Media Wiki - User contributions [en]

Adopt Universal Screening for Pregnant Women

2021-04-06T20:16:58Z

Mredden:

<div class="wiki" id="content_view" style="display: block">
Return to  [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]]

__TOC__

= <br/> Overview =

Another potential strategy is to universally screen all pregnant women for substance abuse.

= Key Information =

= Relevant Research =

 In Kaiser Permanente's [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3057720/ Early Start ]program, pregnant women were screened for substance abuse risk at the first prenatal visit by a self-administered questionnaire and by urine toxicology testing (with signed consent). Universal screening facilitates early identification and treatment of substance use.<sup class="reference">[1]</sup><br/> <br/> '''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3057720/ Early Start: An Integrated Model of Substance Abuse Intervention for Pregnant Women] - Kaiser Permanente'''<br/> ''Overview of program'':

*Universally screen all pregnant women
*No mandated reporting for toxicology
*Mental health provider apart of obstetric care
*Use video conferencing and telephone to provide care to immediate and remote care

''Outcome Successes'':

*Show decrease in morbidity for mothers and babies
*Cost beneficial
*Reduces all barriers to care, including in prenatal care

'''[http://www.ajog.org/article/S0002-9378(16)30383-0/fulltext#tbl4 The role of screening, brief intervention, and referral to treatment in the perinatal period -- Tricia E. Wright, MD, MS]'''<br/> ''Method'':

''Screening Instruments:''

*CAGE -- Cut down, Annoyed, Guilt, Eye opener
*T-ACE -- Takes, Annoyed, Cut down, Eye opener
*TWEAK -- Tolerance, Worry, Eye opener, Amnesia, Cut down
*4Ps -- Past, Present, Parents, Partner
*NIDA Quick Screen -- Uses 3 open-ended questions regarding alcohol, tobacco, and other drugs

''Key Screening Conclusions:''

*Screening should be done for all pregnant women and throughout pregnancy for those at risk
*Screening can be done by a provider using a validated instrument during follow-up or by asking standardized questions during interview
*Screening must be nonjudgemental and open-ended
*Urine toxicology should not be used in place of screening

= Impactful Federal, State, and Local Policies =

= Promising Practices for Standardized Screening =

== Indiana State Department of Health ==

In 2014, because of the high rate of opioid prescriptions, the Indiana General Assembly charged the Indiana State Department of Health (ISDH) to: develop a standard clinical definition of NAS and a standardized process of identifying it, identify the resources hospitals need to do this, and then establish a voluntary pilot program with hospitals to implement this standardized NAS identification. As of 2016, 26 of 89 Indiana Birthing Hospitals are taking part in this pilot screening program

  To understand and address perinatal substance use, accurate data needed to be collected through '''standardized screening and testing:'''

*When any pregnant arrives at the hospital for delivery, hospital personnel conduct a standardized and validated verbal screening regarding substance use.
*Any woman with a positive verbal screen at any point during pregnancy, including at presentation for delivery, is requested to consent to a urine toxicology screening.
*Babies whose mothers had a positive verbal screen or toxicology screen, or babies whose mothers did not consent to the toxicology screen will be tested for evidence of maternal substance use using the infant’s umbilical cord.
**Note: Umbilical cord testing, not meconium stool, was used on all infants.
*Babies also have modified Finnegan scoring initiated to observe for signs and symptoms of NAS.

ISDH noted that universal screening in a [[Shift_from_Punishment_to_Treatment_Approach_for_Opioid_Users|non-punitive]] environment would allow us to understand the true prevalence of Perinatal Substance Use and NAS.<sup class="reference">[2]</sup><br/> <br/> ''See [[Improve_Identifying_and_Data_Collection_on_NAS|Improve Identifying and Data Collecting on NAS]] for more information on defining, testing, and reporting data about NAS.''

= Available Tools and Resources =

[[TR_-_Adopt_Universal_Screening_for_Pregnant_Women|TR - Adopt Universal Screening for Pregnant Women]]

----

= Sources =

#[http://onlinelibrary.wiley.com/doi/10.1111/1552-6909.12531/full [1]]
#[http://www.amchp.org/programsandtopics/BestPractices/InnovationStation/ISDocs/Perinatal%20Substance%20Use.pdf [2]]
</div>
[[Category:SAFE-Full Spectrum Prevention]]

Enhance Collaboration among Medical, Behavioral & Social Services for Mothers with SUDs

2021-02-08T17:21:33Z

Mredden:

<div class="wiki" id="content_view" style="display: block">
Return to [[Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_During_Opioid_Use|Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy During Opioid Use ]]<span style="font-size: 13px;">or </span>[[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]]

= Overview =

<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">Collaborative practice between the dependency court, child welfare, substance use treatment, and other services systems offers a multitude of practical strategies and solutions to improve outcomes for child welfare involved families affected by substance use disorders. Collaborative practice results in a wider realm of resources to address the complex needs of families than is traditionally available through one system. Families present with complex needs that the child welfare system cannot address alone. For instance, children affected by trauma and pre-natal substance exposure often require interventions and treatment, in addition to substance abuse and mental health treatment provided to parents. Emphasis on treatment interventions and supports that focus only on children or parents separately, often result in fragmented and uncoordinated care. Collaborative policies and practices are required to provide access to family-centered interventions that can address the multiple needs of families. Evidence is now emerging that collaborative policy and practice positively influence five core outcomes, or the 5Rs, for families in the child welfare system impacted by substance use disorders <ref>https://ncsacw.samhsa.gov/files/Forum_Brief_FINAL_092314_reduced_508.pdf</ref>:</font></span>

*Recovery: Parental recovery from substance use disorders
*<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">Remain at Home: More children remain in the care of parents</font></span>
*<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">Reunification: Increased number and timeliness of parent-child reunification</font></span>
*<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">Recidivism: Decreased incidence of repeat maltreatment</font></span>
*<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">Re-entry: Decrease in number of children re-entering out-of-home care</font></span>

see Tools & Resources for training examples

= Key Information =

<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">In 1997, the Adoption and Safe Families Act (ASFA) was enacted to address child welfare cases that lingered in the court system while parents cycled in and out of treatment. The legislation created a need to find effective responses to substance abuse and maltreatment within families. Five national reports followed addressing the co-occurring issues of parental substance abuse and child abuse and neglect <ref>https://ncsacw.samhsa.gov/files/Forum_Brief_FINAL_092314_reduced_508.pdf</ref>. These reports are:</font></span>

*Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy (Child Welfare League of America, 1998)
*<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Users (U.S. General Accounting Office, September 1998)</font></span>
*<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">No Safe Haven: Children of Substance-Abusing Parents (The National Center on Addiction and Substance Abuse at Columbia University, 1999)</font></span>
*<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">Healing the Whole Family: A Look at Family Care Programs (Children’s Defense Fund, 1998)</font></span>
*<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection (Dept. of Health and Human Services, 1999)</font></span>

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Practices =

<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">Models of collaborative intervention vary widely in approach. They include innovative strategies such as <ref>https://ncsacw.samhsa.gov/files/Forum_Brief_FINAL_092314_reduced_508.pdf</ref>:</font></span>

*C<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">o-location of substance abuse specialists in child welfare offices or dependency courts</font></span>
*<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">Family Drug Courts or Dependency Drug Courts</font></span>
*C<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">ollaborative case management and planning</font></span>
*D<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">evelopment of collaborative structures</font></span>
*W<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">raparound services</font></span>
*I<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">mproved cross-system communication protocols</font></span>
*C<span style="font-size:small;"><font style="background-color: rgb(255, 255, 255);">ross-agency training of staff</font></span>

== Promising Programs ==

=== Project Nurture ===

'''[http://www.healthshareoregon.org/transforming-health-together/care-innovations/maternal-child-and-family-wellness/project-nurture.html Project Nurture] - Health Share of Oregon'''<br/> ''Program Highlights (NUR)''

*Team-based approach to prenatal care that includes prenatal clinician, addictions specialist, mental health support, case management, peer support and parenting resources
*Clinic and organizational leadership with program accountability and resources
*Transparent, standardized process for screening and monitoring for substance use and for DHS involvement
*Strong commitment to a planned, coordinated approach to the inpatient maternity stay, with protocols for pain management, DHS and social work involvement and discharge planning
*Extended postpartum support lasting a full year, with pediatric care integrated with the mother’s care, ongoing addiction support, and peer support for parenting

''Outcomes Being Tracked''

*Pre-term birth rates
*Cost Savings

= Available Tools and Resources =

[[TR_-_Enhance_Collaboration_among_Medical,_Behavioral_&_Social_Services|TR - Enhance Collaboration among Medical, Behavioral & Social Services]]

= Sources =
</div>
[[Category:SAFE-Prescriptions and Medical Response]]

Improve Identification & Data Collection for NAS

2021-02-08T17:17:33Z

Mredden:

__NOTOC__ Return to [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]] <div class="wiki" id="content_view" style="display: block">__TOC__  
= Overview =
<div class="_">One of the biggest challenges of addressing NAS is that it is not consistently identified, and collection of data and reporting is inconsistent.</div>
= Key Information =

= Relevant Research =

= Impactful Federal, State, and Local Policies =

=== Indiana State Department of Health ===
<div class="_">In 2014, because of the high rate of opioid prescriptions, the Indiana General Assembly charged the Indiana State Department of Health (ISDH) to: develop a standard clinical definition of NAS and a standardized process of identifying it, identify the resources hospitals need to do this, and then establish a voluntary pilot program with hospitals to implement this standardized NAS identification. As of 2016, 26 of 89 Indiana Birthing Hospitals are taking part in this pilot screening program . ISDH noted that universal screening in a [[Shift_from_Punishment_to_Treatment_Approach_for_Opioid_Users|non-punitive]] environment would allow us to understand the true prevalence of Perinatal Substance Use and NAS.<sup class="reference">[1]</sup></div> <div class="_"> </div> <div class="_">The Indiana State Department of Health (ISDH) established a Task Force which defined a '''standard clinical definition of Neonatal Abstinence Syndrome'''</div>
*The infant must:
*Be symptomatic
*Have two or three consecutive modified Finnegan scores equal to or greater than a total of 24
*And have one of the following:
**A positive toxicology test '''OR'''
**A maternal history with a positive verbal screen or toxicology test
ISDH NAS Task Force Final Report: <div class="objectEmbed">[[File/view/Neonatal_Abstinence_Syndrome_Report_Final_Report.pdf/617730023/Neonatal_Abstinence_Syndrome_Report_Final_Report.pdf|[File:http://www.wikispaces.com/i/mime/32/application/pdf.png Neonatal_Abstinence_Syndrome_Report_Final_Report.pdf]]] <div>[[File/view/Neonatal_Abstinence_Syndrome_Report_Final_Report.pdf/617730023/Neonatal_Abstinence_Syndrome_Report_Final_Report.pdf|Neonatal_Abstinence_Syndrome_Report_Final_Report.pdf]]
*[[File/detail/Neonatal_Abstinence_Syndrome_Report_Final_Report.pdf|Details]]
*[[File/view/Neonatal_Abstinence_Syndrome_Report_Final_Report.pdf/617730023/Neonatal_Abstinence_Syndrome_Report_Final_Report.pdf|Download]]
*989 KB
</div> </div> NAS Identification Algorithm <div class="objectEmbed">[[File/view/IPQIC_NAS_Algorithm_Version_4.pdf/617730057/IPQIC_NAS_Algorithm_Version_4.pdf|[File:http://www.wikispaces.com/i/mime/32/application/pdf.png IPQIC_NAS_Algorithm_Version_4.pdf]]] <div>[[File/view/IPQIC_NAS_Algorithm_Version_4.pdf/617730057/IPQIC_NAS_Algorithm_Version_4.pdf|IPQIC_NAS_Algorithm_Version_4.pdf]]
*[[File/detail/IPQIC_NAS_Algorithm_Version_4.pdf|Details]]
*[[File/view/IPQIC_NAS_Algorithm_Version_4.pdf/617730057/IPQIC_NAS_Algorithm_Version_4.pdf|Download]]
*63 KB
</div> </div> '''''See [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|Adopt Universal Screening for Pregnant Women]] for more information on standardized screening and testing for NAS'''''
= <span style="background-color: #ffffff">Available Tools and Resources</span> =
<div class="_">[[TR_-_Adopt_Universal_Screening_for_Pregnant_Women|TR_-_Adopt_Universal_Screening_for_Pregnant_Women]]</div>
= <span style="background-color: #ffffff">Sources</span> =

----

#[http://www.amchp.org/programsandtopics/BestPractices/InnovationStation/ISDocs/Perinatal%20Substance%20Use.pdf [1]]
</div>
[[Category:Pages with broken file links]]

Improve Care for Babies Born Drug Dependent

2021-02-08T17:09:33Z

Mredden:

Return to [[Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_During_Opioid_Use|Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy During Opioid Use]] <div class="wiki" id="content_view" style="display: block"><span style="background-color: #ffffff">or </span>[[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]]
= Overview =

Babies who are born with an opioid dependence experience extraordinary discomfort and trauma.  They can scream and cry, have tremors, struggle with eating, and are not easily comforted.  There are opportunities to help the babies, the mothers, and the often overwhelmed hospital staff that are trying to care for the babies and mothers. 

= Key Information =

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Practices =

== Programs for Volunteers to Cuddle Babies Experiencing Withdrawal ==

There are a growing number of programs that have volunteers come to the hospitals to cuddle the babies.  This helps comfort the babies and reduces the stress on the nurses--two important benefits. 

'''Magee-Womens Hospital "Cuddle the Crisis" '''

*At Magee-Womens Hospital of UPMC in Pennsylvania, volunteers are helping babies born addicted to opioids by cuddling, nurturing, and comforting the babies as they go through withdrawal.
*Cuddlers provide them with additional comfort, as opposed to having to start an IV or give a baby morphine
*Source: [https://www.insideedition.com/headlines/19669-hospital-recruits-volunteers-to-cuddle-with-drug-addicted-babies-going-through-withdrawal https://www.insideedition.com/headlines/19669-hospital-recruits-volunteers-to-cuddle-with-drug-addicted-babies-going-through-withdrawal]

Add more programs here with links to learn more. 

== Music Therapy ==

Using a combination of pacifiers and music therapy, healthcare workers are able to ease the pain of babies born to mothers who used opioids during their pregnancy. If you can improve babies feeding and sleeping, decrease their crying and make them more calm, then you've just eliminated three of the major symptoms that lead babies to have to need medication or hospital stay.<sup class="reference">[1]</sup>

Components:

*A NICU music therapist uses music and live-singing, patting and rocking to match the baby's behavior state, ultimately training the child to soothe itself
*Use of special pressurized pacifier that plays music. See [http://www.wmur.com/article/new-device-helps-tiniest-victims-of-the-opioid-crisis/10370051 video for overview of use]

Visit [https://nortonhealthcare.com/pages/musictherapy.aspx Norton Hospital's Music Therapy Services] and contact for implementation resources for your local hospital

== Best Practices ==

=== Standardized Care ===

The Maryland Patient Safety Center is working with 30 birthing centers to come up with standardized care for babies suffering from NAS.<sup class="reference">[2]</sup> This standard of care is significantly reducing the length of stay for these babies.

Standards can vary from baby to baby, but should include:

*Creating a calming environment with little stimulation - quiet rooms and low loights
*Cuddle rooms where volunteers rock and soothe babies
*Can use massage and music therapy
*Some medicine (morphine or methadone)
*Treat mother's addiction and mental health in conjunction with babies' treatment

== Neonatal Withdrawal Center ==

=== Lily's Place ===

[http://www.lilysplace.org/ Lily's Place] is the first nonprofit infant recovery center for provides services for parents and families struggling with addiction.<sup class="reference">[3]</sup> The center is specifically designed for babies with NAS with small, quiet, dimly-lit nursery rooms and 24-hour nursing staff.<sup class="reference">[4]</sup> Parents are trained to help their babies via therapeutic handling techniques and they learn CPR and basic child care as well as the specifics of NAS.<sup class="reference">[5]</sup><br/> <br/> Contact Lily's Place (304) 523-5459 for more information on [http://www.lilysplace.org/presentations-and-workshops workshops and trainings] including the following:

*Legislation to support NAS centers
*Pre-opening NAS Center Operations Planning
*Funding & fundraising for a NAS center

== Special Daycare Centers for Babies with NAS ==

This [https://www.cnn.com/2019/08/23/health/babies-born-exposed-to-opioids/index.html CNN story] shares more.

= Available Tools and Resources =

[[TR_-_Improve_Care_for_Babies_Born_Drug_Dependent|TR - Improve Care for Babies Born Drug Dependent]]

= Sources =

----

#[http://www.wdrb.com/story/32826632/music-therapy-weaning-babies-off-opioid-addiction-at-kosair-childrens-hospital [1]] [https://www.wdrb.com/news/music-therapy-weaning-babies-off-opioid-addiction-at-kosair-children/article_2175845c-f580-5bad-a568-f43eaee614d2.html https://www.wdrb.com/news/music-therapy-weaning-babies-off-opioid-addiction-at-kosair-children/article_2175845c-f580-5bad-a568-f43eaee614d2.html]
#[https://www.washingtonpost.com/local/number-of-maryland-babies-born-with-drugs-in-their-system-grows/2017/02/19/642c3342-f535-11e6-b9c9-e83fce42fb61_story.html?utm_term=.5fbf45d90890 [2]] [https://www.washingtonpost.com/local/number-of-maryland-babies-born-with-drugs-in-their-system-grows/2017/02/19/642c3342-f535-11e6-b9c9-e83fce42fb61_story.html?noredirect=on&utm_term=.6153e73b3a7a https://www.washingtonpost.com/local/number-of-maryland-babies-born-with-drugs-in-their-system-grows/2017/02/19/642c3342-f535-11e6-b9c9-e83fce42fb61_story.html?noredirect=on&utm_term=.6153e73b3a7a] 
#[http://people.com/human-interest/lilys-place-west-virginia-clinic-nurses-newborns-opioid-withdrawal/ [3]] [https://people.com/human-interest/lilys-place-west-virginia-clinic-nurses-newborns-opioid-withdrawal/ https://people.com/human-interest/lilys-place-west-virginia-clinic-nurses-newborns-opioid-withdrawal/]
#[http://people.com/human-interest/lilys-place-west-virginia-clinic-nurses-newborns-opioid-withdrawal/ [4]]  [https://people.com/human-interest/lilys-place-west-virginia-clinic-nurses-newborns-opioid-withdrawal/ https://people.com/human-interest/lilys-place-west-virginia-clinic-nurses-newborns-opioid-withdrawal/]
#[http://people.com/human-interest/lilys-place-west-virginia-clinic-nurses-newborns-opioid-withdrawal/ [5]] [https://people.com/human-interest/lilys-place-west-virginia-clinic-nurses-newborns-opioid-withdrawal/ https://people.com/human-interest/lilys-place-west-virginia-clinic-nurses-newborns-opioid-withdrawal/]
</div>
[[Category:SAFE-Treatment and Recovery]]

Improve Access to Recovery Coaches for Mothers

2021-02-08T17:05:39Z

Mredden:

= Overview =

= Key Information =

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Practices =

= Available Tools and Resources =

= Sources =

 

 

Expand Perinatal Treatment and Support for Women with SUDs

2021-02-08T16:52:45Z

Mredden:

__NOTOC__ Return to  [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map]] or [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]] <div class="wiki" id="content_view" style="display: block">__TOC__
= Overview =

<span style="display: inline !important; float: none; background-color: rgb(255, 255, 255); color: rgb(34, 34, 34); font-family: sans-serif; font-size: 13.93px; font-style: normal; font-variant: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-decoration: none; text-indent: 0px; text-transform: none; -webkit-text-stroke-width: 0px; white-space: normal; word-spacing: 0px;">Most doctors recommend that pregnant women undergo a long-term treatment plan called drug-assisted stabilization using methadone, also known as harm reduction therapy. This treatment remains sustainable for a woman after she has given birth, because it's covered under Medicaid, so new mothers can still access the treatment, even after their six-week Medicaid-provided postnatal care is done. The treatment also doesn't subject a woman's mind and body through the stress of full withdrawal, allowing her to focus on caring for herself and her baby.</span>

= Key Information =

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Practices =

== Perinatal Addiction Treatment Program ==

<br/> '''[https://geiselmed.dartmouth.edu/psych/care/dhmc_services/perinatal/ Perinatal Addiction Treatment Program] - Dartmouth Hitchcock Medical Center'''<br/> ''Program Highlights''

*Integrated Care Model: Includes maternity care, substance use treatment, behavioral health/psychiatry, pediatrics
*Participant Drive Design
*Private setting 10 minutes from hospital campus
*Tablet-based [http://www.integration.samhsa.gov/clinical-practice/SBIRT SBIRT] screening
*18 week parenting class

''Outcome Successes''

*Perinatal: Average gestational age is over 38 weeks; Average birthweight in the normal range
*Decreased NAS treatment rate
*Decreased neonatal LOS
*Effective use of technology for screening
*2/3 of participants remain in treatment postpartum

== Centering Pregnancy ==
<div class="_">While not specifically focusing on issues of addiction or substance misuse among pregnant women, the [https://www.centeringhealthcare.org/what-we-do/centering-pregnancy CenteringPregnancy] approach has the potential to cost-effectively improve prenatal and perinatal care among women who may be using or be addicted to opioids or other substances. It is a group approach to prenatal and perinatal care. </div>
= Available Tools and Resources =

[[TR_-_Expand_Perinatal_Treatment_for_Women_with_SUDs|TR - Expand Perinatal Treatment for Women with SUDs]]

= <br/> Sources =
</div>
[[Category:SAFE-Treatment and Recovery]]

Expand SBIRT in Maternity Care Clinics

2021-02-08T16:47:41Z

Mredden:

Adopt Universal Screening for Pregnant Women

2021-02-08T16:28:14Z

Mredden:

<div class="wiki" id="content_view" style="display: block">
Return to  [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]]

__TOC__

= <br/> Overview =

Another potential strategy is to universally screen all pregnant women for substance abuse.

= Key Information =

= Relevant Research =

 In Kaiser Permanente's [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3057720/ Early Start ]program, pregnant women were screened for substance abuse risk at the first prenatal visit by a self-administered questionnaire and by urine toxicology testing (with signed consent). Universal screening facilitates early identification and treatment of substance use.<sup class="reference">[1]</sup><br/> <br/> '''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3057720/ Early Start: An Integrated Model of Substance Abuse Intervention for Pregnant Women] - Kaiser Permanente'''<br/> ''Overview of program'':

*Universally screen all pregnant women
*No mandated reporting for toxicology
*Mental health provider apart of obstetric care
*Use video conferencing and telephone to provide care to immediate and remote care

''Outcome Successes'':

*Show decrease in morbidity for mothers and babies
*Cost beneficial
*Reduces all barriers to care, including in prenatal care

'''[http://www.ajog.org/article/S0002-9378(16)30383-0/fulltext#tbl4 The role of screening, brief intervention, and referral to treatment in the perinatal period -- Tricia E. Wright, MD, MS]'''<br/> ''Method'':

''Screening Instruments:''

*CAGE -- Cut down, Annoyed, Guilt, Eye opener
*T-ACE -- Takes, Annoyed, Cut down, Eye opener
*TWEAK -- Tolerance, Worry, Eye opener, Amnesia, Cut down
*4Ps -- Past, Present, Parents, Partner
*NIDA Quick Screen -- Uses 3 open-ended questions regarding alcohol, tobacco, and other drugs

''Key Screening Conclusions:''

*Screening should be done for all pregnant women and throughout pregnancy for those at risk
*Screening can be done by a provider using a validated instrument during follow-up or by asking standardized questions during interview
*Screening must be nonjudgemental and open-ended
*Urine toxicology should not be used in place of screening

= Impactful Federal, State, and Local Policies =

= Promising Practices for Standardized Screening =

== Indiana State Department of Health ==

In 2014, because of the high rate of opioid prescriptions, the Indiana General Assembly charged the Indiana State Department of Health (ISDH) to: develop a standard clinical definition of NAS and a standardized process of identifying it, identify the resources hospitals need to do this, and then establish a voluntary pilot program with hospitals to implement this standardized NAS identification. As of 2016, 26 of 89 Indiana Birthing Hospitals are taking part in this pilot screening program

  To understand and address perinatal substance use, accurate data needed to be collected through '''standardized screening and testing:'''

*When any pregnant arrives at the hospital for delivery, hospital personnel conduct a standardized and validated verbal screening regarding substance use.
*Any woman with a positive verbal screen at any point during pregnancy, including at presentation for delivery, is requested to consent to a urine toxicology screening.
*Babies whose mothers had a positive verbal screen or toxicology screen, or babies whose mothers did not consent to the toxicology screen will be tested for evidence of maternal substance use using the infant’s umbilical cord.
**Note: Umbilical cord testing, not meconium stool, was used on all infants.
*Babies also have modified Finnegan scoring initiated to observe for signs and symptoms of NAS.

ISDH noted that universal screening in a [[Shift_from_Punishment_to_Treatment_Approach_for_Opioid_Users|non-punitive]] environment would allow us to understand the true prevalence of Perinatal Substance Use and NAS.<sup class="reference">[2]</sup><br/> <br/> ''See [[Improve_Identifying_and_Data_Collection_on_NAS|Improve Identifying and Data Collecting on NAS]] for more information on defining, testing, and reporting data about NAS.''

= Available Tools and Resources =

[[TR_-_Adopt_Universal_Screening_for_Pregnant_Women|TR - Adopt Universal Screening for Pregnant Women]]

=   =

 

----

= Sources =

#[http://onlinelibrary.wiley.com/doi/10.1111/1552-6909.12531/full [1]]
#[http://www.amchp.org/programsandtopics/BestPractices/InnovationStation/ISDocs/Perinatal%20Substance%20Use.pdf [2]]
</div>
[[Category:SAFE-Full Spectrum Prevention]]

Adopt Universal Screening for Pregnant Women

2021-02-08T16:27:56Z

Mredden:

<div class="wiki" id="content_view" style="display: block">
Return to  [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]]

__TOC__

= <br/> Overview =

Another potential strategy is to universally screen all pregnant women for substance abuse.

