Hanh: Thank you for joining our webinar series
on “Medication-Assisted Treatment.” This is the first webinar in our two-part series,
so without further ado, I’d like to turn it over to Dr. Nancy Young.
Dr. Nancy K. Young: Thanks very much, Hanh, and thank you to all of you who have joined
us today. As Hanh mentioned, this is the first of two parts on “Medication-Assisted Treatment.”
At the National Center on Substance Abuse and Child Welfare, we have been recognizing
over the last really couple of years increase of attention to this issue in a variety of
ways. In particular, getting questions from practitioners
from around the country about different aspects of medications, and what that means in terms
of child welfare practice. So, we’re going to talk a bit today about some of the other
kinds of questions that we get around child welfare practice and particularly those of
you might be operating in a Family Drug Support setting.
We’re very honored to have Mark Parrino with us today to talk specifically about opioid
treatment and advances that have been made in opioid treatments and what that means for
child welfare practice in particular. Then we’ll have the time at the end of the agenda
to be able to go through some of the questions that you have raised by asking questions in
that box on the side of your screen. As many of you know, the National Center on
Substance Abuse and Child Welfare is a program of both the Substance Abuse and Mental Health
Services Administration and the Administration on Children, Youth, and Families of the Children’s
Bureau. We are actually in our ninth year and are
very happy to know that all of you are out and working very diligently on behalf of families
that crossed over between the system of the need for substance abuse treatment, child
welfare practice and the dependency court. As I mentioned, we’ll introduce in a bit Mark
Parrino, who is the director of the American Association for the Treatment of Opioid Dependence.
We’ll be talking in a bit about some of the specifics about treatment for opioid dependence
and addiction. In the second of our series, we will have
Dr. Karol Kaltenbach who will be talking specifically about the issues of pregnant and parenting
women. That is certainly one of the questions that comes up frequently in child welfare
practice, particularly around issues with both infants and infants who are detected
at birth of having then prenatally exposed to substances.
The treatment and management of opioid dependent during pregnancy will be the focal point of
the next webinar. Let me just check the date on that. We’ll make sure we have that at the
end of August 4th…sorry, I did not have that on the top of my head. If you haven’t
already signed up for that, please do so. We think that will be very informative for
you as well. It’s always interesting to us to know who
is hearing these webinars. As you’re maybe aware, they’re posted on our website that
you can listen to them after they’ve been reported. I was sharing with Mark a little
earlier that this is an interesting group of participants that, in general, our webinars
are often more child welfare audience than substance abuse treatment. It’s interesting
to us that just over 40 percent of the participants that registered were first from Substance
Abuse Treatment Organization. We can speculate that that response is in
part some of these questions that we’re hearing from treatment providers, as well as from
child welfare practitioners about how to handle these different kinds of medications that
are used in treatment, and then of course more specifically some of the issues for opioid
dependent, specifically. I want to spend a little bit of time just
talking about what are we hearing from the field. Certainly one of the things that we’re
hearing quite a bit about is that the use of medical marijuana and what does that mean
for child welfare, and how does child welfare look at this new era of about 15 states who
have passed laws that allowed the use of medical marijuana.
We’re also hearing a lot about prescription medication misuse and abuse. Clearly, that
has been in the news lately and part of the initiative from ONDCP and the Federal Government
as they address these issues of prescription medication misuse and abuse.
Then as we talk about the co-occurring mental health disorders and particularly again in
the family support setting, the complexity of understanding prescription drugs that are
being used with co-occurring mental health issues.
How do dependency courts and family drug courts address these issues of knowing enough about
what’s going on with the individual client that has prescriptions and medications that
are being prescribed for them for mental health issues, at the same time that they are in
substance abuse treatment for another substance dependent and addiction. The focal point really
of this webinar was medication-assisted treatment for substance abuse disorders.
In part, the state of the field is we have looked at this issue, particularly over the
last year. The kind of questions that we get in technical assistance of really what we
would pose as some misunderstandings of the use of medication-assisted treatment, particularly
methadone treatment in substance abuse and how that relates to child safety and how Child
Welfare responds to that. We hear frequently that there may be Child
Welfare practitioners or a Child Welfare policy or family court judges or attorneys that are
involved with what dosing of medication should be prescribed, particularly for women who
have just given birth in the perinatal period or if this is an open case in Child Welfare
and the woman is pregnant, some involvement of understanding what does dosing mean?
As I mentioned, we’ll be talking about these issues specifically in the fourth webinar.
We’ve also heard a lot of medication-assisted treatment as a reason to exclude someone from
a Child Welfare program and particularly family drug court. I had the experience of being
in the office a couple of months ago. Someone was recording that a family drug court
had called in with some TA requests about judges that were eliminating or putting a
criteria, anyone who was receiving any prescription drugs could not participate in the family
drug court. I happened to be in a setting the very next day that I was in a drug court
and, in fact, there was a participant who came up that was had been prescribed Naltrexone.
The judge said to this gentleman, “Well, that will mean that you won’t be able to save up,”
meaning a damp in the phases of the drug court while he was taking Naltrexone. I know this
is an issue that’s out there. I was a little surprised to hear it the very
next day in a very different setting of judges and attorneys in particular that have different
views about the use of medications in treatment and the ways in which that influences their
ability to work with families. We think it’s always important to think and
to go back to this very broad strokes of what do we mean when we’re talking about a parent
with a substance-abuse disorder and risk to children? One of the things that we still
see in practice is the grouping together of all families in one category without making
distinctions between a parent who may be using an illicit substance or in that abuse category,
if you will. Probably if they have come to the attention
of the Child Welfare system and they’re using a substance, they probably meet criteria for
a substance abuse issue. We often find that the case plan looks very much the same in
those kinds of reactions as a parent who is addicted or a parent who is dependent on a
substance. The differentiations between those different
families that Child Welfare is working with doesn’t always happen. Yet, the risk for a
child and the risk and safety assessment that’s being conducted in Child Welfare often doesn’t
take into consideration these different kinds of ways that children are exposed to substances,
both the legal and the illegal use of substances. Clearly the differentiation of when there
is manufacturing that is going on, when there is trafficking that is going on, those kinds
of situations and the safety factors for children are very different then when someone is dependent
on a substance and clearly different when a mother is abusing alcohol, misusing alcohol
or using illicit substances when she is pregnant. We come back to this a lot because we recognize
that those different situations pose different kinds of risks, and they require a different
kind of response. That working together with child welfare and the treatment providers
and the court professionals need to be able to respond to these different kinds of risks
and to understand the different risks and safety factors for children when they’re responding
in case plans and making requirements of the court.
Particularly if there’s been a child that has been removed, or if there is a child that
is being served in-home, what those conditions are for the child to be able to remain at
home. Understanding those differences and, again, the safety and the risk factors for
children are really the key that we’re talking about, and understanding the differences in
not just the illicit substance use, but prescription drug abuse and medications that are being
used for co-occurring disorders. Clearly, I think we know from the prevalence
data that the largest number of children that are exposed to a parent and substance use
disorders are those that are dependent on a drug, that those are the ones that typically
come to the attention of child welfare, and that they are the majority of what child welfare
is working with, with families. Although the other situations that have certainly
are trafficking and manufacturing, as I mentioned, pose certain risks that need to be dealt with
in a very different way. We want to spend a little bit of time just talking about, just
minimally, really, about medical marijuana. It’s because we’re hearing about this, particularly
in family drug court. Sometimes, it’s grouped all together as medication-assisted.
Medication-assisted treatment, in terms of medical marijuana, comes into play when someone
is participating in a case plan, when someone is participating in a family drug court, and
they have a prescription to use medical marijuana. Some information that is more recent, that
we want to make sure that you are aware of, is from the [inaudible 00:13:25] information
about which states that you can obtain information on thehe National Conference of State Legislators,
NCSL. Keep track of these kinds of state legislation on their website, and that link at the bottom
of this page will refer you to the specific state laws in your state that use medical
marijuana. More recently, in fact, just in the last two
weeks, a letter that has come out from the Department of Justice that has went to all
of the attorney generals of all of the states about the federal government’s role in medical
marijuana and the differentiation between medical marijuana that is being used in the
treatment of chronic pain management. Particularly for persons that are being supervised
by pain management specialists, and those states that have recently enacted laws that
would allow larger cultivation of marijuana without, really, the control that is needed
in order to really supervise what does that mean, medically.
If you have not seen this letter, we wanted to make you aware of that. We put it into
the PowerPoint so that you would have the whole thing, so that you know the federal
government’s position on medical marijuana and prosecution for the Controlled Substance
Act and proliferation of marijuana across the United States.
