MEDICATION ASSISTED TREATMENT MAT Presented by NJATOD Officers

MEDICATION ASSISTED TREATMENT (MAT) Presented by: NJATOD Officers Barbara Schlichting, NJATOD Secretary, Somerset Treatment Services Christie Hanvey , NJATOD Vice President, Spectrum Healthcare Center Maiysha Ware, NJATOD President, The Lennard Clinic

WHAT IS MEDICATION ASSISTED TREATMENT? U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment defines MAT as: Any treatment for opioid addiction that includes a medication (e. g. , methadone, buprenorphine, naltrexone) approved by the U. S. Food and Drug Administration (FDA) for opioid addiction detoxification or maintenance treatment. MAT may be provided in an OTP or an OTP medication unit (e. g. , pharmacy, physician’s office) or for buprenorphine a physician’s office or other healthcare setting. Comprehensive maintenance, medical maintenance, interim maintenance, detoxification, and medically supervised withdrawal are types of MAT.

MAT is… MAT combines the use of medication and behavioral therapy to treat substance use disorder. FDA approved medications used in MAT: Methadone, Buprenorphine & Naltrexone. MAT combines counseling with medications that block opioids’ euphoric effects and relieve relapse inducing cravings. MAT increase patient engagement and retention in treatment, decrease drug use, infectious disease transmission and criminal activity.

Methadone What is methadone? Methadone is an opioid medication. Methadone reduces withdrawal symptoms in people addicted to heroin or other narcotic drugs without causing the "high" associated with the drug addiction. Methadone is used as part of drug addiction detoxification or maintenance program. FDA Approved since 1947. Pregnancy Category “C” Safe to use during pregnancy. Half-life of Methadone is between 12 -18 hours. The effects of Methadone last between 24 -36 hours. Methadone is a full agonist, it fully binding to the mu receptors in the brain alleviating symptoms of withdrawal and or cravings, while blocking the effects of other opioids (when at blocking dose).

Buprenorphine What is Buprenorphine (Suboxone)? Suboxone contains a combination of buprenorphine and naloxone. Buprenorphine is an opioid medication. Naloxone blocks the effects of opioid medication, including pain relief or feelings of well-being that can lead to opioid abuse. Buprenorphine is approved for use in both induction and maintenance treatment of opioid dependence in appropriate patients. FDA Approved for clinical use since 2002. Pregnancy Category “C” Safe to use during pregnancy. Buprenorphine is a partial agonist, it is a combination of an agonist and antagonist. As a partial agonist it binds to the mu receptor in the brain and can alleviate withdrawal and or craving, but has the added antagonist properties of preventing other opioids from stimulating the receptor. Partial agonist are less likely to be abused.

Naltrexone What is Naltrexone (Vivitrol)? Vivitrol is the first and only non-addictive, once-monthly medication that, when combined with counseling, is proven to help prevent relapse to opioid dependence, after detox. Vivitrol blocks opioid receptors in the brain while you work with the psychological aspects of counseling. Vivitrol injection is used to prevent relapse in people who became dependent on opioid medicine and then stopped using it. Naltrexone can help keep you from feeling a "need" to use the opioid. Vivitrol injection is also used to treat alcoholism by reducing your urge to drink alcohol. This may help you drink less or stop drinking altogether. FDA Approved for OUD in 2010. Pregnancy Category “C” Safe to use during pregnancy. The effects of Naltrexone last for 28 days. Naltrexone is a antagonist, antagonists bind to the mu opioid receptors but don’t stimulate the production of endorphins. Antagonist prevent other opioids from stimulating the mu receptors.

Medication Comparisons Methadone and buprenorphine are both safe and effective for mothers and babies Buprenorphine use results in milder NAS symptoms, shorter hospital stays, and less morphine in tapering. Methadone has a significantly higher retention rate during pregnancy and after childbirth, and longer recovery outcomes for the mother. Methadone’s impact on children’s health has been studied for 40 years with no developmental impact detected. There is inadequate data on buprenorphine’s long-term effect on children.

A few more… Methadone does not have a “ceiling effect” like buprenorphine. Buprenorphine is effective only to 16 mgs. Anything above that is a placebo. Methadone is cheaper. Methadone is only available through the OTP. Buprenorphine is available through both an OTP and a private physician. Methadone treatment is highly structured with both medical and clinical components. Methadone is associated with better treatment outcomes because of the high activity at the mu receptor, flexible dosing and the ability to adjust to the needs of an individual.

APPROPRIATE MODALITY Physicians should consider: Treatment history (poor response to buprenorphine in the past) History of diversion Severity of drug use Patient reliability Financial resources Family support Transportation issues

Other Services provided: Case management services Stress and Anger Management Individual Counseling Group Counseling AA and NA Education and Developing a non-using support system Intensive Outpatient Services Urinalysis Screening Women’s Intensive Outpatient Services Referrals for Community Support Services Alcohol and Drug Education Transportation Needs Skills Development Co-occurring Disorders Relapse Prevention HIV Testing and Counseling Assertiveness Training Hepatitis C Testing and Referral

Benefits of MAT Medication-Assisted Treatment (MAT) with methadone, buprenorphine, or naloxone, has been proven to help patients recover from opioid addiction. These medications are: Safe Cost-effective Reduce the risk of overdose Increase treatment retention Improve social functioning Reduce the risks of infectious disease transmission Reduce criminal activity *When researchers studied heroin-overdose deaths in Baltimore between 1995 and 2009, they found an association between increasing availability of MAT (methadone and buprenorphine) and an approximately 50% decrease in the number of fatal heroin overdoses.

