AATOD Issues Five-Year Plan: Bottom Line Focus Is Still on Stigma
Study: Benzodiazepines + Prescription Opioids = Caution Needed!
California Will Use Cures Act $80 Million To Expand Treatment With Hub-And-Spoke System
SAMHSA Develops MAPS Project to Determine Where OTPs Are Needed
Buprenorphine Dispensing Problems in Virginia: Coal Country Rules
Why Women Use—and Misuse—Opioids
Tennessee Bill Would Place Full Liability on OTPs for Car Accidents
Mobile Vans: Not Ready for Prime Time
AATOD Issues Concise, Focused Benzodiazepine Guidelines
By Alison Knopf
The five-year plan of the American Association for the Treatment of Opioid Dependence (AATOD) has a goal of increasing access to care in opioid treatment programs (OTPs). Treatment “wherever it is needed”—in the United States and in the world—with the aim of patient care, is a theme running throughout the document.
The first strategic five-year plan was approved in 2001, and updated in 2007 and 2012. The current plan is for 2017-2021.
Sustainability was a guiding principle, with initiatives aimed at expanding access to OTPs, increasing access to third party funding, and working with the World Federation for the Treatment of Opioid Dependence.
AATOD will work with its partners, including the Substance Abuse and Mental Health Services Administration (SAMHSA), to accomplish the following goals:
- Identify existing treatment resources for opioid dependent individuals
- Identify where treatment is needed in underserved areas of the country
- Identify what financial resources are needed
- Work with the criminal justice, behavioral, and primary medical care systems to ensure patients receive comprehensive and coordinated care
AATOD will strive to increase care in drug courts and correctional facilities, as well as in the rest of the criminal justice system, working with the Legal Action Center and other policy partners. This year AATOD will release a criminal justice fact sheet on OTPs.
Below are other key areas highlighted by the five-year plan.
Integrated Service Delivery
The three policy papers developed by AATOD for SAMHSA last year will be the foundation for better integration of care with OTPs and other health care settings. Key to this is reimbursement from third-party payers.
- Medicaid: There are still 16 states that do not allow use of Medicaid funds for OTPs. AATOD will provide guidance to help increase such reimbursement.
- Medicare: Last year, the Centers for Medicare and Medicaid Services (CMS) determined that it does not have the authority to allow Medicare to pay for OTP services. The plan is for AATOD to work with the White House Office of National Drug Control Policy (ONDCP), Medicare, and Congress to make it possible for Medicare to pay for OTP treatment. Again, the leadership of the current administration will be crucial to determining the outcome of these efforts.
- Commercial insurance companies: AATOD will work with commercial insurance companies on model contracts that would allow reimbursement to OTPs. There would also be cross-training opportunities so that insurance companies could better understand what OTPs do.
Working With Partners
- Educating Congress: AATOD developed an educational initiative aimed at Members of Congress, some of whom don’t understand how OTPs function or what services are provided, and the misunderstanding of medications—especially methadone—needs to be rectified. This will require financial resources to coordinate how OTP administrations and patient advocates can meet with Congressional representatives both in district offices and in Washington, D.C.
- Federal Agencies: AATOD will also work with federal agencies, building upon relationships with the ONDCP, SAMHSA, the Drug Enforcement Administration (DEA), the Food and Drug Administration, the National Institute on Drug Abuse, and other federal agencies. With SAMHSA, a key focus will be on cross-training initiatives, enabling OTPs to work with the states. With the DEA and SAMHSA, AATOD will focus on the Narcotic Treatment Program Guidelines, expected out during 2017.
- AATOD will continue to promote all medications approved to treat opioid use disorders through OTPs. This is important if OTPs are to be the “essential hub treatment sites” for opioid use disorders.
- Conferences, Webinars, Communications: AATOD conferences, which began in 1984, are a way to showcase leading initiatives and training to OTP staff. Conferences promote evidence-based practices and patient-centered care. Webinar-based training resources will continue to be used to advocate for AATOD’s goals. The AATOD website itself promotes new training opportunities and helps ensure wide dissemination of policy documents. There will be a mobile version of the website for access on phones and other devices.
