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

AT Forum NEWS NOTES & UPDATES #146

October 2010

Compiled & Edited by Sue Emerson - Publisher

Prior Edition: September 2010

List of all News/Updates

METHADONE AND MEDICATION-ASSISTED TREATMENT (MAT) AND OPIOID ADDICTION

New Recovery-Oriented Methadone Maintenance White Paper

There are growing calls to shift the acute-care model of addiction treatment to a model of sustained recovery support analogous to the long-term management of other chronic diseases. The purpose of this monograph written by William L. White, MA, and Lisa Mojer-Torres, JD, is to explore what this shift means to the design and delivery of methadone maintenance (MM) treatment and the status of MM treatment and MM patients in the United States. The paper published this month can be accessed at: http://atforum.com/addiction-resources/documents/Recovery.pdf

Source: The Institute for Research, Education, and Training in Addictions (IRETA) — October 2010

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EUROPAD Journal — Heroin Addiction and Related Clinical Problems — September 2010 Issue Now Available Online

Heroin Addiction and Related Clinical Problems, the official journal of EUROPAD (European Opiate Addiction Treatment Association), is a peer-reviewed publication for professionals wanting to stay informed of research and opinion on opioid misuse treatment in Europe and around the world. A particular emphasis is on medication-assisted treatments for opioid addiction. Articles in the September issue include:

Psychological performance and sedation following injectable opioid administration
Treatment practices and perceived challenges for European physicians treating opioid dependence
Clinical foundations for the use of methadone in patients with infectious diseases
Bioethical preferences of supporters and opponents of agonist opioid therapy in Russia
The pleasure constant

The September issue can be accessed at: http://atforum.com/documents/HeroinAdd12-3.pdf

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Methadone Treatment Reduces Overall Health-Care Costs for Commercially Insured Patients with Opioid Dependence

Under the Mental Health Parity and Addiction Equity Act, insurers are now required to cover addiction treatment. To assess the costs associated with treating opioid dependence, researchers reviewed data from a not-for-profit health maintenance organization that covered addiction services, including methadone. Patients with at least 2 opioid-dependence diagnoses between 2000 and 2004 (N=1518) were assigned to 1 of 3 addiction treatment categories: no treatment, outpatient treatment without methadone, and methadone treatment. Researchers then compared differences in health-care utilization and costs between groups, controlling for age, gender, and Medicaid status.

Fifty-one percent of opioid-dependent patients received methadone, 34% received outpatient treatment, and 15% did not receive treatment.
Eighty-six percent of patients made at least 1 primary-care visit. Forty-eight percent visited the emergency department (ED), and 24% were hospitalized.
Compared with the outpatient and no-treatment groups, methadone recipients had significantly fewer annual ED visits (1.3 versus 2.6 and 3.7, respectively), primary-care visits (3.8 versus 7.5 and 9.0, respectively), and hospitalizations (0.2 versus 0.6 and 1.1, respectively).
Mean yearly health-care costs were lower for the methadone group compared with the outpatient and no-treatment groups ($7,163 versus $14,157 and $18,695, respectively).

Comments: Although this observational study could not fully account for confounders that influence patterns of health-care utilization, the finding that opioid-dependent patients who participate in methadone treatment are less expensive to insurers than patients who go without it may allay cost concerns as addiction treatment is incorporated into covered services.

Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue July/August 2010. Access checked 10/20/10. Hillary Kunins, MD, MPH, MS

Original Source: McCarty D, Perrin NA, Green CA, et al. Methadone maintenance and the cost and utilization of health care among individuals dependent on opioids in a commercial health plan. Drug Alcohol Depend. June 3, 2010 [E-pub ahead of print].

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Effect of Opioid Agonist Treatment on Survival and Cessation among Patients with Injection Drug Use

Few studies have reported the long-term effectiveness of opioid agonist treatment (OAT) on injection drug use (IDU) cessation and survival. Between 1980-2007, Edinburgh Addiction Cohort researchers identified 794 patients with a history of IDU and flagged them for follow-up with the UK National Registry Office. Between 2005-2007, 432 of the patients were interviewed regarding early life experience, substance use, and health and social histories. In addition, data were extracted from medical and death-registration records for 655 patients.

