Medically Assisted Treatment For
Opiate Addiction
3rd Annual Alcohol and Substance Abuse
Treatment Conference
May 13, 2014
Bruce G. Trigg, MD
Duke City Recovery Toolbox
Albuquerque, NM
Faculty Disclosure
I am employed as a contractor by a
faith-based, for-profit opioid
treatment program in Albuquerque,
where I prescribe methadone and
buprenorphine.
I do not receive any funding from
pharmaceutical companies
Goals of this talk:
• What is MAT?
• What is the scientific evidence supporting
MAT?
• What are the barriers keeping millions of
people who are addicted to opiates from
benefiting from these therapies?
• What is harm reduction and how does this
fit in with treatment of addiction?
What is Medication Assisted
Therapy?
MAT combines
pharmacological intervention
with counseling and behavioral
therapies to treat addiction.
Currently three treatments
approved in US
• Methadone
• Buprenorphine (Suboxone)
• Naltrexone
Overdose Deaths in New Mexico
• Second highest rate in US
• In 2012 – 486 deaths
– 7% decrease from 2011
• More than half of 2012 deaths were from
prescription medications
New Mexico Profile 2010
Other Public Health Impacts of
Opiate Addiction in NM
• Estimated 23,000 IV drug users – mostly
heroin
• 10 to 20% of people living with HIV
acquired their infections from injecting
drugs
• High rates of hepatitis C – more than 32,000
on NM Department of Health registry –
at least 60% acquired from injecting
drugs
Social consequences of drug use
in NM
• High rates of incarceration and criminal
justice sanctions impacting mostly young
people of color
Public Health Approaches to the Opioid
Overdose Epidemic
1- Providing prescribers with the knowledge to
improve their prescribing decisions and the
ability to identify patients’ problems related
to opioid abuse
2- To reduce inappropriate access to opioids
3- To provide substance abuse treatment to
persons addicted to opioids
4- To increase access to effective overdose
treatment
Less Opioid Prescriptions
• NM Depart of Health announced last week
a 13% decrease in prescribed opioids from
2010 to 2013
• Impact of media, provider education
programs, NM Prescription Monitoring
Program, increased vigilance by
professional licensing boards and DEA
“The key driver of the overdose
epidemic is underlying substance
abuse disorder.”
Medication-Assisted Therapies — Tackling the OpioidOverdose Epidemic
4/24/14
NEJM
Dopamin
e
Picture of opiate addiction:
heroin
Picture of opiate addiction: pain pills
What is addiction?
• A term referring to compulsive drug use,
psychological dependence, and continuing
use despite harm.
• Addiction is frequently and incorrectly
equated with physical dependence and
withdrawal. Physical dependence, not
addiction, is an expected result of opioid
use.
NIH Consensus
Statement 1997
• “Whatever conditions may lead to
opiate exposure, opiate dependence
is a brain-related disorder with the
requisite characteristics of a
medical illness.”
Effective Medical Treatment of Opiate Addiction.
NIH Consensus Statement 1997 Nov. 17-19;15(6):4
NNI
Addiction to heroin is a chronic,
relapsing disease with high
morbidity and mortality
• 33 year follow up of 581 male heroin addicts in
Los Angeles found:
–
–
–
–
Nearly half had died
20.7% of those living tested positive for heroin
40% reported using heroin in past year
High rates of disability, hepatitis, mental health
disorders, and criminal activity
– Fewer than 10% were in methadone maintenance Rx.
“Methadone Maintenance and Other Pharmacotherapeutic Interventions in the Treatment
of Opioid Addiction.” April 2002, Vol.III, No. 1
History of Methadone
• Synthesized in Germany during WWII
• In 1960s at Rockefeller University in New
York City, Drs. Vincent Dole and Marie
Nyswander, performed studies showing
effectiveness for treatment of heroin
addiction
• First clinics opened in NYC in mid-1960s
Medication Assisted Therapy
• The substitution of an opiate-like
medication to prevent withdrawal and
minimize craving for opiates.
• A medical model for the treatment of opiate
dependence. Treats opioid dependence as a
chronic, relapsing disease.
• Effective medications – Methadone or
Buprenorphine
Medication Assisted Therapy
(MAT)
The primary goal of MAT is to
reduce illegal heroin and other
opiate use and the crime, diseases,
and deaths associated with opiate
addiction and allow patients to live
healthy and fulfilling lives.
Why is overdose potential low with
buprenorphine?
