Welcome Thank you for joining us today. The webinar will begin in a few moments. If you haven t dialed into the audio (telephone) portion, please do so now: 1 (866) 516-5393 Access Code: 33403311 If you are experiencing technical problems with the GoToWebinar (visual) program, contact the GoToWebinar help desk: 1 (800) 263-6317 Webinar ID: 115389568 Today s presentation and handouts are available for download at http://www.cffutures.com/webinars Type and send your questions through the Question and Answer log located on the bottom half on your panel/dashboard. How Do I Ask Questions? Medication Assisted Treatment (MAT) Series, Part I of II: Understanding MAT for Families Affected by Substance Use Disorders Agenda Environmental Context Medication Assisted Treatment 101 Considerations for Child Welfare Policy and Practice Discussion Nancy K. Young, Ph.D. Mark W. Parrino, M.P.A. 4940 Irvine Blvd., Suite 202 Irvine, CA 92620 714-505-3525 ncsacw@cffutures.org www.ncsacw.samhsa.gov 4 1
A Program of the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment and the Administration on Children, Youth and Families Children s Bureau Office on Child Abuse and Neglect 5 Let s Hear About You Registrants identified as: Substance Abuse Treatment Providers (43%) Child Welfare (33%) Other (17%) Dependency Court or Family Drug Court (6%) Environmental Context Nancy K. Young 7 2
From the Field Medical marijuana Prescription medication misuse and abuse MAT for co-occurring mental health disorders MAT for substance use disorders d State of the Field Misunderstanding of the use of MAT, particularly Methadone treatment, in substance abuse treatment and how it relates to child safety. Requirement of minimal dosing of MAT medications for pregnant women or as a term for reunification. Positive toxicology result for methadone at birth as a presumptive cause for child removal. Use of MAT as exclusionary criteria for child welfare programs, particularly Family Drug Courts. Risks to Children: Different Situations for Children Different Situations Require Different Responses Parent uses or abuses a substance Parent is dependent on a substance Special considerations when Methamphetamine production or home manufacturing is involved Parent involved in a home lab or super lab Parent involved in trafficking Mother abuses alcohol or uses an illicit substance while pregnant Each situation poses different risks and requires different responses Child welfare workers, treatment providers and court professionals need to know the different responses required The greatest number of children are exposed through a parent who uses or is dependent on a drug Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005 11 Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005 12 3
Medical Marijuana Jurisdictions are faced with different legislation 15 states and the District of Columbia have laws that permit medical marijuana as a defense In most states, individual patients and/or their caregivers can cultivate cannabis for medical purposes Some states place limits on the types of medical conditions eligible for medical marijuana Some states allow distribution of marijuana by dispensaries All states mandate that a physician must recommend the use of marijuana for medical purposes Marijuana is classified as a controlled substance, is widely abused and a major cause of drug dependence in the United States For more information, including state specific resources: http://www.ncsl.org/home/searchresults/tabid/702/default.aspx?zoom_query=medical marijuana http://www.whitehousedrugpolicy.gov/drugfact/marijuana/index.html What the Experts Say Continued research is needed on the risk and benefits of smoked marijuana Continued research into the physiological (e.g.: appetite stimulant) and psychological (e.g. anxiety reduction, sedation) effects of marijuana necessary Short-term use of smoked marijuana (less than 6 months) for patients with debilitating symptoms must meet the following conditions: Failure of all approved medications to provide relief The symptoms can reasonably be expected to be relieved by rapid-onset cannabinoid drugs Such treatment is administered under medical supervision in a manner that allows for treatment effectiveness Involves an oversight strategy comparable to an institutional review board process American Society of Addiction Medicine. (September 2010). The Role of the Physician TEXT in PAGE Medical Marijuana. 4
