AT Forum is made possible by an unrestricted educational grant from Covidien Mallinckrodt, St. Louis, MO, a manufacturer of methadone & naltrexone.

AT Forum Volume 18, #1 – Winter 2009 From the Publisher – What Does the Future Hold for MAT in OTPs? OTPs: Past, Current, Future -- Part IV OTP Group Counseling Goes High-Tech Computers Teach Substance Abuse Patients Cognitive Behavioral Therapy Genetics of Drug Addiction: The Memory Connection Research Briefs - Experimenting with Prescription Opioids May Predispose Teenagers and Young Adults to Lifelong Addiction Use of Prescription Pain Relievers During Adolescence Risk-Taking by College Freshman Linked to Abuse of Prescription Opioids D-ATM: The Future of OTP Disaster Preparedness New Resources Available For OTPs Events

 From the Publisher

What Does the Future Hold for MAT in OTPs?

In an interview in the Winter 1996 edition of Addiction Treatment Forum, we asked Dr. Vincent Dole for his perspective on Methadone: The Next 30 Years. His response, in part:

“If you want to characterize my feelings toward all of this from the perspective of my past 30-odd years in the field and my projection 30 years into the future...it's that I've seen substantial progress regarding methadone maintenance treatment as a modality. I am optimistic about the future.”

When we interviewed Dr. Dole, there were many reasons to be optimistic about the future of Medication-Assisted Treatment (MAT) in Opioid Treatment Programs (OTPs). Federal government regulations were being relaxed, reflecting changing attitudes toward drug addiction and its treatment. The number of OTPs was expanding rapidly, and patient census was growing markedly. By the late 1990s, therapeutic methadone dosing levels were increasing substantially.

Today, many challenges face MAT, and in particular, methadone maintenance treatment. The challenges include the increasing number of methadone-associated deaths, limited funding opportunities for OTP expansion, continuing community opposition to opening neighborhood clinics, and the ongoing stigma often associated with methadone maintenance treatment.

For the last of our four-part series, OTPs: Past, Current, Future, we interviewed Mark W. Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence, Inc. (AATOD), for his perspective on current and future challenges facing MAT in OTPs.

Of primary importance: Mr. Parrino calls for OTPs and their patients to improve public perception of methadone treatment and reduce the stigma often associated with methadone therapy. These steps will require a long-term collaborative effort between federal and state governments, OTPs, patients, and their families. The message must come primarily from patients. It is time to put faces and voices to the MAT recovery movement.

Your feedback is important to us. We would like to hear about individual patient success stories, innovative ways OTPs have addressed community opposition, and successful interactions between your OTP or patients and your local community. (See contact information below.)

The complete interview with Dr. Dole from the Winter 1996 edition of AT Forum can be accessed at:
http://atforum.com/SiteRoot/pages/current_pastissues/PastDole.shtml. Accessed checked 1/1/09.

Sue Emerson Publisher
ATForum@ATForum.com

OTPs: Past, Current, Future -- Part IV

Publisher’s Note: To conclude our four-part series on OTPs: Past, Current, Future, we interviewed Mark W. Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence, Inc. (AATOD). Mr. Parrino provided his perspective on the current and future challenges facing Medication-Assisted Treatment (MAT) in Opioid Treatment Programs (OTPs).

Current & Future Challenges Facing OTPs

 

AT FORUM. What do you see as the greatest challenge facing OTPs now, and in the future?

PARRINO. To continue to improve the public’s perception of methadone as a successful treatment modality for opioid-dependent persons, and to reduce the stigma often associated with it.

This will require a multi-year national and local public relations initiative, with medical societies, federal and local government agencies, OTPs, patient advocates, and families, all speaking in a positive way about the treatment system. It must be a collaborative effort to preserve the integrity of methadone maintenance treatment, with a commitment from the federal government to make it work. It won’t be an easy task.

ATF. What specifically needs to be done to initiate this public relations campaign?

PARRINO. We need increased interest from the states, to allocate money and to secure matching federal funds. The Maine Office of Substance Abuse did this very effectively in 2003, using posters, radio commercials, and telephone calling cards. SAMHSA [Substance Abuse and Mental Health Services Administration] provided the funds for promotional activities (see Maine Community Awareness Diversion Campaign, in the Fall 2008 issue of AT Forum).

