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1 Medically Assisted Treatment in Drug Courts and Its Impact on Testing DATIA May 24, 2018, New Orleans, Louisiana Judge Mary A. Celeste (ret.) The following presentation may not be copied in whole or in part without the written permission of the author Celeste Overview The Opioid Epidemic What is MAT How Does MAT Work MAT & Drug Courts MAT & Testing What is New With MAT Does MMJ Have a Role The Opioid Epidemic U.S. Pharmaceuticals Composing Only 5% of the World Population, Americans Take 50% of All Pharmaceutical Drugs U.S. is responsible for approximately 95% of all the Oxycodone used in the world today. Opioid Prescriptions Opioid prescriptions have grown by 140% U.S. since the mid-1990s Statistics show that 4 of 5 heroin addicts were first addicted to prescription drugs Pain killers Some 1.9 million Americans are now addicted to or dependent on painkillers. From 1999 to 2014, about 165,000 people died of overdoses. Opioid Overdoses in the U.S. 16,000 people die every year from prescription opioid overdose 2.1 million people in the United States are dependent upon or abusing opioid pain relievers

2 2016 Year of the Opioids CDC warns doctors about the dangers of prescribing opioid painkillers FDA is reassessing its policies on opioid medications Senate has passed legislation that would expand drug abuse treatment and prevention Feds Give States $53M to Fight Opioid Epidemic Obama s 2017 Budget $1 billion in new mandatory funding over two years to expand access to treatment for prescription drug abuse and heroin use DEA is pushing physicians for more responsible prescribing. The Departments of Veterans Affairs and Defense already have opioid policies for their patients. Comprehensive Addiction and Recovery Act (CARA), 2016 Significantly strengthened drug courts and veterans treatment courts by expanding access to the overdose reversal drug naloxone Provided new funding to expand access to evidence-based treatment, including MAT Improved opioid safety measures at the Department of Veterans Affairs medical centers What is MAT Medication-Assisted Treatment (MAT) A form of pharmacotherapy and refers to any treatment for a substance use disorder that includes a pharmacologic intervention as part of a comprehensive substance abuse treatment plan with an ultimate goal of participant recovery with full social function. MAT Drugs Medications for Alcohol Dependence Naltrexone: (ReVia, Vivitrol, Depade ) Disulfiram: (Antabuse ) Acamprosate: (Campral ) Medications for Opioid Dependence Methadone Buprenorphine: (Suboxone and Subutex ) Naltrexone: (ReVia, Vivitrol, Depade ) MAT Misperceptions Methadone and buprenorphine is merely substituting one addiction for another because the medications are opioid based.

3 Methadone does not create a pleasurable or euphoric feeling; it relieves physiological craving and normalizes functioning. MAT is the recommended treatment for opioid use disorders (AAAP, AMA, NIDA,SAMHSA, NIAAA,CDCP) MAT Misperceptions Lower doses of methadone and buprenorphine are preferable to higher doses. An effective dose, not a low dose. Patients on higher doses stay in treatment longer and use less heroin and other drugs. Pre-conceived beliefs, without scientific basis, that lower doses are preferable, detract from the potential value of MAT. (Center for Court Innovation/Legal Action Center) How Does MAT Work Methadone Methadone is a full agonist. By fully occupying the mu-opioid receptor, methadone lessens the painful symptoms of opiate withdrawal and blocks the euphoric effects of other opioid drugs. Unlike heroin and other misused opioid agonists, methadone is longer lasting, usually 24 to 36 hours, preventing the frequent peaks and valleys associated with drug-seeking behavior. Methadone No optimal length of treatment with methadone has been established; however, 12 months is considered a minimum for methadone maintenance. Methadone Limitations Increased risk when combined with other drugs (Benzodiazapines) Can only be dispensed/administered through an OTP Private can be expensive Heavily regulated, lots of rules, can be time consuming Buprenorphine Buprenorphine is a partial agonist, meaning it does not completely bind to the mu-opioid receptor. As a result, buprenorphine has a ceiling effect, meaning that its effects will plateau and will not increase even with repeated dosing.

