The Role of OTPs (opioid treatment programs) in Managed Care

1. The Role of OTPs (opioid treatment programs) in Managed Care Improved outcomes and lower costs.

2. Changes in Brain Chemistry • Drugs of abuse produce their effects by altering brain chemistry and structure. • Neurotransmitters and associated receptors responsible for everyday functions are altered by the consumption of drugs. • When the drug being abused is an opiate, these changes can be very long lasting.

3. Hypothesis – 1964 Heroin (opiate) addiction is a disease – a “metabolic disease” – of the brain with resultant behaviors of “drug hunger” and drug self-administration, despite negative consequences to self and others. Heroin addiction is not simply a criminal behavior or due alone to antisocial personality or some other personality disorder. (Dole, Nyswander and Kreek, 1966, 2006)

4. Vincent P. Dole, MD - Marie Nyswander, MD - Mary Jeanne Kreek, MD

5. After decades of research and clinical experience and after hundreds of peer reviewed studies in scholarly journals the evidence is clear that the best clinical outcomes for the chronic long-term opiate addict are achieved when addiction medicines are used as part of a comprehensive approach to treatment. This is particularly true if the measure of success is long term abstinence from illicit opiates.

6. When a provider (or treatment modality) claims to have a high degree of success in treating chronic, long-term, opiate addiction how can I decide if I should believe them?

7. What not to believe: • Anecdote • Testimonials & Rallies • Almost anything which begins ….”I can tell you from my personal experience…”. • So-called “data” which is self-generated and which has not been subject to academic and/or peer review, and which has not been published in respected scientific journals.

8. Real proof consists of: • Peer-reviewed outcome studies published in scholarly journals. • Repeated outcome studies by a wide-range of scientists over time which point to a continued and repeated result. Not “One and done”. • Medication Assisted Treatment for opiate addiction meets this standard!

9. NIH Consensus Statement • The National Institutes on Health in 1997 concluded that Methadone “…combined with attention to medical, psychiatric, and socioeconomic issues, as well as drug counseling, has the highest probability of being effective…” in the treatment of opiate addiction.

10. Two Recent Studies in Support of Medication Assisted Treatment • Assessing the Evidence: Medication Assisted Treatment with Methadone • Assessing the Evidence: Medication Assisted Treatment with Buprenorphine

11. To Find All Three Studies Go To: www.compa-ny.org Once on the website go to the “News” section and find each study under the heading “Research in Support of Medication Assisted Treatment”.

12. Use of Methadone in the Treatment for Opioid (Heroin) Addiction • Number of patients currently in treatment: • 212,000 (USA) • >500,000 (worldwide) • Methadone is a medication: used in the detoxification & maintenance treatment of opioid addiction in conjunction with the appropriate social and medical services • Efficacy in “good” treatment programs using adequate doses (80 to 150mg/d): • Voluntary retention in treatment (1+ year) = 50 – 80% • Continuing use of illicit heroin = 5 – 20%

13. OTP Oversight & Regulation • SAMHSA • DEA • OASAS • NYS DOH • LGUs

14. What Services Can You Expect an OTP to Provide?

15. Assessment & Intake • Determine if patient is appropriate for OTP treatment (possible referral) • Intake Physical • Individual Treatment Plan (based on patient goals, not “cookie-cutter”

16. Medication: • Methadone* • Suboxone (a.k.a. Buprenorphine)** • Vivitrol** • Also – An important distinction between dispensing and prescribing. • * Provided by all OTPs • ** Provided by some OTPs

17. Counseling: • Individual (brief & longer) • Group • As called for by individual treatment plan

18. Harm Reduction Interventions: • HIV • HEP C • STDs

19. Services Provided by Some OTPs: • Primary Care • Alternative to Inpatient Detox • Directly Observed Therapy • Social Service & Criminal Justice Supports

20. Typical Benefits of OTP Treatment: • Retention in treatment • Reduction or elimination of illicit opiate use • Reduction or elimination of problematic secondary substance use • Reduction in rates of contracting both HIV and Hepatitis C • Reduction in rates of transmitting HIV, STDs, and Hepatitis C to others • Reduction in the rates of criminal behavior • Reduction in the rate of incarceration and re-incarceration • Reduction in overdose deaths • Reduction in both number and duration of hospital inpatient stays

21. Benefits of OTP Treatment (continued): • Improvement in overall health (especially in pregnant women) • Improved engagement in primary care • Improvement in housing • Improvement in employment / productive engagement

22. Even More Benefits • Lowest cost per successful outcome • Can most often be done in an outpatient setting • Least disruptive to normal patient life – family & work responsibilities

23. With the amazing success rate of medication assisted treatment why isn’t it being used more widely? Why does there continue to be resistance to this treatment?