Every OTP should develop its own media relations campaign. OTPs can integrate their work with the surrounding community—holding local Chamber of Commerce meetings at the clinic, and working with concerned neighbors, precinct councils, and planning boards. SAMHSA offers OTPs a free Community Education Kit with suggestions for reducing stigma through coordinated community education efforts (see ordering information below). SAMHSA is currently developing additional materials to help individual OTPs reduce stigma and integrate recovery into their treatment programs.

To encourage patients to overcome fears of failure and humiliation, we need to put a patient-focused face on treatment: “I am proud to be in my treatment program. I’m successful, I’m not using illegal drugs, my life has been saved. I’ve got my job, I’ve connected with my family, I’m a member of my community.”

ATF. This was done very effectively in the video, The Joy of Being Normal (see ordering information below).

PARRINO. Yes. Those were remarkable patients and their families, speaking openly and very movingly about what methadone treatment means to them. And the buprenorphine campaign in the Northeast, with posters in subway stations, also was very effective.

In early 2009, AATOD will begin to train patient advocates to feel more comfortable speaking with the press and sharing their successful experiences with methadone treatment. I hope that when patients see others doing this successfully, they’ll be willing to say, “You know what? Maybe now I’ll feel less reticent about making my voice heard.”

ATF. Groups questioning the validity of methadone treatment for addiction add stigma and shame as they create opposition to clinics and patients trying to recover from opioid abuse. They continue to highlight the increase in methadone mortality caused mainly by methadone prescribed by pain management physicians and primary care doctors.

PARRINO. Those mortality reports present a major challenge. Methadone is being prescribed for pain management by some doctors who haven’t been adequately trained for it. Nor do some doctors know when pain management crosses the threshold into dependency and addiction.

Many physicians haven’t been taught about the unique half-life of methadone, and that’s particularly critical during the induction period for pain treatment as well as in OTPs. But pain management doctors may write a prescription for a two-week or one-month supply, without educating the patient, whereas in OTPs the patient is seen daily for the first three months of treatment. At the present time, approximately 260,000 patients are enrolled in OTPs and more than 700,000 patients receive methadone prescriptions for pain management through their physicians.

ATF. What can be done about inappropriate prescribing for pain in private practice?

PARRINO. Under a new three-year grant, SAMHSA and ASAM [American Society of Addiction Medicine] are developing a national mentoring program for OTP medical staff and other prescribing physicians. The program will offer clinical updates, education, and evidence-based outcomes related to the appropriate use of methadone for treating pain and opioid addiction. We plan on working with ASAM to ensure that OTP medical practitioners actively utilize this valuable mentoring program.

ATF. How well is OTP accreditation progressing, in terms of raising the level of patient care?

PARRINO. So far, accreditation has been more focused on processes and record-keeping than on patient outcomes. A more clinical focus will require additional expenditures from programs, and funding for accreditation agencies. In some cases, achieving real clinical outcomes will also increase program costs. Accreditation regulations may change eventually, but not significantly in the next year or two. I believe that OTPs cannot wait for federal mandates; they must focus on clinical outcomes now. This will mean implementing evidence-based practices, evaluating progress, and integrating recovery into treatment. OTPs have the ultimate responsibility in treating patients effectively and with compassion.

ATF. How can OTPs become better able to recruit and retain a competent staff?

PARRINO. It’s a matter of how the potential staff perceive the treatment the OTP provides. They need to see the program as successful, and think, “I want to make working in addiction treatment a ‘profession of choice,’ not just a job.”

That takes a long-term commitment. And it takes investment. Fringe benefits. Salaries. Training. Attendance at conferences. It also takes enthusiastic patients. When OTPs acknowledge their patients, the patients understand that the staff care about their progress. It will likely encourage staff, too, because they’ll hear patients say positive things about what the staff and the program have done for them.

Recently I went to a patient celebration ceremony in Rhode Island, where everyone acknowledged the success of patients who have reached a certain level of recovery and stability. It was extremely instructive. Every patient who was being recognized for having achieved a level of success expressed gratitude to a particularly helpful staff member.

ATF. Some OTPs have waiting lists for patient admissions, while many others are not operating at capacity. What can individual OTPs do to attract patients?

PARRINO. One important factor is the perception of the OTP’s current patients. They must be able to say, “I like being here. I like being in this program. I like the way the place looks. It’s nicely lit. It’s nicely painted, and there’s artwork on the walls. The staff are helpful, compassionate, warm, and engaging. I feel accepted as a patient. I’m being helped.” Programs that do street outreach help to convey the program’s interest and willingness to connect with those in need. Other factors can impact admissions, like the availability of buprenorphine in a particular area.

