|AATOD Board Meeting Features Visits With Lawmakers, ONDCP, DEA, and SAMHSA|
|AATOD Board Meeting Features Visits With Lawmakers, ONDCP, DEA, and SAMHSA|
By Alison Knopf
The annual board meeting last December of the American Association for the Treatment of Opioid Dependence (AATOD) was more than just a meeting. Eight board members conducted a number of visits to Capitol Hill, educating Congressional representatives and staff. A key focus of these visits was getting reimbursement for Opioid Treatment Programs (OTPs) from Medicare Part B (which covers nonhospital treatment), said AATOD president Mark Parrino, MPA. “This will be a slow and labor-intensive process, but I believe that at the end, we will be successful,” Mr. Parrino told AT Forum.
The board also met with Richard Baum, MA, MPA, acting director of the Office of National Drug Control Policy (ONDCP); Demetra Ashley, MA, deputy assistant administrator for the Drug Enforcement Administration (DEA); Danielle Johnson Byrd, MPH, director of the Division of Pharmacologic Therapies at the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration; and Ms. Byrd’s staff. “They all led extremely productive discussions among AATOD board members,” said Mr. Parrino.
The ONDCP is expected to release the National Drug Control Strategy in March.
Speaking with the AATOD board, Mr. Baum, a longtime ONDCP official, continued to support the utilization of medication assisted treatment (MAT) for opioid use disorder (OUD), said Mr. Parrino. In addition to the use of medications, Mr. Baum stressed the need for offering comprehensive care services. “He expressed concern that treatment for opioid use disorder needs to reflect the best standards of care, so that we can be certain that patients are being properly treated when medications are selected by various treatment practitioners in the United States,” said Mr. Parrino. “ONDCP and its leadership continue to be supportive of the work of our Association and its members.”
Drug Enforcement Administration
The DEA officials who met with the AATOD board in December focused on three areas: mobile vans, telemedicine, and the new Narcotic Treatment Program Guidelines (NTP is the term the DEA uses).
Finalizing the mobile van policy development would certainly increase the use of mobile vans connected to the bricks-and-mortar OTPs, said Mr. Parrino. “We know that there are several states that want to purchase such vans so that they can expand the reach of OTPs in their areas.” For example, the Evergreen Treatment Services system in Seattle, Washington, is working in this area. In addition, the New York State Office of Alcoholism and Substance Abuse Services has indicated a strong interest in implementing mobile vans, especially in rural and upstate areas.
So, what is holding up the mobile vans issue? The DEA is interested in promulgating the rule, but is “running into some roadblocks regarding how fast they can introduce a new regulatory approach, at a time when deregulation seems to be the primary focus,” said Mr. Parrino. There will be more information at the conference in March when DEA leadership meets with the board of directors.
The release and implementation of the DEA’s new NTP guideline is being held back. The guideline discusses how mobile vans would be used, so it can’t be released until the mobile van policy is resolved.
AATOD is working with the American Academy of Addiction Psychiatry to develop telemedicine guidelines for OTPs. This matter will be discussed during the policy section of the March conference.
Danielle Johnson-Byrd and three of her associates led the discussion on how CSAT is targeting policies affecting OTPs in the United States. “We talked about the importance of proper OTP siting, especially as more treatment programs will be approved by CSAT to operate in the United States,” said Mr. Parrino.
There was also an in-depth discussion of the quality of care services offered through OTPs. CSAT reminded all board members that the agency will continue to promulgate effective oversight to be certain that OTPs follow existing standards, especially during a period of such rapid expansion.
The board also expressed concerns that states clearly demonstrate what they have done in using the grants from the State Targeted Response (STR) to the Opioid Crisis, issued by SAMHSA, for 2017. Are states using this money for MAT for OUDs? This is a matter of accountability, as states work to increase access to treatment; 80% of the STR grants had to be used for direct treatment for OUDs. But the board expressed concern that some states may be marginalizing the use of medications, such as methadone, or marginalizing OTPs themselves. For example, Wyoming decided not to use any STR grant funds for methadone maintenance treatment, and not to site any OTPs, Mr. Parrino noted.
“There are more encouraging reports from other states with regard to STR grant use, and it is expected that this will be reported on during the March conference in New York,” said Mr. Parrino. “There will be a number of policy discussions led by SAMHSA and CSAT representatives and it is certain this topic will come to surface.”
