Recovery-Oriented Medication-Assisted Treatment

1. Recovery-Oriented Medication-Assisted Treatment Joseph Py, D.O. FASAM Mphp Wellness conference June 13, 2019

2. What is Recovery-Oriented Medication-Assisted Treatment? • A person-centered recovery focus using medication, with a shift from an acute care to long term chronic dis-ease management model. • medication wrapped around professional and peer support • the treatment combination that offers the best chance at long term recovery

3. What is Medication-Assisted Recovery? • supervised stabilization at an optimal medication dose/abstinence from illicit, non-prescribed, illegal or legal intoxicating substances/evidence of improved global health & social functioning • remission of primary or secondary substance use disorders/enhancement of personal & family health & functioning/positive community integration • achievement of healthy functioning in the physical, emotional, spiritual, social, civic & community spheres.

4. References • White, W., Mojer-Torres,L. - Recovery-Oriented Methadone Maintenance; August, 2010; Great Lakes Technology Transfer Center • Substance Abuse and Mental Health Services Administration - SAMHSA’s Working Definition of Recovery • Spaniol, L., (2008). What Would a Recovery-Oriented Program Look Like? Int. J. of Psychosocial Rehabilitation, 13(1), 57-66

5. Legal Action Center- Methadone Treatment Memorandum on Driving & Psychomotor Studies & Background on Methadone Maintenance Treatment- April 2000, 99pp • Studies cited involve field & laboratory evaluations on stable methadone-maintained individual’s perceptual, psychomotor & intellectual functioning. Many studies cited are specific to driving. • Gordon, NB - Reviewed laboratory & field-based studies since the early 1970’s assessing functioning, reaction times, sustained attention & perceptual motor skills- MMT at appropriate dosages has little if any effect on the ability to function in any capacity. • Ho, A, et al - No impairment of sustained vigilance in MM “ex-addicts” compared to either non-addict siblings or drug-free “ex-addicts”. MM subjects had less of a tendency to fall asleep under prolonged vigilance testing.

6. Moskowitz, H., et al, - “the major trend of our studies is that individuals stabilized in a methadone maintenance program failed to show impairment in the most relevant skills performance tasks( visual functions, psychomotor & perceptual tasks, tracking tasks & oculomotor functions) • Appel, PW, et al - “…no indications that attentional function of methadone patients is adversely effected by methadone given in a methadone maintenance treatment program. The length of time likewise causes no adverse effects on attention.”

7. Buprenorphine • Hamsa, H. and Bryson, E.O. - Buprenorphine Maintenance Therapy in Opioid -Addicted Health Care Professionals Returning To Clinical Practice: A Hidden Controversy; Mayo Clin Proc 2012 March , 87(3); 260-267

8. Schindler, et al. Euro Addict Res 2004; 10(2) 80—87 - 30 patients receiving maintenance therapy, half with methadone half with buprenorphine- no overall difference in cognitive performance • Soyko, et al. J ClinPsychopharmacol 2005; 25(5) 490-493 - driving-relevant performance in 62 patients with OUD, randomly assigned buprenorphine or methadone, after 10 weeks on treatment and stabilized dosages, both groups showed impairment in various attentional tests, with buprenorphine less so

9. References • Gordon, NB. The Functional Potential of the Methadone Maintained Person. CDR Working Group Monograph, Number 2 (December 1994) pp 43-46 • Ho, A., et al. Auditory Vigilance of Drug-Free Methadone Maintained Exaddicts and NonaddictSiblings. Paper presented at the September 1979 American Psychological Association meeting • Moskowitz, H., et al. Skills Performance in Methadone Patients and Drug-Free Former Addicts. Paper presented at the September 1979 American Psychological Association meeting

10. Federation of State Physician Health Programs • FSPHP website “Guiding Values” - “The FSPHP supports education &research designed to establish best practices for the prevention , treatment & monitoring of physicians experiencing Substance Use Disorders, mental illness & other potentially impairing conditions.” (Author’s emphasis)

11. World Medical Association Statement on Physician Well-Being 2015 • “1. … NMAs (National Medical Associations) should collaboratively promote research to establish best practices that promote physician health & to determine the impact of physician well-being in patient care.” • “5. Physicians at risk for abuse of alcohol or drugs should have access to appropriate medical treatment& comprehensive professional support.”

12. FSPHP • President’s Message, Spring 2019, Paul H. Early, MD, DFASAM • 1. Revised Guidelines for State PHPs finished but not yet available., 2. The new Revised Guidelines are one part of a two part approach. Revised Guidelines are part of the Provider Enhancement and Excellence Review (PEER)- a process of external review to ensure that practices are up to date and continue to grow in sophistication.

13. American College of Physicians • Physician Impairment & Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety: A Position Paper From the American College of Physicians, 6 April, 2019 • “ PHPs should be committed to best practices that safeguard patient safety & the rights of physician-patients.” • “ The privilege of medical practice is predicated on the physician’s & profession’s commitment to providing safe, competent & ethical patient care.” • “Clinical evaluation should be based on standards of care.”

14. Positions - • “ 3. Best practices for PHPs should be developed systematically, informed by available evidence and further research (PHP effectiveness studies vs. Addiction Medicine MAT literature?- author’s addition) • “5. Maintenance of physician wellness with the goal of well-being must be a professional priority of the health care community promoted among colleagues and learners.”

15. “… the implications of use of legal cannabis or medication-assisted treatment (for example, buprenorphine or other partial opioid agonists), also require further study & guidance.” • “ Evaluation & treatment should be clinically based according to standards of care.”

16. Patient Safety • Physician Well-Being • Professional Competence • What is Recovery? • What is Medication-Assisted Treatment? • Recovery-Oriented Systems of Care and Medication-Assisted Treatment • Ensure implementation of best practices and the standard of care