National Perspectives in Medication Assisted Treatment

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2 National Perspectives in Medication Assisted Treatment Addiction Medicine Asheville March 21,2014 Melinda Campopiano, MD Medical Officer Substance Abuse & Mental Health Services Administration

3 Guten Appetit I have no conflicts of interest to disclose. I will not be discussing off-label use of any pharmaceuticals.

4 Topics for Today Medications Mortality Models of care Mothers Marijuana More

5 Medication

6 Medication Assisted Treatment (MAT) A quarter of all treatment admissions report an opioid as the primary drug of abuse In 2011 the treatment plan included medication assisted treatment for only 36% of these admissions MAT is more often part of the treatment plan for older patients

7 Benefits of MAT Reduces all cause mortality Reduces HIV seroconversion Improves adherence to medical treatment Improves social function Decreases criminal behaviors Decreases drug use

8 Medication Selection Both methadone and buprenorphine appear to confer the same benefits. Patients who misuse only opioid analgesics benefit as much as those using heroin and vice versa. Older and younger patients benefit equally. ER Inj-Naltrexone is ideal for specific populations and points in care.

9 Mortality

10 Pretreatment and After Care Interventions to Reduce Mortality Naloxone and ER injectable naltrexone Detainees Detox Discharge

11 Causes of death Persons with substance use disorders (SUD) are at higher risk for suicide Persons with SUD and person on MAT are more likely to die early of common chronic medical conditions. Benzodiazepines and Alcohol

12 A brief look at some interesting NC OTP numbers Private for profit Private non-profit Number of OTPs Physician hours/week RN hours/week % testing for Diabetes 9.5% 29.4% % testing for ETOH use 61.9% 100% % providing Ψ meds <10% 47 to 94%

13 Models of Care

14 Medication Units Alternative dosing/dispensing site New/separate DEA registration but not a new OTP Patients will still have to go to main site for other services Does not have to be free-standing

15 Integration Co-located with primary care, or behavioral health, hospital pharmacy or. pain management Formal cooperative agreements Primary care provided on-site by advanced practice nurses and physician assistants Medical health-homes exception to ACA

16 Expansion of Treatment Services Offer MAT for alcohol use disorders and smoking cessation Offer benzodiazepine or alcohol detox Offer residential treatment or therapeutic community services for MAT patients Extended care for MAT patients

17 Mothers MAT improves pregnancy outcomes Polysubstance use needs to be addressed Treatment must continue after delivery to optimize outcomes for both mom and baby Parenting support, therapeutic daycare and pediatric care

18 Marijuana Still illegal by federal law Associated with greater likelihood of relapse If used medicinally should be managed similar to medically indicated benzodiazepine use

19 More

20 Patient Limit on buprenorphine SAMHSA undertaking a mathematical model of impact of lifting the limit. Consider buprenorphine only OTP How will we count patients on a 6 month implantable device? Care for buprenorphine patients when physician is unavailable or closes up shop

21 Buprenorphine prescribing by APN and PAs SAMHSA has reviewed research protocols to establish comparable safety and efficacy Attempt to introduce legislation underway in New Mexico (need republican support)

22 Inpatient Detox Issues DEA has decided that DATA 2000 doesn t apply to the inpatient setting but the Controlled Substances Act does. Buprenorphine for each patient must be attributable to a specific X-Waiver Pharmacy licensing, EHR In some cases will need to become an OTP

23 Questions?

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