Over a decade ago, Philadelphia’s public health system moved toward recovery for mental health and addiction services. On the mental health side, there had been a belief that recovery wasn’t possible, especially for people with serious mental illness. On the addiction side, recovery was already in wide parlance, but the system was set up to treat the disorder as if it was acute, with no long-term or continuous follow-up care, resulting in relapses. Now, Philadelphia has taken great steps to bring along its providers in adopting a recovery-based framework. We caught up with Roland Lamb, director of addiction services for the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIdS) to get an update on the recovery transformation as it affects patients in medication-assisted treatment (MAT).
“The good news is that we have moved towards more of a person-centered perspective in MAT,” Mr. Lamb said. In other words, providers are learning to look at people as people, not patients.
“We have the richest environment for MAT, with all levels of care,” he told AT Forum. He added that not only is there outpatient methadone, but there is medication-assisted treatment in all levels of care, and there are efforts to reach out to the 144 physicians in the system who are certified to dispense buprenorphine, and to provide access to those they are seeing to all of the treatment resources in Philadelphia.
The Medication ‘Culture’
But, because of the oversight and stigma, it has been a struggle to get providers to focus on the fact that people are people first, and not patients to be “dosed and monitored,” Mr. Lamb said. “The bad news is that we still have to work to overcome the stigma-driven culture of managing the medication, instead of treating addiction and focusing on recovery.”
This medication “culture” isn’t completely the fault of the opioid treatment programs (OTPs), Mr. Lamb noted. “It’s the most regulated form of treatment—in health care—that there is,” he conceded. The preoccupation with regulations, one drug after another, and the diagnosis, is at the cost of focusing on treating the addiction and supporting recovery and other needs. “People lose sight of managing the addiction.” Yes, methadone maintenance is part of recovery, but the medication isn’t the only part of it. “This treatment was created to help people get into recovery, but recovery is more than the medication alone.”
Buprenorphine—the medication—is not on the DBHIDS formulary, said Mr. Lamb. “But we do pay for all the services that surround it—the physical exams, counseling, and the drug screens.”
But whether those in care are taking methadone or buprenorphine, the focus has to be on the individual, said Mr. Lamb. “We are making sure that our providers have what they need—good assessment instruments, evidence-based practices, and psychiatric supports.”
There is a high prevalence of co-occurring mental illness in the MAT population, said Mr. Lamb. “We know a lot of what has happened with those co-occurring illnesses to those in care, who in many cases are self-medicating the very illnesses that they need help with.”
The DHBIdS meets with MAT providers every two months. These include inpatient and outpatient MAT providers, and the state licensing authority and the Drug Enforcement Administration are present as well.
No Involuntary Discharges
One of the key patient-centered initiatives in Philadelphia is this: “We say we don’t want involuntary discharging going on,” said Mr. Lamb, noting that “noncompliance” in addiction treatment is no worse than it is in treatment for high blood pressure or type II diabetes, and that terminating treatment is no solution. The reason for discharge may be violence, or threats of violence, for example, but many times this behavior is a result of untreated mental illness, said Mr. Lamb. Other reasons for discharge are drug dealing on the premises, or, of course, noncompliance with the treatment plan, but aren’t they some of the very reasons treatment is needed?
“We see ourselves as being in a partnership in terms of trying to overcome these issues,” said Mr. Lamb. The person in recovery, the providers, the regulators, and the payers all need to be at the recovery table to make this work.
Another point about person-centered care: OTPs should treat people based upon their need. For example, Pennsylvania requires two and a half hours a month of counseling—but patients should get more if they need it, said Mr. Lamb. “The issue for us is that we want to see counseling based upon the needs of the person.” That’s why the DBHIdS pays based on how much counseling is given. “We track the counseling separately.”
Training in CBT, Other Modalities
“The real challenge for us is to get staff to rethink what they’re doing,” said Mr. Lamb. “We’ve been doing it one staffer at a time.” Staffers are getting training in cognitive behavioral therapy (CBT), dialectal behavioral therapy (DBT), trauma, and the sanctuary model, he said. “All of these are evidence-based practices that we’ve been paying our providers to get trained in.”
There are 11 providers operating 13 OTPs in Philadelphia, treating a total of 5,000 patients a day. “When you think about it, that’s approximately 400 people coming in every day,” said Mr. Lamb. “It would be better if we could have smaller numbers of people in each facility, and more facilities.” He noted that community complaints about traffic would then go down. Of course, for that to happen, there would have to be community cooperation in siting clinics. “There is still so much stigma,” said Mr. Lamb, noting that this comes from the “outside” community and from the drug-addiction treatment community itself.
“Through a recovery focus we have a chance to change the usual ‘down with methadone’ discussion to a discussion about solutions for long-term opioid dependence and long-term recovery,” Mr. Lamb said. This is especially important now, with the burgeoning cohort of people becoming addicted via the non-medical use of prescription opioids, and their conversion to heroin. We need to do a better job of reaching out to, engaging, and retraining this population if we are going to impact the growing number of overdose deaths we are seeing, said Mr. Lamb. “We also need to evolve the recovery focus to one of wellness, and the need for those who are actively recovering to take better care of their health.”