Transcript Heroin Addiction: Prevention, Treatment and Recovery Robert Lubran Director, Division of Pharmacological Therapies Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Maryland.

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Heroin Addiction: Prevention,
Treatment and Recovery
Robert Lubran
Director, Division of Pharmacological Therapies
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Maryland Community Action
Partnership
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May 12, 2015
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Trends in Heroin Use in the
United States: 2002 to 2013
Majority of heroin flowing to U.S. markets is
from South America and Mexico
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Domestic Heroin Seizures: United States,
1999–2013
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Kilograms Seized
6,000
5,000
4,000
3,000
2,000
1,000
NOTE:
Includes deconflicted seizures by all Federal agencies and
0
some
state
local
2001
2002
2003and
2004
2005agencies.
2006 2007 2008 2009 2010 2011 2012 2013
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2/2015
Source: El Paso Intelligence Center. National Seizure System. Unpublished data extracted by ONDCP.
Data for 2001 to 2007 were extracted on December 1, 2012 and data for 2009 to 2013 were
extracted on April 17, 2014.
+ 181%
Change
from
2006 to
2013
Drug poisoning death rates involving heroin
United States
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Deaths per 100,000 population
8
2000
7
2013
6
5
4
3
2
1
0
Age 18-44
Age 45-64
Age 18-44
Age 45-64
Age 18-44
White, non-Hispanic Black, non-Hispanic
SOURCE: CDC/NCHS, National Vital Statistics System, Mortality File
Age 45-64
Hispanic
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Figure 1. Past year initiation of heroin among
individuals aged 12 or older, by age group: 2013
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Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health
(NSDUH), 2013.
Figure 4. Past year heroin use among individuals aged
12 or older, by age group: 2002 to 2013
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*Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health
(NSDUHs), 2002 to 2005, 2006 to 2010 (revised March 2012), and 2011 to 2013.
Figure 9. Past month illicit drug use among individuals
aged 12 or older, by perceived of availability of heroin
and age group: 2013
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*Difference is statistically significant at the .05 level.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health
(NSDUH), 2013.
HHS Opioid Strategy
March 2015
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“Opioid drug abuse is a devastating epidemic
facing our nation. I have seen firsthand, in my
home state of West Virginia, a state struggling
with this very real crisis, the impact of opioid
addiction. That’s why I’m taking a targeted
approach to tackling this issue focused on
prevention, treatment and intervention.
-- Secretary Burwell
HHS Opioid Strategy
March 2015
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Three Priority Areas:
• Provide the training, tools and educational
resources that health care professionals
need to make more informed prescribing
decisions.
• Increase the use of naloxone.
• Use medication-assisted treatment to help
lift people out of opioid addiction
SAMHSA Strategic Initiatives
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 SAMHSA’s opioid activities are included in the
Prevention of Substance Abuse and Mental Illness
Strategic Initiative:
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Goal: Prevent and reduce prescription drug and illicit
opioid misuse and abuse.
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Objective 1: education (health care professionals, public,
stakeholders)
Objective 2: Comprehensive prevention approaches (including
PDMPs and HIEs)
Objective 3: Raise awareness (schools, communities, etc.)
Objective 4: Prevent/reduce opioid overdoses and deaths.
Objective 5: Revise/implement mandatory guidelines for Federal
Drug-free Workplace Program
SAMHSA’s Public Health Approach:
Community-Centric and Science-Based
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• Prevention Interventions
• Treatment & Recovery
• Overdose Prevention & Rescue
Reduce opioid abuse, dependence, & addiction
 Improve treatment services & outcomes
 Increase and sustain recovery
 Reduce OD & improve OD rescue outcomes
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Opioid Use Disorders – DSM V
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The diagnosis of Opioid Use Disorder under DSM V can be applied to someone
who uses opioid drugs and has at least two of the following symptoms within a 12
month period:
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Taking more opioid drugs than intended.
Wanting or trying to control opioid drug use without success.
