Issue Number 4: Medication Assisted...Medication Assisted Treatment (MAT) is an evidence-based practice in which a client is treated for a Substance Use Dis-order through the combined

Best Practice Spotlight Issue Number 4: Medication Assisted Treatment

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What is MAT?

Medication Assisted Treatment

(MAT) is an evidence-based

practice in which a client is

treated for a Substance Use Dis-

order through the combined use

of medications and counseling.

While MAT has been proven

effective in treating depend-

ence to tobacco, alcohol, and

opiates, this Spotlight will pri-

marily focus on the use of MAT

to treat individuals addicted to

opioids.

Opioids have such a powerful

impact on brain chemistry that

medications are often required

to assist the individual in reach-

ing a manageable state. Bene-

fits related to medication in-

clude diminishing cravings, pre-

venting withdrawal symptoms,

and reestablishing brain func-

tion. These positive effects al-

low an individual to regain the

control necessary to shift focus

from maintaining addiction to

achieving recovery.

Historically speaking, treatment

for substance use disorders was

derived solely from the absti-

nence-only framework. The in-

clusion of medication into treat-

ment for dependence was

frowned upon, as many be-

lieved the prescribed medica-

tion replaced one addiction with

another. Today, much more is

known about the science behind

addiction and MAT is widely

seen as the standard in effective

treatment.

The Hazelden Betty Ford Foun-

dation is considered a pioneer in

the field of addiction treatment.

Best Practice Spotlight

In This Issue

What is Medication Assist-ed Treatment?

Medications used by MAT

programs Key Components of MAT

Programs Federal and Kentucky Re-

sponse to Opioid Epidemic Q&A with Allen Brenzel,

M.D. Medical Director for DBHDID

Issue Number 4: Medication Assisted Treatment (MAT) for Opioid Dependence

MAT has been found to reduce morbidity and mortality, decrease overdose deaths, reduce transmission of infec-tious diseases, increase treatment retention, improve so-cial functioning, and reduce criminal activity. SAMHSA—2016.


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Hazelden sought to develop a program that would success-fully treat new clients after wit-nessing a significant rise in their treatment of opioid de-pendence. According to their statistics, Hazelden’s facility for young adults and adoles-cents in Plymouth, Minnesota charted an increase for clients seeking opioid addiction treat-ment from 15 percent in 2001 to 41 in 2011. The national sta-tistics concerning opioids are more staggering. (See Figures 1 and 2) Centers for Disease Control reports that the death toll from prescription painkiller overdose increased more than fivefold in the past decade in the U.S.

Overdose Deaths (total vs. heroin) Over Time

1020 1032979

1034

43

132204 224

0

200

400

600

800

1000

1200

2011 2012 2013 2014

Total OD Deaths

Heroin OD Deaths

Figure 1. Overdose Deaths in Kentucky from Heroin versus all Opi-ates, 2011-2014.

Figure 2. Drug Overdose Death Rates in Kentucky Counties, 2013.


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FIGURE 4. Opioid Dependence: How Does it Work? www.hazeldenbettyford.org

Marvin D. Seppala, MD, Chief Medical Officer of the Hazelden Betty Ford Foundation

Initiation and

Addiction

Opioid molecules travel through the brain and attach to receptors, specialized proteins on the

surface of certain brain cells. The binding of these molecules with their target receptors triggers

the same chemical response in the brain’s reward center that occurs with anything that causes

intense pleasure or is intended to be reinforcing to survival itself. Rewarding and survival-based

activities result in release of dopamine in the brain’s reward center and opioids trigger the release

of dopamine in excess amounts. The brain recognizes this as something that needs to be repeat-

ed.

Maintaining

Addiction;

Increased Doses

Prolonged use of increasingly higher doses of opioids changes the brain so that it functions more

or less normally when the drug is present and abnormally when it is removed. The brain becomes

tolerant and dependent. In addition, the euphoria associated with use tends to diminish with reg-

ular use. The opioid receptors have changed at a cellular level, trying to protect them from over-

stimulation. A user is no longer chasing euphoria, but a sense of normalness.

Withdrawal and

Relapse

Avoiding withdrawal is what typically drives the continuation of use. Withdrawal from opioids

includes agitation, anxiety, itching, irritability, insomnia, goose bumps, rapid heart rate, mild hy-

pertension, vomiting and diarrhea. The withdrawal increases over time and can cause tremors,

intense anxiety, deep bone pain, and other debilitating symptoms. The body is effected long term

as well, resulting in depression, anxiety and cravings for months or years after even while main-

taining sobriety.

Treatment Opioid withdrawal is so intense that many individuals feel as if returning to the drug is their only

option to feel normal again. Most overdoses and deaths occur when a person relapses using the

same dose as when their tolerance was high during active addiction. The use of FDA-approved

medications in treatment provides the sense of “normalcy” needed to begin the healing process.

