Category: USA

America could relax opioid treatment access policies

Canada and the United States (U.S.) face an opioid use disorder and opioid overdose epidemic.

The most effective OUD treatment is opioid agonist therapy (OAT). It means buprenorphine (with and without naloxone) and methadone. Although federal approval for OAT occurred decades ago, in both countries, access to and use of OAT is low. Restrictive policies and complex regulations contribute to limited treatment access.


We did a non-systematic literature scan and reviewed all available policy documents. We studied and compared treatment policies and practice at the federal level in Canada vs. United States. And also at the local level in British Columbia (B.C.) vs. Oregon.

There are differences and similarities between federal and local OAT policies. This applies to access to treatment. In Canada, treatment policy control has shifted from federal to provincial authorities. But in the U.S., federal authorities maintain primary control of treatment regulations. Local OAT health insurance coverage policies differed between B.C. and Oregon. While B.C. had 5 treatment options, Oregon had only 2 OAT options with some limitations.

Relaxation of special federal regulatory policies

The Canadian and U.S. federal OAT policies differ. So do the local OAT access and coverage policies in B.C. and Oregon. And it’s also because of the relaxation of special federal OAT regulatory controls in Canada. Our paper also highlights the complicating contributions and likely policy solutions. For example, the prescription regime and drug control regime within the drug policy sub-domain. Or, the constitutional rights within the broader policy domain.

U.S. policy makers and health officials could consider adopting Canada’s regulatory policy approach to expand treatment access.

Better access mitigates the harms of the ongoing opioid overdose epidemic.

Reference: Priest, K. C., Gorfinkel, L., Klimas, J., Jones, A. A., Fairbairn, N., & McCarty, D. (2019). Comparing Canadian and United States opioid agonist therapy policies. Int J Drug Policy. doi:10.1016/j.drugpo.2019.01.020

If you enjoyed reading this article, you may also enjoy reading about the role of treatment monitoring via drug testing:

Frequent urine testing lacks evidence

Drug court and Addiction, AMERSA conference

golden gate bridge

Is drug court meeting the need of the most vulnerable people who use drugs? What is the drug court judge’s hardest decision? What is social detox? How voluntary is drug court treatment?

November 8th, The Association for Multidisciplinary Education and Research in Substance use and Addiction (AMERSA) met for 42nd time in San Francisco, CA. These, and other questions, pondered five AMERSA speakers at the Thursday’s Interdisciplinary panel session.

Meeting the Need: Collaborative Justice and Treatment.

(Interdisciplinary panel, Thursday, November 8th, 2018, 10:15 – 11:45 am)

The panel was presented by:

Judge Eric Fleming, JD – San Francisco Collaborative Courts

Lisa Lightman, MA – Collaborative Courts, San Francisco Superior Court;

Angelica Almeida, PhD – San Francisco Department of Public Health;

Linda Wu, MSW, LCSW – San Francisco Department of Public Health;

Charles Houston – San Francisco Department of Public Health;

Drug Court Judge’s hardest choice.

Judge Eric Fleming, JD

The court calls people who have addictions participants, not defendants. Among others, the key role is to listen as a judge and to show respect. The hardest decision is to decide who’s going to be terminated; terminating very young people is the hardest. Some people have been fighting addiction for 20 years, but not making enough progress. This raises a question: What is enough progress?

It is one of the most important courts in San Francisco, they devoted a chief to it – not just someone pushing them through the system. The court takes high risk clients, those who haven’t done well in previous programs, facing significant punishment.

They understand that there are layers to the individuals, case can be dismissed if it’s the first case, but not the fourth case. If anything happens the system can send them to jail, but it doesn’t; instead, they talk to them and they listen – give them numerous chances. Relapse is considered as part of the process – if judge understands that, it’s good for the client.

The graduation is pretty awesome, it wasn’t easy for anyone. The judge oversees the ceremony, starts with positive remarks, and then problems. I’m proud of you as a judge, I hope you learned from me, because I learned from you. The judge concluded with a story about a young female user, 22-year old, that he had to terminate, before the termination, he made a couple of phonecalls to make sure that she had a place to go when he terminated her.

 

youth opioid addictionWhere does transitional youth belong?