ATF. To date, buprenorphine hasn’t been widely adopted by OTPs. Why is that?

PARRINO. Legislation enacted when buprenorphine was launched covered its use by physicians in private practice, but did not mention OTPs. A Federal Register notice, now in progress, will give OTPs greater latitude in prescribing buprenorphine. OTPs will be able to treat patients who have less than a one-year history of opioid addiction, and there will be less need for daily visits.

As was the case with LAAM [levo-alpha-acetyl-methadol], OTPs will need time to learn how to properly prescribe buprenorphine. Funding issues and changes in state laws may be involved. Some states have regulations defining the number of patients that can be treated in an OTP setting. This will have to be changed. Eventually, OTPs in the U.S. should see an increase in patient census as a result of buprenorphine.

ATF. Are many MAT patients leaving OTPs to receive buprenorphine treatment for their opioid dependence in physicians’ offices?

PARRINO. About 10 percent of methadone-maintained patients have been switching. Data on direct patient-treatment in physician-based settings are limited, so we don’t know how long patients are staying in buprenorphine treatment, or how much psychosocial care they’re receiving. We do see some patients who switched returning to OTPs.

ATF. What steps will be necessary for future expansion of office-based methadone medical maintenance treatment?

PARRINO. Office-based treatment with methadone, in the way buprenorphine is used, may be slow in coming. Expansion of office-based methadone maintenance should be planned in conjunction with licensed OTPs and physician practices to form a continuum of care. Today, six medical maintenance programs in New York State treat about 500 patients; that’s one percent of the patient population. Other medical maintenance programs operate in Illinois and in Washington State. About eight percent of the patient population would be considered stable enough for a medical maintenance program.

OTPs need to make an ideological shift, becoming more adept at creating networks with physicians: “We want to give our patients the opportunity to leave, or to go to a physician’s office, but remain connected to our program.” OTPs can find some physicians in outpatient settings, contract with them, and refer appropriate patients. But I believe that this concept will be adopted slowly. For the OTP, medical maintenance amounts to a loss of patient control and the ability to continue to treat highly stabilized patients, in a highly regulated system.

Physicians need to determine when their private office is the most appropriate place to treat pain patients. For example, “This patient is no longer appropriate for my pain management practice. He has gone beyond the dependence phase into the addiction phase. He should be treated in an OTP, or by a doctor approved to prescribe buprenorphine. Where is the second quotation mark?

ATF. Do you foresee any trends in the types of opioid dependencies of patients admitted to OTPs?

PARRINO. Currently about 44 percent of patients entering OTPs are dependent on Schedule II prescription opioids, based on findings from longitudinal studies that AATOD initiated during January 2005, through support from the Denver Health and Hospital Authority RADARS System. We are seeing a substantial number of patients who have been getting methadone through pain management practices or from friends or family members, but who have had their source cut off. We do expect an increase in heroin dependence in newly admitted patients. Afghanistan produces 92 percent of the world’s heroin supply, and it has had bumper crops. Also, we expect more veterans returning from the Iraq and Afghanistan wars to have problems of opioid addiction, probably heroin in particular, because of access to drugs in these areas.

ATF. Some European countries that have MAT in OTPs have health care systems very different from ours. What lessons, if any, can we learn from them?

PARRINO. Our European counterparts have a greater interest in experimenting, and they’ve had a more creative thrust. But they do not have our regulatory history, financial challenges, or moral overlay. Perhaps the lessons are: let’s be more creative, more open to change. If something doesn’t work, let’s not be so bound to continue with it.

Sources

SAMHSA grant program will help address methadone poisoning [press release]. Rockville, MD: SAMHSA Press Office; August 18, 2008. http://www.samhsa.gov/newsroom/advisories/0808154000.aspx
Accessed January 1, 2009.

The Joy of Being Normal videotape can be ordered online for $19.95 plus shipping at: http://shop.danya.com/product_p/da116.htm or can be downloaded at: http://www.youtube.com/watch?v=1LSqVT34yQo Accessed January 1, 2009.

 

OTP Group Counseling Goes High-Tech

Opioid Treatment Programs (OTPs) that provide intensive structured counseling, focusing on substance abuse, generally produce better outcomes than OTPs that provide little or no counseling.