= Key Information =

= Relevant Research =

 In Kaiser Permanente's [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3057720/ Early Start ]program, pregnant women were screened for substance abuse risk at the first prenatal visit by a self-administered questionnaire and by urine toxicology testing (with signed consent). Universal screening facilitates early identification and treatment of substance use.<sup class="reference">[1]</sup><br/> <br/> '''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3057720/ Early Start: An Integrated Model of Substance Abuse Intervention for Pregnant Women] - Kaiser Permanente'''<br/> ''Overview of program'':

*Universally screen all pregnant women
*No mandated reporting for toxicology
*Mental health provider apart of obstetric care
*Use video conferencing and telephone to provide care to immediate and remote care

''Outcome Successes'':

*Show decrease in morbidity for mothers and babies
*Cost beneficial
*Reduces all barriers to care, including in prenatal care

'''[http://www.ajog.org/article/S0002-9378(16)30383-0/fulltext#tbl4 The role of screening, brief intervention, and referral to treatment in the perinatal period -- Tricia E. Wright, MD, MS]'''<br/> ''Method'':

''Screening Instruments:''

*CAGE -- Cut down, Annoyed, Guilt, Eye opener
*T-ACE -- Takes, Annoyed, Cut down, Eye opener
*TWEAK -- Tolerance, Worry, Eye opener, Amnesia, Cut down
*4Ps -- Past, Present, Parents, Partner
*NIDA Quick Screen -- Uses 3 open-ended questions regarding alcohol, tobacco, and other drugs

''Key Screening Conclusions:''

*Screening should be done for all pregnant women and throughout pregnancy for those at risk
*Screening can be done by a provider using a validated instrument during follow-up or by asking standardized questions during interview
*Screening must be nonjudgemental and open-ended
*Urine toxicology should not be used in place of screening

= Impactful Federal, State, and Local Policies =

= Promising Practices for Standardized Screening =

== Indiana State Department of Health ==

In 2014, because of the high rate of opioid prescriptions, the Indiana General Assembly charged the Indiana State Department of Health (ISDH) to: develop a standard clinical definition of NAS and a standardized process of identifying it, identify the resources hospitals need to do this, and then establish a voluntary pilot program with hospitals to implement this standardized NAS identification. As of 2016, 26 of 89 Indiana Birthing Hospitals are taking part in this pilot screening program

  To understand and address perinatal substance use, accurate data needed to be collected through '''standardized screening and testing:'''

*When any pregnant arrives at the hospital for delivery, hospital personnel conduct a standardized and validated verbal screening regarding substance use.
*Any woman with a positive verbal screen at any point during pregnancy, including at presentation for delivery, is requested to consent to a urine toxicology screening.
*Babies whose mothers had a positive verbal screen or toxicology screen, or babies whose mothers did not consent to the toxicology screen will be tested for evidence of maternal substance use using the infant’s umbilical cord.
**Note: Umbilical cord testing, not meconium stool, was used on all infants.
*Babies also have modified Finnegan scoring initiated to observe for signs and symptoms of NAS.

ISDH noted that universal screening in a [[Shift_from_Punishment_to_Treatment_Approach_for_Opioid_Users|non-punitive]] environment would allow us to understand the true prevalence of Perinatal Substance Use and NAS.<sup class="reference">[2]</sup><br/> <br/> ''See [[Improve_Identifying_and_Data_Collection_on_NAS|Improve Identifying and Data Collecting on NAS]] for more information on defining, testing, and reporting data about NAS.''

= Available Tools and Resources =

[[TR_-_Adopt_Universal_Screening_for_Pregnant_Women|TR - Adopt Universal Screening for Pregnant Women]]

=   =

 

----

Sources

#[http://onlinelibrary.wiley.com/doi/10.1111/1552-6909.12531/full [1]]
#[http://www.amchp.org/programsandtopics/BestPractices/InnovationStation/ISDocs/Perinatal%20Substance%20Use.pdf [2]]
</div>
[[Category:SAFE-Full Spectrum Prevention]]

Expand Access to MAT for Pregnant Women

2021-02-08T16:11:13Z

Mredden:

__NOTOC__ <div class="wiki" id="content_view" style="display: block">
Return to  [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map]] or [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]]__TOC__

= Overview =

'''Maintenance Therapy Drugs'''<br/> Medically supervised tapering of opioids in pregnant women is associated with high relapse rates as compared to methadone maintenance.<sup class="reference">[1]</sup><br/> <br/> Women who need maintenance therapy drugs often struggle to get them. To get buprenorphine, they must go to one of the state's few doctors with a special license. To get methadone, they must go regularly to a clinic — in Middle Tennessee there's one in Nashville and one in Columbia. Women must often pay out of pocket. And many women of child-bearing age don't qualify for TennCare until they find themselves pregnant. That makes it difficult for an addict to access family planning or mental health preventive care before becoming pregnant.<sup class="reference">[2]</sup><br/> <br/> Tennessee's three managed care companies — Amerigroup, UnitedHealthcare's Medicaid subsidiary and BlueCross BlueShield's BlueCare program — are trying to reach these women earlier to ensure that more babies are born healthy. All have flagged drug-dependent babies as a major cost issue. BlueCross, for example, covered 775 such babies in 2013 [must be nationwide]. [at $50,000 each, which is a low estimate of incremental cost over a normal birth, that cost BlueCross about 38 million.] All three have launched efforts to help expectant mothers beat their addictions.<sup class="reference">[3]</sup>

= Key Information =

*There are often long waiting periods to get women into treatment.<sup class="reference">[4]</sup>
**Although pregnant women actually receive priority for methadone treatment, once they are not pregnant they return tot the long waiting periods and the motivation to pursue treatment may be deterred by these waits<sup class="reference">[5]</sup>
*Women often experience anxiety about what will happen if they can no longer pay for their methadone treatments<sup class="reference">[6]</sup>
**There is a need for increased grant funding to help women stay in treatment once they are enrolled<sup class="reference">[7]</sup>
*Women have misconceptions about methadone and are unclear about the treatment process<sup class="reference">[8]</sup>
*13 states give pregnant women priority access to general programs for drug treatment.<sup class="reference">[9]</sup>
*4 states protect pregnant women from discrimination in publicly funded programs.<sup class="reference">[10]</sup>
*18 states consider substance abuse during pregnancy to be grounds for child abuse.<sup class="reference">[11]</sup>

= Relevant Research =
<div class="_">A 2012 study of medical students in an obstetrics and gynecology rotation found that when students are placed in a residential treatment center for pregnant women (i.e. specialized training) they showed greater comfort in assessing and educating patients about substance abuse during pregnancy compared to those in a regular rotation.<sup class="reference">[12]</sup>[http://pcssmat.org/ Provider's Clinical Support System] (PCSS) fpr MAT provides many free online trainings and resources to help address the opioid crisis, including "[http://pcssmat.org/opioid-dependence-in-pregnancy-clinical-challenges/ Opioid Dependence in Pregnancy: Clinical Challenges]."</div>
== New 2018 Clinical Guide by SAMHSA ==
<div class="_">This new. detailed, 165-page guide has SAMHSA's latest recommendations on [https://store.samhsa.gov/shin/content//SMA18-5054c/SMA18-5054.pdf Clinical Guidance for Treating Pregnant Women with OUD and their Infants].</div>
== Split Dosing to Reduce Risk ==
<div class="_">The following quote shares some insights and potential benefits of "split dosing" of methadone. The article has more details.<sup class="reference">[13]</sup></div> <div class="_">"Part of the confusion relates to the question of whether giving the mother high doses of methadone worsens NAS. A recent meta-analysis of 67 studies found this not to be the case.* The fetus is not exposed to the maternal dose; it is exposed to the maternal plasma level. We know that plasma levels vary significantly, depending on genetics. And pregnant women metabolize methadone more quickly, necessitating dose increases—but these increases do not necessarily increase fetal exposure to methadone.</div> <div class="_"> </div> <div class="_">One mother in our pregnancy program required 270 mg/day of methadone, in four divided doses. Her plasma level, before the morning dose one week before delivery, was undetectable. After birth, the baby required no treatment for NAS. We don’t know how many physicians are willing to prescribe these high, split doses to keep the mother and fetus out of withdrawal. We don’t know whether programs use maternal plasma methadone levels to monitor changes in maternal metabolism and fetal exposure.</div> <div class="_"> </div> <div class="_">In pregnancy, split doses of methadone protect the fetus from exposure to daily cycles of peaks and troughs, which have been shown to have negative physiologic effects on the fetus.* Even high doses, when given as single daily doses, can result in fetal withdrawal distress before the next day’s dose. That may be why high doses, at times, seem to cause more cases of NAS: The fetus may be sensitized to daily episodes of withdrawal.* Some mothers, like our patient who received 270 mg daily, are ultra-rapid metabolizers; the methadone exposure for their fetuses is far more consistent and physiologic when dosing is four times a day."<sup class="reference">[14]</sup></div> <div class="_"> </div> <div class="_">The approach used in one study for women on methadone (that used higher doses split into 2 or 4 doses per day yielded significantly lower rates of NAS.<sup class="reference">[15]</sup></div> <div class="_">Another s[http://atforum.com/2015/10/methadone-split-dosing-less-nas-better-maternal-recovery/ tudy on split dosing] also showed benefits. More research is needed.</div> <div class="_"> </div> <div class="_">Since DNA tests can help to understand the way a person will metabolize different drugs, it could be tested to advance a precision medicine approach to MAT for pregnant women. . More research is needed on this issue.</div>
= Impactful Federal, State, and Local Policies =
<div class="_">SAMHSA’s Substance Abuse Prevention and Treatment block grants have recently been revised to strengthen capacity to deliver MAT for pregnant women with substance use disorders.<sup class="reference">[17]</sup></div>
= Promising Practices =
<div class="_">Methadone clinics should provide information sessions and materials to help pregnant women prepare for the experience of delivering their babies at hospitals. These should include the following:<sup class="reference">[16]</sup></div>
*What to expect in regards to pain management
*Infant withdrawal symptoms
*CPS involvement
*Treatment approaches for withdrawing infants
*How to work with doctors and nurses to help the process go smoothly
*Advice for comforting methadone-exposed babies once they come home

= Available Tools and Resources =

[[TR_-_Expand_Access_to_MAT_for_Pregnant_Women|TR - Expand Access to MAT for Pregnant Women]]

= <br/> <br/> Sources =

----

#ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG committee opinion no. 524: opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol 2012;119:1070–6
#[http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/ [1]]
#[http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/ [2]]
#[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [3]]
#[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [4]]
#[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [5]]
#[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [6]]
#[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [7]]
#[http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403 [8]]
#[http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403 [9]]
#[http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403 [10]]
#[https://www.ncbi.nlm.nih.gov/pubmed/23154692 [11]]
#ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG committee opinion no. 524: opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol 2012;119:1070–6
#[http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/ [12]]
#[http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/ [13]]
#[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [14]]
#[https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm [15]]
</div>
[[Category:SAFE-Treatment and Recovery]]

Expand Motivational Interviewing for Pregnant Women

2021-02-08T15:46:52Z

Mredden:

Increase Access to Contraception

2021-02-08T15:38:01Z

Mredden:

Return to  [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]]
Intro paragraph

= Overview =

Family planning and preconception care for women who use opioids is considered an important strategy to reduce the incidence of NAS.<span style="display: none;"> </span><sup class="reference"><ref>https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm</ref></sup><span style="display: none;"> </span> "CDC and the Office of Population Affairs of the U.S. Department of Health and Human Services recommend that health care providers support family planning services, which include preconception services, pregnancy intention screening, and contraceptive counseling to prevent unintended pregnancy by increasing access to the full range of contraceptive methods, including long-acting reversible contraception (e.g., intrauterine devices and implants)."<sup class="reference"><ref>Gavin L, Moskosky S, Carter M, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep 2014;63(No. RR-4).</ref></sup>

Current Status:

*31% to 47% of US pregnancies are unintended, research suggests that, for women with opioid use disorder, the proportion of unintended pregnancies was higher than 85%.<sup class="reference"><ref>https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm</ref></sup>

*The statistics of a study in Eastern Tennessee were alarming:
**Half of the 320,000 women in Medicaid in Tennessee received an opioid prescription in 2016<sup class="reference"><ref>http://www.empowerhealthusa.com/our-work.html</ref></sup>
**Only 3% of them use a reliable birth control method<sup class="reference"><ref>http://www.empowerhealthusa.com/our-work.html</ref></sup>
**Their general knowledge of birth control is very low<sup class="reference"><ref>http://www.empowerhealthusa.com/our-work.html</ref></sup>

= Key Information =

While there is often disagreement on what type of sex education is appropriate, communities should make it a priority to improve understanding of birth control as a way to avoid unintended pregnancies.

== Prevention through Contraception ==

=== Long-Acting Reversible Contraception (LARC) ===

One-in-two pregnancies in the US are unintended, and approximately half of these end in termination of pregnancy.<ref>Finer L, Henshaw S. Disparities in rates of unintended pregnancy in the United States 1994–2001. Perspect Sex Reprod Health. 2006;38:90.</ref> Unintended pregnancies result from contraceptive failure, incorrect or inconsistent use of a method, or lack of use of any form of contraception.<ref>Jones RK, Darroch JE, Henshaw SK. Contraceptive use among U.S. women having abortions in 2000–2001. Perspect Sex Reprod Health. 2002;34:294–303.</ref><ref>Moreau C, Trussell J, Rodrigues G, Bajoo N, Bouyer J. Contraceptive failure rate in France: results from a population based survey. Hum Reprod Update. 2007;22:2422–7.</ref>Interventions to increase adherence to pills and condoms, such as enhanced counseling, have not consistently improved contraceptive use patterns, continuation rates (ongoing use of the method after 12 months), or unintended pregnancies.<ref>Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet. 2006;368:1810–27.</ref> A US prospective study found that women using user-depended methods (pills, patches, and rings) were 20 times more likely to have an unplanned pregnancy than women using an intrauterine device (IUD) or implant.<ref>Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998–2007.</ref><br/> <br/> The IUDs and the implants are collectively known as LARC methods, and these are the most effective and cost-effective reversible methods available. They have an inherent ability to prevent pregnancy, but their effectiveness also arises from the fact that they are set and forget methods that do not require daily compliance unlike condoms of the oral contraceptive pill. These are attributes that women themselves rate highly when considering their contraceptive options.<ref>Madden T, Secura GM, Nease RF, Politi MC, Peipert JF. The role of contraceptive attributes in women’s contraceptive decision making. Am J Obstet Gynecol. 2015;213(1):e41–6.</ref> Therefore, using LARCs should be promoted. One way may be via the integration of contraceptive services into drug health clinics. In this way, women may be enabled to more easily address their various needs in an environment that is both more familiar and less threatening. Similarly, integrated services may be more successful if they can provide low-threshold service access, ie, services with few or no barriers to access.<ref>Islam MM, Topp L, Conigrave KM, Day CA. Defining a service for people who use drugs as ‘low-threshold’: what should be the criteria? Int J Drug Policy. 2013;24(3):220–2.</ref><ref>Islam MM, Topp L, Conigrave KM, Day CA. Opioid substitution therapy clients’ preferences for targeted versus general primary health-care outlets. Drug Alcohol Rev. 2013;32:211–3.</ref><br/> <br/> An analysis of a publicly funded family planning program calculated that LARC methods save US$7 in costs from unintended pregnancy for every US$1 spent. Thus, improving access to LARC methods is likely to be cost-effective.<ref>Foster D, Rostovtseva D, Brindis C, Biggs MA, Hulett D, Darney PD. Cost savings from the provision of specific methods of contraception in a publicly funded program. Am J Public Health. 2009;99:446–51.</ref>

=== Incentives for LARC use ===

Project Prevention relies on donations and pays women $300 to get on long term birth control<ref>https://www.heraldcourier.com/news/addicted_at_birth/project-prevention-program-aims-to-stop-nas-by-birth-control/article_3ebf4d37-5c7f-57b5-b297-47b1958127a5.html</ref>

=== Organizations Offering Free or Reduced LARC ===

The number of babies born with neonatal abstinence syndrome have dropped nearly 90 percent in one year in counties that have the program.<br/> Tennessee Department of Health officials are sharing the project’s success. Some 41 local jails and methadone clinics now work with county health officials to make available free IUDs. The project is paid for by federal funds for incarcerated women who don't have private insurance or have lost TennCare, which automatically ends during incarceration. Officials stress that the choice to obtain long-acting and reversible contraceptives is up to each incarcerated woman.<ref>https://www.tennessean.com/story/news/2017/02/04/iuds-inmates-seen-tool-combat-opioid-crisis/97056396/</ref><br/> <br/> The Access and Resources in Contraceptive Health (ARCH) Patient Assistance Program provides Bayer IUDs (Kyleena, Mirena, and Skyla) at no cost to women in the United States who do not have either private health insurance or Medicaid coverage for Bayer IUDs and who meet all other program eligibility requirements. Please note that while Bayer provides Bayer IUDs at no cost to patients, patients may incur other costs, such as insertion and removal costs. Please speak with your insurance company or your healthcare provider for more information.<ref>http://www.archpatientassistance.com/</ref><br/> <br/> "A Step Ahead" In East Tennessee - With any appointment for free birth control (LARC), we provide a free "Well Woman's" visit including a pregnancy test and STI test. If you are over 21 and your medical provider deems it medically necessary, you may also receive a free PAP test. They also provide transportation.<ref>http://www.astepaheadeasttn.org/faq.html</ref>

== Offer Contraception at Pain Management/Addiction/Methadone/Suboxone clinics ==

The feasibility of delivery of family planning services at addiction treatment clinics is being actively explored - Study completed in West North Carolina<ref>https://sys.mahec.net/media/onlinejournal/Contraceptive Choices.pdf</ref>

Offer contraception planning in non-traditional venues, such as pediatric clinic within a drug treatment facility<ref>https://doi.org/10.1080/15332985.2011.575723</ref> A barrier is staff education and comfort discussing the issue. Education and availability of appropriate staff would be paramount.

Contraceptive counseling and access to contraceptive services should be a routine part of substance use disorder treatment among women of reproductive age to mitigate the risk of unplanned pregnancy.<ref>https://www.regulations.gov/document?D=SAMHSA-2016-0002-0001</ref>

= Impactful Federal, State, and Local Policies =

Virginia law allows women a full year of birth control covered by insurance vs. the previous 3 month supply

= Relevant Research =

== Research on Birth Control Options ==

See this article on [https://www.bedsider.org/features/224-gold-standard-birth-control-the-iud-and-the-implant preferences and effectiveness of different birth control options]. 

== LARCs ==

Increasing access to [http://www.acog.org/Patients/FAQs/Long-Acting-Reversible-Contraception-LARC-IUD-and-Implant Long Acting Reversible Contraceptives] (LARCs) could be a key part of a strategy. Since 2007, researchers have seen a sharp rise in LARCs, such as intrauterine devices and implants. These forms of birth control last for years once inserted and prevent pregnancy for more than 99 percent of users. That helps explain why they're a big part of the story behind America's plummeting unintended pregnancy rate. <ref>https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud</ref> One of the biggest obstacles to LARC use, historically, has been price. Planned Parenthood has estimated that IUDs can cost between $500 and $900 out of pocket. Insurance plans tended to charge patients more for IUDs than for birth control pills, just because the devices have such high upfront costs.<ref>https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud</ref>  [http://www.latimes.com/health/la-he-0528-birth-control-20160515-snap-story.html This article] makes some interesting points and has information on the relative effectiveness of different types of contraceptives.<br/>  

== Hormone-releasing Implants ==

[https://www.nexplanon.com/static/pdf/combinedlabelfile.pdf NEXPLANON] is a hormone-releasing birth control implant for use by women to prevent pregnancy for up to 3 years.<br/>  

== Non-Hormone IUDs ==

[http://www.paragard.com Paragard] is an IUD that can prevent pregnancy for up to 10 years. Paragard is a hormone-free IUD. It may be 100% covered by insurance. See [http://Paragardbvsp.com Paragardbvsp.com] to learn if benefits cover Paraguard. .

== Overcoming Cost Barriers to Access ==

Healthcare providers or clinics can join a Group Purchasing Organization (GPO) to get lower costs on birth control<br/> Afaxys is a pharma company that produces birth control pills, but they also have a Group Purchasing Organization that provides discount pricing on Bayer IUDs.

== Other Barriers to Access ==

Approximately 1 in 7 ob/gyns believe pelvic inflammatory disease is a significant risk of IUD use, despite substantial research to the contrary.<ref>Luchowski, A.T., et al. (2014). Obstetrician-Gynecologists and contraception: practice and opinions about the use of IUDs in nulliparous women, adolescents and other patient populations. Contraception 89.</ref>

 

== Contraceptive Counseling ==

EmpowerHealth USA provides a [http://www.empowerhealthusa.com/our-work.html telehealth option] for contraception counseling.<ref>http://www.empowerhealthusa.com/our-work.html</ref>

== Statistics ==

*A study of 946 women who were using opioids who gave birth revealed that 86% reported that the pregnacy was unintended.<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052960/</ref>

== Potential Barriers ==

"For example, the ACOG supports placement of LARC devices during the immediate postpartum period to improve the use of LARC among postpartum women;  however, bundled payments for delivery create a relative financial disincentive to place LARC devices at the time of delivery.<ref>https://pediatrics.aappublications.org/content/139/3/e20164070</ref> State Medicaid programs play a critical role in ensuring access to highly effective contraception at the time when it is desired, including the time of delivery. However, recent research suggests that states are variable in aligning financial incentives to ensure access to LARC methods if elected at the time of delivery." <ref>Pace, L.E., Dusetzina, S.B., Fendrick, A.M., Keating, N.L., and Dalton, V.K. The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance. Medical Care. 2013; 51: 959–963</ref><br/> <br/> Patient contraceptive selection is sensitive to copayment. A 2010 analysis confirmed that employer-based plans display significant variation in copayments by contraceptive method, with LARC methods being the most expensive in terms of upfront costs to patients.<ref>Dusetzina, S.B., Dalton, V.K., Chernew, M.E., Pace, L.E., Bowden, G., and Fendrick, A.M. Cost of contraceptive methods to privately insured women in the United States. Women's Health Issues. 2013; 23: e69–71</ref> The Medicaid program has always required that family planning services be fully covered for patients without cost sharing.<ref>National Women's Law Center. (2015). Fact sheet: Contraceptive coverage in the health care law: Frequently asked questions. Accessed August 24, 2015.</ref> The Patient Protection and Affordable Care Act (ACA) similarly required new private health plans to provide no-cost coverage for all FDA-approved contraceptives.<ref>https://www.patientassistance.bayer.us/</ref>

= Promising Programs =

== NAS Primary Prevention Initiative ==

[https://www.tn.gov/health/article/FHW-ppi-brightspots East Tennessee Primary Prevention Initiative] - Tennessee Department of Health<br/> Contact: Erica Wilson, MPH, Community Services Director,  [mailto:erica.wilson@tn.gov erica.wilson@tn.gov]

'''Overview of program''' [[NAS_Reduction_Effort_East_TN_2014.docx|NAS Reduction Effort_East TN_2014.docx]] 

*Partnership with local jails
*Health education sessions
**focus on NAS prevention
**information on effective contraceptives and LARCs
*Partnerships with jails to refer inmates to local health department for family planning
*Among 442 referrals (2014-15), 94% received a contraceptive method, 84% chose a voluntary LARC

''Resources'':

*PowerPoint presentation - to educate community partners <span style="color: #ff0000">[contacted for resource]</span>
*Pamphlet - to educate community partners <span style="color: #ff0000">[contacted for resource]</span>
*Presentation - conducted to inmates on NAS and how it can be prevented <span style="color: #ff0000">[contacted for resource]</span>

== emPOWERhealthUSA ==

<span style="background-color: #ffffff; font-family: lato,'helvetica neue',helvetica,arial,sans-serif; font-size: 14px"><span style="background-color: #ffffff; font-family: lato,'helvetica neue',helvetica,arial,sans-serif; font-size: 14px"><span style="background-color: #ffffff; font-family: lato,'helvetica neue',helvetica,arial,sans-serif; font-size: 14px">[http://www.empowerhealthusa.com/our-work.html emPOWERhealthUSA] has a program that provides telehealth coaching on birth control (among other things) to help more women get LARCs or make other informed decisions on birth control, with a focus on women who are using opioids.</span></span></span>

== Access and Resources in Contraceptive Health (ARCH) Patient Assistance Program ==

This patient assistance program provides Bayer IUDs (intrauterine devices), Kyleena, Mirena and Skyla, at no cost to eligible women.<ref>https://www.patientassistance.bayer.us/</ref> Eligible women include those who do not have either private health insurance or Medicaid coverage for Bayer IUDs and who meet all other program eligibility requirements. Kyleena and Mirena can help prevent pregnancy for up to 5 years and Skyla up to 3 years.<ref>https://www.patientassistance.bayer.us/</ref>

= Available Tools and Resources =

= Sources =

----

 

[[Category:SAFE-Prescriptions and Medical Response]]

Improve Identification of Pregnant Women At Risk

2021-02-08T15:24:40Z

Mredden:

Return to  [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]]

  

= Overview =

= Key Information =

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Practices =

= Available Tools and Resources =

[[TR-Creating_Improve_Identification_of_a_Women_At_Risk_of_having_NAS_Baby|TR-Creating Improve Identification of a Women At Risk of having NAS Baby]]

= Sources<br/>   =

[[Category:SAFE-Treatment and Recovery]]

Expand Fentanyl Testing Options

2021-02-08T15:09:12Z

Mredden:

__NOTOC__ <div class="wiki" id="content_view" style="display: block">
Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map ]]<span style="font-size: 13px;">or </span>[[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]]__TOC__<br/> (Replace this text with the information you will place here.)<br/>  

= Overview =

= Key Information =

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Practices =

= <br/> Available Tools and Resources =

[[TR_-_Expand_Fentanyl_Testing_Options|TR_- Expand_Fentanyl_Testing_Options]]<br/>  

= <span style="font-size: 13px;">Sources</span> =
</div>

Expand Fentanyl Testing Options

2021-02-08T15:08:42Z

Mredden:

Expand Fentanyl Testing Options

2021-02-08T15:08:05Z

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__NOTOC__ <div class="wiki" id="content_view" style="display: block">
Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map ]]<span style="font-size: 13px;">or </span>[[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]]__TOC__<br/> (Replace this text with the information you will place here.)<br/>  

= Overview =

= Key Information =

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Practices<br/> Available Tools and Resources =

[[TR_-_Expand_Fentanyl_Testing_Options|TR_- Expand_Fentanyl_Testing_Options]]<br/>  

= <span style="font-size: 13px;">Sources</span> =
</div>
[[Category:SAFE-Prescriptions and Medical Response]]

Expand Steps to Minimize Substance Use During Pregnancy or Pregnancy During Substance Use

2021-02-08T15:01:06Z

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__NOTOC__ <div class="wiki" id="content_view" style="display: block">
Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map or]] [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|Zoom Map (Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy During Opioid Use)]] or [[ZOOM_MAP_-_Improve_Treatment_&_Enable_Recovery_for_People_with_SUDs|Zoom Map (Improve Treatment & Enable Recovery for People with SUDs)]] View [[Minimize_Babies_born_with_Opioid_Dependence|Minimize Babies Born with Opioid Addictions]]  or [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|ZOOM MAP - Expand Harm Reduction Practices Associated with Opioid Misuse]]__TOC__

= Overview =

= Key Information =

== Help Women Overcome Obstacles to Treatment, Family Planning and Prenatal Care ==
<div class="_">Women who are misusing opioids or who have OUD may have many obstacles to getting treatment, family planning or prenatal care. A strategy to minimize unintentional pregnancies for these women should include plans to help them overcome obstacles to receiving these services. The obstacles include:</div>
*Transportation
*Childcare
*Employment conflicts
*Unsupportive Living Environments
*Unstable Living Environments
*Homelessness
*Partner with a Substance Use Disorder
*Stigma and/or Guilt
*Fear of losing the child
*Fear of incarceration
*Fear of being discovered about misusing substances (by family, employer, etc.)

