Decreasing the Use of Prescription Opiates
and Benzodiazepines Among Individuals
Enrolled in Methadone Programs
Kim Castelnovo, RPh
Pharmacy Manager, Community Care
© 2014 Community Care Behavioral Health Organization
About Community Care
• Behavioral Health Managed Care Company
• Founded in 1996
• Statewide HealthChoices presence; 39 of 67
Pennsylvania counties
• 10 offices across the Commonwealth
• Over 600 employees
© 2014 Community Care Behavioral Health Organization
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About Community Care
• Medicaid/HealthChoices membership: 725,000
• Commercial/Medicare membership: 450,000
• Approximately 110,000 people served annually
• Statewide network of approximately
1,600 providers
© 2014 Community Care Behavioral Health Organization
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Serving 39 Counties
Erie
Warren
McKean
Potter
Tioga
Bradford
Susquehanna
Crawford
Wayne
Forest
Cameron
Venango
Sullivan
Elk
Lycoming
Mercer
Clinton
Jefferson
Clarion
Lawrence
Clearfield
Butler
Centre
Armstrong
Beaver
Allegheny
Mifflin
Indiana
Cambria
Westmoreland
Perry Dauphin
Huntingdon
Washington
Greene
Franklin
Adams
Bucks
Lancaster
Bedford
Fulton
Berks
Lebanon
Montgomery
Cumberland
Somerset
Pike
Pike
Luzerne
Columbia
Monroe
Montour
Union
Carbon
Northumberland
Snyder
Northampton
Schuylkill
Lehigh
Juniata
Blair
Fayette
Wyoming
Lackawanna
York
Chester
Philadelphia
Delaware
Community Care Office
© 2014 Community Care Behavioral Health Organization
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Overview
• Opiate and benzodiazepine use in individuals in
methadone programs
– With overdose deaths from heroin and
prescription pain medications increasing in
the U.S., opioid addiction is an important
concern for Medicaid programs
– Medicaid beneficiaries have higher rates of
opioid addiction than other insured groups
© 2014 Community Care Behavioral Health Organization
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Benzodiazepine Use and Misuse
• Among patients in a methadone program – BMC
Psychiatry, May 2011:
– Benzodiazepines (BZD) misuse and abuse is a serious
public health problem in the U.S.
– This problem is especially pertinent among those with
opiate dependence because these individuals are more
likely to experience elevated anxiety after stopping
use of opiates
– It has been shown that individuals who abuse BZD are
at increased risk of continuing opiate abuse and
failing to stay in methadone treatment
© 2014 Community Care Behavioral Health Organization
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Benzodiazepine Use and Misuse
• In a Baltimore methadone program:
– Survey conducted at a methadone treatment
program in Baltimore
– 194 questionnaires were included in the final
data analysis
• 47% reported using BZD with/without
a prescription
• 25% said that their initial use began with
a prescription
• 54% did not start using BZD until after
entering the methadone program
© 2014 Community Care Behavioral Health Organization
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Benzodiazepine Use and Misuse
• Among patients in a methadone program the
main reasons given for using BZD without
a prescription:
– Curiosity
– To relieve tension or anxiety
– To feel good
– To get high
– To overcome depression or frustration
© 2014 Community Care Behavioral Health Organization
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Benzodiazepine Use and Misuse
• When asked patients in a methadone program if
they would consider reducing or stopping the
use of BZD if the methadone program could
provide help that would work:
– 40% said “Yes, definitely”
– 7% said “Maybe”
– 19% said “No”
– 33% had already stopped using BZD
© 2014 Community Care Behavioral Health Organization
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Benzodiazepine Use
• Among Community Care Medicaid enrollees:
– Analysis includes data for 39 Community
Care counties
– Number of unique members per year filling
benzodiazepines
– Benzodiazepine use very low among children
and adolescents
– Adult benzodiazepine Use ranges from
13-24% of Medicaid enrollment among
Community Care counties
© 2014 Community Care Behavioral Health Organization
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Opiate Use
• Among Community Care Medicaid enrollees:
– Analysis includes data for 39 Community
Care counties
– Number of unique members per year filling
four or more opiate scripts
– Opiate use very low among children
