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February 2018

Gambling and Opioids; Medication for Opioid Use Disorder plus counseling or not?; The making of a website

savvy

The 2018 Problem Gambling Awareness Month (PGAM) is the 14 th year that a grassroots campaign of healthcare  and other organizations, individuals, states, gambling companies, recovery groups  and providers have come together to focus on problem gambling.
As a segue to PGAM in March, George Mladenetz is sharing some SAVVY  tips on the relationship between Gambling Disorder  and another stigmatized manifestation of addiction – the opioid crisis. George has worked in substance use  and mental health treatment for over thirty years within the New Jersey Department of Human Services, Division of Mental Health & Addiction Services. His work has highlighted how important it is that individuals entering treatment for any type of disorder be screened for gambling disorder, as too often the “hidden illness” of gambling disorder goes undetected.
Here is George’s article:
The Nation’s Opioid Epidemic
Everything from alcohol to other drugs to gambling  and risky behavior are all parts of addiction. However, there is one manifestation of addiction which has grown significantly in the last 15 years  and taken tens of thousands of lives. With the opioid epidemic, every day in America, 116 people die from opioid-related overdoses. (U.S. Department of Health  and Human Services, 2017.)
Opioids are often prescribed to relieve severe pain due to injury, cancer, disease or as a post-surgery treatment. Although opioids have many useful effects, when taken too long, they can cause serious physical dependence  and tolerance. Therefore, opioid users must increase their dosage to continue feeling the same physical relief but also to ward off any physical withdrawals that come from dependency.
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Note the connection between Gambling Disorder (GD) and Opioid Use Disorder
There are not many studies on gambling behavior among clients in methadone maintenance treatment programs. However, the early studies which have been conducted, reported:
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Review the nature of the gambling behavior and problems among those receiving Methadone Maintenance
In one study in 2015, Seth Himelhoch  and his colleagues analyzed 185 individuals in an urban methadone maintenance program using the 9 item DSM 5 problem gambling criteria (1) ( Gambling Disorder and Methadone Maintenance).
  • Almost half (46.2%) of the participants qualified for a Gambling Disorder (GD) diagnosis and of these participants, 37% qualified for a severe GD diagnosis.
  • People receiving methadone maintenance engage in a variety of behaviors. The most common types of gambling include the purchasing of lottery tickets.
  • Very few people reported using smart phones or tablets to connect to the Internet to gamble.
Other studies conducted are consistent in their findings. There is significant prevalence of GD according to DSM-5 criteria, in the substance use disorder population (3) ( Gambling disorder andSubstance Use Disorders)
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Be aware of the need for Problem Gambling Screening in Methadone Maintenance Treatment Programs
Society is in the midst of the opioid epidemic; no one knows how long its duration will last. Each day, more individuals than ever are entering opioid treatment  and this number will likely continue to increase.
  • In 2003, there were 1,067 opioid treatment programs reporting to the Substance Abuse & Mental Health Services Administration (SAMHSA).
  • The number rose to 1,482 by the end of 2016.
  • The number of clients receiving methadone in those facilities increased from 227,000 to more than 356,000 through 2015, the latest year with the number of clients. (4)
Since previous research (2) ( Problem gambling, substance use and methadone maintenance) has found that people with GD have worse substance use treatment outcomes than those without GD, it is very important to screen for  and treat GD symptoms in conjunction with opioid use disorder.
Bio:
George Mladenetz possesses a Master’s degree in Counseling from Trenton State College (currently The College of New Jersey). He has been licensed as a Clinical Alcohol  and Drug Counselor (LCADC) since 2005  and is an International Certified Gambling Counselor (ICGC- I). As Treatment Coordinator for the Council on Compulsive Gambling of NJ (CCGNJ), he monitors the operations of seven (7) subcontracted treatment providers who serve disordered gamblers and/or family members/significant others.
References:
1. Himelhoch, S.,H. Miles-McLean, D. Medoff , J. Kreyenbuhl, L. Rugle, J. Brownley, M. Bailey-Kloch, W. Potts  and C. Welsh. Twelve Month Prevalence of DSM-5 Gambling Disorder  and Associated Gambling Behaviors Among Those Attending Methadone Maintenance. Journal of Gambling Studies, 32, 1-10. 2015
2. Ledgerwood, D.M.  and K.K, Downey. Relationship Between Problem Gambling  and Substance Use in a Methadone Maintenance Population. Addictive Behaviors, 27(4), 483-491.2002
3. Rennert, Lori, Cecile Denis, Kyle Peer, Kevin G, Lynch, Joel Gelernter  and Henry R. Kranzler. DSM-5 Gambling Disorder: Prevalence  and Characteristics in a Substance Use Disorder Sample. NCBI. 22(1): 50-56.     February 2014
4. SAMHSA Report Shows Increase in Opioid Treatment Facilities.  https://www.samhsa.gov/data/sites/default/files/report_3192/ShortReport-3192.pdf.
5. Spunt, B., H. Lesieur, D. Hunt  and L.Cahill. Gambling Among Methadone Patients. The International Journal of the Addictions, 30(8), 929-962. 1995
6. Stephens, C. Georgia’s Opioid Epidemic  and Ways to Get Help. Georgia.gov. December 2017
7. The WAGER, Vol. 22(1) – Gambling Disorder Among People in Methadone Maintenance Treatment. The Brief Addiction Science Information Source (BASIS). January 4, 2017
8. U.S. Department of Health  and Human Services.  https://www.hhs.gov/opioids/

