Treatment: The Role of Medication-Assisted Treatment (MAT) in the Nonmedical Opioid Epidemic - Dr. Robert DuPont

1. The
Role
of
Medica.on-­‐Assisted
Treatment
(MAT)
in
the
Nonmedical
Opioid
Epidemic
Na.onal
Rx
Drug
Abuse
Summit
/
Treatment
Track
April
22,
2014
Robert
L.
DuPont,
M.D.
Ins.tute
for
Behavior
and
Health,
Inc.
www.ibhinc.org

2. Disclosure
Statement
• No
conflicts
of
interest
• Professor
of
Clinical
Psychiatry,
Georgetown
University
School
of
Medicine
• President,
Ins=tute
for
Behavior
and
Health
– Non-­‐profit
organiza=on
dedicated
to
iden=fying
new
ideas
to
reduce
illegal
drug
use;
one
if
its
main
priori=es
is
to
reduce
prescrip=on
drug
abuse
• Vice
President,
Bensinger,
DuPont
&
Associates
– Na=onal
consul=ng
firm
dealing
with
substance
abuse
• Chairman,
Prescrip=on
Drug
Research
Center
– Consul=ng
firm
that
develops
risk
minimiza=on
ac=on
plans
and
product
surveillance
programs,
conducts
special
popula=on
surveys
and
forensic
drug
extrac=on
studies,
and
consults
with
pharmaceu=cal
companies
reviewing
abuse-­‐resistant
formula=ons
to
assess
or
reassess
scheduling

3. Learning
Objec.ves
• Describe
the
historical
context
and
current
status
of
medica=on-­‐assisted
treatment
for
opioid
dependence
in
the
past
half
century
• Evaluate
the
body
of
evidence
on
the
efficacy
of
medica=on-­‐assisted
treatment
focusing
on
con=nued
drug
use
and
program
reten=on
• Compare
the
treatment
of
opioid
use
disorders
using
medica=on-­‐assisted
treatment
to
the
management
of
other
chronic
diseases,
and
to
the
system
of
care
management
in
the
state
physician
health
programs

4. • 1898
to
1914
–
Patent
Medicines,
Over-­‐the-­‐Counter
Heroin
(and
Cocaine)
• 1967
to
1978
–
Baby
Boom,
Youth
Culture
Inspired
by
Timothy
Leary:
“Turn
On,
Tune
In,
Drop
Out”
• 2000
to
Present
–
The
Prescrip=on
Opioid
Bonanza
Seeded
a
New
Heroin
Epidemic
Three
American
Heroin
Epidemics

5. How
These
Epidemics
Were
Handled
• 1914
–
All
Supply
Reduc=on
– Pure
Food
and
Drug
Act
of
1906
– Harrison
Narco=cs
Tax
Act
of
1914
• 1978
–
Added
Demand
Reduc=on
– Methadone
Treatment
• Present
–
Both
Supply
and
Demand
Reduc=on
– Restrain
prescrip=on
opiate
use
– Methadone
programs
joined
by
buprenorphine
treatment

6. Demand
Reduc.on
is
More
Than
Treatment
• Preven=on
• Educa=on
• Supply
Reduc=on
is
Demand
Reduc=on
• Reducing
social
acceptance
of
drug
use,
including
with
the
criminal
law
• AND
Treatment

7. Treatment
“Need”
and
Use
• In
2012,
22.2
million
people
age
12
or
older
were
classified
with
a
substance
use
disorder
– 7.3
million
had
substance
use
disorder
related
to
drugs
other
than
alcohol
– 2
million
people
with
substance
use
disorders
related
to
pain
relievers
• 4
million
people
reported
obtaining
some
form
of
treatment
for
problem
• 2.5
million
people
received
treatment
at
a
specialty
facility

8. Mismatch
of
Need
and
Care
• 95%
of
the
people
with
substance
use
disorders
do
not
think
they
need
treatment
• Implica=ons
for
treatment
as
a
response
to
the
current
epidemic
Source:
SAMHSA
2013

9. Received
Most
Recent
Treatment
in
the
Past
Year
for
the
Use
of
Pain
Relievers
Among
Persons
Aged
12
or
Older:
2002-­‐2012
Source:
SAMHSA
2013

10. What
is
the
opiate
addict’s
problem?
• Just
a
bad
habit
that
the
opiate
user
needs
to
break?
OR
• A
changed
brain
crea=ng
a
life=me
risk
of
relapse
and
death?

