1. Medication-Assisted Treatment
There are several key components to a public health approach to addiction:
1) prevent substance use and abuse whenever possible
2) early problem identification and diagnosis
3) effective treatment
4) reduction of harmful consequences to affected person and others
This opening session focuses on the latter two strategies: effective treatment; effective harm reduction for the chronic, severe, and too often deadly disease of opioid addiction
And as we will here in more sessions today and tomorrow, the treatment system cannot manage this opioid epidemic on its own.
The education system and the law enforcement and justice system and the recovery community are necessary partners in those four components I mentioned (prevention, early identification, treatment, harm reduction).
We have learned the hard way that we cannot end this opioid epidemic by ignoring this deadly disease or by punishing or failing to help those who suffer from it and their families.
Samuel A. Ball, PhD
President & CEO, CASA
Professor of Psychiatry, Yale

2. 2.5 Million Americans Have a diagnosed opioid use disorder
Over the past 10 years, the number of Americans meeting diagnostic criteria for opioid use disorders has quadrupled – about ¾ of those 2.5 million involve pills and ¼ heroin.
And according to CDC estimates, about 350 people start using heroin every day.
Most current heroin users started by first misusing prescription pain pills like oxycontin, vicodin or percodan.
A pill epidemic fueled by the over-prescription of these medicines by physicians who were mislead by pharmaceutical companies, accepted their aggressive marketing campaign, or acted unethically and ran pill mill pain clinics.
A shocking 200 million prescriptions are written each year.

3. Most People in Need of Treatment Do Not Receive It
INDIVIDUALS WITH SELECT MEDICAL CONDITIONS WHO RECEIVE TREATMENT
10.9%
71.2%
72.9%
Compounding the tragedy of the opioid epidemic and the health, family, and social consequences, is the terrible disparity in healthcare for those with the disease of addiction in comparison to other chronic psychiatric or medical conditions.
There is a treatment gap of about 20 million people who need addiction treatment but are not receiving it for one reason or another.
And those reasons are many and complex:
77.2%

4. WHY DO SO FEW PEOPLE RECEIVE TREATMENT?
The reasons fall into one of two broad categories:
The first is major factor is Individual Readiness
Many who have a problem do not have the insight, motivation, judgment, or self-care skills.
Deny there is a problem
Don’t want to stop
Don’t need or want treatment
Stigma of seeking treatment
Cost/inability to pay
30.6% of those who wanted treatment said they had no health coverage and/or could not afford the cost of coverage
This is why the importance of having insurance cannot be understated
The second major factor is the availability or access to effective treatment
The type of treatment they need may not be locally available or they have no idea how to find and access it
They may not be able to afford it
Their insurance may not cover all options (MAT)
Treatment available is not based on scientific evidence perceived treatment

5. Misconceptions About Treatment for Severe Opioid Addiction
These are not considered evidenced-based treatment:
Detoxification only
Abstinence-oriented therapy
Mutual support programs (e.g., NA)
Naloxone (Narcan®)
These are important services, but they do not meet expert definitions of effective treatment when it comes to opioid addiction
Detoxification
May be a pre-cursor to treatment to stabilize the patient and ease withdrawal symptoms.
It does not treat the underlying disease
Unless treatment is provided following detoxification, the cessation of use is likely to be temporary, requiring repeat episodes of detoxification. And the high risk of overdose is worsened
Abstinence-based oriented inpatient or outpatient counseling
Useful for other substance abuse and addiction problems, but no evidence that they are better than detox + abstinence oriented peer self-help
Mutual Support Programs/Sober Housing
These provide important supports for individuals who are in recovery but they are not treatment
A little more on Narcan which is a highly effective medicine to save someone’s life, but is not in itself a treatment.

6. What is Naloxone (Narcan®)?
Lifesaving injection or nasal spray that reverses opioid overdose and causes opioid withdrawal
Can be administered anywhere by first responders, family members, schools, peers, etc.
Good Samaritan Laws protect first responders and laypersons from liability for administering naloxone during a perceived overdose
Importance of immediate treatment initiation

7. Effective Treatments For Opioid Use Disorder Methadone
Buprenorphine (or Suboxone)
Naltrexone (or Vivitrol)

8. What is Effective Treatment for Opioid Addiction?
Medication-Assisted Treatment (MAT)
Medications
Behavioral
Therapy
MAT
Medications are particularly important for patients with opioid addiction because abstinence-based treatment is not effective.
However, the professional therapy that are used in abstinence-base treatments are effective for opioid addiction when used in combination with medicine
For patients with opioid addiction, MAT is the most effective treatment
Cognitive behavioral therapy
Community reinforcement approach
Contingency management
Behavioral/couples/family therapy
Individual/group drug counseling
The medicine prevents or manages the physical problems of intoxication, overdose, craving, and withdrawal symptoms
-And they enable the patient to make more effective use of the therapy to improve psychological functioning, family functioning, daily activities, and a recovery focus
Each medication has a different mechanism of action, different side effects, different regulatory restrictions and different protocols and locations for administration.

