Maine Governor Proposes Dramatic Patient Shift from Methadone to Buprenorphine

Addiction Professional, May 6, 2015
by Alison Knopf, Contributing Writer

Budget cuts proposed by Maine Gov. Paul LePage would eliminate all Medicaid funding for treatment with methadone, which is provided only in opioid treatment programs (OTPs) by federal regulation. There are currently 4,000 patients in MaineCare, the state’s Medicaid program, who are getting treated with methadone in OTPs. Under LePage’s proposal, these patients all would transfer to office-based opioid dependence treatment with buprenorphine.

The proposal follows years of the governor’s efforts to cut back on or eliminate MaineCare funding for methadone and buprenorphine. Maine did not expand Medicaid, which means that there is an even greater demand for treatment than is reflected in the current MaineCare rolls.

But there are huge problems with the proposal, according to treatment advocates. First, there aren’t enough physicians who are authorized via federal waivers to prescribe buprenorphine to the 4,000 patients who might need it. Second, advocates say the proposal wouldn’t save costs, since treatment with methadone is one-third of the cost of treatment with Suboxone, the brand formulation of buprenorphine that Maine is planning to use.

The state’s view

But the proposal is not designed to save costs, according to Kevin Flanigan, MD, medical director of MaineCare. Rather, the rationale for the state’s decision is that patients in OTPs were found to have higher general medical costs than patients in buprenorphine treatment, Flanigan said in an interview with Addiction Professional.

“This initiative is not about cost; it is not about management of a single chronic condition,” says Flanigan. “It is about a comprehensive care delivery model focused on the entire patient and management of all of his/her medical conditions so as to ensure optimal health outcomes.”
The fact that treatment with Suboxone is far more expensive than treatment with methadone “makes our point,” he says. “Yes, methadone treatment centers in and of themselves are less costly than brand name Suboxone, but the global cost of care for patients who suffer from addiction is the same whether they are being treated with Suboxone or at a methadone treatment center. We believe that those on Suboxone have access to a more comprehensive care plan because his/her provider will be engaged in all of their care and not just management of addiction. By definition, methadone treatment centers fragment care, and fragmented care leads to higher cost with worse health outcomes on average.”

OTPs and comprehensive care

But opponents of the state's plan say the opposite is true. OTPs do provide comprehensive care for patients, make sure that they have primary care physicians (PCPs), and in fact see their patients on a regular, often daily, basis, says James I. Cohen, a Portland-based attorney who represents a coalition of OTPs in the state.

“From conversations that I’ve had with members of the [LePage] administration, they believe that Suboxone is a more holistic form of treatment and that it’s better integrated with the overall care of the patient,” says Cohen, who adds that he has not met with the governor himself. “We disagree with that assessment. OTPs assist patients in working with PCPs, want patients to have PCPs, and methadone providers see their patients.”

Many office-based physicians see patients once a month to prescribe the medication, whereas many methadone patients visit clinics on a daily or weekly basis, say OTP representatives.

In addition, there’s a big flaw in the budget assumption, which was “not based on comparing the cost of treatment with methadone and the cost of treatment with buprenorphine,” says Cohen. “That would have been appropriate, but they didn’t do that.” Instead, the governor compared the entire cost of healthcare for methadone and buprenorphine patients and found that total healthcare costs were higher for methadone patients—without taking into consideration differences in the patient population, addiction severity, and other variables.

“You can’t assume changes in behavior based on changes in fiscal policy,” says Cohen. In other words, there is no guarantee that forcing sicker patients (from OTPs) into the treatment modality that has attracted healthier patients (buprenorphine) will make the OTP patients healthier.

Clinically, there are big problems with transferring patients from methadone to buprenorphine, says Cohen. One issue is that patients who need to be maintained on high doses of methadone would have to cut back, because buprenorphine’s “ceiling effect” works only up to a certain level. The withdrawal that these patients would experience in cutting back could lead them to relapse. The other problem is that these patients would lose contact with their comprehensive treatment program, he says.

Not enough physicians

Logistically, there are not enough physicians to provide buprenorphine to the 4,000 patients currently in treatment with methadone, says Pat Kimball, president of the Maine Association of Substance Abuse Providers. In addition, office-based PCPs don’t offer addiction counseling, she says.
According to Flanigan, more than 300 providers have completed the training for the license that allows them to prescribe buprenorphine. Asked how many patients are on buprenorphine in Maine now, Flanigan responded that the only data he has involves MaineCare patients. More than 4,000 MaineCare members receive at least one prescription a year for Suboxone, and about 2,700 to 2,800 receive a Suboxone prescription every month.  

The number of patients a physician can treat with buprenorphine is capped at 30 or 100, depending on the level of training. In addition, many physicians have waivers but are not prescribing up to the level that they are allowed, or are not prescribing at all. One program, Discovery House, offered $5,000 bonuses to physicians to sign up to become buprenorphine prescribers, but it got no takers, according to the Bangor Daily News.

There are other states that don’t allow Medicaid to pay for OTP treatment. In these states, patients have to pay out of pocket. Flanigan says the state doesn’t know how many patients on methadone might choose to stay in their OTP and self-pay instead of being transitioned to buprenorphine.

If people can’t afford to pay for their own treatment—and if they’re on MaineCare, they probably can’t—they probably will end up searching for drugs on the street, says Kimball, who is also director of Wellspring Substance Abuse and Mental Health Services in Bangor.

Ironically, Maine was a leader in recognizing that opioid addiction is a public health problem in the state, says Kimball. “Nationally, we’re known for our approach,” she says, which included the work of former single state authority directors Kim Johnson (now with NIATx) and Guy Cousins, who lost his job when it became clear that his views and the governor’s were in conflict.

More OTPs needed

More, not fewer, OTPs are needed in the state to cover the geographic expanse, says Kimball, noting that some patients travel hours every day—with transportation paid by MaineCare—from rural areas. That would represent a savings, if OTPs are eliminated, of about $750,000. “But when I look at that, I say why can’t we talk about opening up more clinics?” she says.

The NIMBY (Not in My Back Yard) issue has largely prevented that. However, what the communities opposing the OTPs don’t realize is that the people who need treatment are living in their midst, Kimball says. “Communities get scared, and they have moratoriums against clinics opening up in their neighborhoods, but the people they’re scared of are already living in their neighborhoods,” she says.

She adds, “The frustrating thing is that the governor sees this [opioid epidemic] as a problem, but his approach is the war on drugs approach. We know from a historic perspective that this doesn’t work.”

Link to article.
Link to LePage's Proposal.
Link to Bangor Daily News May 31, 2015 article: ‘A system that doesn’t exist’: Without methadone, patients rely on addiction treatment few Maine doctors prescribe.
Link to Bangor Daily News May 31, 2015 editorial: The fight to stop treating addicts as if they’re expendable.

