Briefly Noted

A report from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control and Prevention published in Drug and Alcohol Dependence this month, based on a national survey of 46 opioid treatment programs (OTPs), concludes that buprenorphine and Vivitrol are not given equal footing with methadone as medications used by OTPs. All three are approved by the Food and Drug Administration for the treatment of opioid use disorder. Barriers, including costs, are identified. In addition, the report charges that services for HPV, HIV and other infectious diseases are not adequately integrated into OTPs, and that the reach of OTPs should be expanded. The report, “Characteristics and Current Clinical Practices of Opioid Treatment Programs in the United States,” is by Christopher M. Jones and colleagues; Elinore F. McCance‐Katz, M.D., Ph.D., is the senior author.     

Briefly Noted

We asked Jerry Rhodes, former top executive at CRC (now Acadia) and a leader in opioid treatment program management, what he thinks of methadone as a medication to be used in primary care to treat opioid use disorder (OUD), as some people — including former Office of National Drug Control Policy Director Michael Botticelli — recommended last year (see ADAW, July 16, 2018). “I take issue with that,” said Rhodes. “Methadone is a dangerous drug in an unregulated environment,” he told ADAW. Buprenorphine is prescribed this way, but “buprenorphine is a relatively safe drug, and methadone isn't,” he said. A veteran of many battles over methadone, including the near‐elimination of opioid treatment programs, Rhodes told ADAW that “you don't give unfettered access to methadone” to patients with OUD. “Be careful what you wish for” is his advice. This has the potential to cause harm, he said. “Only people who don't understand the history of its utilization would recommend this.”     

THE EFFECTS OF RECREATIONAL MARIJUANA LEGALIZATION AND DISPENSING ON OPIOID MORTALITY

This study documents how the changing legal status of marijuana has impacted mortality in the United States over the past two decades. We use a difference-in-difference approach to estimate the effect of medical marijuana laws (MML) and recreational marijuana laws (RML) on fatalities from opioid overdoses, and we find that marijuana access induces sharp reductions in opioid mortality rates. Our research corroborates prior findings on MMLs and offers the first causal estimates of RML impacts on opioid mortality to date, the latter of which is particularly important given that RMLs are far more expansive in scope and reach than MMLs. In our preferred econometric specification, we estimate that RMLs reduce annual opioid mortality in the range of 20%–35%, with particularly pronounced effects for synthetic opioids. In further analysis, we demonstrate how RML impacts vary among demographic groups, shedding light on the distributional consequences of these laws. Our findings are especially important and timely given the scale of the opioid crisis in the United States and simultaneously evolving attitudes and regulations on marijuana use. (JEL I18, K32, H75)     

AATOD paper confronts methadone controversies

A policy paper released this month by the American Association for the Treatment of Opioid Dependence (AATOD) focuses on some of the challenges facing opioid treatment programs (OTPs) today. For example, it cites an article published in the New England Journal of Medicine (July 5, 2018) by Michael Botticelli that promotes the idea of methadone being available in primary practice settings for the treatment of opioid use disorder (OUD) (see ADAW, July 16, 2018). “AATOD recommends that this proposal should only be considered after careful, conservative, and thoughtful evaluation,” according to the policy paper. “As history and our policies have shown, we do not reject the public health model for increasing access to care for OUD, nor are we ignoring what has been learned about clinical standards of care to treat this illness. It is important to understand, however, the complexity of inducting a new patient into methadone maintenance treatment when developing policies for increasing access to medication assisted treatment.”     

Mallinckrodt donates hand sanitizers to all OTPs

Mallinckrodt, a pharmaceutical company that makes methadone and buprenorphine for opioid treatment programs (OTPs) as well as many other medications, started out making hand sanitizer for its own plant employees when the pandemic began this winter. It wasn't long, however, before the company recognized that OTPs needed hand sanitizer — like everyone else, they were unable to get it. So last month, the St. Louis–based company started distributing it — for free — to all OTPs, not only its customers.     

Under 2% of Medicaid‐covered youths get MAT after OD: Study

Fewer than one‐third of youths receive addiction treatment after an opioid overdose, and only one in 54 receive pharmacotherapy (methadone, buprenorphine or naltrexone), a study published in JAMA Pediatrics reports. The researchers urge interventions to link these youths to treatment after an overdose, and call for improving access to medications: methadone, buprenorphine, and naltrexone.     

OTPs look toward criminal justice as major area for growth

Opioid treatment programs (OTPs), formerly known as methadone clinics, were set for a dramatic expansion several years ago when the opioid crisis was growing at an increasing rate, but now, that expansion is targeted toward one population of patients in particular: those in the criminal justice system. In particular, people who are in prison and jail are most likely to need — and not receive — treatment for opioid use disorder (OUD), and the nation's OTPs are ready to help.     

DEA allows buprenorphine inductions based on telephone only

Last week, the Drug Enforcement Administration (DEA) said opioid treatment programs (OTPs) and Drug Addiction Treatment Act (DATA)–waived prescribers can treat new patients with buprenorphine based on a telephone call only. The Controlled Substances Act (CSA), enforced by the DEA, requires all new patients being treated with controlled substances to have an in‐person — or, for now, telemedicine — physical exam. Now, however, because of the coexisting COVID‐19 pandemic and opioid overdose crisis, the DEA has dropped this requirement. This follows the decision of the Substance Abuse and Mental Health Services Administration (SAMHSA) to allow exemptions from the OTP take‐home regulations allowing stable patients to be given 14 or 28 days of methadone doses, instead of coming in more frequently (see DEA, SAMHSA relax OTP/OBOT regulations due to COVID‐19, ADAW March 23, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32664 ).     