9. Methadone Medication is taken daily (liquid)
Dispensed in opioid treatment programs (with regulated take home bottles)
Numerous federal, state, and local regulations
Methadone has been used for nearly 50 years, making it the oldest, most researched, and most effective treatment for opioid addiction
Reduces opioid use, craving, criminal behavior, injection drug use, needle sharing, HIV/HCV, overdose risk, multiple medical problems, and premature mortality
Increases treatment retention
As a medication, it is considered a full Agonist – meaning it is itself an opioid that fully activates the same parts of the brain as other opioids
But properly prescribed and managed it does not cause intoxication or overdose
It is perhaps the most highly stigmatized, commonly used medicine. Sometimes referred to as a “heroin substitute” or “legal heroin” or “treating a drug problem with a drug.” This type of bias and misinformation has killed 1000s of people
Misuse does signal a problem. Too much and the person can get high and even overdose. Not taking what is prescribed by result in relapse, withdrawal or drug diversion risk and so administration is closely monitored by professionals and tightly regulated by numerous federal, state, and local authorities
Provided in specially licensed clinics where medications administration must be supervised with regular attendance (daily → monthly)
Methadone clinics (OTPs) are not widely accessible across the country

10. Buprenorphine (Suboxone®)
Medication is taken daily (pill or film)
Prescribed by providers and dispensed in pharmacies for at home use
Special requirements on providers and limit on number of patients
A more accessible and effective alternative to methadone for some
Partial agonist mean it only partially activates the opioid receptor; this combined with the addition of naloxone (as Suboxone) decreases some of the rewarding effects and there is less risk of misuse and overdose
Provides greater flexibility for patients than methadone at OTPs; reduces stigma associated with OTPs.
Can only be prescribed by specially qualified medical providers who obtain a waiver from the DEA after special training and certification
In addition to physicians, nurse practitioners and physicians assistants can receive the waiver
Federal law imposes a limit on the number of patients
Highest limit is 275; most can prescribe to
Buprenorphine-waivered physicians are not widely available, especially in certain parts of the country.

11. Oral Naltrexone or Injectable Naltrexone (Vivitrol®)
Medication is taken three times per week (pills) or monthly (injection)
Prescribed or administered at a doctor’s office
No regulations
Naltrexone is the reverse of methadone and buprenorphine in that it is not an opioid, but actually blocks the effects of opioids. This is called an Antagonist
There is no euphoria, pain relief, dependence, or withdrawal experienced
It has no diversion value and is not subject to regulations regarding distribution
Providers do not need to be specially licensed to prescribe/administer naltrexone.
The Oral form of naltrexone (Revia) is a tablet taken 3 times per week at home
The Injectable form Vivitrol is a monthly IM injection from a doctor
Cost ($15 vs. $1,200/month) and compliance differences between the oral and IM
Treatment adherence to oral is poor making it ineffective for all but a subgroup of patients with opioid addiction
Vivitrol does not require daily adherence which makes it more effective one month at a time, but getting patients on to the medicine and taking a 2nd and 3rd shot is not so easy
Can only be used for patients who have not ingested opioids for 7-10 days so a good option for those being released from incarceration or residential treatment

12. Medications Exist, But Are Not Accessible
Discrimination and Other Barriers Limit Access
A 2014 report by the Substance Abuse and Mental Health Services Administration (SAMHSA) found that fewer than 20% of addiction programs offered one of these medications
Barriers to Medication Assisted Treatments:
Misconceptions about substituting one drug for another
Discrimination against methadone patients and the reputation of methadone clinics in many communities
iii. Insufficient numbers of buprenorphine trained physicians, particularly in rural areas
iv. “Fail first” criteria requiring detoxification to abstinence-oriented treatment be tried first

13. Jennifer’s Story