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.     

Most treatment programs in the U.S. don't offer medication for OUD: Study

A study based on N‐SSATS — the National Survey of Substance Abuse Treatment Services — has found that in 2016, the most recent year covered, only 36.1 percent of substance use disorder (SUD) treatment programs in the United States offer at least one of the three medications for treating opioid use disorders (OUDs). These medications are considered the gold standard for OUD treatment.     

Sublocade: Why a placebo arm?

In a time when people are dying from illicit fentanyl overdoses, why would a trial for a new medication to treat opioid use disorder — a formulation of buprenorphine, already proven to be safe and effective in oral form — include a placebo arm? This was the question asked by many when the results of Indivior's trial for Sublocade, a buprenorphine injection that lasts a month, were published last month in The Lancet (see ADAW, Feb. 25). The trial results were what led to Sublocade's approval by the Food and Drug Administration (FDA) for the treatment of opioid use disorder more than a year ago (see ADAW, Dec. 11, 2017).     

CM,only effective treatment for stimulants,on the ropes as methamphetamine surges

Contingency management (CM), which means rewarding drug users not to use drugs, is the only known effective treatment for stimulant use disorder, but it has become caught up in anti‐kickback initiatives. At the heart of the problem is a misunderstanding: CM payments are not kickbacks — they are part of treatment. But “safe harbor” initiatives from the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) are interpreting them as such, and not allowing Medicaid to pay for them (only $75 a year per patient).     

LAC and RTI: Eliminate Medicaid prior auth for bupe

Since April 2018, Medicare limited utilization management — most often done via prior authorization requirements — for buprenorphine to treat opioid use disorder (OUD). In response, virtually all plans that covered this treatment removed prior authorization requirements. Medicaid plans should do the same, according to RTI, writing in the July 9 issue of the Journal of the American Medical Association (JAMA).     

Methadone and buprenorphine in prison: Success in RI

The omnipresence of substance use disorder in prisons and jails cries out for treatment — and so do the inmates — but until recently, it has been scarce. Leading the way is the small state of Rhode Island, where Cranston‐based CODAC, an opioid treatment program (OTP), is providing methadone inside the state's jail/prison facility, with staff working alongside corrections (see ADAW, May 7, 2018).     

Methadone and buprenorphine superior to all other treatments

A very important insurance‐based retrospective study shows clearly what the clinical trials have already shown: Agonist treatment for opioid use disorder (OUD) is better than abstinence‐based or antagonist‐based treatment in terms of reducing overdose and opioid‐related morbidity. (Buprenorphine and methadone are opioid agonists, naltrexone/Vivitrol is an antagonist.)     

More from Louis Baxter on doctors taking MAT

The question of whether or not doctors and other health care professionals on medication‐assisted treatment (MAT) are safe to practice medicine has been debated for the last few years since the advent of Food and Drug Administration (FDA)–approved MAT for opioid use disorder (OUD). The newly approved medications have been primarily buprenorphine formulations for OUD, naltrexone formulations for OUD and alcohol use disorder (AUD), and, most recently, an alpha 2‐adrenergic medication that specifically targets amelioration of opioid‐withdrawal symptoms from OUD (lofexidine). Quite frankly, the question of safety about medications to treat substance use disorder (SUD) has been asked since the development of methadone for OUD treatment more than 30 years ago.     

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.”     

More than a funder,the SSA needs community providers

The Single State Authority — SSA — is an office, but, in reality, is actually a person. This person is in charge of the ongoing Substance Abuse Prevention and Treatment (SAPT) block grant. There is one in every state. This person is also in charge of the STR and SOR grants for opioid use disorder treatment. For this story, we interviewed four longtime former SSAs about their lessons learned and their advice to new SSAs in a role that is in the spotlight both within state government and in the community, as billions of new dollars flow out to their systems. Each SSA is a member of the National Association of State Alcohol and Drug Abuse Directors (NASADAD).     

Drug users who only need treatment should get it,not arrest and incarceration

Many changes at the local, state and federal levels have resulted in getting treatment to at least some people with opioid use disorder (OUD) in prisons and jails — treatment that just a few years ago would have been unthinkable in those very institutions. Lawsuits over inmate deaths have been followed by establishment of methadone and buprenorphine treatment in some locations, while others have been moving toward treatment as a matter of public policy, Paul Samuels, director and president of the Legal Action Center, told the attendees of the American Association for the Treatment of Opioid Dependence (AATOD) conference in Orlando, Florida, last month. He was joined by a jail accreditor, a sheriff and a judge at the plenary on corrections.     