American Society of Addiction Medicine: Recommendations Physicians who choose to discuss the medical use of cannabis and cannabis-based products with patients should: Adhere to the established professional tenets of proper patient care, including: History and good faith examination of the patient Development of a treatment plan with objectives Provision of informed consent, including discussion of risks, side effects and potential benefits Periodic review of the treatment s efficacy Consultation, as necessary Proper record keeping that supports the decision to recommend the use of cannabis American Society of Addiction Medicine: Recommendations Have a bona fide physician-patient relationships with the patient, i.e., should have a pre-existing and ongoing relationship with the patient as a treating physician Ensure that the issuance of recommendations is not a disproportionately large (or even exclusive) aspect of their practice Not issue a recommendation unless the physician has adequate information regarding the composition and dose of the cannabis product Have adequate training in identify substance abuse and addiction American Society of Addiction Medicine. (September 2010). The Role of the Physician TEXT in PAGE Medical Marijuana. American Society of Addiction Medicine. (September 2010). The Role of the Physician TEXT in PAGE Medical Marijuana. Misuse and Abuse of Prescription Medications Treatment Admissions Among Females, Percentage Other Opiates* as Primary Substance of Abuse at Admission, by Age Group: 1998 and 2008 Medications can be prescribed for the treatment of: Pain Management Mental Health Disorders *Primary Pain Relievers Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present 5
Percentage Females Treatment Admissions for Other Opiates* as Primary Substance of Abuse: States with Highest Percentage: 1998 and 2008 (listed in order by 2008 percentage) Overall, primary admissions among females for other opiates comprised 1.9 percent of all female admissions in 1998 and 8.2 percent in 2008. *Primary Pain Relievers Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present Medications for the Treatment of Acute Pain Narcotic and Opioid Analgesics: Usually used only for acute pain for a short period of time due to addiction potential, except in alleviating chronic pain associated with cancer. Includes: Bupreinex Codeine Fentanyl Demorol Morphine OxyContin Vicodin Suboxone (also used for MAT for opioid of opiate dependence) Methadone (also used for MAT for opioid of opiate dependence) For a complete listing, see: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (2008). Substance Abuse Treatment for Persons with Co-Occurring Disorders, A Treatment Improvement Protocol, TEXT TIP PAGE 42. Co-Occurring Mental Health Disorders 50-75% of clients in substance abuse treatment programs had some type of co-occurring mental disorder (usually not severe) 20-50% of clients in mental health settings had a co- occurring substance use disorder Substance use disorders have a complicating presence on the course of treatment for mental illness (e.g. longer time in hospitalization, poorer outcomes higher rates of HIV infection, relapse, rehopsitalizaton, depression and suicide risk) US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (2008). Substance Abuse Treatment for Persons with Co-Occurring Disorders, A Treatment Improvement Protocol, TIP 42. Medications for the Treatment of Mental Health Disorders Antipsychotics/Neuroleptics: Typically used to control psychotic symptoms (e.g. auditory and visual hallucinations, out of touch with reality, etc.) associated with schizophrenia, severe depression or bipolar illness. Sometimes also used to treat brief psychotic episodes caused dby substance abuse. Antimanic Medications: Used in the treatment of bipolar (manic-depressive) illness. Antidepressants: Usually used for moderate to serious depression. Also Used for milder depressions and some anxiety and obsessive-compulsive disorders. 6
Medications for the Treatment of Mental Health Disorders Anti-Anxiety Medications: Used to calm and relax anxious feelings and remove symptoms associated with generalized anxiety disorder, panic, phobia, posttraumatic stress disorder, panic, phobia and obsessive compulsive disorders. Stimulant Medications: Used to treat attention deficit/hyperactivity disorder (AD/HD). Hypnotics: Used to treat sleep disturbances. Classification Antipsychotic Antimanic Antidepressants Anti-anxiety Stimulants Hypnotics Common Medications Used in the Treatment of Mental Health Disorders Medication Thorazine, Haldol, Daxolin Risperdal, Sereoquel, Depakote Paxil, Zoloft, Celexa Xanax, Valium, Adderall, Ritalin, Welbutrin Seconal, Ambien