AT Forum NEWS NOTES & UPDATES #138

February 2010

Compiled & Edited by Sue Emerson - Publisher

Prior Edition: December 2009 / January 2010

List of all News/Updates

 

Contents

METHADONE & MEDICATION-ASSISTED TREATMENT

Risk Management & Patient Safety in Outpatient Methadone Treatment Conference Now Available for Viewing on the Web

PCSSmentor.org Issues Guidelines on Methadone Induction Dosing

Methadone and Other Opioids Not Always Equivalent, Conversion Can Be Lethal

Kentucky Opiate Replacement Treatment Outcome Study (KORTOS): Summary of Results

Diverted Methadone and Buprenorphine Primarily Used to Prevent Withdrawal or to Stop Using Heroin

Adults with Prescription-Opioid Dependence Engage in High Rates of HIV Risk Behaviors

SAMHSA Issues 2008 N-SSATS Report on Substance Abuse Treatment Facilities

GOVERNMENT

Obama Proposes Increased Funding for Treatment and Prevention, but 'Balance' Proves Elusive Goal

ONDCP Introduces New Newsletter

New Recovery Month Resources

MISCELLANEOUS

DSM-V Draft Includes Major Changes to Addictive Disease Classifications

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METHADONE & MEDICATION-ASSISTED TREATMENT (MAT)

Risk Management & Patient Safety in Outpatient Methadone Treatment Conference Now Available for Viewing on the Web

Last October, the Institute for Research, Education, and Training in Addictions (IRETA) and the Northeast Addiction Technology Transfer Center (ATTC) sponsored a one day conference in Chicago on risk management and patient safety in methadone maintenance treatment.

The conference, Effective Strategies in Outpatient Methadone Treatment - Clinical Guidelines and Liability Prevention, included the following presentations that are now available for viewing on the web at no charge.

• Welcome and Opening Remarks
• What's Going On Out There?
• Managing Risk: Basic Definitions, Guiding Principles, and the Relationship Between Risk and Practice in Treatment Today
• Risk Management, Patient Safety and Best Practices
• Tasks for the Profession
• Impairment and Discussion Session

To view the conference presentations register at:
http://ireta.org/workshopOnDemand.html

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PCSSmentor.org Issues Guidelines on Methadone Induction Dosing

On February 20, the Physicians Clinical Support System for methadone (PCSS-M) issued guidelines on methadone induction dosing. PCSS-M is a support system to connect prescribers of methadone with experienced clinicians for one-to-one mentoring regarding the use of this medication. PCSS-M is coordinated by the American Society of Addiction Medicine (ASAM) in conjunction with other leading medical societies, and is made possible by support from the Center for Substance Abuse Treatment (CSAT), and the Substance Abuse and Mental Health Services Administration (SAMHSA).

PCSS-M methadone induction dosing guidelines include:

• Initial daily dose choice:
  •  For highly tolerant person in withdrawal: 30mg (an additional 10 mg dose can be given on day 1 if physician documents in the medical record that 30 mg was insufficient to suppress opioid withdrawal within 2 to 4 hours after the initial dose).
  •  For low tolerant person in withdrawal: 10-15mg.
  •  For persons not in severe withdrawal, regardless of estimated tolerance level, the dose is often kept low on the first day, in the 10-15mg range.
• Early dose adjustments (first week or 10 days):
  •  If comfortable at peak, maintain dose for 5-7 days and re-evaluate.
  •  If in withdrawal at peak, increase dose 5-10 mg, and evaluate at peak daily, or maintain new dose 5-7 days and re-evaluate.
  •  If sedated or intoxicated at peak, reduce next day dose 5-10mg and evaluate daily at peak for continued or increased intoxication.