Angelica Almeida, PhD – San Francisco Department of Public Health

Some of the core functions of the drug court system are: (1) Making sure that the services were coordinated, mental health and addiction behavioral health. (2) Trying to keep people in the least restrictive settings by intervening early.

Sometimes, it is a challenge of being a harm reduction city but working in a court that is historically abstinence based. The drug court is offering outpatient and intensive outpatient services. Also, low threshold services – medication assisted treatment.

Harm reduction principles are really what brings people to treatment; not judging them also makes a big difference. Thinking about how they work with transitional age youth, which don’t quite fit to children or adult services, is still evolving. System made to work with adults, really older adults. The transitional age youth drops out of services too much. Next step after residential treatment is always the hard piece.

alcohol drink, methadose

Sobriety doesn’t take a certain number of days.

Linda Wu, MSW, LCSW.

Drug court treatment center has now become a civil service organisation. It is Co-located with community justice and violence intervention programs. It utilizes onsite urinalysis testing, all observed. Four levels of treatment graduation, graduation rate is 20% but 6 months of sobriety required, also housing and income or training – “you can’t be sober if that’s all you’re working on.” After graduation the case manager can help them even after the case is over, because they are part of dept of public health. Clients making significance progress towards recovery despite ongoing use, finding housing or using less harmful drugs such as cannabis. To be able to offer some choices (voluntary program) is really important and confidence-building.

Challenges of drug courts are many. Clients look at the treatment in terms of their sentence – sometimes, they ask how many days I have to serve? Sobriety doesn’t take a certain number of days.

There is a continuous discussion between harm reduction versus abstinence; it’s challenging at times to find the balance between client centered treatment and also making recommendations to the court. One of the ways they make recommendations to the court is through the UA (commitment, process).

Staff is sometimes feeling pressured to become enforcers because they need to write the court notes for court. It’s very different than writing clinical reports. Clinical note is very different from court note. That takes away the awareness from the what am I (staff) doing – to what are you (client) doing. Lack of community resources in a resource-rich city because lack of space (beds) and big stigma of working in drug services.

lisbon

When change came over him

Charles Houston – public health.

Mr Houston, once a drug court participant – now working for the city and county, as a family liaison – spoke about how important drug court is. He was running (there was a warrant), but then change came over him. He called the court himself. They asked him, do you want to try it – drug court? Judge reviewed monthly progress, fostered accountability. They showed him a different way, the strengths that he had, the ability to make change.

While drug courts benefit certain groups of persons who use drugs, the jury is still out there when judging their overall effectiveness and organisation. Yes, treatment is voluntary but court mandated – the other option is jail.

AMERSA – what’s in the name?

AMERSA, formerly known as the association for medical education and research in substance abuse was recently renamed. Now it is The Association for Multidisciplinary Education and Research in Substance use and Addiction. The association’s mission is to improve health and well-being through interdisciplinary leadership in substance use education, research, clinical care and policy. Text taken from www.amersa.org

If you enjoyed reading about this year’s conference, you may like to read my notes from the previous years:

39th meeting in Washington, DC, November 5th, 2015

38th meeting in San Francisco, CA, November 4th, 2014

Will this patient go into severe alcohol withdrawal?

bottle in bag

New research from the BC Centre on Substance Use (BCCSU) suggests applying easy and effective tool to identify patients at high risk of going into withdrawal, in efforts to modernize alcohol detox. In a study published in the August issue of the peer-reviewed Journal of American Medical Association, BCCSU researchers used data from approximately 71,295 persons taking part in 14 scientific studies to predict which patient will develop serious complications, including seizures and delirium.

Which patient will go into severe alcohol withdrawal?

