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Opening the Way for Medication-Assisted Treatment

in Family Drug Courts

Closed Doors or Welcome Mat?

Oklahoma Specialty Court Conference Thursday September 11, 2014

Erin Hall MSOT| Hon. Kyle B. HaskinsPresenters

This project is supported by Award No. 2013‐DC‐BX‐K002 awarded by the Office of Juvenile Justice and Delinquency Prevention Office of Justice Programs. The opinions, findings, and conclusions or recommendations expressed in this

publication are those of the author(s) and do not necessarily reflect the views of the Department of Justice

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Who is here today?

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The Need for Medication-Assisted Treatment (MAT)

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The Prescription Drug Abuse Problem

• 478millionprescriptionsforcontrolled‐substancesdispensedinU.S.in2010• 7millionAmericansreportedcurrentnon‐medicaluseofprescriptiondrugs

in2010• In2010,2millionpeoplereportedusingprescriptionpainkillersnon‐

medicallyforthefirsttimewithinthelastyear—nearly5,500aday• 1in4peopleusingdrugsforfirsttimein2010beganbyusingaprescription

drugnon‐medically• 6oftop10abusedsubstancesamonghighschoolseniorsareprescription

drugs

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Trends in Emergency Department Visits Involving the Non-medical Use of Opioid Pain Relievers: 2004-2011

0

100000

200000

300000

400000

500000

600000

2004 2005 2006 2007 2008 2009 2010 2011

Num

berofEDVisits

Source:2011SAMHSADrugAbuseWarningNetwork(DAWN)

EDvisitsinvolvingthemisuseorabuseofopioidpainrelieversrose183%from2004to2011.

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Overall Female Treatment Admissions for Other Opiates* as Primary Substance of Abuse

1.9%

8.4%

11.9%

0

2

4

6

8

10

12

14

1998 2008 2011

Percent

Year

Retrieved 09/05/13 fromhttp://wwwdasis.samhsa.gov/webt/newmapv1.htm*Other opiates includes non-prescription use of methadone, codeine, morphine, oxycodone, hydromorphone, meperidine, opium, and other drugs with morphine-like effects. 7

What is MAT?

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ASAM Definition of Addiction

“Addictionisaprimary,chronicdiseaseofbrainreward,motivation,memoryandrelatedcircuitry.Dysfunctioninthesecircuitsleadstocharacteristicbiological,psychological,socialandspiritualmanifestations.Thisisreflectedinanindividualpathologicallypursuingrewardand/orreliefbysubstanceuseandotherbehaviors.”

AdoptedbytheASAMBoardofDirectors4/12/2011

A Chronic, Relapsing Brain Disease•Brainimagingstudiesshowphysicalchangesinareasofthebrainthatarecriticalto• Judgment

• Decisionmaking

• Learningandmemory

• Behaviorcontrol

•Thesechangesalterthewaythebrainworks,andhelpexplainthecompulsionandcontinuedusedespitenegativeconsequences

SubstanceUseDisordersaresimilartootherdiseases,suchasheartdisease.Bothdiseasesdisruptthenormal,healthyfunctioningoftheunderlyingorgan,haveseriousharmfulconsequences,arepreventable,treatable,andifleftuntreated,canresultinprematuredeath

What is Medication-Assisted Treatment (MAT)?

• MATistheuseofmedications,incombinationwithcounselingandbehavioraltherapies,toprovideawhole‐patientapproachtothetreatmentofsubstanceusedisorders(SAMHSA,n.d.)

• MATisclinicallydrivenwithafocusonindividualizedpatientcare

• Researchshowsthatwhentreatingsubstance‐usedisorders,acombinationofmedicationandbehavioraltherapiesismostsuccessful

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Three FDA-approved Medications for Opioid Addiction

•Methadone‐ Dolophine®

•Buprenorphine – Suboxone,® Subutex®

•Naltrexone• oral– ReVia,®Depade®• extendedreleaseinjection‐ Vivitrol®‐

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EH1

Opioid Agonist v. Antagonist

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Source: retrieved from http://www.vivitrol.com/opioidrecovery/howvivitrolworks15

• Accesschallenges• Dailydosesatclinic• Diversioncanbeaconcern

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• Effectivenessiswelldocumented:‐ Withdrawalsymptomsuppression‐ Patientretention‐ Reductionofopioiduse‐ Reductionofopioid‐relatedhealthandsocialproblems(i.e.crime)

Methadone

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EH1 Buprenorphine - less chronic dependency - really?Erin Hall, 8/26/2014

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•Availablefromprimaryandgeneralistphysicianswithwaiver

•Betteraccess

•Higheffectiveness

•Lowerdiversionrisk(butstillsomerisk)

•Noeupohoria,lowerstreetvalue

Buprenorphine

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Naltrexone

•Monthlydosage•Canbeprescribedbyanyhealthcareproviderwithprescriptionauthority•Canonlybeusedwithfullydetoxifiedpatients,causesimmediatewithdrawalifopiatestillinsystem

•Nodiversionrisk•Lesseffectiveforopioidaddiction(betterforalcohol)

Vivitrol

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How do we know it works?