Spending a lot of time obtaining, taking, or recovering from the effects of opioid drugs.
Cravings opioids.
Failing to carry out important roles at home, work or school because of opioid use.
Continuing to use opioids, despite use of the drug causing relationship or social
problems.
Giving up or reducing other activities because of opioid use.
Using opioids even when it is physically unsafe.
Knowing that opioid use is causing a physical or psychological problem, but continuing
to take the drug anyway.
Tolerance for opioids.
Withdrawal symptoms when opioids are not taken.
Health and Mental Health Issues
Associated with Heroin Use
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Heart disease, heart infections, heart failure
Kidney disease, kidney failure
HIV/AIDS and Hepatitis B or C
Impaired immune system resulting in the inability to fight disease
and infection
Drug overdose
Symptoms of withdrawal
Decreased libido
Relationship problems
Legal trouble
Inability to perform roles and responsibilities at school, work, home
and etc.
Financial problems
National Rx Drug Abuse
Prevention Strategy
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Prescriber and consumer
education/awareness
53 percent of people 12 and
older using prescription pain
relievers non-medically got
them from a friend or relative
for free
Expanded and enhanced use of
prescription drug monitoring
programs
Education/awareness about safe
disposal of unused medicines
SAMHSA’s Rx Drug/Opioid Abuse
Prevention/Early Intervention Efforts
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 State Partnerships for Success
grants
 Drug Free Communities grants
 Substance Abuse Block grant
 Prescription Drug Monitoring
Program grants
 Opioid Overdose Prevention
Toolkit
 Federal Drug-Free Workplace
Program
 SAMHSA/CDC Prescription Drug
Abuse Prevention Campaign
 Consumer Education
 Screening, Brief Intervention and
Referral for Treatment
 Not Worth the Risk, Even If It’s Legal
(pamphlet series)
 Prescriber Education
 Continuing medical education
 PCSS-Opioids and PCSS-MAT
 National Prescription Drug Abuse
Summit
Addressing Rx and Opioid Abuse
FY 2016 Proposed Prevention Initiatives
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Preventing Opioid Overdose-Related Deaths: $12 M
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Grants to 10 states to reduce # of opioid overdose-related deaths
Help states purchase naloxone not otherwise covered
Equip first responders in high-risk communities
Support education on use of naloxone and other overdose death
prevention strategies
• Cover expenses incurred from dissemination efforts
Addressing Rx and Opioid Abuse
FY 2016 Proposed Prevention Initiatives
Strategic Prevention Framework for Prescription Drugs
(SPF-Rx): $10 M
• Raise public awareness about dangers of sharing medications
• Work with pharmaceutical and medical communities to raise
awareness on risks of overprescribing
• Develop capacity and expertise in use of data from state
prescription drug monitoring programs (PDMPs) to identify
communities by geography and high-risk populations
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The Treatment Gap
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Source: 2013 NSDUH
Number of Clients Receiving MAT at OTPs &
other Facilities
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3,781
48,148
330,308
Source: N-SSATS
Methadone
Buprenorphine
Vivitrol
Primary Substance of Abuse at Admission
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Opioid Use Disorders and MedicationAssisted Treatment (MAT)
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“Although [methadone] can be abused, it is rarely a primary drug of abuse. Its
therapeutic effectiveness has been clearly demonstrated…”
Federal Regulation of Methadone Treatment. Institute of Medicine. 1995.
“It is now generally agreed that opiate dependence is a medical disorder and that
pharmacologic agents are effective in its treatment. Evidence presented to the panel
indicates that availability of these agents is severely limited and that large numbers of
patients with this disorder have no access to treatment.”
NIH Consensus Statement on Effective Medical Treatment of Opiate Addiction.
November 19, 1997.
“Medications are an important element of treatment for many patients, especially
when combined with counseling and other behavioral therapies.”
