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Medication Assisted Therapy (MAT) for Opiate Addicted Persons Incarcerated in New Mexico Bruce G. Trigg, MD Medical Director, Public Health Program, Bernalillo County Metropolitan Detention Center Mary Murphy, AA, CPhT, CADS Suboxone Project Coordinator . Louise .

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  1. Medication Assisted Therapy (MAT) for Opiate Addicted Persons Incarcerated in New MexicoBruce G. Trigg, MD Medical Director, Public Health Program, Bernalillo County Metropolitan Detention CenterMary Murphy, AA, CPhT, CADSSuboxone Project Coordinator

  2. Louise • Incarcerated 25 year old Hispanic female with 10 year hx of daily IV heroin use attends screeningt of video “Hope and Health – Release, Relapse, & Treatment”(http://echo.unm.edu/dvd_mel.shtml) at BCMDC • Brief interview and SA/medical hx. obtained by Public Health staff. Is given instructions and prescription for 4 tablets of buprenorphine/naloxone (Suboxone) 8/2 mg for post-release. • Picks up medication three days after release and is seen at Dept. of Health (DOH) Suboxone clinic two days later. Has not relapsed.

  3. Louise – continued • Sees clinician and is given one wk prescription for Suboxone. Has urine drug test, liver function tests, HIV, hepatitis C antibody test, RPR, GC/CT urine test, and urine HCG. • Immunization records are checked; completed hepatitis B, is given first hepatitis A vaccine, pneumovax (one pack per day smoker), seasonal and H1N1 vaccine. • Signed up for Harm Reduction Program. Is given 30 syringes and two 2 mg vials of Naltrexone (Narcan) with nasal applicator.

  4. Louise - continued • Over next week meets with Case Manager and signs up for public health insurance program. • Keeps FP appointment at DOH. Starts Depo Provera. • Placed on wait list to see SA treatment counselor. Attends NA meetings. • Seen weekly in Suboxone Program for four weeks. • Is given appt. with PCP at FQHC in one month. • Continues at DOH program until PCP appt. Insurance now pays for Suboxone ($30 to $60 monthly out of pocket)

  5. Louise – continued • Patient reports one relapse to heroin – states she did not get “high.” • 3 months later continues on Suboxone maintenance Rx. Attends classes at community college and is working to regain custody of children.

  6. We now have the tools available to offer evidence-based, effective, comprehensive, humane treatment and services for people who are addicted to heroin and other opiates. Public health departments can take the lead in providing these services or can assure that they are available in every community.

  7. Picture of opiate addiction: heroin

  8. Picture of opiate addiction: pain pills

  9. Public Health Impact of Opiate Addiction in NM • Estimated 23,000 IV drug users – mostly heroin • High rates of overdose deaths. • Two NM counties are among top 25 in nation for drug-induced poisoning deaths • 32,000 on hepatitis C registry

  10. HIV, HBV, and HCV Among Injection Drug Users in New Mexico Samuel MC, Doherty PM, Bulterys M, Jenison SA Epidemiol. Infect. 2001 Dec;127(3):475-84

  11. The New Mexico Harm Reduction Act (1997) The NM Dept. of Health shall: • Establish and administer a harm reduction program for the purpose of sterile hypodermic syringe and needle exchange. • Compile data to assist in planning and evaluation efforts to combat the spread of blood-borne diseases. This statute makes access to clean injection equipment a right rather than a privilege in New Mexico.

  12. New Mexico Harm Reduction Program • Since 1998, over 12 million syringes have been collected and disbursed to over 12,000 individuals. • Currently 12 contractors (fixed and mobile), 2 primary care clinics, and 29 PHOs. • Since 2001, >5000 individuals trained in OD prevention and given naloxone • >1500 OD reversals documented (3/31/09)

  13. Prevalent HIV/AIDS by Mode of Exposure, New Mexico, 2007 Source: NMDOH, HIV & Hepatitis Epidemiology Program; Mar 2008.

  14. Bernalillo County Metropolitan Detention Center (MDC) • Opened June, 2003 • Construction cost: $100 million • Annual budget: $60 million • Medical services – Correctional Medical Services (CMS) • 35th largest jail in U.S. • Current populaton -2700 • 40,000 bookings/year • > 20% with 2 or more admissions • 60% leave within 72 hours • Average length of stay: 90 days

  15. Public Health Program at MDC • Opened Jan. 2004 – 6 mos. after jail Operates under MOA between state and jail • Staff: FT nurse manager, clerk, physician (one day a week), nurse practitioner (two days a week) • hepatitis immunizations and hepatitis C – 2 RNs • HIV Early Intervention/Infectious Disease RNs

  16. Public Health Programs at MDC • Family planning using federal Title X funding • Contraception, Pap smears, STD testing • STD control: screening, treatment, partner notification services • Hepatitis - testing, immunizations, education, follow-up by DOH contracted nurses • HIV screening by DOH contractors • Referrals to community services

  17. Medication Assisted Therapy • A medical model for the treatment of opiate dependence. • Treats opioid dependence as a chronic, relapsing disease. • The substitution of an opiate-like medication to prevent withdrawal and minimize craving for opiates. • Effective medications – methadone or buprenorphine

  18. NIH Consensus Statement 1997 “All opiate-dependent persons under legal supervision should have access to methadone maintenance therapy…” Effective Medical Treatment of Opiate Addiction. NIH Consensus Statement 1997 Nov. 17-19;15(6):2

  19. Treating Drug Abuse and Addiction in the Criminal Justice System Improving Public Health and Safety Conclusions: • Addiction is a chronic brain disease with a strong genetic component that in most instances requires treatment. • The criminal justice system provides a unique opportunity to intervene for individuals who would otherwise not seek treatment. JAMA, January 14, 2009 – Vol 301, No.2

