The Fundamentals of Medication Assisted Treatment - PowerPoint Presentation

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The Fundamentals of Medication Assisted Treatment

Nick Szubiak, MSW, LCSW

Director, Clinical Excellence in Addictions

National Council for Behavioral Health

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Objectives

Understand why and how Medication Assisted Treatment works and why we don't use it by challenging the way we view, judge and think about addiction.

Gain an understanding and recognition of the discrimination and bias that impacts access to evidenced based care for those who need treatment for substance use disorders.

Participants

will identify and describe three differences between integrated MAT treatment practices versus non-integrated MAT treatment practices.

Participants

will list and describe three common barriers to access MAT and identify strategies to increase access to care.

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National Opioid Overdose Epidemic as of 2015

Drug overdose is the leading cause of accidental death in the US, with 52,404 lethal drug overdoses in

Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin

From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers increased in parallel.

overdose death rate in 2008 was nearly four times the 1999 rate;

sales of prescription pain relievers in 2010 were four times those in 1999;

substance use disorder treatment admission rate in 2009 was six times the 1999 rate

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National Opioid Overdose Epidemic as of 2015

In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills.

Four in five new heroin users started out misusing prescription painkillers.

94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.”

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Overdose Deaths

Warner et al.

National Vital Statistics Report, 2016;65(10).

Conclusion:

Rising rate of overdose deaths is driven largely by Heroin and Fentanyl

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Origins of Opioid Crisis

Opioids Myth: Non-AddictivePorter and Jick letter published in New England Journal of Medicine in 1980; frequently cited in marketing of new synthetic opioidsOxyContin brought to market in 1996History of Untreated PainPain was left untreated even for terminally-ill cancer patients Doctors were weary of prescribing opioid medicationsPain As 5th vital signNational initiative rolled out in the late 90sEmergence of Pill MillsUnrestricted prescribing of pain medicationsUnlike legitimate pain clinics, pill mills see greater numbers of patients, write more prescription, and do less medical exams. Most are cash-only. Greater availability of heroinLarger, cheaper supply and more potent than prescription painkillersLeading Cause of Accidental Death Starting in 2008, drug overdoses became the leading cause of injury death in the United States surpassing car accidents and firearms

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Stigma and Discrimination

Stigma refers to negative stereotypesDiscrimination is the behavior that results from the negative stereotype Discrimination in this case means treating someone less favorably than someone else because he or she has a disabilityWould you treat someone less favorably because they were prescribed insulin for diabetes? What about people with high-cholesterol who are prescribed cholesterol-lowering medication?

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Beliefs Perceptions

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How has our definition of addiction changed?

Addiction was thought of as a

moral failing

or

character defect

Drug use: criminal issue vs. health issue

Language matters: move away from

“addicts”

Scientific research has demonstrated that, whether we are aware of it, the use of certain terms implicitly generate biases that can influence the formation and effectiveness of our social and public health policies in addressing them

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Excessive amounts used

Excessive time spent using/obtaining

Tolerance

Withdrawal

Cravings or urges to use

Unsuccessful attempts to cut down

- Hazardous use

Health problemsMissed obligationsInterference with activitiesPersonal problems

Three Stages of Addiction

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SUD is a complex disease that results in chemical and physiologic changes to the brain

SUD must be treated like any other chronic, relapsing condition Slide from C. Cynthia Reilly, MS, BS PharmDirector, Substance Use Prevention and Treatment InitiativeThe Pew Charitable Trusts Reily

www.nida.gov

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Defining Addiction

Addiction is a primary, chronic disease

BiologicalPsychologicalSocialComponents

Primary Disease

- meaning that it’s not the result of other causes such as emotional or psychiatric problems.

Chronic Disease

- like cardiovascular disease or diabetes it must be treated, managed and monitored over a life‐time.  

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“At its core, addiction isn’t just a social problem or a moral problem or a criminal problem. It’s a

brain problem

whose behaviors manifest in all these other areas. “

Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It’s about underlying neurology, not outward actions.”

- Dr. Michael Miller, ASAM

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Defining Addiction

Addiction is a primary, chronic and relapsing brain disease characterized by an individual pathologically pursuing reward and/or relief by substance use and other behaviors

- ASAM

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Beliefs Perceptions

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How has addiction treatment changed?