- International Work: AATOD will continue to work with the World Federation for the Treatment of Opioid Dependence and EUROPAD in increasing access to treatment. The United Nations Office on Drugs and Crime is also helping to increase resources for developing programs. Vietnam and African nations have been using PEPFAR funds to increase access to care. (PEPFAR—the President’s Emergency Plan for AIDS Relief—was created in 2003 to help certain hard-hit countries combat HIV/AIDS, TB, and malaria in hard-hit countries.) AATOD will continue to work with international and United States government organizations to promulgate evidence-based treatment.
- Prescription Drug Use: AATOD will continue working with the Denver Health and Hospital Authority’s RADARS System on patterns of prescription opioid use and heroin use, and with NDRI, AATOD’s research partner, to understand how OTPs can respond to changes in drug use patterns in different parts of the country. Prescription drug monitoring programs (PDMPs) are also important to OTPs. Patient care improves when OTPs access PDMP databases. Finding out what other medications their patients are taking provides increased opportunities for counseling as well.
One of the biggest challenges OTPs have faced—and still face—is opening new facilities. This is part of the challenge AATOD is taking up: how to educate “a wary American public” to overcome the stigma of using medications to treat opioid use disorders.
“Our focus has always been to improve access to care, and when such access is available to be certain that the quality of care is evidence driven and patient centered,” the five-year plan document concludes. “It is anticipated that the next several years will continue to represent major challenges to our system. It is critically important to educate Members of Congress, state legislatures and the American public about the value of treating opioid addiction with medications based on evidence.”
The full version of the plan can be accessed at: http://www.aatod.org/2017-2021/
An executive summary of the plan can be accessed at: http://www.aatod.org/aatod-five-year-plan-executive-summary/
Categories: Addiction, Drug Courts & Criminal Justice, Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids, Overdose
Tags: AATOD, Criminal Justice, Drug Courts, Medicaid, Medicare, Methadone Treatment, Opioid Treatment Programs, SAMHSA, Stigma, Substance Abuse Treatment
By Barbara Goodheart, ELS
Benzodiazepines help patients cope with severe anxiety, panic disorder, or sleep problems; prescription opioids can help relieve severe pain. When prescribed appropriately and with sufficient monitoring, either medication is relatively safe, especially for short-term use.
If a health professional decides a patient needs the benefits of dual therapy—an opioid plus a benzodiazepine—careful monitoring becomes especially important. Either medication can cause respiratory depression, and the combined respiratory effects can lead to serious problems; overdose, even death. Yet, according to the authors of the study described below, dual prescribing is becoming an increasingly common therapeutic tool.
A team from Stanford University School of Medicine, the University of California at San Francisco, and the VA Palo Alto Health Care System, undertook a study to identify the effects of therapy combining an opioid with a benzodiazepine. Using data from 315,428 privately insured U.S. patients aged 18-64 who had dual prescriptions, the team determined the yearly incidence of hospital visits for opioid overdose. BMJ published the results of the study on March 14.
Dual Prescribing: Up Sharply
In 2001, only about 1 in 10 patients taking opioids were also taking a benzodiazepine; by 2013, the figure had almost doubled. Driving the increase was a rise in the number of patients taking an opioid intermittently rather than chronically.
Today, benzodiazepines are present in about 1 in 3 fatalities attributed to “opioid” overdoses, a finding that is causing increasing concern among policymakers and caregivers.
In 2016, two government agencies became sufficiently alarmed to take action. The Centers for Disease Control and Prevention (CDC) published guidelines urging clinicians to avoid prescribing benzodiazepines and opioids simultaneously. The Food and Drug Administration (FDA) established a requirement for Black Box warnings—the highest alert level—on product labels and other printed material, noting the problems associated with dual prescribing.
Key Data on Dual Prescribing
In their report, the authors of the BMJ study underscored key data:
- Patients who used opioids with benzodiazepines were at a “substantially higher risk” of emergency department visits or inpatient admissions for opioid overdose; moreover, the authors found that this group had a “tenfold increased risk of death from overdose”
- Providers could lower the risk of emergency room visits or inpatient admission for opioid overdose by 15%, by eliminating simultaneous use of benzodiazepines and opioids
The authors compared their results with those from several other studies:
- A VA study found that of patients using opioids, nearly one in three were also taking benzodiazepines; dual use was linked with an increased risk of death attributed to opioid overdose
- Almost 4 of every 5 patients taking an opioid were also taking a benzodiazepine; this group faced “a tenfold increased risk of death from overdose”
- A study in Ontario, Canada using toxicology analysis identified benzodiazepines as involved in 60% of deaths from opioid overdose
The authors do not make a blanket recommendation that dual prescribing should be eliminated, but they do recommend that providers “exercise caution in prescribing opioids for patients who are already using benzodiazepines (or vice versa), even in a non-chronic setting.”