Yet intensified individual or group counseling sessions, when available, often are poorly attended. Patients say the sessions are inconvenient, require an extensive time commitment, and entail a loss of privacy.

A pilot study led by Van King, MD, of Johns Hopkins School of Medicine, suggests that these problems can be overcome if intensified sessions are held in the comfort of the OTP patient’s home, conveniently and privately, using Internet-based videoconferencing. This study is the first known randomized evaluation of the clinical response to a real-time videoconferencing platform to intensify OTP treatment schedules.

Study Design. The study, conducted in 2006, enrolled 50 patients from the Addiction Treatment Services OTP in Baltimore, Maryland. All patients had repeatedly tested positive for an illicit substance, and had responded only partially or poorly to lower levels of care. The study period covered six weeks.

Patients were eligible for the study if they reported that they had access to a computer with an Internet connection, and agreed to random assignment to one of the two options for intensified therapy.

Thirty-seven participants were randomly assigned to twice-weekly intensified group counseling. One group had traditional onsite counseling; the other, offsite counseling provided through e-Getgoing real-time videoconferencing. (e-Getgoing is an accredited verbal- and visual-based platform provided by CRC Health Group, Inc.)

Participants in both intense-therapy groups received the same manual-guided relapse-control therapy. This therapy is based on awareness and avoidance of triggers, awareness of warning signs, and drug refusal. Five to ten participants attended each onsite session; one to four took part in each e-Getgoing session. The onsite and offsite sessions were conducted by the same group leaders.

In addition to the group sessions, participants were scheduled for an individual onsite counseling session each week with their primary counselor. Participants were required to provide one urine sample each week, under observation. All participants continued to receive their regularly scheduled methadone doses.

A headset and low-cost microphone to facilitate communication were provided to e-Getgoing participants for use on their home computers during the pre-scheduled one-hour group sessions. A password and log-on identification helped ensure participants’ confidentiality. Participants could not see other group members, but could see the group leader, who had a video camera providing a real-time video display. The group leader could verify on the screen the identity of all participants.

Study Results. The onsite and offsite sessions were well attended and equally effective. All participants greatly reduced their drug use during the six weeks. Most participants in each group were free from substance use for two consecutive weeks, and most returned to a lower intensity of care within several weeks.

The e-Getgoing group preferred the Internet-based program, citing its convenience and confidentiality. Participants with full-time employment or substantial child-care responsibilities especially appreciated the convenience the program provided. Participants found the technology easy to learn and use, and called the study a novel and “fun” experience. Psychotherapists leading the group sessions indicated good acceptance as well.

The authors noted that the results “suggest that Internet-based interventions provide a platform to both facilitate counseling attendance and expand the continuum of care for people with opioid and other substance use disorders.” They also cited the advantages the platform could offer in fixed sites, such as methadone medical maintenance programs and buprenorphine treatment practices based in physicians’ offices.

Comments: Drawbacks of the study include a small sample size and relatively short study period. Participants’ outdated computer equipment and software initially posed problems, especially for those who were not technologically savvy. Some participants needed technical help.

This study suggests that videoconferencing offers an effective way to expand supplemental therapy in OTPs, although substantial challenges exist. Many OTP patients need help obtaining computers and Internet access, and learning the necessary technical skills.

Creative ways exist to cope with some of these problems. Businesses that are upgrading often donate used computers. Volunteers who teach basic computer skills may be willing to instruct patients, or patients’ family members or friends may help. OTPs can pursue these possibilities, and others. By seeking and finding ways to bring new programs and technologies to their facilities, OTPs can make Medication-Assisted Treatment more attractive—not only to current patients, but to those who are considering entering therapy as well.

Sources

King VL, Stoller KB, Kidorf M, et al. Assessing the effectiveness of an Internet-based videoconferencing platform for delivering intensified substance abuse counseling. [published online ahead of print September 3, 2008]. J Sub Abuse Treat. http://www.ncbi.nlm.nih.gov/pubmed/18775625
Accessed January 1, 2009.

Magura S, Nwakeze PC, Kang SY, et al. Program quality effects on patient outcomes during methadone maintenance: a study of 17 clinics. Subst Use Misuse. 1999;34(9):1299-1324.

Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS publication no. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2005.
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.82676. Access checked January 1, 2009.