Aspartofacomprehensivetreatmentprogram,MAThasbeenshownto:• Improvesurvival

• Increaseretentionintreatment

•Decreaseillicitopiateuse

•Decreasecriminalactivities

• Increaseemployment

• Improvebirthoutcomesamongopioiddependentpregnantwomen

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MAT is only part of the solution

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Source: retrieved from http://www.vivitrol.com/opioidrecovery/howvivitrolworks21

Comprehensive Treatment

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• Counseling – individual and group• Drug testing• Trauma/mental health care• Primary healthcare• Intensive case management• Relapse prevention• Aftercare• What else do you consider comprehensive treatment?

Does your FDC provide

comprehensive treatment?

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If we know MAT works why aren’t

FDCs using it?24

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MAT & Drug Courts

• Arecentnationalsurveyfoundthatnearlyhalfofdrugcourtsdonotusemedicationsintheirprograms(Matusow etal,2013)

• Oneoftheprimarybarrierstousingmedicationswasreportedlyalackofawarenessoforfamiliaritywithmedicaltreatments

• Needforsubstantial,targetededucationalinitiativestoincreaseawarenessofthetreatmentandcriminaljusticebenefitsofMATinthedrugcourts

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Why the Closed Doors?

1. Misconceptionofaddictionasamoralweaknessorwillfulchoice

2. Separationfromrestofhealthcare3. Languagemirrorsandperpetuates

stigma4. Failurebycriminaljusticesystemto

defertomedicaljudgmentintreatment

Stigma

Source:OlsenandShafstein,JAMA,201426

Why the Closed Doors?

1. Whencorrectlyprescribedandused:methadonedoesnotcreatea“high”

2. “Using”MATissimilarto“using”Prozactotreatdepressionorinsulintotreatdiabetes,notsimilarto“using”heroin

3. Addictionisatreatablediseaseofthebrainnotamoralfailingorachoice

Lack of knowledge

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How do we incorporate MAT into

our family drug court?

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Without coordinated responses, families are not well served.

Different Agencies

Different Mandates

Different Organizations

Different ProvidersDifferent Goals

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NADCP - MAT

In2012,theNADCPBoardofDirectorsissuedaunanimousresolution:

• MakereasonableeffortstoattainreliableexpertconsultationontheappropriateuseofMATfortheirparticipantsincludingpartneringwithsubstanceabusetreatmentprograms thatofferregularaccesstomedicalandpsychiatricservices.

• DonotimposeblanketprohibitionsagainsttheuseofMATfortheirparticipantsandthedecisionwhetherornottoallowtheuseofMATisbasedonaparticularizedassessmentineachcase.

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1. DoesyourFDChaveapolicythataddressestheuseofMATforparents?Arethereconflictingpoliciesinpartneragencies(i.e.childwelfare)?

2. DoesyourFDChavearequirementofminimal“dosing”ordiscontinuanceofMATmedicationsforreunification?

3. DoesyourFDCuseMATasexclusionarycriteria?

4. DoesyourCWSsystemhaveaplanofsafecareforinfantsandmothersaffectedbyopioiduse?

Policy and Practice Issues

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• Continuetoaccesseducationforallteammembers

• GettoknowthelocaloptionsforMAT

• TourMATprogramsandaskforanexplanationoftheirdosing&drugscreeningpractices

• HaveclientsignReleaseofInformationforMATprovidertofacilitateinformationsharing

• CreateawrittenpolicyforMAT

• EstablishcommunicationprotocolsacrossSAcounselors,MATproviders,court,childwelfareandotherteammembers

• InviteMATproviderstoparticipateinFDCstaffings

Recommendations for FDCs

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• Admissioncriteria– MATshouldnotbeanexclusionarycriteria

• ComprehensiveServices– MATshouldbepairedwith• Counseling,• Drugtestingandmonitoring,• Intensivecasemanagementandsupport(housing,employment,etc)

• Aftercare

Considerations for MAT policy for FDCs

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• Coordinationandcommunicationwithprescribingphysiciansincluding:• Typeofmedication,dosageandfrequency• Attendanceatscheduledappointments• Parentbehaviorandpatternsofconcern

• CommunicationfromFDCtophysician• RequirementsofFDCparticipation• Parentbehaviorandpatternsofconcern(mayindicateneedtoadjustdosage)

Considerations for MAT policy for FDCs, Con’t

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• Linkageswithotheragencies– dopartnershaveoutdatedandconflictingMATpolicies?

