Thursday, March 29, 2012
Prescription drug forum follow up: Panelists' answers to attendees' questions
These are the panelists' answers to the questions we collected from the attendees at our March 5th public forum of the Joint Committee on Mental Health and Substance Abuse.
I thank everyone who attended the forum for their sincere interest in curbing abuse of prescription drugs and encourage everyone to follow the progress of the bill S2125 at http://www.malegislature.gov.
Q1. How long can a patient take Methadone? Is there a limit? Is methadone a viable treatment?
A person could take Methadone for life; there is no limit to the duration of use. It is a viable treatment but the Gosnold philosophy is that the patients who are best candidates for methadone are long time, intractable users of opiates for whom other treatments have been consistently unsuccessful. In other words, a last resort. There are treatment professionals who recommend it to many patients. It really becomes a clinical philosophy issue.
Q2. With the advances in neuroscience, can the panel agree with the following statements?
a. Nobody chooses to be an addict or alcoholic.
That is probably true. Most individuals are probably born with the disease, then at some point in their lives, are introduced to their addiction or addictions of choice.
b. We are treating patients not inmates.
Gosnold would agree with both statements. To clarify (b), treatment professionals are treating patients who have the illness. Their status as “inmates” is determined by the judicial system and the laws of the Commonwealth or federal government.
Q3. What is the success rate of Recovery High Schools?
Recovery High Schools have considered a range of measures of success. Is it reduced absenteeism? Is it abstinence? What role does harm reduction play? I have attached the Executive Summary of a report by a professional evaluator.
An Alternative High School Model For
Adolescents With Substance Use Disorders:
What Are The Outcomes?
Thomas T. Kochanek, Ph.D.
This paper was prepared for the Governor’s Interagency Council on Substance Abuse and Prevention, Department of Public Health, Commonwealth of Massachusetts. The opinions expressed reflect those of the author and not necessarily the position or policy of the Interagency Council.
Copyright © Massachusetts Department of Public Health
The Recovery High School is an alternative, multi-service secondary school for adolescents with substance abuse and dependence problems. In addition to offering a full academic program leading to high school graduation, the school incorporates numerous service components to support a youth’s commitment to recovery (e.g. linkage with a recovery treatment program, teaching avoidance behaviors and promoting resiliency, coordinating multi-agency involvement, and accessing behavioral health support). Three Recovery High Schools (Beverly, Boston, and Springfield) launched their programs in September, 2006. A comprehensive, independent program evaluation has been designed and implemented in order to ascertain the effects and benefits of RHS enrollment. Data gathered for the 2009-2010 school year have identified the following major findings.
Characteristics of the RHS Population
· From 2006-2010, 365 youth were referred to a RHS. Excluding currently enrolled students, 32% graduated (i.e. from a RHS or high school of residence), 47% were enrolled and exited prior to graduation, and 21% did not become engaged in a RHS (i.e. attended school only sporadically and exited in less than two months). The mean number of months engaged in school was as follows: Graduated = 9.1 months; Engaged/Exited = 5.9 months; Not Engaged = 1.7 months.
· For 130 youth referred during school year 2010, primary sources of referral included school districts (29%), substance abuse treatment centers (28%), and state agencies (i.e. DCF, DYS, Court: 21%). Upon enrollment, youth were, on average, 17.0 years of age, and males (65%) outnumbered females (35%).
· With regard to behavioral health status of youth, 100% were diagnosed (DSM – IV) with a substance related disorder. Other prevalent diagnostic categories included depression (25%), mood disorder (18%), and ADHD (18%). The majority of youth have had contact with multiple programs and resources. More specifically, 50% have experienced inpatient substance abuse treatment, 43% outpatient treatment, 32% have had at least one psychiatric hospitalization, and 20% have been placed within a residential behavioral health treatment program.
· Upon RHS enrollment, 85% of youth were actively using substances, most commonly marijuana (46%) and alcohol (28%). Frequency of use approximated 2- 4 occasions per week for alcohol and 3-6 occasions per week for marijuana.
· Results derived from the CAFAS revealed that youth who ultimately graduated manifested a higher level of social/emotional competency upon RHS entry than youth who exited prior to graduation. Youth who graduated were perceived by RHS staff as more committed to school, using substances infrequently, and demonstrated minimal involvement with the legal, behavioral health, and social service systems.
