A New Edition of Slaying the Dragon: The History Of Addiction Treatment And Recovery In America By William L. White

Slaying the Dragon“A new edition of Slaying the Dragon: The History of Addiction Treatment and Recovery in America has just rolled off the presses. The first edition (1998) went through multiple printings and has been used as a text in collegiate addictions studies programs. Of even greater import has been how this history helped many people in recovery see themselves as “a people” and contributed to the rise of a new recovery advocacy movement in the U.S.

Multiple circumstances created the need for a new edition of Slaying the Dragon–recent seminal research on earlier periods of history, the accumulation of more than 16 years of new addiction and recovery research and, of course, events of enormous significance that have transpired since 1998. That addiction treatment has gone through significant challenges and changes in the past 16 years is self-evident, but readers may not appreciate some of the momentous and unprecedented events that have occurred within the larger history of addiction recovery. Such events include the growth and diversification of recovery mutual aid societies, the cultural and political mobilization of people in recovery, the emergence of new grassroots recovery support institutions, the rise of recovery as a potentially new organizing paradigm for national drug policy, key breakthroughs in recovery research, and rising efforts to fundamentally redesign addiction treatment.”

http://www.williamwhitepapers.com/blog/2014/06/year-of-the-dragon.html

Source: WilliamWhitePaper.com – June 29, 2014

To Beat Heroin Addiction, A Turn To Coaches

“Recommendations out this week from a task force on opiate abuse include more peer support and home-based counseling. Health insurers and state Medicaid leaders say they will look at funding for recovery coaches, but there is no plan to do so right now.

Across the country, there’s growing interest in using recovery coaches to help heroin users stop, says Robert Lubran, director of the division of pharmacologic therapies at the federal Substance Abuse and Mental Health Services Administration. At least one state, New York, is paying for coaches to help treat addiction through its Medicaid program.

“This is an evolving field,” Lubran says. “[We are] learning more and more about the best ways to treat addiction and certainly the use of peer counselors, or peer coaches, has become more and more widespread.”

http://commonhealth.wbur.org/2014/06/heroin-recovery-coaches

Source: WBUR’s CommonHealth Reform and Community – June 13, 2014

ASAM Article: Twelve Step Recovery and Medication Assisted Therapies

“You’re not clean and sober if you keep taking that medication from your doctor!”

“You’re just substituting one drug for another.”

“You are depressed because you are not grateful enough.”

These and other statements are often made to 12-step members who are legitimately prescribed and taking FDA approved medications to treat their addictions and other co-occurring illnesses. Unfortunately, this so- called “advice” from well-intended but misinformed members is not founded in scientific or 12-step philosophy and violates a long held 12- step policy of ” AA members should not give medical advice to each other.”

http://www.asam.org/magazine/read/article/2014/06/12/twelve-step-recovery-and-medication-assisted-therapies

Source: American Society of Addiction Medicine – June 12, 2014

Blog by William White: The Language of Recovery Advocacy

RecoverySome will question why we as recovery advocates should invest valuable time debating the words used to convey alcohol and other drug (AOD) problems and their solutions when there are suffering individuals and families that need to be engaged, recovery support resources that need to be created, communities that need to be educated, and regressive, discriminatory policies that need to be changed.  We must invest this time because achieving our broader goals depends on our ability to forge a recovery-oriented vocabulary.

Words have immense power to wound or heal.  The wrong words shame people with AOD problems and drive them into the shadows of subterranean cultures.  The wrong words, by conveying that people are not worthy of recovery and not capable of recovery, fuel self-destruction and prevent or postpone help-seeking. The right words serve as catalysts of personal transformation and offer invitations to citizenship and community service.  The right words awaken processes of personal healing, family renewal, and community and cultural revitalization.  The wrong words stigmatize and disempower individuals, families and communities.

It is time people in recovery rejected imposed language and laid claim to words that adequately convey the nature of our experience, strength and hope.  We must forge a new vocabulary that humanizes AOD problems and widens the doorways of entry into recovery.  We must forever banish language that, by objectifying and demonizing addiction, sets the stage for our sequestration and punishment.  We must counter the clinical language that reduces human beings to diagnostic labels that pigeon-hole our pathologies while ignoring our strengths and resiliencies.  We must also reject the disrespectful and demeaning epithets (e.g., “retreads”, “frequent flyers”) professionals sometimes use to castigate those who need repeated treatment episodes.”

http://www.williamwhitepapers.com/blog/2014/06/the-language-of-recovery-advocacy.html

Source: WilliamWhitePapers.com – June 7, 2014

Pioneer Voices Blog by William White

“When I launched my website in 2010, it seemed a perfect venue to create an archive where interviews could be made available worldwide at the click of a mouse.  Since then, I have more than 100 interviews with addiction treatment and recovery advocacy pioneers.  I would like to call your attention to several of these recently posted interviews.”

  • Dr. Stephanie Covington explores the evolution of her pioneering work in the development of gender-specific treatment and recovery support services in the United States.
  • Karen Moyer and Brian Maus discuss the needs of children affected by addiction and the unique program they have developed to enhance the health and development of such children.
  • A.J. Senerchia is one of the leaders of a new organization, Young People in Recovery (YPR).  Young people are playing an increasingly important role in the new recovery advocacy movement, and the interview with A.J. provides background on YPR and the role of young people in this larger movement.  Very inspiring.
  • Dr. Joan Zweben has made significant contributions to the clinical treatment of addiction.   She was an early voice calling for recovery-oriented psychotherapy within addiction treatment, and she has been one of the pioneers in elevating the quality and recovery orientation of medication-assisted treatment in the U.S.  In this engaging interview, she describes her life and work.