Tennessee Advocates Ask DOJ to Intervene in OTP Siting Case

Alcoholism & Drug Abuse Weekly

February 17, 2014

By Alison Knopf   

 

Tri-Cities Holdings, an opioid treatment program (OTP) that has been trying to get a certificate of need in Johnson City, Tennessee, is waiting to hear from the federal Department of Justice (DOJ) about an appeal it filed based on civil rights violations. Represented by attorney James A. Dunlap Jr. from Atlanta, Georgia, the OTP would serve the 500 to 1,000 people who live near Johnson City but have to drive more than 100 miles across the border to North Carolina to obtain their medication.

The complaint is asking the federal Department of Justice to intervene in the case of Tri-Cities Holdings and eight patients, who have the disability of opioid addiction. The OTP says that the certificate of need process instituted by the state and the ordinances imposed by the city violate the Americans with Disabilities Act (ADA).

 

Lisa Taylor, an attorney with the DOJ Civil Rights Division in Washington, has been investigating the case, which began in June 2013. The violations, according to Dunlap, have gone on for more than a decade, resulting in lost lives.

 

"It’s unconscionable that a state would have in place a certificate of need process that would force a pregnant opioid-dependent woman to drive one to two hours each way every day to receive what is known and accepted as the standard of care for her medical condition.”   Zac Talbott

 

An OTP in Johnson City would be the only clinic within 50 miles in any direction. However, Johnson City and the state Health Services and Development Agency (HSDA), which issues certificates of need, have made it difficult to site the clinic. Since 2003, Johnson City has used a zoning ordinance to block the OTP, according to Dunlap.

 

High need

 

Ironically, Johnson City and the surrounding area have many people with opioid addiction who need treatment. Currently, they drive — often over dangerous mountain roads in the early-morning dark so they can get to work on time — across the border.

 

“It’s unconscionable that a state would have in place a certificate of need process that would force a pregnant opioid-dependent woman to drive one to two hours each way every day to receive what is known and accepted as the standard of care for her medical condition,” said Zac Talbott, the director of the Tennessee Statewide and Northwestern Georgia chapter of the National Alliance for Medication Assisted Recovery (NAMA Recovery). “The certificate of need process in Tennessee blatantly discriminates against opioid-dependent individuals, as no other substance use disorder treatment other than opioid treatment programs is subjected to the certificate of need process in Tennessee.”

 

Talbott told ADAW that he hopes the DOJ will rule, as a result of their investigation, that the certificate of need process in Tennessee and the Johnson City ordinances violate the ADA. “The current certificate of need process in the state of Tennessee is, quite literally, killing people,” he said. “This process has resulted in the blocking of numerous opioid treatment programs from opening over the years.”

 

“NAMA Recovery of Tennessee will continue to advocate for opioid-dependent individuals — both those in treatment and those who are still unable to access the gold standard treatment due to the state’s discrimination — until quality opioid agonist therapy is available on demand for every person who needs it,” Talbott said.

 

Criticism from NC provider

 

And Jana Burson, M.D., a North Carolina internist who treats opioid addiction with buprenorphine and also works in an OTP, said medication-assisted treatment of opioid addiction with methadone “is one of the most evidence-based treatments in all of medicine, yet government officials in Tennessee have repeatedly interfered with the delivery of this essential treatment to its citizens.”

 

Noting that Tennessee has a high rate of overdose deaths, Burson said, “You’d think they would welcome help to treat opioid-addicted citizens instead of thwarting efforts to establish an opioid treatment program.”

 

Johnson City and other towns of Eastern Tennessee rewrote their zoning laws in an effort to prevent methadone clinics from being established, said Burson. Even though Johnson City’s attorney said there was no intentional discrimination against drug addicts, “history speaks for itself,” said Burson. “Multiple facilities have tried and failed to get permission for a methadone clinic in that town over the last ten years,” she said. Future generations will likely judge state and local officials harshly for preventing the treatment of opioid addiction with methadone, since this treatment has been proven to save lives, she said.

 

Word was expected from the Justice Department on the results of its investigations shortly.

 

Bottom Line…

 

The state of Tennessee and a city are charged with violating the civil rights of patients in opioid treatment with methadone.

 

Link to Article

Experts Challenge Decision That Would Make New Jersey the First State to Effectively Outlaw Methadone Treatment for Pregnant Women

AT Forum January 15, 2014

“This week, 76 organizations and experts in maternal, fetal, and child health, addiction treatment, and health advocacy filed an amicus curiae (friend of the court) brief before the New Jersey Supreme Court, urging it to overturn a lower court ruling making the state’s civil child abuse law applicable to women who received medically prescribed methadone treatment while pregnant.

At the center of the case is a woman, identified by the court as Y.N., who had been struggling with a dependency on opioid painkillers. When she found out she was pregnant, she followed medical advice and obtained care that included methadone treatment. She gave birth to a healthy baby who was successfully treated for symptoms of neonatal abstinence syndrome (NAS). NAS is a side effect of methadone treatment and other medications, such as those commonly prescribed to treat depression. Y.N. was reported to the Division of Child Protection and Permanency (DCPP, formerly the Division of Youth and Family Services), and was judged to have abused or neglected her child because she agreed with her physician’s recommendation and followed the prescribed course of methadone treatment while pregnant.

Lawrence S. Lustberg of Gibbons P.C., co-counsel for the amici, explains that “the New Jersey Supreme Court has been a national leader in recognizing that when cases raise scientific, medical, or other technical issues, the evaluation of these issues must be informed by existing scientific knowledge, including expert testimony.” He added, “This case should not be an exception, yet, the decision in the lower court was reached without the input of a single medical expert and without considering the established science addressing the value of methadone treatment to maternal, fetal, and child health, and other key health and social welfare issues in the case.”

Dr. Robert Newman, one of the experts represented in the brief and a nationally and internationally recognized authority on methadone treatment, said, “As a matter of medicine and health care, it is simply nonsensical to regard methadone treatment as a form of child abuse.” He explained, “Decades of research unequivocally demonstrate the benefits of treating a pregnant woman’s addiction to opioids with methadone, an extraordinarily well-studied medication whose benefits to the mother as well as the baby unquestionably outweigh the treatable and transitory side effects that are sometimes seen in the newborns.” He noted that “It is not recommended that women simply stop using opiates during pregnancy” and that “methadone and other related treatments are acknowledged by national and international governmental, academic and clinic authorities to be the best choice for maternal, fetal, and child health, reducing risks of miscarriage, stillbirth, and premature birth.”

