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20/Jan/2019

New England Journal of Medicine – Despite widespread awareness of the opioid-overdose crisis, the epidemic continues to worsen. In 2016, there were 42,249 opioid-overdose deaths in the United States, a 28% increase from the previous year. According to the National Center for Health Statistics, life expectancy in the United States dropped in 2016 for the second consecutive year, partly because of an increase in deaths from unintentional injuries, including overdoses. It was the first 2-year decline since the 1960s. How can we be making so little progress?

Annual Change in Buprenorphine and Methadone Volume Dispensed in the United States, 2006–2016.

In part, the overdose crisis is an epidemic of poor access to care. One of the tragic ironies is that with well-established medical treatment, opioid use disorder can have an excellent prognosis. Decades of research have demonstrated the efficacy of medications such as methadone and buprenorphine in improving remission rates and reducing both medical complications and the likelihood of overdose death.1 Unfortunately, treatment capacity is lacking: nearly 80% of Americans with opioid use disorder don’t receive treatment.2 Although access to office-based addiction treatment has increased since federal approval of buprenorphine, data from the Drug Enforcement Administration (DEA) reveal that annual growth in buprenorphine distribution has been slowing, rather than accelerating to meet demand (see graph). To have any hope of stemming the overdose tide, we have to make it easier to obtain buprenorphine than to get heroin and fentanyl.

We believe there’s a realistic, scalable solution for reaching the millions of Americans with opioid use disorder: mobilizing the primary care physician (PCP) workforce to offer office-based addiction treatment with buprenorphine, as other countries have done. As of 2017, according to the Kaiser Family Foundation, there were more than 320,000 PCPs, plus a broad workforce of nurse practitioners and physician assistants, treating U.S. adults. In contrast, there are just over 3000 diplomates of the American Board of Addiction Medicine, and only 16% of 52,000 active psychiatrists had a waiver to prescribe buprenorphine in 2015 (moreover, 60% of U.S. counties have no psychiatrists).3 Training enough addiction medicine or psychiatric specialists would take years, and most methadone treatment programs are already operating at 80% of capacity or greater.4

However, PCPs and other generalists, including pediatricians, obstetrician–gynecologists, and physicians who treat human immunodeficiency virus (HIV) infection, are well situated to provide buprenorphine treatment. Many have risen to this challenge: PCPs are responsible for most ambulatory care visits for buprenorphine treatment. The importance of mobilizing the PCP workforce while ensuring the availability of sufficient specialists is not unique to the opioid-overdose crisis. During the height of the HIV/AIDS epidemic, for example, access to antiretroviral therapy was urgently needed. Although initially specialists were more likely to prescribe antiretrovirals, by 1990 equal percentages of patients were receiving antiretroviral therapy from PCPs and from specialists.

Myths and Realities of Opioid Use Disorder Treatment.

How can we promote adoption of buprenorphine treatment by PCPs? The relevant federal and state regulatory barriers could be addressed, but they reflect a deeper problem: stigma and myths about buprenorphine treatment inhibit its acceptance (see table).

The first myth is that buprenorphine is more dangerous than other interventions physicians master during training. In fact, PCPs regularly prescribe more complicated and risky treatments. Titrating insulin, starting anticoagulants, and prescribing full-agonist opioids for pain are often more challenging and potentially harmful than prescribing buprenorphine. Yet this perception has been cemented by federal policy. The Drug Addiction Treatment Act of 2000 requires that physicians complete 8 hours of training (sacrificing a full day of work) and apply for a DEA waiver to begin prescribing buprenorphine. After passing these hurdles, physicians are authorized to treat only a limited number of patients. These requirements make buprenorphine treatment intimidating.

The first step toward debunking this myth would be to scale back these federal regulations. Training in appropriate buprenorphine treatment optimizes outcomes and minimizes risks, but such training could be incorporated into existing medical education. All physicians could be trained during medical school and residency, so that both PCPs and other specialists would be equipped to offer this treatment — and, more generally, would be comfortable in caring for patients with opioid use disorder.

