Legislature(2015 - 2016)BUTROVICH 205
02/04/2015 01:30 PM Senate JUDICIARY
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| Audio | Topic |
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| Presentation on Medication Assisted Treatment (mat) | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
ALASKA STATE LEGISLATURE
SENATE JUDICIARY STANDING COMMITTEE
February 4, 2015
1:37 p.m.
MEMBERS PRESENT
Senator Lesil McGuire, Chair
Senator John Coghill, Vice Chair
Senator Mia Costello
Senator Peter Micciche
Senator Bill Wielechowski
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
PRESENTATION ON MEDICATION ASSISTED TREATMENT (MAT)
- HEARD
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
MARK BOESEN, Pharmaceutical Doctor and Juris Doctorate
Policy Manager
Alkermes
POSITION STATEMENT: Presented information on medication assisted
treatment.
PAULA COLESCOTT, MD
Providence Breakthrough
Physician Health Program and
Highland Mountain Correctional Facility
Anchorage, Alaska
POSITION STATEMENT: Presented her experience and perspective on
medication assisted treatment.
REBECCA YOUNG, ANP
Valley Medical Family Practice
Lemon Creek Correctional Facility
Juneau, Alaska
POSITION STATEMENT: Presented her experience and perspective on
medication assisted treatment.
WENDY SMITH, PA-C
Family Practice Physicians
Juneau, Alaska
POSITION STATEMENT: Presented her experience and perspective on
medication assisted treatment.
LISA REYNOLDS
POSITION STATEMENT: Shared her story as the mother of an addict
who has relapsed several times.
PAUL FINCH, PA-C
Gateway to Recovery Detox
Turning Points Counseling
Fairbanks, Alaska
POSITION STATEMENT: Presented his experience and perspective on
medication assisted treatment.
ACTION NARRATIVE
1:37:52 PM
CHAIR LESIL MCGUIRE called the Senate Judiciary Standing
Committee meeting to order at 1:37 p.m. Present at the call to
order were Senators Wielechowski, Costello, Micciche, Coghill,
and Chair McGuire.
^Presentation on Medication Assisted Treatment (MAT)
Presentation on Medication Assisted Treatment (MAT)
1:38:12 PM
CHAIR MCGUIRE announced the business before the committee would
be a presentation on Medication Assisted Treatment (MAT).
1:38:25 PM
MARK BOESEN, Pharmaceutical Doctor and Juris Doctorate, Policy
Manager, Alkermes, introduced himself and stated that he works
for the company that manufactures Vivitrol.
PAULA COLESCOTT, MD, Providence Breakthrough, Physician Health
Program, and Highland Mountain Correctional Facility, introduced
herself and told the committee she works in a methadone clinic
and urgent care. Her specialty is internal medicine and she is
board certified in addiction medicine.
DR. BOESEN explained that he started these presentations in an
effort to educate legislators on underutilized treatment
opportunities and to talk about medication assisted treatment
(MAT) in general. Vivitrol is one drug that is used for treating
both alcoholism and opioid dependency. He explained that opioids
are pain relievers and include prescription drugs like Vicodin,
Percocet, Morphine, and Dilaudid. Heroin is a widely recognized
and potent street version of an opioid. Opioids are all
derivatives of morphine derived from the poppy plant.
CHAIR MCGUIRE asked how Americans are gaining access to these
drugs.
DR. BOESEN replied there are a number of pathways, one of which
is people who are treated with legitimate pain. They are treated
appropriately for their acute or chronic injury, but they
develop a physical dependence to the dopamine surge that comes
with taking opioids. They continue to use or use more and more
until it becomes inappropriate. Once they are cut off from
legitimate access, they do not seek appropriate treatment and
instead seek prescription medications that have been diverted
and sold on the street. Heroin is an inexpensive recreational
medication commonly found on the street and some people turn to
that instead of the more expensive diverted brand-name
medications.
SENATOR MICCICHE asked why the price of heroin has come down and
why is it so affordable.
