View source for Expand Access to Medicated Assisted Treatment/Recovery (MAT/MAR)

= Introductory Paragraph=

Medication-assisted treatment (MAT) combines behavioral therapy and medications to treat substance use disorders. <ref>Chanell, Baylor. (2015, July 21). Medication-Assisted Treatment (MAT). Retrieved December 5, 2019, from https://www.samhsa.gov/medication-assisted-treatment</ref> The President's Commission on Combating Drug Addiction and the Opioid Crisis recommended that the federal government "immediately establish and fund a federal incentive to enhance access to Medication-Assisted Treatment." <ref>https://trumpwhitehouse.archives.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-15-2017.pdf</ref> This report documents that MAT has been proven to:
 
*Reduce overdose deaths 
*Retain persons in treatment 
*Decrease use of heroin 
*Prevent spread of infectious disease

= Key Information =

There are two major types of medications used in MAT - agonists and antagonists. Understanding the difference between the two is foundational for community communications regarding MAT. An opioid '''''agonist''''' activates opioid receptors in the brain. Methadone and Buprenorphine are both agonists. An '''''antagonist''''' blocks opioids by attaching to the opioid receptors without activating them. Naloxone and Naltexone are  antagonists. Suboxone is a hybrid, composed of both an agonist and an antagonist. <ref>Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref>

International addiction experts, published in the Annals of Internal Medicine, consider initial opioid-agonist treatment, with no duration restrictions, ''the evidence-based standard of care'' for opioid-use disorder. <ref>Association, A. P. (n.d.). APA Learning Center The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment (Webinar). Retrieved December 5, 2019, from APA Learning Center website: https://education.psychiatry.org/diweb/catalog/item?id=5913605&_ga=2.63318255.1744877395.1635561868-1008822590.1635561868</ref> Extensive research has demonstrated the effectiveness of opioid agonist treatment in opioid use disorder. A meta-analysis of 50 studies showed Methadone's retention rate ranging from 70% to 84% at one year, Buprenorphine ranging from 60% to 90% at one year, with both treatments resulting in significant reductions in overdose death, illicit drug use, criminal activity, arrests, risk behaviors, HIV and hepatitis C incidence, as well as improvements in health status, functioning, and quality of life. <ref>https://www.chcf.org/wp-content/uploads/2017/12/PDF-Why-Health-Plans-Should-Go-to-the-MAT.pdf</ref>

However, only 36 percent of SUD treatment programs offer at least one medication to treat opioid use disorder, and only 6 percent offer access to all three -- Methadone, Buprenorphine, and Naltrexone. <ref>Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M. Medication treatment for opioid use disorders in substance use treatment facilities. Health Affairs. 2019;38(1):14–23.</ref> According to SAMHSA data, 40 percent of the physicians who have a waiver do not prescribe Buprenorphine at all. This may be due to physicians' reluctance to have patients with addictive disorders frequenting their offices or due to concerns about DEA audits, among other reasons.  
One analysis found that 11 states (IA, IL, MD, MI, MO, NC, NH, OH, VA, WI, WV) located in the Midwest and Mid-Atlantic and DC have significantly lower-than-average rates of providers who prescribe Buprenorphine compared to opioid overdose deaths.<ref>https://avalere.com/press-releases/midwest-and-mid-atlantic-states-face-provider-shortage-to-address-opioid-epidemic</ref> 

'''Ways to Improve and Optimize MAT.''' The effectiveness of MAT is enhanced when there is an emphasis on a broad range of treatment and recovery supports, not just providing the medication part of the MAT. This involves continuous improvement of all aspects of the treatment plan, with special emphasis on the specific needs of each individual as much as practical. Some of the ways that MAT can be optimized are listed below:
*Consider Co-occurring Disorders. Co-occurring disorders, or dual diagnosis, refers to having a simultaneous mental health disorder and substance use disorder. It is common for people with addictions to also suffer from depression, anxiety, or more severe mental illnesses such as schizophrenia or bipolar disorder. Research shows that people who use alcohol or other drugs early in life are more likely to have mental or emotional problems. It’s also true that many people with mental illnesses “self-medicate” with alcohol or other drugs to numb emotional pain, relieve anxiety, or quiet their thoughts. In the past, the medical profession treated one disorder first, typically the substance use disorder, before addressing the other. It is now understood that treating both simultaneously leads to better outcomes. Any successful addiction treatment program will include a mental health assessment and treat co-occurring disorders at the same time. <ref>Weiss, R. D., Potter, J. S., Fiellin, D. A., Byrne, M., Connery, H. S., Dickinson, W., … Ling, W. (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: A 2-phase randomized controlled trial. Archives of General Psychiatry, 68(12), 1238–1246. https://doi.org/10.1001/archgenpsychiatry.2011.121
</ref>
*Precision medication (see SAFE wiki article titled "Expand DNA Testing to Improve Precision MAT Therapies" <ref>https://www.yoursafesolutions.us/wiki/Expand_DNA_Testing_to_Improve_Precision_MAT/MAR_Therapies</ref>
*A coordinated, proactive, whole-person care plan
*Community engagement 
*Use of innovative technologies  

