7/13/2011. Welcome. How Do I Ask Questions? Agenda

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Medication Assisted Treatment

(MAT) Series, Part I of II:

Understanding MAT for Families

Affected by Substance Use

Disorders

4 9 4 0 I r v i n e B l v d . , S u i t e 2 0 2 4 9 4 0 I r v i n e B l v d . , S u i t e 2 0 2 I r v i n e , C A 9 2 6 2 0 I r v i n e , C A 9 2 6 2 0 7 1 4 7 1 4 -- 5 0 55 0 5 -- 3 5 2 53 5 2 5 n c s a c w @ c f f u t u r e s . o r g n c s a c w @ c f f u t u r e s . o r g w w w . n c s a c w . s a m h s a . g o v w w w . n c s a c w . s a m h s a . g o v

Nancy K. Young, Ph.D.

Mark W. Parrino, M.P.A.

Agenda

• Environmental Context

• Medication Assisted Treatment 101

• Considerations for Child Welfare Policy and Practice • Discussion

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A Program of the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment and the Administration on Children, Youth and Families Children’s Bureau Office on Child Abuse and Neglect 5

Let’s Hear About You

Registrants identified as:

• Substance Abuse Treatment Providers (43%)

• Child Welfare (33%)

Other (17%)

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• Other (17%)

• Dependency Court or Family Drug Court (6%)

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Environmental

Context

Nancy K. Young

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From the Field

• Medical marijuana

• Prescription medication misuse and abuse

• MAT for co-occurring mental health disorders

MAT f

b

di

d

• MAT for substance use disorders

State of the Field

• Misunderstanding of the use of MAT, particularly

Methadone treatment, in substance abuse

treatment and how it relates to child safety.

• Requirement of minimal “dosing” of MAT

medications for pregnant women or as a term for

reunification.

• Positive toxicology result for methadone at birth

as a presumptive cause for child removal.

• Use of MAT as exclusionary criteria for child

welfare programs, particularly Family Drug

Courts.

Risks to Children:

Different Situations for Children

• Parent uses or abuses a substance

• Parent is dependent on a substance

• Special considerations when Methamphetamine

production or home manufacturing is involved

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production or home manufacturing is involved

–

Parent involved in a home lab or super lab

• Parent involved in trafficking

• Mother abuses alcohol or uses an illicit

substance while pregnant

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005 11

Different Situations Require

Different Responses

• Each situation poses different risks and requires

different responses

• Child welfare workers, treatment providers and

court professionals need to know the different

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responses required

• The greatest number of children are exposed

through a parent who uses or is dependent on a

drug

Source: Nancy Young, Ph.D., Testimony before the U.S. House of Representatives Government Reform Subcommittee on Criminal Justice, Drug Policy, and Human Resources, July 26, 2005 12

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Medical Marijuana

• Jurisdictions are faced with different legislation

– 15 states and the District of Columbia have laws that permit medical marijuana as a defense

– In most states, individual patients and/or their caregivers can cultivate cannabis for medical purposes

Some states place limits on the types of medical conditions

TEXT PAGE – Some states place limits on the types of medical conditions

eligible for medical marijuana

– Some states allow distribution of marijuana by dispensaries – All states mandate that a physician must recommend the use

of marijuana for medical purposes

• Marijuana is classified as a controlled substance, is widely abused and a major cause of drug dependence in the United States

For more information, including state specific resources:

http://www.ncsl.org/Home/SearchResults/tabid/702/Default.aspx?zoom_query=medical marijuana http://www.whitehousedrugpolicy.gov/drugfact/marijuana/index.html

What the Experts Say

• Continued research is needed on the risk and benefits of smoked marijuana

• Continued research into the physiological (e.g.: appetite stimulant) and psychological (e.g. anxiety reduction, sedation) effects of marijuana necessary

• Short-term use of smoked marijuana (less than 6 months) for patients with debilitating symptoms must meet the following

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patients with debilitating symptoms must meet the following conditions:

– Failure of all approved medications to provide relief – The symptoms can reasonably be expected to be relieved by

rapid-onset cannabinoid drugs

– Such treatment is administered under medical supervision in a manner that allows for treatment effectiveness

– Involves an oversight strategy comparable to an institutional review board process

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American Society of Addiction Medicine:

Recommendations

Physicians who choose to discuss the medical use of cannabis and cannabis-based products with patients should:

• Adhere to the established professional tenets of proper patient care, including:

– History and good faith examination of the patient Development of a treatment plan with objectives

TEXT PAGE – Development of a treatment plan with objectives – Provision of informed consent, including discussion of

risks, side effects and potential benefits – Periodic review of the treatment’s efficacy – Consultation, as necessary

– Proper record keeping that supports the decision to recommend the use of cannabis

American Society of Addiction Medicine. (September 2010). The Role of the Physician in “Medical” Marijuana.

