1. Kim Castelnovo, RPh Pharmacy Manager, Community Care
Decreasing the Use of Prescription Opiates and Benzodiazepines Among Individuals Enrolled in Methadone Programs
Kim Castelnovo, RPh Pharmacy Manager, Community Care
© 2014 Community Care Behavioral Health Organization

2. About Community Care Behavioral Health Managed Care Company
Founded in 1996
Statewide HealthChoices presence; 39 of 67 Pennsylvania counties
10 offices across the Commonwealth
Over 600 employees
© 2014 Community Care Behavioral Health Organization

3. About Community Care Medicaid/HealthChoices membership: 725,000
Commercial/Medicare membership: 450,000
Approximately 110,000 people served annually
Statewide network of approximately 1,600 providers
© 2014 Community Care Behavioral Health Organization

4. Serving 39 Counties Pike Erie Warren Susquehanna McKean Potter Tioga
Bradford
Crawford
Wayne
Forest
Wyoming
Cameron
Sullivan
Lackawanna
Venango
Elk
Lycoming
Pike
Mercer
Clinton
Jefferson
Luzerne
Clarion
Columbia
Monroe
Lawrence
Clearfield
Centre
Montour
Union
Butler
Carbon
Armstrong
Northumberland
Snyder
Northampton
Beaver
Mifflin
Schuylkill
Lehigh
Indiana
Juniata
Allegheny
Blair
Berks
Perry
Dauphin
Bucks
Cambria
Lebanon
Huntingdon
Westmoreland
Montgomery
Washington
Cumberland
Lancaster
Bedford
Fayette
Chester
Somerset
Franklin
York
Philadelphia
Greene
Fulton
Adams
Delaware
Community Care Office
© 2014 Community Care Behavioral Health Organization

5. Overview
Opiate and benzodiazepine use in individuals in methadone programs
With overdose deaths from heroin and prescription pain medications increasing in the U.S., opioid addiction is an important concern for Medicaid programs
Medicaid beneficiaries have higher rates of opioid addiction than other insured groups
© 2014 Community Care Behavioral Health Organization

6. Benzodiazepine Use and Misuse
Among patients in a methadone program – BMC Psychiatry, May 2011:
Benzodiazepines (BZD) misuse and abuse is a serious public health problem in the U.S.
This problem is especially pertinent among those with opiate dependence because these individuals are more likely to experience elevated anxiety after stopping use of opiates
It has been shown that individuals who abuse BZD are at increased risk of continuing opiate abuse and failing to stay in methadone treatment
© 2014 Community Care Behavioral Health Organization

7. Benzodiazepine Use and Misuse
In a Baltimore methadone program:
Survey conducted at a methadone treatment program in Baltimore
194 questionnaires were included in the final data analysis
47% reported using BZD with/without a prescription
25% said that their initial use began with a prescription
54% did not start using BZD until after entering the methadone program
© 2014 Community Care Behavioral Health Organization

8. Benzodiazepine Use and Misuse
Among patients in a methadone program the main reasons given for using BZD without a prescription:
Curiosity
To relieve tension or anxiety
To feel good
To get high
To overcome depression or frustration
© 2014 Community Care Behavioral Health Organization

9. Benzodiazepine Use and Misuse
When asked patients in a methadone program if they would consider reducing or stopping the use of BZD if the methadone program could provide help that would work:
40% said “Yes, definitely”
7% said “Maybe”
19% said “No”
33% had already stopped using BZD
© 2014 Community Care Behavioral Health Organization

10. Benzodiazepine Use Among Community Care Medicaid enrollees:
Analysis includes data for 39 Community Care counties
Number of unique members per year filling benzodiazepines
Benzodiazepine use very low among children and adolescents
Adult benzodiazepine Use ranges from % of Medicaid enrollment among Community Care counties
© 2014 Community Care Behavioral Health Organization

11. Opiate Use Among Community Care Medicaid enrollees:
Analysis includes data for 39 Community Care counties
Number of unique members per year filling four or more opiate scripts
Opiate use very low among children and adolescents
Adult opiate use ranges from 11-21% of Medicaid enrollment among Community Care counties
© 2014 Community Care Behavioral Health Organization

