Kenneth Stoller, M.D. - Texas Council of Community Centers

Medication Assisted Treatment: Opportunities for Community Centers

Kenneth Stoller, M.D. Johns Hopkins University School of Medicine Asst. Prof., Department of Psychiatry and Behavioral Sciences Director, Johns Hopkins Hospital Broadway Center for Addiction

Texas Council of Community Centers 31st Annual Conference, San Antonio, TX

Thursday, June 23, 2016

Disclosure to Participants

June 23, 2016 Ken Stoller: Texas Council of Community Centers

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Disclosures: Dr. Stoller

•  No relevant financial relationships with commercial interest over the past year.

•  No discussion of unapproved uses of a commercial product, or investigational use of a product not yet approved for this purpose

Ken Stoller: Texas Council of Community Centers

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Opioid Epidemic


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Beyond Opioids: Benzodiazepine ED visits


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The Dawn Report

12/2014

Beyond Opioids: Alcohol Use Disorder (AUD)


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16.3 million adults (6.8%) had an AUD. This includes 10.6 million men (9.2%) and 5.7 million women (4.6%). 679,000 youth 12–17y (2.7%) had AUD, (3.0% of girls and 2.5% of boys).

2014 National Survey on Drug Use and Health (NSDUH)

SUD in mental health settings

Epidemiologic Catchment Area (ECA) study, conducted in the United States between 1980-1984: Individuals with a psychiatric disorder were 2.7 times more likely to have a substance use disorder Patients with co-occurring MH and SUD problems need to be treated concurrently for both.


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SUD in mental health settings

This presents both a: •  Problem (untreated SUD makes recovery from

mental illness less likely), …as well as an… •  Opportunity (to improve outcome by assuring

MH and SUD are both treated)


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Problems and Opportunities: It’s all about PERSPECTIVE


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Problems and Opportunities: It’s all about PERSPECTIVE


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We will examine the problem of SUD from these perspectives:


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Public Health, Policy, Gov’t Agency

Payor

Behavioral Health (BH) Clinician

BH Program Administrator

Medical Provider

But first the nuts and bolts…


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Drug Classes By Predominant Effect

•  Depressants •  Stimulants •  Opioids •  Hallucinogens •  Solvents •  Others

Examples: •  Alcohol •  Benzodiazepines •  Barbiturates


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Examples: •  Cocaine •  Methamphetamine •  Caffeine •  Nicotine



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Examples: •  Heroin •  Morphine •  Codeine •  Methadone •  Buprenorphine



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Examples: •  Lysergic acid (LSD) •  Nitrous oxide •  Psilocybin (“Shrooms”) •  MDMA (“Ecstasy”)


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Examples: •  Lacquer thinner •  Benzene •  Gasoline •  Toluene


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Examples: •  Marijuana/Cannabis •  Phencyclidine (PCP)


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Drug Classes treatable through maintenance pharmacotherapies

•  Depressants (alcohol) •  Stimulants •  Opioids •  Hallucinogens •  Solvents •  Others


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Medication Assisted Therapies (MAT)

For Alcohol: •  Disulfiram (Antabuse®)•  Naltrexone (oral and monthly injectable) •  Acamprosate For Opioids: •  Methadone •  Buprenorphine (sublingual, buccal, implant) •  Naltrexone (oral and monthly injectable)


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Alcohol: Pharmacotherapy

Disulfiram (Antabuse®): •  Only after detoxed •  Interferes with alcohol processing •  Severe reaction if alcohol is used •  Need to monitor liver function •  Adherence is the challenge


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Naltrexone (ReVia®, Vivitrol®):•  Opioid antagonist•  Pill or monthly intramuscular injection•  Decreases craving•  Decreases pleasurable effects•  Need to monitor liver function•  Adherence is the challenge


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Acamprosate (Campral®):•  Mechanism of efficacy not clear•  Long history of use in Europe•  Lowers likelihood of drinking•  Thrice daily dosing•  Adherence is the challenge


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Opioids: Pharmacotherapy

Methadone•  Full opioid agonist taken orally (liquid) daily•  Very well studied, used for over 40 years•  Works by:

–  Preventing withdrawal–  Reducing craving–  Blocking effects of other opioids (e.g., heroin)

•  Opioid Treatment Programs: –  1400 OTP’s in 48 states


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Methadone•  Mandated services that can enhance outcome:

–  Supervised dosing (and earned take-homes)–  Counseling–  Drug testing–  Addressing other rehabilitative goals

•  Quality and quantity of these elements can vary among OTPs.


