review of medication and impact of the opiate epidemic · 12/12/2019 · opiate epidemic. › nchs...

Review of medication and Impact of the Opiate Epidemic

httpswwwcdcgov rsaquo nchs rsaquo products rsaquo databriefs

In 2017 there were 70237 drug overdose deaths in the United States The age-adjusted rate of drug overdose deaths in 2017 (217 per 100000) was 96 higher than the rate in 2016 (198)

The age-adjusted rate of drug overdose deaths in2016 (198 per 100000) was 21 higher than the rate in 2015 (163)

ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquo

By Abby Goodnough Josh Katz and Margot Sanger-Katz

July 17 2019 -NYT

Death rates increasing for opioids

Drug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon

= FENTANYLDrug and Opioid-Involved Overdose Deaths mdash United States 2013ndash2017 MMWR Morb Mortal Wkly Rep 2019671419ndash1427 DOI httpdxdoiorg1015585mmwrmm675152e1external icon


Cocaine deaths rising due to opioids

Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse Potential mdashUnited States 2003ndash2017 MMWR Morb Mortal Wkly Rep 201968388ndash395 DOI httpdxdoiorg1015585mmwrmm6817a3

Methamphetamine deaths rising independent of opioids


Opioid Overdose Deaths (1999 - 2017)

Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC) National Center for Health Statistics Multiple Cause of Death 1999-2017 on CDC WONDER Online Database released 2018 Data are from the Multiple Cause of Death Files 1999-2017 as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program

Drug Overdose Deaths Drop inUS for First Time Since 1990


July 17 2019 -NYT

San Francisco 2018 - 150 increase

bull according to the San Francisco Department of Public Health (released data 82019)

bull 89 people died from accidental overdoses of fentanyl last year (2018)

bull 36 fentanyl-related deaths in 2017

West Mountain West

httpswwwkfforgotherstate-indicatoropioid-overdose-deaths-by-raceethnicity

New England


Mid-Atlantic Appalachia


Rand 2019 The Future of Fentanyl and Other Synthetic Opioids


Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States Julyndash

December 2017 to JanuaryndashJune 2018

MMWR Morb Mortal Wkly Rep 201968737ndash744

If cannot reduce supply ndash Reduce Demand

bull Preventionbull Treatment bull ldquoHarm reductionrdquo

ASAM Short Definition of Addiction

ndash Addiction is a primary chronic disease of brain reward motivation memory and related circuitry

ndash Dysfunction in these circuits leads to characteristic biological psychological social and spiritual manifestations

ndash This is reflected in an individual pathologically pursuing reward andor relief by substance use and other behaviors

ASAM Short Definition of Addiction (continued)

ndash Addiction is characterized by inability to consistently abstain impairment in behavioral control craving diminished recognition of significant problems with onersquos behaviors and interpersonal relationships and a dysfunctional emotional response

ndash Like other chronic diseases addiction often involves cycles of relapse and remission

ndash Without treatment or engagement in recovery activities addiction is progressive and can result in disability or premature death

Recovery

Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as

ldquoa process of change through which individuals - improve their health and wellness - live a self-directed life - and strive to reach their full potentialrdquo

httpswwwsamhsagovbrss-tacsrecovery-support-tools-resources

Recovery-Related Values and Beliefs bull People who suffer from substance use disorders

(recovering or not) have essential worth and dignity bull The shame and discrimination that prevents many

individuals from seeking help must be vigorously combated

bull Recovery can be achieved through diverse pathways and should be celebrated

bull Access to high-quality treatment is a human right although recovery is more than treatment

bull People in recovery and their families have valuable experiences and encouragement to offer others who are struggling with substance use

US Department of Health and Human Services (HHS) Office of the Surgeon General Facing Addiction in America The Surgeon Generalrsquos Report on Alcohol Drugs and Health Washington DC HHS November 2016

Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENT

PROGRAMS (January 2015)bull Recovery-oriented systems of care (ROSC) are based on the substance use

treatment communityrsquos concept of recovery and recovery management bull Recovery is defined as a voluntary self-directed ongoing process where

patientsndash access formal and informal resources ndash manage their care and their addiction ndash and rebuild their lives relationships and health to lead full meaningful lives

bull While recovery is patient directed recovery management comprises the clinically based structured processes used to coordinate and facilitate the delivery of recovery support services after the acute stage of treatment

httpsstoresamhsagovshincontentPEP15-FEDGUIDEOTPPEP15-FEDGUIDEOTPpdf

Recovery versus Remissionbull Remission is a medical term meaning that major

disease symptoms are eliminated or diminished below a predetermined harmful level

bull Recovery from substance use disorders has had several definitions Although specific elements of these definitions differ all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person


