Transcript (6-E) Factors Influencing Medication Assisted Treatment in

Factors Influencing Medication
Assisted Treatment in Ohio Halfway
Houses and Community Based
Correctional Facilities
Kimberly Sperber, PhD
Director
Amber N. Manzo, MS
Senior Research Associate
This research was supported by grant number 2014-JG-E01-6020, awarded by the
Office of Criminal Justice Services, Edward Byrne Memorial Funding, to Talbert House. Points of view or opinions
contained within are those of the authors and do not necessarily represent the official opinions or policies of the U.S.
Department of Justice or the Office of Criminal Justice Services.
Setting the Stage
• Opiate overdose is the second leading cause of
injury related death nationally, surpassed only
by car accidents (Nosyk et al., 2013).
• In Ohio, accidental overdoses are the leading
cause of death and have been since 2007.
– 472% increase in drug overdose deaths from 1999
to 2013 (Ohio Department of Health, 2015).
• These deaths cost Ohio $3.6 billion annually,
with nonfatal overdoses costing an additional
$31.9 million.
Setting the Stage
• Number of Ohio substance abuse
treatment clients with a primary diagnosis
of opioid dependence rose from 5790 in
FY01 to 24,833 in FY12.
• The largest percentage of clients with this
diagnosis in any county in FY01 was
14.3%; in FY12 it was 69.7%.
Ohio Department of Health
Increased Risk
• Overall increase in persons with opioid
disorders = increase in community
corrections clients with opioid disorders
• Increased risk to correctional programs
and their clients:
–
–
–
–
AWOLs
Program failures
Recidivism
Death
Investigating Barriers to MAT in
Community Corrections
(2015)
• Study Methodology
– Replication of National Institutes of Health studies
conducted in private and public substance abuse
programs
– Replicated in Ohio halfway houses and CBCFs
– Sought to examine (1) barriers to medication
assisted treatment (MAT) and (2) staff attitudes
toward MAT.
– Funded by OCJS
Data Collection
• Structured, face-to-face interview with select
key staff
–
–
–
–
Program Director
1 Clinical Supervisor
2 Counselors
1 Medical
• Use of structured interview guide to gather
information on key independent variables
within a number of domains.
• Completed 181 key informant interviews
Data Collection
• Staff Surveys to all staff in each facility
– Knowledge about MAT
– Beliefs about the effectiveness and
appropriateness of MAT for offenders
– Endorsement of myths about MAT
• 1876 surveys distributed
• Response rate = 49% (n=910)
Sample Findings
INTERVIEW RESPONSES
Program Characteristics
• 28 halfway houses, 21 CBCFs
• Estimates of opioid abuse/dependence
on average of 44% for HHs and 64%
for CBCFs
• 61.2% had no detox services
available
– 34.7% had access to external detox providers, while
only 4.1% provided their own detox
Access to Medical Staff
Item
Finding physicians who are willing to contract with correctional treatment
programs to provide primary care services to clients?
Finding physicians or psychiatrists who are willing to contract with
correctional treatment programs to provide mental health care to clients?
Finding physicians with experience treating clients with substance abuse
disorders?
Finding nurses who are willing to contract with correctional treatment
programs to provide primary care services to clients?
Finding nurses who are willing to contract with correctional treatment
programs to provide mental health care to clients?
Finding nurses with experience treating clients with substance abuse
disorders?
Percent Indicating
“Somewhat Easy” or “Very
Easy”
51.7
50.6
46.9
38.5
51.3
46.8
Role of Single State Agency
Item
OHMAS is supportive of the use of medications for treating substance abuse in
community corrections settings.
OHMAS has adequately disseminated information about how to implement
medication-assisted treatment in community corrections programs.
OHMAS has offered sufficient training opportunities about using medications to
treat substance abuse.
Percent of PDs
Indicating “Agree”
or “Strongly Agree”
83.0
37.5
36.2
Accessing Info on MAT
Item
Journals, newsletters, or other professional (trade) publications?
Percent Indicating
“Moderate” to
“Very Great” Extent
54.8
Contacts or promotional materials from pharmaceutical companies?
29.2
Conversations with staff of other substance abuse treatment organizations?
76.2
Ohio Mental Health and Addictions Services?
58.5
Ohio Department of Rehabilitation and Correction?
58.0
National Institute on Drug Abuse’s website and publications?
43.5
NIDA’s annual “Blending” conferences?
8.6
Your area’s Addiction Technology Transfer Center (ATTC)?
Technical Assistance Publications (TAPs), Treatment Improvement Protocols
(TIPs), and other publications from the Center for
Substance Abuse Treatment (CSAT)?
