By Alison Knopf
There were more than 2,000 attendees at the 2018 conference of the American Association for the Treatment of Opioid Dependence (AATOD), held at the Marriott Marquis in New York City in March.
The five-day meeting was full of presentations, workshops, and formal and informal gatherings, where leaders and staffers in the field of treatment of opioid use disorders exchanged knowledge and experience.
Open Board Meeting: Concerns About STR Funding
The open board meeting, which took place March 10, was an important time to share concerns about funding and regulatory matters with federal agencies. Board members had many questions for the Substance Abuse and Mental Health Services Administration (SAMHSA). The questions were related to the State Targeted Response (STR) to the Opioid Crisis grant program, which added $1 billion to the opioid treatment landscape via state funds.
SAMHSA’s Onaje Salim, EdD, conducted his agency’s presentation at the open board meeting. He was confronted by questions about why so much of the STR funding was going to pay for buprenorphine, naloxone kits, and prevention messages, but relatively few contracts with opioid treatment programs (OTPs) were being funded, to expand treatment in a more comprehensive way.
Dr. Salim was very sympathetic to the concerns of the AATOD board members. Formerly the administrator of an OTP in Atlanta, Dr. Salim was the first Georgia delegate to the AATOD board of directors. Later he became the Single State Authority for Georgia, before going on to SAMHSA.
But concern persisted at the board meeting: Would the STR funding be used for the same projects in year 2 as in year 1? And how would SAMHSA be able to guarantee that the funds were being put to good use? “How do you give the same level of funding if you don’t understand if it worked the first year?” as AATOD president Mark Parrino, MPA, put it.
OTPs’ Missed Opportunity
The time for OTPs to have made their case, however, was back in December of 2016 when the STR grants were announced. States prepared their applications then, and although a new federal administration was coming in, the funding process was underway. OTPs needed to go to the states at that time to present their arguments.
“I did say to my board members and provider colleagues that if you guys want to get these funds, you have to plant yourselves in the state offices,” Mr. Parrino told AT Forum.
On the other hand, states also have an obligation to use federal funds judiciously and to reach out to the appropriate partners, including OTPs, said Mr. Parrino. If states are not including OTPs as part of their treatment expansion strategies, then that needs to be explained as well. While a number of federal and state agencies are moving quickly to increase access to treatment, it is also important to be accountable in how these funds are spent.
And it is up to SAMHSA to hold states accountable for their use of STR funds, said Mr. Parrino. “SAMHSA should be holding the states’ feet to the fire. This is a straightforward issue.”
Buprenorphine Data 2000 Prescribers—Where Are Comprehensive Services?
The challenge from DATA 2000 practices—buprenorphine prescribers who do not necessarily provide comprehensive services—is felt keenly by the OTP community.
SAMHSA is invested in quality treatment services. Still, how this need for quality is implemented in DATA 2000 practices “is going to be a mystery,” said Mr. Parrino. While Elinore McCance-Katz, MD, PhD, who heads SAMHSA, says she wants coordinated services, how does this apply to DATA 2000 practices, which only have to prescribe buprenorphine and not provide any other care?
It is also true that there are many DATA 2000 practices that are offering excellent care. There should be some consideration in identifying treatment providers who do provide excellent treatment utilizing evidence-base practices, said Mr. Parrino. This issue will take on greater importance as insurance companies use a number of strategies to identify providers, which should be part of their network.
AATOD supports all three medications approved to treat opioid use disorder, but, like Dr. McCance-Katz, it endorses treatment that is comprehensive, not just restricted to prescribing and dispensing medication.
Mobile Vans Haven’t Yet Hit the Road
The Drug Enforcement Administration’s Jim Arnold, section chief of the liaison and policy section, explained to the AATOD board that mobile vans are not a reality yet because of President Trump’s executive order calling for eliminating two regulations for every new one. He said that the DEA was trying, however, and had sent it to the general counsel, but got it back with 70 requested modifications.
“So it’s slowed down,” said Mr. Parrino. “It’s not that anyone is saying ‘We don’t want to do this,’ because the DEA does want to do it,” he said.
The holdup is a problem in the way states use the STR money, as well. For example,
Molly Carney, executive director of Evergreen Treatment Services, wanted to use Washington’s STR grant for 2017 to get two new vans. She couldn’t, because of the DEA.
Awards Banquet: Former New Jersey Governor Attacks Stigma
If there were any questions as to why Chris Christie was chosen for the Friend of the Field award, the passionate acceptance speech by the former governor of New Jersey answered them. He attacked stigma directly, as the main reason for access problems for patients seeking methadone and buprenorphine treatment.
The Nyswander/Dole “Marie” awards at the banquet, which was sponsored by Mallinckrodt Pharmaceuticals, went to:
- Gloria Baciewicz, MD (a psychiatrist based in Rochester, New York, who broke ground 25 years ago in getting upstate communities to start to accept methadone);
- Hope Bolger, RPh (among many other credits, she has been the State Opioid Treatment Authority for Virginia, where the number of opioid treatment programs tripled during her tenure);
- Jonas Coatsworth, MA, LPC, CAC-II (a leader in methadone and recovery in South Carolina);
- Gabriele Fischer, MD (an Austria-based psychiatrist who has promoted methadone maintenance through the World Health Organization and the United Nations Office on Drugs and Crime);
- Kathleen Maurer, MD (the medical director of Connecticut’s Department of Correction, where she instituted methadone maintenance treatment in prisons);
- Stacey Pearce, CAS (treatment program director and methadone treatment advocate in Georgia); and
- Vickie L. Walters, LCSW-C (a treatment advocate based in Maryland).
The Richard Lane/Robert Holden Patient Advocacy Award went to Paul Bowman, CMA, Boston National Alliance for Medication Assisted Recovery chapter director, patient advisor to Habit OPCO, consultant to residency programs, and more.
Connectivity and Importance of Staff
The conference itself was a chance for OTP staff from around the country to get together. Looking over the history of the conference programs, it’s easy to see trends in the field. Mr. Parrino believes the conferences promote “connectivity,” so that stakeholders and conference attendees can understand how their work is related to regulatory changes and other moves on the state and federal levels.
Now that the field has the money—from the STR grant program, with new funding expected—the question is, do OTPs have the infrastructure? Programs are opening, and in some states, the growth is dramatic. “In Ohio, it’s like the gold rush,” said Mr. Parrino. But, as he said at the open board meeting, as OTPs expand, they must be sure that they have the workforce to do this properly, and that they have the money to support the workforce.
“There’s a connection between retaining staff and retaining patients,” said Mr. Parrino. Success in treatment is driven by the characteristics of the treatment program, not the characteristics of the patient, as the John Ball study showed (see citation, below).
Currently, there are about 1,600 OTPs in the United States. By October of 2019, when the next AATOD conference takes place in Orlando, that number will be 1,800, Mr. Parrino told AT Forum. “I’d like it to be 2,000,” he said. “But remember, the number must be reflected in the ability to open and staff the programs.”
Ball JC, Lange WR, Myers CP, Friedman SR. Reducing the risk of AIDS through methadone maintenance treatment. J Health Soc Behav. 1988;Sep;29(3):214-226.