New Resources and Events Available on ATForum.com

Have you visited ATForum.com lately? Over 30 new meetings, conferences, and webinars have been added to the site in addition to key new resources including the following on medication-assisted treatment.

Neonatal Abstinence Syndrome: How States Can Help Advance the Knowledge Base for Primary Prevention and Best Practices of Care
Association of State and Territorial Health Officials – March 2014.

Confronting the Stigma of Opioid Use Disorder—and Its Treatment
Journal of the American Medical Association – February 26, 2014.

Medication-Assisted Treatment With Methadone: Assessing the Evidence
Psychiatric Services – February 1, 2014.

Medication-Assisted Treatment With Buprenorphine: Assessing the Evidence
Psychiatric Services – February 1, 2014.

Medscape Ask the Pharmacist: Methadone or Buprenorphine for Maintenance Therapy of Opioid Addiction: What’s the Right Duration
Medscape – February 3, 2014. Note: A Medscape account is required to view this article. If you do not have a Medscape account you can create one for free.

Advancing Service Integration in Opioid Treatment Programs for the Care and Treatment of Hepatitis C Infection
International Journal of Clinical Medicine – January 2014.

Advancing Access to Addiction Medications Report
American Society of Addiction Medicine (ASAM) – December 2013.

IRETA Blog: Women Have Been Particularly Affected By the War on Drugs, Part II

“How can we use what we know about women and the War on Drugs to create real drug policy reform?

In our first installment about women, addiction, and the criminal justice system, we shared some stark facts about the impact of “War on Drugs” policies on American women.  Here are two:

  • The number of women in prison has grown by over 800% in the past three decades. The female prison population grew by 832% from 1977 to 2007. The male prison population grew 416% during the same time period.
  • Two thirds of women in prison are there for non-violent offenses, many for drug-related crimes. In the 10-year period from 1999 to 2008, arrests of women for drug violations increased 19%, compared to 10% for men.

This blog addresses three ways to make drug policy reform matter to women.

  • Expand alternatives to incarceration
  • Improve access to treatment for incarcerated women
  • Make prisons and correctional services more gender-responsive

The blog can be accessed at: http://iretablog.org/2014/03/14/women-have-been-particularly-affected-by-the-war-on-drugs-part-ii/

Source: Institute for Research, Education and Training in Addictions – March 14, 2014

Teenagers Treated for Headache Were Prescribed Opioids Almost Half of the Time, According to Study in Journal of Adolescent Health

adolescentClinicians prescribed opioids for almost half of the teenagers they treated for headache when medications, such as aspirin, ibuprofen and naproxen, are recommended as first-line therapies, according to a study today in the Journal of Adolescent Health.

The study was conducted by WellPoint and HealthCore, the outcomes research subsidiary for WellPoint a health benefits company, in conjunction with representatives selected by the American Academy of Pediatrics, American Academy of Family Physicians and American Academy of Neurology. The study included 8,373 adolescents from 13 to 17 years of age with recurring headaches.

“Pediatric and adolescent use of opioids is a concern,” said Dr. Eric Wall, past chair of the American Academy of Family Physicians’ Commission on Science. “The risk of abuse, as well as the potential for redirection, such as sharing with others, is high among adolescents.”

Forty-six percent of those complaining of headache received an opioid prescription. Of those who received a prescription, nearly half – or 48 percent — received only one prescription, while 23 percent received two prescriptions and 29 percent received three or more prescriptions.

Teenagers with visits for headache to the emergency department had twice the rate of opioid prescriptions as those who had not visited the emergency department. And, those who had three or more emergency department visits were four times more likely to have opioid prescriptions.