American Society of Addiction Medicine:

Recommendations

• Have a bona fide physician-patient relationships with the

patient, i.e., should have a pre-existing and ongoing relationship with the patient as a treating physician • Ensure that the issuance of “recommendations” is not a

disproportionately large (or even exclusive) aspect of their practice

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• Not issue a recommendation unless the physician has adequate information regarding the composition and dose of the cannabis product

• Have adequate training in identify substance abuse and addiction

American Society of Addiction Medicine. (September 2010). The Role of the Physician in “Medical” Marijuana.

Misuse and Abuse of

Prescription Medications

Medications can be prescribed for the treatment of:

• Pain Management

• Mental Health Disorders

Treatment Admissions Among Females, Percentage Other Opiates* as Primary Substance of Abuse at Admission, by Age Group:

1998 and 2008

*Primary Pain Relievers

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Percentage Females Treatment Admissions for Other Opiates* as Primary Substance of Abuse: States with Highest Percentage: 1998

and 2008 (listed in order by 2008 percentage)

Overall, primary admissions among females for other opiates comprised 1.9 percent of all female admissions in 1998 and 8.2 percent in 2008.

*Primary Pain Relievers

Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present

Medications for the Treatment of

Acute Pain

Narcotic and Opioid Analgesics: Usually used only for acute pain for a short period of time due to addiction potential, except in alleviating chronic pain associated with cancer. Includes:

• Bupreinex • Codeine • Fentanyl TEXT PAGE • Demorol • Morphine • OxyContin • Vicodin

• Suboxone (also used for MAT for opioid of opiate dependence) • Methadone (also used for MAT for opioid of opiate dependence) For a complete listing, see:

US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (2008). Substance Abuse Treatment for

Persons with Co-Occurring Disorders, A Treatment Improvement Protocol, TIP 42.

Co-Occurring Mental Health Disorders

• 50-75% of clients in substance abuse treatment programs had some type of co-occurring mental disorder (usually not severe)

• 20-50% of clients in mental health settings had a co-occurring substance use disorder

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occurring substance use disorder

• Substance use disorders have a complicating presence on the course of treatment for mental illness (e.g. longer time in hospitalization, poorer outcomes – higher rates of HIV infection, relapse, rehopsitalizaton, depression and suicide risk)

US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (2008). Substance Abuse Treatment for Persons with Co-Occurring Disorders, A Treatment Improvement Protocol, TIP 42.

Medications for the Treatment of

Mental Health Disorders

• Antipsychotics/Neuroleptics: Typically used to control

psychotic symptoms (e.g. auditory and visual

hallucinations, out of touch with reality, etc.) associated with schizophrenia, severe depression or bipolar illness. Sometimes also used to treat brief psychotic episodes

d b b t b

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caused by substance abuse.

• Antimanic Medications: Used in the treatment of bipolar (manic-depressive) illness.

• Antidepressants: Usually used for moderate to serious depression. Also Used for milder depressions and some anxiety and obsessive-compulsive disorders.

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Medications for the Treatment of

Mental Health Disorders

• Anti-Anxiety Medications: Used to calm and relax

anxious feelings and remove symptoms associated with generalized anxiety disorder, panic, phobia,

posttraumatic stress disorder, panic, phobia and obsessive compulsive disorders.

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• Stimulant Medications: Used to treat attention deficit/hyperactivity disorder (AD/HD).

• Hypnotics: Used to treat sleep disturbances.

Common Medications Used in the

Treatment of Mental Health Disorders

Classification Medication

Antipsychotic Thorazine, Haldol, Daxolin

Antimanic Risperdal, Sereoquel, Depakote

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Antidepressants Paxil, Zoloft, Celexa Anti-anxiety Xanax, Valium, Stimulants Adderall, Ritalin, Welbutrin Hypnotics Seconal, Ambien

For a complete listing:

MAT for Substance Use Disorders (SUD)

• MAT for SUD offers help in suppressing withdrawal symptoms during detoxification.

• Medically assisted detoxification is not in itself "treatment" it is only the first step in the treatment

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treatment —it is only the first step in the treatment process.

• Patients who go through medically assisted withdrawal but do not receive any further treatment show drug abuse patterns similar to those who were never treated.