skills

Some recent studies on medications for Opioid Use Disorder (OUD) have published results, which indicate “no additional benefit” of adding behavioral counseling to just prescribing mnedication. The FDA  Prescribing Information for these medications however, declares that medication “should be used as part of a complete treatment plan to include counseling  and psychosocial support.”

If you read just the brief abstract conclusions of the studies, it is easy to go away thinking physicians need only prescribe medication and not worry about adding counseling for their patients. 

On February 20, 2018, the Providers Clinical Support System (PCSS) provided a webinar on  The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment presented by Roger D. Weiss, MD, Professor of Psychiatry, Harvard Medical School; Chief, Division of Alcohol  and Drug Abuse, McLean Hospital, Belmont, MA.
Although counseling is a required part of office-based buprenorphine treatment of opioid use disorders, what constitutes appropriate counseling is unclear  and sometimes controversial. The webinar:
  • Reviewed the literature on the role, nature, and intensity of behavioral interventions in office-based buprenorphine treatment for patients with opioid use disorders.
  • Identified clinician’s responsibilities in office-based buprenorphine treatment to best tailor their practice to meet the needs of their patients.
You can download the webinar slides  PCSS webinar
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Be cautious in concluding that behavioral treatments and counseling add no benefit to just giving medication for OUD
Having heard Dr. Weiss’s excellent presentation, here are facts to be aware of:
  • The conclusion of “no additional benefit” of counseling when giving addiction medication only applies to 50% or less than 50% of subjects. Why? Because 50% or more of the study subjects dropped out before the full 24 weeks of follow-up were done.
  • These results only apply for the study period of 24 weeks. Addiction treatment andrecovery takes a lot longer than 24 weeks.
  • Research subjects who used substances in weeks 1-2 of the study had worse outcomes and may definitely need counseling and engagement to retain them in treatment and help them cut short their substance use.
  • Other research subjects with co-occurring disorders was a subgroup who definitely need counseling to achieve good outcomes.
So a blanket conclusion that behavioral treatments add no benefit to just prescribing medication has to be taken in the context of all of the facts above.  The study conclusions are much more nuanced than first appears.  

