SAMHSA’s Tools ForTreatment Dr. Melinda Campopiano, MD Medical Officer, Substance Abuse and Mental Health Services and Administration (SAMSHA) Suzanne Fields, MSW, LICSW Senior Advisor to the SAMHSA Administration on Health Care Financing, SAMHSA
Learning Objectives1. Identify SAMHSA’s tools for treatment.2. Identify the methods for medicated- assisted treatment.3. Analyze the ACA and its effect on access to treatment
Disclosure Statement• Melinda Campopiano has no financial relationships with proprietary entities that produce health care goods and services.• Suzanne Fields has no financial relationships with proprietary entities that produce health care goods and services.
The linked image cannot be displayed. The ﬁle may have been moved, renamed, or deleted. Verify that the link pointsto the correct ﬁle and location. Tools and Strategies Addressing Prescription Drug Misuse Melinda Campopiano von Klimo, MD Division of Pharmacologic Therapies Center for Substance Abuse Treatment
Prescription Drug Misuse• Surveillance• Risk and population specific interventions • Medication Assisted Treatment • Overdose Prevention Education & Naloxone • Appropriate Prescribing • Effective monitoring • Effective Screening
Prescription Drug Overdose• 57% of fatal overdoses involve pharmaceuticals• Exceeds the number of overdose deaths annually due to heroin and cocaine combined.• Opioids were found in most deaths involving benzodiazepines, anti-depressants,• 29.4% of fatalities involved opioids alone• Increase in overall overdose death rates since 1999 driven by increased prescribing of opioid analgesics Morbidity and Mortality Weekly Report, November 4, 2011/60(43);1487-1492 Pharmaceutical Overdose Deaths, United States, 2010. JAMA, February 20, 2013-Vol 309, No. 7
Overdose Risk Factors• Any prescription for an opioid• High dose opioid prescription• Poverty (Medicaid)• Poly-substance use• Recent abstinence (jail, detox, treatment)• Age• Illness
Overdose Intervention Education & NaloxoneMost overdoses occur in the presence of others.Fatal overdoses usually happen over the course of several hours.There is an antidote to opioid overdose.Poly-drug overdoses may benefit from naloxone if opioids are present.
Prevention Messages• Don’t use drugs alone• Know how to recognize an overdose• Activate 911• Position of safety• Rescue Breathing
Naloxone• Timely use of naloxone• Greater availability of naloxone • More first responders equipped and trained to use it. • Greater physician prescribing of naloxone for patients at risk of overdose.
Treatment is Prevention• methadone maintenance treatment is effective in reducing morbidity and mortality associated with continued use of heroin and other illicit opiates, as well as HIV-related morbidity• “…the all cause mortality rate for patients receiving methadone maintenance treatment was similar to the mortality rate for the general population whereas the mortality rate of untreated individuals using heroin was more than 15 times higher.”Modesto-Lowe et al., 2010; Gibson, 2008; Mattick, 2003; Bell and Zador, 2000; Marsch, 1998
Maintenance on Opioid Agonist Therapy 1996 Subutex and methadone 600 500 French population in No. of deaths 400 1999 = 60,000,000 300 Patients receiving 200 buprenorphine (1998): N= 55,000 100 Patients receiving methadone 0 (1998): N= 5,360 19691971197319751977197919811983198519871989199119931995 997 1999 1 Year Auriacombe et al., 2001
Placebo Controlled Study of Maintenance vs. Detoxification with Methadone Whitehall, 1974
Placebo Controlled Study of Maintenance vs. Detoxification with Buprenorphine Kaplan-Meier curve of cumulative retention in treatment 20 Number remaining in treatment 15 Buprenorphine 10 5 P=0.0001 Control 0 0 50 100 150 200 250 300 350 Time from randomization (days)
Prescribers’ Clinical Support System for Opioid Therapies (PCSS-O)Supports:• Innovative approaches to educating allclinicians who prescribe opioidsFocus:• Safe use of opioids in treatment of painincluding training on how to recognizemisuse, abuse, and addiction in thosewith pain• Use of opioid therapies for treatment ofopioid dependence
Prescribers’ Clinical Support System for Opioid Therapies (PCSS-O)Year One Year Two Online Archived Phone App Mentors Mentees Listserv Total Webinars Webinars Modules Webinar Downloads Par=cipants Number Views Trained 2850 2249 818 1,365 733 37 97 194 8343 • Developed 15 online modules and a 2 hr, 2 CME course available through the California Academy of Family Physicians. • More than 90% satisfied or very satisfied with quality of training and information presented and would recommend the training to colleagues.