Full Agonist Partial versus Antagonist

Treatment Improvement Protocol (TIP) 63 ndash Medications for Opioid Use Disorder -Part 3 (February 2018)

Safest

Least Safe

Safer



Safest

Least Safe

Safer

MOST STIGMATIZED

LEAST STIGMATIZED

Medication As Treatment

bull A treatment is provided to improve chances of certain outcomes

bull Agonist and partial agonist medications maintain tolerance to respiratory depressant effects of acute exposure

bull Stabilizes brain chemistry and reduces cravingsbull There are risks and benefits to all treatmentsbull Ex Aspirin prevents clot formation in CAD (it does not prevent

plaque rupture)

Which medication to recommend for Opioid Use Disorder (OUD)

ie treat people with Addiction who use opioids

bull All 3 medications approved to treat OUD work as long as the patient will take the medication

bull Which medication to prescribe for OUD ndash The one the patient will takendash Discussions with the patient about the pros and

cons of each option are keyndash Noncompliance with (or discontinuation of)

medication regimen is associated with very poor outcomes (death)

All cause mortality rates in and out of opioid substitution treatment with methadone or buprenorphine 1974-2016

Luis Sordo et al BMJ 2017357bmjj1550

copy2017 by British Medical Journal Publishing Group

3x



2x


ldquoMedication Assisted Treatmentrdquo

bull The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT

bull Does the medication assist the behavioral interventionsbull Or do behavioral interventions assist adherence to the

medication regimenbull Does one require the other

Center for Substance Abuse Treatment Medication-assisted treatment for opioid addiction in opioid treatment programs Rockville (MD) Substance Abuse and Mental Health Services Administration (US) 2005 (Treatment Improvement Protocol (TIP) Series No 43)


bull Long held belief that best practice includes non-pharmacologic interventions as well as appropriate medications

bull Included popularized in TIP 43 in 2005bull Programs require participation in counseling twelve step in

order to receive medicationbull ldquoLow Barrier Low Thresholdrdquo programs do not require more

than statefederal minimums


MAT ldquoMedication Assisted Treatmentrdquo

bull Does required participation in counseling community support work (versus voluntary ie self ndash directed)

bull What are the consequences if patient refuses or is unable to participate

bull Is it appropriate to refuse medication to those who struggle along the recovery path


bull Term has caused confusion (reduces access to care)bull Coined at a time when death rate with relapse was low and

stigma was very highbull Often a barrier to access to life saving medication bull What is the treatment the medication is assisting

Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient

outcomesFormerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system

Abstinence from opiates and cocaine at 6 month follow-up (based on zero days of self-reported use in the past 30 days and a negative urine test for these drugs) Abstinence rather than reduction in use was selected as the endpoint of interest because of 12-step groupsrsquo emphasis on this outcome

J Subst Abuse Treat 2015 Oct 57 89ndash95


outcomes

At 6 months 63 in treatment 33 abstinent

Formerly drug-free treatment programs that adopted buprenorphine in a city initiative promoting expansion of buprenorphine throughout the publicly-funded treatment system



- Observational study showing improved outcomes for those willing to attend NA

- ldquoeach additional NA meeting attended over the course of 6 months was associated with a 1 increase in the odds of being abstinent at 6 monthsrdquo

- ldquo(Extrapolating from this finding the odds of abstinence would be expected to increase by 26 for those attending just 1 NA meeting a week vs no meetings over the 6 month period)rdquo

- No benefit seen when patients had counselors who required attendance


MAT and Counseling

bull Obvious benefits of 12 step and counseling for those who engagehellip little evidence supports any incremental improvement in outcomes over medication alone in most studies

bull ldquoForcedrdquo participation in counseling 12 ndash step probably not helpful

bull Voluntary (self directed) participation is evidence of Recovery (and better outcomes)

The role of behavioral interventions in buprenorphine maintenance treatment A reviewAm J Psychiatry 2017 Aug 1 174(8) 738ndash747

Medication IS the Treatment

bull Aspirin is much more dangerous than buprenorphine (salicylate poisoning GI bleed)

bull No one would deny those with CAD Aspirinndash Even if they were not active in cardiac rehabilitation program exercising

eating healthy seeing their doctor nutritionist exercise therapist andor going to community support groups

bull Yet there is no doubt that cardiac non-pharmacological interventions improve outcomes

bull Non- pharma treatment benefits many people with many diseases

Medication IS the Treatment for Addiction involving Opioids

bull For preventing overdose deathsbull Decreasing use of illicit substancesbull Reducing cravingbull Decreasing transmission of infectionsbull Decreasing criminalitybull Keep people alive so they can find their path of recovery

bull Break

MAR

bull The phrase ldquoMedication-Assisted Recoveryrdquo is a practical accurate and non-stigmatizing way to describe a pathway to recovery made possible by physician-prescribed and monitored medications along with other recovery supports eg counseling and peer support

