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Treatment: The Role of Medication-Assisted Treatment (MAT) in the Nonmedical Opioid Epidemic - Dr. Robert DuPont

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Tx 1 dupont

  1. 1. The  Role  of  Medica.on-­‐Assisted  Treatment   (MAT)  in  the  Nonmedical  Opioid  Epidemic   Na.onal  Rx  Drug  Abuse  Summit  /  Treatment  Track   April  22,  2014   Robert  L.  DuPont,  M.D.   Ins.tute  for  Behavior  and  Health,  Inc.   www.ibhinc.org    
  2. 2. Disclosure  Statement   •  No  conflicts  of  interest   •  Professor  of  Clinical  Psychiatry,  Georgetown  University   School  of  Medicine   •  President,  Ins=tute  for  Behavior  and  Health   –  Non-­‐profit  organiza=on  dedicated  to  iden=fying  new  ideas  to  reduce   illegal  drug  use;  one  if  its  main  priori=es  is  to  reduce  prescrip=on  drug   abuse   •  Vice  President,  Bensinger,  DuPont  &  Associates   –  Na=onal  consul=ng  firm  dealing  with  substance  abuse   •  Chairman,  Prescrip=on  Drug  Research  Center   –  Consul=ng  firm  that  develops  risk  minimiza=on  ac=on  plans  and  product   surveillance  programs,  conducts  special  popula=on  surveys  and  forensic   drug  extrac=on  studies,  and  consults  with  pharmaceu=cal  companies   reviewing  abuse-­‐resistant  formula=ons  to  assess  or  reassess                     scheduling  
  3. 3. Learning  Objec.ves   •  Describe  the  historical  context  and  current  status  of   medica=on-­‐assisted  treatment  for  opioid  dependence   in  the  past  half  century   •  Evaluate  the  body  of  evidence  on  the  efficacy  of   medica=on-­‐assisted  treatment  focusing  on  con=nued   drug  use  and  program  reten=on   •  Compare  the  treatment  of  opioid  use  disorders  using   medica=on-­‐assisted  treatment  to  the  management  of   other  chronic  diseases,  and  to  the  system  of  care   management  in  the  state  physician  health                     programs  
  4. 4. •  1898  to  1914  –  Patent  Medicines,  Over-­‐the-­‐Counter   Heroin  (and  Cocaine)   •  1967  to  1978  –  Baby  Boom,  Youth  Culture  Inspired  by   Timothy  Leary:  “Turn  On,  Tune  In,  Drop  Out”     •  2000  to  Present  –  The  Prescrip=on  Opioid  Bonanza   Seeded  a  New  Heroin  Epidemic     Three  American  Heroin  Epidemics  
  5. 5. How  These  Epidemics  Were  Handled   •  1914  –  All  Supply  Reduc=on     – Pure  Food  and  Drug  Act  of  1906   – Harrison  Narco=cs  Tax  Act  of  1914   •  1978  –  Added  Demand  Reduc=on   – Methadone  Treatment     •  Present  –  Both  Supply  and  Demand  Reduc=on   – Restrain  prescrip=on  opiate  use   – Methadone  programs  joined  by  buprenorphine   treatment  
  6. 6. Demand  Reduc.on  is     More  Than  Treatment   •  Preven=on   •  Educa=on   •  Supply  Reduc=on  is  Demand  Reduc=on   •  Reducing  social  acceptance  of  drug  use,   including  with  the  criminal  law   •  AND  Treatment  
  7. 7. Treatment  “Need”  and  Use     •  In  2012,  22.2  million  people  age  12  or  older   were  classified  with  a  substance  use  disorder     – 7.3  million  had  substance  use  disorder  related  to   drugs  other  than  alcohol   – 2  million  people  with  substance  use  disorders   related  to  pain  relievers     •  4  million  people  reported  obtaining  some  form   of  treatment  for  problem   •  2.5  million  people  received  treatment  at  a   specialty  facility  
  8. 8. Mismatch  of  Need  and  Care   •  95%  of  the   people  with   substance  use   disorders  do  not   think  they  need   treatment   •  Implica=ons  for   treatment  as  a   response  to  the   current  epidemic   Source:  SAMHSA  2013  
  9. 9. Received  Most  Recent  Treatment  in  the  Past  Year  for  the  Use   of  Pain  Relievers  Among  Persons  Aged  12  or  Older:  2002-­‐2012   Source:  SAMHSA  2013  
  10. 10. What  is  the  opiate  addict’s  problem?     •  Just  a  bad  habit  that  the  opiate  user  needs  to   break?   OR   •  A  changed  brain  crea=ng  a  life=me  risk  of   relapse  and  death?  
