Madras served as the deputy director for demand reduction for the White House Office of National Drug Control Policy; She was nominated by President George W. Bush in July, 2005, and unanimously confirmed by the United States Senate in 2006. in the Federal budget for Medicaid reimbursement, assurances that the majority of federal employees' healthcare insurers would reimburse for these procedures, that certain State Medicaid plans would reimburse for SBI services, that the Veterans' Administration would mandate SBI for alcohol throughout the VA system, that the Federal Health Resource Services Administration would implement these services in underserved populations.
Response to opioid fatalities
Although her term was largely consumed by oversight of federally funded programs, upon assuming office as deputy director of the ONDCP, Madras became aware of a newly emerging threat, fentanyl overdose deaths in heroin addicts. She rapidly organized a conference in Philadelphia with treatment providers, emergency responders, emergency room professionals, law enforcement officials, representatives from city governments, other healthcare professionals, to create a coordinated response to eliminate this threat to life. Within months and for a number of reasons, fentanyl overdose deaths declined rapidly. Of over 170 media events and interviews during her term, she gave two interviews on Narcan distribution to heroin addicts and friends. At that time, she strongly supported narcan rescue by trained healthcare personnel, but opposed distribution to heroin users and their friends, of overdose rescue kits of opiate-antidote naloxone "the induction of an acute withdrawal syndrome "the effect of naloxone may wear off prematurely when used for treatment of opioid-induced respiratory depression and require multiple doses and long-term vigilance". "Risks warranting the cautious use of naloxone and adequate monitoring of the cardiorespiratory status of the overdose person after naloxone administration where indicated". Based on the Seal study, she was concerned that Narcan kits may encourage 35% of drug abusers to use greater amounts of heroin because they thought overdosing isn't as likely, again leading to unintended consequences. Madras also felt that in the presence of healthcare professionals, the opportunity to provide detoxification and referral to treatment would be greater than in a "take-home" narcan provision program. She was concerned that in a "take-home" narcan program, not all resuscitated heroin overdose events could be safely left alone. This concern was based on an article by Etherington et al. : "In the medical community, it is recommended that patients with heroin overdose be watched for 4 to 24 hours after naloxone. In a recent study, overdose patients were formally assessed 1 hour after receiving naloxone for presumed opioid overdose. Of 573 patients, 48% were discharged in less than 2 hours, 23% in 2–4 hours and 29% in >4 hours. 94 patients who were held in the emergency department or admitted required a critical intervention, including supplemental oxygen for hypoxia, repeat naloxone, antibiotics administered intravenously , assisted ventilations, fluid bolus for hypotension, charcoal for associated life-threatening overdose, IV inotropic agents, antiarrhythmics for sustained tachycardia >130 beats/min, and administration of bicarbonate for arterial <5 or venous CO2 <5 ". This study concluded that emergency physicians can clinically identify patients at risk of deterioration after naloxone reversal of suspected opioid overdose. She was concerned that in the "take-home program", additional emergency room measures needed for a significant number of people, would not be available. Finally, the majority of the scientific literature on take-home narcan was based on pilot studies, feasibility studies, or letters to the editor, an inadequate body of research for developing public policy or advocating a major change in medical procedures that could potentially save or cost precious lives.
Research
Madras has authored over 130 scientific manuscripts and book chapters, and she recently co-edited a book on the Cell Biology of Addiction. Along with her collaborators, she is the recipient of 19 patents.