“At the near-end of my career, I have had the pleasure of learning insights gleaned from the lives of these and other pioneers in the addictions field.  What I would have given to have had such access when I began this work in the 1960s.  For those at all stages of your careers, here is such an opportunity.” The 100+ interviews are posted at: http://www.williamwhitepapers.com/leadership_interviews/

Source: WilliamWhitePapers.com – May 24, 2014

SAMHSA Blog: Recovery Includes Medical Treatment

samhsa“Within the health domain, clinical treatment plays a critical role in recovery.  Access to safe and effective medications is a vital tool on the path to recovery for many people with mental and/or substance use disorders.  We can think of recovery as a process by which people learn to manage their conditions and lead productive lives.  It is facilitated by working with providers via medications, counseling, rehabilitative services, stress and relapse management, and other services and supports.  Just as with other health conditions, medication is often a key part in achieving positive outcomes. However, medication is not effective for everyone or for every mental health condition, so there needs to be individualized approaches to care and treatment.  The recovery model incorporates all of these variables and provides new hope to many individuals with serious mental illnesses.

To optimize the use of medications to assist recovery, consumers/peers, families, and providers need to be fully informed, engaged, and involved.  SAMHSA has developed evidence-based approaches in areas such as shared decision-making, family psychoeducation, medication treatment, evaluation, and management, and provider training and clinical decision support.”

http://blog.samhsa.gov/2014/05/01/recovery-includes-medical-treatment/#.U3Z6YptALzZ

Source: Substance Abuse and Mental Health Services Administration -May 1, 2014

Blog by William L. White: Waiting For Breaking Good: The Media and Addiction Recovery

“The major media outlets have long been chastised for the content and style of their coverage of alcohol- and drug-related problems.  Such criticisms include the glamorization of drug use, the demonization of drug users, and charges that the media is complicit in ineffective drug policies.  Few have raised parallel concerns that popular media coverage of addiction recovery is rare, often poorly selected, and told through a lens that does little to welcome the estranged person back into the heart of community life.  If media representatives do not “get it” (“it” being recovery), then what precisely is it that they don’t get?  What are the mistold and untold stories and their personal and public consequences to which media leaders ought to be held accountable?

Having closely observed such coverage for nearly half a century, I would offer twelve points from the perspective of a long-tenured recovery advocate.”

Blog available at: http://www.williamwhitepapers.com/blog/2014/03/waiting-for-breaking-good-the-media-and-addiction-recovery.html

The 5-page paper can we accessed at: http://www.williamwhitepapers.com/pr/2014%20The%20Media%20and%20Addiction%20Recovery.pdf

Source: WilliamWhitePapers.com – March 1, 2014

From the Publisher—Special Issue on Recovery From Opioid Addiction

people-sunlight

For six decades methadone maintenance has been an approved treatment for opioid addiction. People who are taking methadone are no different from those who manage their diabetes by taking insulin: they are in recovery. Yet some policymakers—and even some medical, and yes, some addiction authorities—don’t believe it. Although that may change as more and more professionals buy into the scientific fact that addiction is a brain disease, and therefore it can be treated, and people can recover from it.

The federal government, from the Substance Abuse and Mental Health Services Administration (SAMHSA) to the Office of National Drug Control Policy (ONDCP), states that medication-assisted treatment (MAT) is recovery. In this issue, we write about a comprehensive literature review funded by SAMHSA demonstrating the efficacy of MAT. And we cover an article by William L. White describing the stigma and other obstacles methadone patients face when joining 12-step groups—and the important role these groups could play in helping patients in recovery. We also interview Walter Ginter, peer, patient, and advocate, who spoke before the ONDCP in December on the topic of recovery and MAT. Mr. Ginter, a methadone patient in long-term recovery, is an articulate spokesman for methadone and for patients, helping to guide peer services across the country from his position at MARS, in New York City. We also interview Zac Talbott, based in the less-welcoming South, about his work as an advocate.

Not all of the news is good: In New Jersey, a state that strongly endorses methadone as a treatment for opioid-dependent pregnant women, a woman is facing child abuse and neglect charges simply for being in a methadone program while pregnant. The Supreme Court is due to hear the case, and legal and medical authorities are hopeful that the court will not in effect ban MAT for pregnant women. The woman was in recovery, doing the right thing for herself and her baby, yet was reported, and was held by a lower court to have committed child abuse and neglect by being on methadone while pregnant. On the bright side, the best legal and medical minds who know about MAT have filed a friend of the court brief on the mother’s behalf.

In Philadelphia, where AT Forum attended the AATOD conference last fall, recovery transformation is happening in a solid way, moving from treating addiction as an acute episode to a continuum instead, in which someone enters recovery as a person, not a patient. Roland Lamb discusses efforts to help opioid treatment programs (OTPs) provide what is needed for recovery, with more of a focus on the person than on the dosage and the monitoring. Methadone is a way to recovery—that’s why it was created—but the person taking it is the point of recovery.

Finally, a new evidence-based document from ASAM provides guidance for safe methadone induction and stabilization in OTP patients. This is the first time this vital information has been brought together in one place. Our article by Stewart Leavitt is recommended reading for everyone interested in methadone maintenance treatment.

I hope you enjoy this issue, and we look forward to your comments and feedback.

