Joel Millard, DSW, LCSW Dave Felt, LCSW

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1 Joel Millard, DSW, LCSW Dave Felt, LCSW

2 1. Provide an overview of the effectiveness of medication assisted treatment, to include a discussion of the different types of medications and how they are used effectively; 2. Dispel many of the common myths and misperceptions that have led to prohibitions on medications even when they are clinically indicated; 3. Discuss how properly administered MAT can support the goals of DCFS, Probation and the Client, reduce costs and improve outcomes. 4. Describe the benefits of using medications where clinically indicated. 5. Help understand OTP Clinic structure and controls used to ensure that MAT is not diverted or misused.

3 Since 2008, prescription drug deaths have exceeded auto fatalities in Utah Opioids (heroin and prescriptions) are the number one cause of admission to treatment behind alcohol Since 2002, prescription pain medications have been responsible for more drug deaths in Utah than all other drug categories, such as antianxiety medications, over-the-counter medications, or illicit drugs. Prescription pain medication deaths have outnumbered heroin and cocaine deaths combined since 2002.

4 Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. American Society of Addiction Medicine (ASAM)

5 Recovery A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Key concept: There are many roads to recovery Withdrawal An extremely painful physiological response to the lack of opioids on the body opioids receptors. Abstinence Traditional Refraining from use of any addictive substance Recovery Refraining from the abuse of medications and use of illicit substances

6 SUD Treatment level and intensity should be based on Risk and Need Readiness to change Bio-psycho-social factors Past Treatment History Evidence based Individualized and person centered Goal of SUD treatment is Recovery, Which MAY include abstinence as traditionally defined,

7 Addiction is often a traumatic response to life experiences that threaten the life or sense of being of the individual The function of the response is the whole brain response to the threatening event or events. With the goal of restoring a viable sense of being. In opioid addiction this is achieved by the organizing features of drug seeking behaviors, using behaviors, the experience of the drug its self. All of which support the dissociative defense from the problematic life events.

8 As emotional management is done through self medication normal management systems appear to atrophy from lack of use Coping mechanisms that remain are often those related to drug seeking behavior

9 It s effect on pain management Sensitivity to pain increases Endorphin levels are lower than non opioid users Emotional and physical pain becomes more undifferentiated in the services of managing the disassociated pain from the traumatic injury. Pain is experientially understood as with withdrawal systems Pain and fear of pain becomes the driver in decision making Pain is often seen as the disease not the indicator of the disease

10 Some chronic conditions are treated by medications alone: But all mental health disorders have been shown to most effectively treated with a combination of medications and therapy. Opioid Medication Assisted Treatment consists of: Medications Counseling/Clinic Components Medical Monitoring

11 Methadone is an full agonist suppresses withdrawal symptom for 24 to 36 hours It is given in liquid form at the clinics It is generally a single oral dose Administered and observed by nursing staff ORT medication is not a pain management tool Suboxone is a partial agonist with an antagonist added for diversion control

12 Naltrexone is an antagonist that binds to the receptor sites It replaces opioids on the sites and block opioids from accessing the sites given orally: daily, every other day, 3 time a week, or twice a week Vivitrol is a form of Naltrexone Vivitrol is given by injection with a special needle Will last for up to 30 days.

13 ORT uses well-tested medications (primarily methadone and buprenorphine) to help individuals addicted to opiates enter into recovery. These Medications: Block the craving for opioids that is a major factor in relapse. Suppress the symptoms of opioid withdrawal for 24 to 36 hours. Block the effects of administered heroin. Do not cause euphoria, intoxication, or sedation. The medication in MAT will bring the opiate addicted brain to the table. The conversations at the table will promote the brain growth essential for sustained recovery

14 OTP s (Methadone Clinics) (Clinic model) Use Methadone, Suboxone, Subutex Provide daily dosing and supervision Provides Counseling and SUD treatment at 1.0 level Highly regulated Office Based Opioid Treatment (OBOT) Based in Physician s offices Uses Suboxone only No counseling Referral to treatment required No follow up to referral required Little regulation

