Medication is not a part of treatment.

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2 Medication is not a part of treatment. Medication can be an effective part of treatment. Medication is used in the treatment of many diseases, including addiction. Medical decisions must be made by trained and certified medical providers. Decisions about using medications are based on an objective assessment of the individual client s needs.

3 Medicines are drugs, too. Drugs are used to get high, but medications are used to get better. Medicine (n.) an innovation of the human species which has given us a competitive advantage for thousands of years; innovations in science & medicine have historically been helpful and progressive.

4 Methadone used for addiction treatment is prescribed and dosed in liquid form Methadone used for pain management generally is prescribed in pill form

5 Take more than intended Desire/unsuccessful efforts to cut back or quit Time spent using, obtaining or recovering Craving- brain pushes the person to use, or else Failure to fulfill work, school, home obligations Continued use despite problems (social, psychological, physical) Activities given up- Leads to loss of identity Use in hazardous situations Tolerance Withdrawal

6 It is estimated that at least 980,000 people in the United States are currently addicted to heroin and other opioids (such as oxycontin, dilaudid, and hydrocone)

7 It is estimated that 5,000-10,000 IV drug users die of drug overdoses every year Many of these are addicted to heroin

8 Methadone is a synthetic agent that works by "occupying" the brain receptor sites affected by heroin and other opiates. Methadone: blocks the euphoric and sedating effects of opiates; relieves the craving for opiates that is a major factor in relapse; relieves symptoms associated with withdrawal from opiates; does not cause euphoria or intoxication itself (with stable dosing), thus allowing a person to work and participate normally in society; is excreted slowly so it can be taken only once a day.

9 The use of medications in combination with behavioral therapies to treat SUDs can help reestablish more normal brain functioning prevent relapse reduce cravings

10 The person must learn new ways of coping and The brain changes must be addressed

11 Must meet DMHA certification standards State Opioid Treatment Authority regulates from DMHA Comply with state and federal laws Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines DEA requirements-highly regulates liquid methadone Indiana Board of Pharmacy Accreditation by recognized national body (CARF/Joint Commission) Licensing/inspection in accordance with local codes Indiana Central Registry of Opioid Patoient Enrollment Registry (ICOPE) Insures that patients are not dually enrolled in clinics

12 Medical Director Licensed physician in Indiana At least 1 year experience as physician in an OTP Have admitting privileges in at least one local hospital Write and establish that policy and procedures for all medical protocols Provide supervision for Nurse Practitioners and all authorized healthcare professionals

13 Program Physician (ratio 1:1000) Must be a licensed physician in Indiana Can be the Medical Director Nurses ratio (1:200) Nurses must have appropriate licenses to perform delegated and assigned nursing functions Program Director Run day to day operations of the OTP Supervision of OTP staff

14 Clinical Supervisors (ratio 1:10) ALL have appropriate credentialing in Indiana LCSW (Licensed Clinical Social Worker) LMHC (Licensed Mental Health Counselor) LMFC (Licensed Marriage and Family Therapist) Also being added are LCAC and LAC and CADAC 1-4 OTP Counselors (ratio 1:55) ALL have appropriate credentialing in Indiana LCSW LMHC LMFC Also being added are LCAC and LAC and CADAC 1-4

15 Some providers do take private insurance It is a State by State decision to make reimbursement for medicated assisted treatment (MATS) funds available through Medicaid The State of Indiana at this time does not reimburse for methadone in an OTP Examples of States that do reimburse through Medicaid are Maryland, Illinois and Minnesota

16 13 DMHA certified Opioid Treatment Programs Certified to provide medication assisted treatment for addiction to use of opiate drugs (heroin, OxyContin, etc.) Opiate Treatment Programs do NOT treat for pain management Pain Management does not treat or prescribe for addiction recovery

17 Charlestown Gary Southern IN Treatment Center Edgewater** Semoran Treatment Center Indianapolis Midtown** Indpls Treatment Center Lawrenceburg East IN Treatment Center Merrillville Northwest IN Treatment Center Fort Wayne Center for Behavioral Health Marion Premier Care Richmond Richmond Treatment Center Valparaiso Porter-Starke Recovery Center** South Bend Victory Clinical Services Evansville Evansville Treatment Center ** Refers to OTP clinics with Mental Health Care Providers

18 Be addicted to an opiate drug Became addicted at least one year before admission Voluntarily choose treatment Provide written informed consent to treatment

19 Naltrexone (Vivitrol) Program Buprenorphine Maintenance Program Methadone Maintenance Program Opiate Addiction

20 Time in Tx <90 days days days 1 year+ Requirement 4 hours counseling/month 2 hours counseling/month 1 hour counseling/month Based on individual need

21 Maintenance=help avoid negative consequences of illicit opiate use Dosed once daily- slow acting and resists tolerance build up < mg daily When properly managed Reduce narcotics related deaths Reduce users' involvement in crime Reduce IV Drug Use and risky behaviors Gain more control of their lives If used correctly, few side effects, no high

22 Detoxification is associated with: high rates of spontaneous abortions premature delivery in the third trimester Babies exposed to heroin have lower birth weights Babies exposed to heroin were more likely to require morphine than those with methadone treated mothers (40% vs. 19%) Current recommendations: Treat with Methadone or Buprenorphine

23 Current rule requires a drug test upon admission (expected to be illicit) A minimum of 8 drug tests per year. Patients are expected to test licit Test failure requires medical and treatment team review and restriction from take home medications until a subsequent drug test is passed. Must comply with treatment team clinical requests A treatment plan will be updated to address the illicit drug screen 4

24 Privilege earned through clean drug screens Incentive for good behavior Provides a continuum of care to: Become more independent Become more responsible To take more ownership of life Improves compliance, sobriety from other drugs

25 Exceptions outside of this schedule MUST be requested from SAMHSA and then the State of Indiana Old Schedule 1-90 days= = = =6 After 1 Year= 14 After 2 Years= 31 New 1218 Schedule 1-90 days= = = =6 After 1 Year= 6 After 2 Years= 6 After 1 year anything over seven (7) days of take-home will require an exception request to SAMHSA and then DMHA for review and approval

26 Number of clients with methadone take-home privileges by length of time in treatment 0-90 days days days days year years 661 >2 years 1102 In CY 2013, there were 1653 take home medication exceptions approved by SAMHSA and DMHA over 13 days. This represents 10.8% of the patients treated.

27 15,242 total patients treated in CY < > Male Female 2

28 Indiana Kentucky Ohio Michigan Illinois Other

29 <90 days 90 days- 1 year 1-2 years 2-3 years 3-6 years 6-10 years >10 years 5

30 Close supervision: daily dosing reduced mortality - the median death rate of opiate-dependent individuals in OTP is 30 percent of the rate of those not in OTP Enforce therapy Take-Home Medication incentives Requires a high degree of commitment Time Travel cost

31 Provision effective 7/1/14 Reporting requirements 10/1 summary of medications dispensed, number of doses, quantities, number of days of supply dispensed, patient demographic information

32 Provisions effective upon rule promulgation Reduced take home meds to 7 days and limits exceptions Protocols for patient assessment for the appropriate medication Protocols to ensure patient education regarding maintenance treatment and side effects of each medication Move appropriate patients from methadone to other approved medications Report due 4/1 number of DMHA prior authorizations for take home medications Rule amendments have been drafted and is proceeding through the review and approval process.

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