Figure 3. Depicts the

performance of ago-

nist drugs (e.g., meth-

adone) and antagonist

drugs (e. g. naloxone)

with the receptor

cites in the brain.


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Figure 5 Major Treatment Medications

Characteristics Methadone Buprenorphine Naltrexone

Brand Names Dolophine, Methadose Subutex, Suboxone, Zub-solv

Depade, ReVia, Vivitrol

Class

Agonist (fully activates opioid receptors)

Partial agonist (activates opioid receptors but produces a dimin-

ished response even with full occupancy)

Antagonist (blocks the opioid recep-tors and interferes with the reward-ing and analgesic effects of opioids)

Use and Effects

Taken once per day orally to reduce opioid cravings and

withdrawal symptoms

Taken orally or sublingually (usually once a day) to relieve

opioid cravings and withdrawal symptoms

Taken orally or by injection to dimin-ish the reinforcing effects of opioids

(potentially extinguishing the associ-ation between conditioned stimuli

and opioid use)

Advantages High strength and efficiency as long as oral dosing (which

slows brain uptake and reduc-es euphoria) is adhered to;

excellent option for patients who have no response to oth-

er medications

Eligible to be prescribed by cer-tified physicians, which elimi-nates the need to visit special-ized treatment clinics and thus

widens availability

Not addictive or sedating and does not result in physical dependence; a recently approved depot injection

formulation, Vivitrol, eliminates the need for daily dosing

Disadvantages

*Volkow, N.D., Frieden, T.R., Hyde, P.S. & Cha, S.S.

(2014) Medication-assisted therapies – tack-ling the opioid-overdose epidemic. The New Eng-land Journal of Medicine.

Mostly available through ap-proved outpatient treatment

programs, which patients must visit daily

Subutex has measureable abuse liability; Suboxone diminishes this risk by including naloxone,

an antagonist that induces with-drawal if the drug is injected

Poor patient compliance (but Vivitrol should improve compliance); initia-

tion requires attaining prolonged (e.g., 7-day) abstinence, during

which withdrawal, relapse, and early dropout may occur

Methadone has been proven to be a safe and effective option for treating individuals for opioid de-pendence. Maintenance treat-ment typically leads to reduction or cessation of illicit opioid use and its adverse consequences, includ-ing cellulitis, hepatitis, and HIV infection from nonsterile injection

equipment, as well as criminal behavior associated with obtain-ing drugs. Additional positive out-comes include a proven reduction in psychiatric symptoms, unem-ployment, and family or social problems (SAMHSA, TIP 43, 2014).

There are a few health risks relat-

ed to the use of methadone in-

cluding the concern of neonatal

abstinence syndrome (NAS) for

babies exposed to narcotics, such

as methadone, in the womb. The

official definition of NAS as out-

lined by the National Institutes of

Health reads, “Neonatal absti-

nence syndrome (NAS) is a group

of problems that occur in a new-

MEDICATIONS USED IN MEDICATION ASSISTED TREATMENT


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Quick Facts: Neonatal Abstinence Syndrome (NAS)

In the United States, 5.9% of pregnant women 15 to 44 years of age used illicit drugs in the past month (MacMullen, Dulsk & Blobaum, 2014).

Prenatal NAS—due to prenatal maternal use of substances. Abuse may result in withdrawal symptoms in the ne-onate once the placental access to the substance is no longer available.

Opiates can produce a longer and more threatening withdrawal.

The effect of drugs on body systems is also influenced by the type of drug, the combination of drugs, the amount and frequency of use, the trimester in which the drug is used, the timing of withdrawal, and the genetic suscepti-bility of the fetus/neonate (MacMullen, Dulsk & Blobaum, 2014).

The primary recommendation for assisting babies with NAS is to match the drug used to treat withdrawal to the type of drug abused (e.g., opiates are given to the neonate if withdrawing from opiates).

Only 24% of opioid-dependent mother’s breastfeed and 60% stop on the average after 5.9 days

Breastfeeding could potentially decrease the severity of NAS, delay its onset, and decrease the need for pharma-cologic treatment (MacMullen, Dulsk & Blobaum, 2014).

Concentrations of methadone and buprenorphine found in human milk are low (Pritham, Paul & Hayes, 2012); breastfeeding should be permitted and mothers educated on its benefits.