The guidelines can be accessed at:
http://www.pcssmethadone.org/pcss/documents2/PCSSM_OpioidTxProgramMethadoneInductionDosing_020910.pdf

Source: PCSSmentor.org — February 10, 2010

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Methadone and Other Opioids Not Always Equivalent, Conversion Can Be Lethal

In a comprehensive literature review of poisoning deaths involving opioids from 1999 - 2009, the deaths involving methadone were found to be disproportionately high. Methadone represented less than five percent of all opioid prescriptions but is responsible for a third of the deaths. After four years of investigation, the major underlying cause was found to be fundamental misunderstandings about the properties of the medicine — a "knowledge deficit" — especially when converting patients from other opioids.

After a rapid increase of opioid-related deaths was reported in Utah, then president of the Utah Academy of Pain Medicine, Dr. Lynn Webster decided to find out why, and then find a solution. By reviewing state and federal sources as well as PubMed, he was able to assess demographics, prevalence, and other risk factors related to this significant increase in poisoning deaths involving opioids. Webster found that methadone deaths had more to do with misunderstandings about when to prescribe it, how to convert patients to it from other pain medicines, and how to inform patients about its risks. The research also showed that one-third of the deaths occurred within five days after a dosage change — also suggesting that unfamiliarity with the medicine could lead to accidental deaths.

Webster then brought this information to a consensus conference sponsored by the LifeSource Foundation where a panel of colleagues helped him determine root causes of the problem. After reviewing and discussing the data, the panel identified the following as probable causes underlying the spike: physician error due to knowledge deficits, patient non-adherence to medication regimen, unanticipated medical and psychiatric co-morbidities (including substance abuse), and payer policies that mandate methadone as a first-line coverage.

"Not all pain medicines — even within a class — and not all patients — are created equally," said Dr. Webster. "Methadone is a safe and effective opioid with pharmacokinetics and pharmacodynamics unlike other opioids, so knowledge about it and how it may affect a specific patient is paramount to a positive clinical outcome. Education about pain medicine is the best safeguard against the unintended deaths and side effects we've seen with methadone in the last decade."

According to Webster, simple conversion from one opioid twice a day to another twice a day is not safe. Patient pharmacogenetics (a patient's unique response to medicine based on his or her genetics), especially when converting between opioids, along with the properties of the medicine, must be taken under advisement to determine appropriate therapy. In addition, he advises that switching a patient to methadone must be done slowly and over time: start with a low dose, and titrate from there in increments that make sense for the patient and the pain condition.

Source: PRNewswire.com — February 4, 2010

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Kentucky Opiate Replacement Treatment Outcome Study (KORTOS): Summary of Results

The KORTOS project collects data on patients in Kentucky who are active participants in medication-assisted treatment (MAT) in opioid treatment programs (OTPs). The overall goal of the KORTOS project is to examine the social functioning of patients who are participating in maintenance treatment.

The following data is based on 191 patients who completed both an intake and a follow-up interview between March 1, 2007 and December 30, 2009.

The initial outcomes report for the first sample of follow-up interviews indicates positive shifts occurring for patients in MAT in the areas of legal involvement, substance abuse, and participation in recovery support groups.

Outcome Category	% at Intake	% at Follow-up
Legal Involvement
Arrested on any charge	41.4%	9.4%
Spent one or more nights in jail	12.0%	6.3%
Currently on probation	7.9%	9.4%
Currently on parole	1.6%	1.0%
Substance Abuse
Alcohol	58.6%	18.3%
Cocaine	36.1%	7.9%
Marijuana	49.7%	14.1%
Heroin	18.3%	5.2%
Prescription opioids	95.8%	27.2%
Methadone without a prescription	57.6%	8.4%
Stimulants	19.4%	3.7%
Used more than one substance per day (excluding tobacco)	79.1%	12.0%
Recovery Support in Past 30 Days
Attended AA/NA/MA or other self-help group meetings	20.4%	35.6%

 

OTP patient employment patterns and education levels were stable between intake and follow-up.