The study showed much higher rates of opioid prescription than rates of around 12 percent that had been reported previously.

http://www.businesswire.com/news/rxtimes/20140228005350/en/Teenagers-Treated-Headache-Prescribed-Opioids-Time-Study

Source: BusinessWire.com – February 28, 2014

Fewer Opioid Treatment Programs Offer HIV Testing

“According to a study, fewer opioid treatment programs are offering onsite testing for HIV and sexually transmitted infections (STIs), despite guidelines from the Centers for Disease Control and Prevention (CDC) recommending routine HIV testing in all health care settings.

The absolute number of programs offering testing for HIV, STIs, and HCV increased from 2000 to 2011. However, the percentage of programs offering HIV testing decreased significantly, by 18%, and the percentage of those offering testing for STIs fell by 13% throughout the study. Testing for each infection did not change over time in public programs, but HIV testing dropped by 20% among for-profit programs and 11% in nonprofit programs.

http://www.pharmacytimes.com/publications/issue/2014/February2014/Fewer-Opioid-Treatment-Programs-Offer-HIV-Testing

Source: PharmacyTimes.com - February 19, 2014

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

From NIDA Notes: Medications That Treat Opioid Addiction Do Not Impair Liver Health

A trial that compared buprenorphine/naloxone (Bup/Nx) to methadone produced no evidence that either medication damages the liver. Researchers concluded that Bup/Nx and methadone are equally safe for the liver, and Bup/Nx may be considered a first line alternative to the more established medication for treating opioid addiction.

Dr. Andrew Saxon at the Veterans Affairs Puget Sound Health Care System in Seattle, and Dr. Walter Ling at the University of California, Los Angeles Integrated Substance Abuse Program, conducted the trial with colleagues in the NIDA Clinical Trials Network. Dr. Saxon’s team randomly assigned 1,269 new patients in 8 U.S. opioid treatment programs to therapy with either Bup/Nx or methadone. The study findings reflect the experiences of 731 patients who provided blood samples for liver function tests at baseline, completed the 24 weeks of active treatment, and submitted blood for at least 4 of 8 scheduled tests of liver function during treatment. These tests include measuring the levels of two enzymes (alanine aminotransferase and aspartate aminotransferase) that the liver releases when it is injured.

Most trial participants maintained enzyme levels that indicate healthy liver function throughout the study. In 15.5 percent, enzyme levels increased to higher than twice the upper end of the normal range, indicating some ongoing liver injury. A few patients developed extreme elevations to 10 times the upper limit of normal or had other laboratory signs of severe liver injury.

The percentages of Bup/Nx and methadone patients who experienced each outcome were so close as to be statistically equivalent, warranting the conclusion that both medications were similarly safe. Although the researchers could not definitively rule out the possibility that the medications contributed to some of the observed worsening of liver function, their analysis produced no evidence to this effect. Instead, they say the changes most likely resulted from hepatitis, the toxicity of illicit drugs, and impurities in those drugs. Infection with hepatitis B or C doubled a patient’s odds of a significant change in enzyme levels and was the only predictor of worsening liver function. Most extreme increases in enzyme levels occurred when a patient seroconverted to hepatitis B or C, or used illicit drugs during the study.

The researchers note that about 44 percent of those screened for the study did not meet its enrollment criteria, suggesting that the participant group was healthier than many who visit clinics for addiction treatment. The ineligible population was also older, had a higher rate of stimulant use, and was less likely to be white than patients in the enrolled group, suggesting that the evaluable patient group might not be representative of all opioid-dependent patient groups.

Graphs available at: http://www.drugabuse.gov/news-events/nida-notes/2013/12/medications-treat-opioid-addiction-do-not-impair-liver-health

Source: National Institute on Drug Abuse (NIDA) Notes – December 2013

Genes Play a Large Role in Opioid Dependence

dna“There is reason to think that opioid dependence is at least 60 percent inherited. Now a genomewide association study appears to have led to the identification of major genes contributing to this risk.

Some major genes that contribute to the risk for opioid dependence appear to have been identified. The genes make proteins that influence calcium signaling or potassium signaling within neurons.