DR. BOESEN replied it has always been relatively inexpensive. It
isn't difficult or expensive to manufacture, the market demand
is high, and there is a lot of competition to sell it on the
street. He explained that heroin was brought to the commercial
market in the late 1800s as a pain reliever and cough
suppressant. It was also used to wean people off of morphine
before the dangers were recognized.
SENATOR COGHILL commented on the abuse of methamphetamine in his
area and his understanding that heroin is less damaging. He
asked Dr. Colescott to comment.
DR. COLESCOTT said methamphetamine is directly neurotoxic to the
brain and there is no effective treatment for dependency. The
opioids also change the brain but there is effective, brain
stabilizing treatment for dependency. She noted that on a per
dose basis the most addictive drug is nicotine, followed by
heroin, then the stimulants like methamphetamine and coke, then
alcohol, and finally cannabis.
SENATOR COGHILL vouched for the addictive qualities of nicotine.
1:47:56 PM
DR. BOESEN added that regardless of the substance, there is a
growing problem and a need for effective treatment. He directed
attention to a quote from the National Institute on Drug Abuse
to stress the point that addiction treatment is not one size
fits all. It is important to match treatment settings,
interventions and services to a person's particular problems. He
said the clinicians will discuss how to do a proper assessment,
the challenges to identifying treatment modalities, where
treatment is delivered, and the gaps in care in Alaska.
He advised that recovery is a lifelong process; addiction is a
chronic disease and absolutely not a matter of poor willpower.
Treatment needs to include a combination of medical and
psychosocial interventions along with family and peer support.
"Wrap-around services are critical and is a process that is
going to last someone their entire life."
SENATOR COGHILL admitted that he struggled with calling
addiction a disease because it is not something you catch. He
suggested that pushback from legislators may stem from this
perception.
DR. BOESEN replied it is a different disease model than the
infectious disease model and some people who are addicted
arguably made poor choices. However, it does not negate the fact
that it is a disease. Some evidence shows that there may be a
genetic predisposition to addiction and other evidence shows
that once the neurotransmitter pathways are significantly
altered, the surge that comes with injecting or taking opioids
or consuming alcohol is something that the brain continues to
crave. This cannot be overcome with willpower. It requires
medical and psychosocial intervention.
SENATOR COGHILL reiterated his perspective.
CHAIR MCGUIRE added that part of the point of the presentation
to learn about the disease model and the cost of addiction to
the state.
1:52:40 PM
DR. BOESEN said it supports the disease model that some people
abuse substances and never get addicted, while others use a
substance and get addicted. It is not clear how to differentiate
those two populations, he said.
DR. BOESEN displayed a picture depicting the two regions of the
brain affected by dependence: the limbic region whose role is
the primal drives such as fight or flight, cravings, rewards,
and pleasure; and the cerebral cortex whose role is reasoning,
thinking, learning, and decision making. The problem when it
comes to addiction is that the limbic region is such a powerful
driver that it can override the cerebral cortex. Despite an
addict's best thinking, he/she will still drink that next drink,
inject that next heroin, take that next morphine tablet or
whatever it is.
He said what is remarkable about Vivitrol is that it works on
the limbic region of the brain to normalize the
neurotransmitters so that the cravings are dissipated. It is
particularly effective for patients who take opioids. It
decreases the cravings so the noise from the limbic region
doesn't overpower the cerebral cortex so counseling can work
better. He stressed the point that medication alone is not the
answer; it has to be combined with counseling and psychosocial
support.
SENATOR COSTELLO asked what the side effects are for Vivitrol.
DR. BOESEN explained that 4 ccs of the medication is injected
into the buttock every 30 days. Soreness and reaction at the
injection site is the most commonly reported side effect, but
they also monitor for adverse effects on the liver, for
pneumonia, and for allergic reaction. They have found that fewer
than 2 percent of the people who receive Vivitrol have to drop
out of the program because of an adverse reaction. The people
who drop out tend to do so for reasons other than experiencing
an adverse effect.
1:57:09 PM
SENATOR WIELECHOWSKI asked what Vivitrol costs.