4 Buprenorphine does not produce euphoria and does not have some of the dangerous side effects associated with other opioids. Buprenorphine The optimal duration of treatment is unknown, and decisions to discontinue treatment with buprenorphine are patient-specific. Once this decision is made, the process of safely tapering the buprenorphine dose often spans many months. Buprenorphrine Benefits Increased anonymity and less intrusive, vs. attending a MAT clinic daily. Increased treatment options/access to treatment. Decrease in high-risk behaviors. Good step down option for those tapering from Methadone. Naltrexone Naltrexone is an opioid antagonist, meaning that it covers, rather than activates, the mu-opioid receptor, effectively blocking the effects of opioids if they are used. Opioid antagonists do not produce any euphoric effects, so no physical dependence is associated with their use. Naltrexone Opioid antagonists are recommended for relapse prevention and for abstinence-based treatment, not for withdrawal management. Will Naltrexone Test Positive on an Opiate Drug Test? YES Because it is actually a special narcotic drug that blocks the effects of other narcotic medicines and alcohol Naltrexone Treatment can cost $1,000 per month As of states cover the costs Numerous side effects Naltrexone Efficacy

5 Research is split Pierce County Washington having good results 2016 New England Journal of Medicine Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders. Once the injections stopped, many that had not relapsed while on Vivitrol previously, did so then. Research on long-term effectiveness is still to come Center for Court Innovation Methods of Dispensing Methadone patients typically take their dose under observation by the provider (in liquid doses at the clinic) so cannot misuse their medication as easily. Buprenorphine patients typically take home a month s worth Naltrexone is generally injected by a physician, and therefore, viewed as the least divertible medication. SAMHSA Who May Prescribe or Dispense Extended Release Injectable Naltrexone: Any individual who is licensed to prescribe medicines (e.g., physician, physician assistant, nurse practitioner) may prescribe and/or order administration by qualified staff. Methadone: SAMHSA-certified Opioid Treatment Programs dispense methadone for daily administration either on site or, for stable patients, at home. Certification of OTPs OTP Accreditation Accreditation is a peer-review process that evaluates an OTP against SAMHSA s opioid treatment standards and the accreditation standards of SAMHSA-approved accrediting bodies. The accreditation process includes site visits by specialists with experience in opioid treatment medications and related treatment activities. SAMHSA Who May Prescribe or Dispense Buprenorphine: Physicians must have board certification in addiction medicine or addiction psychiatry and/or complete special training to qualify for the federal waiver to prescribe buprenorphine, but any pharmacy can fill the prescription. There are no special requirements for staff members who dispense buprenorphine under the supervision of a waivered physician.

6 Length of Time in Treatment How Long is MAT Needed? Minimum of 12 months (NIDA 2009) Longer is recommended (Magura & Rosenblum 2001) Disincentives and structural barriers for long-term MAT can result in increased death rates following discharge. State Opioid Treatment Program Kentucky Division of Behavioral Health No perfect medication that is one size fits all. All 3 medications work significantly better when utilized in combination with counseling, drug screens, etc. MAT may be appropriate for pregnant women but must be closely monitored and have informed consent. Individuals receiving MAT are in recovery! NADCP Position on Course of Treatment The best course of treatment for an opioid dependent person is to use medications, including buprenorphine, to detox the individual Once fully detoxed, place them on long-acting, injectable naltrexone. Once stable, immerse them in a year or more of intensive psychosocial counseling, trauma and other mental health therapy, 12- step work, and close monitoring MAT & Drug Courts U.S. DOJ s Bureau of Justice Assistance and SAMSHA Recently began requiring that all drug courts receiving federal money permit MAT The 2015 Best Practices Standards Report issued by the NADCP also recommends that courts grant access to addiction medications when recommended by a physician Prohibition of MAT can violate federal anti-discrimination law protecting individuals with disabilities MAT & Drug Courts Traditionally, the criminal justice system has been opposed to methadone and, more recently, buprenorphine; the same is true for many drug courts.

7 In general, courts prefer the non-agonist medication Vivitrol over methadone and buprenorphine, both opioids Drug Courts Using MAT programs in 17 states using various forms of MAT, with varying protocols in place. Drug courts in Massachusetts began to accept participants using MAT in the 1990 s Most other reporting drug courts having begun using MAT starting in the early 2000 s, With a few beginning during the past few years Opioid Use Disorder in Drug Courts Demographics What demographic has the highest percentage of opioid use disorder in drug courts? Urban Suburban Rural Opioid Abuse in Drug Courts Demographics In a 2014 survey of all state and territorial drug court coordinators in the U.S. Opioids were ranked as the primary substance of abuse 20% of adult urban drug courts 30% of rural and suburban drug courts Drug Courts Prescription Opioids v. Heroin The National Trend More drug court participants reported nonmedical use of prescription opioids (66%) than reported use of heroin (26%) This trend was more pronounced in rural and suburban areas than in urban areas Methadone Maintenance Methadone is the dispensing of methadone in the treatment of an individual for dependence on heroin or other morphine like drugs Methadone Maintenance 67.5 % of drug courts indicated that detoxification was available.