US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (2008). Substance Abuse Treatment for Persons with Co-Occurring Disorders, A Treatment Improvement Protocol, TEXT TIP PAGE 42. For a complete listing: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (2008). Substance Abuse Treatment for Persons with Co-Occurring Disorders, A Treatment Improvement Protocol, TEXT TIP PAGE 42. MAT for Substance Use Disorders (SUD) MAT for SUD offers help in suppressing withdrawal symptoms during detoxification. Medically assisted detoxification is not in itself "treatment" it is only the first step in the treatment process. Patients who go through medically assisted withdrawal but do not receive any further treatment show drug abuse patterns similar to those who were never treated. National Institute on Drug Abuse (NIDA), 2011) Medications used in MAT for Substance Use Disorders (SUD) Alcohol Dependence*: Antabuse Tobacco Dependence: Nicotine Patch Bupropion Barenicline *For a complete listing, see: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (2008). Substance Abuse Treatment for Persons with Co-Occurring Disorders, A Treatment Improvement Protocol, TEXT TIP PAGE 42. 7
Medications used in MAT for Substance Use Disorders (SUD) Opiate/Opioid Dependence: Opiates: Naturally derived from the opium poppy plant. Includes morphine and codeine. Opioids: Synthetically derived to mimic the analgesic or painkiller effects of opiates. Includes heroin, oxycodone and hydrocodone. Medications to treat dependence: Naltroxene Buprenerophine (aka Suboxene) Methadone Polling Question #1 There is no way a parent who is receiving MAT for substance dependence can be an effective parent. Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (2008). Substance Abuse Treatment for Persons with Co-Occurring Disorders, A Treatment Improvement Protocol, TEXT TIP PAGE 42. MAT 101 for the Treatment of Opiate Dependency Mark W. Parrino 8
2007 Update: Consistent Rise in Distribution of Buprenorphine to Pharmacies 2007 Update: Consistent Rise in Distribution of Buprenorphine to OTPs 60 450,000 50 40 30 20 10 DEA ARCOS: Suboxone/Subutex, Drug Units to Pharmacies (in Millions, 2007 projected) 400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 DEA ARCOS: Suboxone/Subutex, Drug Units to OTPs ( 2007 projected) 0 2003 2004 2005 2006 2007 0 2003 2004 2005 2006 2007 33 34 Polling Question #2 People who abuse alcohol or drugs have a disease for which they need treatment. Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree Addiction Is a Brain Disease Issues In Science and Technology, Spring 2001 Alan I. Leshner 9
A core concept that has been evolving with scientific advances over the past decade is that drug addiction is a brain disease that develops over time as a result of the initially voluntary behavior of using drugs. The consequence is virtually uncontrollable compulsive drug craving, seeking and use that interferes with, if not destroys, an individual s functioning in the family and in society. This medical condition demands formal treatment. Principles of Drug Addiction Treatment: A Research-Based Guide National Institute on Drug Abuse National Institutes of Health May 2009 Issues In Science and Technology, Spring 2001 http://www.nida.nih.gov/podat/principles.html Addiction affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. Some individuals are more vulnerable than others to becoming addicted, depending on genetic makeup, age of exposure to drugs, other environmental influences and the interplay of all these factors. NIDA http://www.kap.samhsa.gov/products/trainingcurriculums/pdfs/tip43_curriculum.pdf 10
Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs A Treatment Improvement Protocol TIP 43 U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 2005 Discussions about whether addiction is a medical disorder or a moral problem have a long history. For decades, studies have supported the view that opioid addiction is a medical disorder that can be treated effectively with medications administered under conditions consistent with their pharmacological efficacy, when treatment includes comprehensive services, such as psychosocial counseling, treatment for co-occurring disorders, medical services, vocational rehabilitation services and case management services. TIP 43 Dr. Vincent Dole described the medical basis for methadone maintenance as follows: The treatment is corrective, normalizing neurological and endocrinologic processes in patients who endogenous ligand-receptor function has been deranged by a long-term use of powerful narcotic drugs. Why some people who are