Sue Emerson
Publisher

Walter Ginter on the Importance of Peers in Recovery With Medication-Assisted Treatment

walterStigma is a common theme among people seeking recovery from the disease of opioid addiction, but it’s particularly poignant for people in medication-assisted treatment (MAT), because stigma can itself prevent recovery from taking place. People who don’t understand MAT—and that’s a big group, including many employers, politicians, and even friends and family members—don’t believe methadone or buprenorphine treatment means being in recovery. But it does. And that’s the message that Walter Ginter, CMA, project director of Medication- Assisted Recovery Services (MARS), and the country’s foremost patient advocate, brings to patients. On December 9, he brought this message to the first White House drug policy conference.

Sponsored by the Office of National Drug Control Policy (ONDCP), the conference included a panel that focused on stigma and drug addiction. Michael Botticelli, deputy director of the ONDCP, and himself in recovery, invited Mr. Ginter to participate. “He called me himself to ask me to be on that panel, and afterwards I got a nice handwritten note from him thanking me for participating,” said Mr. Ginter.  Mr. Botticelli, formerly the official in charge of substance use disorder services for Massachusetts, is a strong supporter of MAT. “This direction and focus that we are seeing from the Obama Administration is encouraging,” continued Mr. Ginter “It would strengthen that effort to see Mr. Botticelli promoted and the recovery community is hopeful that he will fill the opening as director of the ONDCP.”

 Stigma Impedes Recovery

The main stigma patients face in terms of methadone comes from believing what people who know nothing about MAT tell them. They learn to believe the myth that methadone is a substitute drug, and that they aren’t really in recovery. What peer recovery support services can do for patients is to help them eliminate feelings of stigma by helping them understand that they are in treatment with a medication, just like someone with any other disease. “If people come into treatment with the idea that methadone is just substituting one addiction for another,” said Mr. Ginter, “that attitude makes them feel as if recovery isn’t an option, for them. This discouraging prospect sets the stage for a less than optimal outcome. They ask themselves what difference does it make if they use a little benzodiazepines or smoke a little pot, if recovery isn’t an option anyway? That is how stigma stops patients from achieving recovery.”

 Peers Believe Peers

Peers—other people who are in MAT—can help support patients’ recovery in a way that nobody else—not a physician and not other people who are not taking methadone—can. “In the recovery community, you always hear people say they ‘support all pathways to recovery,’” said Mr. Ginter, “but often this is just lip service and not really an endorsement, with too many anti-MAT people weighing in and adding to the stigma. A lot of people support it and understand it’s evidence based practice, but still they don’t accept it as a legitimate pathway.”

At the MARS project, patients learn from peers that methadone and buprenorphine are “not substitute drugs, they’re medications,” said Mr. Ginter. “And suddenly, that person is a candidate for recovery. Before that, they never had a choice.”

When people are given the option of being in recovery, they choose it. Once they realize that taking methadone or buprenorphine is not the same as using, they stop using other drugs and alcohol. Yes, they were in treatment, but neither the opioid treatment program nor the physician could convince them that they were in recovery—it took another person in MAT to do that. “Peers believe things from other peers that they would not believe from anyone else,” said Mr. Ginter.

 Feeling Good

One of the magical things about erasing stigma is this: Once people start to feel good about themselves, the community starts to look at them differently. That’s why one exercise patients can use is to write down three nice things that happen each day.“ At the end of a few weeks, people start to feel better,” said Mr. Ginter. “For us to do well in recovery, we have to feel good about ourselves.”

Calling addiction a brain disease—which it is—takes away a lot of guilt, said Mr. Ginter. That internal feeling of guilt is magnified by stigma coming from the outside world.

In some ways, stigma from the outside world isn’t getting any better. “There are these nice dissertations out there about your rights, but if you’re in jail because you got picked up outside your methadone clinic, you can’t tell the cop he’s wrong,” said Mr. Ginter. It would help if drug courts and parole officers saw more patients for whom treatment is working, and not just those for whom it isn’t, he added.

Finally, fear of stigma keeps people from even saying that they are on buprenorphine or methadone. Thousands of people are doing well in treatment—not just the few, like Mr. Ginter, who publicly identify themselves.

As an anecdote illustrating this, Mr. Ginter related that visitors from overseas at the MARS booth at the AATOD conference last fall were amazed that two of the people working at their display booth were patients. “They couldn’t believe that peer recovery support services were provided by ‘real’ methadone patients,” he said.

 Other Participants

The ONDCP half-day meeting also featured panels on public health approaches to drug policy, being “smart on crime” instead of “tough on crime,” with an emphasis on drug courts using MAT, and a screening of The Anonymous People. Mr. Ginter related that the drug court speaker, magistrate Alby Zweig from Denver, was shocked to hear that many of his colleagues require participants to stop using methadone or buprenorphine before they can be admitted.

Note: MARS is a project of the National Alliance of Medication-Assisted (NAMA) Recovery. NAMA chapters are small groups of individuals who organize around advocacy to teach patients about their rights and to support them in their rights. Patient advocates are not the same as peer recovery support.

For more information, go to www.marsproject.org.

Interview: Zac Talbott on Being a Patient and Certified Advocate for Medication-Assisted Treatment

Zac 2-9-14Patients and other individuals who are advocates are a growing force in medication-assisted treatment (MAT) for opioid dependence, providing information and support to patients as well as assistance to opioid treatment programs (OTPs). Advocates also are an essential link between patients and OTPs. They are not as well known as they should be, there aren’t enough of them, and they are in dire need of funding.