9.2
35.4
Medical Staff Barriers
Item
Procedures to refer and approve a client for medication-assisted treatment.
Time required to adequately assess and monitor clients for adherence, side
effects, and progress.
Additional documentation requirements.
Inadequate frequency of urinalysis available to adequately monitor clients on
medication-assisted treatment.
Lack of knowledge by non-medical staff about the medications in use at the
facility to treat substance use disorders.
Line staff send provide contradictory messages to clients about the
effectiveness of medications for substance abuse treatment.
Percent Indicating
“Moderate” to “Very
Great” Extent
49.9
24.0
27.3
18.2
72.8
27.3
What Do 910 Practitioners Have to Say?
SURVEY RESPONSES
Staff Characteristics
Characteristic
Percent
Female
59.3
1st Shift
72.1
At Least 4 Year Degree
54.8
Administration
20.3
Clinical
27.7
Medical
1.1
Security/Operations
40.7
Other Positions
9.2
In Recovery
9.1
Diffusion and Staff Perceptions
by Medication
Distribution of pharmacotherapy diffusion and staff perceptions, % or mean (SD)
Variable
Dependent variables
Diffusion
Perceived effectiveness
Perceived acceptability
Buprenorphine
35.1%
1.95 (.82)
2.06 (1.08)
Methadone
37.2%
1.80 (.80)
1.81 (1.01)
Oral Naltrexone
55.4%
2.31 (.90)
2.54 (1.20)
Vivitrol
44.0%
2.74 (.99)
2.83 (1.20)
Summary of Variable Impact on Odds of Endorsing an Opinion about Each Medication
Injectable
Naltrexone
Variable
Methadone
Buprenorphine
Oral Naltrexone
Parent agency
Not Significant
Not Significant
Increased Odds
Increased Odds
Female
Increased Odds
Increased Odds
Not Significant
Increased Odds
Hours worked
Not Significant
Not Significant
Not Significant
Not Significant
Clinical position
Not Significant
Not Significant
Decreased Odds
Not Significant
Operations position
Decreased Odds
Decreased Odds
Decreased Odds
Decreased Odds
Recovery status
Increased Odds
Increased Odds
Not Significant
Not Significant
Level of education
Increased Odds
Increased Odds
Not Significant
Not Significant
Information on MAT
Increased Odds
Increased Odds
Increased Odds
Increased Odds
12-step orientation
Not Significant
Decreased Odds
Not Significant
Not Significant
Facility provides MAT
Increased Odds
Not Significant
Increased Odds
Increased Odds
Increased Odds
Increased Odds
Increased Odds
Increased Odds
Not Significant
Not Significant
Increased Odds
Increased Odds
Facility provides access to
MAT
Works in a CBCF
Summary
• Sufficient information on MAT and working in a
facility that provided some level of MAT was
predictive of diffusion across all 4 medications
• Operations status predictive across all 4 medications;
negative relationship
• Gender predictive across 3 of the 4 medications
• 12-step orientation only predictive of Buprenorphine
diffusion; negative relationship
• Gender, recovery status, level of education consistent
predictors of diffusion for methadone and
buprenorphine
Practitioner Knowledge About MAT
• Operations staff provided significantly lower ratings of
agreement on items that reflected benefits of MAT
–
–
–
–
–
–
Reduces relapse
Increases employment
Reduces crime
Reduces or blocks the effects of opioids
Increases family stability
Improves birth outcomes for children born to addicted mothers.
• They provided significantly higher ratings of agreement to
items indicating beliefs about negative outcomes of MAT
– MAT rewards criminals for being drug users and interferes with the ability to
drive a car.
•
Supervisory staff provided significantly higher ratings of
agreement than both groups of line staff for two items – MAT
lowers death rates and MAT increases program retention.
Staff Opinions and Concerns
• Operational staff were more likely to agree with
negative statements associated with medicationassisted treatment.
• These items were:
– Using medications to treat addiction is substituting one drug for
another.
– Using medications to treat addiction in correctional programs
causes too many problems with diversion and contraband within
the facility.
– Medications are drugs and you cannot be clean if you are taking
drugs.
– Using medication in substance abuse treatment is promoting the
pharmaceutical companies.