By Alison Knopf
California has embraced the hub-and-spoke concept in implementing its State Targeted Response (STR) to the Opioid Crisis funding from the 21st Century Cures Act. The hub-and-spoke system was established in Vermont almost 10 years ago, with funding from the Affordable Care Act. The hub is an opioid treatment program (OTP) that does evaluations and assessments for all new admissions. Patients who need to stay in an OTP, stay in the hub for treatment. Those who are referred for office-based opioid treatment (OBOT) are referred to the physician offices, or spokes.
Jason Kletter, PhD, president of BayMark Health Services, which operated some of the original hubs in the Vermont system, is pleased to be helping the STR implementation in California. “Hub and spoke is a fantastic model,” he said. “It’s consistent with the chronic disease model, and provides evidence-based and high-quality treatment while creating a continuum of services.” If a patient is not doing well in a spoke, for example, the patient goes back to the hub.
Using its STR grants, California will set up 19 hub-and-spoke systems, mainly in the northern, rural part of the state, Dr. Kletter told AT Forum. “The providers who are doing this are knocking hard on doors,” he said, referring to the effort to engage prescribers.
Creating Hub-Spoke Connections
“Our organization, BayMark, got four grants” from the STR money, but not for new OTPs, said Dr. Kletter, who is also president of the California Opioid Maintenance Providers (COMP) group that represents opioid treatment programs in California. Rather, BayMark got the money to build a network of prescribers and create the relationship between OTPs (hubs) and spokes (OBOTs). The key component is the MAT (medication-assisted treatment) team, consisting of a nurse, and a counselor/case manager, the team goes to the spokes and provides support services. “We hear all the time that physicians want the support to provide good care,” Dr. Kletter said.
One of the biggest challenges is getting enough buprenorphine prescribers—to get physicians to use or apply for the DATA waiver—said Dr. Kletter. “We are trying to get people who have not been waivered to agree to it. The problem is that many get the waiver, but don’t prescribe, or prescribe to just a few patients,” he said. But what was learned in Vermont is that the hub and spoke helped physicians become more willing to prescribe. “If the doctors have the MAT team as support and the OTP as a backstop, they know that if the patient relapses, they can increase treatment intensity in their practice or always refer them back to the OTP.”
Patients who have good support systems in their lives—an involved family, a stable place to live, a job, a strong reason to get and stay well—don’t always need the robust structure of an OTP, said Dr. Kletter. “That’s the reality.” But they need more than just getting a prescription for buprenorphine.
The spokes have a full-time case manager and nurse for every 100 patients, said Dr. Kletter.
For a program that was announced just over a year ago, gave states one month to write their applications, and has been in operation for just over half a year, STR funding is moving forward well. In California, it’s moving at “lightning speed,” said Dr. Kletter. “California is moving faster than I’ve ever seen them move on any initiative,” he said. “They have UCLA contracted to manage the data collection and learning collaborative.”
That said, “systems change isn’t easy,” said Dr. Kletter. “We went out and hired people; we’re executing contracts with spokes and with pharmacies, patients are being enrolled in treatment, capacity is expanding. But contracts take time to work out.”
Dr. Kletter would like every state to be doing something similar with their STR money, and welcomes scrutiny from SAMHSA and the Department of Health and Human Services. “The feds need to look closely at how states are using this money,” he said. “I’d like to see it taken away from states that aren’t using the money well.”
The bottom line: “We have to save lives.”
By Alison Knopf
The hubs—OTPs—treat patients who have been assessed as needing the OTP level of care. These patients are given methadone, buprenorphine, or naltrexone. Patients in the spokes—physicians’ offices—are given buprenorphine or naltrexone.
The study findings are in a 185-page report completed by Richard A. Rawson, PhD, a research professor with the Vermont Center on Behavior and Health, University of Vermont. Funding came from three sources: a $199,200 grant from the Vermont Department of Health; $150,000 from the federal Centers for Disease Control and Prevention; and $49,200 from the Substance Abuse and Mental Health Services Administration.
Vermont’s hub and spoke system is called the Care Alliance for Opioid Addiction.
The 96% decrease represented a drop in average days of opioid use, from 86 to only 3. The study included 100 opioid users; 80 in treatment and 20 out of treatment.
“This report gives me hope,” said Mark Levine, MD, Vermont’s health commissioner. “All across the country, our friends, neighbors, and communities are struggling against the toll brought about by addictive, and all-too-plentiful, illicit drugs. By reviewing the data, and listening to the people who are working hard to recover, we see that our Hub-and-Spoke system is beginning to bend the curve against the opioid epidemic.”
