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Addiction Treatment Forum reports on substance abuse news of interest
to opioid treatment programs and patients in methadone maintenance treatment.

NEWS NOTES & UPDATES #129

March 2009

Compiled & Edited by Sue Emerson - Publisher

Prior Edition: February 2009

List of all News/Updates

MEDICATION-ASSISTED TREATMENT (MAT)

AATOD Issues Policy Advisory on QTc Screening in Methadone Treatment

Last month we reported on an article regarding Clinical Guidelines titled “QTc Screening in Methadone Treatment” that was published in the March 17 print edition of Annals of Internal Medicine. The article is

available online (no charge) at: http://www.annals.org/cgi/content/full/0000605-200903170-00103v1

Annals of Internal Medicine also offers a webpage where you can submit feedback to the published QTc article. Responses to date can be accessed at: http://www.annals.org/cgi/eletters/0000605-200903170-00103v1

In response to the published QTc guidelines in the Annals, the American Association for the Treatment of Opioid Dependence, Inc. (AATOD) issued their own policy and guideline statement on QTc Interval Screening in March which can be accessed at: http://www.aatod.org/qtc.html

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West Virginia Proposes State Tax on Methadone

The West Virginia Gazette reported on March 21 that there is a proposed bill in the West Virginia House of Delegates that would tax nine Opioid Treatment Programs (OTPs) $1 for each dose of methadone that they dispense. Projected yearly tax revenues are estimated at $1.5 million. The tax revenues would fund prevention, early intervention, and recovery programs for opioid-dependent people.

One OTP regional director called the proposed tax “discriminatory” citing that “the legislation wouldn’t tax people who get methadone for pain treatment. Nor would it tax other medications used in opioid addiction treatment.” Supporters of the tax say the state is looking for a more versatile approach to addiction recovery including increasing the number of beds for long-term recovery. The article can be accessed at: http://wvgazette.com/News/200903210417

Source: West Virginia Gazette – March 21, 2009

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Methadone Patients Fare as Well as Other Patients in Therapeutic Community Treatment for Opioid Dependence

Many therapeutic communities (TCs) adhere to a drug-free philosophy and refuse to admit patients receiving methadone maintenance treatment (MMT). Many drug-treatment professionals also believe MMT patients do less well in treatment.

To learn whether MMT and non-MMT patients benefit equally from participation in a TC, researchers compared outcomes in 125 patients receiving MMT and 108 patients not receiving MMT who participated in a 12-month treatment program for opioid dependence. Psychiatric history, criminal justice pressure to undergo treatment, and expected lengths of stay were similar between groups. Interviews and urine testing were conducted at baseline, 6, 12, 18, and 24 months.

The mean number of days in treatment was similar between groups (166.5 days for the MMT group and 180.2 days for the comparison group).
At each assessment, the proportion of the MMT group testing positive for illicit opioids was indistinguishable from the proportion testing positive in the comparison group.
Stimulant and alcohol use, injection, and sex-risk behaviors were similar between the 2 groups.
Benzodiazepine use was similar between groups for all assessments except at 24 months, where 7% of the MMT group and none of the comparison group tested positive for benzodiazepines.

Comments by Michael Levy, PhD: These results demonstrate that MMT patients in TC treatment do as well as non-MMT patients with opioid dependence. Although members of the TC in this study had the benefit of prior training and experience working with MMT patients, results suggest residential treatment programs should accept MMT patients. Prior staff training and preparation should occur.

Reference: Sorensen JL, Andrews S, Delucchi KL, et al. Methadone patients in the therapeutic community: a test of equivalency. Drug Alcohol Depend. 2009;100(1–2):100–106.

Source: JoinTogether.org – Treatment Practitioner’s Research Bulletin - March 2009

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RESEARCH IN THE NEWS

What Is the Impact of High-Quality Clinical Supervision on Substance Abuse Treatment Staff Turnover?

Clinical staff turnover is high in addiction treatment programs and is associated with disrupting the clinical relationship and lowering the quality of care. Efforts to implement evidence-based practices may be hampered by staff turnover, and replacing personnel is costly. The relationship between substance abuse counselors' perceptions of clinical supervision and their intent to leave employment was studied among community treatment programs participating in the National Institute of Drug Abuse Clinical Trials Network. A total of 1643 questionnaires were mailed, and 1001 were returned (response rate, 60.9%). Of these, 823 met inclusion criteria. Results indicated that high-rated clinical supervision was associated with:

Less intention on the part of counselors to leave their jobs.
Less emotional exhaustion.
Greater feelings of autonomy.
Higher perception of procedural justice (i.e., fairness of decision making within their organization).
Higher perception of distributive justice (i.e., fairness of job demands and rewards).

Comments by Michael G. Boyle, MA: Training clinical supervisors and reviewing the quality of clinical supervision is time-consuming and expensive. However, opening the "black box" of supervision to observe its impact and modifying it as necessary may be worth this investment. The counselors surveyed in this study were part of a unique research network, and their situation may not be representative of other programs in the United States. Nonetheless, high-quality clinical supervision can improve the quality of addiction treatment while simultaneously reducing the financial costs that result from staff turnover. Addiction counselors should advocate for it within their organizations.