DR. BOESEN replied it ranges between $600 and $1,300 per month
depending on the kind of patient, the kind of insurance, and the
kind of payer. A state pays much less than commercial payers.
SENATOR WIELECHOWSKI asked if he expects that Vivitrol would be
available to many more people in the state of Alaska if Medicaid
were expanded.
DR. BOESEN replied the Medicaid authority in Alaska recognizes
the value, but the medication is only as good as the number of
clinicians who are available to treat and care for people
affected by dependence.
He then discussed the three types of opioids that are classified
by the effect that they have on the mu receptors. They are full
agonists, partial agonists, and antagonists. An agonist
stimulates the neurotransmitter to produces a dopamine surge. An
antagonist blocks an effect.
Methadone is an example of a full agonist. It binds to the mu
receptor in the brain and produces the dopamine surge. It
produces that same lightning storm benefit as the recreational
drug, but it is administered in a controlled, safer environment
under the monitor of nurses, physicians, and counselors. Full
agonists are useful for certain people who still need that
dopamine surge in order to help with their therapy.
Buprenorphine-type medications are examples of partial agonists.
They bind primarily to mu receptors and cause them to produce
endorphins. Although the dopamine surge is less pronounced,
there is still a stimulation of the dopamine reward system that
calms the limbic center of the brain so the cerebral cortex is
not overpowered so counseling works.
Vivitrol is an example of a full opioid antagonist. It binds to
the opioid receptors but does not stimulate or produce
endorphins. It does not completely stop the dopamine reward
system, but it does not activate it so there are more normal
levels of dopamine in the brain. During the 30-day period when
Vivitrol is in the brain, getting high will not produce the
desired effect.
CHAIR MCGUIRE asked if Vivitrol is analogous to Wellbutrin to
treat nicotine addiction.
DR. BOESEN said no; the medications work in completely different
ways.
Turning to the safety information, he stated that a benefit to
using Vivitrol when treating alcoholics is that it can be used
in the outpatient setting, it does not require detoxification,
and it can be administered fairly early in the treatment cycle.
One of the barriers to using a drug like Vivitrol on opioid
dependent people and why sometimes Methadone and Buprenorphine
are better choices is that the medication works so well at
blocking the receptor, that if there is any sort of opioid in
the system the medication will bump off the receptor and put the
person into the life-threatening condition called precipitative
withdrawal. He noted that Mr. Finch would talk about the
importance of detox and the shortage of resources. He called it
the critical message of the day.
CHAIR MCGUIRE asked if there is any worry about depression or
suicide for an alcoholic or opioid addict who is being treated
with Vivitrol and they are unable to get a dopamine surge.
DR. BOESEN deferred to Dr. Colescott.
DR. COLESCOTT said some people who have been opioid or alcohol
dependent do extremely well on Vivitrol, but there is also a
population that does not. The post-acute withdrawal syndrome
(PAWS) phase can last for months and her experience is that the
opioid addict finds this phase extremely intolerable. Their
world is gray; they are hard to motivate, they sleep poorly,
they're emotionally unstable and they react poorly to stress.
This can improve if the addict is able to remain sober, but this
population has difficulty getting to that point. It is
particularly difficult for individuals who have a preexisting
emotional or psychiatric problem that may not have been
diagnosed or effectively treated because of their drug use.
She advised that a person can release their own dopamine, but
they have to learn how. That is where a treatment team is so
essential.
2:09:01 PM
DR. BOESEN reviewed the contraindications of Vivitrol. It should
not be used for people: receiving opioids analgesics; with
current physiologic opioid dependence; in acute opioid
withdrawal; who have failed the naloxone challenge test or have
a positive urine screen for opioids; and who have exhibited
hypersensitivity to naltrexone, polylactide-co-glycolid
carboxymethylcellulose, or any other compounds of the diluent.