Respiratory suppression, death
Opioid
Effects
Agonist: Methadone,
Heroin, etc.
Partial Agonist: Buprenorphine
Antagonist: Naltrexone
Log dose
Functions of Drugs at mu Receptor
Full agonists such as methadone:
• Occupy the receptor and activate that
receptor
• Increasing doses of the drug produce
increasing receptor-specific effects until a
maximum or toxic effect is achieved
• Most abused opioids are full agonists
Pharmacologic Properties of
Heroin and Methadone
Onset of action
Heroin
Immediate
Methadone
30 minutes
Duration
4 to 6 hours
24 to 36 hours
Route of
administration
Injection,
Snorting, or
Smoking
Oral
What is the abuse potential?
• “Methadone’s half-life is approximately 24
hours and leads to a long duration of action
and once-a-day dosing. This feature,
coupled with its slow onset of action, blunts
its euphoric effect, making it unattractive as
a principle drug of abuse.”
Effective Medical Treatment of Opiate Addiction.
NIH Consensus Statement 1997 Nov. 17-19;15(6):14
Treatment Outcome Data:
Methadone Maintenance
•
•
•
•
•
•
4-5 fold reduction in death rate
reduction of drug use
reduction of criminal activity
engagement in socially productive roles
reduced spread of HIV
excellent retention
• (see: Joseph et al, 2000, Mt. Sinai J.Med., vol 67, # 5, 6)
© Martin, J. 2012
Methadone IS effective
• After 1 year, 60% reduction in drug use
• After 2 years, 85%
• 70% reduction in crime within 4 months
• Ball and Ross 1991
• Decreased transmission of blood-borne diseases
• Less HIV infection: 5% seroconversion in treated
versus 26% non-treatment group
– Metzger 1993
Crime Among 491 Patients Before and
During MMT at 6 Programs
Crime Days Per Year
300
250
200
Before TX
During TX
150
100
50
0
A
B
C
D
E
F
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
Opioid Agonist Treatment of Addiction - Payte - 1998
Note: This shows criminal activity at six different methadone maintenance programs, comparing rates before
treatment (pink) to during treatment (yellow).
© Martin, J. 2012
HIV Conversion In Treatment
35%
30%
25%
20%
IT
OT
15%
10%
5%
0%
Base line
6 Month
12 Month
18 Month
HIV infection rates by baseline treatment status. In treatment (IT) n=138, not
in treatment (OT) n=88
Source: Metzger, D. et. al. J of AIDS 6:1993. p.1052
Opioid Maintenance Pharmacotherapy - A Course for Clinicians - 1997
Note: This slide shows protection from HIV sero-conversion by enrollment in MMT: the longer the treatment
the more relative protection from HIV.
© Martin, J. 2012
How should methadone be
prescribed?
Best outcomes achieved when patients:
• are maintained for long periods of time (at
least one year) Relapse rate c. 80% in 1
year.
• receive high doses (usually 80 to 120 mg
daily)
– low dose prevents withdrawal symptoms.
– higher doses minimize craving for opiates.
Exhibit 5-3. Heroin Use in Preceding 30 Days (407 Methadone-Maintained
Patients by Current Methadone Dose)
Adapted from Ball and Ross, The Effectiveness of Methadone Maintenance
Treatment: Patients, Programs, Services, and Outcome, Appendix B, p. 248, with
permission
Methadone Regulation
• Can only be dispensed by licensed Opioid
Treatment Programs (OTPs)
• Must follow federal and state regs
• Requires daily dispensing ( six days a week)
for first 90 days
• By one year can receive up to 2 weeks of
take-home doses
• Eventually may receive 14 to 30 day supply
NIH Consensus
Statement 1997
• “Although a drug-free state represents an
optimal treatment goal, research has
demonstrated that this goal cannot be
achieved or sustained by the majority of
opiate-dependent people.”
Effective Medical Treatment of Opiate Addiction.
NIH Consensus Statement 1997 Nov. 17-19;15(6):5
Should MMT Ever be Discontinued?
• Opioid addiction is a chronic, relapsing
condition, so long-term treatment is
indicated.
• Prognosis after withdrawal from MMT is
dismal: most patients relapse before 12
mos. (compare this to diabetes,
hypertension, epilepsy, etc. – other
chronic conditions that require ongoing
medication)
© Martin, J. 2012
Relapse to IV Drug Use After MMT
Should
MMT
Everwho
be Left
Discontinued?
