10/30/16 Doug McVay

This week we listen in on a hearing at the New Mexico State Legislature about opiate use and heroin maintenance treatment.

Century of Lies
Sunday, October 30, 2016
Doug McVay
Drug War Facts
Download: Audio icon col103016.mp3



OCTOBER 30, 2016


DEAN BECKER: The failure of drug war is glaringly obvious to judges, cops, wardens, prosecutors, and millions more now calling for for decriminalization, legalization, the end of prohibition. Let us investigate the Century Of Lies.

DOUG MCVAY: Hello, and welcome to Century Of Lies. Century Of Lies is a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I'm your host Doug McVay, editor of DrugWarFacts.org.

The New Mexico State Legislature is currently between sessions. They are still at work however, with several committees holding intersessional hearings for informational purposes and to potentially shape future policies. On Friday October 28, the state's Legislative Health and Human Services Committee and the Courts, Corrections, and Justice Committee, both of which are House-Senate joint committees, met together to talk about opiate policies, including prescription monitoring, alternative healthcare, and addiction treatment.

On today's show, we're going to hear part of their discussion on medication-assisted treatment. We used to call that methadone maintenance, but nowadays we have other choices, including buprenorphine and suboxone. Substitution treatment is another term for the concept, but the idea of substituting one drug for another raises red flags for some people, even if there are huge benefits to both society and the user from getting them to switch, and even though years of experience and intensive research shows that substitution – sorry, medically-assisted treatment – works. In fact it's the only treatment modality for which we have solid evidence of its effectiveness.

I could go on, but instead, you can look this stuff up on DrugWarFacts.org, and for now, we'll listen to that hearing. The voices you're about to hear include Eugenia Oviedo-Joekes, an associate professor at the School of Population and Public Health at the University of British Columbia, Canada; Miriam Suzanne Komaromy, MD, an associate professor of medicine at the University of New Mexico; and Andrew Hsi, MD, a professor of family and community medicine at the UNM. The first speaker on the panel is Lindsay LaSalle, a senior staff attorney for the Drug Policy Alliance.

LINDSAY LASALLE: I am very excited about the opportunity to present a novel form of medication assisted treatment to you today that is not yet available in the United States. I first want to frame the issue brieflly, and I'm going to hand it over to my colleague from the University of British Columbia, who will speak to the research behind this treatment, and specifically to the clinical trials that she's been a principal investigator of, and then I will circle back to expound a little bit on how I think we can move this unique treatment modality forward in the United States.

The treatment that I am referring to diacetylmorphine assisted treatment. It's also called heroin assisted treatment, and it is quite simply providing pharmaceutical grade heroin to people who are dependent on heroin. It has been studied rigorously in nine different countries, it currently operates in, six countries: Germany, Switzerland, the Netherlands, Denmark, clinical trials going in Canada, and all of the research has pointed to it being an incredibly effective treatment for the small percentage of people who do not respond well to the typical forms of medication assisted treatment such as methadone and buprenorphine. Those are incredibly useful treatments that serve the vast majority of the population, but for a slim percentage, it doesn't work, and so we want this kind of second line treatment to be available to New Mexicans.

Why New Mexico? I mean, I think partly, you guys have an incredible history of kind of pushing the ball forward on innovative drug policy reform. The first state to license the production and distribution of medical marijuana, which at the time was seen as incredibly radical, and now how many states have we seen follow in your footsteps? Now we're to the point where recreational marijuana is being legalized. It's no longer seen as taboo, rather it's seen as the legitimate medicine that it is. The first state to pass a Good Samaritan Law, to recognize the crisis that you are facing in your backyard and how best to address it.

And so again, this is another intervention or treatment modality that at first glance might seem a bit radical, but when you hear the research that my colleague presents, I think you will see that it's grounded in science, that it's grounded in common sense, and I think it's something that, when I come back to address it a little bit, that we can really move forward in the United States, particularly if New Mexico is at the helm. So with that, I'll let my colleague speak.