Reference: Knudsen HK, Ducharme LJ, Roman PM. Clinical supervision, emotional exhaustion, and turnover intention: a study of substance abuse treatment counselors in the clinical trials network of the National Institute of Drug Abuse. J Subst Abuse Treat. 2008;35(4):387–395.

Source: JoinTogether.org – Treatment Practitioner’s Research Bulletin - February 2009

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Overdose Management Training and Take-home Naloxone for Opiate-Using Persons May Save Lives

Opiate overdose is the cause of most drug-related mortality, and witnesses are commonly present. An initiative to provide training in the management of overdose was delivered to staff in 20 drug treatment facilities across England during 2005/2006. These staff then provided 239 opiate-using addiction treatment patients with training in management of overdose and a take-home supply of naloxone. The patients completed surveys before, immediately after, and 3 months after the training. At baseline, more than 90% of patients could recognize some signs of opioid overdose.

Among the 186 patients (78%) who completed 3-month follow-up:

90% reported still using illicit opiates.
Over 96% recalled the correct intramuscular injection sites for the naloxone, 77% retained knowledge of the recovery breathing position, and almost 98% remained confident in their ability to recognize and manage an overdose.
Close to 80% retained their naloxone, and 28% had trained a friend or family member to administer it should the participant overdose.
18 reported witnessing or experiencing an overdose during the 3-month period. Patients used their naloxone to revive other people on 10 occasions, and 2 received naloxone from ambulance staff.
1 death resulted among the 6 overdoses where naloxone was not administered.
No adverse reactions were reported.

Comments by Michael Levy, PhD: Despite a short follow-up period, this study suggests that patients in addiction treatment can be taught to recognize and treat opiate overdose with intramuscular naloxone. Many of the patients also taught friends and family how to administer naloxone. Providing such training may prevent fatal opiate overdose and, as such, should be considered both for addicts as well as for their friends and family members.

Reference: Strang J, Manning V, Mayet S, et al. Overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses. Addiction. 2008;103(10):1648–1657.

Source: JoinTogether.org – Treatment Practitioner’s Research Bulletin - February 2009

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Hepatitis C Virus Can Be Transmitted by Nasal Drug Use

In most cases of hepatitis C virus (HCV), the virus is transmitted through contact with infected blood, usually through the sharing of needles and other drug injection instruments. However, for up to 20 percent of HCV infections, the method of transmission is unknown.

Researchers have suggested that for some of these cases, HCV may be transmitted through the nose via the use of contaminated drug-sniffing implements. To test this hypothesis, investigators tested mucus samples from 38 intranasal drug users with chronic, active HCV infection for the presence of blood and HCV. They also asked participants to snort air through a straw in a way that would mimic their normal drug-sniffing behavior to determine whether sniffing implements became contaminated. The straws were then tested for blood and HCV.

The investigators found trace amounts of blood in 74 percent of mucus samples and on 8 percent of the straws used for sniffing. In addition, they detected HCV in 13 percent of mucus samples and on 5 percent of the straws. Only 8 percent of the samples contained both HCV and trace amounts of blood. Participants had a high rate of nasal inflammation and other nasal problems, including nosebleeds and damage to the inside of the nose from drug use, which may have contributed to the passage of blood and HCV from the nose. These results lend support to the hypothesis that HCV can be transmitted through shared use of contaminated sniffing implements, stated the authors.

Reference: Aaron S, McMahon JM, Milano D, Torres L, Clatts M, Tortu S, Mildvan D, Simm M. Intranasal transmission of hepatitis C virus: Virological and clinical evidence. Clin Infect Dis. 2008;47(7):931–934.

Source: National Institute on Drug Abuse (NIDA) News Scan #60 – March 24, 2009

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DRUGGED DRIVING

N.M. Seeks Standards for Drugged Driving

States have universally adopted a .08-percent blood-alcohol level as presumption of drunk driving, but no such standard exists for driving under the influence of other drugs. New Mexico, however, is seeking to establish guidelines that other states could emulate.

The Associated Press reported Feb. 19 that New Mexico Gov. Bill Richardson is backing a plan to establish blood-concentration levels for five illicit drugs as a legal presumption of intoxication. The drugs are marijuana, cocaine, heroin, amphetamine, and methamphetamine.

Supporters said the standards would be especially useful for when drivers mix alcohol and other drugs, since it can be difficult to prosecute offenders if their blood-alcohol level is below .08 percent. In New Mexico, 90 percent of drivers who failed field sobriety tests but had blood-alcohol levels below .08 percent tested positive for marijuana, researchers found.

Currently, many states consider any positive test for the presence of illicit drugs per-se evidence of impairment.

Source: JoinTogether.org – February 26, 2009

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La. Legislator Seeks Special License Plates for Drug Dealers

A state representative in Louisiana has filed legislation that would require special license plates and driver's licenses for individuals convicted of drug-related offenses, the News-Star reported Feb. 16.

