Medication Assisted Treatment (MAT) for Opioid Dependence in Job Corps

1. Medication Assisted Treatment (MAT) for Opioid Dependence in Job Corps John Kulig, MD, MPH Lead Medical Specialist Office of Job Corps

2. Learning Objectives • Participants will be able to: • Compare medication assisted treatment (MAT) options for opioid dependence • Describe criteria for Job Corps enrollment if an applicant is prescribed MAT • List which MAT services can be provided on center and which cannot • Describe appropriate use of MAT in JC students with mental health comorbidity or pregnancy

3. Definitions • opiate - a drug containing opium or its derivatives - e.g., morphine, codeine, heroin • opioid - any synthetic narcotic that has opiate-like activities, but is not derived from opium – e.g., hydrocodone, oxycodone, fentanyl, methadone • Note: The term “opioid” will be used throughout this presentation to include both opiates and opioids

4. Origins of the Epidemic • Prescribing policies changed in 1990s when patient advocacy groups/pain specialists successfully lobbied state medical boards/legislatures to change statutes/regulations to lift prohibition of chronic opioid use for non-cancer pain.  • In 1996, the American Pain Society (APS) introduced the phrase “pain as the 5th vital sign.” In 2016, AMA and AAFP voted to drop pain as a “vital sign.” • The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced standards for the assessment and management of pain in accredited hospitals and other health care settings. (August 1999) • Allegations that chronic pain was inadequately treated by physicians resulted in a dramatic increase in prescription opioid sales. • Repeated studies have documented a strong and consistent linear relationship between opioid sales volume and morbidity and mortality.

6. Scope of the Problem • Estimated 2.6 million opioid addicts in the US • Average of 142 Americans die each day of opioid overdose – more than motor vehicle crash deaths, HIV deaths and gun deaths at their peak – and the toll continues to rise • In 2014, 467,000 adolescents were current nonmedical users of pain reliever, with 168,000 having an addiction to prescription pain meds • In 2014, an estimated 28,000 adolescents had used heroin in the past year, and an estimated 16,000 were current heroin users

14. Prescription Opioids

15. Heroin

16. Fentanyl • Fentanyl pill, patch, liquid for injection, oral transmucosal lozenges – 80 to 100 times the potency of morphine. • Fentanyl is cheaper to make than heroin and very potent. • Manufacturers can create more doses per batch. • "There's a huge profit margin."

17. Carfentanil • Carfentanil or carfentanyl (also known as 4-carbomethoxyfentanyl) is an analog of the synthetic opioid analgesic fentanyl – 100 times the potency of fentanyl. • Not approved for human consumption - used as a tranquilizer for large animals. • In humans, 20 micrograms is considered a fatal dose - the amount of pure carfentanil that can kill a person is smaller than the average grain of salt.

19. Medication Assisted Treatment (MAT) • In combination with behavioral therapy, MAT is an effective strategy to treat opioid addiction. • Medications work by reducing cravings and withdrawal symptoms. • Mental status is not altered during maintenance therapy. • Withdrawal can be precipitated if the medication is abruptly discontinued rather than slowly tapered.

20. MAT has been shown to … • Increase treatment retention • Reduce opioid use • Reduce risk behaviors that transmit HIV and hepatitis C virus infection • Reduce recidivism • Reduce mortality

21. Treatment Options: MAT

22. Treatment Options: MAT

23. MAT Options 1.) Daily methadone by mouth obtained at licensed clinics only. 2.) Daily buprenorphine/naloxone by mouth (brand name Suboxone). This is a tablet or film that is taken and absorbed under the tongue on a daily basis. It must be prescribed by a physician with specific training and a distinct DEA registration number.  

24. MAT Options 3.) Buprenorphine/naloxone subdermal implant (brand name Probuphine): This must be inserted by a qualified clinician. It is effective for six months and is indicated only for patients on Suboxone 8 milligrams or less daily. Supplemental sublingual Suboxone may be needed. 4.) Monthly naltrexone by intramuscular (IM) injection (brand name Vivitrol).

28. Severity of Opioid-Use Disorder • If two or three items cluster together in the same 12 months, the disorder is mild. • If four or five items cluster, the disorder is moderate. • If six or more items cluster, the disorder is severe. • If the opioid is taken only as prescribed, the need for increased doses or withdrawal when dose is decreased does not count toward a diagnosis of an opioid-use disorder. Diagnostic and Statistical Manual of Mental Disorders, 5th edition

31. COWS Scoring Only signs and symptoms related to opioid withdrawal should be scored: • 5-12 mild withdrawal • 13-25 moderate withdrawal • 25-36 moderately severe withdrawal • > 36 severe withdrawal

32. Summary of Recommendations for Adolescents • Clinicians should consider treating adolescents who have opioid use disorder using the full range of treatment options, including pharmacotherapy. • Opioid agonists (methadone and buprenorphine) and antagonists (naltrexone) may be considered for treatment of opioid use disorder in adolescents. Age is a consideration in treatment, and federal laws and US FDA approvals need to be considered for patients under age 18. • Psychosocial treatment is recommended in the treatment of adolescents with opioid use disorder. • Concurrent practices to reduce infection (e.g., sexual risk reduction interventions) are recommended as components of comprehensive treatment for the prevention of sexually transmitted infections and blood-borne viruses. • Adolescents may benefit from treatment in specialized treatment facilities that provide multidimensional services. ASAM National Practice Guideline 2015