Key findings among Hub-and-Spoke system study participants:
No treatment participants had overdosed in the 90 days before the study interview. In contrast, 25% had overdosed in the 90 days before entering treatment. Other findings: family conflict had lessened, and feelings of depression, anxiety, and anger had decreased. Patients reported being much more satisfied with their lives.
For the hub-and-spoke report, go to: http://www.healthvermont.gov/sites/default/files/documents/pdf/ADAP_Hub_and_Spoke_Evaluation_2017_1.pdf.
By Alison Knopf
Boston is not the only city with a powerful push by academics and providers for medication-assisted treatment (MAT), but it’s definitely one with a high profile. We talked with Janice F. Kauffman, RN, MPH, and Sarah Wakeman, MD, about how opioid treatment programs (OTPs), specifically, can help fight stigma against MAT.
Education is important, but by itself won’t work because of pre-existing bias, said Ms. Kauffman, who is vice president of Addiction Treatment Services for North Charles Foundation, Inc., director of addictions consultation for the Department of Psychiatry, Cambridge Health Alliance, and assistant professor of Psychiatry, Harvard Medical School. “I spend a good amount of my time talking to community members, talking to police, trying to educate people in the community,” Ms. Kauffman told AT Forum. “But I don’t think education is as helpful as we hope it will be, because people come with pre-existing opinions.”
In other words, if someone is predisposed to believe methadone is “trading one addiction for another,” that person will believe it, regardless of the information they are given.
“I often teach police officers,” said Ms. Kauffman. “And I’m impressed that I can spend an hour giving them information—in particular, about the efficacy of methadone maintenance. But at the end of the day there are many who maintain that you should be off the medication, that this isn’t really a disease like other diseases.”
One problem is that substance use disorders are still conflated with crime, in the mind of many in law enforcement. Those people don’t need to be educated about cancer, dental caries, or other diseases. Perhaps it’s too much of a stress to even try to educate them about addiction—but, in fact, many police officers, especially in Massachusetts, the home of PAARI (Police Assisted Addiction and Recovery Initiative), would rather help people get treatment than arrest them. The question is, what kind of treatment? Massachusetts currently has an initiative focused on getting residential treatment for people with opioid use disorders, and favoring antagonist treatment with Vivitrol instead of buprenorphine or methadone. This is also true for people under civil commitment—a process that falls in line with many beliefs of law enforcement.
Ms. Kauffman also said that OTPs need to do a better job of educating the media, which is in general not well informed about methadone maintenance, a treatment that’s proven efficacious for decades. “The media does not do us justice,” she said. “Their stories have focused on people who don’t do well.” She added that some stories look at people in the community who are not doing well, mostly because of benzodiazepines and other drugs of misuse. “This is what happened in the Boston area, with stories about what the media dubbed ‘Methadone Mile.’ Even when behavior doesn’t involve methadone, the media automatically connect it. They think that neighborhoods with OTPs are places people deal drugs—but people deal drugs everywhere.”
It would help for successful patients to come forward, but they’re afraid to, because of the effects on their jobs and lives and families, said Ms. Kauffman. “I’ve been doing this work since the early 1970s. I’ve lived this stigma for a long time, and I’ve watched our patients suffer from it.”
So, what is the solution? Perhaps OTPs should ask employers to publicly support methadone maintenance—“especially employers who are willing to come forward, and who know that their patients are in methadone treatment and doing well. That would be better than putting it on the backs of patients,” said Ms. Kauffman. “Employers could say, ‘Some people who are working for me are methadone patients, and they’re doing very well,’” said Ms. Kauffman. “This would show that people are willing to employ our patients, who have a disease like any other disease.”
The North Charles Foundation produced “Waking Up: A Story in Four Parts,” a short film on its program, specifically designed to address stigma, as part of a grant. In a narrative therapy group in the film, patients told how they got into trouble with drugs, and what methadone treatment was like. (The grant was from Johnson and Johnson, the Harvard Medical School’s division on addictions, and a private family foundation.) “We showed the film to over 100 medical, social-service and substance use treatment providers in the greater Boston area, for a pre-test and a post-test,” said Ms. Kauffman. Before they saw the film, viewers were biased against methadone. After they saw it, their feelings changed. “They were struck by how the patients suffered, and what happened privately in their lives. They were also impressed with how the patients got better, and became contributing members of society.”