Based on their data, they see a similar risk for chronic and intermittent opioid users, and they note that opioids “should be prescribed cautiously—even if only for a short term course—among patients who are also using benzodiazepines.”
The authors also suggest that policymakers and providers focus not just on opioid prescribing, but on benzodiazepine prescribing as well, so they “can play an important role in mitigating the risks of opioid prescriptions.”
They recommend educational programs warning prescribers and patients about the risks of dual prescribing, and suggest that the Veterans Health Administration’s system-wide opioid safety initiative (https://www.va.gov/PAINMANAGEMENT/Opioid_Safety_Initiative_Toolkit.asp) could be used as a model.
See related article in this issue on AATOD Issue Benzodiazepine Guidelines for OTPs available at: http://atforum.com/2017/04/aatod-issues-concise-focused-benzodiazepine-guidelines/
Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey S. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ. 2017;356:j760. doi: https://doi.org/10.1136/bmj.j760.
Karaca-Mandic P, Meara E, Morden NE. The growing problem of co-treatment with opioids and benzodiazepines [editorial]. BMJ. 2017;356:j1224. doi: https://doi.org/10.1136/bmj.j1224.
By Alison Knopf
The Cures Act, signed in December 2016 by President Obama, gave $920 million over a two-year period to states to devote to opioid use disorder treatment. States submitted their applications for funding to the Substance Abuse and Mental Health Services Administration (SAMHSA), and are already making plans with what to do with their money.
California is getting $40 million a year for two years, and it’s going to use it to develop a hub-and-spoke model similar to that in Vermont. Jason Kletter, PhD, president of California Opioid Maintenance Providers, whose BAART clinics are providers in Vermont, told AT Forum how the project will work in California.
Cures Act Allocations Will Expand Access to Programs
States get a Cures Act allocation based on need, and in California, the money will be used to expand access to Opioid Treatment Programs (OTPs). OTPs will be the center of the system—the hub—and office-based opioid treatment (OBOT) will be the spokes.
“Hub and spoke is a great model to expand access, to get more doctors involved and more community prescribers,” Dr. Kletter said.
States had the benefit of SAMHSA’s maps (see related story), which helped indicate where treatment is needed. Of course, COMP already knows. And the problem in California is typical of the problem in New York—many programs in urban areas and none in rural areas. For Vermont, basically a rural state, the issue was that treatment was needed everywhere.
“We’ve got a density of programs in Los Angeles and very few in the north above Sacramento,” said Dr. Kletter.
Fewest Overdoses in Counties With OTPs
One national map—the so-called heat map published in the New York Times (https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html)—shows where overdose deaths are. This map can be compared to the SAMHSA map showing where OTPs are. “The counties with the most overdoses are the ones with no OTPs,” said Dr. Kletter. “That makes sense to us. It’s a striking visual to see those two maps side by side.”
Officials in California hope that Cures Act money will be used to develop programs where they don’t currently exist. The OTPs would help people move across the continuum of care—which is what often happens in reality. “When someone relapses, it’s important to get them back to a center of excellence, and keep them there until they are stable and doing well,” he said.
The hubs are OTPs that conduct assessments on new patients, stabilize them, and, if the patients are taking buprenorphine and determined a good fit for OBOT, they will go to the spokes. “If they’re taking methadone, they won’t be going out to the spokes, but if they’re taking buprenorphine they can be stepped down” said Dr. Kletter. Some patients being treated with buprenorphine will remain in the OTPs, due to needed extra services provided in that setting, just as is currently happening in Vermont.
“There isn’t a goal either way—keeping people in one setting or another,” said Dr. Kletter. “The goal is to get people to the right setting. If they’re stable and doing well, they should be in a less restrictive setting.” Patients taking methadone, as he mentioned, must remain in an OTP, due to federal regulations.
“I’m very proud of our state for using this money in this way,” said Dr. Kletter. “This Cures Act program is intended to be a rapid response to increasing access, and the hub-and-spoke model is a proven strategy for increasing access based on the strengths of the existing OTP system.”