National Institute on Drug Abuse (NIDA), 2011)

Medications used in MAT for Substance Use Disorders (SUD)

• Alcohol Dependence*: – Antabuse • Tobacco Dependence: TEXT PAGE – Nicotine Patch – Bupropion – Barenicline

*For a complete listing, see:

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Medications used in MAT for Substance Use Disorders (SUD)

Opiate/Opioid Dependence:

• Opiates: Naturally derived from the opium poppy plant. Includes morphine and codeine.

• Opioids: Synthetically derived to mimic the analgesic or “painkiller” effects of opiates Includes heroin

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or painkiller effects of opiates. Includes heroin, oxycodone and hydrocodone.

• Medications to treat dependence: – Naltroxene

– Buprenerophine (aka Suboxene) – Methadone

Polling Question #1

There is no way a parent who is receiving MAT for

substance dependence can be an effective parent.

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

MAT 101 for the

Treatment of

Opiate

Dependency

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2007 Update: Consistent Rise in Distribution

of Buprenorphine to Pharmacies

40 50 60 0 10 20 30 2003 2004 2005 2006 2007 DEA ARCOS: Suboxone/Subutex, Drug Units to Pharmacies (in Millions, 2007 projected)

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2007 Update: Consistent Rise in

Distribution of Buprenorphine to OTPs

300,000 350,000 400,000 450,000 0 50,000 100,000 150,000 200,000 250,000 2003 2004 2005 2006 2007 DEA ARCOS: Suboxone/Subutex, Drug Units to OTPs ( 2007 projected) 34

Polling Question #2

People who abuse alcohol or drugs have

a disease for which they need

treatment.

Strongly Agree

Agree

Neither Agree or Disagree

Disagree

Strongly Disagree

“Addiction Is a Brain Disease”

Issues In Science and Technology, Spring 2001

Alan I. Leshner Alan I. Leshner

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“A core concept that has been evolving with scientific advances over the past decade is that drug addiction is a brain disease that develops over time as a result of the initially voluntary behavior of using drugs. The consequence is virtually uncontrollable compulsive drug craving, seeking and use that interferes with, if not destroys, an individual’s functioning in the family and in society. This medical condition demands formal y treatment.”

Issues In Science and Technology, Spring 2001

Principles of Drug Addiction Treatment: A Research-Based Guide

National Institute on Drug Abuse National Institutes of Health National Institutes of Health

May 2009

http://www.nida.nih.gov/PODAT/Principles.html

“Addiction affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. Some individuals are more vulnerable than others to becoming addicted, depending on genetic makeup, age of exposure to drugs, other environmental influences and the interplay of all these factors.”

NIDA

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Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs

A Treatment Improvement Protocol TIP 43

U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment 2005

“Discussions about whether addiction is a medical disorder or a moral problem have a long history. For decades, studies have supported the view that opioid addiction is a medical disorder that can be treated effectively with medications administered under conditions consistent with their pharmacological efficacy, when treatment includes comprehensive services, such as psychosocial counseling, treatment for co-occurring disorders, medical services, vocational rehabilitation services and case management services.”

TIP 43

“Dr. Vincent Dole described the medical basis for methadone maintenance as follows: ‘The treatment is corrective, normalizing neurological and endocrinologic processes in patients who endogenous ligand-receptor function has been deranged by a long-term use of powerful narcotic drugs. Why some people who are exposed to narcotics are more susceptible than others to this derangement and whether the long-term addicts can recover normal functions without maintenance therapy are questions for the future. At present, the most that can be said is that there seems to be a specific neurological basis for the compulsive use of heroin by addicts and that methadone taken in optimal doses can correct the disorder.”

TIP 43

Matching Patients to

Individual Needs

No single treatment is appropriate for all individualsNo single treatment is appropriate for all individuals

Effective treatment attends to multiple needs of Effective treatment attends to multiple needs of

individual not just his/her drug use individual not just his/her drug use individual, not just his/her drug use individual, not just his/her drug use

Treatment must address medical, psychological, Treatment must address medical, psychological,

social , vocational and legal problems social , vocational and legal problems

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Polling Question #3

After 6 months, a parent receiving MAT for After 6 months, a parent receiving MAT for substance dependence should be completely drug substance dependence should be completely drug free, including from MAT medications.

free, including from MAT medications.