From the press release by British Columbia Centre on Substance Use (Aug 28, 2018):

Research sheds light on how to improve diagnosis and treatment of severe alcohol withdrawal syndrome
The treatment of alcohol withdrawal urgently needs to be modernized in order to improve patient outcomes and safety and reduce health care cost, according to new research from the BC Centre on Substance Use (BCCSU).
The study, published today in the Journal of the American Medical Association, involved a multi-year systematic review involving more than 71,000 patients and sought to determine how best to identify the risks of developing severe, complicated alcohol withdrawal – a potentially life-threatening emergency. Those who consume alcohol in quantities above low-risk recommendations may develop this syndrome when they abruptly stop or substantially reduce their alcohol consumption.
Researchers found that patients are commonly over-admitted into inpatient alcohol withdrawal management care, resulting in a poor patient experience and unnecessary health care resource consumption. The review identified highly valid and easily administered screening tools to properly assess symptoms and risks before recommending acute treatment such as withdrawal management, and to look at outpatient care to improve patient outcomes and reduce the burden on the health system.
“Alcohol addiction is not only the most common substance use disorder, it’s among the most devastating in terms of both health impacts and the costs to our health system,” said Dr. Evan Wood, executive director of the BCCSU and lead author of the study. “This study demonstrates that there are more sophisticated tools that the health system should be employing to provide more appropriate care for patients, which will result not only in better outcomes but also free-up resources for high-priority needs.”
According to a study released by the University of Victoria’s Canadian Institute for Substance Use Research (CISUR) and the Canadian Centre on Substance Use and Addiction (CCSA), alcohol use costs Canadians $14.6 billion per year in health care, lost production, criminal justice, and other direct costs – higher than all other substances combined.
B.C. has the highest rate in the country of hospitalizations entirely caused by alcohol, and consumption is rising faster in the province than elsewhere in Canada. Research from the Canadian Institute for Health Information published last year found that British Columbians who use alcohol consume, on average, 9.4 litres of pure alcohol each year —  the equivalent of roughly 14 bottles of beer or two-and-half bottles of wine each week.
“Hospital wards are often filled with individuals suffering the consequences alcohol addiction,” said Dr. Keith Ahamad, a co-author on the study and Medical Director at Vancouver Coastal Health’s Regional Addiction Program. “This study helps identify those who truly need admission and demonstrates that many patients can be better treated as outpatients, even in primary care.”
The BCCSU is funded by the provincial government and is currently developing provincial guidelines for treating alcohol use disorder, expected to be released later this. They will be the first evidence-based guidelines of their kind for the province.

(Text taken from http://www.bccsu.ca/news-releases/)

From: Will This Hospitalized Patient develop Severe Alcohol Withdrawal Syndrome?: The Rational Clinical Examination Systematic Review. JAMA (In Press) JAMA Network: jama.jamanetwork.com

If you’re interested in alcohol, read more about my alcohol research here.

For more information about the study or to schedule an interview, please contact:
Kevin Hollett, BC Centre on Substance Use
778-918-1537
khollett[at]cfenet.ubc.ca

Systematic reviews enhance drugs conference

conference meeting

Systematic reviews are the cream of the research crop. Those who understand their value thrive at an opportunity to meet the review authors at scientific conferences. This year, the annual meeting of the College on Problems of Drug Dependence (CPDD) in San Diego featured several important reviews. Here’s a listing of all the posters presenting reviews from the session on Wednesday, June 13th, 2018.

Overdose

Non-fatal overdose prevalence among people who inject drugs Samantha Colledge (June 11, 2018);

Prescription drug monitoring programs on nonfatal and fatal drug overdoses David Fink;

Gender

Limited inclusion of women in functional neuroimaging studies of opioid-use disorder Hestia Moningka;

Women’s prescription drug misuse Bridgette Peteet;

Gender differences in HIV, anti-HCV and HBsAg prevalence among people who inject Janni Leung;

Services

Case for hospital teams in treatment of opioid use disorders Kelsey Priest;

Addiction-related characteristics of substances users in harm reduction settings Charlotte Kervran;

STDs and injecting

Extremely low HIV incidence among PWID: Terminology, high/middle income settings, methodology, and addressing new outbreaks Don Des Jarlais;

Use of opioids and stimulants by people who inject drugs Amy Peacock;

Factors associated with uptake or willingness to use pre-exposure prophylaxis (PrEP) among people who inject drugs Yohansa Fernández;

Pre-exposure prophylaxis (PrEP) for people who inject drugs? Angela Bazzi;

Cannabis

Cannabis and cannabinoids for the treatment of people with chronic non-cancer pain conditions Emily Stockings;

Medical marijuana laws and adolescent marijuana use in the US Aaron Sarvet;

Does liberalization of cannabis policy influence adolescents’ levels of use? Maria Melchior;

Other topics

Clinical and toxicological profile of NBOMESs Nino Marchi;

Sensation-seeking personality trait and its association to drug seeking behavior in adolescents Thiago Fidalgo.

