Stigma – Addiction Treatment Forum

AATOD Conference Recap: Field Has Funding, Now Needs Infrastructure

April 17, 2018

By Alison Knopf

There were more than 2,000 attendees at the 2018 conference of the American Association for the Treatment of Opioid Dependence (AATOD), held at the Marriott Marquis in New York City in March.

The five-day meeting was full of presentations, workshops, and formal and informal gatherings, where leaders and staffers in the field of treatment of opioid use disorders exchanged knowledge and experience.

Open Board Meeting: Concerns About STR Funding

The open board meeting, which took place March 10, was an important time to share concerns about funding and regulatory matters with federal agencies. Board members had many questions for the Substance Abuse and Mental Health Services Administration (SAMHSA). The questions were related to the State Targeted Response (STR) to the Opioid Crisis grant program, which added $1 billion to the opioid treatment landscape via state funds.

SAMHSA’s Onaje Salim, EdD, conducted his agency’s presentation at the open board meeting. He was confronted by questions about why so much of the STR funding was going to pay for buprenorphine, naloxone kits, and prevention messages, but relatively few contracts with opioid treatment programs (OTPs) were being funded, to expand treatment in a more comprehensive way.

Dr. Salim was very sympathetic to the concerns of the AATOD board members. Formerly the administrator of an OTP in Atlanta, Dr. Salim was the first Georgia delegate to the AATOD board of directors. Later he became the Single State Authority for Georgia, before going on to SAMHSA.

But concern persisted at the board meeting: Would the STR funding be used for the same projects in year 2 as in year 1? And how would SAMHSA be able to guarantee that the funds were being put to good use? “How do you give the same level of funding if you don’t understand if it worked the first year?” as AATOD president Mark Parrino, MPA, put it.

OTPs’ Missed Opportunity

The time for OTPs to have made their case, however, was back in December of 2016 when the STR grants were announced. States prepared their applications then, and although a new federal administration was coming in, the funding process was underway. OTPs needed to go to the states at that time to present their arguments.

“I did say to my board members and provider colleagues that if you guys want to get these funds, you have to plant yourselves in the state offices,” Mr. Parrino told AT Forum.

On the other hand, states also have an obligation to use federal funds judiciously and to reach out to the appropriate partners, including OTPs, said Mr. Parrino. If states are not including OTPs as part of their treatment expansion strategies, then that needs to be explained as well. While a number of federal and state agencies are moving quickly to increase access to treatment, it is also important to be accountable in how these funds are spent.

And it is up to SAMHSA to hold states accountable for their use of STR funds, said Mr. Parrino. “SAMHSA should be holding the states’ feet to the fire. This is a straightforward issue.”

Buprenorphine Data 2000 Prescribers—Where Are Comprehensive Services?

The challenge from DATA 2000 practices—buprenorphine prescribers who do not necessarily provide comprehensive services—is felt keenly by the OTP community.

SAMHSA is invested in quality treatment services. Still, how this need for quality is implemented in DATA 2000 practices “is going to be a mystery,” said Mr. Parrino. While Elinore McCance-Katz, MD, PhD, who heads SAMHSA, says she wants coordinated services, how does this apply to DATA 2000 practices, which only have to prescribe buprenorphine and not provide any other care?

It is also true that there are many DATA 2000 practices that are offering excellent care. There should be some consideration in identifying treatment providers who do provide excellent treatment utilizing evidence-base practices, said Mr. Parrino. This issue will take on greater importance as insurance companies use a number of strategies to identify providers, which should be part of their network.

AATOD supports all three medications approved to treat opioid use disorder, but, like Dr. McCance-Katz, it endorses treatment that is comprehensive, not just restricted to prescribing and dispensing medication.

Mobile Vans Haven’t Yet Hit the Road

The Drug Enforcement Administration’s Jim Arnold, section chief of the liaison and policy section, explained to the AATOD board that mobile vans are not a reality yet because of President Trump’s executive order calling for eliminating two regulations for every new one. He said that the DEA was trying, however, and had sent it to the general counsel, but got it back with 70 requested modifications.

“So it’s slowed down,” said Mr. Parrino. “It’s not that anyone is saying ‘We don’t want to do this,’ because the DEA does want to do it,” he said.

