Addiction Treatment Forum reports on substance abuse news of interest to opioid treatment programs and patients in methadone maintenance treatment.
The Fix evaluates Vivitrol, the newest anti-addiction drug—actually an injectable form of an old pill. It’s definitely better than nothing. But is it $1,100 a month better?
http://www.thefix.com/content/vivitrol-naltrexone-addiction-craving8033?page=all
Source: The Fix.com – April 30, 2013
“A single hospital’s costs to treat neonatal abstinence syndrome in infants born to opioid-dependent mothers who received opioid replacement therapy during pregnancy totaled more than $4 million during a 3-year period, a new study shows.
The average length of stay for infants in the study ranged from 15.1 days in year 2 to 16.2 days in year 3, Dr. Roussos-Ross reported. The average total charge per infant and per hospitalization ranged from $19,535 in year 2 to $28,592 in year 3. Hospital costs per year for treating these neonates were $1.1 million in the first year, nearly $1.5 million in the second, and $1.8 million in the third year, according to the data presented.”
http://www.medscape.com/viewarticle/803656
Source: Medscape.com – May 6, 2013
“Under healthcare reform, millions of people will become eligible for insurance coverage starting in January. The number of people seeking addiction treatment could double the article notes.
The federal government is urging states to expand their Medicaid programs. If 20 states do so, an additional 3.8 million patients with addiction problems would receive insurance, the AP notes. If almost all of the states expanded their Medicaid program, that number could reach 5.5 million. The law also designates addiction treatment as an “essential health benefit” for most commercial health plans.”
Source: JoinTogether.org – April 17, 2013
In an exclusive interview, The Fix talks with the co-chairs of the Congressional Addiction, Treatment and Recovery Caucus about what the US is getting right and wrong.
It’s been said that addiction and recovery don’t get enough attention in Washington, DC—a result of the stigma attached to the disease, as well as the reluctance of some sober people to speak out about what they and their families have been through. And the latter is precisely what is needed to push forward a positive legislative agenda on addiction and recovery, according to Rep. Tim Ryan, Democrat of Ohio, who co-chairs the 62-member Congressional Addiction, Treatment and Recovery Caucus alongside Rep. John Fleming, Republican of Louisiana, who is a physician.
Questions and Answers include:
Source: TheFix.com – May 3, 2013
This new Information Brief made available from Carnevale Associates examines the financing and provision of substance abuse treatment under the Affordable Care Act.
“In the wake of the 2010 Patient Protection and Affordable Care Act (ACA), American healthcare financing is at a crossroads. The ACA contains numerous provisions to reduce healthcare costs, improve quality, and expand coverage. In addition to offering states the opportunity to expand their Medicaid programs, the ACA features many chances to explore new funding mechanisms, including integrated care and payment models. If states adopt the ACA’s changes, the law will have profound effects throughout the healthcare industry. This brief considers the likely impact of the ACA on the financing and provision of substance abuse treatment. The ACA will:
The Information Brief concluded, “The ACA will significantly alter the behavioral health landscape, affecting clients, providers, and payers for years to come. Although it is too early to predict the exact impact of the confluence of Medicaid expansions, Affordable Insurance Market-places, EHBs, care integration, MHPAEA, and accountable payment systems, providers will surely face new clients, a notable shift in payers, and changing financing schemes. With Medicaid and private insurance set to take on larger roles, providers and clients will face serious challenges and profound opportunities.”
Source: CarnevaleAssociates.com – April 2013
“To reduce the significant burden of our Nation’s drug problem on our people and our economy, the President’s Budget supports a 21st century approach to drug policy that acknowledges drug use is a public health issue, not just a criminal justice one. Time and again, research has shown that prevention, treatment, early intervention in health settings, and smarter law enforcement efforts, working together, can make a real difference in saving lives and making our Nation safer and stronger. That’s why the Budget the President released today requests $25.4 billion in Fiscal Year 2014 to support evidence-based drug control programs – an increase of about $1 billion over FY 2012.
Most notably, the President’s Budget includes a request for an increase of $1.5 billion over the FY 2012 level to fund drug treatment and prevention services in America – a 16 percent increase over FY 2012. As a result, the President’s Budget requests more for treatment and prevention – $10.7 billion – than for Federally-funded domestic drug law enforcement and incarceration – $9.6 billion.”
The 2014 drug control budget highlights PDF file can be accessed at: http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/fy_2014_drug_control_budget_highlights_3.pdf
Source: WhiteHouse.gov – April 10, 2013
A new book on addiction was released April 2 that has received a lot of press coverage.