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Practices =

== Draft Driver Diagram ==
<div class="_">The Public Health Foundation worked with the Department of Public Health at the University of Tennessee Knoxville to create a Driver Diagram for improving perinatal care and reducing Neonatal Abstinence Syndrome (NAS). This format is different from a strategy map, but has useful ideas that could be integrated into this strategy map template.<br/> [http://www.phf.org/resourcestools/Documents/TN%20NAS%20driver%20diagram%20Revised%2012-15-15.pdf [1]]</div>
== Increase Access to Contraception ==

The National Preconception Health and Health Care Initiative provides educational resources to clinicians and their patients, and coordinates outreach and social media campaigns related to improving preconception health, including reducing substance use and treating substance use disorders before pregnancy.

= Available Tools and Resources =

[[TR_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy|TR - Expand Steps to Minimize Opioid Use During Pregnancy]]

= <br/> Sources =
</div>
[[Category:SAFE-Treatment and Recovery]] [[Category:SAFE-Prescriptions and Medical Response]]

Improve Screening for Infectious Disease among Those with SUDs

2021-02-08T14:30:44Z

Mredden:

__NOTOC__Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map]] or [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">__TOC__
= Overview =

= Key Information =

*Hep C virus (HCV) infections tripled between 2010 and 2015
*Substance abuse and infectious diseases shared common populations, risk factors, social determinants, and even contracting venues<sup class="reference">[1]</sup>
*There was little collaboration between programs that provided services to these populations<sup class="reference">[2]</sup>
*Methadone clinics would be optimal venues for service integration because these clinics serve a population that is 60% injection drug users; have medical staff performing brief health assessments for all new clients; and already have some infectious disease screenings in place, including routine tuberculosis testing and intermittent opt-in HIV testing<sup class="reference">[3]</sup>
*One study showed that 68% of opioid treatment programs nationwide had staff capacity for HCV testing, but only 33% actually offered on-site HCV testing<sup class="reference">[4]</sup>
*<span style="background-color: #ffffff; color: #333333; font-family: roboto,'helvetica neue',helvetica,arial,sans-serif; font-size: 16px">Awareness of HCV infection among this particular population may motivate them to reduce their consumption and hopefully high-risk behavior</span>

 

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Programs =

== Philly Website ==

[http://www.phillyhepatitis.org/support-care/ phillyhepatits.org] is an example of a resource for people seeking to identify if they have hepatitis, next steps they can take, and where they can find care or assistance.<br/>  

== TLC Awareness Campaign ==

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342624/ "Test, Listen, Cure" (TLC) Hepatitis C Community Awareness Campaign] provides information about how HCV infection is transmitted, risk factors for the disease, the importance of screening and treatment, and the availability of improved treatment for the disease.

= Available Tools and Resources =

[[TR_-_Improve_Screening_for_Infectious_Disease_among_Opioid_Users|TR - Improve Screening for Infectious Disease among Opioid Users]]<br/>  

= <span style="font-size: 13px;">Sources</span> =

----

#[https://www.cdc.gov/nchhstp/programintegration/successstories-tx/inf-disease-screening.html [2]]
#[https://www.cdc.gov/nchhstp/programintegration/successstories-tx/inf-disease-screening.html [3]]
#[https://www.cdc.gov/nchhstp/programintegration/successstories-tx/inf-disease-screening.html [4]]
##
##*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3670662/ [5]]
</div>
[[Category:SAFE-Prescriptions and Medical Response]]

Increase Access to Overdose Reversal Medications

2021-02-08T14:23:52Z

Mredden:

<div class="wiki" id="content_view" style="display: block">
Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map or]] [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] or [[ZOOM_Map-_Improve_Access_to_Treatments_that_Prevent_Overdose_Deaths|ZOOM MAP - Improve Access to Treatment that ]][[ZOOM_Map-_Improve_Access_to_Treatments_that_Prevent_Overdose_Deaths|Prevent]][[ZOOM_Map-_Improve_Access_to_Treatments_that_Prevent_Overdose_Deaths| Overdose Deaths]]

= Overview =

[[Additional_Info_on_Naloxone|Naloxone]] (Narcan) is a prescription medicine that can reverse an opioid overdose or prevent it long enough for the person to receive adequate medical care. It blocks the opioid receptors in the brain to prevent an opioid user’s breathing and heart rates from slowing to fatal levels. Beginning in 2016, thirty-five states have made Narcan available to the general public as an over-the-counter drug to use as a nasal spray. Many other states are now working to pass laws that give police, first responders, and concerned family members the ability to carry and administer Narcan when called to a possible overdose situation. It is either injected or administered in a nasal spray.<br/> <br/> While [[Additional_Info_on_Naloxone|Naloxone]] is not readily available by ordinary citizens, it can be easily administered with little or no formal training. State laws have made it difficult for citizens to obtain the life-saving medication, due to third-party prescription and prescription via standing order policies. The third party-prescription law prohibits the prescription of drugs to a third party other than whom the drugs will be given to, while the standing order law prohibits the prescription of drugs to a person not personally examined by the prescribing physician. Although, the drug could potentially save more lives if more widely distributed, there is fear of bystanders not summoning medical assistance due to possible prosecution against them.<br/> <br/> According to a report by CADCA, a small community in Connecticut has made training for first responders to an overdose mandatory. Officers found a man in an unconscious state and realized he was overdosing. With the administration of Narcan, the man was able to recover from the overdose and regain consciousness.<br/> <br/> Narcan has the potential to be very beneficial in communities with a high opioid problem. Making a community aware of it's existence, and it's power to reverse overdose is a benefit unlike any other. Narcan will allow victims of abuse to be more likely to survive an overdose when first responders are rightly prepared. This medicine is one of need if a community is struggling with an opioid problem.<br/> It has been effective in saving lives, giving people with addiction a chance to realize the depth of their problem and a chance to ask for help.<sup class="reference">[1]</sup>

= Key Information =

There is some evidence that opioid overdose education and naloxone distribution programs increase knowledge of appropriate overdose response among participating opioid users and others likely to encounter an overdose situation. Naloxone distribution through such programs is associated with reduced overdose deaths and appears to increase participant's confidence in their ability to respond effectively to overdose situations. However, additional evidence is needed to confirm effects.

Communities that implement programs to train potential bystanders to identify an opioid overdose and respond with naloxone appear to reduce opioid overdose death rates more than communities that do not implement such programs.

Family and friends of opioid users have greater knowledge of opioid overdose and ability to respond appropriately after receiving training in naloxone administration than peers who learn about opioid overdose and naloxone via na information booklet. Current or former opioid users who have received training in overdose response appear to identify overdose and recognize conditions when naloxone is appropriate as accurately as medical experts. Some studies suggest that opioid users who have participated in only a brief 5-10 minute training or learned naloxone administration through social networks can respond appropriately to an overdose.

Training first responders such as police, firefighters, and EMTs to administer naloxone may reduce time to overdose rescue, possibly decreasing overdose-related injury and death. Law enforcement officers who participate in naloxone administration adn overdose training report increases in knowledge and confidence in managing opioid overdose emergencies after program completion.

= Relevant Research =

A recent study in Massachusetts found that cities that have naloxone distribution programs have [http://www.bmj.com/content/346/bmj.f174 lower overdose death] rates than those that don’t. Similarly, the [http://www.nchrc.org/programs-and-services/ North Carolina Harm Reduction Coalition] has given out 52,000 naloxone kits since 2013 through their statewide grass roots network that includes syringe exchange and naloxone distribution, with more than 8,700 overdose reversals reported.<br/> [http://www.cadca.org/resources/coalition-action-meriden-healthy-youth-coalition-mhyc-provides-life-saving-overdose CADCA: Narcan Awareness]<sup class="reference">[2]</sup>

== Educate about Dangers of Dual use ==

In 2013 there were 23,153 opioid overdose deaths -- 16,235 involving opioid painkillers, 8,260 involving heroin/opium, and at least 1,342 involving a combination of the two. However, opioid overdoses are seldom due to opioid use along; the majority are a result of mixing an opioid with some other drug. The best way to avoid opioid overdose is not taking opioids; the next best thing is to avoid drug mixing entirely. If you insist on mixing drugs in spite of the inherent dangers, then it is imperative to take extra safety precautions to not die when mixing drugs. These include:

*Don't use alone
*Limit the amount of drugs you have available
*Stick to less lethal combinations of drugs
*Use smaller amounts of each drug
*Use the least impairing drug first
*Have Narcan on hand
*When injecting drugs of unknown strength and purity (street heroin), start with a small "tester" shot to gauge the strength of the drug before injecting a full dose
*When using a drug or drug combination for the first time, start with a small dose to gauge your innate tolerance
*Make sure your friends (or at least someone) knows what drug combinations you have taken
*Have a plan in place in case something goes wrong

Narcan only works on opioids, but doesn't harm an individual in the case on non-opioid overdose. So if there's any question as to what a person took, use narcan; it can only help.<sup class="reference">[6]</sup>

= Impactful Federal, State, and Local Policies =

== Good Samaritan Laws ==

People often hesitate to seek treatment or call medical assistance in fear of incarceration or other form of punishment. In August of 2015, the White House announced a treatment-based initiative with $2.5 million going toward a pilot program that will engage law enforcement officers and public health professional to collect data on the movement of heroin along the East coast, and to train first responders on when it is adequate to administer Naloxone.<sup class="reference">[9]</sup>

In 2006, New Mexico passed a [http://www.nytimes.com/2007/04/05/us/05drugs.html "Good Samaritan Law"] that "granted limited immunity from prosecution on simple possession chargers for people who dialed 911 to report a drug overdose". By 2015, 28 states in addition to the District of Columbia had passed similar laws.

In Minnesota, a "Good Samaritan" law was passed to assure that people who call the police or emergency responders to help with an overdose situation will not face legal consequences for their involvement, use of, or possession of legal or illegal opioids. This removes a potential barrier--fear of arrest--that sometimes leads to help not being called and lives being lost to overdose.<sup class="reference">[10]</sup>

 [http://www.ncsl.org/research/civil-and-criminal-justice/drug-overdose-immunity-good-samaritan-laws.aspx Drug Overdose Immunity and Good Samaritan Laws] for minimizing the fears of calling for help in the case of an overdose.

== Increasing Awareness of Law ==

*A University of Washington study evaluating the initial results of Washington state’s Good Samaritan policy found in a survey that drug users who were aware of the law were 88 percent more likely to call 911 in the event of an overdose than before.<sup class="reference">[11]</sup><br/> [http://adai.uw.edu/pubs/infobriefs/ADAI-IB-2011-05.pdf University of Washington study]
*After New York state passed its Good Samaritan law in 2011, for example, the Drug Policy Alliance printed 1 million cards and posters that explained the law and offered basic instructions on how to initially respond to an overdose, and worked with various agencies to help distribute these materials to vulnerable populations.<br/> [http://www.drugpolicy.org/sites/default/files/documents/DPA_911_GoodSam_Wallet_Card_v10_PRINTABLE.PDF Example Cards]<br/> [http://www.drugpolicy.org/sites/default/files/documents/DPA_911_Good_Samaritan_Flyer_EN_v3.pdf Example Posters]

== Federal Changes to Address Problem ==

Various federal organizations came together to encourage good faith prescription of naloxone to ordinary citizens and the second was to encourage bystanders to become "Good Samaritans" by summoning emergency responders without fear of negative legal consequences.

== State Law Passage ==

By the end of 2016, all but 3 states, Kansas, Montana, and Wyoming, have passed laws to improve ordinary person naloxone access.

== Pharmacists ==

In California, The California State Board of Pharmacy passed a policy that allows pharmacists to give out Naloxone (Narcan) without a prescription in case of emergencies.<sup class="reference">[12]</sup>

== New in 2016: Improved Access to Nasal Narcan ==
New Public Interest Pricing $37.50 per dose <div class="objectEmbed">[[Media:Press_Release_for_Adapt_Pharma_and_Public_Interest_Pricing.pdf|Press Release for Adapt Pharma and Public Interest Pricing.pdf]]  (230 KB)</div> <br/> Free case of Narcan Nasal for any school. (Only 9 states allow as of Jan 2016). <div class="objectEmbed"><div>[[Media:Free_Narcan_Nasal_Spray_and_Education_for_High_Schools.pdf|Free Narcan Nasal Spray and Education for High Schools.pdf]]  (164 KB)</div> </div>
== Law Enforcement Use of Naloxone ==

*A 2016 report by the Police Executive Research Forum provides case examples of law enforcement naloxone programs instituted in Fayetteville (NC), Lummi Nation (WA), Virginia Beach (VA), Staten Island (NY), Camden County (CJ), Mongomery County (MD), and Hagerstown (MD) including descriptions of training, funding, administration and support.<sup class="reference">[13]</sup>
*[[EI_-_Librarians_&_Access_to_Overdose_Treatment|EI - Librarians & Access to Overdose Treatment]] The Bureau of Justice Assistance (BJA) maintains an online toolkit featuring resources and information on naloxone, including a section on liability and risk for law enforcement officers and their employers associated with naloxone administration.<sup class="reference">[14]</sup>

== Database of State Legislative Efforts ==

This [http://www.ncsl.org/research/health/prevention-of-prescription-drug-overdose-and-abuse.aspx site] has many examples of policy efforts that have been attempted or passed.

=== Prevent Overdose strategies ===

This [https://www.overdosepreventionstrategies.org/ link] is a resource that has put every state's strategy into an online resource hub. This gives users a free resource to see what is being enacted in other states and lets people compare and contrast. This will allow for communities to enter and see what works and what does not.

 [https://www.overdosepreventionstrategies.org/ Overdose Prevention Strategies]

= Promising Practices =

[[CP_-_Improve_Access_to_Treatments_that_Prevent_Overdose_Deaths|CP - Improve Access to Treatments that Prevent Overdose Deaths]]

== Waive Copays ==

Many people who are prescribed Narcan (nearly 35%) don’t pick it up—presumably because they can’t afford the co-pay.<sup class="reference">[7]</sup><br/> Having insurers eliminate the co-pay is one strategy to help address that. [https://www.aetna.com/index.html?cid=ppc-700000001035216-National_Always%20On_Branded_Aetna_Exact-Aetna-aetna&s_dfa=1&gclid=Cj0KCQiA38jRBRCQARIsACEqIeuilyQ_mSIjuCUt394XAuPY7X7VLnJ16hmHFgFYPcLvvOwo4NUwmxkaAsEhEALw_wcB&gclsrc=aw.ds Aetna] is currently the first national payer to waive copays for Narcan for its fully-insured commercial members. This will "increase access and remove possible financial barriers to the lifesaving drug."<sup class="reference">[8]</sup>

= Tools & Resources =

[[TR_-_Improve_Access_to_Treatment_that_Prevent_Overdose_Deaths|TR - Improve Access to Treatment that Prevent Overdose Deaths]]<br/> [http:///file/view/SAMHSA_Opioid_Overdose_Prevention_TOOLKIT.pdf/613626145/SAMHSA_Opioid_Overdose_Prevention_TOOLKIT.pdf SAMHSA- Opioid Overdose Prevention Toolkit] - In particular, sections Facts for Community Members and Information for Prescribers may be of special interest.

== Actions to Take ==

[[PA_-_Improve_Access_to_Treatment_that_Prevent_Overdose_Deaths|Actions for Coalitions]]

[[PAI_-_Improve_Access_to_Treatment_that_Prevent_Overdose_Deaths|Actions for Individuals]]

= <br/> Sources =

----

#Hazelden Betty Ford Foundation. Heroin and Prescription Painkillers: A Toolkit for Community Action. 2016.
#CACDA Administration of Narcan. 2017  [http://www.cadca.org/resources/coalition-action-meriden-healthy-youth-coalition-mhyc-provides-life-saving-overdose [1]]
#100 Million Healthier Lives City, Town-Wide, and Regional Efforts.[https://www.baltimorecountymd.gov/news/baltimorecountynow/Kamenetz_Announces_Significant_County_Substance_Abuse_Initiatives_ https://www.baltimorecountymd.gov/news/baltimorecountynow/Kamenetz_Announces_Significant_County_Substance_Abuse_Initiatives_]
#100 Million Healthier Lives City, Town-Wide, and Regional Efforts [https://www.baltimorecountymd.gov/news/baltimorecountynow/Kamenetz_Announces_Significant_County_Substance_Abuse_Initiatives_ https://www.baltimorecountymd.gov/news/baltimorecountynow/Kamenetz_Announces_Significant_County_Substance_Abuse_Initiatives_]
#100 Million Healthier Lives City, Town-Wide, and Regional Efforts.[https://www.baltimorecountymd.gov/news/baltimorecountynow/Kamenetz_Announces_Significant_County_Substance_Abuse_Initiatives_ [2]]
#[http://www.rehabs.com/pro-talk-articles/the-ultimate-harm-reduction-guide-to-drug-mixing/ http://www.rehabs.com/pro-talk-articles/the-ultimate-harm-reduction-guide-to-drug-mixing/]
#[https://news.aetna.com/2017/12/aetna-announces-new-policies-improve-access-narcan-combat-overprescribing/ https://news.aetna.com/2017/12/aetna-announces-new-policies-improve-access-narcan-combat-overprescribing/]
#[https://news.aetna.com/2017/12/aetna-announces-new-policies-improve-access-narcan-combat-overprescribing/ https://news.aetna.com/2017/12/aetna-announces-new-policies-improve-access-narcan-combat-overprescribing/]
#[http://www.slate.com/articles/news_and_politics/crime/2015/08/good_samaritan_drug_laws_they_save_lives_and_more_states_should_pass_them.html http://www.slate.com/articles/news_and_politics/crime/2015/08/good_samaritan_drug_laws_they_save_lives_and_more_states_should_pass_them.html]
#[http://www.minnesotarecovery.org/files/FINAL_Good_Samaritan_Postcard.pdf http://www.minnesotarecovery.org/files/FINAL_Good_Samaritan_Postcard.pdf]
#[http://www.slate.com/articles/news_and_politics/crime/2015/08/good_samaritan_drug_laws_they_save_lives_and_more_states_should_pass_them.html http://www.slate.com/articles/news_and_politics/crime/2015/08/good_samaritan_drug_laws_they_save_lives_and_more_states_should_pass_them.html]
#[http://www.pharmacy.ca.gov/publications/naloxone_media_release.pdf http://www.pharmacy.ca.gov/publications/naloxone_media_release.pdf]
#Police Executive Research Forum. 2016. Building Successful Partnerships between Law Enforcement and Public Health Agencies to Address Opioid Use. COPS Office Emerging Issues Forums. Washington, DC: Office of Community Oriented Policing Services.<br/> [https://ric-zai-inc.com/Publications/cops-p356-pub.pdf https://ric-zai-inc.com/Publications/cops-p356-pub.pdf]
#[https://www.bjatraining.org/tools/naloxone/Liability-and-Risk https://www.bjatraining.org/tools/naloxone/Liability-and-Risk]
</div>
[[Category:SAFE-Full Spectrum Prevention]] [[Category:SAFE-Treatment and Recovery]]

Increase Access to Overdose Reversal Medications

2021-02-08T14:23:24Z

Mredden:

<div class="wiki" id="content_view" style="display: block">
Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map or]] [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] or [[ZOOM_Map-_Improve_Access_to_Treatments_that_Prevent_Overdose_Deaths|ZOOM MAP - Improve Access to Treatment that ]][[ZOOM_Map-_Improve_Access_to_Treatments_that_Prevent_Overdose_Deaths|Prevent]][[ZOOM_Map-_Improve_Access_to_Treatments_that_Prevent_Overdose_Deaths| Overdose Deaths]]

= Overview =

[[Additional_Info_on_Naloxone|Naloxone]] (Narcan) is a prescription medicine that can reverse an opioid overdose or prevent it long enough for the person to receive adequate medical care. It blocks the opioid receptors in the brain to prevent an opioid user’s breathing and heart rates from slowing to fatal levels. Beginning in 2016, thirty-five states have made Narcan available to the general public as an over-the-counter drug to use as a nasal spray. Many other states are now working to pass laws that give police, first responders, and concerned family members the ability to carry and administer Narcan when called to a possible overdose situation. It is either injected or administered in a nasal spray.<br/> <br/> While [[Additional_Info_on_Naloxone|Naloxone]] is not readily available by ordinary citizens, it can be easily administered with little or no formal training. State laws have made it difficult for citizens to obtain the life-saving medication, due to third-party prescription and prescription via standing order policies. The third party-prescription law prohibits the prescription of drugs to a third party other than whom the drugs will be given to, while the standing order law prohibits the prescription of drugs to a person not personally examined by the prescribing physician. Although, the drug could potentially save more lives if more widely distributed, there is fear of bystanders not summoning medical assistance due to possible prosecution against them.<br/> <br/> According to a report by CADCA, a small community in Connecticut has made training for first responders to an overdose mandatory. Officers found a man in an unconscious state and realized he was overdosing. With the administration of Narcan, the man was able to recover from the overdose and regain consciousness.<br/> <br/> Narcan has the potential to be very beneficial in communities with a high opioid problem. Making a community aware of it's existence, and it's power to reverse overdose is a benefit unlike any other. Narcan will allow victims of abuse to be more likely to survive an overdose when first responders are rightly prepared. This medicine is one of need if a community is struggling with an opioid problem.<br/> It has been effective in saving lives, giving people with addiction a chance to realize the depth of their problem and a chance to ask for help.<sup class="reference">[1]</sup><br/>  

= Key Information =

There is some evidence that opioid overdose education and naloxone distribution programs increase knowledge of appropriate overdose response among participating opioid users and others likely to encounter an overdose situation. Naloxone distribution through such programs is associated with reduced overdose deaths and appears to increase participant's confidence in their ability to respond effectively to overdose situations. However, additional evidence is needed to confirm effects.

Communities that implement programs to train potential bystanders to identify an opioid overdose and respond with naloxone appear to reduce opioid overdose death rates more than communities that do not implement such programs.

Family and friends of opioid users have greater knowledge of opioid overdose and ability to respond appropriately after receiving training in naloxone administration than peers who learn about opioid overdose and naloxone via na information booklet. Current or former opioid users who have received training in overdose response appear to identify overdose and recognize conditions when naloxone is appropriate as accurately as medical experts. Some studies suggest that opioid users who have participated in only a brief 5-10 minute training or learned naloxone administration through social networks can respond appropriately to an overdose.

Training first responders such as police, firefighters, and EMTs to administer naloxone may reduce time to overdose rescue, possibly decreasing overdose-related injury and death. Law enforcement officers who participate in naloxone administration adn overdose training report increases in knowledge and confidence in managing opioid overdose emergencies after program completion.

= Relevant Research =

A recent study in Massachusetts found that cities that have naloxone distribution programs have [http://www.bmj.com/content/346/bmj.f174 lower overdose death] rates than those that don’t. Similarly, the [http://www.nchrc.org/programs-and-services/ North Carolina Harm Reduction Coalition] has given out 52,000 naloxone kits since 2013 through their statewide grass roots network that includes syringe exchange and naloxone distribution, with more than 8,700 overdose reversals reported.<br/> [http://www.cadca.org/resources/coalition-action-meriden-healthy-youth-coalition-mhyc-provides-life-saving-overdose CADCA: Narcan Awareness]<sup class="reference">[2]</sup><br/>  

== Educate about Dangers of Dual use ==

In 2013 there were 23,153 opioid overdose deaths -- 16,235 involving opioid painkillers, 8,260 involving heroin/opium, and at least 1,342 involving a combination of the two. However, opioid overdoses are seldom due to opioid use along; the majority are a result of mixing an opioid with some other drug. The best way to avoid opioid overdose is not taking opioids; the next best thing is to avoid drug mixing entirely. If you insist on mixing drugs in spite of the inherent dangers, then it is imperative to take extra safety precautions to not die when mixing drugs. These include:

*Don't use alone
*Limit the amount of drugs you have available
*Stick to less lethal combinations of drugs
*Use smaller amounts of each drug
*Use the least impairing drug first
*Have Narcan on hand
*When injecting drugs of unknown strength and purity (street heroin), start with a small "tester" shot to gauge the strength of the drug before injecting a full dose
*When using a drug or drug combination for the first time, start with a small dose to gauge your innate tolerance
*Make sure your friends (or at least someone) knows what drug combinations you have taken
*Have a plan in place in case something goes wrong

Narcan only works on opioids, but doesn't harm an individual in the case on non-opioid overdose. So if there's any question as to what a person took, use narcan; it can only help.<sup class="reference">[6]</sup>

= Impactful Federal, State, and Local Policies =

== Good Samaritan Laws ==

People often hesitate to seek treatment or call medical assistance in fear of incarceration or other form of punishment. In August of 2015, the White House announced a treatment-based initiative with $2.5 million going toward a pilot program that will engage law enforcement officers and public health professional to collect data on the movement of heroin along the East coast, and to train first responders on when it is adequate to administer Naloxone.<sup class="reference">[9]</sup>

In 2006, New Mexico passed a [http://www.nytimes.com/2007/04/05/us/05drugs.html "Good Samaritan Law"] that "granted limited immunity from prosecution on simple possession chargers for people who dialed 911 to report a drug overdose". By 2015, 28 states in addition to the District of Columbia had passed similar laws.

