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    

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  

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  

•  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  

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  

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  

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  

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  

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  

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?  

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  

Treatment  –  For  How  Long?  

•  Two  examples  from  model  methadone  and  buprenorphine  programs  

Pa.ent  Reten.on  in  a    Methadone  Program  

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  

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        

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?  

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    

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  

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  

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?  

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?  

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  

“Recovery”  from  Opiate    Substance  Use  Disorders  

•  Is  recovery  even  possible?    

•  How  is  recovery  achieved?    

•  With  what  reliability?    

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?  

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  

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  

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)  

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  

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  

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”  

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”  

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  

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  

•  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  

Elements  of  HOPE  

•  Treatment  is  available  but  only  required  when  monitoring  fails  –  “Behavioral  Triage”    

•  12-­‐step  par=cipa=on  is  encouraged  but  not  required  

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  

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  

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  

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  

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    

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  

Conclusion  

•  The  benefit  of  treatment  can  only  be  realized  when  outcomes  are  measured  by  the  ability  to  make  recovery  the  expected  outcome  

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  

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  

Thank  you!  

Discussion  

Now  I  want  to  hear  from  YOU!  

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    

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.”