== Different Medications Used in MAT: ==

===Buprenorphine=== 

Treatment with buprenorphine has been proven effective in opioid addiction, decreasing mortality by approximately 50%. Patients treated with buprenorphine show improved social functioning with increased retention in treatment (67% at one year) compared to drug-free treatment (7% to 25% at one year), reduced criminal activity, lower rates of illicit substance abuse, and reduced risk of HIV and hepatitis infection.<sup class="reference"><ref>Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref>

*Buprenorphine is used in MAT to help people reduce or quit their use of heroin or other opiates, such as pain relievers like Morphine. One study showed that 50% of the people in treatment who were also on Buprenorphine stayed on treatment compared with 7% who only had treatment. <ref>Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref>  
*Buprenorphine is a partial agonist that suppresses opioid withdrawal symptoms. It can produce opioid agonist effects, such as euphoria. It is milder than full agonists such as Methadone. <ref>https://www.drugabuse.gov/download/21349/medications-to-treat-opioid-use-disorder-research-report.pdf?v=99088f7584dac93ddcfa98648065bfbe</ref> 
*Buprenorphine can be prescribed by physicians in an outpatient setting who have completed a training course and received a DEA DATA 2000 waiver. It is taken as a pill or sublingual film. Buprenorphine was also approved in a 6-month implant form in 2016 <ref>https://archives.drugabuse.gov/news-events/news-releases/2016/05/fda-approves-six-month-implant-treatment-opioid-dependence</ref>  
*Training for Buprenorphine providers is an 8-hour course (24 hours for Nurse Practitioners and Physician Assistants) and allow for the following patient loads and responsibilities: <ref>Medication-Assisted Treatment: Buprenorphine in the HCH Community (2016), National Health Care for the Homeless Council, Retrieved From: https://nhchc.org/wp-content/uploads/2019/08/policy-brief-buprenorphine-in-the-hch-community-final.pdf</ref> 
**30 Addiction Treatment Patients per provider for the first year **100 patients each year thereafter
**An additional 175 (totaling 275) patients can be allotted if the physician is board certified in addiction or if a facility has 24 call coverage for patients, uses an EMR/EHS to monitor and update patient records, provides of care management services, subscribes to a state-led Drug Management System, and accepts third-party insurance. 

It should be noted that only around 10% of those who wish to seek treatment can find qualified providers to allow for it. <ref>https://www.fiercehealthcare.com/practices/only-10-eligible-primary-care-providers-can-prescribe-buprenorphine-to-treat-patients-for</ref> As a result, there are cases where medication diversion does occur, and there is a black market for the drug for self-treatment purposes. <ref>Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref>

=== Suboxone ===

*Suboxone is a brand name for a hybrid that is three parts Buprenorphine and one part Naloxone. 
*Suboxone is more difficult to misuse because it will cause the patient to enter opioid withdrawal if it is misused in any way, such as injection.<sup class="reference"><ref> Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref> 

=== Probuphine ===

*Probuphine was an implant that contained the medicine Buprenorphine. It wasdiscontinued in October 2020.

=== Methadone ===

*Methadone, sold under the brand name [https://www.drugs.com/cdi/dolophine.html Dolophine] among others, is used in MAT to help with detoxification or as part of [https://en.wikipedia.org/wiki/Maintenance_therapy maintenance therapy] or [https://en.wikipedia.org/wiki/Opioid_replacement_therapy Opioid Replacement Therapy]. 
*Methadone is an opioid replacement. It works by changing how the brain and nervous system respond to pain. It lessens the painful symptoms of opiate withdrawal and blocks the euphoric effects of opiate drugs such as heroin, morphine, and codeine, as well as semi-synthetic opioids like oxycodone and hydrocodone.<sup class="reference"><ref>[16]Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref></sup> 
*Methadone is to be prescribed as part of a comprehensive treatment plan that includes counseling and participation in social support programs. 
*Methadone can only be dispensed at SAMHSA-certified outpatient treatment programs or in hospitals in an emergency. <sup class="reference"><ref>17]Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref></sup> 
*Methadone has been used to treat chronic pain, however, this use is limited because of the serious risk of dependence and overdose.<sup class="reference"><ref>[18]Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref> 
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/methadone SAMSHA page on Methadone]