Treatment of co-occurring psychiatric disorders with antidepressants, benzodiazepines, or antipsychotics may

increase the effects of NAS (Pritham, Paul & Hayes, 2012).

born who was exposed to addictive

opiate drugs while in the mother’s

womb.” This condition may also

be referred to as neonatal narcotic

withdrawal syndrome. This is a

major concern for women who are

prescribed methadone while preg-

nant, as the baby is likely to suffer

withdrawal upon birth and experi-

ence intense discomfort. Risks al-

so exist for adults who are exposed

to methadone. The drug has the

potential to affect cardiac electro-

physiology which is linked to seri-

ous heart arrhythmias and sudden

death (Thomas et al., 2014). Risks

are manageable as long as the cli-

ent is using methadone as pre-

scribed and adheres to the guid-

ance of his or her physician. An

alternative to methadone is bu-

prenorphine, a partial agonist,

which has proven to be somewhat

safer than methadone.

Buprenorphine When compared

to methadone, buprenorphine pro-

duced similar rates of treatment

retention, abstinence from illegal

drugs, and proved to substantially

reduce illicit opioid use (SAMHSA,

TIP 43, 2014). The drug has also

been shown to improve self-help

group attendance and to be effec-

tive for both youths and adults

(Hazelden). In addition, Buprenor-

phine does not affect cardiac elec-

trophysiology and therefore, no

risk exists for lethal cardiac ar-

rhythmias. Buprenorphine howev-

er, can cause respiratory depres-

sion if taken in extremely high dos-

es. Studies also indicate that the

risk of NAS is lower for fetuses ex-

posed to buprenorphine than

those exposed to methadone

(Thomas et al., 2014).

Naltrexone When used as di-

rected, naltrexone is highly effec-

tive in reducing cravings and pre-

venting relapse (SAMHSA, TIP 43,

2014). Poorer outcomes have

been linked to clients who were

prescribed a methadone regimen

prior to beginning naltrexone

treatment. Studies also indicate

increased compliance when nal-

trexone therapy is supported with

payment scheduling and vouchers

(SAMSHA, TIP 43, 2014). A major

benefit associated with the pre-

scription of naltrexone is that it

cannot be abused by clients be-

cause an injectable version of nal-

trexone (Vitriol) is available to cli-

ents monthly causing no chance of


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MAT PROGRAMS

The design of MAT programs var-

ies but the basic components re-

main the same: medications bun-

dled with counseling. The follow-

ing section discusses COR-12, Ha-

zelden Betty Ford’s pioneer pro-

gram, and characteristics related

to alternative available MAT pro-

grams based on suggestions from

SAMHSA TIP 43.

COR-12 Hazelden has been in-

strumental in advocating for the

use of these FDA-approved medi-

cations in treatment for opioid de-

pendence. COR-12 was developed

in response to the growing need

for effective opioid treatment and

was fully implemented in 2013.

The official description of COR-12

as provided by Hazelden reads:

“COR-12 is the extended, adjunctive

use of medicines – in combination

with psychological and psychiatric

care; Twelve Step based counseling

and other therapies – to increase

the potential for those who have

the disease of addiction to achieve

long-term recovery.”

– 2013, Hazelden Foundation

COR-12 offers three primary path-

ways to those recovering from opi-

oid dependence: no medication,

buprenorphine/naltrexone, and

extended-release naltrexone. The

client always has a choice as to

how he or she prefers to receive

treatment and the pathways are

clearly outlined. Hazelden utilizes

an interdisciplinary team to en-

gage clients and pinpoint their ex-

act individualized treatment

needs. These teams analyze a cli-

ent’s medical and substance use

history, treatment and recovery

history, co-occurring mental

health issues, recovery environ-

ment and support network, and

risk of relapse to suggest the most

appropriate pathway for each cli-

ent. Hazelden’s individualized ap-

proach also offers a variety of

treatment settings in an effort to

provide the most effective treat-

ment possible. A key characteris-

tic of COR-12 pertains to how it

defines abstinence for clients en-

gaged in a medical pathway op-

tion for treatment. The develop-

ers of COR-12 were greatly influ-

enced by the creators of Over-

eaters Anonymous (OA) and Sex

Addicts Anonymous (SAA) when

formulating a concept of absti-

nence that involves a “drug” that

cannot be completely eliminated.

Participants in OA and SAA recog-

Figure 6 Other Opioid Addiction Treatments

Medication Assisted Treatment uses not only medication to treat opioid dependence but also a combination of counseling, case management, behavioral treatments and psychothera-pies based on the client’s individualized needs. Programs may vary in the services provided however, the following briefly outlines SAMHSA’s suggestions for counseling components in MAT.

Counseling and Case Management Individual Counseling – focus on feelings, coping skills, barriers, etc. Group Counseling – reduces sense of isolation with inclu-sion of peer support Case Management – Assistance pertaining to housing, medical care, etc.

Cognitive and Behavioral Therapies Node-link Mapping Community Reinforcement Approach Contingency Management Motivational Enhancement

Psychotherapy Modify or remove problematic thoughts, feelings, be-haviors; useful for chronic psychological and social prob-lems

Miscellaneous Topics for Treatment Effects of sexual abuse

Living with HIV/AIDS and Hepatitis C

Domestic Violence

From TIP 43: Medication-Assisted Treatment for Opioid Ad-diction in Opioid Treatment Programs, 2014.