11. Mismatch
of
Dura.on
• Treatment
is
short-­‐term
• Addic=on
is
for
life
• Lesson
from
the
tragic
death
of
Philip
Seymour
Hoffman
– Youth
drug
addic=on
– 20+
years
of
sobriety
– An
innocuous
prescrip=on
opiate
to
treat
pain
triggered
a
relapse
to
a
fatal
overdose

12. Treatment
–
For
How
Long?
• Two
examples
from
model
methadone
and
buprenorphine
programs

13. Pa.ent
Reten.on
in
a
Methadone
Program

14. Pa.ent
Reten.on
in
a
Buprenorphine
Treatment
Program
103
26
106
5
0
20
40
60
80
100
120
Baseline
(9/1/2011-­‐
11/30/2011)
Follow-­‐Up
1/1/2013
#
Ac.ve
Pa.ents
Prior
Admit
New
Admit
Status
at
Baseline

15. Addic.on
Treatment
Dura.on
• Medica=on-­‐free
programs
retain
opiate-­‐
dependent
pa=ents
for
even
shorter
periods
of
=me!
• The
vast
majority
of
opiate
addicts
do
not
want
treatment
• Many
addicts
who
come
to
treatment
drop
out
before
comple=ng
a
program
• Most
addicts
who
complete
treatment
relapse,
usually
rapidly

16. What
does
it
mean
-­‐-­‐
• That
only
5%
of
all
drug-­‐dependent
people
want
treatment?
• That
many
drop
out
of
treatment?
• That
many
of
those
who
complete
an
episode
of
treatment
relapse?

17. It’s
Not
Rocket
Science!
• Drugs
hijack
the
brain
and
distort
judgment
• Our
culture
normalizes
drug
use
• Drug
addic=on
is
chemical
slavery
• Addicts
alone
are
mostly
helpless
• Recovery
is
emancipa=on
from
chemical
slavery

18. The
Future
of
Opiate
Treatment
• Today’s
opiate
problem
must
be
dealt
with
from
outside
of
the
hijacked
addicted
brain
• Those
around
the
opiate
dependent
user
–
family,
health
care,
even
the
criminal
jus=ce
system
–
must
intervene
• They
are
essen=al
for
preven=on,
treatment
and
recovery

19. Where
is
the
Magic?
• The
magic
is
not
in
treatment
only
• For
many
it
is
in
the
12-­‐step
fellowships
–
and
• It
is
in
extended
random
monitoring
with
swip,
certain
and
serious
consequences
for
ANY
use
of
alcohol
or
other
drugs
–
not
just
the
use
of
opiates

20. A
New
Look
at
Treatment
• What
the
public
and
policymakers
think:
“Get
opiate-­‐dependent
people
into
treatment”
–
end
of
story
• The
treatment
“fix”
is
a
dangerous
illusion
• So
then
what?

21. Rethink
the
Goals
of
Treatment
• Possible
treatment
goals:
1) Reduce
opiate
use
2) Reduce
harms
from
drug
use
–
HIV
and
overdose
3) Reduce
alcohol
and
reduce
all
other
drug
use
(including
opiates)
4) Abs=nence
–
no
use
of
alcohol
or
all
other
drugs
• Rethink
dura=on
–
for
the
dura=on
of
treatment
or
for
the
addict’s
life=me?

