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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
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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
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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
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• 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
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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
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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
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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
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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
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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
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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?
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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
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Treatment – For How Long?
• Two examples from model methadone and buprenorphine programs
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Pa.ent Reten.on in a Methadone Program
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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
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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
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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?
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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
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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
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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
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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?
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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?
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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
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“Recovery” from Opiate Substance Use Disorders
• Is recovery even possible?
• How is recovery achieved?
• With what reliability?
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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?
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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
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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
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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)
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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
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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
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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”
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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”
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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
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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
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• 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
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Elements of HOPE
• Treatment is available but only required when monitoring fails – “Behavioral Triage”
• 12-‐step par=cipa=on is encouraged but not required
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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
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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
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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
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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
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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
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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
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Conclusion
• The benefit of treatment can only be realized when outcomes are measured by the ability to make recovery the expected outcome
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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
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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
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Thank you!
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Discussion
Now I want to hear from YOU!
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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
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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.”