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Methadone, Newsletter, OBOT, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Addiction, Buprenorphine, Methadone Treatment, Substance Abuse Treatment
By Alison Knopf
The Center for Behavioral Health Statistics and Quality (CBHSQ) has been hard at work determining where in each state opioid treatment programs (OTPs) are needed, due to lack of services. CBHSQ is a division of the Substance Abuse and Mental Health Services Administration (SAMHSA).
The maps won’t be ready for public distribution until later this spring, but SAMHSA gave states preliminary drafts to help them prepare their applications for Cures Act funding. Those applications were due February 17 and went through Single State Authorities in charge of the Substance Abuse Prevention and Treatment (SAPT) block grant, also administered by SAMHSA.
Funding for Opioid Use Disorders
The Cures Act was passed by Congress and signed by President Obama in December of 2016. It provides $500 million in funding for each of fiscal years 2017 and 2018, 80% of which must go directly to treatment for opioid use disorders.
This is an excellent opportunity to bring what’s being done best in some states to other states—for example, the Hub and Spoke system of Vermont (in fact, through the Cures Act money, California is now going to adopt this system—see related story).
“It’s too early to put the maps out in public,” Kimberly A. Johnson, PhD, director of SAMHSA’s Center for Substance Abuse Treatment, told AT Forum. CBHSQ is working on an academic paper describing the methodology for the maps, she said, adding, “We want to make sure that we haven’t left anything out” that would make the methodology inaccurate.
According to Dr. Johnson, useful data for determining where the needs are include more requests for treatment, waiting lists at current OTPs, and higher rates of overdose. Poison control centers also have important information, she said.
There are ways that treatment can be expanded in current OTPs, but they are problematic. Interim methadone isn’t a solution for many programs; although it would allow them to enroll new patients without providing extra services, such as counseling, the additional services would have to be in place within 120 days.
The Africa story Dr. Johnson tells—of clinics that simply give methadone to anybody who comes in and needs it—is not possible in the United States, due to regulations. Why can’t it happen here? “It should,” she said.
Goal: Expand Access to Care
In the meantime, SAMHSA is working on expanding access to care. “That is a clear goal for us,” said Dr. Johnson. “That is a goal that the administration has expressed, including expanding funding to the States.”
Categories: Addiction, Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Opioid Treatment Programs, Overdose, SAMHSA, Substance Abuse Treatment
By Alison Knopf
The Virginia Board of Medicine, backed by the state, has banned the use of buprenorphine with the exception of treating pregnant patients in both office based opioid treatment (OBOT) programs and in opioid treatment programs (OTPs). OTPs may use the mono-product for on-site administration but no longer may use it for take-homes. Part of a broad set of regulations aimed at opioid prescribing in general, including for pain, this was a surprising turn of events in a state where OTPs have been dispensing take-home buprenorphine mono-product for years.
The reasoning for the decision by the Board of Medicine was that the mono-product would be diverted.
“Approximately 1,100 Virginians died of an opioid overdose in 2016, a 30% increase over 2015,” said Maria Reppas, communications director for the Richmond Department of Behavioral Health and Developmental Services (DBHDS). “DBHDS has worked closely with the Board of Medicine and other state agencies, state and local organizations, and concerned citizens to address this epidemic,” she added. “DBHDS supports the actions of the Board of Medicine to improve patient health and safety in the treatment of the deadly epidemic disease of opioid addiction.”
In Virginia, there “continues to be concern about diversion of buprenorphine products, which contributes to opioid abuse,” she said, noting that the sublingual combination product containing naloxone was developed to curtail this risk. The governor’s task force therefore recommended that the Virginia Board of Medicine, in collaboration with DBHDS, convene a workgroup of physicians experienced with utilizing buprenorphine to review standards of care from a variety of sources. The result was a guidance document, which then became the regulations.
Buprenorphine with naloxone cannot be melted down and injected, as the naloxone would render the buprenorphine inactive. However, the generic mono-product is much less expensive than the combination buprenorphine-naloxone product.
Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), wrote to William L. Harp, MD, executive director of the Virginia Board of Medicine, in February, describing the regulations governing take-home medication from OTPs. The OTPs are also conservative in providing the patient with any take-home medication. From the letter:
“Generally speaking, most patients are being medicated at the OTP five days per week,” the letter continued. When take home medication is provided to the patient through the OTP, the patient must meet eight clinical standards, which have been enforced since the regulatory authority of the Food and Drug Administration that continued under the regulatory oversight of the Substance Abuse and Mental Health Services Administration (SAMHSA).
“These criteria include absence of recent drug abuse, which is determined through toxicology reports in addition to established regularity of clinic attendance, absence of serious behavioral problems, absence of known recent criminal activity, stability in the patients’ home environment, length of time in comprehensive maintenance treatment, ensuring that take home medication can be safely stored within the patient’s home and whether the rehabilitative benefit the patient derives from decreasing the frequency of clinic attendance outweighs potential risk. Compliance with the regulations is mandatory.
“The Virginia Department of Behavioral Health and Developmental Services gave approval to OTPs to begin using the mono-formula of buprenorphine in OTPs under the rules and regulations that are in place or all methadone maintained patients,” Mr. Parrino’s letter noted.
Mr. Parrino also noted that in Virginia, the coal mining industry is biased against treatment using methadone. Despite the fact that it would be a violation of the Americans with Disabilities Act, employers would likely terminate someone even for the therapeutic use of methadone. The same bias does not exist for buprenorphine, which is why some patients in Virginia prefer it.
There were about 600 patients in Virginia being treated in OTPs with the mono-buprenorphine product at the time the ban went into effect.
About 300 patients were being treated using the mono-buprenorphine at the four Acadia Healthcare treatment centers in Virginia. The same criteria used for take-home privileges for patients being treated with methadone were used for take-home buprenorphine, said Ed Ohlinger, Acadia Healthcare’s Regional Director for Virginia and North Carolina.
The history is this: 10 years ago, the Virginia State Opioid Treatment Authority (SOTA) gave OTPs permission to give take-home buprenorphine-naloxone–at the time, the only available product was the Suboxone tablet. About 5 years ago, when the tablet was replaced with film, the price became unaffordable for patients. But the generic mono-product was affordable, and that’s what the OTPs were dispensing.
“We know the mono-product brings to treatment people who wouldn’t come if the only medication available was methadone,” said Mr. Ohlinger. “The coal mining industry has a zero tolerance for methadone,” he said. “This is a longstanding Appalachian phenomenon.”
Absorbing Costs of the Combination Product
So when the new rules were announced, Acadia switched all of its mono-buprenorphine patients in Virginia to the combination product, and—at least for now—is absorbing the added costs. “We have not increased their rates to stay in treatment, as we continue to work closely with the medical board,” said Mr. Ohlinger, who was in the process of appealing the regulations to get a special exemption for OTPs. “We’re incurring significantly higher medication costs at the present time. We’re not passing that on until we get through an appeal and see where we go—it is what it is, and Acadia has chosen to do the right thing.”
Of the 300 patients being treated by Acadia at the time of the ban, nine have transferred to treatment programs in North Carolina either because of an allergy to naloxone or because they have not done well on the combination product in the past, said Mr. Ohlinger.
But things are looking up. At the end of March, representatives of the Virginia Board of Medicine attended part of the Virginia Provider Association’s 10-year anniversary conference. “We had a very frank, very open, positive 45-minute conversation where we clearly delineated for them why we are different from OBOTs [office-based opioid treatment],” said Mr. Ohlinger.
There is a problem with diverted mono-buprenorphine, as found in recent arrests and other criminal activities. “But this is mono-product that was coming out of OBOTs in North Carolina, Tennessee, and Kentucky,” he said. “I know that some OBOT practices do a really good job, but we know that some don’t provide any services” other than induction and prescribing of buprenorphine.
The situation is reminiscent of what happened a decade ago, when methadone diverted from pain clinics was blamed on OTPs. “This is history repeating itself,” said Mr. Ohlinger.
The Board of Medicine officials “walked us through the process for filing an appeal, or through a process that could exempt us from the regulations,” said Mr. Ohlinger. “They were very open-minded to our explanation about what we do.”
A decision from the Board of Medicine was expected in early April.
For more information, see:
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Newsletter, OBOT, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Buprenorphine, FDA, Methadone Treatment, naloxone, SAMHSA, Substance Abuse Treatment
By Barbara Goodheart, ELS
How different are women from men, when it comes to using—and misusing—opioids?