We also wanted to make sure that you’re aware of the American Society of Addiction Medicine
report that was in September, 2010, that addresses the role of physicians in medical marijuana
and their recommendations. This is available. If you send us an email, we can send this
report to you in a PDF. They discussed the medical marijuana and the
about when the use of smoked marijuana. Making a recommendation that it would be something
that would be for less than six months, really noting the concern about the recognition of
tobacco products and what that means for smoking tobacco and the idea that smoked marijuana
has little research about what that means, in terms of the inhalation effect, itself.
They really take a medical view of, “When would it be appropriate to use medical marijuana?”
These bullet points are what ASAM, American Society of Addiction Medicine, proposes as
when that would be appropriate. We thought that was important for you to know
because if you’re struggling particularly in a family drug court setting or in child
welfare practice about when should a prescription from a parent for medical marijuana be considered
in a case plan, that you’d have some guidelines from, again, from ASAM about what they recommend
about when that is appropriate. If you’re making state or local policy about
medical marijuana in child welfare practice, that this would be something that was very
helpful to you. In particular, the paper gives exactly what they, ASAM, would expect a physician
conduct to be in prescribing medical marijuana. We think that this is important because it
can help you with making your own state or local policy about how to handle the use of
medical marijuana, if you’re in those 15 states that have passed state legislation that allows
prescriptions to be used a defense if a person should be charged with the possession or cultivation
of marijuana. In general, that’s what the state laws do.
It allows this to be an exception to the state laws around the cultivation and use of marijuana.
We didn’t want to spend a lot of time on that, but again, wanted you to be aware of these
resources if you have not been, because it is something that we are hearing quite a bit
from child welfare sites. Then, the second part that we want to talk
about just a bit is a lot of the information that we’re getting from sites around the country
about prescription drug abuse. This is something that’s been on the cover of the weekly news
magazines, that we recognize that this is something that has very much increased in
the country and that child welfare and family courts are struggling with, “What does this
mean, in terms of prescription use, in the context of child welfare practice and child
safety?” Certainly, recognizing that medications for
the use of pain management, as well as for mental health disorders, are in fact those
kinds of medications that are being reported to us that are being used, that need policies
set around. These are data from the treatment episodes
data set of treatment agencies, known as the TED data, that show treatment admissions among
just women. This is the percentage of other opiates, not methadone treatment, not heroin,
but a primary substance of abuse of admission by the age group.
You can see that those that are in that age group of 25 to 34, with nearly a quarter of
treatment admissions for these particular substances, other opiates, are in that age
group and certainly, that age group of parenting women and childbearing ages of the 18 to 24-year-olds.
We recognize that this is a somewhat newer phenomenon for child welfare to be working
with. Then, if you look at the treatment admissions
for other opiates, not heroin, not methadone, as primary substance of abuse, the state with
the highest percentage of women admissions, and if you happen to be in one of those states,
then you’re certainly dealing with, “What does this mean, in the context of child welfare
practice?” We also recognize, and while this isn’t clearly
a complete list of the kinds of medications that are narcotics and analgesics that are
used for pain management, these are usually short-term. They have a high addiction potential.
They’re short-term pain relievers that you may be giving individuals in practice that
are using these kinds of medications. I think although itis probably more widely
used than the issues that ASAM was addressing in medical marijuana, but those standards
that they lay out for physicians seem to be applicable in this, also.
And not unreasonable for child welfare practice to look at those standards about making sure
that this is a physician that has a relationship with the patient, that there is a diagnosed
condition that is being treated by using these kinds of medications.
But again, important to recognize that it’s the context of risk and safety for the child
and individualizing, “What does the use of this particular substance mean for that particular
family, in the context of medical conditions, versus the context of substance abuse, that
is posing risk to children?” particularly as you look at neglect kinds of situations.
Finally, the other aspect that we wanted to recognize, because we have this coming into
us, it’s all jumbled up, in terms of the different kinds of medications and the different kinds
of substance abuse that’s going on. It’s the recognition that the co-occurring
mental health disorders, in practice, that about more than half, typically, in substance
abuse treatment, have some type of co-occurring mental disorder. Usually, they’re anxiety,
depression kinds of related. Also, they may be the more serious kinds of
mental disorders, but that the other side of that, that those individuals coming into
mental health settings, that somewhat less than half of them have a co-occurring substance
use disorder. This is information from the Treatment Improvement
Protocol, put out by the Center for Substance Abuse Treatment on substance abuse treatment
for persons with co-occurring disorders. If you don’t have that in your office, it’s readily
available to you and would be very helpful, as you’re looking at child welfare policy
about medications and the use of medications. Certainly, recognizing that the complicating
presence of co-occurring disorders, meaning that there may be a longer time that the person
is in treatment, that they may have a re-hospitalization for depression, they may pose suicide risks
when there’s co-occurring disorders. Those are all complicating factors for substance
abuse treatment agencies that child welfare needs to be aware of.
We don’t intend to go through an exhaustive list of these medications, but recognizing,
again, the different types of medications that are being used for co-occurring disorders,
we think is important, particularly if those of you that are participating today may be
in charge of training programs for child welfare. This is information that’s available to you
through some of the training resources of the National Center, but recognizing that
child welfare workers need the information about the different kinds of medications that
are being used in the treatment of co-occurring disorders, as well as the treatment of substance
use disorders. We put this into the PowerPoint, so you have
these lists that you can come back to and refer you to the TIP 42 for more information
about each of these different kinds of categories, and wanted you to have some of the drug names
that you would often hear as the kinds of prescriptions that are being used with persons
with co-occurring disorders. Then, we want to turn our attention to medication-assisted
treatment for substance use disorders that we’re talking about, more specifically, used
in a treatment setting during detox or perhaps for ongoing maintenance of recovery for individuals
with substance dependence and addiction. Recognizing that the detox phase of treatment
says specifically, the National Institute on Drug Abuse, is not showing that that is
different than patterns of use after detox, unless there is a referral to ongoing treatment.
We hear frequently, in child welfare practice, that they may even have paid for detox for
an individual without ongoing support for ongoing treatment.
And that it’s recognized that that detox process and medications that may be used during detox
is only that first step in the treatment process and, in and of itself, is not sufficient to
provide that long-term stability that a parent may need, in order to satisfy the requirements
of safety for their child, over the long-term. Recognizing that there are substances that
are used and medications that are used for the treatment of substance use disorders,
particularly for the legal substances in alcohol and tobacco, and there are other drugs that
are also being used in alcohol dependence that Mark may speak to, specifically, as he
gets into his presentation. There are other substances, besides Antabuse,
now that are being used for the withdrawal period of alcohol and showing promise in using
that, in terms of ongoing recovery from alcohol dependence.
Then, getting into the main focus of the remainder of this webinar with looking at opiate dependence
and the kinds of information that Mark will be talking about more specifically.
With the difference between the opiates and opioids, the synthetics that are painkillers,
including oxycodone and hydrocodone, which is commonly known as Vicodin, and the medications
that are available to treat dependence that you may be hearing about from treatment providers
that child welfare practitioners are working with and some of the advances that are being
made in medication development. That’s exciting news in the treatment of substance
use disorders, but our sense is not particularly well understood yet, in policy and practice
in child welfare. We have a polling question, just to get started, before I turn things
over to Mark. Hanh, I’m going to turn this back over to you, so you can conduct the poll.
Hanh: Great. We wanted to ask you to respond to this statement: “There is no way a parent
who is receiving medication-assisted treatment for substance dependence can be an effective
parent.” It looks like the majority of you either strongly disagree or disagree.
Nancy: Let’s turn things over to Mark with the results of that and have him, perhaps,
take that into context, as he begins his presentation. Mark Parrino: A very good prelude, and it
certainly indicates to me that there seems to be disagreement that when you’re using
medications to treat opiate addiction, with either methadone or buprenorphine or perhaps
these newer medications like Vivitrol that are being used, that by virtue of the individual
taking such medications to treat the opiate addiction, that prevents them from being an
effective parent. I take it, Hanh, that I am correct in making that assessment.
Hanh: Yes, you are correct. Mark: Let me tell you a bit about what you
will see in the following slides. First, we’ll be giving you a sense of where we are in the
United States at the present time in treating chronic opiate addiction, the history of the
science, the evidence supporting what that treatment does, the medications that are primarily
used to treat opiate addiction right now, which is methadone and buprenorphine.
Then, where we are in terms of the use of methadone for pain management which has increased
in the past 10 years, and the difficulties and challenges that has created. Then, a research
study that we’ve done and as was already discussed in the prelude to this discussion that prescription
opioid use, abuse, and addiction are now becoming a very critical national problem.