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nize that food and sex are unavoid-

able, but have grown to under-

stand the choices and behaviors

that classify an action as A key

characteristic of COR-12 pertains

to how it defines abstinence for

clients engaged in a medical path-

way for treatment. The develop-

ers of COR-12 were greatly influ-

enced by the creators of Over-

eaters Anonymous (OA) and Sex

Addicts Anonymous (SAA) when

formulating a concept of absti-

nence that involves a “drug” that

cannot be completely eliminated.

Participants in OA and SAA recog-

nize that food and sex are unavoid-

able, but have grown to under-

stand the choices are behaviors

that classify an action as recovery-

based or relapsing. Recovery for

opioid dependence is achieved

when the individual is using medi-

cation as directed and not for the

use of intoxication, and if the client

is applying new

MAT programs may use alterna-

tive approaches to the application

of counseling without specifically

referring to the twelve-step pro-

cess. SAMHSA summarized the

possible avenues of counseling in

their TIP 43 on medication assisted

treatment. While these are not

requirements for MAT programs, it

provides details on what some pro-

grams offer clients in addition to

their medication. Encouraging cli-

ents to engage in counseling helps

them address psychological needs

that may have been the underlying

motivator of the addiction or a

barrier to recovery. Figure 6 briefly

outlines SAMHSA’s

suggestions for meet-

ing psychological

needs in MAT pro-

grams.

Federal Initiatives

Ample evidence sup-

porting the use of

MAT to treat opioid dependence

motivated the Substance Abuse

and Mental Health Services Ad-

ministration (SAMHSA) to award

grants to 39 states with the high-

est rates of primary treatment ad-

missions for heroin and opioids.

SAMHSA created Targeted Capac-

ity Expansion: Medication Assisted

Treatment – Prescription Drug and

Opioid Addiction (MAT-PDOA) RFA

No. T1-15-007. “The purpose of

this program is to provide funding

to states to enhance or expand

their treatment service systems to

increase capacity and provide ac-

cessible, effective, comprehensive,

coordinated care, and evidence-

based medication assisted treat-

ment (MAT) and recovery support

services to individuals with opioid

use disorders seeking or receiving

MAT (http://www.samhsa.gov/

grants/grant-announcements/ti-15

-007)”. This Funding Opportunity

Announcement (FOA) outlines

three key goals for states who re-

ceive funding:

1. Increase the number of individ-uals receiving MAT through pro-grams offering FDA-approved pharmacotherapies

2. Increase the number of individ-uals receiving integrated care

3. Decrease illicit drug use at 6-month follow-up

Kentucky was one of the states

selected to receive the grant based

on its need for expanded treat-

ment for opioid dependence. The

following section discusses Ken-

tucky’s need for an effective treat-

ment response to opioid addiction,

and outlines the grant and

DBHDID’s implementation of MAT

programs statewide.

MAT in Kentucky

The statistics related to Kentucky’s

opioid epidemic are startling, es-

tablishing the need for a compre-

hensive and effect treatment re-

sponse. Currently, overdose

deaths are more frequent than

motor vehicle deaths in Kentucky

with exceptionally high rates of

OD deaths seen in women of

childbearing age (18-44). (See Fig-

ure 7). In fact, Kentucky’s rates of

overdose deaths for women be-

tween the ages of 18 and 44 great-

ly surpass that of the national aver-

age. In addition, Kentucky has wit-

nessed a dramatic increase in the

number of babies hospitalized for

Figure 7. Source: Kentucky Injury Prevention and

Research Center


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NAS with numbers increasing

from 67 in 2001 to 1,016 in 2014.

Without effective treatments

available, mothers are often una-

ble to reach a state of stabilization

in which critical bonding and at-

tachment may occur between

mother and child. Healthy inter-

actions among mother and child

are critical to a child’s brain devel-

opment. MAT may facilitate at-

tachment between mother and

child as the mother can be posi-

tively engaged in parenting with

treatment.

These findings collectively sup-

ported the drive to expand treat-

ment services and to increase ca-

pacity for evidence-based MAT

and other recovery support ser-

vices to pregnant and parenting

women.

Kentucky’s Response

Kentucky’s program is known as

SMARTS (Supporting Mothers to

Achieve Recovery through Treat-

ment and Supports) INITIATIVE.

The project length is three years

with $1,000,000 being awarded

by SAMHSA every year for a total

of $3,000,000. These programs

treat women through a

partnership with two Community

Mental Health Centers in high-risk

areas of Kentucky: Cumberland

River Behavioral Health in Corbin

and Bluegrass.org in Lexington.