 

Online at ATForum.com only

Computers Teach Substance Abuse Patients Cognitive Behavioral Therapy

Could a computer program teach cognitive behavioral therapy—a relatively sophisticated therapeutic process—to patients with substance dependency? A Yale team headed by Kathleen M. Carroll, PhD, decided to find out.

The Yale researchers gave their study a catchy title: CBT4CBT—computer-based training for cognitive behavioral therapy. This type of therapy covers the following six core concepts:

• Understanding and changing the patterns of substance use
• Coping with craving
• Refusing offers of drugs and alcohol
• Identifying and changing thoughts about substances of abuse
• Developing problem-solving skills
• Improving decision-making skills

The design for CBT4CBT followed a standard manual on cognitive behavioral therapy written by Dr. Carroll and published by the National Institute on Drug Abuse (NIDA) (see Sources).

Study Design. The study was a randomized, controlled, eight-week trial enrolling 77 participants in a community outpatient setting in Bridgeport, Connecticut. The participants were seeking treatment for dependence on alcohol, cocaine, opioids, marijuana, or a combination of these substances. About 80 percent used more than one type of drug, or used alcohol and drugs.

Participants were divided into two groups: one given treatment as usual (TAU), and the other given TAU and CBT4CBT. (TAU entailed weekly individual and group drug-counseling sessions.) Both groups underwent twice-weekly monitoring, assessment, and urine-specimen collection.

The CBT4CBT program was designed to help users learn new ways to change problem behavior and avoid using drugs. CBT4CBT comprised six user-friendly lessons covering the core concepts of cognitive behavioral therapy listed above. An ID password system protected confidentiality. A research associate showed participants how to use the program, and remained available during each session. Participants attended the sessions alone, in a small private room at the clinic. Each 45-minute session included short “movie” segments and interactive assessments of behavioral skills. Brief homework projects were assigned.

Study Results. Compared with patients assigned to TAU alone, the group receiving supplemental twice-weekly CBT4CBT submitted fewer urine specimens testing positive for substances of abuse (2.2 vs 4.3; statistically significant) and had longer urine-confirmed periods of abstinence (22 vs 17 days). CBT4CBT participants were well-satisfied with the program, calling it “highly engaging.”

Could computer-based training somehow devalue the patient-therapist relationship? Not according to William Sledge, MD, of Rockefeller University. Instead, the Yale study “demonstrated how a low-cost but carefully conceived procedure can enhance conventional treatment and add additional elements of richness and effectiveness to its power.”

Comments: As was the case with the e-Getgoing article on videoconferenced home therapy, published in the winter issue of the AT Forum newsletter, this study suggests that computer-based technologies can provide an effective, relatively low-cost way to enhance and expand supplemental therapy in patients with substance dependency. This will give counselors a better opportunity to focus on individual care, and to address the needs of individual patients.

Sources

Carroll KM, Ball SA, Martino S, et al. Computer-assisted delivery of cognitive-behavioral therapy for addiction: a randomized trial of CBT4CBT [published online ahead of print May 1, 2008].
http://ajp.psychiatryonline.org/cgi/content/abstract/165/7/881
Accessed January 1, 2009. Published in final edited form as: Am J Psychiatry. 2008;165(7):881-888.

Greist J. A promising debut for computerized therapies [editorial]. Am J Psychiatry. [Published online ahead of print July 2008; 165-167]. http://ajp.psychiatryonline.org/cgi/content/full/165/7/793.
Accessed January 1, 2009.

National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA). A Cognitive-Behavioral Approach: Treating Cocaine Addiction. NIH Publication No. 98-4308, Rockville, MD, April 1998. http://www.drugabuse.gov/txmanuals/cbt/cbt1.html. Accessed January 1, 2009.

Genetics of Drug Addiction: The Memory Connection

Some people are more susceptible to drug addiction disorders than others. One person can use a prescription opioid repeatedly for pain, and stop its use once the pain subsides, without becoming addicted. Another may become dependent and crave opioids after relatively few exposures.

Why do some people become addicted, others not? Studies of identical twins indicate that as much as half of an individual’s risk of becoming addicted to opioids or other drugs depends on genetic makeup. The other half of addiction-risk results from environmental factors such as external conditions, friends, family, and associates. If drugs are not available, a person with a genetic susceptibility cannot develop an addiction disorder. And someone who is not genetically predisposed may develop an addiction disorder if influenced by peer pressure to experiment repeatedly with an addicting drug.