and adolescents
– Adult opiate use ranges from 11-21% of
Medicaid enrollment among Community
Care counties
© 2014 Community Care Behavioral Health Organization
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A Quality Improvement Initiative
Between Counties, Methadone
Providers, and Community Care
Community Care Methadone
Provider Initiative
© 2014 Community Care Behavioral Health Organization
Objective
• To identify members enrolled in methadone
treatment programs who are concurrently filling
benzodiazepine and /or opiate prescriptions
• Collaborate with methadone providers to reduce
the incidence of concurrent utilization and
ultimately improve care
© 2014 Community Care Behavioral Health Organization
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Intervention
• Community Care generates member reports on a
monthly basis and sends to the methadone
providers in Allegheny County
• Member report includes medications filled and
prescriber information
• Methadone provider uses the information to
help address any clinical issues with the member
© 2014 Community Care Behavioral Health Organization
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Frequency of Benzodiazepine Use
Frequency of benzodiazepine use among members in methadone
programs in Allegheny County
Time period
# of members with at least 10
# of members in methadone
days of methadone + 1 Rx of
for at least 10 days (den)
Benzo (num)
Percent
(num/den)
2009-Q4
1462
524
35.8%
2010-Q2
1424
509
35.7%
2010-Q4
1463
536
36.6%
2011-Q2
1473
486
33.0%
2011-Q4
1512
503
33.3%
2012-Q2
1529
502
32.8%
2012-Q4
1523
469
30.8%
2013-Q2
1516
424
28.0%
2013-Q4
1479
384
26.0%
© 2014 Community Care Behavioral Health Organization
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Frequency of Opiate Use
Frequency of opiate use among members in methadone programs in
Allegheny County
# of members in methadone
Time period
for at least 10 days (den)
# of members with at least 10
days of methadone + 1 Rx of
opiate (num)
Percent
(num/den)
2009-Q4
1462
436
29.8%
2010-Q2
1424
377
26.5%
2010-Q4
1463
387
26.5%
2011-Q2
1473
381
25.9%
2011-Q4
1512
348
23.0%
2012-Q2
1529
377
24.7%
2012-Q4
1523
328
21.5%
2013-Q2
1516
267
17.6%
2013-Q4
1479
262
17.7%
© 2014 Community Care Behavioral Health Organization
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Assessing Impact of Interventions
Pre Intervention Metrics
May-June 2012 (N = 636)
• Members with at least
10 days of Methadone
Claims = 636
22.00%
17.80%
B only
© 2014 Community Care Behavioral Health Organization
60.20%
B+O
O only
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Assessing Impact of Interventions
Post Intervention Metrics
May-June 2013 (N = 485)
• Members with at least
10 days of Methadone
Claims = 485
40.60%
40.60%
7.40% 11.30%
© 2014 Community Care Behavioral Health Organization
B only
B+O
O only
No B + No O
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Comparison
Pre-Period
(May-June 2012)
Post-Period
(May-June 2013)
Members on Benzodiazepines Only
60.2%
40.6%
Members on Opiates Only
22.0%
7.4%
Members on Both Medications
17.8%
11.3%
Members on No Medications
© 2014 Community Care Behavioral Health Organization
40.6%
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Conclusions
• The decrease in concurrent medication over the
past four years is encouraging
• Provider feedback has been very positive about
this initiative
• Providers have adopted new policies when
caring for individuals on concurrent
benzodiazepines or opiates to ensure
appropriate use
© 2014 Community Care Behavioral Health Organization
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Collaboration of Care Implementation
Guideline
Presented by:
Sara Remaley, MSPC, CAADC, Clinical Supervisor WPIC NATP
Valerie Gualazzi, MS, CADC, Program Director WPIC NATP
Western Psychiatric Institute and Clinic
Western Psychiatric Institute and Clinic
Narcotic Addiction Treatment Program (NATP) -Addiction Medicine Services
• WPIC NATP is a clinic specializing in opioid dependency in
addition to psychiatric comorbidity.
• WPIC offers methadone maintenance treamtent, suboxone
treatment, psychiatric care and medication management,
mental health, and addiction therapy.
• WPIC currently treats approximately 420 patients on a
regular basis.
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Rationale
• NATP recognized a need to address the misuse and
abuse of prescription benzodiazepines by patients
enrolled in medication assisted treatment.
