Medication-Assisted Treatment

Medication-Assisted Treatment

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  Benjamin Wilbur Assignment– Topic Paper Human Services 183 5/11/2017 Medication-Assisted Treatment Introduction With the “War on Drug” still being waged on our streets everyday, the hope was that fewer people would suffer from addiction. The expectation was that with all the money, man-power and experience of the last 5 decades, things would at least not be getting worse. Unfortunately, the United States has not been a careful student of the problem. It appears collectively we haven't learned much from the past (alcoholism of the 17&1800's, see Appendix), others countries solutions to this same problem (e.g. in the Netherlands and Portugal) or even the solutions that have been shown to work on a small scale right here in the US (harm reduction through needle exchange, naloxone kits for addicts, and medication). As a society we still are working hard to deal with addiction by getting rid of the supply of drugs (see Figure 1.), and punish the addiction out of the addict (see Figure 2.). 1 Figure 1. U.S. Rates of Past Month Drug Use compared to annual spending of Drug Control per 100 people from 1970-2010. (From http://www.mattgroff.com/updating-the-1315-chart/)
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  So clearly throwingmoney at the drug abuse problem like any problem doesn't fix it. The number of people abusing drugs has remained relatively constant despite a 100x increase in spending on drug control (~90% spent on supply reduction). With record number of people enduring the intense trauma of incarceration (more than any other country in the world, 710 per 100K population), strictest sentencing guidelines, and record numbers law enforcement officers, are we at least making things safer? (see Figure 3.) Absolutely not. Rates of property and violent crime have remained basically the same before and after the era of incarceration (1980-present). The “War on Drugs” is intellectually dead. No expert can justify the use of money and manpower used in supply reduction, the police brutality in dealing with “junkies”, or the insanity of incarcerating addicts. Even with the explosion of new scientific information about addiction over the past century, 2 Figure 2. Number of people incarcerated in America from 1920-2013 with several key drug abuse related policy changes noted. (From https://endnewjimcrowde.org/about/)
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  addiction treatment andrates of recovery haven't changed much. So its long past time for some new ideas about addiction. The current model does not explain the illusive problem of addiction or show how recovery is possible for the masses. If the model is broken, how can we fix it? Well that's beyond the scope of this paper. I would like to discuss Medication-Assisted Treatment (MAT) as one of the incremental changes to the culture of addiction treatment that is long overdue. MAT is defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as the use of medications in combination with counseling and behavioral therapies for the treatment of substance use disorders. According to SAMHSA-HRSA Center for Integrated Health Solutions website physicians are being actively sought to join the ranks of health care providers fighting the epidemic of substance abuse (http://www.integration.samhsa.gov/). Center for Integrated Health Solutions promotes the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in behavioral health or primary care provider settings. To say we even need such a Center is to say our system of health care delivery is broken, seriously broken. Hopefully this is 3 Figure 3. Changes in violent and property crime corelated to inmate and total incarcerated population from 1960-2007. (From http://cepr.net/publications/reports/the-high-budgetary-cost-of-incarceration)
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  just the beginningof much larger changes in the structure of how health care and addiction treatment are delivered here in the US. Medication-Assisted Treatment Medications have been found to be effective in easing the detoxification process, reducing drug cravings, reducing the relapse rate and ultimately increasing survival for addicts. Medications have been FDA approved for curbing addictions to tobacco (nicotine), alcohol and opioids. Research is ongoing for some drugs that may help cocaine and amphetamine addicts. Even though these medications have been shown to be safe and effective, some in use for decades in Europe, there use in the U.S. has been slowed by numerous barriers to there adoption. Barriers to Adoption Many states will not pay for the medications. To be readily available for use the medications would need to be on formulary with Medicaid and available through 340B programs that administer community health centers. Even when patients have insurance, many private sector physicians are not using the medications. Treatment programs have been resistant to the use of medication in the treatment of addictions. There may be problems of lack of provider education or acceptance of medications as beneficial for patients with addictions. Treatment programs and health centers may be geographically distant from one another. There may not be any interaction between physicians and treatment programs, let alone networking to provide integrated services. Often physicians in private practice don't have any way to assure that counseling services accompany use of medications in addictions treatment. There are often workforce issues in implementing MAT. There aren't enough physicians and nurses trained in how to provide MAT. Often providers, physicians and treatment programs, don't even accept the “medical model” of addiction thus see no role for medications in treating addiction. Finally, there are significant 4