22. Defining
Recovery
• Lifelong
abs=nence
from
the
use
of
alcohol
and
other
drugs
and
character
change
exhibited
through
healthy
living
and
produc=ve
engagement
• Besy
Ford
Ins=tute
Expert
Group,
2007:
A
voluntarily
maintained
lifestyle
characterized
by
sobriety,
personal
health,
and
ci8zenship

23. “Recovery”
from
Opiate
Substance
Use
Disorders
• Is
recovery
even
possible?
• How
is
recovery
achieved?
• With
what
reliability?

24. New
Treatment
Goal
• Today
relapse
is
the
expected
outcome
of
treatment
• The
New
Goal:
Make
recovery
the
expected
outcome
of
treatment
• Where
is
the
evidence
for
recovery
from
opiate
dependence?

25. Evidence
that
Sustained
Recovery
is
Possible
and
Reliably
Achieved
• The
evidence
is
found
in
a
unique
system
of
care
management
used
for
physicians,
nurses,
commercial
pilots
and
lawyers
• This
model
has
been
used
for
four
decades
and
is
well-­‐researched

26. Physician
Health
Program
(PHP)
System
of
Care
Management
• Comprehensive
evalua=on
• Signed
contract
for
monitoring
and
consequences
• Ini=al
intensive,
high
quality
treatment
for
substance
use
disorders
and
comorbid
disorders
• Random
tes=ng
for
5+
years
for
alcohol
and
other
drugs
of
abuse
with
zero
tolerance
for
ANY
use

27. Elements
of
the
PHP
System
of
Care
Management
• Leaving
the
PHP
or
relapse
to
substance
use
means
risk
of
losing
the
license
to
prac=ce
medicine
• Immersion
in
recovery
fellowships,
mostly
Alcoholics
Anonymous
(AA)
and
Narco=cs
Anonymous
(NA)

28. PHP
Long-­‐Term
Drug
Test
Results
• Over
the
course
of
5
years:
– 78%
of
all
physicians
had
zero
posi.ve
drug
tests
– 14%
had
only
1
posi=ve
drug
test
– 3%
had
only
2
posi=ve
drug
tests
– 5%
had
3
or
more
posi=ve
drug
tests

29. Same
Results
for
Opioid
Users
• Same
impressive,
long-­‐term
outcomes
are
possible
with
opioid
users!
• No
significant
differences
among
opioid
users
–
with
or
without
IV
drug
use
–
related
to:
– Posi=ve
drug
tests
over
5-­‐year
period
– Contract
status
at
follow-­‐up
– Occupa=onal
status
at
follow-­‐up

30. New
Follow-­‐Up
Study
Underway
• Among
physicians
who
successfully
completed
substance
use
disorder
contracts
with
PHPs
five
years
later…
• Preliminary
results
show
they
most
valued:
– 12-­‐step
fellowships
– Treatment
experiences
(typically
1-­‐3
months)
– Prolonged
monitoring
• Nearly
80%
reported
“My
PHP
experience
saved
by
career”

31. Ini.al
Results
of
Ongoing
PHP
Follow-­‐Up
Study
• More
than
90%
completed
PHP
contract
with
no
episodes
of
relapse
• Since
comple=ng
PHP
contract,
about
80%
report
no
use
of
alcohol
and
over
90%
report
no
use
of
drugs
• More
than
90%
asended
12-­‐step
mee=ngs
since
PHP
contract
comple=on;
nearly
70%
asended
12-­‐step
mee=ngs
in
the
past
year
• Nearly
all
consider
themselves
to
be
currently
“in
recovery”

32. A
New
Paradigm
• The
PHPs
are
part
of
a
new
paradigm
for
care
management
used
among
other
popula=ons
including
within
the
criminal
jus=ce
system
• The
power
is
in
the
long-­‐term
random
monitoring
with
rapid
interven=on
for
any
use
of
alcohol
and/or
drugs
• This
gets
addicts
into
treatment,
keeps
them
there
through
comple=on,
and
extends
the
benefits
of
treatment
by
making
recovery
the
expected
outcome

