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«Initiative promoted by Dane County  District Attorney Ismael Ozanne. Hired Opiate Substance Abuse Counselor  to focus solely on Opiate-related ...»

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Face of Addiction  RESPONSIBILITY  THE ABILITY TO RESPOND Things continually fall off the map: It  literally becomes a trail of loose ends, undone paperwork, lost or misplaced unpaid bills, forgotten appointments, a tornadic display moving toward depletion.

In the Moment Profile… 61% female, age range 20-43.

 39% male, age range 20-44.

 Many without valid transportation; DL issues,  fines, no auto insurance, OAR’s, unresolved OWI’s, or no vehicle, etc.

Many without consistent work, unable to get a  job (CCAP), fired or quit, poor work history, little to no money. Many with significant debt A few that have been temporarily homeless.

 Assessing If you want to fully understand and embrace  opiate addicts, standard screen/assess forms are not enough!

There is a litany of questions to ask so as to  better track where someone has been, and what are more prevalent risks than others.

With the DPU Opiate Participants, assignment  #1 is to answer 24 questions, which also spring further questions. Assessing is ongoing.

Treatment Opioid Addiction is not going away any time too  soon.

We have an acute response to a chronic  condition. Opioid & heroin addiction is recognized as a disease-not a defect of character.

OST is proximal for many. It should not be “the  all” of a treatment package, but should not be dismissed, excused, or forgotten due to many levels of opinion, belief, hardship, or politics.

Treatment National Association of State Alcohol and Drug  Abuse Directors (NASADAD): Consensus Statement on the Use of Medications in Treatment of Substance Use Disorders, January, 2013.

May or may not be necessary, but should be  considered and supported as viable treatment strategy in conjunction with other evidencebased practices.

Other support: WHO, NIDA, NADCP.

 Treatment The three medications (following) should be  made readily available and covered by both private and state plans, rather than overdose, relapse, injury, and death.

Should not have dosing or time-specific limits,  complex pre-auth or re-auth, minimal counseling coverage or debated rationale for additional coverage.

Should not be prioritized by “fail first therapy.”  Buprenorphine A semi-synthetic opioid, available as Suboxone,  Subutex, and now Zubsolv. Schedule III controlled substance.

Available as a sublingual tablet, sublingual film,  and transdermal patch ( Butrans) Is a partial agonist/partial antagonist.

 (Agonist=same receptor response / Antagonist=prevents receptor response) A form of Opiate/Opioid Replacement Therapy.

 Buprenorphine Dose efficacy range is 8-16 mgs, with some  needing 28-32 mgs. for full effect. Cost: $20-32 a day.

Suboxone contains the opioid buprenorphine  and the opioid blocker, naloxone. When taken sublingually, it reduces cravings and “pushes” other opioids off the receptors. When snorted or used intravenously, it can precipitate withdrawal.

Subutex does not contain naloxone.

 Buprenorphine The Drug Addiction Act of 2000 allowed for  medical professionals to prescribe and manage.

This represents a huge change from the Supreme Court rulings of 1914-1920, which stated that detox and “maintenance” were not forms of medical treatment.

Any physician with the required hours training in  buprenorphine can now prescribe and manage.

Buprenorphine Physicians have been able to take 30 patients,  and after one year, increase to 100.

ASAM proposing to US Dep’t of Health and  Human Services, July, 2014, to increase prescribing patient limit for those physicians with certification in addiction medicine by ABAM, phased over two years, to 250 patients for year 1, and then 500 patient limit for year 2.

Non-addiction physicians will require additional  training.

Methadone A synthetic opioid, full agonist, very potent, used  in pain management and as an anti-addictive agent.

Has long duration of action, elimination half-life  of 15-60 hours, with the mean at 22 hours.

It mitigates opioid withdrawal syndrome and  blocks euphoric effects of drugs like heroin.

Available in pill, sublingual, and liquid.

 Methadone Maintenance Therapy Wisconsin, 2008-2012, those enrolled in substance  abuse treatment programs that offered Methadone increased 98.2%. (Medicaid statistic) Therapeutic doses vary but usually at least 75-150 mgs.

 daily. Tapering highly recommended to stop.

Methadone is a Schedule II substance. Very strict  federal regulations about the dispensing of methadone in clinics.

Most clinics in phase system. Phase I requires coming in  to dose daily. In Madison, it is between $17.50-23.00 per day. ($525-690 per month) Naltrexone First approved for opiate dependence 1984, then  for alcohol dependence 1994.

An opioid receptor antagonist.

 Vivitrol, naltrexone ER, approved for alcohol  treatment 2006, and for the prevention of opiate relapse 2010.

Vivitrol is a once per month intramuscular  injection, 380 mgs., at about $1100 per shot.

A very distinct treatment option from opioid  agonist treatments.

Naltrexone Persons treated with Vivitrol must be off opioids  for several days.