Short-term acute interventions vs. chronic disease management modelRelapse is a part of the disease, NOT a failureSimilar to other chronic diseases, addiction often involves cycles of relapse and remission Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death

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Welcome MAT

Medications

Recovery Work Intensive Psycho, Social and Behavioral treatments

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OUD Drugs: Distinct Pharmacology and Roles in Treatment

http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorder

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The Case for MAT

MAT is “the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders.”--SAMHSA Research indicates that methadone and buprenorphine have a strong evidence base supporting their clinical effectiveness. Strong support for Vivitrol.MAT is the gold standard for opioid use disorder (OUD) treatment:Reduces drug useReduces risk of overdosePrevents injection behaviorsReduces criminal behavior

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MAT Supports Recovery

persistent intentional

abstinence

from intoxication

engagement

in daily life

gaining

employment

reestablish

family and social ties

being

present

in everyday life

being able to weather the challenges, daily lows and highs of life

without substances

as an external coping skills that has negative side effects and consequences

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An Unmet Need

20.2 Million People Have SUD 2 million had a substance use disorder involving prescription pain relievers and 591,000 had a substance use disorder involving heroin10% to 40% of individuals with addictions receive treatmentOnly a fraction of those that get treatment get MAT300,000-400,000 people on methadone in a given year40,000 on buprenorphine5-10,000 on Naltrexone Only 10% of the people who need to be on MAT for opioid use disorder (OUC) are receiving it More than two-thirds of U.S. clinics and treatment centers still do not offer MAT medications (Stateline, 2016)

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Evidenced Based- Utilization

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The Bias Against MAT

Belief

that use of medication conflicts with abstinence-based treatment programs like 12-step programs*

*Not all 12-step programs prohibit MAT and mutual support groups remain an important part of addiction treatment and recovery.

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The Bias Against MAT

Belief

that abstinence is more effective than MAT

Many people, including individuals who have worked in the treatment field, have recovered from addiction without the use of medications

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The Bias Against MAT

Perception

that MAT is not treating the underlying causes of addiction.

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The Bias Against MAT

Negative

perceptions

around methadone clinics; patients may try to limit their time there

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The Bias Against MAT

Belief

that people on MAT are not in recovery; not “clean”

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The Bias Against MAT

Belief

that MAT is a substitution of one drug for the other; fighting fire with fire

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The Bias Against MAT

Belief

that opioid use is not in my scope an should be treated by specialty addiction providers

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There is no evidence to support stopping MAT95% of methadone patients do not achieve abstinence when attempting to taper off (Nosyk, et al. 2013)Over 90% of buprenorphine patients relapse within 8 weeks of taper completion (Weiss, et al. 2011)Successful patients are commonly maintained onMethadone for 24+ months, Buprenorphine for 18+ months Typically patients with continuous sobriety for 1-2+ years have the best outcomesTreatment <6 months has worse outcomes

Stopping/Tapering MAT

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VERDICT

Bias against MAT is deadly

Leading Cause of Accidental Death

Starting in 2008

, drug overdoses became the leading cause of injury death in the United States surpassing car accidents and firearms

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Sound Familiar?

Similar to the 1990s with patients who had suicidal depression and were being judged for taking Prozac

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Patient Impact

Neglected a full range of treatment optionsPressure from child welfare, jail, prison, and parole/probation systems to stop MATRestricted access to recovery support servicesFor example, many recovery houses do not allow residents to be on MATThe previous two points can lead patients stop MAT before it is clinically appropriate

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Biases within MAT

Methadone and buprenorphine are narcoticsBias towards using Vivitrol because it is “safer”Diversion of methadone and buprenorphine Used to get “high” and street value“Addiction doctors agree that all three medications should be available to patients, because one may be more effective than another, depending in part on the person’s age, length of time as an addict , home and work environment and underlying mental health issues. The American Medical Association, the American Academy of Addiction Psychiatry and the American Society of Addiction Medicine unequivocally support their use.” (Stateline, 2016)

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MAT Methadone Bias

Treating and opioid with an opioid? Fire with Fire?

