The Fundamentals of Medication Assisted Treatment - PowerPoint Presentation

Slide1

The Fundamentals of Medication Assisted Treatment

Nick Szubiak, MSW, LCSW

Director, Clinical Excellence in Addictions

National Council for Behavioral HealthSlide2

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.Slide3

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 rateSlide4

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.”Slide5

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 Slide6

Origins of Opioid Crisis

Opioids Myth: Non-Addictive

Porter and Jick letter published in New England Journal of Medicine in 1980; frequently cited in marketing of new synthetic opioids

OxyContin brought to market in 1996

History of Untreated Pain

Pain was left untreated even for terminally-ill cancer patients

Doctors were weary of prescribing opioid medications

Pain As 5

th

vital sign

National initiative rolled out in the late 90s

Emergence of Pill Mills

Unrestricted prescribing of pain medications

Unlike 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 firearmsSlide7

Stigma and Discrimination

Stigma refers to

negative stereotypes

Discrimination 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 disability

Would you treat someone less favorably because they were prescribed insulin for diabetes? What about people with high-cholesterol who are prescribed cholesterol-lowering medication?Slide8

Beliefs PerceptionsSlide9

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 Slide10
Slide11

Excessive amounts used

Excessive time spent using/obtaining

Tolerance

Withdrawal

Cravings or urges to use

Unsuccessful attempts to cut down

- Hazardous use

Health problems

Missed obligations

Interference with activities

Personal problems

Three Stages of AddictionSlide12

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 Pharm

Director, Substance Use Prevention and Treatment Initiative

The Pew Charitable Trusts

Reily

www.nida.govSlide13

Defining Addiction

Addiction is a primary, chronic

disease

Biological

Psychological

Social

Components

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.  Slide14

“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, ASAMSlide15

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

- ASAMSlide16

Beliefs PerceptionsSlide17

How has addiction treatment changed?

Short-term acute

interventions vs.

chronic disease

management model

Relapse is a part of the disease,

NOT

a failure

Similar 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 deathSlide18

Welcome MAT

Medications

Recovery Work

Intensive Psycho, Social and Behavioral treatmentsSlide19

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-disorderSlide20

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 use

Reduces risk of overdose

Prevents injection behaviors

Reduces criminal behaviorSlide21

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 Slide22

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 heroin

10% to 40% of individuals with addictions receive treatment

Only a fraction of those that get treatment get MAT

300,000-400,000 people on methadone in a given year

40,000 on buprenorphine

5-10,000 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)Slide23

Evidenced Based- Utilization

Slide24

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. Slide25

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 medicationsSlide26

The Bias Against MAT

Perception

that MAT is not treating the underlying causes of addiction. Slide27

The Bias Against MAT

Negative

perceptions

around methadone clinics; patients may try to limit their time thereSlide28

The Bias Against MAT

Belief

that people on MAT are not in recovery; not “clean”Slide29

The Bias Against MAT

Belief

that MAT is a substitution of one drug for the other; fighting fire with fireSlide30

The Bias Against MAT

Belief

that opioid use is not in my scope an should be treated by specialty addiction providersSlide31

There is no evidence to support stopping MAT

95% 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 on

Methadone for 24+ months, Buprenorphine for 18+ months

Typically patients with continuous sobriety for 1-2+ years have the best outcomes

Treatment <6 months has worse outcomes

Stopping/Tapering MAT Slide32

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 firearmsSlide33

Sound Familiar?

Similar to the 1990s with patients who had suicidal depression and were being judged for taking Prozac Slide34

Patient Impact

Neglected a full range of treatment options

Pressure from child welfare, jail, prison, and parole/probation systems to stop MAT

Restricted access

to recovery support services

For example, many recovery houses do not allow residents to be on MAT

The previous two points can lead patients stop MAT before it is clinically appropriateSlide35

Biases within MAT

Methadone and buprenorphine are narcotics

Bias 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)Slide36

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) Slide37

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. Slide38

How do we impact discrimination

?

Share the evidence!

Recognize MAT for what it is:

The gold standard of OUD treatmentSlide39

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.Slide40

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_TvytPYSlide41

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 Slide42

Embracing Many Pathways to Recovery

All patients are offered MAT: Methadone, Buprenorphine, Naltrexone

Patient 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 needs

Treatment works better with patient buy-inSlide43

The Fundamentals of Medication Assisted Treatment:

An Integrated Approach to Recovery for Individuals with Co-Occurring Disorders

Angele Moss-Baker, LPC, LMFT, MAC, EAS-C

Comprehensive Addiction & Psychological Services, LLCSlide44

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.

