Silvana Mazzella of Prevention Point Philadelphia gave this presentation on medication assisted treatment to the Philadelphia EMA HIV Integrated Planning Council on March 8, 2018.

1. INCREASING TREATMENT ACCESS
AND SAVING LIVES IN THE
CONTEXT OF THE DUAL OPIOID
AND OVERDOSE EPIDEMIC
PREVENTION POINT PHILADELPHIA FOR THE OFFICE OF HIV PLANNING
3/8/18

2. GOALS OF TODAY’S TALK:
 Increased understanding of what is happening nationally and locally with respect to opioids
and overdose
 Increased understanding of what is being done locally to reduce opioid use, improve access
to opioid treatment, and, most importantly, reduce fatal and non-fatal overdose
 Increased understanding of addiction and dependence, particularly opioid addiction and
dependence, and what is unique about opioids
 Increased understanding of stigma, its role in reducing access and increasing mortality, and
how we can work to reduce stigma
 Increased understanding of evidence based treatment modalities
 Increased understanding of what the EMA and planning partners can do to reduce stigma,
improve access to substance use treatment, improve outcomes, and reduce fatality

11. CONTINUUM OF DRUG USE
RECREATIONAL
SITUATIONAL
HABITUAL, DAILY
ADDICTION
CHEMICAL DEPENDENCE

12. CONTINUUM OF DRUG USE
Experimental, Social, Situational, Binge, Misuse/Abuse, Dependence, Persistent Dependence
NEWER SCIENCE ON ADDICTION
 Dopamine neurotransmitter of reward pathway
 Dopamine released after receipt of rewards
 When dopamine and other neurotransmission replaced with synthetic process, reward pathway malfunctions, and neurotransmission only
possible with drug
 Smoking and injecting most efficient, reach brain faster, activate reward faster
NEWER SCIENCE ON DEPENDENCE
 With repeated use of opiates, dependence occurs, develops at cellular level
 Dependence develops when the neurons adapt to repeated drug exposure, cant fire without more of drug, and function normally in presence of
the drug
 When the drug is withdrawn, physiologic reactions occur that can be mild, painful and life altering, or life threatening, needs to use to avoid
withdrawal. Dependence can have a psychological component
SELF MEDICATION
 Self-medication can pre-date, or begin after formal diagnosis
 People use drugs in same class of medications they might be prescribed
 Discussing managing drug use or drug treatment can focus on what the person self medicates for and in what dose, what effects drugs being
used have on other diagnoses, quality of life, creatively prescribing a new regimen

13. BIOLOGICAL VERSUS PSYCHOLOGICAL EFFECTS,
CRAVING, NEED, AND WITHDRAWAL
 Physical side effects versus mental side effects of a drug (euphoria, confidence and self-esteem,
no longer feeling out of sync with everyone and being able to participate in society, feeling like
your best self, trauma management, phantom pain)
 Physical craving versus mental craving (thinking about something all the time, itching,
headaches, nausea)
 Physical need versus mental need (to alleviate suffering or have personal efficacy)
 Physical withdrawal versus mental withdrawal (pain, fear, depression, mania, voices, vomiting,
chills, diarrhea, seizures)

14. ADDICTION VERSUS DEPENDENCE
 Addiction
 Dependence
 Misuse with no addiction
 Addiction with no dependence
 Dependence with no addiction
 The spectrum of these states varying by substance, licit and illicit
 Lapse and relapse
MAIN VERSUS NON-MAIN DRUGS

15. THE ROLE OF STIGMA ON HEALTH OUTCOMES
 Substance use is so heavily stigmatized; this leads to hiding drug use
 Substance use, and what some people have to do to survive during their addiction, can be
traumatic
 The stigma of substance use can be traumatizing
 Recovery and substance use treatment is also stigmatized
 Many people hide their interest in treatment, or get told that entering substance use
treatment with MAT is continuing their addiction
 The stigma of substance use and recovery can lead to reduced access to treatment
 The stigmatization of medication assisted treatment, and particularly methadone, contributes
to decreased access to treatment, increasing the trauma of opioid dependence and overdose
risk

