understanding medication assisted treatment (mat) for families … · understanding medication...

Understanding Medication

Assisted Treatment (MAT) for

Families Affected by Substance

Use Disorders

4 9 4 0 I r v i n e B l v d . , S u i t e 2 0 2

I r v i n e , C A 9 2 6 2 0

7 1 4 - 5 0 5 - 3 5 2 5

n c s a c w @ c f f u t u r e s . o r g

w w w . n c s a c w . s a m h s a . g o v

March 20, 2013

Pamela Petersen-

Baston, MPA, CAP, CPP

A Program of the

Substance Abuse and Mental Health Services AdministrationCenter for Substance Abuse Treatment

and the

Administration on Children, Youth and FamiliesChildren’s Bureau

Office on Child Abuse and Neglect

2

Developing knowledge and

providing technical assistance to

federal, state, local agencies and tribes to

improve outcomes for families with

substance use disorders in the

child welfare and family court systems

NCSACW Mission

Important Definitions


I r v i n e , C A 9 2 6 2 0

7 1 4 - 5 0 5 - 3 5 2 5



Important definitions

• Nonmedical use: Use of prescription drugs

without a prescription, or use that occurred

simply for the experience or feeling the effects

caused by the drug rather than for legitimate

medical reasons (over-the-counter use and

legitimate use of prescription pain relievers are

not included).1

Important definitions

• Medication-Assisted Treatment (MAT) is the use

of medications, in combination with counseling

and behavioral therapies, to provide a whole-

patient approach to the treatment of substance

use disorders2 with an ultimate goal of patient

recovery with full social function.3

• MMT: Methadone Maintenance Treatment -

Dispensing methadone at stable dosage levels

for a period in excess of 21 days in the

supervised treatment of an individual for opioid

addiction.4

Goals of MAT

MAT is prescribed to address very specific and

highly individualized goals that vary by person:

• Prevention or reduction of withdrawal symptoms

• Prevention or reduction of drug craving

• Prevention of relapse to use of addictive drug

• Restoration to or toward normalcy of any

physiological function disrupted by drug abuse

• Blockade of euphoric effects of illicit self-

administered

MAT is not a new practice

• MAT is not new! While you may be hearing more

about the use of medications (in combination

with behavioral therapies) to address the

emerging prescription painkiller epidemic, MAT

has been in place as a proven effective practice

for decades e.g. Disulfiram (Antabuse®) for

more than 50 years and methadone for more

than 40 years.5

Treatment of alcohol dependence

In the US, MAT has been demonstrated to be

effective in the treatment of alcohol dependence

with Food and Drug Administration (FDA)

approved drugs such as:

• Disulfiram (Antabuse®)

• Naltrexone (oral = ReVia®, Depade® or monthly

extended-release injectable Vivitrol®)

• Acamprosate (Campral®)6

Other medications for alcohol

• In addition, some benzodiazepines (Valium and

Xanex) have been approved to treat alcohol

withdrawal symptoms.7

• Other drugs are not FDA-approved to treat

alcohol abuse, but have, in a research setting,

shown promise in reducing drinking.8

Medical marijuana

• Marijuana has been used to treat

– Loss of vision from glaucoma

– Nausea that can come with AIDS and cancer

treatments

– The pain of multiple sclerosis

• Marinol is a prescription medicine that contains

marijuana’s active ingredient.

• Marinol is used to treat nausea and vomiting.9

• Note: There is no reason to believe that inhaled smoke is

an acceptable delivery mode.10

MI’s nonmedical use of pain relievers

• Michigan rates among the top 15 at 5.11%

nationally for nonmedical use (e.g. misuse) of

pain relievers among persons 12 and older

(2010-2011 NSDUH data) and also among 18-

25 year olds 11.74%.