12. Community Care Methadone Provider Initiative
A Quality Improvement Initiative Between Counties, Methadone Providers, and Community Care
Community Care Methadone Provider Initiative
© 2014 Community Care Behavioral Health Organization

13. Objective
To identify members enrolled in methadone treatment programs who are concurrently filling benzodiazepine and /or opiate prescriptions
Collaborate with methadone providers to reduce the incidence of concurrent utilization and ultimately improve care
© 2014 Community Care Behavioral Health Organization

14. Intervention
Community Care generates member reports on a monthly basis and sends to the methadone providers in Allegheny County
Member report includes medications filled and prescriber information
Methadone provider uses the information to help address any clinical issues with the member
© 2014 Community Care Behavioral Health Organization

15. Frequency of Benzodiazepine Use
Frequency of benzodiazepine use among members in methadone programs in Allegheny County
Time period
# of members in methadone for at least 10 days (den)
# of members with at least 10 days of methadone + 1 Rx of Benzo (num)
Percent (num/den)
2009-Q4
1462
524
35.8%
2010-Q2
1424
509
35.7%
2010-Q4
1463
536
36.6%
2011-Q2
1473
486
33.0%
2011-Q4
1512
503
33.3%
2012-Q2
1529
502
32.8%
2012-Q4
1523
469
30.8%
2013-Q2
1516
424
28.0%
2013-Q4
1479
384
26.0%
© 2014 Community Care Behavioral Health Organization

16. Frequency of Opiate Use
Frequency of opiate use among members in methadone programs in Allegheny County
Time period
# of members in methadone for at least 10 days (den)
# of members with at least 10 days of methadone + 1 Rx of opiate (num)
Percent (num/den)
2009-Q4
1462
436
29.8%
2010-Q2
1424
377
26.5%
2010-Q4
1463
387
2011-Q2
1473
381
25.9%
2011-Q4
1512
348
23.0%
2012-Q2
1529
24.7%
2012-Q4
1523
328
21.5%
2013-Q2
1516
267
17.6%
2013-Q4
1479
262
17.7%
© 2014 Community Care Behavioral Health Organization

17. Assessing Impact of Interventions
Members with at least 10 days of Methadone Claims = 636
© 2014 Community Care Behavioral Health Organization

18. Assessing Impact of Interventions
Members with at least 10 days of Methadone Claims = 485
© 2014 Community Care Behavioral Health Organization

19. Comparison Pre-Period (May-June 2012) Post-Period (May-June 2013)
Members on Benzodiazepines Only
60.2%
40.6%
Members on Opiates Only
22.0%
7.4%
Members on Both Medications
17.8%
11.3%
Members on No Medications
© 2014 Community Care Behavioral Health Organization

20. Conclusions
The decrease in concurrent medication over the past four years is encouraging
Provider feedback has been very positive about this initiative
Providers have adopted new policies when caring for individuals on concurrent benzodiazepines or opiates to ensure appropriate use
© 2014 Community Care Behavioral Health Organization

21. Collaboration of Care Implementation Guideline Presented by: Sara Remaley, MSPC, CAADC, Clinical Supervisor WPIC NATP Valerie Gualazzi, MS, CADC, Program Director WPIC NATP Western Psychiatric Institute and Clinic

22. WPIC currently treats approximately 420 patients on a regular basis.
Western Psychiatric Institute and Clinic Narcotic Addiction Treatment Program (NATP) -Addiction Medicine Services
WPIC NATP is a clinic specializing in opioid dependency in addition to psychiatric comorbidity.
WPIC offers methadone maintenance treamtent, suboxone treatment, psychiatric care and medication management, mental health, and addiction therapy.
WPIC currently treats approximately 420 patients on a regular basis.

23. Rationale
NATP recognized a need to address the misuse and abuse of prescription benzodiazepines by patients enrolled in medication assisted treatment.
High rates of patients were enrolling in treatment and concurrently becoming addicted to and abusing benzodiazepines, posing health risks, adverse effects, and ultimately untimely discharge from treatment.