24. Facing the Facts about Medication- Supported Recovery • Overcome “Data Resistance” (hiding from evidence). • Urgent need for good scienceto triumph over…– SPAM – Stigma, Prejudice, And “MythUnderstandings.”

25. Myth • Methadone was invented by the Nazis as a form of “chemical handcuffs”. As proof people say an early name for the drug “Dolophine” was a tribute to Adolf Hitler.

26. Fact • Methadone was invented in 1937 by the German pharmaceutical company IG Farben prior to World War II as a pain killer. • Beyond initial laboratory testing it was never used in Nazi Germany. • At the end of the war Eli Lilly obtained all the IG Farben facilities and patents and named the drug Dolophine as a combination of the Latin word dolor (pain) and the French word fin (end).

27. Myth • Patients on Methadone are getting high from the drug and it’s just substituting one drug for another.

28. Fact • When a patient is properly stabilized on Methadone there is no “high”. • The drug is slow acting and it takes more than24 hours for the drug to be fully metabolized. • Virtually all drugs which produce a “high” are fast acting and achieve high levels in the blood stream quickly. • Methadone is not just replacing one drug for another since Methadone treats an imbalance which has been created in the brain from the extended use of short acting drugs like heroin.

29. Myth • Methadone patients are sedated, behave like “zombies” and are said to be “on the nod”. Thus they are incapable of productive engagement like work or school, and they should not be allowed to drive a car.

30. Fact • Once a patient is stabilized on Methadone there is no sedation or cognitive imparement. • There is no reason a Methadone patient should not be allowed to drive a car.

31. Myth • Methadone is harder to kick that heroin.

32. Fact • Once the brain has been altered by long term opiate addiction it is very difficult for many patients to achieve a “drug free” state without the use of addiction medicines. • Transitioning from Methadone to a “drug free” state is no more problematic than transitioning from illicit opiate addiction to a drug free state.

33. Myth • Methadone rots your bones, and produces a number of other negative Physical health consequences.

34. Fact • Just the opposite is true. The drug itself does no harm when taken correctly. • The patient in Methadone treatment pays more attention to their physical health and well being since they are no longer preoccupied by drug seeking behavior. • The result is a dramatic improvement in overall health.

35. Myth • Methadone is unsafe. This is proven by the fact that there has been a dramatic increase in Methadone related deaths and Methadone overdoses.

36. Fact • Methadone (like all opiates) can suppress respiration. Until an opiate tolerance is established a sufficient dose of Methadone can cause serious illness and death. • A GAO (General Accounting Office) report on Methadone deaths had two major finding: • Because of a lack of standardization in how deaths are reported, a death may be called “Methadone related” if there was any Methadone in the post-mortem toxicology report. This does not prove Methadone was the cause of death.

37. Fact (Continued) • The vast majority of true Methadone overdose deaths involved patients who were prescribed Methadone for home use for pain management. • Patients were not properly informed of the dangers of the medication, or failed to use the drug as prescribed or to store it safely. • In very few cases was death linked to the use of Methadone for the purposes of opiate addiction management.

38. Myth • Methadone is a “crutch” for people too weak to go drug free.

39. Fact • The physical changes in brain chemistry have nothing to do with strength of will. • Once addiction has occurred and the brain chemistry and physiology has been altered the brain will constantly seek an opiate drug to address this craving. • Addiction medication (Methadone, Buprenorphine, & Vivitrol) resolves this physical craving and dramatically reduces the likelihood of relapse to illicit opiate use.

40. Using Addiction Medicines is Against our Philosophy

41. Etymology of “Philosophy” Philo - loving Sophia - wisdom

42. How is it possible to love wisdom and reject science?

43. Where can I find an OASAS licensed OTP near me?

44. Go to the OASAS Website: • www.oasas.ny.gov/providerdirectory • Click on “Treatment Providers”, then • Under “Provider Type” scroll down to “Methadone Treatment” * • * Of course it should say “Opioid Treatment Programs”!

45. For more information about Opioid Treatment & Opioid Treatment Programs, contact: Allegra Schorr President COMPA(Committee of Methadone Program Administrators of New York State Inc.) 911 Central Avenue, #322 Albany, NY 12206 allschorr@westmidtownmedical.com