15 Behavioral structuring, monitoring 1. Time limits 2. Attendance expectations 3. Emotional management 4. Self care 5. Urinalysis 6. Participation expectations for privileges (Take out dynamics)

16 Medication needs are based on physiological withdrawal indicators as opposed to emotional pain management needs Medications are dispensed based on the therapist s and medical staff s assessment of the patient s biological indicators as differentiated from the psychological and social dimensions Generally the primary motivation for coming to the clinic is the medication (to avoid withdrawal) Over time, the client learns to differentiate between emotional and physiological pain and to develop skills to deal with each differently

17 Talk therapy strategies such as Individual therapy Group therapy Family therapy Psycho-educational treatment Parenting and family development training The function of the therapies is to use language to facilitate the individual finding a new normal in the service of sustainable recovery Language is a natural tool of the brain to organize both internal and external experiences in ways that make sense to the individual in terms of survivability of the self

18 Is methadone maintenance treatment effective? But aren t you just replacing one drug with another one? But ALL my clients will want it. So who should use ORT? Aren t OTPs just semi legal Drug Dealers? Is methadone safe for pregnant women and their infants?

19 Yes. Research has demonstrated that methadone maintenance treatment is an effective treatment for heroin and prescription narcotic addiction when measured by: Reduction in the use of illicit drugs Reduction in criminal activity Reduction in HIV infection reports of rates and transmission Reduction in commercial sex work Reduction in needle sharing conditions Improvements in social health treatment and productivity Reduction in suicide Reduction in the number of multiple sex partners Cost-effectiveness Improvements in health Retention in addiction Reduction in lethal over dose

20 Isn t that what Diabetics do with insulin? Don t they replace one chemical that the body doesn t produce with a similar one that will let the body function normally? Isn t that how we treat depression? Isn t that how we treat anxiety? Isn t that what virtually all Medications do? MAT doesn t produce a high when used properly Virtually all medications have some abuse potential

21 ORT is not for every one: But consider this: Opiates are the most common drug of choice at admission in Utah, behind alcohol (ahead of all other drugs) Relapse from abstinence is common (85% of formerly opioid dependent people relapse within a year of going drug-free) and relapse is life threatening. Do you want to give your clients the best possible chance of recovery based on evidence and research? If so, then keep MAT as an option in your tool box The goal is recovery and a return to health and productivity, not a specific lifestyle based on a philosophy

22 Long time opiate users with one year or more history of dependence and current signs of dependence (42 CFR, Part 8) Individuals with shorter history may be given a short term detoxification Individuals who have relapsed after treatment or significant periods of abstinence Pregnant women using opiates Individuals who are already stable on ORT A way to think about it: It s like with Diabetes you don t start with insulin, but you may end up there

23 SAMHSA regulations address each critical legal, clinical, safety, and program management area related to the treatment of patients and SAMHSA must approve each program, physician and program manager. All accredited methadone programs operate under the authority of DEA regulations that govern the dispensing of controlled substances. These regulations stipulate requirements for the type of registration required, qualifications for physicians who dispense methadone, and rules for physician record-keeping. Methadone maintenance programs must go through an accreditation process in order to operate. (JACHO or CARF in Utah) All OTPs in Utah must be licensed (which is not true for all OP Programs Methadone programs are more highly regulated, better accredited and more closely supervised than any other treatment program in UTAH

24 Yes. Since the early 1970s, methadone maintenance treatment has been used successfully with pregnant women. There is consensus that methadone can be safely administered during pregnancy with little risk to mother and infant. Maintenance on methadone is necessary to prevent relapse to illicit opioid use and thus to maintain optimal health during pregnancy. (NIDA)

25 The majority of infants exposed to methadone in utero are healthy and have fewer adverse outcomes than infants exposed to heroin and other illicit drugs. (Kaltenbach and Finnegan, 1984). Methadone maintenance treatment for pregnant women can reduce in utero growth retardation and neonatal morbidity and mortality, in comparison with women not in treatment (Kaltenbach and Finnegan, 1984).

