On March 2, much of the Northeast was being hammered by heavy winds and snow, and even the federal government in Washington, D.C., was shut down. But that didn't stop Elinore McCance‐Katz, M.D., assistant secretary in the Department of Health and Human Services and director of the Substance Abuse and Mental Health Services Administration (SAMHSA), from talking to us about treatment for opioid use disorders (OUDs) and the new Treatment Improvement Protocol (TIP) 63, which she had recently updated from TIP 40.While TIP 63 (see ADAW, March 5) is about the use of medications to treat OUDs, there are still many areas of discussion in the treatment field. We touched on some of the more controversial points with McCance‐Katz.What happened to the “no wrong door” approach to treatment settings? In the substance use disorder field, it still seems to be the case that if you go to an opioid treatment program (OTP), you get methadone; if you go to an office‐based opioid treatment provider, you get buprenorphine; if you go to a Vivitrol provider, you get Vivitrol; and if you go to a residential abstinence‐based facility, you get abstinence. “It shouldn't work this way,” said McCance‐Katz, although she noted that OTPs in particular are expanding the services they offer. “We have some very forward‐thinking methadone providers who offer buprenorphine and are even able to offer naltrexone,” she said. “But it should not be one‐size‐fits‐all.” Patients should have choices about their medical care, she said. “These are medical conditions for which we have effective medical treatments,” she said.Buprenorphine capThere are some who want to remove the patient cap for buprenorphine: currently, one physician can only prescribe for a maximum of 275 patients. “The problem in my opinion is not the cap; the problem is that most of the people who have the waiver don't prescribe,” said McCance‐Katz, echoing the concerns of many at SAMHSA, which, along with the Drug Enforcement Administration (DEA), is responsible for promulgating the DATA regulations. “As someone who has been treating people with OUDs since 1990, I am very concerned about pill mills,” she said. “One of the things I hear is that we don't put limits on doctors who are prescribing opioids for pain. But one of the reasons for that is that pain patients are not coming to us with addiction — they come to us with pain. Most of them won't go on to become addicted, so they do not engage in the aberrant behaviors that are part of opioid use disorder.”‘These are medical conditions for which we have effective medical treatments.’Elinore McCance‐Katz, M.D.Opioid use disorder is a “constellation of behaviors that need to be addressed, in addition to providing medication,” she said. Patients need support, in addition to meth‐adone, buprenorphine or naltrexone, she said. “They need psychosocial service, they need counseling, peer support, they may need marriage and family therapy,” she said. “How can a doctor or prescriber with a limitless number of patients provide this?”McCance‐Katz strongly supports office‐based treatment of OUDs, saying it is “critically important” to getting people the care and treatment they need. “But if we mess it up by creating a bunch of pill mills, there's going to be a backlash that will make it very difficult,” she said.In fact, federal regulators, including McCance‐Katz (who was at SAMHSA previously), have been concerned about this from the beginning, with H. Westley Clark, M.D., then director of SAMHSA's Center for Substance Abuse Treatment, and Nora D. Volkow, M.D., director of the National Institute on Drug Abuse, challenging assertions made by lawmakers that buprenorphine caps were unnecessary (see ADAW, June 23, 2014) and successfully keeping the caps to a minimum.Vivitrol's detox hurdleWhat advances have been made to getting over the “detox hurdle” for Vivitrol, in which patients must be abstinent from opioids for a week before starting the medication? McCance‐Katz said that recent research has found that by using buprenorphine to assist in detoxification, Vivitrol could be started earlier. “It's important to know that you don't have to be in inpatient treatment for detoxification,” she said. “If people want to be detoxed, that should be encouraged, particularly in these times when heroin is laced with fentanyl, and counterfeit pills have fentanyl that is killing people.”Finally, McCance‐Katz said that most patients do not want to stay on medication for their whole lives. “They come to a point when they have a plan to get off the medications,” she said. “So I like the idea of stabilizing someone — getting them to a point where they are stable enough in their lives.” Then they can think about a taper, and continuing their recovery. But if that doesn't work or appeal to them, they should definitely stay on the medication, she said.
Alcoholism and Drug Abuse Weekly – Wiley
Published: Jan 12, 2018
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