=== Naltrexone ===

*Naltrexone is a nonaddictive medicine that serves as an opioid receptor antagonist and not an opioid replacement, unlike methadone and buprenorphine. It is a primary ingredient in the treatment of alcohol and opioid dependence. Naltrexone blocks certain receptors in the part of the brain that triggers dopamine release so they cannot be activated. Dopamine release reinforces the vicious and compulsive addiction feedback loop. When we block these areas of the brain, the craving for alcohol and opiates is eliminated or significantly reduced. The pleasure is very limited and the uncontrollable cascade of relapse is much less likely, if alcohol is consumed after the implant procedure, in addition, if opiates are consumed after the procedure, there are no effects. <ref>Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref> 
*Naltrexone is administered in a long-active, injectable formulation administered once a month. <ref>Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref>  
*Naltrexone does not prevent withdrawal symptoms so it is recommended for patients who do not have opioids in their system. <ref>Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref>  
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/naltrexone SAMSHA page on Naltrexone] (The 30-day injectable version is commercially known as Vivitrol)

=== Naloxone ===

*Naloxone is an opioid antagonist used to reverse opioid overdose 
*Naloxone (commercially known as Narcan) is available in intravenous or intramuscular injection and nasal delivery options. Intramuscular injection or intranasal delivery is safe for administration by any person. <ref>Murphy, K, Becker, M, Locke, J, Kelleher, C, (2016), Finding Solution to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association Center, Retrieved from: https://www.nga.org/wp-content/uploads/2019/08/1607NGAOpioidRoadMap.pdf</ref> 
*Naloxone works within minutes and effects last for up to an hour. Multiple doses may be required depending on the severity of respiratory depression. <ref>Garcia-Portilla, M. P., Bobes-Bascaran, M. T., Bascaran, M. T., Saiz, P. A., & Bobes, J. (2014). Long term outcomes of pharmacological treatments for opioid dependence: Does methadone still lead the pack? British Journal of Clinical Pharmacology, 77(2), 272–284. https://doi.org/10.1111/bcp.12031
</ref> 
*Naloxone does not produce tolerance or dependence.  <ref>Moving from Stigma to Science in Treating Addiction. (2016, December 17). Retrieved December 5, 2019, from California Health Care Foundation website: https://www.chcf.org/blog/moving-from-stigma-to-science-in-treating-addiction/</ref> 
*Link to [https://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone SAMSHA page on Naloxone] 

Find information on physical ailments often diagnosed in MAT patients. Also known as [http://www.samhsa.gov/medication-assisted-treatment/treatment/common-comorbidities common comorbidities], these include viral hepatitis, HIV, and AIDS.

Medications Used in Addiction Treatment**< <ref>The Case for Medication-Assisted Treatment. (n.d.). Retrieved December 5, 2019, from http://pew.org/2kdLIf2
</ref> 

{| border="1" class="wiki_table"
|-
| Sept 2017
| Where it can be provided
| FDA indications
| Effectiveness
| Administration
|-
| Methadone
| OUD. Licensed opioid treatment programs<br/> Pain. Any Drug Enforcement Agency (DEA)-licensed prescriber
| OUD and pain management
| 74% to 80% <ref>https://www.chcf.org/wp-content/uploads/2017/12/PDF-Why-Health-Plans-Should-Go-to-the-MAT.pdf</ref> 
| OUD. Daily pill, liquid, and wafer forms; injectable form in hospitalized patients unable to take oral medications<br/> Pain. Injectable, transdermal, and buccal film
|-
| Buprenorphine and buprenorphine/naloxone
| 
*Prescribed by community physicians and dispensed by pharmacies, available in some opioid treatment programs. 
*Physicians receive federal waivers after eight hours of training; nurse practitioners and physician assistants require 24 hours. Patient panels are capped at 30, 100, and 275 per provider (depending on experience and setting). <ref>Why Health Plan Should Go to the “MAT” in the Fight against Opioid Addiction(2017), California Health Care Foundation, Retrieved form: https://www.chcf.org/wp-content/uploads/2017/12/PDF-Why-Health-Plans-Should-Go-to-the-MAT.pdf</ref> <ref>[28]Garcia-Portilla, M. P., Bobes-Bascaran, M. T., Bascaran, M. T., Saiz, P. A., & Bobes, J. (2014). Long term outcomes of pharmacological treatments for opioid dependence: Does methadone still lead the pack? British Journal of Clinical Pharmacology, 77(2), 272–284. https://doi.org/10.1111/bcp.12031
</ref> <ref>Kakko, J., Svanborg, K. D., Kreek, M. J., & Heilig, M. (2003). 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: A randomised, placebo-controlled trial. The Lancet, 361(9358), 662–668. https://doi.org/10.1016/S0140-6736(03)12600-1
</ref> 
*Any DEA-licensed provider can prescribe buprenorphine for pain. 

