Intro Slide

Intro Slide

The Fundamentals of Medication Assisted Treatment Nick Szubiak, MSW, LCSW Director, Clinical Excellence in Addictions National Council for Behavioral Health Objectives Understand why and how Medication Assisted Treatment works and why we don't use it by challenging the way we view, judge and think about addiction. Gain an understanding and recognition of the discrimination and bias that impacts access to evidenced based care for those who need treatment for substance use disorders. Participants will identify and describe three differences between integrated

MAT treatment practices versus non-integrated MAT treatment practices. Participants will list and describe three common barriers to access MAT and identify strategies to increase access to care. National Opioid Overdose Epidemic as of 2015 Drug overdose is the leading cause of accidental death in the US, with 52,404 lethal drug overdoses in Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers

increased in parallel. overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999; substance use disorder treatment admission rate in 2009 was six times the 1999 rate National Opioid Overdose Epidemic as of 2015 In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills. Four in five new heroin users started out misusing prescription painkillers. 94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because

prescription opioids were far more expensive and harder to obtain. Overdose Deaths Conclusion: Rising rate of overdose deaths is driven largely by Heroin and Fentanyl Warner et al. National Vital Statistics Report, 2016;65(10). Origins of Opioid Crisis

Opioids Myth: Non-Addictive History of Untreated Pain

Unrestricted prescribing of pain medications Unlike legitimate pain clinics, pill mills see greater numbers of patients, write more prescription, and do less medical exams. Most are cash-only. Greater availability of heroin National initiative rolled out in the late 90s Emergence of Pill Mills

Pain was left untreated even for terminally-ill cancer patients Doctors were weary of prescribing opioid medications Pain As 5th vital sign Porter and Jick letter published in New England Journal of Medicine in 1980; frequently cited in marketing of new synthetic opioids OxyContin brought to market in 1996

Larger, cheaper supply and more potent than prescription painkillers Leading Cause of Accidental Death Starting in 2008, drug overdoses became the leading cause of injury death in the United States surpassing car accidents and firearms Stigma and Discrimination Stigma refers to negative stereotypes Discrimination is the behavior that results from the negative stereotype Discrimination in this case means treating someone less

favorably than someone else because he or she has a disability Would you treat someone less favorably because they were prescribed insulin for diabetes? What about people with highcholesterol who are prescribed cholesterol-lowering medication? Beliefs Perceptions How has our definition of addiction changed? Addiction was thought of as a moral failing or character defect Drug use: criminal issue vs. health issue

Language matters: move away from addicts Scientific research has demonstrated that, whether we are aware of it, the use of certain terms implicitly generate biases that can influence the formation and effectiveness of our social and public health policies in addressing them Three Stages of Addiction Excessive amounts used Tolerance

Excessive time spent using/obtaining Withdrawal Cravings or urges to use Unsuccessful attempts to cut down -

Hazardous use Health problems Missed obligations Interference with activities Personal problems SUD is a complex disease that results in chemical and physiologic changes to the brain SUD must be treated like any other chronic, relapsing condition Slide from C. Cynthia Reilly, MS, BS Pharm Director, Substance Use Prevention and Treatment Initiative The Pew Charitable Trusts Reily Defining Addiction Biological Addiction is a primary, chronic disease Psychological Social Components

Primary Disease - meaning that its not the result of other causes such as emotional or psychiatric problems. Chronic Disease - like cardiovascular disease or diabetes it must be treated, managed and monitored over a lifetime.time. At its core, addiction isnt just a social problem or a moral problem or a criminal problem. Its a brain problem whose behaviors manifest in all these other areas. Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. Its about underlying neurology, not outward actions. - Dr. Michael Miller, ASAM Defining Addiction Addiction is a primary, chronic and relapsing brain disease

characterized by an individual pathologically pursuing reward and/or relief by substance use and other behaviors - ASAM Beliefs Perceptions How has addiction treatment changed? Short-term acute interventions vs. chronic disease management model Relapse is a part of the disease, NOT a failure Similar to other chronic diseases, addiction often involves

cycles of relapse and remission Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death Welcome MAT Medications Recovery Work Intensive Psycho, Social and Behavioral treatments OUD Drugs: Distinct Pharmacology and

