On June 20, 2014 the New England CEPAC held a public meeting in Burlington, VT at which the Council discussed a systematic review of published evidence on options for the management of patients with opioid dependence. CEPAC held votes on the comparative clinical effectiveness and value of different management strategies, and then explored how best to apply the evidence to practice and policy with a distinguished Policy Expert Roundtable of patient advocates, clinical experts, and policy leaders from across New England. In evaluating the evidence on different treatment options, CEPAC determined that long-term "maintenance" treatment approaches using methadone or Suboxone to reduce the craving for opioids have been found to be more effective than short-term managed withdrawal methods that seek to discontinue all opioid use and "detoxify" patients. Short-term withdrawal management typically starts with maintenance treatment but attempts to wean patients off all opioids within 30 days, while maintenance treatment assumes that patients will remain on maintenance medication for longer periods. Studies comparing methadone and Suboxone found no major differences between them in reducing illicit drug use and preventing overdose or death. Although clinicians generally do not want to keep patients on medication indefinitely, there is little evidence or consensus on whether or how best to taper patients off maintenance therapy. Limited evidence suggests that patients who have not been addicted for long, do not inject heroin or other drugs, and who have a strong social support system may do well in "opioid withdrawal" programs that use injectable naltrexone, a drug that blocks the effects of opioids entirely. CEPAC reviewed the results of economic modeling of different treatment options and voted that expanding access to maintenance therapy with either methadone or Suboxone represents "high value" because the added health care costs of treatment are offset by reductions in other health care costs that occur when individuals with opioid dependence begin treatment. Moreover, when broader societal costs such as criminal activity and work productivity are included, maintenance treatment is estimated to produce substantial overall savings. For every additional dollar spent on treatment, $1.80 in savings would be realized. These savings imply that moving just 10% of untreated individuals in New England into treatment would generate over $550 million in societal savings for the region. Based on the evidence and expert input, CEPAC concluded that coordinated efforts are needed to improve access to opioid dependence treatment for the large number of individuals in New England who lack adequate access to high quality care options. An important component of achieving this goal will be to improve access for individuals in the criminal justice system by creating jail diversion programs in which non-violent offenders are assessed for addiction and referred to appropriate treatment in lieu of incarceration and by providing maintenance therapy to individuals who will be in prison for long periods. At the level of the healthcare delivery system, efforts to train and support more clinicians with capacity to treat addiction are needed. In addition, states should explore options to develop coordinated care networks to maximize existing capacity by allowing patients to receive short-term intensive outpatient care at specialized treatment units, following which they can be referred outward to other outpatient practices for lower levels of ongoing care in primary care settings or community-based practices.
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