  11. 11. Mismatch  of  Dura.on   •  Treatment  is  short-­‐term   •  Addic=on  is  for  life   •  Lesson  from  the  tragic  death  of  Philip  Seymour   Hoffman   – Youth  drug  addic=on   – 20+  years  of  sobriety   – An  innocuous  prescrip=on  opiate  to  treat  pain   triggered  a  relapse  to  a  fatal  overdose  
  12. 12. Treatment  –  For  How  Long?   •  Two  examples  from  model  methadone  and   buprenorphine  programs  
  13. 13. Pa.ent  Reten.on  in  a     Methadone  Program  
  14. 14. Pa.ent  Reten.on  in  a  Buprenorphine   Treatment  Program   103   26   106   5   0   20   40   60   80   100   120   Baseline  (9/1/2011-­‐   11/30/2011)   Follow-­‐Up  1/1/2013   #  Ac.ve  Pa.ents   Prior  Admit   New  Admit   Status  at   Baseline  
  15. 15. Addic.on  Treatment  Dura.on   •  Medica=on-­‐free  programs  retain  opiate-­‐ dependent  pa=ents  for  even  shorter  periods   of  =me!   •  The  vast  majority  of  opiate  addicts  do  not   want  treatment   •  Many  addicts  who  come  to  treatment  drop   out  before  comple=ng  a  program   •  Most  addicts  who  complete  treatment   relapse,  usually  rapidly        
  16. 16. What  does  it  mean  -­‐-­‐   •  That  only  5%  of  all  drug-­‐dependent  people   want  treatment?   •  That  many  drop  out  of  treatment?   •  That  many  of  those  who  complete  an  episode   of  treatment  relapse?  
  17. 17. It’s  Not  Rocket  Science!   •  Drugs  hijack  the  brain  and  distort  judgment   •  Our  culture  normalizes  drug  use     •  Drug  addic=on  is  chemical  slavery   •  Addicts  alone  are  mostly  helpless     •  Recovery  is  emancipa=on  from  chemical   slavery    
  18. 18. The  Future  of  Opiate  Treatment   •  Today’s  opiate  problem  must  be  dealt  with   from  outside  of  the  hijacked  addicted  brain   •  Those  around  the  opiate  dependent  user  –   family,  health  care,  even  the  criminal  jus=ce   system  –  must  intervene   •  They  are  essen=al  for  preven=on,  treatment   and  recovery  
  19. 19. Where  is  the  Magic?   •  The  magic  is  not  in  treatment  only   •  For  many  it  is  in  the  12-­‐step  fellowships  –  and     •  It  is  in  extended  random  monitoring  with   swip,  certain  and  serious  consequences  for   ANY  use  of  alcohol  or  other  drugs  –  not  just   the  use  of  opiates  
  20. 20. A  New  Look  at  Treatment   •  What  the  public  and  policymakers  think:    “Get  opiate-­‐dependent  people  into    treatment”  –  end  of  story   •  The  treatment  “fix”  is  a  dangerous  illusion   •  So  then  what?  
  21. 21. Rethink  the  Goals  of  Treatment   •  Possible  treatment  goals:     1)  Reduce  opiate  use   2)  Reduce  harms  from  drug  use  –  HIV  and  overdose   3)  Reduce  alcohol  and  reduce  all  other  drug  use   (including  opiates)   4)  Abs=nence  –  no  use  of  alcohol  or  all  other  drugs   •  Rethink  dura=on  –  for  the  dura=on  of   treatment  or  for  the  addict’s  life=me?  