| OUD and pain management (depending on formulation and dose)
| 60% to 90% <ref>McNicholas, L.(n.d).Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, U.S Department of Health and Human Rights, Retrieved from : https://www.naabt.org/documents/TIP40.pdf</ref> | OUD. Daily sublingual, buccal, film, and tablet, or six-month intradermal device<br/> Pain. Injectable, transdermal, and buccal film
|-
| Naltrexone
| No restrictions
| Opioid and alcohol use disorders
| OUD. 10% to 21% <ref> Miranda, A., & Taca, A. (2018). Neuromodulation with percutaneous electrical nerve field stimulation is associated with reduction in signs and symptoms of opioid withdrawal: A multisite, retrospective assessment. The American Journal of Drug and Alcohol Abuse, 44(1), 56–63. https://doi.org/10.1080/00952990.2017.1295459
</ref> 
| Daily pill or monthly injectable
|-
| Naloxone (used only for overdose reversal, not addiction treatment)
| Any setting: prescribed or dispensed by a clinician, furnished by a pharmacy without a prescription (legal in several states), dispensed by lay staff in community settings (by standing order), or carried by law enforcement or other first responders.
| To reverse respiratory suppression in suspected opioid overdose
| May require high doses for extremely high-potency illicit drug use (fentanyl and carfentanyl)
| Intranasal spray, or intravenous, intramuscular, or subcutaneous injectable
|}

== Stages of MAT with Buprenorphine ==

=== Induction ===
<div class="_">"Induction is the first stage of buprenorphine treatment and involves helping patients begin the process of switching from the opioid of abuse to buprenorphine. The goal of the induction phase is to find the minimum dose of buprenorphine at which the patient discontinues or markedly diminishes use of other opioids and experiences no withdrawal symptoms, minimal or no side effects, and no craving for the drug of abuse." <ref>Addiction experts look to new and expanded opioid treatment options in 2017. (2017, January 13). Retrieved December 5, 2019, from FOX 61 website: https://fox61.com/2017/01/13/addiction-experts-look-to-new-and-expanded-opioid-treatment-options-in-2017/
</ref> New non-pharmacological approaches to treat opioid withdrawal could provide alternative pathways to help a patient manage withdrawal symptoms as they transition into MAT. The [https://i-h-s.com/ BRIDGE]® is a noninvasive, percutaneous electrical nerve field stimulator developed to target pain. An article published in 2018 in The American Journal of Drug and Alcohol Abuse shared significant promising results in using the BRIDGE to help people transition to MAT. The neurostimulation rapidly and dramatically reduced the [https://www.drugabuse.gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf COWS scores] of the participants, and 64 of the 73 people successfully transitioned to MAT.

Some training programs suggest that [https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=99a59495-2a48-4276-bbe3-cdd55a45aba4 Clonidine] or [https://www.webmd.com/drugs/2/drug-16910-8296/ondansetron-oral/ondansetron-disintegrating-tablet-oral/details Ondansetron] may be used to ease the withdrawal symptoms during induction.<ref> [35]Vermont Global Commitment to Health Section 1115 Demonstration Fact Sheet (2018). Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/vt/vt-global-commitment-to-health-fs.pdf</ref>

=== Stabilization ===
"The stabilization phase has begun when a patient is experiencing no withdrawal symptoms, is experiencing minimal or no side effects, and no longer has uncontrollable cravings for opioid agonists. Dosage adjustments may be necessary during early stabilization, and frequent contact with the patient increases the likelihood of compliance." 

=== Maintenance ===
"The longest period that a patient is on buprenorphine is the maintenance phase. This period may be indefinite. During the maintenance phase, attention must be focused on the psychosocial and family issues that have been identified during the course of treatment as contributing to a patient’s addiction." 