In January, Zac Talbott, a patient who is the director of the Tennessee Statewide and Northwestern Georgia chapter of the National Alliance for Medication Assisted Recovery (NAMA Recovery), shared his experiences with addiction, treatment, recovery, and patient advocacy with AT Forum.

 Getting Started in Advocacy: The CMA

Patients and others who want to be advocates need to first have a good knowledge of advocacy and the various issues surrounding MAT. Taking the CMA (Certified Medication Assisted Treatment Advocate) course and obtaining certification gives both patients and health care professionals the basic grounding for advocacy. Certification is essential to being a credible advocate. “There are patients out there who often are well-meaning, who claim to be advocates, but who can do harm,” he said. “A lot of folks without training do not realize that advocates have a code of ethics, and one of the main ethical guidelines is confidentiality. It goes to the heart of our professional credibility. There has never once been a case of a patient’s confidentiality being violated by a CMA working with NAMA-R.”

The second crucial skill that CMAs have is knowing how to communicate with OTPs on behalf of a patient. “You can make things worse for the patient you’re trying to help if you come off like an attack dog. Patients and OTPs agree on more than 90 percent of the issues, and that should always remain the primary focus. It’s also important to remember that the job of a patient advocate is to advocate for what the patient wants. We can’t take off and start a crusade without that patient wanting us to,” he said.

NAMA-R developed the CMA training course with no funding, which was a tremendous challenge. However, the course has been strongly supported by the American Association for the Treatment of Opioid Dependence (AATOD), and the federal Center for Substance Abuse Treatment (CSAT).

 Volunteering and Funding

Some NAMA-R chapters could do significantly more if their expenses were paid. Members are committed people who largely volunteer their time and give of themselves without any compensation.

NAMA Recovery chapters do need funding. NAMA-R is a 501c3 non-profit organization, so donations are tax-deductible. All other industrialized countries fund organizations like NAMA-R, said Mr. Talbott. “The United States is the exception. This leaves NAMA-R dependent on donations from patients, for-profit OTPs, and the pharmaceutical industry.”

In Tennessee—and in many other states—Medicaid won’t currently pay for MAT with methadone. “It’s all cash down here,” he said. The fee for patients is $300 to $400 a month—frequently all the money a patient has.

Mr. Talbott hopes NAMA Recovery can partner with OTPs for funding and support. “We had a wonderful meeting with Chief Operating Officer Jerry Rhodes and the regional managers of CRC Health Group during the AATOD Conference in Philadelphia this past November,” he said. “They recognize that advocacy is extremely important.”

 Insurance and the ACA

Whether the Affordable Care Act (ACA) will help fund MAT is still unclear, said Mr. Talbott. “It’s supposed to, but insurance companies are good at finding loopholes.” Implementation and enforcement are still problematic.

In Tennessee, for example, the state is making it impossible for new OTPs to open, which means that facilities are opening up across the state border. “Programs in other states are treating the patients that Tennessee isn’t,” said Mr. Talbott. If Tennessee Medicaid were to say that patients had to be treated in a Tennessee facility, that might make it more attractive for programs to open in Tennessee.

Even though his organization is in Tennessee, most of Mr. Talbott’s calls come from outside the state—just because there are so many patients, especially in nearby southern states, who need help. NAMA-R has always had difficulty recruiting individuals willing to make a commitment to advocacy and start a chapter. Stigma, prejudice, and just plain fear have been barriers in southeastern states.

 From Pain Medication to Heroin

Mr. Talbott’s addiction started—as with many people—with a prescription for hydrocodone for a chronic painful condition. Most people feel sick when they take opioids, but Mr. Talbott is part of the 10 percent of the population that is susceptible to addiction. “I loved them,” he said of opioids. His addiction sent him to buying pills from a pill mill and eventually to the street, where he also bought heroin. “This was in the late 90s,” he recalled. “Within eight years I went from a couple of prescribed hydrocodone a day to 25 prescribed 30-milligram doses of oxycodone.” He became an intravenous drug user within four years of initially starting the pills.

“The opposite of the stereotypical drug user,” Mr. Talbott had two college degrees when he first became addicted to opioids, and came from a well-known and well-respected family—“church folks,” he explained.

 Recovery

Then, there was treatment. “I went for all the wrong reasons—I didn’t go because I was seeking recovery,” Mr. Talbott said of his treatment in an OTP. “People who are drug users think that there’s no withdrawal, and that you might even get a little buzz.” But six months after entering the OTP and starting methadone, he found that he was in recovery—by accident. “I had no craving. I stopped using the needle. I was thinking about my life again—by accident. The person I was prior to the addiction quickly started to re-emerge. That’s the beauty of methadone.”

After that, it took Mr. Talbott a year to focus on recovery and life. “There’s so much you need to do, straightening out your credit, fixing everything you did when that disease is active.” When his addiction was at its height, he was in the middle of his masters’ in clinical social work. Ultimately, the addiction took over and he left the program. But even before his addiction, he had always wanted to be in a helping profession—a mental health counselor, an Episcopal priest, or a lawyer. “I wanted to help people,” he said. “Once I was in recovery, that part of me came back quickly.”

He found NAMA Recovery because his counselor recommended it as an alternative to driving to the clinic for four group meetings during his induction period in treatment. “I had to drive more than two hours one way to the OTP because I was so rural. So my counselor said to go to the website—methadone.org—print out, read, and bring in one of the Education Series to discuss ‘and that will count as one of your groups.’” Ultimately, he wrote to the NAMA-R chapter coordinator and said a NAMA Recovery chapter was needed in Tennessee.