The holdup is a problem in the way states use the STR money, as well. For example,

Molly Carney, executive director of Evergreen Treatment Services, wanted to use Washington’s STR grant for 2017 to get two new vans. She couldn’t, because of the DEA.

Awards Banquet: Former New Jersey Governor Attacks Stigma

If there were any questions as to why Chris Christie was chosen for the Friend of the Field award, the passionate acceptance speech by the former governor of New Jersey answered them. He attacked stigma directly, as the main reason for access problems for patients seeking methadone and buprenorphine treatment.

The Nyswander/Dole “Marie” awards at the banquet, which was sponsored by Mallinckrodt Pharmaceuticals, went to:

Gloria Baciewicz, MD (a psychiatrist based in Rochester, New York, who broke ground 25 years ago in getting upstate communities to start to accept methadone);
Hope Bolger, RPh (among many other credits, she has been the State Opioid Treatment Authority for Virginia, where the number of opioid treatment programs tripled during her tenure);
Jonas Coatsworth, MA, LPC, CAC-II (a leader in methadone and recovery in South Carolina);
Gabriele Fischer, MD (an Austria-based psychiatrist who has promoted methadone maintenance through the World Health Organization and the United Nations Office on Drugs and Crime);
Kathleen Maurer, MD (the medical director of Connecticut’s Department of Correction, where she instituted methadone maintenance treatment in prisons);
Stacey Pearce, CAS (treatment program director and methadone treatment advocate in Georgia); and
Vickie L. Walters, LCSW-C (a treatment advocate based in Maryland).

The Richard Lane/Robert Holden Patient Advocacy Award went to Paul Bowman, CMA, Boston National Alliance for Medication Assisted Recovery chapter director, patient advisor to Habit OPCO, consultant to residency programs, and more.

Connectivity and Importance of Staff

The conference itself was a chance for OTP staff from around the country to get together. Looking over the history of the conference programs, it’s easy to see trends in the field. Mr. Parrino believes the conferences promote “connectivity,” so that stakeholders and conference attendees can understand how their work is related to regulatory changes and other moves on the state and federal levels.

Now that the field has the money—from the STR grant program, with new funding expected—the question is, do OTPs have the infrastructure? Programs are opening, and in some states, the growth is dramatic. “In Ohio, it’s like the gold rush,” said Mr. Parrino. But, as he said at the open board meeting, as OTPs expand, they must be sure that they have the workforce to do this properly, and that they have the money to support the workforce.

“There’s a connection between retaining staff and retaining patients,” said Mr. Parrino. Success in treatment is driven by the characteristics of the treatment program, not the characteristics of the patient, as the John Ball study showed (see citation, below).

Currently, there are about 1,600 OTPs in the United States. By October of 2019, when the next AATOD conference takes place in Orlando, that number will be 1,800, Mr. Parrino told AT Forum. “I’d like it to be 2,000,” he said. “But remember, the number must be reflected in the ability to open and staff the programs.”

Reference

Ball JC, Lange WR, Myers CP, Friedman SR. Reducing the risk of AIDS through methadone maintenance treatment. J Health Soc Behav. 1988;Sep;29(3):214-226.

How OTPs Can Help Reduce Stigma: The Boston Experience

February 11, 2018

By Alison Knopf

Boston is not the only city with a powerful push by academics and providers for medication-assisted treatment (MAT), but it’s definitely one with a high profile. We talked with Janice F. Kauffman, RN, MPH, and Sarah Wakeman, MD, about how opioid treatment programs (OTPs), specifically, can help fight stigma against MAT.

Education is important, but by itself won’t work because of pre-existing bias, said Ms. Kauffman, who is vice president of Addiction Treatment Services for North Charles Foundation, Inc., director of addictions consultation for the Department of Psychiatry, Cambridge Health Alliance, and assistant professor of Psychiatry, Harvard Medical School. “I spend a good amount of my time talking to community members, talking to police, trying to educate people in the community,” Ms. Kauffman told AT Forum. “But I don’t think education is as helpful as we hope it will be, because people come with pre-existing opinions.”