Then, some closing points, which are responding to some of the frequently asked questions,
which I think are reflected in that first poll. Just briefly, before I tell you what
this map means, the association represents 850 programs, opiate treatment programs, in
the United States and in Mexico. We work with our international associates,
EuroPad ] , which represents 23 nations and another 500 treatment programs. The map that
you see is from the Center for Substance Abuse Treatment. These dots represent independent
opioid treatment programs, otherwise known as OTPs, and that’s how I’ll reference them,
during the course of the webinar. There are about 1,230 of these treatment programs.
All of them are certified by the Center for Substance Abuse Treatment in SAMHSA. They
collectively treat about 285,000 patients on any given day. The clear majority of these
patients, of these 285,000, receive access to methadone maintenance in these treatment
programs. About 5,000 are using buprenorphine. I’ll
explain that in a moment, what that means. You will notice there are three states in
particular that do not provide any access to care andthat’s North Dakota, South Dakota,
and Wyoming. In addition to the federal government regulating
these programs through CSAT, and that’s an accreditation-based system of care, most of
the programs are either accredited by JCo, The Joint Commission, or CARF. Again, that’s
under CSAT jurisdiction. In addition to the federal oversight, you have additional oversight
from the state authorities, which are called the State Opioid Treatment Authorities.
As a prelude to the next slide, it’s fair to state that these medications represent
the most studied and evaluated medications for the treatment of any disease that we’ve
got. That is not a grandiose point. That’s a point in fact.
Why don’t we go to the next slide, which will show the increase in the use of buprenorphine,
which is one of the more newly developed medications. This slide shows you the increase of the use
of buprenorphine through pharmacy distribution. Specifically, this mean this is the medication
that is prescribed out of a physician’s office, and this is a physician’s office that is certified
and approved by CSAT under federal legislation called the Drug Abuse Treatment Act of 2000.
As you’ll note in reviewing the slide, that it shows that you have medication that was
started early on and then it was used through, and it’s used at the present time, in 2003.
What you will also see is that there are approximately, and I’ll give you the numbers for this, there
are approximately 300,000 patients who gain access to this medication in physician practice
settings. We don’t know much more about that because
it’s not a centrally collected number. That is reported through the Center for Substance
Abuse Treatment. We imagine through their reports that there are over 7,500 physicians
who are actively using this medication to treat chronic opioid dependence through their
private practice. When you go to the next slide, you will see
the comparison of how buprenorphine is used in an opioid treatment program, or an OTP.
You’ll see in that slide that it’s a much smaller number. This slide shows millions
of units of buprenorphine used. The next slide shows that there are about 450,000 units prescribed
in OTPs. That converts to about 5,000 patients. Once again, it shows you that there’s been
a limited distribution in the OTPs. This is primarily because the medication was intended
originally to be used by physicians in private practice in treating their patients. We anticipate
that CSAT will issue a federal registered notice very shortly, which is likely to allow
the increased use of this medication in the OTP.
The point of this webinar, both medications are extremely effective in treating opioid
addiction. The difference is, in understanding their use is understanding pharmacology.
The general rule of thumb is that if a patient has a longer term narcotic addiction prior
to entering treatment, if they have a more significant opioid dependence, that they are
likely to use or benefit from a medication like methadone, which is a pure agonist, whereas
buprenorphine is a partial agonist and antagonist. Generally speaking, buprenorphine will be
used in a population that is not having as much long-term pretreatment duration of opioid
use, or generally can stabilize on a slightly lesser dose. I know there may be some questions
about that, but that sets us a prelude. Once again, they’re both extremely effective medications.
There is oversight for the OTP system at the federal and state level, which I discussed.
There are no standards per se in how physicians will use buprenorphine in their practice setting.
The requirements of physicians under the Center for Substance Abuse Treatment, which follows
the federal legislation, is that the patient has to have access to the medication and the
physician will generally experience an eight-hour training course, which are offered by professional
medical societies. Vivitrol is a new medication which has just
been approved by the FDA to treat chronic opioid addiction. It has been used to treat
alcoholism. The difference is it’s an injectable medication. It’s used once a month as opposed
to methadone, which is used each day, generally with most of the patients going to the treatment
program either four or five times a week. Buprenorphine is generally given to a patient
by prescription, and patients typically get a month’s supply once they’re stabilized.
Now let’s go to the next slide. Nancy: Mark, can I interrupt for just a second
and ask you to go back to the explanation of agonist and antagonist? Could you just
do a little bit of an explanation about that? Mark: Yes. An agonist, a full agonist like
methadone, they’re binding to neuroreceptor sites in the brain. A subsequent slide is
going to describe the neurochemistry of this in explaining how the medications will bind.
Methadone binds in such a way that it is an agonist. It’s sort of imagining a lock-and-key
fit into the brain, where if somebody tries to use another opioid, let’s say heroin as
an example, that the access of methadone into the neuroreceptor site will prevent an individual
from feeling the euphoric effect of the medication, in this case more heroin, the other drug.
Whereas, an antagonist, if the individual uses a drug, if a person uses heroin and they’re
maintained on methadone, if they’re on the right dosage of methadone, what’s called the
blockade dosage, they are not going to experience any euphoria from using heroin. However, they
won’t be made to feel sick. They just won’t feel the euphoric effect.
With an antagonist like naltrexone, or even a partial antagonist like buprenorphine, if
the patient uses heroin or other drugs, opioids, they will feel withdrawal symptoms. That’s
the antagonist nature of the drug. It also binds to the same neuroreceptor sites in the
brain, but it produces a very specific reaction. Patients will go into withdrawal if they use
an opioid on top of an antagonist. Hopefully that clarifies the question.
Nancy: Yeah. One more follow-up to that. Something I hear a lot from practitioners is that people
use methadone to get high, and that they get high using methadone. Can you explain that?
Mark: Methadone, because it is a pure agonist, can create a euphoric effect, especially if
the patient is not stable in treatment or if the patient isn’t using the medication
at a stable dose each day and under supervision. Does methadone cause euphoria or will it create
a high in a patient who is stable in treatment, who is not using other drugs? The answer is
no. It does not create a euphoric effect. It just cannot create a buzz.
Sometimes people will report, “The patient says they feel good while they’re on methadone.”
Let’s presume for the moment that these people are not using or abusing other drugs, they’re
not drinking, they’re not using marijuana, they’re not using benzodiazepines like Valium
or Xanax, and that they are simply maintained on a steady dose state of methadone. This
will not create euphoria. It will not create a state of being high.
This is not a speculation. This is not an opinion. This is based on science, all the
research that NIDA has supported over the years, and clinical practice. Can patients,
if they want to, get high on methadone? The answer is yes, but it generally means they
are unstable, or they are not in a treatment program, or they are using or abusing other
medications. Does that provide some clarity? Nancy: Yes. Thank you very much.
Mark: OK. I see that there’s another polling question up.
Hanh This is Hanh. I’ll go ahead and read the polling question. Let me go ahead and
launch it. All right. Please respond to the statement, “People who
abuse alcohol or drugs have a disease for which they need treatment.” All right. It
looks like almost half of you strongly agree with the statement and about a third of you
agree with the statement. Mark: OK. This may run slightly counter to
the first polling reaction. Let me go to that, addiction is a brain disease, and give you
an underpinning to what I perceive as your response.
Alan Leshner is the former Director of the National Institute on Drug Abuse. He wrote
an article in the publication “Science and Technology” during 2001. It really talked
about addiction as a brain disease. The next slide is a quote from Dr. Leshner’s article.
While you can read it, the core concept has been evolving with scientific advances over
the past decade, that drug addiction is a brain disease that develops over time as a
result of the initial 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 its society. This medical condition demands
formal treatment. What Dr. Leshner is getting at is not what
we talked about in terms of a person who occasionally uses drugs or individuals who have the ability
to use drugs, walk away from them, not become either dependent on them or addicted to them
later. These are individuals that are chronically
abusing drugs. It is uncontrollable. It’s gone past the issue of willpower. These are
individuals who are not able to function either at work or in society, lose family relationships
or disrupt family relationships, and then do need access to formal treatment.
Interestingly, approximately 15 percent of people who need access to formal treatment
are getting it. That is related to either resources. It is related to access to treatment
programs in a respective community. It’s perception on the part of the individual that says, “I
don’t have a problem,” even though they may have lost a job or they may have lost a relationship.
They still perceive they don’t have a problem. Dr. Leshner is getting at the fact, and some
subsequent slides will support this, that this is a chronic and relapsing disorder.