The second myth is that buprenorphine is simply a “replacement” and that patients become “addicted” to it — a belief still held by some physicians. But addiction is defined not by physiological dependence but by compulsive use of a drug despite harm. If relying on a daily medication to maintain health were addiction, then most patients with chronic health conditions such as diabetes or asthma would be considered addicted.

A closely related myth is that abstinence-based treatment, usually implying short-term detoxification and rehabilitation, is more effective than medication for addiction treatment. This belief underpins widespread advocacy for more substance use treatment “beds” as a key solution for the overdose crisis. But whereas there’s a strong evidence base for buprenorphine and methadone treatment, no study has shown that detoxification or 30-day rehabilitation programs are effective at treating opioid use disorder.5 In fact, these interventions may increase the likelihood of overdose death by eliminating the tolerance that a patient had built up. To address myths about the effectiveness of buprenorphine and abstinence treatment, we can start with advocacy and education about the evidence to counter misleading depictions of addiction treatment in the media.

Another myth is that providing buprenorphine treatment is particularly onerous and time consuming. In our experience, it is no more burdensome than treating other chronic illnesses. A typical visit includes assessing medication adherence, examining disease control (e.g., cravings and use), titrating doses, and ordering laboratory tests. Moreover, buprenorphine treatment provides one of the rare opportunities in primary care to see dramatic clinical improvement: it’s hard to imagine a more satisfying clinical experience than helping a patient escape the cycle of active addiction. The fact that, for in-office inductions, patients must wait until withdrawal begins to take an initial buprenorphine dose under observation undoubtedly contributes to fears about the demand on physicians’ time. But this process has not been shown to be more effective than having patients start the medication outside the office. In fact, buprenorphine management provided by a PCP is effective with or without additional psychosocial interventions. This myth could be countered by developing and disseminating protocols emphasizing home induction and primary care models for treatment, including approaches consistent with efforts to transform practices into patient-centered medical homes.

Finally, some observers believe that physicians should simply stop prescribing so many opioids. The crisis began with increased opioid prescribing, yet as prescribing rates have fallen since 2011, overdose deaths have accelerated. If prescribing patterns were the sole driver of overdoses, then decreased prescribing should have had a measurable effect on opioid-related mortality over the past several years. In reality, research has demonstrated that interventions like the introduction of abuse-deterrent Oxycontin, which reduce access to frequently misused prescription opioids, have resulted in people shifting their opioid of choice predominantly to heroin. Rising overdose mortality despite decreasing opioid prescribing suggests that merely reducing the prescription-opioid supply will have little positive short-term impact. Reducing prescribing could even increase the death toll as people with opioid use disorder or untreated pain shift into the unstable, illicit drug market. Instead, we need safer, more thoughtful opioid prescribing and accessible support, such as electronic consultations with addiction specialists, to help physicians offer buprenorphine for people with opioid use disorder.

We are in the midst of a historic public health crisis that demands action from every physician. Without dramatic intervention, life expectancy in the United States will continue to decline. Mobilizing the PCP workforce to offer office-based buprenorphine treatment is a plausible, practical, and scalable intervention that could be implemented immediately. The opioid-overdose epidemic is complex and will require concerted efforts on multiple fronts, but few other evidence-based actions would have such an immediate lifesaving effect. It won’t be easy, but we are confident that U.S. PCPs have the clinical skill and grit to take on this challenge.


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20/Jan/2019

First bill often indicates state lawmakers’ top priority

Denver Post, January 4, 2019 – State Senate President Leroy Garcia wants to rapidly expand a program that provides medical treatment to southern Coloradans battling opioid addiction, according to a draft of a bill obtained by The Denver Post.

Senate Bill 1, which usually reflects the most pressing issue for the party in power, would send $5 million to a program run by the University of Colorado that is operated in Pueblo and Routt counties. Along with the infusion of cash, the program would expand to cover the entire San Luis Valley.

In his opening-day speech, Garcia said fighting the opioid crisis in this state would be just one example of how Democrats and Republicans can work together.

“Colorado is a special place — it is a state filled with people who innovate and find solutions, and I am absolutely confident that this body will be able to find many of those solutions,” he said.