In other words, if someone is predisposed to believe methadone is “trading one addiction for another,” that person will believe it, regardless of the information they are given.

Teaching Police

“I often teach police officers,” said Ms. Kauffman. “And I’m impressed that I can spend an hour giving them information—in particular, about the efficacy of methadone maintenance. But at the end of the day there are many who maintain that you should be off the medication, that this isn’t really a disease like other diseases.”

One problem is that substance use disorders are still conflated with crime, in the mind of many in law enforcement. Those people don’t need to be educated about cancer, dental caries, or other diseases. Perhaps it’s too much of a stress to even try to educate them about addiction—but, in fact, many police officers, especially in Massachusetts, the home of PAARI (Police Assisted Addiction and Recovery Initiative), would rather help people get treatment than arrest them. The question is, what kind of treatment? Massachusetts currently has an initiative focused on getting residential treatment for people with opioid use disorders, and favoring antagonist treatment with Vivitrol instead of buprenorphine or methadone. This is also true for people under civil commitment—a process that falls in line with many beliefs of law enforcement.

The Media

Janice F. Kauffman, RN, MPH

Ms. Kauffman also said that OTPs need to do a better job of educating the media, which is in general not well informed about methadone maintenance, a treatment that’s proven efficacious for decades. “The media does not do us justice,” she said. “Their stories have focused on people who don’t do well.” She added that some stories look at people in the community who are not doing well, mostly because of benzodiazepines and other drugs of misuse. “This is what happened in the Boston area, with stories about what the media dubbed ‘Methadone Mile.’ Even when behavior doesn’t involve methadone, the media automatically connect it. They think that neighborhoods with OTPs are places people deal drugs—but people deal drugs everywhere.”

It would help for successful patients to come forward, but they’re afraid to, because of the effects on their jobs and lives and families, said Ms. Kauffman. “I’ve been doing this work since the early 1970s. I’ve lived this stigma for a long time, and I’ve watched our patients suffer from it.”

Employers

So, what is the solution? Perhaps OTPs should ask employers to publicly support methadone maintenance—“especially employers who are willing to come forward, and who know that their patients are in methadone treatment and doing well. That would be better than putting it on the backs of patients,” said Ms. Kauffman. “Employers could say, ‘Some people who are working for me are methadone patients, and they’re doing very well,’” said Ms. Kauffman. “This would show that people are willing to employ our patients, who have a disease like any other disease.”

The North Charles Foundation produced “Waking Up: A Story in Four Parts,” a short film on its program, specifically designed to address stigma, as part of a grant. In a narrative therapy group in the film, patients told how they got into trouble with drugs, and what methadone treatment was like. (The grant was from Johnson and Johnson, the Harvard Medical School’s division on addictions, and a private family foundation.) “We showed the film to over 100 medical, social-service and substance use treatment providers in the greater Boston area, for a pre-test and a post-test,” said Ms. Kauffman. Before they saw the film, viewers were biased against methadone. After they saw it, their feelings changed. “They were struck by how the patients suffered, and what happened privately in their lives. They were also impressed with how the patients got better, and became contributing members of society.”

Ms. Kauffman uses this film when she teaches doctors training in hospitals as residents. “It’s powerful,” she said.

One Day at a Time

There’s a commonly held notion that methadone maintenance is forever, which can be daunting, creating a stigma of its own. It’s similar to what happens when people with alcohol use disorders are overwhelmed by the idea that they can never drink again. “We have lots of patients who come to treatment saying they want methadone only for a certain period,” said Ms. Kauffman. “I would never say ‘no,’ to that. We say, ‘Let’s get you stabilized, let’s help you look at this.’” Often it’s the stigma that makes patients want to leave treatment quickly.

“If you have to deal with the notion of needing to do this for the rest of your life—that’s hard for patients to wrap their minds around,” she said. But OTPs help new patients normalize their lives as soon as possible, and most patients see that they can have normal, good lives without giving up their medication, and without switching medications.

Sarah Wakeman, MD

Language Counts

Dr. Wakeman, who is medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Massachusetts General Hospital, co-chair of the Mass General Opioid Task Force, and an assistant professor in medicine at Harvard Medical School, is a big proponent of using proper language to reduce stigma.