NAMA Recovery’s main goal is advocacy, and that is where Mr.Talbott saw his life heading. “It’s a natural fit,” he said. “To be a MAT advocate is to advocate for the patient in treatment, but we’re not patient advocates only or specifically. ‘The patient comes first,’ as Rokki [Roxanne Baker, NAMA-R president] often says.”

 Partnership With OTPs

Patient advocates can have a lot of power, not only on behalf of patients, but on behalf of providers. When onerous restrictions are imposed by states, especially states that don’t have an AATOD chapter, providers call NAMA Recovery. “We are more than just patient advocates, we are MAT advocates,” said Mr. Talbott. “We advocate for the entire modality.”

About a third of the calls he gets—Tennessee joined AATOD just last fall—are from OTPs, said Mr. Talbott. “Sometimes patients and providers don’t have the best relationship. Some OTPs view advocates as whistleblowers and troublemakers, and sometimes the OTPs get defensive as soon as advocates call them. Several of us are trying to stress to OTPs and patients that we’re all on the same team.”

Technically, the provider advocacy organization is AATOD. But when there is an issue that draws both patient and provider complaints, Mr. Talbott reaches out to consult with AATOD president Mark Parrino or the state chapter of AATOD. “We can strategize together,” he said. Sometimes the approach involves filing a complaint with the Department of Justice or SAMHSA’s CSAT, which regulates OTPs. Often, OTPs haven’t even heard of NAMA Recovery, and sometimes haven’t heard of AATOD either, he said.

“The way to go is moving away from patient advocacy specifically and toward MAT advocacy as a modality,” said Mr. Talbott. And patients who are certified advocates can be of immense help to OTPs, whether they are testifying before the legislature or making a complaint to the Department of Justice. Patients and providers aren’t always going to agree, but ultimately they’re fighting the same battles and striving for the same goals.

Recovery Transformation in Philadelphia OTPs: Person-centered, not Patient-centered

RecoveryOver 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.”

LETTER to the Editor: Treating Opioid Addiction – Response to the NY Times Article Addiction Treatment With a Dark Side from ASAM

ASAM logoIn mid-November the New York Times ran an article “A Double-Edged Drug - Addiction Treatment on the Dark Side.”  As of December 19, the article has generated almost 400 responses and numerous other websites/blogs have responded to the article.

On November 25, Stuart Gitlow, R. Jeffrey Goldsmith, and Louis E. Baxter Sr. of the American Society of Addiction Medicine (ASAM) sent a Letter to the Editor responding, “Physicians alone cannot solve our nation’s opioid epidemic. Public education about the benefits of treatment, recovery and quality care can. We hope that your article encourages a national dialogue about the importance of expanding access to quality care for a highly stigmatized, underserved patient population.”

The writers are, respectively, president, president-elect and past president of ASAM.

http://www.nytimes.com/2013/11/26/opinion/treating-opioid-addiction.html

Source: NYTimes.com – November 25, 2013

MARS™ Thought-Leadership Helps Raise Profile of Peer Recovery Support Services: Ginter Joins Plenary, Will Showcase Innovative Trainings at 2013 AATOD Conference

Medication-Assisted Recovery Services (MARS™), part of a leading national nonprofit organization that provides peer support services and training to address the needs of the medication-assisted recovery community, announced its Project Director has been invited to deliver a plenary presentation at the upcoming 2013 AATOD Conference in Philadelphia. Walter Ginter will join other prominent treatment and recovery leaders during the middle plenary session to talk about “Keeping Recovery the Focus”.

In his plenary session, Mr. Ginter will focus specifically on how methadone became the pathway for him to reach his full potential and how he has taken that experience to create the MARS™ Project, a structured program of education and peer support that is helping many others across the country who are in medication-assisted treatment to strengthen their recovery. He will also share his work as an advocate for medication-assisted recovery, helping overcome the barriers and stigma that can fight against recovery efforts.

Mr. Ginter will participate in the plenary session entitled “Keeping Recovery the Focus”, which hones in on a new era that will require programs to adapt to the ongoing implementation of health care reform. Emphasis will be on the 50-year evolution of methadone treatment and where the field is today as an accredited, science-based modality.

The press release can be accessed at: http://www.prweb.com/releases/2013/10/prweb11226954.htm

Source: PRWeb.com – October 14, 2013

Blog: The Work of Recovery by William L. White

“Research on addiction recovery is quite scant compared to the volumes of research on addiction-related pathologies and clinical interventions.  Additionally, some of the most important research on addiction recovery is buried in academic journals rarely if ever read by the people who need it most–addiction treatment professionals and people needing, seeking or in recovery.  Such is the case of studies on the role of work in addiction recovery.”

So here’s the question: if employment is such a critical factor in recovery initiation and recovery stability, and if addiction treatment programs really are committed to science-informed addiction treatment; then why do we not see vocational education and training programs integrated as a service option within all addiction treatment programs?”

http://www.williamwhitepapers.com/blog/2013/08/the-work-of-recovery.html

Source: WilliamWhite Papers.com – August 11, 2013

What’s New in the Draft Opioid Treatment Program Federal Guidelines: Midlevel Providers and the Importance of Recovery and Retention

guidelinesUnder the federal draft guidelines for opioid treatment programs (OTPs) issued by the Substance Abuse and Mental Health Services Administration (SAMHSA) May 16, nurse practitioners (NPs) and physician assistants (PAs) are explicitly given a much bigger role in methadone induction and dosing, something that medication-assisted treatment (MAT) advocates hope will be embraced by state accreditation authorities and recognized by the Drug Enforcement Administration (DEA).

