Medications to Treat Addiction - Masspartnership · 2017. 11. 4. · 1. Addiction is a complex but...

InstituteforBehavioralHealthSCHNEIDERINSTITUTESFORHEALTHPOLICY

Institute for Behavioral HealthSCHNEIDER INSTITUTES FOR HEALTH POLICY

MedicationstoTreatAddiction

SharonReif,Ph.D.

Improving Quality and Integration of Substance Use Disorder Treatment in the Era of Accountable CareMBHP/MassHealth Provider Conference -- November 7, 2017


• Colleagues– ConnieHorgan;DeborahGarnick,AndreaAcevedo,CathyFullerton;CindyParksThomas;MaureenStewart,TimCreedon,Ann-MarieMatteucci,DominicHodgkin

• Brandeis-HarvardNIDACentertoImproveSystemPerformanceofSubstanceUseDisorderTreatment

• Noconflictsofinterest

Acknowledgments


• Settingthestage• Pharmacotherapy• Barriers• Effectiveness• Opportunitiesforimprovement

Today’spresentation


SETTINGTHESTAGE

(twitter 10/30/2017)


Identify

Treat

AbstinenceRecovery


Cascadeofcare

POPULATION

DIAGNOSEDwithSUD

LINKTOCARE

INITIATEMAT(orEBP)

RETENTION

ContinuousAbstinenceRecovery

38% initiation rate for all SUD, Medicaid2

11% engagement rate, Medicaid2

18% with SUD access any treatment1

7.5% have SUD1

1 NSDUH 2016; 2 MBHP IET website, national averages


1. Addictionisacomplexbuttreatablediseasethataffectsbrainfunctionandbehavior

2. Nosingletreatmentisappropriateforeveryone3. Treatmentneedstobereadilyavailable4. Effectivetreatmentattendstomultipleneeds,notjustSUD5. Remainingintreatmentforadequatetimeiscritical6. Behavioraltherapiesaremostcommonlyused7. Medicationsareanimportantelement,especially

combinedwithbehavioraltherapies

Principlesofeffectivetreatment

NIDA Principles of Drug Abuse Treatment, 3rd edition, 2012


PHARMACOTHERAPY(MEDICATION-ASSISTEDTREATMENT)


• Medicationsto:– stoporreducesubstanceuse– reducecraving

• FDA-approvedmedicationsavailableforalcohol,opioids– naloxone≠ treatment

• Psychosocialtreatmentrecommendedinconjunction– yetfindingsaremixed,especiallyforopioidusedisorders

• Responsemightvaryacrosspatientsub-groups

• EndorsedbyNQF,NIDA,ASAM,meta-analyses,manyresearchstudies• Treatmentguidelinesexist(seeresourcesatend)

Pharmacotherapy/MAT

NIDA Principles of Effective Treatment: Medications are an important element, especially combined with behavioral therapies

1st Consensus Standard for SUD Treatment: Pharmacotherapy (for withdrawal and for dependence)

ASAMPublicPolicyStatement,OUDNationalPracticeGuidelines:PharmacologicaltherapycanbeapartofeffectiveprofessionaltreatmentforOUD…bestaccompaniedbyandprovidedinconjunctionwithevidence-basedpsychosocialtreatmentsandrecoverysupportinterventions

Medications Development: Treatment for alcohol use disorder includes behavioral treatments…as well as pharmaceutical treatments


• Pharmacotherapyforaddictionhasevolvedsignificantly– typesofmedications,modesofadministration

• Improvedacceptabilityandaccess– specialtysettingsthattraditionallyusedanabstinence-basedapproachareincreasinglyusingmedicationstotreataddictions

– buprenorphineandothermedicationsavailablewithinoffice-basedsettings– lessrelianceonopioidtreatmentprograms(OTPs)– medicationsbeyondmethadoneavailableinOTPs– roleforprimarycare,psychiatry,communityhealthcenters,etc.