Ms. Kauffman uses this film when she teaches doctors training in hospitals as residents. “It’s powerful,” she said.
One Day at a Time
There’s a commonly held notion that methadone maintenance is forever, which can be daunting, creating a stigma of its own. It’s similar to what happens when people with alcohol use disorders are overwhelmed by the idea that they can never drink again. “We have lots of patients who come to treatment saying they want methadone only for a certain period,” said Ms. Kauffman. “I would never say ‘no,’ to that. We say, ‘Let’s get you stabilized, let’s help you look at this.’” Often it’s the stigma that makes patients want to leave treatment quickly.
“If you have to deal with the notion of needing to do this for the rest of your life—that’s hard for patients to wrap their minds around,” she said. But OTPs help new patients normalize their lives as soon as possible, and most patients see that they can have normal, good lives without giving up their medication, and without switching medications.
Dr. Wakeman, who is medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Massachusetts General Hospital, co-chair of the Mass General Opioid Task Force, and an assistant professor in medicine at Harvard Medical School, is a big proponent of using proper language to reduce stigma.
“One of the greatest struggles we have is reducing stigma, not just about addiction but about treatment,” she said. “If we change our language, using medically appropriate terminology just as we do for other illnesses, we can change how the rest of the world thinks of treatment.”
A very simple but necessary change is to stop using the terms “clean” and “dirty,” she said. “You can say a toxicology test was positive or negative, or you can say the results are appropriate or inappropriate.” The point is not just to switch the words, it’s to stop being judgmental. “When I talk with a patient about diabetes testing, I refer to results as being within range or out of range. OTP counselors telling patients about a positive drug test can begin by saying, “There were unexpected findings in your toxicology report,” she said. “Stay away from judgement-laden language.”
This isn’t just a matter of being politically correct, said Dr. Wakeman. If treatment programs convey this kind of stigma against patients, how are people supposed to avoid it?
Dr. Wakeman also points out that “dependence” should not be confused with addiction. Being dependent on a medication is not the same as being addicted—it’s not pathological. “If someone is taking long-term opioids appropriately for pain, that person is dependent,” she said. “If someone is taking methadone for addiction, that person is dependent.”
Involving OTPs in the General Medical System
“The more we can engage OTPs in the general medical system, the better for patients,” said Dr. Wakeman. Her facility does not have its own OTP, but works closely with OTPs, she said. “We have agreements with OTPs. It’s important to have these agreements with OTPs as a hospital system,” she said. “That way we can link patients directly into ongoing care. It’s been great for us to work with OTPs.”
In deciding whether to refer a patient to an OTP or to office-based opioid treatment (OBOT) with buprenorphine, Dr. Wakeman said the most important factor is “what the patient wants and what the patient thinks will be effective.” Most patients prefer to start with buprenorphine, said Dr. Wakeman. “But if the patient reports having done well on methadone in the past, we go that way. If someone has tried both in the past, if they’ve done well on one but not the other, that helps us decide.”
Legacy for Methadone
For methadone, Dr. Wakeman uses a 1965 New Yorker profile of Marie Nywswander, MD, who, with Vincent Dole, MD, developed methadone maintenance treatment. Called “The Treatment of Patients,” the profile, by Nat Hentoff, explains how methadone works. “I still use this now, in 2018,” said Dr. Wakeman. “A molecule of methadone is no more problematic than a molecule of insulin.”
Dr. Wakeman has patients who work at Harvard or Mass General and are taking methadone. “You wouldn’t know it,” she said. “These people are doing well and going about their business and living their lives.
“We need to make addiction treatment seem scientific and a part of the medical mainstream,” she said. “And we need to hold them to the same standards and expectations we use for any other treatment provider.”
It would be beneficial to hear more patient narratives of recovery on MAT, said Dr. Wakeman, who agreed with Ms. Kauffman that the media promotes some stigma. “We need to hear from patients on MAT saying, ‘This is how much better my health and my life are now.’”
By Barbara Goodheart, ELS
Here’s an eye-catching statistic: only about 3% of the world’s population is infected with hepatitis C virus (HCV)—but the infection rate in methadone users is a mind-boggling 70% to 90%.
This high rate of infection is especially surprising now that better treatments, including an oral medication, are available for HCV infection. The new treatments are well tolerated, with few side effects, and can cure HCV infection in only 8 to 12 weeks.
So, why are so many methadone users still HCV positive? What motivates some patients to start treatment, and what keeps others away?