105 Male
Patients
Treatment
Exhibit 5-3. Heroin Use in Preceding 30 Days (407 Methadone-Maintained
Patients by Current Methadone Dose)
Adapted from Ball and Ross, The Effectiveness of Methadone Maintenance
Treatment: Patients, Programs, Services, and Outcome, Appendix B, p. 248, with
permission
100
Percent IV Users
• Opioid
addiction
is
a
chronic,
relapsing
82.1
80
72.2
condition, so long-term treatment
is
60
57.6
indicated.
45.5
40
• Prognosis28.9
after withdrawal from MMT is
20
dismal: most patients relapse before 12
0
mos.
(compare
this
to
diabetes,
IN
1 to 3
4 to 6
7 to 9
10 to 12
hypertension,
epilepsy,
etc. – other
Treatment
Months Since Stopping
chronic conditions Treatment
that require ongoing
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
medication)
Opioid Agonist Treatment of Addiction - Payte - 1998
Note: When patients taper off of methadone maintenance, relapse is almost universal. There is no way to predict
who are the 18% of patients who will not relapse within a year. During medically supervised withdrawal, close
© Martin, J. 2012
observation and keeping open the possibility of resuming therapeutic doses promptly is indicated.
Myth #1
Methadone substitutes one addiction
for another; a patient on methadone is
still a drug “addict”
Methadone Reality
• A patient on methadone treatment is not a
“drug addict” because addiction is compulsive
use of drug despite knowing it is causing harm.
A methadone patient is being prescribed a
medication in a controlled environment for
treatment of addiction.
• Methadone substitutes a legal, long-acting,
safe, prescribed opiate-like medicine for an
illegal, dangerous, short-acting opioid.
Myth #2
Methadone is more “addictive” and
“harder to kick” then heroin
Kosten & O’Connor, NEJM 2003
Myth #3
Higher doses of methadone are harder
to “kick” therefore patients should be
only low does of methadone
Methadone Reality
• Patients need to be on methadone for a
minimum of one to two years, and many
will need to be on MMT longer.
• Therefore they should aim for a dose that
enables them to be free of withdrawal
symptoms, cravings for opiates, and that
will block use of illegal opiates. For most
this will be 80 to 120 mg.
Myth #4
Patients should get off methadone as
quickly as possible
Methadone Reality
• Most patients need a minimum of one year of
methadone to stabilize their life and their
health.
• Treatments for other chronic diseases; high
blood pressure, diabetes, high cholesterol are
long-term.
• Relapse carries with it the risk of overdose
death, infection with HIV and hepatitis,
incarceration, and violent death from a life of
crime
Myth #5
Methadone is a form of social control
used by the government
Methadone Reality
• Methadone is the standard of care in at least 75 countries
and is endorsed by US public health and medical
organizations and international public health organizations
such as WHO and UN
• The patient should decide when to start and when to
discontinue treatment. Patients should be involved in all
decisions about lowering and raising doses unless their
safety is at stake
• The patient can decide to taper off methadone (detox) any
time they wish.
• A safe taper should be slow (10% dose reduction every 5
to 10 days) and under the control of the patient; the patient
is allowed to stop a taper or to resume a higher dose if
they wish.
Myth #6
Patients on methadone relapse
because they are weak, immoral, or
unreliable
A Chronic, Relapsing Disease…
• Similar to other chronic, relapsing diseases, such as
diabetes, asthma, or heart disease, drug addiction can
be managed successfully.
• As with other chronic diseases, it is not uncommon for
a person to relapse and begin abusing drugs again.
• Relapse ≠ failure. It means that treatment should be
adjusted, alternative treatment considered, and
psychosocial support increased to help the individual
regain control and recover.
NIDA InfoFacts: Understanding Drug Abuse and Addiction, June 2008
Percent of Patients Who Relapse
Relapse Rates Are Similar for Drug Dependence
And Other Chronic Illnesses
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Addiction Treatment Does Work
Drug
Dependence
Type 1
Diabetes
Hypertension
Asthma
Source: McLellan, A.T. et al., JAMA, Vol 284 (13), October 4, 2000.
Compliance rates for chronic illnesses
McClellan AT et al, JAMA 2000, 284:1689
Myth #7
Methadone causes damage to the
teeth, the bones, the liver, and ….