The DBHDID Project Director for

this initiative is Kris Shera, MPA.

Ms. Shera has outlined the

primary components currently

being implemented:

Creating a new system of care with evidence-based, compre-hensive, integrated, communi-ty coordinated service delivery systems for pregnant and par-enting women up to two years post birth with opioid use disor-der that addresses current ser-vices deficits and includes ac-cess to MAT; includes Hazelden Betty Ford Foundation’s Com-prehensive Opioid Response – Twelve-Steps (COR-12) ap-proach; and includes wrapa-round services to assist these clients with meeting medical, social, childcare, housing, edu-cation, and vocational needs that serve as barriers to treat-ment and recovery.

Figure 8. Source: Kentucky Department of Medicaid Services Claims Database


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Quick Facts for SMARTS SMARTS goal is to create a sustainable and comprehensive array of interconnected services.

Target population: pregnant and postpartum women up to 2-years post-birth who have an opioid use

disorder. Each enrolled client should receive services appropriate to her treatment and recovery sup-

port needs for minimum 12 months after delivery, and up to 24 months as needed. Services should in-

clude parenting training and coordination of care for the infant.

Target Numbers: Grant project will serve a total of 500 pregnant and parenting women over three years

of the project.

o Bluegrass – 58 in first year, total 290 over 3 years

o Cumberland – 42 in the first year, total of 210 over the 3 years

Eligibility: Referrals accepted from any source; woman must be pregnant or postpartum 6 months post

birth with an opioid disorder and accept services.

Enrollment: Case managers complete an assessment and enroll the woman; will also identify appropri-

ate level of care through ASAM criteria and develop with the client a service plan. Client is entered into

the Service Point system, MAT is explained and offered as an option, and medication is decided upon

with medical team approval.

Promoting community partner-ships by facilitating meetings and work sessions to examine how to best provide these com-prehensive services promote community education and max-imize efficient use of resources.

Enhancing information sharing through technology infrastruc-ture to support service delivery.

Providing extensive training and workforce development oppor-tunities for both the medical and behavioral health work-force.

Kentucky’s ultimate goal is to cre-

ate a sustainable program that

provides a comprehensive array of

interconnected services that ex-

tends well beyond the life of the

grant. SMARTS has established

five expected outcomes:

1. Increased access to MAT, wrapa-round services and treatment;

2. Increased number of individuals receiving comprehensive, integrat-ed, community coordinated care;

3. Reduction in adverse childhood experiences and intergenerational substance abuse patterns;

4. Decreased illicit drug use among the target population at 6 months follow-up; and

5. Formation of a comprehensive, sustainable system of care that can be replicated throughout the Commonwealth.

When the project officially con-

cludes in late July 2018, the hope is

that the SMARTS will have created

lasting improvement to treatment

access and services for pregnant

and parenting women. While

women constitute a large popula-

tion of underserved individuals

with opioid dependence, many

other individuals are in need of

quality, evidence-based treat-

ments. The next section discusses

Narcotic Treatment Programs

(NTPs), existing treatment pro-

grams which are available to a

wide variety of clients with opioid

dependence.

Narcotic Treatment Programs (NTPs)


(also known as Opioid Treatment

Programs or OTPs) are in 21 sepa-

rate locations in Kentucky for any-

one struggling with opioid de-

pendence. Ron Easterly, M.D.,

MPH, with BHDID, is the state’s

acting State Opioid Treatment Au-

thority (SOTA) and discussed the

role of NTPs in opioid depend-

ence. The narcotic treatment pro-

grams (NTPs) within the state of

Kentucky’s opioid treatment re-

sponsibility falls under the regula-

tory requirements of 908 KAR

1:340 (narcotic treatment pro-

grams) and 908 KAR 1:370


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(licensing procedures nd stand-

ards for persons and agencies op-

erating nonmedical-based and

nonhospital-based alcohol and

other treatment programs).

There are NTPs spread around

the state, and they each provide

medication-assisted treatment

for individuals whose goal is to

reduce and eliminate an individu-

al’s dependence upon an opioid

substance. (See Figure 9.) The

primary treatment medication

prescribed is methadone, but a

number of programs also are eli-

gible to dispense buprenorphine

in addition to methadone. health

and safety of the clients as well as

ensure the security and control of

the medications. This control in-

volves the regulation, storage,

dosing and administration and to

maintain efficacy and verify ac-

countability.

The NTPs themselves provide

medically monitored drug treat-

ment and related counseling ser-

vices to patients who are physio-

logically dependent upon a nar-

cotic drug such as heroin, mor-

phine and other opioids such as

oxycodone and hydrocodone.