It is a disease. It’s not perceived as a moral failing. It’s an illness that is treatable,
and we do have effective treatments. I’ll say something else, which is slightly
tangential to the discussion. While I’m focusing on the issue of medication-assisted treatment
for opioid addiction, which includes the medications that have been discussed – methadone, buprenorphine,
naltrexone – and now the newly developed and approved Vivitrol, it’s also understood that
medication-assisted treatment involves other services, counseling and ancillary services,
which we’ll talk about. However, this is not to suggest that every
person who becomes opioid-addicted will need a medication. There are some patients who
will go into inpatient therapeutic communities and do well also. While our focus is the use
of medication, I’m not saying that it is the exclusive treatment intervention that’s available
for a patient. If we go to the next slide, we get into the
“Principles of Drug Addiction Treatment.” This is a research-based guide, which is developed
by the National Institute on Drug Abuse. It was revised in 2009. It was originally published
in 1999. I recommend this for your reading. I believe
that this is made available. You can see the reference for electronic access on the bottom
of this slide. This is an extremely effective presentation of the best research that’s been
done in this particular area. The next slide focuses on one of the references
from this, which is addiction affects multiple brain circuits, including those involved in
reward and motivation, learning and memory, and inhibitory control of behavior. Some individuals
are more vulnerable than others to becoming addicted, depending on genetic makeup, age
of exposure to drugs, other environmental influence, and the interplay of these factors.
What this says to you is what you have already determined, I would imagine, is that addiction
is a disease, there are multiple pathways, and you can say, “How come some individuals
with similar exposure to the use of a drug become addicted and some others don’t become
addicted?” That’s directed based on what’s in this slide
from the NIDA research booklet, which is that some brains are different. They are more susceptible,
making the patient more vulnerable than others. This is based on genetic makeup and the other
factors that are listed. The next slide is going to reference a critically
important resource to the programs in the country. Once again, you see the electronic
access at the bottom of the slide. The title of this, this is the SAMHSA CSAT TIP 43. It’s
“Medication-Assisted Treatment for Opioid Addiction and Opioid Treatment Programs.”
This is recommended reading. There’s also a chapter specifically on medication-assisted
treatment for opioid addiction during pregnancy. That’s chapter 13 in this reference book.
This reference is used by all of the OTPs in the country. It is comparable to the regulations
through accreditation oversight that CSAT has over the programs. This is a very unique
thing, where you have this treatment approved in protocol, which provides the most comprehensive
available reference for the use of these medications in treating chronic opioid addiction, but
it is matched by regulatory oversight. One of the guiding principles in this TIP
43 in the next slide…You see that this is the reference. It’s published in 2005. The
next slide goes into the issue of discussions about whether addiction is a medical disorder
or a moral problem that have a long history. Decades of studies have supported the view
that opioid addiction is a medical disorder that can be treated effectively with medication
administered under conditions consistent with a pharmacological efficacy.
This goes to when treatment includes comprehensive services, psychosocial counseling, treatment
for co-occurring disorders, medical vocational rehab services, and case management services.
The reason I reference this particular quote from TIP 43 is to underscore the fact and
a principle that the use of medication alone to treat a chronic opioid addiction is not
what is recommended for the principle patients that come into our treatment programs.
Other services are going to be essential. That’s why they call it medication-assisted
treatment. The medication is a component of treatment. Medication is not in and of itself
the treatment intervention. This is an evolving issue, especially as patients discuss their
recovery from their prior addiction. People can be in recovery and still use medication
to treat their chronic addiction. Recovery does not mean that the individual must discontinue
either the use of methadone or buprenorphine or Vivitrol, if it comes to it. This is an
issue that may come up later or might be reflecting some of the attitudes that were reflected
in the first polling results. If you go to the next slide…
Nancy: Mark, before we do that, we actually had a question that came in specific to the
use of Vivitrol for alcohol dependence. The implications for child welfare, particularly
when it’s getting exactly at the point that you’re making, that Vivitrol being used in
place of, if you will, traditional treatment, that child welfare is grappling with, an individual
parent comes in and say, “I’m on Vivitrol, not participating in a comprehensive treatment
program.” What would you recommend to that child welfare
practitioner who is trying to work with that particular situation? Clearly, your statement
that this is not sufficient, that it’s medication-assisted…What should this individual do in terms of trying
to work with that individual? Mark: The first thing I’d do is get that individual
to sign a consent. If I’m the child welfare worker, I want to talk to the physician who
is treating that patient. I want to ask that person, “What else is being done aside from
giving this individual Vivitrol? What has been recommended in terms of access to counseling,
other therapeutic services, whether it’s family, counseling? What is happening to that human
being? What’s happening in the life of that human being, aside from the fact that they’re
getting access to a medication to treat their addiction?”
The first issue is that it is important, and it is therapeutic, since they are getting
access to a medication. It’s a sort of obvious point, but it is also insufficient if that
individual…Let’s face it. While I’m providing, some general guidelines and recommendation,
it’s sufficient to say that no two people are alike here. There are general principles
that guide their treatment. Is it possible that someone along the line,
after taking these medications for an extended period of time, Vivitrol, methadone, buprenorphine,
will not need access to other services because they’ve been stabilized, they’ve had access
to counseling, they’ve worked through a number of problems associated with their addiction
and their disease. The answer is yes, but it’s when that happens, at what point?
So if a person comes into a child welfare worker and says, “By the way, I’m on Vivitrol,
I’ve been using this medication for a couple of months, and that’s what I’m doing right
now, and there isn’t any other access to treatment andnd I claim to be perfectly fine, I’ve worked
through many of the issues that I got me to abusing and addicted to alcohol in the first
place,” that’s where the child welfare worker really does need to be in contact with the
practitioner to determine exactly what is being offered to the patient. Does that help?
Nancy: Great, thank you very much. Mark: So now we get into the second statement
from TIP 43, and this is the last point I’ll make about the science and the neurology of
addiction. Dr. Vincent Dole, along with his wife, Dr. Marie Nyswander, worked with folks
at the Rockefeller University, including Dr. Mary Jeanne Kreek, and really developed the
use of methadone maintenance as the treatment for opiate addiction.
It was the first medication that’s used in this country and in other countries, and this
is an important quote which comes from also Dr. Dole’s original research. He describes
the medical basis of methadone maintenance as a treatment that’s corrective.
It’s normalizing neurologic, and endocrinologic processes in patients whose androgynous ligand
receptor function has been deranged by 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 are questions for the
future. At present, the most that could be said is
that there seems to be a specific neurological basis for the compulsive use of heroin by
addicts, and the methadone taken in an optimal dose can correct the disorder. I bring this
slide up as a method of indicating that there is a bedrock of science and evidence to support
the use of medications to treat chronic opiate dependence and addiction.
It’s important as you read through the references that have been made, and obviously this is
too limited an opportunity to guide you through all of the evidence, that’s why you have the
two specific references in both the NIDA research guide, and TIP 43. I advise you to read them,
they’re both accessible electronically. The issue here, and you’ll see this in a subsequent
slide about duration of treatment, is that what you don’t want to do as child welfare
workers, or even as treatment providers or state officials, is to provide some arbitrary
limit on the individual’s duration of treatment. There is no arbitrary limit, there’s no point
where you can say, “You’ve been in treatment for one year. That should be sufficient, now
you should end your treatment, and that will make you a better human being, or that will
make you more recovered, or that will make you a better parent.”
This is the crux of part of this presentation, which is the use of medications when properly
supervised, and I mean properly supervised in the hands of a practitioner, whether it’s
an OTP which is regulated, or a Data 2000 practitioner using buprenorphine. The issue
here becomes is the patient progressing in treatment. What you don’t want to do is say
to the individual, “We think your treatment has run its course, it’s long enough.”
In this particular case the rough equivalent would be let’s say a psychiatrist saying to
a chronic depressed person who’s tried for years various interventions, but seems to
only be stabilized while they take an anti-depressant, “You achieve stability, now let’s see what
happens to you once you leave or your stop taking the anti-depressant.”
Or, a cardiologist saying to a hypertensive, “You’ve been stable now, your blood pressure
now within normal limits, that blood pressure has been driven by better exercise, let’s
say, healthier eating, but also taking this medication. We think it’s now time for you
to stop the medication.” You almost never hear a cardiologist say that,
because most practitioners, once they have a patient’s disease under control, tend not
to disrupt the use of the medication that helps achieve that stability, which takes
us to the next slide. This comes from the National Institute on
Drug Abuse. This slide talks about matching patients to individual needs. You’ve heard
me reference this already, in that no single treatment is appropriate for all individuals,
and effective treatment that tends to the multiple needs of the individual, not just
his or her drug use. Then the treatment must address these broader issues.
