“Medication is not a part of treatment.”
Medication can be an effective part of treatment. Medication is used in the treatment of many diseases,
including addiction.
Medical decisions must be made by trained and certified medical providers.
Decisions about using medications are based on an objective assessment of the individual client’s needs.
“Medicines are drugs, too.”
Drugs are used to get high, but
medications are used to get better.
Medicine (n.) an innovation of the human species which has given us a competitive advantage for thousands of years; innovations in science &
medicine have historically been helpful and progressive.
Methadone used for addiction treatment
is prescribed and dosed in liquid form
Methadone used for pain management
generally is
prescribed in pill form
Take more than intended
Desire/unsuccessful efforts to cut back or quit Time spent using, obtaining or recovering
Craving- brain pushes the person to use, “or else” Failure to fulfill work, school, home obligations
Continued use despite problems (social, psychological, physical) Activities given up- Leads to loss of identity
Use in hazardous situations Tolerance
It is estimated that at least 980,000 people in the United States are currently addicted to heroin and other opioids (such as oxycontin,
• It is estimated that 5,000-10,000 IV drug users die of drug overdoses every year
Methadone is a synthetic agent that works by
"occupying" the brain receptor sites affected by heroin and other opiates. Methadone:
– blocks the euphoric and sedating effects of opiates; – relieves the craving for opiates that is a major factor in
relapse;
– relieves symptoms associated with withdrawal from opiates;
– does not cause euphoria or intoxication itself (with stable dosing), thus allowing a person to work and participate normally in society;
reestablish more normal brain
functioning prevent relapse reduce cravings
The use of medications in combination with behavioral therapies to
The person must learn new ways of coping
and
• Must meet DMHA certification standards
• State Opioid Treatment Authority regulates from DMHA • Comply with state and federal laws
– Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines
– DEA requirements-highly regulates liquid methadone – Indiana Board of Pharmacy
• Accreditation by recognized national body (CARF/Joint Commission)
• Licensing/inspection in accordance with local codes • Indiana Central Registry of Opioid Patoient Enrollment
Registry (ICOPE)
• Medical Director
– Licensed physician in Indiana
– At least 1 year experience as physician in an OTP – Have admitting privileges in at least one local
hospital
– Write and establish that policy and procedures for all medical protocols
– Provide supervision for Nurse Practitioners and all authorized healthcare professionals
• Program Physician (ratio 1:1000)
– Must be a licensed physician in Indiana – Can be the Medical Director
• Nurses ratio (1:200)
– Nurses must have appropriate licenses to perform delegated and assigned nursing functions
• Program Director
– Run day to day operations of the OTP – Supervision of OTP staff
• Clinical Supervisors (ratio 1:10)
– ALL have appropriate credentialing in Indiana • LCSW (Licensed Clinical Social Worker)
• LMHC (Licensed Mental Health Counselor)
• LMFC (Licensed Marriage and Family Therapist)
• Also being added are LCAC and LAC and CADAC 1-4 • OTP Counselors (ratio 1:55)
– ALL have appropriate credentialing in Indiana • LCSW
• LMHC • LMFC
• Some providers do take private insurance • It is a State by State decision to make
reimbursement for medicated assisted
treatment (MATS) funds available through Medicaid
• The State of Indiana at this time does not reimburse for methadone in an OTP
• Examples of States that do reimburse through Medicaid are Maryland, Illinois and Minnesota
• 13 DMHA certified Opioid Treatment Programs
• Certified to provide medication assisted
treatment for addiction to use of opiate drugs (heroin, OxyContin, etc.)