 

Outcome Category	% at Intake	% at Follow-up
Employment Pattern
Employed full or part-time	73.8%	68.1%
Unemployed	26.2%	31.9%
Highest Completed Education Level
Less than 12th grade	18.8%	14.7%
HS grad or GED	38.7%	37.7%
Post-secondary education	42.4%	47.6%

 

The authors of the KORTOS Study report Erin Stevenson and Robert Walker concluded "the initial findings from the KORTOS project indicate positive changes for clients in long-term medication assisted treatment. Decreased substance use, fewer arrests, less time spent in jail, stable employment patterns, increased educational attainment, and increased use of social supports all point towards effective recovery being made by clients in Kentucky?s medication-assisted treatment data. These initial findings support the positive effects that medication assisted treatment have for clients, their families, and society as a whole."

Source: University of Kentucky CDAR on behalf of the Kentucky Division of Behavioral Health — January 21, 2010

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Diverted Methadone and Buprenorphine Primarily Used to Prevent Withdrawal or to Stop Using Heroin

Opioid agonist treatment (OAT) with methadone or buprenorphine is effective for reducing illicit drug use among opioid-dependent patients. However, the diversion of these agents may be harmful. As part of a larger longitudinal study conducted in Baltimore, MD, between 2004 and 2007, a subsample of the original 515 opioid-dependent subjects, most of whom were seeking methadone treatment, were recruited to undergo in-depth interviews regarding their use of diverted methadone or buprenorphine.

• Twenty-two people (24% of the subjects interviewed) reported using diverted methadone or buprenorphine. Of these, 17 used methadone only, 4 used methadone and buprenorphine, and 1 used buprenorphine only.
• Those who used diverted methadone were more likely to have been enrolled in OAT in the past and were less likely to have used heroin or cocaine in the past month.
• Most of the diverted methadone used was in liquid form. Only 2 people had taken the pill form.
• All but 1 subject used the diverted medication to prevent withdrawal symptoms or to stop using heroin, and all generally took modest doses (about 30-40 mg per day of methadone and 4 mg per day of buprenorphine).

Comments: Although this was a small sample of an opioid-dependent population in 1 locale, it is reassuring that diverted methadone and buprenorphine was primarily taken to reduce heroin use, and that modest doses were used. However, this study does not allay concern about the potential dangers of these drugs among the less experienced people who use them.

Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue November/December 2009. Access checked 2/10/10. Darius A. Rastegar, MD

Original Source: Mitchell SG, Kelly SM, Brown BS, et al. Uses of diverted methadone and buprenorphine by opioid-addicted individuals in Baltimore, Maryland. Am J Addict. 2009;18(5):346-355

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Adults with Prescription-Opioid Dependence Engage in High Rates of HIV Risk Behaviors

Heroin users, particularly those who engage in injection drug use (IDU), are well known to be at increased risk for HIV infection. Less is known about the risk behaviors of those who abuse prescription opioids. Researchers compared data on HIV risk behaviors obtained via interview from persons seeking detoxification treatment for heroin (n=27) or oxycodone (n=23) dependence at an inpatient psychiatric hospital. Demographic characteristics were similar between groups.

• Patients who used oxycodone reported more days of use in the past 30 days than patients who used heroin and were more likely to report marijuana use (13% versus 2%).
• None of the patients using oxycodone engaged in IDU, while 89% of the patients using heroin did.
• Past-month rates of sexual activity (68%), unprotected intercourse (47%), sex while intoxicated (51%), and sex with strangers (18%) were similar between groups; however, patients who used oxycodone were more likely to report having multiple partners (30% versus 4%).
• Patients who used oxycodone were also less likely to report having an HIV test in the past year (33% versus 71%).

Comments: Although this study looked at a small number of subjects at a single institution, the findings suggest that prescription-opioid-dependent adults engage in risky sexual behaviors at rates comparable to, if not higher than, their heroin-dependent counterparts. It also suggests that more needs to be done to screen these individuals for HIV infection and counsel them regarding their risk.

Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue November/December 2009. Access checked 2/10/10. Darius A. Rastegar, MD

Original Source: Meade CS, McDonald LJ, Weiss RD. HIV risk behavior in opioid dependent adults seeking detoxification treatment: an exploratory comparison of heroin and oxycodone users. Am J Addict. 2009;18(4):289-293.

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SAMHSA Issues 2008 N-SSATS Report on Substance Abuse Treatment Facilities

The Substance Abuse and Mental Health Services Administration (SAMHSA) has released findings from the 2008 National Survey of Substance Abuse Treatment Services (N-SSATS), an annual census of substance abuse treatment facilities that provides data on the location and characteristics of alcohol and drug abuse treatment services throughout the US.

The report?s findings include:

• Approximately 13,688 facilities participated in the survey, reporting more than 1.2 million patients in treatment on March 31, 2008.
• In 2008, 1,132 facilities operated opioid treatment programs (OTPs) certified by SAMHSA which is consistent to the 1,108 OTPs in 2007.
• A total of 268,071 patients received methadone treatment in 2008, compared to 262,684 patients in 2007. Only 4,280 patients received buprenorphine treatment in OTPs during the study period.
• Half (49 percent) of OTPs were operated by private for-profit organizations.
• Two-thirds (65 percent) of OTPs were accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) and one-third (33 percent) were accredited by The Joint Commission.
• The vast majority of OTPs were located in metropolitan areas, with 45 percent in a large central metropolitan area, 16 percent in a large fringe metropolitan area and 32 percent in a small metropolitan area.
• Half (50 percent) of OTPs accepted private health insurance, almost two-thirds (64%) accepted Medicaid, and 30 percent accepted Medicare. One-third (34%) offered free treatment for patients who could not afford to pay. Half (51 percent) of the surveyed OTPs offered a sliding fee scale.

The 230 page report can be accessed at:
http://atforum.com/addiction-resources/documents/nssats2k8.pdf

Source: The Substance Abuse and Mental Health Services Administration — January 20, 2009

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GOVERNMENT

Obama Proposes Increased Funding for Treatment and Prevention, but 'Balance' Proves Elusive Goal

The following provides highlights of a news feature article written by Bob Curly from JoinTogether.org.

The Obama administration's first stab at crafting its own national drug-control budget priorities (PDF) adds new funding for addiction treatment and prevention, but does little to close the huge gap between spending on drug supply- and demand-reduction efforts despite promises of a "balanced" strategy.

The FY2011 National Drug Control Budget released by the Office of National Drug Control Policy (ONDCP) on Feb. 1 includes a 13.4 percent increase in spending on alcohol and other drug prevention programs and a 3.7 percent increase for addiction treatment.

"The new budget proposal demonstrates the Obama administration's commitment to a balanced and comprehensive drug strategy," said ONDCP Director Gil Kerlikowske. "In a time of tight budgets and fiscal restraint, these new investments are targeted at reducing Americans' drug use and the substantial costs associated with the health and social consequences of drug abuse."

"We usually have to go to Capitol Hill to dig ourselves out of the cellar, but this year's that's not the case," said Rob Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD). "Some will look at the [increases] and say they're marginal, but looking at the history it's a darn good start."

However, the budget plan also calls for modest increases in spending on domestic law enforcement, interdiction, and international programs. So, the bottom line is that the Obama administration is proposing to spend 64 percent of its anti-drug budget on supply reduction efforts and just 36 percent on demand-reduction programs like drug treatment and prevention -- numbers that are virtually indistinguishable from the ratio in the final drug budget produced under the Bush administration.

"I was hoping for large cuts on the supply side, especially after the previous administration allocated at least $1 billion more each to interdiction and source-country programs that accomplished absolutely nothing," said drug budget and policy expert John Carnevale. "This nation must stop blaming source countries for our problems and face the fact that we can do more to reduce drug use by focusing on treatment, prevention, and diversion programs."

Incremental 'Change You Can Believe In'

Carnevale and others thought that Kerlikowske might define 'balance' by moving to equalize spending on the demand and supply sides of the budget, perhaps by shifting funds from overseas programs to domestic treatment and prevention services. The 2011 plan contains no such revolutionary proposals, however.