Strongly AgreeStrongly Agree AA

AgreeAgree

Neither Agree or DisagreeNeither Agree or Disagree

DisagreeDisagree

Strongly DisagreeStrongly Disagree

Duration of Treatment

Depends on patient problems/needsDepends on patient problems/needs

Less than 90 days is of limited/no effectiveness for Less than 90 days is of limited/no effectiveness for

residential/outpatient setting residential/outpatient setting

A minimum of 12 months is required for methadone A minimum of 12 months is required for methadone

maintenance maintenance

Longer treatment is often indicatedLonger treatment is often indicated

Source: National Institute on Drug Abuse (NIDA)

Polling Question #4

In assessing the effects of substance use, the In assessing the effects of substance use, the standard we should use for deciding when to standard we should use for deciding when to remove or reunify children with their parents is remove or reunify children with their parents is whether the parent(s) are fully abstaining from all whether the parent(s) are fully abstaining from all substances including MAT medications

substances including MAT medications substances, including MAT medications. substances, including MAT medications.

Strongly AgreeStrongly Agree

AgreeAgree

Neither Agree or DisagreeNeither Agree or Disagree

DisagreeDisagree

Strongly DisagreeStrongly Disagree

“Leaving Methadone Treatment: Lessons Learned, Lessons Forgotten, Lessons

Ignored”

Mt. Sinai Journal of Medicine

Jan ar 2001 January 2001

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Crime among 491 patients before and

during MMT at 6 programs

Baltimore

Baltimore –

– Philadelphia

Philadelphia –

– New York City

New York City

250 300 y s P e r Y ear 0 50 100 150 200 A B C D E F Before TX During TX

Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

Crime Da

y

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“The problem was one of the rehabilitating people with a very complicated mixture of social problems on top of a specific medical problem, and that (practitioners) ought to tailor their programs to the kind of problem they were dealing with. The strength of the early programs as designed by Marie Nyswander was

p g g y y

in their sensitivity to individual human problems. The stupidity of thinking that just giving methadone will solve a complicated problem seems to me beyond comprehension.”

Vincent P. Dole, M.D., 1989 Source:

Source: Courtwright, et. Al. Addiction Who SurvivedCourtwright, et. Al. Addiction Who Survived

Lifetime and Recent Prevalence of Psychiatric Symptoms Lifetime and Recent Prevalence of Psychiatric Symptoms Among Male Methadone Maintenance Patients

Among Male Methadone Maintenance Patients

Psychiatric Symptoms Psychiatric Symptoms Serious depressions Serious depressions Serious anxiety Serious anxiety Hallucinations Hallucinations

Percent with Symptom Percent with Symptom Lifetime Past 30 days Lifetime Past 30 days

48.3 48.3 16.616.6 51.7 51.7 22.922.9 8.6 8.6 2.32.3 Hallucinations Hallucinations

Difficulty Understanding, concentrating, Difficulty Understanding, concentrating,

remembering remembering

Trouble controlling violent behavior Trouble controlling violent behavior Thoughts of suicide

Thoughts of suicide Suicide attempt Suicide attempt Had one or more symptoms Had one or more symptoms Valid cases Valid cases –– 567567 28.0 28.0 16.616.6 24.9 24.9 7.97.9 15.3 15.3 3.53.5 8.5 8.5 0.40.4 68.4 68.4 35.435.4

Source: Ball and Ross. The Effectiveness of Methadone Maintenance Treatment

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U.S. Department of Justice National Drug Intelligence Center

Methadone Diversion, Abuse and Misuse: Deaths Increasing at Alarming Rate

November 2007 November 2007

“From 1999-2006, the number of methadone related deaths increased significantly. Most deaths are attributed to the abuse of methadone diverted from hospitals, pharmacies, practitioners and pain

management physicians. Some deaths result from misuse of legitimately prescribed from misuse of legitimately prescribed methadone or methadone obtained from narcotic treatment programs, including use in combination with other drugs and/alcohol.”

DOJ

Methadone – Associated Overdose Deaths

Factors Contributing to Increased Deaths and Efforts to Prevent Them

United States Government Accountability Office GAO

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“Most officials from federal and state agencies, as well as experts in addiction treatment and pain management that we spoke with, cited the increased availability of methadone due to its use for pain management as a key factor in the rise in deaths, while some added that addiction treatment in OTPs was not related to addiction treatment in OTPs was not related to increased deaths.”

GAO

Changing Drug Use Patterns Among Patient Admissions to the Methadone

Treatment Programs in the U.S.