== Medically Supervised Withdrawal (Detoxification) ==
<div class="_">As an alternative to the three stages above, the goal of using buprenorphine for medically supervised withdrawal from opioids is to provide a transition from the state of physical dependence on opioids to an opioid-free state, while minimizing withdrawal symptoms (and avoiding side effects of buprenorphine). Medically supervised withdrawal with buprenorphine consists of an induction phase and a dose-reduction phase. The consensus panel recommends that patients dependent on short-acting opioids (e.g., hydromorphone, oxycodone, heroin) who will be receiving medically supervised withdrawal be inducted directly onto buprenorphine/naloxone tablets. The use of buprenorphine (either as buprenorphine monotherapy or buprenorphine/naloxone combination treatment) to taper off long-acting opioids should be considered only for those patients who have evidence of sustained medical and psychosocial stability.</div>

= Relevant Research =

*'''Emergency Department Treatment Protocols''' In a randomized trial performed by Yale, it was found that individuals who receive buprenorphine while getting medical care within an emergency room are more likely to adhere to treatment protocols and have a better chance at ceasing opioid use when compared to those who have received referrals to receive the treatment, or those who received motivational support.<ref>[39] Weiss, R. D., Potter, J. S., Griffin, M. L., Provost, S. E., Fitzmaurice, G. M., McDermott, K. A., … Carroll, K. M. (2015). Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study. Drug and Alcohol Dependence, 150, 112–119. https://doi.org/10.1016/j.drugalcdep.2015.02.030</ref> This can be an initiation point for treatment of opioid dependence and can be followed up by primary care facilities. This has shown to decrease the need for in-patient facilities. This can be attributed to engaging patients at the optimal point of access. <ref>Health plan offers financial incentives for MAT training | Psychiatry & Behavioral Health Learning Network. (n.d.). Retrieved December 5, 2019, from https://www.psychcongress.com/article/policy/health-plan-offers-financial-incentives-mat-training</ref>

*In California, where more people have been diagnosed with opioid disorder than in any other U.S. state, ''publicly funded treatment programs require patients to “fail” - twice - at a three-week course of medically supervised withdrawal before they become eligible for OAT''. Policymakers likely maintained this medically managed withdrawal requirement under the belief it was saving money. The study demonstrates, however, that the policy creates significantly greater long-term costs for criminal justice and healthcare systems. 
**The study concludes OAT would have saved as much as $850 million over five years, not including savings to the criminal justice system, and more than $2 billion, including the cost of arrests and prosecutions. Over 10 years, the total savings would rise to $2.87 billion.<ref>Krebs, E., Enns, B., Evans, E., Urada, D., Anglin, M. D., Rawson, R. A., … Nosyk, B. (2018). Cost-Effectiveness of Publicly Funded Treatment of Opioid Use Disorder in California. Annals of Internal Medicine, 168(1), 10. https://doi.org/10.7326/M17-0611</ref> 
**“In order to see overdose deaths come down, we need to make sure people who have opioid addiction are able to access effective treatment more easily than they can access heroin, fentanyl or pain pills." 
**"We need a model whereby patients can get immediate access to opioid-agonist treatment, a lifesaving intervention, without obstacles." 
**“Among experts in the field of addiction, we already know that detox doesn’t work, that they’re going to relapse and when they relapse, they’re going to be at great risk for an overdose, that they’ll be at great risk for hepatitis,” Kolodny said. “Opioid addiction is a life-threatening illness."   

*'''Cost-Benefit Analysis.''' This article talks of how the use of buprenorphine reduces the cost of opioid addiction<ref>Behavioral Healthcare Executive | Psychiatry & Behavioral Health Learning Network. (n.d.). Retrieved December 5, 2019, from https://www.psychcongress.com/node/721</ref>

*''' Weiss and Carroll.''' In an article published in the American Journal of Psychiatry, Weiss and Carroll state: "Finally, with 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, we must explore innovative strategies for enhancing retention in buprenorphine treatment." <ref>https://pubmed.ncbi.nlm.nih.gov/27978771/</ref> Their report reveals the need for significantly more studies that can yield additional insights to inform MAT practices. Current literature focuses mainly on the outcome of treatment retention and negative urine drug screens. Enhanced research would look at broader outcomes of social functioning including employment, stable housing and other measures of well-being. Also, research would ideally have information on many other factors such as information on co-occurring disorders and the types of behavioral treatments that would be appropriate for different individuals. Weiss and Carroll highlight the following key points: 
**Buprenorphine is an excellent medication, but there is still much room for improvement in how MAT is done. 
**Research designs, such as the intensity of Medication Management, the dose of buprenorphine, and the characteristics of the group participants, influence outcomes. 
**Different sub-groups respond differently to different elements of treatment plans. 
**Early treatment response has a major impact on long-term success, and a better understanding of that insight may help decision-making. Patients who abstain from opioids in the first two weeks of treatment have a good chance of a good 12-week outcome. Patients who use opioids during the first two weeks of treatment have very little chance of abstaining by week 12.   
**There is evidence that the use of Contingency Management (CM), including the use of computer-based therapies, seems to increase success rates. <ref>https://drugabuse.com/treatment/therapy/contingency-management/</ref>
**Patients' dependent on prescription opioids seemed to respond more positively to Cognitive Behavioral Therapy (CBT) than those who were primarily heroin users. 
**Different treatment approaches appeal to different patients, and using approaches that appeal to the patients helps to increase their retention rates. 
**More data is needed to better understand what treatment options are best for different individuals.