Amazon.com describes the book as “Addiction is a preventable, treatable disease, not a moral failing. As with other illnesses, the approaches most likely to work are based on science — not on faith, tradition, contrition, or wishful thinking. These facts are the foundation of Clean, a myth-shattering look at drug abuse by the author of Beautiful Boy. Based on the latest research in psychology, neuroscience, and medicine, Clean is a leap beyond the traditional approaches to prevention and treatment of addiction and the mental illnesses that usually accompany it. The existing treatment system, including Twelve Step programs and rehabs, has helped some, but it has failed to help many more, and David Sheff explains why. He spent time with scores of scientists, doctors, counselors, and addicts and their families to learn how addiction works and what can effectively treat it. Clean offers clear, cogent counsel for parents and others who want to prevent drug problems and for addicts and their loved ones no matter what stage of the illness they’re in. But it is also a book for all of us — a powerful rethinking of the greatest public health challenge of our time.”
The link to the book at Amazon.com is: http://www.amazon.com/Clean-Overcoming-Addiction-Americas-Greatest/dp/054784865X/ref=sr_1_4?s=books&ie=UTF8&qid=1364908254&sr=1-4&keywords=clean
Join Together interviewed David Sheff the book’s author to discuss his exploration into the science, prevention and treatment of addiction. The two part interview is available at:
http://www.drugfree.org/join-together/addiction/david-sheff-author-of-clean-interview-part-2-of-2?utm_source=Join%20Together%20Daily&utm_campaign=35128f3594-JT_Daily_News_David_Sheff_Author_of&utm_medium=email
David Sheff also wrote an opinion article for Time.com that is available at:
http://ideas.time.com/2013/04/03/we-need-to-rethink-rehab/
Sources: Amazon.com, JoinTogether, Time.com – April 2013
Legendary methadone treatment advocate Robert G. Newman, MD, is retiring. But, he hastens to add, he is not leaving the field. “What I’m leaving,” he told AT Forum in February, “is the office.”
Dr. Newman announced via a January 26 e-mail that he would be giving up his “formal role” as director of Beth Israel’s Baron Edmond de Rothschild Chemical Dependency Institute. He will continue to work through June, but Hindy Bernstein, his assistant of the past 25 years, will be leaving in April. “Hindy is leaving me for Florida,” he said. Although he will no longer have the financial support of Beth Israel, he will continue advocacy efforts.
An Advocate
“The challenges are at least as great today as they were 40 years ago when I started my advocacy work,” Dr. Newman said. He will continue to be a fly in the ointment, but he does want to see more “noise” from the rest of the opioid treatment program (OTP) community.
His days will continue to begin and end the way they have for years, he told AT Forum. “I go to the Internet, I get the Google alerts, which very often have some particularly horrendous feature that I’m obliged to respond to.”
There is a lot of “bad news” for Dr. Newman to blog, write letters to the editor, and send e-mails about. And he does so very articulately. For example, some states are cutting off methadone treatment arbitrarily, trying to limit it to one or two years. Regulators are confounding addiction and dependence, not recognizing that maintenance medication is treatment, not a “substitute” for heroin. Unbelievable as it is that this non-science is going on today, some 50 years after medication-assisted treatment (MAT) has been proven effective, and in the face of federal officials, Dr. Newman sees it happening. And he isn’t going to be quiet about it.
NIMBY
NIMBY—the “not in my back yard” phenomenon in which even people who claim to support MAT don’t want programs in their neighborhoods—is illegal, violating the Americans with Disabilities Act (ADA). But despite the various ADA wins that OTPs have achieved, they are never “precedent-setting,” and therefore need to be fought over and over again. “This is terribly frustrating to me,” said Dr. Newman.
Dr. Newman said the opioid-treatment field can help with this fight. “There are many reasons for NIMBY, and some of those reasons have to do with the field, how we have allowed our treatment, our patients, our services to be viewed,” he said. “It isn’t just misperception on the part of communities and politicians. Some of the anti-methadone- patient bias reflects the way the field has chosen to isolate itself and adopt and embrace unique practices that make this treatment separate.”
Office-based Methadone
Dr. Newman is glad that buprenorphine has been made available to OTPs and to office-based opioid treatment (OBOT) providers, as a treatment tool for caring for opioid dependence. He notes that more than 40 years ago he proposed that private physicians be permitted to offer methadone maintenance, in addition to OTPs. And now that buprenorphine can be utilized in OBOT, why not methadone, he asks rhetorically. Dr. Newman also notes the extremely limited willingness of office-based physicians to become “waivered” to prescribe buprenorphine. “I think some of the practices of programs are so foreign to what is done in every other field of medicine that medical colleagues view this as something that is from Mars and refuse to get involved in any form of opioid-dependence treatment.”