33. Opioid Agonists: Methadone and Buprenorphine • Agonist medications are indicated for the treatment of patients who are aged 18 years and older. • The Federal Code on opioid treatment – 42 CFR § 8.12 – offers an exception for patients aged 16 and 17 years, who have a documented history of at least two prior unsuccessful withdrawal management attempts, and have parental consent. • ASAM National Practice Guideline 2015

34. Job Corps and MAT • Directive: Job Corps Program Instruction Notice No. 16-21 • Medication Assisted Treatment (MAT) for Opioid Addiction in Job Corps • Issued November 18, 2016 • Purpose: To provide guidance on using MAT for opioid addiction on Job Corps centers

35. Use of MAT in Job Corps • Increasing numbers of applicants are presenting in the maintenance phase of MAT for opioid addiction. Job Corps may be able to serve students in the maintenance phase of MAT where community resources are available. • Access to MAT is especially difficult from rural or remote Centers. It is recommended that students be placed in or transferred to Centers where MAT is available in the community. • Centers should explore the availability of MAT and compile a list of resources in their community. • Centers can locate a certified buprenorphine treatment physician by city, state and zip code using the SAMHSA website: http://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator

36. MAT and Disability • Under Federal non-discrimination laws, Job Corps students who no longer engage in the illegal use of drugs and who have been successfully rehabilitated or who are currently participating in a supervised rehabilitation program may qualify as students with a disability, and may be eligible for reasonable accommodations. • An applicant or student who is successfully completing MAT for opioid addiction will most often be entitled to reasonable accommodations in order to participate in the program since he or she is no longer using illegal drugs and is participating in a supervised rehabilitation program. • Daily transportation costs to the students’ supervised rehabilitation program, if required, should be covered by centers as part of reasonable accommodations for their disability.

37. Payment for MAT • Although centers may have obligations to reasonably accommodate students undergoing MAT, individual students are responsible for the cost of MAT. Per Policy and Requirements Handbook (PRH) Chapter 6, Exhibit 6-4 Job Corps Basic Health Care Responsibilities, Job Corps does not cover substance abuse treatment or long term therapy. • MAT is expensive as it includes the cost for office visits, medications, urine drug testing, and individual/group therapeutic services. Most addiction treatment centers have policies that require health insurance as it discourages illegal activity to pay for services. In most states, Medicaid covers the cost of MAT.

38. Advance Planning • Advanced planning is critical to ensure that all services are in place prior to arrival in order to avoid interrupting treatment and risking withdrawal and opioid use relapse. • Consider choice of center and residential status based upon availability of treatment services nearby. If the student’s use of MAT is disclosed during the application process, this should be established prior to enrollment, as in many areas waiting lists for MAT are extensive and establishing access as a new patient is difficult.

39. Advance Planning • The center is responsible for obtaining treatment records from off-center providers regarding the monitoring process of MAT, in order to provide continuity of care on center. Transmission and storage of medical information must be HIPAA compliant as outlined in PRH Appendix 607. • If students do not disclose use of MAT on their ETA 6-53 Job Corps Health Questionnaire and arrive on center without prior notification, the center should determine whether MAT is available in the community. • If MAT is not reasonably available in the community, the center should follow steps for separation or transfer to a center where MAT is available in the local community.

40. MAT and Mental Health Comorbidity • Essential that substance use disorder and psychiatric diagnoses both be addressed • Potentially lethal drug interactions with alcohol and/or benzodiazepines • Off-center clinician may obtain urine drug testing for ethyl glucuronide(EtG) and specific benzodiazepines (illicit or prescribed)

41. MAT and Pregnancy • Harm reduction approach • Continued MAT preferable to relapse or withdrawal symptoms • Switch to Subutex – buprenorphine only – or switch to methadone • Risk of neonatal abstinence syndrome/ neonatal opioid withdrawal syndrome • Buprenorphine can be used when breastfeeding

42. Medications on Center • Methadone cannot be stored in the Wellness Center – must be administered daily off center at a licensed clinic • Suboxone can be stored in the Wellness Center and administered daily on center • Vivitrol injections can be stored in the Wellness Center and administered monthly on center

43. Suboxone[buprenorphine-naloxone] • sublingual film or tablet – no effect if swallowed – multiple strengths – typical dose 8/2 mg – 16/4 mg each morning – single daily dose • must be prescribed by a clinician with a DATA-2000 waiver – 8 hours of training – unique DEA number – patient limits (30/100/275) • Schedule III drug, not Schedule II • “15-15-15” method – no eating, drinking, smoking, talking for 15 minutes before, during and after self-administration • may use a drop of warm water under tongue for dry mouth

44. Case Management • Case management on center should involve the Center Physician (CP), Center Mental Health Consultant (CMHC), and Trainee Employee Assistance Program (TEAP) specialist. • Access to addiction treatment services beyond medications is essential for successful remission and enhanced employability. While most of these services would be utilized off center, some components might be incorporated in the TEAP on center.

45. Urine Drug Testing • MAT includes periodic urine drug testing as part of the monitoring process. • Urine drug testing is part of MAT treatment and is to be done off-center outside the scope of Job Corps’ drug testing program. • Urine drug screening as part of the on-center admissions process is not impacted by MAT. Buprenorphine, methadone, naloxone, and naltrexone will not result in a positive urine drug screen with the current CDD panel.

46. Resources Online • http://www.nejm.org/doi/full/10.1056/NEJMra1604339#t=article – Schuckit MA. Treatment of Opioid-Use Disorders N Engl J Med 2016; 375:357-368 • https://www.naabt.org/education.cfm - The National Alliance of Advocates for Buprenorphine Treatment • https://www.drugabuse.gov/drugs-abuse/opioids - NIDA information on opioids • http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf - ASAM facts and figures 2016