Methadone Reality
• Methadone does not damage the liver
(many patients have chronic hepatitis C)
• Methadone does not damage the teeth
(many patients have not taken care of their
teeth)
• Methadone does not “get into the bones”
rather some patients may be experiencing
withdrawal due to being on an inadequate
dose of methadone
Methadone in NM
• More than 2,000 patients
• Clinics in 4 cities: ABQ (5 programs, 6
clinics), Santa Fe, Espanola, Belen, Las
Cruces
• Soon to open in Farmington, Gallup,
Roswell
• Also a methadone maintenance program at
Bernalillo County Metropolitan Detention
Center (MDC) for persons on methadone at
Buprenorphine: Newer Medication
for Treating Opiate Addiction
• First synthesized as an analgesic in England, 1969.
• Recognized as potential addiction treatment by
NIDA researchers in 1970s.
• NIDA created Medications Development Division
to focus on developing drug treatments for
addiction, 1990.
• NIDA formed an agreement with the original
developer to bring buprenorphine to market in the
U.S., 1994.
Buprenorphine
 Drug Addiction Treatment Act of 2000 allows
qualified physicians to prescribe Schedule III-V
drugs for treatment of opiate dependence
(Buprenorphine is Schedule III)
 Approved by the FDA, 2002
 Requires physicians to complete 8 hours of
training/certification
 Designed for treatment in primary care practices
Buprenorphine
 Nurse practitioners and Physician Assistants
cannot prescribe buprenorphine
 Registered physicians can treat up to 30
patients at one time with buprenorphine
 After one year may apply to increase to 100
patients at one time
 Physician must be able to refer for
counseling services
Buprenorphine in use
 Suboxone: buprenorphine + naloxone (Narcan)
 Naloxone lowers abuse potential → causes
withdrawal if other opiates are present
 Naloxone not active when taken by sublingual
route
– Subutex: just buprenorphine (no naloxone) – used
most commonly with pregnant women
• Suboxone sublingual film approved by FDA in
2010 (no Subutex film)
• Zubsolv is a generic buprenorphine/naloxone
sublingual tablet that is equivalent to Suboxone
Why is overdose potential low with
buprenorphine?
Respiratory suppression, death
Opioid
Effects
Agonist: Methadone,
Heroin, etc.
Partial Agonist: Buprenorphine
Antagonist: Naltrexone
Log dose
Why isn’t buprenorphine
abused?
• Most drugs of abuse are full agonists
• Drugs of abuse are injected, smoked,
“snorted”, not taken orally/sublingually
• Except for in pregnancy, most patients receive
a combined buprenorphine and naloxone form
of the medication (Suboxone and Zubsolv)
• When taken under the tongue, the naloxone is
not absorbed and so is not active
• When injected, the naloxone is active and
causes withdrawal
Suboxone 8/2 mg
and 2/.5 mg
sublingual tablets
Buprenorphine and heroin overdose

Increasing use of buprenorphine in France
associated with 1,2
– Decrease in arrests for heroin (77% decline since
1995)
– Decrease in overdose deaths (81% decline since
1995)
1. Auriacombe 2004, Am J Addict;13.
2. Lepere 2001, Ann Med Interne (Paris);152 Suppl 3.
Buprenorphine vs Methadone
Like Methadone…
• Reduces IVDU
• Retains patients
in treatment
• Decreases craving
• Stops withdrawal
• Costs $ 5-13 per
day
Unlike
Methadone….
• Low potential for
OD
• Prescribed in MD
office
• Less sedation
• Easy taper/detox
Why People Switch from
Methadone to Buprenorphine?
•
•
•
•
•
•
•
•
Cost, insurance coverage
Safety –risk of fatal overdose for kids!
Stigma
Ability to receive take-home doses and other lifestyle,
transportation, and confidentiality concerns
Personal preference: “I like how I feel on buprenorphine”
Medical issues
Legal issues (Drug Courts may prohibit methadone)
Inaccurate information
Transitioning Stable Methadone Maintenance
Patients to Buprenorphine Maintenance
• J Addict Med 2010;4: 88-92
• Methods: Retrospective study, 104 patients
on low methadone doses (5 to 80mg)
offered conversion to buprenorphine - 25
accepted
• Results: all succeeded. Found low-moderate
association between pretransfer methadone
dose and posttransfer bupe dose.