He reviewed the attributes of Vivitrol. It is: a monthly
extended-release injectable formulation of naltrexone;
administered by a healthcare professional; an effective
complement to psychosocial treatment; and a competitive opioid
blocker. It is not a narcotic, pleasure producing, addictive, or
associated with abuse. It is not a drug that is diverted to the
street.
DR. BOESEN warned that because Vivitrol blocks the effects of
exogenous opioids for approximately 28 days after
administration, patients are more likely to have reduced
tolerance to opioids after detoxification. As the block
dissipates, use of previously tolerated doses of opioids could
result in potentially life-threatening opioid intoxication.
2:12:14 PM
DR. COLESCOTT explained that when someone uses an opioid
repeatedly, it changes the sensitivity of the receptors covering
the brain over the long term. Once the receptors are stimulated,
it creates a cascade within the nerve that affects the way the
nerve functions down to the nucleus and how it expresses itself
genetically. She cited a study that followed 900 IV heroin users
for 40 years that found that less than 22 percent were able to
remain sober. She opined that the statistics for oral opioids is
probably less than that. The brain knows it can release dopamine
by using the drug so when the person is depressed, angry,
disappointed, or worried the survival area of the brain will
sense the need for dopamine and look for ways to get it. She
said she lays out the treatment options for her clients and
warns that they are in a marathon. Their treatment may include
methadone, Vivitrol, or Buprenorphine but the constant is to
have a team to help navigate through the process.
CHAIR MCGUIRE directed attention to her website for resources to
further the discussion about addiction.
SENATOR WIELECHOWSKI asked how receptive addicts are to
treatment and what legislators can do to encourage people to
take advantage of treatment.
DR. COLESCOTT said her experience is that people enter treatment
when their back is against the wall and something salient is at
stake. With regard to the second question, she proposed a pilot
project to give Vivitrol to the women coming out of Highland
Correction Center who are detoxed but still dependent on opioids
or alcohol. It would save money and provide a meaningful
reintegration.
DR. BOESEN suggested expanding the treatment and wellness courts
and offering treatment alternatives to any municipal or state
court. He offered to share the results from other states.
SENATOR MICCICHE asked which states have successful treatment
programs.
DR. BOESEN named Colorado, Missouri, Ohio, Massachusetts,
Maryland, California, and Illinois. The programs usually start
with pilot projects and it's easy to see whether or not it's
working within 3-6 months. Colorado, for example, did a pilot
program that focused on parolees and they saw a 45 percent
reduction in recidivism for parolees treated with Vivitrol as
opposed to parolees who were not. He noted that the medication
is not administered prior to release. Rather, a parolee who has
a technical violation is given the option to enroll in the
program. Those who have elected to do so are doing very well.
CHAIR MCGUIRE suggested it would be advantageous to offer the
treatment prior to release.
DR. BOESEN agreed that would be optimal and that is happening in
Massachusetts and Maryland.
SENATOR COGHILL offered his belief that jails have done
inadequate risk assessments for behavioral health issues. The
second point is to look at how to administer new programs.
DR. BOESEN said elected officials, governors, and governor's
staff in states with these programs are more than willing to
share their experience and how to identify the low hanging fruit
that may already exist in the system.
2:26:50 PM
SENATOR MICCICHE commented that people who have addiction
problems probably get less of a dopamine reward from life
experiences and more reward from the drug.
DR. COLESCOTT agreed. She said that people with opioid and
alcohol addiction know how to modulate their affect and instead
of developing normal coping mechanisms, they have reverted to a
drug to deal with any kind of distress. These people may have
been abused, raped, and poorly nurtured, but on top of that
their mu opioid receptors may not be normal.
SENATOR MICCICHE asked if treatment can normalize the brain.
DR. COLESCOTT replied her impression is that some people are
able to get off the medication, but not without developing a
robust dopamine network and having a support system.
SENATOR COGHILL offered his experience that young brains are
more easily affected.
DR. COLESCOTT agreed, and added that she did not know if the
system could be changed back or if the brain is simply overlaid
with other dopamine receivers.
CHAIR MCGUIRE said this hearing opens the dialog.