Among interviewees, 135 (31%) were currently using injection drugs; of these, 83% were also receiving OAT.
Among patients followed up via medical records, 558 (85%) received OAT at some point during the follow-up period. Of these, 277 achieved long-term cessation (at least 5 consecutive years of no IDU), and 228 died. The leading causes of death were HIV infection (45%), drug overdose (24%), and liver disease (11%).
In adjusted analyses, each additional year of OAT decreased risk of death before long-term cessation by 13%.
Among patients who did not receive OAT, probability analysis indicated that 25% would be dead within 25 years of first injection compared with 6% of patients who received at least 5 years of OAT.
Opiate agonist treatment was inversely associated with long-term IDU cessation.

Comments: This study showed a cumulative survival benefit among patients receiving OAT but also showed that OAT does not reduce, and may even increase, the overall duration of IDU. The benefits on survival applied to patients with evidence of continuing IDU as well; therefore, withdrawing these patients from treatment programs would negatively impact their survival. These results support a risk-reduction approach to OAT that retains patients with continuing use.

Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue July/August 2010. Access checked 10/20/10. Nicolas Bertholet, MD, MSc

Original Source: Kimber J, Copeland L, Hickman M, et al. Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment. BMJ. July 1, 2010 (E-pub ahead of print).

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Prescription Opioid Abuse and Dependence Increases as Younger Nonmedical Users Grow Older

Researchers compared the findings of 2 surveys — the 1991-1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES) and the 2001-2002 National Epidemiologic Study on Alcohol and Related Conditions (NESARC) — to determine whether increases in nonmedical prescription opioid use, abuse, and dependence were due to increases in all age groups (period effect), increases by age (age effect), or increases by year of birth (cohort effect). Analyses were limited to subjects aged 18-57 divided into 4 age cohorts: 18-27, 28-37, 38-47, and 48-57.

There was no change in lifetime nonmedical use of prescription opioids within birth cohorts as they aged, suggesting initiation after age 27 is rare.
There were significant increases in past-year use and a past-year opioid use disorder (OUD) within most age cohorts, consistent with an age effect.
Lifetime and past-year prevalence of OUD was highest among more recent birth cohorts, consistent with a cohort effect.
Lifetime prevalence of OUD increased among almost all pairs of birth cohorts, particularly younger birth cohorts, consistent with a period effect.

Comments: This study found period, age, and cohort effects have contributed to increases in prescription opioid abuse and dependence. The fact that nonmedical use of prescription opioids is usually initiated by people in their early 20s, becoming more of a problem as these individuals age, suggests we face an even larger problem in the future. Thus, prevention efforts should target youths to prevent the initiation of nonmedical use.

Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue July/August 2010. Access checked 10/20/10. Darius A. Rastegar, MD

Original Source: Martins SS, Keyes KM, Storr CL, et al. Birth-cohort trends in lifetime and past-year prescription opioid-use disorder resulting from nonmedical use: results from two national surveys. J Stud Alcohol Drugs. 2010;71(4):480—487.

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GOVERNMENT

American Public Overwhelmingly Responds to DEA Prescription Drug Take-Back Effort

The United States Drug Enforcement Administration announced on Oct 5, the overwhelmingly successful results of the first-ever national prescription drug "Take-Back" campaign. The American public turned in more than 242,000 lbs of prescription drugs for safe and proper disposal. More than 4,000 take back sites were available in all 50 states.

"The Take-Back Campaign was a stunning nationwide success that cleaned out more than 121 tons of pills from America's medicine cabinets, a crucial step toward reducing the epidemic of prescription drug abuse that is plaguing this nation," said DEA Acting Administrator Michele M. Leonhart. "Thanks to our state and local law enforcement and community partners—and the public—we not only removed these dangerous drugs from our homes, but also educated countless thousands of concerned citizens about the dangers of drug abuse."

DEA and other law enforcement working at disposal sites around the country reported huge turnouts of people ridding their medicine cabinets of unused or unwanted drugs. For example, in Troy, Missouri, a man literally brought his kitchen drawer full of medication to the collection site to empty. At another site in Jacksonville, Ill., a woman brought in nearly 50 years' worth of medicines for disposal.