= Impactful Federal, State, and Local Policies =

*'''Canadian Guidelines.''' This document has details on the MAT Methadone guidelines from Canada. <ref>https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Prescribing-Drugs/Advice-to-the-Profession-Prescribing-Drugs</ref>

*'''SAMHSA''' provides a "Guide for Medications for Opioid Use Disorder.''' <ref>https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Executive-Summary/SMA18-5063EXSUMM</ref>

*'''National Healthcare For Homeless Council''' has policy recommendations of policy to control the prescription of opiates and the treatment of opioid addiction. They are as follows: <ref>https://nhchc.org/wp-content/uploads/2019/08/addressing-the-opioid-crisis-priorities-for-the-hch-community.pdf</ref>
**Remove the cap on the number of patients a physician can treat with buprenorphine. Existing limits are arbitrary and create barriers to accessing treatment. While put in place to mitigate diversion, cap limits may inadvertently aid diversion by limiting the supply of MAT, leading to individuals pursuing self-treatment by purchasing diverted drugs. Ironically, there are no limits to the number of patients a physician can prescribe other opioid drugs that present a much greater risk of causing addiction, overdose, and death (e.g., Methadone, Oxycodone, Hydrocodone, and Fentanyl). Removing the caps will allow providers to determine the number of patients they are able to treat based on the capacity of their practice and other factors, thereby increasing access to treatment. 
**Expand prescribing rights to all clinicians who are eligible to prescribe Class III, IV, and V CDS drugs. Limiting prescribing rights to physicians creates an additional barrier to accessing treatment and is incongruent with the existing scope of many clinical practices. Expanding prescribing rights to Nurse Practitioners, Physicians Assistants, and other clinicians who are authorized to prescribe Class III, IV, and V CDS drugs will expand treatment opportunities and decrease barriers to care. Clinicians who can prescribe opioids for pain should also be able to prescribe buprenorphine to treat the addictions that sometimes result. 
**Require training to prescribe all opioids, not just buprenorphine. Specialized training is required to prescribe buprenorphine, but no other drug (opioid or otherwise) requires this as a condition of practice. Given the lower risks associated with diversion of buprenorphine, and the elevated risk associated with many opiates that can be prescribed with few restrictions, training should be extended to the prescribing of any opioid and focus on administering and monitoring prescriptions and understanding the nature of addiction. In addition, prescribers should have greater access to technical assistance and resources to develop plans to identify and avoid diversion. 
**Enforce parity laws. Substance abuse treatment and other behavioral health services should be just as easy to access as primary care services. Parity laws are in place to ensure insurance plans treat these services equally, and should be enforced. Health insurance practices that require prior authorizations for opioid treatment should be scrutinized, especially when they create barriers to behavioral health care that do not exist for primary care. Just as there are no prior authorizations required for opioid drugs prescribed for pain management, there should be no prior authorizations required for MAT. Addiction is a time-sensitive condition to treat, and presenting for treatment is a big step for patients; even a delay of one day can be the difference in someone getting treatment or not. 
**Reduce stigma and treat addiction as a disease. The main barrier to any type of treatment for persons experiencing homelessness is a lack of stable housing. In addition, drug screens are often required when accessing housing, and employers often require drug screens for employment. Landlords and employers need to accept buprenorphine prescribed as part of a MAT plan as a medical treatment process, and not have it count negatively against a person by including it as a prohibited substance. Addiction needs to be seen as a disease and not a moral failing, and engagement in MATs as a health care intervention should not be a liability to accessing housing or employment. 
**Train all health care disciplines on addiction. Expanding awareness of addiction and providing substance abuse education for medical students, residents, practicing physicians, and all other health care providers is essential. Curricula which treat substance use conditions similarly to other chronic disorders and provide more adequate basic preparation need to be implemented. In addition, continuing education opportunities to learn about evidence-based practices for the treatment of SUDs need to be provided, and programs to support the adoption of MAT, screening, brief intervention, and referral to treatment need to be identified and implemented.