24. Collaboration of Care
2012- WPIC NATP redesigned the program’s philosophy and position regarding concurrent use and abuse of prescription benzodiazepines and opiates while taking methadone.
Contraindications and potential for adverse effects helped NATP move in the direction of ‘therapeutic no tolerance’.
The “Collaboration of Care” Procedure : indicating NATP’s willingness to work with patients currently on prescription benzodiazepines to taper off and receive evidence based interventions and seek alternative treatment options as needed.

25. Collaboration of Care
The Collaboration of Care Procedure was developed as a way to inform patients of the new treatment philosophy indicating: use of benzodiazepines and opiates while on methadone is no longer permissible.
With the understanding that tapering from these type of medication can be a difficult and lengthy process with potential for relapse, NATP developed a procedural guideline to assist both patients and staff through this new process.

27. Barriers to addressing bzd use:
Difficult tapering process, risk related to withdrawal symptoms, and potential need for medically supervised detoxification.
High Relapse rates with benzodiazepines.
Concurrent rates of psychiatric comorbidity and the need to address/treat underlying mental health conditions.
Collaborating with providers (prescribing physicians) vs. illicit street use.
Addressing diversion…How does this fit?

28. Let the collaboration begin….
Step 1: Staff Education
Development of Procedural Guideline highlighting philosophy, procedures and interventions, and processes for team to follow.
Step 2: Patient Education
An FAQ was developed and handed out to all patients indicating the new Collaboration of Care and Program Philosophy regarding Concurrent use of benzodiazepines while in treatment.

29. FAQ

30. Step 3: Patient Acknowledgement and Responsibilities:
Reviewing the new philosophy and Collaboration of Care with patients, and asking them to acknowledge with their signatures that they have been informed.
A part of this process is also to explain to patients, the risks, as well as their rights. Albeit patients may reserve the right to refuse collaboration, they are also informed how this may directly impact their ability to remain in treatment.

31. Step 4: Interventions
Once the Collaboration of Care is initiated, the following procedures /interventions may be followed:
Urine Drug Screens and CCBHO Report reviewed.
Contact with the prescribing physician (physician to physician) to discuss recommendations and to create a tapering regimen.
Pill Counts
Illicit Street Use: Assessing need for medically supervised detoxification. Resources: Mercy Hospital Emergency Room, WPIC DEC (Diagnostic Evaluation Center).
UDS Confirmatory tests to determine if “levels” are decreasing- indicating progress/regression.

32. Interventions Continued:
Assessing underlying mental health and psychiatric disorders such as anxiety, depression, mood disorder, bipolar disorder, etc. Choosing a modality to effectively work with and treat these disorders in addition to addiction.
CBT, REBT, Gestalt Therapy, DBT, Motivational Interviewing, Person Centered etc.
Modifying treatment plans: Increasing therapy, regular appointments with Psychiatrist, following a medication regimen, ongoing collaboration.
Maintaining focus on individualized care through individualized recommendations. Assessing Progress: How is this done? Regular team meetings and supervision.

33. Response to Interventions
What happened after the Collaboration of Care was initiated?
NATP experienced responses similarly associated with the Change Curve (Kubhler-Ross)
Shock, Denial, Anger, Acceptance, Integration

34. Response to Interventions
How long did it take before a change was noticeable?
Integration took time and CONSISTENCY IS KEY
Response to change implementation included:
Compliance and Collaboration.
Increase in individual/group therapy- engagement in regular psychotherapy.
Increase in psychiatric treatment and psychopharmacology.
Exacerbation of symptoms/negative behaviors.
Increase in referrals to Higher LOC’s.
Decrease in bzd rates.
Increase in compliance/privilege status.