The Role of Genes
Genes are the functional units of our DNA. They provide the information that directs our bodies’ basic cellular activities. Almost all the genes in two individuals are identical. But 0.1 percent of the genes have minor but profoundly important differences (also referred to as variants). These gene variants contribute to visible differences between individuals, like height and hair color, and to invisible differences, such as increased risk of addiction.

Some disorders, such as cystic fibrosis, are caused by an error in a single gene. Medical research has been strikingly successful at unraveling the mechanisms of these single-gene disorders. But most diseases, including addiction, are more complicated; variations in many different genes contribute to an individual’s overall level of risk or resistance.

Perhaps as many as 100 of our 30,000 genes are involved in susceptibility to drug misuse and dependence. Genes can affect how the body reacts to drugs, how quickly a drug is metabolized, how difficult it is to stop taking the drug, and how severe the withdrawal process will be.

Genetics plays a role in all addiction disorders, not just opioid addiction. Genes involved in susceptibility to addiction are not necessarily unique to a given drug. Some people become dependent on several drugs; others become dependent on one drug, but are not at greater risk of susceptibility to other drugs.

Genes: The Memory Connection to Addiction

Dr. George Uhl and colleagues at the National Institute on Drug Abuse (NIDA) analyzed almost 1,000 DNA samples between 1990 and 2005. Of the 89 genes associated with drug abuse, the team was most interested in 21 genes, most of which are linked to active regions in the brain that play roles in memory. According to Dr. Uhl, “Finding this group of gene variants in people who are dependent on addictive substances underscores the important role memory plays in addiction and will help us understand why addicts can relapse decades after their last use of an addictive drug.”

Dr. Uhl suggests that addiction involves how the body reacts to drugs. Explicit memory is immediate and conscious. Implicit memory, in contrast, influences our behavior unconsciously. "Remembering what you need to pick up from the store tonight is a good example of explicit memory," Dr. Uhl says. "But if you are considering those items while you are driving to work and suddenly realize you've gone 10 miles along your route without thinking about it, your implicit memory system is what got you there."

When vulnerable people feel the effects of an addictive drug, Dr. Uhl suggests, their brains may store that experience deep in the implicit-memory system. “Implicit memory may play a more important role than euphoria in the long-term story of a drug addiction." He further elaborates: "Although drug highs produced by the brain's reward system motivate repeated use in the early stages of addiction, many addicts in later stages say they rarely experience dramatic euphoria and complain instead that their drug use is driven by compulsion. They also say they can crave their drug of choice long after they stop using it when they are reminded of it by environmental or social situations. That testimony is consistent with a process in which the brain's pleasure centers help addiction get started, but memory-like features maintain it over time."

Our understanding of genetics has progressed dramatically, and is changing how patients are treated. Armed with a better understanding of genetics, health care providers may become better equipped one day to match patients with the most suitable addiction treatment, adjust medication dosages to individual needs and circumstances, and avoid or minimize adverse reactions.

Sources:

Madras BK. The biology of addiction: voluntary behavior and genetics. http://www.randomstudentdrugtesting.org/newsletter/summer_fall_08/page6.html.
Accessed January 1, 2009.

National Institute on Drug Abuse. Genetics of Addiction – A Research Update from the National Institute on Drug Abuse – April 2008. NIDA Topics in Brief.
http://www.drugabuse.gov/tib/genetics.html. Updated August 5, 2008. Accessed January 1, 2009.

National Institute on Drug Abuse. New Technique Links 89 Genes to Drug Dependence. NIDA Notes. 2008;22(1). http://www.drugabuse.gov/NIDA_notes/NNvol22N1/New.html. Updated September 15, 2008. Accessed January 1, 2009.

RESEARCH BRIEFS

Experimenting with Prescription Opioids May Predispose
Teenagers and Young Adults to Lifelong Addiction

As the brain matures during adolescence and early adulthood, individuals have immature risk-assessment skills and are especially susceptible to opioid exposure. The current high misuse of prescription opioids by these groups suggests that use and addiction may rise in the coming years.

Use of Prescription Pain Relievers During Adolescence

To the curious teenager, it seemed like a harmless thing to try. So she took one of her mother’s pills. The doctor had prescribed the pill for her mother’s back pain, so she thought that taking one wasn’t dangerous. After all, she wasn’t experimenting with drugs, like some of her friends were.

The pill gave her a fuzzy, dreamy feeling. Over the next few days she took several more.