PROFESSOR EUGENIA OVIEDO-JOEKES, PHD: Thank you. Good afternoon, Mister Chair, members of the Committee, thank you very much for having us today here. My name is Eugenia Oviedo-Joekes. I'm a researcher and faculty member at the School of Population and Public Health, University of British Columbia. I'm trained as a clinical psychologist, and then did a PhD in Behavioral Science Methodologies, and mostly started working on -- in Spain in public health and finding alternative treatments for people, you know, struggling with opiate dependency, and also socially excluded, so mostly for the most vulnerable folks in our communities that we need treatments available to them.

This is -- I have been in Canada for ten years. I've been part of the NAOMI clinical trial, testing injectable diacetylmorphine compared to ordinary methadone. That study was published in the New England Journal of Medicine. Then after that, the federal government did not allow us to continue providing injectable diacetylmorphine, so we set up a second study, bringing up an opiate pain medication that a short-acting and potent, that is called hydromorphone, here it's known as Dilaudid. And we did double-blind study that I'm the PI, Principal Investigator. We've finished, we showed that again, injectable hydromorphone and diacetylmorphine, both medications very effective, and we publish in JAMA Psychiatry in past April.

These are two of the 8 randomized clinical trials, that is the gold standard to test treatments, and to make evidence available to the healthcare system to start providing them. As Lindsay was saying, diacetylmorphine, that is, pharmaceutical grade heroin, has shown to be extremely, extremely effective for a small group of people. And you have these slides that I have, just for guidance, I'm not going to go through all of them, but if -- I wanted to speak about a bit -- about, the -- in page number two, the second slide, where we call this supervised mode of care. It is very important for the work we're doing and what exactly we are testing when we are testing injectable diacetylmorphine.

This model of care started in Switzerland, and when -- if you, many of you might know how the Switzerland healthcare system works, it's a very rich and conservative country, and once they had supervised facilities for their people to use their medication, the drugs, and inject, or smoke, in the facilities, they had methadone, at the time there were the -- buprenorphine was not yet available, and they had all this in place and still, an important minority of people were injecting heroin in the streets. So, as commonsense was guiding them, they opened what they called a clinic, that is actually a room with a backroom, and studied providing pharmaceutical grade heroin.

In that way, they will engage people into care, provide a safe place for using medication that is medically prescribed, and if something happened to the patient, somebody will be there to act promptly and prevent a fatal overdose. This model spread really quickly in every other European country that was willing to implement, and then Canada tried to do so with the US. In the beginning we had, for the NAOMI study, three US sites that were going to participate, but the barriers for our cousins were too high, and we went ahead with two sites in Canada, Montreal and Vancouver.

After that, it was decided that we have -- right now we have -- right now, one clinic operating and, based on -- our healthcare provider is a Catholic institution, Providence Healthcare. They are the ones bringing pharmaceutical grade heroin and also providing hydromorphone. 140 patients receive either hydromorphone or diacetylmorphine injectable, and right now, last week, two other patients are receiving, outside of our clinic, in also safe -- a safe environment, another community clinic, injectable hydromorphone. We can access the pharmaceutical grade heroin through the Special Access Program, since it's not really licensed yet in Canada, but the hydromorphone is licensed for pain, so we use it off-label with the blessing of the College of Physicians.

So, what are the best outcomes that we can show with this treatment? Once you have offered your patients either methadone or suboxone and they're still not dong well in those treatments, means they're still using, injecting opiates in the street, it's time to offer an alternative, and that's what this treatment does. In places where this is a problem, it does not account for more than ten percent of everybody in treatment. This has a very small but very important in the addiction treatment system, and helps people to stay engaged in care.

The supervised model of care is a place where the patients come and use the medications on site, and the medications cannot leave the facility. This ensures that the patient's going to be safe if anything happens, and then that you don't have a potent opioid in the streets, that raises the liabilities of the healthcare system and the healthcare providers.

The importance of offering a short-acting opioid that seems to be very enticing and gives this amount of motivation that some of our folks need to re-engage in structured care. The people we see in our treatment are people that have been using injectable, mostly heroin but other opioids if there are shortages of heroin, and other opioids get into the market, have been injecting for 15 years, they have many chronic illnesses -- Hep C, ninety percent of our patients have Hep C. We have patients dealing with other chronic illnesses like cancer, smoking, problems in their lungs. So when we engage them in treatment, we meet them where they're at, they stop using, injecting in the street, and we have an opportunity to see them three times daily, that's the number of times they come, and offer them comprehensive care.