“One of the greatest struggles we have is reducing stigma, not just about addiction but about treatment,” she said. “If we change our language, using medically appropriate terminology just as we do for other illnesses, we can change how the rest of the world thinks of treatment.”

A very simple but necessary change is to stop using the terms “clean” and “dirty,” she said. “You can say a toxicology test was positive or negative, or you can say the results are appropriate or inappropriate.” The point is not just to switch the words, it’s to stop being judgmental. “When I talk with a patient about diabetes testing, I refer to results as being within range or out of range. OTP counselors telling patients about a positive drug test can begin by saying, “There were unexpected findings in your toxicology report,” she said. “Stay away from judgement-laden language.”

This isn’t just a matter of being politically correct, said Dr. Wakeman. If treatment programs convey this kind of stigma against patients, how are people supposed to avoid it?

Dr. Wakeman also points out that “dependence” should not be confused with addiction. Being dependent on a medication is not the same as being addicted—it’s not pathological. “If someone is taking long-term opioids appropriately for pain, that person is dependent,” she said. “If someone is taking methadone for addiction, that person is dependent.”

Involving OTPs in the General Medical System

“The more we can engage OTPs in the general medical system, the better for patients,” said Dr. Wakeman. Her facility does not have its own OTP, but works closely with OTPs, she said. “We have agreements with OTPs. It’s important to have these agreements with OTPs as a hospital system,” she said. “That way we can link patients directly into ongoing care. It’s been great for us to work with OTPs.”

In deciding whether to refer a patient to an OTP or to office-based opioid treatment (OBOT) with buprenorphine, Dr. Wakeman said the most important factor is “what the patient wants and what the patient thinks will be effective.” Most patients prefer to start with buprenorphine, said Dr. Wakeman. “But if the patient reports having done well on methadone in the past, we go that way. If someone has tried both in the past, if they’ve done well on one but not the other, that helps us decide.”

Legacy for Methadone

For methadone, Dr. Wakeman uses a 1965 New Yorker profile of Marie Nywswander, MD, who, with Vincent Dole, MD, developed methadone maintenance treatment. Called “The Treatment of Patients,” the profile, by Nat Hentoff, explains how methadone works. “I still use this now, in 2018,” said Dr. Wakeman. “A molecule of methadone is no more problematic than a molecule of insulin.”

Dr. Wakeman has patients who work at Harvard or Mass General and are taking methadone. “You wouldn’t know it,” she said. “These people are doing well and going about their business and living their lives.

“We need to make addiction treatment seem scientific and a part of the medical mainstream,” she said. “And we need to hold them to the same standards and expectations we use for any other treatment provider.”

It would be beneficial to hear more patient narratives of recovery on MAT, said Dr. Wakeman, who agreed with Ms. Kauffman that the media promotes some stigma. “We need to hear from patients on MAT saying, ‘This is how much better my health and my life are now.’”

Drug Users Are Forming Unions To Protect Their Rights And Safety

December 20, 2017

“Some days, Jess Tilley sits and talks with the parents of teens who’ve begun using heroin. On others, she lectures medical professionals on how to approach opioid users ― traveling to conferences to talk to colleagues about needle exchanges and drug-testing strips.

At 41, Tilley has two decades of experience working with people who use drugs ― and even more years as a drug user herself. Tilley is the founder of the New England User’s Union, a self-organized group of primarily opioid users working together to stay alive and fight the stigma of drug use, whether or not they’re trying to quit.”

Source: HuffingtonPost.co.uk – December 19, 2017

Trump’s FDA is making a big push for opioid addiction medications. That’s great.

October 31, 2017

“The head of the Food and Drug Administration wants Congress — and doctors — to know there is a real treatment solution for the opioid epidemic: medication-assisted treatment (MAT).

In testimony to the House on Wednesday, FDA Commissioner Scott Gottlieb said that his agency plans to leverage the use of medications for opioid addiction, including methadone, buprenorphine, and naltrexone, to confront America’s drug overdose crisis.