The pill was oxycodone (OxyContin).

During the next few weeks, the teenager bought oxycodone from her friends’ supplier. Eventually her parents caught on.

But the story doesn’t end there. Oxycodone abuse during adolescence may trigger permanent changes in the brain—changes that increase the drug’s pleasure-producing characteristics. Adolescents who abuse oxycodone become more vulnerable to addiction if they use the drug as an adult, even for medical purposes.

This finding was recently reported by researchers at Rockefeller University. The research team, led by Mary Jeanne Kreek, MD, currently Professor and Head of the Laboratory of the Biology of Addictive Diseases at Rockefeller University; and lead author, Yong Zhang, MD, PhD, compared levels of dopamine—a chemical messenger associated with pleasure sensations—in adolescent and adult mice, in response to increasing doses of oxycodone. Mice that had self-administered oxycodone during adolescence and were later re-exposed to the drug as adults had significantly higher levels of dopamine in an area of the brain associated with pleasure than adult mice self-administering oxycodone for the first time.

It’s well known that the brain changes markedly during adolescence. Researchers believe that these changes include an increased production of dopamine receptors. At mid-adolescence, dopamine production usually drops, or the number of receptors declines. But when adolescents abuse oxycodone, the brain may keep more receptors than it needs. Later exposure to oxycodone causes an intense rush of euphoria that may
be highly addictive. Thus, according to Dr. Kreek, “the neurobiological changes seem to sensitize the brain to the drug’s powerfully rewarding properties,” so that adolescents who abuse oxycodone “may be preparing their brain for a life-long battle with addiction.”

Sources

Zhang Y, Picetti R, Butelman ER, et al. Behavioral and neurochemical changes induced by oxycodone differ between adolescent and adult mice [published online ahead of print September 10, 2008]. Neuropsychopharmacology.
http://www.nature.com/npp/journal/vaop/ncurrent/full/npp2008134a.html. Accessed January 1, 2009.

Painkiller abuse can predispose adolescents to lifelong addiction [press release]. New York, NY; Rockefeller University; September 10, 2008. http://www.newswise.com/p/articles/view/544184/
Accessed January 1, 2009.

Risk-Taking by College Freshman Linked to Abuse of Prescription Opioids

Freshman college students who are “sensation-seekers” are less likely to abuse prescription opioids if they perceive potential harm. But students classified as “high sensation-seekers” are likely to do so, regardless of how harmful they perceive the drugs to be.

These are the findings reported by a group led by Dr. Amelia Arria of the Center for Substance Abuse Research at the University of Maryland. The conclusions are based on interviews of 1,253 freshmen at entry to a major university, and twice more at six-month intervals.

Dr. Arria described sensation-seekers as “students who like novel experiences, who want to try something new and a little dangerous, like jumping off the highest diving board or placing themselves in high-risk situations. They are much more likely to use pain killers nonmedically even if they perceive the drugs to be quite harmful.” The study classified students as “sensation-seekers” or “high sensation-seekers.”

Only about one-fourth of the students perceived prescription analgesics and stimulants as having great risk, compared with almost three-quarters who attributed great risk to cocaine. Marijuana and alcohol were classified as having great risk by only 7 percent and 17 percent of the students, respectively.

The study linked perceived harmfulness with behavior. Students who perceive a drug as relatively harmless are ten times more likely to use it than those who consider it extremely harmful. But “high sensation-seekers” used drugs they considered extremely harmful.

Sensation-seeking peaks during the late teen years, suggesting that college-age students might be better-equipped to make appropriate risk appraisals during college years.

The study was funded by the National Institute on Drug Abuse.

Source:

Arria AM, Caldeira KM, Vincent KB, et al. Perceived harmfulness predicts nonmedical use of prescription drugs among college students: interactions with sensation-seeking. Prev Sci. 2008;9(3):191-201.

D-ATM: The Future of OTP Disaster Preparedness

Immediately after the September 11, 2001 attack, many patients in Opioid Treatment Programs (OTPs) could not obtain their daily methadone dose, because their home clinic had been destroyed or was inaccessible. The attack provided the impetus for OTPs to prepare a disaster plan. The Center for Substance Abuse Treatment (CSAT), under the Substance Abuse and Mental Health Services Administration (SAMHSA), then began to develop a centralized database/information system that would allow a “guest” clinic to dispense medication in emergencies.