NAAA is NOT Treatment (but it is useful)bull Mutual aid society (separate from treatment)

ndash voluntaryndash community of shared experience ndash members regularly meet to offer supportndash not externally regulated

ndash are based on experiential rather than expert knowledge

ndash make no formal diagnoses ndash maintain no medical recordsndash and require no service fees

White W Galanter M Humphreys K amp Kelly J (2016) The paucity of attention toNarcotics Anonymous in current public professional and policy responses to rising opioidaddiction Posted at wwwwilliamwhitepaperscom

Twelve- Step Facilitation (TSF)bull Is done professionally and is evidence based

effective (in non-opioid using population)bull The evidence demonstrate usefulness bull Need good boundariesbull If medications are indicated should be offeredbull Patients can have both medicine and TSF

rdquoWhen addiction treatment drifts across the border into mutual aid (eg clinical abandonment)those served fail to receive care at current standards of acceptable practice and they pay for activities that are free within mutual aid organizationsrdquo


MAR

bull Better term because it includes the concept of recoverybull Medication is the treatment bull Recovery is a process pathbull Helps dispel the myth that patients on methadone

buprenorphine are not abstinent and thus ldquonot in recoveryrdquo

Abstinence

bull Are people on medication abstinentbull Are they in recoverybull Is the prescription of medications harm reduction

THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208

of the Acts of 2018 March 2019

bull A spectrum of evidence-based and evidence-informed strategies including safer use managed use and abstinence to meet people who use drugs (PWUD) ldquowhere theyrsquore atrdquo preserve their dignity and address conditions of use along with the use itself

bull There is no universal definition or formula for implementation As harm reduction approaches and interventions should reflect specific individual and community needs program and policy design must reflect the diversity of settings and input from all relevant stakeholders

httpswwwmassgovfilesdocuments20190301Harm20Reduction20Commission20Report20283-1-201929pdf

ASAM definition of Harm Reduction

bull A treatment and prevention approach that encompasses individual and public health needs aiming to decrease the health and socio-economic costs and consequences of addiction-related problems especially medical complications and transmission of infectious diseases without necessarily requiring abstinence

bull Abstinence-based treatment approaches are themselves a part of comprehensive Harm Reduction strategies A range of recovery activities may be included in every Harm Reduction strategy

httpswwwasamorgdocsdefault-sourcepublic-policy-statements1-terminology

Harm Reduction

bull Isnrsquot all of medicine the balance between risks and benefitsbull Needle exchange program or supervised injection facility =

ldquoHarm Reductionrdquobull Another stigmatizing term that does not add value to the

argument bull Medication saves lives and allows people to move towards

recovery

Abstinence

bull No longer using the drug (or behavior) bull Is a goal but the definition of the disease includes relapse and

remissionbull Stigmatizing those who struggle with abstinence as an

outcome may not helpful

Time Course to Abstinence versus Recovery

bull Remission from a substance use disorder can take several years and multiple episodes of treatment Recovery Support Services andor mutual aid

bull There are many paths to recovery People will choose their pathway based onndash their cultural values ndash their socioeconomic status ndash their psychological and behavioral needs ndash and the nature of their substance use disorder

httpsaddictionsurgeongeneralgovkey-findingsrecovery

Recovery Support Servicesbull Well-supported scientific evidence

demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions

bull Evidence for the effectiveness of other recovery supports (educational settings drug-focused mutual aid groups and recovery housing) is promising

bull Many other recovery supports have been studied little or not at all

The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence asldquoWell-supportedrdquo when evidence is derived from multiple controlled trials or large-scale population studies ldquoSupportedrdquo when evidence is derived from rigorous but fewer or smaller trials and ldquoPromisingrdquo when evidence is derived from a practical or clinical sense and is widely practiced

Recovery and Medication

bull Medication ought to be prescribed for all who need it bull Recovery support services (RSS) should be offered and

encouraged to allbull Medication should not be withheld if participation with RSS is

low non-existent

Pharmacotherapyand mutual support benefits our

patientsbull Medications save livesbull Recovery work improves livesbull Hazelden Betty Ford residential program

combines the two modalities since 2012ndash Improved treatment retention (unplanned

discharges for those admitted struggling with using opioids went from 22 down to 25 once Buprenorphine added to Twelve-Step Facilitation)