More different than you might think, it turns out, according to CDC Vital Signs, a publication of the Centers for Disease Control and Prevention. Women are more likely than men to have chronic pain, and to use prescription opioids for longer periods, in higher doses. They also tend to become physically dependent on opioids more easily than men, even after using smaller amounts for shorter periods.
The outcomes of opioid use and misuse reflect women’s greater susceptibility. Between 1999 and 2010, overdose deaths from prescription pain killers increased 237% among men, but the rise was far higher among women—more than 400%.
The situation with heroin usage is similar. CDC Vital Signs indicates that between 2002 and 2013, heroin use rose 50% among men, but it increased 100% among women. These examples are from a new 35-page report, White Paper: Opioid Use, Misuse, and Overdose in Women, published in December by the Office on Women’s Health (OWH), U.S. Department of Health and Human Services (HHS).
This article summarizes the White Paper and highlights important data about women and opioid use and misuse.
Overview: The HHS White Paper
Contents. The White Paper opens with a description of the opioid epidemic and the three areas of the HHS Opioid Initiative (see table), then moves on to prevention and treatment of opioid use disorders (OUDs).
|HHS Opioid Initiative
In addition to citing data, the White Paper highlights factors involved in a woman’s path to opioid misuse, among them life experiences, biological and social influences, geography, and demographic characteristics.
Purpose. The White Paper was commissioned to educate enrolled participants in advance of a September 2016 HHS-OWH national meeting. The goal of the meeting was to prepare participants to understand the impact of the opioid epidemic on women, across age, race, geography, and income, and to issue a post-meeting report on possible solutions to some of the problems discussed in the White Paper.
Underlying Psychological Differences in Women Lead to Riskier Behavior
Why do women behave differently from men when it comes to opioids? Psychological differences, such as women’s more intense opioid cravings, account for some of the riskier behavior. While both sexes are susceptible to psychological and emotional distress, a key difference exists: these distresses are actual risk factors for hazardous prescription opioid use in women, and only in women, studies show; men react to these distresses in other ways.
SAMHSA data (2015) reveal that 4% of females ages 12 and older misused prescription pain relievers during the previous year. Because misuse often leads to involvement of the health care system, it’s not surprising that, CDC data show, every three minutes another woman visits an emergency department because of prescription painkiller misuse.
Women with a substance use disorder are at increased risk of injection drug use, which can lead to viral hepatitis or to HIV. From 2010 to 2014, new cases of hepatitis C among women rose more than 260%—with substance use in part responsible. Younger women risk transmitting the infection to their infants—yet many, serving as caregivers and lacking childcare options, find it difficult to arrange for treatment for their disorder.
Preventing OUDs and Overdoses in Women
Few data exist on preventive measures for women, and studies tend to involve substances other than opioids. The tendency of women to quickly become physically dependent on opioids, mentioned earlier, involves several physiological differences that exist between men and women: metabolic rate, hormone levels, and percentages of body fat. With the risk of opioid-related harm higher in women, investigators see screening and early intervention as key steps in helping to protect women from OUDs and overdoses.
The HHS Opioid Initiative
Opioid Prescribing Practices
Between 2008 and 2012, more than one-third of Medicaid-enrolled women aged 18-44 and more than one-fourth of privately insured women in the same age group were prescribed opioids.
Expanding Naloxone Use in Women
Naloxone offers potentially life-saving treatment, but is under-used in women. A 2016 study found that men were almost three times more likely than women to be given naloxone in resuscitation efforts. With a nasal spray and an auto-injector formulation now available, perhaps more women who need naloxone will be able to obtain it.
The White Paper notes: “Given the trends in increased heroin use among women, increased availability and usage of naloxone may soon be that much more critical to prevent death from overdose among women.”
MAT for Women
Despite “overwhelmingly positive” evidence that MAT is effective, and a recommendation from the CDC that patients with an OUD be offered MAT, each year only 20% of adults—men and women—with an OUD receive MAT. The barriers: cost, access, and stigma.
Many women with an OUD lack the financial and child-care resources available to other women. Even those who can find affordable treatment and decide to enter a program may have problems arranging for child care.