Youth Outcomes Upon RHS Exit
· Exit data for 170 youth revealed that 65 (38%) graduated. Of these, 75% exhibited a commitment to higher education or entered the labor force. Given the complex histories of youth enrolled in a RHS, this is a major index of success and achievement.
· With respect to declared commitments by youth to their recovery upon RHS exit, data revealed more favorable outcomes for youth who graduated vs. youth who exited prior to graduation. For nearly all five indicators, twice as many graduates vs. non-graduates evidenced important protective factors (e.g. will attend AA/NA meetings; will use behavioral health support; has a permanent sponsor; has close friends who do not abuse substances).
· With regard to resistance and independent problem solving skills demonstrated by youth upon exit, again, graduates evidenced markedly higher ratings than non-graduates. Graduates were perceived as possessing “adequate” skill levels in risk assessment, self-regulation, and their ability to safely use community and recreational resources.
· In contrasting CAFAS ratings at RHS entry vs. exit, findings revealed an increase in youth’s social/emotional competency for both students who graduated as well as those exiting prior to graduation.For GAIN: SS scores at entry and exit, data revealed no remarkable change in mean item ratings.
· In comparing primary substance use data at entry vs. exit, with respect to the prevalence of use among youth, no change was noted (i.e. 66% of youths at entry vs. 63% at exit). Of great significance however, was that finding that abuse frequency decreased by approximately 50%. That is, while abuse frequency approximated 1-2 times/week at entry, the rate declined to one time per month at exit. Given that youth, overall, were enrolled for only approximately seven months, this is an impressive and noteworthy finding.
Long-Term Outcomes for RHS Youth
· One-hundred nine students (i.e. 50 graduates and 59 non-graduates) were contacted by phone for a brief semi-structured interview by RHS staff. The mean length of elapsed time from RHS exit to phone interview was 20.1 months. For graduates, results were extremely positive with 90% of youth engaged in either higher education or employment. For youth who exited prior to graduation, again, results were favorable with 72% either enrolled in school or working at least on a part-time basis. 85% of youth were residing with their families or living independently.
· When youth were queried regarding relapses that had occurred within one week of the interview, 80% of youth did not experience a regressive episode. For relapses that occurred within six months of phone contact, 52% did not disclose a relapse. Moreover, regarding frequency of use for disclosed relapses, 57% were described as infrequent (i.e. 1-2 incidents per month).
· Regarding commitments to recovery, graduates performed better than non-graduates. Specifically, graduates disclosed attending AA/NA meetings more often (64% to 29%), had used behavioral health provider support (44% to 20%), and had friends who did not abuse substances (76% to 34%). All youth were also asked questions pertaining to resistance behaviors and risk assessment. Overall, RHS staff ratings approximated the “adequate” range which suggested that resistance and risk assessment skills were firmly intact even 20 months after RHS exit.
· Finally, recovery commitments by youth were also contrasted between RHS exit and follow-up. Overall, results were very positive and indicated that for approximately one-half of youth interviewed, commitments were made to an array of supports (AA/NA meetings, behavioral health) that are central to the foundation of recovery support. Furthermore, youth behavior ratings indicated that nearly two years after school exit, youth continue to demonstrate a core of behaviors and commitments that provide a pathway to successful and ongoing recovery.
Q4. What is being done to regulate sober houses?
As an opinion, Gosnold does not advocate State regulations for sober houses. They are not treatment settings. They essentially are domiciles that have, as a requirement, abstinence from alcohol and other drugs.
I won’t speak for Mr. Botticelli, but I did have a conversation with him about this issue maybe a year ago. He indicated that there are draft regulations being worked on at the DPH, but my take on it is that issuance of such regulations is not imminent, perhaps for the reason stated by Mr. Tamasi.