The experts’ brief addresses the fact that the lower court did not consider health measures that can be taken after birth to reduce symptoms of NAS, including keeping the new mother and baby together and encouraging breast feeding. The brief also notes that there is nothing in the lower court’s decision that limits its ruling to pregnant women who receive methadone treatment and could be applied to any pregnant woman, including those who experience health conditions such as epilepsy, depression, and blood clots that require medication that have potential adverse effects in the newborn.

Lynn Paltrow, Executive Director of National Advocates for Pregnant Women and co-counsel representing the experts, explained that, “unless the lower court decision is reversed, New Jersey would become the only state in the U.S. to effectively ban pregnant women from receiving methadone treatment.” She added, “DCPP’s position and the lower court’s decision is inexplicable and irrational. They not only fly in the face of the recommendations of the World Health Organization and the U.S. government, but New Jersey itself, which, through collaborations between the New Jersey Department of Mental Health and Addiction Services and DCPP, provides methadone treatment to pregnant women and families in the child welfare system.”

The court is expected to hear oral arguments this term. The group of expert amici included the American College of Obstetricians and Gynecologists, American Psychiatric Association, American Public Health Association, American Society of Addiction Medicine, Medical Society of New Jersey, New Jersey Psychiatric Association, New Jersey Obstetrical and Gynecological Society, National Council on Alcoholism and Drug Dependence, and National Council on Alcoholism and Drug Dependence-NJ. A full list of amici is available Here.

In 2013, more than 50 national and international experts published an open letter urging that media coverage of prenatal exposure to opioids be based on science, not stigma and misinformation. This letter is available  Here.

Resource:  Experts to New Jersey Supreme Court

Source:  National Advocates for Pregnant Women January 9, 2013

From At Forum

NIMBY and Other Problems: Still an Uphill Battle For OTPs, But Hope Seen In Patient Advocacy

ATForum November 15, 2013

The NIMBY (Not In My Back Yard) syndrome is one significant challenge for opioid treatment programs (OTPs), which can’t operate if they can’t get approval from municipalities. Methadone maintenance treatment has been proven effective and producing good outcomes for five decades, but that isn’t preventing politicians from pandering to prejudice and discrimination. Still, the field is forging ahead, opening new programs and providing access to treatment to needy patients.

Sally Friedman, legal director with the Legal Action Center, said that local authorities often try to zone out drug and alcohol programs in general, but it’s even more difficult to site a methadone program. “It’s challenging to site any type of facility that serves people who folks don’t want around,” she said. “I’ve seen this from examining case law—there’s NIMBY for everything, the elderly, group homes, communities want to keep out all types of social services.”

But a special place in NIMBY-land is reserved for OTPs. In 1977 the Legal Action Center won a landmark discrimination case in which a federal court prevented White Plains in New York from zoning out alcohol and drug abuse treatment programs—and while it wasn’t specific to OTPs, OTPs are included. “Stereotypes and myths” play a part in the NIMBY decisions, said Ms. Friedman.
The Americans with Disabilities Act (ADA) clearly supports OTPs and their patients, and municipalities and their lawyers can easily lose in federal court since the law is so clear. “But there’s a lot of political calculation,” said Ms. Friedman. Local politicians think they have more to gain politically from keeping the facility out, so they’re willing to risk the lawsuit and let the court tell them what they have to do.

MAT First

One point that the substance abuse treatment field in general needs to make more strongly is that medication is the first-line evidence-supported treatment for opioid addiction. “Myth and misunderstanding continue to plague not just methadone alone but medication-assisted treatment [MAT] in general,” said Michal Botticelli, deputy director of the White House Office of National Drug Control Policy [ONDCP]. For opioid dependence in particular, medication is the “first line in our arsenal,” he said. “We have to make sure people understand that this is the standard of care.”
Mr. Botticelli added that there is an opportunity to create a greater consumer voice in favor of MAT. “People have done exceedingly well on methadone maintenance.” Some people need more than medication—other social supports and the structure of an OTP—but others don’t.

As states continue to express concern about prescription drug abuse and overdoses, mainly surrounding opioids, the ONDCP is increasing its stress on the importance of access to methadone and buprenorphine, as well as social supports provided in an OTP. “If we really want to deal with overdose deaths, we need to make sure that we have adequate access to MAT.”

The same myths and stereotypes that bolster NIMBY apply to the criminal justice system, which routinely denies access to medication-assisted treatment. The biggest myth is the one that methadone and buprenorphine are “substituting one addiction for another,” which couldn’t be farther from the truth. Patients in MAT are not addicted—they are not pursuing drugs, they are in recovery, employed, productive members of society. But proponents of discrimination don’t understand how the medications work.

Lack of Negative Impact

It’s also easy to demonstrate the lack of a negative impact in NIMBY siting cases. Jerry Rhodes, chief operating officer of CRC Health Group, said it’s important to bring out studies that show crime goes down when clinics are deployed. “There is science that shows methadone treatment has good results,” he said. But here’s the problem: the issue is an emotional, not a logical, one.

The studies showing that methadone works have been ignored by many public policy makers. And while OTPs had been hoping to enlist government officials and regulators in support of MAT, that isn’t working either. “We’ve had the rug pulled out from under us,” said Mr. Rhodes. “We’re trying to get a more robust commitment.”

Support From Patients

One thing OTPs could do better is to involve the support of patients, said Mr. Rhodes. “There are often compelling personal stories around the need for treatment, and the effectiveness of MAT.”
In general, the OTP field has done a poor job of rallying patients. But Mr. Rhodes understands that it’s hard to get patients to come forward. “You could lose your job, your neighbor could say something, there’s a fear of being seen as a patient in a clinic.”

The field is beginning to recognize that OTP patients, like other people in recovery, can be a significant voting bloc. For example, there are 5,000 to 6,000 OTP patients in West Virginia. In a small state like West Virginia, 5,000 votes—in some places, even 1,000 votes—can swing an election. When there is no access to MAT, patients—and prospective patients, who also vote—suffer.
“This is a job for the National Alliance for Medication Assisted Recovery  (NAMA),” Mr. Rhodes said.

Collaboration

Another good advocacy tactic involves collaborating with other groups. Mr. Rhodes cited the effectiveness of the autism advocacy movement, which is spearheaded by parents who are fierce advocates for their children. Drug addicts, alcoholics, people with mental illness need the same kind of advocates, but have always been treated as marginal populations, which is what drives the stigma. “We can do a better job of working with other constituents,” he said.
Even as a field, various types of treatment are fragmented—medication, no medication, alcohol, drugs—and OTPs could benefit by these groups working together and bringing OTPs into the tent.