Prescribers’ Clinical Support System for Opioid Therapies (PCSS-O)-Content • A Review of Considerations in the Assessment and Treatment of Pain and Risk for Opioid Misuse • Advances in Recognition and Treatment of Substance Use Disorders in Primary Care • Clinical Guidelines for Opioid Use in Chronic Non- Cancer Pain • Considerations in Medication Assisted Treatment of Opiate Dependence • Implementation of Evidence Based Practice • Medication Assisted Treatment for Substance Use Disorders in Primary Care
Clinical Practice Guidelines• Treatment Improvement Protocols (TIPs) • Detoxification and Substance Abuse Treatment • Medication Assisted Treatment (MAT) for Opioid Addiction in Opioid Treatment Programs • Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders • Hepatitis C• Advisories • Prescription misuse, Oxycontin®, methadone, Opana® (TTP) • Vivitrol®
“Prescribing Opioids for ChronicPain: Balancing Safety & Efficacy” 25
“Prescribing Opioids for Chronic Pain: Balancing Safety & Efficacy”In-person course using national and local faculty47 sites in 25 statesCollaborate with local organizations or agencies.Tailored to local issues based on state-specific surveillance data.Specialized courses developed for IHS and DODAlmost 9,000 practicing health professionals trained Physicians, Advance Practice Nurses, Physician’s Assistants, Dentists, Oral Surgeons
Course Content• best practices and clinical protocols for the use of methadone and other opioids to treat pain,• evidence-based strategies for patient selection, risk assessment, and education,• techniques for effective patient monitoring, including the use of state prescription drug monitoring programs,• the risks and benefits of opioids, as well as how to incorporate clinical and administrative practices that reduce such risks and enhance patient outcomes• how to use state Prescription Drug Monitoring Programs (PDMPs)
Course Impact• Evaluations of the courses by participants and independent experts have been very positive,• average score of 6.0 on a scale of 1 to 7, with 7 designated “superior.”• In a 2012 follow-up survey, more than 76% of physicians who had completed a course reported that they made changes in the way they practice as a result of what they learned.
www.opioidprescribing.com• a series of 30-minute modules• each targeted to a specific audience or addressing a particular aspect of opioid prescribing.• In 2012 alone, more than 7,330 registrants completed at least one module for CME credit• another 15,163 certificates of completion were issued to individuals who completed more than one module• a total of 22,493 modules completed
Online Modules• Opioid Efficacy and Safety; Assessment and Monitoring Tools for Primary Care Settings• Communicating with Patients About Chronic Opioid Use• Managing Patients with Pain, Psychiatric Co- Morbidity and Addiction• Case Studies in Opioid Prescribing• Issues in Clinical Practice• Exit Strategies from Outpatient Opioid Therapy for Pain• Managing Chronic Pain in Returning Military Personnel and Their Families• Use of State Prescription Drug Monitoring Programs (PDMPs) in Clinical Practice
Course Impact• Developed in partnership with Boston University• Consistently receives highest rating for content• The Accreditation Council for Continuing Medical Education (ACCME) “Accreditation with Commendation.”• The American Nurses Credentialing Center (ANCC) awarded BU “Accreditation with Distinction, the highest recognition awarded by the American Nurses Credentialing Center’s Accreditation Program.”• The American Academy of Family Physicians (AAFP) “The procedures established for conducting CME activities at your institution are exemplary.”
Prescription Drug Monitoring Programs• Real-time data entry and access• Easy Prescriber Access• Cross-boarder sharing of state data.• Physicians encouraged or required to use PDMP.• Opioid Treatment Programs must check PDMP
Screening, Brief Intervention and Referral to Treatment• Systematic screening for harmful or hazardous substance use and risk factors for overdose where most opioid prescribing is done.• Brief motivational discussion focused on feasible, positive behavior change.• Education targeted to specific risks.• More effective treatment referral.