A team from Philadelphia conducted a research study to find the answers to these questions. They published their results online December 18, 2017 in the Journal of Health Communication.
The risks of chronic HCV infection are generally well known: cirrhosis (20% of those infected), liver cancer or end-stage liver disease (10%), and liver transplant, or death due to the HCV infection (3%). Yet fewer than 10% of methadone patients start HCV treatment.
Getting those patients into treatment would accomplish important goals. It would help lower the death rate from HCV infection, and would reduce what’s known as “community reservoirs”—people in the community who provide an ongoing source of HCV infection. In short, it would reduce the spread of HCV.
But getting patients into treatment is an issue that poses problems of its own. See “The Forgotten,” below.
|The “Forgotten”—Those Who Fail to Reach the Eligible Pool
It’s one of those truisms we tend to be unaware of until someone points it out, but the only patients who have a chance for HCV treatment are those who reach the “eligible” pool. And it seems that few patients get that far—as few as 1 in 6, according to a PLoS One study.
The key: The patient-provider relationship.
Patients deemed eligible for HCV treatment by those providing their care described more positive relationships with their provider; those less likely to be eligible reported concerns about the provider.
Patients wanted communication and connection with their providers. They wanted information directly, through conversation, instead of being given pamphlets.
“The provider . . . wasn’t interested in anything I had to say . . . was going through a series of motions; didn’t care . . . wouldn’t even provide information about the treatment . . . “
“Don’t send literature. Ask the people. My eyes are so shot . . . And they give me a big pamphlet with all these wee little lines and I’m going to sit there with a magnifying glass and make my way through it?”
Using highly sophisticated commercial marketing techniques, the Philadelphia research team analyzed data from 100 methadone patients who tested positive for HCV. (Techniques of the study are too detailed to cover here; readers who are interested can go to the original publication.)
The data yielded key information on barriers that tended to keep patients out of treatment, and the factors that could motivate patients to begin treatment.
Findings, Themes, and Messages
The main findings: patients didn’t tend to see the benefits to HCV treatment, and they felt closely occupied with barriers and concerns about treatment.
As an approach, the authors suggested emphasizing positive messages in communicating with patients:
The authors also suggested emphasizing previous positive relationships and experiences with health care providers. (This finding ties in with the PLoS ONE conclusion that a good patient-provider relationship is key in getting patients into HCV treatment.)
Based on their results, the authors suggested that caregivers focus on six specific “themes”—in other words, six specific thoughts and concerns patients described. The first two are listed below, along with the suggested messages for providers to share with patients.
Theme (Patients’ Thoughts and Concerns)
Message to Emphasize
|I’ve heard some about the new Hep C treatment. What are the benefits to me?||HCV can be cured. The treatment is easy and cures quickly. Getting treated makes you feel in charge.|
|I’m not sure how the new treatment is different from the old treatment. What might be a barrier to me getting treated?||Doctors do want to treat you; paperwork and transportation issues can be addressed.|
(See the published article for a complete list of themes and messages.)
Comparisons With Other Studies
Similarities. Patients were highly confident about their knowledge of HCV, and were willing to take part in educational activities. Yet they had fears about HCV medication, particularly the side effects. And they were fearful about HCV itself, a disease largely without symptoms.
Differences. In this study, patients’ perception of doctors was generally positive. Concerns did exist about logistics, such as transportation and paperwork. And some patients worried that doctors might not know enough about HCV treatment.
In closing, the authors emphasized the importance of caregivers’ “understanding how HCV+ individuals in MMT programs perceive HCV and its treatment.” Once caregivers have gained this understanding, the authors believe, they will be able to plan interventions to encourage patients to begin HCV treatment.
Bass SB, Jessop A, Maurer L, Gashat M, Al HajJi M, Gutierrez M. Mapping the barriers and facilitators of HCV treatment initiation in methadone maintenance therapy patients: Implications for intervention development. J Health Commun. 2017. doi:10.1080/10810730.2017.1414902.
Rogol SS, Arnold RM, Chapko M, et al. The patient-provider relationship is associated with hepatitis C treatment eligibility: A prospective mixed-methods cohort study. PLoS ONE. 2016; 11(2): e0148596. doi:10.1371/journal.pone.0148596.