Back to NIMBY

The bottom line is, OTPs need facilities, and that means they need certificates of occupancy. Mr. Rhodes warns clinics against going into a community to develop a clinic and not garnering support first. “You can’t do this and not deal with NIMBY, but you can do a better job of trying to support these efforts.”

Here are some of the things you can expect to hear when you try to site a program. “This isn’t our problem.” That’s pretty easy to refute, because an OTP usually has done research and knows that there is an opioid problem. For example, at one meeting, someone stood up and said, “I don’t want this town becoming a methadone mecca.” A physician who was there then said, “You don’t understand, this town is already a heroin mecca.”

The OD Bandwagon

Despite the many newspaper articles about prescription opioid abuse and overdoses, there are rarely any discussions of the cure—treatment. “People don’t understand how prescription opioid abuse relates to methadone treatment,” said Mr. Rhodes. “We rarely address the cure, we just talk about the magnitude of the problem.”

“Education is key,” agreed Ms. Friedman. “We need to explain how the disease works, how the treatments work, and how we produce successful outcomes.”

Link to ATForum NIMBY and Other Problems

Methadone coverage could return to Medicaid menu

Chicago Healthcare Daily November 05, 2013

By Kristen Schorsch

 

The Illinois Medicaid program is weighing whether to resume covering methadone treatments, a proposal that is likely to stir up controversy after the practice was halted about 20 years ago amid criticism about the soaring costs of substance abuse care.

Restarting the coverage of treatment for heroin addicts is among several recommendations contained in a Sept. 27 report to Gov. Pat Quinn by the Illinois Department of Healthcare and Family Services, which runs the state's Medicaid program, and the state Department of Human Services. The report addresses the impact on inpatient hospital detox services of the so-called Smart Act, a $2.7 billion package of budget cuts and tax increases passed in 2012 intended to help the struggling Medicaid program stay afloat.

 

Resources

 

Illinois Department of Healthcare and Family Services. SMART Act Implementation Status Report.

Senate Appropriation Committee Hearing, March 19, 2013

http://www.methadone.org/downloads/documents/2013 0319IHFS-SMARTActImplementationReport.pdf

 

Illinois Department of Healthcare and Family Services. Report on the Detoxification Services Planning Process and Resulting Recommendations as per the Save Medicaid Access and Resources Together (SMART) Act. Senate Bill 2840- Public Law 97- 0689. September 27, 2013.

http://www.methadone.org/downloads/documents/2013 0926IHFS-Report on SMART Act.pdf

 Illinois Association for the Medication Assisted Addiction Treatment. White Paper on Medicaid Coverage for Methadone Treatment for Opioid Dependence. October 2013.

http://www.methadone.org/downloads/documents/2013IAMAAT-Benefits of Including Methadone-Treatment in Illinois State Medicaid Plan (White Paper).pdf

  

 

Download

2013 1105ChicagoHealthcareDaily-Methadone coverage could return to Medicaid menu.pdf 

IRETA Developes Guidelines for the Management of Benzodiazepines in MAT

November 1, 2013

EXECUTIVE SUMMARY

In  2012,  under  contract  with  the  Philadelphia  Department  of  Behavioral  Health  and  Intellectual disAbility Services (DBHIDS), and with additional support from Community Care Behavioral Health Organization  (Community  Care),  the  Institute  for  Research,  Education  and  Training  in  Addictions (IRETA)  conducted  a  project  to  determine  best  practice  guidelines  for  the  management  of  benzodiazepines in medication-assisted treatment (MAT). The project was conceived in response to frequent  benzodiazepine  use  among  individuals  in  MAT  and  a  relative  absence  of  research -based guidance  on  clinically  effective  treatment  strategies  for  managing  their  use.  Designed  to  be  a resource for clinicians, these guidelines aim to distinguish areas of scientific/clinical consensus and areas where that does not exist.   They are not intended to dictate clinical practice.

This  report  details  the  development  of  the  project,  methods,  results  and  the  final  list  of  practice guidelines.  IRETA  utilized  the  RAND/UCLA  Appropriateness  Method  to  determine  appropriate guideline statements based on the research and clinical experience of a panel of experts in the field. The two-round rating process and half-day expert panel meeting yielded 225 guideline statements, which IRETA  distilled into  a  shorter list of guidelines for practitioners to  use in real-world clinical settings.

Recommendations from the expert panel members include:

• CNS depressant use is not an absolute contraindication for the use of either methadone or buprenorphine in MAT, but is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, antidepressants, or alcohol.

• Individuals who use benzodiazepines, even if used as a part of long-term therapy, should be considered at risk for adverse drug reactions including overdose and death.

• Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment.

• MAT should not generally be discontinued for persistent benzodiazepine abuse, but requires the implementation of risk management strategies.

• Clinicians should ensure that every step of decision-making is clearly documented.

During  the  half-day  meeting  in  September  2012,  expert  panelists  added  an  additional  guideline statement:  “Clinicians  would  benefit  from  the  development  of  a  toolkit  about  the  management  of benzodiazepines in methadone treatment that includes videos and written materials for individuals in  MAT.”   This  recommendation  is  consistent  with  the  overarching  theme  of  patient  education, which was discussed lengthily at the project’s Kickoff Conference in February 2012 and emerged as a significant issue in the final practice guidelines.

Download: Management of Benzodiazepines in MAT

Resource:  IRETA

 

Reckitt Benckiser may sell pharmaceuticals business

By Martinne Geller

LONDON (Reuters) - Reckitt Benckiser may sell its pharmaceuticals unit, which has been suffering from declining sales of its main heroin addiction drug, to focus on growing consumer health and household cleaning products businesses.

The British consumer goods group said on Tuesday it was reviewing options for the pharmaceuticals business, which analysts said could fetch over 2 billion pounds ($3.2 billion) and appeal to international drugmakers.

Download:

http://www.methadone.org/downloads/documents/2013 1023Reuters Reckitt Benckiser may sell pharmaceuticals business.pdf

The Benefits of Including Methadone Treatment in Illinois’ State Medicaid Plan

The Illinois Association for Medication Assisted Addiction Treatment
October 2013

Executive Summary

Methadone is an inexpensive medication approved by the U.S. Food and Drug Administration for the treatment of heroin and other opioid dependence. Studies indicate that methadone reduces relapse, emergency department visits and hospital admissions. In general, the stability methadone provides helps patients better manage their overall health.

Including methadone treatment in Illinois’ State Medicaid Plan will reduce healthcare costs and help the state address the growing epidemic of opioid dependence. Patients can only access methadone treatment for their opioid dependence through the highly regulated Opioid Treatment Program (OTP) system. The system requires programs be registered with the Drug Enforcement Administration, certified by the federal Health and Human Services’ Center for Substance Abuse Treatment and licensed by the Illinois Department of Human Services’ Division of Alcoholism and Substance Abuse.