The lead scientist, Joel Gelernter, M.D., a professor of psychiatry, genetics, and neurobiology at Yale University, told Psychiatric News that he was surprised by this finding. He had expected genes that code for opioid receptors to turn out to be major contributors, he said. But that was not the case.

Gelernter and his coworkers conducted a genomewide association study to see whether they could significantly link any gene variants with a risk for opioid dependence. They used a relatively large sample—some 5,700 subjects (over a third with opioid dependence and the rest controls). Afterward they conducted two more studies—one with some 4,000 subjects and the other with some 2,500 ones—to see whether they could replicate their initial findings.

They were able to link variants of a number of genes with a risk for opioid dependence. But the variants that were most strongly associated with opioid dependence risk were those from genes involved in calcium or potassium signaling within neurons.”

http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1820456

Source: Psychiatryonline.org – January 28, 2014

MAT With Methadone or Buprenorphine: Assessing the Evidence for Effectiveness

evidenceIt’s not surprising that a thorough review of the efficacy of medication-assisted treatment (MAT) with methadone or buprenorphine reveals  a high level of evidence for the positive impact of MAT in keeping patients in treatment and reducing or eliminating illicit opioid use.

What is surprising is that the stigma against MAT persists—even though evidence suggests that methadone maintenance treatment (MMT) has a positive impact on drug-related HIV risk behaviors and criminal activity—and thus could make clinic neighborhoods safer, rather than less desirable.

The research findings on MMT and buprenorphine or buprenorphine-naloxone maintenance treatment (BMT) were published in November 2013 in two peer-reviewed articles (see References) as part of the Assessing the Evidence Base (AEB) Series sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).

The Assessing the Evidence Base Series

SAMHSA sponsored the AEB Series to help guide providers’ decisions about which behavioral health services public and commercially funded plans should cover. The Affordable Care Act (ACA) greatly expands health care coverage and provides the opportunity “for federal and state agencies to work with private and nonprofit sectors to transform the American health care system” by developing a comprehensive set of community-based, recovery-oriented, and evidence-based services for people with mental and substance use disorders. The ACA doesn’t specify specific treatments, leaving the decision to federal, state, and local agencies, managed care organizations, and commercial and private insurers.

Deciding which services have verified effectiveness isn’t an easy task. To help in the decision-making process, the AEB Series provides a literature evaluation for 14 behavioral health services. For people with substance use disorders, they include, in addition to MMT and BMT, residential treatment, peer-recovery support, and intensive outpatient programs. The goal of the AEB Series is “to provide a framework for decision makers to build a modern addictions and mental health service system for the people who use these services and the people who provide them.”

The Studies

Authors of the MMT and BMT studies searched major databases and other sources to review meta-analyses, reviews, and individual studies from 1995 through 2012.

In brief, the studies found that with adequate dosing, MMT (> 60 mg) and BMT (16 mg-32 mg) caused a similar reduction in illicit opioid use, but MMT was associated with better treatment retention and BMT with a lower risk of adverse events. In pregnancy, MMT and BMT (without naltrexone) showed similar efficacy, but MMT was better than BMT in retaining pregnant women in treatment, and BMT was associated with improved maternal and fetal outcomes, compared to no MAT.

MMT and BMT showed similar occurrence rates of neonatal abstinence syndrome, “but symptoms were less severe for infants whose mothers were treated with BMT.” BMT is associated with a lower risk of adverse events, and has the advantage of greater availability (office facilities improve access and provide earlier care). MMT may be needed for patients who require high doses of opioid agonist treatment, and has the advantage of a possible positive effect on mortality, drug-related HIV risk behaviors, and criminal activity.

The authors advise that MMT “should be a covered service available to all individuals,” and that BMT “should be considered for inclusion as a covered benefit.”

Sprinkled within the two articles are qualifiers such as “possible,” “associated with,” and “suggestive.” That’s because the statistical significance shown in some large, well-designed studies tends to disappear when data from individual studies are merged. Merging changes drug dosages, length of treatment, patient characteristics of the group, and other data; these changes may make reaching statistical significance impossible.