Q5. Would the panel consider addiction and epidemic or a pandemic? Can anyone on the panel identify what addiction is? Does the panel agree that a proactive approach would improve a person’s ability to no develop an addiction?
a) Gosnold wouldn’t consider it either an epidemic or a pandemic, given the classic definitions of those terms. It is not an outbreak of disease that spreads quickly
(epidemic) nor does it affect an exceptionally high proportion of the population (pandemic). However, it is a major public health problem whose consequences lead
to serious medical complications.
b) The most recent updated definition of Addiction is:
“A primary, chronic disease of the brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursing reward and/or relief by substance use. 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. Addiction often involves cycles of relapse and remission. Without treatment, addiction is progressive and can result on disability or premature death.”
c) Proactive meaning earlier identification and intervention along with aggressive prevention strategies? YES
Dr. Rob Friedman:
Pandemic usually consists of a widespread outbreak of an infectious disease such as influenza or HIV across large geographical areas, so I would not consider the increase in opioid abuse and dependence a pandemic, but it is certainly an epidemic, and the increased availability and strength of various prescription drugs such as Oxycontin and high strength oxycodone has certainly contributed to the problem.
Addiction is a brain disease, a chronic one that is always present, a constant battle between the pleasure center in the brain, and the rational cerebral cortex, that manifests as a compulsion to do something to severe excess even when that action results in harm, and even when the individual recognizes that the action may result in harm or death.
Q6. I recommend passing a law to make a 12-step program mandatory while in prison with outside sponsors who have long term sobriety. Most prisoners in jail get out with no help, relapse and die. There is emphasis on “lifers” who kill cops after out, while no emphasis on drug addicted who get out and die. Last month, someone who served two years in jail got out, stayed with me one night and overdosed the next day in Hyannis.
Dr. Rob Friendman:
I agree that education is most important in this disease. Barnstable County is taking great initiative in piloting its Vivitrol program, where we can incorporate a medical tool in helping with the cravings that these individuals will experience upon release, and also continuing counseling, monitoring and education upon release.
Q7. Does the legislation include parental notification of children under 18 for alcohol poisoning? If not, why not?
Yes, S2125 requires parental or legal guardian notification for a drug or alcohol overdose.
Q8. Addiction often includes "poly-substance" abuse. a) Will this bill include tracking of other class addictive prescriptions as well, beyond opiates? b) Will psychiatrists be included? c) Will insurance companies be targeted to increase coverage?
c) Nothing in this bill mandates insurance companies to pay for (or cover) a predetermined length of treatment. Those decisions are based upon interpretation of medical necessity.
Dr. Rob Friendman:
Everyone that is enrolled in our Vivitrol sobriety management program is tested at every visit for many other drugs of abuse including alcohol, benzo's, barbiturates, THC, amphetamines, PCP, cocaine, synthetic opiod's. We focus on addiction as a global disease, and recognize that single agent addiction is far less common than poly-substance abuse.
Q9. a) How do we get insurance companies to cover services before chronic rehab takes place? b) Why is MA affected so much? c) When does the doctors’ part in all of this come into play? d) Can something be done to assist parents so the choice isn’t police/court and putting your kid on the street? e) Does this stem from ADD medication?
a) Insurance companies do cover services before “chronic rehab takes place.” They cover outpatient treatment and other lesser levels of care.
b) Massachusetts is not the only State affected. All States are dealing with addiction.
c) Doctors can be involved much earlier if the emphasis shifts from crisis and emergency care (Detox) to early identification, universal screening, and prevention.
d) There are other options for families beside police/courts/the street. There are intervention programs at Gosnold that are successful in getting people to accept treatment. Problem is that this illness doesn’t go away after one brief treatment, remission is challenging and requires consistent clinical intervention.
e) ADD medication link is not conclusive but defer to MD’s
Dr. Rob Friedman:
Insurance coverage is a huge issue, and ultimately comes down to money and politics. The amount of monies devoted to treatment vs law enforcement at this time is less than 25% to over 75%. We need to shift that balance so that the percent favors treatment and education. Then we would not need to spend so much on the law enforcement percentage.
Q10. Much attention is being paid to the supply side of prescription drugs, but how can we as a community address demand? How aware is the community of the level of pain that people seek to alleviate, and how can we address the root causes of this pain? Where does it originate? Is it inevitable? If so, where is there hope?
I presume the questioner is talking about psychic pain as well as physical pain. Regarding psychic pain, this is a larger cultural question about how the society finds inner solace and comfort. The eroding of societal values contributes to the “lostness” of a generation. So some people seek to fill that void and find meaning through the use of mind-altering substances. Others are genetically predisposed and are likely to develop addiction even in the face of strong family systems and values.
