MedicationAssisted Recovery and the Modern Recovery Movement Ben

Medication-Assisted Recovery and the Modern Recovery Movement Ben G. Bass August 7, 2019

Working with communities to address the opioid crisis. ² SAMHSA’s State Targeted Response Technical Assistance (STR-TA) grant created the Opioid Response Network to assist STR grantees, individuals and other organizations by providing the resources and technical assistance they need locally to address the opioid crisis. ² Technical assistance is available to support the evidence-based prevention, treatment, and recovery of opioid use disorders. 2

Working with communities to address the opioid crisis. ² The Opioid Response Network (ORN) provides local, experienced consultants in prevention, treatment and recovery to communities and organizations to help address this opioid crisis. ² The ORN accepts requests for education and training. ² Each state/territory has a designated team, led by a regional Technology Transfer Specialist (TTS), who is an expert in implementing evidence-based practices. 3

Contact the Opioid Response Network ² To ask questions or submit a technical assistance request: • Visit www. Opioid. Response. Network. org • Email orn@aaap. org • Call 401 -270 -5900 4

Substance Abuse and Mental Health Services Administration (SAMHSA) Funding for this initiative was made possible (in part) by grant no. 6 H 79 TI 080816 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U. S. Government. 5

Approach: To build on existing efforts, enhance, refine and fill in gaps when needed while avoiding duplication and not “re-creating the wheel. ” 6

Overall Mission To provide training and technical assistance via local experts to enhance prevention, treatment (especially medication-assisted treatment like buprenorphine, naltrexone, and methadone), and recovery efforts across the country addressing state and local - specific needs. 7

Learning Objectives ² What is the Recovery Movement and how has it evolved? ² What do we mean by “Medication-Assisted Recovery? ” ² What can we do to support this movement? 8

A LOOK BACK…. 9

1750 to early 1800 s Alcoholic mutual aid societies, sobriety circles provide early recovery. Handsome Lake of the Seneca, after recovering from alcoholism brings the Gaihwiyo, or “Good Word” of how to live free from alcohol to his tribe in 1799. Source: William L. White. Slaying the Dragon: The History of Addiction Treatment and Recovery in America. 1998 10

1870 Keeley alcoholism cures spread. Founded by Dr. Leslie Keeley, who opened more than 120 Keeley Institutes in North America and Europe, these consisted of addiction cure institutes and proprietary home cures, such as bottled "Double Chloride of Gold Cures for drunkenness. " Source: William L. White. Slaying the Dragon: The History of Addiction Treatment and Recovery in America. 1998 11

“Double Chloride of Gold Cures” It was reported by various sources to actually contain: § § § Coca Morphine Strychnine Arsenic And other deadly ingredients Keeley claimed a 95% cure rate on this treatment. Scientist and patients’ families disputed this as they began to report side effects ranging from insanity to relapse to death. Source: William L. White. Slaying the Dragon: The History of Addiction Treatment and Recovery in America. 1998 12

Marty Mann was an AA Member and an Early Recovery Advocate and Public Voice for the Organization that led to NCADD 13

Faces and Voices of Recovery • • Organizing the recovery community in the U. S. • Provides training and advocacy at the federal level to support initiatives that promote recovery, such as Parity legislation, the Comprehensive Addiction Recovery Act and current efforts to protect confidentiality for people seeking recovery Started after the Recovery Summit in St Paul MN in 2001. 14

Treatment, Peoria Illinois, 1969 15

Morphine Maintenance Clinics 1919 -1924 Communities established morphine maintenance clinics to treat people with morphine addiction. Most eventually close for legal reasons. Source: William L. White. Slaying the Dragon: The History of Addiction Treatment and Recovery in America. 1998 16

Methadon e In 1964, Dr. Vincent Dole, an endocrinologist, and Dr. Marie Nyswander, a psychiatrist, introduced methadone to treat narcotic addiction. The FDA approved it to treat heroin addiction in 1972. 17

Overdose Reversal FDA approves Narcan in 1971. Narcan counter opioid overdose effects, usually within 2 minutes. It was first made available as an injectable solution and is now also available as a nasal spray. 18

Naltrexone was approved for alcoholism in 1994 and became the second drug the FDA approved for alcoholism. Naltrexone is non-addictive and does not react with alcohol. It blocks opioid receptors in the brain, preventing the pleasurable effects. 19