• High rates of patients were enrolling in treatment and
concurrently becoming addicted to and abusing
benzodiazepines, posing health risks, adverse
effects, and ultimately untimely discharge from
treatment.
Collaboration of Care
• 2012- WPIC NATP redesigned the program’s
philosophy and position regarding concurrent use
and abuse of prescription benzodiazepines and
opiates while taking methadone.
• Contraindications and potential for adverse effects
helped NATP move in the direction of ‘therapeutic
no tolerance’.
• The “Collaboration of Care” Procedure : indicating
NATP’s willingness to work with patients currently
on prescription benzodiazepines to taper off and
receive evidence based interventions and seek
alternative treatment options as needed.
Collaboration of Care
• The Collaboration of Care Procedure was
developed as a way to inform patients of the
new treatment philosophy indicating: use of
benzodiazepines and opiates while on
methadone is no longer permissible.
• With the understanding that tapering from these
type of medication can be a difficult and lengthy
process with potential for relapse, NATP
developed a procedural guideline to assist both
patients and staff through this new process.
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Barriers to addressing bzd use:
• Difficult tapering process, risk related to withdrawal
symptoms, and potential need for medically
supervised detoxification.
• High Relapse rates with benzodiazepines.
• Concurrent rates of psychiatric comorbidity and the
need to address/treat underlying mental health
conditions.
• Collaborating with providers (prescribing physicians)
vs. illicit street use.
• Addressing diversion…How does this fit?
27
Let the collaboration begin….
• Step 1: Staff Education
– Development of Procedural Guideline highlighting
philosophy, procedures and interventions, and processes
for team to follow.
• Step 2: Patient Education
– An FAQ was developed and handed out to all patients
indicating the new Collaboration of Care and Program
Philosophy regarding Concurrent use of benzodiazepines
while in treatment.
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FAQ
29
• Step 3: Patient Acknowledgement and
Responsibilities:
– Reviewing the new philosophy and Collaboration of Care with
patients, and asking them to acknowledge with their signatures that
they have been informed.
– A part of this process is also to explain to patients, the risks, as well as
their rights. Albeit patients may reserve the right to refuse
collaboration, they are also informed how this may directly impact their
ability to remain in treatment.
• Step 4: Interventions
– Once the Collaboration of Care is initiated, the following
procedures /interventions may be followed:
• Urine Drug Screens and CCBHO Report reviewed.
• Contact with the prescribing physician (physician to
physician) to discuss recommendations and to create a
tapering regimen.
– Pill Counts
• Illicit Street Use: Assessing need for medically supervised
detoxification. Resources: Mercy Hospital Emergency Room,
WPIC DEC (Diagnostic Evaluation Center).
• UDS Confirmatory tests to determine if “levels” are
decreasing- indicating progress/regression.
• Interventions Continued:
• Assessing underlying mental health and psychiatric disorders such
as anxiety, depression, mood disorder, bipolar disorder, etc.
Choosing a modality to effectively work with and treat these
disorders in addition to addiction.
– CBT, REBT, Gestalt Therapy, DBT, Motivational
Interviewing, Person Centered etc.
• Modifying treatment plans: Increasing therapy, regular appointments
with Psychiatrist, following a medication regimen, ongoing
collaboration.
• Maintaining focus on individualized care through individualized
recommendations. Assessing Progress: How is this done? Regular
team meetings and supervision.
Response to Interventions
• What happened after the Collaboration of Care was
initiated?
– NATP experienced responses similarly associated with the Change
Curve (Kubhler-Ross)
• Shock, Denial, Anger, Acceptance, Integration
Response to Interventions
• How long did it take before a change was noticeable?
– Integration took time and CONSISTENCY IS KEY
• Response to change implementation included:
– Compliance and Collaboration.
– Increase in individual/group therapy- engagement in regular
psychotherapy.
– Increase in psychiatric treatment and psychopharmacology.
– Exacerbation of symptoms/negative behaviors.
– Increase in referrals to Higher LOC’s.
– Decrease in bzd rates.
– Increase in compliance/privilege status.
34
Evaluating Effectiveness
• Establishing pre and post intervention baselines:
–
–
–
–
–
–
–
35
Rates of bzd use/abuse among patients.
Urine Drug Screen Results (including break-down of levels)
Individualized Progress
Relapse rates
Decrease in attaining prescriptions.
