Challenges and Opportunities (July 2012)

Progress Report on AATOD Activities
I am providing a progress report on AATOD’s activities over the course of the past year since the “Challenges/Solutions” policy paper was published during June 2011.

AATOD Conference
AATOD had a successful National Conference which convened in Las Vegas, Nevada during April 2012. Approximately 1,400 people participated in this conference, making it one of the best attended conferences in recent history. The content was rich, including a number of pre-conference sessions focusing on patient advocacy training, tobacco cessation, integrating Hepatitis therapy in OTPs, increasing access to Medication Assisted Treatment in Drug Courts, the Opioid Maintenance Pharmacotherapy Course for Clinicians, and training for using buprenorphine in OTPs.

The theme of the conference, “Recovery for Patients, Families, and Communities”, was reiterated during a plenary session as well as a number of the workshop topics. As many people in the field know, producing this conference is our Association’s method of providing the most current clinical and policy information to our associates in the United States and abroad.

Health Care Reform
The AATOD Board of Directors is of the judgment that Health Care Reform is one of the most critical issues affecting our patients and the future of our treatment system. AATOD has been working with the Legal Action Center and the Coalition for Whole Health in developing policies in support of how Medication Assisted Treatment for Opioid Addiction will be made available to Americans who would benefit from such treatment. Many of us in the field of addiction treatment were surprised when the federal government decided to allow the states to determine what Essential Health Benefits would be covered under Health Care Reform. Now that the Supreme Court has upheld the Affordable Care Act AATOD will continue its partnership with the Coalition in working with state provider organizations as a method of advocating for our patients. We also realize that this is an especially daunting task given the weak economy and shrinking state budgets.

In spite of these issues, we will continue to advocate through every possible avenue on behalf of our patients and improving this treatment system as we increase access to Medication Assisted Treatment for Opioid Addiction.

Criminal Justice
AATOD has continued its work in the Criminal Justice System, which was initially articulated in the aforementioned “Challenges/Solutions” policy paper. The Substance Abuse and Mental Health Services Administration convened an important meeting during October 2011, “Medication Assisted Treatment for the Criminal Justice Population.” SAMHSA coordinated the work of many of its federal agency counterparts in this area in addition to working with AATOD and other associations, especially TASC and representatives from the Criminal Justice System. AATOD has also worked with NDRI in New York City and Brown University in developing two attitudinal studies about the use of Medication Assisted Treatment for Opioid Addiction. The first was conducted with the cooperation of the National Association of Drug Court Professionals and presented during the SAMHSA meeting, as referenced above. This information was also available during the AATOD conference in Las Vegas. Ultimately, the most positive news emerging from this attitudinal study was that Drug Courts would be willing to consider referring Drug Court participants to Medication Assisted Treatment for Opioid Addiction if they were able to learn more about its effectiveness. A similar study was performed in cooperation with the American Probation and Parole Association, gauging how their members viewed the use of such medication in their population. Once again, similar findings were reported.

The Legal Action Center also wrote an influential policy paper, “The Legality of Denying Access to Medication Assisted Treatment in the Criminal Justice System” during December 2011. People can access this paper through the Legal Action Center website. This paper reviewed a number of the Constitutional issues in support of providing access to Medication Assisted Treatment in different parts of the Criminal Justice setting. The Legal Action Center wrote this paper through the support provided by AATOD and a grant from Reckitt-Benckiser.

Finally, a pre-conference session convened during the AATOD conference in cooperation with the National Association of Drug Court Professionals to better understand the challenges of providing access to medications to treat chronic opioid addiction through the Drug Court setting. It underscored the relationship between AATOD and NADCP in educating Drug Court representatives about approved medications and responding to what we learned through the NDRI/Brown University attitudinal survey.

Prescription Opioid Use/Addiction
AATOD continues its work with 75 Opioid Treatment Programs in more than 30 states under the aegis of the Denver Health and Hospital Authority to determine the prevalence of prescription opioid abuse and addiction as patients are admitted to treatment. At the time of this update, more than 56,000 patients have completed this survey since January of 2005. We continue to see the patient population admitted at younger ages (over 40% in their 20s), being predominantly white (over 70%) and employed (over 40%), and gaining access to these prescription opioids through dealers (over 75%).

We will continue this study in conjunction with NDRI in New York through the Denver Health and Hospital Authority into the foreseeable future. We have learned a great deal about the changing characteristics of our patient population, and the fact that more than 30% of patients who report addiction to prescription opioids as they enter treatment are using these medications intravenously.

AATOD also published its guidelines to the field encouraging OTPs to access Prescription Monitoring Program databases in improving the safety of patient care. We have learned a good deal about prescription opioid abuse in our patient population, based on the results of the aforementioned survey. The AATOD Board agreed that OTPs should be accessing PMP databases and we have supported the SAMHSA position on this topic, which was published on September 27, 2011. We have heard from a number of OTPs in the US who are accessing PMP databases and it is improving the integrity of treatment services to our patients.