Overdose trends in the US: Long acting or extended release

Methadone is long acting – stays in your system 24-36 hours but the pain control or analgesia only lasts 6-8 hours

Pain management vs OUD treatment

Talking about pill form vs liquid form

Observed in clinic vs pills taken in the community (diversion)

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3 P’s: Providers, Perceptions, Payment

Perceptions: The perceptions of MAT and its value among patients, practitioners, and institutions

Some practitioners do not believe that MAT is more effective than abstinence-based treatment—when patients are treated without medication—despite science-based evidence

Providers: The availability of qualified practitioners and their capacity to meet patient demand for MAT

Hiring physicians can be expensive for clinics, especially small centers Physicians receive little education in addiction care & are reluctant to extend their practice to patients with addictions

Payment: The availability and limits of insurance coverage for MAT

Few private insurers and state Medicaid programs cover all of the MAT medications approved by the Food and Drug Administration. Other face hurdles such as prior authorization requirements or “fail first” policies.

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How do we impact discrimination?

Share the evidence!Recognize MAT for what it is: The gold standard of OUD treatment

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Defining Recovery

A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

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What is recovery?

A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

Health

:  overcoming or managing one’s disease(s) or symptoms—for example, abstaining from use of alcohol, illicit drugs, and non-prescribed medications if one has an addiction problem—and for everyone in recovery, making informed, healthy choices that support physical and emotional wellbeing.

Home:

  a stable and safe place to live;

Purpose:

  meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society; and

Community

:  relationships and social networks that provide support, friendship, love, and hope.

https://blog.samhsa.gov/2012/03/23/defintion-of-recovery-updated/#.WLY7_TvytPY

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What is recovery?

Persistent intentional abstinence from intoxication

Engagement in daily life

Gaining employment

Re-establish family and social ties

Being present in everyday life

Being able to weather the challenges, daily lows and highs of life without using substances as an external coping skills that has negative side effects and consequences

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Embracing Many Pathways to Recovery

All patients are offered MAT: Methadone, Buprenorphine, NaltrexonePatient Centered Care: All patients have an option of any of the three medications to treat SUD. There are pros and cons to each. There should be consideration of where they are in life, phase of treatment, and what the patient needsTreatment works better with patient buy-in

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The Fundamentals of Medication Assisted Treatment:

An Integrated Approach to Recovery for Individuals with Co-Occurring DisordersAngele Moss-Baker, LPC, LMFT, MAC, EAS-C Comprehensive Addiction & Psychological Services, LLC

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Traditional Approaches to Treatment

Sequential treatment - The client is treated in one system, then the Agencies work largely independent of each other.Parallel model – The client is treated simultaneously, but by two separate agencies. The patient participates in two systems simultaneously. Coordination is not consistent.

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Falling Through the Cracks

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2015: Co-Occurring Mental Health and Substance Use – Adults

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SUD and Mental Illness

SUD,

No Mental Illness

11.5 Million

19.6 MillionHad SUD

8.1Million

35.4 Million

43.4 Million Had Mental Illness

Mental Illness, No SUD

Results from 2015 National Survey on Drug Use and Health

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Comorbidities and MAT

Psychiatric Comorbidity

The most common are: Major Depression, Anxiety, Bipolar, PTSD.

Psychiatric comorbidities may complicate buprenorphine treatment.

NOTE:

C

ombining medications used in MAT with anxiety treatment medications can be fatal. Benzodiazepines are highly associated with overdose fatalities when combined with opioids.

Medical Comorbidity

The most common are: HIV, Hepatitis B and C, Tuberculosis, Syphilis.

MAT and drug interactions - antiretroviral medications, vital hepatitis medical treatment.

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Which Comes First?

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Integrated Treatment

An approach that involves simultaneous treatment of both disorders in a setting designed to accommodate both problems in a unified and comprehensive treatment program. An approach to meet the substance use, medical and mental health, and social needs of a patient

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Essential Principles and Competencies for COD and MAT

Integrated Treatment

or highly coordinated when not on site.

Monitor patient progress and compliance with off-site treatment

Staff competency

– Cross training

Co-occurring psychiatric and medical conditions

Psychotropic medications

- prescribed when significant impairment exists.

Prescribing medications with abuse potential such as benzodiazepines (opt

Serax

)

All medications are monitored

Alleviate shame and stigma

to receive treatment for co-occurring disorders

Intensive therapy for those with CODs, than those without CODs.