= Available Tools and Resources =

The Provider's Clinical Support System offers a module for CME credit on the Stigma on Maintenance Treatment. This can address the primary perceived and actual stigmas from patients as well as follow professionals.<ref>https://pcssnow.org</ref>

BupPractice <ref>http://www.buppractice.com/</ref>
This is a DATA 2000 accredited resource for providing either an 8-hour training for Physicians or a 24-hour training session for Physician Assistants and Nurse Practitioners, both for $199 per full series. It also offers up to 9 AMA PRA Category 1 Credits, and is further supported by the ASAM (American Society of Addiction Medicine).

'''SAMHSA Treatment for Homeless''' <ref>https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/mat-can-improve-health-outcomes</ref><br/> This document shows current resources for those attempting to handle behavioral health topics, particularly in homeless populations, as well as strategies to develop one's own programs.

SAMHSA provides more information on Buprenorphine <ref>https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/buprenorphine</ref>

Where Can Clinicians Get Training and Support? Buprenorphine training sessions are offered at several locations and websites. The training takes about eight hours and can be attended in person, online, or a combination of both. Buprenorphine waiver training can be valuable to any clinician (medical or behavioral) as it covers the basics of opioid addiction and how buprenorphine works. Clinicians can only prescribe buprenorphine for addiction after receiving certified training and a Drug Enforcement Administration (DEA) waiver. However, any DEA-licensed clinician can prescribe buprenorphine for pain. Training opportunities are posted on the following websites: Substance Abuse and Medical Health Services Administration (SAMHSA), American Academy of Addiction Psychiatry (AAAP), American Osteopathic Academy of Addiction Medicine (AOAAM), and Providers’ Clinical Support System (PCSS).24-27 Some sites also offer other tools and resources. PCSS offers online mentorship, and Project ECHO28 offers video and monthly case review. The Clinicians Consultation Center at UCSF offers expert clinical advice, Monday through Friday, 7 a.m. to 3 p.m. PST.29 Substance Use Warmline: (855) 300-3595. <ref>https://nccc.ucsf.edu/about-the-center/</ref>

= Promising Practices =


== New & Expanded Treatment Options ==

=== Connecticut ===
Connecticut's Department of Mental Health and Addiction Services (DMHAS) recently received two federal grants, one of which is meant to go to medication-assisted treatment, the other toward prevention efforts. DMHAS is also collaborating with the Connecticut Community for Addiction Recovery on a new program that will enable people who were saved from overdose through the use of naloxone to work with a recovery coach who can connect them to services and a support network. <ref>Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial | Emergency Medicine | JAMA | JAMA Network. (n.d.). Retrieved December 5, 2019, from https://jamanetwork.com/journals/jama/fullarticle/2279713
</ref> 

=== Vermont ===
Vermont's Health Home for Opioid Addiction has employed a "Hub & Spoke" system in handling the Opioid Crisis, called the "Care Alliance for Opioid Addiction," which has seen some success in treating addicted individuals while helping lift the burden of care from singular doctors and clinics. The system is composed of the following parts :  
*The Hub, a designated provider of specialty addiction treatment, is designed as an Opioid Treatment Program which is operated by Community Behavioral Health Agencies. 
*The Spokes are health care teams led by physicians who can prescribe Buprenorphine and are regulated as Office Based Opioid Treatment providers. 

Payment infrastructure for providers are structured after already existing Medicare and Medicaid Structures, which are documented in the Vermont Global Commitment To Health Section 1115 Demonstration Fact Sheet. <ref>Kashef, Z. (2015, April 28). Emergency department treatment for opioid addiction better than referrals. Retrieved December 5, 2019, from YaleNews website: https://news.yale.edu/2015/04/28/emergency-department-treatment-opioid-addiction-better-referrals</ref>

**An evaluation of the Care Alliance for Opioid Addiction has shown that people in treatment for opioid addiction reported a 96 percent decrease in opioid use, and a 100 percent drop in overdose incidences, according to a [http://www.healthvermont.gov/media/newsroom/hub-and-spoke-evaluation-shows-significant-impact-january-22-2018 new report] from the Vermont Department of Health released 1/22/18. 
**Additional findings include: 
***92% drop in injection drug use. 
***89% decrease in emergency department visits. 
***90% reduction in both illegal activities and police stops/arrests. 
***Zero participants in treatment had overdosed in the 90 days leading up to the study interview, compared to 25% who had overdosed in the 90 days before entering treatment. 
***Family conflict, feelings of depression, anxiety and anger decreased, and participants reported being much more satisfied with their lives.     
<ref>https://www.healthvermont.gov/sites/default/files/documents/pdf/adap_HubSpokeEvaluationBrief.pdf</ref>