OTPs utilize a multidisciplinary team comprised of physicians, nurses, and counselors to address the bio-psycho-social needs of each individual patient. This holistic approach to treatment has been in place in OTPs for more than 40 years, long before most other systems embraced the health home model. The strong positive relationships between patients and professionals in OTPs helps patients feel empowered to address their own health needs.

Numerous studies have documented the cost savings generated by stabilizing opioid dependent individuals on methadone and helping them manage their comorbid conditions. Emergency department visits and hospital admissions are significantly reduced because patient health is carefully monitored and addressed. In spite of medical evidence documenting the effectiveness of methadone treatment and the cost savings achieved, some health plans have excluded this treatment modality. Patient advocates have suggested this is largely due to the stigma related to heroin addiction.

Untreated opioid dependence in Illinois leads to unnecessary emergency department visits and hospital admissions. Some of these visits are due to drug overdoses or attempts to seek treatment for withdrawal symptoms. However, others are due to the multiple unmanaged comorbid conditions, such as diabetes and hypertension, which are highly prevalent in opioid dependent individuals.

Illinois’ administrative leadership has demonstrated its commitment to resolving Illinois’ fiscal crisis. The cost savings achieved by covering methadone treatment in Illinois’ State Medicaid Plan can be part of this solution. In addition to saving taxpayer dollars in unnecessary hospitalizations, providing increased access to treatment aligns with three core objectives of Illinois’ Budgeting for Results initiative: 1) to improve the overall health of Illinois residents; 2) to meet the needs /improve the quality of life for the most vulnerable persons; and 3) to increase individual and family self-sufficiency.

Download

http://www.methadone.org/downloads/documents/2013IAMAAT-Benefits of Including Methadone-Treatment in Illinois State Medicaid Plan (White Paper).pdf  

Report on the Save Medicaid Access and Resources Together (SMART) Act

From the Illinois Departments of Healthcare and Family Services
and Human Services, Division of Alcohol and Substance Abuse

September 27, 2013

Report on the Detoxification Services Planning Process and Resulting Recommendations as per the Save Medicaid Access and Resources Together (SMART) Act

Senate Bill 2840- Public Law 97- 0689

The Save Medicaid Access and Resources Together (SMART) Act (P.A. 97-689) made two changes in the Illinois Medicaid Program for our clients with substance use disorders who are admitted to hospitals for in-patient detoxification services.

First, the new law placed limitations and required concurrent review for every hospital detoxification stay within 60 days of a previous detoxification stay. Second, it required the Department of Healthcare and Family Services (HFS), along with our sister agency, the Division of Alcoholism and Substance Abuse (DASA) of the Department of Human Services (DHS), to “convene a workgroup to develop recommendations for quality standards, diversion to other settings, and admission criteria for patients who need inpatient detoxification”. Pursuant to P.A. 98-104 and stakeholder involvement, these recommendations are being published.

We understood from the outset that restrictions on hospital admissions and readmissions would not alone achieve the State’s goal: to facilitate access to medically appropriate detoxification services, in the most appropriate setting, with appropriate linkages to community based substance abuse treatment and recovery support services. That is why we are working with providers and managed care entities to build integrated delivery systems around these clients, which will offer a network of health, behavioral health and social services, with assistance from a care coordinator to help navigate the system. In the short term, we will test the effectiveness of these linkages through a demonstration program which partners hospitals and community-based providers.

This report is the product of a deliberative process that included representatives from hospitals, community-based providers, managed care entities and state agencies. We invite your feedback and comments, as we set about to implement these new policies. We are convinced that the implementation of new policies, programs and protocols with greater access to medication assisted treatment, and a cohesive and coordinated approach to care will improve health outcomes for these clients with behavioral health needs.

 Download

http://www.methadone.org/downloads/documents/2013 0926IHFS-Report on SMART Act.pdf

SMART Act Implementation Status Report

Illinois Department of Healthcare and Family Services
March 19, 2013

Senate Appropriation Committee Hearing

(Spreadsheet)

 

Download

http://www.methadone.org/downloads/documents/2013 0319IHFS-SMARTActImplementationReport.pdf

Some MaineCare Patients will still have Access to Methadone

Portland Press Herald
By WANDA CURTIS Kennebec Journal Correspondent

A task force developed criteria for continued MaineCare coverage of certain drug treatments.

Health officials say Mainers who need certain drugs to treat addiction won't be cut off entirely, despite legislation to cut off treatment for some.

MaineCare coverage for treatment with methadone and Suboxone is due to end Tuesday for those who have been covered for at least 24 months. A bill passed by the Legislature established the 24-month lifetime limit.

But a task force of medical providers, substance abuse treatment providers, government officials and patient advocates has developed criteria for continued MaineCare coverage of medically necessary methadone and Suboxone treatments.

That may avert what was predicted to become an unprecedented drug withdrawal crisis in January. Methadone and Suboxone are used to treat opiate addiction.

The medical director of MaineCare services, Kevin Flanigan, said the task force developed guidelines for continued coverage for people who need the treatment. He said Suboxone funding will end Jan. 1 for people who have reached the two-year limit -- the 24 months don't need to be consecutive -- only if medical providers are unable to get authorization to continue the treatment before the deadline.

Flanigan said the task force has identified specific behavior that may help indicate whether Suboxone treatment has been successful. He said people reviewing authorization applications will ask questions about clients such as:

• Have they been able to reunite with their families?
• Have they been able to return to work?
• Have they been able to engage in social or community or recreational activities again?
• Is there a spiritual component to their life that was absent before?
• Are they no longer having difficulties with the legal system?
• Are they in constructive activities their provider has asked them to participate in?

Flanigan said providers will also be asked whether a client is receiving the lowest optimal dose, in determining whether Suboxone treatment has been effective for them.

He said that if the provider says the person relapsed every time weaning was attempted, then treatment hasn't been successful and the provider should discuss other options.

Flanigan said that if Suboxone treatment has been deemed successful and it's determined to be medically necessary, coverage for the treatment will be approved for six-month increments, and the provider will be required to reapply every six months.

Flanigan said that if a client is denied, the provider can reapply after the client is given another opportunity to meet the criteria.

Flanigan said no one would be required to discontinue Suboxone treatment cold turkey if MaineCare funding is denied. He said the patient would be allowed a three-month tapering period during which treatment would still be funded.

Flanigan said people who will reach the 24-month coverage limit in January should contact their medical providers immediately to determine whether the provider applied for authorization or whether the client must seek another payment source.