Their mission is to empower per-

sons with Opioid Use Disorder so

they can recover their health and

improve their quality of life. The

goal of NTPS is to provide a safe

environment that includes a com-

prehensive, structured recovery

program of counseling, educa-

tion, medical care and case man-

agement. Patients are required

to abstain from illegal and unap-

proved drug use. Through treat-

ment, patients can reestablish

and recover family and social re-

lationships and pursue or main-

tain meaningful employment.

(See a complete list of NTP’s in

Figure 10.)

In addition to the ongoing over-

sight of the NTPs, the program is

also responsible for the evalua-

tion of requests from the pro-

grams for approval of waivers or

exceptions to the regulations for

individual clients whose particular

circumstances may require an ad-

justment or change in the medi-

cation dosing routine. These re-

quests are examined in accord-

ance with guidelines to assure

compliance with the regulatory

requirements and approved or

denied accordingly. Where ap-

propriate, comments or explana-

tions are provided with the deci-

sion in order to assure there is

complete understanding on the

part of the requesting program.

Information and data relating to

the NTPs is maintained by

DBHDID to evaluate trends, asso-

ciations, or disparities in the oper-

ations of the programs. This also

includes a tracking system and

evaluation checklist that accom-

panies each incoming waiver or

Figure 9. Narcotics Treatment Programs/Opioid Treatment Programs in 19 cities with 21 locations around Kentucky


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Program Name Street City Zip Phone

Ultimate Treatment Center 3655 Winchester Avenue Ashland 41101 (606) 393-4632

Center for Behavioral Health Ky, Inc. 1990 Louisville Road, Suite 110 Bowling Green 42101 (270) 782-2100

BHG XXXIV, LLC 967 South Hwy. 25 West Corbin 40702 (606) 526-9348

NKY Med Clinic, LLC 1717 Madison Avenue Covington 41011 (859) 360-0250

E-Town Addiction Solutions, LCC 2645 Leitchfield Road, Suite 104 Elizabethtown 42701 (270) 234-8180

Center for Behavioral Health Ky, Inc. 2225 Lawrenceburg Rd., Building C Frankfort 40601 (502) 352-2111

BHG XXVI, LLC 48 Independence Drive Hazard 41701 (606) 487-1646

Western KY Medical, LLC 609 Hammond Plaza Hopkinsville 42240 (270) 887-8333

BHG XXXV, LLC 340 Legion Drive, Suites 32 Lexington 40504 (859) 276-0533

Bluegrass Narcotics Addictions Program 3161 Custer Drive Suite 4 Lexington 40517 (859) 977-6080

Methadone Opiate Rehabilitation Ed. Ctr. 1448 South15th St. Louisville 40210 (502) 574-6414

Center for Behavioral Health Kentucky, 1402-A Browns Lane Louisville 40207 (502) 894-0234

BHGXXXIII, LLC 4625 Falcon Crest Paducah 42001 (270) 443-0096

BHG XXIV, LLC 628 Jefferson Ave. Paintsville 41240 (606) 789-6966

BHG XXV, LLC 368 South Mayo Trail Pikeville 41501 (606) 437-0047

Pinnacle Health, Carroll 539 A 11th St. Carrollton 41008 (502 ) 732-3070

Pinnacle Health, Simpson 2714 Nashville Rd. Franklin 42134 (270) 253-3078

Pinnacle Health, Georgetown 105 Eastside Drive Georgetown 40324 (502) 868-0664

Pinnacle Health, Maysville 152 E. 2nd St. Maysville 41056 (606) 564-0303

Pinnacle Health, Daviess 3032 Hwy 60 Owensboro 42303 (270) 685-5029

Center for Behavioral Health Ky, Inc., 1018 Ival James Blvd., Ste C Richmond 40475 (502) 352-2111

Figure 10. Kentucky NTP/OTP Contact Information

exception request in order to en-

sure accuracy and maintain ac-

countability. The information and

data relating to the NTPs is main-

tained by DBHDID as the state

oversight agency in order to as-

sure that the NTP meet the high-

est standards of accountability in

the performance of their NTP ser-

vice responsibilities.


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Lockbox Distribution Campaigns – done in

partnership with law enforcement, DCBS,

pain clinics, etc.