  22. 22. Defining  Recovery   •  Lifelong  abs=nence  from  the  use  of  alcohol   and  other  drugs  and  character  change   exhibited  through  healthy  living  and   produc=ve  engagement   •  Besy  Ford  Ins=tute  Expert  Group,  2007:      A  voluntarily  maintained  lifestyle    characterized  by  sobriety,  personal  health,    and  ci8zenship  
  23. 23. “Recovery”  from  Opiate     Substance  Use  Disorders   •  Is  recovery  even  possible?     •  How  is  recovery  achieved?     •  With  what  reliability?    
  24. 24. New  Treatment  Goal   •  Today  relapse  is  the  expected  outcome  of   treatment   •  The  New  Goal:  Make  recovery  the  expected   outcome  of  treatment   •  Where  is  the  evidence  for  recovery  from   opiate  dependence?  
  25. 25. Evidence  that  Sustained  Recovery   is  Possible  and  Reliably  Achieved   •  The  evidence  is  found  in  a  unique  system  of   care  management  used  for  physicians,  nurses,   commercial  pilots  and  lawyers   •  This  model  has  been  used  for  four  decades   and  is  well-­‐researched  
  26. 26. Physician  Health  Program  (PHP)     System  of  Care  Management     •  Comprehensive  evalua=on     •  Signed  contract  for  monitoring  and  consequences   •  Ini=al  intensive,  high  quality  treatment  for   substance  use  disorders  and  comorbid  disorders   •  Random  tes=ng  for  5+  years  for  alcohol  and  other   drugs  of  abuse  with  zero  tolerance  for  ANY  use  
  27. 27. Elements  of  the  PHP     System  of  Care  Management     •  Leaving  the  PHP  or  relapse  to  substance  use   means  risk  of  losing  the  license  to  prac=ce   medicine   •  Immersion  in  recovery  fellowships,  mostly     Alcoholics  Anonymous  (AA)  and  Narco=cs   Anonymous  (NA)  
  28. 28. PHP  Long-­‐Term  Drug  Test  Results   •  Over  the  course  of  5  years:     –  78%  of  all  physicians  had   zero  posi.ve  drug  tests   –  14%  had  only  1  posi=ve   drug  test   –  3%  had  only  2  posi=ve  drug   tests   –  5%  had  3  or  more  posi=ve   drug  tests  
  29. 29. Same  Results  for  Opioid  Users   •  Same  impressive,  long-­‐term  outcomes  are   possible  with  opioid  users!     •  No  significant  differences  among  opioid  users  –   with  or  without  IV  drug  use  –  related  to:   – Posi=ve  drug  tests  over  5-­‐year  period   – Contract  status  at  follow-­‐up   – Occupa=onal  status  at  follow-­‐up  
  30. 30. New  Follow-­‐Up  Study  Underway   •  Among  physicians  who  successfully  completed   substance  use  disorder  contracts  with  PHPs   five  years  later…   •  Preliminary  results  show  they  most  valued:     – 12-­‐step  fellowships   – Treatment  experiences  (typically  1-­‐3  months)   – Prolonged  monitoring   •  Nearly  80%  reported  “My  PHP  experience   saved  by  career”  
  31. 31. Ini.al  Results  of  Ongoing  PHP   Follow-­‐Up  Study   •  More  than  90%  completed  PHP  contract  with  no   episodes  of  relapse   •  Since  comple=ng  PHP  contract,  about  80%  report   no  use  of  alcohol  and  over  90%  report  no  use  of   drugs     •  More  than  90%  asended  12-­‐step  mee=ngs  since   PHP  contract  comple=on;  nearly  70%  asended   12-­‐step  mee=ngs  in  the  past  year   •  Nearly  all  consider  themselves  to  be  currently         “in  recovery”  
  32. 32. A  New  Paradigm   •  The  PHPs  are  part  of  a  new  paradigm  for  care   management  used  among  other  popula=ons   including  within  the  criminal  jus=ce  system   •  The  power  is  in  the  long-­‐term  random  monitoring   with  rapid  interven=on  for  any  use  of  alcohol   and/or  drugs   •  This  gets  addicts  into  treatment,  keeps  them   there  through  comple=on,  and  extends  the   benefits  of  treatment  by  making  recovery  the   expected  outcome  
  33. 33. Extension  of  the  New  Paradigm   •  HOPE  Proba=on  in  Hawaii  –  popula=on  of   mostly  poorly  educated,  high-­‐risk,  recidivist     offenders  with  long  histories  of  drug-­‐related   problems,  including  crime   •  Most  are  dependent  on  smoked   methamphetamine  or  IV  opiates  
