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Body:Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

DEA Alert Conference November 13, 2008 DEA Alert Conference DEA Alert Conference November 13, 2008 November 13, 2008

Nick Reuter Division of Pharmacologic Therapy Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Overview Overview

. Opioid Assisted Treatment SAMHSA (methadone/buprenorphine) . Methadone abuse/mortality increasing. . National Assessments

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA Active Opioid Treatment Programs by State as of June 2008 (1,192)

= Bottom 6 States

= Top 5 States

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

States Where Methadone Treatment is not States Where Methadone Treatment is not Available Available

. 2000 - Idaho - Mississippi - Montana - New Hampshire - North Dakota - South Dakota - Vermont - West Virginia

. 2008 - Montana - North Dakota - South Dakota - Wyoming

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Modest Increase in Patients Modest Increase in Patients

Patients in MMTPS

0

50000

100000

150000

200000

250000

300000

1997 1998 1999 2000 2002 2003 2004 2005 2006

Year

Number of Patients

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Increase in Methadone Patients Increase in Methadone Patients

. 2002 - 2006 (260,000) . US - 2.3% . TX - 27 % . Oklahoma -114 % . Louisiana -25 % . Source National Survey on Substance Abuse Treatment Services, SAMHSA

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA Dependence on or Abuse of Specific Illicit Drugs in the Dependence on or Abuse of Specific Illicit Drugs in the Past Year among Persons Aged 12 or Older: 2007 Past Year among Persons Aged 12 or Older: 2007

Fig 7.2

Numbers of Persons with Drug Use Disorder

154,000

164,000

213,000

368,000

406,000

443,000

1,598,000

1,707,000

3,932,000

0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000

Sedatives

Inhalants

Heroin

Hallucinogens

Stimulants

Tranquilizers

Cocaine

Pain Relivers

Marijuana

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Treatment Gap? Treatment Gap?

. 260,000 methadone patients . 305,000 buprenorphine . Total 560,000 . Rx Pain Dependence - 1.56 million . Heroin dependence - 0.23 million . Total 1.9 million . Gap ~ 1.4 million

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA OTP Characteristics OTP Characteristics

. Treatment capacity - average 208 patients . Mean size-253 patients . Range-20 to 2,000 patients . Public/Non-profit-approximately 52% (2004) . 44.6 % non-profit; 41% for-profit, 14.4%, run by a government agency . Less than one/third of patients without insurance . Of patients with insurance, two-thirds covered for OTP treatment.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

OTP Characteristics (2) OTP Characteristics (2)

. Typical pt: white male, 26-50 years old . 75% treated for heroin addiction; 14.6, oxycodone and 5.7%, morphine addiction. . Less than 1% treated with buprenorphine . Mean years in treatment: 6.3 . Mean length, current treatment episode: 25.9 months

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

SAMHSA Regulations 42 CFR § 8 SAMHSA Regulations 42 CFR § 8 . Federal opioid treatment standards, e.g. - Patient Admission Criteria - Medication administration, dispensing - Unsupervised use - Diversion control - Required medical, drug testing and other services . SAMHSA Certification . Certification Based Upon - Accreditation - DEA Registration - State Approval . SAMHSA approval of accreditation bodies . Suspension or revocation of OTP certification . Collaboration with State Authorities - Conference calls - Annual meeting

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Federal Opioid Treatment Standards (§8.12) . Administrative and organizational structure . Quality assurance/improvement . Diversion Control Plan . Staff credentials . Patient admission criteria . Required services . Record keeping and patient confidentiality . Medication administration, dispensing . Unsupervised use . Interim maintenance . Detoxification

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Diversion Control Plan - Surveillance and Monitoring

. How are diversion problems addressed? - Change frequency of take-home reviews, if needed investigate source of diversion special/intensified groups or individual counseling sessions

- Establish patient committee to advise on policies, procedures and problem solving

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Take Home Schedule - 6 Steps . A patient may receive a single take home dose for a day the program is closed, AND

- 0 - 90 days - patient may receive a single dose each week - 90 - 180 days - patient may receive up to two doses per week