33. Extension
of
the
New
Paradigm
• HOPE
Proba=on
in
Hawaii
–
popula=on
of
mostly
poorly
educated,
high-­‐risk,
recidivist
offenders
with
long
histories
of
drug-­‐related
problems,
including
crime
• Most
are
dependent
on
smoked
methamphetamine
or
IV
opiates

34. • Intensive
random
drug
tes=ng
for
up
to
5
years
• Zero
tolerance
for
any
viola=on
of
proba=on
including
drug
use,
missed
tests,
missed
proba=on
appointments,
etc.
• Most
viola=ons
lead
to
brief
incarcera=ons
– If
offender
admits
use
and
tests
posi=ve,
given
2-­‐3
days
in
jail
– If
offender
denies
use
and
tests
posi=ve,
aper
laboratory
confirma=on,
likely
spends
15
days
in
jail
– Failure
to
appear
for
drug
test/appointment
and
law
enforcement
finds
absconder,
offender
will
spend
30
days
in
jail
– Repeat
absconding
leads
to
a
prison
sentence
Elements
of
HOPE
Proba.on

35. Elements
of
HOPE
• Treatment
is
available
but
only
required
when
monitoring
fails
–
“Behavioral
Triage”
• 12-­‐step
par=cipa=on
is
encouraged
but
not
required

36. HOPE
vs.
Standard
Proba.on
• Randomized
control
study
showed
that
in
a
one-­‐
year
period,
HOPE
proba=oners
were:
– 55%
less
likely
to
be
arrested
for
a
new
crime
– 72%
less
likely
to
use
drugs
– 61%
less
likely
to
skip
appointments
with
their
supervisory
officer
– 53%
less
likely
to
have
their
proba=on
revoked
• HOPE
proba=oners
were
sentenced
to,
on
average,
48%
fewer
days
of
incarcera=on
than
the
standard
proba=on
group

37. Distribu.on
of
Posi.ve
Drug
Tests
Over
One
Year
Period
Data courtesy of A. Hawken, Pepperdine University
51%
28%
12%
5%
2%
1%
1%
0%
10%
20%
30%
40%
50%
60%
0
1
2
3
4
5
6
Number
of
Posi.ve
Drug
Tests

38. Implica.ons
for
Treatment
of
Prescrip.on
Opiate
Abuse
• Outcomes
reflect
the
sevngs
in
which
the
decision
to
use
or
not
use
drugs
is
made
– When
the
environment
permits
or
encourages
drug
use,
it
usually
con=nues
– When
the
environment
quickly
and
effec=vely
iden=fies
any
drug
use
and
intervenes
swiply
with
serious
consequences,
it
usually
stops
– Par=cipa=on
in
recovery
fellowships
extends
the
benefits
of
treatment
for
a
life=me

39. Next
Steps
• Making
recovery
the
expected
outcome
of
treatment
means
thinking
outside
treatment
to
the
environment
in
which
the
decision
is
made
to
use
or
to
not
use
alcohol
and
drugs
• The
key
to
widespread
achievement
of
recovery
is
in
the
care
management:
– Over
many
years
– With
leverage
to
enforce
abs=nence
from
any
use
of
alcohol
or
other
drugs

40. Where
is
the
Leverage?
• Leverage
can
be
applied
by
families,
the
criminal
jus=ce
system,
in
health
care,
the
workplace,
schools
and
elsewhere
• Like
the
leverage
now
used
by
licensing
boards
for
physicians,
nurses,
commercial
pilots,
and
lawyers

41. Looking
Ahead
• Is
the
country
ready
for
this
new
mission?
• Surely
the
na=on’s
treatment
programs
are
not
currently
organized
to
fulfill
this
new
mission
• First
the
new
vision:
The
opiate
dependence
problem
is
lifelong
and
so
must
the
solu.on
be
lifelong
–
with
Recovery
as
the
goal