“There’s a wealth of information supporting the use of these medications,” Gottlieb said, according to STAT. “We’re focusing on the data in the drug labeling that can help drive broader and appropriate prescribing. So one concept that FDA is actively pursuing is the research necessary to support a label indication for medication-assisted treatment for everyone who presents with an overdose, based on data showing a reduction in death at a broader population-level. Such an effort would be a first for FDA.”

As the nation’s primary drug regulator, the FDA can push doctors to make greater use of some medications — by, for example, tinkering with drug labeling to combat stigma attached to certain drugs. Based on Gottlieb’s remarks to Congress, that seems to be the goal here.”

The statement can be accessed at: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm582031.htm

Source: Vox.com – October 25, 2017

Adolescent Opioid-Related Deaths Are Soaring; We Can’t Wait “Until Things Get Worse”!

October 24, 2017

By Barbara Goodheart, ELS

In September of last year, the American Academy of Pediatrics (AAP) issued a policy statement calling for making drug therapy available to adolescents with opioid use disorder (OUD).

The statement caused hardly a ripple. Those who treat adolescents reported that some families, clinicians, even some patients, consider the medications—methadone, buprenorphine/naloxone, naltrexone—a last resort.

Now, a year later, several articles have addressed this issue and offer recommendations. One article underscores the risks of waiting “until things get worse” (see “Recommendations” under “Commentary,” below). This AT Forum article summarizes the recent findings and the many recommendations from these articles.

Rise in Opioid-Related Deaths Follows a Two-Year Hiatus

In 1999, adolescent death rates from overdoses involving opioids began rising sharply. Rates have zigzagged downward since about 2007, but began rising again between 2014 and 2015 (see figure below). How many young people have died from overdoses involving opioids isn’t known, but following the trend of the line in the figure below gives a clue to the severity of the situation.

Drug Overdose Death Rates Involving Opioids;
Adolescents Aged 15–19, United States, 1999–2015

Adapted from NCHS, National Vital Statistics System, Mortality. Curtin SC, Tejada-Vera B, Warner M. Drug overdose deaths among adolescents aged 15–19 in the United States: 1999–2015. NCHS data brief No. 282, August 2017. Hyattsville, MD: National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db282.pdf.

Timely, appropriate treatment would have saved some of these young lives. Especially tragic: in 2015, about 80% of adolescent deaths were unintentional. Attitudes are beginning to change, however: many clinicians now realize that the need for treating adolescents with OUDs has indeed become urgent.

The AAP Policy Statement—

American Academy of Pediatrics. Medication-Assisted Treatment of Adolescents With Opioid Use Disorders. Pediatrics, 2016.

The 2016 publication, the first official policy statement on treating OUDs from a professional pediatric organization, indicated an important shift in professional thinking. Starting out by briefly reviewing the history, consequences, and treatment of opioid misuse, it went on to note the availability but underuse of effective medications and counseling, and the impediments to treating young patients: federal regulations that block most methadone programs from enrolling patients younger than age 18, and restrictions limiting buprenorphine treatment in patients younger than age 16.

Recommendations. The Policy Statement called for offering available treatment to adolescents with OUDs, and developing new treatments “to save and improve lives of youth with opioid addiction.” (The term “youth” in this context refers to adolescents and young adults.)

The AAP group recommends improving access to medication-assisted treatment (MAT) in the young, both in primary care and through counseling in community centers; conducting further research on “primary and secondary prevention, behavioral interventions, and medication treatment. It also recommends that pediatricians consider offering MAT to patients, or discussing referrals.

Commentary—

Addressing Stigma in Medication Treatment of Adolescents With Opioid Use Disorder. Bagley et al. American Society of Addiction Medicine, 2017.

Regarding the AAP Policy Statement, the clinical experience of the Commentary’s authors indicated that some patients, families, even clinicians perceive using medications to treat OUDs in adolescents “a last resort;”—believing it’s necessary to wait to treat “until things get worse.”

The authors, who are addiction specialists with the American Society of Addiction Medicine (ASAM), strongly disagree. Stressing that their role requires them to identify and prevent risky use and use disorders, intervene early, “and offer timely, evidence-based treatment,” they see treating adolescents not as a last resort, but as an opportunity “to prevent the long term medical, psychiatric, and social consequences of ongoing substance use.”