On October 13, President Obama signed the "Secure and Responsible Drug Disposal Act" into law.

The press release can be accessed at: http://www.justice.gov/dea/pubs/pressrel/pr100510.html

Source: Drug Enforcement Agency — October 5, 2010

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SAMHSA Awards Up to $6.8 Million in Funding For Its Recovery Community Services Program

The Substance Abuse and Mental Health Services Administration (SAMHSA) is awarding up to $6.8 million over the next four years in grants to provide support for peer-to-peer recovery support services that help prevent relapse and promote sustained recovery from alcohol and drug use disorders.

Peer-to-peer recovery support services enhance and promote sustained recovery, help those who relapse to get back on the road to recovery, and in general help individuals develop the life skills necessary for full health, and productive lives.

Peer counselors generally design and deliver support services during recovery. Successful peer recovery support services' initiatives network and build strong and mutually supportive relationships with formal systems in their communities.

The program includes support services for specific populations such as veterans, people with disabilities and other segments of the recovery community. Peer-to-peer systems work in addition to existing resources in the community to meet the needs of people at every stage of their recovery process.

It is expected that about $1.8 million per year will be available to fund up to five grants. Awardees are eligible for up to $350,000 per year for up to four years. The actual amounts may vary, depending on the availability of these funds and the performance of the grantees.

The awardees and the first year amounts of their grants are:

Council on Substance Abuse-NCADD, Montgomery, AL $350,000
Center for Veterans Issues, Milwaukee, WI. $350,000
Community Connections, Inc., Washington, D.C. $346,941
Detroit Recovery Project, Detroit, MI. $350,000
National Alliance of Methadone Advocates, New York, NY $350,000 — Note: See article on the MARS Peer Project in the Fall 2010 issue of the AT Forum quarterly newsletter available at http://atforum.com/newsletters/2010fall.php#peerrecoveryquarterly newsletter

Source: The Substance Abuse and Mental Health Services Administration — October 13, 2010

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New SAMHSA Substance Abuse Treatment Advisory: "Protracted Withdrawal"

The Substance Abuse and Mental Health Services Administration (SAMHSA) has issued a "Protracted Withdrawal," Substance Abuse Treatment Advisory, Volume 9, Issue 1, to help substance abuse treatment professionals manage their clients' protracted withdrawal in recovery. This Advisory differentiates acute withdrawal from protracted withdrawal and provides an overview of protracted withdrawal signs and symptoms. It also provides guidance on differentiating between protracted withdrawal (which resolves over time) and a co-occurring mental disorder.

The 8-page advisory can be accessed at: http://kap.samhsa.gov/products/manuals/advisory/pdfs/SATA_Protracted_Withdrawal.pdf

Source: The Substance Abuse and Mental Health Services Administration — September 30, 2010

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New Study Shows Significant Changes Occurring in the Sociodemographic Conditions of Older Admissions to Substance Abuse Treatment

Admissions for substance abuse treatment among those aged 50 and older have more than doubled, and their sociodemographic characteristics have significantly changed, between 1992 and 2008, according to a study by the Substance Abuse and Mental Health Services Administration (SAMHSA).

The findings indicate that sociodemographic factors such as unemployment, lack of income and homelessness all increased among this treatment group during this period.

From 1992 to 2008, the changes in sociodemographic characteristics of substance abuse treatment admissions aged 50 and older include:

Unemployment rose from 19.4 percent in 1992 to nearly 31 percent in 2008.
Full-time employment declined from 23.4 percent in 1992 to 16.7 percent in 2008.
Wages/salary as a principle source of income dropped from 32.3 percent in 1992 to 24.4 percent in 2008.
The percentage reporting no principal source of income at the time of admission to substance abuse treatment more than doubled from 1992 (11 percent) to 2008 (28.8 percent).

"This rise in substance abuse treatment among older adults and the changes in the socioeconomic situation of this treatment group reflect the changing landscape over the past 17 years and highlights the importance of providing additional specialized treatment services and social supports to address these needs," said SAMHSA Administrator Pamela S. Hyde, J.D.

