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Decreasing the Use of Prescription Opiates and Benzodiazepines Among Individuals Enrolled in Methadone Programs. Kim Castelnovo, RPh Pharmacy Manager, Community Care. About Community Care. Behavioral Health Managed Care Company Founded in 1996

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slide1

Decreasing the Use of Prescription Opiates and Benzodiazepines Among Individuals Enrolled in Methadone Programs

Kim Castelnovo, RPhPharmacy Manager, Community Care

about community care
About Community Care
  • Behavioral Health Managed Care Company
  • Founded in 1996
  • Statewide HealthChoices presence; 39 of 67 Pennsylvania counties
  • 10 offices across the Commonwealth
  • Over 600 employees
about community care1
About Community Care
  • Medicaid/HealthChoices membership: 725,000
  • Commercial/Medicare membership: 450,000
  • Approximately 110,000 people served annually
  • Statewide network of approximately 1,600 providers
serving 39 counties
Serving 39 Counties

Erie

Warren

Susquehanna

McKean

Potter

Tioga

Bradford

Crawford

Wayne

Forest

Wyoming

Cameron

Sullivan

Lackawanna

Pike

Venango

Elk

Lycoming

Pike

Mercer

Clinton

Jefferson

Luzerne

Clarion

Columbia

Monroe

Lawrence

Montour

Clearfield

Centre

Union

Butler

Carbon

Armstrong

Northumberland

Snyder

Northampton

Beaver

Mifflin

Schuylkill

Lehigh

Indiana

Juniata

Allegheny

Blair

Berks

Perry

Dauphin

Bucks

Cambria

Lebanon

Huntingdon

Westmoreland

Montgomery

Washington

Cumberland

Lancaster

Bedford

Fayette

Chester

Somerset

Franklin

York

Philadelphia

Greene

Fulton

Adams

Delaware

Community Care Office

overview
Overview
  • Opiate and benzodiazepine use in individuals in methadone programs
    • With overdose deaths from heroin and prescription pain medications increasing in the U.S., opioid addiction is an important concern for Medicaid programs
    • Medicaid beneficiaries have higher rates of opioid addiction than other insured groups
benzodiazepine use and misuse
Benzodiazepine Use and Misuse
  • Among patients in a methadone program – BMC Psychiatry, May 2011:
    • Benzodiazepines (BZD) misuse and abuse is a serious public health problem in the U.S.
    • This problem is especially pertinent among those with opiate dependence because these individuals are more likely to experience elevated anxiety after stopping use of opiates
    • It has been shown that individuals who abuse BZD are at increased risk of continuing opiate abuse and failing to stay in methadone treatment
benzodiazepine use and misuse1
Benzodiazepine Use and Misuse
  • In a Baltimore methadone program:
    • Survey conducted at a methadone treatment program in Baltimore
    • 194 questionnaires were included in the final data analysis
      • 47% reported using BZD with/without a prescription
      • 25% said that their initial use began with a prescription
      • 54% did not start using BZD until after entering the methadone program
benzodiazepine use and misuse2
Benzodiazepine Use and Misuse
  • Among patients in a methadone program the main reasons given for using BZD without a prescription:
    • Curiosity
    • To relieve tension or anxiety
    • To feel good
    • To get high
    • To overcome depression or frustration
benzodiazepine use and misuse3
Benzodiazepine Use and Misuse
  • When asked patients in a methadone program if they would consider reducing or stopping the use of BZD if the methadone program could provide help that would work:
    • 40% said “Yes, definitely”
    • 7% said “Maybe”
    • 19% said “No”
    • 33% had already stopped using BZD
benzodiazepine use
Benzodiazepine Use
  • Among Community Care Medicaid enrollees:
    • Analysis includes data for 39 Community Care counties
    • Number of unique members per year filling benzodiazepines
    • Benzodiazepine use very low among children and adolescents
    • Adult benzodiazepine Use ranges from 13-24% of Medicaid enrollment among Community Care counties
opiate use
Opiate Use
  • Among Community Care Medicaid enrollees:
    • Analysis includes data for 39 Community Care counties
    • Number of unique members per year filling four or more opiate scripts
    • Opiate use very low among children and adolescents
    • Adult opiate use ranges from 11-21% of Medicaid enrollment among Community Care counties
objective
Objective
  • To identify members enrolled in methadone treatment programs who are concurrently filling benzodiazepine and /or opiate prescriptions
  • Collaborate with methadone providers to reduce the incidence of concurrent utilization and ultimately improve care
intervention
Intervention
  • Community Care generates member reports on a monthly basis and sends to the methadone providers in Allegheny County
  • Member report includes medications filled and prescriber information
  • Methadone provider uses the information to help address any clinical issues with the member
assessing impact of interventions
Assessing Impact of Interventions
  • Members with at least 10 days of Methadone Claims = 636
assessing impact of interventions1
Assessing Impact of Interventions
  • Members with at least 10 days of Methadone Claims = 485
conclusions
Conclusions
  • The decrease in concurrent medication over the past four years is encouraging
  • Provider feedback has been very positive about this initiative
  • Providers have adopted new policies when caring for individuals on concurrent benzodiazepines or opiates to ensure appropriate use
slide21