Changingenvironment

Reif et al., 2017, JSAT


UNDER-UTILIZED


• Smallproportionareprescribedaddictionmeds• e.g.<2.5%ofalcohol-dependentpatientsintheVAreceivedaprescriptionfororalnaltrexoneorothermedicationforalcoholdependence

• <33%ofclinicallyappropriatepatientsreceivedprescriptionsinspecialtytreatmentprogramsthatprescribeanyaddictionmeds

• Prescribingforaddictionismuchlesscommonthanformentaldisorders• e.g.70%ofthosewithpsychiatricdiagnosesreceivedpsychiatricprescriptionsinthesamespecialtyprograms

Fewwhowouldbenefitreceiveprescriptions

as cited in Reif et al. 2017, JSAT


• <50%ofspecialtytreatmentprogramsprescribedanyaddictionmeds1– Buprenorphineprescribedin58%OTPsand21%non-OTPs2

– Injectablenaltrexoneprescribedin23%OTPsand16%non-OTPs2

• Mostbuprenorphineprescriberspracticewellundertheircurrentpatientlimitandhavenumerousmonthswithnopatientepisodes3– Buprenorphineprescriberstreated13patientspermonth,onaverage,withamedianofonly4patientspermonth

– Evenprescriberswiththe100+patientwaivertreatedonlyabout33patientspermonth,onaverage,medianof23

Limitedprescribingbythosewhocoulddoso

1 as cited in Reif et al. 2017, JSAT; 2 SAMHSA CBHSQ Report 2017; 3 Thomas et al. 2017, DAD – 3 state study


BARRIERS…


• Complexclients• Training• Implementation• Fidelity• Clinicalinertia• Lackofmedicalstaff• Researchtopracticedelay• Practicetoresearchgap• Reimbursement

Barrierstoadoptinganynewpractice


• Ambivalenceaboutgettingtreatment• Knowledge

– effectiveness,wheretogethelp• Stigma

– patient,family,providers– OTPdailyclinicattendanceandrequirementsreinforce“personwithSUD”

• Cost– prescriberswhodon’tacceptMedicaidorotherinsurance

• Availability– waiveredprescribers,prescribersacceptingnewpatients,geographicaccess

Patientbarriers

Reif et al. 2017, J Psychoactive Drugs; Reif et al. 2017, JSAT


• Knowledgeandtraining,confidence– effectiveness,appropriateness,induction,psychosocialsupports

• Structural– buprenorphinewaiverandprescribinglimits,lackofmedicalstaff,injectionorimplantrequirements

andcapability,storageofmedications,drugscreens,prescribingandpsychosocialsupportpartners• Practiceconstraints

– time,multipleprioritiesduringofficevisit,reimbursementissues– anti-medicationbias(philosophical/cultural)– worrythatwillbecomeinundatedwithmedicationrequests

• Diversionconcerns• Stigma

– amongproviders,mayalsolimitknowledge,screening,referraltotreatment• Notinterested

– addictionoverall,treatingaddictionpatients,increasingaddictionpatientload

Prescriberbarriers

Reif et al. 2017, J Psychoactive Drugs; Reif et al. 2017, JSAT


EFFECTIVENESS

InstituteforBehavioralHealthSCHNEIDERINSTITUTESFORHEALTHPOLICY http://addictionblog.org/infographics/medications-for-opiate-and-opioid-addiction/


• Disulfiram[Antabuse]• Naltrexone– oral1 [Revia]

– greatlyreducedriskofheavydrinkingcomparedtoplacebo– slightdecreaseindrinkingdays,heavydrinkingdays,amountofalcoholconsumed– reducescraving,betterthanacamprosate– effectonabstinencebestifabstinentbeforestartingnaltrexone

• Naltrexone– extendedreleaseinjectable2 [Vivitrol]– comparabletooralnaltrexonebutnotbetter– improvedadherence(long-actinginjection)

• Acamprosate3 [Campral]– greatlyreducedriskofanydrinkingcomparedtoplacebo– effectonabstinenceisbestifdetoxedbeforestartingacamprosate– noeffectonheavydrinking