Garcia is one of numerous state lawmakers who have expressed interest in tackling the opioid epidemic. He was the sponsor of a 2017 bill that originally created the treatment program Senate Bill 1 intends to extend.

However, the issue was not among the major issues Democrats across the state ran on during the 2018 elections.

While last year’s first Senate bill went on to become a major bipartisan compromise on transportation funding, other bills with a similar distinction have been smaller in scope. In 2016, Republicans used the first bill to expand a state income tax deduction for military retirement benefits and in 2017 to ease regulations on small businesses.

Both bills were killed in the Democratic-controlled House.


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20/Jan/2019

In Maine, as in most other states in the U.S., patients on medication-assisted treatment for opioid use disorder weren’t allowed to take their life-saving medications while incarcerated.

All that changed in October of this year, when the American Civil Liberties Union settled a lawsuit with the Maine Department of Corrections. The ACLU sued on behalf of Zach Smith, who has been on Suboxone for five years as treatment for opioid use disorder. He was told he would have to stop taking Suboxone during his incarceration. I wrote of the pending case in my blog on August 12, 2018.

We know that if denied his medication, he would go through physical opioid withdrawal and would be at higher risk for overdose death, particularly immediately after release from incarceration.

The ACLU took his case and settled a lawsuit with the Maine Department of Corrections, which ultimately agreed to allow him to continue on his medication. Jailers warn that this was a “special case” and that they would not necessarily allow other prisoners to take buprenorphine as prescribed by a physician. However, this appears to be a clear precedent for other patients and other lawsuits.

I think this is a landmark case for our patients. MAT is the standard of care, and it should be illegal to refuse to provide this treatment to people who are sentenced to incarceration. The diversion of Suboxone films has been an issue for many years beause patients in opioid withdrawal can’t access suboxone through any legal channel. This creates a black market for suboxone, and jailers across the country have complained loudly about this situation – that is of their own creation.

The ACLU is supporting patients in their fight to continue medication-assisted treatments during incarceration is other states, too. According to the ACLU website, a similar case is pending in Washington state.

If you are a patient – or know a patient – who is being denied medication-assisted treatment during incarceration, I hope you have a lawyer who is willing for fight for your rights. If you do not, consider reaching out to the ACLU in your state:


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20/Jan/2019

Please join us November 29th for this free event.

5:30-7:30pm
CMC’s Albright Auditorium

Topics include:

  • Encourage sober behavior with positive communication and natural consequences for substance abuse.
  • Build self-esteem with healthy social supports, self-care, and skills to live successfully.
  • Inspire treatment with “motivational hooks” used during windows of opportunity.

Appetizers will be served. Please RSVP by November 24th.  (2 CME)

RSVP NOW

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20/Jan/2019

About International Overdoes Awareness Day – August 31, 2018

International Overdose Awareness Day aims to raise awareness of overdose and reduce the stigma of a drug-related death.

It is also an opportunity to stimulate discussion about evidence-based overdose prevention and drug policy.

International Overdose Awareness Day acknowledges the grief felt by families and friends remembering those who have died or suffered permanent injury due to drug overdose.

International Overdose Awareness Day spreads the message about the tragedy of drug overdose death and that drug overdose is preventable.

The goals of International Overdose Awareness Day are:

  • To provide an opportunity for people to publicly mourn loved ones in a safe environment, some for the first time without feeling guilt or shame.
  • To include the greatest number of people in International Overdose Awareness Day events, and encourage non-denominational involvement.
  • To give community members information about the issue of fatal and non-fatal overdose.
  • To send a strong message to current and former people who use drugs that they are valued.
  • To stimulate discussion about overdose prevention and drug policy.
  • To provide basic information on the range of support services that are available.
  • To prevent and reduce drug-related harm by supporting evidence-based policy and practice.
  • To inform people around the world about the risk of overdose.