Awareness Campaigns – use of brochures,

billboards, social media, radio, and televi-

sion PSAs concerning opioids

Coordinating community and professional

trainings and policy regarding substance

use, opioid addiction, naltrexone, MAT, and

needle exchanges

Conducting trainings with school nurses,

health department staff, parents, coalition

groups, physicians, first responders, and law

enforcement

Assisting community partners in developing

curricula and policy regarding substance us

Holding community forums to discuss the

opioid crisis

FIGURE 11. REGIONAL PREVENTION CENTERS:

RESPONSE TO OPIOID ADDICTION CRISIS

Regional Prevention Centers

The opioid crisis in the state of Kentucky requires

strong prevention. Currently underway are coordi-

nated actions to curb increasing rates of opioid use

and dependence. The Prevention Branch within

DBHDID provides federal and state funding and oth-

er support to the Regional Prevention Centers

throughout Kentucky. The principle funding source

for RPCs is the SAMHSA Substance Abuse Preven-

tion and Treatment (SAPT) Block Grant Regional

Prevention Centers (RPC) work in a variety of set-

tings and with diverse partners to address substance

use in Kentucky. RPCs are regionally based and cov-

er anywhere from five to 17 counties. There are 14

RPCs in Kentucky. RPCs are charged with the respon-

sibility of working with community partners to re-

duce drug use and abuse. The goal is to empower

communities through skills training and technical as-

sistance so that they become mobilized around sub-

stance use prevention. RPC’s work with community

coalitions whose purpose it is to address problems

locally. RPC’s provide support to local Drug Free Co-

alitions (DFCs), Agencies for Substance Abuse Pre-

vention groups (ASAP), faith community, schools,

law enforcement, treatment providers, and the med-

ical community.


13 | P a g e

Q & A with Dr. Allen J. Brenzel, M.D., MBA

Medical/Clinical Director for Department for Behavior-

al Health, Developmental & Intellectual Disabilities

Medication Assisted Treatment

Q: What is your philosophy concerning Medication Assisted Treat-

ment (MAT)?

Brenzel: MAT is a critical tool in our toolbox of interven-

tions to allow those with opiate dependence to enter and

maintain recovery. Opiate Addiction changes brain chemis-

try in profound ways. For some, medications are the critical

first step in allowing the individual to develop control over

intense cravings and diminish withdrawal symptoms to

manageable levels. It is at this point that healing can begin

and the individual is capable of benefitting from associated

interventions.

Q: There is a great deal of concern about MAT drugs being diverted

for non-prescribed use. Do you see this as a problem and if so what is

DBHDID (the Cabinet) doing about it? Are there any messages that

you think are important related to diversion?

Brenzel: Some of the medications used in MAT have po-

tential for misuse and illegal diversion. Because of this,

Methadone for addiction treatment is prescribed in moni-

tored setting with close monitoring and limited take home

dosing. Buprenorphine can be prescribed for up to 30 day

supplies; however, for it to be prescribed appropriately,

those in treatment should be seen regularly, have random

drug screens, and be required to be in active therapies and

supports such as peer mediated support network. CHFS

has worked with the Kentucky Board of Medical Licensure

to issue revised scope of practice regulations that set expec-

tation for appropriate prescribing and monitoring. The Cab-

inet has worked with Managed Care Organizations to insure

that Managed Care Medicaid plans provide preauthoriza-

tion requirements that specify dosing and monitoring are

occurring and that individuals are in treatment as well re-

ceiving medications. BHDID is working to develop access

to high quality MAT services through increasing provider

networks.

Continued on page 14..


14 | P a g e

More of the Interview with Dr. Brenzel

Q: In reality there still appears to be a great deal of stigma within the general public

(and perhaps among providers) about the use of MAT in treating SUD. There also

appears to be a continuing belief that abstinence is the only approach that works.

Do you see any progress on this front?

Brenzel: It must be recognized that addiction is a brain disorder and that especial-

ly opiate addiction involves changes to brain chemistry are so substantial that

medications may be required. Relapse rates in abstinence only based treatment

indicate that many individuals may not be able to directly to abstinence based re-

covery. I do believe we are making progress in recognizing that the best treat-

ment is individualized to the person and that MAT is not “substituting one addic-

tion for another” but a lifesaving and appropriate treatment.

Q: Another long held concern about MAT is the view that it is trading one drug for

another. Do people really ever get off opiate replacement drugs completely? How

long is the maintenance phase on average?

Brenzel: With MAT, the initial goal is tapering and discontinuing the medication

support when clinically appropriate. For some, due to the chronic and relapsing

nature of addiction, medication support may be required on an on—going basis.

Science has not yet determined what percentage of individuals may require long

term medication. It could be as high as 30 percent.

Q: What is the Department of Behavioral Health, Developmental and Intellectual

Disabilities (or the Cabinet) doing to ensure access for individuals who want MAT?

Brenzel: The key will be working to create an adequate network of high quality

providers through education, advocacy for appropriate reimbursement including

considering bundled payment options, and ongoing training and support for pro-

viders.

Q: Despite all the bad news in the press about the spread of heroin and the related

overdose deaths, is there any good news out there related to our efforts to either

reduce the availability of opioids and/or improve treatment for those who are ad-

dicted?

Brenzel: With the addition of Substance Abuse Treatment ser-

vices as a covered benefit in the Medicaid program, and the en-

actment and emerging enforcement of the Mental Health and

Substance Abuse Parity Act, we are beginning to see improved

access to treatment and the development of a more robust and

evidence based provider network.


