SAMHSA’s Tools For Treatment

Dr. Melinda Campopiano, MD Medical Officer, Substance Abuse and Mental Health

Services and Administration (SAMSHA)

Suzanne Fields, MSW, LICSW Senior Advisor to the SAMHSA Administration on Health

Care Financing, SAMHSA

Learning Objectives

1.  Identify SAMHSA’s tools for treatment.

2.  Identify the methods for medicated-assisted treatment.

3.  Analyze the ACA and its effect on access to treatment

Disclosure Statement

•  Melinda Campopiano has no financial relationships with proprietary entities that produce health care goods and services.

•  Suzanne Fields has no financial relationships with proprietary entities that produce health care goods and services.

Tools and Strategies Addressing Prescription Drug Misuse

Melinda Campopiano von Klimo, MD Division of Pharmacologic Therapies Center for Substance Abuse Treatment

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Prescription Drug Misuse

•  Surveillance •  Risk and population specific

interventions •  Medication Assisted Treatment •  Overdose Prevention Education & Naloxone •  Appropriate Prescribing •  Effective monitoring •  Effective Screening

Rates of Prescription Drug Misuse

www.SAMHSA.gov/data

Prescription Drug Overdose

•  57% of fatal overdoses involve pharmaceuticals

•  Exceeds the number of overdose deaths annually due to heroin and cocaine combined.

•  Opioids were found in most deaths involving benzodiazepines, anti-depressants,

•  29.4% of fatalities involved opioids alone •  Increase in overall overdose death rates

since 1999 driven by increased prescribing of opioid analgesics

Morbidity and Mortality Weekly Report, November 4, 2011/60(43);1487-1492 Pharmaceutical Overdose Deaths, United States, 2010. JAMA, February 20, 2013-Vol 309, No. 7

Overdose Risk Factors

•  Any prescription for an opioid •  High dose opioid prescription •  Poverty (Medicaid) •  Poly-substance use •  Recent abstinence (jail, detox,

treatment) •  Age •  Illness

Overdose Intervention Education & Naloxone

Most overdoses occur in the presence of others.

Fatal overdoses usually happen over the course of several hours.

There is an antidote to opioid overdose. Poly-drug overdoses may benefit from

naloxone if opioids are present.

Prevention Messages

•  Don’t use drugs alone •  Know how to recognize an overdose •  Activate 911 •  Position of safety •  Rescue Breathing

Naloxone

•  Timely use of naloxone •  Greater availability of naloxone

•  More first responders equipped and trained to use it.

•  Greater physician prescribing of naloxone for patients at risk of overdose.

Treatment is Prevention

•  methadone maintenance treatment is effective in reducing morbidity and mortality associated with continued use of heroin and other illicit opiates, as well as HIV-related morbidity

•  “…the all cause mortality rate for patients receiving methadone maintenance treatment was similar to the mortality rate for the general population whereas the mortality rate of untreated individuals using heroin was more than 15 times higher.”

Modesto-Lowe et al., 2010; Gibson, 2008; Mattick, 2003; Bell and Zador, 2000; Marsch, 1998

Maintenance on Opioid Agonist Therapy

French population in 1999 = 60,000,000

1996 Subutex and methadone

1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Year

No.

of d

eath

s

600

500

400

300

200

100

0 Patients receiving methadone (1998): N= 5,360

Patients receiving buprenorphine (1998): N= 55,000

Auriacombe et al., 2001

Placebo Controlled Study of Maintenance vs. Detoxification with Methadone

Whitehall, 1974

Kaplan-Meier curve of cumulative retention in treatment

Time from randomization (days)

Num

ber r

emai

ning

in tr

eatm

ent

Control

Buprenorphine

P=0.0001

15

20

10

5

0 0 250 200 150 100 50 300 350

Placebo Controlled Study of Maintenance vs. Detoxification with Buprenorphine

www.pcss-o.org

Prescribers’ Clinical Support System for Opioid Therapies (PCSS-O)

Supports: • Innovative approaches to educating all clinicians who prescribe opioids Focus: • Safe use of opioids in treatment of pain including training on how to recognize misuse, abuse, and addiction in those with pain • Use of opioid therapies for treatment of opioid dependence

Prescribers’ Clinical Support System for Opioid Therapies (PCSS-O)

•  Developed 15 online modules and a 2 hr, 2 CME course available through the California Academy of Family Physicians.

•  More than 90% satisfied or very satisfied with quality of training and information presented and would recommend the training to colleagues.