• Opiate Treatment Programs do NOT treat for pain management
• Pain Management does not treat or prescribe for addiction recovery
• Charlestown
– Southern IN Treatment Center
• Gary
– Edgewater**
– Semoran Treatment Center
• Indianapolis
– Midtown**
– Indpls Treatment Center
• Lawrenceburg
– East IN Treatment Center
• Merrillville
– Northwest IN Treatment Center
• Fort Wayne
– Center for Behavioral Health
• Marion
– Premier Care
• Richmond
– Richmond Treatment Center
• Valparaiso
– Porter-Starke Recovery Center**
• South Bend
– Victory Clinical Services
• Evansville
– Evansville Treatment Center
Provide written informed consent to treatment Voluntarily choose treatment
Became addicted at least one year before admission Be addicted to an opiate drug
Opiate Addiction Buprenorphine Maintenance Program Naltrexone (Vivitrol) Program Methadone Maintenance Program
• Time in Tx Requirement
• <90 days 4 hours counseling/month
• 90-180 days 2 hours counseling/month
• 180-365 days 1 hour counseling/month
• Maintenance=help avoid negative consequences of illicit opiate use
• Dosed once daily- slow acting and resists tolerance build up
• <80-100 mg daily
• When properly managed
– Reduce narcotics related deaths – Reduce users' involvement in crime
– Reduce IV Drug Use and risky behaviors – Gain more control of their lives
• Detoxification is associated with:
– high rates of spontaneous abortions
– premature delivery in the third trimester
– Babies exposed to heroin have lower birth weights
• Babies exposed to heroin were more likely to require morphine than those with methadone treated mothers (40% vs. 19%)
• Current recommendations: Treat with
• Current rule requires a drug test upon admission (expected to be illicit)
• A minimum of 8 drug tests per year.
– Patients are expected to test licit
• Test failure requires medical and treatment team review and
– restriction from take home medications until a subsequent drug test is passed.
– Must comply with treatment team clinical requests – A treatment plan will be updated to address the illicit
drug screen
• Privilege earned through clean drug screens • Incentive for “good behavior”
• Provides a continuum of care to:
– Become more independent – Become more responsible
– To take more ownership of life
• Improves compliance, sobriety from other drugs
Exceptions outside of this schedule MUST be requested from SAMHSA and then the State of Indiana
• Old Schedule – 1-90 days=1 – 91-180=2 – 181-270=3 – 271-365=6 – After 1 Year= 14 – After 2 Years= 31 • New 1218 Schedule – 1-90 days=1 – 91-180=2 – 181-270=3 – 271-365=6 – After 1 Year= 6 – After 2 Years= 6
After 1 year anything over seven (7) days of take-home will require an exception request to SAMHSA and then DMHA for review and approval
In CY 2013, there were 1653 take home medication exceptions approved by SAMHSA and DMHA over 13 days.
This represents 10.8% of the patients treated.
• Number of clients with methadone take-home privileges by length of time in treatment
– 0-90 days 360 – 91-180 days 599 – 181-270 days 438 – 271-365 days 1265 – 1 year 1528 – 2 years 661 – >2 years 1102
2
15,242 total patients treated in CY 2013.
0 5 10 15 20 25 30 35 40 45 50 <18 18-24 25-34 35-49 50-59 >60 0 10 20 30 40 50 60 Male Female
0 2000 4000 6000 8000 10000 12000
5 0 5 10 15 20 25 30 <90 days 90
• Close supervision: daily dosing
• reduced mortality - the median death rate of
opiate-dependent individuals in OTP is 30 percent of the rate of those not in OTP
• Enforce therapy
• Take-Home Medication incentives
• Requires a high degree of commitment
– Time – Travel – cost
Provision – effective 7/1/14
– Reporting requirements
• 10/1 – summary of medications dispensed, number of doses, quantities, number of days of supply dispensed, patient demographic information
• Provisions – effective upon rule promulgation
– Reduced take home meds to 7 days and limits exceptions
– Protocols for patient assessment for the appropriate medication – Protocols to ensure patient education regarding maintenance
treatment and side effects of each medication
– Move appropriate patients from methadone to other approved medications
– Report due 4/1 – number of DMHA prior authorizations for take home medications
• Rule amendments have been drafted and is proceeding through the review and approval process.