Work with Federal Agencies
OTPs and Buprenorphine: We have continued to work with SAMHSA and anticipate that its Federal Register Notice will be published shortly with regard to the expanded use of buprenorphine in OTPs. This has been a long term process over the course of the last several years, and we anticipate that OTPs will have greater clinical flexibility in using this medication in the OTP setting. At the present time, we know through SAMHSA that there are approximately 1,250 certified OTPs in the country, treating approximately 308,000 patients on any given day. The vast majority of these patients receive methadone through the OTP and approximately 8,000 patients gain access to buprenorphine. We believe that these numbers will increase as the Federal Register Notice is finalized.

Buprenorphine Mentorship Program: AATOD is also in the process of working with the American Association of Addiction Psychiatry since it has funding through SAMHSA for a buprenorphine mentorship program. We also know through a recently completed SAMSHA survey that 75% of medial professionals in the OTP have taken the DATA 2000 course in treating patients with buprenorphine. AATOD has recently released recommendations to OTPs in AATOD Board member states, which have been shared with NASADAD and the State Opioid Treatment Authorities, encouraging all medical practitioners in the OTPs to take the DATA 2000 eight hour training course so that buprenorphine will be safe to use in the OTP setting.

From AATOD’s point of view, the expanded use of buprenorphine in OTPs makes sense given the fact that the OTPs provide an array of comprehensive services under the watchful regulatory oversight of SAMHSA through approved accrediting entities and the State Opioid Treatment Authorities. AATOD’s Medications Committee is also in the process of developing guidelines for the use of Vivitrol/naltrexone in OTPs as a relapse prevention medication for our patients as they end their maintenance treatment. We expect to release these guidelines before the end of 2012.

DEA NTP Best Practice Guidelines: AATOD has also been encouraging the Drug Enforcement Administration to publish an updated set of guidelines based on the success of the DEA publication of April 2000, “Narcotic Treatment Programs Best Practice Guidelines”. The previous DEA publication helped to stabilize policymaking through OTPs to be in greater compliance with DEA requirements. It also provided a template for how OTPs would meet the DEA’s operating requirements in addition to providing similar information to DEA field agents throughout the United States. It is hoped that the DEA will publish an updated set of guidelines which will provide additional stability in policymaking among DEA field agents, other federal and state agencies, and providers throughout the US.

Challenges in the States
AATOD has continued to work with our provider associates in a number of states as greater challenges come to surface through state legislators. We have supported our associates in Maine and in opposition to limits on duration of treatment as well as substandard weekly Medicaid reimbursement rates for patients in treatment. We are of the judgment that the Maine legislative recommendations will create disastrous results and compromise the integrity of patient care as well as potentially force patients to leave treatment in their home state to access care in adjacent states.

We are working with our Tennessee provider associates to oppose some of the draconian regulatory measures as proposed by the State of Tennessee which would compromise the efficacy of treatment by forcing patients out of treatment. We also believe that the state agency in Tennessee has taken an incorrect stance in indicating that Methadone Maintenance Treatment is not a recovery based model and the concept of maintenance treatment is not generally supported in the addiction treatment community. We believe that such a position is an enormous disservice to patients who struggle to improve their lives through maintenance treatment and we are working to educate state officials about the evidence in support of ongoing care.

International Work
We have continued to work with EUROPAD, AATOD’s partner in forming the World Federation for the Treatment of Opioid Dependence (WFTOD). We convened a full day of international presentations during the recent AATOD conference which featured updates from our associates in Europe, China, Macao, Vietnam, Cambodia, and nations in Africa, reporting on their progress in expanding access to Medication Assisted Treatment throughout the world.

We joined our associates in WFTOD in co-sponsoring a meeting with the government of the Ukraine and the United Nations Office on Drugs and Crime during May 2012. It is clear that the government of the Ukraine is serious about expanding access to Medication Assisted Treatment as a method of providing care to untreated opioid addicted individuals who have high HIV and Hepatitis C infections rates. We are grateful for the support of the United Nations Office on Drugs and Crime, which was evident as Dr. Gilberto Gerra made an opening presentation during our conference in Las Vegas.

We also worked in support of the EUROPAD conference in Barcelona, Spain during May 2012 as we cooperated with our international associates in sharing the most current clinical practice information in support of the use of Medication Assisted Treatment throughout the world. The EQUATOR study was released during this meeting, which compares patient outcome in ten European countries. While the data are still being analyzed, the results are quite compelling in evaluating different patient outcomes depending on medications being used to treat chronic opioid addiction, the economic landscape of a nation, the patient’s co-morbid conditions, employment background, and access to therapeutic care.

Conclusion
AATOD will continue to work with all of our policy partners in its work in the coming year and the AATOD Board of Directors is of the opinion that our field should know of our progress since the last report of June 2011.

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