16. OPIOID ADDICTION AND DEPENDENCE IS UNIQUE, & NEEDS A
UNIQUE, TRAUMA INFORMED, WARM HANDOFF
 We are in a twin opioid and overdose epidemic, w/ 1200 deaths in 2017 (Phila.)
 Opioid addiction is different than other substance use addiction
 Chemical dependence on opioids is different from addiction
 Any period of abstinence from opioids increases overdose risk
 Lengthy assessments and waiting for drug treatment referral, approval, and linkage
provide enough of a period of abstinence to increase overdose risk, fatality
 Drug use after a missed opportunity to link to treatment can result in fatality
 Individuals who use opioids need to be offered services with urgency

17. END STIGMA REGARDING NOT ONLY DRUG
USE BUT DRUG TREATMENT
 Less than 10% of people who die of overdose in Phila. died with methadone in their system (only
recently started testing for other opioid substation or treatment medications)
 Reducing the time to get methadone and getting dosed adequately is critical to preventing overdose
 People can call themselves whatever they like related to their drug use but we have to use person first
language (person with addiction, person facing or affected by addiction, not addict)
 Our own perceptions of drug treatment or those of physicians or other providers might not be in line
with the newest science on addiction and how to treat it
 Opioid dependence is not a state of mind that can be fixed by bucking up cold turkey
 As with HIV or hypertension, people with opioid dependence need tailored treatments
(NORA VOLKOW AND NIDA ON BIOLOGY OF ADDICTION AND DEPENDENCE)
 https://www.youtube.com/watch?v=X1AEvkWxbLE
 https://www.youtube.com/watch?v=M2uNoeB7AsA

18. DRUG TREATMENT FUNDING
(Medicaid & medicaid eligible)
 Philadelphia is its own SCA, (CBH), nested within the Department of Behavioral Health and
Intellectual Disability Services, which is also the designated managed care entity for behavioral
health
 The SCA makes the determination, not the physical health carrier, regarding what types of
benefits to authorize and for how long, and how often
 CBH determines level of need, authorizes treatment, pays for treatment to funded providers, and
then bills Medicaid for those patients treated
 For uninsured Medicaid eligible patients, OAS created the Behavioral Health Special Initiative
(BHSI) as a separate managed care entity
 Patients who are Medicaid funded or Medicaid eligible can move back and forth between CBH
and BHSI as they get covered or lose insurance

19. DBH DRUG TREATMENT OPTIONS
 Several tens of thousands people treated for opioid use disorder through city funding
 City funds nearly 6,000 Methadone slots and just over 1,000 buprenorphine slots
 City funded 14 outpatient sites, 4 residential, recently some providers offer Vivitrol
 Training and technical assistance to providers, funded and un-funded, to facilitate provision of
Buprenorphine in current methadone providers, mental health providers, and funded and un-
funded medical providers
 DBH is now requiring providers of drug free treatment to provide MAT, or a bridge to MAT
ACCESSING DBH SUPPORTED DRUG TREATMENT OPTIONS
 CBH (Medicaid insured) 215-413-3100
888-545-2600
 BHSI (uninsured but Medicaid eligible) 215-546-1200
http://www.dbhids.org/community-behavioral-health

20. CHALLENGES TO MEDICAID, MA ELIGIBLE
PATIENTS
 Despite more flexibility in approval, there are still denials
 Denials are typically related to not having completed previously approved treatment, having signed
out AMA, having signed out AMA of inpatient treatment but not having attempted outpatient
treatment, having prescription shopped for opioids and benzodiazepines while in treatment
 Most common treatment denials are for identification as id required for MAT
 People can be turned away for lack of beds
 Huge response to create outpatient slots, medicate more quickly in the outpatient setting
 Frequent flier status will flag patient (777), unless chronically homeless (111)
 Awareness of access points is low
 Methadone and publicly funded suboxone are scarce in other counties, driving out of county
residents to Philadelphia where resources are overwhelmed