And they note that caregivers and patients may incorrectly assume that young people may need to continue medication for life, a misconception the authors attribute to stigma, possibly explaining the resistance to treating OUDs with medication.

The authors stress that the medication course can in fact be limited in younger patients, and “it is possible that earlier treatment in adolescence may lead to sustained recovery in adulthood.”

They acknowledge, however, that more needs to be known about selecting the medication and the length of treatment.

Recommendations. To destigmatize medication treatment, the authors recommend launching a coordinated effort that begins with the federal government, uses evidence-based interventions, and targets all players—parents, behavioral health providers, and state agencies. They say that the treatment models used in younger patients may need to be adapted to include family in treatment, and to account for developmental differences. They also emphasize reducing the stigma associated with using medications in treating this group.

MAT for Adolescents in Specialty Treatment—

Medication-Assisted Treatment for Adolescents in Specialty Treatment for Opioid Use Disorder. Feder et al. Journal of Adolescent Health, 2017.

This study, covering 139,092 patients, found that only 2.4% of adolescents treated for heroin use received MAT, compared to 26.3% of adults treated. For treatment related to prescription opioids, the corresponding numbers were only 0.4% of adolescents and 12.0% of adults. The data were from publicly funded programs in specialty treatment programs.

The authors noted severe restrictions on methadone access for patients aged 16 and 17 years. Methadone clinics need special wavers to treat adolescents, and require proof of two failed attempts by the patient to discontinue drug use.

Recommendations: Regarding Medicaid and CHIP (Children’s Health Insurance Program): include MAT in the early periodic screening, detection, and treatment benefit of state Medicaid programs, and include adolescents in ongoing Medicaid demonstrations to expand MAT. In addition, “policy and practice changes are needed to expand access,” as recommended by the AAP.

Trends: An Original Investigation—

Trends in Receipt of Buprenorphine and Naltrexone for Opioid Use Disorder Among Adolescents and Young Adults, 2001-2014. Hadland et al. JAMA Pediatrics, 2017.

A large retrospective study looked at insurance and treatment data from 20,822 commercially insured OUD patients aged 13 to 25 years. Although medication dispensing fluctuated, only one out of every four commercially insured youth ever received medication (buprenorphine or naltrexone). Moreover, investigators observed “disparities based on sex, age, and race/ethnicity.”

Those less likely to receive medication were younger, or female, or nonwhite. The authors commented, “Intervening early in the development of OUD is critical for preventing premature death and lifelong harm.”

Both the AAP policy statement and the 2016 surgeon general’s report reiterate the need to intervene early; in fact, two-thirds of patients being treated first used opioids before age 25; one-third, before age 18.

The team criticized the AAP Committee for not releasing a policy statement until September of 2016—during a worsening youth opioid epidemic, “despite preexisting recommendations from the Substance Abuse and Mental Health Services Administration.” This, the Committee said, may have delayed pediatricians’ adoption of drug therapy for their young patients.

Recommendations. Include drug therapy in pediatric primary care, and improve access to evidence-based treatment for adolescents—for example, by adding pediatric addiction subspecialists. In addition, expand the use of pharmacotherapy for youth, and ensure equitable access for all affected youth.

Editorial: Closing the Gap—

Closing the Medication-Assisted Treatment Gap for Youth With Opioid Use Disorder. Saloner et al. JAMA Pediatrics, 2017.

An editorial in the same issue of JAMA Pediatrics as the Hadland article includes many recommendations. We list some of them below.

Recommendations

Have pediatricians refer youth to a methadone clinic or other specialty treatment for MAT
Build capacity in pediatric primary care, giving physicians knowledge and support to prescribe MAT
Expand the office-based prescriber workforce; include pediatricians
Integrate primary and specialty care (for example, adapt “hub-and-spoke”)
Reduce stigma toward MAT
Improve health insurance policy support of youth access to MAT
Arrange for payment through insurance programs for counseling and recovery management;
Close the gap in evidence-based care for youth through comprehensive policy changes and individual practice changes.(See the published articles for details of all studies.)

# # #

References

AAP Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3):e20161893. doi:10.1542/peds.2016-1893.