• During this same time period, Michigan’s rate

among 12- 17 year olds was 6.35%.11

Common Opioids12, 13

Heroin (injected, smoked, or nasally inhaled)

Buprenorphine (e.g., Suboxone, Subutex)

Fentanyl (Duragesic patch, lozenge, solution)

Hydromorphone (Dilaudid)

Hydrocodone (e.g., Vicodin, Lortab, Lorcet)

Methadone (Dolophine or Methadose in

diskette/wafer, pills, liquid)

Morphine (MSContin, MSIR, Avinza, or Kadian)

Oxycodone (e.g., OxyContin, Percodan, Percocet)

Codeine—an ingredient in some cough syrups and

in one Tylenol product

Treatment of opioid dependence14

In the US, MAT has been demonstrated to be

effective in the treatment of opioid dependence

with:

• Methadone (Dolophine or Methadose)

• Buprenorphine (Subutex, Suboxone)

• Naltrexone (oral = ReVia®, Depade® or monthly

extended-release injectable Vivitrol®)

Methods of Dispensing

• Methadone to treat addiction is dispensed only

at specially licensed treatment centers.

Buprenorphine and naltrexone are dispensed at

treatment centers or prescribed by doctors.15

• A doctor must have special approval to prescribe

buprenorphine. Some people go to the treatment

center or doctor’s office every time they need to

take their medication. People who are stable in

recovery may be prescribed a supply of

medication to take at home.16

Methadone

• Methadone is a synthetic opioid that blocks the

effects of heroin and other prescription drugs

containing opiates. Used successfully for more

than 40 years, methadone has been shown to

eliminate withdrawal symptoms and relieve drug

cravings from heroin and prescription opiate

medications.17

• Methadone has been in use since the 1960s to

treat heroin addiction and is still an excellent

treatment option today.18

Methadone

• Methadone is an agonist that mitigates opioid

withdrawal symptoms and, at higher doses,

blocks the effects of heroin and other drugs

containing opiates. Methadone compliance

reduces injection opioid use, thereby helping to

close off one route of HIV transmission for

patients.19

Methadone

• Methadone must be dispensed to patients at a

Substance Abuse and Mental Health Services

Administration (SAMHSA)-certified opioid

treatment program (OTP) facility—with daily

doses provided at the clinic—until the patient is

deemed stable enough to receive take-home

doses.20

Methadone treatment

Methadone is taken daily

(liquid and a wafer form).

It has been used

successfully for more than

40 years in the treatment

of opioid dependence.

Medication is integrated

with psychosocial therapy

to address the unique

needs of each patient.

Buprenorphine for opioid dependence

• Buprenorphine (Suboxone® and Subutex®)

relieves drug cravings without producing the

“high” or dangerous side effects of other opioids.

• The FDA approved buprenorphine in 2002, is

available at OTPs, but is most often prescribed

by physicians in office-based settings making it

more accessible than methadone.

• Physicians have to first receive special training,

be granted a DEA waiver and can only treat up

to 100 patients at a time.

How different from methadone?

• Only qualified doctors with the necessary DEA

(Drug Enforcement Agency) identification

number are able to start in-office buprenorphine

treatment and provide prescriptions for ongoing

medication. CSAT (Center for Substance Abuse

Treatment) will maintain a database to help

patients locate qualified doctors. These

medications are available in most commercial

pharmacies.21

Naltrexone for opioid dependence

• Naltrexone is a non-addictive antagonist that

prevents opioid receptors from being activated by

agonist compounds, such as heroin or prescription

pain killers, and is reported to reduce craving and

prevent relapse.22

• If a patient who has been administered naltrexone

attempts to continue taking opioids, he or she is

unable to feel any of the opioid’s effects due to

naltrexone’s blocking action.23

Naltrexone for opioid dependence

• Naltrexone can be prescribed by any healthcare

provider who is licensed to prescribe medications

(e.g., physician, doctor of osteopathic medicine,

physician assistant, and nurse practitioner).

Special training is not required; the medication can

be administered in OTP clinics.24

MAT for opioid has 3 elements

• Medication-assisted treatment is one way to help

those with opioid addiction recover their lives.