21. DRUG TREATMENT OPTIONS/MODALITIES
 Inpatient and outpatient
 Short term and long term
 Full mu receptor agonist-methadone
 Full antagonists- naloxone, naltrexone
 Partial agonist/antagonist- buprenorphine
 Drug free inpatient and outpatient
 Self help and 12 step programs

22. INPATIENT VERSUS OUTPATIENT
 Inpatient care is typically regarded as the most effective treatment modality, regardless of whether or not
medication is utilized
 The most effective inpatient treatment lasts 90 days or more, with treatment efficacy measured by length of post
 Inpatient care may not be the first approval for reasons already discussed related to insurance and MCO approval,
as well as bed availability
 There are determinations of levels of care that include drug free as well as medication assisted treatment
PROS:
 Inpatient care removes the environmental stimuli of drugs, drug using peers, “people places and things”, provides
medical management of withdrawal symptoms, even if that only includes medical supervision and adjunct
medications, and provides an opportunity to obtain ancillary medical and mental health treatment, as well as co-
located case management, peer support, group and individual therapy and support groups, as well as,
theoretically, aftercare planning
CONS:
 Inpatient care is an artificial environment that the patient will not be able to replicate once the detoxification or
stabilization period is over. As such, it may be less effective than outpatient treatment for many

23. SHORT TERM VERSUS LONG TERM
 Though there is considerable debate regarding the optimal course of treatment, it is generally
accepted that the longer a treatment course is implemented, the higher likelihood of success, as
measured by length of abstinence from drugs or length of adherence to medication assisted
treatment
 It was a standard to receive an initial 7 days, then request and additional 7, and so on until a 30
day treatment course was obtained with an additional request for residential treatment
 Today the standard treatment in a publicly funded facility typically involves 5 days or
detoxification or stabilization, with an additional request
 Complete detoxification from all substances, as well as detoxification from illicit drugs and
stabilization on medication assisted treatment should be determined by the score on the PCPC
(in Pennsylvania) or ASAM, or some other objective criteria that include lifetime length of use,
daily use amounts, urinary drug screen results, psychosocial history and other clinical history,
medical history and medication history, as well as patient choice
 Patient choice and objective determination of level of care are not always congruent

24. DRUG FREE INPATIENT & OUTPATIENT
 There is considerable debate about the efficacy of drug free treatment in the scientific community,
and equal debate about the efficacy and appropriateness of medication assisted treatment in the
behavioral health treatment world, though this only applies to D&A treatment
 For many in the drug free treatment world, utilizing medication assisted treatment is considered
to be replacing one drug for another, and it is in fact called opioid replacement therapy in some
jurisdictions
 Drug free treatment is more sustainable long term due to cost
 Drug free treatment is provided by some of the most nationally recognized treatment providers,
and can include medical supervision, on-site therapy, case management, housing aftercare
planning, co-located support groups and vocational rehabilitation, as well as 12 step support
 Outcomes for drug free treatment are lower
 When detoxification outcomes are high, they decrease without transition to another level of care

27. FULL MU RECEPTOR AGONIST-
METHADONE

28. PARTIAL AGONIST/ANTAGONIST-
BUPRENORPHINE

29. FULL ANTAGONISTS- NALOXONE,
NALTREXONE

35. HOW MAT WORKS
• MAT works for opioid dependence and addiction by specifically disrupting
the cycle of EUPHORIA, CRASH, AND CRAVING
• MAT removes the euphoria associated with opioid dependence, by instead
providing an equal dose, at timed intervals, of opioid that partially covers
MU receptors so that an individual feels well, but not high
• MAT specifically disrupts the crash associated with opioid dependence, by
removing the crash through, as stated above, providing an equal dose, at
timed intervals, of opioid to partially cover MU receptors and prevent
withdrawal if dosing continues
• MAT specifically disrupts the craving associated with opioid dependence, by
removing the need to crave opioids to address physical withdrawal (though
emotional craving still exists)