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Methadone Regulations: •  Highly specific and detailed•  Federal regulation through SAMHSA, DEA•  States and localities have additional regs•  Accreditation is required (e.g., The Joint

Commission, or CARF)•  Cannot be “prescribed” outside OTP’s


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Criticism often based in stigma:Despite 40+ years of experience and 1000’s of scientific studies supporting good outcome and societal benefits, stigma sustains opinions like:•  “It is just a crutch”•  “It is just substituting one drug for another”•  “It makes them high – I see them nodding”•  “They’re not really in recovery”


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“It’s just a crutch”


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Opioids agonist maintenance: The truth…

•  Normalize body functioning that was impaired by years of opioid misuse.

•  Enables meaningful recovery activities.•  Do NOT create a “high.” DO relieve craving.•  Can still get high from other drugs, alcohol.•  Other medications can sedate (esp. psych meds).•  There is no need to segregate patients.•  Patients include social workers, lawyers, engineers,

roofers, gardeners, retired, administrators, gov’t workers, teachers, business owners…


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•  Buprenorphine•  Sublingual, buccal, or skin implant•  Partial opioid agonist (makes safer)•  Combined with naloxone (discourages diversion)•  Can be prescribed in doctor’s office if “waivered”•  Mainstreams treatment•  Expands treatment capacity•  Does not usually mandate counseling


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Naltrexone (ReVia®, Vivitrol®):•  Opioid antagonist•  Blocks opioid effects•  Decreases cravings•  Pill or monthly injection•  Effective in studies•  Tricky to start - has to be opioid-free•  Limited by poor compliance•  Most effective with motivated patients


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SUD: Treatment Approaches


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Medication: •  Methadone •  Buprenorphine •  Naltrexone •  Disulfiram •  Acamprosate •  Nicotine quitting aids

such as nicotine replacement, varenicline

Behavioral: •  Counseling •  Psychotherapy

(e.g., cognitive-behavioral) •  Contingency management

(e.g., voucher-based) •  Mandated abstinence •  Mandated treatment •  Self-help support groups

(e.g., AA, NA) •  Supportive housing

Integrated approaches work best


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Examples: •  Detoxification or maintenance + psychotherapy •  Behaviorally Contingent Pharmacotherapy •  Voucher-based reinforcement in methadone-

maintained patients •  Collaborative buprenorphine treatment •  Nicotine patch + behavioral therapy

Buprenorphine (DATA 2000) Waivers are Under-utilized.

•  Few waivered physicians… •  Who often do not prescribe at all, and… •  Typically treating far fewer than 100 patients

(maximum cap) •  Psychiatrists are underrepresented


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Buprenorphine Waivers are Under-utilized

National study of 545 waivered MD’s (Kissin et al., 2006): •  Only 58% had prescribed •  Barriers: Induction logistics, poor compliance, limited

counseling Study of 330 waivered MD’s (Center for a Healthy MD, 6/2007): •  Only 50% were prescribing •  Barrier: Perceptions that effective treatment of

addiction is difficult and time-consuming.


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Treatment Gap: Need for MAT exceeds capacity


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Christopher Jones et al., Amer J Pub Hlth, 8/2015

Past year OUD

Total MAT Capacity (bup, meth)

Total OBB Capacity (bup)

OTP patients (meth)

Barriers to PCP Prescribing Buprenorphine


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Eliza Hutchinson, et al., Annals of Family Medicine, 2014

Reluctance to obtain or use buprenorphine waivers

MH/SUD providers can encourage PCP waivers and support physician practice, by addressing concerns through collaborative models: •  Initial assessment: time-consuming •  Induction: initially intimidating •  Instability (relapse, diversion, nonadherence):

How to intervene to avoid consequences to office, community, patients?