Dr Rob Friedman:
In our practice, we see far more mental pain than physical pain. Prescription pain killers are not designed to treat mental pain. There are many better ways of treating mental pain, but it requires resources and education.
Q11. When will the government stem the tide of production? Pharmaceutical companies spend more lobbying $$ than any other industry. Overproduction is the issue. OxyContin was originally produced as an end of life pain medication, not for wisdom teeth extractions for 16-year-olds.
The bill can actually impact widespread prescribing of pain medication so it will help. Ongoing physician education about the danger of these drugs when unnecessarily prescribed will help.
Q12. Is there any movement to add nurses to the PMP? This would greatly impact the use of this service as they are often the front line for physicians.
S2125 requires a practitioner who prescribes controlled substances to register as a participant in the PMP when obtaining or renewing their Massachusetts Controlled Substances Registration. The Department of Public Health (DPH) may also specify the circumstances under which licensed support staff may use the PMP on behalf of a registered participant. DPH is also currently considering allowing any licensed health care provider to register with the PMP.
Q13. What additional services or supports will there be to assist providers when they are sitting with a patient confronting their issue of addiction? Services are limited and difficult now. Given the magnitude of the problem we need to have a system to deal with this so we are not just “shutting patients off” from medications. We need more treatment and resources. We know patients in treatment do better and the cost to society will be less.
More services is one thing; access to them is another. There are obstacles by insurers, reimbursement systems, and there is a reliance on emergency interventions at the expense of earlier actions. Most of the State dollars (98%) spent on substance abuse go to deal with consequences. Only 1% is spent on treatment; 1% on prevention. So one option might be to re-allocate existing resources to get out in front of the issue instead of waiting to deal with it when it is advanced and harder to treat.
Q14. Have other states passed legislation that is comparable in its breadth and depth to Senate 2125? If so, are there data yet describing the impact (if enough has passed to measure impact)? The focus tonight has been opiates. I don’t know the numbers, but misuse of prescribed medication for ADHD is apparently increasing. Can you comment on the use trends and prevention/treatment for these types of drugs (Adderall, etc)?
The rise in prescription drug abuse and misuse is a problem that every state is trying to solve. S2125 is a coordinated effort to actively address prescription drug abuse and misuse in Massachusetts with a focus on opiates but also on other prescription drugs in Schedule II and Schedule III.
Q15. Has there been a change in the prescribing recommendations for the opioids? I believe the term is the “schedule” under which these drugs are prescribed. Would you recommend a change in prescribing criteria to require more oversight in outpatient prescriptions, fewer pills dispensed at a time and restrictions in refills allowed for these drugs? Would it be helpful if under the prescription monitoring program prescription centers be required to register a patient’s history of prescription?
S2125 requires the Commissioner of the Department of Public Health to convene a joint policy working group to investigate and study best practices including those in education, screening, tracking, monitoring and treatment to promote safe and responsible opioid and other abused prescription drugs prescribing practices with the goal of reducing diversion, abuse and addiction. Based on the working group’s report and recommendations the Commissioner shall promulgate rules and regulations to achieve these goals.
Q16. Does the bill cover Nurse Practitioners and other prescribers as well as doctors? What are the prospects of passage? I recommend turning best practices into rules.
Yes, S2125 requires any practitioner who prescribes controlled substances to register as a participant in the PMP when obtaining or renewing their Massachusetts Controlled Substances Registration. The bill passed the Senate unanimously and is currently before the House Ways & Means Committee.
Q17. Education/Prevention- I believe it will take the efforts of the entire community to deal with the issue of drugs & alcohol abuse. How do we involve the different parts- schools, businesses, medical, legal etc?
There has to be collaboration between the various community entities and I believe this exists and is improving. But there is still widespread disagreement about the problem--some believe in treatment, others don’t--so the split makes it difficult to allocate taxpayer resources to treatment. There is a role for everyone but again, Gosnold’s position is that if we wait until an individual’s use brings them into contact with police, emergency services, family court, etc. we have let it go too long. Education in the school will help but education alone has not proven to be a significant deterrent to youth use. Restricting access to drugs and alcohol will help but won’t solve the problem. Treatment services will help but if we wait until a person needs professional intervention, we’ve missed the boat. So, the culture of the community has to change to have any lasting effect. There is still too much ambivalence about drug use--“it’s only pot” or “At least he/she is only using alcohol”. These are ridiculous positions and open the society up to the kinds of problems with which we are now struggling.