In fact, the requirement that patients go to a clinic every day is a barrier to care. Dr. Newman is skeptical about the effect of the Affordable Care Act (ACA) on OTPs in particular. “I have seen repeated references to the notion that under the ACA, there’s going to be a sudden upsurge of demand for addiction treatment,” he said. “Increased demand, maybe,” he said. “But how is that demand going to be met? You can have all the insurance you want, but an awful lot of people who need treatment will avoid OTPs because of the requirements and the stigma, and there are not that many OBOT providers.”
Nevertheless, he noted that hundreds of thousands of patients do go to OTPs for MAT, which shows how motivated these patients are. “How many people would have the motivation to deal with obesity, smoking, hypertension, or a great many other medical problems if the treatment regimen required many months of daily attendance and a host of other demands? The fact that there are 300,000 people enrolled in MAT is amazing.”
Methadone Safety and Dosing
With an appropriate dosage schedule, methadone is an extremely safe medication, said Dr. Newman. But he warned that some OTPs give induction increments that are too great. The federal regulations state that the dose on the starting day must not be more than 40 milligrams—the first dose has to be no more than 30, and an additional dose that day can be 10, said Dr. Newman. But after that, there are some programs that raise the dose too quickly. “Some programs have induction protocols of 30, 40, 50, 60, 70,” with the dose going up daily, he said. The rule of thumb—“start low, go slow, aim high”—needs more of an emphasis on “go slow.”
Federal Exclusions
Finally, Dr. Newman would like to see more support for methadone treatment at the federal level. The insurance plans of the federal Department of Veterans Affairs and the Department of Defense have an exclusion against methadone and buprenorphine maintenance treatment, something Dr. Newman has long railed against. “Tom McLellan (then deputy director of the federal Office of National Drug Control Policy) and other very high-level officials have said the exclusion is bad, and that they were trying to change it,” said Dr. Newman. “But it persists, and that’s inexcusable and shameful. “
What Dr. Newman wants advocates to do is to speak up. “Silence equals death,” he said, citing an oft-used slogan of AIDS activists years ago. And he is not going to be silent. “There are a lot of windmills still out there.”
The top state officials in substance abuse treatment approved a consensus statement in December that states that medication-assisted treatment (MAT) should be paid for by public and private health insurance plans. This was the first time that the board of directors of the National Association of State Alcohol and Drug Abuse Directors (NASADAD) approved a statement that endorsed MAT as evidence-based treatment. The statement was released January 15. It focuses on MAT for opioid addiction, and is essentially an anti-stigma document, aimed at supporting single state agencies (SSAs)—the authorities over the Substance Abuse Prevention and Treatment block grant.
The consensus statement is footnoted and includes the following assertions:
Medications such as methadone, buprenorphine, and naltrexone (both oral and extended release injection) have been shown to reduce opioid use; and naltrexone, disulfiram, and acamprosate have been shown to be effective in the treatment of alcohol dependence. The appropriate use of these medications allows individuals to experience sustained recovery from opioid and alcohol dependence, including through long-term management using medication maintenance. The medications should be made available to individuals who could benefit from them.
It is recommended that any medication-assisted treatment be combined with psychosocial and behavioral strategies that are clinically matched to the severity of the individual’s addiction.
Longitudinal studies show that treatment initiated in the criminal justice system and continued in the community garners lasting reductions in criminal activity and drug abuse. This includes medication-assisted treatment (e.g., methadone, buprenorphine/naloxone, and injectable naltrexone) for some prisoners with opioid dependence.
“There is still ambivalence around the use of addiction medications,” says Belinda Greenfield, PhD, the State Opioid Treatment Authority (SOTA) for New York. “That’s why NASADAD and the Opioid Treatment Network say MAT is important to be considered as a treatment option.” The SOTAs became part of NASADAD last year when the association formed the Opioid Treatment Network (OTN). Dr. Greenfield, president of the OTN, is also director of the Bureau of Treatment, Addiction Medicine & Self Sufficiency Services of the Office of Alcoholism and Substance Abuse Services (OASAS) in New York State.