States call on HHS to immediately change year‐1 bupe cap

A coalition of 22 states and territories is requesting that the federal Department of Health and Human Services (HHS) lift restrictions on providing buprenorphine, one of the only three federally approved medications to treat opioid use disorder (OUD). “Buprenorphine is an essential tool in the fight to end the opioid epidemic,” said Howard Zucker, M.D., commissioner of health for New York state, which is leading the initiative. “Removing federal restrictions on prescribing buprenorphine will ultimately save lives and eliminate unnecessary barriers that prevent people with opioid use disorder from having access to treatment,” he said.     

Saffron as good as methylphenidate in treating ADHD

Short‐term treatment with saffron — which comes from the crocus plant and is known to cooks as one of the most important and expensive ingredients of various dishes — is as effective in treatment of attention deficit hyperactivity disorder (ADHD) as methylphenidate, researchers have found in one small trial. The study, “Crocus sativus L. Versus Methylphenidate in Treatment of Children with Attention‐Deficit/Hyperactivity Disorder: A Randomized Double‐Blind Pilot Study,” was published in the February issue of the Journal of the American Academy of Child and Adolescent Psychopharmacology. Methylphenidate is a controlled substance, a stimulant with addictive properties.     

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.     

‘Secret shopper’ study finds many barriers to OUD treatment

Treatment programs that don't accept insurance, but only cash, create a barrier for opioid use disorder (OUD) treatment, according to a study by Stephen Patrick, M.D., and colleagues, many of whom are from the Vanderbilt Center for Child Health Policy at Vanderbilt University Medical Center in Nashville. And despite the fact that pregnant women with OUD are a priority population for treatment due to the risks to the fetus of continued opioid abuse, nonpregnant women are more likely than pregnant women to be given an appointment for treatment with a buprenorphine‐waivered clinician.     

Fiellin: Keep the prescriber training for buprenorphine

It seems that almost everyone wants to deregulate buprenorphine for opioid use disorder (OUD) — with proposed legislation focused on getting rid of the Drug Addiction Treatment Act of 2000 (DATA 2000) waiver altogether (see ADAW, Oct. 11, “Bill to deregulate buprenorphine raises concerns among OTPs,” https://onlinelibrary.wiley.com/doi/10.1002/adaw.32510 ).     

NY AG ends Emergent's exclusivity for Narcan nasal spray

Narcan, the lifesaving opioid overdose reversal drug, has been the only naloxone spray allowed on the market due to an exclusivity agreement between the pharmaceutical company that owns it — Emergent BioSolutions — and the company that makes the spray device. This deal is ending thanks to New York Attorney General Letitia James, who has made it possible, via an agreement with Emergent, for other companies to use the patented, proprietary spray technology. Emergent, which bought Adapt, the creator of Narcan, will have to renegotiate these terms, James announced on Jan. 2. “Given the tragic, devastating effects of the opioid crisis, and the urgent need for additional drugs for the emergency treatment of opioid overdoses, my office will do whatever possible to ensure that there are no unnecessary impediments to the development of additional lifesaving opioid overdose reversal drugs,” she said. “I'm proud to announce that, starting today, additional companies will be able to gain access to these nasal spray devices. With more companies able to access this easy‐to‐use technology, our hope is that we can reduce the number of opioid overdose deaths across New York and this nation and save millions of additional lives.” A little history here: Adapt Pharma launched Narcan in February 2016, a year before the State Targeted Response (STR) grants were issued. Narcan is patented, but naloxone had been used for decades in the emergency treatment of opioid overdoses, by first responders and medical workers. In October 2018, in the middle of the lucrative STR (which no longer had to be 80% treatment) and State Opioid Response funding cycles, Emergent bought Adapt — for Narcan. Adapt had already entered into the contract with the nasal spray device manufacturer. Other pharmaceutical companies had been trying to develop a nalmefene overdose reversal drug using the device.     

Names in the News

At the American Association for the Treatment of Opioid Dependence (AATOD) conference awards banquet Oct. 22, Zachary Charles Talbott , director of clinical services at ReVIDA Recovery, longtime opioid treatment program operator and a nationally recognized expert in comprehensive opioid use disorder treatment, received the 2019 Richard Lane/Robert Holden Patient Advocacy Award. Talbott gave an impassioned speech on the importance of confidentiality and 42 CFR Part 2 to patients and providers.