Dr. Ray Friedman:
I agree 100%. We need more forums like the one we just had. We need more people to speak out. We need more non addicting medications for management of sobriety, once attained. Vivitrol is an opiate blocker. It has no addiction or diversion potential,, it merely blocks cravings and the ability to get high from on opiate. I am fundamentally against using drugs like Suboxone or methadone except in rare cases of long, long term drug addiction and harm reduction, and certainly not for adolescents and young adults. We have to change the whole perception out in the community. If the disease of addiction and specifically substance dependence is recognized early in life, NON OPIATE/OPIOID treatment should be the first choice, not Suboxone or methadone. We are lucky to be living in Massachusetts where most of us are insured, and most of the insurance companies will pay for a great medication such as Vivitrol, that allows individuals to get on with their lives without being strung out on a substitute opioid drug, has no negative connotations, is not divertable, does not keep someone feeling high, yet controls the intense cravings, that so often lead to relapse.
Q18. How can I, a recovering alcoholic and addict, I am extremely suspect of using drugs to treat drug addiction. My concerns range from further enriching the drug companies to substituting one addiction for another. I know addicts who have been taking Suboxone for over a year. They still exhibit addictive behavior. I know heroin addicts who quit cold and work a constructive recovery program- theirs is a stark difference in the quality of their lives. What is the protocol for treating drug addicts?
The recovering community can help educate by talking about their experience and going public. Too much of recovery is hidden under a bushel and the community most often is exposed to the negative consequences of addiction, the newsworthy stories, etc. Medication assisted recovery can help in the early stages but it is not a panacea and without “a program”, most patients will return to active use. There are non-addicting medications that are not like Suboxone that can help. The individual’s program of recovery needs to be tailored to them and monitored by a professional who understands addiction and remains current with the latest research instead of jumping on the pharmaceutical bandwagon each time a new “miracle” drug comes down the pike.
Lisa Murphy, Mashpee Parents Support Group Leader:
Here is an inclusive answer to the questions regarding insurance companies and the pharmaceutical industry.
When your employer negotiates the contract on your insurance it is then that it is decided whether or not it will include detox, IOP (intense outpatient), or long term treatment (30/60/90 day in-patient treatment). many times it is the parents or person searching for treatment that pays out of pocket. Be part of the process if possible when negotiating your contract for coverage of long-term treatment, because long-term treatment should be a "must" with detox. No insurance company should ever have the right to deny a person from long term treatment, even if it costs parents a few dollars extra in their insurance it is better than taking out a 2nd mortgage on their home to pay for treatment.
The pharmaceutical company:
As was said in the beginning of the forum: "It is not about blame." That is true, but it is about "responsibility," today laws have been changed so that "kickbacks" are not given to providers of these medications to push the supply of them, however only a few short years ago this was not the case, which has played a huge role in the epidemic we are in today.
I have proposed that the pharmaceutical companies take an active role in the treatment of these individuals, which includes the pharmaceutical companies pay for long-term treatment or part of a persons long-term treatment, also pay for educating the public on the dangers of these medications, as well as paying for the treatment of individuals who are incarcerated due to crimes related to addiction.
Today we see commercials about the dangers of smoking. When have you seen a commercial on the dangers of pills in your medicine cabinet or in someone else's?. Another state has taken on the pharmaceutical company in court and proved their role in the epidemic their state is in, I believe we need to do the same.
We are being educated on the drugs in our medicine cabinets and thankfully now we have the Internet to look up prescriptions online. (What type of medicine we have; is it an opiate? Is it addictive?) This is our "responsibility" to know what we are dealing with and how to keep it out of the reach of someone else. It is also the "responsibility" of the pharmaceutical company to be part of this process and if no one is willing to take this on, then maybe we should look at telling the pharmaceutical companies "If you want to do business in our state, then you will pay a tax in the state of Massachusetts, from which all dollars will go for these programs."