The problem—not accepting MAT—is particularly significant outside of the methadone field, but even in the substance abuse treatment world, a substantial number of providers espouse “drug-free” treatment, says Henrick Harwood, research director for NASADAD. “Many public-sector programs feel on principle that drug-free is the best approach,” he says. . However, he points out that over the last several years, many have been changing their point of view. “There’s been growing support for MAT.”
Fight Stigma from Within
Dr. Greenfield says that opioid treatment programs (OTPs) themselves could be better advocates for MAT: they need to be vocal about the fact that patients in MAT are in recovery—they should be called “drug-free” because they’re taking a medication, not seeking a drug. “People in MAT are stable and drug-free, and are maintained on an addiction medication.”
Unfortunately, to some degree, Dr. Greenfield says, patients don’t consider themselves part of the recovery community, and that’s something that OTPs should be working to correct, partly by educating staff. “OTPs should be really actively involved in ROSC functions,” she says, referring to Recovery-Oriented Systems of Care.
It also would help for OTPs to acknowledge that it is not only methadone that constitutes treatment, but buprenorphine, and behavioral therapies as well, says Dr. Greenfield. “We need to consider addiction medications as one of the options. We can’t say we use only methadone. Patients aren’t that cookie-cutter anymore.”
The Medical Mainstream
Stigma relates directly to the mainstreaming of OTPs, says Mr. Harwood. “It’s important to communicate that methadone treatment has moved in the direction of mainstream medication.” Accreditation by the Joint Commission and CARF are helping to promote the fact that OTPs are in the medical mainstream, he says.
Dr. Greenfield also says part of making MAT better accepted means involving patients more—something that is being encouraged in the rest of medicine, as well. “The language around patient-centered care needs to be better integrated in an OTP setting,” she says, noting that patient advisory committees can be helpful in implementing patient-centered care.
Finally, OTP staff need support as well, because they feel stigmatized, says Dr. Greenfield. They should be proud to tell their family and friends that they are working in an OTP, with patients on MAT. “As long as working in an OTP setting doesn’t seem desirable, this is a problem,” she says. “How do we elevate the cachet of working in an OTP and having staff feel proud of the work we do?”
Challenges for SOTAs
In some states, SOTAs themselves have challenges promoting MAT with their own governors and legislature.
“SOTAs are doing everything they can to advocate within their own states,” says Dr. Greenfield. The problem is that despite the scientific literature, methadone isn’t well understood—the fact that it prevents relapse. “Why can’t this rest with the clinicians and physicians?” she asks. Unfortunately, there are places where the legislature and state administrations oppose methadone and OTPs. This hasn’t been a problem in New York. “But the SOTAs and the SSAs in many states have a huge undertaking and a huge task in trying to advocate for methadone.”
One argument that might help sway some MAT opponents is cost-effectiveness. Mr. Harwood notes that the literature documents the cost-effectiveness of methadone and OTPs. “This is something that advocates need to keep in mind,” he says. “It’s not just that MAT is effective. It’s a win-win for society and communities to provide MAT, especially for opioid addiction.”
For the consensus statement, go to http://nasadad.org/wp-content/uploads/2013/01/13-January-15-NASADAD-Statement-on-MAT.pdf
Prescription drug abuse—something a whole industry of monitoring and law enforcement is growing up around—is a public health problem first, according to the state substance abuse officials responsible for treatment and prevention. That said, these same directors—the single state agencies (SSAs) with authority over the Substance Abuse Prevention and Treatment block grant—also want to participate in the prescription drug abuse conversation, explains Rob Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD).
Based on an inquiry of its entire membership, NASADAD staff found that single state agencies consider prescription drug misuse and abuse very important—for some, the most important—issue they face. The inquiry took place last year and was released in fall of 2012.
Forty-seven states responded to the inquiry, which yielded the following results:
There are continued challenges to SSAs trying to address prescription drug misuse and abuse “related to data, funding constraints, collaboration, workforce development, public education, and ease of access to pills,” according to the report. It found that “although PDMPs and the data they provide are useful to SSAs, the level of oversight, access, and involvement of SSAs continues to be limited.”
Great emphasis has been placed on addressing the utility of PDMPs, but it’s important for the SSAs, as the public health and treatment experts, to be involved. SSAs would like to have more oversight, access, and involvement with PDMPs, according to the report.
In only three states—Vermont, Maine, and Maryland—is the PDMP operated under the purview of the SSA, and the agency could use the information to help get people who are misusing or abusing medications into appropriate treatment. “We have a steep growth curve here,” says Henrick Harwood, research director of NASADAD. “We need to increase the education so prescribers can help people get into treatment.”