The centralized system—Digital Access to Medication (D-ATM)—is now ready for pilot testing and eventual implementation. D-ATM enables patients to obtain their methadone during extensive service disruptions, such as a disaster, a major storm, or interruptions in transportation systems.

To dispense methadone to patients in need, guest OTPs must have rapid access to specific information that is limited, but up to date, about each patient’s medication dosage. D-ATM will acquire, store, and—in an emergency—provide this information, following all confidentiality rules.

Voluntary patient enrollment takes about one minute. It starts with a brief consent form and digital finger-imaging. A numerical “description” of the image is stored with D-ATM. This number is the patient’s only identification, thus ensuring confidentiality. Other data stored are 1) the patient’s current physician-prescribed methadone dose, 2) date of the last dose and any take-home doses provided, 3) take-home schedule, and 4) the home clinic’s name, location, and contact information. The system will alert the home clinic of any methadone dispensed at the guest OTP.

Other benefits D-ATM may offer OTPs and their patients include:

• Reassuring patients that they will have access to their medication
• Minimizing dual patient-enrollment within and across state lines
• Managing routine situations, such as methadone needs when patients are traveling
• Helping participating OTPs meet disaster-plan requirements for SAMHSA/CSAT accreditation
• Providing incentives for OTPs to augment information technology capabilities

The first pre-pilot test was conducted at a New York City OTP in February 2007. CSAT has just awarded a three-year grant to Westat, a contract research organization, for further D-ATM development. A company with extensive experience in introducing new technologies into clinical settings, Westat will initiate Phase III and complete pilot testing to ensure that the system is fully operational. Westat will then “roll out” D-ATM in the New York metropolitan area, possibly followed by the Gulf Coast and other areas to be determined.

For more information, visit the D-ATM website at: http://datm.samhsa.gov/

New Resources Available for OTPs

In-service Training Manual Based on TIP 43 (MAT for Opioid Addiction in OTPs)

A new in-service training manual is available for SAMHSA TIP 43 MAT for Opioid Addiction in OTPs. The manual provides an in-service training curricula for introducing treatment professionals to opioid use disorders; assessment/treatment planning; pharmacology and dosing, and evidence-based best practice for treatment.

The training manual which includes 13 modules with PowerPoint slides is available for download at: http://www.kap.samhsa.gov/products/trainingcurriculums/tip43.html.

Hard copies of the manual can be ordered by calling (1-877-726-4727.) Ask for publication order number (SMA) 08-4341.

SAMHSA’s OTP Mortality Reporting Form Now Available Online

The Opioid Treatment Program (OTP) Mortality Reporting Form allows OTPs to voluntarily report mortality data on patients who, at the time of death, were receiving medication-assisted treatment (methadone or buprenorphine) at a SAMHSA certified OTP.

To date, there has been no means of estimating the number of patients dying while enrolled in OTPs and the causes of those deaths. Under the statutory authority of The Public Health Service Act, SAMHSA is responsible for supporting activities that will improve treatment for substance abuse and coordinating federal policy with respect to methadone. The proposed information gathering relating to mortalityis ultimately in adherence to this legislative mandate.

SAMHSA is requesting that this information be voluntarily reported to SAMHSA. Given national concerns over drug poisoning deaths, and the belief that a SAMHSAcertified OTP should represent safe and competent addiction treatment of patients who have become dependent on heroin or prescription opioid drugs, SAMHSA
may propose new rules requiring mandatory mortality reporting.

The OTP Mortality Report Form can be accessed at: http://www.dpt.samhsa.gov/providers/OTPmortalityreport.aspx.

Events to Note

The American College of Psychiatrists (ACP) Annual Meeting
February 25 - March 1, 2009
Tucson, Arizona
Contact: www.acpsych.org

The NAADAC/NAATP Advocacy in Action Conference 2009
March 8-10, 2009
Washington, DC
Contact: 800-548-0497

American Counseling Association (ACA) Annual Conference and Exposition
March 19-23, 2009
Charlotte, North Carolina
Contact: 800-347-6647 or http://www.counseling.org

American Association for the Treatment of Opioid Dependence (AATOD) Conference
April 25-28, 2009
New York, New York
Contact: 212-566-5555 or http://AATOD.org

For additional postings, including international meetings, see: www.atforum.com.

© 2012 AT Forum

Privacy/Terms of Use   |   Contact Us

Updated August 24, 2011