Areas for Future Research

The authors identified several areas where additional data would be helpful. For methadone, these include the impact of MMT on secondary outcomes, the efficacy and safety tradeoffs of doses > 100 mg, and confirmation of results of interim treatment for improved outcome. (In interim treatment, patients receive methadone daily under supervision for up to 120 days, and emergency counseling, while awaiting placement in a program.)  Another research area: the use of MMT in subpopulations—racial and ethnic minority groups, and people who misuse prescription drugs.

For buprenorphine, suggested research areas include the impact of BMT on secondary outcomes, appropriate dosing to enhance outcomes, and confirmation of stepped-care results. (Stepped-care involves gradually increasing buprenorphine doses to 32 mg—higher doses “do not provide additional efficacy;” patients requiring more medication are switched—“stepped-up”—to high-dose methadone.) Other research areas: the use of BMT in subpopulations (described above), and improved induction protocols to minimize retention problems.

A box in each publication summarizes the authors’ findings for each treatment. We reproduce them below, as they appeared in print.

 

Evidence for the effectiveness of MMT: high

Evidence clearly shows that MMT has a positive impacta on:

  • Retention in treatment
  • Illicit opioid use

Evidence is less clear but suggestive that MMT has a positive impact on:

  • Mortality
  • Illicit drug use (non-opioid)
  • Drug-related HIV risk behaviorsb
  • Criminal activity

Evidence suggests that MMT has little impact on:

  • Sex-related HIV risk behaviorsc

 

a Compared with placebo, detoxification, drug-free rehabilitation, or wait-listing
b Sharing injection equipment.
c Having unprotected sexual relations.

 

Evidence for the effectiveness of BMT: high

Evidence clearly shows that BMT has a positive impact compared with placebo on:

  • Retention in treatment
  • Illicit opioid use

Evidence is mixed for its impact on:

  • Non-opioid illicit drug use

 

Regarding retention in treatment and illicit opioid use, BMT had a positive effect compared to placebo, while MMT had a positive effect compared to placebo, detoxification, drug-free protocols, or wait-listing protocols.

Closing Statements

The authors note the importance of MAT, especially considering the poor success rates of abstinence-based treatments, and recognize both MMT and BMT as important treatment options. Below are summaries of their closing statements.

Methadone: The authors point out the need for educating providers, consumers, and family members about the benefits of MMT and ways to avoid the significant adverse events that can occur (referring to respiratory depression and cardiac arrhythmias). They also note the need for education about “appropriate doses to improve efficacy” and “appropriate initiation to minimize adverse events.”

They close with: Because of MMT’s relative efficacy, efforts should be made to increase access to MMT for all individuals who struggle with opioid use disorders. Directors of state mental health and substance abuse agencies and community health organizations should look for methods to increase access to MMT, and purchasers of health care services should cover appropriately monitored MMT.”

Buprenorphine: Noting the key advantage of buprenorphine—its availability—and the “limited access to and more restrictive safety profile of MMT,” the authors consider BMT an important treatment for opioid dependence. “Policy makers have reason to promote access to BMT for patients in substance use treatment who may wish to choose BMT as a potentially safer alternative to MMT.

They close with: “Administrators of substance use treatment programs, community health centers, and managed care organizations and other purchasers of health care services, such as Medicare, Medicaid, and commercial insurance carriers, should give careful consideration to BMT as a covered benefit.”

#     #     #

References

Fullerton CA, Kim M, Thomas CP, et al. Medication-assisted treatment with methadone: assessing the evidence. Psychiatric Services in Advance. November 18, 2013; doi: 10.1176/appi.ps.201300235.

Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: Assessing the Evidence. Psychiatric Services in Advance. November 18, 2013; doi: 10.1176/appi.ps.201300256.