AlcoholUseDisorders

1 Rosner et al. 2010a; Maisel et al. 2012; 2 Maisel et al. 2012; Gastfriend 2011; 3 Rosner et al. 2010b


• Methadone1– reducesillicitopioiduse– improvestreatmentretention– somepositiveeffectsonmortality,otherdruguse,HIVriskbehaviors,criminalactivity– responserelatedtodosage(60mgatminimum)

• Buprenorphinewithnaloxone2 [Suboxone]– effectscomparabletomethadone,withfewersideeffects

• Naltrexone– extendedreleaseinjectable3 [Vivitrol]– comparedtoplacebo,higherratesofabstinence,opioidfree-days,treatmentretention,

andlesscraving– aseffectiveasbuprenorphineforshort-termabstinence(long-termdatanotavailable)

OpioidUseDisorders

1 Fullerton et al. 2014; 2 Thomas et al. 2014; 3 Krupitsky et al. 2011; Gastfriend 2011; Tanum et al. 2017


• Somehaveimpliedthatmethadoneisnolongernecessary,butitisclearlystillthebesttreatmentforsome,especiallythosewithmoresevereOUDsorwhoareunsuccessfulinoffice-basedsettings

Reif et al. 2017, J Psychoactive Drugs; ASAM 2015; Knopf 2016; Mattick et al. 2014


READMISSIONSEXAMPLE


• PeoplewithSUDshave– greatercomplexityofcare– morehospital-relatedcomplications– longerlengthsofstay– highercosts– highratesofreadmissions

• Promptreceiptoffollow-upSUDservicescouldreducereadmission– Outpatientservicesincommunitymentalhealthcenters(CMHC)reducereadmissionforMH/SUDpatients

– Follow-upservicespost-detoxreducedetoxreadmission

Background

Reif et al. 2017, Psychiatric Services


• Dotargetedfollow-upservicesreceivedshortlyafterdischargefrominpatienthospitalorresidentialdetoxificationreducelikelihoodofpost-dischargebehavioralhealthadmissionsamongMedicaidbeneficiarieswithanSUDdiagnosis

• Follow-upbehavioralhealthservicesinclude– Medication-assistedtreatment(MAT)

• definedasaprescriptionfillofbuprenorphine,disulfiram,acamprosate,ornaltrexoneoraHCPCSservicecodeformethadone,buprenorphine,ornaltrexone

– Outpatient(OP)– Intensiveoutpatientorpartialhospitalization(IOP)– Residential(RES)

Researchquestion



Sample:• Medicaidenrollees(FFSonly),withanindexinpatientadmissionwithSUDdiagnosis(whetherornot

primary)• adults18-64• excludesdualMedicare/Medicaid• 2008claimsin10states– allofferedOPandMAT,5offeredIOP,3offeredRES

Outcome• timetoaBHadmissioninthe90daysfollowingdischargefromindexadmission

– inpatientadmissionwithanSUD/MHprimarydiagnosisOR– residentialdetoxificationadmission

Follow-upServices:MAT,OP,IOP,RES• receiptofeachserviceduring14-dayspost-discharge• #daystothefirstofanyofthefollow-upservicesreceivedwithin14-dayspost-discharge

Covariates:sociodemographics,SUDtype,comorbiddiagnoses,priorBHtreatment,indexLOS

Methods



Example

InpatientDischarge

(Day 0)

14 days post-

discharge window

90 days post-discharge

MAT initiated Readmitted



0

20

40

60

80

100

CT IL IN MN MO NC NY VT WV WI

%ofA

dmission

s

RES IOP OP NoRES,IOPorOPservice

KeyIndependentVariable:Follow-UpBHServicesin14DaysPost-Discharge



0

20

40

60

80

100


%ofA

dmission

s

MAT

KeyIndependentVariable:Follow-UpMATin14DaysPost-Discharge



0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

%ofA

dmission

s

DaysPost-Discharge


KeyIndependentVariable:DaystoFirstBHFollow-UpService(OP,IOP,RES,MAT)