American Association for the Treatment of Opioid Dependence, Inc. (AATOD)

National Development & Research Institutes (NDRI)

Study Aims

• Determine lifetime and current

prescription opioid prevalences among

OTP enrollees

• Identify factors associated with primary

i ti

i id b

prescription opioid abuse

• Determine source for prescription opioids

Opioids

• Heroin

• Buprenorphine (e.g., Suboxone, Subutex) • Fentanyl (patch, lozenge, solution) • Hydromorphone (Dilaudid) • Hydrocodone (e.g., Vicodine) • Methadone (diskette/wafer, pills, liquid) • Morphine

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Patient and opioid treatment program (OTP) participation Patient and opioid treatment program (OTP) participation

Data collected January 2005 – January 2011

#

States: 35

OTPs to date:

75 Subjects:

> 46,157

Characteristics among OTP enrollees, by primary drug of Characteristics among OTP enrollees, by primary drug of

choice choice

Rx Opioid Heroin

First OTP episode (%) 70 31*

Chronic Pain (%) 45 32*

Pain a reason for enrolling 33 32

*p<.001 January 1, 2005 – Present g in OTP (%) Withdrawal pain (1-5); Mean 3.91 3.76* Craving (1-5); Mean 4.47 4.29*

Ever injected primary drug (%) 33 77* 2500 3000 3500 4000

Age Distribution

0 500 1000 1500 2000 12-1₇ 18-2₅ 26-2₉ 30-3₄ 35-3₉ 40-4₄ 45-4₉ 50-5₄ 55-5₉ 60-6₄ >65 Age range (years)

13 29 53 85 emergency room doctor's prescription friend or relative dealer

Source of primary RX opioid (%) Source of primary RX opioid (%)

2 3 3 7 0 10 20 30 40 50 60 70 80 90 100 other way forged prescription internet theft

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Closing Points

• Methadone in a stabilized patient will not cause sedation or prevent the individual from being a responsible parent.

• Methadone maintenance treatment and buprenorphine do not have the narcotizing effects of heroin and does not trade one addiction for another.

• Methadone is not harmful to the fetus if the mother is stable and under the medical care of an OTP.

Closing Points

• Methadone has been accepted since the late 1970s to treat opioid addiction during pregnancy. In 1998, a National Institutes of Health consensus panel recommended methadone maintenance as the standard of care for pregnant women with opioid addiction. • Effective medical maintenance treatment with

methadone has the same benefits for pregnant patients as for patients in general. In addition, methadone substantially reduces fluctuations in maternal serum opioid levels, so it protects a fetus from repeated withdrawal episodes

Closing Points

• Breast-feeding is safe unless the mother has an infectious disease, such as HIV. Hepatitis C-positive women are able to safely breastfeed but should check with their physicians first. • CPS representatives should work with OTPs

and read the SAMHSA/CSAT publication TIP #43, “Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs”, especially Chapter 13- Treating Pregnancy.

Considerations for Child Welfare

Policy and Practice

Nancy K. Young

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Child Abuse Prevention and Treatment

Reauthorization Act (CAPTA) of 2010

Ensures that all States have the capacity to provide services and improve child protective service (CPS) systems, including operation of a statewide program that includes policies and procedures to address the needs of substance exposed infants (e.g. Fetal Alcohol Spectrum Di d ) i l di

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Disorder), including:

• Primary care providers are required to notify CPS of instances of substance exposed infants. Notification should not be construed as an automatic finding of child abuse or neglect under Federal law.

• The development of a plan of safe care for the infant.

Child Abuse Prevention and Treatment

Reauthorization Act (CAPTA) of 2010

• Improvement of training protocols for mandated reporters.

• Implementation of procedures for cross-systems collaboration in investigations, interventions and the delivery of services.

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y

Policy and Practice Considerations

• Collaboration with multiple stakeholders –

primary care providers, substance abuse

treatment/ MAT providers and the courts – is

essential.

esse t a

• Cross systems release of information

• Cross systems role clarification

• Clearly written policies and guidelines for clients

• Clearly written policies and guidelines for staff

Thank You!

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• Please register for the second webinar in this

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• Please register for the second webinar in this

series, Medication Assisted Treatment During

Pregnancy, Postnatal and Beyond, on Thursday,

August 04, 2011:

https://www1.gotomeeting.com/register/485348649

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Nancy K. Young, PhD, MSW

Director

National Center on Substance Abuse And Child Welfare, Children and Family Futures

Phone: 1 (866) 493-2758 E il @ ff

Contact Information

Mark W. Parrino, MPA

President American Association for the Treatment of Opioid Dependence, Inc.

Phone: (212) 566-5555 E-mail: mark.parrino@aatod.org

E-mail: ncsacw@cffutures.org

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FOR RESOURCES and MATERIALS FROM THIS WEBINAR

Please visit our websites:

http://www.ncsacw.samhsa.gov/ www.aatod.org