Bagley SM, Hadland SE, Carney BL, Saitz R. Addressing stigma in medication treatment of adolescents with opioid use disorder. J Addict Med. 2017 [Epub ahead of print]. PMID: 28767537. ISSN: 1932-0620/16/0000-0001. doi:10.1097/ADM.0000000000000348.

Feder KA, Krawczyk N, Saloner B. Medication-assisted treatment for adolescents in specialty treatment for opioid use disorder. Adolescent health brief. J Adolesc Health. 2017;60:747e750. PMID: 28258807. doi:10.1016/j.jadohealth.2016.12.023.

Hadland SE, Wharam JF, Schuster MA, Zhang F, Samet JH, Larochelle MR. Trends in receipt of buprenorphine and naltrexone for opioid use disorder among adolescents and young adults, 2001-2014. [Epub June 19, 2017.] JAMA Pediatr. 2017;171(8):747-755. PMID:28628701. doi:10.1001/jamapediatrics.2017.0745.

Saloner B, Feder KA, Krawczyk N. Closing the medication-assisted treatment gap for youth with opioid use disorder. Editorial. [Epub June 19, 2017.] JAMA Pediatr. 2017;171(8);729-731. PMID:28628699. doi:10.1001/jamapediatrics.2017.1269.

SAMHSA Issues Brief Update on Use of Medication-Assisted Treatment

October 24, 2017

By Barbara Goodheart, ELS

This update from the Substance Abuse and Mental Health Services Administration (SAMHSA) reports trends in the use of methadone, buprenorphine, and extended-release, injectable naltrexone—an option for treating opioid use disorder. Not included in the report are data from private physicians who aren’t affiliated with a treatment facility or program.

Paralleling the recent increase in deaths from heroin and other opioids, the number of opioid treatment programs (OTPs) and other medication-assisted treatment options for preventing such tragedies has also risen. The figure below summarizes key information from the August 22 CBHSQ Report, a SAMHSA publication.

Trends in Treatment at Substance Abuse Treatment Facilities: 2003-2016

+ + +

Reference

Alderks CE. Trends in the Use of Methadone, Buprenorphine, and Extended-release Naltrexone at Substance Abuse Treatment Facilities: 2003-2015 (Update). The CBHSQ Report: August 22, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD. https://www.samhsa.gov/data/sites/default/files/report_3192/ShortReport-3192.pdf.

AATOD Issues Five-Year Plan: Bottom Line Focus Is Still on Stigma

April 13, 2017

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.

Increasing OTPs

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.

Other Issues

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/

Research Results: Opioid Agonist Treatment Versus Detoxification in Lowering the Costs of Crime

February 13, 2017

By Barbara Goodheart, ELS

A recent study compared opioid agonist treatment (OAT) and detoxification in patients with opioid use disorders. The goal was to see which treatment approach is associated with costs of crime.

A team of six investigators, supported by a grant from the National Institute on Drug Abuse (NIDA), led the study. They published their findings last December in the online version of Addiction.

Study Group

Included were more than 31,650 patients. Treatment took place in publicly funded facilities in California from the beginning of 2006 to the end of 2010. The median treatment time was 130 days; median observation time was 2.3 years.

Patients’ Characteristics:

Median age at treatment admission: 32 years
Men: 64.2% of the population
Substances used (%): prescription opioids, 37.1; marijuana, 15.1; opiates that have not been prescribed, such as fentanyl,14.9; heroin, 6.6; alcohol, 4.7; stimulants, 2.0
Some involvement with the criminal justice system: 43.2%

Costs of Crime: Justice System and Victimization

Justice system costs included policing, court, and corrections. Costs related to victimization included crime-specific medical expenses, cash losses, property theft or damage, and earnings lost due to injury, etc. The team was especially interested in the difference in crime costs during and after OAT, a time-unlimited (maintenance) treatment.

Costs were compiled in 2014 US dollars; see the full report for details.

Analysis

Medications. Treatment in publicly funded programs “predominantly entailed” offering patients methadone, rather than buprenorphine, buprenorphine/ naloxone, or naltrexone.

Costs. Average daily costs of crime per person, over an assumed 1-year period—including treatment and post-treatment categories—were $113.