So, this treatment is meant for a small minority of people that have gone through a lot and they reach the healthcare system with a lot of needs, and we give an opportunity to start working with those. Once we engage them in our care, we can refer them to proper treatments when they are available, either for housing or for HIV treatment. We provide HIV treatment and smoking cessation and Hep C treatment on site. We also have counselors on site, or close by, in that way we don't miss our opportunity to have them on hand. And over the months, on treatment, we have an 80 percent retention in treatment. For any of you that have been working in this field, you will know that that on its own is something to take advantage of. It's not very easy to have an 80 percent retention in treatment, and that is an opportunity to do a lot for our clients.

I don't want to take too much more time. Sometimes I get the question about issues with the dosing. I have left some data for you there. In a summary, for dosing, our patients reach a safe and effective dose, and after that, they don't continue increasing, because patients want to have a dose that allows them to still feel something when they inject, and there is a safe dose that's not going to cause an overdose.

If you look at page five, the last -- the second slide, of 197,000 treatment injections that we provided, within the two clinical trials, we only had 27 episodes of overdoses that required Narcan. So more than -- almost 200,000 injections, and only 27 overdoses. That sometimes happens. Nobody had to be -- nobody died, nobody had to go to the hospital. Promptly treated with Narcan. It's that sometimes you're not the same person when you wake up, some other people might have used other stuff in the street, like crack cocaine, that might be laced. Or some days, the tolerability has been different. But nothing has happened, and everybody has been cared for promptly.

So before passing it to Lindsay, I just want to reiterate our conclusion, that we have a large pool of data that support implementing this treatment for the very small but very important minority of people, the people that show up mostly daily in emergency rooms that do not seem very enticed to follow structured treatment when they are the ones that need it the most. And this treatment modality is, even in countries where it's really available, Switzerland has 23 clinics, two of them in prison, they never were over capacity, they are 90 percent capacity. So, thank you very much, and I'll pass it to Lindsay.

LINDSAY LASALLE: Thank you. And before I get into how we can move this forward in the United States, I want to just follow up a bit on what Eugenia said. In addition to having an 80 percent retention rate in treatment, when we think about why would we want to push this forward in the United States and why is it important, even though it is a small minority of people that we are reaching, this is the group of people that actually take up the most societal resources, through things like emergency room visits, overdoses, the healthcare that is associated with abscesses or lesions.

And, in terms of the criminal justice costs, these are the folks that are cycling in and out of our criminal justice system, over a period of decades, literally decades, because the eligibility criteria for some of these clinical trials have been 20-plus years of usage, so you're talking about 20 years of cycling in and out of the criminal justice system, and the results that have come out of these randomized controlled trials have been that retention in treatment is great, illicit substance use goes down because they're receiving their medication in a clinical setting. All of the acquisitive crime, the crime that people commit in order to be able to pay for their drugs, goes down. Crime and kind of nuisance concerns within the neighborhood of the clinic goes down.

You see improved functioning on many different levels, whether it be social, you know, familial relationships, health, and in addition to kind of the initial, like, preventing overdose and treating infectious diseases and preventing infectious diseases. So there's this body of evidence that has been amassed, in an international context, that really supports moving this forward here, particularly nationally. And in your state, that has kind of had the highest overdose death rates and kind of is, you know, an example of the kind of severity of our opioid crisis in this country, why it's needed here.

And Eugenia mentioned that initially, the trial in Canada was North American, and that was because there were supposed to be sites in the United States. That didn't move forward because we were working directly with the federal government. Now, this is going to require federal government assistance. Heroin is an illicit substance. In order to move this forward, we are going to need a research exemption that would be granted by the Attorney General, and then in order to import the heroin for use in the trial, we would have to go through the DEA, who would reach out to the International Narcotics Review [sic] Board to actually import that in.

So the federal government's going to have to be involved. So then the question is, what role is there for the state? And I think there's a very important role. I mean, I think that the history of drug policy in our country has always shown that states really move the ball forward with respect to drug policy, and then the federal government follows. Quite frankly, the federal government is not concerned with what's happening in your backyard. They're not concerned with the overdose deaths that you guys are faced with daily, or the resources that those require, and the output of effort that is required in order to meet that public health challenge.

