Kim Castelnovo, RPh Pharmacy Manager, Community Care

1. Decreasing the Use of Prescription Opiates and Benzodiazepines Among Individuals Enrolled in Methadone Programs Kim Castelnovo, RPhPharmacy Manager, Community Care

2. About Community Care • Behavioral Health Managed Care Company • Founded in 1996 • Statewide HealthChoices presence; 39 of 67 Pennsylvania counties • 10 offices across the Commonwealth • Over 600 employees

3. About Community Care • Medicaid/HealthChoices membership: 725,000 • Commercial/Medicare membership: 450,000 • Approximately 110,000 people served annually • Statewide network of approximately 1,600 providers

4. Serving 39 Counties Erie Warren Susquehanna McKean Potter Tioga Bradford Crawford Wayne Forest Wyoming Cameron Sullivan Lackawanna Pike Venango Elk Lycoming Pike Mercer Clinton Jefferson Luzerne Clarion Columbia Monroe Lawrence Montour Clearfield Centre Union Butler Carbon Armstrong Northumberland Snyder Northampton Beaver Mifflin Schuylkill Lehigh Indiana Juniata Allegheny Blair Berks Perry Dauphin Bucks Cambria Lebanon Huntingdon Westmoreland Montgomery Washington Cumberland Lancaster Bedford Fayette Chester Somerset Franklin York Philadelphia Greene Fulton Adams Delaware Community Care Office

5. Overview • Opiate and benzodiazepine use in individuals in methadone programs • With overdose deaths from heroin and prescription pain medications increasing in the U.S., opioid addiction is an important concern for Medicaid programs • Medicaid beneficiaries have higher rates of opioid addiction than other insured groups

6. Benzodiazepine Use and Misuse • Among patients in a methadone program – BMC Psychiatry, May 2011: • Benzodiazepines (BZD) misuse and abuse is a serious public health problem in the U.S. • This problem is especially pertinent among those with opiate dependence because these individuals are more likely to experience elevated anxiety after stopping use of opiates • It has been shown that individuals who abuse BZD are at increased risk of continuing opiate abuse and failing to stay in methadone treatment

7. Benzodiazepine Use and Misuse • In a Baltimore methadone program: • Survey conducted at a methadone treatment program in Baltimore • 194 questionnaires were included in the final data analysis • 47% reported using BZD with/without a prescription • 25% said that their initial use began with a prescription • 54% did not start using BZD until after entering the methadone program

8. Benzodiazepine Use and Misuse • Among patients in a methadone program the main reasons given for using BZD without a prescription: • Curiosity • To relieve tension or anxiety • To feel good • To get high • To overcome depression or frustration

9. Benzodiazepine Use and Misuse • When asked patients in a methadone program if they would consider reducing or stopping the use of BZD if the methadone program could provide help that would work: • 40% said “Yes, definitely” • 7% said “Maybe” • 19% said “No” • 33% had already stopped using BZD

10. Benzodiazepine Use • Among Community Care Medicaid enrollees: • Analysis includes data for 39 Community Care counties • Number of unique members per year filling benzodiazepines • Benzodiazepine use very low among children and adolescents • Adult benzodiazepine Use ranges from 13-24% of Medicaid enrollment among Community Care counties

11. Opiate Use • Among Community Care Medicaid enrollees: • Analysis includes data for 39 Community Care counties • Number of unique members per year filling four or more opiate scripts • Opiate use very low among children and adolescents • Adult opiate use ranges from 11-21% of Medicaid enrollment among Community Care counties

12. A Quality Improvement Initiative Between Counties, Methadone Providers, and Community Care Community Care Methadone Provider Initiative

13. Objective • To identify members enrolled in methadone treatment programs who are concurrently filling benzodiazepine and /or opiate prescriptions • Collaborate with methadone providers to reduce the incidence of concurrent utilization and ultimately improve care

14. Intervention • Community Care generates member reports on a monthly basis and sends to the methadone providers in Allegheny County • Member report includes medications filled and prescriber information • Methadone provider uses the information to help address any clinical issues with the member

15. Frequency of Benzodiazepine Use

16. Frequency of Opiate Use

17. Assessing Impact of Interventions • Members with at least 10 days of Methadone Claims = 636

18. Assessing Impact of Interventions • Members with at least 10 days of Methadone Claims = 485

19. Comparison

20. Conclusions • The decrease in concurrent medication over the past four years is encouraging • Provider feedback has been very positive about this initiative • Providers have adopted new policies when caring for individuals on concurrent benzodiazepines or opiates to ensure appropriate use