By Alison Knopf
People who get incarcerated—in prisons or jails—tend to be people with more advanced addiction. If they have opioid use disorders, they typically spend their term without any opioids. When they are released, their tolerance has decreased, and if they relapse—which is likely—they may overdose. That danger was never as great as it is now, explained Josiah D. Rich, MD, MPH, professor of Medicine and Epidemiology at The Warren Alpert Medical School of Brown University, and director of the Center for Prisoner Health and Human Rights at The Miriam Hospital in Providence, Rhode Island.
“The stakes have gotten a lot higher,” Dr. Rich told AT Forum. “We send them back out into the community when the illicit opioid supply has never been so lethal.”
Rhode Island, under the leadership of Gov. Gina Raimondo, has led the state’s initiative to expand opioid treatment with medications to the prison and jail system. She put over $1 million a year into her budget that the General Assembly approved to screen incarcerated people for opioid use disorder and offer them medications for addiction treatment (MAT). Dr. Rich, who treats incarcerated patients, works as a consultant to the Department of Corrections, alongside CODAC Behavioral Healthcare, a not-for-profit opioid treatment program (OTP) that delivers methadone and buprenorphine to inmates.
“We screen everybody coming into prison and jail for opioid use disorders,” said Dr. Rich. “We offer treatment to everybody, using clinical criteria to determine which medication someone should get: methadone, buprenorphine, or naltrexone.” Naltrexone is by far the least popular medication.
Half on Methadone, Half on Buprenorphine
Under the Rhode Island program, which started in July 2016, 100 incarcerated individuals a month are leaving the system on one of the medications—well over 1,000 people, so far. “About half walk out on methadone, about half walk out on buprenorphine, and about a dozen walk out on naltrexone.
“The Department of Corrections has a contract with CODAC,” said Dr. Rich, noting that the OTP has several programs around the state, which is critical—released inmates will be able to attend a program near them. CODAC offers all three medications. CODAC is contracted to come into the prisons and jails, induct treatment, and enroll inmates into their system. Many times, jailed inmates who are not sentenced have no idea when they will be released. But no matter when it is, they can go to their nearest CODAC facility, which will look them up in their system, find out when they got their last dose and what it was, and continue treatment.
Inmates don’t have to go to CODAC—they can go to any program—Dr. Rich noted. But the transition makes it easy for inmates to know they have somewhere they can go and get dosed whenever they get out.
CODAC manages delivery of the methadone. “It’s on their license,” said Dr. Rich. Many years ago, the state’s department of corrections did have their own license. “It was easier to turn the logistics and accountability over to CODAC,” he added.
Until recently, CODAC poured the doses on their own premises, and each dose was labeled with the patient’s name and delivered to the nursing station in the prison and jail, where corrections nursing staff would dispense the methadone to the inmate. This is about to change; the correctional facility constructed a separate pharmacy, and CODAC nursing staff will dispense the methadone doses from there.
When Dr. Rich conducted a clinical trial many years ago, he hired CODAC nurses to dispense in the correctional facility. “When we first started, there was a negative attitude, with staff saying, ‘Why are we giving this stuff to them?’,” he recalled. “But attitudes evolved and changed.” This new initiative was first rolled out in the women’s facility; the MAT produced good results that were obvious to staff. When they saw that the women getting medicine were doing well, and the women not on medicine were not doing well, they started suggesting that some of the inmates actually needed help. “They would say, ‘Hey, Mrs. Jones looks like she’s hurting, and could probably use some of this.’”
In addition, the opioid epidemic is so widespread that a large proportion of the custodial staff probably has someone—a family member or friend—who is affected. The message is getting out that this is a disease, not a moral failing.
The OTP at Rikers
Jonathan Giftos, MD, clinical director of substance use treatment for the Division of Correctional Health Services at Rikers Island, a New York City jail, has two unusual and helpful aspects of jail-based treatment going for him. First, Rikers has its own OTP. Secondly, correctional health services in New York City is a division of the city’s public hospital system, NYC Health + Hospitals, not part of corrections.
The OTP at Rikers started in 1987. Clinical staff are, for the most part, supportive of it. But still, when Dr. Giftos got there in 2016, he saw that some changes were necessary.
First of all, it’s a jail, meaning that the majority of patients are pretrial detainees, with a small percentage of patients serving a jail sentence of a year or less. While patients could receive methadone or buprenorphine maintenance in the New York City jail system, the New York State prison system is unable to continue these treatments. For this reason, patients admitted to jail with felony charges historically were not eligible to continue maintenance due to the possibility that they may be state-sentenced. This meant that many patients with felony charges had their methadone or buprenorphine discontinued on jail admission.
