Methadone Treatment for Opiate Addiction Health and Human Services Finance Committee Minnesota House of Representatives December 6, 2012 Gavin Bart, MD FACP FASAM Director, Division of Addiction Medicine Department of Medicine Hennepin County Medical Center Associate Professor of Medicine University of Minnesota bartx005@umn.edu
Addiction is a brain disease This is not my opinion or a political statement open to debate it is clear and unequivocal. It s a fact borne out by decades of study and research. And it is a fact that neither government nor the public can ignore. Gil Kerlikowske The Drug Czar
Outline The need to address opiate addiction Comparison of approaches Methadone deaths Cost effectiveness
Opiate Addiction: Cost Utilization Opiate addicts use more healthcare resources Emergency Inpatient medical and mental health HIV viral hepatitis Increased health expenditure $15,884 v. $1,830 $13,393 v. $5,357 Masson et al. 2002; White et al. 2005
Opiate Deaths Increasing MMRW 2011
MN Treatment Entry TEDS 2011; MN DHS 2012
Behavioral Treatment Alone Inadequate evidence to prove effectiveness Contingency and Reinforcement-based treatment better than counseling alone Best abstinence-based treatment available 83% failed within 2 years Farrell 2010; Pescor, 1943; Vaillant 1973
Death After Behavioral Treatment Time after discharge Risk of Death CI (95%) 4 weeks 29.9 13.4-66.5 5-26 weeks 1.7 0.4-7.0 26-52 weeks 1.5 0.4-6.0 1-2 years 2.7 1.3-5.6 Mean age 31 years (17-49) Time in treatment 54 weeks (0-172) Increased 4 week mortality not explained by Age Time in treatment / leaving treatment early Time in prison Past overdoses Alcohol use Ravndal and Amundsen DAD,2010
Detoxification Medications are superior to none Retention in detox Withdrawal severity Clonidine methadone buprenorphine Farrell et al. 2010
After Detoxification Gossop et al. 1987
After Detoxification Most will use again (80% within 4 weeks) Half become addicted again 9x greater risk of death Day and Strang 2011; Gossop et al. 1987; Cornish et al. 2010
Increased Methadone Deaths: Not Explained by OTPs GAO and CDC reports Due to expansion of methadone for pain Not due to use in methadone treatment clinics Poor physician education on prescribing Increased diversion of pill form GAO 2003; CDC 2006; GAO 2009
Methadone Once daily oral medication Opiate Reduces craving Blocks effect of other opiates Decreases drug use Reduces HIV Reduces crime Improves quality of life Normalizes stress response reducing relapse
Methadone Treatment Short-term methadone 80% failed within 2 years After methadone 9 x death in first 2 weeks 3.5 x death in first 2 years Vaillant 1973; Sees 2000; Cornish 2010; Woody 2007
The 5% Good Outcome Miscalculation Methadone Maintenance Therapy 15%-35% drop out after 1 year Diabetes 12% drop out after 1 visit 33% drop out every 6 months 40% subjects rebound months 6-12 Hypertension 25% non-adherent after 1 year 45% non-adherent after 3 years Hyperlipidemia 70% non-adherence after 2 years Graber et al. 1992; Perreault et al. 2005; Jackevicius et al. 2002; Sees et al. 2000
Reduced Mortality Cornish et al. 2010
Opiate Addiction Treatment: Cost Utilization Methadone No methadone 0-1 addiction visits Outpatient 69.6% 31.1% 100% Residential 2.8% 4.3% 21.8% No methadone 2+ addiction visits ER visits 1.32/person 3.69/person 2.63/person Inpatient 0.24/person 1.08/person 0.58/person Primary Care 3.79/person 8.96/person 7.47/person Mean yearly cost $7,163 $18,695 $14,157 McCarty et al. 2010
Barnett and Hui 2000 Methadone Cost Effectiveness Methadone $5200/QALY
Conclusion Methadone is standard of care WHO list of essential medications Multiple USG agency reports Medical societies Methadone reduces morbidity Decreases HIV and HCV spread Decreases crime Methadone is cost effective Benefits exist only while taking methadone Chronic disease management
The Most Famous Methadone Patient? JFK had adrenal insufficiency due to Addison s disease Required cortisone Osteoporosis Recurrent vertebral fractures Chronic pain Meperidine Methadone