In Minnesota, a "Good Samaritan" law was passed to assure that people who call the police or emergency responders to help with an overdose situation will not face legal consequences for their involvement, use of, or possession of legal or illegal opioids. This removes a potential barrier--fear of arrest--that sometimes leads to help not being called and lives being lost to overdose.<sup class="reference">[10]</sup>

 [http://www.ncsl.org/research/civil-and-criminal-justice/drug-overdose-immunity-good-samaritan-laws.aspx Drug Overdose Immunity and Good Samaritan Laws] for minimizing the fears of calling for help in the case of an overdose.

== Increasing Awareness of Law ==

*A University of Washington study evaluating the initial results of Washington state’s Good Samaritan policy found in a survey that drug users who were aware of the law were 88 percent more likely to call 911 in the event of an overdose than before.<sup class="reference">[11]</sup><br/> [http://adai.uw.edu/pubs/infobriefs/ADAI-IB-2011-05.pdf University of Washington study]
*After New York state passed its Good Samaritan law in 2011, for example, the Drug Policy Alliance printed 1 million cards and posters that explained the law and offered basic instructions on how to initially respond to an overdose, and worked with various agencies to help distribute these materials to vulnerable populations.<br/> [http://www.drugpolicy.org/sites/default/files/documents/DPA_911_GoodSam_Wallet_Card_v10_PRINTABLE.PDF Example Cards]<br/> [http://www.drugpolicy.org/sites/default/files/documents/DPA_911_Good_Samaritan_Flyer_EN_v3.pdf Example Posters]

== Federal Changes to Address Problem ==

Various federal organizations came together to encourage good faith prescription of naloxone to ordinary citizens and the second was to encourage bystanders to become "Good Samaritans" by summoning emergency responders without fear of negative legal consequences.

== State Law Passage ==

By the end of 2016, all but 3 states, Kansas, Montana, and Wyoming, have passed laws to improve ordinary person naloxone access.

== Pharmacists ==

In California, The California State Board of Pharmacy passed a policy that allows pharmacists to give out Naloxone (Narcan) without a prescription in case of emergencies.<sup class="reference">[12]</sup>

== New in 2016: Improved Access to Nasal Narcan ==
New Public Interest Pricing $37.50 per dose <div class="objectEmbed">[[Media:Press_Release_for_Adapt_Pharma_and_Public_Interest_Pricing.pdf|Press Release for Adapt Pharma and Public Interest Pricing.pdf]]  (230 KB)</div> <br/> Free case of Narcan Nasal for any school. (Only 9 states allow as of Jan 2016). <div class="objectEmbed"><div>[[Media:Free_Narcan_Nasal_Spray_and_Education_for_High_Schools.pdf|Free Narcan Nasal Spray and Education for High Schools.pdf]]  (164 KB)</div> </div>
== Law Enforcement Use of Naloxone ==

*A 2016 report by the Police Executive Research Forum provides case examples of law enforcement naloxone programs instituted in Fayetteville (NC), Lummi Nation (WA), Virginia Beach (VA), Staten Island (NY), Camden County (CJ), Mongomery County (MD), and Hagerstown (MD) including descriptions of training, funding, administration and support.<sup class="reference">[13]</sup>
*[[EI_-_Librarians_&_Access_to_Overdose_Treatment|EI - Librarians & Access to Overdose Treatment]] The Bureau of Justice Assistance (BJA) maintains an online toolkit featuring resources and information on naloxone, including a section on liability and risk for law enforcement officers and their employers associated with naloxone administration.<sup class="reference">[14]</sup>

 

== Database of State Legislative Efforts ==

This [http://www.ncsl.org/research/health/prevention-of-prescription-drug-overdose-and-abuse.aspx site] has many examples of policy efforts that have been attempted or passed.

=== Prevent Overdose strategies ===

This [https://www.overdosepreventionstrategies.org/ link] is a resource that has put every state's strategy into an online resource hub. This gives users a free resource to see what is being enacted in other states and lets people compare and contrast. This will allow for communities to enter and see what works and what does not.

 [https://www.overdosepreventionstrategies.org/ Overdose Prevention Strategies]

= Promising Practices =

[[CP_-_Improve_Access_to_Treatments_that_Prevent_Overdose_Deaths|CP - Improve Access to Treatments that Prevent Overdose Deaths]]

== Waive Copays ==

Many people who are prescribed Narcan (nearly 35%) don’t pick it up—presumably because they can’t afford the co-pay.<sup class="reference">[7]</sup><br/> Having insurers eliminate the co-pay is one strategy to help address that. [https://www.aetna.com/index.html?cid=ppc-700000001035216-National_Always%20On_Branded_Aetna_Exact-Aetna-aetna&s_dfa=1&gclid=Cj0KCQiA38jRBRCQARIsACEqIeuilyQ_mSIjuCUt394XAuPY7X7VLnJ16hmHFgFYPcLvvOwo4NUwmxkaAsEhEALw_wcB&gclsrc=aw.ds Aetna] is currently the first national payer to waive copays for Narcan for its fully-insured commercial members. This will "increase access and remove possible financial barriers to the lifesaving drug."<sup class="reference">[8]</sup>

= Tools & Resources =

[[TR_-_Improve_Access_to_Treatment_that_Prevent_Overdose_Deaths|TR - Improve Access to Treatment that Prevent Overdose Deaths]]<br/> [http:///file/view/SAMHSA_Opioid_Overdose_Prevention_TOOLKIT.pdf/613626145/SAMHSA_Opioid_Overdose_Prevention_TOOLKIT.pdf SAMHSA- Opioid Overdose Prevention Toolkit] - In particular, sections Facts for Community Members and Information for Prescribers may be of special interest.

== Actions to Take ==

[[PA_-_Improve_Access_to_Treatment_that_Prevent_Overdose_Deaths|Actions for Coalitions]]

[[PAI_-_Improve_Access_to_Treatment_that_Prevent_Overdose_Deaths|Actions for Individuals]]

= <br/> Sources =

----

#Hazelden Betty Ford Foundation. Heroin and Prescription Painkillers: A Toolkit for Community Action. 2016.
#CACDA Administration of Narcan. 2017  [http://www.cadca.org/resources/coalition-action-meriden-healthy-youth-coalition-mhyc-provides-life-saving-overdose [1]]
#100 Million Healthier Lives City, Town-Wide, and Regional Efforts.[https://www.baltimorecountymd.gov/news/baltimorecountynow/Kamenetz_Announces_Significant_County_Substance_Abuse_Initiatives_ https://www.baltimorecountymd.gov/news/baltimorecountynow/Kamenetz_Announces_Significant_County_Substance_Abuse_Initiatives_]
#100 Million Healthier Lives City, Town-Wide, and Regional Efforts [https://www.baltimorecountymd.gov/news/baltimorecountynow/Kamenetz_Announces_Significant_County_Substance_Abuse_Initiatives_ https://www.baltimorecountymd.gov/news/baltimorecountynow/Kamenetz_Announces_Significant_County_Substance_Abuse_Initiatives_]
#100 Million Healthier Lives City, Town-Wide, and Regional Efforts.[https://www.baltimorecountymd.gov/news/baltimorecountynow/Kamenetz_Announces_Significant_County_Substance_Abuse_Initiatives_ [2]]
#[http://www.rehabs.com/pro-talk-articles/the-ultimate-harm-reduction-guide-to-drug-mixing/ http://www.rehabs.com/pro-talk-articles/the-ultimate-harm-reduction-guide-to-drug-mixing/]
#[https://news.aetna.com/2017/12/aetna-announces-new-policies-improve-access-narcan-combat-overprescribing/ https://news.aetna.com/2017/12/aetna-announces-new-policies-improve-access-narcan-combat-overprescribing/]
#[https://news.aetna.com/2017/12/aetna-announces-new-policies-improve-access-narcan-combat-overprescribing/ https://news.aetna.com/2017/12/aetna-announces-new-policies-improve-access-narcan-combat-overprescribing/]
#[http://www.slate.com/articles/news_and_politics/crime/2015/08/good_samaritan_drug_laws_they_save_lives_and_more_states_should_pass_them.html http://www.slate.com/articles/news_and_politics/crime/2015/08/good_samaritan_drug_laws_they_save_lives_and_more_states_should_pass_them.html]
#[http://www.minnesotarecovery.org/files/FINAL_Good_Samaritan_Postcard.pdf http://www.minnesotarecovery.org/files/FINAL_Good_Samaritan_Postcard.pdf]
#[http://www.slate.com/articles/news_and_politics/crime/2015/08/good_samaritan_drug_laws_they_save_lives_and_more_states_should_pass_them.html http://www.slate.com/articles/news_and_politics/crime/2015/08/good_samaritan_drug_laws_they_save_lives_and_more_states_should_pass_them.html]
#[http://www.pharmacy.ca.gov/publications/naloxone_media_release.pdf http://www.pharmacy.ca.gov/publications/naloxone_media_release.pdf]
#Police Executive Research Forum. 2016. Building Successful Partnerships between Law Enforcement and Public Health Agencies to Address Opioid Use. COPS Office Emerging Issues Forums. Washington, DC: Office of Community Oriented Policing Services.<br/> [https://ric-zai-inc.com/Publications/cops-p356-pub.pdf https://ric-zai-inc.com/Publications/cops-p356-pub.pdf]
#[https://www.bjatraining.org/tools/naloxone/Liability-and-Risk https://www.bjatraining.org/tools/naloxone/Liability-and-Risk]
</div>
[[Category:SAFE-Full Spectrum Prevention]] [[Category:SAFE-Treatment and Recovery]]

Adopt Harm Reduction Practices in Jails and Prisons

2021-02-08T14:11:37Z

Mredden:

Expand Number of Safe Injection Sites

2021-02-08T14:05:30Z

Mredden:

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= Overview =

= Key Information =

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Practices =

= Available Tools and Resources =

= Sources =

Expand Access to Medication-Assisted Treatment (MAT)

2021-02-08T13:20:17Z

Mredden:

__NOTOC__ Return to [[ZOOM_MAP_-_Expand_Access_to_Optimized_MAT|Zoom Map - Expand Access to Optimized MAT]] or  [[ZOOM_MAP_-_Improve_Treatment_&_Enable_Recovery_for_People_with_SUDs|Zoom Map (Improve Treatment & Enable Recovery for People with SUDs)]] or the [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">
<br/> __TOC__

= Overview =
<div class="_">Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders.<sup class="reference"><ref>[1]chanell.baylor. (2015, July 21). Medication-Assisted Treatment (MAT) [Text]. Retrieved December 5, 2019, from https://www.samhsa.gov/medication-assisted-treatment
</ref></sup> Information on medications used in MAT can be found further down on this page. The President's [https://www.whitehouse.gov/ondcp/presidents-commission Commission on Combating Drug Addiction and the Opioid Crisis] has recommended that federal government "immediately establish and fund a federal incentive to enhance access to Medication-Assisted Treatment (MAT)."<sup class="reference"><ref>[2]Commission to the President (2016), Retrieved from: https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf</ref></sup></div> <div class="_">The above reports documents that MAT has been proven to:</div>
*Reduce overdose deaths
*retain persons in treatment
*decrease use of heroin
*Prevent spread of infectious disease

== Key Information ==

=== The Value of MAT (or Opioid-Agonist Treatment) ===

*International addiction experts consider initial opioid-agonist treatment, or OAT, ''with no duration restrictions'', the evidence-based standard of care for opioid-use disorder, the authors write online November 20, 2018 in Annals of Internal Medicine.<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: http://education.psychiatry.org/Users/ProductDetails.aspx?ActivityID=6092
</ref>
*But 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 false 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>
**“If we want 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.

Access the study here:<ref>What’s this agonist / antagonist stuff? (n.d.). Retrieved December 5, 2019, from https://www.naabt.org/faq_answers.cfm?ID=5
</ref>

This article talks of how the use of Buprenorphine reduces the cost of opioid addiction<ref>[1]Behavioral Healthcare Executive | Psychiatry & Behavioral Health Learning Network. (n.d.). Retrieved December 5, 2019, from https://www.psychcongress.com/node/721
</ref>

 

= Relevant Research =
<div class="_">An article in the August 2017 issue of the American Journal of Psychiatry, by Roger D. Weiss, MD, the Chief of the Division of Alcohol and Drug Abuse at McLean Hospital (Belmont, MA) and Professor of Psychiatry at Harvard Medical School and Kathleen Carroll, Ph.D. concluded: "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."</div> <div class="_"> </div> <div class="_">This 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 and well-being 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 different types of behavioral treatments that would be appropriate for different individuals, While not mentioned specifically in that article, a person's history of trauma or ACEs, length of time with an SUD, current level of supports and genetic factors such as the rates at which they metabolize different drugs would all impact what type of treatment would be most appropriate. All of these unique factors and the wide range of potential interventions are reasons that more research is needed, and conclusions from studies that look at a limited number of inputs and outcomes and lack visibility into all the unique factors that influence what might impact successful outcomes should be seen as early insights in a journey of finding the optimal forms of treatment for each person's situation.</div> <div class="_"> </div> <div class="_">Weiss and Carroll highlight some key findings from their report in a Webinar done through the American Journal of Psychiatry learning center.<sup class="reference">[3]</sup> Key points include:</div>
*
**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.
**Paients 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 chances of abstaining by week 12.
*There is evidence that the use of [https://drugabuse.com/library/contingency-management/ Contingency Management ](CM), including the use of computer-based therapies, seems to increase success rates
*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,

== 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.   MAT is optimized when those providing and funding the treatment keep striving to improve all aspects of the treatment plan, optimized for each individual as much as practical. 

Some of the ways that MAT can be optimized are listed below::

*Precision medication ([[Expand_DNA_Testing_to_Improve_Precision_MAT_Therapies|Expand DNA Testing to Improve Precision MAT]])
*A coordinated, proactive, whole-person care plan ([[Integrate_MAT_into_a_Whole_Person_Care_Model|Integrate MAT into whole-person care model]])
*Community engagement ([[Expand_community_engagement_to_improve_MAT|Expand community engagement to improve MAT]])
*Use of innovative technologies ([[Use_innovative_technologies_to_enhance_MAT|Use innovative technologies to enhance MAT]])

== Current Status of MAT Practices ==

*Only 10% of conventional drug treatment facilities in the United States provide MAT for opioid use disorders (need source and date)
*According to SAMHSA data collected in early 2017, 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.<sup class="reference">[4]</sup>
*Avalere’s analysis finds 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<sup class="reference">[5]</sup>
</div>
== 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> [6]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>

== Different Medications Used in MAT: ==

=== Agonists & Antagonists ===
<div class="_">An opioid agonist activates opioid receptors in the brain. An antagonist blocks opioids by attaching to the opioid receptors without activating them.<sup class="reference"><ref>[7]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/</ref></sup>[Detoxification vs. Stabilization]</div> <div class="_"> </div> <div class="_">Buprenorphine</div>
*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.<sup class="reference"><ref>[8]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/</ref></sup>
*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.<sup class="reference"><ref>[9]Page Not Found</ref></sup>
*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 May 2016<sup class="reference"><ref>[10]Page Not Found</ref></sup>
*Training for Buprenorphine providers is an 8 hour course (24 for Nurse Pracitioners and Physician Assistants) and allow for the following patient loads and responsibilities:<sup class="reference"><ref>[11]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></sup>

#30 Addiction Treamtent Patients per provider for the first year
#100 patients each year thereafter
#An additional 175 (totalling 275) patients can be alloted is the Physician is board certified in addiction, or a facility:

*Has 24 Call Coverage for patients
*Uses an EMR/EHS to monitor and update patient records (for those looking for an entry level EHS, PracticeFusion is a free system)
*Provision of Care Management Services
*Subscribing to a State led Drug Management System
*Acceptance of 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<sup class="reference"><ref>[12]Page Not Found</ref></sup> . As a result, there are cases where medication diversion do occur, and there is a black market for the drug for self-treatment purposes.<sup class="reference"><ref>[13]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/</ref></sup><br/> <br/> 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>[14]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/</ref></sup>

*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine SAMSHA page on Buprenorphine]
*[[More_info_on_Buprenorphine|More info on Buprenorphine]]

For more information, one can visit the information page on [[File/view/BupForOUD.pdf/614583113/BupForOUD.pdf|Buprenorphine for Patients and Families]], which includes information on side effects, information to share with providers and other useful information. This document was compiled by Intermountain Health Care.

=== 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>[15]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/</ref></sup>
*[[More_info_on_Suboxone|More info on Suboxone]] (including generic options)

=== Probuphine ===

*Probuphine is an implant that contains the medicine buprenorphine. Probuphine is used to treat certain adults who are addicted to (dependent on) opioid drugs (either prescription or illegal). Probuphine is part of a complete treatment program that also includes counseling and behavioral therapy.
*Because Probuphine contains buprenorphine, it may cause physical dependence.
*Four implants are inserted under the skin of your upper arm during a procedure done in your physician's office or Opioid Treatment Program (OTP).
*The implants remain in your arm for six months.
*After the six-month period, your doctor must remove the implants.
*If you wish to continue Probuphine, your doctor may insert new implants to continue treatment.
*The implants can be removed sooner if you want to stop treatment.
*Patients must continue to see their doctor at least every month while on Probuphine therapy.
*[https://probuphine.com/ For more information visit their website.]

=== 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/</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/</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/</ref></sup>
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/methadone SAMSHA page on Methadone]
*[[More_Information_on_Methadone|More info on Methadone]]

=== Naltrexone ===

*Naltrexone is a nonaddictive medicine that serves as an opioid receptor antagonist and not an opioid replacement unlike methadone and buprenophine. 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.<sup class="reference"><ref>[19]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/</ref></sup>
*Naltrexone is administered in a long-active, injectable formulation administered once a month.<sup class="reference"><ref>[20]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/</ref></sup>
*Naltrexone does not prevent withdrawal symptoms so it is recommended for patients who do not have opioid in their system.<sup class="reference"><ref>[21]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/</ref></sup>
*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)
*[[More_info_on_Naltrexone_and_Vivitrol|More info on Naltrexone and 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 as safe for administration by any person.<sup class="reference"><ref>[22]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/</ref></sup>
*Naloxone works within minutes and effects last for up to an hour. Multiple doses may be required depending on the severity of respiratory depression.<sup class="reference"><ref>[23]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></sup>
*Naloxone does not produce tolerance or dependence. <sup class="reference"><ref>[24]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></sup>
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone SAMSHA page on Naloxone]
*[[More_info_on_Naloxone|More info on Naloxone]] (including discounted public pricing and free Narcan for schools)
*(for [http://www.samhsa.gov/medication-assisted-treatment/treatment/opioid-overdose opioid overdose])

<br/> 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.<br/> <br/> Medications Used in Addiction Treatment**<sup class="reference"><ref>[25]The Case for Medication-Assisted Treatment. (n.d.). Retrieved December 5, 2019, from http://pew.org/2kdLIf2
</ref></sup>

{| 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%<sup class="reference"><ref>[26]Summary: Major components of the HHS final rule. Effective August 8, 2016. (n.d.). Retrieved December 5, 2019, from https://www.asam.org/resources/publications/magazine/read/article/2016/07/06/summary-of-the-major-components-of-the-hhs-final-rule-which-will-be-effective-on-august-5-2016
</ref></sup>
| 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).<sup class="reference"><ref>[27]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></sup><sup class="reference"><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></sup><sup class="reference"><ref>[29]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></sup>
*Any DEA-licensed provider can prescribe buprenorphine for pain.

| OUD and pain management (depending on formulation and dose)
| 60% to 90%<sup class="reference"><ref>[30]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></sup>
| 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%<sup class="reference"><ref>[31]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></sup>
| Daily pill or monthly injectable
|-
| Naloxone<br/> (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
|}
<div class="_">Extensive research has demonstrated the effectiveness of opioid agonist treatment (methadone and buprenorphine) 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.<sup class="reference"><ref>[32]Page Not Found</ref></sup><br/>  </div>
== 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."<sup class="reference"><ref>[33]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></sup></div> <div class="_">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.<br/> Some training program 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></div> <div class="_">[[More_information_on_buprenorphine_induction|More information on buprenorphine induction]].</div> <div class="_"> </div>
=== Stabilization ===
<div class="_">"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."</div> <div class="_"> [[More_information_on_buprenorphine_stabilization|More information on buprenorphine stabilization]].</div>
=== Maintenance ===
<div class="_">"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."</div> <div class="_">[[More_information_on_buprenorphine_maintenance|More information on buprenorphine maintenance]]</div>
== 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 shortacting 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 longacting opioids should be considered only for those patients who have evidence of sustained medical and psychosocial stability,</div>
= Impactful Federal, State, and Local Policies =

== New 2018 SAMHSA Guide for Medications for Opioid Use Disorder ==

This latest, detailed [https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Executive-Summary/SMA18-5063EXSUMM 330-page report] can be downloaded for free. 

= Promising Practices =

== New & Expanded Treatment Options ==

=== Connecticut ===
<div class="_">Connecticut's Department of Mental Health and Addiction Services (DMHAS) recently received two federal grants, one of which is meant to go to medical 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> [36]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></div>
=== Vermont ===
<div class="_">Vermont's Health Home for Opioid Addiction have 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<ref> [37] 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>:</div>
*The Hub, a designated provider of specialty addiction treatment, designed as an Opioid Treatment Program which are operated by Community Behavioral Health Agencies.
*The Spokes, which 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<br/> Vermont Global Commitment To Health Section 1115 Demonstration Fact Sheet<sup class="reference"><ref>[38]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></sup>

*
**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.

More information can be found at: <ref>[3]Hub and Spoke Evaluation Shows Significant Impact (January 22, 2018). (2018, January 22). Retrieved December 5, 2019, from Vermont Department of Health website: https://www.healthvermont.gov/media/newsroom/hub-and-spoke-evaluation-shows-significant-impact-january-22-2018

</ref>

== Emergency Department Treatment Protocols ==
<div class="_">In a Yale Randomized trial, 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 of in patient facilities. This can be attributed to engaging patients at the optimal point of access. <sup class="reference"><ref>[40]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></sup></div>
== National Healthcare For Homeless Council ==
<div class="_">Aa one may assume, there is cross-over between the homeless and addicted communities. The National Healthcare for the Homeless Council have 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:</div> <div class="_">  • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.</div> <div class="_"> </div> <div class="_">More information can be found on the [[File/view/HCHBrief.pdf/614804863/HCHBrief.pdf|Policy Document]] itself.</div>
== Opioid Treatment Program Directory ==
<div class="_">Select [http://dpt2.samhsa.gov/treatment/directory.aspx this directory] to view the opioid treatment programs in each state</div>
== Moving from Stigma to Science ==

=== Pennsylvania and New Jersey ===
<div class="_">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>[41] Page Not Found</ref>Underlying problems still exist in restrictive medication regiment 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.<ref> [42]Page Not Found</ref></div>
=== National Healthcare For Homeless Council ===

The National Healthcare for the Homeless Council also have recommendations of policy that not only controls the prescription of opiates, but also the treatment of opioid addiction. They are as follows:
<div class="_">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 selftreatment 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.</div>
*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.

More information can be seen in this [[File/view/HCHBrief.pdf/614804863/HCHBrief.pdf|Policy Brief Document]].

== 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."<sup class="reference"><span style="background-color:#f1c40f;">[43]</span></sup> 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.

== Canadian Guidelines ==
<div class="_">This [https://www.cpso.on.ca/uploadedFiles/policies/guidelines/office/buprenorphine_naloxone_gdlns2011.pdf document ]has details on the MAT Buprenorphine guidelines from Canada</div>
= Available Tools and Resources =

[[TR_-_Expand_Access_to_Medication-Assisted_Treatment|TR - Expand Access to Medication-Assisted Treatment]]<br/> <br/> PCSS<br/> The Provider's Clinical Support System offers a [[File/view/StigmaandMethadone.pdf/614518761/StigmaandMethadone.pdf|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. <sup class="reference"><span style="background-color:#f1c40f;">[44]</span></sup><br/> <br/> [http://www.buppractice.com/ BupPractice]<br/> is a DATA 2000 accredited resource for providing either an 8 hour training for Physicians or 24 training session for Physician Assistants and Nurse Practitioners, both for $199 per full series. Offers up to 9 AMA PRA Category 1 Credits, and is further supported by the ASAM (American Society of Addiction Medicine).<br/> <br/> [[File/view/ADAPTINGPRACTICE.pdf/614804967/ADAPTINGPRACTICE.pdf|HCH Clinician's Network]]<br/> This resource provides recommendations for one's practice when dealing with opioid addicted patients, particularly those who also happen to be homeless.<br/> <br/> [[File/view/BHSHomeless.pdf/614805019/BHSHomeless.pdf|SAMSHA's Treatment Improvement Protocol for Homeless Persons]]<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.<br/> <br/> Where Can Clinicians Get Training and Support? Buprenorphine trainings 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 telementoring 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.<sup class="reference"><span style="background-color:#f1c40f;">[45]</span></sup><br/>  

<br/> PAGE MANAGER: [insert name here]<br/> SUBJECT MATTER EXPERT: [fill out table below]

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= Sources =

[[Category:SAFE-Treatment and Recovery]]

Expand Access to Medication-Assisted Treatment (MAT)

2021-02-08T13:13:15Z

Mredden:

__NOTOC__ Return to [[ZOOM_MAP_-_Expand_Access_to_Optimized_MAT|Zoom Map - Expand Access to Optimized MAT]] or  [[ZOOM_MAP_-_Improve_Treatment_&_Enable_Recovery_for_People_with_SUDs|Zoom Map (Improve Treatment & Enable Recovery for People with SUDs)]] or the [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">
<br/> __TOC__

= Overview =
<div class="_">Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders.<sup class="reference"><ref>[1]chanell.baylor. (2015, July 21). Medication-Assisted Treatment (MAT) [Text]. Retrieved December 5, 2019, from https://www.samhsa.gov/medication-assisted-treatment
</ref></sup> Information on medications used in MAT can be found further down on this page. The President's [https://www.whitehouse.gov/ondcp/presidents-commission Commission on Combating Drug Addiction and the Opioid Crisis] has recommended that federal government "immediately establish and fund a federal incentive to enhance access to Medication-Assisted Treatment (MAT)."<sup class="reference"><ref>[2]Commission to the President (2016), Retrieved from: https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf</ref></sup></div> <div class="_">The above reports documents that MAT has been proven to:</div>
*Reduce overdose deaths
*retain persons in treatment
*decrease use of heroin
*Prevent spread of infectious disease

 

= Key Information =

== The Value of MAT (or Opioid-Agonist Treatment) ==

*International addiction experts consider initial opioid-agonist treatment, or OAT, ''with no duration restrictions'', the evidence-based standard of care for opioid-use disorder, the authors write online November 20, 2018 in Annals of Internal Medicine.<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: http://education.psychiatry.org/Users/ProductDetails.aspx?ActivityID=6092
</ref>
*But 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 false 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>
**“If we want 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.