35. Evaluating Effectiveness
Establishing pre and post intervention baselines:
Rates of bzd use/abuse among patients.
Urine Drug Screen Results (including break-down of levels)
Individualized Progress
Relapse rates
Decrease in attaining prescriptions.
Patient Discharges
Sustained abstinence

36. Summary
Addressing concurrent use/abuse of benzodiazepines through the following steps:
Develop Program Philosophy
Identify Perceived Barriers
Education Staff
Educate Patients
Identify intervention strategies and evidenced based practices
Identify pre and post intervention baseline data

37. Enrolled in methadone programs”
“Meeting Needs …..Renewing Life”
Timothy H. Reese, M.D., MRO, SAP
Medical Director
1425 Beaver Avenue
Pittsburgh, PA
Phone: Ext. 109
Fax: /
“Decreasing the use of prescription opiates and benzodiazepines among individuals
Enrolled in methadone programs”

38. HISTORY OF TADISO
ESTABLISHED IN 1968 AS NON-PROFIT
700 PATIENTS—24 FULL TIME COUNSELORS—1 MEDICAL DIRECTOR
1 PA.
POPULATION: 2/3 NON-HISPANIC WHITE AND 1/3 AFRO-AMERICAN AND OTHER

39. DEMOGRAPHICS
NON-HISPANIC WHITES YEARS…….FASTEST
NON-HISPANIC WHITES YEARS………FASTEST OF THE FAST
NON-HISPANIC WHITES YEARS………SHOOTING MORE
NON-HISPANIC WHITES YEARS……….INHALING MORE

40. PENNSYLVANIA
PERSONS ENROLLED IN SUBSTANCE ABUSE TREATMENT PROGRAMS WHICH PRESCRIBED METHADONE INCREASED 18.9%

41. MESSAGE
WE ARE IN THE MIDST OF AN EPIDEMIC OF OPIOID ADDICTION AND ITS DEVASTATING TOLL ON SOCIETY!
METHADONE IS AND CAN BE AN EVEN GREATER PART OF OUR ARSENAL AGAINST THIS DEADLY FOE!

42. PATHOPHYSIOLOGY OF
OPIOID ADDICTION
--MEDULLA LOCUS CAERULEUS---90% OF CATECHOLAMINES IN CNS
--RESPONSIBLE FOR THE VEGETATIVE FUNCTIONS OF THE ORGANISM (SUPPORT LIFE)
--THERMOSTAT ANALOGY AND THE OPIOID WITHDRAWAL SYNDROME

43. CLINICAL MANIFESTATIONSOF
OPIOID WITHDRAWAL
VITAL SIGNS: TACHYCARDIA
HYPERTENSION
FEVER

44. CLINICAL MANIFESTATIONSOF
OPIOID WITHDRAWAL
CENTRAL NERVOUS SYSTEM:
RESTLESSNESS
IRRITABILITY
INSOMNIA
CRAVING
YAWNING

45. CLINICAL MANIFESTATIONSOF
OPIOID WITHDRAWAL
MUCOCTANEOUS: RHINORRHEA
EYES: LACRIMATION
PUPIL DILATION
SKIN: PILOERECTION (GOOSEFLESH)

46. CLINICAL MANIFESTATIONSOF
OPIOID WITHDRAWAL
GASTROINTESTINAL TRACT:
NAUSEA
VOMITING
DIARRHEA

47. CLINICAL MANIFESTATIONSOF
OPIOID WITHDRAWAL
PSYCHOSOMATIC WITHDRAWAL?
PSEUDO-WITHDRAWAL?
REAL WITHDRAWAL?

48. CLINICAL MANIFESTATIONSOF
OPIOID WITHDRAWAL
*ACCIDENTAL OVERDOSE AFTER A SUCCESSFUL DETOXIFICATION*

49. CLINCAL MANIFESTATIONS
OF OPIOID WITHDRAWAL
MU-AGONIST EFFECT WITH BEGINNERS!

50. DOPAMINE
----VTA/NUCLEUS ACCUMBENS (FOREBRAIN)
DRUG ABUSE DUMPS MASSIVE AMOUNTS OF DOPAMINE INTO THIS AREA.
REINFORCES BEHAVIOUR THAT IS PARAMOUNT TO SURVIVAL OF THE SPECIES

51. UP-REGULATION OF
DOPANINERGIC NEURONS
--AFTER REPEATED EXPOSURE (DRUG ABUSE) TO THESE MASSIVE AMOUNTS
OF DOPAMINE THE TARGET NEURONS BECOME PROGRESSIVELY LESS
RESPONSIVE! NET RESULT MORE STIMULATION GIVE LESS RESPONSE THUS
PROPELLING THE ADDICTION PROCESS!