For methadone coverage, Flanigan said the two-year countdown begins Jan. 1.

Unlike the new rules for Suboxone treatment, it's not retroactive.

He said that count starts "whether it's their first day of treatment or the first day of their ninth year of treatment."

Both of those funding decreases, which are part of state budget cuts, come at a time when Maine reports the highest per capita rate of people seeking treatment for opiate addiction in the country.

Roy Miller, a physician who practices at Sheepscot Valley Health Center in Coopers Mills, said providers are re-examining their prescribing practices because they've been warned that narcotics have been overprescribed in the past.

"We're cutting back," he said.

Miller said the limit was established because of financial constraints, not because two years was proven to be the optimal time to discontinue treatment.

He said some addiction specialists suggest teenagers who get addicted to certain drugs may need lifelong treatment because the drugs affect their brains.

Miller said the time needed for treatment to be effective varies from client to client.

Miller said Suboxone is expensive -- $7 to $8 per pill -- but it allows people with opiate addiction to live more normal lives because they don't have to travel to a methadone clinic daily for treatment.

A generic medication costs less but doesn't produce the same results, he said.

Miller said Suboxone has been effective with patients he's treated over the last four years.

"After they've received treatment, many of them are able to hold jobs and get their families back together," he said.

Clinicians Say Giving Addicts Maintenance Methadone Serves Them and Society Best

By Christopher Williams, Sun Journal

Bangor Daily News May 27, 2012

When Zachary Tomaselli was sent to prison for sex crimes last month, he asked the judge to delay his sentence for a week.

The Lewiston man said he needed those seven days to wean himself off methadone, the drug he had been getting at a clinic to help him kick a prescription drug habit.

Thousands of addicts living “on the outside” visit Maine’s for-profit clinics for weeks, months and even years for their prescribed methadone doses. A large majority of those addicts are MaineCare clients, paying for methadone treatments with taxpayer dollars.

According to the Department of Health and Human Services, Maine spends about $9 million in state and federal funds every year to dose just over 3,100 MaineCare and Medicare clients every day. The state spends another $7 million a year to transport clients to methadone clinics.

That’s $5,140 per MaineCare patient per year.

Under the recently passed state budget, MaineCare clients are subject to a 24-month lifetime cap for methadone treatment. That cap is expected to save Maine more than $1.3 million a year.

According to Susan Sullivan, director of CAP Quality Care Clinic in Westbrook, patients there “are anxious and afraid of losing their treatment. Some are looking to be proactive and starting to taper themselves out because they don’t know what’s going to happen.”

If Tomaselli believed he could lick his drug habit in just a week, why wouldn’t — or shouldn’t — every drug addict do the same?

The answer, according to experts, is as complex as the subject of drug addiction itself.

Withdrawal is harsh reality

The good news for Tomaselli, experts say, is that he likely wasn’t in any danger of serious health risks had he decided to go cold turkey before trading his street clothes for jail garb.

The bad news — depending on how long he had been treated with methadone and at what dosage — is that his withdrawal might have been more grueling than his looming 3½-year prison sentence.

Dr. Michael E. Kelley, chief of psychiatry at St. Mary’s Regional Medical Center in Lewiston, said the effects of withdrawal from methadone are unique.

Because the medication is used as a maintenance narcotic for clients limited to a single dose each day, the drug typically stays in the body longer than other narcotics, he said.

“It is incredibly long-lasting,” he said.

That means withdrawal from that drug can linger for a week or longer. Sometimes up to a month.

Although not physically dangerous in an otherwise healthy adult, withdrawal can make you feel like you’re dying, Kelley said in an interview at the hospital, where he works as an addiction specialist, treating people with chemical dependency in residential and day programs.

“They can have a very miserable withdrawal,” he said.

It often includes severe flulike symptoms, including vomiting, diarrhea, sweating, chills and muscle cramps.

“But you won’t die,” Kelley said. The only possible medical risk is dehydration, he said.

The greater risk for narcotic addicts is relapse, experts say.

‘Jail isn’t a hospital’

While withdrawal from narcotics, including methadone, is usually safe, withdrawal from certain other drugs and alcohol can be dangerous, even fatal, according to medical experts.

Withdrawal from alcohol, benzodiazepines (tranquilizers) and barbiturates can be “very dangerous,” Kelley said.

Stopping those drugs too quickly can sometimes trigger seizures, heart arrhythmias and delirium tremens (in alcoholics), he said. The latter can be dangerous because those patients become disoriented and may inadvertently harm themselves.

Jails sometimes bring prisoners into the emergency room if they’re suspected of alcoholism or addiction to tranquilizers and show signs of withdrawal, Kelley said.

While the jail might let someone addicted to narcotics “tough it out,” they won’t take a chance on the other addictive populations, Kelley said.

“The jail’s not going to risk that,” he said. “The jail isn’t a hospital.”

When inmates come to St. Mary’s emergency department for medical clearance, hospital staff screens patients for drugs and toxic substances, checking their general health.

Doctors quiz the patients about drug use.

“Hopefully, they’ll be honest.” he said. But, too often they’re not. They fear their candor might get back to their probation officers. Although emergency room chats with doctors are confidential, inmates are on their guard generally and may not confide in the medical staff.

“Sometimes they lie to us,” Kelley said, “which is part of the scary thing.”

Doctors typically watch inmates suspected of drug or alcohol abuse for 12-16 hours, he said, but added, “There is no magic [time] line.” And there is no predicting a patient’s tolerance based on his or her history of drug or alcohol use.

No methadone for prisoners

At Maine’s correctional facilities, including its prisons, the state contracts its medical services with Corizon, a national company based in Tennessee. Three county jails in Maine, including Androscoggin County Jail in Auburn, also have contracts with Corizon.

The company has 150 health care professionals working at the state facilities. An additional 65 workers staff the three jails, according to Pat Nolan, a company spokesman.

Corizon would provide only written answers to questions posed by the Sun Journal for this story.

While it declined to detail how chemically dependent inmates are treated during intake at Maine’s prisons and jails, the company said it uses “standard, humane and medically approved detox protocols for these addictions.”

Inmates who attend methadone clinics prior to incarceration are not dispensed methadone at any of the correctional facilities where Corizon is under contract. Pregnant inmates using methadone are treated by an off-site OB-GYN doctor licensed in prescribing Buprenorphine, a semisynthetic opioid used to treat opiate-based drug addiction. After delivery, those inmates follow the standard detox protocols, Nolan said.

If an inmate were to come to jail or prison with a current prescription for Oxycontin or oxycodone, those drugs wouldn’t be dispensed, except in “very rare” cases, the company said.