Access the study here:<ref>What’s this agonist / antagonist stuff? (n.d.). Retrieved December 5, 2019, from https://www.naabt.org/faq_answers.cfm?ID=5
</ref>

This article talks of how the use of Buprenorphine reduces the cost of opioid addiction<ref>[1]Behavioral Healthcare Executive | Psychiatry & Behavioral Health Learning Network. (n.d.). Retrieved December 5, 2019, from https://www.psychcongress.com/node/721
</ref>

 

= Relevant Research =
<div class="_">An article in the August 2017 issue of the American Journal of Psychiatry, by Roger D. Weiss, MD, the Chief of the Division of Alcohol and Drug Abuse at McLean Hospital (Belmont, MA) and Professor of Psychiatry at Harvard Medical School and Kathleen Carroll, Ph.D. concluded:<br/>   "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."</div> <div class="_">  This 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 and well-being 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 different types of behavioral treatments that would be appropriate for different individuals, While not mentioned specifically in that article, a person's history of trauma or ACEs, length of time with an SUD, current level of supports and genetic factors such as the rates at which they metabolize different drugs would all impact what type of treatment would be most appropriate. All of these unique factors and the wide range of potential interventions are reasons that more research is needed, and conclusions from studies that look at a limited number of inputs and outcomes and lack visibility into all the unique factors that influence what might impact successful outcomes should be seen as early insights in a journey of finding the optimal forms of treatment for each person's situation.</div> <div class="_">  Weiss and Carroll highlight some key findings from their report in a Webinar done through the American Journal of Psychiatry learning center.<sup class="reference">[3]</sup> Key points include:</div> <div class="_"> </div>
*
**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.
**Paients 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 chances of abstaining by week 12.
*There is evidence that the use of [https://drugabuse.com/library/contingency-management/ Contingency Management ](CM), including the use of computer-based therapies, seems to increase success rates
*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,

 

== 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.   MAT is optimized when those providing and funding the treatment keep striving to improve all aspects of the treatment plan, optimized for each individual as much as practical. 

Some of the ways that MAT can be optimized are listed below::

*Precision medication ([[Expand_DNA_Testing_to_Improve_Precision_MAT_Therapies|Expand DNA Testing to Improve Precision MAT]])
*A coordinated, proactive, whole-person care plan ([[Integrate_MAT_into_a_Whole_Person_Care_Model|Integrate MAT into whole-person care model]])
*Community engagement ([[Expand_community_engagement_to_improve_MAT|Expand community engagement to improve MAT]])
*Use of innovative technologies ([[Use_innovative_technologies_to_enhance_MAT|Use innovative technologies to enhance MAT]])

<br/>  

== Current Status of MAT Practices ==

*Only 10% of conventional drug treatment facilities in the United States provide MAT for opioid use disorders (need source and date)
*According to SAMHSA data collected in early 2017, 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.<sup class="reference">[4]</sup>
*Avalere’s analysis finds 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<sup class="reference">[5]</sup>

 
</div>
== 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> [6]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>

== Different Medications Used in MAT: ==

=== Agonists & Antagonists ===
<div class="_">An opioid agonist activates opioid receptors in the brain. An antagonist blocks opioids by attaching to the opioid receptors without activating them.<sup class="reference"><ref>[7]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/</ref></sup><br/>   [Detoxification vs. Stabilization]</div> <div class="_"> </div> <div class="_">Buprenorphine</div>
*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.<sup class="reference"><ref>[8]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/</ref></sup>
*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.<sup class="reference"><ref>[9]Page Not Found</ref></sup>
*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 May 2016<sup class="reference"><ref>[10]Page Not Found</ref></sup>
*Training for Buprenorphine providers is an 8 hour course (24 for Nurse Pracitioners and Physician Assistants) and allow for the following patient loads and responsibilities:<sup class="reference"><ref>[11]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></sup>

#30 Addiction Treamtent Patients per provider for the first year
#100 patients each year thereafter
#An additional 175 (totalling 275) patients can be alloted is the Physician is board certified in addiction, or a facility:

*Has 24 Call Coverage for patients
*Uses an EMR/EHS to monitor and update patient records (for those looking for an entry level EHS, PracticeFusion is a free system)
*Provision of Care Management Services
*Subscribing to a State led Drug Management System
*Acceptance of Third Party Insurance

<br/> It should be noted that only around 10% of those who wish to seek treatment can find qualified providers to allow for it<sup class="reference"><ref>[12]Page Not Found</ref></sup> . As a result, there are cases where medication diversion do occur, and there is a black market for the drug for self-treatment purposes.<sup class="reference"><ref>[13]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/</ref></sup><br/> <br/> 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>[14]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/</ref></sup>

*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine SAMSHA page on Buprenorphine]
*[[More_info_on_Buprenorphine|More info on Buprenorphine]]

For more information, one can visit the information page on [[File/view/BupForOUD.pdf/614583113/BupForOUD.pdf|Buprenorphine for Patients and Families]], which includes information on side effects, information to share with providers and other useful information. This document was compiled by Intermountain Health Care.

=== 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>[15]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/</ref></sup>
*[[More_info_on_Suboxone|More info on Suboxone]] (including generic options)

=== Probuphine ===

*Probuphine is an implant that contains the medicine buprenorphine. Probuphine is used to treat certain adults who are addicted to (dependent on) opioid drugs (either prescription or illegal). Probuphine is part of a complete treatment program that also includes counseling and behavioral therapy.
*Because Probuphine contains buprenorphine, it may cause physical dependence.
*Four implants are inserted under the skin of your upper arm during a procedure done in your physician's office or Opioid Treatment Program (OTP).
*The implants remain in your arm for six months.
*After the six-month period, your doctor must remove the implants.
*If you wish to continue Probuphine, your doctor may insert new implants to continue treatment.
*The implants can be removed sooner if you want to stop treatment.
*Patients must continue to see their doctor at least every month while on Probuphine therapy.
*[https://probuphine.com/ For more information visit their website.]

=== 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/</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/</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/</ref></sup>
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/methadone SAMSHA page on Methadone]
*[[More_Information_on_Methadone|More info on Methadone]]

=== Naltrexone ===

*Naltrexone is a nonaddictive medicine that serves as an opioid receptor antagonist and not an opioid replacement unlike methadone and buprenophine. 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.<sup class="reference"><ref>[19]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/</ref></sup>
*Naltrexone is administered in a long-active, injectable formulation administered once a month.<sup class="reference"><ref>[20]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/</ref></sup>
*Naltrexone does not prevent withdrawal symptoms so it is recommended for patients who do not have opioid in their system.<sup class="reference"><ref>[21]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/</ref></sup>
*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)
*[[More_info_on_Naltrexone_and_Vivitrol|More info on Naltrexone and 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 as safe for administration by any person.<sup class="reference"><ref>[22]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/</ref></sup>
*Naloxone works within minutes and effects last for up to an hour. Multiple doses may be required depending on the severity of respiratory depression.<sup class="reference"><ref>[23]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></sup>
*Naloxone does not produce tolerance or dependence. <sup class="reference"><ref>[24]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></sup>
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone SAMSHA page on Naloxone]
*[[More_info_on_Naloxone|More info on Naloxone]] (including discounted public pricing and free Narcan for schools)
*(for [http://www.samhsa.gov/medication-assisted-treatment/treatment/opioid-overdose opioid overdose])
* 

<br/> 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.<br/> <br/> Medications Used in Addiction Treatment**<sup class="reference"><ref>[25]The Case for Medication-Assisted Treatment. (n.d.). Retrieved December 5, 2019, from http://pew.org/2kdLIf2
</ref></sup>

{| 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%<sup class="reference"><ref>[26]Summary: Major components of the HHS final rule. Effective August 8, 2016. (n.d.). Retrieved December 5, 2019, from https://www.asam.org/resources/publications/magazine/read/article/2016/07/06/summary-of-the-major-components-of-the-hhs-final-rule-which-will-be-effective-on-august-5-2016
</ref></sup>
| 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).<sup class="reference"><ref>[27]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></sup><sup class="reference"><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></sup><sup class="reference"><ref>[29]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></sup>
*Any DEA-licensed provider can prescribe buprenorphine for pain.

| OUD and pain management (depending on formulation and dose)
| 60% to 90%<sup class="reference"><ref>[30]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></sup>
| 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%<sup class="reference"><ref>[31]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></sup>
| Daily pill or monthly injectable
|-
| Naloxone<br/> (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
|}
<div class="_">Extensive research has demonstrated the effectiveness of opioid agonist treatment (methadone and buprenorphine) 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.<sup class="reference"><ref>[32]Page Not Found</ref></sup><br/> <br/> <br/>  </div> <div class="_"> </div>
== 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."<sup class="reference"><ref>[33]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></sup></div> <div class="_">  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.<sup class="reference"><ref>[34]Page Not Found</ref></sup><br/>   Some training program 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></div> <div class="_"> [[More_information_on_buprenorphine_induction|More information on buprenorphine induction]].</div> <div class="_"> </div>
=== Stabilization ===
<div class="_">"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."</div> <div class="_"> [[More_information_on_buprenorphine_stabilization|More information on buprenorphine stabilization]].<br/>  </div> <div class="_"> </div>
=== Maintenance ===
<div class="_">"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."</div> <div class="_"> [[More_information_on_buprenorphine_maintenance|More information on buprenorphine maintenance]]<br/>  </div> <div class="_"> </div>
== 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 shortacting 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 longacting opioids should be considered only for those patients who have evidence of sustained medical and psychosocial stability,</div> <div class="_"> </div>
= Impactful Federal, State, and Local Policies =

== New 2018 SAMHSA Guide for Medications for Opioid Use Disorder ==

This latest, detailed [https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Executive-Summary/SMA18-5063EXSUMM 330-page report] can be downloaded for free. 

= Promising Practices =

== New & Expanded Treatment Options ==

=== Connecticut ===
<div class="_">Connecticut's Department of Mental Health and Addiction Services (DMHAS) recently received two federal grants, one of which is meant to go to medical 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> [36]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><br/>  </div> <div class="_"> </div>
=== Vermont ===
<div class="_">Vermont's Health Home for Opioid Addiction have 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<ref> [37] 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>:</div> <div class="_"> </div>
*The Hub, a designated provider of specialty addiction treatment, designed as an Opioid Treatment Program which are operated by Community Behavioral Health Agencies.
*The Spokes, which 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<br/> Vermont Global Commitment To Health Section 1115 Demonstration Fact Sheet<sup class="reference"><ref>[38]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></sup>

*
**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.

More information can be found at: <ref>[3]Hub and Spoke Evaluation Shows Significant Impact (January 22, 2018). (2018, January 22). Retrieved December 5, 2019, from Vermont Department of Health website: https://www.healthvermont.gov/media/newsroom/hub-and-spoke-evaluation-shows-significant-impact-january-22-2018

</ref><br/>  

== Emergency Department Treatment Protocols ==
<div class="_">In a Yale Randomized trial, 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 of in patient facilities. This can be attributed to engaging patients at the optimal point of access. <sup class="reference"><ref>[40]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></sup><br/> <br/>  </div> <div class="_"> </div>
== National Healthcare For Homeless Council ==
<div class="_">Aa one may assume, there is cross-over between the homeless and addicted communities. The National Healthcare for the Homeless Council have 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:</div> <div class="_">  • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.</div> <div class="_">  More information can be found on the [[File/view/HCHBrief.pdf/614804863/HCHBrief.pdf|Policy Document]] itself.</div> <div class="_"> </div>
== Opioid Treatment Program Directory ==
<div class="_">Select [http://dpt2.samhsa.gov/treatment/directory.aspx this directory] to view the opioid treatment programs in each state</div> <div class="_"> </div>
== Moving from Stigma to Science ==

=== Pennsylvania and New Jersey ===
<div class="_">  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>[41] Page Not Found</ref>Underlying problems still exist in restrictive medication regiment 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.<ref> [42]Page Not Found</ref></div>
===   National Healthcare For Homeless Council<br/>   The National Healthcare for the Homeless Council also have recommendations of policy that not only controls the prescription of opiates, but also the treatment of opioid addiction. They are as follows: ===
<div class="_">  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 selftreatment 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.<br/>  </div> <div class="_"> </div>
*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.

More information can be seen in this [[File/view/HCHBrief.pdf/614804863/HCHBrief.pdf|Policy Brief Document]].<br/>  

== 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."<sup class="reference"><span style="background-color:#f1c40f;">[43]</span></sup> 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.<br/>  

== Canadian Guidelines ==
<div class="_">This [https://www.cpso.on.ca/uploadedFiles/policies/guidelines/office/buprenorphine_naloxone_gdlns2011.pdf document ]has details on the MAT Buprenorphine guidelines from Canada</div>
= Available Tools and Resources =

[[TR_-_Expand_Access_to_Medication-Assisted_Treatment|TR - Expand Access to Medication-Assisted Treatment]]<br/> <br/> PCSS<br/> The Provider's Clinical Support System offers a [[File/view/StigmaandMethadone.pdf/614518761/StigmaandMethadone.pdf|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. <sup class="reference"><span style="background-color:#f1c40f;">[44]</span></sup><br/> <br/> [http://www.buppractice.com/ BupPractice]<br/> is a DATA 2000 accredited resource for providing either an 8 hour training for Physicians or 24 training session for Physician Assistants and Nurse Practitioners, both for $199 per full series. Offers up to 9 AMA PRA Category 1 Credits, and is further supported by the ASAM (American Society of Addiction Medicine).<br/> <br/> [[File/view/ADAPTINGPRACTICE.pdf/614804967/ADAPTINGPRACTICE.pdf|HCH Clinician's Network]]<br/> This resource provides recommendations for one's practice when dealing with opioid addicted patients, particularly those who also happen to be homeless.<br/> <br/> [[File/view/BHSHomeless.pdf/614805019/BHSHomeless.pdf|SAMSHA's Treatment Improvement Protocol for Homeless Persons]]<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.<br/> <br/> Where Can Clinicians Get Training and Support? Buprenorphine trainings 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 telementoring 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.<sup class="reference"><span style="background-color:#f1c40f;">[45]</span></sup><br/>  

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= Sources =

[[Category:SAFE-Treatment and Recovery]]

Expand Access to Medication-Assisted Treatment (MAT)

2021-02-08T13:03:14Z

Mredden:

__NOTOC__ Return to [[ZOOM_MAP_-_Expand_Access_to_Optimized_MAT|Zoom Map - Expand Access to Optimized MAT]] or  [[ZOOM_MAP_-_Improve_Treatment_&_Enable_Recovery_for_People_with_SUDs|Zoom Map (Improve Treatment & Enable Recovery for People with SUDs)]] or the [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">
<br/> __TOC__

= Overview =
<div class="_">Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders.<sup class="reference"><ref>[1]chanell.baylor. (2015, July 21). Medication-Assisted Treatment (MAT) [Text]. Retrieved December 5, 2019, from https://www.samhsa.gov/medication-assisted-treatment
</ref></sup> Information on medications used in MAT can be found further down on this page.</div> <div class="_">  The President's [https://www.whitehouse.gov/ondcp/presidents-commission Commission on Combating Drug Addiction and the Opioid Crisis] has recommended that federal government "immediately establish and fund a federal incentive to enhance access to Medication-Assisted Treatment (MAT)."<sup class="reference"><ref>[2]Commission to the President (2016), Retrieved from: https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf</ref></sup></div> <div class="_">  The above reports documents that MAT has been proven to:</div> <div class="_"> </div>
*Reduce overdose deaths
*retain persons in treatment
*decrease use of heroin
*Prevent spread of infectious disease

 

= Key Information =

= Relevant Research =
<div class="_">An article in the August 2017 issue of the American Journal of Psychiatry, by Roger D. Weiss, MD, the Chief of the Division of Alcohol and Drug Abuse at McLean Hospital (Belmont, MA) and Professor of Psychiatry at Harvard Medical School and Kathleen Carroll, Ph.D. concluded:<br/>   "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."</div> <div class="_">  This 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 and well-being 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 different types of behavioral treatments that would be appropriate for different individuals, While not mentioned specifically in that article, a person's history of trauma or ACEs, length of time with an SUD, current level of supports and genetic factors such as the rates at which they metabolize different drugs would all impact what type of treatment would be most appropriate. All of these unique factors and the wide range of potential interventions are reasons that more research is needed, and conclusions from studies that look at a limited number of inputs and outcomes and lack visibility into all the unique factors that influence what might impact successful outcomes should be seen as early insights in a journey of finding the optimal forms of treatment for each person's situation.</div> <div class="_">  Weiss and Carroll highlight some key findings from their report in a Webinar done through the American Journal of Psychiatry learning center.<sup class="reference">[3]</sup> Key points include:</div> <div class="_"> </div>
*
**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.
**Paients 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 chances of abstaining by week 12.
*There is evidence that the use of [https://drugabuse.com/library/contingency-management/ Contingency Management ](CM), including the use of computer-based therapies, seems to increase success rates
*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,

 

= 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.   MAT is optimized when those providing and funding the treatment keep striving to improve all aspects of the treatment plan, optimized for each individual as much as practical. 

Some of the ways that MAT can be optimized are listed below::

*Precision medication ([[Expand_DNA_Testing_to_Improve_Precision_MAT_Therapies|Expand DNA Testing to Improve Precision MAT]])
*A coordinated, proactive, whole-person care plan ([[Integrate_MAT_into_a_Whole_Person_Care_Model|Integrate MAT into whole-person care model]])
*Community engagement ([[Expand_community_engagement_to_improve_MAT|Expand community engagement to improve MAT]])
*Use of innovative technologies ([[Use_innovative_technologies_to_enhance_MAT|Use innovative technologies to enhance MAT]])

<br/>  

= Current Status of MAT Practices =

*Only 10% of conventional drug treatment facilities in the United States provide MAT for opioid use disorders (need source and date)
*According to SAMHSA data collected in early 2017, 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.<sup class="reference">[4]</sup>
*Avalere’s analysis finds 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<sup class="reference">[5]</sup>

 

= The Value of MAT (or Opioid-Agonist Treatment) =

*International addiction experts consider initial opioid-agonist treatment, or OAT, ''with no duration restrictions'', the evidence-based standard of care for opioid-use disorder, the authors write online November 20, 2018 in Annals of Internal Medicine.<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: http://education.psychiatry.org/Users/ProductDetails.aspx?ActivityID=6092
</ref>
*But 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 false 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>
**“If we want 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.

Access the study here:<ref>What’s this agonist / antagonist stuff? (n.d.). Retrieved December 5, 2019, from https://www.naabt.org/faq_answers.cfm?ID=5
</ref><br/>  
This article talks of how the use of Buprenorphine reduces the cost of opioid addiction<ref>[1]Behavioral Healthcare Executive | Psychiatry & Behavioral Health Learning Network. (n.d.). Retrieved December 5, 2019, from https://www.psychcongress.com/node/721
</ref> <div class="_"> </div> </div>
= Impactful Federal, State, and Local Policies =

== New 2018 SAMHSA Guide for Medications for Opioid Use Disorder ==

This latest, detailed [https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Executive-Summary/SMA18-5063EXSUMM 330-page report] can be downloaded for free. 

= 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> [6]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>

= Different Medications Used in MAT: =

== Agonists & Antagonists ==
<div class="_">An opioid agonist activates opioid receptors in the brain. An antagonist blocks opioids by attaching to the opioid receptors without activating them.<sup class="reference"><ref>[7]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/</ref></sup><br/>   [Detoxification vs. Stabilization]</div> <div class="_"> </div> <div class="_">Buprenorphine</div>
*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.<sup class="reference"><ref>[8]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/</ref></sup>
*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.<sup class="reference"><ref>[9]Page Not Found</ref></sup>
*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 May 2016<sup class="reference"><ref>[10]Page Not Found</ref></sup>
*Training for Buprenorphine providers is an 8 hour course (24 for Nurse Pracitioners and Physician Assistants) and allow for the following patient loads and responsibilities:<sup class="reference"><ref>[11]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></sup>

#30 Addiction Treamtent Patients per provider for the first year
#100 patients each year thereafter
#An additional 175 (totalling 275) patients can be alloted is the Physician is board certified in addiction, or a facility:

*Has 24 Call Coverage for patients
*Uses an EMR/EHS to monitor and update patient records (for those looking for an entry level EHS, PracticeFusion is a free system)
*Provision of Care Management Services
*Subscribing to a State led Drug Management System
*Acceptance of Third Party Insurance

<br/> It should be noted that only around 10% of those who wish to seek treatment can find qualified providers to allow for it<sup class="reference"><ref>[12]Page Not Found</ref></sup> . As a result, there are cases where medication diversion do occur, and there is a black market for the drug for self-treatment purposes.<sup class="reference"><ref>[13]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/</ref></sup><br/> <br/> 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>[14]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/</ref></sup>

*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine SAMSHA page on Buprenorphine]
*[[More_info_on_Buprenorphine|More info on Buprenorphine]]

For more information, one can visit the information page on [[File/view/BupForOUD.pdf/614583113/BupForOUD.pdf|Buprenorphine for Patients and Families]], which includes information on side effects, information to share with providers and other useful information. This document was compiled by Intermountain Health Care.

== 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>[15]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/</ref></sup>
*[[More_info_on_Suboxone|More info on Suboxone]] (including generic options)

== Probuphine ==

*Probuphine is an implant that contains the medicine buprenorphine. Probuphine is used to treat certain adults who are addicted to (dependent on) opioid drugs (either prescription or illegal). Probuphine is part of a complete treatment program that also includes counseling and behavioral therapy.
*Because Probuphine contains buprenorphine, it may cause physical dependence.
*Four implants are inserted under the skin of your upper arm during a procedure done in your physician's office or Opioid Treatment Program (OTP).
*The implants remain in your arm for six months.
*After the six-month period, your doctor must remove the implants.
*If you wish to continue Probuphine, your doctor may insert new implants to continue treatment.
*The implants can be removed sooner if you want to stop treatment.
*Patients must continue to see their doctor at least every month while on Probuphine therapy.
*[https://probuphine.com/ For more information visit their website.]

== 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/</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/</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/</ref></sup>
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/methadone SAMSHA page on Methadone]
*[[More_Information_on_Methadone|More info on Methadone]]

== Naltrexone ==

*Naltrexone is a nonaddictive medicine that serves as an opioid receptor antagonist and not an opioid replacement unlike methadone and buprenophine. 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.<sup class="reference"><ref>[19]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/</ref></sup>
*Naltrexone is administered in a long-active, injectable formulation administered once a month.<sup class="reference"><ref>[20]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/</ref></sup>
*Naltrexone does not prevent withdrawal symptoms so it is recommended for patients who do not have opioid in their system.<sup class="reference"><ref>[21]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/</ref></sup>
*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)
*[[More_info_on_Naltrexone_and_Vivitrol|More info on Naltrexone and 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 as safe for administration by any person.<sup class="reference"><ref>[22]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/</ref></sup>
*Naloxone works within minutes and effects last for up to an hour. Multiple doses may be required depending on the severity of respiratory depression.<sup class="reference"><ref>[23]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></sup>
*Naloxone does not produce tolerance or dependence. <sup class="reference"><ref>[24]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></sup>
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone SAMSHA page on Naloxone]
*[[More_info_on_Naloxone|More info on Naloxone]] (including discounted public pricing and free Narcan for schools)
*(for [http://www.samhsa.gov/medication-assisted-treatment/treatment/opioid-overdose opioid overdose])
* 

<br/> 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.<br/> <br/> <br/> <br/> Medications Used in Addiction Treatment**<sup class="reference"><ref>[25]The Case for Medication-Assisted Treatment. (n.d.). Retrieved December 5, 2019, from http://pew.org/2kdLIf2
</ref></sup>

{| 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%<sup class="reference"><ref>[26]Summary: Major components of the HHS final rule. Effective August 8, 2016. (n.d.). Retrieved December 5, 2019, from https://www.asam.org/resources/publications/magazine/read/article/2016/07/06/summary-of-the-major-components-of-the-hhs-final-rule-which-will-be-effective-on-august-5-2016
</ref></sup>
| 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).<sup class="reference"><ref>[27]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></sup><sup class="reference"><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></sup><sup class="reference"><ref>[29]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></sup>
*Any DEA-licensed provider can prescribe buprenorphine for pain.

| OUD and pain management (depending on formulation and dose)
| 60% to 90%<sup class="reference"><ref>[30]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></sup>
| 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%<sup class="reference"><ref>[31]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></sup>
| Daily pill or monthly injectable
|-
| Naloxone<br/> (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
|}
<div class="_">Extensive research has demonstrated the effectiveness of opioid agonist treatment (methadone and buprenorphine) 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.<sup class="reference"><ref>[32]Page Not Found</ref></sup><br/> <br/> <br/>  </div> <div class="_"> </div>
= 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."<sup class="reference"><ref>[33]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></sup></div> <div class="_">  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.<sup class="reference"><ref>[34]Page Not Found</ref></sup><br/>   Some training program 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></div> <div class="_"> [[More_information_on_buprenorphine_induction|More information on buprenorphine induction]].</div> <div class="_"> </div>
== Stabilization ==
<div class="_">"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."</div> <div class="_"> [[More_information_on_buprenorphine_stabilization|More information on buprenorphine stabilization]].<br/>  </div> <div class="_"> </div>
== Maintenance ==
<div class="_">"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."</div> <div class="_"> [[More_information_on_buprenorphine_maintenance|More information on buprenorphine maintenance]]<br/>  </div> <div class="_"> </div>
== 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 shortacting 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 longacting opioids should be considered only for those patients who have evidence of sustained medical and psychosocial stability,</div> <div class="_"> </div>
== Canadian Guidelines ==
<div class="_">This [https://www.cpso.on.ca/uploadedFiles/policies/guidelines/office/buprenorphine_naloxone_gdlns2011.pdf document ]has details on the MAT Buprenorphine guidelines from Canada</div> <div class="_"> </div>
= New & Expanded Treatment Options =

== Connecticut ==
<div class="_">Connecticut's Department of Mental Health and Addiction Services (DMHAS) recently received two federal grants, one of which is meant to go to medical 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> [36]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><br/>  </div> <div class="_"> </div>
== Vermont ==
<div class="_">Vermont's Health Home for Opioid Addiction have 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<ref> [37] 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>:</div> <div class="_"> </div>
*The Hub, a designated provider of specialty addiction treatment, designed as an Opioid Treatment Program which are operated by Community Behavioral Health Agencies.
*The Spokes, which 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<br/> Vermont Global Commitment To Health Section 1115 Demonstration Fact Sheet<sup class="reference"><ref>[38]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></sup>

*
**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.