Roles in Treatment The Case for MAT MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders.--SAMHSA Research indicates that methadone and buprenorphine have a strong evidence base supporting their clinical effectiveness. Strong support for Vivitrol. MAT is the gold standard for opioid use disorder (OUD) treatment: Reduces drug use

Reduces risk of overdose Prevents injection behaviors Reduces criminal behavior MAT Supports Recovery

persistent intentional abstinence from intoxication engagement in daily life gaining employment reestablish family and social ties being present in everyday life being able to weather the challenges, daily lows and highs of life without substances as an external coping skills that has negative side effects and consequences An Unmet Need 20.2 Million People Have SUD 2 million had a substance use disorder involving prescription pain relievers and 591,000 had a substance use disorder involving heroin 10% to 40% of individuals with addictions receive treatment

Only a fraction of those that get treatment get MAT 300,000-400,000 people on methadone in a given year 40,000 on buprenorphine 5-10,000 on Naltrexone Only 10% of the people who need to be on MAT for opioid use disorder (OUC) are receiving it More than two-thirds of U.S. clinics and treatment centers still do not offer MAT medications (Stateline, 2016) Evidenced Based- Utilization The Bias Against MAT

Belief that use of medication conflicts with abstinence-based treatment programs like 12-step programs* *Not all 12-step programs prohibit MAT and mutual support groups remain an important part of addiction treatment and recovery. The Bias Against MAT Belief that abstinence is more effective than MAT Many people, including individuals who have worked in the treatment field, have recovered from addiction without the use of medications

The Bias Against MAT Perception that MAT is not treating the underlying causes of addiction. The Bias Against MAT Negative perceptions around methadone clinics; patients may try to limit their time there The Bias Against MAT

Belief that people on MAT are not in recovery; not clean The Bias Against MAT Belief that MAT is a substitution of one drug for the other; fighting fire with fire The Bias Against MAT Belief that opioid use is not in my scope an should be treated

by specialty addiction providers Stopping/Tapering MAT There is no evidence to support stopping MAT 95% of methadone patients do not achieve abstinence when attempting to taper off (Nosyk, et al. 2013) Over 90% of buprenorphine patients relapse within 8 weeks of taper completion (Weiss, et al. 2011) Successful patients are commonly maintained on Methadone for 24+ months, Buprenorphine for 18+ months Typically patients with continuous sobriety for 1-2+ years have the best outcomes

Treatment <6 months has worse outcomes VERDICT Bias against MAT is deadly Leading Cause of Accidental Death Starting in 2008, drug overdoses became the leading cause of injury death in the United States surpassing car accidents and firearms Sound Familiar? Similar to the 1990s with patients who had suicidal depression and were being judged for taking Prozac Patient Impact

Neglected a full range of treatment options Pressure from child welfare, jail, prison, and parole/probation systems to stop MAT Restricted access to recovery support services For example, many recovery houses do not allow residents to be on MAT The previous two points can lead patients stop MAT before it is clinically appropriate Biases within MAT Methadone and buprenorphine are narcotics Bias towards using Vivitrol because it is safer Diversion of methadone and buprenorphine

Used to get high and street value Addiction doctors agree that all three medications should be available to patients, because one may be more effective than another, depending in part on the persons age, length of time as an addict , home and work environment and underlying mental health issues. The American Medical Association, the American Academy of Addiction Psychiatry and the American Society of Addiction Medicine unequivocally support their use. (Stateline, 2016) MAT Methadone Bias Treating and opioid with an opioid? Fire with Fire? Overdose trends in the US: Long acting or extended release Methadone is long acting stays in your system 24-36 hours but the pain control or analgesia only lasts 6-8 hours