Collaboration of Care Implementation GuidelinePresented by:Sara Remaley, MSPC, CAADC, Clinical Supervisor WPIC NATPValerie Gualazzi, MS, CADC, Program Director WPIC NATPWestern Psychiatric Institute and Clinic

slide22
Western Psychiatric Institute and Clinic Narcotic Addiction Treatment Program (NATP) -Addiction Medicine Services
  • WPIC NATP is a clinic specializing in opioid dependency in addition to psychiatric comorbidity.
  • WPIC offers methadone maintenance treamtent, suboxone treatment, psychiatric care and medication management, mental health, and addiction therapy.
  • WPIC currently treats approximately 420 patients on a regular basis.
rationale
Rationale
  • NATP recognized a need to address the misuse and abuse of prescription benzodiazepines by patients enrolled in medication assisted treatment.
  • High rates of patients were enrolling in treatment and concurrently becoming addicted to and abusing benzodiazepines, posing health risks, adverse effects, and ultimately untimely discharge from treatment.
collaboration of care
Collaboration of Care
  • 2012- WPIC NATP redesigned the program’s philosophy and position regarding concurrent use and abuse of prescription benzodiazepines and opiates while taking methadone.
  • Contraindications and potential for adverse effects helped NATP move in the direction of ‘therapeutic no tolerance’.
  • The “Collaboration of Care” Procedure : indicating NATP’s willingness to work with patients currently on prescription benzodiazepines to taper off and receive evidence based interventions and seek alternative treatment options as needed.
collaboration of care1
Collaboration of Care
  • The Collaboration of Care Procedure was developed as a way to inform patients of the new treatment philosophy indicating: use of benzodiazepines and opiates while on methadone is no longer permissible.
  • With the understanding that tapering from these type of medication can be a difficult and lengthy process with potential for relapse, NATP developed a procedural guideline to assist both patients and staff through this new process.
barriers to addressing bzd use
Barriers to addressing bzd use:
  • Difficult tapering process, risk related to withdrawal symptoms, and potential need for medically supervised detoxification.
  • High Relapse rates with benzodiazepines.
  • Concurrent rates of psychiatric comorbidity and the need to address/treat underlying mental health conditions.
  • Collaborating with providers (prescribing physicians) vs. illicit street use.
  • Addressing diversion…How does this fit?
let the collaboration begin
Let the collaboration begin….
  • Step 1: Staff Education
    • Development of Procedural Guideline highlighting philosophy, procedures and interventions, and processes for team to follow.
  • Step 2: Patient Education
    • An FAQ was developed and handed out to all patients indicating the new Collaboration of Care and Program Philosophy regarding Concurrent use of benzodiazepines while in treatment.
slide30

Step 3: Patient Acknowledgement and Responsibilities:

    • Reviewing the new philosophy and Collaboration of Care with patients, and asking them to acknowledge with their signatures that they have been informed.
    • A part of this process is also to explain to patients, the risks, as well as their rights. Albeit patients may reserve the right to refuse collaboration, they are also informed how this may directly impact their ability to remain in treatment.
slide31

Step 4: Interventions

    • Once the Collaboration of Care is initiated, the following procedures /interventions may be followed:
      • Urine Drug Screens and CCBHO Report reviewed.
      • Contact with the prescribing physician (physician to physician) to discuss recommendations and to create a tapering regimen.
        • Pill Counts
      • Illicit Street Use: Assessing need for medically supervised detoxification. Resources: Mercy Hospital Emergency Room, WPIC DEC (Diagnostic Evaluation Center).
      • UDS Confirmatory tests to determine if “levels” are decreasing- indicating progress/regression.
slide32

Interventions Continued:

      • Assessing underlying mental health and psychiatric disorders such as anxiety, depression, mood disorder, bipolar disorder, etc. Choosing a modality to effectively work with and treat these disorders in addition to addiction.
        • CBT, REBT, Gestalt Therapy, DBT, Motivational Interviewing, Person Centered etc.
      • Modifying treatment plans: Increasing therapy, regular appointments with Psychiatrist, following a medication regimen, ongoing collaboration.
      • Maintaining focus on individualized care through individualized recommendations. Assessing Progress: How is this done? Regular team meetings and supervision.
response to interventions
Response to Interventions
  • What happened after the Collaboration of Care was initiated?
    • NATP experienced responses similarly associated with the Change Curve (Kubhler-Ross)
      • Shock, Denial, Anger, Acceptance, Integration
response to interventions1
Response to Interventions
  • How long did it take before a change was noticeable?
    • Integration took time and CONSISTENCY IS KEY
  • Response to change implementation included:
    • Compliance and Collaboration.
    • Increase in individual/group therapy- engagement in regular psychotherapy.
    • Increase in psychiatric treatment and psychopharmacology.
    • Exacerbation of symptoms/negative behaviors.
    • Increase in referrals to Higher LOC’s.
    • Decrease in bzd rates.
    • Increase in compliance/privilege status.
evaluating effectiveness
Evaluating Effectiveness
  • Establishing pre and post intervention baselines:
    • Rates of bzd use/abuse among patients.
    • Urine Drug Screen Results (including break-down of levels)
    • Individualized Progress
    • Relapse rates
    • Decrease in attaining prescriptions.
    • Patient Discharges
    • Sustained abstinence
summary
Summary
  • Addressing concurrent use/abuse of benzodiazepines through the following steps:
    • Develop Program Philosophy
    • Identify Perceived Barriers
    • Education Staff
    • Educate Patients
    • Identify intervention strategies and evidenced based practices
    • Identify pre and post intervention baseline data
slide37

“Meeting Needs …..Renewing Life”

Timothy H. Reese, M.D., MRO, SAP

Medical Director

1425 Beaver Avenue

Pittsburgh, PA 15233

Phone: 412-322-8415 Ext. 109

Fax: 412-322-9224/421-322-3352

“Decreasing the use of prescription opiates and benzodiazepines among individuals

Enrolled in methadone programs”

slide38

HISTORY OF TADISO

ESTABLISHED IN 1968 AS NON-PROFIT

700 PATIENTS—24 FULL TIME COUNSELORS—1 MEDICAL DIRECTOR

1 PA.

POPULATION: 2/3 NON-HISPANIC WHITE AND 1/3 AFRO-AMERICAN AND OTHER

slide39

DEMOGRAPHICS

NON-HISPANIC WHITES 20-44 YEARS…….FASTEST

NON-HISPANIC WHITES 20-34 YEARS………FASTEST OF THE FAST

NON-HISPANIC WHITES 20-34 YEARS………SHOOTING MORE

NON-HISPANIC WHITES 20-44 YEARS……….INHALING MORE

slide40

PENNSYLVANIA

2008-2012 PERSONS ENROLLED IN SUBSTANCE ABUSE TREATMENT PROGRAMS WHICH PRESCRIBED METHADONE INCREASED 18.9%

slide41

MESSAGE

WE ARE IN THE MIDST OF AN EPIDEMIC OF OPIOID ADDICTION AND ITS DEVASTATING TOLL ON SOCIETY!

METHADONE IS AND CAN BE AN EVEN GREATER PART OF OUR ARSENAL AGAINST THIS DEADLY FOE!

slide42

PATHOPHYSIOLOGY

OF

OPIOID ADDICTION

--MEDULLA LOCUS CAERULEUS---90% OF CATECHOLAMINES IN CNS

--RESPONSIBLE FOR THE VEGETATIVE FUNCTIONS OF THE ORGANISM (SUPPORT LIFE)

--THERMOSTAT ANALOGY AND THE OPIOID WITHDRAWAL SYNDROME

slide43

CLINICAL MANIFESTATIONS

OF

OPIOID WITHDRAWAL

VITAL SIGNS: TACHYCARDIA

HYPERTENSION

FEVER

slide44

CLINICAL MANIFESTATIONS

OF

OPIOID WITHDRAWAL

CENTRAL NERVOUS SYSTEM:

RESTLESSNESS

IRRITABILITY

INSOMNIA

CRAVING

YAWNING

slide45

CLINICAL MANIFESTATIONS

OF

OPIOID WITHDRAWAL

MUCOCTANEOUS: RHINORRHEA

EYES: LACRIMATION

PUPIL DILATION

SKIN: PILOERECTION (GOOSEFLESH)

slide46

CLINICAL MANIFESTATIONS

OF

OPIOID WITHDRAWAL

GASTROINTESTINAL TRACT:

NAUSEA

VOMITING

DIARRHEA

slide47

CLINICAL MANIFESTATIONS

  • OF
  • OPIOID WITHDRAWAL
  • PSYCHOSOMATIC WITHDRAWAL?
  • PSEUDO-WITHDRAWAL?
  • REAL WITHDRAWAL?
slide48

CLINICAL MANIFESTATIONS

OF

OPIOID WITHDRAWAL

*ACCIDENTAL OVERDOSE AFTER A SUCCESSFUL DETOXIFICATION*

slide49

CLINCAL MANIFESTATIONS

OF OPIOID WITHDRAWAL

MU-AGONIST EFFECT WITH BEGINNERS!

slide50

DOPAMINE

----VTA/NUCLEUS ACCUMBENS (FOREBRAIN)

DRUG ABUSE DUMPS MASSIVE AMOUNTS OF DOPAMINE INTO THIS AREA.