Updates

  • County Commissioners provided approval to post easels with poster board on them on the courthouse lawn for community members to place their handprint
  • Old Town Pub chose to take a back seat on their participation due to concerns of sending the wrong message by using a liquor establishment as our base
  • Bank of the West agreed to allow us to put up flags in the lawn showing the number of lives affected nationally
  • Confirming with Kali’s Boutique to make sure we can use the full lawn space (don’t anticipate it to be an issue)
  • Secured interest from the paper as well as Steamboat Radio to cover the event pre and post; as soon as we have a confirmed location I’ll start working on the press materials
  • In communication with the schools to secure interest and the possibility of allowing students to place a handprint on poster board signifying how they’ve been impacted by overdose
  • More to come on that as we hear back
  • Steamboat Police and Fire Departments have also said they would help support during the day and we are working with them to determine exactly what that looks like
  • CMC has declined to light up the campus this year due to not enough turnaround time and ability to navigate what is needed to accomplish this

Volunteer Needs

  • Signup.com – Susan Petersen is setting this up as soon as we have a confirmed location and times for the event
  • Volunteer needs will include placing flags, securing supplies, set up, breakdown and staffing throughout the day (Courthouse lawn – hopefully, and within the schools, if needed)
  • Promotion and social media posts
  • Lindsey is creating the poster to announce events during the day
  • Once the posters are complete we will need help posting them around town
  • We are working on social media posts and ask that anyone and everyone share on their person/business feeds to help get the word out
  • Please follow Grand Futures on Facebook to make sure you are seeing these posts and can re-post as appropriate
  • Lindsey is drafting all media materials to share with the radio and paper
  • Educational materials
  • Maddison and Mara have been working together to create handouts to inform people about overdose and specific drugs (e.g., opioids, Naloxone, etc.)

Questions? Contact Lindsey Simbeye

Grand Futures Prevention Coalition | Executive Director

Phone: 970-819-7805 | Email: lindsey@grandfutures.org


20/Jan/2019

Denver – August 2018 – Road to Recovery ‐ Lakewood was accepted into the Colorado State Innovation Model (SIM), a federally funded, governor’s office initiative that helps primary care providers deliver whole‐person care. It is one of 21 practices in Jefferson County to be accepted into the federally funded, governor’s office initiative, which runs through July 2019.

“SIM providers in these cohorts must focus on the entire patient, which means addressing mind, body and mental wellness,” said Donna Lynne, Lieutenant Governor and Chief Operating Officer, who has many years of leadership experience in the health care sector. “That complete approach to health is what makes the SIM initiative is so valuable. Patients get the care they need when they need it, and providers learn how to succeed with new payment models. It’s a great example of meaningful reform in our state.”

Patients interviewed by SIM staff notice and appreciate the work done by practices. “It’s powerful for me, as a patient, to land somewhere I feel well taken care of,” said Mary Catherine Conger, a patient at Roaring Fork Family Practice, during a SIM podcast (https://bit.ly/2nzuieO).

Whole‐person care Colorado was the only state (out of 11 selected for a SIM model test award) to focus on integrated behavioral and physical health care supported by public and private payers as its primary goal. The initiative helps providers progress along an integrated care path continuum that might start with referrals and could lead to co‐location of behavioral and physical health professionals in primary care settings. Integrated care improves patient outcomes, reduces health care costs and enhances provider morale. About 1,847 SIM providers in cohorts 1‐2 deliver care during 3,342,018 annual patient visits.

The efforts also benefit providers. “It’s energizing to give the kind of care you envision instead of being frustrated every day,” said Gary Knaus, MD, Roaring Fork Family Practice, a SIM cohort‐1 practice. “Somewhere in your gut you feel like, ‘God, I could do better.’”

SIM launched with 100 practice sites in 2016, added 155 practices in 2017 and will help about 25% of the state’s primary care sites and four community mental health centers deliver whole‐person care.

Colorado will receive $65 million from the Centers for Medicare & Medicaid Services (CMS) to implement this model for health care innovation, which is expected to save or avoid $126.6 million in health care costs for CMS with a 1.95 return on investment during its four‐year time frame.

Learn more:

  • SIM website: www.colorado.gov/healthinnovation
  • Proof that integrated care improves health: www.colorado.gov/healthinnovation/sim‐data‐hub

Download this article.


Copyright Road to Recovery 2018. All rights reserved.