Pain management vs OUD treatment Talking about pill form vs liquid form Observed in clinic vs pills taken in the community (diversion) 3 Ps: Providers, Perceptions, Payment Perceptions: The perceptions of MAT and its value among patients, practitioners, and institutions Some practitioners do not believe that MAT is more effective than abstinence-based treatmentwhen patients are treated without medicationdespite science-based evidence Providers: The availability of qualified practitioners and their capacity to meet patient demand for MAT Hiring physicians can be expensive for clinics, especially small centers Physicians

receive little education in addiction care & are reluctant to extend their practice to patients with addictions Payment: The availability and limits of insurance coverage for MAT Few private insurers and state Medicaid programs cover all of the MAT medications approved by the Food and Drug Administration. Other face hurdles such as prior authorization requirements or fail first policies. How do we impact discrimination? Share the evidence! Recognize MAT for what it is: The gold standard of OUD treatment Defining 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. What is 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. Health: overcoming or managing ones disease(s) or symptomsfor example, abstaining from use of alcohol, illicit drugs, and non-prescribed medications if one has an addiction problemand for everyone in recovery, making informed, healthy choices that support physical and emotional wellbeing. Home: a stable and safe place to live; Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking,

or creative endeavors, and the independence, income and resources to participate in society; and Community: relationships and social networks that provide support, friendship, love, and hope. What is recovery?

Persistent intentional abstinence from intoxication Engagement in daily life Gaining employment Re-establish family and social ties Being present in everyday life Being able to weather the challenges, daily lows and highs of life without using substances as an external coping skills that has negative side effects and consequences Embracing Many Pathways to Recovery All patients are offered MAT: Methadone, Buprenorphine, Naltrexone Patient Centered Care: All patients have an option of any of the three medications to treat SUD. There are pros and cons to each.

There should be consideration of where they are in life, phase of treatment, and what the patient needs Treatment works better with patient buy-in The Fundamentals of Medication Assisted An Integrated Approach to Recovery Treatment: for Individuals with Co-Occurring Disorders

Angele Moss-Baker, LPC, LMFT, MAC, EAS-C 44 Traditional Approaches to Treatment Sequential treatment - The client is treated in one system, then the Agencies work largely independent of each other. Parallel model The client is treated simultaneously, but by two separate agencies. The patient participates in two systems simultaneously. Coordination is not consistent.

Falling Through the Cracks 45 47 2015: Co-Occurring Mental Health and Substance Use Adults SUD and Mental Illness SUD,

No Mental Illness 11.5 Million 19.6 Million Had SUD 8.1 Million 35.4

Million Mental Illness , No SUD 43.4 Million Had Mental Illness Results from 2015 National Survey on Drug Use and Healt

Comorbidities and MAT Psychiatric Comorbidity o The most common are: Major Depression, Anxiety, Bipolar, PTSD. o Psychiatric comorbidities may complicate buprenorphine treatment. NOTE: Combining medications used in MAT with anxiety treatment medications can be fatal. Benzodiazepines are highly associated with overdose fatalities when combined with opioids. Medical Comorbidity o The most common are: HIV, Hepatitis B and C, Tuberculosis, Syphilis. o MAT and drug interactions - antiretroviral medications, vital hepatitis medical treatment.

49 Which Comes First? 51 Integrated Treatment An approach that involves simultaneous treatment of both disorders in a setting designed to accommodate both problems in a unified and comprehensive treatment program. An approach to meet the substance use, medical

and mental health, and social needs of a patient Essential Principles and Competencies for COD and MAT Integrated Treatment or highly coordinated when not on site. o Monitor patient progress and compliance with off-site treatment Staff competency Cross training o Co-occurring psychiatric and medical conditions Psychotropic medications - prescribed when significant impairment exists. o Prescribing medications with abuse potential such as benzodiazepines (opt Serax) o All medications are monitored Alleviate shame and stigma to receive treatment for co-occurring

Quadrants of MH/SUD Services 53 Alcohol and other drugs High Intensi ty Low Intensit y

Category III Substance Abuse System Severe SUD, Mild MI Med-Monitored IPWM, PHP, RTF, MAT DDC/DDE Category I Primary Health Care Mild MI, Mild SUD PCP, OP, IOP Category IV Acute Care Hospitals