  20. Treating Drug Abuse and Addiction in the Criminal Justice System Improving Public Health and Safety Conclusion: • “Punishment alone is a futile and ineffective response to drug abuse, failing as a public safety intervention for offenders whose criminal behavior is directly related to drug use.” JAMA, January 14, 2009 – Vol 301, No.2

  21. MDC Methadone Maintenance Treatment (MMT) Program • Started November 2005 • Voluntary treatment by private contractor for those currently enrolled in MMT and pregnant women • No charge; public funding ($200K) • 40 to 60 doses/day • 2000 enrolled by end 2008 • Follow up shows that most return to community clinic after release

  22. A New Medication Assisted Rx: Buprenorphine • Drug Addiction Treatment Act of 2000 (DATA 2000) allows office-based prescription by PCPs • FDA approves Subutex® and Suboxone® sublingual tablets for opioid addiction rx 2002 • Product launched 2003

  23. Buprenorphine • Partial agonist - safer than methadone (less overdose potential) • Combined with naloxone (Narcan) as “Suboxone” • causes withdrawal if injected when other opiates are present • decreases value as street drug • naloxone not active when taken by sublingual route • Long-term maintenance treatment generally necessary

  24. Intrinsic Activity: Full Agonist (methadone), Partial Agonist (buprenorphine), Antagonist (naloxone) death 100 90 Full Agonist (methadone) 80 70 Intrinsic Activity 60 Partial Agonist analgesia 50 (buprenorphine) 40 30 20 10 Antagonist (naloxone) 0 -10 -9 -8 -7 -6 -5 -4 Log Dose of Opioid

  25. RCT of buprenorphine 40 Heroin addicts Buprenorphine 8mg/day vs taper + placebo All received counseling, groups Followed for 1 year Kakko et al, Lancet 2003

  26. Buprenorphine Patient Outcomes: Specific Criminal Activities Percent of Patient Sample n=379 Source: SAMHSA Patient Longitudinal Study, November 2005

  27. Buprenorphine and heroin overdose • Increasing use of buprenorphine in France associated with 1,2 • Decrease in arrests for heroin (77% decline since 1995) • Decrease in overdose deaths (81% decline since 1995) • Auriacombe 2004, Am J Addict;13. • Lepere 2001, Ann Med Interne (Paris);152 Suppl 3.

  28. DOH Buprenorphine in Las Cruces, NM – started in 2007 • Provides free Suboxone maintenance program for opiate dependent persons • Uses Suboxone for opiate withdrawal in jail – funded by county government • Suboxone maintenance at jail for those on treatment at time of arrest • Referrals to DOH for continuation of Rx after release • Treatment of hepatitis C with support of UNM ECHO Program (telemedicine)

  29. Department of Health Suboxone Induction Program Albuquerque, NM Started November 2008 – over 200 inductions Uninsured heroin injecting drug users Priority populations: - personsrecently released from MDC (http://echo.unm.edu/dvd_mel.shtml) - pre-release Suboxone Prescription Program - harm reduction clients -Provides two months free Suboxone Clients enrolled in public insurance program

  30. Department of Health Suboxone Induction Program • Case management and counseling referrals • Public health services: harm reduction (SEP and naloxone), STDs, family planning, TB, hepatitis, immunizations • Referral to PCP for continuation of office-based treatment • Initial funding $40,000 first year for medication • Program staff: 0.5 FTE coordinator • 3 physician prescribers, 2 NPs see patients

  31. Total physician/NP visits – 681 Males – 127 Females – 74 Hispanic – 114 Anglo – 57 Known HCV + 73 Tested for HCV – 86 Tested HCV+ 39 (45%) HIV tests – 120 all neg. RPRs – 83 – 1 pos. GC/CT tests – 60 tested – 10% positive Av. Injections/wk before Rx – 25 Av. injections/wk after Rx – 0.57 Hepatitis A vaccines – 41 Hepatitis B vaccines – 22 Combined A/B – 41 Pneumovax – 71 Referred by MDC – 39 Albuquerque Suboxone Induction Program - first 200 patients

  32. Santa Fe DOH Suboxone Program • Newest DOH program • 12 clients currently enrolled • Maintenance program – no public insurance • County jail continues persons on Suboxone who were on rx at time of arrest

  33. Albuquerque Healthcare for the Homeless • $2 million CSAT grant to link 100 recently released inmates/year X 5 • Pays for one year of buprenorphine maintenance in primary care setting • Case management and other psychosocial support services

  34. Bernalillo County Government and MDC • Currently funds DOH Suboxone Program • MDC medical contractor provides Suboxone for persons on rx at time of arrest – 15 currently on Rx • Plan to use Suboxone for opioid withdrawal syndrome • Over 3,000 “detoxed” annually • Drug courts, parole/probation, community custody programs allow Suboxone rx. • Planning a large outpatient Suboxone rx program

  35. Why Public Health Can Link Traditional Public Health Programs, Harm Reduction and Rx of Addiction? Allows us to address complex and seemingly intractable and interconnected public health issues - HIV, STDs, Hepatitis B and C, opiate addiction, OD deaths, the health impact of mass incarceration End of federal ban on funding of SEPs will increase our role in harm reduction interventions for IDUs.

  36. Why Public Health? • “Safety net” role - private sector generally not engaged • Extensive experience working with impoverished, disenfranchised, marginalized, and stigmatized populations.

  37. Why Public Health? • Strong commitment to addressing disparities/inequities and understanding of social determinants of health • Experience working with/in correctional settings. • Surveillance, evaluation, health education, prevention orientation. • Public policy expertise. • NO ONE ELSE IS GOING TO DO IT!

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