AT Forum interviewed Ron Jackson, LICSW, who retired in December 2012 as executive director of Evergreen Treatment Services in Washington State, and H. Westley Clark, MD, director of SAMHSA’s Center for Substance Abuse Treatment (CSAT), about the impact of the guidelines on OTPs across the country. The interviews took place before the comment period closed July 16.

“We know that the Affordable Care Act (ACA) is going to create demand on many OTPs to take on additional patients with health insurance, and it’s going to force OTPs to think about how they’re going to deliver services,” said Dr. Clark. None of this was foreseen in 2007 when the last guidelines came out, but now, areas across the country will be facing physician shortages, he said.

Many OTPs are already using midlevel providers for this purpose, said Mr. Jackson, who was the representative from the American Association for the Treatment of Opioid Dependence (AATOD) for the committee that developed the draft guidelines. There is nothing in the regulations governing OTPs that prohibits it, and some state accrediting bodies specifically allow it. (The regulations, issued by SAMHSA in 2001, do require that the medical director be a physician.)

3rd Revision

This is the third set of federal guidelines for OTPs. The first set of guidelines was released in 1999, two years before the final rule governing OTPs was issued. In 2007 the second set of guidelines was released. The final guidelines are expected in time for the AATOD conference in Philadelphia November 9-13.

The guidelines were created by consensus, starting in January of 2012 when a committee convened to work on the guidelines revision, said Mr. Jackson, who served on the second revision committee as well. The committee included SAMHSA representatives, State Opioid Treatment Authorities (SOTAs), patient advocates, and OTP medical directors. After that, the bulk of the work was done by conference call and e-mail exchanges of drafts, said Mr. Jackson.

Nicholas Reuter, MPH, was the CSAT representative most closely involved with the guidelines revision, said Mr. Jackson. (Mr. Reuter left CSAT in February and went to work for Reckitt Benckiser, manufacturer and marketer of Suboxone.)

Message to the DEA

The guidelines are just that—unenforceable guidelines—but SAMHSA expects them to be used to direct state accreditation policies. “Our hope is that the accreditation bodies will adopt these guidelines and make them enforceable by the accreditation bodies themselves,” said Dr. Clark, adding that states often pay close attention to what is happening at the federal level.

In addition, Mr. Jackson hopes that the DEA will take the message from the guidelines that indeed, midlevel providers are allowed to do inductions. “We need to always keep in mind that we have to negotiate things with our colleagues at the DEA,” said Dr. Clark. The DEA was involved as an “outside commenter or editor” in the draft guidelines, according to Mr. Jackson. “I’m trying to be optimistic about it,” he said of the DEA’s approval of midlevels.

“From AATOD’s perspective, it was my job to make sure midlevels got the responsibility they needed,” said Mr. Jackson of his role in developing the guidelines. “I was upset by the Dear Colleague letter that said physicians had to do the face-to-face.” In fact, “qualified health professionals” are authorized to do the face-to-face contact in the state of Washington and under the federal rules governing OTPs, he said. (That Dear Colleague letter was sent to OTPs in September, 2007. For a link, go to http://www.dpt.samhsa.gov/pdf/dearColleague/09-04-07%20DearColleagueLetter%20on%20Dosing.pdf.)

Mr. Reuter was the among the more resistant committee members when it came to giving midlevel people this authority, said Mr. Jackson. But in Washington State, NPs and PAs have Schedule II prescribing authority (methadone is Schedule II). Mr. Jackson’s argument to Mr. Reuter was always, “How can you constrain them from doing inside a facility what they do outside?” When the Dear Colleague letter came out, Mr. Jackson didn’t change what he was doing at Evergreen —having midlevel people perform the face-to-face contact. “I don’t know if other people did,” he told AT Forum. “My midlevels have been doing this for 20 years. You can imagine how many inductions they’ve done.”

Having midlevel people do the face-to-face contact is going to become the standard model, because there aren’t enough physicians, said Mr. Jackson. And if the midlevels are sufficiently qualified and trained, and supervised by the medical provider, patient care won’t be diminished. “I wouldn’t have been promoting this if I thought any patients would be harmed,” he said. “If you had to have physicians do all this work, that’s how patients would be harmed—you wouldn’t be able to find enough physicians, so you would have to limit the number of patients.”

Telemedicine

A section in the guidelines on the use of telemedicine remains vague because of “a big discussion with the DEA” about the degree to which medication ordering has to be face-to-face, said Mr. Jackson. One of the biggest challenges for OTPs is siting. “It’s really hard to get new methadone clinics open,” he said, noting that the “classic Not in My Back Yard (NIMBY) syndrome” is endemic. In the northwest, where heroin addiction is raging, there is a pressing need for OTPs, especially in rural areas. But Mr. Jackson was unable to open a clinic even in Bremerton, one of the least populated areas of the state.

“Nick took on the responsibility to put telemedicine in there, as a placeholder,” said Mr. Jackson, noting that the DEA is particularly skittish of orders via telemedicine. “If the ACA is going to be successful, and I hope it is, it’s going to force us to do things somewhat differently. I think telemedicine is going to be a big part of that.”