Challenges of MAT 1. Negative stigma of MAT particularly methadone 2. Lack of access to opioid maintenance treatment. 3. Affects the attitudes of medical and healthcare professionals; social service agencies and workers; paraprofessionals; employers, families, and friends of persons who are opioid addicted; and others who formerly abused substances. Stigma has also influenced criminal justice policies, created political opposition and limited funding and space for OTPs. Only 10 percent of the 23 million Americans with addictions and substance use disorders (SUD) receive any care in a given year. The lack of treatment access is also significant for justice-involved individuals – those in the courts, incarcerated, reentering society, or under community supervision like probation. Of the 2. 4 million people currently in prison, an estimated 65 percent are clinically addicted to drugs or alcohol, but only 11 percent receive any professional treatment while incarcerated. In addition, more than half of those on parole or probation continue to go untreated. Lack of training and education about MAT and its benefits

More Challenges… 4. Medication-assisted treatment has saved many lives, but it is still not often accepted by the public. Patients seeking MAT for opioid use disorder sometimes find that their healthcare providers may have a negative opinion of MAT despite medical evidence of its many benefits. 5. Limited number of licensed physicians prescribing buprenorphine. While it can be dispensed in sublingual form in a physician’s office, unlike methadone, which requires patients to seek out treatment in a qualified methadone treatment center, it is not linked to counseling and other treatment services which are used to provide better outcomes for the patient.

MAT: Myths and FAQs MAT just trades one addiction for another MAT bridges the biological and behavioral components of addiction. Research indicates that a combination of medication and behavioral therapies can successfully treat SUDs and help sustain recovery. MAT is only for the short term. Research shows that patients on MAT for at least 1 -2 years have the greatest rates of long-term success. There is currently no evidence to support benefits from cessation. Patients with long-term abstinence can follow a slow taper schedule under a physician’s direction, when free of stressors, to attempt dose reduction or total cessation. “I’ve known a few people who could stop using opioids without help from any kind of medication. MAT is only for the weak. “ Though opioid abuse may begin with a series of poor judgments, addiction involves real, physical changes in the brain. While some people are eventually able to quit using opioids on their own, the majority of patients go though many dangerous cycles of relapse and recovery. MAT can make the recovery process much safer, and has saved many lives by preventing death from overdose or dangerous behaviors associated with “street” drug use.

MAT: Myths and FAQs My patient’s condition is not severe enough to require MAT utilizes a multitude of different medication options (agonists, partial agonists and antagonists) that can be tailored to fit the unique needs of the patient. MAT increases the risk for overdose in patients. MAT helps to prevent overdoses from occurring. Even a single use of opioids after detoxification can result in a life-threatening or fatal overdose. Following detoxification, tolerance to the euphoria brought on by opioid use remains higher than tolerance to respiratory depression. Providing MAT will only disrupt and hinder a patient’s recovery process. MAT has been shown to assist patients in recovery by improving quality of life, level of functioning and the ability to handle stress. Above all, MAT helps reduce mortality while patients begin recovery.

MAT: Myths and FAQs There isn’t any proof that MAT is better than abstinence. MAT is evidence-based and is the recommended course of treatment for opioid addiction. The National Institute on Drug Abuse, Substance Abuse and Mental Health Services Administration, National Institute on Alcohol Abuse and Alcoholism, Centers for Disease Control and Prevention, and other agencies emphasize MAT as first line treatment. MAT is not effective because it does not immediately end drug dependence. Opioid use disorder or Addiction is not “cured” by the use of MAT. Addiction is a “chronic” (long-lasting) disease. Medical treatment for addiction can be compared to medical treatment for other common chronic diseases like diabetes or high blood pressure. Just as diabetes is not “cured” by the use of insulin, and people with high blood pressure often continue taking medications for many years, so people with opioid addiction are not “cured” but instead well-managed by MAT.

MAT: Myths and FAQs How long will I need to be on methadone, suboxone or vivitrol? The length of treatment can vary from patient to patient. The decision to discontinue therapy with these medications after a period of maintenance should be made as part of a comprehensive treatment plan. It is up to you, your doctor, and your therapist or counselor to decide on the appropriate length of treatment. Does methadone, suboxone or vivitrol interact with other drugs or medications? If you are taking any other prescription medications for physical or psychological reasons, make your physician aware prior to starting these medications. It is possible for these medications to negatively interact with other medications; therefore, it is important to discuss the use of other medications to avoid any adverse interactions.