There are three, equally important parts to this

form of treatment:

• Medication

• Counseling

• Support from family and friends.25

• As we will discuss later, system support is also

essential as is reducing MAT barriers and

stigma.

Duration of treatment medication

• People can safely take treatment medication as

long as needed— for months, a year, several

years, even for life. Plans to stop taking a

medication should ALWAYS be discussed with a

doctor.26

Benefits of MAT27

As part of a comprehensive treatment program,

MAT has been shown to:

• Improve survival

• Increase retention in treatment

• Decrease illicit opiate use

• Decrease hepatitis and HIV seroconversion

• Decrease criminal activities

• Increase employment

• Improve birth outcomes among opioid

dependent pregnant women

Pregnancy and MAT


I r v i n e , C A 9 2 6 2 0

7 1 4 - 5 0 5 - 3 5 2 5



Treating opioid dependency during

pregnancy28

• Methadone has been accepted since the late

1970s to treat opioid addiction during pregnancy.

• In 1998, an NIH consensus panel recommended

methadone maintenance as standard of care for

pregnant women with opioid addiction.

• The FDA licensed and regulated methadone

treatment programs, including treatment for

pregnant women starting in 2001.

ASAM/ACOG Committee Opinion

• The current state of care for pregnant women

with opioid dependence is referral for opioid-

assisted therapy with methadone, but emerging

evidence suggests that buprenorphine also

should be considered. Medically supervised

tapered doses of opioids during pregnancy often

result in relapse to former use. Abrupt

discontinuation of opioids in an opioid-

dependent pregnant woman can result in

preterm labor, fetal distress, or fetal demise.29

Methadone and Pregnancy30

• Withdrawal for pregnant women is especially

dangerous because it causes the uterus to

contract and may bring on miscarriage or

premature birth. By blocking withdrawal

symptoms, MMT can save the baby’s life.

Additionally, MMT can help the mother stop

using needles, which is a primary route of

infection for drug users. More importantly, it can

allow the mother to regain quality of life.

Methadone and pregnancy31

• Undergoing MMT while pregnant will not cause

birth defects for the baby, but some infants may

go through withdrawal after birth. Withdrawal

does not mean the baby is addicted.

• Studies have shown that the dose of medication

has no bearing on whether or not the baby

experiences withdrawal. Infant withdrawal

usually begins a few days after the baby is born

but may begin two to four weeks after birth.

Buprenorphine and pregnancy32

• Current guidelines recommend that

buprenorphine be prescribed to pregnant

women only when the benefits outweigh the

risks and the patent has refused methadone

(CSAT, 2004)

Child Welfare Issues


I r v i n e , C A 9 2 6 2 0

7 1 4 - 5 0 5 - 3 5 2 5



TEXT PAGE

Issues for Child Welfare Systems

What are the issues?

• Use of MAT as exclusionary criteria for child welfare

programs, particularly Family Drug Courts.

• Misunderstanding of the use of MAT, particularly

Methadone treatment, in substance abuse treatment

and how it relates to child safety.

• Requirement of minimal “dosing” of MAT

medications for pregnant women or as a term for

reunification.

• Positive toxicology result for methadone at birth as a

presumptive cause for child removal.

MAT Misunderstood

• Not all court officials, child welfare staff, or even

behavioral health professionals understand that

MMT is the recommended course of treatment

for pregnant opioid-dependent women and that it

reflects a mother’s commitment to living a sober

and responsible life.

Medically assisted detoxification

• For opioid abusers who do not wish to enter

treatment or do not qualify for ongoing

maintenance therapy, some treatment programs

provide medically assisted detoxification

services, which involve weaning patients off

addictive substances and managing withdrawal.