21. Collaboration of Care Implementation GuidelinePresented by:Sara Remaley, MSPC, CAADC, Clinical Supervisor WPIC NATPValerie Gualazzi, MS, CADC, Program Director WPIC NATPWestern Psychiatric Institute and Clinic

22. Western Psychiatric Institute and Clinic Narcotic Addiction Treatment Program (NATP) -Addiction Medicine Services • WPIC NATP is a clinic specializing in opioid dependency in addition to psychiatric comorbidity. • WPIC offers methadone maintenance treamtent, suboxone treatment, psychiatric care and medication management, mental health, and addiction therapy. • WPIC currently treats approximately 420 patients on a regular basis.

23. Rationale • NATP recognized a need to address the misuse and abuse of prescription benzodiazepines by patients enrolled in medication assisted treatment. • High rates of patients were enrolling in treatment and concurrently becoming addicted to and abusing benzodiazepines, posing health risks, adverse effects, and ultimately untimely discharge from treatment.

24. Collaboration of Care • 2012- WPIC NATP redesigned the program’s philosophy and position regarding concurrent use and abuse of prescription benzodiazepines and opiates while taking methadone. • Contraindications and potential for adverse effects helped NATP move in the direction of ‘therapeutic no tolerance’. • The “Collaboration of Care” Procedure : indicating NATP’s willingness to work with patients currently on prescription benzodiazepines to taper off and receive evidence based interventions and seek alternative treatment options as needed.

25. Collaboration of Care • The Collaboration of Care Procedure was developed as a way to inform patients of the new treatment philosophy indicating: use of benzodiazepines and opiates while on methadone is no longer permissible. • With the understanding that tapering from these type of medication can be a difficult and lengthy process with potential for relapse, NATP developed a procedural guideline to assist both patients and staff through this new process.

27. Barriers to addressing bzd use: • Difficult tapering process, risk related to withdrawal symptoms, and potential need for medically supervised detoxification. • High Relapse rates with benzodiazepines. • Concurrent rates of psychiatric comorbidity and the need to address/treat underlying mental health conditions. • Collaborating with providers (prescribing physicians) vs. illicit street use. • Addressing diversion…How does this fit?

28. Let the collaboration begin…. • Step 1: Staff Education • Development of Procedural Guideline highlighting philosophy, procedures and interventions, and processes for team to follow. • Step 2: Patient Education • An FAQ was developed and handed out to all patients indicating the new Collaboration of Care and Program Philosophy regarding Concurrent use of benzodiazepines while in treatment.

29. FAQ

30. Step 3: Patient Acknowledgement and Responsibilities: • Reviewing the new philosophy and Collaboration of Care with patients, and asking them to acknowledge with their signatures that they have been informed. • A part of this process is also to explain to patients, the risks, as well as their rights. Albeit patients may reserve the right to refuse collaboration, they are also informed how this may directly impact their ability to remain in treatment.

31. Step 4: Interventions • Once the Collaboration of Care is initiated, the following procedures /interventions may be followed: • Urine Drug Screens and CCBHO Report reviewed. • Contact with the prescribing physician (physician to physician) to discuss recommendations and to create a tapering regimen. • Pill Counts • Illicit Street Use: Assessing need for medically supervised detoxification. Resources: Mercy Hospital Emergency Room, WPIC DEC (Diagnostic Evaluation Center). • UDS Confirmatory tests to determine if “levels” are decreasing- indicating progress/regression.

32. Interventions Continued: • Assessing underlying mental health and psychiatric disorders such as anxiety, depression, mood disorder, bipolar disorder, etc. Choosing a modality to effectively work with and treat these disorders in addition to addiction. • CBT, REBT, Gestalt Therapy, DBT, Motivational Interviewing, Person Centered etc. • Modifying treatment plans: Increasing therapy, regular appointments with Psychiatrist, following a medication regimen, ongoing collaboration. • Maintaining focus on individualized care through individualized recommendations. Assessing Progress: How is this done? Regular team meetings and supervision.

33. Response to Interventions • What happened after the Collaboration of Care was initiated? • NATP experienced responses similarly associated with the Change Curve (Kubhler-Ross) • Shock, Denial, Anger, Acceptance, Integration

34. Response to Interventions • How long did it take before a change was noticeable? • Integration took time and CONSISTENCY IS KEY • Response to change implementation included: • Compliance and Collaboration. • Increase in individual/group therapy- engagement in regular psychotherapy. • Increase in psychiatric treatment and psychopharmacology. • Exacerbation of symptoms/negative behaviors. • Increase in referrals to Higher LOC’s. • Decrease in bzd rates. • Increase in compliance/privilege status.