- 180 - 270 days - patient may receive up to three doses per week - 270 - 365 days - patient may receive up to six doses per week - After 1 year continuous treatment - up to a 2 week supply - After 2 years of continuous treatment - up to a 30 day supply

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Take Home Determinations

. 8 Criteria unchanged

. More reliance on clinical judgement of medical director and program physicians . Less reliance on regulatory test results, complex probation monitoring or drug testing

. Programs must have diversion control plans

. No Federal approval necessary for TH doses above 100 mg

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Solid Dosage Forms

. Permitted under new regulations

. All opioid treatment medications pose a risk of diversion

. Diskettes lower potential than tablets

. Physician determines that patient can responsibly handle diskettes

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Federal Confidentiality Law Federal Confidentiality Law

. Applies to substance abuse treatment programs, including methadone programs . Restricts disclosure of patient information . Court order required for undercover investigations

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Is methadone effective? Is methadone effective?

. Methadone maintenance treatment is safe and effective when used appropriately, when treatment is individualized to each patient, and when provided with counseling and other services. . Has saved thousands of lives from overdose, HIV- AIDS . NIH concluded most effective for opiate addiction.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Emerging Issues Methadone Emerging Issues Methadone Treatment Treatment

. Program Closures - Georgia, Texas, Illinois, New Mexico - Failure to comply with regulations . Civil fines for failing to adhere to Federal dispensing schedule. ($25,000 each, under CSA) . Cardiac Conductivity - TDP . FDA Labeling Revision

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Is Methadone Abused? Is Methadone Abused?

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Nonmedical Use of Pharmaceuticals, Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2006 Selected Opiates/Opioids, 2006

16

58

20

65

50

80

15

44

7

25 26

71

0

10

20

30

40

50

60

70

80

90

100

Fentanyl* Hydrocodone* Morphine* Oxycodone*

Visits (thousands)

Source: National estimates from DAWN, 2006

* Single- & multi-ingredient formulations

CI lower bound estimate CI upper bound

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Nonmedical Use of Pharmaceuticals, Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2006 Selected Opiates/Opioids, 2006

51

4

45

36

0.8

38

64 54

8

0

10 20

30

40 50

60

70

80 90

100

Opiates/opioids not specified Buprenorphine* Methadone

Visits (thousands)

Source: National estimates from DAWN, 2006

* Single- & multi-ingredient formulations

CI lower bound estimate CI upper bound

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

0

5,000

10,000

15,000

20,000

Darvocet, Darvon, or Tylenol with Codeine

Percocet, Percodan, or Tylox

Vicodin, L ortab, or L orcet

Codeine

Demerol

Dilaudid

Hydrocodone

Oxycontin

Methadone

Morphine

Nonmedical Use of Specific Pain Relievers in Lifetime, Numbers in Thousands, 2007 Nonmedical Use of Specific Pain Relievers in Lifetime, Numbers in Thousands, 2007

Source: NSDUH 2007

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA Past Month Illicit Drug Use among Persons Aged 12 or Past Month Illicit Drug Use among Persons Aged 12 or Older: 2007 Older: 2007

Fig 2.1

1 Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically.

Numbers in Millions

0.2

0.6

1.0

2.1

6.9

14.4

19.9

0 5 10 15 20 25

Heroin

Inhalants

Hallucinogens

Cocaine

Psychotherapeutics

Marijuana

Illicit Drugs 1

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA Past Month Use of Selected Illicit Drugs among Persons Aged Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002 12 or Older: 2002 - - 2007 2007

Fig 2.2

Percent Using in Past Month

2.1

0.8 0.3 0.3 0.3 0.3 0.3 0.2

8.0

8.3 8.1 7.9 8.2 8.3

5.8

6.0 6.0 6.1 6.2 6.2

2.8 2.9 2.7 2.5 2.7 2.7

2.1 1.9 2.0 1.9 1.8 +

1.0 1.0 0.8 1.0 0.9

0

1

2

3

4

5

6

7

8

9

2002 2003 2004 2005 2006 2007

Marijuana

Psycho- therapeutics

Pain Relievers

Cocaine

Illicit Drugs

+ Difference between this estimate and the 2007 estimate is statistically significant at the .05 level.