Dougherty RH, Lyman DR, George P, Ghose SS, Daniels AS, Delphin-Rittmon ME.

Assessing the Evidence Base for Behavioral Health Services: Introduction to the Series.

Psychiatric Services. 2014; doi: 10.1176/appi.ps.201300214

http://ps.psychiatryonline.org/article.aspx?articleID=1759202

Prescription Drugs a ‘Tipping Point’ For Dating Violence among Urban Youth

A new University of Michigan Injury Center study recently found a link between misuse of prescription drugs and physical violence among dating partners.

Alcohol and other drugs have been a well-studied health concern among youth with a history of substance use. Previous studies asking youth about daily use over the course of a month show that alcohol and drugs are more likely to be used on days in which violence, both dating and nondating, occurs than on days when there was no violence.

This latest research indicates a connection with misusing prescription sedatives and opioids prior to incidents of dating violence, which many youth or adults may not think of as a risk factor for dating violence.

“Without the alcohol or prescription drugs involved, they simply might walk away from a potentially violent situation,” said Quyen Epstein-Ngo, a fellow at the U-M Injury Center and researcher at the Institute for Research on Women and Gender. “The alcohol and other substance use may be the tipping points.”

The study examined substance use—prescription sedatives and opioids—immediately preceding dating violent conflicts on the day of the conflict among high-risk urban youths. Data was collected from 575 participants ages 14-24 in the Flint Youth Injury Study, funded by the National Institutes of Health and supported by the U-M Injury Center, which looks at substance use and violence among youth treated in an urban emergency room. They reported substance use and instances of violence over a12-month period.

 http://www.healthcanal.com/substance-abuse/46532-prescription-drugs-a-tipping-point-for-dating-violence-among-urban-youth.html

Source:  HealthCanal.com – January 11, 2014

New Mexico Jail Methadone Program Shows Mixed Results

jail croppedjailjail cropped
jail cropped“A recent study conducted by the University of New Mexico found that inmates in the methadone maintenance program, which provides a daily dose of methadone to inmates already enrolled in a community-based methadone program, spent almost 40 days longer out of jail than their opiate-addicted counterparts not enrolled in a methadone program. That amounts to per-inmate savings to taxpayers of almost $2,700, according to the study, as taxpayers shell out around $69 to house an inmate per day.

The study published in early December, however, contains another finding that erases the savings: Inmates enrolled in the methadone program tended to stay in jail 36 days longer than other inmates. It’s unclear what causes methadone inmates to stay longer, though the program’s directors and others have a couple guesses – that methadone-receiving inmates are more comfortable in jail than those addicted to heroin, and that inmates getting methadone tend to prefer serving their full sentences and leaving jail without probation.”

http://www.abqjournal.com/331644/news/methadone-program-shows-mixed-results.html

Source:  ABQJournal.com – January 6, 2014

Beating the Poppy Seed Defense: New Test Can Distinguish Heroin Use from Seed Ingestion

“Heroin is one of the most widely used illegal drugs in the world, but drug testing has long been challenged by the difficulty in separating results of illicit heroin users from those who have innocently eaten poppy seeds containing a natural opiate. Research in Drug Testing and Analysis explores a new test which may present a solution to this so-called ‘poppy seed defense.’

The team sought to identify an acetylated derivative which is known to be present in street heroin, but would not be found in either poppy seeds or medicines containing opiates. The authors identified a unique glucuronide metabolite (designated ‘ATM4G’) which could be used as a marker of street heroin use. A high frequency for the presence of ATM4G in urine strongly suggests that detection of this metabolite may offer an important advance in workplace drug testing and forensic toxicology, providing a potential solution to the poppy seed defense.