35. Evaluating Effectiveness • Establishing pre and post intervention baselines: • Rates of bzd use/abuse among patients. • Urine Drug Screen Results (including break-down of levels) • Individualized Progress • Relapse rates • Decrease in attaining prescriptions. • Patient Discharges • Sustained abstinence

36. Summary • Addressing concurrent use/abuse of benzodiazepines through the following steps: • Develop Program Philosophy • Identify Perceived Barriers • Education Staff • Educate Patients • Identify intervention strategies and evidenced based practices • Identify pre and post intervention baseline data

37. “Meeting Needs …..Renewing Life” Timothy H. Reese, M.D., MRO, SAP Medical Director 1425 Beaver Avenue Pittsburgh, PA 15233 Phone: 412-322-8415 Ext. 109 Fax: 412-322-9224/421-322-3352 “Decreasing the use of prescription opiates and benzodiazepines among individuals Enrolled in methadone programs”

38. HISTORY OF TADISO ESTABLISHED IN 1968 AS NON-PROFIT 700 PATIENTS—24 FULL TIME COUNSELORS—1 MEDICAL DIRECTOR 1 PA. POPULATION: 2/3 NON-HISPANIC WHITE AND 1/3 AFRO-AMERICAN AND OTHER

39. DEMOGRAPHICS NON-HISPANIC WHITES 20-44 YEARS…….FASTEST NON-HISPANIC WHITES 20-34 YEARS………FASTEST OF THE FAST NON-HISPANIC WHITES 20-34 YEARS………SHOOTING MORE NON-HISPANIC WHITES 20-44 YEARS……….INHALING MORE

40. PENNSYLVANIA 2008-2012 PERSONS ENROLLED IN SUBSTANCE ABUSE TREATMENT PROGRAMS WHICH PRESCRIBED METHADONE INCREASED 18.9%

41. MESSAGE WE ARE IN THE MIDST OF AN EPIDEMIC OF OPIOID ADDICTION AND ITS DEVASTATING TOLL ON SOCIETY! METHADONE IS AND CAN BE AN EVEN GREATER PART OF OUR ARSENAL AGAINST THIS DEADLY FOE!

42. PATHOPHYSIOLOGY OF OPIOID ADDICTION --MEDULLA LOCUS CAERULEUS---90% OF CATECHOLAMINES IN CNS --RESPONSIBLE FOR THE VEGETATIVE FUNCTIONS OF THE ORGANISM (SUPPORT LIFE) --THERMOSTAT ANALOGY AND THE OPIOID WITHDRAWAL SYNDROME

43. CLINICAL MANIFESTATIONS OF OPIOID WITHDRAWAL VITAL SIGNS: TACHYCARDIA HYPERTENSION FEVER

44. CLINICAL MANIFESTATIONS OF OPIOID WITHDRAWAL CENTRAL NERVOUS SYSTEM: RESTLESSNESS IRRITABILITY INSOMNIA CRAVING YAWNING

45. CLINICAL MANIFESTATIONS OF OPIOID WITHDRAWAL MUCOCTANEOUS: RHINORRHEA EYES: LACRIMATION PUPIL DILATION SKIN: PILOERECTION (GOOSEFLESH)

46. CLINICAL MANIFESTATIONS OF OPIOID WITHDRAWAL GASTROINTESTINAL TRACT: NAUSEA VOMITING DIARRHEA

47. CLINICAL MANIFESTATIONS • OF • OPIOID WITHDRAWAL • PSYCHOSOMATIC WITHDRAWAL? • PSEUDO-WITHDRAWAL? • REAL WITHDRAWAL?

48. CLINICAL MANIFESTATIONS OF OPIOID WITHDRAWAL *ACCIDENTAL OVERDOSE AFTER A SUCCESSFUL DETOXIFICATION*

49. CLINCAL MANIFESTATIONS OF OPIOID WITHDRAWAL MU-AGONIST EFFECT WITH BEGINNERS!

50. DOPAMINE ----VTA/NUCLEUS ACCUMBENS (FOREBRAIN) DRUG ABUSE DUMPS MASSIVE AMOUNTS OF DOPAMINE INTO THIS AREA. REINFORCES BEHAVIOUR THAT IS PARAMOUNT TO SURVIVAL OF THE SPECIES