Buprenorphine FDA approves buprenorphine for clinical use in 2002. It’s a medication-assisted treatment (MAT) for opioid addiction. Unlike methadone, which is dispensed within a structured clinic, specially qualified physicians can prescribe buprenorphine. 20

Peer-Based Recovery Support Systems Recovery coaches, rather than being legitimized through traditionally acquired education credentials, draw their legitimacy from: ² Experiential knowledge ² Experiential expertise Source: Thomasina Borkman. “Experiential knowledge: a new concept for the analysis of self-help groups. ” The Social Service Review, 1976. 21

Recovery & Medication Status Consensus Statement “…formerly opioid-dependent individuals who take naltrexone, buprenorphine, or methadone as prescribed and are abstinent from alcohol and all other nonprescribed drugs would meet this definition of sobriety” (Journal of Substance Abuse Treatment, 2007) 22

This perspective requires: Distinguishing: from: • Physical Dependence • Tolerance, Withdrawal • Addiction • Craving, obsession, compulsion • Drugs that compromise recovery status • Medications that may enhance recovery stability 23

This Perspective Requires Challenging the myths we discussed earlier, and educating others in a compassionate way Not being part of the paradigm shift, but a shifter of the paradigm. 24

Recovery Oriented Methadone Maintenance Originally written as ROMM, or, Recovery Oriented Methadone Maintenance, we have expanded the original writing to include MARS as an approach to treatment of opioid addiction that combines medication and a sustained menu of professional and peer-based recovery support services to assist patients and families in initiating and maintaining long-term recovery. Source: William L. White and Lisa Mojer-Torres. Recovery-Oriented Methadone Maintenance. 2010. 25

Problems of MAT addressed by MARS include: Low rate of attraction (6 -15 years before 1 st admission; 22 years prior to achieving recovery stability) Problems of access (25 -50% of persons on waiting list drop out before admission) Subclinical dosing and dose manipulations or administrative discharge for rule infractions Continued drug use while in MMT related to withdrawal distress (often linked to subtherapeutic doses of methadone), dysphoric emotional states, pleasureseeking, and impulsive responses to social opportunities to use (Best et al. , 1999). Source: William L. White and Lisa Mojer-Torres. Recovery-Oriented Methadone Maintenance. 2010. 26

Problems of MAT addressed by MARS include: Low rate of sustained engagement (24% dropout in first 60 days; 60. 2% drop-out by one year) High rate of drop-out/discharge without planned tapering (11% as planned; 45% drop out; 17% transferred; 13% AD; 15% other) High rate of post-discharge relapse (50%+ in first year after discharge; most in first 30 days) and high mortality risk (8 -20 times greater than patients in treatment) Low linkage to indigenous recovery communities or alternative recovery support institutions Role of self-stigma and professional/social stigma attached to MMT as obstacle to community reintegration Source: William L. White and Lisa Mojer-Torres. Recovery-Oriented Methadone Maintenance. 2010. 27

MARS shall NOT: Raise the bar of admission to MAT Set arbitrary limits on dosage or duration of MAT Impose pressure for patients to end MAT Force counseling or peer support services on patients who do not want or would not benefit from them Extrude patients who do not adopt the goal of full recovery Impose remission/recovery criteria on MAT patients different that those applied to other patients with SUDs. Source: William L. White and Lisa Mojer-Torres. Recovery-Oriented Methadone Maintenance. 2010. 28

Attract people at earlier stages of problem development Include assertive community education & outreach MARS Does Seek To: Ensure rapid access to MAT / Resolve obstacles to treatment Streamline intake and assertive waiting-list management Assure safe, individualized, optimum dose stabilization Connect with close medical monitoring during induction and treatment 29

MARS Does Seek To: Utilize assessment processes that are global, family-centered, strengths-based and continual Transition each patient from a professionally-directed treatment plan to a patient-directed recovery plan Former aimed at remission (-); latter aimed at recovery (+) Expand the service team- peers, primary care, families Shift the service relationship from a directive expert model to a recovery partnership/consultation model Source: William L. White and Lisa Mojer-Torres. Recovery-Oriented Methadone Maintenance. 2010. 30

MARS Does Seek To: Assure minimum/optimum duration of MAT Encourage minimum 1 -2 years (Patients who taper after 1 -2 years have better long-term post-Tx outcomes than those ending treatment before 1 year) Offer option of prolonged, if not lifelong, maintenance Focus is on recovery not duration of medication support Expand the service menu & imbed services in vibrant culture of recovery Source: William L. White and Lisa Mojer-Torres. Recovery-Oriented Methadone Maintenance. 2010. 31