‘This research report addresses a longstanding analytical problem in forensic toxicology and workplace drug testing, by identifying a urinary marker that differentiates street heroin users from those whom have ingested morphine present in poppy seeds’ said Dr. Andrew Kicman, from the Department of Forensic and Analytical Science at King’s College, London.”

http://www.eurekalert.org/pub_releases/2014-01/w-btp010714.php

Source:  Eurekalert.org – January 7, 2014

Among Prescription Painkillers, Drug Abusers Prefer Oxycodone

prescriiption pad“A nationwide survey of opioid drug abusers in rehab indicates that because of the high it produces, the prescription painkiller oxycodone is the most popular drug of choice. Hydrocodone, also prescribed to treat pain, is next in line. In all, some 75 percent of those surveyed rated one of these drugs as their favorite.

Researchers at Washington University School of Medicine in St. Louis and Nova Southeastern University in Miami questioned more than 3,500 people in 160 drug-treatment programs across the United States, asking which drugs they abuse and why. Oxycodone was favored by 45 percent, and hydrocodone was preferred by about 30 percent.

Although the drugs are meant to be taken orally, almost 64 percent of oxycodone abusers and just over one-quarter of hydrocodone abusers crushed the tablets and inhaled the drug, while one in five oxycodone abusers reported that they sometimes dissolved the drug in water and injected it. Less than 5 percent reported taking hydrocodone intravenously.

Personality, age and gender all played a role in drug preferences, the research showed. Oxycodone was attractive to those who enjoy taking risks and prefer to inject or snort drugs to get high. Young, male drug users tend to fit that profile.

In contrast, hydrocodone is the more popular choice among women, older people, people who don’t want to inject drugs and those who prefer to deal with a doctor or friend rather than a drug dealer.

The research is published in the current issue of the journal PAIN.

“Opioids are prescribed to treat pain, but their misuse has risen dramatically in recent years,” said principal investigator Theodore J. Cicero, PhD, a Washington University researcher who studies prescription drug abuse. “Our goal is to understand the personal characteristics of people who are susceptible to drug abuse, so we can detect problems ahead of time.”

Among those surveyed, 54 percent said the quality of the high was considered much better for oxycodone, compared with 20 percent who preferred the high they got from hydrocodone.

“Among the reasons addicts prefer oxycodone is that they can get it in pure form,” Cicero said. “Until recently, all drugs with hydrocodone as their active ingredient also contained another product such as acetaminophen, the pain reliever in Tylenol. That turns out to be very important because addicts don’t like acetaminophen.”

Acetaminophen causes considerable irritation when it’s injected, and when taken orally in large amounts, it can cause severe liver damage, he explained.

“Interestingly, addicts, while they’re harming their health in one respect by taking these drugs, report being very concerned about the potentially negative side effects of acetaminophen,” said Cicero, a professor of neuropharmacology in psychiatry.

Those side effects, combined with a preference for the high provided by oxycodone, have led drug abusers to seek out that drug, either on the street or by visiting physicians and attempting to convince doctors that they have pain severe enough to warrant a prescription pain killer.

Cicero is concerned with the U.S. Food and Drug Administration’s (FDA) recent approval of a new, pure form of hydrocodone without acetaminophen, a formulation he expects will be attractive to abusers.

The study also found that even among people in treatment for drug dependence, there seems to be little appetite for moving to stronger prescription narcotics such as fentanyl or various derivatives of morphine.”

The press release can be accessed at: http://news.wustl.edu/news/Pages/26204.aspx

Source: Washington University School of Medicine – November 25, 2013

 

Treatment of Opioid Dependence: A Call for an Evidence-Based Approach

evidenceDespite decades of accumulated data on the effectiveness of medication-assisted treatment (MAT), gaps remain between evidence-based standards and current practices. The authors of a recent study attribute these gaps largely to “regulatory constraints and pervasive suboptimal clinical practices.” The study appeared in August in Health Affairs; the authors are affiliated with U.S. or Canadian medical institutions. This article focuses on the findings and recommendations pertaining to the U.S.