42. Conclusion
• The
benefit
of
treatment
can
only
be
realized
when
outcomes
are
measured
by
the
ability
to
make
recovery
the
expected
outcome

43. The
New
Paradigm
-­‐-­‐
1) Fits
with
the
Mental
Health
and
Addic=on
Parity
Act
and
the
Affordable
Care
Act
2) Fits
with
the
new
focus
in
medicine
on
chronic
disease
monitoring
and
management
3) This
approach
to
opiate
addic=on
treatment
dovetails
with
the
new
approach
to
the
management
of
chronic
(and
fatal)
diseases
such
as
diabetes
and
hypertension

44. What’s
Next?
• The
stage
now
is
set
by
the
current
opiate
addic=on
epidemic
for
a
revolu=on
in
addic=on
treatment
• This
change
will
make
Recovery
–
Not
Relapse
–
the
Expected
Outcome
of
Treatment

45. Thank
you!

46. Discussion
Now
I
want
to
hear
from
YOU!

47. www.IBHinc.org
• For
more
informa=on
on
other
important
ideas
to
reduce
illegal
drug
use
visit
the
home
website
of
the
Ins=tute
for
Behavior
and
Health

48. References
• Besy
Ford
Ins=tute
Consensus
Panel.
(2007).
What
is
recovery?
A
working
defini=on
from
the
Besy
Ford
Ins=tute.
Journal
of
Substance
Abuse
Treatment,
33(3),
221-­‐228.
• DuPont,
R.
L.,
&
Humphreys,
K.
(2011).
A
new
paradigm
for
long-­‐term
recovery.
Substance
Abuse,
32(1),
1-­‐6.
• DuPont
R.
L.,
McLellan
A.
T.,
White
W.
L.,
Merlo
L.,
and
Gold
M.
S.
(2009).
Sevng
the
standard
for
recovery:
Physicians
Health
Programs
evalua=on
review.
Journal
for
Substance
Abuse
Treatment,
36(2),
159-­‐171.
• Hawken,
A.
(2010).
Behavioral
triage:
a
new
model
for
iden=fying
and
trea=ng
substance-­‐abusing
offenders.
Journal
of
Drug
Policy
Analysis,
3(1),
1-­‐5.
• Hawken,
A.,
&
Kleiman,
M.
(2009,
December).
Managing
drug
involved
proba=oners
with
swip
and
certain
sanc=ons:
Evalua=ng
Hawaii’s
HOPE.
Na=onal
Ins=tute
of
Jus=ce,
Office
of
Jus=ce
Programs,
U.S.
Department
of
Jus=ce.
Award
number
2007-­‐IJ-­‐CX-­‐0033.
• McLellan,
A.
T.,
Skipper,
G.
E.,
Campbell,
M.
G.
&
DuPont,
R.
L.
(2008).
Five
year
outcomes
in
a
cohort
study
of
physicians
treated
for
substance
use
disorders
in
the
United
States.
Bri=sh
Medical
Journal,
337:a2038
• Substance
Abuse
and
Mental
Health
Services
Administra=on.
(2013).
Results
from
the
2012
Na=onal
Survey
on
Drug
Use
and
Health:
Summary
of
Na=onal
Findings,
NSDUH
Series
H-­‐46,
HHS
Publica=on
No.
(SMA)
13-­‐4795.
Rockville,
MD:
Substance
Abuse
and
Mental
Health
Services
Administra=on.
• Unpublished
ongoing
study
data:
“Long-­‐Term
Follow-­‐up
of
Physician
Health
Program
(PHP)
Par=cipants.”
• Unpublished
manuscript,
“Recovery
from
opioid
dependence:
Lessons
from
the
treatment
of
opioid-­‐dependent
physicians.”