And so whether it be in the context of medical marijuana, where the states pushed that out and then the federal government, you know, ultimately issued the memo that says, okeh, we're going to let states go forward with the policy that they feel is most appropriate in their jurisdictions, or in the context of harm reduction services and syringe exchange, I mean, it took the states coming forward and saying, we have to provide syringe exchanges so that our citizens do not die of HIV and AIDS. And then you see that the federal government comes along and says, okeh, we're going to, you know, remove the federal funding restrictions on syringe exchange.

And so there's this history there, and so without really moving this forward at a state level, and saying, we as a state feel that this is a necessary intervention for our population, the federal government is not going to act. But, if the state really is pushing this, then there is a much higher chance that there is cooperation from the federal government to kind of jump over these purely logistical barriers. I mean, the heroin is imported and people do studies, not in this exact framework, but it happens quite frequently. So it's really just a mattter of political will, and putting that pressure on the federal government.

And so to that end, both Nevada and Maryland have introduced legislation that would establish a pilot heroin assisted treatment program in their states. They did that last session, it did not pass initially. We recognize that these are probably going to be multi-year efforts, just based on the amount of education that needs to be done around this totally new treatment modality, but they will be introduced again this session. And that other benefit is that they are tailored to the needs of that state, so if you have something that's run at the federal government level, it's not going to be tailored to the unique challenges that you might face in New Mexico that are going to be wholly different than a heroin assisted treatment program operating out of New York City.

So I thank you very much for your time and consideration of this really important medical treatment.

DOUG MCVAY: You're listening to Century of Lies, a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I'm your host Doug McVay, editor of DrugWarFacts.org. We're listening to a hearing before two joint committees of the New Mexico state legislature, they're discussing opiates, medication assisted treatment, and heroin maintenance. Let's get back to that hearing.

PROFESSOR MIRIAM SUZANNE KOMAROMY, MD: I'm Dr. Miriam Komaromy, I'm an internal medicine physician and an addiction specialist, and I was invited to come and talk a little bit about our work at ECHO in increasing access to treatment using medications for opioid use disorder.

I think many of you are familiar with the ECHO model, so I will just briefly touch on that. On the front page you can see a picture that shows a typical tele-ECHO clinic. And as many of you are familiar with, in the large picture, there are experts at the University of New Mexico, and they are connected by video conference with multiple primary care providers. So I'm on the front page, in the middle picture there.

So these specialists at the University are providing consultation and teaching to primary care teams around the state or around the region. And this model has been in existence for 13 years. We here in New Mexico are the originators of it, and it has now spread around the country and increasingly around the world, is a teaching modality to help primary care providers, frontline providers, to acquire skills and knowledge that allows them to expand the types of treatment that they're able to offer in their own communities.

As you know, also, ECHO is an evidence based modality. We now have a number of studies showing the effectiveness of this method for promoting effective treatments, such as treatment of hepatitis C that can be delivered as safely and effectively by primary care teams with ECHO support as specialists in the university setting can do.

On page three, I turn to the issue of what Project ECHO has been doing with substance use disorders. So, for the last 11 years, I have been running a tele-ECHO program focused on substance use disorders, and also that discusses other behavioral health issues. So for 11 years, for two hours every week, we convene at the university of New Mexico and we have primary care providers join us by video to present patients from their own clinics. Through this method we've trained now hundreds of physicians and other healthcare providers to treat substance use disorders of various different kinds.

Increasingly we have folks joining from other states as well who have an interest in learning more about how to treat substance use disorders. Down at the bottom of page three you can see a snapshot just from 2014, of all of the different sites in New Mexico who joined our tele-ECHO clinics. You can see that we had great penetration into rural and typically underserved areas in the state, although there were a lot in Albuquerque, where most of the humans live, there were lots of other humans out in the periphery who got care as well because other communities had providers who joined.

We average about 147 participants a year, and these are healthcare providers, these are not patients, so close to 150 healthcare providers a year participate in our tele-ECHO clinics and learn about treatment of substance use disorder from presenting patients to us. And opioids have been the type of substance use disorder that's been the most commonly presented. In the middle of page four, you can see a bit of data about the impact of the kind of case based learning that we offer.