However, research shows such programs are

closely associated with relapse.33


• Medically assisted detoxification is only the first

stage of addiction treatment and by itself does

little to change long-term drug abuse. Although

medically assisted detoxification can safely

manage the acute physical symptoms of

withdrawal and can, for some, pave the way for

effective long-term addiction treatment,

detoxification alone is rarely sufficient to help

addicted individuals achieve long-term

abstinence. 34


• Patients should be encouraged to continue drug

treatment following detoxification. Motivational

enhancement and incentive strategies, begun at

initial patient intake, can improve treatment

engagement.35

• Because tolerance to opioids fades rapidly even

during a short period of abstinence, one episode

of opioid misuse following detoxification can

result in a life-threatening or deadly overdose.36

MAT myth busters

• “Methadone clients are ‘still using’ (continuing drug

use) and not really engaged in recovery.”

• “Clients get high on methadone and Suboxone.”

• FACT: Taking medication for opioid addiction is

like taking medication to control heart disease or

diabetes. It is NOT the same as substituting one

addictive drug for another. Used properly, the

medication does NOT create a new addiction. It

helps people manage their addiction so that the

benefits of recovery can be maintained.37 With

correct dosing, MAT clients’ withdrawal symptoms

are ameliorated and no high is produced.

MAT myth busters38

• Some child welfare system-involved pregnant

women participating in MAT are being told by

some child welfare staff to get off of the MAT as

they are harming their baby. Others are asked

about their plans to decrease their doses and

discontinue MAT.

• FACT: Methadone is not harmful to the fetus if the

mother is stable and under the medical care of an

OTP. No one should practice medicine without a

license! Moreover, this advice is contraindicated

and could result in far more harm to both mother,

fetus and baby.

MAT myth busters

• Often recommended to reduce maternal

methadone dose to avoid “harming” fetus.

• FACT: A non-therapeutic maternal dose may

promote supplemental drug use and increase

risk to the fetus.39

• Bottom line …MAT involves extremely complex,

highly individualized medical treatments that

should only be considered after consultation with

a physician who has received training in these

therapies.

MAT myth busters40

• Positive toxicology result for methadone at birth

as a presumptive cause for child removal.

• FACT: Methadone (or other properly

administered medication) in a stabilized patient

will not cause sedation or prevent the individual

from being a responsible parent.

• Methadone maintenance treatment and

buprenorphine do not have the narcotizing

effects of heroin and does not trade one

addiction for another.

MAT myth busters41

• Use of MAT as exclusionary criteria for child

welfare programs, particularly Family Drug

Courts. Some parents are required by child

welfare and/or court systems to discontinue MAT

as a pre-requisite to reunification.

• FACT: If parents are pushed to abandon their

MAT protocol destabilization of a family could

result.

Myth busters42

• It is not safe for mothers receiving MAT to

breast-feed their baby.

• FACT: Breast-feeding is safe unless the mother

has an infectious disease, such as HIV. Hepatitis

C-positive women are able to safely breastfeed

but should check with their physicians first.

• CPS representatives should work with OTPs and

read the SAMHSA/CSAT publication TIP #43,

“Medication-Assisted Treatment for Opioid

Addiction in Opioid Treatment Programs”,

especially Chapter 13- Treating Pregnancy.

Considerations for Child Welfare

Policy and Practice


I r v i n e , C A 9 2 6 2 0

7 1 4 - 5 0 5 - 3 5 2 5



MAT Policy and Practice Considerations

Discussion & jurisdiction examples of:

• Collaboration with multiple stakeholders –

primary care providers, substance abuse

treatment/ MAT providers and the courts

• Cross systems release of information

• Cross systems role clarification

• Clearly written policies and guidelines for

clients/parents

• Clearly written policies and guidelines for staff

Policy and Practice Framework: Five Points of Intervention (Apply to SEI)

1. Pre-pregnancy awareness of

substance use effects

2. Prenatal screening

and assessment

Initiate enhanced

prenatal services

3. Identification

at BirthChild Parent

4. Ensure infant’s safety and

respond to infant’s needs

Respond to parents’

needs

5. Identify and respond

to the needs of

● Infant ● Preschooler● Child ● Adolescent

Identify and respond

to parents’ needs

System

Linkages

System

Linkages

SEI - The Framework: Five Points of

Intervention

• Pre-pregnancy and public awareness

• Prenatal screening and support

• Screening at birth

• Services to infants 0-3 and beyond

• Services to parents

So—the birth event is one of several opportunities

to make a difference, not the only one!

