review of medication and impact of the opiate epidemic · 12/12/2019 · opiate epidemic. › nchs...
TRANSCRIPT
Review of medication and Impact of the Opiate Epidemic
httpswwwcdcgov rsaquo nchs rsaquo products rsaquo databriefs
In 2017 there were 70237 drug overdose deaths in the United States The age-adjusted rate of drug overdose deaths in 2017 (217 per 100000) was 96 higher than the rate in 2016 (198)
The age-adjusted rate of drug overdose deaths in2016 (198 per 100000) was 21 higher than the rate in 2015 (163)
ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquo
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
Death rates increasing for opioids
Drug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon
= FENTANYLDrug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon
Death rates increasing for opioids
Cocaine deaths rising due to opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Methamphetamine deaths rising independent of opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Opioid Overdose Deaths (1999 - 2017)
Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC) National Center for Health Statistics Multiple Cause of Death 1999-2017 on CDC WONDER Online Database released 2018 Data are from the Multiple Cause of Death Files 1999-2017 as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program
Drug Overdose Deaths Drop inUS for First Time Since 1990
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
San Francisco 2018 - 150 increase
bull according to the San Francisco Department of Public Health (released data 82019)
bull 89 people died from accidental overdoses of fentanyl last year (2018)
bull 36 fentanyl-related deaths in 2017
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
httpswwwcdcgov rsaquo nchs rsaquo products rsaquo databriefs
In 2017 there were 70237 drug overdose deaths in the United States The age-adjusted rate of drug overdose deaths in 2017 (217 per 100000) was 96 higher than the rate in 2016 (198)
The age-adjusted rate of drug overdose deaths in2016 (198 per 100000) was 21 higher than the rate in 2015 (163)
ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquo
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
Death rates increasing for opioids
Drug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon
= FENTANYLDrug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon
Death rates increasing for opioids
Cocaine deaths rising due to opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Methamphetamine deaths rising independent of opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Opioid Overdose Deaths (1999 - 2017)
Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC) National Center for Health Statistics Multiple Cause of Death 1999-2017 on CDC WONDER Online Database released 2018 Data are from the Multiple Cause of Death Files 1999-2017 as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program
Drug Overdose Deaths Drop inUS for First Time Since 1990
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
San Francisco 2018 - 150 increase
bull according to the San Francisco Department of Public Health (released data 82019)
bull 89 people died from accidental overdoses of fentanyl last year (2018)
bull 36 fentanyl-related deaths in 2017
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquo
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
Death rates increasing for opioids
Drug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon
= FENTANYLDrug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon
Death rates increasing for opioids
Cocaine deaths rising due to opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Methamphetamine deaths rising independent of opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Opioid Overdose Deaths (1999 - 2017)
Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC) National Center for Health Statistics Multiple Cause of Death 1999-2017 on CDC WONDER Online Database released 2018 Data are from the Multiple Cause of Death Files 1999-2017 as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program
Drug Overdose Deaths Drop inUS for First Time Since 1990
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
San Francisco 2018 - 150 increase
bull according to the San Francisco Department of Public Health (released data 82019)
bull 89 people died from accidental overdoses of fentanyl last year (2018)
bull 36 fentanyl-related deaths in 2017
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Death rates increasing for opioids
Drug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon
= FENTANYLDrug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon
Death rates increasing for opioids
Cocaine deaths rising due to opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Methamphetamine deaths rising independent of opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Opioid Overdose Deaths (1999 - 2017)
Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC) National Center for Health Statistics Multiple Cause of Death 1999-2017 on CDC WONDER Online Database released 2018 Data are from the Multiple Cause of Death Files 1999-2017 as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program
Drug Overdose Deaths Drop inUS for First Time Since 1990
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
San Francisco 2018 - 150 increase
bull according to the San Francisco Department of Public Health (released data 82019)
bull 89 people died from accidental overdoses of fentanyl last year (2018)
bull 36 fentanyl-related deaths in 2017
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
= FENTANYLDrug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon
Death rates increasing for opioids
Cocaine deaths rising due to opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Methamphetamine deaths rising independent of opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Opioid Overdose Deaths (1999 - 2017)
Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC) National Center for Health Statistics Multiple Cause of Death 1999-2017 on CDC WONDER Online Database released 2018 Data are from the Multiple Cause of Death Files 1999-2017 as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program
Drug Overdose Deaths Drop inUS for First Time Since 1990
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
San Francisco 2018 - 150 increase
bull according to the San Francisco Department of Public Health (released data 82019)
bull 89 people died from accidental overdoses of fentanyl last year (2018)
bull 36 fentanyl-related deaths in 2017
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Cocaine deaths rising due to opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Methamphetamine deaths rising independent of opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Opioid Overdose Deaths (1999 - 2017)
Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC) National Center for Health Statistics Multiple Cause of Death 1999-2017 on CDC WONDER Online Database released 2018 Data are from the Multiple Cause of Death Files 1999-2017 as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program
Drug Overdose Deaths Drop inUS for First Time Since 1990
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
San Francisco 2018 - 150 increase
bull according to the San Francisco Department of Public Health (released data 82019)
bull 89 people died from accidental overdoses of fentanyl last year (2018)
bull 36 fentanyl-related deaths in 2017
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Methamphetamine deaths rising independent of opioids
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3
Opioid Overdose Deaths (1999 - 2017)
Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC) National Center for Health Statistics Multiple Cause of Death 1999-2017 on CDC WONDER Online Database released 2018 Data are from the Multiple Cause of Death Files 1999-2017 as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program
Drug Overdose Deaths Drop inUS for First Time Since 1990
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
San Francisco 2018 - 150 increase
bull according to the San Francisco Department of Public Health (released data 82019)
bull 89 people died from accidental overdoses of fentanyl last year (2018)
bull 36 fentanyl-related deaths in 2017
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Opioid Overdose Deaths (1999 - 2017)
Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC) National Center for Health Statistics Multiple Cause of Death 1999-2017 on CDC WONDER Online Database released 2018 Data are from the Multiple Cause of Death Files 1999-2017 as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program
Drug Overdose Deaths Drop inUS for First Time Since 1990
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
San Francisco 2018 - 150 increase
bull according to the San Francisco Department of Public Health (released data 82019)
bull 89 people died from accidental overdoses of fentanyl last year (2018)
bull 36 fentanyl-related deaths in 2017
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Drug Overdose Deaths Drop inUS for First Time Since 1990
By Abby Goodnough Josh Katz and Margot Sanger-Katz
July 17 2019 -NYT
San Francisco 2018 - 150 increase
bull according to the San Francisco Department of Public Health (released data 82019)
bull 89 people died from accidental overdoses of fentanyl last year (2018)
bull 36 fentanyl-related deaths in 2017
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
San Francisco 2018 - 150 increase
bull according to the San Francisco Department of Public Health (released data 82019)
bull 89 people died from accidental overdoses of fentanyl last year (2018)
bull 36 fentanyl-related deaths in 2017
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
West Mountain West
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
New England
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Mid-Atlantic Appalachia
httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash
December 2017 to JanuaryndashJune 2018
MMWR Morb Mortal Wkly Rep 201968737ndash744
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
If cannot reduce supply ndash Reduce Demand
bull Preventionbull Treatment bull ldquoHarm reductionrdquo
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
ASAM Short Definition of Addiction
ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry
ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations
ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
ASAM Short Definition of Addiction (continued)
ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response
ndash Like other chronic diseases addiction often involves cycles of relapse and remission
ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Recovery
Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as
ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo
httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Recovery-Related Values and Beliefs bull People who suffer from substance use disorders
(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many
individuals from seeking help must be vigorously combated
bull Recovery can be achieved through diverse pathways and should be celebrated
bull Access to high-quality treatment is a human right although recovery is more than treatment
bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT
PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use
treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where
patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives
bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment
httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Recovery versus Remissionbull Remission is a medical term meaning that major
disease symptoms are eliminated or diminished below a predetermined harmful level
bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person
US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Full Agonist Partial versus Antagonist
Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)
Safest
Least Safe
Safer
MOST STIGMATIZED
LEAST STIGMATIZED
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Medication As Treatment
bull A treatment is provided to improve chances of certain outcomes
bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure
bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent
plaque rupture)
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Which medication to recommend for Opioid Use Disorder (OUD)
ie treat people with Addiction who use opioids
bull All 3 medications approved to treat OUD work as long as the patient will take the medication
bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and
cons of each option are keyndash Noncompliance with (or discontinuation of)
medication regimen is associated with very poor outcomes (death)
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
3x
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Luis Sordo et al BMJ 2017357bmjj1550
copy2017 by British Medical Journal Publishing Group
2x
All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
ldquoMedication Assisted Treatmentrdquo
bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT
bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the
medication regimenbull Does one require the other
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
ldquoMedication Assisted Treatmentrdquo
bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications
bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in
order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more
than statefederal minimums
Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
MAT ldquoMedication Assisted Treatmentrdquo
bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)
bull What are the consequences if patient refuses or is unable to participate
bull Is it appropriate to refuse medication to those who struggle along the recovery path
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
MAT ldquoMedication Assisted Treatmentrdquo
bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and
stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome
J Subst Abuse Treat 2015 Oct 57 89ndash95
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomes
At 6 months 63 in treatment 33 abstinent
Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient
outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system
- Observational study showing improved outcomes for those willing to attend NA
- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo
- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo
- No benefit seen when patients had counselors who required attendance
J Subst Abuse Treat 2015 Oct 57 89ndash95
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
MAT and Counseling
bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies
bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful
bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)
The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Medication IS the Treatment
bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)
bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising
eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups
bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes
bull Non- pharma treatment benefits many people with many diseases
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Medication IS the Treatment for Addiction involving Opioids
bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
bull Break
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
MAR
bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)
ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated
ndash are based on experiential rather than expert knowledge
ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based
effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF
rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo
White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
MAR
bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone
buprenorphine are not abstinent and thus ldquonot in recoveryrdquo
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Abstinence
bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208
of the Acts of 2018 March 2019
bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself
bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders
httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
ASAM definition of Harm Reduction
bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence
bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy
httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Harm Reduction
bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =
ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the
argument bull Medication saves lives and allows people to move towards
recovery
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Abstinence
bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and
remissionbull Stigmatizing those who struggle with abstinence as an
outcome may not helpful
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Time Course to Abstinence versus Recovery
bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid
bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder
httpsaddictionsurgeongeneralgovkey-findingsrecovery
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Recovery Support Servicesbull Well-supported scientific evidence
demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions
bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising
bull Many other recovery supports have been studied little or not at all
The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Recovery and Medication
bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and
encouraged to allbull Medication should not be withheld if participation with RSS is
low non-existent
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Pharmacotherapyand mutual support benefits our
patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program
combines the two modalities since 2012ndash Improved treatment retention (unplanned
discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)
Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Medication First
httpsdoiorg101016jjsat201906015
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
The four key principles of the Medication First approach are
bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions
bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits
bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy
bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition
httpsdoiorg101016jjsat201906015
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
MO Public Funded
httpsdoiorg101016jjsat201906015
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Commercially Insured
httpsdoiorg101016jdrugalcdep201902031
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use
disorder in a United States commercially insured cohort
bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment
httpsdoiorg101016jdrugalcdep201902031
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Hazelden Betty Ford (COR-12)
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes
httpsdoiorg101016jjsat201906009
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program
bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge
bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all
httpsdoiorg101016jjsat201906009
Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)
bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trial
httpsonlinelibrarywileycomdoi101111add14737
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized
clinical trialbull The effectiveness of linking people from short-term in-patient
managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown
bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)
bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol
httpsonlinelibrarywileycomdoi101111add14737
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
Summary
bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all
bull Recovery may occur with or without treatment with medication
bull Preventing OD and stressing the importance of recovery work ought not be in competition
bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
We can do both
(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-
We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with
us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of
treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests
and prejudice ndash They would hope that you could lead the way to rational measures of
prevention and a variety of effective nonpunitive treatments for various addictions
ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed
- Review of medication and Impact of the Opiate Epidemic
- Slide Number 2
- ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Death rates increasing for opioids
- Death rates increasing for opioids
- Cocaine deaths rising due to opioids
- Methamphetamine deaths rising independent of opioids
- Opioid Overdose Deaths (1999 - 2017)
- Slide Number 9
- Slide Number 10
- Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT
- Slide Number 12
- San Francisco 2018 - 150 increase
- West Mountain West
- New England
- Mid-Atlantic Appalachia
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Rand 2019 The Future of Fentanyl and Other Synthetic Opioids
- Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018
- Slide Number 20
- If cannot reduce supply ndash Reduce Demand
- ASAM Short Definition of Addiction
- ASAM Short Definition of Addiction (continued)
- Recovery
- Recovery-Related Values and Beliefs
- Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)
- Recovery versus Remission
- Full Agonist Partial versus Antagonist
- Full Agonist Partial versus Antagonist
- Medication As Treatment
- Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids
- Slide Number 32
- Slide Number 33
- ldquoMedication Assisted Treatmentrdquo
- ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- MAT ldquoMedication Assisted Treatmentrdquo
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes
- MAT and Counseling
- Medication IS the Treatment
- Medication IS the Treatment for Addiction involving Opioids
- Slide Number 44
- MAR
- NAAA is NOT Treatment (but it is useful)
- Twelve- Step Facilitation (TSF)
- MAR
- Abstinence
- THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019
- ASAM definition of Harm Reduction
- Harm Reduction
- Abstinence
- Time Course to Abstinence versus Recovery
- Recovery Support Services
- Recovery and Medication
- Pharmacotherapyand mutual support benefits our patients
- Medication First
- The four key principles of the Medication First approach are
- MO Public Funded
- Commercially Insured
- Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort
- Hazelden Betty Ford (COR-12)
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results
- Slide Number 66
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial
- Slide Number 69
- Summary
- We can do both
- We can do both
-