of addiction if state governments and insurance companies remove roadblocks to the use of these medications,” said Stuart Gitlow, MD, President of ASAM. “Treatment professionals need every evidence-based tool available to end suffering from this chronic disease. State lawmakers and insurance company administrators would never deny needed medication to people suffering from other chronic diseases, like diabetes and hypertension. But it happens every day to people with addiction.”

Strong evidence of effectiveness

The report on effectiveness of opioid medications, conducted by the Treatment Research Institute, examined 642 unique studies that evaluated buprenorphine, methadone, oral naltrexone and injectable naltrexone. The report found that these medications show substantive evidence of effectiveness and safety. They’re shown to decrease the frequency and quantity of drug use, withdrawal and craving, infectious diseases, criminal behavior and overdose, and to improve social functioning.

The medications show clear evidence of effectiveness only when used as long-term treatment, much like insulin for diabetes. There is very little indication of short-term benefit.

These medications also are cost-effective, with costs for maintenance medications to treat opioid addiction roughly comparable to costs for diabetes medications.

Complex, arbitrary restrictions

The reports on state Medicaid and insurance company restrictions were conducted through surveys by The AVISA Group and the Treatment Research Institute. The researchers reported that insurance company managers were reluctant to respond to questions about opioid medication restrictions.

The state Medicaid coverage report showed that while every state covers at least one FDA-approved opioid addiction medication, restrictions vary widely from state to state and often create de facto denial of access. Coverage limits for lifetime benefits and daily dosages are common. Restrictive prior authorizations add another level of obstacles. Information about restrictions and compliance regarding these medications is very difficult to obtain from state agencies. Many states require other treatments to fail first before addiction medications are covered.

Similarly, private insurance companies’ restrictions on opioid addiction medications are complex, contradictory and often arbitrary. Insurance companies widely use utilization management techniques like prior authorization that impedes the use of addiction medications, and they also limit coverage on quantities of medication.

Dosage and quantity restrictions on opioid addiction medications by insurance companies and state Medicaid programs contravene recommendations from professional medical associations and the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). These restrictions may risk patient safety and lead to suffering and death with no clear therapeutic objective. With no single national practice guideline on use of pharmacotherapies for opioid addiction, states and payers are filling in a much-needed gap.

Denial of access ‘unethical’

“The fact that patients are frequently denied access to the full spectrum of treatment options for addiction is unethical and would constitute malpractice in other medical specialties and chronic disease treatment,” said Thomas McLellan, a report author who is CEO of the Treatment Research Institute and former Deputy Director of the White House Office of National Drug Control Policy. “Treatment of addiction must be raised to the same medical and ethical standards as treatment for other chronic diseases. This needs to be acknowledged by the treatment community, medical specialties, insurance companies and all levels of government.”

According to the reports, none of the medications by themselves can be considered effective treatments for opioid dependence. All medications are designed for use as part of comprehensive treatment strategies that usually include counseling, social supports and behavioral change strategies. But research shows they can be vital treatment components that raise treatment success rates.

“Medical science supports the use of addiction medications to effectively treat the disease of addiction,” Dr. Gitlow said. “This science must be the basis of state policies, insurance coverage and national standards for the treatment of addiction. We want to work with public and private payers to identify models of patient access that can be shared broadly. Restrictions by states and insurance companies make no sense when opioid addiction and overdose deaths have grown into a national epidemic.”

The full report is available at: http://www.asam.org/docs/advocacy/Implications-for-Opioid-Addiction-Treatment

http://www.asam.org/docs/default-source/pressreleases/effective-rx-thwarted-for-deadly-opioid-epidemic-2013-06-20.pdf?sfvrsn=2

Source: American Society of Addiction Medicine – June 20, 2013

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