Metham- phetamine

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA Past Month Use of Selected Illicit Drugs among Youths Past Month Use of Selected Illicit Drugs among Youths Aged 12 to 17: 2002 Aged 12 to 17: 2002 - - 2007 2007

Fig 2.5

Percent Using in Past Month

9.5

6.7

3.3

9.8 9.9 10.6 + 11.2 + 11.6 +

6.7 6.8 7.6 + 7.9 + 8.2 +

3.3 3.3 3.6 4.0 + 4.0 +

1.2 1.3 1.2 1.2 1.3 1.2

0.7 0.7 0.8 0.8 1.0 + 1.0 + 0

2

4

6

8

10

12

14

2002 2003 2004 2005 2006 2007

Marijuana

Psycho- therapeutics

Inhalants Hallucinogens

Illicit Drugs

+ Difference between this estimate and the 2007 estimate is statistically significant at the .05 level.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA Past Month Use of Selected Illicit Drugs among Young Past Month Use of Selected Illicit Drugs among Young Adults Aged 18 to 25: 2002 Adults Aged 18 to 25: 2002 - - 2007 2007

Fig 2.6

Percent Using in Past Month

19.7

16.4

6.0

19.8 20.1 19.4 20.3 20.2

16.3 16.6 16.1 17.0 17.3

6.5 6.3 6.1 6.1 5.5

1.7 2.0 2.2 + 2.6 + 2.1 + 2.2 +

1.5 1.5 1.7 1.5 1.9 + 1.7 0

5

10

15

20

25

2002 2003 2004 2005 2006 2007

Marijuana

Psycho- therapeutics

Cocaine Hallucinogens

Illicit Drugs

+ Difference between this estimate and the 2007 estimate is statistically significant at the .05 level.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Methadone Associated Mortality? Methadone Associated Mortality?

. 2003-2007 National Assessments . NCHS Data - National/West Virginia

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

NCHS Data NCHS Data

. Crude Death Rates, methadone-related unintentional deaths/100M . 1999 - 2004 . WV - 25 fold (4 to 99 deaths) . KY - 15 fold (8 to 121 deaths, decr in 2004) . NC - 7 fold (34 to 245) . US - 5 fold (623 to 3202) 4462 in 2005

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

CDC MMWR Data CDC MMWR Data - - 2007 2007

. Nearly all poisoning deaths in the United States are attributed to drugs, and most drug poisonings result from the abuse of prescription and illegal drugs . West Virginia Unintentional Poisoning Deaths Increased 550% between 1999-2004

. NCHS Methadone Mentions increased 390% between 1999-2004 . Methadone Distribution (ARCOS) Increased 390% between 1990-2004

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Reasons for methadone toxicity Reasons for methadone toxicity

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Pharmacology Pharmacology

. Slow onset . Long duration of action - Half life 24-36 hours - Steady state 4-5 days - Half of each days dose remains to be added to next days dose. . Accumulation . Tolerance - respiratory depression slower than pain relief . Interactions with depressants

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Methadone Toxicity Varies Methadone Toxicity Varies Greatly Across Individuals Greatly Across Individuals - - 100x 100x

. Enhanced by other drugs/alcohol - interactions not fully quantified. . Enhanced by natural disease - e.g., pathology due to history of drug use, sleep apnea, heart, lung, or liver disease. . Enhanced by circumstances - e.g., airway position, temperature, food.

Source: Sorg 2002

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

. Has methadone distribution increased in recent years?

. If so, how?

