In a far-reaching policy paper to be published next year, a draft copy of which was obtained by AT Forum, the American Association for the Treatment of Opioid Dependence (AATOD) takes stock of the increasing prevalence of opioid use disorder (OUD). “Medications Used to Treat Opioid Use Disorder: Learning from Past Lessons to Guide Policy,” by Mark Parrino, MPA, AATOD president, discusses the current state of methadone maintenance treatment,
The overdose epidemic started with prescription opioid misuse and transitioned to heroin use; now, illicit fentanyl is the main substance involved in overdoses.
The question is, what can opioid treatment programs (OTPs), the AATOD members, do to help?
The treatment system, including OTPs and DATA 2000 (office-based buprenorphine prescribers) is expanding. The criminal justice system is increasingly involved, and there is a greater interest in treatment of OUDs in prisons and jails.
The policy paper asks key questions, including:
- Should we view treating OUD as a public health intervention, with the principal component of care utilizing federally approved medications (methadone, buprenorphine, and Vivitrol/naltrexone)?
- Should we devote resources to treating this disorder with medications and additional clinical services?
- Should we better-coordinate organized service delivery to treat this illness through a continuum of service delivery components?
- Should there be a better connection between DATA 2000 practices and OTPs, to facilitate referrals from one practice to the next?
The Meaning of “Assisted”
The very phrase Medication Assisted Treatment (MAT) suggests that medication alone is not sufficient to treat the complex disorder, the policy paper notes. Indeed, the National Institute on Drug Abuse says this in “Principles of Drug Addiction Treatment,” as does the Substance Abuse and Mental Health Services Administration (SAMHSA), in its “Treatment Improvement Protocol #43: Medication Assisted Treatment for Opioid Addiction in Opioid Treatment Programs.” The AATOD policy paper notes this also.
The policy paper includes a brief description of the early history of the development of methadone maintenance, and a discussion of the value of providing comprehensive treatment services.
The policy paper also goes through a history of MAT. One point was made by Vincent Dole, MD, who postulated that “the high rate of relapse of addicts after detoxification from heroin use is due to persistent derangement of the endogenous ligand-narcotic receptor system, and that methadone, in an adequate daily dose, compensates for this defect.” While some patients can do well after treatment is terminated, the majority do not, he wrote. “The treatment, therefore, is corrective but not curative for severely addicted persons.”
OTPs with methadone were developed through a closed panel system following regulation by the Food and Drug Administration (FDA) in 1972. However, the first compendium of clinical guidelines was not published until 1993, through SAMHSA’s first “Treatment Improvement Protocol State Methadone Treatment Guidelines.”
Then there was the General Accounting Office Report of 1990: “Methadone Maintenance—Some Treatment Programs Are Not Effective; Greater Federal Oversight Needed.” Although the FDA had regulatory oversight, along with the Drug Enforcement Administration (DEA), the GAO found that the FDA’s oversight was inadequate. After this, regulations became stricter.
The policy paper also cites the findings of John Ball, PhD, that a significant determinant of the effectiveness of methadone maintenance on reducing IV drug use and needle sharing is long-term retention, along with high rates of attendance, and an enduring relationship with staff.
The bottom line point here is that the program characteristics are more important in determining patient outcome than pre-treatment patient characteristics, writes Mr. Parrino.
And a key point is that these findings are equally applicable to DATA 2000 practices—or should be, although there is little research about what DATA 2000 practices are doing, compared to OTPs.
In 2001, SAMHSA took over regulation of OTPs, using accreditation to monitor quality assurance. The National Commission on Correctional Heath Care implemented similar accreditation procedures for treatment in correctional settings.
The paper goes on to discuss problems of diversion, noting that the biggest problems occurred when physicians started to prescribe methadone to treat pain. Take-home methadone from OTPs has much greater restrictions than pain medications do.
With the advent of DATA 2000 practices and buprenorphine, however, the value of oversight seemed to be “forgotten,” writes Mr. Parrino.
The decision not to have any federal oversight for DATA 2000 practices was driven by several variables, he writes. The first was the attempt to normalize addiction treatment so that clinical practitioners could treat this illness without the regulatory burden that had been implemented for OTPs.
AATOD agrees with making standards of care required as a method of guiding clinical care in DATA 2000 practices, based on the history of treating this disorder with medications, writes Mr. Parrino.
The policy paper also discusses the importance of care coordination, which includes models such as the Vermont Hub and Spoke system, with OTPs as the hubs and DATA 2000 practices as spokes. This model has been very successful.
“There are large states that could certainly benefit from the coordinated models, by breaking them into counties or municipalities,” writes Mr. Parrino. “The point is that coordination of care is critically necessary as first responders save an individual from overdose through the administration of Narcan [naloxone]”, getting the individual to an emergency department, where trained personnel can get the person evaluated and referred to treatment.
Finally, the paper focuses on the emerging importance of the criminal justice system, citing positive initiatives in Connecticut and Rhode Island, in particular, where OTPs are operating within prisons and jails. The results from both state experiences is a significant reduction in recidivism: individuals do not return to the correctional system, and there is a dramatic reduction in opioid mortality, writes Mr. Parrino. That’s what happens when inmates are released to community-based practice settings, and smoothly transition into the OTP to continue their treatment, he said. Without question, this kind of intervention should be repeated throughout the United States, so that inmates with OUD can have access to treatment during incarceration, and referred to outpatient treatment facilities upon release.
The policy paper which was released in January 2019 can be accessed at: http://www.aatod.org/wp-content/uploads/2019/01/2019-Policy-Paper-4.pdf