  34. 34. •  Intensive  random  drug  tes=ng  for  up  to  5  years   •  Zero  tolerance  for  any  viola=on  of  proba=on  including   drug  use,  missed  tests,  missed  proba=on  appointments,   etc.   •  Most  viola=ons  lead  to  brief  incarcera=ons     –  If  offender  admits  use  and  tests  posi=ve,  given  2-­‐3  days  in  jail   –  If  offender  denies  use  and  tests  posi=ve,  aper  laboratory   confirma=on,  likely  spends  15  days  in  jail   –  Failure  to  appear  for  drug  test/appointment  and  law   enforcement  finds  absconder,  offender  will  spend  30  days  in  jail   –  Repeat  absconding  leads  to  a  prison  sentence   Elements  of  HOPE  Proba.on  
  35. 35. Elements  of  HOPE   •  Treatment  is  available  but  only  required  when   monitoring  fails  –  “Behavioral  Triage”     •  12-­‐step  par=cipa=on  is  encouraged  but  not   required  
  36. 36. HOPE  vs.  Standard  Proba.on   •  Randomized  control  study  showed  that  in  a  one-­‐ year  period,  HOPE  proba=oners  were:   –  55%  less  likely  to  be  arrested  for  a  new  crime   –  72%  less  likely  to  use  drugs   –  61%  less  likely  to  skip  appointments  with  their   supervisory  officer   –  53%  less  likely  to  have  their  proba=on  revoked   •  HOPE  proba=oners  were  sentenced  to,  on   average,  48%  fewer  days  of  incarcera=on  than   the  standard  proba=on  group  
  37. 37. Distribu.on  of  Posi.ve  Drug  Tests  Over   One  Year  Period   Data courtesy of A. Hawken, Pepperdine University 51%   28%   12%   5%   2%   1%   1%   0%   10%   20%   30%   40%   50%   60%   0   1   2   3   4   5   6   Number  of  Posi.ve  Drug  Tests  
  38. 38. Implica.ons  for  Treatment  of   Prescrip.on  Opiate  Abuse   •  Outcomes  reflect  the  sevngs  in  which  the   decision  to  use  or  not  use  drugs  is  made   –  When  the  environment  permits  or  encourages  drug   use,  it  usually  con=nues   –  When  the  environment  quickly  and  effec=vely   iden=fies  any  drug  use  and  intervenes  swiply  with   serious  consequences,  it  usually  stops   –  Par=cipa=on  in  recovery  fellowships  extends  the   benefits  of  treatment  for  a  life=me  
  39. 39. Next  Steps   •  Making  recovery  the  expected  outcome  of   treatment  means  thinking  outside  treatment   to  the  environment  in  which  the  decision  is   made  to  use  or  to  not  use  alcohol  and  drugs   •  The  key  to  widespread  achievement  of   recovery  is  in  the  care  management:     – Over  many  years   – With  leverage  to  enforce  abs=nence  from  any  use   of  alcohol  or  other  drugs  
  40. 40. Where  is  the  Leverage?   •  Leverage  can  be  applied  by  families,  the   criminal  jus=ce  system,  in  health  care,  the   workplace,  schools  and  elsewhere   •  Like  the  leverage  now  used  by  licensing  boards   for  physicians,  nurses,  commercial  pilots,  and   lawyers    
  41. 41. Looking  Ahead   •  Is  the  country  ready  for  this  new  mission?   •  Surely  the  na=on’s  treatment  programs  are   not  currently  organized  to  fulfill  this  new   mission   •  First  the  new  vision:  The  opiate  dependence   problem  is  lifelong  and  so  must  the  solu.on   be  lifelong  –  with  Recovery  as  the  goal  
  42. 42. Conclusion   •  The  benefit  of  treatment  can  only  be  realized   when  outcomes  are  measured  by  the  ability  to   make  recovery  the  expected  outcome  
  43. 43. The  New  Paradigm  -­‐-­‐   1)  Fits  with  the  Mental  Health  and  Addic=on   Parity  Act  and  the  Affordable  Care  Act   2)  Fits  with  the  new  focus  in  medicine  on   chronic  disease  monitoring  and  management     3)  This  approach  to  opiate  addic=on  treatment   dovetails  with  the  new  approach  to  the   management  of  chronic  (and  fatal)  diseases   such  as  diabetes  and  hypertension  
  44. 44. What’s  Next?   •  The  stage  now  is  set  by  the  current  opiate   addic=on  epidemic  for  a  revolu=on  in   addic=on  treatment     •  This  change  will  make  Recovery  –  Not  Relapse   –  the  Expected  Outcome  of  Treatment  
  45. 45. Thank  you!  