It reinforces the point that I was asked about Vivitrol. This is based on absolutely hundreds
of millions of dollars of research over the course of 40 years. We have not concluded
these matters lightly or without external scientific evidence.
We get to the next slide about duration of treatment. This is also from the National
Institute on Drug Abuse. Again, the duration depends on the patient, the problem, the needs,
that less than 90 days is of limited or no effectiveness, and a minimum of 12 months
is required for methadone maintenance, and longer treatment is often indicated. There’s
a polling question that’s come up, so I will turn this back over to you, Hanh.
Hanh: All right. Please respond to the statement, “After six months, a parent receiving medication-assisted
treatment for substance dependence should be completely drug-free, including from medication-assisted
treatment medication.” Nancy: While we’re doing that, Mark, let me
just mention that, in fact, one of the questions that came in is that it’s very difficult sometimes
for child welfare practitioners to look at medication-assisted treatment and the, perhaps,
longevity of that in the context of the time requirements that they have in terms of making
decisions about reunification or termination of parental rights. They have time pressures
for making those decisions and a permanent plan for a child in a year.
What sort of things should they be looking for in terms of stability for a parent who
may be on long-term methadone or other medications that perhaps they are appropriate to be on
long-term medication? What kinds of things should they be looking at in terms of stability
that goes along with the use of those medications for making decisions about permanency for
their children? Mark: Certainly, some of the markers or the
indicators of stability is, does the patient appear to be stable? In other words, not in
crisis, that the patient is able, from one day to a next, to demonstrate that they are
taking care of themselves, first and foremost, that they are compliant with the program’s
policies. Which means that the patient should sign a
release or a consent of information so that someone from child welfare can speak directly
with the people responsible for that patient’s care, whether it’s in an OTP, an Opioid Treatment
Program, or a DATA 2000 physician’s practice. From my point of view, that’s an important
communication. The issue of stability or markers, based on
what the patient presents is, if the patient has complied, is the patient participating
in counseling and the program? Is the patient stable, not using or abusing other drugs?
This, by the way, includes marijuana. It includes other drugs of use and abuse.
It goes to the issue of somebody saying, “Well, I have a psychiatric comorbidity. I need an
antidepressant.” Fine. Who is prescribing that antidepressant? Is that treatment coordinated
through the OTP? The other issues of stability is that, obviously,
is the patient…We assume that, and this is from CSAT as well as NIDA, that a patient
is not involved in the criminal justice system, that this individual, if they are taking medications,
are using them as prescribed and they are stable in their care, and that they have a
stable living home environment. Obviously if before you get into reunification
with a child, the patient has to be in a stable living situation. These are basic markers,
and the truth is it will not be materially significant if the patient continues to be
enrolled in a medication-assisted treatment program.
That does not imply any lack of stability. In fact, what the research has shown is that
it supports stability of the patient, and that’s the case given the high relapse rate
for individuals who leave treatment either if they’re discharged, or they voluntarily
discharge themselves. The rate of relapse is very high at about 75 percent. Hanh, do
you want to go through the polling result? Nancy: This is Nancy. Yeah, I think what’s
really important in this slide as well as the other polling questions that we’ve done,
although the vast majority have been in one direction, either disagreeing or strongly
disagreeing, in this example there are some who don’t, who hold an opposing view. I think
that this is what we hear frequently in classes is that there may be some individuals who
don’t see it the same way as perhaps the majority. If an individual family has a case worker
or a judge who feels the opposite, or believes the opposite, in this example a person receiving
medication-assisted treatment after six months that they should be completely drug free.
There’s a small percentage, but if you do the either agree or disagree, about one out
of five are saying that they disagree with that statement, that they should be completely
drug free. We’ve recognized that there’s not only a value
base to these decisions, there’s a scientific basis that education that needs to happen.
If you’re in a jurisdiction that you’re running into these kinds of situations that there
are some individuals who perhaps are in policymaking positions.
We would invite you to contact the national center if we can be helpful to you in ensuring
that the basic information and education that needs to happen around these issues is available
to these people who may hold the view that value-based or a belief that may not be consistent
with the science about treatment for addictive disorders.
Mark: I think this is a fairly important point here. If you ask the question and say, “Would
it be best for a parent who is addicted to opiates, or who has been previously addicted
to opiates, to be completely abstinent from the use of all medications, all, including
methadone, buprenorphine? Isn’t that the best state in some theoretical world?” The answer
could be yes. On the practical side, however, the question
becomes, “Does it necessarily make the parent more responsible, better able to attend to
the needs of the child if they are not using a medication such as methadone, buprenorphine,
or Vivitrol.” The answer to that is no. Forcing the individual patient to discontinue their
drug use based on a theoretical perspective, disconnected from how the patient is doing,
is incorrect. This is not a supposition, this is based on
what we know to be the evidence that says if patients who are chronically opiate addicted
are compelled to leave treatment, either to be reunited with children and family, that
ultimately you risk forcing that person into an eventual relapse. That relapse may not
be seen immediately, it may come in a month or three months, but forcing the individual
to discontinue their treatment ultimately sets that patient and that family up.
Because you’re taking a risk, given what we know about a 75 percent plus relapse, that
that patient is going to be forced into some future relapse based on the elimination of
the medication. You can discuss this in broad philosophical terms, why should that be? Which
is why you saw the prior slides on the neurology, on what Dr. Alan Leshnersaid that addiction
is a brain disease, the NIDA research in support of it. That’s what that scientific underpinning
is all about. Does that provide some clarity? Nancy: It absolutely does, thank you very
much for that. I think Hanh we can move on to the next slide?
Mark: Sure, the next slide basically makes this point which is leaving methadone treatment,
lessons learned, lessons forgotten, lessons ignored. This is from the Mount Sanai School
of Medicine. We finish with the duration of treatment slide, this is the slide that follows
it. This is really the one that makes the point about this, which is by Dr. Stephen
Magura and his associates, it’s the Mount Sanai Journal of Medicine, in January of 2001.
I’ll say to you if you have an interest in accessing this, Hanh and Nancy, I am happy
to get this to you as well. What this study did is look to 30 separate research studies,
which looked at what happened to patients when they were discharged from medication-assisted
treatment. In this case, the opioid treatment programs which principally use methadone.
So Dr. Magura and his associates looked at over 30 studies in this field and concluded
definitively, and I’m quoting from it that “the detrimental consequences of leaving methadone
treatment are dramatically indicated by greatly increased death rates following discharge.”
Ultimately, this recommendation that says, “the patient should withdraw is not based
on what we know to be long-term, clinical evidence.”
That’s generally used to suit the values of individuals who are not as aware of the consequences
of what they’re recommending. We go to the next slide, which is one of the foundations,
and it goes to the issue of stability, and I’ll put this in, it’s the slide about crime
among the patients. This is the purple slide with the reddish and yellow bars to it. This
is not the quote by Vincent Dole, that’s it. That Dr. John Ball completed the study, while
this is dated to 1991, this is as applicable now as it was then, basically, I guess where
the purple bars represent pre-admission crime among the patients. Then the yellow bars represent
crime after the patient has been admitted to treatment.
The hallmark of this treatment almost from the beginning has been the reduction of drug-related
crime as the patient enters and remains in treatment. This has been replicated in many
studies in the United States and throughout the world.
Dr.Ball’s study focused on treatment programs in Baltimore, Philadelphia, and New York.
It is a foundation issue, so what happens when the patient is forced to end treatment?
The reverse applies. You have now then the issue of forcing the patient back out into
using various drugs. By the way, while this was a time when most
of the admissions to OTPs were based on heroin use, clearly we’ve seen a shift, which I’ll
talk about in a subsequent slide on a study that’s been done, which shows that prescription
opioid use, whether it’s oxycodone, hydrocodone products, have now dominated admissions to
treatment programs throughout the country, but most especially in the Southeast and along
the Appalachian Trail. Now we can go to the next slide, which really
makes the point and sets up what we deal with in terms of psychiatric comorbidity. Dr. Dole
was, again, one of the founders of methadone maintenance as a treatment intervention for
opiate addiction, says the problem was one of rehabilitating people with a complicated
mixture of social problems on top of specific medical problems and that practitioners should
tailor in the programs to the kind of problem they were dealing with.
He talks about the strength of the early programs as designed by his wife, Dr. Neiswander, was
the sensitivity to individual problem. The stupidity of thinking that just giving methadone
will solve a complicated problem seems to me beyond comprehension.