2:32:20 PM
REBECCA YOUNG, ANP, Valley Medical Family Practice, Lemon Creek
Correctional Facility introduced herself and explained that
weekdays she does contract work at the prison and family
practice work at Valley Medical. On weekends she is either in
the emergency room (ER) at Bartlett Regional Hospital or she's
with the National Guard. In the course of a week she sees about
200 people, many of whom are addicted to opioids or alcohol.
WENDY SMITH, PA-C, Family Practice Physicians, introduced
herself and related that she is a primary care provider in
Juneau. She is the "go to" for opioid abuse in the clinic.
MS. YOUNG provided her perspective for some of the questions
posed earlier. She said that in Juneau heroin is coming into the
community primarily by airplane and inside the bodies of females
who are serving as mules. If they are caught and arrested, she
sees them either at Lemon Creek before they're taken to federal
prison or in the ER when she removes the heroin from their
bodies. She noted that some men are mules and the drug sometimes
comes in by ferry but both are less common. As to why heroin is
affordable, she explained that it is a less expensive
alternative to diverted prescription medications. Several years
ago, OxyContin was a big street drug in Juneau and a number of
people became addicted. They switched to heroin when they could
no longer afford OxyContin or there wasn't a supply on the
street. She noted that in an effort to keep prescription drugs
off the street, the medical community cross checks with
different pharmacies and has put in place pain contracts. There
is also a state-sponsored drug monitoring program. As yet there
isn't a good procedure to get heroin off the street or a way to
monitor it, she said.
SENATOR COSTELLO asked if she is familiar with the Medi-Set
program, because it seems that it would reduce the opportunity
for abuse if a patient could only get medications for a week at
a time.
MS. YOUNG explained that a prescription can't be written short
term if the insurance pays for a 30-day supply. Also, people who
are looking for street drugs aren't necessarily looking for a
large volume. They're happy to find "left over" medications in a
home medicine cabinet. She cited a personal example and
cautioned that the heroin addict or alcoholic in the community
doesn't always fit the preconceived stereotype. A few of the
addicts she has treated have worked in a bank, the post office,
a beauty salon, a state office, on a road crew, on electric
lines, and in high school. You don't know who it is, she said.
2:39:00 PM
SENATOR MICCICHE asked if people regularly try to get the same
prescription from more than one pharmacy and what happens if
that happens.
MS. YOUNG said that when she knows the patient recently filled a
prescription from another source she tells him or her that she
is uncomfortable prescribing the medication. Generally they
respond to honest communication, but once in a while the
reaction is violent, she said.
2:39:58 PM
SENATOR WIELECHOWSKI asked if Alaska has adequate treatment
centers.
MS. YOUNG answered no. She described the limited and expensive
options available in Juneau.
SENATOR WIELECHOWSKI asked if Medicaid covers treatment.
MS. SMITH replied she doesn't know of any adults who have used
Medicaid for treatment.
MS. YOUNG added that Medicaid only pays if the person goes to a
state facility and there are few treatment facilities for
children under age 18 in Alaska.
2:42:15 PM
MS. SMITH said it's disturbing that so few providers are willing
to treat substance abusers, but it takes a lot of time and
energy to deal with all the barriers that come with substance
abuse including no shows, late arrivals and non-payers. It's a
problem in her own clinic.
MS. YOUNG said that she and one other practitioner see the bulk
of the substance abusers at her clinic. She observed that a
person who has uncontrolled diabetes may be just as non-
compliant as a substance abuser but they don't have trouble
being seen because they don't have the onerous addict label.
CHAIR MCGUIRE asked how the healthcare community would describe
the difference because they're both diseases.
MS. YOUNG opined that addicts are perceived to be liars. She
said that providers believe a heroin addict will lie just to get
treatment. They commonly do lie, she said, but she's also had
diabetics and breast feeding mothers lie about their behavior.
The difference is they don't get the same stigma as the heroin
addict
CHAIR MCGUIRE asked for a few thoughts that the committee as
policymakers should know.