exposed to narcotics are more susceptible than others to this derangement and whether the long-term addicts can recover normal functions without maintenance therapy are questions for the future. At present, the most that can be said is that there seems to be a specific neurological basis for the compulsive use of heroin by addicts and that methadone taken in optimal doses can correct the disorder. TIP 43 Matching Patients to Individual Needs No single treatment is appropriate for all individuals Effective treatment attends to multiple needs of individual, not just his/her drug use Treatment must address medical, psychological, social, vocational and legal problems Source: National Institute on Drug Abuse (NIDA) 11
Polling Question #3 After 6 months, a parent receiving MAT for substance dependence should be completely drug free, including from MAT medications. Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree Duration of Treatment Depends on patient problems/needs Less than 90 days is of limited/no effectiveness for residential/outpatient setting A minimum of 12 months is required for methadone maintenance Longer treatment is often indicated Source: National Institute on Drug Abuse (NIDA) Polling Question #4 In assessing the effects of substance use, the standard we should use for deciding when to remove or reunify children with their parents is whether the parent(s) are fully abstaining from all substances, including MAT medications. Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree Leaving Methadone Treatment: Lessons Learned, Lessons Forgotten, Lessons Ignored Mt. Sinai Journal of Medicine January ar 2001 Stephan Magura, Ph.D., and Andrew Rosenblum, Ph.D. 12
ys Per Year Crime Day Crime among 491 patients before and during MMT at 6 programs Baltimore Philadelphia New York City 300 250 200 150 100 50 0 A B C D E F Before TX During TX The problem was one of the rehabilitating people with a very complicated mixture of social problems on top of a specific medical problem, and that (practitioners) ought to tailor their programs to the kind of problem they were dealing with. The strength of the early programs as designed by Marie Nyswander was in their sensitivity to individual human problems. The stupidity of thinking that just giving methadone will solve a complicated problem seems to me beyond comprehension. Vincent P. Dole, M.D., 1989 Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991 49 Source: Courtwright, et. Al. Addiction Who Survived Lifetime and Recent Prevalence of Psychiatric Symptoms Among Male Methadone Maintenance Patients USA Today February 13, 2007 Psychiatric Symptoms Serious depressions Serious anxiety Hallucinations Difficulty Understanding, concentrating, remembering Trouble controlling violent behavior Thoughts of suicide Suicide attempt Had one or more symptoms Percent with Symptom Lifetime Past 30 days 48.3 16.6 51.7 22.9 8.6 2.3 28.0 16.6 24.9 7.9 15.3 3.5 8.5 0.4 68.4 35.4 Valid cases 567 Source: Ball and Ross. The Effectiveness of Methadone Maintenance Treatment 13
U.S. Department of Justice National Drug Intelligence Center Methadone Diversion, Abuse and Misuse: Deaths Increasing at Alarming Rate November 2007 From 1999-2006, the number of methadone related deaths increased significantly. Most deaths are attributed to the abuse of methadone diverted from hospitals, pharmacies, practitioners and pain management physicians. Some deaths result from misuse of legitimately prescribed methadone or methadone obtained from narcotic treatment programs, including use in combination with other drugs and/alcohol. Methadone Associated Overdose Deaths Factors Contributing to Increased Deaths and Efforts to Prevent Them United States Government Accountability Office GAO March 2009 DOJ 14
Most officials from federal and state agencies, as well as experts in addiction treatment and pain management that we spoke with, cited the increased availability of methadone due to its use for pain management as a key factor in the rise in deaths, while some added that addiction treatment in OTPs was not related to increased deaths. Changing Drug Use Patterns Among Patient Admissions to the Methadone Treatment Programs in the U.S. American Association for the Treatment of Opioid Dependence, Inc. (AATOD) National Development & Research Institutes (NDRI) GAO Study Aims Determine lifetime and current prescription opioid prevalences among OTP enrollees Identify factors associated with primary prescription opioid id abuse Determine source for prescription opioids Heroin Opioids Buprenorphine (e.g., Suboxone, Subutex) Fentanyl (patch, lozenge, solution) Hydromorphone (Dilaudid) Hydrocodone (e.g., Vicodine) Methadone (diskette/wafer, pills, liquid) Morphine Oxycodone (e.g., OxyContin, Percodan) 15