Patient Discharges
Sustained abstinence
Summary
• Addressing concurrent use/abuse of benzodiazepines
through the following steps:
–
–
–
–
–
–
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Develop Program Philosophy
Identify Perceived Barriers
Education Staff
Educate Patients
Identify intervention strategies and evidenced based practices
Identify pre and post intervention baseline data
“Meeting Needs
…..Renewing Life”
Timothy H. Reese, M.D., MRO, SAP
Medical Director
1425 Beaver Avenue
Pittsburgh, PA 15233
Phone: 412-322-8415 Ext. 109
Fax: 412-322-9224/421-322-3352
“Decreasing the use of prescription opiates and benzodiazepines among individuals
Enrolled in methadone programs”
HISTORY OF TADISO
ESTABLISHED IN 1968 AS NON-PROFIT
700 PATIENTS—24 FULL TIME COUNSELORS—1 MEDICAL DIRECTOR
1 PA.
POPULATION: 2/3 NON-HISPANIC WHITE AND 1/3 AFRO-AMERICAN AND OTHER
DEMOGRAPHICS
NON-HISPANIC WHITES 20-44 YEARS…….FASTEST
NON-HISPANIC WHITES 20-34 YEARS………FASTEST OF THE FAST
NON-HISPANIC WHITES 20-34 YEARS………SHOOTING MORE
NON-HISPANIC WHITES 20-44 YEARS……….INHALING MORE
PENNSYLVANIA
2008-2012 PERSONS ENROLLED IN SUBSTANCE ABUSE
TREATMENT PROGRAMS WHICH PRESCRIBED METHADONE
INCREASED 18.9%
MESSAGE
WE ARE IN THE MIDST OF AN EPIDEMIC OF OPIOID
ADDICTION AND ITS DEVASTATING TOLL ON SOCIETY!
METHADONE IS AND CAN BE AN EVEN GREATER PART OF
OUR ARSENAL AGAINST THIS DEADLY FOE!
PATHOPHYSIOLOGY
OF
OPIOID ADDICTION
--MEDULLA LOCUS CAERULEUS---90% OF CATECHOLAMINES IN
CNS
--RESPONSIBLE FOR THE VEGETATIVE FUNCTIONS OF THE
ORGANISM (SUPPORT LIFE)
--THERMOSTAT ANALOGY AND THE OPIOID WITHDRAWAL
SYNDROME
CLINICAL MANIFESTATIONS
OF
OPIOID WITHDRAWAL
VITAL SIGNS: TACHYCARDIA
HYPERTENSION
FEVER
CLINICAL MANIFESTATIONS
OF
OPIOID WITHDRAWAL
CENTRAL NERVOUS SYSTEM:
RESTLESSNESS
IRRITABILITY
INSOMNIA
CRAVING
YAWNING
CLINICAL MANIFESTATIONS
OF
OPIOID WITHDRAWAL
MUCOCTANEOUS:
RHINORRHEA
EYES:
LACRIMATION
PUPIL DILATION
SKIN:
PILOERECTION (GOOSEFLESH)
CLINICAL MANIFESTATIONS
OF
OPIOID WITHDRAWAL
GASTROINTESTINAL TRACT:
NAUSEA
VOMITING
DIARRHEA
CLINICAL MANIFESTATIONS
OF
OPIOID WITHDRAWAL
I.
PSYCHOSOMATIC WITHDRAWAL?
II. PSEUDO-WITHDRAWAL?
III. REAL WITHDRAWAL?
CLINICAL MANIFESTATIONS
OF
OPIOID WITHDRAWAL
*ACCIDENTAL OVERDOSE AFTER A SUCCESSFUL DETOXIFICATION*
CLINCAL MANIFESTATIONS
OF OPIOID WITHDRAWAL
MU-AGONIST EFFECT WITH BEGINNERS!
DOPAMINE
----VTA/NUCLEUS ACCUMBENS (FOREBRAIN)
DRUG ABUSE DUMPS MASSIVE AMOUNTS OF DOPAMINE INTO THIS AREA.
REINFORCES BEHAVIOUR THAT IS PARAMOUNT TO SURVIVAL OF THE SPECIES
UP-REGULATION
OF
DOPANINERGIC NEURONS
--AFTER REPEATED EXPOSURE (DRUG ABUSE) TO THESE MASSIVE AMOUNTS
OF DOPAMINE THE TARGET NEURONS BECOME PROGRESSIVELY LESS
RESPONSIVE!