Recovery, Retention

Another new section of the guidelines refers to Recovery Oriented Systems of Care (ROSC), which explicitly refers to the work of William L. White. The section emphasizes that people in methadone maintenance are in real recovery, said Mr. Jackson.

The guidelines also stress the importance of retention in treatment, as a part of recovery. This means that sometimes, especially in early treatment, patients shouldn’t necessarily be discharged for abusing benzodiazepines, for example. “People who come to OTPs have had years of drug use, chaotic lives, and come in with multiple health problems that have been undiagnosed and untreated,” said SAMHSA’s Dr. Clark. “Turning people’s lives around doesn’t happen overnight or in a vacuum.” With the ACA’s focus on health homes, retention in treatment is a key indicator of a good outcome, he said. (A health home is the one place where a patient gets all health needs attended to, either directly or via connections to specialists. OTPs can be health homes.)

Being in treatment is better than not being in treatment, said Mr. Jackson, and he was glad that there was a focus on the importance of retention. But he is also wary of keeping patients on methadone if they are also abusing benzodiazepines uncontrollably. “The great dilemma we have is that sometimes it gets dangerous to continue to dispense methadone,” Mr. Jackson said. “Sometimes patients are their own worst enemy.

As the ACA takes effect and OTPs see many more patients come through their doors, they should look at the guidelines as a way to provide comprehensive care, said Dr. Clark. “We’re stressing the importance of OTPs as medical providers, and not just dose-and-run.”

For the Federal Register notice, the draft guidelines, and the accompanying Dear Colleague letter, go to http://www.dpt.samhsa.gov/pdf/FederalGuidelinesforOpioidTreatment5-6-2013revisiondraft_508.pdf, and http://www.dpt.samhsa.gov/pdf/dearColleague/DearColleagueAccredGuidelines5-16-13.pdf.

 For AATOD’s response to the Draft Guidelines dated July 12, go to http://www.aatod.org/wp-content/uploads/2013/07/Reduced-Size-WashingtonSmith-SAMHSA_Ltr071213-21.pdf.

 

5 Myths about Addiction that Undermine Recovery

“Honest, courageous and insightful aren’t words typically used to describe drug addicts. But if given the chance, many addicts end up developing these qualities and contributing to society in a way they never imagined possible. These successes occur in spite of major obstacles, from the ever-present threat of relapse to the pervasive stereotypes addicts encounter along the way. Even with three decades of myth-busting research behind us, some of the most damaging beliefs about addiction remain.” The five myths include:

  • Addicts are bad people who deserve to be punished.
  • Addiction is a choice.
  • People usually get addicted to one type of substance.
  • People who get addicted to prescription drugs are different from people who get addicted to illegal drugs.
  • Treatment should put addicts in their place.

http://www.psychologytoday.com/blog/where-science-meets-the-steps/201305/5-myths-about-addiction-undermine-recovery

Source: PsychologyToday.com – May 14, 2013

New Book Available – Clean: Overcoming Addiction and Ending America’s Greatest Tragedy

CleanA new book on addiction was released April 2 that has received a lot of press coverage.

Amazon.com describes the book as “Addiction is a preventable, treatable disease, not a moral failing. As with other illnesses, the approaches most likely to work are based on science — not on faith, tradition, contrition, or wishful thinking. These facts are the foundation of Clean, a myth-shattering look at drug abuse by the author of Beautiful Boy. Based on the latest research in psychology, neuroscience, and medicine, Clean is a leap beyond the traditional approaches to prevention and treatment of addiction and the mental illnesses that usually accompany it. The existing treatment system, including Twelve Step programs and rehabs, has helped some, but it has failed to help many more, and David Sheff explains why. He spent time with scores of scientists, doctors, counselors, and addicts and their families to learn how addiction works and what can effectively treat it. Clean offers clear, cogent counsel for parents and others who want to prevent drug problems and for addicts and their loved ones no matter what stage of the illness they’re in. But it is also a book for all of us — a powerful rethinking of the greatest public health challenge of our time.”

The link to the book at Amazon.com is: http://www.amazon.com/Clean-Overcoming-Addiction-Americas-Greatest/dp/054784865X/ref=sr_1_4?s=books&ie=UTF8&qid=1364908254&sr=1-4&keywords=clean

Join Together interviewed David Sheff the book’s author to discuss his exploration into the science, prevention and treatment of addiction. The two part interview is available at:

http://www.drugfree.org/join-together/addiction/david-sheff-author-of-clean-interview-part-1-of-2?utm_source=Join%20Together%20Daily&utm_campaign=a87b199533-JT_Daily_News_David_Sheff_Author_of&utm_medium=email

http://www.drugfree.org/join-together/addiction/david-sheff-author-of-clean-interview-part-2-of-2?utm_source=Join%20Together%20Daily&utm_campaign=35128f3594-JT_Daily_News_David_Sheff_Author_of&utm_medium=email

David Sheff also wrote an opinion article for Time.com that is available at:
http://ideas.time.com/2013/04/03/we-need-to-rethink-rehab/

Sources: Amazon.com, JoinTogether, Time.com – April 2013

Two Kinds of Roles for OTP Peers under the Affordable Care Act

flag and stetPeers—patients in medication-assisted treatment (MAT) who are in recovery—are gradually being enlisted into the workforce, thanks to the Affordable Care Act (ACA). Two kinds of roles are surfacing: recovery coaches, and “navigators” who help enroll uninsured people in private insurance through health insurance exchanges. The recovery coaching idea is not new, but the navigator one is—especially at the level of actually enrolling patients.