8 Only 20.9 percent offered methadone-to-abstinence treatment Only 18. % stated that methadone maintenance was available. Many drug court programs will not admit individuals who are already using methadone. BUREAU OF JUSTICE ASSISTANCE (BJA) DRUG COURT TECHNICAL ASSISTANCE/CLEARINGHOUSE PROJECT Drug Testing Is there any testing conducted to be sure the individual is taking the medication? What action is taken if a person tests positive for drugs while taking the medication? Is that action different from what would be taken if the person tested positive for drugs and was not taking medication? MAT & Testing NIDA Effective drug abuse intervention programs are: Individualized and dynamic Attending and adjusting to the multiple needs of people with co-occurring conditions Involving both behavioral and pharmacological approaches. Drug Testing The more frequently Drug Courts and probation programs perform urine drug testing, the better their outcomes in terms of higher graduation rates and lower drug use and criminal recidivism. Adult Drug Court Best Practices Standard Vol. II Testing to Confirm Participant s Use of MAT Testing to Ensure Participant is taking the medication Testing practices appear to vary among drug courts with none consistently testing to ensure the participant is taking the medication Testing to Confirm Participant s Use of MAT The use of Vivitrol, with its monthly injections administered by a physician, obviates the need for routine testing to be sure a participant is following the prescribed MAT, so that testing can focus on the presence of prohibited substances

9 Center for Court Innovation Recommended Strategies Monitoring for illicit use of MAT is a key component of the program and can be accomplished in deferent ways. Courts use a range of methods: Urine tests Pill/strip counting Behavioral observations to detect misuse or abuse of medication. Center for Court Innovation Recommended Strategies These methods generally are not that different from those used to monitor illicit drug use by other non-mat participants. Some courts do more of the monitoring themselves, while others may rely primarily on treatment programs with which they communicate with regularly How Do Courts Monitor Compliance For Illicit Use of MAT Medication? Some courts expect the treatment programs to take the lead on monitoring participants compliance How Do Courts Monitor Compliance For Illicit Use of MAT Medication? The court expects treatment programs to conduct observed urine testing at least two times per week. The court generally only tests participants (1) upon admission (2) when they move between phases, (3) if tests are missing from the program (4) upon completion Recommended Testing Strategies MAT in Drug Courts Who tests and how? Urine Testing The court conducts its own random testing of all participants at least weekly.

10 Participants are required to call the court every weekday to find out if they need to report for random testing. Recommended Testing Strategies MAT in Drug Courts The court does not rely on the programs to test because some of them seem to test on predictable days i.e. Every Monday, unobserved tests or do no test frequently enough. Recommended Testing Strategies MAT in Drug Courts Frequency? The drug court team emphasizes the importance of testing at least weekly, sometimes more, and making sure the schedule is unpredictable i.e. the court sometimes tests someone two days in a row or even twice in one day Recommended Testing Strategies MAT in Drug Courts Extra testing for medication? All participants are tested for buprenorphine and methadone whether or not they receive MAT List of Possible Cross Reactions Methadone (MTD) Verapamil Metabolites Dolophine Methadose Physetone (Methadone Hydrochloride) Oxycodone If oxycodone is a major substance of abuse in your jurisdiction, you should consider a separate drug test for oxycodone as part of your initial screening analysis. Best Practice Confirmation Testing GC/MS or LC/MS/MS Drug molecules separated by physical characteristics Identified based on chemical finger-print Considered gold standard Refer to NADCP Adult Drug Court Best Practice Standards - Volume II

11 Funding for MAT Medicaid Private Insurance Self-pay Pharmaceutical company coupons Opioid Treatment Program sliding scale Generic version of buprenorphine Samhsa Grants State Grant Programs MAT-PDOA- The MAT-PDOA grant program helps states expand or enhance their treatment systems to improve access to evidence-based MAT services State Targeted Response to the Opioid Crisis Grants (Opioid-STR) - The Opioid-STR grant program helps states, territories and jurisdictions expand prevention, treatment and recovery support services for individuals with an opioid use disorder (OUD). What is New With MAT Drug Addiction Treatment Act of 2000 (DATA 2000) Expands the clinical context of medication-assisted opioid dependency treatment. Qualified physicians are permitted to dispense or prescribe specifically approved Schedule III, IV, and V narcotic medications (medications that have a lower risk for abuse, like buprenorphine) in settings other than an opioid treatment program (OTP) such as a methadone clinic. The regulation shifted administrative responsibility and oversight of these treatments from FDA to SAMHSA. F.D.A. to Expand MAT for Opioid Addicts Feb., 2018 To encourage new treatments for opioid addiction, the FDA plans to begin permitting pharmaceutical companies to sell medications that help temper cravings, even if they don t fully stop addiction. THE OPIOIDS CRISIS 2017 Trump Administration Response In September, 2017 SAMHSA awarded $144 million in grants to support opioid and other substance abuse efforts:

12 $35 million for the Medication Assisted Treatment (MAT) Prescription Drug and Opioid Addiction Targeted Capacity Expansion grants Trump Officials Approve Medicaid Waivers for Opioid Treatment 11/01/17 The Trump administration approved Medicaid waivers in Utah and New Jersey to help improve access to treatment for opioid addiction The waivers were the first to be approved under a new policy from the Centers for Medicare and Medicaid Services (CMS) that will allow states to design demonstration projects to let Medicaid to pay for opioid use disorder treatments. CMS called for more states to apply in a Nov., 2017 letter to Medicaid directors. Opioid Funding for Treatment Courts March, % increase over last year Department of Justice & Bureau of Justice Assistance (BJA) $75 mil Drug Court Grants $20 mil Vet Treatment Courts $70 mil SAMHSA 50% increase over last year SAMHSA Releases New MAT App for Healthcare and Treatment Providers Substance Abuse and Mental Health Services Administration (SAMHSA) has released a brandnew mobile app, MATx, to support medication-assisted treatment (MAT) of opioid use disorders (OUDs). Research has demonstrated that MAT is associated with significantly reduced use of unauthorized opioids among probationers, parolees, and other persons with OUDs in the criminal justice system. MRO & Testing Some employers are now opting to remove MJ from their testing program or are treating it as a substance with legitimate medical explanation meaning a laboratory positive could be overturned by a medical review officer if a doctor patient relationship can be verified.

13 Truckers Synthetic Opioids Beginning Jan. 1, 2018 truck drivers being administered random pre-employment and postaccident drug tests will be screened for four additional synthetic opioids The new requirement likely will slow down the process for MROs to screen an increasing number of positive test results SAMHSA Updated MRO Guidance Manual April, 2018 MMJ as Opioid Harm Reduction and Pain Management Scientific data growing in support of the notion that MMJ can mitigate opioid use and abuse. States Adding MMJ for Opioid Use Disorder March, 2018 Arizona Legislature Ready to Approve Using Medical Marijuana to Treat Opioid Use Disorder On Nov. 4, 2016, the Medical Cannabis Advisory Board to the New Mexico Medical Cannabis Program MMJ as MAT Harm Reduction Several studies indicate that MMJ can complement or substitute opioid medicine. Thereby decreasing the potential for opioid overdose and cross prescription complications NIDA June, 2016 Finding new methods of opioid addiction treatment to supplement effective medications such as methadone, buprenorphine, and naltrexone Developing safe, effective, non-addictive treatments to provide better pain management in place of opioids MJ for Pain National Center for Biotechnology Information Clinical trials seem to indicate that either extracts of the Cannabis sativa plant containing known amounts of the active compounds (mainly THC and CBD) or diverse synthetic derivatives of THC are promising treatments for painful conditions MMJ v. Opioids for Pain

14 Michigan University Study, 2016 Patients using MMJ to control chronic pain reported a 64 % reduction in their use of opioids MMJ reduces use of opioid pain meds, decreases risk for some with chronic pain Do States with MMJ Laws have a Reduction in Opioid Abuse & Deaths? Marijuana legalization is linked to lower rates of opioid-related harm. Increased access to legal marijuana has been associated with reductions in some of the most troubling harms associated with opioids, including opioid overdose deaths and untreated opioid use disorders. 3 Studies JAMA RAND Health Affairs But in Arizona, the opioid death rate was falling before MMJ was legalized. Subsequently, between 2012 and 2016, the opioid death rate increased by nearly 75 %. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence : Jan., 2017 Substantial Evidence: chronic pain in adults; chemotherapy-induced nausea and vomiting; MS spasticity symptom Moderate Evidence: sleep disturbance associated with obstructive sleep apnea syndrome; fibromyalgia, chronic pain, and MS Limited Evidence: MS: Tourette syndrome; PTSD; dementia; glaucoma; social anxiety disorders The Concerns with MMJ Use Lack of Scientific Basis & Research Cannabis/MJ Use Disorder Impact on the Brain with Chronic Use Dr. Marilyn Huestis Former Chief of the Chemistry and Drug Metabolism Section at NIDA We know there are therapeutic benefits, but we haven t been able to separate the psychoactive effects from the therapeutic benefits NADCP Position on MMJ

15 Unequivocally stands against the legalization of marijuana and the use of smoked marijuana as medicine.