The Office of National Drug Control Policy (ONDCP) has been very helpful in issuing a strategy and structure around which to build a public health approach to prescription drug abuse, says NASADAD’s Mr. Morrison.
Connection to MAT
There is a clear connection between prescription opioid abuse and medication-assisted treatment (MAT). Many patients newly admitted to treatment are dependent on opioids—either because they started taking them for pain, then began misusing them, or abused them from the beginning. When they try to stop, they go into withdrawal. So some states have increased training for treatment staff, in particular on prescription drug abuse and on MAT.
And there are particular challenges for states in addressing prescription drug abuse. For example, PDMP data aren’t always of good quality or easy to utilize, according to the report. And substance use disorder treatment providers don’t always have a way to access it. There is also a dearth of financial resources, with lack of adequate funding for MAT and lack of funding for naloxone overdose kits, a promising public health response to overdoses, according to the report. And there are problems with states’ proposing to restrict MAT funding.
The NASADAD report is available at: http://nasadad.org/wp-content/uploads/2012/10/NASADAD-Report-SSAs-and-Prescription-Drug-Misuse-and-Abuse-09.20121.pdf
Our first article in this series, “Becoming Addicted: It’s Different—and Riskier—for Women,” delved into the vulnerabilities that challenge women who have an opioid use disorder (OUD).
Now we examine the potentially daunting barriers women face in seeking and getting substance abuse treatment. Some barriers are largely internal, based on the woman’s attitudes; others are generated by society; still others exist within treatment programs.
As noted in the first article, few women misuse a single substance, so many studies we cite yield data for substance use disorders (SUDs) rather than for OUDs alone.
Finding Treatment
Barriers to treatment confront women from the outset, and it’s no surprise that most women with an SUD are never treated for it. Compared to men with OUDs, women are likely to be at a socioeconomic and educational disadvantage, to be underemployed or unemployed, and to have primary child-care responsibilities. Their OUD comes on more quickly, and they progress more rapidly to serious consequences. Yet women tend to see their substance abuse as stress-related, a temporary crutch that will go away without treatment.
Women are less likely than men to know how and where to get treatment. Typically they refer themselves, sometimes prompted by family or friends, or are referred by the criminal justice system or social service agencies. Men usually are referred by employers, doctors, or the legal system—sources generally considered more knowledgeable about treatment options.
Women may consider private residential clinics too time-consuming, expensive, and tightly regulated to be an option. Television and print media lead many to think that treatment means substance withdrawal, and that methadone is a drug to avoid (see Hearing Bad Things About Methadone Treatment? Thank “Dr. Drew”—Summer 2012 issue). So it’s no surprise that women account for less than half of treatment admissions for opioid abuse.
Internal (Patient-Related) Barriers
According to Susan M. Gordon, PhD, in addition to misperceptions about programs, internal barriers include low motivation for treatment, denial of problems, psychological problems, internalization of negative social attitudes toward women with SUDs, self-definition, and independent attitudes about help-seeking and self-reliance. Dr. Gordon is director of research at the Caron Foundation Treatment Center in Wernersville, Pennsylvania.
In particular, depression and anxiety may lead women to delay or do without treatment. Studies suggest that high levels of estrogen can enhance the stress response in subcortical regions of the brain, contributing to the higher prevalence of depression and anxiety in women.
Many women with an SUD have a history of sexual, emotional, or physical abuse, as well as suicidal thoughts and attempts. Post-traumatic stress disorder is common, resulting from trauma or abuse. If a woman with an SUD has a history of emotional, physical, or sexual abuse perpetrated by men—and most do—the very idea of a treatment environment that includes men can be distressing.
Women are more likely than their male counterparts to have a drug-using partner supporting her drug use. These women generally receive little encouragement to enter treatment, and may instead encounter resistance.
Health professionals are less likely to identify substance abuse in women than in men; often they refer women to mental health care providers instead of treatment programs. Women themselves are partly responsible; they often choose psychological or psychiatric help rather than substance abuse treatment. Shame and guilt, or lack of awareness of the significance or severity of their addiction, may keep them from sharing their substance history with the mental health provider. So their true problem may go undiagnosed, and they lose the opportunity for treatment for their SUD.
Social Barriers
Society stigmatizes women who abuse substances—especially women who have children or are pregnant. Communities and families often fail to provide the support women need, including child care and encouragement to enter treatment.