In response to the increasing impact of the opioid crisis on women, the HHS OWH held a national meeting on September 29-30, 2016. The meeting convened a national conversation on how best to address some of the problems described in the White Paper. AT Forum will check with HHS OWH later regarding its findings and recommendations, and, if appropriate, will publish a follow-up article.
* * *
AAFP Supports Turn the Tide Rx Campaign to End Opioid Abuse. August 9, 2016. American Academy of Family Physicians Web site. http://www.aafp.org/news/health-of-the-public/20160809turntide.html. Accessed April 12, 2017.
Anson P. Post-Surgical Pain Guidelines Reduce Use of Opioids. Pain News Network Web site. February 18, 2016. https://www.painnewsnetwork.org/stories/2016/2/18/guidelines-for-post-surgical-pain-discourage-use-of-opioids. Accessed April 12, 2017.
CDC Vital Signs citing National Survey on Drug Use and Health 2002-2013. http://www.cdc.gov/vitalsigns/heroin/index.html#modalIdString_CDCImage_0. Accessed April 12, 2017.
Center for Substance Abuse Treatment. Chapter 13 – Medication-Assisted Treatment for Opioid Addiction During Pregnancy. In: Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.) http://www.ncbi.nlm.nih.gov/books/NBK64148/# 6.
Chou, R. et al. Management of Postoperative Pain: A Clinical Practice Guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. February 2016, Volume 17, Issue 2, Pages 131-157. http://www.jpain.org/article/S1526-5900%2815%2900995-5/fulltext#back-bib18. Accessed April 12, 2017.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. doi: http://dx.doi.org/10.15585/mmwr.rr6501e1.
Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.
By Alison Knopf
A bill winding its way through the Tennessee legislature would make opioid treatment programs (OTPs) liable for any injury or death caused by a patient who had just received methadone. This is similar to laws that hold restaurants and bars liable for injuries or deaths caused by people driving drunk after consuming alcohol at their establishments.
Under the bill, the defense to liability would be:
- Offering to call a friend, relative, or taxi to transport the patient; or
- Immediately notifying law enforcement personnel that an employee of the OTP has either observed the patient leave treatment by driving in an impaired state or heard the patient’s stated intent to drive while in an impaired state
OTPs say the proposal is unfair because it doesn’t take into account the fact that the accident may be caused by the other person, or by something unrelated to methadone.
“We work very hard to ensure that our patients are not impaired in any way,” said Deb Crowley, past president and board delegate of the Tennessee Provider Group. “We take every precaution to make sure they do not walk out impaired. We have onsite drug testing. We have them see the doctor. We have more steps in place than dentists or regular physicians. We call taxis.”
Methadone Patients Aren’t Sedated; Bill Assumes They Are
Patients treated with a therapeutic dose of methadone are not sedated. What is distressing about the bill is that it assumes that they are, OTPs say. “Someone could be completely functional, not impaired in any way, and if someone else hits them, it would put the treatment center in a liability situation,” Ms. Crowley told AT Forum.
“Our patients don’t even receive take-homes,” said Ms. Crowley. “We do a mini-assessment every time they come in.”
State Representative Micah Van Huss is the author of the bill, which is still in various committees in the House of Representatives. “It’s similar to what we currently do here in Tennessee with bars,” Representative Van Huss said, the Johnson City Press reported. “If bars let people go intoxicated, then they are held partially liable if someone gets in an accident.”
The bill includes a defense to liability if the clinic tried to prevent the patient from driving, and according to Representative Van Huss, applies only if the driver was impaired.
Tennessee is sorely in need of more OTPs. The legislation was drafted because there will soon be more OTPs—including a jointly operated program to open in Gray, run by Mountain States Health Alliance and East Tennessee State University (ETSU).
“People with these issues certainly need medical assistance, and that should be provided in a medical environment,” said Danny Sells, head of the Citizens to Maintain Gray. “However, Mountain States, ETSU, and Johnson City cannot expect our community to relinquish our expectation of safety, either personally or from the traffic hazard this will cause, in providing those services to these individuals.”
OTPs: Bill Discriminates Against OTPs and Stigmatizes Patients
Behavioral Health Group runs 10 of the 12 OTPs in the state, and Derek Walsh, vice president of operations, testified against the bill at the committee hearing in early April. “If the logic around the bill is that we’re going to punish health care providers that provide narcotics to patients, and hold them accountable for patient actions after they leave, that shouldn’t be singularly affecting the 12 opioid treatment programs in the state of Tennessee,” Mr. Walsh said, according to the Johnson City Press.