52. BENZODIAZEPINES
INTERNEURONS IN THE VTA APPLY INHIBITORY EFFECTS ON DOPAMINERGIC NEURONS
THESE INHIBITORY INTERNEURONS EXERT THEIR EFFECT ON THE DOPAMINERGIC NEURONS BY WAY OF GABA (GAMMA AMINO BUTYRIC ACID)
BENZODIAZEPINES INHIBIT THIS INHIBITORY EFFECT. THIS INHIBITION RESULTS IN A MASSIVE RELEASE OF DOPAMINE FROM THE DOPAMINERGIC NEURONS.
THIS IS THE SYNERGISM WHICH OCCURS WHEN BENZODIAZEPINES ARE GIVEN WITH AN OPIOID; E.G., METHADONE.

53. OPIOIDS
IN A STABILIZED METHADONE PATIENT ANY ADDITIONAL OPIOID WILL CAUSE DESTABLIZATION ;
IF THE OPIOIDS ARE TAKEN TO AN ANALGESIC LEVEL ONLY THE DESTABILIZATION WILL MAINLY AFFECT THE MEDULLA LOCUS CAERULEUS.
IF THE OPIOIDS ARE TAKEN TO THE EUPHORIC LEVEL THE DESTABILIZATION WILL AFFECT THE DOPAMINERGIC NEURONS AS WELL.

54. CLONIDINE IN
SEARCH OF DOPAMINE
SINCE THE OPIOID WITHDRAWAL SYNDROME IS DUE IN PART TO HYPERACTIVITY OF THE MEDULLA LOCUS CAERULEUS AND EXCESSIVE CATECHOLAMINES, A DRUG WHICH BLOCKS THIS EFFECT SHOULD TREAT THIS PART OF THE OPIOID WITHDRAWAL SYNDROME.
CLONIDINE( CATAPRESS) IS A CENTRALLY ACTING ALPHA-2 BLOCKER AND DOES THIS WELL.
WHAT ABOUT THE DOPAMINE DEFICIENCY? A BENZODIAZEPINE WAS NEEDED TO BE ADDED TO THE ABOVE REGIMEN TO MAKE THE TREATMENT PALABLE TO THE PATIENT. THIS BENZODIAZEPINE VIA INHIBITING GABA IN INTERNEURONS OF THE VTA SUPPLIED THE DOPAMINE.

55. REPRESENTATIVE VIGNETTES
DR. COMPLETELY COOPERATIVE—MOST COMMON SCENARIO
DR. COOPERATIVE BUT DILATORY---NEEDS SOME PRODING
DR. COOPERATIVE BUT SELECTIVE---”NOT TO YOUR PATIENT”
DR. COOPERTIVE BUT NOT REALLY---REDUCE BUT WON’T STOP!

56. CCBHO INITIATIVE
THE EXPRESSED PURPOSE OF THIS INITIATIVE WAS TO DECREASE THE USE OF BENZODIAZEPINES AND OPIOIDS IN METHADONE CENTERS….AND IT WORKED!
CCBHO GIVES THE METHADONE CLINICS A LISTING OF PATIENTS WHO ARE GETTING BENZODIAZEPINE AND/OR OPIOID SCRIPTS. THESE PRESCRIPTIONS WOULD NOT BE REGISTERED AT THE CLINIC NOR WOULD EVIDENCE OF THE DRUGS SHOW IN THE ROUTINE URINES.

57. CCBHO INITIATIVE
THIS SCENARIO WAS VIRTUALLY UNCHANGED.
DOCTOR TO DOCTOR COMMUNICATION SPOILED THE ENTERPRISE.

59. IN CONCLUSION, THE INTERVENTIONS I HAVE DESCRIBED WITH THE ASSISTANCE OF CCHBO DID AND CONTINUES TO MAKE A DIFFERENCE FOR THE BETTERMENT OF THE LIVES OF THE PATIENTS AT TADISO.