But here’s the problem: many people are accused of a felony, but prosecutors only use this as a bargaining chip, and people never end up serving out that sentence. “If you were admitted with felony arraignment charges, you would often be tapered off your methadone,” said Dr. Giftos.
So when he arrived, he had an analysis conducted. He found that of all the jail admissions with an opioid use disorder and felony arraignment charges, only 30% of patients were sentenced to time in the state prison system. The other 70% were eventually discharged directly from jail back into the community. The predictive model used to guide eligibility for continued maintenance treatment was not particularly accurate.
“We don’t fully understand prosecutorial decision-making, but arraignment charges were imperfectly predictive of how a case may eventually be resolved in court,” said Dr. Giftos. “We needed better coordination with the district attorney’s office.”
Now, Rikers gets daily reports of every inmate who is convicted of a felony, at the point of conviction. Sentencing usually takes place a month or so later. If the patient is state sentenced, they still need to be tapered off treatment before transfer. If the patient is sentenced to “city time” or time-served, they can remain on treatment and are linked to community treatment on discharge. This has allowed CHS to adopt essentially “universal eligibility” for continued maintenance treatment on jail-admission, said Dr. Giftos.
Every new inmate arriving to jail on community methadone maintenance has a dose verification with their OTP during the first 24 hours at Rikers, is courtesy guest-medicated for the first few days, and eventually is enrolled in the Rikers OTP.
For new inmates who come in not on methadone or buprenorphine, but are dependent on opioids such as heroin, medically supervised withdrawal is done with methadone (starting at 20 milligrams and slowly tapered down) to manage symptoms. After that, the goal is to explore whether the patient is interested in starting methadone maintenance.
While patients coming from the community on buprenorphine can be continued during their incarceration, only city-sentenced inmates with known discharge dates are eligible to be newly inducted on buprenorphine, said Dr. Giftos. This is because discharge planning for detainees with unknown discharge date can be difficult. “If you are a sentenced patient, you have a known discharge date, and we can make an appointment in the community for you, ideally within four days of release,” he said. “We also give patients four days of buprenorphine to bridge them to their appointment
Detainees, who are charged but not convicted, don’t know when they are going home, so starting buprenorphine is unfortunately not an option yet. “With methadone, a community OTP is notified at point of enrollment,” said Dr. Giftos. “If the patient is suddenly discharged from jail, the patient can just show up and the OTP will courtesy guest-medicate them—that is much harder to do with buprenorphine.” (Of course, OTPs can technically dispense buprenorphine as well as methadone, but the issue is payment.)
At Rikers, out of the 2,000 patients with an opioid use disorder, the overwhelming majority are detainees, said Dr. Giftos.
Dr. Giftos credits community OTPs with helping his patients. “My experience working with OTPs has been very positive,” he said. “They are reliably available to patients in the early days of reentry. Patients are able to be courtesy guest-medicated while they go through the process of enrolling in the treatment program. OTPs also provide other important onsite services such as recovery groups, case management and primary medical and mental health care.
Dr. Giftos was a social worker before he went to medical school, and did his first rotation as a medical student in the jail system with Dr. Ross Macdonald, who is now chief medical officer at Rikers.
Study in Connecticut
Kathleen Maurer, MD, medical director for the Connecticut Department of Correction, forged a path to enable OTPs to deliver methadone to their existing patients in the state’s prison and jail system, and then got the program funded and fully licensed. She has just published a study, with co-authors, showing that the methadone maintenance treatment for inmates is associated with positive results, both during and after incarceration.
There are barriers in federal and state regulations, but in her study, a community OTP provided the methadone to inmates, and the study found that compared to a control group of inmates who underwent forced withdrawal, the methadone-maintained inmates were less likely to receive “disciplinary tickets.” Moreover, for those who continued treatment after release, there was reduced risk of arrest, new charges, and re-incarceration, compared with those who did not re-engage (see reference).
After visiting Rikers, Dr. Maurer convinced her department to allow OTPs to bring in medication for their patients. The Connecticut OTPs participated without funding at first, because they were losing all their patients who became incarcerated.
Meanwhile, Dr. Rich and his colleagues conducted an evaluation of the impact of their program on statewide overdose deaths, which is likely to be published in coming weeks. “In my 25 years and hundreds of published articles, this has a possibility of being among the most impactful,” he told AT Forum.