Buprenorphine induction
• Buprenorphine will cause withdrawal if given to
an opiate-dependent patient
• Must wait until patient is in mild-moderate
withdrawal before starting buprenorphine
• Dose adjustment over the first week to find most
effective dose
• Usual dose is 16 mg buprenorphine and
recommended range is 12 to 16 mg. Higher doses
generally discouraged.
RCT of buprenorphine
• 40 Heroin addicts
• Buprenorphine
8mg/day vs
taper + placebo
• All received
counseling, groups
• Followed for 1 year
Buprenor
-phine
Retained
at 1 yr
Placebo
70%
0
0
20%
% died
Kakko et al, Lancet 2003
Percent of Patient Sample
Buprenorphine Patient Outcomes:
Specific Criminal Activities
“In the past 30 days were you involved in any of the following
activities…?”
20%
Baseline
16%
30 Day
6 Month
15%
10%
10%
10%
5%
3%
1%
1%
1%
2%
1%
0%
Drug Dealing
Prescription Fraud
Other Crimes
n=379
Source: SAMHSA Patient Longitudinal Study, November 2005
Methadone and Buprenorphine
• Providers should discuss the advantages and
disadvantages of methadone and
buprenorphine with all patients before
starting treatment
• Buprenorphine patients should be made
aware that methadone is an alternative Rx
if they repeatedly relapse
Why People Switch from
Methadone to Buprenorphine?
•
•
•
•
•
•
•
•
Cost
Safety – death risk for kids!
Stigma
Lifestyle/transportation/confidentiality
“I like how I feel on buprenorphine”
Medical issues
Legal issues (Drug Court prohibits methadone)
Inaccurate information
Who May Do Better on
Methdone?
• Persons with a longer addiction history
• Those maintained on very high doses of
methadone
• People who relapse repeatedly on buprenorphine
(especially if at risk of imprisonment or with
serious medical problems/mental health).
• People who need more structured Rx program
with mandatory counseling, drug tests, etc. .
Induction to Buprenophine from
Methadone
• Important to facilitate transfer to a new
provider since relapse risk is
• Patient should be on 30 mg or less of
methadone for at least one week before
switching
• Discontinue methadone for 48 to 72 hours
so patient is in mild to moderate withdrawal
(COWS 12 or higher)
Special Populations
• Methadone approved starting at 18 years
old but special waivers can be obtained
• Buprenorphine approved starting at 16 years
but off-label use in high risk situations not
unreasonable
• Pregnancy – more experience with
methadone but recent study showed safety
of buprenorphine and less NAS than with
methadone
National Institute of Health
(NIH) Consensus
Statement 1997
“All opiate-dependent persons under legal
supervision should have access to
methadone maintenance therapy…”
Effective Medical Treatment of Opiate Addiction.
NIH Consensus Statement 1997 Nov. 17-19;15(6):2
Mortality Rates among Former Inmates of the Washington State
Department of Corrections during Study Follow-up (Overall) and According
to 2-Week Periods after Release from Prison.
N Engl J Med 2007;356:157-65.
The dashed line represents the adjusted mortality rate for residents of the
State of Washington (223 deaths per 100,000 person-years), and the solid
line represents the crude mortality rate among inmates of the state prison
system during incarceration (201 deaths per 100,000 inmate person-years).
Why MAT in Jails
and Prisons?
•
•
•
•
•
•
•
•
Significantly less injecting during incarceration
Decreases HIV and hepatitis C transmission
Facilitates continuity of treatment
Reduces mortality
Facilitates post-release treatment
Reduces criminal recidivism
Positive effect on prison environment
Decreases overdoses
Evidence for Action Technical Papers
INTERVENTIONS TO ADDRESS HIV IN PRISONS
DRUG DEPENDENCE TREATMENTS
World Health Organization, UNODC, UNAIDS / Geneva, 2007
Untreated Heroin Dependency has the highest Recidivism rate for
women at NM Women’s Correctional Facility in Grants
No Substance Abuse
Alcoholic Only
Cocaine Addict*
Heroin Addict*
Other Addict*
Recidivism Rate
100%
80%
60%
40%
20%
0%
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38
Time (months)
Senate Joint Memorial 29 study from 1997-2000
Countries (+territories) that have
Methadone in prison
• Australia
• Austria (+ buprenorphine,
morphine)
• Belgium (detox only)
• Canada
• Denmark
• England
• Estonia
• France (+buprenorphine)
• Germany (+ NEX)
• Indonesia
• Ireland
• Iran
•
•
•
•
•
•
•
•
•
•
•
•
Italy (detox only)
Luxembourg
Netherlands
N. Ireland (detox only)
Poland
Portugal
Puerto Rico
Scotland
Slovenia
Spain
Switzerland (+heroin, NEX)
United States (jail only)
Sources: Dolan 2001, EMCDDA
2002, updated 2011
Respiratory suppression, death
Opioid
Effects
Agonist: Methadone,
Heroin, etc.