Severe MI, Severe SUD Med-Managed IPWM, IP Psych, Residential Category II Mental Health System Severe MI, Mild SUD OP, IOP, PHP, ACT, GH Mental High Intensi

ty 54 ASAM Treatment Levels of Service Level III Level IV Med-Monitored IPWM Clinically-Managed Residential WM Medically-Monitored Intensive Inpatient Clinically-Managed High-Intensity Residential Clinically Managed Population-Specific High

Intensity Residential Services Clinically-Managed Low-Intensity Residential Med-Managed IPWM Medically-Managed Intensive Inpatient Level I Level II Ambulatory Withdrawal Management without Extended On-Site Monitoring Outpatient Services

Ambulatory WM with Extended On-Site Monitoring Partial Hospitalization Intensive Outpatient Level 0.5 Early Intervention OPIOID TREATMENT SERVICES (OTS) Opioid Treatment Program (OTP) Agonist meds: methadone, buprenorphine; Office Based Opioid Treatment (OBOT) Antagonist medication naltrexone

ASAM Practice Guideline for the Treatment of Co-Occurring Psychiatric Disorders A comprehensive assessment including determination of mental health status should evaluate whether the patient is stable. Patients with suicidal or homicidal ideation should be referred immediately for

treatment and possibly hospitalization. Reduce, manage, and monitor suicide risk Management of patients at risk for suicide should include: reducing immediate risk managing underlying factors associated with suicidal intent

monitoring and follow-up Assessment for psychiatric disorder should occur at the onset of agonist or antagonist treatment. Reassessment using a detailed mental status examination should occur after stabilization with methadone, buprenorphine or naltrexone.

Pharmacotherapy in conjunction with psychosocial treatment should be considered for patients with opioid use disorder and a co-occurring psychiatric disorder. Quadrant of Care: Where Does Treatment Begin? Patients in acute psychiatric danger Patients presenting with suicidal or homicidal ideation or threats, that may interfere with their safety and ability to function should be assessed and treated immediately whether resulting from: acute intoxication or withdrawal, or an independent co-occurring disorder or substance-induced disorder Although their symptoms may be short lived, admission to a psychiatric unit for brief treatment may be necessary if outpatient care is too risky or

problematic. Immediate administration of antipsychotic drugs, benzodiazepines, or other sedatives may be required to establish behavioral control. A physician, physician's assistant, or nurse practitioner on staff can prescribe medications at the OTP. Quadrant of Care: Where Does Treatment Begin? Patients with established severe co-occurring disorders who are not in acute danger Should receive medication with the lowest abuse potential for their condition. If an OTP is staffed appropriately and prepared to treat patients with severe co-occurring disorders, these patients

can be treated on site. If there is no such OTP, patients may need to remain in a less optimal OTP but receive psychiatric treatment at another facility with effective highly collaborative communication between OTPs and mental health providers to coordinate treatment. Quadrant of Care: Where Does Treatment Begin? Patients with less severe, persisting or emerging symptoms of co-occurring disorders. Patients in MAT with non-disabling symptoms of less severe co-occurring disorders (e.g., mood, anxiety, and personality disorders) should continue or begin medication,

psychotherapy, or both for their co-occurring disorders. These patients should continue in MAT if the OTP is staffed to treat them. Quadrant of Care: Where Does Treatment Begin? Patients with less severe, presumptively substance-induced co-occurring disorders. Patients in MAT with symptoms of a psychiatric disorder, without a history of CODs, receive no new psychotropic medications until they are stabilized on MAT - because their symptoms might remit or significantly diminish after a period of substance abuse treatment. Exceptions include patients who have acute, substanceinduced disorders such as extreme anxiety or paranoia

that are likely to be transitory but require temporary sedation or antianxiety medication. Effective Integrated Service Delivery Based on principles of effective integrated service delivery: Collaboration and Coordinated Care o 42 CFR 2 - CONFIDENTIALITY OF SUBSTANCE USE DISORDER PATIENT RECORDS Motivational Interviewing Stage-Wise Treatment Effective Integrated Service Delivery

Collaboration/ Coordinated Care With Psychiatric Providers With MAT Physician With Primary Care and other medical providers Coordinating with Specialty Providers Motivational Interviewing

Empathic Nonjudgment al Roll with Resistance Stage-Wise Treatment Precontemplati on Contemplation Preparation Action

Maintenance References Medication Assisted Treatment: A Standard of Care. Elinore McCanceKatz, SAMHSA 2014. A Family Guide to Concurrent Disorders. Centre for Addiction and Mental Health.