“Once a woman has developed an addiction, she deviates more from the female norm, compared with a man with an addiction,” according to Drs. Dorte Hecksher and Morten Hesse, writing in Women’s Issues. She’s viewed by some—and often by the woman herself—as a “fallen woman.” She worries about the disapproval of friends, family, co-workers, and employers, if she enters substance abuse treatment, especially if she is pregnant, or a mother. Her concerns about providing child care and the possibility of losing custody are a heavy burden.
Treatment Program Barriers
Denial. “Breaking the denial is a necessary first step to assisting substance-dependent women to get into treatment,” according to Ozietta D. Taylor, PhD, MEd, LCPC, assistant professor at Coppin State University, Baltimore, Maryland. The Taylor reference below discusses ways of using methods of intervention to help get a woman into treatment.
Socioeconomic barriers. Substance-abusing women are less likely than men to have insurance or full-time jobs, and public funding often means a long wait. Getting to a program is another issue; many don’t have a car or driver’s license, or even money for public transportation.
Therapies and relationships. Men tend to enter treatment with an aggrandized sense of self, according to addictions and trauma expert Claudia Black, PhD, while women are more likely to have a diminished view of themselves, because of their primary role as caregiver. Dr. Black is a senior fellow at The Meadows, a trauma and addiction treatment facility in Wickenburg, Arizona.
Women entering treatment have different needs than men. According to Mary Jeanne Kreek, MD, of The Rockefeller University, “a strong positive correlation exists between troubled relationships, family violence, sexual abuse and poor self-esteem as integral factors in substance abuse among women.” These factors don’t apply to men, and lack of gender-specific services in treatment programs is a definite barrier for women.
Women with SUDs benefit most from supportive therapies and a relationship of mutual respect, empathy, and compassion, according to TIP 51, but “the type of confrontation used in traditional programs tends to be ineffective for women, unless a trusting, therapeutic relationship has been developed.”
The Meadows in Arizona uses a multidisciplinary approach “to address women who present with more complex trauma and addiction issues, and more dual diagnoses,” according to Nancy Bailey, PhD, clinical director, who has commented that many programs still focus on one primary issue.
Overcoming Barriers
Programs can do little to overcome barriers generated by the patient and by society, but the opportunities are many once women reach treatment. TIP 51 and the Taylor reference below offer many excellent suggestions.
In particular, women need substance abuse treatment that is multimodal and addresses social services such as vocational rehabilitation. Comprehensive services can mean the difference between treatment failure and success.
Factors encouraging treatment retention include supportive therapy, a collaborative therapeutic alliance, and onsite child care and children’s services. For women who have lost child custody, comprehensive services can be a powerful motivational tool to stay in therapy. Pregnant women especially need comprehensive services. It’s estimated that as few as four percent of women are pregnant when entering treatment, and the services they sorely need are difficult to come by.
Successful treatment often means walking a fine line. Some women believe they are expected to maintain relationships, even abusive ones, and dependency or economic factors may motivate them to do so. If a woman’s drug use has involved a relationship with a spouse or significant other, OUD treatment may threaten that relationship—and the woman’s physical well-being.
Caregivers need to keep this in mind, and avoid focusing on maintaining relationships while excluding women’s other important needs. Dr. Black has stressed the importance of a woman’s building support and relationships with female peers. The insight of other women in treatment can help her work through a troublesome relationship, and, if necessary, break it off.
According to Dr. Gordon of the Caron Foundation, programs that increase the chances women will complete treatment comprise mixed-gender programs, services for women, and integrated treatment for co-occurring psychological and physical conditions.
Dr. Gordon believes that “internal and social barriers present more daunting obstacles” than treatment program barriers, and she calls for a change in public attitudes, “if women are to reduce their own feelings of shame and sense of denial.”
She maintains that these are not impossible goals. “Public education campaigns have eliminated the stigma from cancer, and have increased dramatically the numbers of people who are screened, diagnosed and successfully treated for this disease. We can achieve the same results for addiction in women.”
* * *
Sources
Back SE, Payne RL, Wahlquist MS, et al. Comparative profiles of men and women with opioid dependence: Results from a national multisite effectiveness trial. Am J Drug Alcohol Abuse. 2011;37(5):313-323. doi: 10.3109/00952990.2011.596982.
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series 51. HHS Publication No. (SMA) 09-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009. http://kap.samhsa.gov/products/manuals/tips/pdf/TIP51.pdf
Goldstein JM, Jerram M, Abbs B, Whitfield-Gabrieli S, Makris N. Sex differences in stress response circuitry activation dependent on female hormonal cycle. J Neurosci. 2010;30(2)431-438. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827936/
Gordon SM. Barriers to treatment for women. Counselor. 2007; 8(3):22-29.