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Methadone Prescriptions Methadone Prescriptions

. 1998-2003 Rx for hydrocodone, oxycodone, methadone increased. . Methadone Rx increased 0.5- 1.8 million . Unique Patient Rx methadone increased 80% from 2005-2006 . Correlation between increases in methadone dispensed by pharmacies and increases in methadone associated mortality

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Methadone Rx Increases Methadone Rx Increases - - 2006 2006

. Out of all strengths of methadone, the largest growth in sales is seen with methadone 40mg with a 240% growth in combined sales since 2001. (10mg 150%, 5mg 91%). . Sales of methadone 40mg to chain stores and independent pharmacies have increased 700% and 450%, respectively since 2001.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA Sales of opioids by type, Sales of opioids by type, US, 1997 thru 3 US, 1997 thru 3 rd rd quarter, 2006 quarter, 2006 (DEA ARCOS data) (DEA ARCOS data)

0

20

40

60

80

100

120

140

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06

Year

Mg/person

oxycodone hydrocodone codeine morphine methadone meperidine fentanyl

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Patient Patient - - level data: Total number of unique patients receiving a level data: Total number of unique patients receiving a prescription for methadone in U.S. outpatient retail pharmacies, prescription for methadone in U.S. outpatient retail pharmacies, Years 2002 Years 2002 - - 2006, Verispan, Total Patient Tracker (TPT) 2006, Verispan, Total Patient Tracker (TPT)

Verispan, Total Patient Tracker, Years 2002 - 2006, Extracted July 2007.

355

484 549

653 721

0

100

200

300

400

500

600

700

800

Unique Patients (thousands)

2002 2003 2004 2005 2006

Years

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Pain Reliever Cost Comparison Pain Reliever Cost Comparison

. Estimated Monthly Drug Costs

. Agent Dosage Cost*

. Methadone 90 pills $ 8.00 . SR morphine 60 pills 101.50 . MS Contin 60 pills 113.50 . Oxycontin 60 pills 176.50 . Duragesic 10 patches 154.00*

-Estimated cost to the pharmacist based on average wholesale prices, rounded to the nearest half dollar, in Red book. Montvale, N.J.: Medical Economics Data, 2004. Cost to the patient will be higher, depending on prescription filling fee.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Opioid Treatment and Mortality Opioid Treatment and Mortality

. Texas . North Carolina . Maine . West Virginia

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Maxwell Maxwell - - NTP Patient Deaths NTP Patient Deaths - - Texas Texas - - 1994 1994 - - 2002 2002 - - 1 1

. Compared to general population NTP patients: . 4.6 x drug overdose . 3.4 x liver disease . 1.7 x respiratory disease . 1.5 x cancer

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Maxwell Maxwell - - NTP Patient Deaths NTP Patient Deaths - - Texas Texas - - 1994 1994 - - 2002 2002 - - 2 2

. Older cohort - chronic disease . Younger cohort - trauma, overdose . Knowledge of Toxicity - 14 % aware of overdose risk during 1 st 2 weeks - 15% aware of risks of starting patients at 30 mg or higher

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Activities Activities - - Education/Training Education/Training

. FDA Revised Labeling . Black-box warning - Methadone for pain, second line - accidental overdose - death due to respiratory depressant effects - death due to cardiac conduction effects . Dosing revision - lower starting dose and greater inter-dose interval - conversion from other opioids - stresses unique pharmacology and caution during initiation and conversion from other opioids

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

FDA Advisory FDA Advisory - - 1 1

. Patients should take methadone exactly as prescribed. Taking more methadone than prescribed can cause breathing to slow or stop and can cause death. A patient who does not experience good pain relief with the prescribed dose of methadone, should talk to his or her doctor. . Patients taking methadone should not start or stop taking other medicines or dietary supplements without talking to their health care provider. Taking other medicines or dietary supplements may cause less pain relief. They may also cause a toxic buildup of methadone in the body leading to dangerous changes in breathing or heart beat that may cause death.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

FDA Advisory FDA Advisory - - 2 2

. Health care professionals and patients should be aware of the signs of methadone overdose. Signs of methadone overdose include trouble breathing or shallow breathing; extreme tiredness or sleepiness; blurred vision; inability to think, talk or walk normally; and feeling faint, dizzy or confused. If these signs occur, patients should get medical attention right away.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Methadone Physician Training Methadone Physician Training - - 1 1