These findings suggest that this population may need financial assistance with the costs associated with substance abuse treatment. Additional case management programs and services may be needed to help individuals in this age group who are currently in treatment or transitioning out of treatment find housing and employment. The data show that increasing numbers of admissions in this age group reported that they had never married.

The full report can be accessed at: http://oas.samhsa.gov/2k10/240/240OlderAdm2k10.cfm

Source: The Substance Abuse and Mental Health Services Administration (SAMHSA) — September 9, 2010

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MISCELLANEOUS

More Courts for Diverting Veterans to Treatment

Therapeutic courts tailored for veterans of the armed forces are now in 29 states, the Spokesman-Review in Spokane, Wash. reported Sept. 19.

Veterans treatment courts are designed to link participants with treatment for substance use and mental health issues, rather than simply repeatedly jailing them for their offenses.

Modeled after drug courts and mental health courts, veterans courts usually serve individuals who commit non-violent crimes. They require participants to engage in treatment and report back to the judge on a regular basis. Those who do not comply face jail time or other sanctions. Those who succeed can get their charges dismissed or reduced.

Unlike traditional treatment courts, veterans courts usually rely on the Department of Veterans Affairs to provide veterans with treatment. According to a National Association of Drug Court Professionals (NADCP) brief (PDF), the courts "involve the U.S. Department of Veterans Affairs health care networks, the Veterans Benefits Administration, State Departments of Veterans Affairs, volunteer veteran mentors and veterans and veterans family support organizations."

The courts are popular; the first was founded in 2006, and there are now nearly 50 of them in 29 states. In its Sept. 19 article, the Spokesman-Review reported on a new veterans courts set up in Spokane County, Wash. that serves both veterans and men and women on active duty. A similar court launched recently in Los Angeles, Calif., the L. A. Times reported Sept. 14, and another one will start operating this fall in Clark County, Wash., the Oregonian reported Sept. 10.

Why the focus on veterans? According to the Spokesman-Review, vets account for about 10 percent of criminal offenders; approximately 72,000 are incarcerated nationally. The NADCP cites statistics that one in six veterans from the wars in Iraq and Afghanistan has a substance abuse problem and about 20 percent have "symptoms of a mental disorder or cognitive impairment."

Unlike drug courts or mental health courts, veterans courts are unusual in that they use selection criteria that are not solely based on their offense or clinical need. According to the Spokesman Review, some people object to the idea of treating veterans differently than others when it comes to violating the law. Supporters, however, believe that specialized care is appropriate.

The first veterans court was set up in Buffalo, NY by Judge Robert T. Russell Jr. in 2006. Hundreds have graduated from his veterans court. "None of the graduates has been re-arrested," he said.

The Veterans Assistance Project in Bergen County, New Jersey has also been quite successful. "So far I haven't heard of anyone coming back to court," said Allen Quintavella, criminal division manager in Superior Court in Hackensack.

By comparison, the drug court in Spokane County, Wash., which has operated since 1996 and graduated 475 people, has a recidivism rate of 22 percent.

The complete article can be accessed at: http://www.jointogether.org/blog/posts/2010/veterans-courts.html

More information on veterans courts is available from the NADCP National Clearinghouse for Veterans Treatment Courts

Source: JoinTogether.org — October 14, 2010 by Benjamin Chambers

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Risk Of Marijuana's 'Gateway Effect' Overblown, New UNH Research Shows

New research from the University of New Hampshire shows that the "gateway effect" of marijuana — that teenagers who use marijuana are more likely to move on to harder illicit drugs as young adults — is overblown.

Whether teenagers who smoked pot will use other illicit drugs as young adults has more to do with life factors such as employment status and stress, according to the new research. In fact, the strongest predictor of whether someone will use other illicit drugs is their race/ethnicity, not whether they ever used marijuana.

Conducted by UNH associate professors of sociology Karen Van Gundy and Cesar Rebellon, the research appears in the September 2010, issue of the Journal of Health and Social Behavior in the article, "A Life-course Perspective on the 'Gateway Hypothesis.' "

"In light of these findings, we urge U.S. drug control policymakers to consider stress and life-course approaches in their pursuit of solutions to the 'drug problem,' " Van Gundy and Rebellon say.