Cannabis and alcohol use in young adults: Connections

People with HIV, as well as those who are uninfected, do well on long‐term treatment with opioids (methadone or buprenorphine), researchers have found. There is a strong dose‐response relationship between mortality (all causes), unnatural death and overdose, with the higher morphine equivalent daily doses having the best outcomes, according to the study, by Ajay Manhapra, M.D., and colleagues and published online Sept. 16 in the Journal of Drug and Alcohol Dependence. “Opioid risk mitigation approaches should be expanded to address the potential effects of higher dose on all‐cause mortality in addition to unnatural and overdose fatalities,” the researchers conclude in the abstract. For the study, there were 22,996 patients on long‐term treatment, 6,578 (29%) with HIV and 16,418 (71%) uninfected. Among 5,222 (23%) deaths, 12% were unnatural deaths and 6% overdoses. The study, “All‐cause mortality among males living with and without HIV initiating long‐term opioid therapy, and its association with opioid dose, opioid interruption and other factors,” also found that benzodiazepine use was associated with overdose.     

From starter OTP to acquisition by BayMark: A 3‐year journey

BayMark Health Services has acquired Counseling Solutions, a treatment provider focusing on methadone and buprenorphine treatment with locations in Chatsworth, Georgia, and Brasstown, North Carolina. When Zachary Talbott first started working to open his opioid treatment program (OTP) in Chatsworth more than three years ago, he had no plans to sell it (see ADAW, Aug. 17, 2015).     

Views on medication's role in treatment begin to converge amid deadly epidemic

In “Intervention stigma: How medication‐assisted treatment marginalizes patients and providers,” a researcher writes about one of the biggest paradoxes facing those treating and being treated for opioid use disorders (OUDs): the fact that the “gold standard” for treatment — methadone and buprenorphine — subjects both providers and patients to stigma, both within and outside addiction treatment communities.     

Naloxone administration for suspected opioid overdose: An expanded scope of practice by a basic life support collegiate-based emergency medical services agency

Opioid abuse is a growing and significant public health concern in the United States. Naloxone is an opioid antagonist that can rapidly reverse the respiratory depression associated with opioid toxicity. Georgetown University's collegiate-based emergency medical services (EMS) agency recently adopted a protocol, allowing providers to administer intranasal naloxone for patients with suspected opioid overdose. While normally not within the scope of practice of basic life support prehospital agencies, the recognition of an increasing epidemic of opioid abuse has led many states, including the District of Columbia, to expand access to naloxone for prehospital providers of all levels of training. In particular, intranasal naloxone is a method of administering this medication that potentially avoids needlestick injuries among EMS providers. Universities with collegiate-based EMS agencies are well positioned to provide life-saving treatments for patients acutely ill from opioid overdose.     

Becoming Overweight without Gaining a Pound: Weight Evaluations and the Social Integration of Mexicans in the United States

Mexican women gain weight with increasing duration in the United States. In the United States, body dissatisfaction tends to be associated with depression, disordered eating, and incongruent weight evaluations, particularly among white women and women of higher socioeconomic status. However, it remains unclear how being overweight and obesity are interpreted by Mexican women. Using comparable data of women aged 20–64 from both Mexico (the 2006 Encuesta Nacional de Salud y Nutricion; N = 17,012) and the United States (the 1999–2009 National Health and Nutrition Examination Surveys; N = 8,487), we compare weight status evaluations among Mexican nationals, Mexican immigrants, US‐born Mexicans, US‐born non‐Hispanic whites, and US‐born non‐Hispanic blacks. Logistic regression analyses, which control for demographic and socioeconomic variables and measured body mass index and adjust for the likelihood of migration for Mexican nationals, indicate that the tendency to self‐evaluate as overweight among Mexicans converges with levels among non‐Hispanic whites and diverges from blacks over time in the United States. Overall, the results suggest a US integration process in which Mexican‐American women's less critical self‐evaluations originate in Mexico but fade with time in the United States as they gradually adopt US white norms for thinner body sizes. These results are discussed in light of prior research about social comparison and negative health assimilation.     

Is counseling ‘required’ with medications to treat opioid use disorder?

In “No Strings Attached: More Opioid Addicts Get Meds Without Talk Therapy,” an article by Beth Schwartzapfel of the Marshall Project published in USA Today May 9 ( https://www.usatoday.com/story/news/investigations/2019/05/09/opioid‐crisis‐drugs‐no‐therapy/1131110001/ ), both sides were excellently reported. Kenneth B. Stoller, M.D., longtime methadone researcher from Johns Hopkins, was quoted as saying that medications without any talking is “selling patients short.” Some Twitter participants immediately charged that Stoller was kicking patients off medication if they weren't participating in counseling (which he doesn't do and the article doesn't say he does), and a protracted debate on Mother's Day led us to ask Stoller himself — who does not tweet — to respond. We copied and pasted the comments so he could see them. His response is below. (To see the Twitter thread, go to https://twitter.com/ADAWnews/status/1127175604959436800 .)     

DEA proposal for mobile methadone finally released

The federal Drug Enforcement Administration (DEA) has issued a long‐awaited proposed rule that would allow opioid treatment programs (OTPs) — treatment programs that use methadone — to transport the medication to patients via “conveyances” (such as vans). This means that patients would no longer have to go to the brick‐and‐mortar OTP.