Galanter M Combining medically assisted treatment and twelve-step programmingA perspective and review Am J Drug Alcohol Abuse 20171ndash9

Medication First

httpsdoiorg101016jjsat201906015

The four key principles of the Medication First approach are

bull 1) Clients receive pharmacotherapy as quickly as possible prior to lengthy assessments or treatment planning sessions

bull 2) Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits

bull 3) Individualized psychosocial services are offered but not required as a condition of pharmacotherapy

bull 4) Pharmacotherapy is discontinued only if it is worsening the clients condition


MO Public Funded


Commercially Insured

httpsdoiorg101016jdrugalcdep201902031

Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use

disorder in a United States commercially insured cohort

bullThe opioid overdose crisis is deadly but medication treatment is uncommonbullBuprenorphine therapy significantly reduced the risk of opioid related overdosebullOverdose risk on naltrexone was not significantly different from no treatment


Hazelden Betty Ford (COR-12)


Medication-assisted treatment for opioid use disorder within a 12-step based treatment center Feasibility and initial results

bullThe use of medications for treating OUD was examined in a traditional 12 step treatment setting (Hazelden Betty Ford)bullNearly all participants successfully completed residential treatmentbullPatients who were compliant with medications had positive outcomes after treatmentbullPatients who were not compliant with naltrexone had especially unfavorable outcomes


bull In summary the findings reported here demonstrate the feasibility of including MAT within a 12-step based professionally led treatment program

bull Despite concerns about philosophical disagreements or provider bias the majority of patients elected to begin taking either buprenorphine-naloxone or naltrexone with the intention of maintaining on the medications after discharge

bull Some interesting differences emerged among medication groups suggesting patients with higher craving and more severe withdrawal symptoms may be more likely to elect buprenorphine-naloxone maintenance over naltrexone options or no medications at all



bull substantial improvements in OUD patient retention since implementing the COR-12 program with atypical discharge rates (eg leaving against staff advice) dropping from 22 to 6 in its residential program (Klein 2017)

bull The only significant contrast that emerged between the three compliant drug conditions was that injectable naltrexone patients who took their medication as prescribed were more likely to be continuously abstinent at 6thinspmonths than buprenorphine-naloxone patients who were similarly compliant This suggests injectable naltrexone may have the potential to be more efficacious than buprenorphine-naloxone in preventing relapse to drugs or alcohol in patients with OUD However this finding should be replicated in a larger trial with biochemical confirmation of drug compliance and abstinence in order to determine if there is a real difference in efficacy

Initiating buprenorphine treatment for opioid use disorder during short-term in-patient lsquodetoxificationrsquo a randomized

clinical trial

httpsonlinelibrarywileycomdoi101111add14737


clinical trialbull The effectiveness of linking people from short-term in-patient

managed withdrawal programs (lsquodetoxificationrsquo) to long-term primary care-based buprenorphine is unknown

bull tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM)

bull Among people with opioid use disorder initiation of and linkage to office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol


ldquoGiven extensive research evidence that pharmacotherapy is the most effective treatment for opioid use disorder (OUD) and the unabating rise in opioid overdose deaths it is increasingly apparent that detoxification and ldquodrug-freerdquo treatment should be replaced by medication induction and long-term pharmacotherapy as the first-line standard of carerdquo

Summary

bull Medication is first-line treatment for those with addiction involving opioids and encouraged for all

bull Recovery may occur with or without treatment with medication

bull Preventing OD and stressing the importance of recovery work ought not be in competition

bull The death toll is too great to allow shaming stigmatizing arguments limit access to lifesaving medication (or recovery services)

We can do both

(Vincent P Dole MD ndashThe ldquofather of methadone maintenancerdquo and class A Trustee of AA)

We can do bothbull ldquoMarie Nyswander Bill Wilson and Edward Dowling are no longer with

us but their inspiration remains For each life was a continuing Twelve Step They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected They would have welcomed the strength and scientific discipline that you bring to the fieldhellip (V Dole in Address to Addiction Medicine Soc) ndash They would expect you to study and debate the technical details of

treatment while being united in compassion for addicts ndash They would look to you for leadership that rises above special interests

and prejudice ndash They would hope that you could lead the way to rational measures of

prevention and a variety of effective nonpunitive treatments for various addictions

ndash Certainly they would expect you to be concerned with the enormous public health problem of addiction tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated It would be their fervent hope that you succeed