Results:LikelihoodofBHinpatientadmission90dpost-dcg

• MATassociatedwith~40%reducedlikelihoodofBHinpatientadmission90dayspost-discharge– whencontrollingforotherfollow-upservicesreceived(OP,IOP,RES)– RESalsoassociatedwith~50%reducedlikelihood,butonlytestedin3states

– Controllingforstate,reasonforMedicaideligibilityandothercovariates

• Resultsconsistentwithotherstudies


OPPORTUNITIESFORIMPROVEMENT


• Traininginaddictionmedicinebroadlyandpharmacotherapy– confidenceassessingandacknowledgingaddiction,providingcaretopatientswithSUD– Increasedwillingnesstoprescribeanddevelopsupportsystemsforwhentheydoso– roleforprofessionalorganizations,healthplans,federalandstateagencies

• Disseminateguidelinesforuseofaddictionpharmacotherapy• Increasenumberofprescribers

– primarycareproviders,psychiatrists,addictionmedicine,others– nurses,physicianassistants– specialtytreatmentprogramswithtraditionalabstinence-basedapproach– roleforhealthplans,

SAMHSA,otherstoencourageandsupporttransition• Assistinidentifyingpsychosocialservicesandrecoverysupports

– Developcommunitypartnersandinformationnetworks• Workwithexperts/championstosupportless-experiencedprescribers

Increasingprescribers

Reif et al. 2017, JSAT


• Performancemeasures,incentivestructures,recognitionprograms– emphasizepharmacotherapyasanevidence-basedpracticeandrewardquality

• Pharmaceuticalcompanyrole,similartootherareasofmedicine– educatingortrainingproviders,offeringassistancewithmedicationrequirements,

subsidizingcopaysformedications• Partnershipswithprimarycaresettings

– accesstomedicalcareforaddictiontreatmentprogramswithoutin-housemedicalresources

– “hubandspoke”asonemodel• Otherconditionsmightoffermodelsforchange

– depressionandHIV,asmedicalconditionswhosetreatmentwasoncehighlystigmatizedandrelegatedonlytospecialtyproviders

Encouraginguseofpharmacotherapy

as cited in Reif et al. 2017, JSAT


SUMMARY


• Medicationstotreataddictionareeffectiveandcost-effective• Utilizationbypatients,prescribers,andaddictiontreatmentprogramsisincreasing,butthereisstillalongwaytogo

• Barriersarewide-ranging• Manyopportunitiestosurmountbarriersandincreasemedicationuse• BeachampionformedicationasEBP• Recoveryremainsthegoal


QUESTIONS?Thankyou!

Sharon Reif, PhD, [email protected] for Behavioral HealthHeller School for Social Policy and Management, Brandeis University


• ASAMNationalPracticeGuidelinefortheUseofMedicationsintheTreatmentofAddictionInvolvingOpioidUse

• https://asam.org/resources/guidelines-and-consensus-documents/npg

• SAMHSATIP43- Medication-AssistedTreatmentForOpioidAddictioninOpioidTreatmentPrograms• https://store.samhsa.gov/shin/content//SMA12-4214/SMA12-4214.pdf

• SAMHSATIP49- IncorporatingAlcoholPharmacotherapiesIntoMedicalPractice• https://store.samhsa.gov/shin/content//SMA13-4380/SMA13-4380.pdf

• SAMHSA– PocketGuide:Medication-AssistedTreatmentofOpioidUseDisorder• https://store.samhsa.gov/shin/content/SMA16-4892PG/SMA16-4892PG.pdf

• NIAAAHelpingPatientsWhoDrinkTooMuch:AClinician'sGuide• https://www.niaaa.nih.gov/guide

• SAMHSA– MedicationfortheTreatmentofAlcoholUseDisorder:ABriefGuide• https://store.samhsa.gov/shin/content//SMA15-4907/SMA15-4907.pdf

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