Summary of Variable Impact on Odds of Agreeing that Each Medication is Acceptable
Variable
Methadone
Buprenorphine
Oral Naltrexone
Injectable
Naltrexone
Parent agency
Not Significant
Not Significant
Not Significant
Not Significant
Female
Not Significant
Not Significant
Not Significant
Increased Odds
Hours worked
Not Significant
Not Significant
Not Significant
Not Significant
Recovery status
Not Significant
Not Significant
Not Significant
Not Significant
Staff beliefs
Not Significant
Increased Odds
Increased Odds
Increased Odds
Education level
Not Significant
Not Significant
Not Significant
Increased Odds
12-step orientation
Not Significant
Not Significant
Not Significant
Not Significant
Staff information
Not Significant
Not Significant
Not Significant
Not Significant
Facility provides MAT
Decreased Odds
Not Significant
Increased Odds
Increased Odds
Clinical staff
Not Significant
Not Significant
Decreased Odds
Not Significant
Operations staff
Not Significant
Not Significant
Decreased Odds
Decreased Odds
Works in CBCF
Not Significant
Decreased Odds
Not Significant
Not Significant
Staff concerns
Decreased Odds
Decreased Odds
Decreased Odds
Not Significant
Summary
•
•
•
Staff who demonstrated a higher level of agreement with statements
indicating positive outcomes of MAT were significantly more likely to
endorse the use of buprenorphine, oral naltrexone, and injectable
naltrexone as acceptable.
Higher endorsement of items reflecting concerns with MAT produced a
significantly lower odds of agreeing that three of the medications were
acceptable for use with correctional clients; these medications were
methadone, buprenorphine, and oral naltrexone. While not
statistically significant at the p=.05 level, staff concerns did approach
significance as a predictor of acceptability for injectable naltrexone as
well (p=06).
Working in a facility that directly provided MAT was also a statistically
significant predictor of endorsing the acceptability of methadone, oral
naltrexone, and injectable naltrexone. it served to decrease the
probability that staff would endorse methadone as acceptable,
however.
Summary of Variable Impact on Odds of Agreeing that Each Medication is Effective
Injectable
Naltrexone
Variable
Methadone
Buprenorphine
Oral Naltrexone
Parent agency
Not Significant
Not Significant
Not Significant
Not Significant
Female
Not Significant
Not Significant
Not Significant
Not Significant
Hours worked
Not Significant
Not Significant
Not Significant
Not Significant
Recovery status
Not Significant
Not Significant
Not Significant
Not Significant
Staff beliefs
Increased Odds
Increased Odds
Increased Odds
Increased Odds
Education level
Not Significant
Not Significant
Not Significant
Not Significant
12-step orientation
Not Significant
Not Significant
Not Significant
Not Significant
Staff information
Not Significant
Not Significant
Not Significant
Not Significant
Facility provides MAT
Not Significant
Not Significant
Increased Odds
Not Significant
Clinical staff
Not Significant
Not Significant
Not Significant
Not Significant
Operations staff
Not Significant
Not Significant
Decreased Odds
Decreased Odds
Works in CBCF
Decreased Odds
Decreased Odds
Not Significant
Not Significant
Staff concerns
Decreased Odds
Not Significant
Not Significant
Not Significant
Summary
• Endorsement of outcomes predictive across all 4
medications
• MAT implementation was predictive of perceptions of
effectiveness of only one medication – oral naltrexone
• Working as operations staff predicted lower
endorsement of effectiveness for both forms of
naltrexone
• Working in a CBCF predicted lower endorsement of
effectiveness for methadone and buprenorphine
• Higher endorsement of concerns associated with MAT
was predictive of lower endorsement of effectiveness of
methadone only
Implications
• Identification of key structural barriers to MAT
adoption in community corrections settings
• Overall low diffusion of knowledge about MAT
• Overall low ratings of acceptability and
effectiveness of MAT
• A mixture of individual and organizational
attributes that may be important to future
efforts to change staff perceptions
Practitioner Toolkit
• Staff Education
– Fact Sheets
– Webinars
• Advocacy
• Implementation
– Implementation Matrix
• Client Education
Staff Education - Sample Topics
• Brain science
• Addiction as a chronic care
condition
• Understanding the role of
medication in long-term recovery
• Myth busting
• Scope of practice
Substance Use and the Brain
• Repeated use of addictive drugs eventually
changes how the brain functions
• These changes can last for months or even
years
• These changes accompany the transition from
abuse to addiction and may continue to increase
risk of relapse even once someone has stopped
using drugs
Objective Evidence
NIDA (2007) Bringing the Power of Science to Bear on Drug Abuse and Addiction. Rockville, MD : U.S. Dept. of Health
and Human Services, National Institutes of Health.