. Explain the criteria for determining when methadone is appropriately used in the management of pain. . Describe approaches to devising an appropriate dosing regimen. . Describe the considerations involved in patient selection and monitoring. . Discuss the special precautions to be taken during the induction phase of methadone use.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Methadone Rx Training Methadone Rx Training - - 2 2

. Explain the special issues involved in managing pain in the methadone- maintained patient. . Describe the legal and administrative requirements for the use of methadone to treat pain. . Discuss steps that can be taken to minimize the risks of drug diversion and abuse.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Dear Colleague Letter Dear Colleague Letter - - Dosing Dosing . SAMHSA cannot emphasize strongly enough that determining the admitting diagnosis, admitting the patient, and setting the initial dose must only be done by the OTP physician who possesses the demonstrated competency to diagnose and treat patients with opioid intoxication, dependency. . . . "steady-state concentrations are not usually attained until 3 to 5 days of dosing,"

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Methadone Induction Methadone Induction

. Dose "holding" (first few weeks) - Judge dose by how the patient feels during the peak period (2 to 4 hrs after dosing) rather than during the trough period (just prior to the next dose) generally 24 hrs after ingestion - Patients waking up "sick" during the first few days of induction are often convinced that they need a dose increase, when in fact more time is needed to reach steady state.

TIP #43: Chapter 5 - Clinical Pharmacology

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Comparison Comparison - - Methadone Dosing Methadone Dosing Schedules Schedules Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Dose Schedule A 30 30 30 30 30 30 50% 15 22.5 26.25 28.125 29.0625 Effect 45 52.5 56.25 58.125 59.0625

Dose Schedule B 30 30 40 40 40 40 50% 15 22.5 31.25 35.625 37.8125 Effect 45 62.5 71.25 75.625 77.8125

Dose Schedule C 30 40 50 60 60 60 50% 15 27.5 38.75 49.375 54.6875 Effect 55 77.5 98.75 109.375 114.688

Dose Schedule D 30 50 70 70 70 70 50% 15 32 51 60.5 65.25 Effect 65 102 121 130.5 135.25 Dose Schedule L Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 30 40 50 60 70 80 15 27.5 38.75 49.375 59.6875 55 77.5 98.75 119.375 139.688

Opioid Maintenance Pharmacotherapy - A Course for Clinicians

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

George B George B

. 37 yo, opioid dependence, heroin, age first use 27; cocaine, age first use 21; ETOH age first use 12 . Intake, reported daily heroin, for past 3yrs, varying amounts, based upon how much money available; denied cocaine . UDS + opiates . +HCV, HBV

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

George B George B

Father called clinic, advised of patient's demise on 1/17/07; funeral was at 1:00 pm

X No Follow up COWS not available Physiologic al dependence

80 70 60 50 40 30 Dose Schedule

1/22/07 1/17/07 1/16/07 1/15/07 1/14/07 1/13/07 1/12/07

Day 7 Day 6 Day 5 Day 4 Day 3 Day 2 Day 1

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

How Are States Responding How Are States Responding - - wv wv

. programs are required to be open 7 day a week . Programs must check the PMP periodically. . Programs must assess for tapering, withdrawal, detox . Take home revoked for positive drug test . Moratorium on new programs.

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Other Recommendations ?? Other Recommendations ??

. Induction period dangerous and should only be carried out inpatient . Programs must be open seven days per week. . Patients who continue to abuse illicit substances should not continue treatment . No take homes - trust

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Summary/conclusions Summary/conclusions

. Methadone and Buprenorphine treatment expanding. . Methadone associated mortality continues to be an increasing problem. . Increases not associated with addiction treatment source. - However, cases of deaths during induction are not uncommon - SAMHSA will emphasize caution in induction process for OTPs

Center for Substance Abuse Treatment Center for Substance Abuse Treatment

SAMHSA SAMHSA

Opioid Treatment Issues Opioid Treatment Issues CSAT CSAT

Nick Reuter Center for Substance Abuse Treatment Nicholas.reuter@samhsa.hhs.gov 240-276-2716