Hecksher D, Hesse M. Women and substance use disorders. Women’s Issues. 2009;7(1):50-62. doi: 10.4103/0973-1229.42585. PMID:21836779. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3151455/
Jamison RN, Butler SF, Budman SH, Edwards RR, Wasan AD. Gender differences in risk factors for aberrant prescription opioid use. J Pain. 2010;11(4):312-320. doi:10.1016/j.pain.2009.07.016.
Kreek MJ, Borg L, Ducat E, Ray B. Pharmacotherapy in the treatment of addiction: Methadone. J Addict Dis. 2010;29(2):200-216. doi:10.1080/10550881003684798. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2885886/
National Abandoned Infants Assistance Resource Center, UC Berkeley. Prenatal Substance Exposure. Fact Sheet. http://aia.berkeley.edu/media/pdf/AIAFactSheet_PrenatalSubExposure_2012.pdf
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2000-2010. National Admissions to Substance Abuse Treatment Services. DASIS Series S-61, HHS Publication No. (SMA) 12-4701. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. http://www.samhsa.gov/data/2k12/TEDS2010N/TEDS2010NWeb.pdf
Patients in methadone maintenance treatment (MMT) exchange a variety of prescription drugs—but little is known about why this happens, and how common it is.
Given the risks of this practice—drug interactions, side effects, addiction, antibiotic resistance, birth defects, and possible interruption of MMT—a group affiliated with Butler Hospital and Brown University, Providence, RI, decided to find out. They published their findings in the January 1, 2013 issue of Drug and Alcohol Dependence. From December 2008 through January 2012, the team screened 767 individuals who enrolled in a smoking cessation trial in nine MMT sites in Southern New England. Characteristics of the 315 participants recruited were:
Study Results
About 79 percent of participants had been prescribed at least one medication during the previous year. The drugs include allergy medications, antibiotics, blood pressure medications, erectile dysfunction drugs, antidepressants, tranquilizers, and drugs of abuse: sedatives, medications for ADHD, sleep medications, pain medications, and Suboxone (buprenorphine and naloxone).
About 20 percent of participants reported sharing their medication, and almost 40 percent said they had used medication not prescribed to them. While these rates may not be significantly higher than those in the general population, they represent a substantial risk to MMT patients. According to the Centers for Disease Control and Prevention (CDC), people with substance abuse histories are particularly vulnerable to overdose and adverse events related to illicit prescription drug use. Moreover, the authors note that MMT confers significant health benefits, and continued use of non-prescribed prescription medications may interrupt treatment.
Medications most often shared (given or sold) and received (borrowed or bought) were those with abuse potential—pain medications, sleep medications, and sedatives.
Sources of Drugs of Abuse
|
Sources, by Patients’ Responses |
|||||
|
Drug |
No. of Patients |
No. of Responses |
Given by Friend or Family Member, No. (%) |
Bought From Someone Patient Knew, No. (%) |
Bought on The Street, No. (%) |
| ADHDa medications |
8 |
9 |
6 (66.7) |
0 (0.0) |
3 (33.3) |
| Pain medications |
61 |
71 |
39 (54.9) |
2 (2.8) |
30 (42.3) |
| Sedatives |
61 |
78 |
45 (57.7) |
10 (12.8) |
23 (29.5) |
| Sleep medications |
43 |
41 |
40 (97.6) |
1 (2.4) |
0 (0.0) |
| Suboxoneb |
34 |
40 |
16 (40.0) |
0 (0.0) |
24 (60.0) |
aAttention deficit hyperactivity disorder.
bBuprenorphine and naloxone.
As the table shows, patients generally received medications of abuse from friends or family, rather than buying them. Of interest, the only exception was Suboxone; 40 percent of patients (n=16) received the buprenorphine and naloxone medication from friends or family, and 60 percent (n=24) bought it on the street. In contrast, 66.7 percent of patients received their ADHD drug from friends or family, and 33.3 percent bought on the street; the corresponding percentages for pain medications were 54.9 from friends or family, 42.3 from street purchases, and 2.8 from acquaintance purchases.
The authors commented that the frequent receipt of buprenorphine from nonmedical sources “is consistent with an earlier study of opioid users, where 76% reported that they had used illicit buprenorphine.”
The authors did not list the specific prescription sedatives and pain medications bought on the street, but the former group includes benzodiazepines and barbiturates, and the latter group, opioids and nonsteroidal anti-inflammatory drug (NSAID) combinations.