More information can be found at: <ref>[3]Hub and Spoke Evaluation Shows Significant Impact (January 22, 2018). (2018, January 22). Retrieved December 5, 2019, from Vermont Department of Health website: https://www.healthvermont.gov/media/newsroom/hub-and-spoke-evaluation-shows-significant-impact-january-22-2018

</ref><br/>  

== Emergency Department Treatment Protocols ==
<div class="_">In a Yale Randomized trial, 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 of in patient facilities. This can be attributed to engaging patients at the optimal point of access. <sup class="reference"><ref>[40]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></sup><br/> <br/>  </div> <div class="_"> </div>
== National Healthcare For Homeless Council ==
<div class="_">Aa one may assume, there is cross-over between the homeless and addicted communities. The National Healthcare for the Homeless Council have 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:</div> <div class="_">  • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.</div> <div class="_">  More information can be found on the [[File/view/HCHBrief.pdf/614804863/HCHBrief.pdf|Policy Document]] itself.</div> <div class="_"> </div>
= Opioid Treatment Program Directory =
<div class="_">Select [http://dpt2.samhsa.gov/treatment/directory.aspx this directory] to view the opioid treatment programs in each state</div> <div class="_"> </div>
= Moving from Stigma to Science =
<div class="_">Pennsylvania and New Jersey</div> <div class="_">  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>[41] Page Not Found</ref>Underlying problems still exist in restrictive medication regiment 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.<ref> [42]Page Not Found</ref></div> <div class="_">  National Healthcare For Homeless Council<br/>   The National Healthcare for the Homeless Council also have recommendations of policy that not only controls the prescription of opiates, but also the treatment of opioid addiction. They are as follows:</div> <div class="_">  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 selftreatment 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.<br/>  </div> <div class="_"> </div>
*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.

More information can be seen in this [[File/view/HCHBrief.pdf/614804863/HCHBrief.pdf|Policy Brief Document]].<br/>  

= 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."<sup class="reference"><span style="background-color:#f1c40f;">[43]</span></sup> 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.<br/>  

= Tools & Resources =

[[TR_-_Expand_Access_to_Medication-Assisted_Treatment|TR - Expand Access to Medication-Assisted Treatment]]<br/> <br/> PCSS<br/> The Provider's Clinical Support System offers a [[File/view/StigmaandMethadone.pdf/614518761/StigmaandMethadone.pdf|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. <sup class="reference"><span style="background-color:#f1c40f;">[44]</span></sup><br/> <br/> [http://www.buppractice.com/ BupPractice]<br/> is a DATA 2000 accredited resource for providing either an 8 hour training for Physicians or 24 training session for Physician Assistants and Nurse Practitioners, both for $199 per full series. Offers up to 9 AMA PRA Category 1 Credits, and is further supported by the ASAM (American Society of Addiction Medicine).<br/> <br/> [[File/view/ADAPTINGPRACTICE.pdf/614804967/ADAPTINGPRACTICE.pdf|HCH Clinician's Network]]<br/> This resource provides recommendations for one's practice when dealing with opioid addicted patients, particularly those who also happen to be homeless.<br/> <br/> [[File/view/BHSHomeless.pdf/614805019/BHSHomeless.pdf|SAMSHA's Treatment Improvement Protocol for Homeless Persons]]<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.<br/> <br/> Where Can Clinicians Get Training and Support? Buprenorphine trainings 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 telementoring 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.<sup class="reference"><span style="background-color:#f1c40f;">[45]</span></sup><br/>  

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[[Category:SAFE-Treatment and Recovery]]

Expand Access to Medication-Assisted Treatment (MAT)

2021-02-08T13:01:30Z

Mredden: Undo revision 20361 by Mredden (talk)

__NOTOC__ Return to [[ZOOM_MAP_-_Expand_Access_to_Optimized_MAT|Zoom Map - Expand Access to Optimized MAT]] or  [[ZOOM_MAP_-_Improve_Treatment_&_Enable_Recovery_for_People_with_SUDs|Zoom Map (Improve Treatment & Enable Recovery for People with SUDs)]] or the [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">
<br/> __TOC__

= Medication-Assisted Treatment =
<div class="_">Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders.<sup class="reference"><ref>[1]chanell.baylor. (2015, July 21). Medication-Assisted Treatment (MAT) [Text]. Retrieved December 5, 2019, from https://www.samhsa.gov/medication-assisted-treatment
</ref></sup> Information on medications used in MAT can be found further down on this page.</div> <div class="_">  The President's [https://www.whitehouse.gov/ondcp/presidents-commission Commission on Combating Drug Addiction and the Opioid Crisis] has recommended that federal government "immediately establish and fund a federal incentive to enhance access to Medication-Assisted Treatment (MAT)."<sup class="reference"><ref>[2]Commission to the President (2016), Retrieved from: https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf</ref></sup></div> <div class="_">  The above reports documents that MAT has been proven to:</div> <div class="_"> </div>
*Reduce overdose deaths
*retain persons in treatment
*decrease use of heroin
*Prevent spread of infectious disease

 

= Opportunity to Enhance Common MAT Research and Practices =
<div class="_">An article in the August 2017 issue of the American Journal of Psychiatry, by Roger D. Weiss, MD, the Chief of the Division of Alcohol and Drug Abuse at McLean Hospital (Belmont, MA) and Professor of Psychiatry at Harvard Medical School and Kathleen Carroll, Ph.D. concluded:<br/>   "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."</div> <div class="_">  This 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 and well-being 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 different types of behavioral treatments that would be appropriate for different individuals, While not mentioned specifically in that article, a person's history of trauma or ACEs, length of time with an SUD, current level of supports and genetic factors such as the rates at which they metabolize different drugs would all impact what type of treatment would be most appropriate. All of these unique factors and the wide range of potential interventions are reasons that more research is needed, and conclusions from studies that look at a limited number of inputs and outcomes and lack visibility into all the unique factors that influence what might impact successful outcomes should be seen as early insights in a journey of finding the optimal forms of treatment for each person's situation.</div> <div class="_">  Weiss and Carroll highlight some key findings from their report in a Webinar done through the American Journal of Psychiatry learning center.<sup class="reference">[3]</sup> Key points include:</div> <div class="_"> </div>
*
**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.
**Paients 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 chances of abstaining by week 12.
*There is evidence that the use of [https://drugabuse.com/library/contingency-management/ Contingency Management ](CM), including the use of computer-based therapies, seems to increase success rates
*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,

 

= 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.   MAT is optimized when those providing and funding the treatment keep striving to improve all aspects of the treatment plan, optimized for each individual as much as practical. 

Some of the ways that MAT can be optimized are listed below::

*Precision medication ([[Expand_DNA_Testing_to_Improve_Precision_MAT_Therapies|Expand DNA Testing to Improve Precision MAT]])
*A coordinated, proactive, whole-person care plan ([[Integrate_MAT_into_a_Whole_Person_Care_Model|Integrate MAT into whole-person care model]])
*Community engagement ([[Expand_community_engagement_to_improve_MAT|Expand community engagement to improve MAT]])
*Use of innovative technologies ([[Use_innovative_technologies_to_enhance_MAT|Use innovative technologies to enhance MAT]])

<br/>  

= Current Status of MAT Practices =

*Only 10% of conventional drug treatment facilities in the United States provide MAT for opioid use disorders (need source and date)
*According to SAMHSA data collected in early 2017, 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.<sup class="reference">[4]</sup>
*Avalere’s analysis finds 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<sup class="reference">[5]</sup>

 

= The Value of MAT (or Opioid-Agonist Treatment) =

*International addiction experts consider initial opioid-agonist treatment, or OAT, ''with no duration restrictions'', the evidence-based standard of care for opioid-use disorder, the authors write online November 20, 2018 in Annals of Internal Medicine.<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: http://education.psychiatry.org/Users/ProductDetails.aspx?ActivityID=6092
</ref>
*But 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 false 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>
**“If we want 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.

Access the study here:<ref>What’s this agonist / antagonist stuff? (n.d.). Retrieved December 5, 2019, from https://www.naabt.org/faq_answers.cfm?ID=5
</ref><br/>  
This article talks of how the use of Buprenorphine reduces the cost of opioid addiction<ref>[1]Behavioral Healthcare Executive | Psychiatry & Behavioral Health Learning Network. (n.d.). Retrieved December 5, 2019, from https://www.psychcongress.com/node/721
</ref> <div class="_"> </div> </div>
= New 2018 SAMHSA Guide for Medications for Opioid Use Disorder =

This latest, detailed [https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Executive-Summary/SMA18-5063EXSUMM 330-page report] can be downloaded for free. 

= 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> [6]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>

= Different Medications Used in MAT: =

== Agonists & Antagonists ==
<div class="_">An opioid agonist activates opioid receptors in the brain. An antagonist blocks opioids by attaching to the opioid receptors without activating them.<sup class="reference"><ref>[7]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/</ref></sup><br/>   [Detoxification vs. Stabilization]</div> <div class="_"> </div> <div class="_">Buprenorphine</div>
*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.<sup class="reference"><ref>[8]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/</ref></sup>
*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.<sup class="reference"><ref>[9]Page Not Found</ref></sup>
*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 May 2016<sup class="reference"><ref>[10]Page Not Found</ref></sup>
*Training for Buprenorphine providers is an 8 hour course (24 for Nurse Pracitioners and Physician Assistants) and allow for the following patient loads and responsibilities:<sup class="reference"><ref>[11]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></sup>

#30 Addiction Treamtent Patients per provider for the first year
#100 patients each year thereafter
#An additional 175 (totalling 275) patients can be alloted is the Physician is board certified in addiction, or a facility:

*Has 24 Call Coverage for patients
*Uses an EMR/EHS to monitor and update patient records (for those looking for an entry level EHS, PracticeFusion is a free system)
*Provision of Care Management Services
*Subscribing to a State led Drug Management System
*Acceptance of Third Party Insurance

<br/> It should be noted that only around 10% of those who wish to seek treatment can find qualified providers to allow for it<sup class="reference"><ref>[12]Page Not Found</ref></sup> . As a result, there are cases where medication diversion do occur, and there is a black market for the drug for self-treatment purposes.<sup class="reference"><ref>[13]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/</ref></sup><br/> <br/> 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>[14]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/</ref></sup>

*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine SAMSHA page on Buprenorphine]
*[[More_info_on_Buprenorphine|More info on Buprenorphine]]

For more information, one can visit the information page on [[File/view/BupForOUD.pdf/614583113/BupForOUD.pdf|Buprenorphine for Patients and Families]], which includes information on side effects, information to share with providers and other useful information. This document was compiled by Intermountain Health Care.

== 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>[15]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/</ref></sup>
*[[More_info_on_Suboxone|More info on Suboxone]] (including generic options)

== Probuphine ==

*Probuphine is an implant that contains the medicine buprenorphine. Probuphine is used to treat certain adults who are addicted to (dependent on) opioid drugs (either prescription or illegal). Probuphine is part of a complete treatment program that also includes counseling and behavioral therapy.
*Because Probuphine contains buprenorphine, it may cause physical dependence.
*Four implants are inserted under the skin of your upper arm during a procedure done in your physician's office or Opioid Treatment Program (OTP).
*The implants remain in your arm for six months.
*After the six-month period, your doctor must remove the implants.
*If you wish to continue Probuphine, your doctor may insert new implants to continue treatment.
*The implants can be removed sooner if you want to stop treatment.
*Patients must continue to see their doctor at least every month while on Probuphine therapy.
*[https://probuphine.com/ For more information visit their website.]

== 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/</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/</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/</ref></sup>
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/methadone SAMSHA page on Methadone]
*[[More_Information_on_Methadone|More info on Methadone]]

== Naltrexone ==

*Naltrexone is a nonaddictive medicine that serves as an opioid receptor antagonist and not an opioid replacement unlike methadone and buprenophine. 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.<sup class="reference"><ref>[19]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/</ref></sup>
*Naltrexone is administered in a long-active, injectable formulation administered once a month.<sup class="reference"><ref>[20]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/</ref></sup>
*Naltrexone does not prevent withdrawal symptoms so it is recommended for patients who do not have opioid in their system.<sup class="reference"><ref>[21]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/</ref></sup>
*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)
*[[More_info_on_Naltrexone_and_Vivitrol|More info on Naltrexone and 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 as safe for administration by any person.<sup class="reference"><ref>[22]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/</ref></sup>
*Naloxone works within minutes and effects last for up to an hour. Multiple doses may be required depending on the severity of respiratory depression.<sup class="reference"><ref>[23]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></sup>
*Naloxone does not produce tolerance or dependence. <sup class="reference"><ref>[24]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></sup>
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone SAMSHA page on Naloxone]
*[[More_info_on_Naloxone|More info on Naloxone]] (including discounted public pricing and free Narcan for schools)
*(for [http://www.samhsa.gov/medication-assisted-treatment/treatment/opioid-overdose opioid overdose])
* 

<br/> 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.<br/> <br/> <br/> <br/> Medications Used in Addiction Treatment**<sup class="reference"><ref>[25]The Case for Medication-Assisted Treatment. (n.d.). Retrieved December 5, 2019, from http://pew.org/2kdLIf2
</ref></sup>

{| 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%<sup class="reference"><ref>[26]Summary: Major components of the HHS final rule. Effective August 8, 2016. (n.d.). Retrieved December 5, 2019, from https://www.asam.org/resources/publications/magazine/read/article/2016/07/06/summary-of-the-major-components-of-the-hhs-final-rule-which-will-be-effective-on-august-5-2016
</ref></sup>
| 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).<sup class="reference"><ref>[27]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></sup><sup class="reference"><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></sup><sup class="reference"><ref>[29]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></sup>
*Any DEA-licensed provider can prescribe buprenorphine for pain.

| OUD and pain management (depending on formulation and dose)
| 60% to 90%<sup class="reference"><ref>[30]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></sup>
| 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%<sup class="reference"><ref>[31]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></sup>
| Daily pill or monthly injectable
|-
| Naloxone<br/> (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
|}
<div class="_">Extensive research has demonstrated the effectiveness of opioid agonist treatment (methadone and buprenorphine) 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.<sup class="reference"><ref>[32]Page Not Found</ref></sup><br/> <br/> <br/>  </div> <div class="_"> </div>
= 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."<sup class="reference"><ref>[33]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></sup></div> <div class="_">  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.<sup class="reference"><ref>[34]Page Not Found</ref></sup><br/>   Some training program 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></div> <div class="_"> [[More_information_on_buprenorphine_induction|More information on buprenorphine induction]].</div> <div class="_"> </div>
== Stabilization ==
<div class="_">"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."</div> <div class="_"> [[More_information_on_buprenorphine_stabilization|More information on buprenorphine stabilization]].<br/>  </div> <div class="_"> </div>
== Maintenance ==
<div class="_">"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."</div> <div class="_"> [[More_information_on_buprenorphine_maintenance|More information on buprenorphine maintenance]]<br/>  </div> <div class="_"> </div>
== 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 shortacting 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 longacting opioids should be considered only for those patients who have evidence of sustained medical and psychosocial stability,</div> <div class="_"> </div>
== Canadian Guidelines ==
<div class="_">This [https://www.cpso.on.ca/uploadedFiles/policies/guidelines/office/buprenorphine_naloxone_gdlns2011.pdf document ]has details on the MAT Buprenorphine guidelines from Canada</div> <div class="_"> </div>
= New & Expanded Treatment Options =

== Connecticut ==
<div class="_">Connecticut's Department of Mental Health and Addiction Services (DMHAS) recently received two federal grants, one of which is meant to go to medical 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> [36]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><br/>  </div> <div class="_"> </div>
== Vermont ==
<div class="_">Vermont's Health Home for Opioid Addiction have 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<ref> [37] 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>:</div> <div class="_"> </div>
*The Hub, a designated provider of specialty addiction treatment, designed as an Opioid Treatment Program which are operated by Community Behavioral Health Agencies.
*The Spokes, which 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<br/> Vermont Global Commitment To Health Section 1115 Demonstration Fact Sheet<sup class="reference"><ref>[38]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></sup>

*
**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.

More information can be found at: <ref>[3]Hub and Spoke Evaluation Shows Significant Impact (January 22, 2018). (2018, January 22). Retrieved December 5, 2019, from Vermont Department of Health website: https://www.healthvermont.gov/media/newsroom/hub-and-spoke-evaluation-shows-significant-impact-january-22-2018

</ref><br/>  

== Emergency Department Treatment Protocols ==
<div class="_">In a Yale Randomized trial, 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 of in patient facilities. This can be attributed to engaging patients at the optimal point of access. <sup class="reference"><ref>[40]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></sup><br/> <br/>  </div> <div class="_"> </div>
== National Healthcare For Homeless Council ==
<div class="_">Aa one may assume, there is cross-over between the homeless and addicted communities. The National Healthcare for the Homeless Council have 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:</div> <div class="_">  • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.</div> <div class="_">  More information can be found on the [[File/view/HCHBrief.pdf/614804863/HCHBrief.pdf|Policy Document]] itself.</div> <div class="_"> </div>
= Opioid Treatment Program Directory =
<div class="_">Select [http://dpt2.samhsa.gov/treatment/directory.aspx this directory] to view the opioid treatment programs in each state</div> <div class="_"> </div>
= Moving from Stigma to Science =
<div class="_">Pennsylvania and New Jersey</div> <div class="_">  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>[41] Page Not Found</ref>Underlying problems still exist in restrictive medication regiment 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.<ref> [42]Page Not Found</ref></div> <div class="_">  National Healthcare For Homeless Council<br/>   The National Healthcare for the Homeless Council also have recommendations of policy that not only controls the prescription of opiates, but also the treatment of opioid addiction. They are as follows:</div> <div class="_">  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 selftreatment 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.<br/>  </div> <div class="_"> </div>
*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.

More information can be seen in this [[File/view/HCHBrief.pdf/614804863/HCHBrief.pdf|Policy Brief Document]].<br/>  

= 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."<sup class="reference"><span style="background-color:#f1c40f;">[43]</span></sup> 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.<br/>  

= Tools & Resources =

[[TR_-_Expand_Access_to_Medication-Assisted_Treatment|TR - Expand Access to Medication-Assisted Treatment]]<br/> <br/> PCSS<br/> The Provider's Clinical Support System offers a [[File/view/StigmaandMethadone.pdf/614518761/StigmaandMethadone.pdf|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. <sup class="reference"><span style="background-color:#f1c40f;">[44]</span></sup><br/> <br/> [http://www.buppractice.com/ BupPractice]<br/> is a DATA 2000 accredited resource for providing either an 8 hour training for Physicians or 24 training session for Physician Assistants and Nurse Practitioners, both for $199 per full series. Offers up to 9 AMA PRA Category 1 Credits, and is further supported by the ASAM (American Society of Addiction Medicine).<br/> <br/> [[File/view/ADAPTINGPRACTICE.pdf/614804967/ADAPTINGPRACTICE.pdf|HCH Clinician's Network]]<br/> This resource provides recommendations for one's practice when dealing with opioid addicted patients, particularly those who also happen to be homeless.<br/> <br/> [[File/view/BHSHomeless.pdf/614805019/BHSHomeless.pdf|SAMSHA's Treatment Improvement Protocol for Homeless Persons]]<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.<br/> <br/> Where Can Clinicians Get Training and Support? Buprenorphine trainings 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 telementoring 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.<sup class="reference"><span style="background-color:#f1c40f;">[45]</span></sup><br/>  

<br/> PAGE MANAGER: [insert name here]<br/> SUBJECT MATTER EXPERT: [fill out table below]

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= Sources =

[[Category:SAFE-Treatment and Recovery]]

Expand Access to Medication-Assisted Treatment (MAT)

2021-02-08T12:59:43Z

Mredden:

__NOTOC__ Return to [[ZOOM_MAP_-_Expand_Access_to_Optimized_MAT|Zoom Map - Expand Access to Optimized MAT]] or  [[ZOOM_MAP_-_Improve_Treatment_&_Enable_Recovery_for_People_with_SUDs|Zoom Map (Improve Treatment & Enable Recovery for People with SUDs)]] or the [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">
= Overview =

<span style="font-size: 13px;">Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders.</span><sup class="reference"><span aria-label="span widget" contenteditable="false" role="region" tabindex="-1"><ref>[1]chanell.baylor. (2015, July 21). Medication-Assisted Treatment (MAT) [Text]. Retrieved December 5, 2019, from https://www.samhsa.gov/medication-assisted-treatment
</ref></span></sup><span style="font-size: 13px;">Information on medications used in MAT can be found further down on this page.</span> The President's [https://www.whitehouse.gov/ondcp/presidents-commission Commission on Combating Drug Addiction and the Opioid Crisis] has recommended that federal government "immediately establish and fund a federal incentive to enhance access to Medication-Assisted Treatment (MAT)."<sup class="reference"><ref>[2]Commission to the President (2016), Retrieved from: https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf</ref></sup>
<div class="_">The above reports documents that MAT has been proven to:</div>
*Reduce overdose deaths
*retain persons in treatment
*decrease use of heroin
*Prevent spread of infectious disease

= Key Information =

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.   MAT is optimized when those providing and funding the treatment keep striving to improve all aspects of the treatment plan, optimized for each individual as much as practical. 

Some of the ways that MAT can be optimized are listed below::

*Precision medication ([[Expand_DNA_Testing_to_Improve_Precision_MAT_Therapies|Expand DNA Testing to Improve Precision MAT]])
*A coordinated, proactive, whole-person care plan ([[Integrate_MAT_into_a_Whole_Person_Care_Model|Integrate MAT into whole-person care model]])
*Community engagement ([[Expand_community_engagement_to_improve_MAT|Expand community engagement to improve MAT]])
*Use of innovative technologies ([[Use_innovative_technologies_to_enhance_MAT|Use innovative technologies to enhance MAT]])

== Current Status of MAT Practices ==

*Only 10% of conventional drug treatment facilities in the United States provide MAT for opioid use disorders (need source and date)
*According to SAMHSA data collected in early 2017, 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.<sup class="reference">[4]</sup>
*Avalere’s analysis finds 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<sup class="reference">[5]</sup>

== The Value of MAT (or Opioid-Agonist Treatment) ==

*International addiction experts consider initial opioid-agonist treatment, or OAT, ''with no duration restrictions'', the evidence-based standard of care for opioid-use disorder, the authors write online November 20, 2018 in Annals of Internal Medicine.<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: http://education.psychiatry.org/Users/ProductDetails.aspx?ActivityID=6092
</ref>
*But 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 false 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>
**“If we want 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.

== 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> [6]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>

= Relevant Research =
<div class="_">An article in the August 2017 issue of the American Journal of Psychiatry, by Roger D. Weiss, MD, the Chief of the Division of Alcohol and Drug Abuse at McLean Hospital (Belmont, MA) and Professor of Psychiatry at Harvard Medical School and Kathleen Carroll, Ph.D. concluded: "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."</div> <div class="_"> </div> <div class="_">This 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 and well-being 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 different types of behavioral treatments that would be appropriate for different individuals, While not mentioned specifically in that article, a person's history of trauma or ACEs, length of time with an SUD, current level of supports and genetic factors such as the rates at which they metabolize different drugs would all impact what type of treatment would be most appropriate. All of these unique factors and the wide range of potential interventions are reasons that more research is needed, and conclusions from studies that look at a limited number of inputs and outcomes and lack visibility into all the unique factors that influence what might impact successful outcomes should be seen as early insights in a journey of finding the optimal forms of treatment for each person's situation.</div> <div class="_"> </div> <div class="_">Weiss and Carroll highlight some key findings from their report in a Webinar done through the American Journal of Psychiatry learning center.<sup class="reference">[3]</sup> Key points include:</div>
*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.
**Paients 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 chances of abstaining by week 12.
*There is evidence that the use of [https://drugabuse.com/library/contingency-management/ Contingency Management ](CM), including the use of computer-based therapies, seems to increase success rates
*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 =
</div>
This latest, detailed [https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Executive-Summary/SMA18-5063EXSUMM 330-page report] can be downloaded for free. 

= Promising Practices =

== Agonists & Antagonists ==
<div class="_">An opioid agonist activates opioid receptors in the brain. An antagonist blocks opioids by attaching to the opioid receptors without activating them.<sup class="reference"><ref>[7]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/</ref></sup><br/>   [Detoxification vs. Stabilization]</div> <div class="_"> </div> <div class="_">Buprenorphine</div>
*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.<sup class="reference"><ref>[8]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/</ref></sup>
*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.<sup class="reference"><ref>[9]Page Not Found</ref></sup>
*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 May 2016<sup class="reference"><ref>[10]Page Not Found</ref></sup>
*Training for Buprenorphine providers is an 8 hour course (24 for Nurse Pracitioners and Physician Assistants) and allow for the following patient loads and responsibilities:<sup class="reference"><ref>[11]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></sup>

#30 Addiction Treamtent Patients per provider for the first year
#100 patients each year thereafter
#An additional 175 (totalling 275) patients can be alloted is the Physician is board certified in addiction, or a facility:

*Has 24 Call Coverage for patients
*Uses an EMR/EHS to monitor and update patient records (for those looking for an entry level EHS, PracticeFusion is a free system)
*Provision of Care Management Services
*Subscribing to a State led Drug Management System
*Acceptance of 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<sup class="reference"><ref>[12]Page Not Found</ref></sup> . As a result, there are cases where medication diversion do occur, and there is a black market for the drug for self-treatment purposes.<sup class="reference"><ref>[13]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/</ref></sup><br/> <br/> 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>[14]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/</ref></sup>

*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine SAMSHA page on Buprenorphine]
*[[More_info_on_Buprenorphine|More info on Buprenorphine]]

For more information, one can visit the information page on [[File/view/BupForOUD.pdf/614583113/BupForOUD.pdf|Buprenorphine for Patients and Families]], which includes information on side effects, information to share with providers and other useful information. This document was compiled by Intermountain Health Care.