Slide Number 2

ldquoDrug Overdose Deaths Drop inUS for First Time Since 1990rdquoBy Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT






Slide Number 9

Slide Number 10

Drug Overdose Deaths Drop inUS for First Time Since 1990By Abby Goodnough Josh Katz and Margot Sanger-Katz July 17 2019 -NYT

Slide Number 12


West Mountain West

New England




Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines Cocaine and Methamphetamine mdash 25 States JulyndashDecember 2017 to JanuaryndashJune 2018

Slide Number 20




Recovery

Recovery-Related Values and Beliefs

Recovery OrientedFEDERAL GUIDELINES FOR OPIOID TREATMENTPROGRAMS (January 2015)

Recovery versus Remission




Which medication to recommend for Opioid Use Disorder (OUD)ie treat people with Addiction who use opioids

Slide Number 32

Slide Number 33





Buprenorphine treatment and 12-step meeting attendance Conflicts compatibilities and patient outcomes



MAT and Counseling



Slide Number 44

MAR

NAAA is NOT Treatment (but it is useful)

Twelve- Step Facilitation (TSF)

MAR

Abstinence

THE HARM REDUCTION COMMISSION REPORT - MAestablished by Section 100 of Chapter 208 of the Acts of 2018 March 2019


Harm Reduction

Abstinence


Recovery Support Services


Pharmacotherapyand mutual support benefits our patients

Medication First


MO Public Funded


Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort




Slide Number 66

Initiating buprenorphine treatment for opioid use disorder during short‐term in‐patient lsquodetoxificationrsquo a randomized clinical trial


Slide Number 69

Summary

We can do both

We can do both

httpswwwcdcgov rsaquo nchs rsaquo products rsaquo databriefs

In 2017 there were 70237 drug overdose deaths in the United States The age-adjusted rate of drug overdose deaths in 2017 (217 per 100000) was 96 higher than the rate in 2016 (198)

The age-adjusted rate of drug overdose deaths in2016 (198 per 100000) was 21 higher than the rate in 2015 (163)



July 17 2019 -NYT













July 17 2019 -NYT





West Mountain West


New England



















Recovery























Safest

Least Safe

Safer



Safest

Least Safe

Safer

MOST STIGMATIZED

LEAST STIGMATIZED





plaque rupture)










3x



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both



July 17 2019 -NYT













July 17 2019 -NYT





West Mountain West


New England



















Recovery























Safest

Least Safe

Safer



Safest

Least Safe

Safer

MOST STIGMATIZED

LEAST STIGMATIZED





plaque rupture)










3x



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both













July 17 2019 -NYT





West Mountain West


New England



















Recovery























Safest

Least Safe

Safer



Safest

Least Safe

Safer

MOST STIGMATIZED

LEAST STIGMATIZED





plaque rupture)










3x



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both





West Mountain West


New England



















Recovery























Safest

Least Safe

Safer



Safest

Least Safe

Safer

MOST STIGMATIZED

LEAST STIGMATIZED





plaque rupture)










3x



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both

New England



















Recovery























Safest

Least Safe

Safer



Safest

Least Safe

Safer

MOST STIGMATIZED

LEAST STIGMATIZED





plaque rupture)










3x



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both


















Recovery























Safest

Least Safe

Safer



Safest

Least Safe

Safer

MOST STIGMATIZED

LEAST STIGMATIZED





plaque rupture)










3x



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both




















Safest

Least Safe

Safer



Safest

Least Safe

Safer

MOST STIGMATIZED

LEAST STIGMATIZED





plaque rupture)










3x



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both



Safest

Least Safe

Safer

MOST STIGMATIZED

LEAST STIGMATIZED





plaque rupture)










3x



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both





plaque rupture)










3x



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both










3x



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both



2x

























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both
























outcomes










MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both








MAT and Counseling













bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both









bull Break

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both

MAR











MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both










MAR



Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both

Abstinence











Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both










Harm Reduction




recovery

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both

Abstinence
















low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both













low non-existent






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both






Medication First








MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both







MO Public Funded





















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both




















clinical trial









Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both








Summary





We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both

We can do both









Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both








Slide Number 2







Slide Number 9

Slide Number 10


Slide Number 12


West Mountain West

New England





Slide Number 20




Recovery








Slide Number 32

Slide Number 33








MAT and Counseling



Slide Number 44

MAR



MAR

Abstinence



Harm Reduction

Abstinence





Medication First


MO Public Funded






Slide Number 66



Slide Number 69

Summary

We can do both

We can do both

review of medication and impact of the opiate epidemic · 12/12/2019 · opiate epidemic. › nchs...

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