Cognitive Deficits
• Memory
• Difficulty with abstraction
• Diminished impulse control
• Brain performs similarly to an individual
with brain damage
Addiction as Chronic Care
Condition
• Many with addiction will require multiple episodes of
treatment over the course of years before
demonstrating any sustained period of recovery
• In one study, estimated median time from first use to at
least 1 drug-free year was 27 years
• Estimated median time from first treatment to 1 alcohol
and drug-free year was 9 years with 3-4 episodes of
treatment (Dennis et al., 2005)
• Time to recovery is also impacted by age of first use
and duration of use prior to treatment
Understanding the
Medications
• What is the difference between an
agonist, a partial agonist, and an
antagonist?
• How do these medications
function?
• How do these medications function
differently from heroin?
Opioid Medications
High
Opioid
Effect
Full Agonist
(e.g., methadone)
Activate opioid
receptor in the
brain; subjective
feeling of “high”
Block the opioid
receptor; NO
subjective
feeling of “high”
Partial Agonist
(e.g. buprenorphine)
Antagonist
(e.g. naloxone)
Low
Dose of Opioid
SOURCE: ATTC
Developed by Dr. Erin Winstanley for Talbert House
Phases of MAT
• Detoxification
– Weaning patients off of addictive
substances and managing withdrawal
– Used alone, we see high rates of
relapse
• Stabilization
– Withdrawal management,
assessment, medication induction,
psychosocial counseling
Phases of MAT
• Maintenance
– Medication maintenance and deeper counseling work
• Ongoing Rehabilitation
– Patient and provider might choose to wean from
medication or pursue indefinite medication
maintenance
• SAMHSA consensus group recommended that
patients never be coerced into tapering off of
their medications
– Decision is to be jointly made between physician and
patient
Myths
• MAT substitutes one addiction for
another
• Addiction medication is a crutch
that prevents true recovery
• MAT should not be long term
Scope of Practice
• Prohibitions against MAT and implications
for Americans with Disabilities Act and
Rehabilitation Act of 1973
• Implications of recommendations against
MAT made by non-medical professionals
• Agency policy versus individual staff
opinion
The Opioid Crisis Continues
Current CHHSR Projects
Complicating Factors
• The recent influx of fentanyl has served to
further exacerbate the risk of overdose deaths
in Ohio
– Number of fentanyl overdose deaths increasing 500% from 2013
to 2014
– Ohio leads the country in the number of confiscations by law
enforcement of illicit fentanyl. The second highest rate of
confiscations is in Massachusetts, which is only about half that of
Ohio.
– According to a 2015 Center for Disease Control EpiAid report on
risk factors for fentanyl-related overdose deaths in Ohio, the
highest fentanyl overdose rates can be found in Hamilton,
Montgomery, Summit, Butler, Cuyahoga, and Clermont Counties.
Complicating Factors
• Risk factors associated with an increased
risk of a fentanyl-related overdose death
included:
– Age, gender, current mental health problem,
history of a substance abuse problem, history of
opioid abuse, lower education, and recent
release from a correctional institution.
Reentry and Risk of OD
• Highest risk time for a drug overdose for individuals
involved in the criminal justice system is 2 weeks postrelease from a correctional facility.
• For example, a 2010 meta-analysis found that drug
overdose was the cause of 59% of deaths within 3
months of release from prison and 76% of deaths within
2 weeks of release.
• Research findings demonstrate that the relative risk of
death post-release is 3 to 8 times higher during first 2
weeks compared with the subsequent 10 weeks postrelease.
Current CHHSR Statewide Study
2016
• Factors Influencing Opioid Overdose
Preventions and Response Practices in
Ohio Community Corrections and
Substance Abuse Programs
• Includes HHs, CBCFs, OP substance
abuse, residential substance abuse
Methodology
• Telephone interview with program
director
• Use of semi-structured interview
guide
• Anonymous, paper-and-pencil
survey of staff
– Random selection of half
Areas of Interest
• Document the prevalence of naloxone
distribution (ND) programs
• Document prevalence of structured
overdose prevention education programs
• Identify barriers to naloxone distribution
programs and OD prevention programs
• Examine staff attitudes toward ND
programs and OD prevention programs
Development of OOPP
• Structured, replicable approach to
education
• OOPPs have been shown to:
– Increase knowledge of overdose prevention and
overdose risk factors
– Increase application of such knowledge during
overdose events
– Increase the ability to respond appropriately in
overdose situation
Agency-Wide Initiatives
• Opioid Oversight Committee
• Mandatory Opioid 101 training for
all staff
• Community outreach
• Drug lab testing for fentanyl
Conclusions
• We treat and supervise a population at high
risk for opioid addiction, overdose, and
death
• We have a responsibility to deploy evidencebased practices to best of our ability
• Requires an understanding of all barriers and
opportunities
• Requires long-term planning and advocacy
Questions & Answers
[email protected]