Systematic reviews cream of the crop from Brazil through Egypt

NIDA International poster session on Monday, June 11, 2018

Three Australians, two North Americans; an Egyptian, African and Brazilian had one poster on systematic review each. Five were meta-analyses.

The Australian reviews dealt with overdose, STDs and injecting:

Nonfatal overdose prevalence among people who inject drugs S. Colledge, (UK, Australia);

Gender differences in HIV, anti-hepatitis C virus, and hepatitis B virus surface antigen prevalence among people who inject drugs J. Leung, (Australia, UK, Portugal);

Use of opioids and stimulants by people who inject drugs: A. Peacock, (Australia);

 

The North-Americans reviewed drug monitoring programmes:

Global review of drug-checking services 2017 L.J. Maier, (California);

Urinalysis frequency and health outcomes for persons on opioid agonist therapy: J. McEachern, (Canada);

 

Anger, brain stimulation and antipsychotics were reviewed too:

Anger in users of psychoactive substances H.V. Laitano, (Brazil);

Noninvasive brain stimulation in addiction medicine A. Elaghoury.(Egypt);

Atypical versus typical antipsychotics for the treatment of addiction: S. Hanu. (Ghana).

With the increasing demands on scientists’ workloads, systematic reviews are an effective way of staying up to date with the most recent developments in the field. See also my previous blog posts about CPDD from the previous years:

 

2017: Dr Wood tells the forum recipe for research-centre success

2016: Changing the ways of CPDD – College on Problems of Drug Dependence – June 12-16, #CPDD2016

2015: Getting the most out of the Conference of the College on Problems of Drugs Dependence #CPDD2015

2014: 76th Annual Conference of College on Problems of Drug Dependence: Decide to be fearless& fabulous 

2013: My itinerary for the Conference – College on Problems of Drug Dependence, San Diego, June 15-20 

Changing the ways of CPDD – College on Problems of Drug Dependence – June 12-16, #CPDD2016

Change is the ultimate law of life. Those that do not change and adapt, do not survive. In the life of scientific meetings, this means constantly improving the organisation of the events and tailoring them to the changing needs of the conference delegates. This year, the annual meeting of the College on Problems of Drug Dependence (CPDD) introduced several improvements and more are on the way in next years.

cpdd logo

photocredit: cpdd.org

 

Bye Bye Tote Bags

Many of us were used to the traditional design of the CPDD tote bags. Each year had a different colour. For years when conference visited a warm region, such as Phoenix, AR, the tote bag included a special layer for keeping the contents cool. The non-bag policy brought the desired recognition of sustainability and (un-)expected diversity among the conference bags – everyone was different.

Bye Bye Printed Programs

For years, the conference book was a comprehensive bible for the conference week. Everybody read it and most followed it. Although the College printed a limited number of copies, this year, the e-programs drained participants smartphones’ batteries. What more, they offered note-taking and photograph uploading that many appreciated. Welcome to the digital age.

Hello Mentors

Since the early days, the senior delegates offered mentorship to junior delegates. Mostly informal. Following the new trends adopted at other conferences, such as AHSR or NAPCRG, the CPDD sent out emails to all Members in Training (MIT), offering to match them with a potential mentor (mentor bios included). If both parties agreed, the match-maker introduced them via email. I have learned a lot from my mentor. Especially that the decision makers may not read addiction journals, also that the team identity strengthens sense of ownership among team members and that the road to the research success can be long and winding. Let’s hope that the beneficial mentoring program continues in future.

Hello Shorter Conference

With the increasing demands on scientists’ workloads, there is a chance that the upcoming conferences will be shorter.

See also my previous blog posts about CPDD from the previous years:

2015Getting the most out of the Conference of the College on Problems of Drugs Dependence #CPDD2015

2014: 76th Annual Conference of College on Problems of Drug Dependence: Decide to be fearless& fabulous 

2013: My itinerary for the Conference – College on Problems of Drug Dependence, San Diego, June 15-20