This is problematic for many opiate abusers:

 cannot withstand the withdrawal sickness, using opportunities present, the waiting element very anxiety producing.

This is a part of the treatment plan-not the end  all. There should be connection to a viable counseling service/program prior to detox and continuing post-detox/Vivitrol initiation.

Antidote for Overdose Antagonist: A chemical which  blocks the action of a substance.

Naloxone (Narcan): Is a prime  example as it blocks opiate receptors, therefore reversing the effects of heroin.

Is now readily available to other  users and friends of users. Many addicts have a Narcan supply.

Antidote for Overdose American Society of Addiction Medicine (ASAM)  endorses OTC availability of naloxone.

Police in New York announced in May, 2014,  that 20,000 officers will be equipped with naloxone.

Overdose prevention videos produced, i.e.

 Boston Public Health.

https//m.youtube.com/watch?v=Uq6AxrEY3Vk One Step Up & Two Steps Back The FDA recommends rescheduling of  Hydrocodone products from Schedule III to II, placing it in a category of more abuse potential.

8/18/14: Tramadol put into Schedule IV.

 At one in the same time, the FDA approves  Zohydro ER. It is an extended-release opioid analgesic, oral formulation of hydrocodone bitartrate. There is no protective coating as with OP’s; twice the hydrocodone than Vicodin.

Toward Legislation December, 2011: Legal Action Center compiles  “Legality of Denying Access to Medication Assisted Treatment In The Criminal Justice System”

Residential Substance Abuse Treatment:

 Medication Assisted Treatment (MAT) for Offender Populations; an RSAT Training Tool, published through BJA/DOJ March, 2013.

Advancing Access to Addiction Medications;

 www.asam.org/docs/advocacy/Implications-forOpiate-Addiction-Treatment Legislation Bills introduced by Rep. John Nygren, R Marinette, 2013 Assembly Bills 445, 446, 447, 448, 668, 701, and 702; signed 4/7/2014.

Covers allowance for more first responders to  carry Naloxone, grant immunity for drug possession charges to users who call 911 for overdose, expand collection of unwanted prescription drugs, create grants for diversion treatments, create opioid treatment in rural area Other… 3/27/14: Governor Deval Patrick, Mass., declares public 

health emergency, actions to address opiate addiction:

dedicates $20 million to enhance substance treatment;

universally permit first responders to give Naloxone;

prescription monitoring.

8/6/14: This action turns into law as Patrick signs  substance abuse law, S.2142; an Act to Increase Opportunities for Long-Term Substance Abuse Recovery.

Requires insurers to reimburse patients for addiction trmt. From licensed providers, and, removes prior auth for outpatient and up to 14 days inpatient, et.al.

More 4/10/14: 16 senators sign letter to Attorney  General Eric Holder, asking for DOJ to initiate multi-state program utilizing anti-addiction medications to support offender reentry.

5/13/14: Sen. Jen Flanagan, D-Leominster,  Mass, chaired drug addiction committee, a vote to require insurance companies to cover AODA treatments w/no prior auth.

Other The Senate unanimously approved this bill,  188/Senate/S2133, which addresses abuse deterrent drugs and strengthens the Prescription Monitoring Program.

It also: Removes prior auth for Acute Treatment  Services (Mass) Health Managed Care Entities, requiring coverage up to 15 days of clinical stabilization; same for commercial insurers, coverage up to 21 days.

And… Directs the Health Policy Commission, alongside  Dept. Public Health, to determine standards of evidence-based substance abuse treatments, a certification process for providers, and with those certs, insurance carriers prohibited from requiring prior auth, along with guaranteed reimbursement for those substance abuse services.

There is also a review of the accessibility of  substance abuse treatment and adequacy of insurance coverage.

Also… June 18, 2014: Senators Carl Levin (D-MI) and Orrin  Hatch (R-UT) hosted forum on Opioid Addiction; focused on obstacles that are making it difficult for patients to have access to Buprenorphine. Discussion of raising the 100 patient limit. ASAM weighs in, patient limits be lifted in graduated, thoughtful approach, with higher levels of training for docs.

July, 2014: Congressman Bill Foster (D-IL), and Sean  Maloney (D-NY) introduced legislation to increase inpatient treatment access for low-income and uninsured for heroin and opiate abuse: Expanding Opportunities for Recovery Act (H.R. 5339) Family Support Learn to Cope: www.learn2cope.org ,Support for AFM of opiates.

www.addictinthefamily.org (also a book)  www.patmoorefoundation.com  Locally, www.parentaddictionnetwork.org  www.recoverysolutionsofwi.com 


Transitions are difficult…from one dance move  to the next, from a martial arts posture to its emptying, from an old house to new digs, the ending of one relationship or the beginning of another, from one job position to the newer one, and from a drug-centered lifestyle to a world of recovery. The transition is the uncomfortable “middle”, that place that wants resolve where no quick resolve lies.

In Parting… Take Care Out There…

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