36. THE SCIENCE OF MAT cont’d
 Timed dosing with MAT removes the reward associated with substance
use, rewiring the reward pathway over time
 Consistent and timed dosing in MAT changes tolerance, and re-adjusts it
so that an individual’s tolerance does not lower or increase during
treatment, resulting in lower rates of overdose Despite higher and more
constant time released doses of opioids. MAT also lowers overdose rates
by preventing relapse
 Less than 10% of Philadelphians and even fewer people across the
country, die with methadone in their system
 MAT reduces overdose

37. WHAT CAN WE DO AS AN EMA AND
PLANNING GROUP?
 De-stigmatize drug use, use person first language
 Incorporate harm reduction focused, and strength based care
 De-stigmatize treatment and recovery, particularly evidence-based MAT
 Implement safer prescribing, slow tapers of opioids, and offer to transition people who
would be removed from prescribed opioids on to MAT
 Routinize SBIRT and other screening in ED, ID, PCP, and specialty care
 Routinize relapse and overdose screening, prevention education, and naloxone prescribing
and dispensing
 Implement warm handoff to treatment, and reduce barriers to treatment
 Make sure our system and programs build an open door/no wrong door access, and then
make sure we keep those doors open
 Integrate substance use treatment, particularly MAT, in the context of other care,
particularly HIV primary care

38. STIGMA AND TRAUMA: WHAT’S IN A NAME?
PEJORATIVE PERSON FIRST
 Addict, junkie, fiend Person with an addiction
 Clean (urine, state of recovery) Sober, drug free, recovered
 Dirty urine Positive for opioids
 Substance abuse[r] Substance misuse
 Drug user, IDU Person who uses drugs, Person who injects drugs
 Addicted Person facing addiction, chemically dependent
 Brain disease Chemical dependence, medical condition
 Rock bottom Motivational moment
 Medication assisted treatment Medication assisted recovery

39. ALL HIV PRIMARY CARE & MCM PROVIDERS
CAN DEVELOP PROTOCOLS TO
 respond to patient overdoses in their facilities
 implement brief screening for substance use, relapse, & overdose risk with patients
 implement brief education to reduce overdose risk
 make referrals to Medication Assisted Treatment (MAT)
 consider implementing MAT within the HIV primary care setting
 prescribe and ideally dispense naloxone to patients
 bill for naloxone effectively through Medicaid, Medicare, SPBP, and private insurance to sustain
naloxone distribution and scale up
 routinize this behavioral health screening, MAT referral, and overdose prevention

40. STEP is the Stabilization, Treatment, and Engagement Program at Prevention Point Philadelphia.
Essential components of the program include:
- Physician-administered Medication Assisted Treatment for opioid dependence through three MAT options:
o Buprenorphine (Suboxone/Subutex)
o Naltrexone
o Extended-release naltrexone (Vivitrol)
- Case Management and Care Coordination (goal planning, assistance applying for and referral to benefits, housing, legal help, and other social supports)
- Referral and escort to outpatient mental health treatment
- Recovery support through a dedicated Certified Recovery Specialist
This program is best for clients who:
- Are not interested in methadone treatment
- Have long histories of opiate use, relapse, and overdose
- Are residents of Kensington or North Philadelphia
- Already have a relationship with Prevention Point (using our drop-in center, receiving mail here, etc.)
- Are mono-lingual Spanish speakers
- Have Medicaid insurance
How STEP is different from other programs:
- Harm-reduction-based treatment
- Flexible appointment schedules
- Participant-driven case management and recovery goals
- Flexible levels of intensity of case management tailored to participant’s level of need
- No co-pay or fee for treatment
What a typical visit looks like at STEP:
- Come to Prevention Point and inform receptionist that client is here for a STEP appointment.
- Within 10 minutes, provide UDS
- Meet with case manager to discuss current goals and progress
- Meet with Certified Recovery Specialist for support (if applicable)
- Meet with medical student (if applicable) for medication and withdrawal symptom review
- Meet with prescribing physician to receive Rx
- Plan next appointment
- Receive 2 tokens
If a client has other questions, please encourage them to reach out to Alli Elkin at 267-600-6079.

41. QUESTIONS / DISCUSSION
Silvana@ppponline.org
267-975-5419