MS. SMITH stated that she would like every heroin abuser to have
health insurance so that isn't a barrier to seeking treatment.
SENATOR MICCICHE questioned how to get ahead of the burgeoning
drug problems in the state and whether law enforcement should be
part of the discussion to improve the process for intersecting
the supply of drugs.
MS. SMITH said she believes the focus should be on getting
people to choose not to use drugs.
CHAIR MCGUIRE recognized the next presenters, Lisa Reynolds and
Paul Finch.
2:51:15 PM
LISA REYNOLDS said she is speaking as a concerned Mom who has
struggled to find help for her 20-year-old son who is a drug
addict and alcoholic. She is telling her story in hopes that it
will help to get funding for treatment facilities, recovery
facilities, medical treatment, and sober living. These are
things she has struggled to find since she learned that her son
is an addict. It has been a long and difficult journey for the
family.
Because of the lack of programs and facilities in Alaska, she
had no alternative but to engage an interventionist from
Washington to help get her son into rehab in Utah. The facility
was top notch and admitted her son with just insurance and no
upfront costs. Her son was in rehab for 92 days and she traveled
there every other week to attend family group therapy and
counseling. When her son came home, he did not get the treatment
he needed and relapsed shortly thereafter. He was readmitted to
the program for 30 days and when he returned to Alaska it was a
struggle to find a doctor to help with his medical treatment,
counseling and other things that must be in place to help with
treatment.
MS. REYNOLDS said that when her son relapsed a second time she
was able to get him to Gateway to Recovery Detox in Fairbanks.
Before he left Gateway he got a Vivitrol shot and Neurontin to
help with anxiety. The medications as well as counseling and
meetings saved him from relapse upon returning home. She said it
is one day at a time, but she hasn't seen her son this clear-
minded in years. The current struggle is to find him sober
living in Anchorage where he can be close to family. This is a
challenge because drugs make their way into sober-living
facilities.
She said it is astonishing that resources are so scarce,
particularly in light of the fact that Alaska ranks among the
ten highest of all the states for drug and alcohol abuse.
Addicts and alcoholics can go on to live happy, sober lives, but
they can't do it alone. She expressed hope that telling her
story will help get the funding, programs, and medical treatment
that Alaska desperately needs.
2:59:02 PM
PAUL FINCH, PA-C, Gateway to Recovery Detox, Turning Points
Counseling, said he does detox and medication assisted treatment
and he believes that one of the biggest barriers to treatment is
the fear of withdrawal. He appreciates the comments about the
reluctance to treat addicts, but his perspective is that it
should be mainstreamed in family practice clinics.
MR. FINCH explained that Gateway is a 16-bed inpatient facility
that is administered by the Fairbanks Native Association. Two of
the beds are designated to opioids and they are always full.
There is a critical need for more beds, but there isn't staffing
or resources for that at this time.
CHAIR MCGUIRE asked if there is anything the state can do to
increase the number of beds.
MR. FINCH replied he can't speak for FNA leadership, but he
doesn't think the answer should always come from government. He
instead suggested trying to attract a leader in the industry to
establish a state of the art facility in Alaska.
CHAIR MCGUIRE commented on the alarming cost of treatment.
MR. FINCH stated that the business model at Turning Point is fee
for service. The treatment is very good, but it's expensive.
CHAIR MCGUIRE thanked the presenters.
3:04:07 PM
There being no further business to come before the committee,
Chair McGuire adjourned the Senate Judiciary Standing Committee
meeting at 3:04 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| 2_4_2015 JUD MAT Presentation.pptx |
SJUD 2/4/2015 1:30:00 PM |
|
| 2_4_2015 JUD Testimony Aryeh Levenson.pdf |
SJUD 2/4/2015 1:30:00 PM |
|
| 2_4_2015 JUD Testimony Family Practice Physicians.pdf |
SJUD 2/4/2015 1:30:00 PM |
|
| 2_4_2015 JUD Testimony Intervention Helpline.docx |
SJUD 2/4/2015 1:30:00 PM |