Reasons for Exchanging Medications of Abuse
The only factor significantly associated with sharing drugs of abuse was younger age.
Four factors were significantly associated with receiving medications of abuse: younger age, being male, recent use of heroin or cocaine, and financial hardship.
The authors noted the important impact of financial hardship and low socioeconomic status on sharing and receiving. In the previous 6 months, 21 percent of the study population had at times gone without food, clothing, or housing to pay for medicine, and 8 percent had gone without needed medical care to pay for those necessities.
Moreover, the MMT population “has high rates of being uninsured or underinsured”—thus is more likely to share and receive various medications, not just illicit opioids. Many participants had public rather than private insurance, so “medication access, continuity, and affordability may still be a concern,” the authors said.
Value of the Study
This early study sheds light on the high rate of medication exchanges among MMT patients, and on some characteristics that lead to sharing and receiving—in particular, vulnerability, financial hardship, “and the need to self-medicate a physical health problem.”
These reasons underscore the need for better approaches to help this at-risk population. The authors note that while many resources for studying, defining, and understanding prescription drug exchange focus on trafficking, “doctor shopping,” and internet purchase of illegal prescriptions, prescription medication sharing also contributes to illegal use.
Reasons for sharing and receiving need further examination both to prevent the exchange of prescription drugs and to “maximize care to a vulnerable and underserved population,” the authors said.
* * *
Caviness CM, Anderson BJ, de Dios MA, et al. Prescription medication exchange patterns among methadone maintenance patients. Drug Alcohol Depend. 2013; 127(1-3):232-238. doi: 10.1016/j.drugalcdep.2012.07.007.
First, Maine imposed two-year caps on methadone and buprenorphine treatment, if paid for by MaineCare, the state’s Medicaid program. The caps were due to take effect January 1, but treatment advocates were able to work out a medical-necessity exemption, which said that as long as patients were doing well, they could stay past the two-year limit.
Never mind that this made no sense—patients who are not doing well should be kicked off treatment—to go where, the streets? In any event, it was better than nothing. But in March, a new bill was introduced that would have eliminated even the medical necessity exemption. Two years on treatment, and that’s it.
Mark Publicker, MD, president of the Northern New England Society of Addiction Medicine, who helped lead the advocates’ battle for the medical necessity exemption, is “back in the saddle”—pressing the state legislature and the regulators for a reasonable approach.
Under the proposed bill, as of January 1, 2015 no patient would be allowed to be on methadone or buprenorphine for more than two years, if paid for by Medicaid.
“It’s outrageous,” he told AT Forum.
The Affordable Care Act (ACA) will revolutionize the field of substance abuse treatment, according to A. Thomas McLellan, PhD, CEO and co-founder of the Treatment Research Institute.
“As addiction becomes treated as a chronic illness, pharmaceutical companies will be much more interested in developing new medications. “Immense markets are being created,” he said. “Until now, there have been about 13,000 treatment providers for substance use disorders, and less than half of those are doctors. Now, 550,000 primary care doctors, in addition to nurses who can prescribe medications, will be caring for these patients.”
Source: JoinTogether.org – February 27, 2013
“A law that makes it easier for Americans to gain access to mental health and substance abuse services is working to get patients hospital care, but rapidly rising out-of-pocket costs could deter many from treatment, new research indicates.
A new study from the nonprofit Health Care Cost Institute showed a 19.5 percent increase in hospital admissions for substance abuse treatment in 2011, which was the first year most employers began adhering to new rules finalized for the Mental Health Parity and Addiction Equity Act, which was passed by Congress and signed into law in 2008 by then President George W. Bush.
For example, the average price paid by an employer and worker for a substance abuse admission in 2011 was $7,230 with the consumer’s share of out-of-pocket costs at $889, or 12 percent of the total cost. Meanwhile, the average price paid by an employer for a “medical/surgical” admission in 2011 was three times that, or $20,103 but the co-payment was more than $100 cheaper at $796, or just four percent of the share of out-of-pocket costs.”
The Forbes article can be accessed at: http://www.forbes.com/sites/brucejapsen/2013/02/27/mental-health-law-increases-access-to-substance-abuse-treatment-but-costs-rising/
The Health Care Cost Institute report can be accessed at: http://www.healthcostinstitute.org/news-and-events/press-release-impact-mental-health-parity-and-addiction-equity-act-inpatient-admissi
Source: Forbes.com – February 27, 2013
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