Under the proposal presented by Rep. Rickey Hardy (D-Lafayette), individuals who have two or more convictions for distributing drugs would have to pay for a bright orange license plate labeled boldly with "Controlled Substance Conviction."

The proposed law states that following a second felony drug conviction, the offender would apply for the special license plate, pay an extra $10 administration fee plus $25 for the plate, and that the license plates would remain on the offender's vehicle for eight years.

Hardy conceded that the bill's purpose is to embarrass and create social pressure on repeat drug offenders. "If they don't want to be upstanding citizens, make them stand out. They want a badge of honor? Here it is," Hardy said.

The proposed legislation also asks for a one-year suspension of driving privileges for failure to comply with the requirements of the proposed law.

Source: JoinTogether.org – February 25, 2009

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NEW GOVERNMENT RESOURCES

New TEDS Report - Treatment Admissions for Prescription Pain Killers are
on the Rise

The Substance Abuse and Mental Health Services Administration (SAMHSA) recently released the Treatment Episode Data Set (TEDS) 2007 Highlights report. The report provides demographic data and other information on substance abuse treatment admissions from state licensed treatment facilities (most of them publicly-funded) across the country.

Five substances accounted for 96 percent of all TEDS admissions in 2007: alcohol (40 percent); opiates (19 percent; primarily heroin); marijuana/hashish (16 percent); cocaine (13 percent); and stimulants (8 percent, primarily methamphetamine).

The percentage of treatment admissions for primary heroin abuse is at about the same level it was a decade ago (14 percent). Primary heroin abuse admissions in 2007 were 246,871 compared to 264,599 in 2006.

Massachusetts (43.1%), New Jersey (36.8%) Connecticut (34.7%), Illinois (26.1%), and Maryland (25.7%) had the highest percentage of admissions for heroin abuse.

Treatment admissions for prescription opioid abuse has increased significantly over the past decade – representing one percent of all admissions in 1997 compared to five percent in 2007. Primary prescription opioid abuse admissions in 2007 were 90,516 compared to 80,131 in 2006.

Maine (24.1%), Tennessee (16.9%), Vermont (16.8%), Kentucky (15.1%), and Louisiana (10.8%) had the highest percentage of primary admissions for prescription opioid abuse.

Medication-Assisted Treatment (MAT) was planned for 29 percent of primary heroin admissions and 20 percent of admissions for prescription opioids.

Primary admissions for prescription opioids were almost twice as likely as heroin admissions to be entering treatment for the first time (42.8% compared to 22.9%).

Note: TEDS is an admission-based system, and TEDS admissions do not represent individuals. Thus, for example, an individual admitted to treatment twice within a calendar year would be counted as two admissions.

The full report can be accessed at: http://oas.samhsa.gov/TEDS2k7highlights/TOC.cfm

Source: Substance Abuse and Mental Health Services Administration, Office of Applied Studies – March 17, 2009

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SAMHSA Report Highlights Important Substance Abuse, Mental Health, Treatment and Grant Information for Each State and the District of Columbia

The Substance Abuse and Mental Health Services Administration (SAMHSA) has developed 51 new short reports providing key information about the level of substance abuse and mental health problems prevalent in the population (age 12 and older) of each state and the District of Columbia. The reports also provide data on treatment facilities and admission data for each state and the District of Columbia, as well as the funding each state and the District of Columbia received from SAMHSA.

Entitled “States in Brief,” the reports provide the following information for each individual state and the District of Columbia through a variety of charts, graphs and accompanying text including:

Prevalence of illicit substance and alcohol use
Number and type of substance abuse treatment facilities
Numbers and trends on those seeking treatment for substance abuse
Levels of those needing, but not receiving substance abuse treatment
Mental health indicators
SAMHSA funding, both under block and formula grants

Much of the data included in these “States in Brief” reports is drawn from the National Survey on Drug Use and Health – a SAMHSA-sponsored annual survey of approximately 67,500 people throughout the country. Additional sources of information include SAMHSA’s Treatment Episode Data Set and its National Survey on Substance Abuse Treatment Services.

The reports are available on the web at http://www.samhsa.gov/StatesInBrief/.

Source: The Substance Abuse and Mental Health Services Administration – February 9, 2009

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Notice:

All facts and opinions are those of the sources cited. News reports may have been edited for length and/or modified for clarity without altering essential data as originally published.

Addiction Treatment Forum and its associates do not endorse any medications, products, or treatments described, mentioned, or discussed in any of the sources referenced. Nor are any representations made concerning efficacy, appropriateness, or suitability of any such products or treatments. This News Update is made possible by an unrestricted educational grant from Covidien Mallinckrodt a manufacturer of methadone and naltrexone.

In view of the possibility of human error or advances in medical knowledge, Addiction Treatment Forum and its associates do not warrant the information contained in the above news updates is in every respect accurate or complete, and they are not responsible nor liable for any errors or omissions that may be found in such information or for results obtained from use of such information.

NEWS NOTES & UPDATES #129

March 2009