== National Healthcare For Homeless Council ==
As one may assume, there is cross-over between the homeless and addicted communities. The National Healthcare for the Homeless Council has as a result, released a policy brief that may be of some use for both policy makers and health care providers alike. Within the brief, a basic strategy is considered as follows when treating addicted and homeless/addicted patients:
*'''Establish stability'''. Stable housing is central to attaining treatment goals as it provides patients with stability, a sense of safety, an increased ability to meet basic needs, and an opportunity to have increased control over their lives and environment. Securing stable housing as early as possible is key to the treatment and recovery process.
*'''Address comorbidities using integrated care'''. Untreated medical and/or other behavioral health conditions may complicate MAT. The most successful interventions are provided through integrated care models of interdisciplinary teams made up of medical, mental health, substance use, and social service providers. Each discipline should not only be co-located, but should work collaboratively as a team with multiple services offered in the same visit.
*'''Treat the whole person'''. Substance use disorders cannot be treated apart from addressing the needs of the whole person in the context of his or her environment. In addition to addressing comorbidities, assistance in accessing food, clothing, shelter/housing, financial assistance, counseling, job training, employment services, and other needs as identified must be included alongside MAT.
*'''Take a harm reduction approach'''. Harm reduction therapy is an evidence-based practice that supports and respects a person’s experience and treats them with dignity, which is especially important for persons experiencing homelessness who regularly interact with systems and situations that limit self-determination and lack respect. Harm reduction therapy relies on collaboration, respect, and stage-based interventions that acknowledge self-defined positive change. Harm reduction therapy focuses on client-defined priorities and acknowledges that any improvement that reduces harm is beneficial. The key to harm reduction therapy is low barrier, integrated care that is trauma informed and respectful of the collaborative therapeutic relationship.
*'''Utilize evidence-based best practices'''. In addition to harm reduction, using other evidence-based best practices such as the use of peer specialists, motivational interviewing, and individual and group therapy can help patients maintain recovery and have successful treatment outcomes.
*'''Be patient centered'''. Building trust and developing relationships is essential to providing high-quality care and achieving good health outcomes. Engaging in patient centered care based on a patient’s individual needs, strengths, goals, and timeframe rather than on a pre-determined benchmark for outcomes is one way to build relationships and empower patients in the process. Patients should be actively involved in setting goals and planning their treatment.
*'''Be flexible'''. There is no one-size-fits-all treatment that will work for all patients. While MAT recommends a combination of medication and behavioral health therapy, treatment should be flexible and individualized to the patient’s needs, especially the frequency/schedule for therapy. For some, medication alone and regular consultation with a primary care provider is enough to maintain and recover from addiction, while others may need the additional supports provided by behavioral health therapy.

== Opioid Treatment Program Directory ==
Select [http://dpt2.samhsa.gov/treatment/directory.aspx this directory] to view the opioid treatment programs in each state 

== Moving from Stigma to Science ==

=== Pennsylvania  ===
The Department of Behavioral Health and Intellectual Disability Services of Pennsylvania has taken actions to ensure that halfway houses and other rehabilitation facilities cannot turn away individuals using MAT as a means of treating Opioid Abuse. <ref>https://dbhids.org/MAT/</ref> Underlying problems still exist in restrictive medication regimen practices, insurance coverage, and Public-Private partnerships, which require support to overturn previous hard-lined policies. An evidence-based approach has shown that introduction of MAT, especially with Buprenorphine, has had an increased mitigation effect on relapse and a higher chance of long-term recovery.

== Financial Incentives for MAT training ==

'''Neighborhood Health Plan''' (NHP) of Massachusetts has announced a series of initiatives to increase access to substance use disorder treatments. This non-profit health plan is providing financial incentives to encourage more prescribers to train and be certified to prescribe buprenorphine products. NHP will reimburse prescribers $500, which is roughly the cost of required training, for earning their certification in buprenorphine product dispensing. Prescribers can receive an additional $2,000 if they provide documentation showing that at least 10 patients have been treated after becoming certified. This financial incentive has become increasingly popular, as NHP has received several inquiries about the program from prospective prescribers within days of its announcement. Other initiatives include hiring recovery coaches to work with patients as part of their follow-up care as well as waiving member copays for naloxone. "Pharmacists will be reminded to notify plan members that they are eligible for free naloxone supplies when they pick up high-dose narcotic painkilling prescription medications."<ref>https://www.hmpgloballearningnetwork.com/site/behavioral/article/policy/health-plan-offers-financial-incentives-mat-training</ref> Another initiative is to offer a benefit design that encourages plan members to seek alternatives to opioid medications. NHP waives copays for alternative treatments to prescription painkillers including chiropractic care, acupuncture, and physical therapy.

= Sources =

[[Category:SAFE-Treatment and Recovery]]