REINFORCES BEHAVIOUR THAT IS PARAMOUNT TO SURVIVAL OF THE SPECIES

slide51

UP-REGULATION

OF

DOPANINERGIC NEURONS

--AFTER REPEATED EXPOSURE (DRUG ABUSE) TO THESE MASSIVE AMOUNTS

OF DOPAMINE THE TARGET NEURONS BECOME PROGRESSIVELY LESS

RESPONSIVE! NET RESULT MORE STIMULATION GIVE LESS RESPONSE THUS

PROPELLING THE ADDICTION PROCESS!

slide52

BENZODIAZEPINES

INTERNEURONS IN THE VTA APPLY INHIBITORY EFFECTS ON DOPAMINERGIC NEURONS

THESE INHIBITORY INTERNEURONS EXERT THEIR EFFECT ON THE DOPAMINERGIC NEURONS BY WAY OF GABA (GAMMA AMINO BUTYRIC ACID)

BENZODIAZEPINES INHIBIT THIS INHIBITORY EFFECT. THIS INHIBITION RESULTS IN A MASSIVE RELEASE OF DOPAMINE FROM THE DOPAMINERGIC NEURONS.

THIS IS THE SYNERGISM WHICH OCCURS WHEN BENZODIAZEPINES ARE GIVEN WITH AN OPIOID; E.G., METHADONE.

slide53

OPIOIDS

IN A STABILIZED METHADONE PATIENT ANY ADDITIONAL OPIOID WILL CAUSE DESTABLIZATION ;

IF THE OPIOIDS ARE TAKEN TO AN ANALGESIC LEVEL ONLY THE DESTABILIZATION WILL MAINLY AFFECT THE MEDULLA LOCUS CAERULEUS.

IF THE OPIOIDS ARE TAKEN TO THE EUPHORIC LEVEL THE DESTABILIZATION WILL AFFECT THE DOPAMINERGIC NEURONS AS WELL.

slide54

CLONIDINE

IN

SEARCH OF DOPAMINE

SINCE THE OPIOID WITHDRAWAL SYNDROME IS DUE IN PART TO HYPERACTIVITY OF THE MEDULLA LOCUS CAERULEUS AND EXCESSIVE CATECHOLAMINES, A DRUG WHICH BLOCKS THIS EFFECT SHOULD TREAT THIS PART OF THE OPIOID WITHDRAWAL SYNDROME.

CLONIDINE( CATAPRESS) IS A CENTRALLY ACTING ALPHA-2 BLOCKER AND DOES THIS WELL.

WHAT ABOUT THE DOPAMINE DEFICIENCY? A BENZODIAZEPINE WAS NEEDED TO BE ADDED TO THE ABOVE REGIMEN TO MAKE THE TREATMENT PALABLE TO THE PATIENT. THIS BENZODIAZEPINE VIA INHIBITING GABA IN INTERNEURONS OF THE VTA SUPPLIED THE DOPAMINE.

slide55

REPRESENTATIVE VIGNETTES

  • DR. COMPLETELY COOPERATIVE—MOST COMMON SCENARIO
  • DR. COOPERATIVE BUT DILATORY---NEEDS SOME PRODING
  • DR. COOPERATIVE BUT SELECTIVE---”NOT TO YOUR PATIENT”
  • DR. COOPERTIVE BUT NOT REALLY---REDUCE BUT WON’T STOP!
slide56

CCBHO INITIATIVE

THE EXPRESSED PURPOSE OF THIS INITIATIVE WAS TO DECREASE THE USE OF BENZODIAZEPINES AND OPIOIDS IN METHADONE CENTERS….AND IT WORKED!

CCBHO GIVES THE METHADONE CLINICS A LISTING OF PATIENTS WHO ARE GETTING BENZODIAZEPINE AND/OR OPIOID SCRIPTS. THESE PRESCRIPTIONS WOULD NOT BE REGISTERED AT THE CLINIC NOR WOULD EVIDENCE OF THE DRUGS SHOW IN THE ROUTINE URINES.

slide57

CCBHO INITIATIVE

THIS SCENARIO WAS VIRTUALLY UNCHANGED.

DOCTOR TO DOCTOR COMMUNICATION SPOILED THE ENTERPRISE.

slide59

IN CONCLUSION, THE INTERVENTIONS I HAVE DESCRIBED WITH THE ASSISTANCE OF CCHBO DID AND CONTINUES TO MAKE A DIFFERENCE FOR THE BETTERMENT OF THE LIVES OF THE PATIENTS AT TADISO.

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