NET RESULT MORE STIMULATION GIVE LESS RESPONSE THUS
PROPELLING THE ADDICTION PROCESS!
BENZODIAZEPINES
INTERNEURONS IN THE VTA APPLY INHIBITORY EFFECTS ON DOPAMINERGIC NEURONS
THESE INHIBITORY INTERNEURONS EXERT THEIR EFFECT ON THE DOPAMINERGIC
NEURONS BY WAY OF GABA (GAMMA AMINO BUTYRIC ACID)
BENZODIAZEPINES INHIBIT THIS INHIBITORY EFFECT. THIS INHIBITION RESULTS IN A
MASSIVE RELEASE OF DOPAMINE FROM THE DOPAMINERGIC NEURONS.
THIS IS THE SYNERGISM WHICH OCCURS WHEN BENZODIAZEPINES ARE GIVEN WITH AN
OPIOID; E.G., METHADONE.
OPIOIDS
IN A STABILIZED METHADONE PATIENT ANY ADDITIONAL OPIOID WILL CAUSE
DESTABLIZATION ;
IF THE OPIOIDS ARE TAKEN TO AN ANALGESIC LEVEL ONLY THE DESTABILIZATION
WILL MAINLY AFFECT THE MEDULLA LOCUS CAERULEUS.
IF THE OPIOIDS ARE TAKEN TO THE EUPHORIC LEVEL THE DESTABILIZATION WILL
AFFECT THE DOPAMINERGIC NEURONS AS WELL.
CLONIDINE
IN
SEARCH OF DOPAMINE
SINCE THE OPIOID WITHDRAWAL SYNDROME IS DUE IN PART TO HYPERACTIVITY
OF THE MEDULLA LOCUS CAERULEUS AND EXCESSIVE CATECHOLAMINES, A DRUG
WHICH BLOCKS THIS EFFECT SHOULD TREAT THIS PART OF THE OPIOID
WITHDRAWAL SYNDROME.
CLONIDINE( CATAPRESS) IS A CENTRALLY ACTING ALPHA-2 BLOCKER AND DOES
THIS WELL.
WHAT ABOUT THE DOPAMINE DEFICIENCY? A BENZODIAZEPINE WAS NEEDED
TO BE ADDED TO THE ABOVE REGIMEN TO MAKE THE TREATMENT PALABLE TO
THE PATIENT. THIS BENZODIAZEPINE VIA INHIBITING GABA IN INTERNEURONS
OF THE VTA SUPPLIED THE DOPAMINE.
REPRESENTATIVE VIGNETTES
A.
DR. COMPLETELY COOPERATIVE—MOST COMMON SCENARIO
B.
DR. COOPERATIVE BUT DILATORY---NEEDS SOME PRODING
C.
DR. COOPERATIVE BUT SELECTIVE---”NOT TO YOUR PATIENT”
D.
DR. COOPERTIVE BUT NOT REALLY---REDUCE BUT WON’T STOP!
CCBHO INITIATIVE
THE EXPRESSED PURPOSE OF THIS INITIATIVE WAS TO DECREASE THE USE OF
BENZODIAZEPINES AND OPIOIDS IN METHADONE CENTERS….AND IT
WORKED!
CCBHO GIVES THE METHADONE CLINICS A LISTING OF PATIENTS WHO ARE
GETTING BENZODIAZEPINE AND/OR OPIOID SCRIPTS. THESE PRESCRIPTIONS
WOULD NOT BE REGISTERED AT THE CLINIC NOR WOULD EVIDENCE OF THE
DRUGS SHOW IN THE ROUTINE URINES.
CCBHO INITIATIVE
THIS SCENARIO WAS VIRTUALLY UNCHANGED.
DOCTOR TO DOCTOR COMMUNICATION SPOILED THE ENTERPRISE.
IN CONCLUSION, THE INTERVENTIONS I HAVE
DESCRIBED WITH THE ASSISTANCE OF CCHBO
DID AND CONTINUES TO MAKE A DIFFERENCE
FOR THE BETTERMENT OF THE LIVES OF THE
PATIENTS AT TADISO.