MAT: Myths and FAQs What if I no longer wish to take methadone? Can I stop or switch to a different medication? Every individual who takes methadone is going to take it for a different length of time. If during your treatment, you wish to no longer take methadone or want to switch to a different medication, your treatment provider can assist you in tapering off methadone or prescribe another medication that can meet your needs. This process is necessary to prevent patients from experiencing adverse effects or withdrawal during this process. To learn more about ceasing the use of methadone or changing prescriptions, it is important to have a conversation with the doctor. Most insurance plans don’t cover MAT. As of May 2013, 31 state Medicaid FFS programs covered methadone maintenance treatment provided in outpatient programs. State Medicaid agencies vary as to whether buprenorphine is listed on the Preferred Drug List (PDL), and whether prior authorization is required (a distinction often made based on the specific buprenorphine medication type). Extendedrelease naltrexone is listed on the Medicaid PDL in over 60 percent of states.

MAT Success Stories and Outcomes Outcome data for STS MAT population includes: ü 70% Reduction in substance abuse ü 78% Compliance with treatment plan goals ü 94% Reduction of criminal activity Leonard’s recovery journey… "Leonard" came into our agency in 2012, using 15 -20 bags of heroin intravenously on a daily basis. He was unemployed and living with an opiate-addicted woman. He had various legal charges, including an old DUI. Leonard had been incarcerated previously. After his admission to MAT, he still used some heroin sporadically during the first year. However, after a year, he began attending IOP services on a regular basis. He then attended weekly groups as well as individual counseling. Leonard has now been abstinent from illicit drugs for over two and a half years. He is also gainfully employed and has purchased a home, in which he lives with a new girlfriend, who is also drug free. Leonard has chosen to utilized the available treatment tools of MAT, IOP, etc. to help him find a path toward successful long-term recovery.

MAT Success Stories and Outcomes TLC Overall Outcomes & Reputation *as of 12/31/17 ü 70% of respondents would recommend TLC to others. ü 81. 5% of respondents report life has improved since entering the program. ü 71. 5% of UDS are negative of illicit drugs. ü 45% of patients have of length of stay of 2 years or more. ü 57. 2% of patients have 2 or more take home bottles Ron’s recovery journey… “Ron” came to treatment on March 21, 2016. He is a 73 Black male with (2) previous unsuccessful treatment that he admitted leaving AMA due to his withdrawals and not being able to pay for treatment. He receives SSD; he has Medicare which does not pay for OTP. He came to TLC and requested admission on the MATOP program because he suffers from COPD and Emphysema and his health was deteriorating due to his substance use disorder. He started pulmonary treatment regularly and since being on the MATOP his health has improved. He receives oxygen tanks weekly and is now able to have some mobility. He struggled with becoming drug free for the first 6 months in treatment however since then he has submitted consecutive negative urine drug screens. Ron has one sister that lives out of state which visits him regularly, reminding him that she is proud of him. Ron is grateful for the MATOP program for giving him a chance to become drug free, he is a Phase 5 client and comes to the clinic 2 times a week and has his Individual Counseling Sessions 2 times a month. Counselor has a cohesive relationship with medical professionals involved in Ron’s care and works collaboratively with them to ensure he can live a productive and healthy life. He feels a sense of accomplishment and hope, thanks to the efforts of the MATOP program and in particular his counselor and his sister who has been instrumental in his treatment progress.

MAT Success Stories and Outcomes Joe’s recovery journey… “Joe” came into treatment on December 29, 2015. He stated he came to treatment after hearing from some friends that TLC had a free program called MATOP. Joe was living with his mother in her living room couch before reconciling with his ex-wife. He was taking illicit substances such as Xanax, Klonopin and other illicit substances that were not prescribed to him. He was given a referral to our in-house psychiatrist and our psychotherapist. Joe was prescribed psychotropic medication and met with the mental health team weekly, which he reported he has helped him cope with major trauma he experienced with his father and other family members. Joe’s wife filed for divorce due to his addiction and losing the family business they had for years. Joe has more than 20 months drug free since coming into treatment. He has been addressing his addiction, health and mental health issues. Recently he was diagnosed with Cirrhosis of the liver, and is currently on medication. He stated he is getting better with his treatment and was able to establish and amend his relationship with his ex wife who is very supportive of him now that he been drug free. Joe recently lost with mother due to her battle with cancer and dementia; he was there for her every step of the way through her transition last month. Joe’s ex-wife, which he lives with was recently diagnose with Lou Gehrig disease aka known as ALS. He has been accompanying her to her appointments in New York City at least two times a month. While Joe has been going through a lot within the last 9 months, he has chosen not to pick up any illicit substances to deal with life on life’s terms. Joe is currently a 6 take-home bottle carrier and comes to the clinic 1 x per week with Individual Counseling Sessions 2 x per month. His counselor has a cohesive relationship with the medical professionals involved in his care and works collaboratively with them to ensure he can live a productive and healthy life. Joe feels a sense of accomplishment and hope, thanks to the efforts of the MATOP program and in particular his primary counselor and medical professionals who have been instrumental in his treatment progress. Joe and his ex-wife are hoping to re marry by the beginning of the year.