15 | P a g e

This Just In… New legislation made possible KRS

217.186 which supports the use of Nalox-

one and protects any person administer-

ing Naloxone in good faith from criminal

and civil liability.

201 KAR 2:360 – pharmacists are permit-

ted to dispense Naloxone if they have

received the required training and have

an agreement with a doctor to dispense.

Some insurance plans may cover the cost

of the kit however; many will have to pay

out-of-pocket. Humana Care Source, a

Medicaid Managed Care Organization,

has agreed to cover the cost. The Ken-

tucky Board of Pharmacy has trained

roughly 500 pharmacists across the state.

Kroger in northern Kentucky has required

all pharmacists to receive training, while

CVS has also proven adamant about in-

creasing the availability of Naloxone. See

Figure 9 for a portrayal of how Nalox-

one reverses the effects of opioids.

Narcan is the trade name for Naloxone;

the FDA has approved a Narcan nasal

product and Adapt Pharma has agreed to

sell kits to the public sector for $75.00.

The Clinton Foundation has teamed up

with Adapt Pharma to fund one kit for

every single high school in the US – Ken-

tucky included. BHDID children’s branch

will be available to teach schools how to

screen and refer youth with substance

use issues for treatment services.

People Advocating Recovery (PAR), KY

Harm Reduction Coalition, UK Hospital,

UofL Hospital, St. Elizabeth Hospital and

UK Adolescent Psychiatry are working

toward distributing naloxone kits.

Figure 12. Demonstrates how an opioid overdose oc-

curs and how Naloxone is able to intervene and reverse

the overdose.


16 | P a g e

References

Fullerton, C.A., Meelee, K., Thomas, C.P., Lyman, D.R., Montejano,

L.B., Dougherty, R.H., … Delphin-Rittmon, M.E. (2014). Medica-

tion-assisted treatment with methadone: Assessing the evidence.

Psychiatric Services, 65(2), 146-157.

MacMullen, N.J., Dulsk, L.A., & Blobaum, P. (2014). Evidence-based

Interventions for neonatal abstinence syndrome: Pediatric Nurs-

ing, 40(4), 165-203 39p.

Pritham, U.A., Paul, J.A., & Hayes, M.J. (2012). Opioid dependency in

Pregnancy and length of stay for neonatal abstinence syndrome.

JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 41

(2), 180-190 11p. doi:10.1111/j.1552-6909.2011.01330.x

Substance Abuse and Mental Health Services Administration. (2014).

Treatment Improvement Protocol: TIP 43. Rockville, MD: U.S. De-

partment of Health and Human Services.

Thomas, C.P., Fullerton, C.A., Meelee, K., Montejano, L., Lyman,

R.D., Dougherty, R.H., … Delphin-Rittmon, M.E. (2014). Medica-

tion-assisted treatment with buprenorphine: Assessing the evi-

dence. Psychiatric Services, 65(2), 158-170.

Volkow, N.D., Frieden, T.R., Hyde, P.S. & Cha, S.S. (2014) Medication

Assisted therapies – tackling the opioid-overdose epidemic. The

New England Journal of Medicine, 370(22), 2063-2066.

Resources

For more information on COR-12 please visit www.hazeldenbettyford.org

For more information on Medication Assisted Treatment and the evidence

supporting its use visit:

http://www.samhsa.gov/medication-assisted-treatment

https://www.whitehouse.gov/sites/default/files/ondcp/recovery/

medication_assisted_treatment_9-21-20121.pdf

http://attcnetwork.org/about/about.aspx

Institute for Excellence in

Behavioral Health

Louis Kurtz, M.Ed. Interim Director

351 Perkins Hall

Eastern Kentucky University

Office: 859-622-7281

[email protected]

[email protected]

Website: www.iebh.eku.edu

Kentucky Department of Behavioral Health Developmental and Intellectual

Disabilities

KY SMARTS Grant Initiative

Kristopher Shera, MPA MAT-PDOA Pro-ject Director,

[email protected]

502-782-7802


Ron Easterly, M.D., MPH State Opioid Treatment Authority [email protected]

502-782-6250

Regional Prevention Centers

Phyllis H Millspaugh, M.A. Branch Man-ager, [email protected]

502-782-6234

Printed in part or whole with federal or state funds M/D/F

Contact Information

The Institute for Excellence in Behavioral Health is a contracted initiative of the Department for Behavioral Health, Developmen-tal and Intellectual Disabilities in

partnership with the Training Resource Center.

Documents

Issue Number 4: Medication Assisted...Medication Assisted Treatment (MAT) is an evidence-based practice in which a client is treated for a Substance Use Dis-order through the combined