Stigma – Addiction Treatment Forum

States Are Legalizing Nonprescription Syringe Sales in Pharmacies; How Well Is That Working?

June 18, 2018

By Barbara Goodheart, ELS

Nonprescription sales of syringes in pharmacies are being met with some enthusiasm, some resistance, and a tinge of stigma. But they offer an accessible, affordable, reliable way to lower the risks of HIV/AIDS and infectious hepatitis, and, if managed well, they can help control health care costs and save lives.

Attitudes—and Consequences

Some people sincerely question the wisdom of selling syringes (cylinders with hollow needles attached) to people who inject drugs (PWIDs). They see it as granting permission to continue misuse. Others think that people who misuse drugs “should suffer the consequences.” Those consequences are substantial; they include blood-borne infections and painful illnesses. As the data below show, they also include soaring medical costs—clearly impacting society as well.

Greatly boosting the medical costs are the sheer numbers involved. CDC data show that at least 3.5 million people in the U.S. are infected with hepatitis C virus (HCV). The C. Everett Koop Institute estimates the total lifetime costs for those currently infected with HCV could reach $9 billion. But if 80% develop chronic liver disease, the total costs over a lifetime would be “a staggering $360 billion in today’s dollars.” Adding medical costs, and all costs for other types of infectious hepatitis, along with costs for HIV/AIDS, boosts total expenditures to unbelievable levels.

Beyond those costs are other serious consequences that cannot be measured—broken ties with loved ones, untimely tragedies. Most of us know of a young person who had much to offer, but instead tragically succumbed to a drug overdose.

Stigma: The Not-So-Good News

Local stigma is a common problem, and California is no exception. California pharmacies have been selling nonprescription syringes since 2012—and The New York Times has identified areas where PWIDs face severely limited treatment options. An official blames local stigma— “county supervisors who don’t want a treatment program located in their area.”

Syringes for Diabetic Patients—But Not for PWIDs

A study in the International Journal of Drug Policy points to areas of stigma in California’s Central Valley. A purchase trial found that only one in five PWIDs were able to buy syringes, despite legalization. The study also found that only about 29% of pharmacists and staff would sell to PWIDs—but 79% would sell to patients with diabetes.

Pharmacists turned down people they thought might be PWIDs, based on appearance. Some participants donned conservative clothes and covered their injection scars, but were refused syringes nevertheless. Their attempts to buy, they said, were “embarrassing and stigmatizing,” and “forced them to ‘out’ themselves as drug users.” Some PWIDs who heard these reports didn’t even bother to try purchasing syringes.

Methadone Stigma

Stigma is no stranger to people taking methadone, participants learned. Methadone treatment was even “more stigmatized than injecting drugs,” they said, noting that many local sober living homes barred methadone patients.

Amanda, a study participant, said:

. . . if you get on methadone, you are just as bad as any junkie heroin addict, so you might as well just do the heroin because then nobody knows you are at a methadone clinic . . .

[We] hated people who were on methadone and talked crap about them, because, for whatever reason, we thought we were so much better.

Amanda and her husband eventually enrolled in methadone treatment, but she wished they’d done so sooner, instead of letting their daughter live elsewhere, “because she had heroin addicts her whole life as parents.”

Choices

What motivates some PWIDs to head for a pharmacy to purchase syringes, instead of sharing or reusing syringes on hand—their own, or others’—as many PWIDs do?

Perhaps they are aware of their risks, and ready to accept advice and help. Some may be standing on the brink—almost ready for treatment—waiting for someone to offer a hand.

The Pharmacist Is In

Enter the pharmacist. He or she is among the most trusted and knowledgeable sources patients approach for health care information.

In some states it’s standard to require pharmacists to provide information to people buying syringes. Pharmacists in California are called upon to offer guidance about testing and treatment for HIV and hepatitis, and to provide safe disposal of sharps. Some pharmacy programs give links to support groups and detailed help about entering treatment programs.

To date, more than half the states offer nonprescription sales of syringes in pharmacies. Some states have a counseling agreement resembling California’s.