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  regulatory barriers toMAT. Often the state legislature is not educated about the use of medications in addiction treatment. There may even be statutes on the books blocking such treatment. Certainly there is little will to increase state funding for addiction treatment, especially to increased spending on addiction treatment related to the introduction of medications. Given the patch work of state regulations, Medicaid formularies, outdated attitudes toward using medications to treat addiction MAT 5 Figure 4. State requirements for opioid MAT medications. a. Methadone is only covered by Medicaid in 31 states. b. Buprenorphine has lifetime coverage limits in several states. While this information is not complete (Yellow = unknown) it certainly demonstrates the lack of education regarding maintenance treatment. c. Suboxone prescriptions require a prior authorization in most states. d. Counseling and documentation of counseling are required in most states for Suboxone coverage. (Source: AAAM 2013 Report by ASAM)
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  has an uphillbattle on its hand to find acceptance and adoption. In fact SAMHSA has a implementation checklist that they put together to help anyone in addiction treatment that might want to work to help get these issues addressed and MAT implemented in their state (http://www.integration.samhsa.gov/ clinical-practice/mat/MAT_Implementation_Checklist_FINAL.pdf appended to the end of this paper). As of 2005, methadone treatment was still not available in six states: Idaho, Mississippi, Montana, North Dakota, South Dakota, and Wyoming (SAMHSA TIP-43). I did find information that methadone is only covered by Medicaid in 31 states and Suboxone is covered by Medicaid in all 50 states (Advancing Access to Addiction Medication (AAAM), ASAM Report 2013, https://www.asam.org/ docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final). However, prior authorization and counseling requirements for the Suboxone to actually be covered (see Figures 4). MAT for Nicotine Addiction (Tobacco Use Disorder) Addiction is responsible for more deaths than any other cause (see Table 1). In 2000, tobacco use accounts for the most deaths followed by alcohol use at #3 and illicit drugs at #9. “Cigarette smoking is the chief, single avoidable cause of death in our society and the most important public health issue of 6 Table 1. Actual Causes of Death in the United States in 1990 and 2000. (Source Ali H. Mokdad; James S. Marks; Donna F. Stroup; et al. Actual Causes of Death in the United States, 2000. JAMA. 2004;291(10):1238-1245
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  7 Figure 5. Tobaccolast month use (left) and Tobacco attributable deaths by cause (right). (Sources (left) 2015 National Survey on Drug Use and Health (right) CDC https://www.cdc.gov/tobacco/infographics/health-effects/pdfs/pie-chart-2017.pdf?s_cid=bb-osh- effects-graphic-001) Table 2. Formulary for Nicotine Addiction (Source https://www1.nyc.gov/assets/doh/downloads/pdf/csi/tobacco-med-brief-instructions.pdf)
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  our time,” accordingto the Surgeon General. About 24% of the US population used tobacco last month. That's a staggeringly high figure given the destruction smoking causes. Smoking tobacco contributes to death almost entirely from chronic causes (see Figure 5). Tobacco use leads to death from lung cancer, chronic obstructive pulmonary disease, heart disease, other cancers, strokes and other diseases for a total of about 480,000 people killed each year. Given the annual total deaths, the daily toll is 1315 people each day. There are three basic treatments for nicotine addiction nicotine replacement, varenicline, and bupropion.(see Table 2). All of these treatments have been shown to be more effective than placebo or counseling alone (see Table 3). Bupropion (Zyban) is an antidepressant drug. Bupropion increases levels of dopamine and norepinephrine, brain chemicals that are also boosted by nicotine. Typically, started one week before 8 Table 3. Effectiveness and abstinence rates of individual treatments versus placebo at 6 months postquit (n=83 different studies). (Source Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. CPG Table 6.26 https://www.ncbi.nlm.nih.gov/books/NBK63943/)
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  stopping smoking. Dueto mild stimulant effects, bupropion has the advantage of helping to minimize weight gain after you quit smoking. Common side effects include insomnia, agitation, headache and dry mouth. Patients with a history of seizures or serious head trauma, such as a skull fracture should not take this drug. Varenicline (Chantix) is a medication that acts on the brain's nicotine receptors, decreasing withdrawal symptoms and reducing the feelings of pleasure you get from smoking. Patients should start varenicline at least one week and possible 3 weeks before they stop smoking. Common side effects include nausea, headache, insomnia and vivid dreams. Rarely, varenicline has been associated with serious psychiatric symptoms, such as depressed mood and suicidal thoughts. Both bupropion and varenicline are generally taken for at least 12 weeks to help reduce the chances of relapse in early recovery. MAT for Alcohol Use Disorder In 2015, about 15.7 million people had alcohol use disorder (see Figure 6). Alcohol consumption is the cause of approximately 106000 deaths each year between 2006-2010. These deaths are roughly half 9 Figure 6. Number of People 12 or Older with Past Year Substance Use Disorder 2015 (Source National Survey of Drug Use and Health 2015 )