“There are lots of places that gives patients narcotics. If we’re going to apply a rule, it should be fairly applied to anybody who dispenses narcotics.” Mr. Walsh added that OTPs already conduct the procedures the bill cites as defenses to liability. “I’ve personally taken patients’ keys before to keep them from driving,” he added. OTPs take issue with the bill because it treats them as the only providers of opioid treatment, he said.
Mountain States Vice President Lindy White called the bill “discriminatory” and said it would create more stigma for patients.
Here is the most recent text of the bill (House Bill 1033): A nonresidential substitution-based treatment center for opiate addiction, as defined by § 68-11-1602, shall be liable for damage or injuries caused by a patient who, upon leaving the treatment center after receiving treatment, commits driving under the influence under § 55-10-401, vehicular assault under § 39-13-106, aggravated vehicular assault under § 39-13-115, vehicular homicide under § 39-13-213(a)(2), or aggravated vehicular homicide under § 39-13-218, and the patient’s impairment is due to the treatment provided by the center. (b) It shall be a defense to liability under subsection (a) that the nonresidential substitution-based treatment center for opiate addiction took reasonable efforts to prevent the patient from driving while impaired. Reasonable efforts include, but are not limited to: (1) Offering to call a friend, relative, or taxi to transport the patient; or (2) Immediately notifying law enforcement that an employee of the center has either observed the patient leave treatment by driving in an impaired state or heard the patient’s stated intent to drive while the patient was in an impaired state.
The bill would take effect July 1, 2017. The Gray OTP is set to open in August.
Categories: Addiction, Drug Courts & Criminal Justice, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Addiction, Methadone Treatment, Opioid Treatment Programs
By Alison Knopf
Yes, there are regulations in preparation to address the use of mobile vans to dispense medication-assisted treatment. When connected to brick-and-mortar opioid treatment programs (OTPs), these vans can help patients who don’t have transportation, as we reported in our recap of the American Association for the Treatment of Opioid Dependence (AATOD) conference last year. At that conference, Demetra Ashley, associate deputy assistant administrator of the Office of Diversion Control of the Drug Enforcement Administration (DEA), told the AATOD board that the project was under way.
Licensing of mobile vans as narcotic treatment programs could be done as an adjunct to existing OTPs, or as stand-alone clinics. It was unclear whether methadone or buprenorphine or both would be part of the proposal, which is expected out this summer in the form of a notice of proposed rulemaking.
Almost 20 years ago, mobile vans were being used to get medication to outlying areas in rural parts of Washington State, where Evergreen Treatment Center was a pioneer in the concept.
Under the rubric of harm reduction, mobile vans have also been providing syringe services, naloxone, and referral to treatment in various parts of the country.
Many experts think that the DEA’s plan to license mobile vans to help treat opioid use disorders is a groundbreaking move that will greatly expand access. Stay tuned for more about the DEA’s proposal later this year.
By Alison Knopf
On April 6, the American Association for the Treatment of Opioid Dependence (AATOD) released its long-awaited report, Guidelines for Addressing Benzodiazepine Use in Opioid Treatment Programs (OTPs). The guidelines can be downloaded at: http://www.aatod.org/guidelines-for-addressing-benzodiazepine-use-in-opioid-treatment-programs-otps/.
The purpose of the AATOD report is to offer guidance, instead of restrictive procedures, to help OTPs treat these patients. The report notes that both careful monitoring and coordination of care that is “respectful but not capricious or punitive” are essential to ensure safe, effective, and individualized care for OTP patients.
See related article in this issue – Study: Benzodiazepines + Prescription Opioids = Caution Needed! available at: http://atforum.com/2017/04/study-benzodiazepines-prescription-opioids-caution-needed/
American Psychiatric Association (APA) Annual Meeting
May 20-24, 2017
San Diego, California
National Association of Addiction Treatment Providers (NAATP) 39th Annual Conference
May 21-23, 2017
National Association of State Alcohol and Drug Abuse Directors (NASADAD) Annual Meeting
May 24-26, 2017
College of Problems on Drug Dependence Annual Meeting
June 17-22, 2017