Kerlikowske said effective drug policy "does not call for an all-or-nothing, false choice between demand reduction and supply reduction. Instead, it must be a balanced, evidence-based approach that blends the benefits of effective demand reduction with effective supply reduction," he said.

Arthur Dean, chairman and CEO of Community Anti-Drug Coalitions of America (CADCA), said that expectations of radical change should be tempered by the fact that this was Kerlikowske's first crack at crafting a drug strategy. "I hope that they are committed to making some significant changes," said Dean while acknowledging, "Change has been slow so far."

$100 Million More for Treatment, But No New Funds for Block Grant

About $100 million in new funding for treatment programs within the Substance Abuse and Mental Health Services Administration (SAMHSA) would be spread over a variety of programs, notably the Second Chance Act, which would receive $20 million more to provide community-based treatment services to ex-offenders.

Also receiving new funds are programs to add new addiction counselors to federal health systems, increase the use of Screening, Brief Intervention and Referral to Treatment, the Access to Recovery program ($9.9-million budget increase), and $10 million more for drug courts.

None of the new money would go to the keystone, $1.779-billion Substance Abuse Prevention and Treatment Block Grant, however. Also level-funded for FY2010 would be the $30-million Residential Substance Abuse Treatment (RSAT) program, which provides services inside correctional facilities. "It would be nice to see increases, but we're always glad when we don't see cuts," said Morrison, who nonetheless said NASADAD would urge lawmakers in Congress to increase block grant funding.

The full feature article can be accessed at:
http://www.jointogether.org/news/features/2010/obama-proposes-increased.html

Source: JoinTogether.org — News Feature by Bob Curley - February 5, 2010

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ONDCP Introduces New Newsletter

ONDCP Update, is a new monthly newsletter of the Office of National Drug Control Policy (ONDCP). The newsletter will be published monthly by ONDCP?s Office of Public Affairs and Office of Intergovernmental and Public Liaison, a new component dedicated to building partnerships with state, local and tribal government leaders, law enforcement officials, substance abuse professionals, and state and national organizations. The newsletter is free and distributed via e-mail, as well as posted online at www.ONDCP.gov.

The goal of the newsletter is to keep readers informed about ONDCP?s effort to reduce substance abuse, help those recovering from addiction, and disrupt the illegal drug trade. The January debut issue presents articles on the 2010 Drug Control Strategy, a letter from the Director, the vital role of recovery, good news and troubling trends and drug-impaired drivers which can be accessed at: http://www.whitehousedrugpolicy.gov/update/update-jan2010.pdf

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New Recovery Month Resources

2010 Webinar Series

RecoveryMonth.gov has posted their 2010 schedule for monthly webinars on alcohol and drug addiction including the following:

• March - Homelessness and Substance Use Disorder Treatment: Recovery-Oriented Housing and Achieving Healthy Lifestyles
• April - Ignoring Instructions: The Importance of Using Prescription and Over-the-Counter Medications Properly
• May - Maintaining Resiliency and Sustaining Recovery: Ensuring That Recovery Lasts a Lifetime
• June - Recovery at Any Age: Young People Can and Do Recover
• July - Recovery and the Media: Addiction and Treatment in Entertainment and News
• August - Embracing Diversity: Crossing Barriers To Deliver Treatment to Everyone
• September - Language Matters: Talking About Addiction and Recovery

For more information visit: http://www.recoverymonth.gov/Multimedia/Road-to-Recovery-Television-Series.aspx

New Online Media Newsletter

Once a month Recovery Month will distribute a new online media e-newsletter that provides tips for leveraging new online media tools and platforms for promoting work and activities in addiction treatment. The newsletter will also be posted on the Recovery Month website. It will include information on new tools, tactics to reach new audiences, tips on how to effectively engage audiences online, and other information that will help readers delve into this new and ever-changing landscape.