Integrated Service Delivery Models for Opioid Treatment Programs in an Era of Increasing Opioid Addiction, Health Reform, and Parity. Kenneth B. Stoller, Mary Ann C. Stephens, Allegra Schorr. American Association for the Treatment of Opioid Dependence, July 2015. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs: TIP 43. SAMHSA 2012. Federal Guidelines for Opioid Treatment Programs. SAMHSA January 2015.

The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use. American Society of Addiction Medicine. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-occurring Conditions Thank You! Angele Moss-Baker Comprehensive Addiction & Psychological Services, LLC [email protected]

Policy Interventions Affordable Care Act/Medicaid expansion Individuals with mental health and substance use disorders were the single largest beneficiaries of Medicaid expansion with nearly one-third of new Medicaid enrollees having a either a mental health and/or Substance Use Disorder Physician Buprenorphine Prescribing Limit Raised to 275 Patients June 2016 SAMHSA raised doctor prescribing limit from 100 to 275 patients Comprehensive Addiction & Recovery Act (CARA) Allows Nurse Practitioners and Physician Assistants to prescribe buprenorphine for up to 30 patients First addiction bill passed through Congress in 40 years 21st Century Cures Act Allocated $1 billion in State Targeted Response grants to curb opioid abuse and increase treatment capacity Surgeon General Report

First Surgeon General report on addiction Resources on Opioid Use Centers for Disease Control and Prevention Overdose Data Guidelines for Prescribing Opioids for Chronic Pain Substance Abuse and Mental Health Services Agency Data on Prescription Opioid and Heroin Use from the annual National Survey on Drug Use and Health Medication-Assisted Treatment Information on certification, oversight, DATA-2000 waivers, legislation, regulation, and more Office on National Drug Control Policy (archived website)

National Drug Control Strategy Data on Methadone, Buprenorphine treatment and drug poisoning deaths National Institutes on Drug Abuse Opioid Epidemic Strategies & Resources mat/ PCSS-MAT is a collaborative effort led by American Academy of Addiction Psychiatry in partnership with: American Osteopathic Academy of Addiction Medicine, American Psychiatric Association, American Society of Addiction Medicine and Association for Medical Education and Research in Substance Abuse.

For more information visit: For questions email: [email protected] Twitter: @PCSSProjects Funding for this initiative was made possible (in part) by Providers Clinical Support System for Medication Assisted Treatment (grant no. 5U79TI024697) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. Treatment Works, People Recover Research shows that the earlier drug use begins, the more likely it will progress to addiction | Teen alcohol and drug use is declining More and more individuals are engaged in MAT Over 23 million Americans are in recovery from addiction to

alcohol and other drugs References 1 National Institute on Drug Abuse. (2015). Drugs of Abuse: Opioids. Bethesda, MD: National Institute on Drug Abuse. Available at 2 American Society of Addiction Medicine. (2011). Public Policy Statement: Definition of Addiction. Chevy Chase, MD: American Society of Addiction Medicine. Available at publicypolicy-statements/1definition_of_addiction_long_4-11.pdf?sfvrsn=2. 3 Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from data/. 4 National Institute on Drug Abuse. (2014). Drug Facts: Heroin. Bethesda, MD: National Institute on Drug Abuse. Available at

5 Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths United States, 20102015. MMWR Morb Mortal Wkly Rep 2016;65:14451452. DOI: Thank You! Nick Szubiak, MSW, LCSW Integrated Health Consultant Director, Clinical Excellence in Addictions National Council for Behavioral Health LinkedIn: Nick Szubiak, MSW,LCSW Twitter: @nszubiak [email protected] Office

202.621.1625 C. 808.895.7679

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