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  from chronic disease(57221) and half from acute accidental causes (49544) (see Figure 7). The FDA-approved medications for alcohol use disorder are disulfiram, acamprosate and naltrexone (see Table 4). Disulfiram (Antabuse) can help to prevent drinking, although it won't cure alcohol use disorder or remove the compulsion to drink. If a patient drinks alcohol, the drug produces a very unpleasant physical reaction that may include flushing, nausea, vomiting and headaches. Evidence to show that this medication is effective is weak at best if not equivocal (see Table 5). Acamprosate (Campral®) may help you combat alcohol cravings once a patient has stopped drinking. Acamprosate 10 Figure 7. Alcohol-Attributable Deaths per year average in US 2006-2010 broken down by cause. Chronic disease (dark) and acute injury (light), due to any alcohol use for all ages. (Source Centers for Disease Control and Prevention. Alcohol Related Disease Impact (ARDI) application, 2013. Available at www.cdc.gov/ARDI.) Alcoholic liver disease 22549 Cancer 13624 Stroke 8480 Heart Disorder 4468 Other chronic 8100 Other acute 3557 Alcohol poisoning 1647 Fall injuries 7541 Homicide 7756 Suicide 8179 Poisoning (not alcohol) 8404 Car Accidents 12460
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  acts on thegamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems and is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria. Acamprosate has been shown to help dependent drinkers maintain abstinence for several weeks to months, and it may be more effective in patients with severe dependence. Naltrexone (Revia®) blocks opioid receptors that are involved in the rewarding effects of drinking and the craving for alcohol. Naltrexone helps to prevent heavy drinking and reduce the urge to drink. Vivitrol®, the injectable version of naltrexone, is administered once a month by a health care professional. The injectable 11 Table 4. Formulary for Alcohol Use Disorder (Source Helping patients who drink too much. A Clinician's Guide 2005 p. 16 NIAAA https://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/guide.pdf)
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  12 Table 5: Summaryof Findings and Strength of Evidence from trials assessing efficacy of FDA- Approved medications for alcohol use disorders. (Source Pharmacotherapy for Adults With Alcohol Use Disorders in Outpatient SettingsA Systematic Review and Meta-analysis. JAMA. 2014;311(18):1889-1900. doi:10.1001/jama.2014.3628)
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  version of thedrug may be easier for people recovering from alcohol use disorder to use consistently. Unlike disulfiram, naltrexone and acamprosate do not cause any physical reaction if alcohol is ingested. There is only sufficient evidence to recommend acamprosate and oral naltrexone 50 mg daily. And that evidence is only modest. While a number of behavioral treatments have been shown to be effective in the treatment of alcohol addiction, it does not appear that an additive effect exists between behavioral treatments and pharmacotherapy. Studies have shown that just getting help is one of the most important factors in treating alcohol addiction; the precise type of treatment received is not as important. MAT for Opioid Use Disorder There is a rapidly escalating crisis of drug overdose deaths. The latest available number show that in 2015 the number of deaths exceeded the height of the HIV/AIDS epidemic in 1995 (see Figure 8). MAT for opioid users is broadly supported with significant supporters including SAMSHA, NIDA, 13 Figure 8. Deaths from Drug Overdoses, Guns, Car Accidents, and HIV/AIDS in the US from 1980-2015 (Source CDC Wonder database queries) 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 0 10000 20000 30000 40000 50000 60000 Drug Overdose Guns Car Accidents HIV/AIDS
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  White House Officeof National Drug Control Policy, NIH, Depart of Health and Human Services, and numerous state governments. With good reason given that, 1) opioid users overdose 2x more frequently when in abstinence only compared to medication assisted treatments, and 2) 70-90% of individuals relapse in abstinence only treatment. Effective treatment of OUD has been identified as a national priority to reduce the rates and societal costs of individual disability associated with OUD, the infectious disease burden associated with intravenous opioid use (especially hepatitis C [HCV] and HIV transmission), and escalating rates of accidental opioid overdose deaths and pediatric opioid ingestions. Three medications are FDA-approved for the treatment of opioid use disorders, methadone, buprenorphine with/without naloxone and naltrexone. Methadone is a long-acting synthetic opioid agonist medication that can prevent withdrawal symptoms and reduce craving in opioid-addicted 14 Table 6: Comparison of medications for opioid use disorders. (Source Connery, HS. Medication- Assisted Treatment of Opioid Use Disorder: Review of the Evidence and Future Directions. Harvard Review of Psychiatry 23(2) 2015)