So, when someone presents a case to us, we ask them about what was the value of the clinical input that you received from your presentation? And the participants' average response was 4.8 out of a possible 5, so they really valued the input that they received, and when we asked them whether the input changed their management plan, three quarters of the participants said that they changed their plan after presenting their patient on our ECHO substance use disorder clinic, so indicating that they really had need for that expert consultation in order to provide best quality care.

I was asked to talk a little bit about the options that are available for medication assisted treatment in the United States. And the medications that are approved, as you probably know, are methadone; buprenorphine, which is the active ingredient in Suboxone; and injectable Naltrexone, which is the long-acting opioid blocker. All three of these have been shown to have effectiveness, and so we teach about all of them in the ECHO substance use disorder clinic. They have somewhat different indications, and it's important to really have access to all of them for folks who have an opioid use disorder.

You'll note that I don't use the term "medication assisted treatment," because to me, that's kind of standing the issue on its head. The part of the treatment of opioid use disorder that has been clearly shown to have the greatest effect at saving lives and reducing relapse is the medication. The behavioral health component is extremely important as well, but when we say medication assisted treatment, it makes it sound like that's the optional part and it's really the counseling that's need. In fact it's the other way around, that the medication is the bedrock of treatment and it is what's been shown most effectively to save lives.

So, at the top of page five, you can see a few of the many benefits that have been demonstrated for medication treatment of opioid use disorder. Probably most important is that it's life prolonging, people are less likely to die of their substance use disorder if they're on medication treatment. Particularly it reduces overdose death. Medication also reduces infection with HIV and hepatitis C, and obviously if we prevent people with substance use disorders from developing these infections, it also decreases risk to the entire community because there's not this reservoir of infection that can be spread throughout the community. It reduces crime and it reduces drug dealing.

So these medications have powerful effects for the individual, and for the community, who's receiving medication treatment.

I'm going to talk just about two bits of evidence along these lines, on the bottom two slides on page five. In the middle of page five you can see what to me is one of the most powerful studies related to the effect of buprenorphine, and this is a small study, it was published in 2003 in The Lancet, but it tells such a simple and powerful message.

So in this trial, these investigators randomized a small group of young people who were addicted to heroin to either receive placebo or receive active buprenorphine, Suboxone. Everybody in the trial, whether they had placebo or they had medication, received state of the art counseling. They had masters-level trained therapists three times a week, and they had individual counseling every week. So what happened? After 50 days, all of the folks who had gotten the placebo had dropped out of treatment, so they were all getting the three times a week groups and the counseling, they had all left and presumably relapsed. However in the group that was getting the medication, at the end of the year, 70 percent of them were still engaged in treatment or coming to their groups and their individual therapy, and had the vast majority of their urine samples were negative for opiates.

So this little trial demonstrates how effective these medications are in helping people not only to stabilize and show up for treatment, but also to engage in the behavioral therapy that helps them to put their lives back together once they stop using the drugs.

DOUG MCVAY: That was from a hearing before two joint committees of the New Mexico Legislature, they were discussing opiate use, medication assisted treatment, and heroin maintenance. The speakers included Eugenia Oviedo-Joekes, an associate professor at the School of Population and Public Health at the University of British Columbia, Canada; Miriam Suzanne Komaromy, MD, an associate professor of medicine at the University of New Mexico; Andrew Hsi, MD, a professor of family and community medicine at the UNM, and Lindsay LaSalle, a senior staff attorney for the Drug Policy Alliance.

And well, that's all the time we have. Thank you for joining us. You've been listening to Century Of Lies. We're a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I'm your host Doug McVay, editor of DrugWarFacts.org. Drug Truth Network is on Facebook, please give its page a like. Drug War Facts is on Facebook too, give it a like and share it with friends. You can follow me on Twitter, I'm @DougMcVay and of course also @DrugPolicyFacts.

We'll be back next week with thirty minutes of news and information about the drug war and this Century Of Lies. For now, for the Drug Truth Network, this is Doug McVay saying so long. So long!

For the Drug Truth Network, this is Doug McVay asking you to examine our policy of drug prohibition: the century of lies. Drug Truth Network programs archived at the James A. Baker III Institute for Public Policy.