Community-based organizations in New York City have already signed up to be navigators, and the National Alliance for Medication Assisted Recovery (NAMA) hopes to be a part of this, says Joycelyn Woods, executive director.

Ms. Woods, like many observers, thinks there are going to be many glitches in getting people enrolled, and doubts that everyone who isn’t insured will be by next January. NAMA received a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) for educating patients and training navigators. “What SAMHSA is trying to do is to educate people,” explains Ms. Woods.

Recovery coaches will be a great asset to opioid treatment programs (OTPs), because they will make the programs more like the early ones in which “half the staff were patients,” says Ms. Woods. “They would hire patients and social workers and pair them together. The social worker would teach the patient about the academic part, and the patient would teach the social worker about the other part.” The “other part” is the experience of being a patient, a person with addiction, a person in a program.

Training

Training is based on the Connecticut Community for Addiction Recovery (CCAR) protocol. As it is being used in the FOR-NY Recovery Coach Academy, the training consists of 30 hours. CCAR includes regular follow-up telephone calls—that probably won’t happen with Medicaid, which requires face-to-face contact, says Ms. Woods. But in New York City, which is not rural like Connecticut, it’s likely that face-to-face counseling can be done.

There are also issues with the payment structure for the peers doing coaching, and the state is still working on those.

Some methadone counselors have already participated in training, because they want the recovery coach credential, says Ms. Woods. Although recovery coaching spans all addiction, including alcohol, in New York State anyone doing recovery coaching in a methadone program must also have four hours of training in MAT. This is essential, says Ms. Woods. “Can you imagine people from abstinence-based programs doing recovery coaching in an OTP?”

The NYCB recovery coach credential which requires 60 total hours of training requires 4 hours of MAT training for all coaches wanting the credential, explains Mr. Ginter. The NYCB is the only certification board currently requiring this for their recovery coach credential.

Navigator vs Peercoaching

There’s a subtle difference between what a navigator does, and what the peer acting as a navigator does, says Tom Hill, director of programs at Faces and Voices of Recovery, which has been a major guiding light in the peer recovery coaching movement. “The peer assister or navigator does outreach and pulls people in to walk through the insurance enrollment process,” says Mr. Hill. “There’s one port of entry, and depending on the income, the person would be routed to Medicaid or the exchanges.”

The enrollment process for Medicaid has always been cumbersome, but the Center for Medicare and Medicaid Services (CMS) says it has simplified that process, notes Mr. Hill. “An organization that is able to conduct outreach and get someone to a computer can walk them through the process and get them enrolled.” The Centers for Medicare and Medicaid Services (CMS) is soon to issue a request for applications for navigator grants, says Mr. Hill.

The SAMHSA grants are small: only $25,000 for and there were only eight awarded, says Mr. Hill. “They’re not very detailed because there’s only so much you can do with that amount,” he says. “Some of the grants deal directly with developing enrollment strategies—but others are more generally focused on educating the community,” he says.

There’s a lot of pressure to enroll uninsured people by October 1, says Mr. Hill. “We’ve been pretty clear that the folks we have on the ground in addiction recovery communities are capable of doing the assisting and the navigating,” he says. “Now it’s just a matter of everything falling into place.”

New York City is a good litmus test for the navigator grants, says Mr. Hill, noting that the NAMA grant is good model.

The NAMA contract is to educate MAT patients about the ACA, says Walter Ginter, project director of the Medication Assisted Recovery Support (MARS) project at NAMA. “We’re going to contact all the doctors, and through focus groups and webinars, provide the education about the exchanges,” he says. But he is concerned that the education isn’t going to go far enough, and that actually enrolling people in insurance is a task that has not been well thought out.

“There’s a lot going on at breakneck speed right now,” he says. “It’s exciting and scary and terrifying.”

Prepaid Card Designed to Help Those in Recovery From Addiction Manage Money

Three men who met while in recovery have developed a prepaid card designed to help others who are recovering from addiction manage their money, the New York Daily News reports.

They have launched the Next Step Prepaid MasterCard, a reloadable card designed for people in recovery, and for those who are financially supporting them. The card gives family members and guardians control over funds, while teaching people in recovery how to manage their money, the article notes.

http://www.drugfree.org/join-together/addiction/prepaid-card-designed-to-help-those-in-recovery-from-addiction-manage-money?utm_source=Join+Together+Daily&utm_campaign=07bd0ab527-JT_Daily_News_Prepaid_Card_Designed&utm_medium=emailSource: JoinTogether.org – January 31, 2013

Drug Czar Says Addiction is a Health Problem, Not a Moral Failing

Drug czar Gil Kerlikowske says the Obama administration has changed its thinking about people addicted to drugs — and you should too.

In a speech Monday at the Betty Ford Center in Rancho Mirage, Kerlikowske said it was time to stop believing that the millions of Americans who abuse drugs are moral failures
 and instead realize that they have a disease.

The drug czar continued: “By talking about addiction in the light of day—and by celebrating recovery out loud—we can help correct the misinformation and stigma that become obstacles for people who want to live healthy, productive lives.”

http://www.latimes.com/health/boostershots/la-heb-drug-addiction-mental-illness-kerlikowske-20120611,0,7677562.story

Note: See related opinion article: Will Treating Addiction as a ‘Disease’ Combat a Growing Epidemic? http://www.latimes.com/news/opinion/opinion-la/la-ol-drug-addiction-disease-epidemic-20120612,0,3883594.story

Source: LATimes.com – June 11-12, 2012

 

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