MARS Does Seek To: Affirm that recovery is contagious Expanded menu of ancillary services Extend delivery of recovery support services into the community e. g. , Co-location; delivery of recovery support services outside the clinic Source: William L. White and Lisa Mojer-Torres. Recovery-Oriented Methadone Maintenance. 2010. 32

MARS Does Seek To: Link patients/families to recovery community support resources Practice assertive versus passive linkage procedures Provide post-treatment monitoring, support and, if and when needed, early re-intervention. 33

Missing Voices in MAT Discussions ² Patients and Families ² Need for vanguard of individuals/families to put faces and voices on medicationassisted recovery ² There are signs that this vanguard is emerging ² That vanguard needs to be engaged in RM/ROSC/ROMM design and evaluation efforts Source: William L. White and Lisa Mojer-Torres. Recovery-Oriented Methadone Maintenance. 2010. 34

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There are many paths of recovery Natural Recovery Mutual Aid Groups Medication. Assisted Recovery Peer-Based Recovery Supports Family Recovery Technology. Based Recovery Alternative Recovery Supports Faith-Based Recovery 36

Medication-assisted recovery § Methadone, buprenorphine, extendedrelease naltrexone § Improves patient survival § Increases retention in treatment § Decreases illicit opioid and other criminal activity § Increases ability to gain and maintain employment § Improves birth outcomes among women who have substance use disorders and are pregnant 37

Alternative recovery tools Amino Acid Therapies The Artist’s Way Cognitive Therapy Dance, Music, Art, Journaling/Therapeutic Writing Equine Therapy Fitness for Recovery Holistic Health and Natural Alternatives Hypnotherapy MBSR (Mindful-Based Stress Reduction) MBRP (Mindful-Based Relapse Prevention) Meditation Nutrition Therapy for Biochemical Recovery Wolf Therapy WRAP - Wellness Recovery Action Plan Yoga in Recovery 38

Non-Stigmatizing Language "By using accurate, nonstigmatizing language, we can help break the stigma surrounding this disease so people can more easily access treatment, reach recovery, and live healthier lives. " Michael Botticelli, Former Director White House ONDCP 39

Language Matters Don't Say Do Say ² Substance Abuse ² Substance use or ² Former Addict ² ² Alcoholics & Addicts ² ² Clean or Dirty urine Drug Screen ² Lapse or Relapse ² ² misuse Person in recovery People with alcohol or other drug problems Positive or Negative screen Return to use or recurrence 40

Language Audit ² Perform a “language audit” of existing materials for language that may be stigmatizing, then replace with more inclusive language. ² Example: Using the search and replace function for electronic documents, search for “addict” and replace with “person with a substance use disorder, ” or search for “abuse” and replace with “use” or “misuse. ” ² Make sure to review both internal documents (e. g. , mission statements, policies) as well as external ones (e. g. , brochures, patient forms). SAMHSA/CAPT, 2017 41

Change Language to Improve Care: The Addictionary ² Avoid: “dirty, ” “clean, ” “abuse, ” and “abuser” ² Consider changing: Medication Assisted Treatment – Medications for addiction treatment are life-saving similar to insulin for diabetes, which is not called “insulin assisted treatment” despite importance of behavioral interventions with diabetes care ² “Medically-supervised withdrawal" also more accurate and less stigmatizing than ”detox" 42

What Can Clinicians Do? ² Treat addiction with science-based strategies – MD/NP/PA Get Waivered! ² Speak out against stigma & discrimination ² Keep hope alive ² Treat affected individuals with dignity ² Partner with peer recovery specialists ² Be mindful of language 43

SAMHSA’s Definition of Recovery A process of change through which individuals improve their health and wellness, live selfdirected lives, and strive to reach their full potential. = 44

Advocacy If you believe recovery is possible, you are the perfect person in the perfect place at the perfect time to help reduce the stigma Join in the advocacy through educating people who may not understand. It is important that we not engage in arguments but share information in an effective way. Examples of Major Organizations (Not exclusive): Faces and Voices of Recovery (FAVOR) NAADAC TAAP 45

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Thanks for your attention! Ben Bass Recovery Alliance of El Paso 3501 Hueco Avenue El Paso, Texas 79903 (915) 775 -0505 bbass@recoveryalliance. net 47