Principles of Drug Addiction Treatment A Research-Based Guide. National Institute on Drug Abuse
October 1999
Opioid Use Disorders and
MAT
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 MAT is a direct service that provides a person who has
an opioid (heroin) use disorder with pharmacotherapy
in conjunction with behavioral therapies as treatment
for associated symptoms or disabilities. Treatment is
individualized.
 Medications include methadone, buprenorphine and
naltrexone. Methadone can only be dispensed at a
SAMHSA certified opioid treatment program (OTP) to a
person with an opioid use disorder
Source: Psychiatric Services 65:146–157, 2014; doi: 10.1176/appi.ps.201300235
SAMHSA Regulations and
Guidelines for OTPs
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42 CFR Part 8 sets forth requirements for
OTPs including mandatory accreditation, DEA
registration, state licensure.
 OTPs are expected to provide access to the
full range of FDA approved medications.
 OTPs must provide recovery support directly or via
referral to adequate & accessible community services.
 Peers are recovering individuals who have experienced
the challenges as well as the successes of treatment.
 Peers often have more credibility and impact than nonpeer clinicians.
Addressing Rx and Opioid Abuse
FY 2015 Proposed Treatment Initiatives
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Targeted Capacity Expansion Grant to
States for Prescription Drug and Opioid
Addiction:
• $12M in FY 2015 appropriation
• States would focus on high risk communities
to address opioid use disorders
• 39 states are eligible based on high rates of
admission for opioid addiction treatment
Addressing Rx and Opioid Abuse
FY 2016 Proposed Treatment Initiatives
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Medication Assisted Treatment (MAT) for
Prescription Drug and Opioid Addiction:
$13 M
• $12M in FY 2015 appropriation
• Targeted Capacity Expansion—General Program
• Grants to states to focus on high risk communities to
address opioid use disorders
• Improve access to MAT services for individuals with opioid
use disorders
MAT Language in FY 2015 Treatment RFAs
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SAMHSA has added language to the following
RFAs to emphasize the use of MAT in broader
populations.
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Drug Courts
Offender Reentry Program
State Youth Treatment Implementation
Targeted Capacity Expansion – HIV for High Risk
populations
Recovery
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MAT is an important component in sustaining
recovery.
“Medication-Assisted Treatment is a BIG part
of my recovery, but staying sober depends on
more than just medication. I do service work,
go to meetings, stay away from
drugs/alcohol, and surround myself with
supportive people.”1
- Ian C. Minneapolis, MN
1Legal
Action Center (March 2015) Confronting an epidemic: the case for eliminating barriers to medicationassisted treatment of heroin and opioid addiction. www.lac.org
Recovery
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Many Paths, One Future “A process of change
Recovery
through which
individuals improve
their health and
wellness, live a selfdirected life, and
strive to reach their
full potential.”
Recovery: Health Determinants
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https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health
Recovery: Hope & Hard Work
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Recovery looks forward; and while it learns
lessons from the past, it does not use the past
as a metric for the present or as a prognosis for
the future.
Recovery focuses on an individual’s strengths;
on housing, employment, and education; on
societal engagement and contribution as well as
support; on wellness; and on holistic health.
Narcotics Anonymous
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We make a distinction between drugs used by drug
replacement programs and other prescribed drugs
because such drugs are prescribed specifically as
addiction treatment. Our program approaches
recovery from addiction through abstinence,
cautioning against the substitution of one drug for
another. However, we have absolutely no opinion on
methadone maintenance or any other program
aimed at treating addiction.
NA WORLD SERVICE BOARD OF TRUSTEES BULLETIN #29
Regarding Methadone and Other Drug Replacement Programs
Recovery: SAMHSA’s Central Tenets
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Health: Promote health and recovery-oriented
service systems.
Home: Ensure that permanent housing and
supportive services are available.
Purpose: Increase gainful employment and
educational opportunities.
Community: Promote peer support and the
social inclusion (e.g., Peer recovery Support
Services, PRSS).
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Thank you!
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Questions?
[email protected]