The Bottom Line

The pharmacy staff’s interactions with customers can have far-reaching effects. Pharmacists who are nonjudgmental and understanding can do much more than provide helpful information and safe syringes; they can help PWIDs take those difficult first steps, perhaps even opening the door to treatment.

A Note To Our Readers—

This article certainly isn’t meant to encourage readers to use illicit drugs. But we do want to spread the word that, for drug users not in treatment, access to clean syringes can lower the risk of contracting or spreading HIV and viral hepatitis. Moreover, the opportunity to contact a pharmacist or other health care provider for advice may increase the likelihood that a person who is using drugs will consider treatment.

Sue Emerson, Publisher, Addiction Treatment

References

Edlin BR, Eckhardt BJ, Shu MA, et al. Toward a more accurate estimate of the prevalence of hepatitis C in the United States. Hepatology. 2015;62(5):1353-1363. (Free PMC Article.) doi: 10.1002/hep.27978.

The C. Everett Koop Institute. Dartmouth Medical School. Hepatitis C: The Facts: The Epidemic: Associated Health Costs—United States. http://www.epidemic.org/thefacts/theEpidemic/USHealthCareCosts.

Del Real JA. Needle by needle, a heroin crisis grips California’s rural north. The New York Times. May 8, 2018. https://www.nytimes.com/2018/05/08/us/california-heroin-opioid.html.

Paquette CE, Syvertsen JL, Pollini RA. Stigma at every turn: Health services experiences among people who inject drugs. Int J Drug Policy. 2018;(57)104-

Resources

Meyerson BE, Davis A, Agley JD, et al. Predicting pharmacy syringe sales to people who inject drugs: Policy, practice and perceptions. Int J Drug Policy. 2018;56:46-53.

HIV and Injection Drug Use. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. November 2016. https://www.cdc.gov/hiv/pdf/risk/cdc-hiv-idu-fact-sheet.pdf.

A New Study Shows Stigma Is Hurting Our Response to the Opioid Epidemic

June 11, 2018

“When it comes to combating opioid misuse and addiction, needle exchanges and safe injection sites have decades of evidence behind them. Yet a new study published in Preventive Medicine found that a majority of Americans oppose both — and stigmatizing attitudes toward people with addiction appear to be to blame.

For the study, researchers conducted a survey of more than 1,000 Americans asking about their attitudes on needle exchanges, safe injection sites, and addiction more broadly. They found that about 39 percent of Americans support needle exchanges, while around 29 percent back safe injection sites.

The survey also measured respondents’ stigmatizing attitudes toward addiction, putting together a composite of questions — whether they’d be willing to have a person who is using opioids marry into their family or start working closely with them on a job, and their overall feelings of people who use opioids.

The researchers concluded: “Individuals with higher stigma toward people who use opioids were less likely to support legalization of safe consumption sites … or syringe services programs.”

Source: Vox.com – June 7, 2018

Blog: Reversing Stigma Is Key to Stemming the Opioid Epidemic

May 9, 2018

“After two years of bitterly partisan debate on health reform, Congress appears poised to unite on a response to the opioid epidemic. Leaders in both parties should add one essential ingredient to the developing bills: a multiyear, comprehensive public education campaign to reduce the stigma around addiction.

I know our lawmakers are keenly aware of this agonizing issue. On a visit to Washington recently, days before the Senate Health, Education, Labor and Pensions Committee approved the “Opioid Crisis Response Act” last week, I was struck by how many members of Congress shared their feelings with me about the stigma tormenting substance users in their communities.”

Source: TheHill.com – May 4, 2018

Nursing Homes Routinely Refuse People on Addiction Treatment — Which Some Experts Say Is Illegal

April 25, 2018

“Nursing facilities routinely turn away patients seeking post-hospital care if they are taking medicine to treat opioid addiction, a practice that legal experts say violates the Americans with Disabilities Act.

After discharge from the hospital, many patients require further nursing care, whether for a short course of intravenous antibiotics, or for a longer stay, such as to rehabilitate after a stroke. But STAT has found that many nursing facilities around the country refuse to accept such patients, often because of stigma, gaps in staff training, and the widespread misconception that abstinence is superior to medications for treating addiction.”

Source: StatNews.com – April 17, 2018

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.)

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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

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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.