Inmates with a medical marijuana certificate won’t be dispensed that drug at Maine’s prisons and jails, either, but substitutions could be considered on a case-by-case basis, the company said.

In all, roughly 90 percent of the inmates who enter Maine’s prisons and other correctional facilities have a history of addiction to one or more drugs (including narcotics, benzodiazepines or barbiturates) or alcohol.

Relapse rate is high

So, why don’t all methadone addicts spend a week weaning themselves from the drug like Tomaselli?

Some may try. But most will need more time. And a small percentage likely will need to stay on methadone until they die, experts say.

Sullivan, the director at CAP, where opioid addicts are treated with methadone, said the first goal is to stabilize clients on a suitable dose of medication.

Opioid addiction is a brain disease, she said, best treated with medication and psychosocial support. Clients who come to her clinic get both.

Like any addiction, “It’s a progressive disease,” she said. “The longer you use, the worse it gets and the more you use … so that treatment is based on the individual.”

Studies have found that patients with this chronic disease undergo a change in brain chemistry in which they are lacking free endorphins which, for many, means they likely will need medication throughout their lifetimes, she said.

The long-term goal of treatment is to improve a client’s ability to function at home, at a job and in the world.

Studies show it works.

Typically, relapse rates are 70-90 percent among those who leave methadone maintenance treatment, she said, even among those who taper to zero.

An alternative for opioid addicts to being on a maintenance program at a methadone clinic may be to seek street drugs, which can expose addicts to hepatitis C and HIV through shared and dirty needles, blood clots and possible overdose, among other health risks.

Some may try prescription shopping, a ploy medical professionals are increasingly more aware of and on which federal and state drug agencies have cracked down.

A patient on Sullivan’s caseload was in methadone treatment before he tapered his dosage to zero and left, she said.

“Within a year, he relapsed,” she said. “And then he came to this clinic and he’s been here about 9½ years and he’s tapering out, decreasing his medication so he can leave. To zero eventually. That’s his desire.”

By taking a gradual approach, that client is more likely to succeed, she said.

She said patients and staff at CAP are anxious about the new 24-month MaineCare cap. Under the new DHHS rule, that cap can be exceeded with prior MaineCare authorization.

However, Sullivan said, “We’re waiting for the criteria for prior authorization. We have no idea what that’s going to be.” Once that process is established, “that will probably be the determinant on who loses treatment,” she said.

In the 10 years her clinic has been open, Sullivan said the number of clients has averaged about 550 at any given time.

“We’ve had over 3,000 patients come and go,” she said. “And some stay.”

The MaineCare cap will have an adverse effect on methadone clinics across the state, Sullivan said. Nearly 70 percent of all clients are on MaineCare. And, under the MaineCare reimbursement cap, that patient load is likely to decrease if MaineCare-capped patients can’t pay out-of-pocket.

Fewer than 200 methadone patients pay for treatments with private insurance, which leaves about 1,000 patients without MaineCare or private insurance paying for their own treatments.

Although her clinic exists to treat addiction to narcotics, some people who became addicted started with a doctor’s prescription for pain, she said.

Pain and narcotic addiction “are not necessarily mutually exclusive,” she said.

“Even addicts get real pain,” St. Mary’s Dr. Kelley said. Those are the ones who are likely to stay on methadone or Suboxone (a partial narcotic, offered by St. Mary’s instead of methadone) the rest of their lives, he said.

The other group that would have to stay on clinical treatment includes those who are so addicted they likely would harm themselves otherwise through risky drug behavior. No rehab program, however proven and long-term, is going to work for them.

“There’s just that once-in-a-while person that everything’s failed, no matter what,” he said.

But studies he’s seen show that opioid addicts who attend methadone clinics are less likely to contract HIV or hepatitis C and less likely to be charged with crimes. They work more days and achieve higher levels of education.

“So it does reduce the harm, not only to them, but to society, in many ways [to maintain methadone treatments],” he said.

St. Mary’s approach to addiction is that 99.9 percent of addicts can be weaned off and can stay off drugs and alcohol — “all chemicals,” Kelley said.

“And that requires a hell of a lot more than just taking a pill,” he said. “It requires learning about yourself, doing what we call the recovery work … learning why I use, how I can cope with life without drugs.”

Addicts who have been using drugs to cope with life will have to relearn how to cope without them. “That’s how they dealt with every single emotion,” he said.

And some addicts who have been abusing drugs since their early teens will have to learn those coping skills for the first time.

“How many coping skills do you have at 13 years old?” Kelley said. “Once you start using drugs for everything, you don’t learn new coping skills because you don’t need to. You’ve got a coping skill. It’s right there in your pocket. And so, some of these people are starting from scratch.”

Link to Poll

United Insurance Company of America Pays $37,500 To Resolve EEOC Disability Discrimination Lawsuit

United Insurance Company of America Pays $37,500 To Resolve EEOC Disability Discrimination Lawsuit
Federal Information & News Dispatch, Inc.
1-23-12

United Insurance Company of America Pays $37,500 To Resolve EEOC Disability Discrimination LawsuitCompany Rescinded Job Offer to Recovering Drug Addict Because of His Disability, Agency ChargedRALEIGH, N.C. - United Insurance Company of America will pay $37,500 and furnish other relief to resolve a disability discrimination lawsuit filed by the U.S. Equal Employment Opportunity Commission (EEOC), the agency announced today.According to the EEOC's lawsuit, Craig Burns is a recovering drug addict who has been enrolled in a methadone treatment program since 2004. In January 2010, United Insurance offered Burns a position as an insurance agent in its Raleigh office, conditioned upon Burns' passing a drug test. After Burns' drug test showed the presence of methadone in his system, Burns submitted a letter to United Insurance from his treatment provider explaining that he was participating in supervised methadone treatment program and taking legally prescribed medication as part of the treatment. Upon receiving this information, United Insurance notified Burns that he was not eligible for hire and withdrew its offer of employment.Such alleged conduct violates the Americans with Disabilities Act (ADA), which protects employees and applicants from discrimination based on their disabilities. The EEOC filed suit in August 2011 in U.S. District Court for the Eastern District of North Carolina (Civil Action No. 5:11cv00430), after first attempting to reach a pre-litigation settlement through its conciliation process.In addition to monetary damages, the two-year consent decree resolving the suit requires United Insurance to conduct training on, among other things, an employer's obligation to conduct an individualized assessment in determining whether an employee or applicant is disabled under the ADA; appropriate methods of determining whether an employee or applicant poses a direct threat under the ADA; and the obligation to engage in an interactive process under the ADA when an employee or applicant requests a reasonable accommodation. United Insurance will also post a copy of its anti-discrimination policy at its headquarters in St. Louis."The ADA requires employers to make an individualized assessment of whether an individual can do the job rather than relying on fears or stereotypes," said Lynette A. Barnes, regional attorney for the EEOC's Charlotte District, which includes the Raleigh Area Office, where the original charge of discrimination was filed. "We are pleased that, in resolving this case, United Insurance is taking action to ensure that it fulfills its obligations under the ADA."