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Quadrants of MH/SUD Services

Category IIISubstance Abuse System Severe SUD, Mild MI Med-Monitored IPWM, PHP, RTF, MATDDC/DDECategory IVAcute Care Hospitals Severe MI, Severe SUD Med-Managed IPWM, IP Psych, ResidentialCategory I Primary Health Care Mild MI, Mild SUD PCP, OP, IOPCategory IIMental Health SystemSevere MI, Mild SUDOP, IOP, PHP, ACT, GH

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Alcohol and other drugs

High Intensity

Low Intensity

High Intensity

Mental Illness

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ASAM Treatment Levels of Service

Level III Med-Monitored IPWM Clinically-Managed Residential WM Medically-Monitored Intensive InpatientClinically-Managed High-Intensity Residential Clinically Managed Population-Specific High Intensity Residential ServicesClinically-Managed Low-Intensity ResidentialLevel IV Med-Managed IPWM Medically-Managed Intensive Inpatient Level I Ambulatory Withdrawal Management without Extended On-Site MonitoringOutpatient ServicesLevel 0.5Early InterventionLevel IIAmbulatory WM with Extended On-Site Monitoring Partial Hospitalization Intensive OutpatientOPIOID TREATMENT SERVICES (OTS)Opioid Treatment Program (OTP) – Agonist meds: methadone, buprenorphine; Office Based Opioid Treatment (OBOT) Antagonist medication – naltrexone

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ASAM Practice Guideline for the Treatment of Co-Occurring Psychiatric Disorders

A comprehensive assessment

including determination of mental health status should evaluate whether the patient is stable.

Patients with suicidal or homicidal ideation should be referred immediately for treatment and possibly hospitalization.

Reduce, manage, and monitor suicide risk

Management

of patients at risk for suicide should include:

reducing immediate risk

managing underlying factors associated with suicidal intent

monitoring and follow-up

Assessment for psychiatric disorder

should occur at the onset of agonist or antagonist treatment.

Reassessment using a detailed mental status examination should occur after stabilization with methadone,

buprenorphine

or

naltrexone

.

Pharmacotherapy

in conjunction with psychosocial treatment should be considered for patients with

opioid

use disorder and a co-occurring psychiatric disorder.

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Quadrant of Care:Where Does Treatment Begin?

Patients in acute psychiatric danger –

Patients presenting with suicidal or homicidal ideation or threats, that may interfere with their safety and ability to function should be assessed and treated immediately whether resulting from:

acute intoxication or withdrawal, or

an independent co-occurring disorder or substance-induced disorder

Although their symptoms may be short lived, admission to a psychiatric unit for brief treatment may be necessary if outpatient care is too risky or problematic.

Immediate administration of antipsychotic drugs, benzodiazepines, or other sedatives may be required to establish behavioral control.

A physician, physician's assistant, or nurse practitioner on staff can prescribe medications at the OTP.

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Quadrant of Care:Where Does Treatment Begin?

Patients with established severe co-occurring disorders who are not in acute danger

Should receive medication with the lowest abuse potential for their condition.

If an OTP is staffed appropriately and prepared to treat patients with severe co-occurring disorders, these patients can be treated on site.

If there is no such OTP, patients may need to remain in a less optimal OTP but receive psychiatric treatment at another facility with effective highly collaborative communication between OTPs and mental health providers to coordinate treatment.

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Quadrant of Care:Where Does Treatment Begin?

Patients with less severe, persisting or emerging symptoms of co-occurring disorders.

Patients in MAT with non-disabling symptoms of less severe co-occurring disorders (e.g., mood, anxiety, and personality disorders) should continue or begin medication, psychotherapy, or both for their co-occurring disorders.

These patients should continue in MAT if the OTP is staffed to treat them.

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Quadrant of Care:Where Does Treatment Begin?

Patients with less severe, presumptively substance-induced co-occurring disorders.

Patients in MAT with symptoms of a psychiatric disorder, without a history of CODs, receive no new psychotropic medications until they are stabilized on MAT - because their symptoms might remit or significantly diminish after a period of substance abuse treatment.

Exceptions include patients who have acute, substance-induced disorders such as extreme anxiety or paranoia that are likely to be transitory but require temporary sedation or antianxiety medication.

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Effective Integrated Service Delivery

Based on principles of effective integrated service delivery:

Collaboration and Coordinated Care

42 CFR § 2 - CONFIDENTIALITY OF SUBSTANCE USE DISORDER PATIENT RECORDS

Motivational Interviewing

Stage-Wise Treatment

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Effective Integrated Service Delivery

With Psychiatric ProvidersWith MAT PhysicianWith Primary Care and other medical providersCoordinating with Specialty Providers

EmpathicNonjudgmentalRoll with Resistance

PrecontemplationContemplationPreparationActionMaintenance

Collaboration/Coordinated Care

Motivational Interviewing

Stage-Wise

Treatment

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References

Medication Assisted Treatment: A Standard of Care

. Elinore

McCance

-Katz, SAMHSA 2014.