  46. 46. Discussion   Now  I  want  to  hear  from  YOU!  
  47. 47. www.IBHinc.org     •  For  more  informa=on   on  other  important   ideas  to  reduce  illegal   drug  use  visit  the  home   website  of  the  Ins=tute   for  Behavior  and  Health    
  48. 48. References   •  Besy  Ford  Ins=tute  Consensus  Panel.  (2007).  What  is  recovery?  A  working  defini=on   from  the  Besy  Ford  Ins=tute.  Journal  of  Substance  Abuse  Treatment,  33(3),  221-­‐228.     •  DuPont,  R.  L.,  &  Humphreys,  K.  (2011).  A  new  paradigm  for  long-­‐term  recovery.   Substance  Abuse,  32(1),  1-­‐6.   •  DuPont  R.  L.,  McLellan  A.  T.,  White  W.  L.,  Merlo  L.,  and  Gold  M.  S.  (2009).  Sevng  the   standard  for  recovery:  Physicians  Health  Programs  evalua=on  review.  Journal  for   Substance  Abuse  Treatment,  36(2),  159-­‐171.     •  Hawken,  A.  (2010).  Behavioral  triage:  a  new  model  for  iden=fying  and  trea=ng   substance-­‐abusing  offenders.  Journal  of  Drug  Policy  Analysis,  3(1),  1-­‐5.   •  Hawken,  A.,  &  Kleiman,  M.  (2009,  December).  Managing  drug  involved  proba=oners   with  swip  and  certain  sanc=ons:  Evalua=ng  Hawaii’s  HOPE.  Na=onal  Ins=tute  of  Jus=ce,   Office  of  Jus=ce  Programs,  U.S.  Department  of  Jus=ce.  Award  number  2007-­‐IJ-­‐CX-­‐0033.   •  McLellan,  A.  T.,  Skipper,  G.  E.,  Campbell,  M.  G.  &  DuPont,  R.  L.  (2008).  Five  year   outcomes  in  a  cohort  study  of  physicians  treated  for  substance  use  disorders  in  the   United  States.  Bri=sh  Medical  Journal,  337:a2038   •  Substance  Abuse  and  Mental  Health  Services  Administra=on.  (2013).  Results  from  the   2012  Na=onal  Survey  on  Drug  Use  and  Health:  Summary  of  Na=onal  Findings,  NSDUH   Series  H-­‐46,  HHS  Publica=on  No.  (SMA)  13-­‐4795.  Rockville,  MD:  Substance  Abuse  and   Mental  Health  Services  Administra=on.   •  Unpublished  ongoing  study  data:  “Long-­‐Term  Follow-­‐up  of  Physician  Health  Program   (PHP)  Par=cipants.”   •  Unpublished  manuscript,  “Recovery  from  opioid  dependence:  Lessons  from  the   treatment  of  opioid-­‐dependent  physicians.”