Closing: Making the business

case for MAT


I r v i n e , C A 9 2 6 2 0

7 1 4 - 5 0 5 - 3 5 2 5



SAMHSA

• MAT is the use of medications, in combination

with counseling and behavioral therapies, to

provide a whole-patient approach to the

treatment of substance use disorders. Research

shows that when treating substance-use

disorders, a combination of medication and

behavioral therapies is most successful.

Medication assisted treatment (MAT) is clinically

driven with a focus on individualized patient

care.43

White House/ONDCP

• … “Insurers and policy makers must strive to

learn about available medicines and promote

policies that ensure that use of these

medications is covered as part of a

comprehensive approach to treating prescription

and illicit drug dependence.”44

NIDA

• The National Institute of Drug Abuse (NIDA)

Principles of Effective Treatment states the

following: “Medications are an important element

of treatment for many patients, especially when

combined with counseling and other behavioral

therapies. For example, methadone,

buprenorphine, and naltrexone (including a new

long-acting formulation) are effective in helping

individuals addicted to heroin or other opioids

stabilize their lives and reduce their illicit drug

use.”45

NIDA cont.

• Acamprosate, disulfiram, and naltrexone are

medications approved for treating alcohol

dependence. For persons addicted to nicotine, a

nicotine replacement product (available as

patches, gum, lozenges, or nasal spray) or an

oral medication (such as bupropion or

varenicline) can be an effective component of

treatment when part of a comprehensive

behavioral treatment program.46

The National Quality Forum

• The National Quality Forum has developed

consensus standards for addressing substance

use illnesses. Four of the eleven standards

focus on the use of medications. Specifically,

they state that everyone receiving detoxification

or treatment for opiate, alcohol, or nicotine

dependency should be offered medications.47

Summary

• Medications may also become an essential

component of an ongoing treatment plan,

enabling opioid-addicted persons to regain

control of their health and their lives.48

Resources


I r v i n e , C A 9 2 6 2 0

7 1 4 - 5 0 5 - 3 5 2 5



TEXT PAGE

10 Element Framework

Training and Staff Development

Understanding Substance Abuse and

Facilitating Recovery:

A Guide for Child Welfare Workers

• Discusses the relationship of alcohol and

drugs to families in the child welfare system

• Provides information on the biological,

psychological, and social processes of

alcohol and drug addiction to help staff

recognize when substance abuse is a risk

factor in their cases

• Describes strategies to facilitate and

support alcohol and drug treatment and

recovery for families affected by substance

use disorders

Available online at

www.ncsacw.samhsa.gov

http://www.ncsacw.samhsa.gov/

Web-based Screening Tool

• NIDA provides a Web-based tool that helps

clinicians screen for tobacco, alcohol, and illicit

and nonmedical prescription drug use, and

suggests levels of intervention.

• http://www.drugabuse.gov/nmassist

http://www.kap.samhsa.gov/products/trainingcurriculums/

pdfs/tip43_curriculum.pdf

Buprenorphine

• For more information about contact the Center

for Substance Abuse Treatment (CSAT)

Buprenorphine Information Center at 866-BUP-

CSAT, or via email at

[email protected] or

http://buprenorphine.samhsa.gov/

mailto:[email protected]

http://buprenorphine.samhsa.gov/

To Obtain a Copy:

http://www.ncsacw.samhsa.gov

/improving/daily-practice-client.aspx

Pamela Petersen-Baston, MPA, CAP, CPP

828.817.0385

National Center on Substance Abuse

And Child Welfare,

Children and Family Futures

Phone: 1 (866) 493-2758

E-mail: [email protected]

Contact Information

62

Questions and

Discussion

understanding medication assisted treatment (mat) for families … · understanding medication...

Documents