Year  One  Webinars  

Year  Two  Webinars  

Online  Modules  

Archived  Webinar  Views  

Phone  App  Downloads  

Mentors   Mentees   Listserv  Par=cipants  

Total  Number  Trained  

2850   2249   818   1,365   733   37   97   194   8343  

Prescribers’ Clinical Support System for Opioid Therapies (PCSS-O)-Content

• A Review of Considerations in the Assessment and Treatment of Pain and Risk for Opioid Misuse • Advances in Recognition and Treatment of Substance Use Disorders in Primary Care • Clinical Guidelines for Opioid Use in Chronic Non- Cancer Pain • Considerations in Medication Assisted Treatment of Opiate Dependence • Implementation of Evidence Based Practice • Medication Assisted Treatment for Substance Use Disorders in Primary Care

www.pcss-b.org

Treatment Improvement Protocols and Advisories

Clinical Practice Guidelines

•  Treatment Improvement Protocols (TIPs) •  Detoxification and Substance Abuse Treatment •  Medication Assisted Treatment (MAT) for Opioid

Addiction in Opioid Treatment Programs •  Managing Chronic Pain in Adults With or in Recovery

From Substance Use Disorders •  Hepatitis C

•  Advisories •  Prescription misuse, Oxycontin®, methadone,

Opana® (TTP) •  Vivitrol®

“Prescribing Opioids for Chronic Pain: Balancing Safety & Efficacy”

25  

“Prescribing Opioids for Chronic Pain: Balancing Safety & Efficacy”

In-person course using national and local faculty 47 sites in 25 states Collaborate with local organizations or agencies. Tailored to local issues based on state-specific

surveillance data. Specialized courses developed for IHS and DOD Almost 9,000 practicing health professionals trained

Physicians, Advance Practice Nurses, Physician’s Assistants, Dentists, Oral Surgeons

Course Content

•  best practices and clinical protocols for the use of methadone and other opioids to treat pain,

•  evidence-based strategies for patient selection, risk assessment, and education,

•  techniques for effective patient monitoring, including the use of state prescription drug monitoring programs,

•  the risks and benefits of opioids, as well as how to incorporate clinical and administrative practices that reduce such risks and enhance patient outcomes

•  how to use state Prescription Drug Monitoring Programs (PDMPs)

Course Impact

•  Evaluations of the courses by participants and independent experts have been very positive,

•  average score of 6.0 on a scale of 1 to 7, with 7 designated “superior.”

•  In a 2012 follow-up survey, more than 76% of physicians who had completed a course reported that they made changes in the way they practice as a result of what they learned.

www.opioidprescribing.com

www.opioidprescribing.com

•  a series of 30-minute modules •  each targeted to a specific audience or

addressing a particular aspect of opioid prescribing.

•  In 2012 alone, more than 7,330 registrants completed at least one module for CME credit

•  another 15,163 certificates of completion were issued to individuals who completed more than one module

•  a total of 22,493 modules completed

Online Modules

•  Opioid Efficacy and Safety; Assessment and Monitoring Tools for Primary Care Settings

•  Communicating with Patients About Chronic Opioid Use

•  Managing Patients with Pain, Psychiatric Co-Morbidity and Addiction

•  Case Studies in Opioid Prescribing •  Issues in Clinical Practice •  Exit Strategies from Outpatient Opioid Therapy for Pain •  Managing Chronic Pain in Returning Military Personnel and

Their Families •  Use of State Prescription Drug Monitoring Programs (PDMPs)

in Clinical Practice

Course Impact

•  Developed in partnership with Boston University •  Consistently receives highest rating for content •  The Accreditation Council for Continuing Medical

Education (ACCME) “Accreditation with Commendation.”

•  The American Nurses Credentialing Center (ANCC) awarded BU “Accreditation with Distinction, the highest recognition awarded by the American Nurses Credentialing Center’s Accreditation Program.”

•  The American Academy of Family Physicians (AAFP) “The procedures established for conducting CME activities at your institution are exemplary.”

Prescription Drug Monitoring Programs

•  Real-time data entry and access •  Easy Prescriber Access •  Cross-boarder sharing of state data. •  Physicians encouraged or required to

use PDMP. •  Opioid Treatment Programs must

check PDMP

Screening, Brief Intervention and Referral to Treatment

•  Systematic screening for harmful or hazardous substance use and risk factors for overdose where most opioid prescribing is done.

•  Brief motivational discussion focused on feasible, positive behavior change.

•  Education targeted to specific risks. •  More effective treatment referral.

SBIRT Billing and Coding Guidance

Tools and Strategies

•  Overdose education •  SBIRT •  PDMPs •  Treatment •  Physician Education •  Surveillance

Contact

melinda.campopiano@samhsa.hhs.gov