ASAM Redefines Addiction as a Brain Disease

ASAM Redefines Addiction as a Brain Disease
Pain-topics.org
August 26, 2011 (Friday)

Addiction is a primary, chronic brain disease, not just bad behavior or bad choices, according to a new definition from the American Society of Addiction Medicine (ASAM). Pain practitioners need to understand the ramifications of addiction — especially involving Rx-opioid use — as a complicating factor in patient care. However, casual use of the term “addiction” or inaccurate diagnosis of the disorder is counterproductive for effective pain management and unjustly stigmatizing to patients.

According to ASAM in a news release, when people see compulsive and damaging behaviors in friends or family members — or public figures such as celebrities or politicians — they often focus only on the behaviors or substance use as the problem. However, these outward signs are actually manifestations of an underlying disease that involves various areas of the brain.

“At its core, addiction isn't just a social problem or a moral problem or a criminal problem. It's a brain problem whose behaviors manifest in all these other areas,” said Michael Miller, MD, past president of ASAM who oversaw the development of the new definition. “Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It's about underlying neurology, not outward actions.”

The new definition resulted from an intensive, 4-year process with more than 80 experts actively working on it, including top addiction authorities, addiction medicine clinicians, and leading neuroscience researchers from across the country. The full Public Policy Statement on addiction also includes this short version of the definition:

“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.” “Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

By defining addiction as a primary disease, ASAM stresses that it is not the result of other causes, such as emotional or psychiatric problems. Addiction also is recognized as a chronic disease — like cardiovascular disease or diabetes — that must be treated, managed, and monitored over a life-time.

Two decades of advancements in neurosciences convinced ASAM that addiction needed to be redefined by what is going on in the brain. Research shows that the disease of addiction affects neurotransmission and interactions within neural reward circuitry, leading to addictive behaviors that supplant healthy ones, while memories of previous experiences with food, sex, alcohol, and other drugs trigger craving and renewal of addictive behaviors.

Meanwhile, brain circuitry that governs impulse control and judgment also is altered in this disease, resulting in the dysfunctional pursuit of rewards such as alcohol and other drugs. This area of the brain is still developing during teen-age years, which may be why early exposure to alcohol and drugs is related to greater likelihood of addiction later in life.

“There is longstanding controversy over whether people with addiction have choice over anti-social and dangerous behaviors,” said Raju Hajela, MD, in the news release (he is past president of the Canadian Society of Addiction Medicine and was chair of the ASAM committee on the new definition). He further states, “the disease creates distortions in thinking, feelings and perceptions, which drive people to behave in ways that are not understandable to others around them. Simply put, addiction is not a choice. Addictive behaviors are a manifestation of the disease, not a cause.”

However, Hajela continues, “Choice still plays an important role in getting help. While the neurobiology of choice may not be fully understood, a person with addiction must make choices for a healthier life in order to enter treatment and recovery. Because there is no pill which alone can cure addiction, choosing recovery over unhealthy behaviors is necessary.”

COMMENTARY: The interface of pain, opioid analgesics, and addiction has been of great concern in the pain management field. Commonly, the term “addiction” has been loosely applied by practitioners, researchers, and the public, and this has frequently resulted in faulty diagnoses, unjust accusations, and stigmatization of patients.

Furthermore, there have been many studies in the field using definitions that inaccurately assess addiction among patients with pain prescribed opioid analgesics; consequently, more often than not, the prevalence of addiction has been inflated. Good quality studies, of which there have been few, suggest that de novo iatrogenic addiction in patients appropriately prescribed opioid analgesics for chronic pain is a relatively rare occurrence [see UPDATE here].

Will this reinterpretation of addiction from ASAM help to clarify the issues or add further confusion? In many respects, the definition is comprehensive but not entirely new thinking. In 2001, a trio of organizations — the American Academy of Pain Medicine, American Pain Society, and ASAM — released a consensus document, “Definitions Related to the Use of Opioids for the Treatment of Pain,” that defined addiction as follows:

“Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.”

The new definition, from ASAM, notes that addiction is characterized by 5 features:
1. Inability to consistently Abstain;
2. Impairment in Behavioral control;
3. Craving, or increased “hunger” for drugs or rewarding experiences;
4. Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and
5. A dysfunctional Emotional response.

These are quite similar to features noted in the consensus statement of a decade ago, and ASAM emphasizes that the 5 “new” features are not diagnostic criteria for addiction. Rather, the diagnosis of addiction requires “a comprehensive biological, psychological, social and spiritual assessment by a trained and certified professional.” However, this raises some concerns about the new definition:

• Who is a “trained and certified professional” qualified to make a bona fide diagnosis of addiction in a patient? Presumably, ASAM members are qualified; pain practitioners are not. However, chronic pain and instinctual human drives for pain relief may result in expression of any or all of the 5 features of addiction noted above, which can confound the diagnosis by someone inexperienced in both pain and addiction medicine.
  


• The ASAM document catalogs many of the interesting and important neurobiological structures and functions that have been discovered in research studies to play a role in addictive processes. However, this knowledge has not been translated into everyday clinical application for the diagnosis and treatment of addiction.



• ASAM further notes that “genetic factors account for about half of the likelihood that an individual will develop addiction,” and these are further influenced by environmental factors. This may be of some importance from prevention perspectives but, since a person’s genetic makeup cannot be remediated, it is unhelpful in the treatment of current addiction.



• The inclusion by ASAM of a spiritual dimension in their definition and the assessment of addiction, which is so prominent and important in 12-Step recovery groups, is controversial from a medical science standpoint. Delving into patients’ connections (or disconnects) with a “Higher Power” is generally outside the bounds of typical clinical practice.

Finally, it is curious that ASAM released this extensive definition of addiction at this time, when the American Psychiatric Association (APA) is finalizing the 5th revision of their Diagnostic & Statistical Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Is this new ASAM definition intended to complement DSM-5, to supersede the APA’s work in defining addictive disorders, or as a standalone interpretation of the disorders by ASAM? Interestingly, other than a major section heading in DSM-5 titled “Substance Use and Addictive Disorders,” the APA continues to shun use of the term “addiction” as a descriptor, as they have in the past.
In any case, the new ASAM document is recommended reading for all healthcare providers who want an understanding of addiction and addictive behaviors.

American Society of Addiction Medicine ASAM