Moore KE, Oberleitner L, Smith KMZ, et al. Feasibility and effectiveness of continuing methadone maintenance treatment during incarceration compared with forced withdrawal [Epub ahead of print]. J Addict Med. 2018;Jan 16. doi: 10.1097/ADM.0000000000000381.
Results of Seven Merged National Polls, 2016 and 2017, New England Journal of Medicine – February 1, 2018
By Barbara Goodheart, ELS
How serious is the opioid crisis? Data from the Centers for Disease Control and Prevention give an idea: The annual rate of drug overdose deaths involving synthetic opioids (other than methadone) rose on average 18% from 1999 to 2006. Methadone’s overdose death rates started dropping in 2007 and have continued to decrease since then. Rates for the other opioids changed little during the next six years, but then rose by a staggering 88% per year from 2013 to 2016.
Many of us would consider this an emergency.
But the public doesn’t, apparently—at least not those recently polled. While 53% termed the opioid crisis a major problem, only 28% considered it a national emergency.
(The publication’s authors warned that many of the poll’s findings “may surprise people who have been following this issue in professional journals and the media.”)
So, what are your thoughts about the opioid crisis? Here are three quick questions. You can compare your answers with those from the poll.
Answers, from the poll:
Of those saying yes, 53% think a year or more of therapy will be necessary for a cure; 43% say less than a year
More opinions, from the poll:
▬ 33% blamed doctors who inappropriately prescribe painkillers
▬ 28% blamed people who illegally sell the medications
▬ only 10% believe those who take the opioids are mainly responsible
Are Attitudes Starting to Improve?
Perhaps. Responding to the statement “Prescription drug abuse is an extremely serious public health issue,” only 19% voted yes in 2013—but 38% did so in October 2017.
Importance of the Poll
Here’s why the results of this poll are especially important. Efforts are ongoing to increase government funding for opioid addiction treatment programs—something that’s clearly needed. But many people remain on the sidelines, underestimating the seriousness of the problem, and uncertain about the effectiveness of treatment.
This attitude could dampen public support for treatment programs—and could undermine support for a government requirement that insurance cover the cost of addiction treatment.
Clearly, the authors point out, the medical and scientific communities need to further educate the public.
Contributors to the Poll
Harvard T. H. Chan School of Public Health Poll, Kaiser Family Foundation Polls, PBS Newshour—Marist Poll, Pew Research Center Polls, Politico-Harvard T. H. Chan School of Public Health Poll, and STAT-Harvard T.H. Chan School of Public Health Poll.
For details of the poll, and sources of poll data, go to http://www.nejm.org/doi/full/10.1056/NEJMp1714529?query=featured_home.
Blendon RJ, Benson JM. Perspective: The public and the opioid-abuse epidemic. N Engl J Med. February 1 2018;378:407-411. doi:10.1056/NEJMp1714529.
Hedegaard H, Warner M, Minino AM. Drug overdose deaths in the United States, 1999-2016. NCHS Data Brief, No 294. Hyattsville, MD: National Center for Health Statistics. 2017.
American Association for the Treatment of Opioid Dependence, Inc. (AATOD) 2018 Conference
March 10-14, 2018
New York City at the Marriott Marquis
National Rx Drug Abuse and Heroin Summit 2018
April 2-5, 2018
ASAM Annual Conference
April 12-15, 2018
San Diego, California
National Commission on Correctional Health Care Spring Conference
April 21-24, 2018
24th Annual National TASC Conference on Drugs, Crime and Reentry
April 25-27, 2018
St. Petersburg, Florida
|AT Forum Turns 25: Reporting on Opioid Use Disorders and Medication-Assisted Treatment|
|Health Care Uncertainty Leaves Questions for OTPs; Self-Pay May Continue|
|Opioid STR Grant Funding Formula Stays in Effect for Year 2|
|24/7 Access to OTPs Opened in Arizona With Federal STR Funds|
|Older Adults with Opioid Use Disorders—The Forgotten Generation|
|Need for Medicare Reimbursement for OTPs Cited in DC Briefing|
|FDA: Keep Patients on Methadone or Buprenorphine, Even if They Test Positive for Benzodiazepines|
|How President Trump’s Opioid Commission Supports OTPs and Comprehensive Treatment|
|“Adolescent Opioid-Related Deaths are Soaring . . .”— An Update|
|NIDA Launches Tools for Assessing Adolescents’ Risk of Opioid Use Disorder, Opening the Door to Medication-Assisted Treatment|
|Still Under a Moratorium, OTPs in West Virginia Finally Get Medicaid Payments|