That reinforces our discussion about Vivitrol, and about the use of medications, and what
in fact child welfare workers should be looking at as people are in treatment for chronic
opiate addiction. The reason that we’re dealing with a complex problem is also seen in the
next slide, which deals with the lifetime and recent prevalence of psychiatric comorbidity
among methadone maintenance patients. Dr. Ball, again, the study of 1991 is focusing
in his sample among male methadone patients. All you need to do is look at the top two
items, serious depression and serious anxiety. You’ve flipped ahead to the “USA Today” article,
so I would go back to the psychiatric comorbidity, this slide.
I will frankly concede that part of the problem here is that in my judgment, there is not
sufficient recognition of diagnosing and treating the psychiatric comorbidity in this patient
population. We know the serious depression and anxiety.
When people ask, or childcare welfare workers ask, “Why is it that people who are stabilized
on methadone continue to use or abuse other drugs?” Generally it’s because the psychiatric
comorbidity has not been sufficiently diagnosed or treated.
Part of this is that you don’t have psychiatrists at the program site in many OTPs, or there’s
limited referral capability or communication between the OTPs and available psychiatrists
in the community where they’re close enough to the physical space of the OTP, is a significant
issue. This is why we’re dealing with a complex disorder, aside from the issue of hepatitis
C or HIV infection. It’s a significant issue, and one that bears discussing.
Next we go to a series of slides, and now we’re coming to really the end stage of the
presentation. The next slide is showing this “USA Today” article about deadly abuse of
methadone tops other prescription drugs. Clearly, this is a significant issue because
methadone has been used now more widely for treating pain than it is in treating chronic
opiate addiction. As you may recall from the prior slide, the map I showed from CSAT, there
were 285,000 patients in roughly 1,230 OTPs in the country.
When you go to the next slide, which is from the Food and Drug Administration, you will
notice since 2002 the increase in the use of methadone for the treatment of pain. This
is a very significant issue. This is the slide with the purple bars, and it’s the slide after
this “USA Today” article. This FDA slide shows that methadone has been
used to treat chronic pain increasingly from 2002, and this goes to 2009. Are you able
to load up this particular slide? There it is.
You will notice that this is in unique patients in thousands. This means that more than twice
the number of people who are being treated in opioid treatment programs with methadone
are receiving it for pain, and the majority of the physicians prescribing this medication
are family practitioners. We’ve also seen as a result of this prescribing
an increase in methadone mortality, over 5,000 patients per year are assessed to have died
from methadone-related mortality. There have been four published national reports
on this topic. That’s seen in the next slide by the US Department of Justice and the National
Drug Intelligence Center of November of 2007, and the following slide shows the quote “from
1999 to 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. Some deaths result from misuse of legitimately prescribed methadone,
or methadone obtained from the OTPs, including use in combination with other drugs and alcohol.”
I’ll make a point of this. When you have methadone-associated deaths in the OTP setting, usually it’s in
the first two to three weeks of treatment as the patient is being stabilized and is
likely abusing other drugs, most specifically benzodiazepine and alcohol.
This is a particularly lethal combination for patients who are in treatment programs
because methadone is a central nervous system depressant, as are benzodiazepines and certainly
alcohol. That’s where you have mortality generally through the OTP.
When you look at the next slide, which talks about methadone and associated overdose death,
this is the United States General Accountability Office. This is the last published national
report of March 2009. It makes the point in the slide in the quote
that follows, which is the subsequent slide, that most officials from federal and state
agencies, as well as experts in addiction treatment and pain management cited increased
availability of methadone due to the use of pain as a key factor in the rise of deaths.
While some added that addiction treatment was not related to these increased deaths,
and that is the case, and CSAT’s about to release its own report very shortly based
on a large meeting they convened approximately one year ago.
We get now into the last phase of this discussion, which is the result of a study that AATOD
has managed through the auspices of the Denver Health and Hospital Authority. It’s called
the RADARS System. It’s a risk surveillance system, and ATOD
has one of the five signal sites in the system, which involves approximately 75 active OTPs
in the United States. The National Development and Research Institutes, NDRI, is the entity
that analyzes all the data that will follow. We started this in January of 2005, and we
did this because we were becoming more aware that prescription opioid addiction became
a leading cause of patient admissions to OTPs. I’d already referenced this in some of the
Southeastern states, but it’s a significant issue, and these data support this.
The next slide basically shows the primary study aims, which is: determine the lifetime
and current prescription opioid prevalence among OTP enrollees to identify factors associated
with primary prescription opioid abuse, and the source of the prescription opioids. The
next slide shows the prescription opioids that are under study.
This is similar to the previous slide that was shown during Nancy’s presentation at the
beginning of the webinar. There’s a consistency in the medications that we ask patients to
check as they’re being admitted to treatment. The next slide shows, this is a large study
involving over 46,000 patients, and this is just capturing the data from January of ’05
to January of 2011. The subsequent slide really talks about the
characteristics of the patients, being these new OTP enrollees. You’re going to see two
bars here. One has when patients indicate they’re abusing prescription opioids at admission
to treatment, versus they are using heroin. If there are some significant issues to focus
on this particular finding. You will note that for the patients who are primarily using
prescription opioids as they’re admitted, it’s the first time they’re in treatment in
an OTP, versus their counterparts who are using heroin, who’ve previously been treated
in an OTP. When you go down a bit, you will also note
difference that when the patient has ever injected the primary drug, and this was a
surprise to us at the beginning of the study, that 33 percent of the patients who indicate
that they’re abusing prescription opioids inject them. We’re obviously not surprised
to see that 77 percent of people who are using heroin are injecting the drug.
What you’ll also see is a change in the next slide of age distribution. This is also significant.
About 10 years ago, many people in the treatment sector knew that the patient population was
aging, is getting older. Now with prescription opioid abuse and addiction, it’s reversed
itself. Of the 46,000 patients who were in this study since January of 2005, you will
note the significant number of patients in the 18 to 25 age group, or 26 to 29.
You will also notice in the source of primary opioids and prescription opioids, you will
notice this in the next slide, of these 46,000 patients, they can opt to endorse different
responses, so dealers, friends. They have multiple options.
But you will note, and this is consistent with other federal findings in this topic,
that when patients say who do they get their prescription opioids from, the answer is 85
percent get it from a dealer and 53 get it from a friend or relative. Doctor’s prescription
directly to the patient is 29 percent. ER is 13 percent. A myth is that prescription
opioids are purchased through the Internet. That is not the case, and our findings are
consistent with federal agency findings, as well.
What I’d like to do is go to my closing points and then respond to questions that have come
up, or the poll findings that have come up, as well. These closing points are an attempt
to respond to what I perceive as some of the most frequently asked questions in this area.
One is that methadone in a stabilized patient will not cause sedation or prevent the individual
from being a responsible parent. I recognize this runs counter to one of the earlier poll
findings. This is what we know to be the scientific evidence in support of this treatment.
We also know that methadone maintenance treatment and buprenorphine do not have the narcotizing
effects of heroine, and does not trade one addiction for another.
Many times the critics of maintenance pharmacology for opiate dependence addiction take the position,
and they use this in a disparaging sort of way, that giving these medications to treat
chronic opiate addiction is like giving bourbon to someone who is addicted, or alcoholic,
with scotch. The reason that is not true is because these
medications do not create the euphoric effect of heroin, or a number of the prescription
opioids, which are crushed or snorted or injected. This is an important sort of difference to
understand that the medication specifically binds to the neurological sites, and I’ve
talked about the endorphin system in a prior slide. This issue of, “Well, it’s trading
one addiction for another,” does not bear the evidence that we know in science. This
is more of a pejorative opinion. This is a sort of “feeling” opinion, rather than one
that’s based in reality. Methadone is not harmful to the fetus, if
the mother is stable and under the medical care of an OTP. Another critical point, this
is already incorporated in the Treatment Improvement Protocol that I referenced. Again, I suggest
you read Chapter 13, you have that electronically available to you.
I know that in the subsequent webinar you’ll have Dr. Karol Kaltenbach discuss these issues
in much greater detail. She’s certainly one of the nation’s foremost authorities on this
topic, is extremely respected, is not only an expert treatment practitioner, but a fantastic
researcher. She will go into this in greater detail.
This issue, however, that says, “Well, the mom is in treatment of either methadone or
buprenorphine. Let us make sure that that mom gets off treatment before the baby is
delivered.” This is the worst thing you could possibly recommend.
This will put the fetus into great distress, and runs counter to proper established therapeutic
care for the mom, and certainly for the baby. Remember, you’re treating the mom, who is
the patient, and if the mom is stable, the fetus will be stable too.
This idea of saying to a patient, “You’re in your third trimester. Isn’t it better to
be not using methadone?” or prematurely withdraw the patient, this almost always creates a
condition that puts the fetus into acute distress, and could create spontaneous abortion.