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If the Prescriber gives comprehensive medical management (MM) with each medication visit, that may be sufficient counseling, with no added behavioral counseling needed
 
The medical management in these studies was more intensive than the community standard  andincluded the following ‘Active ingredients’ of MM’:
  • It spanned 15-20 minutes, not a quick prescription renewal 5 minute visit
  • Overall health check to catch any concurrent conditions
  • Urine monitoring to monitor substance use and adherence to treatment
  • Check on medication: efficacy, adherence, tolerability
  • Monitor craving to help prevent or limit substance use
  • Advice to abstain to engage the patient in movement towards recovery
  • Advice to attend mutual-help groups for ongoing support
If prescribers actually put in the time to do this kind of comprehensive MM, then they  are doing the kind of behavioral counseling that is needed. But that is a far cry from simply renewing prescriptions.

 

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Taking medication for OUD is just one part of addiction treatment and recovery
If the only goals of buprenorphine, naltrexone or methadone treatment are medication adherence  and retention in taking medication, then psychosocial treatments may or may not be vital. However if addiction treatment has goals of helping people embrace recovery, then retention in medication treatment is  not addiction treatment in its totality.
If  recovery is the goal, psychosocial treatments would not just be recommended, but essential for positive outcomes.
  • Detox and withdrawal management doesn’t equal addiction treatment for recovery goals.
  • Nor do medications alone equal addiction treatment for recovery goals.
  • If you stand for recovery and full addiction treatment, there is a distinction between psychosocial treatments for retention in medication treatment versus psychosocial treatments to achieve addiction recovery.
Psychosocial treatments may or may not improve adherence  and retention in an episode of withdrawal management (WM). But we don’t say that WM is sufficient in addiction treatment  andsimultaneously cast doubt on the value of psychosocial treatments.
The same applies to the question on whether counseling adds any benefit to medication for addiction. The danger of casting doubt on the value of psychosocial treatments reinforces the notion for patients, prescribers  and the public that medication  IS indeed all that is needed for the opioid crisis.
 
References:
Carroll KM, Weiss RD : “The role of behavioral interventions in buprenorphine maintenance treatment: A review.”  Am J Psychiatry 174: 738-747, 2017
David A. Fiellin, M.D., Michael V. Pantalon, Ph.D., Marek C. Chawarski, Ph.D., Brent A. Moore, Ph.D., Lynn E. Sullivan, M.D., Patrick G. O’Connor, M.D., M.P.H.,  and Richard S. Schottenfeld, M.D:
“Counseling plus Buprenorphine-Naloxone Maintenance Therapy for Opioid Dependence”
N Engl J Med 2006; 355:365-374
Fiellin DA1, Barry DT, Sullivan LE, Cutter CJ, Moore BA, O’Connor PG, Schottenfeld RS:
“A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine.”
Am J Med. 2013 Jan;126(1):74
Walter Ling, Maureen Hillhouse, Alfonso Ang, Jessica Jenkins, Jacqueline Fahey:
“Comparison of behavioral treatment conditions in buprenorphine maintenance”
Addiction Vol108, Issue 10 October 2013 Pages 1788-1798

soul

This month, I have been developing a new website…my website…with my name right in the website name. There’s no hiding behind a company name like Crocodile Dundee Training  andConsulting or Aussie Addiction Associates (AAA). The website puts my name ( and face) up front  and center…… davidmeelee.com.
It’s a work in progress, but coming along nicely. See what you think. There’s lots more I want to do – add more resources  and improve its usefulness to anyone visting the site. But it is a good start.
How is it that there’s a new website just now after 22 years of fulltime training  and consulting? Hasn’t there always been a  davidmeelee.com website?
While I continue a close collegial relationship with The Change Companies (TCC)  and its sister training company, Train for Change (T4C), my formal company relationship as Senior Vice President ended January 1, 2018.   I am not closing my doors  and hanging a “ Gone Fishing” sign on the office door.   I am, however, looking to create more spaces in my schedule  and craft that ever-illusive balance between work  and play.
Along with resurrecting  davidmeelee.com, I plan to improve  Tips  and  Topics  and its nearly 15 years of archived editions.  You can watch for that in the near future.
So I better get back to it……What photos do I use? How should I word that description? What will I include in my Bios?  What sort of Calendar to construct etc etc.?
Take a look around at  davidmeelee.com
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