== 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>[15]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/</ref></sup>
*[[More_info_on_Suboxone|More info on Suboxone]] (including generic options)

== Probuphine ==

*Probuphine is an implant that contains the medicine buprenorphine. Probuphine is used to treat certain adults who are addicted to (dependent on) opioid drugs (either prescription or illegal). Probuphine is part of a complete treatment program that also includes counseling and behavioral therapy.
*Because Probuphine contains buprenorphine, it may cause physical dependence.
*Four implants are inserted under the skin of your upper arm during a procedure done in your physician's office or Opioid Treatment Program (OTP).
*The implants remain in your arm for six months.
*After the six-month period, your doctor must remove the implants.
*If you wish to continue Probuphine, your doctor may insert new implants to continue treatment.
*The implants can be removed sooner if you want to stop treatment.
*Patients must continue to see their doctor at least every month while on Probuphine therapy.
*[https://probuphine.com/ For more information visit their website.]

== 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/</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/</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/</ref></sup>
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/methadone SAMSHA page on Methadone]
*[[More_Information_on_Methadone|More info on Methadone]]

== Naltrexone ==

*Naltrexone is a nonaddictive medicine that serves as an opioid receptor antagonist and not an opioid replacement unlike methadone and buprenophine. 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.<sup class="reference"><ref>[19]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/</ref></sup>
*Naltrexone is administered in a long-active, injectable formulation administered once a month.<sup class="reference"><ref>[20]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/</ref></sup>
*Naltrexone does not prevent withdrawal symptoms so it is recommended for patients who do not have opioid in their system.<sup class="reference"><ref>[21]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/</ref></sup>
*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)
*[[More_info_on_Naltrexone_and_Vivitrol|More info on Naltrexone and 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 as safe for administration by any person.<sup class="reference"><ref>[22]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/</ref></sup>
*Naloxone works within minutes and effects last for up to an hour. Multiple doses may be required depending on the severity of respiratory depression.<sup class="reference"><ref>[23]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></sup>
*Naloxone does not produce tolerance or dependence. <sup class="reference"><ref>[24]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></sup>
*Link to [http://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone SAMSHA page on Naloxone]
*[[More_info_on_Naloxone|More info on Naloxone]] (including discounted public pricing and free Narcan for schools)
*(for [http://www.samhsa.gov/medication-assisted-treatment/treatment/opioid-overdose opioid overdose])

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.<br/> Medications Used in Addiction Treatment**<sup class="reference"><ref>[25]The Case for Medication-Assisted Treatment. (n.d.). Retrieved December 5, 2019, from http://pew.org/2kdLIf2
</ref></sup>

{| 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%<sup class="reference"><ref>[26]Summary: Major components of the HHS final rule. Effective August 8, 2016. (n.d.). Retrieved December 5, 2019, from https://www.asam.org/resources/publications/magazine/read/article/2016/07/06/summary-of-the-major-components-of-the-hhs-final-rule-which-will-be-effective-on-august-5-2016
</ref></sup>
| 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).<sup class="reference"><ref>[27]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></sup><sup class="reference"><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></sup><sup class="reference"><ref>[29]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></sup>
*Any DEA-licensed provider can prescribe buprenorphine for pain.

| OUD and pain management (depending on formulation and dose)
| 60% to 90%<sup class="reference"><ref>[30]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></sup>
| 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%<sup class="reference"><ref>[31]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></sup>
| Daily pill or monthly injectable
|-
| Naloxone<br/> (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
|}

Extensive research has demonstrated the effectiveness of opioid agonist treatment (methadone and buprenorphine) 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.<sup class="reference"><ref>[32]Page Not Found</ref></sup><br/>  

== 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."<sup class="reference"><ref>[33]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></sup></div> <div class="_">  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.<sup class="reference"><ref>[34]Page Not Found</ref></sup><br/>   Some training program 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></div> <div class="_"> [[More_information_on_buprenorphine_induction|More information on buprenorphine induction]].</div>
=== Stabilization ===
<div class="_">"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."</div> <div class="_"> [[More_information_on_buprenorphine_stabilization|More information on buprenorphine stabilization]].</div>
=== Maintenance ===
<div class="_">"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."</div> <div class="_"> [[More_information_on_buprenorphine_maintenance|More information on buprenorphine maintenance]]<br/>  </div>
== 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 shortacting 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 longacting opioids should be considered only for those patients who have evidence of sustained medical and psychosocial stability,</div>
== Canadian Guidelines ==
<div class="_">This [https://www.cpso.on.ca/uploadedFiles/policies/guidelines/office/buprenorphine_naloxone_gdlns2011.pdf document ]has details on the MAT Buprenorphine guidelines from Canada</div> <div class="_"> </div>
== New & Expanded Treatment Options ==

=== Connecticut ===
<div class="_">Connecticut's Department of Mental Health and Addiction Services (DMHAS) recently received two federal grants, one of which is meant to go to medical 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> [36]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></div>
=== Vermont ===
<div class="_">Vermont's Health Home for Opioid Addiction have 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<ref> [37] 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>:</div>
*The Hub, a designated provider of specialty addiction treatment, designed as an Opioid Treatment Program which are operated by Community Behavioral Health Agencies.
*The Spokes, which 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<br/> Vermont Global Commitment To Health Section 1115 Demonstration Fact Sheet<sup class="reference"><ref>[38]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></sup>

*
**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.

More information can be found at: <ref>[3]Hub and Spoke Evaluation Shows Significant Impact (January 22, 2018). (2018, January 22). Retrieved December 5, 2019, from Vermont Department of Health website: https://www.healthvermont.gov/media/newsroom/hub-and-spoke-evaluation-shows-significant-impact-january-22-2018

</ref>

== Emergency Department Treatment Protocols ==
<div class="_">In a Yale Randomized trial, 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 of in patient facilities. This can be attributed to engaging patients at the optimal point of access. <sup class="reference"><ref>[40]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></sup></div>
== National Healthcare For Homeless Council ==
<div class="_">Aa one may assume, there is cross-over between the homeless and addicted communities. The National Healthcare for the Homeless Council have 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:</div> <div class="_">  • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.<br/>   • 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.</div> <div class="_">  More information can be found on the [[File/view/HCHBrief.pdf/614804863/HCHBrief.pdf|Policy Document]] itself.</div>
== Moving from Stigma to Science ==

=== Pennsylvania and New Jersey ===
<div class="_">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>[41] Page Not Found</ref>Underlying problems still exist in restrictive medication regiment 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.<ref> [42]Page Not Found</ref></div>
National Healthcare For Homeless Council<br/> The National Healthcare for the Homeless Council also have recommendations of policy that not only controls the prescription of opiates, but also the treatment of opioid addiction. They are as follows:
<div class="_">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 selftreatment 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.</div>
*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.

More information can be seen in this [[File/view/HCHBrief.pdf/614804863/HCHBrief.pdf|Policy Brief Document]].

== 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."<sup class="reference"><span style="background-color:#f1c40f;">[43]</span></sup> 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.

= Tools & Resources =

== Opioid Treatment Program Directory ==
<div class="_">Select [http://dpt2.samhsa.gov/treatment/directory.aspx this directory] to view the opioid treatment programs in each state</div>
[[TR_-_Expand_Access_to_Medication-Assisted_Treatment|TR - Expand Access to Medication-Assisted Treatment]]<br/> <br/> PCSS<br/> The Provider's Clinical Support System offers a [[File/view/StigmaandMethadone.pdf/614518761/StigmaandMethadone.pdf|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. <sup class="reference"><span style="background-color:#f1c40f;">[44]</span></sup><br/> <br/> [http://www.buppractice.com/ BupPractice]<br/> is a DATA 2000 accredited resource for providing either an 8 hour training for Physicians or 24 training session for Physician Assistants and Nurse Practitioners, both for $199 per full series. Offers up to 9 AMA PRA Category 1 Credits, and is further supported by the ASAM (American Society of Addiction Medicine).<br/> <br/> [[File/view/ADAPTINGPRACTICE.pdf/614804967/ADAPTINGPRACTICE.pdf|HCH Clinician's Network]]<br/> This resource provides recommendations for one's practice when dealing with opioid addicted patients, particularly those who also happen to be homeless.<br/> <br/> [[File/view/BHSHomeless.pdf/614805019/BHSHomeless.pdf|SAMSHA's Treatment Improvement Protocol for Homeless Persons]]<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.<br/> <br/> Where Can Clinicians Get Training and Support? Buprenorphine trainings 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 telementoring 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.<sup class="reference"><span style="background-color:#f1c40f;">[45</span></sup>

Increase Access to Needle Exchanges

2021-02-05T20:29:07Z

Mredden:

__NOTOC__ Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map or]] [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">  __toc__
= Overview =

Needle exchange programs (NEPs) are programs which distribute sanitized needles in exchange for contaminated or used needles. NEPs reduce the spread of blood borne diseases like HIV and Hepatitis C. 

= Key Information =

Many organizations have endorsed needle exchange including NIH (National Institute of Health), CDC (Center for Disease Control), the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organization and others. The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C.<ref>https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.1840360703 </ref> <span style="line-height:normal"><span style="color:black">As such sharing needles has become the most common mode of HIV transmission among injection drug users (IDUs). In addition, used syringes and needles are a potential biohazard within which users primarily reside, and beyond it as well. </span></span><span style="line-height:normal"><span style="color:black">Harm reduction services such as the provision of sterile needles and syringes can effectively prevent hepatitis C and HIV transmission among people who inject drugs, provided they are accessible and delivered at the required scale.</span></span>

== Importance for Harm Reduction Practice and Education ==

Needle exchange programs help educate and inform injection drug users regarding injection practices, safety steps, non-sharing behavior, and other risk reduction methods. “The need for and value of targeted education and behavior modification efforts directed at injection drug users at risk of HIV transmission have been clearly demonstrated in programs that do not include needle exchange (Wiebel et al., 1993).”<font color="#000000"><ref>https://www.ncbi.nlm.nih.gov/books/NBK232350/</ref></font>

Needle exchanges and safe injection sites have decades of evidence behind them - but not public support.<ref>https://opioidaction.org/2018/06/vox-a-new-study-shows-stigma-is-hurting-our-response-to-the-opioid-epidemic/</ref>

= Relevant Research =

<span style="line-height:normal"><span style="color:black">Needle exchanges have been estimated to be a cost effective prevention practice. An analysis of the cost-effectiveness of a New York City needle syringe exchange estimated that the program would result in a baseline one year savings to the government of $1,300 to $3,000 per client. Another analysis by the CDC approximated that increasing access to clean syringes through an additional annual U.S. investment of $10 million would lead to:</span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">194 HIV infections averted in one year </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">And A lifetime treatment cost savings of $75.8 million which would be a return on investment of $7.58 for every $1 spent </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>

== Do Needle Exchanges Increase Drug Injection Rates? ==

<span style="line-height:normal"><span style="font-family:"><span style="color:black">A review of needle exchange done by the office of the Surgeon General and the assistant secretary for health found that needle exchange did not cause an increase in drug injection, but rather typically led to a decrease in injection rates when these programs were used.<ref>http://www.csdp.org/research/surgeongennex.pdf</ref></span></span></span>

Another study sought to answer the question "is the number of needles distributed from needle exchange programs proportionate to the number of needles returned to needle exchange programs?" It was found that in the United States the return rate was on average over 90% (~315,000 needles distributed and ~283,000 needles returned). <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

This finding has been further substantiated by another review which found that supplying IDUs (Injecting Drug Users) with clean or sanitized needles does not lead to more "dirty" needles in a community. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

= Impactful Federal, State, and Local Policies =

= Promising Practices =

<span style="line-height:normal"><span style="font-family:"><span style="color:black">There are currently several different models for syringe exchanges that have different advantages and limitations. The models include:</span></span></span>

<span style="line-height:normal"><span style="font-family:"><span style="color:black">'''Primary and Secondary Needle and Syringe Programs''':</span></span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They are fixed sites that are typically located in areas with high levels of injecting drug use.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They can be located in many different areas such as community centers, pharmacies, or specialized voluntary counselling and testing centers.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Those who attend will be able to receive clean paraphernalia and safely dispose of used paraphernalia. </span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

'''Mobile or On-Call Service''':

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Mobile programs operate from a van or bus with clean needles that are distributed.</span></span></span></span>
**Larger mobile programs typically provide testing and other healthcare services and operate along regular reoutes at fixed times, often at night at times when increased use occurs.
**Mobile services can also be smaller and choose to target specific populations.
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list 1.0in"><span style="vertical-align:baseline">Typically, mobile programs are more accessible to injection drug users and face less opposition from a community.</span></span></span></span> <span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000" face="calibri, sans-serif"><span style="font-size: 14.6667px">Dispensing Machine Distribution</span></font> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A newer strategy, countries in Europe as well as Australia have begun to use syringe vending machines in addition to other forms of NSPs.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Syringe vending machines work through the use of non-currency tokens, that are distributed by outreach workers for injection drug users to use in return for harm reduction packs. An example of what is included in Australia’s machines are needles and syringes as well as alcohol swabs, cotton wool, sterile water and spoons. Others sometimes contain educational materials.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Typically, these machines act in conjunction with fixed sites that are meant to provide needles and syringes 24 hours a day, 7 days a week.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A clinical trial has found that this strategy can be highly effective for reaching populations who are most marginalized or otherwise hard to reach.</span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000"><font face="calibri, sans-serif"><span style="font-size:14.6667px">Peer Service Distribution Networks</span></font></font> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Peer-based strategy, is a process where clients of needle exchanges provide service to their peers, distributing of needles, syringes, and associated injection equipment.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">These clients are trained to assist peers access exchangers, distribute information about safer drug use and safer sex, and facilitate referrals to other health services.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">This model, in addition to disseminating safer practices and helping make needle exchange programs reach a larger population, may have a psychological impact and help make interventions more effective. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241304/</ref></span></span></span></span>

== <span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Prison-Based Facilities</span></span></span></span> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Still a newly developing practice, only used in 3 of 24 UN countries that have needle exchange programs for the public.<ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">High need because prison populations have higher cases of Hepatitis C and HIV than the average population. <ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>

== Success Stories ==

'''Scott County, Indianna'''

Before Scott County set up its syringe exchange (plus more) program in 2015, the rural county in Indiana was seeing 10-20 new HIV cases every week. Almost immediately after, the number of new cases was slowed to 1-2 a month

Miami, Florida

<span style="line-height:normal"><span style="color:black">“In three years of operation, Miami's pilot program has pulled more than a quarter million used needles out of circulation, according to reports the program filed with the Florida Department of Health.” By handing out Narcan as well at the needle exchange, it has helped prevent more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C and connects people to medical care and rehabilitation services. <ref>https://www.npr.org/sections/health-shots/2019/06/27/725462715/key-florida-republicans-now-say-yes-to-clean-needles-for-drug-users</ref></span></span>

'''<span style="line-height:normal"><span style="color:black">Philidelphia, Pennsylvania</span></span>'''

A case study found that Prevention Point, a needle exchange located in Philadelphia helped prevent 10,000 People From Contracting HIV Over 10 Years. The researchers from George Washington University estimate that the total lifetime taxpayer savings from this needle exchange averting 10,000 cases of HIV saved them $1.8 billion. <ref>https://www.phillymag.com/news/2019/10/31/prevention-point-syringe-exchange-study/</ref>

= Available Tools and Resources =

[[TR_-_Increase_Access_to_Needle_Exchanges|TR - Increase Access to Needle Exchanges]]  

= Sources =

----
</div>
[[Category:SAFE-Full Spectrum Prevention]]

Increase Access to Needle Exchanges

2021-02-05T20:27:44Z

Mredden:

__NOTOC__ Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map or]] [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">  __toc__
= Overview =

Needle exchange programs (NEPs) are programs which distribute sanitized needles in exchange for contaminated or used needles. NEPs reduce the spread of blood borne diseases like HIV and Hepatitis C. 

= Key Information =

Many organizations have endorsed needle exchange including NIH (National Institute of Health), CDC (Center for Disease Control), the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organization and others. The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C.<ref>https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.1840360703 </ref> <span style="line-height:normal"><span style="color:black">As such sharing needles has become the most common mode of HIV transmission among injection drug users (IDUs). In addition, used syringes and needles are a potential biohazard within which users primarily reside, and beyond it as well. </span></span><span style="line-height:normal"><span style="color:black">Harm reduction services such as the provision of sterile needles and syringes can effectively prevent hepatitis C and HIV transmission among people who inject drugs, provided they are accessible and delivered at the required scale.</span></span>

== Importance for Harm Reduction Practice and Education ==

Needle exchange programs help educate and inform injection drug users regarding injection practices, safety steps, non-sharing behavior, and other risk reduction methods. “The need for and value of targeted education and behavior modification efforts directed at injection drug users at risk of HIV transmission have been clearly demonstrated in programs that do not include needle exchange (Wiebel et al., 1993).”<font color="#000000"><ref>https://www.ncbi.nlm.nih.gov/books/NBK232350/</ref></font>

Needle exchanges and safe injection sites have decades of evidence behind them - but not public support.<ref>https://opioidaction.org/2018/06/vox-a-new-study-shows-stigma-is-hurting-our-response-to-the-opioid-epidemic/</ref>

= Relevant Research =

<span style="line-height:normal"><span style="color:black">Needle exchanges have been estimated to be a cost effective prevention practice. An analysis of the cost-effectiveness of a New York City needle syringe exchange estimated that the program would result in a baseline one year savings to the government of $1,300 to $3,000 per client. Another analysis by the CDC approximated that increasing access to clean syringes through an additional annual U.S. investment of $10 million would lead to:</span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">194 HIV infections averted in one year </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">And A lifetime treatment cost savings of $75.8 million which would be a return on investment of $7.58 for every $1 spent </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>

== Do Needle Exchanges Increase Drug Injection Rates? ==

<span style="line-height:normal"><span style="font-family:"><span style="color:black">A review of needle exchange done by the office of the Surgeon General and the assistant secretary for health found that needle exchange did not cause an increase in drug injection, but rather typically led to a decrease in injection rates when these programs were used.<ref>http://www.csdp.org/research/surgeongennex.pdf</ref></span></span></span>

Another study sought to answer the question "is the number of needles distributed from needle exchange programs proportionate to the number of needles returned to needle exchange programs?" It was found that in the United States the return rate was on average over 90% (~315,000 needles distributed and ~283,000 needles returned). <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

This finding has been further substantiated by another review which found that supplying IDUs (Injecting Drug Users) with clean or sanitized needles does not lead to more "dirty" needles in a community. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

= Promising Practices =

<span style="line-height:normal"><span style="font-family:"><span style="color:black">There are currently several different models for syringe exchanges that have different advantages and limitations. The models include:</span></span></span>

<span style="line-height:normal"><span style="font-family:"><span style="color:black">'''Primary and Secondary Needle and Syringe Programs''':</span></span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They are fixed sites that are typically located in areas with high levels of injecting drug use.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They can be located in many different areas such as community centers, pharmacies, or specialized voluntary counselling and testing centers.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Those who attend will be able to receive clean paraphernalia and safely dispose of used paraphernalia. </span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

'''Mobile or On-Call Service''':

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Mobile programs operate from a van or bus with clean needles that are distributed.</span></span></span></span>
**Larger mobile programs typically provide testing and other healthcare services and operate along regular reoutes at fixed times, often at night at times when increased use occurs.
**Mobile services can also be smaller and choose to target specific populations.
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list 1.0in"><span style="vertical-align:baseline">Typically, mobile programs are more accessible to injection drug users and face less opposition from a community.</span></span></span></span> <span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000" face="calibri, sans-serif"><span style="font-size: 14.6667px">Dispensing Machine Distribution</span></font> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A newer strategy, countries in Europe as well as Australia have begun to use syringe vending machines in addition to other forms of NSPs.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Syringe vending machines work through the use of non-currency tokens, that are distributed by outreach workers for injection drug users to use in return for harm reduction packs. An example of what is included in Australia’s machines are needles and syringes as well as alcohol swabs, cotton wool, sterile water and spoons. Others sometimes contain educational materials.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Typically, these machines act in conjunction with fixed sites that are meant to provide needles and syringes 24 hours a day, 7 days a week.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A clinical trial has found that this strategy can be highly effective for reaching populations who are most marginalized or otherwise hard to reach.</span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000"><font face="calibri, sans-serif"><span style="font-size:14.6667px">Peer Service Distribution Networks</span></font></font> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Peer-based strategy, is a process where clients of needle exchanges provide service to their peers, distributing of needles, syringes, and associated injection equipment.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">These clients are trained to assist peers access exchangers, distribute information about safer drug use and safer sex, and facilitate referrals to other health services.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">This model, in addition to disseminating safer practices and helping make needle exchange programs reach a larger population, may have a psychological impact and help make interventions more effective. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241304/</ref></span></span></span></span>

== <span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Prison-Based Facilities</span></span></span></span> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Still a newly developing practice, only used in 3 of 24 UN countries that have needle exchange programs for the public.<ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">High need because prison populations have higher cases of Hepatitis C and HIV than the average population. <ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>

== Success Stories ==

'''Scott County, Indianna'''

Before Scott County set up its syringe exchange (plus more) program in 2015, the rural county in Indiana was seeing 10-20 new HIV cases every week. Almost immediately after, the number of new cases was slowed to 1-2 a month

Miami, Florida

<span style="line-height:normal"><span style="color:black">“In three years of operation, Miami's pilot program has pulled more than a quarter million used needles out of circulation, according to reports the program filed with the Florida Department of Health.” By handing out Narcan as well at the needle exchange, it has helped prevent more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C and connects people to medical care and rehabilitation services. <ref>https://www.npr.org/sections/health-shots/2019/06/27/725462715/key-florida-republicans-now-say-yes-to-clean-needles-for-drug-users</ref></span></span>

'''<span style="line-height:normal"><span style="color:black">Philidelphia, Pennsylvania</span></span>'''

A case study found that Prevention Point, a needle exchange located in Philadelphia helped prevent 10,000 People From Contracting HIV Over 10 Years. The researchers from George Washington University estimate that the total lifetime taxpayer savings from this needle exchange averting 10,000 cases of HIV saved them $1.8 billion. <ref>https://www.phillymag.com/news/2019/10/31/prevention-point-syringe-exchange-study/</ref>

= Available Tools and Resources =

[[TR_-_Increase_Access_to_Needle_Exchanges|TR - Increase Access to Needle Exchanges]]  

= Sources =

----
</div>
[[Category:SAFE-Full Spectrum Prevention]]

Increase Access to Needle Exchanges

2021-02-05T20:26:27Z

Mredden:

__NOTOC__ Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map or]] [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">  __toc__
= Overview =

Needle exchange programs (NEPs) are programs which distribute sanitized needles in exchange for contaminated or used needles. NEPs reduce the spread of blood borne diseases like HIV and Hepatitis C. 