The next slide of these closing points, and this is also based on the TIP and the scientific
studies, that methadone has been accepted since the late-1970s to treat opiate addiction
during pregnancy. In 1998, the National Institutes of Health Consensus recommended methadone
maintenance as the standard of care for pregnant women in opiate addiction.
This would equally apply to buprenorphine, and I’ll let Dr. Kaltenbach refer to her recent
study with her associates, which compares methadone to buprenorphine in the neonates,
and the differences in withdrawal systems or length of stay in hospital. That’s more
appropriate, I would suggest, to Dr. Kaltenbach. I’m just planting the seed for those of you
who plan to participate in that webinar as well.
The next of the closing points is that effective medical maintenance treatment with methadone
has the same benefits for pregnant patients as for patients in general. In addition, methadone
substantially reduces fluctuation in the total serum opioid levels, so it protects a fetus
from repeated withdrawal episodes. That is a significant issue about an opiate-addicted
mom who is not in treatment. Whether it’s heroin or prescription opioids, this is the
mom taking these medications when she can get access to them. As a result, the mom is
not stable, there are lots of spikes, instability, neurological activity, and it affects the
mom, and then the baby. Finally, this issue about breast feeding being
safe. Breast feeding is safe for the methadone maintained mom and her baby. It is not something
that should be discouraged, and this is also referenced in Chapter 13 of the TIP that’s
been referenced. The problem here is if the mother has an infectious
disease, such as HIV infection. Hepatitis-C positive women are also able to safely breastfeed,
but they should check with their physicians first. Dr. Karol Kaltenbach, I’m sure, will
go over this. Finally, the recommendation which reinforces
what’s been said along is that representatives should work with OTPs and read the publication
TIP 43, and especially the chapter on treating pregnancy.
The last two slides only talk about where our next conference will be, in April of 2012,
and my contact information, should you have any questions and want to get to me, although
you have now a fair amount of information and reference points.
I know there may be questions, so I will basically conclude my presentation to allow for as much
of an interactive portion as possible in the time remaining for the webinar.
Nancy: Mark, thank you so much. We have had a series of questions around a couple of broad
themes. One of them is around payment for medication-assisted treatment. Now, I recognize
that Medicaid plans vary by state, in terms of what their coverage is for drug treatment,
broadly. But what could you answer about medication-assisted treatment, and particularly opiate treatment
that varies by states under Medicaid? Mark: There are about 47 states and the District
of Columbia, Puerto Rico, and Guam that have access to the use of methadone and buprenorphine
for patients. I’d say there are roughly 15 states that still don’t provide any access
to Medicaid reimbursement. This is a problem that we’ve discussed with
various states, and also with SAMHSA as well. What happens in these states is that the people
that are able to access care, if there is no Medicaid reimbursement, is if either the
City or the County or the State provides funding to the treatment program, and allows indigent
patients to be treated without charge. The second, and far more prevalent, is that
patients are then making out-of-pocket payments for treatment. These out-of-pocket payments
vary, but the standard weekly payment structure is somewhere between $70 and $80 per week.
There are obvious variations in that, but that’s generally what happens to patients
who are accessing care, especially in states where there’s no Medicaid reimbursement.
Generally, priority is given, certainly at the federal level and the Center for Substance
Abuse treatment, priority is given to women in need of access to treatment, and that’s
generally where you see states, cities, or counties providing access to funding, but
that is not always the case. The final point I’d make on this is, in advance
of health care reform, which goes fully implemented in 2014, we however are urging OTPs and states
to engage in the discussion of having Medicaid reimbursement for patients who are eligible
for such care. Nancy: Thanks very much for that. I know that
this is an evolving situation in the era of implementing the Affordable Care Act, so those
of you that may be in state agencies that may be grappling with some of those issues,
how this plays out in your state is certainly a priority to work through, and for this particular
population in Child Welfare, specifically. There are also a few different questions that
came in around dosing, and we hear about this in terms of…We mentioned previously that
we’ve had situations come to our attention that judges may require a particular patient
to reduce their dose, or they want to see a reduced dose before they will reunify of
methadone. Also, questions about are there standards,
or is there a formal dosing guideline that Child Welfare should be aware of? Can you
speak a little bit about how dosing is determined, and how Child Welfare and the family court
should be looking at the doses of methadone or other substances that are being used for
opiate addiction? Mark: Certainly. Again, this is imbedded and
the response is included in the chapters of TIP 43. That’s the federal guidelines, compendium
of recommendations on dosing. The first response to the question is that
the dosage that the patient is on is not a significant issue at all, and it should not
be, as long as the patient is stabilized. You might as well ask the question, “Well,
do you have the use of an antidepressant? What’s the dosage for that antidepressant?
What’s the dosage of the patient using a hypertensive medication?”
In such instances, the dosages are not relevant. The principle question is what is happening
with the patient? Is the patient doing well? Will the patient do better on 60 milligrams
versus 80 milligrams of methadone? The answer is, not necessarily.
If the patient is stable on 80 milligrams, or 120 milligrams, that’s what the patient
needs. Remember, we go back to what Dr. Alan Leshner said in his article, that addiction
is a brain disease, and it’s on top of other obvious social issues, which is where the
counseling comes in. However, if you accept the premise that we
are treating a disease, and we have the medication, or series of medications, which are effective
in treating that disease, what you don’t do is play doctor, judges. Child protection workers
should not be engaged in saying to the individual, “By the way, we think you should be on a lower
dosage.” Based on what? Does that necessarily make
the patient more stable? The answer is, you have the patient in front of you. We frankly
don’t understand the court interventions, when the majority of the individuals in a
court don’t have a medical background. They don’t have the understanding of the pharmacology
of the medication. While it’s safe to conclude that the average
therapeutic daily dose of methadone, let’s say, is somewhere in the range of 80 to 120
milligrams per patient per day, there are lots of variations on that.
The issue of dosage is, is the patient stabilized? Is the patient using other drugs? If a patient
is in a program and is using heroine, almost always the dosage is simply not adequate,
it’s not a therapeutic dosage range, and that’s between the patient and the program.
That’s why the program is supposed to be collecting toxicology reports on the patients, and then
the clinicians are supposed to be using those toxicology report results as a way to guide
therapeutic dosing and decision making. But the bottom line here is that it is unwise
to tinker with the dosage unless you have access to all of the information, which either
the programs do, or the physician prescribing buprenorphine or Vivitrol would do. But this
is issue of, “If you’re on a lesser dose of medication, you are improved,” is not based
on evidence. That is mostly based on an opinion. Does that help clarify?
Nancy: I think so. Thank you. There’s also a couple of questions or statements from practitioners
in a couple of different places that say that frankly the department, meaning Child Welfare
Department, will not support returning a child when the parent is on methadone.
Obviously some of this is basic education that needs to happen, but what advice would
you give to treatment providers that are providing medication-assisted treatment, and they have
this sort of either local or state policy in Child Welfare. How would you advise them
to proceed? Mark: This is an important policy question.
This goes beyond the individual treatment or the pharmacology. You have two parts of
this. One, are the treatment providers providing access to good information to the child healthcare
workers, to the child protective services? But also this is a function of the state governments,
too. In each and every state where opioid treatment exists, you have a single state
alcohol and drug abuse authority. Under their authority, you generally have what are called
SOTAs, and these are the individuals that provide regulatory oversight to the OTPs.
These are the State Opioid Treatment Authorities, SOTAs for short.
In this particular case, when you have policy at the state or county level, what you are
looking for is optimally an integration, so that the alcohol and drug abuse authority,
which has the basic information about the efficacy of treatment, the services that are
provided by the OTPs in their state, that they are informing the policies of child protective
societies, workers, state administrations, which basically support the points that have
been discussed. I’ll step back from this for a moment. The
issue here is driven by practicality, that for policies to work, for parents to be unified
with children, if that’s the ultimate goal of all of this, that you want to be certain
that your policies are working in conjunction with the goals you aspire to attain. You don’t
want to come up with dysfunctional policies, which subvert those very goals.
In this particular case what I have found, in talking with states from one to another
over the course of more than 25 years, is that the states and their policymakers tend
not to be connected to one another. So my basic recommendation is for these states and
counties to really share this information, so that they’re not creating policy in a vacuum.
Nancy: Thank you. That’s very helpful. There were a couple of things that I think I can
answer briefly. A question that came in about which of the states have medical marijuana
laws, and refer you back to the NCSL website that maintains a registry of all of the state
laws, and you can do a search on their website for things that are specific to medical marijuana.
There was also a question that came in related to confidentiality, that the communication
between Child Welfare and the OTPs is limited by 42 CFR. There are a lot of materials on
the National Center’s website, so the website address that you see at the bottom of the
screen, ncsacw.samhsa.gov, related to creating confidentiality agreements.