The researchers used survey data from 1,286 young adults who attended Miami-Dade public schools in the 1990s. Within the final sample, 26 percent of the respondents are African American, 44 percent are Hispanic, and 30 percent are non-Hispanic white.

The researchers found that young adults who did not graduate from high school or attend college were more likely to have used marijuana as teenagers and other illicit substances in young adulthood. In addition, those who used marijuana as teenagers and were unemployed following high school were more likely to use other illicit drugs.

However, the association between teenage marijuana use and other illicit drug abuse by young adults fades once stresses, such as unemployment, diminish.

"Employment in young adulthood can protect people by 'closing' the marijuana gateway, so over-criminalizing youth marijuana use might create more serious problems if it interferes with later employment opportunities," Van Gundy says.

In addition, once young adults reach age 21, the gateway effect subsides entirely.

"While marijuana use may serve as a gateway to other illicit drug use in adolescence, our results indicate that the effect may be short-lived, subsiding by age 21. Interestingly, age emerges as a protective status above and beyond the other life statuses and conditions considered here. We find that respondents 'age out' of marijuana's gateway effect regardless of early teen stress exposure or education, work, or family statuses," the researchers say.

Source: University of New Hampshire Press Release — September 2, 2010

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Expert on American Drug-Control Policy Dies at 74

David F. Musto, M.D., author of a pioneering history of drug-control policy and a former advisor on drug control to the Carter Administration, died Oct. 8 of a heart attack, the New York Times reported Oct. 13. He was 74.

Musto's best-known book, "The American Disease: Origins of Narcotic Control," was published in 1973 — the same year that President Nixon established the Drug Enforcement Administration (DEA).

"The American Disease" covered the history of drug use and drug control policy in America from the 1860s onward, and, according to the New York Times, it "struck a nonpolemical tone rare in a field dominated by partisan zealots." Among other things, the book correlated fear of minority groups with public outcry over specific drugs. New editions were released in 1987 and 1999.

"Societies tend to react against drugs slowly, and the reaction usually comes just after the popularity of drugs has peaked," Musto observed in a 1986 interview with The New York Times. "Learning to hate drugs comes not so much from a government brochure as from repeated observation of the damage to acquaintances and society."

Musto served on the faculty at Yale Medical School since 1969.

Source: JoinTogether.org — October 19, 2010

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AT Forum NEWS NOTES & UPDATES #146

October 2010

Contents

MEDICATION-ASSISTED TREATMENT (MAT) AND OPIOID ADDICTION

GOVERNMENT

MISCELLANEOUS

SUGGESTED READING

METHADONE AND MEDICATION-ASSISTED TREATMENT (MAT) AND OPIOID ADDICTION

New Recovery-Oriented Methadone Maintenance White Paper

EUROPAD Journal — Heroin Addiction and Related Clinical Problems — September 2010 Issue Now Available Online

Methadone Treatment Reduces Overall Health-Care Costs for Commercially Insured Patients with Opioid Dependence

Effect of Opioid Agonist Treatment on Survival and Cessation among Patients with Injection Drug Use

Prescription Opioid Abuse and Dependence Increases as Younger Nonmedical Users Grow Older

GOVERNMENT

American Public Overwhelmingly Responds to DEA Prescription Drug Take-Back Effort

SAMHSA Awards Up to $6.8 Million in Funding For Its Recovery Community Services Program

New SAMHSA Substance Abuse Treatment Advisory: "Protracted Withdrawal"

New Study Shows Significant Changes Occurring in the Sociodemographic Conditions of Older Admissions to Substance Abuse Treatment

MISCELLANEOUS

More Courts for Diverting Veterans to Treatment

Risk Of Marijuana's 'Gateway Effect' Overblown, New UNH Research Shows

Expert on American Drug-Control Policy Dies at 74

SUGGESTED READING

Experts Mull Impact of Proposed 'National Institute on Addictions'

Will the Government's Drug 'Take-Back' Do Anything to Reduce Misuse?