26

27 No clear answers from Research Some evidence of less infant withdrawal Clear evidence that you shouldn t switch medications during pregnancy Suboxone doesn t work for everyone Neither does methadone Clear evidence that you shouldn t stop medications during pregnancy

28 Yes: Both methadone and buprenorphine can be diverted from their intended recipients. HOWEVER, In studies that have compared death rates from heroin overdose among those who are untreated and those who receive methadone, deaths are higher among untreated opioid-dependent individuals (Capelhorn, Dalton, Haldar, et al., 1996,; Zanis and Woody, 1998). The provision of methadone and buprenorphine treatment was associated with a 75-percent decrease in fatal heroin overdoses in France (Lepere, Gourarier, Sanchez, et al., 2001; Auriacombe, Fatseas, Dubernet, et al., 2004). 85% of opioid dependent abstinence based clients relapse within a year.

29 Methadone is dosed not prescribed 98+% of methadone used in Utah OTPs is liquid (if they are using tablets, they re from a pain clinic.) Take home medication is strictly regulated 1 take home dose (THD) for day clinic is closed 1 additional THD can be earned in 1 st 90 days (2) 1 additional THD can be earned home in 2 nd 90 days (3) 1 additional THD can be earned in 3 rd 90 days (4) 2 additional THD can be earned in 4 th 90 (6) It takes a full year to get weekly take homes Exceptions to above approved by State and CSAT Case by case basis

30 Methadone versus Suboxone Liquid Pill/strips Dosed Prescribed Observed Unobserved Max doses on hand 7 (after one year) 90 (after first visit) Through OTPs Dr s Offices Clinic Model OBOT model Available only in Urban Areas Statewide Counseling/treatment required Recommended

31 ORT is the most highly researched and most effective treatment available for Opioid Dependent Clients The goals of ORT, Probation and DCFS are virtually identical To have fully functioning individuals who are stable in their recovery and provide a safe environment for their families and the public Recovery is not defined by traditional abstinence Research shows that ORT should be maintained for at least a year, giving time for the behavioral and cognitive changes to take place Taking individuals off ORT prematurely almost guarantees relapse And is associated with high death rates.

32 Successful treatment and case management is best achieved through methods based on research, not philosophy I don t believe in ORT is equivalent to saying I don t believe in using insulin for diabetics they should control their disease in other ways. MAT/MAR is not for everybody, but it is the best treatment for some people.

33 The process begins and ends with the patient s story The major challenge is to create a climate where the patient will tell it The story will evolve over time of use and time in treatment The evolution will disclose the client s progress The medication in MAT will bring the opiate addicted brain to the table. The conversations at the table will promote the brain growth essential for sustained recovery Without MAT it is very hard to get the patient to bring the opiate addicted brain to the table MAT can help your clients achieve their goals (and yours)

34 Treatment Improvement Protocol # 43Medication Assisted Treatment for Opioid addiction in Opioid Treatment Programs Marsch LA. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis. Addiction 1998;93(4):

35 Thank you for your time and attention Questions?

36 Joel Millard Dave Felt Project Reality DSAMH

37 ORT Opioid Replacement Therapy OTP Opioid Treatment Program Diversion Use of medication by unauthorized individual SAMHSA Substance Abuse and Mental Health Services Administration DEA Drug Enforcement Agency SOTA State Opioid Treatment Authority CSAT Center for Substance Abuse Treatment Take Homes Number of doses of medication allowed by Federal regulations based on 8 point criteria 8 Point Criteria used to determine eligibility for Criteria methadone maintenance and take home doses Stable Level at which patient does not experience with- Dose drawal and can function appropriately

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