When investigators compared the costs of crime per patient during treatment, they found daily costs were $126 lower than after treatment for the group receiving OAT, and $144 lower than after treatment for those undergoing detoxification.

But the picture changed when they included length of treatment time—161 days for the OAT group, much longer than the 19 days for the detoxification group.

The bottom line: When totaling the costs of publicly funded treatment in California over a postulated 6-month time frame, the cost savings of crime per patient became clear: “enrolling an individual in OAT as opposed to detoxification would save $17,550.”

The table below shows how that figure was calculated.

Resources

Birnbaum HG, White AG. Schiller M, Waldman T, Cleveland JM, Roland CL. Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States. [Epub March 10, 2011]. Pain Med. 2011; Apr;12(4):657-667. PMID:21392250. doi: 10.1111/j.1526-4637.2011.01075.x.

Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care. 2016; Oct;54(10):901-906. PMID: 27623005. doi: 10.1097/MLR.0000000000000625.

Krebs E, Urada D, Evans E, Huang D, Hser Y, Nosyk B. The costs of crime during and after publicly funded treatment for opioid use disorders: a population-level study for the state of California. [Epub ahead of print December 15, 2016.] Addiction. doi: 10.1111/add.13729.

New Document: How the Words We Use Can Support People on The Path to Recovery

January 25, 2017

“The White House Office of National Drug Control Policy prepared a document for Federal agencies about terminology related to substance use and substance use disorders. The document was developed in consultation with external research, policy, provider, and consumer stakeholders and in collaboration with Federal government agencies. It addresses the role stigma plays, identifies scientific and medical literature demonstrating how certain terminology adversely affects the quality of health care and treatment outcomes, and promotes the use of person-first language and terminology that aligns with the current edition of The Diagnostic and Statistical Manual of Mental Disorders (5th ed., American Psychiatric Association, 2013).

Because stigma and shame may deter help-seeking behavior among individuals with substance use disorders and their families, the document draws attention to terminology that may cause confusion or perpetuate stigma.”

The document can be accessed at: https://s3.amazonaws.com/core-products-s3/e81e0e06-a767-415c-a8bc-ad5f64295b95?response-content-type=application%2Fpdf&response-content-disposition=inline%3B%20filename%3D%22Memo%2520-%2520Changing%2520Federal%2520Terminology%2520Regrading%2520Substance%2520Use%2520and
%2520Substance%2520Use%2520Disorders.pdf%22%3B%20filename%2A%3DUTF-8%27%27Memo%2520-%2520Changing%2520Federal%2520Terminology%2520Regrading%2520Substance%2520Use%2520
and%2520Substance%2520Use%2520Disorders.pdf&X-Amz-Content-Sha256=e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAJEJX3SFQYQNRCXMQ%2F20170125%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20170125T155430Z&X-Amz-SignedHeaders=Host&X-Amz-Expires=604800&X-Amz-Signature=0acf5c71be584de8791e1f30117adbd00a70cc193ba6c1ab13b53baec67277f2

Source: Office of National Drug Control Policy – January 9, 2017

Fifty Years After Landmark Methadone Discovery, Stigmas and Misunderstandings Persist

December 13, 2016

“Methadone, the first pharmacological treatment for heroin addiction, was pioneered 50 years ago by Rockefeller University’s Mary Jeanne Kreek and her colleagues. Since then the drug, which is widely used in treatment programs across the globe, has saved countless lives and allowed millions of heroin users to transition into normal lives.

Yet in the United States, where medical treatment of addiction is controversial, the drug’s use has remained limited even as deaths due to heroin-related overdoses have surged to expose a towering public health problem. Kreek’s career, spanning more than six decades, has not only led to medical treatments for various diseases of addiction, but has taught us much about the molecular and genetic underpinnings of drug cravings. In addition, she has been championing the implementation of drug treatment programs worldwide.

“Addictions are diseases, they are diseases of the brain,” says Kreek. “They are not criminal behaviors, and they are not weaknesses. They however do respond to treatments—and it’s unfortunate that we have tools available to treat opiate addiction, but we’re not using them.”

Source: Rockefeller.edu – December 9, 2016