The February issue of the newsletter can be accessed at:
http://www.recoverymonth.gov/Resources-Catalog/2010/Newsletter/February-Newsletter.aspx

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MISCELLANEOUS

DSM-V Draft Includes Major Changes to Addictive Disease Classifications

The first draft of the American Psychiatric Association's (APA) latest Diagnostic and Statistical Manual of Mental Disorders (DSM-V) eliminates the disease categories for substance abuse and dependence and replaces it with a new "addictions and related disorders" — just one of several major changes to the "Bible" used almost universally to diagnose (and get insurance reimbursement for) behavioral-health problems.

"Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system," the APA explained in a Feb. 10 press release.

"The term dependence is misleading, because people confuse it with addiction, when in fact the tolerance and withdrawal patients experience are very normal responses to prescribed medications that affect the central nervous system," said Charles O'Brien, M.D., Ph.D., chair of the APA's DSM Substance-Related Disorders Work Group. "On the other hand, addiction is compulsive drug- seeking behavior which is quite different. We hope that this new classification will help end this wide-spread misunderstanding."

The new category for addictive diseases would include a variety of "substance-use disorders" broken down by drug type, such as "cannabis-use disorder" and "alcohol-use disorder." Diagnostic criteria for these disorders in DSM-V would remain "very similar" to those found in the current DSM-IV, according to APA. However, the symptom of "drug craving" would be added to the criteria, while a symptom that referred to "problems with law enforcement" would be eliminated "because of cultural considerations that make the criteria difficult to apply internationally," APA said.

Also new to the DSM-V are diagnostic criteria for "cannabis withdrawal," which the APA says is caused by "cessation of cannabis use that has been heavy and prolonged," results in "clinically significant distress or impairment in social, occupational, or other important areas of functioning," and is characterized by at least three of these symptoms: irritability, anger or aggression; nervousness or anxiety; sleep difficulties (insomnia); decreased appetite or weight loss; restlessness; depressed mood; and or physical symptoms such as stomach pain, shakiness or tremors, sweating, fever, chills, and headache.

Battle Over 'Addiction' and 'Dependence'

The APA has gone back and forth between use of the terms "addiction" and "dependence" to describe alcohol and other drug problems, noted researcher Stanton Peele, Ph.D. "Every book I've written has the word "addiction" in the title, so I'm glad the term will now be recognized," wrote Peele in the Huffington Post on Feb. 11. "But the change back may make us wonder whether we will have to reconsider every twenty years or so whether it is more beneficial or harmful to use a word loaded with cultural meanings ("addiction"), or a more neutral term ("dependence")."

In fact, "dependence" made it into the DSM-IV by just a single vote, O'Brien noted in a May 2006 editorial in the American Journal of Psychiatry co-authored by Nora Volkow, M.D., director of the National Institute on Drug Abuse, and T-K Li, M.D., then-head of the National Institute on Alcohol Abuse and Alcoholism.

"Experience over the past two decades has demonstrated that this decision was a serious mistake," the trio wrote. "The term 'dependence' has traditionally been used to describe 'physical dependence,' which refers to the adaptations that result in withdrawal symptoms when drugs, such as alcohol and heroin, are discontinued. Physical dependence is also observed with certain psychoactive medications, such as antidepressants and beta-blockers. However, the adaptations associated with drug withdrawal are distinct from the adaptations that result in addiction, which refers to the loss of control over the intense urges to take the drug even at the expense of adverse consequences."

Comments Deadline: April 20

APA is accepting public comments on the DSM-V revisions until April 20. "This is the first complete revision of the DSM since 1994," said Volkow in a Feb. 11 letter to addiction professionals. "... In light of the advances in research on substance abuse and addiction since the last revision, many suggested changes have been proposed in this revision. Therefore, this is an important opportunity to offer your comments on the new criteria."

All of the proposed changes and information about submitting comments can be found on the DSM-V website.

Source: JoinTogether.org — News Feature by Bob Curley — February 12, 2010

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