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  individuals. It canalso block the effects of illicit opioids. It has a long history of use in treatment of opioid dependence in adults and is taken orally. Methadone maintenance treatment is available in all but three States through specially licensed opioid treatment programs or methadone maintenance programs. Research has shown that methadone maintenance is more effective when it includes individual and/or group counseling, with even better outcomes when patients are provided with, or referred to, other needed medical/psychiatric, psychological, and social services (e.g., employment or family services). Buprenorphine is a synthetic opioid medication that acts as a partial agonist at opioid 15 Table 7. Formulary for Opioid Use Disorder (Source Connery, HS. Medication-Assisted Treatment of Opioid Use Disorder: Review of the Evidence and Future Directions. Harvard Review of Psychiatry 23(2) 2015)
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  receptors—it does notproduce the euphoria and sedation caused by heroin or other opioids but is able to reduce or eliminate withdrawal symptoms associated with opioid dependence and carries a low risk of overdose. Buprenorphine treatment for detoxification and/or maintenance can be provided in office- based settings by qualified physicians who have received a waiver from the Drug Enforcement Administration (DEA), allowing them to prescribe it. The availability of office-based treatment for opioid addiction is a cost-effective approach that increases the reach of MAT and the options available to patients. The evidence from several randomized controlled trials shows that both buprenorphine/naloxone and methadone are significantly more effective at maintaining opioid abstinence than naltrexone or placebo. (See Table 8.) Relapse rates for patients on placebo only treatments ranged from 70-94%. Conclusions Medication-assisted treatment is not widely available for numerous reasons including a lack of trained providers, numerous regulatory blocks and an attitude of mistrust and opposition among addiction 16 Table 8. Efficacy of medications for opioid disorder compared to placebo. (Source Connery, HS. Medication-Assisted Treatment of Opioid Use Disorder: Review of the Evidence and Future Directions. Harvard Review of Psychiatry 23(2) 2015)
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  treatment professional. FDA-approvedmedications are available for nicotine, alcohol and opioid addictions. These medications effectively reduce cravings and relapse. The number of lives lost each year to these addictions make MAT and any other effective technique for controlling this epidemic demand our full attention. 17
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  Appendix The rates ofalcohol use in America have varied widely. However, even with Prohibition the rate hasn't varied as much as it did with the Temperance Movement. During the Temperance Movement (especially 1830-50) colonial rates of heavy consumption finally decreased. Thanks largely to the lead from the pulpit, some 6,000 local temperance groups in many states were up and running by the 1830s. The movement existed in a matrix of unrest and intellectual ferment in which such other social ills as slavery, neglect and ill-treatment of marginalized people, were addressed by liberals and conservatives alike. Sometimes called the First Reform Era, running through the 1830s and '40s, it was a period of inclusive humanitarian reform. (From http://www.u-s-history.com/pages/h1054.html) The three largest movements for reform were temperance/abstinence from alcohol, abolition of slavery, and the women's rights movement. So what did the First Reform Era do right that we can't seem to replicate now for all our efforts (money, incarceration)? 18 Figure 9. In the United States the per capita consumption of pure alcohol at present is 2.2 gallons but as this chart shows, the rate has varied wildly with the rise and fall of prohibition movements, health concerns, and availability of a good water supply. Adapted from David F. Musto's Alcohol in American History, Scientific American, April 1996. (From http://www.theathlete.org/drug- abuse/epidemiology_alcohol.htm, also http://www.fourpoundsflour.com/tomorrow-drinking-like-a- colonial-american/)
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  19 Figure 10 Drugoverdose death rate by state, age-adjusted. 2015 (Source CDC https://www.cdc.gov/drugoverdose/data/statedeaths.html) Figure 11: Buperinorphine treatment capacity per 100K population by state as of 2017. (Source SAMHSA)
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  I constructed amap of the U.S. showing how many law enforcement organizations in each state have started carrying Narcan while on duty (see Figure 12). 20 Figure 12. Number of Law Enforcement organizations per state that carry Narcan, the opioid overdose reversal drug. Pennsylvanian is the national leader with 595, many states in white still don't have a single department carrying this life saver. (Data from North Carolina Harm Reduction Coalition, current as of 5/2017)