Partial Agonist: Buprenorphine
Antagonist: Naltrexone
Log dose
Naltrexone for Extended-Release Injectable
Suspension (Vivitrol)
• Approved by FDA for treatment of opiate
addiction in 2010
• Approved for:
– treatment of alcohol dependence in patients
who are able to abstain from alcohol in an
outpatient setting prior to initiation of treatment
– prevention of relapse to opioid dependence,
following opioid detoxification
Opiate antagonist therapy:
Naltrexone
•
•
•
•
Blocks action of opiates
Problem: adherence and cravings
Only 20% success at 6 months 1
More effective in highly structured
situations: >90% success for health care
professionals 2
• Long-acting injectable form available but
very expensive.
1
2
Rothenberg JL et al, J Subst Abuse Treatment 2002
Roth A et al, J Subst Abuse Treatment 1997
Naltrexone
• Must be abstinent for 7 days before starting
treatment
• More experience now with people leaving
abstinence-based rehab programs,
incarceration or who discontinue MAT
Successful Treatment of Opiate
Addiction
• MAT in a supportive, structured
environment
• Balance limit-setting with understanding
• Behavioral therapy: counseling and/or
group
• Address mental health issues
Successful Treatment of Opiate
Addiciton
• Case Management: Assist with
obtaining benefits, jobs, housing if
needed
• Relapse is the rule, not the exception
• Staying in treatment for an adequate
period of time is best predictor of
success; maintenance more effective
than detox
• Non-judgmental, empathic care
• Assurance of confidentiality
Paying for MAT in NM
• Methadone maintenance therapy and
buprenorphine are covered by Medicaid
• Buprenorphine generally paid for by private
insurance
• Methadone not generally paid for by private
insurance
• VA in Albuquerque has a buprenorphine
but not a methadone program
TREATMENT OF
OPIATE
DEPENDENCE
Abstinence-based
therapy
Opiate -replacement
therapy
methadone
Opiate antagonist
therapy:
naltrexone
buprenorphine
Abstinence-based therapy
Goals: development of recovery skills, ability
to deal with emerging mental and emotional
issues, sober community
• Counseling
• Peer support: 12-step, Smart Recovery,
Double Trouble
• Social services
– Housing
– Vocational rehab
– Childcare
A study of heroin overdose deaths in
Baltimore between 1995 and 2009
found an association between the
increasing availability of methadone
and buprenorphine and an
approximately 50% decrease in the
number of fatal overdoses.
Schwartz RP, Gryczynski J, O’Grady KE, et al. Opioid agonist
treatments and heroin overdose deaths in Baltimore, Maryland,
1995-2009. Am J Public Health 2013;103:917- 22.
The New Mexico Harm
Reduction Act (1997)
The NM Dept. of Health shall:
• Establish and administer a harm reduction
program for the purpose of sterile
hypodermic syringe and needle exchange.
• Compile data to assist in planning and
evaluation efforts to combat the spread of
blood-borne diseases.
This statute makes access to clean injection equipment a
right rather than a privilege in New Mexico.
What is Harm Reduction?
HARM REDUCTION is any intervention or policy
designed to reduce the negative consequences
of drug use without requiring drug use
cessation.
Another way to think about it…
HARM REDUCTION is a way of working with
drug users to improve their health even if they
are not ready or willing to quit using drugs.
4 Key Harm Reduction
Strategies
Needle/Syringe Exchange
Overdose Prevention with
provision of naloxone
Increasing access to MAT
Condom availability
Why Talk about Harm Reduction
at a presentation on MAT?
• Relapse is common in people in MAT as with
any chronic disease
• Useful to discuss the possibility of relapse and
precautions to take to decrease harm
• All MAT patients should be referred for Harm
Reduction services:
– Needle/Syringe Program including safer injecting
info
– Overdose prevention education and naloxone
– HIV, Hepatitis B and C testing and education
– Immunization for hepatitis B
Harm Reduction Program
Goals
 Reduce the incidence of blood-borne infections
 HIV, HBV, HCV
 Reduce the incidence of other diseases caused
by reusing or sharing syringes  abscesses,
endocarditis, septicemia
 Prevent deaths from accidental overdose
 Educate clients on safer use strategies
 Assist clients to access drug treatment and
other related health services
What is Naloxone?