Based on evidence from many randomized trials, large-scale longitudinal studies, and meta-analyses that show the effectiveness of MAT, the authors recommend four policy changes:

  • Eliminate restrictions on office-based methadone prescribing, and adopt the direct administration and dispensing of methadone in pharmacies. This will require changes in federal and, in some cases, state law.
  • Reduce financial barriers to treatment, such as copayment variations. Provide universal coverage for MAT via public and private insurers.
  • Reduce reliance on opioid detoxification; strong scientific evidence shows that some types are ineffective and possibly harmful.
  • Create and evaluate mechanisms to integrate emerging treatments, such as slow-release buprenorphine implants.

These steps, the authors believe, “can greatly reduce the harms of opioid dependence by maximizing the individual and public health benefits of treatment.”

Following is a discussion of the authors’ specific concerns and recommendations.

Office-based methadone prescribing. The authors note that access to methadone in the U.S. is heavily regulated and “more restricted in the United States than elsewhere in the developed world.” Fewer than 10 percent of all opioid-dependent people in the U.S. currently receive treatment—yet the number of methadone-prescribing facilities has changed little since 2002. Currently only about 8 percent of all substance abuse treatment facilities offer methadone maintenance treatment (MMT).

Treatment in doctors’ offices would offer a less-stigmatizing environment, and would facilitate care of co-occurring conditions, such as HIV and hepatitis C. Moreover, providing methadone under direct observation would virtually eliminate any risk of methadone abuse or diversion.

Experience in Canada shows that office-based MMT could greatly increase patients’ access to treatment. Canada implemented office-based MMT in 1996. In 2012, the number of patients receiving methadone treatment in British Columbia increased from 2,800 to 13,000, and in Ontario it rose from 700 to almost 30,000. These figures suggest that office-based MMT in the U.S. could help meet the increased demand that health reform is expected to produce.

Expanded access would require greater participation by physicians. The authors suggest mandating addiction education in medical schools and increasing the financial incentives for providing treatment, including specifying physician billing codes.

Financial barriers. Evidence clearly shows the economic value of treating drug dependence, yet public and private insurers do not provide widespread coverage of opioid misuse disorders. Moreover, privatization of methadone clinics is increasing, leaving few options for patients who lack insurance and are unable to pay.

Detoxification. The authors come down hard on detoxification leading to planned abstinence, calling it “the most damaging aspect of current treatment of opioid dependence.” They refer specifically to two regimens: detoxification after maintenance treatment, and detoxification (typically 12 weeks) designed to taper the methadone dose to zero. They cite evidence revealing a high risk of relapse into illicit opioid use, and an increased risk of mortality within the month after relapse. 

Potentially useful, however, is detoxification lasting up to one week, designed to treat patients who have overdosed or have severe withdrawal symptoms. Sustained abstinence is not a goal, but subsequent long-term MAT is an option patients have.

Emerging treatments. The past decade has seen several new or potential treatments for opioid dependence. They include slow-release buprenorphine implants, injectable naltrexone, and agents that bind to and activate opioid receptors (eg., injectable diacetylmorphine or heroin maintenance as a second-line treatment for heroin dependence). Although the future status of these emerging treatments is uncertain, the authors stress the benefits of having options available.

The authors note that the Affordable Care Act has the potential to eliminate gaps in treatment coverage, and it “mandates the inclusion of substance abuse and mental health services in the essential benefits that the new state insurance exchanges must offer.”

The authors also emphasize that their recommendations are initial steps, and their list is not exhaustive. “The social and structural reasons behind the low rates of access to this treatment—including stigma and discrimination perpetuated by contradictory social policies that simultaneously treat addiction as a health problem and a crime—must also be addressed.”

Reference

Nosyk B, Anglin MD, Brissette S, Kerr T, et al. A call for evidence-based medical treatment of opioid dependence in the United States and Canada. Health Aff (Millwood). 2013; Aug;32(8):1462-1469. doi: 10.1377/hlthaff.2012.0864.

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.)

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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.

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

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