44Slide45

Falling Through the Cracks

45Slide46
Slide47

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

47

SUD and Mental Illness

SUD,

No Mental

Illness

11.5 Million

19.6 Million

Had SUD

8.1

Million

35.4

Million

43.4 Million Had Mental Illness

Mental Illness,

No SUD

Results from 2015 National Survey on Drug Use and HealthSlide48

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.Slide49

Which Comes First?

49Slide50
Slide51

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

51Slide52

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 disordersIntensive therapy for those with CODs, than those without CODs.Slide53

Quadrants of MH/SUD Services

Category III

Substance Abuse System

Severe SUD, Mild MI

Med-Monitored IPWM,

PHP, RTF, MAT

DDC/DDE

Category IV

Acute Care Hospitals

Severe MI, Severe SUD

Med-Managed IPWM, IP Psych, Residential

Category I

Primary Health Care

Mild MI, Mild SUD

PCP, OP, IOP

Category II

Mental Health System

Severe MI, Mild SUD

OP, IOP, PHP, ACT, GH

53

Alcohol and other drugs

High Intensity

Low Intensity

High Intensity

Mental IllnessSlide54

ASAM Treatment Levels of Service

Level III

Med-Monitored IPWM

Clinically-Managed Residential WM

Medically-Monitored Intensive Inpatient

Clinically-Managed High-Intensity Residential

Clinically Managed Population-Specific High Intensity Residential Services

Clinically-Managed Low-Intensity Residential

Level IV

Med-Managed IPWM

Medically-Managed Intensive Inpatient

Level I

Ambulatory Withdrawal Management without Extended On-Site Monitoring

Outpatient Services

Level 0.5

Early Intervention

Level II

Ambulatory WM with Extended On-Site Monitoring

Partial Hospitalization

Intensive Outpatient

OPIOID TREATMENT SERVICES (OTS)

Opioid

Treatment Program (OTP) – Agonist meds: methadone,

buprenorphine

;

Office Based

Opioid

Treatment (OBOT) Antagonist medication –

naltrexone

54Slide55

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.Slide56

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.Slide57

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.Slide58

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. Slide59

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. Slide60

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 TreatmentSlide61

Effective Integrated Service Delivery

With Psychiatric Providers

With MAT Physician

With Primary Care and other medical providers

Coordinating with Specialty Providers

Empathic

Nonjudgmental

Roll with Resistance

Precontemplation

Contemplation

Preparation

Action

Maintenance

Collaboration/Coordinated

Care

Motivational

Interviewing

Stage-Wise

TreatmentSlide62

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 ConditionsSlide63

Thank You!

Angele Moss-Baker

Comprehensive Addiction & Psychological Services, LLC

Caps.therapy@yahoo.com

www.caps-therapy.comSlide64

Policy Interventions

Affordable Care Act/Medicaid expansion

Individuals 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 Patients

June 2016 SAMHSA raised doctor prescribing limit from 100 to 275 patients

Comprehensive Addiction & Recovery Act (CARA)

Allows Nurse Practitioners and Physician Assistants to prescribe buprenorphine for up to 30 patients

First addiction bill passed through Congress in 40 years

21st Century Cures Act

Allocated $1 billion in State Targeted Response grants to curb opioid abuse and increase treatment capacity

Surgeon General Report

First Surgeon General report on addictionSlide65

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 & ResourcesSlide66

https://www.thenationalcouncil.org/mat/Slide67

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.org

For questions email:

pcssmat@aaap

.org

Twitter:

@

PCSSProjectsSlide68

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 MAT

Over 23 million Americans are in recovery from addiction to alcohol and other drugsSlide69

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.mm655051e1Slide70

Thank You!

Nick Szubiak, MSW, LCSW

Integrated Health Consultant

Director, Clinical Excellence in Addictions

National Council for Behavioral Health

LinkedIn: Nick Szubiak, MSW,LCSW

Twitter: @

nszubiak

nicks@thenationalcouncil.org

Office

202.621.1625

C.

808.895.7679