A Family Guide to Concurrent Disorders.

Centre for Addiction and Mental Health.

Integrated Service Delivery Models for Opioid Treatment Programs in an Era of Increasing Opioid Addiction, Health Reform, and Parity.

Kenneth B.

Stoller

, Mary Ann C. Stephens, Allegra

Schorr

. American Association for the Treatment of Opioid Dependence, July 2015.

Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs: TIP 43.

SAMHSA 2012.

Federal Guidelines for Opioid Treatment Programs.

SAMHSA January 2015.

The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving

Opioid

Use.

American Society of Addiction Medicine. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-occurring Conditions

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Thank You!

Angele Moss-Baker

Comprehensive Addiction & Psychological Services, LLC

Caps.therapy@yahoo.com

www.caps-therapy.com

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Policy Interventions

Affordable Care Act/Medicaid expansionIndividuals with mental health and substance use disorders were the single largest beneficiaries of Medicaid expansion with nearly one-third of new Medicaid enrollees having a either a mental health and/or Substance Use Disorder Physician Buprenorphine Prescribing Limit Raised to 275 PatientsJune 2016 SAMHSA raised doctor prescribing limit from 100 to 275 patientsComprehensive Addiction & Recovery Act (CARA)Allows Nurse Practitioners and Physician Assistants to prescribe buprenorphine for up to 30 patientsFirst addiction bill passed through Congress in 40 years21st Century Cures ActAllocated $1 billion in State Targeted Response grants to curb opioid abuse and increase treatment capacity Surgeon General ReportFirst Surgeon General report on addiction

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Resources on Opioid Use

Centers for Disease Control and Prevention

Overdose Data

Guidelines for Prescribing Opioids for Chronic Pain

Substance Abuse and Mental Health Services Agency

Data on

Prescription Opioid and Heroin Use

from the annual National Survey on Drug Use and Health

Medication-Assisted Treatment

Information on certification, oversight, DATA-2000 waivers, legislation, regulation, and more

Office on National Drug Control Policy

(

archived website

)

National Drug Control Strategy

Data

on Methadone, Buprenorphine treatment and drug poisoning deaths

National Institutes on Drug Abuse

Opioid Epidemic Strategies & Resources

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https://www.thenationalcouncil.org/mat/

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 Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Medication Assisted Treatment (grant no. 5U79TI024697) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

PCSS-MAT

is a collaborative effort led by American Academy of Addiction Psychiatry in partnership with: American Osteopathic Academy of Addiction Medicine, American Psychiatric Association, American Society of Addiction Medicine and Association for Medical Education and Research in Substance Abuse. For more information visit: www.pcssmat.orgFor questions email: pcssmat@aaap.org Twitter: @PCSSProjects

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Treatment Works, People Recover

Research shows that the earlier drug use begins, the more likely it will progress to addiction | Teen alcohol and drug use is declining More and more individuals are engaged in MATOver 23 million Americans are in recovery from addiction to alcohol and other drugs

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References

1 National Institute on Drug Abuse. (2015). Drugs of Abuse: Opioids. Bethesda, MD: National Institute on Drug Abuse. Available at http://www.drugabuse.gov/drugs-abuse/opioids.

2 American Society of Addiction Medicine. (2011). Public Policy Statement: Definition of Addiction. Chevy Chase, MD: American Society of Addiction Medicine. Available at http://www.asam.org/docs/publicypolicy-statements/1definition_of_addiction_long_4-11.pdf?sfvrsn=2.

3 Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://www.samhsa.gov/data/.

4 National Institute on Drug Abuse. (2014). Drug Facts: Heroin. Bethesda, MD: National Institute on Drug Abuse. Available at http://www.drugabuse.gov/publications/drugfacts/heroin.

5 Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR

Morb

Mortal

Wkly

Rep 2016;65:1445–1452. DOI: http://dx.doi.org/10.15585/mmwr.mm655051e1

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Thank You!

Nick Szubiak, MSW, LCSWIntegrated Health ConsultantDirector, Clinical Excellence in AddictionsNational Council for Behavioral HealthLinkedIn: Nick Szubiak, MSW,LCSWTwitter: @nszubiaknicks@thenationalcouncil.orgOffice 202.621.1625 C. 808.895.7679