• Compliancemonitoring‐ specifywhoandhowwillthisbeaccomplished?

• Responsestobehavior– therapeutic,withconsiderationforstageofrecovery,phaseinFDC,etc.

Considerations for MAT policy for FDCs, Con’t

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Special Considerations for Pregnant Women

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•Current (2012) standard of care for pregnant women with opioid dependence is referral for opioid-assisted therapy with methadone

•NAS is an expected and treatable condition that follows prenatal exposure to opioid agonists

Source: The American College of Obstetricians and Gynocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076.

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MOTHERS StudyThe first randomized controlled trial data to support the safety and efficacy of bupernorphine. Findings include:

• Maternal outcomes, pain management considerations, and breastfeeding recommendations are similar between medications.

• Buprenorphine is an effective option for pregnant women who are new to treatment or maintained on buprenorphine pre‐pregnancy.

Hendree Jones, Presented at the NADCP Annual meeting, May 28, 2014, Anaheim, CA.

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Children and Recovering Mothers (CHARM) Overview

• A multidisciplinary group of agencies serving pregnant women with opiate addiction and their infants  

• Provides comprehensive care coordination for pregnant women with opiate addiction and consultation for child welfare, medical, and addiction professionals across the state of Vermont

• The CHARM collaborative serves about 200 women and their infants annually.

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Key Elements of CHARM

• In person meeting 2 hours each month

• Two year effort to create Memorandum or Understanding

• Team effort to engage women and get release of information singed 

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Key Elements of CHARM• Child welfare can begin providing services 30 prior to due

date

• State statute allows for Child Safety Teams to act on behalf of child safety

• 24/7 telephone support for families with infants needing methadone at home 

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The Tulsa Experience

Hon. Kyle B. Haskins

Opening the Doors in Family Drug Courts

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HastheTulsaCountyFDCalwaysbeenopentoMAT?

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WhatweresomeofthekeybarriersinacceptingMATclientsinyourFDC?

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WhyisitrecommendedthatFDCsnotconsiderMATasanexclusionarycriteria?

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WhataresomeapproachesineducatingCWS,AOD,andCourtsregardingMAT?

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WhatarenextstepsinregardstopolicyandpracticeinvolvingMATclientsinyourFDC?

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Next Steps & Resources

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Todownload,pleasevisit:http://www.lac.org/doc_library/lac/publications/MAT_Report_FINAL_12‐1‐2011.pdf

LegalityofDenyingAccesstoMedicationAssistedTreatmentintheCriminalJusticeCenter(LegalJusticeCenter,December2011)

Resource

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Resource

AdultDrugCourtBestPracticesStandards,SectionG,“Medications”,page44

DrugCourtJudicialBenchbook,VI.,Section4.14,“AddictionMedicine”,page76 52

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To download, please visit: www.ncsacw.samhsa.gov/files/Substance-Exposed-Infants.pdf

Resource

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FDC LEARNING ACADEMY WEBINAR SERIESTHIS CHANGES EVERYTHING

in 2014Please join us

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March 6th Tested and Proven – Utilization of Recovery Support Specialists as a Key Engagement and Retention Strategy in FDC (and Beyond)

April 10th Our Grant is Over – Now What? Re-financing and Re-Directing as Real Sustainability Planning for Your FDC

June 19th Closed Doors or Welcome Mat? Opening the Way for Mediction-Assisted Treatment in FDC

July 10th So How Do You Know They Are Really Ready? Key Considerations for Assessing Families in Recovery for Reunification

Aug. 14th Exploring Solutions Together – The Issue of Racial and Ethnic Disproportionality in FDCs

Sept. 18th Matching Service to Need – Exploring What “High- Risk, High-Need” Means for FDCs

This Changes Everything - 2014

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Contact Information

Erin Hall, MSOT Hon. Kyle B. Haskins

Program AssociateChildren & Family Futures25371 Commercentre Dr.Suite 140 Lake Forest, CA 92630(714) 505‐3625ehall@cffutures.org

Tulsa County Juvenile Bureau315 S. Gilcrease Museum Rd.14th Judicial Dist., State of OKTulsa, OK 74127 918‐596‐5910  kyle.haskins@oscn.net

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