Naloxone (brand name Narcan) is
a prescription drug that reverses
the effects of an opioid overdose
by blocking the opioid’s action on
the brain and restoring breathing.
Naloxone’s only purpose is to
reverse overdose; it is not a
“recreational” drug and does not
cause a “high.” The use of
naloxone, in combination with
rescue breathing, can save a life.
Naloxone in Action
Providing naloxone to IDUs in NM
• Participants receive training in recognizing
opiate overdose, rescue breathing and
naloxone administration
• Dispensed by licensed clinicians
• Naloxone is prescribed to a specific named
individual
• The “911 – Good Samaritan Act”
NM’s Good Samaritan 911 Law
• In 2007, NM passed the 1st Good Samaritan 911 law
in the nation.
• It allows someone to call 911 or take someone to the
hospital for a drug overdose without being charged for
possession.
• The law covers both the caller and person who OD’d.
• The law does NOT protect someone if:
– they are on probation, parole, or have arrest warrants
– there is evidence of drug dealing → scales, baggies,
drugs or money in plain sight
– there is evidence of other crimes, including weapons’
possession or DUI
Approximately 2,000 opioid
overdose reversals were reported
to the New Mexico Department
of Health Harm Reduction
Program through 2012.
Data
Suggests
Naloxone
Program
Saving
Lives,
KUNM,
4/5/13
“So without the presence of Naloxone in Rio Arriba, the death rate
could have been absolutely astronomical.”
(Brad Wharton, NMDOH Drug Epidemiologist)
“Consider prescribing naloxone along with the patient’s
initial opioid prescription. With proper education, patients
on long-term opioid therapy and others at risk for overdose
may benefit from having a naloxone kit to use in the event
of overdose.”
Candidates for naloxone include those who:
• take high doses of opioids long-term for pain management
• take any dose of opioid for legitimate pain management
combined with suspected or confirmed history of substance
abuse, dependence, or non-medical use of opioids
• recently completed opioid detox or inpatient treatment
program
• recently were released from incarceration with a past history
of opioid abuse
• recently experienced an overdose
SAMSHA Opioid Overdose Toolkit: Information for Prescribers, 2013
Methadone and buprenorphine
are the “nicotine patches” of
heroin addiction treatment
Of the 2.5 million Americans
who abused or were dependent on
opioids in 2012, fewer than than 1
million received a medication
assisted therapy (MAT)
National Survey on Drug Use and Health conducted by
SAMHSA
What are the barriers to MAT?
• Too few trained prescribers
• Stigma and misunderstanding by the public,
medical, mental health and criminal justice
workers
• Policy and administrative (ie insurance
coverage)
Recommendations
• Every patient who is addicted to heroin or
other opioids should be given accurate and
non-judgmental information about MAT
and referred for further information or
treatment if they wish.
• Refer all people who inject drugs to a harm
reduction program for needles and syringes
and anyone using chronic legal or illicit
opioids for naloxone
Recommendations
• All persons under control of the criminal
justice system should have access to the
community standard of treatment for opiate
addiction – MAT
• Drug courts should follow evidence-based
standards of addiction care and not exclude
people on MAT and encourage people with
opiate addiction to seek MAT
Recommendations
• Peer support (12 Step Programs, NA, etc),
should not discriminate against nor
ostracize people who receive MAT. People
on MAT are in recovery from addiction.
• Health insurance companies must be
required to pay for evidence-based
treatments for addiction as for any other
medical condition.
Recommendations
• Consider how medical and treatment
communities contribute to stigma of
addiction and of MAT.
• Language used in treatment programs (for
example “drug free,” as opposed to people
on MAT, “drug addicts or junkie,” “detox”
instead of tapering for MAT, “dirty or
clean” urine tests rather than positive or
negative” etc. )
UNM Project ECHO
Offers free buprenorphine training courses
and physician certification
Next scheduled for Farmington, NM on
May 31, 2014
Weekly telemedicine conference
on Fridays, 12 to 2 pm
Training for community health workers to
work in treatment of opiate addiction.
Contact:
Jeanne Block
505-272-8338
Thank you
Bruce G. Trigg, MD
trigabov@gmail.com