Patient and opioid treatment program (OTP) participation Data collected January 2005 January 2011 # States: 35 OTPs to date: 75 Subjects: > 46,157 Characteristics among OTP enrollees, by primary drug of choice Rx Opioid Heroin First OTP episode (%) 70 31 * Chronic Pain (%) 45 32 * Pain a reason for enrolling 33 32 in OTP (%) Withdrawal pain (1-5); 3.91 3.76 * Mean Craving (1-5); Mean 4.47 4.29 * Ever injected primary drug (%) 33 77 * *p<.001 January 1, 2005 Present Age Distribution Source of primary RX opioid (%) 4000 3500 3000 2500 2000 1500 1000 500 0 >65 60-64 55-59 50-54 45-49 40-44 35-39 30-34 26-29 18-25 12-17 Age range (years) dealer 85 friend or relative 53 doctor's prescription 29 emergency room 13 theft 7 internet 3 forged prescription 3 other way 2 0 10 20 30 40 50 60 70 80 90 100 16
Closing Points Methadone in a stabilized patient will not cause sedation or prevent the individual from being a responsible parent. Methadone maintenance treatment and buprenorphine do not have the narcotizing effects of heroin and does not trade one addiction for another. Methadone is not harmful to the fetus if the mother is stable and under the medical care of an OTP. Closing Points Methadone has been accepted since the late 1970s to treat opioid addiction during pregnancy. In 1998, a National Institutes of Health consensus panel recommended methadone maintenance as the standard of care for pregnant women with opioid addiction. Effective medical maintenance treatment with methadone has the same benefits for pregnant patients as for patients in general. In addition, methadone substantially reduces fluctuations in maternal serum opioid levels, so it protects a fetus from repeated withdrawal episodes Closing Points Breast-feeding is safe unless the mother has an infectious disease, such as HIV. Hepatitis C- positive women are able to safely breastfeed but should check with their physicians first. CPS representatives should work with OTPs and read the SAMHSA/CSAT publication TIP #43, Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs, especially Chapter 13- Treating Pregnancy. Considerations for Child Welfare Policy and Practice Nancy K. Young 4940 Irvine Blvd., Suite 202 Irvine, CA 92620 714-505-3525 ncsacw@cffutures.org www.ncsacw.samhsa.gov 17
Child Abuse Prevention and Treatment Reauthorization Act (CAPTA) of 2010 Ensures that all States have the capacity to provide services and improve child protective service (CPS) systems, including operation of a statewide program that includes policies and procedures to address the needs of substance exposed infants (e.g. Fetal Alcohol Spectrum Disorder), including: Primary care providers are required to notify CPS of instances of substance exposed infants. Notification should not be construed as an automatic finding of child abuse or neglect under Federal law. The development of a plan of safe care for the infant. Child Abuse Prevention and Treatment Reauthorization Act (CAPTA) of 2010 Improvement of training protocols for mandated reporters. Implementation of procedures for cross-systems collaboration in investigations, interventions and the delivery of services. Policy and Practice Considerations Thank You! Collaboration with multiple stakeholders primary care providers, substance abuse treatment/ MAT providers and the courts is essential. Cross systems release of information Cross systems role clarification Clearly written policies and guidelines for clients Clearly written policies and guidelines for staff Please take a moment to complete our evaluation. You will be re-directed to the evaluation after exiting the webinar. Please register for the second webinar in this series, Medication Assisted Treatment During Pregnancy, Postnatal and Beyond, on Thursday, August 04, 2011: https://www1.gotomeeting.com/register/485348649 72 18
Contact Information Nancy K. Young, PhD, MSW Director National Center on Substance Abuse And Child Welfare, Children and Family Futures Phone: 1 (866) 493-2758 E-mail: ncsacw@cffutures.org Mark W. Parrino, MPA President American Association for the Treatment of Opioid Dependence, Inc. Phone: (212) 566-5555 E-mail: mark.parrino@aatod.org FOR RESOURCES and MATERIALS FROM THIS WEBINAR Please visit our websites: http://www.ncsacw.samhsa.gov/ www.aatod.org 74 Questions and Discussion 4940 Irvine Blvd., Suite 202 Irvine, CA 92620 714-505-3525 ncsacw@cffutures.org www.ncsacw.samhsa.gov 19