= Key Information =

Many organizations have endorsed needle exchange including NIH (National Institute of Health), CDC (Center for Disease Control), the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organization and others. The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C.<ref>https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.1840360703 </ref> <span style="line-height:normal"><span style="color:black">As such sharing needles has become the most common mode of HIV transmission among injection drug users (IDUs). In addition, used syringes and needles are a potential biohazard within which users primarily reside, and beyond it as well. </span></span><span style="line-height:normal"><span style="color:black">Harm reduction services such as the provision of sterile needles and syringes can effectively prevent hepatitis C and HIV transmission among people who inject drugs, provided they are accessible and delivered at the required scale.</span></span>

== Importance for Harm Reduction Practice and Education ==

Needle exchange programs help educate and inform injection drug users regarding injection practices, safety steps, non-sharing behavior, and other risk reduction methods. “The need for and value of targeted education and behavior modification efforts directed at injection drug users at risk of HIV transmission have been clearly demonstrated in programs that do not include needle exchange (Wiebel et al., 1993).”<font color="#000000"><ref>https://www.ncbi.nlm.nih.gov/books/NBK232350/</ref></font>

Needle exchanges and safe injection sites have decades of evidence behind them - but not public support.<ref>https://opioidaction.org/2018/06/vox-a-new-study-shows-stigma-is-hurting-our-response-to-the-opioid-epidemic/</ref>

= Relevant Research =

<span style="line-height:normal"><span style="color:black">Needle exchanges have been estimated to be a cost effective prevention practice. An analysis of the cost-effectiveness of a New York City needle syringe exchange estimated that the program would result in a baseline one year savings to the government of $1,300 to $3,000 per client. Another analysis by the CDC approximated that increasing access to clean syringes through an additional annual U.S. investment of $10 million would lead to:</span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">194 HIV infections averted in one year </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">And A lifetime treatment cost savings of $75.8 million which would be a return on investment of $7.58 for every $1 spent </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>

== Do Needle Exchanges Increase Drug Injection Rates? ==

<span style="line-height:normal"><span style="font-family:"><span style="color:black">A review of needle exchange done by the office of the Surgeon General and the assistant secretary for health found that needle exchange did not cause an increase in drug injection, but rather typically led to a decrease in injection rates when these programs were used.<ref>http://www.csdp.org/research/surgeongennex.pdf</ref></span></span></span>

Another study sought to answer the question "is the number of needles distributed from needle exchange programs proportionate to the number of needles returned to needle exchange programs?" It was found that in the United States the return rate was on average over 90% (~315,000 needles distributed and ~283,000 needles returned). <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

This finding has been further substantiated by another review which found that supplying IDUs (Injecting Drug Users) with clean or sanitized needles does not lead to more "dirty" needles in a community. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

== Promising Practices ==

<span style="line-height:normal"><span style="font-family:"><span style="color:black">There are currently several different models for syringe exchanges that have different advantages and limitations. The models include:</span></span></span>

<span style="line-height:normal"><span style="font-family:"><span style="color:black">'''Primary and Secondary Needle and Syringe Programs''':</span></span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They are fixed sites that are typically located in areas with high levels of injecting drug use.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They can be located in many different areas such as community centers, pharmacies, or specialized voluntary counselling and testing centers.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Those who attend will be able to receive clean paraphernalia and safely dispose of used paraphernalia. </span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

'''Mobile or On-Call Service''':

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Mobile programs operate from a van or bus with clean needles that are distributed.</span></span></span></span>
**Larger mobile programs typically provide testing and other healthcare services and operate along regular reoutes at fixed times, often at night at times when increased use occurs.
**Mobile services can also be smaller and choose to target specific populations.
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list 1.0in"><span style="vertical-align:baseline">Typically, mobile programs are more accessible to injection drug users and face less opposition from a community.</span></span></span></span> <span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000" face="calibri, sans-serif"><span style="font-size: 14.6667px">Dispensing Machine Distribution</span></font> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A newer strategy, countries in Europe as well as Australia have begun to use syringe vending machines in addition to other forms of NSPs.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Syringe vending machines work through the use of non-currency tokens, that are distributed by outreach workers for injection drug users to use in return for harm reduction packs. An example of what is included in Australia’s machines are needles and syringes as well as alcohol swabs, cotton wool, sterile water and spoons. Others sometimes contain educational materials.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Typically, these machines act in conjunction with fixed sites that are meant to provide needles and syringes 24 hours a day, 7 days a week.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A clinical trial has found that this strategy can be highly effective for reaching populations who are most marginalized or otherwise hard to reach.</span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000"><font face="calibri, sans-serif"><span style="font-size:14.6667px">Peer Service Distribution Networks</span></font></font> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Peer-based strategy, is a process where clients of needle exchanges provide service to their peers, distributing of needles, syringes, and associated injection equipment.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">These clients are trained to assist peers access exchangers, distribute information about safer drug use and safer sex, and facilitate referrals to other health services.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">This model, in addition to disseminating safer practices and helping make needle exchange programs reach a larger population, may have a psychological impact and help make interventions more effective. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241304/</ref></span></span></span></span>

<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">'''Prison-Based Facilities''':</span></span></span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Still a newly developing practice, only used in 3 of 24 UN countries that have needle exchange programs for the public.<ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">High need because prison populations have higher cases of Hepatitis C and HIV than the average population. <ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>

== Success Stories ==

'''Scott County, Indianna'''

Before Scott County set up its syringe exchange (plus more) program in 2015, the rural county in Indiana was seeing 10-20 new HIV cases every week. Almost immediately after, the number of new cases was slowed to 1-2 a month

Miami, Florida

<span style="line-height:normal"><span style="color:black">“In three years of operation, Miami's pilot program has pulled more than a quarter million used needles out of circulation, according to reports the program filed with the Florida Department of Health.” By handing out Narcan as well at the needle exchange, it has helped prevent more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C and connects people to medical care and rehabilitation services. <ref>https://www.npr.org/sections/health-shots/2019/06/27/725462715/key-florida-republicans-now-say-yes-to-clean-needles-for-drug-users</ref></span></span>

'''<span style="line-height:normal"><span style="color:black">Philidelphia, Pennsylvania</span></span>'''

A case study found that Prevention Point, a needle exchange located in Philadelphia helped prevent 10,000 People From Contracting HIV Over 10 Years. The researchers from George Washington University estimate that the total lifetime taxpayer savings from this needle exchange averting 10,000 cases of HIV saved them $1.8 billion. <ref>https://www.phillymag.com/news/2019/10/31/prevention-point-syringe-exchange-study/</ref>

= Available Tools and Resources =

[[TR_-_Increase_Access_to_Needle_Exchanges|TR - Increase Access to Needle Exchanges]]  

= Sources =

----
</div>
[[Category:SAFE-Full Spectrum Prevention]]

Increase Access to Needle Exchanges

2021-02-05T20:16:39Z

Mredden:

__NOTOC__ Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map or]] [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">  __toc__
= Overview =

Needle exchange programs (NEPs) are programs which distribute sanitized needles in exchange for contaminated or used needles. NEPs reduce the spread of blood borne diseases like HIV and Hepatitis C. 

= Key Information =

Many organizations have endorsed needle exchange including NIH (National Institute of Health), CDC (Center for Disease Control), the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organization and others. The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C.<ref>https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.1840360703 </ref> <span style="line-height:normal"><span style="color:black">As such sharing needles has become the most common mode of HIV transmission among injection drug users (IDUs). In addition, used syringes and needles are a potential biohazard within which users primarily reside, and beyond it as well. </span></span><span style="line-height:normal"><span style="color:black">Harm reduction services such as the provision of sterile needles and syringes can effectively prevent hepatitis C and HIV transmission among people who inject drugs, provided they are accessible and delivered at the required scale.</span></span>

= Relevant Research =

<span style="line-height:normal"><span style="color:black">Needle exchanges have been estimated to be a cost effective prevention practice. An analysis of the cost-effectiveness of a New York City needle syringe exchange estimated that the program would result in a baseline one year savings to the government of $1,300 to $3,000 per client. Another analysis by the CDC approximated that increasing access to clean syringes through an additional annual U.S. investment of $10 million would lead to:</span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">194 HIV infections averted in one year </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">And A lifetime treatment cost savings of $75.8 million which would be a return on investment of $7.58 for every $1 spent </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>

== Do Needle Exchanges Increase Drug Injection Rates? ==

<span style="line-height:normal"><span style="font-family:"><span style="color:black">A review of needle exchange done by the office of the Surgeon General and the assistant secretary for health found that needle exchange did not cause an increase in drug injection, but rather typically led to a decrease in injection rates when these programs were used.<ref>http://www.csdp.org/research/surgeongennex.pdf</ref></span></span></span>

Another study sought to answer the question "is the number of needles distributed from needle exchange programs proportionate to the number of needles returned to needle exchange programs?" It was found that in the United States the return rate was on average over 90% (~315,000 needles distributed and ~283,000 needles returned). <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

This finding has been further substantiated by another review which found that supplying IDUs (Injecting Drug Users) with clean or sanitized needles does not lead to more "dirty" needles in a community. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

== Importance for Harm Reduction Practice and Education ==

Needle exchange programs help educate and inform injection drug users regarding injection practices, safety steps, non-sharing behavior, and other risk reduction methods. “The need for and value of targeted education and behavior modification efforts directed at injection drug users at risk of HIV transmission have been clearly demonstrated in programs that do not include needle exchange (Wiebel et al., 1993).”<font color="#000000"><ref>https://www.ncbi.nlm.nih.gov/books/NBK232350/</ref></font>

Needle exchanges and safe injection sites have decades of evidence behind them - but not public support.<ref>https://opioidaction.org/2018/06/vox-a-new-study-shows-stigma-is-hurting-our-response-to-the-opioid-epidemic/</ref>

= Promising Practices =

<span style="line-height:normal"><span style="font-family:"><span style="color:black">There are currently several different models for syringe exchanges that have different advantages and limitations. The models include:</span></span></span>

<span style="line-height:normal"><span style="font-family:"><span style="color:black">'''Primary and Secondary Needle and Syringe Programs''':</span></span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They are fixed sites that are typically located in areas with high levels of injecting drug use.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They can be located in many different areas such as community centers, pharmacies, or specialized voluntary counselling and testing centers.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Those who attend will be able to receive clean paraphernalia and safely dispose of used paraphernalia. </span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

'''Mobile or On-Call Service''':

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Mobile programs operate from a van or bus with clean needles that are distributed.</span></span></span></span>
**Larger mobile programs typically provide testing and other healthcare services and operate along regular reoutes at fixed times, often at night at times when increased use occurs.
**Mobile services can also be smaller and choose to target specific populations.
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list 1.0in"><span style="vertical-align:baseline">Typically, mobile programs are more accessible to injection drug users and face less opposition from a community.</span></span></span></span> <span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000" face="calibri, sans-serif"><span style="font-size: 14.6667px">Dispensing Machine Distribution</span></font> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A newer strategy, countries in Europe as well as Australia have begun to use syringe vending machines in addition to other forms of NSPs.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Syringe vending machines work through the use of non-currency tokens, that are distributed by outreach workers for injection drug users to use in return for harm reduction packs. An example of what is included in Australia’s machines are needles and syringes as well as alcohol swabs, cotton wool, sterile water and spoons. Others sometimes contain educational materials.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Typically, these machines act in conjunction with fixed sites that are meant to provide needles and syringes 24 hours a day, 7 days a week.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A clinical trial has found that this strategy can be highly effective for reaching populations who are most marginalized or otherwise hard to reach.</span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000"><font face="calibri, sans-serif"><span style="font-size:14.6667px">Peer Service Distribution Networks</span></font></font> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Peer-based strategy, is a process where clients of needle exchanges provide service to their peers, distributing of needles, syringes, and associated injection equipment.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">These clients are trained to assist peers access exchangers, distribute information about safer drug use and safer sex, and facilitate referrals to other health services.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">This model, in addition to disseminating safer practices and helping make needle exchange programs reach a larger population, may have a psychological impact and help make interventions more effective. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241304/</ref></span></span></span></span>

<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">'''Prison-Based Facilities''':</span></span></span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Still a newly developing practice, only used in 3 of 24 UN countries that have needle exchange programs for the public.<ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">High need because prison populations have higher cases of Hepatitis C and HIV than the average population. <ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>

== Success Stories ==

'''Scott County, Indianna'''

Before Scott County set up its syringe exchange (plus more) program in 2015, the rural county in Indiana was seeing 10-20 new HIV cases every week. Almost immediately after, the number of new cases was slowed to 1-2 a month

Miami, Florida

<span style="line-height:normal"><span style="color:black">“In three years of operation, Miami's pilot program has pulled more than a quarter million used needles out of circulation, according to reports the program filed with the Florida Department of Health.” By handing out Narcan as well at the needle exchange, it has helped prevent more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C and connects people to medical care and rehabilitation services. <ref>https://www.npr.org/sections/health-shots/2019/06/27/725462715/key-florida-republicans-now-say-yes-to-clean-needles-for-drug-users</ref></span></span>

'''<span style="line-height:normal"><span style="color:black">Philidelphia, Pennsylvania</span></span>'''

A case study found that Prevention Point, a needle exchange located in Philadelphia helped prevent 10,000 People From Contracting HIV Over 10 Years. The researchers from George Washington University estimate that the total lifetime taxpayer savings from this needle exchange averting 10,000 cases of HIV saved them $1.8 billion. <ref>https://www.phillymag.com/news/2019/10/31/prevention-point-syringe-exchange-study/</ref>

= Available Tools and Resources =

[[TR_-_Increase_Access_to_Needle_Exchanges|TR - Increase Access to Needle Exchanges]]  

= Sources =

----
</div>
[[Category:SAFE-Full Spectrum Prevention]]

Increase Access to Needle Exchanges

2021-02-05T20:14:29Z

Mredden:

__NOTOC__ Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map or]] [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">  __toc__
= Overview =

Needle exchange programs (NEPs) are programs which distribute sanitized needles in exchange for contaminated or used needles. NEPs reduce the spread of blood borne diseases like HIV and Hepatitis C. 

= Key Information =

Many organizations have endorsed needle exchange including NIH (National Institute of Health), CDC (Center for Disease Control), the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organization and others. The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C.<ref>https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.1840360703 </ref> <span style="line-height:normal"><span style="color:black">As such sharing needles has become the most common mode of HIV transmission among injection drug users (IDUs). In addition, used syringes and needles are a potential biohazard within which users primarily reside, and beyond it as well. </span></span><span style="line-height:normal"><span style="color:black">Harm reduction services such as the provision of sterile needles and syringes can effectively prevent hepatitis C and HIV transmission among people who inject drugs, provided they are accessible and delivered at the required scale.</span></span>

= Relevant Research =

<span style="line-height:normal"><span style="color:black">Needle exchanges have been estimated to be a cost effective prevention practice. An analysis of the cost-effectiveness of a New York City needle syringe exchange estimated that the program would result in a baseline one year savings to the government of $1,300 to $3,000 per client. Another analysis by the CDC approximated that increasing access to clean syringes through an additional annual U.S. investment of $10 million would lead to:</span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">194 HIV infections averted in one year </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">And A lifetime treatment cost savings of $75.8 million which would be a return on investment of $7.58 for every $1 spent </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>

== Do Needle Exchanges Increase Drug Injection Rates? ==

<span style="line-height:normal"><span style="font-family:"><span style="color:black">A review of needle exchange done by the office of the Surgeon General and the assistant secretary for health found that needle exchange did not cause an increase in drug injection, but rather typically led to a decrease in injection rates when these programs were used.<ref>http://www.csdp.org/research/surgeongennex.pdf</ref></span></span></span>

Another study sought to answer the question "is the number of needles distributed from needle exchange programs proportionate to the number of needles returned to needle exchange programs?" It was found that in the United States the return rate was on average over 90% (~315,000 needles distributed and ~283,000 needles returned). <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

This finding has been further substantiated by another review which found that supplying IDUs (Injecting Drug Users) with clean or sanitized needles does not lead to more "dirty" needles in a community. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

== Importance for Harm Reduction Practice and Education ==

Needle exchange programs help educate and inform injection drug users regarding injection practices, safety steps, non-sharing behavior, and other risk reduction methods. “The need for and value of targeted education and behavior modification efforts directed at injection drug users at risk of HIV transmission have been clearly demonstrated in programs that do not include needle exchange (Wiebel et al., 1993).”<font color="#000000"><ref>https://www.ncbi.nlm.nih.gov/books/NBK232350/</ref></font>

Needle exchanges and safe injection sites have decades of evidence behind them - but not public support.<ref>https://opioidaction.org/2018/06/vox-a-new-study-shows-stigma-is-hurting-our-response-to-the-opioid-epidemic/</ref>

= Promising Practices =

<span style="line-height:normal"><span style="font-family:"><span style="color:black">There are currently several different models for syringe exchanges that have different advantages and limitations. The models include:</span></span></span>

<span style="line-height:normal"><span style="font-family:"><span style="color:black">'''Primary and Secondary Needle and Syringe Programs''':</span></span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They are fixed sites that are typically located in areas with high levels of injecting drug use.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They can be located in many different areas such as community centers, pharmacies, or specialized voluntary counselling and testing centers.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Those who attend will be able to receive clean paraphernalia and safely dispose of used paraphernalia. </span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

'''Mobile or On-Call Service''':

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Mobile programs operate from a van or bus with clean needles that are distributed.</span></span></span></span>
**Larger mobile programs typically provide testing and other healthcare services and operate along regular reoutes at fixed times, often at night at times when increased use occurs.
**Mobile services can also be smaller and choose to target specific populations.
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list 1.0in"><span style="vertical-align:baseline">Typically, mobile programs are more accessible to injection drug users and face less opposition from a community.</span></span></span></span> <span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000" face="calibri, sans-serif"><span style="font-size: 14.6667px">'''Dispensing Machine Distribution''':</span></font> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A newer strategy, countries in Europe as well as Australia have begun to use syringe vending machines in addition to other forms of NSPs.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Syringe vending machines work through the use of non-currency tokens, that are distributed by outreach workers for injection drug users to use in return for harm reduction packs. An example of what is included in Australia’s machines are needles and syringes as well as alcohol swabs, cotton wool, sterile water and spoons. Others sometimes contain educational materials.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Typically, these machines act in conjunction with fixed sites that are meant to provide needles and syringes 24 hours a day, 7 days a week.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A clinical trial has found that this strategy can be highly effective for reaching populations who are most marginalized or otherwise hard to reach.</span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000"><font face="calibri, sans-serif"><span style="font-size:14.6667px">'''Peer Service Distribution Networks'''</span></font></font><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black">:</span></span></span></span> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Peer-based strategy, is a process where clients of needle exchanges provide service to their peers, distributing of needles, syringes, and associated injection equipment.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">These clients are trained to assist peers access exchangers, distribute information about safer drug use and safer sex, and facilitate referrals to other health services.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">This model, in addition to disseminating safer practices and helping make needle exchange programs reach a larger population, may have a psychological impact and help make interventions more effective. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241304/</ref></span></span></span></span>

<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">'''Prison-Based Facilities''':</span></span></span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Still a newly developing practice, only used in 3 of 24 UN countries that have needle exchange programs for the public.<ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">High need because prison populations have higher cases of Hepatitis C and HIV than the average population. <ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>

== Success Stories ==

'''Scott County, Indianna'''

Before Scott County set up its syringe exchange (plus more) program in 2015, the rural county in Indiana was seeing 10-20 new HIV cases every week. Almost immediately after, the number of new cases was slowed to 1-2 a month

Miami, Florida

<span style="line-height:normal"><span style="color:black">“In three years of operation, Miami's pilot program has pulled more than a quarter million used needles out of circulation, according to reports the program filed with the Florida Department of Health.” By handing out Narcan as well at the needle exchange, it has helped prevent more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C and connects people to medical care and rehabilitation services. <ref>https://www.npr.org/sections/health-shots/2019/06/27/725462715/key-florida-republicans-now-say-yes-to-clean-needles-for-drug-users</ref></span></span>

'''<span style="line-height:normal"><span style="color:black">Philidelphia, Pennsylvania</span></span>'''

A case study found that Prevention Point, a needle exchange located in Philadelphia helped prevent 10,000 People From Contracting HIV Over 10 Years. The researchers from George Washington University estimate that the total lifetime taxpayer savings from this needle exchange averting 10,000 cases of HIV saved them $1.8 billion. <ref>https://www.phillymag.com/news/2019/10/31/prevention-point-syringe-exchange-study/</ref>

= Available Tools and Resources =

[[TR_-_Increase_Access_to_Needle_Exchanges|TR - Increase Access to Needle Exchanges]]  

= Sources =

----
</div>
[[Category:SAFE-Full Spectrum Prevention]]

Increase Awareness of Treatment, Recovery & Support Services

2021-02-05T20:13:21Z

Mredden:

<div class="wiki" id="content_view" style="display: block">
Return to  <span style="background-color: transparent; font-family: arial, helvetica, sans-serif; font-size: 13px; color: rgb(255, 43, 0);">[[Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_During_Opioid_Use|Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy During Opioid Use ]]</span><span style="background-color: transparent; color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 13px;">or </span><span style="background-color: transparent; font-family: arial, helvetica, sans-serif; font-size: 13px; color: rgb(255, 43, 0);">[[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]]</span>   

= Overview =

= Key Information =

= Relevant Research =

= Impactful Federal, State, and Local Policies =

= Promising Practices =

= Available Tools and Resources =

= Sources =
</div>

Increase Access to Needle Exchanges

2021-02-05T20:12:49Z

Mredden:

__NOTOC__ Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map or]] [[ZOOM_MAP_-_Expand_Harm_Reduction_Practices_Associated_with_Opioid_Misuse|Zoom Map (Expand Harm Reduction Practices Associated with Opioid Misuse)]] <div class="wiki" id="content_view" style="display: block">  __toc__
= Overview =

Needle exchange programs (NEPs) are programs which distribute sanitized needles in exchange for contaminated or used needles. NEPs reduce the spread of blood borne diseases like HIV and Hepatitis C. Many organizations have endorsed needle exchange including NIH (National Institute of Health), CDC (Center for Disease Control), the American Bar Association, the American Medical Association, the American Psychological Association, the World Health Organization and others. The NIH estimates that in the United States, between fifteen and twenty percent of injection drug users have HIV and at least seventy percent have hepatitis C.<ref>https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.1840360703 </ref> <span style="line-height:normal"><span style="color:black">As such sharing needles has become the most common mode of HIV transmission among injection drug users (IDUs). In addition, used syringes and needles are a potential biohazard within which users primarily reside, and beyond it as well. </span></span><span style="line-height:normal"><span style="color:black">Harm reduction services such as the provision of sterile needles and syringes can effectively prevent hepatitis C and HIV transmission among people who inject drugs, provided they are accessible and delivered at the required scale.</span></span>

= Key Information =

= Relevant Research =

<span style="line-height:normal"><span style="color:black">Needle exchanges have been estimated to be a cost effective prevention practice. An analysis of the cost-effectiveness of a New York City needle syringe exchange estimated that the program would result in a baseline one year savings to the government of $1,300 to $3,000 per client. Another analysis by the CDC approximated that increasing access to clean syringes through an additional annual U.S. investment of $10 million would lead to:</span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">194 HIV infections averted in one year </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">And A lifetime treatment cost savings of $75.8 million which would be a return on investment of $7.58 for every $1 spent </span></span></span></span><span style="line-height:normal"><span style="color:black"><ref>https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html</ref></span></span>

== Do Needle Exchanges Increase Drug Injection Rates? ==

<span style="line-height:normal"><span style="font-family:"><span style="color:black">A review of needle exchange done by the office of the Surgeon General and the assistant secretary for health found that needle exchange did not cause an increase in drug injection, but rather typically led to a decrease in injection rates when these programs were used.<ref>http://www.csdp.org/research/surgeongennex.pdf</ref></span></span></span>

Another study sought to answer the question "is the number of needles distributed from needle exchange programs proportionate to the number of needles returned to needle exchange programs?" It was found that in the United States the return rate was on average over 90% (~315,000 needles distributed and ~283,000 needles returned). <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

This finding has been further substantiated by another review which found that supplying IDUs (Injecting Drug Users) with clean or sanitized needles does not lead to more "dirty" needles in a community. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC419716/</ref>

== Importance for Harm Reduction Practice and Education ==

Needle exchange programs help educate and inform injection drug users regarding injection practices, safety steps, non-sharing behavior, and other risk reduction methods. “The need for and value of targeted education and behavior modification efforts directed at injection drug users at risk of HIV transmission have been clearly demonstrated in programs that do not include needle exchange (Wiebel et al., 1993).”<font color="#000000"><ref>https://www.ncbi.nlm.nih.gov/books/NBK232350/</ref></font>

Needle exchanges and safe injection sites have decades of evidence behind them - but not public support.<ref>https://opioidaction.org/2018/06/vox-a-new-study-shows-stigma-is-hurting-our-response-to-the-opioid-epidemic/</ref>

= Promising Practices =

<span style="line-height:normal"><span style="font-family:"><span style="color:black">There are currently several different models for syringe exchanges that have different advantages and limitations. The models include:</span></span></span>

<span style="line-height:normal"><span style="font-family:"><span style="color:black">'''Primary and Secondary Needle and Syringe Programs''':</span></span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They are fixed sites that are typically located in areas with high levels of injecting drug use.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">They can be located in many different areas such as community centers, pharmacies, or specialized voluntary counselling and testing centers.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Those who attend will be able to receive clean paraphernalia and safely dispose of used paraphernalia. </span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

'''Mobile or On-Call Service''':

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Mobile programs operate from a van or bus with clean needles that are distributed.</span></span></span></span>
**Larger mobile programs typically provide testing and other healthcare services and operate along regular reoutes at fixed times, often at night at times when increased use occurs.
**Mobile services can also be smaller and choose to target specific populations.
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list 1.0in"><span style="vertical-align:baseline">Typically, mobile programs are more accessible to injection drug users and face less opposition from a community.</span></span></span></span> <span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000" face="calibri, sans-serif"><span style="font-size: 14.6667px">'''Dispensing Machine Distribution''':</span></font> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A newer strategy, countries in Europe as well as Australia have begun to use syringe vending machines in addition to other forms of NSPs.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Syringe vending machines work through the use of non-currency tokens, that are distributed by outreach workers for injection drug users to use in return for harm reduction packs. An example of what is included in Australia’s machines are needles and syringes as well as alcohol swabs, cotton wool, sterile water and spoons. Others sometimes contain educational materials.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Typically, these machines act in conjunction with fixed sites that are meant to provide needles and syringes 24 hours a day, 7 days a week.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">A clinical trial has found that this strategy can be highly effective for reaching populations who are most marginalized or otherwise hard to reach.</span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black"><ref>https://www.avert.org/professionals/hiv-programming/prevention/needle-syringe-programmes</ref></span></span></span></span>

== <font color="#000000"><font face="calibri, sans-serif"><span style="font-size:14.6667px">'''Peer Service Distribution Networks'''</span></font></font><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"><span style="color:black">:</span></span></span></span> ==

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Peer-based strategy, is a process where clients of needle exchanges provide service to their peers, distributing of needles, syringes, and associated injection equipment.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">These clients are trained to assist peers access exchangers, distribute information about safer drug use and safer sex, and facilitate referrals to other health services.</span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">This model, in addition to disseminating safer practices and helping make needle exchange programs reach a larger population, may have a psychological impact and help make interventions more effective. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241304/</ref></span></span></span></span>

<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">'''Prison-Based Facilities''':</span></span></span></span>

*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">Still a newly developing practice, only used in 3 of 24 UN countries that have needle exchange programs for the public.<ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>
*<span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="vertical-align:baseline">High need because prison populations have higher cases of Hepatitis C and HIV than the average population. <ref>http://blogs.biomedcentral.com/on-health/wp-content/uploads/sites/8/2016/10/Prison-based-needle-and-syringe-programmes-PNSP-final.pdf</ref></span></span></span></span>

== Success Stories ==

'''Scott County, Indianna'''

Before Scott County set up its syringe exchange (plus more) program in 2015, the rural county in Indiana was seeing 10-20 new HIV cases every week. Almost immediately after, the number of new cases was slowed to 1-2 a month

Miami, Florida

<span style="line-height:normal"><span style="color:black">“In three years of operation, Miami's pilot program has pulled more than a quarter million used needles out of circulation, according to reports the program filed with the Florida Department of Health.” By handing out Narcan as well at the needle exchange, it has helped prevent more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C and connects people to medical care and rehabilitation services. <ref>https://www.npr.org/sections/health-shots/2019/06/27/725462715/key-florida-republicans-now-say-yes-to-clean-needles-for-drug-users</ref></span></span>

'''<span style="line-height:normal"><span style="color:black">Philidelphia, Pennsylvania</span></span>'''

A case study found that Prevention Point, a needle exchange located in Philadelphia helped prevent 10,000 People From Contracting HIV Over 10 Years. The researchers from George Washington University estimate that the total lifetime taxpayer savings from this needle exchange averting 10,000 cases of HIV saved them $1.8 billion. <ref>https://www.phillymag.com/news/2019/10/31/prevention-point-syringe-exchange-study/</ref>

= Available Tools and Resources =

[[TR_-_Increase_Access_to_Needle_Exchanges|TR - Increase Access to Needle Exchanges]]  

= Sources =

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[[Category:SAFE-Full Spectrum Prevention]]

Increase Awareness of Treatment, Recovery & Support Services

2021-02-05T19:39:02Z

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