I think when Mark was asked, “What would you do if you were a child welfare worker about
a particular case?” His first statement was, “I would seek a confidentiality provision,
so that you could discuss the particular family with that particular provider.”
If that isn’t available in your jurisdiction, again I would ask you to get in touch with
us, so we might be able to help with that. If there is a reason that that individual
patient is not willing to sign that confidentiality agreement, sort of delving into more of what
are those clinical issues that are going on, that that communication is not being provided
needs to be addressed in work that the worker could do, without an individual parent.
But there are certainly ways to make that communication happen, and we would invite
you to contact us if there are specific questions about that.
Mark, there’s a question about why those three particular states…The question came in as
why the three states don’t have regulatory oversight of OTPs. I think that might be somewhat
misunderstood in the state having the oversight versus the availability of OTPs in those particular
states. Could you address that, please? Mark: Yes. The state authorities exist, there
is no access to treatment in those states, which means there’s simply no opioid treatment
programs operating in those states at the present time. Why is that? As I understand
it, the states have claimed that there is no need for treatment in those states. I’ve
not spoken with those state directors recently. We do know from the studies we’ve done and
from communication with the OTPs that there are a number of patients who cross state boundaries
to access care. As an example, in the study I referenced earlier there were 46,000 patients
that completed that opioid prescription study. We know that 15 percent of those 46,000 patients
crossed state lines, based on the zip code data that we’ve analyzed from the patients
completing the survey instruments. We assume that a number of people in those states of
North and South Dakota and Wyoming probably are crossing the borders to access care in
the adjacent states. We don’t have a lot of information on it. We know there’s some of
it. Nancy: Thanks. There’s also a couple of questions
about different medications, and are they addictive. It seems to me that we need to
do an explanation of the difference between dependence and addiction. In particular, the
question came in, “Is Suboxone addictive?” That explanation needs to still perhaps be
addressed. Mark: All medications that have either agonist
properties, or partial agonist properties, methadone or buprenorphine are dependency
producing. That’s true. The reason you want to separate this from the term addiction,
is addictive behaviors are either drug-seeking behaviors, they are self-destructive behaviors.
As an example, if you have a person who’s using heroin or prescription opioids, and
they’ve crossed the line, they are addicted to them. They’re engaged in the behaviors,
doctor shopping, or the classic issue of someone let’s say, as an example, a realtor showing
a house, going to the medicine cabinet, and taking drugs from the medicine cabinet, or
people who are out on the street using heroin or other drugs, cocaine.
Addiction is also a matter of behavior. It’s a matter of the drugs they’re using. Dr. Leshner
talked about it and NIDA Publication talked about it, this issue of uncontrollable craving.
Dependence. You are dependent, and this is important [inaudible 01:47:19] to know about
dependents. You take a certain medication or a drug, or alcohol, or coffee, or nicotine.
You stop using it, you’re going to have physical symptoms of withdrawal. You’re going to be
in discomfort. Depending on the length of time you’ve used
the drug or the amount of drug you’ve used, that this continuance of this use of drugs
creates physical withdrawal symptoms. That defines dependence. Without any question,
the use of methadone, the use of buprenorphine are dependency causing drugs.
When you are in a treatment program or you’re under the physicians care and the DATA 2000
practice, it is not proper to reference that patient as being addicted to that drug. They
are dependent on that medication. That is the more accurate, scientific nomenclature
to choose. Nancy: Thanks. Are there medications that
are available for other kinds of addictions for other substances? Would you address what’s
being done with cocaine, marijuana, methamphetamine, in terms of medication?
Mark: Those medications are still in trial. I know that NIDA has funded a number of studies
that have had mixed results. We do not have a comparable medication as an example, to
treat cocaine addiction. We just don’t have that, we haven’t been able to track that yet.
The focus of using medications whether it’s Naltrexone, or Vivitrol for alcohol and chronic
opioid addiction are medications I know that in the future so-called generation of medications
you’re dealing with delivery systems such as implants, like a six-month buprenorphine
implant. These are in early trials of research. The
question always come in, as a repeat, from earlier in the discussion is, “What is provided
in addition to these medications?” But these are primarily the medications that are used
either for treating addiction or alcohol which is approved by the federal government. The
point is there are not many of them, and there is nothing that has been demonstrated to be
effective in treating cocaine addiction at the present time.
Nancy: All right, thank you Mark. Two questions that are somewhat related, and I am mindful
of the time, so we’ll do these quickly, but one is frankly a statement that says, “Are
you suggesting that a person would never withdraw from methadone?” And parallel to that is,
“So when would a person be stable for a child to return home if they are on methadone?”
Mark: The answer to the first question, is that no I am not suggesting that patients,
that all people, will need to be using such medications for the rest of their lives. But,
some will be using their medications for the rest of their lives, and we should not treat
that any differently than the use of medications to treat any chronic, relapsing disorder.
However, I can tell you that, and by inference, if 75 percent of the patients will relapse,
that means 25 percent or so will not relapse as a corollary.
So there are a number of patients who will successfully withdraw from the use of medications,
whether it’s methadone or buprenorphine. Again, it’s related to brain chemistry, it’s a matter
of genetic makeup, and it’s a matter of duration, of pre-treatment opioid addiction, it’s related
to stability, working, family life, connection to the community, general health.So those
are general issues related to will a person be able to discontinue their use of treatment.
Some will, the majority will not. The rule of thumb basically, which most treatment practitioners
know is, withdrawing from the use of a medication is not the critical issue. It’s sustaining
the withdrawal. In other words it’s sustaining being in a so-called completely drug-free
state. The issue of stability of when a family is
reunited when the mom can recover custody of the child, or reunify it’s not going to
be related to the issue of is the person in medication-assisted treatment or the dosage
that they happen to be on, it’s a matter of their general stability.
You arrive at that by obviously meeting with the patient and discussing the case with the
treatment program, once the release of information has been obtained. If the mom is actively
using other drugs and is enrolled in a methadone program, obviously that is not a person who
should be reunited with their children. That’s a fairly straightforward approach.
If the mom is clearly involved with criminal action, or there are behaviors that clearly
indicate that this is not going to be a stable parent, these are different issues, so it
is not related to when is the mom stable. Now, the question becomes if the mom enters
treatment, and is in treatment for one week, does that mean the mom is stable? Almost always
the answer is no. It generally takes several months for stability to be achieved, but this
is also directly related to the individual. Generally, from a pharmacologic perspective,
it’s generally going to take at least one month of continuous treatment for an individual
to become stable from a purely pharmacologic standpoint. It may take longer in certain
patient’s cases. In some cases, they may never achieve that sort of stability. There may
be difficulties that the patient encounters continually.
Nancy: Thanks Mark, very much. There was a final question that I’ll address related to
providing education to judges. At the National Center we are very involved with that effort
both through the National Council of Juvenile and Family Court Judges, if you’re not familiar
with them, they’re a national organization based in Nevada that provides training to
judges. In addition to that, the Children’s Bureau
funds in all of the states a court improvement project that is funded out of the Child Abuse
Prevention and Treatment Act. The court improvement project, or CIP, provides education to judges
in all of the states. If you are not familiar with who runs the
court improvement project in your state, please be in touch with us and we can refer you to
that state director of the CIP, because generally, particularly all of the large states hold
training conferences for judges at least annually. We would encourage you, if you are a treatment
provider that believes that your particular state, that the judges need education about
this, that this is something that would be we’d ask you to reach out to that court improvement
project state director, and get on their agenda, and be able to provide the education in your
own state about the programs that you deliver, and about medication-assisted treatment in
the context of child protection and child welfare services.
If we can be helpful to you in that regard, we again invite you to be in touch with us
about that. Let me just thank Mark one more time for being with us today, I would invite
you to visit his website and also to take a moment to complete the evaluation. When
you close out of the webinar, you’ll be directed to an evaluation. We would appreciate your
feedback. If there are questions that we did not answer
today, please be in touch with us so that we can make sure that, or we can address those
in the webinar that will be held on August 4th, and you’ve heard a bit about that already.
We would encourage you to register for that with Dr. Karol Kaltenbach. With that, let
me ask Hahn and Cathleen, any further details we need to cover?
Hanh: Nope. Cathleen: No.
Nancy: Thank you so much all of you for your participation today, we look forward to hearing
from you in the future. Again, Mark and your organization, thank you for the work that
you’re doing on behalf of families across the country.
Mark: You’re welcome, thanks for the opportunity to participate.
Nancy: All right, bye. Transcription by CastingWords