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“Clinical Integration”

The extent to which patient care services are coordinated across people, functions, activities, and sites over time so as to maximize the value of services delivered to patients. Source: S.M. Shortell, R.R. Gillies, D.A. Anderson, et al. Remaking Healthcare in America: The Evolution of Organized Delivery Systems, 2nd edition, San Francisco:Jossey-Bass, 2000.


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Integration models

“Multispecialty Team”

“Co-Location” or

“Shared Space” “Collaboration”

Single Location Multiple Locations

Single Provider Entity:

Multiple Provider Entities:


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Collaborative Opioid Prescribing (“CoOP”) model*

Aim: Increase access to and effectiveness of office-based buprenorphine through concurrent OTP-based counseling, case management, collaborative stepped care, and expert consultation.

*Stoller, K.B., 2015. A collaborative opioid prescribing (CoOP) model linking opioid treatment programs with office-based buprenorphine providers. Addiction Science & Clinical Practice 10, A63 (published abstract).


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Collaborative Care: OTP + OBB’s


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Incentives to provide MAT from various perspectives:


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Payor



Medical Provider

Public Health, Policy, Governmental perspective:


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Costs of SUD to Society Criminal Justice: Police, prosecution, defense, court,

incarceration, parole, probation Crime Victims: Medical, property damage, lost

productivity Theft Losses: Value of stolen items Health Care: Medical, mental health, treatment Lost Earnings: Lack of legitimate income Income Transfers: Public assistance, disability

insurance



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Societal Benefits to Costs ratio Daily savings during treatment: $30.47 Daily cost for tx: $6.37 Societal benefit to cost ratio: 5 : 1 Source: Adapted from CALDATA General Report (1994), table 35



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Some other (non-monetary) benefits •  Quality of life •  Health of our communities •  Gun violence •  Family integrity

Incentives to provide MAT from various perspectives::


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Payor



Medical Provider

Payor perspective:


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Medical problems more likely addressed: •  168 new buprenorphine patients •  122 (73%) had no primary care provider •  (74%) reported at least one established chronic

condition at the initial visit •  68% of the diagnoses were not being treated, and of

those, 48% were, within a year •  28% patients had a new chronic condition identified,

and 72% received treatment (Rowe et al., Addict Sci Clin Pract 2012)

Payor perspective:


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Study examining MassHealth claims data 2003-2007 (from Clark et al., Health Affairs, 2011)

•  MAT associated with lower expenditure, fewer relapse events, decreased mortality



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Payor



Medical Provider

BH Clinician perspective:


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MAT through direct provision or coordination: •  Reduces drug use •  Improves effectiveness of MH treatment •  Improves psychiatric stability •  Increases show-rates, engagement, retention •  Clinically very satisfying Keep in mind SUD is already present; the question is whether it is detected, addressed, treated effectively



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Payor



Medical Provider

BH Program administrator perspective:


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•  Provides a wider spectrum of services •  Treatments more tailored to patient need •  Increased referrals fosters program growth •  Improved adherence generates volume, revenue •  Collaboration with medical providers regarding

complex co-occurring conditions



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Payor



Medical Provider

Partnering medical provider perspective:


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•  Facilitates buprenorphine provision •  Previously untreated addiction is addressed •  Medical problems more likely addressed •  Improve medical adherence, morbidity •  Support and ready access to expertise •  Provides partners in managing behaviorally

challenging cases

Summary: Medication Assisted Therapies (MAT)


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•  Current patterns of substance use represent a public health crisis.

•  MAT can effectively augment alcohol and opioid use disorder treatment.

•  Treatment gap: MAT is underutilized. •  Integrative models can support access. •  Provision of MAT is incentivized at all levels of

health care and society.

Resources

Ken Stoller: TX Council of Comm. Ctrs 57 June 23, 2016

SAMHSA publications: store.samhsa.gov/ SAMHSA-funded PCSS-MAT: pcssmat.org SAMHSA-HRSA Center for Integrated Health Solutions:

www.integration.samhsa.gov/ The National Council for Behavioral Health:

www.thenationalcouncil.org/ Center for Health Care Strateties: www.chcs.org/

Ken Stoller’s contact info: [email protected]

410-614-0654

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Kenneth Stoller, M.D. - Texas Council of Community Centers

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