Why Patients With OUDs and Co-Occurring Mental Illness May Have a Better Chance in an OTP Than in Other Treatments
By Barbara Goodheart, ELS and Alison Knopf
When a patient with an opioid use disorder (OUD) fails to respond to treatment—despite the best efforts of counselors in the substance use disorder (SUD) treatment program—the problem may be a co-occurring mental health disorder, perhaps one that hasn’t yet been diagnosed. Under federal law, opioid treatment programs (OTPs) using methadone or buprenorphine are required to provide counseling, medical, vocational, educational, and other assessment and treatment services.
This puts OTPs way above the outpatient offices, which prescribe buprenorphine (not methadone) and do not even assess for mental illness, much less treat it.
Two recent publications have documented the shortfallings of treatment in general, and of the need to expand mental health treatment for people with OUD and co-occurring mental illness.
A recent study in the Journal of Substance Abuse Treatment looks at the link between OUDs and various degrees of mental illness severity, types of treatment, and other parameters. The study is based on the 2008-2014 National Survey on Drug Use and Health, and concludes that of all people with OUD—many not in any treatment (the survey is based on self-report), estimates are that between half and three-quarters of people with an OUD may have a co-occurring mental health disorder.
No Treatment—or Inappropriate Treatment
Interestingly, the Novak study found that most people with an OUD who received any treatment were likely to receive only mental health treatment. In other words, their OUD was left untreated by anything—including the gold standards methadone or buprenorphine.
The most common treatment was a prescription medication for a mental health problem—but, the authors noted, “this was true regardless of whether or not the individual had any mental illness.”
“A high proportion of individuals with OUD and co-occurring mental illness are not receiving needed care,” the authors emphasize. “However, nearly one in five of those with OUD but no diagnosed mental illness is receiving prescription medication for mental illness.” The authors underscore the need for facilitating access to behavioral health care and coordinating access across settings.
Type of Treatment Selected
By Severity of Mental Illness
In People with OUD
(N = 3398)
|Behavioral Health Treatment||No mental
|Mental health only||14||26||38|
OTPs Not Involved in Either Study
The authors suggest that patients afflicted with OUDs and mental illness have complex treatment needs, as is well-known. Patients (not necessarily in OTPs) with co-occurring disorders are
- Less likely to finish treatment
- Likely to have worse treatment outcomes
Citing other studies, the authors noted that people with OUD but no mental illness are more likely to get mental health treatment than treatment for their OUD. Not surprisingly, their treatment outcomes are worse.
Treating OUD in Mental Health Settings?
But instead of giving credit to OTPs for providing—as it requires—mental health services, SAMHSA seems to be suggesting in a recent communication that OUD could be treated in mental health settings. A communication recently written by SAMHSA authors and published in Drug and Alcohol Dependence used the same National Survey source as the first study, but selected data from different years—2015-2017—and focused on SUDs. The authors, including Elinore McCance-Katz, MD, PhD, director of SAMHSA and assistant secretary of the Department of Health and Human Services, noted: “Of particular concern was the high prevalence of mental illness among people with OUD, including 1 in 4 adults with OUD having co-occurring SMI [serious mental illness] in the past year.”
The SAMHSA authors point to the “often missed opportunity” to provide SUD treatment at the same time as mental health treatment. For some time, SAMHSA has been in favor of blending SUD and mental health services, aiming to merge the block grants. The Substance Abuse Prevention and Treatment block grant is much bigger than the Community Mental Health Services block grant, and states that merge the two among their provider bases are interested in this as well. Regarding current efforts to make medication-assisted treatment for OUD more available, they stress the importance of including “a continuum of treatment and recovery support services to address the co-occurring mental and substance use disorders.”
They also cite innovative service delivery models as promising approaches to providing comprehensive services to people with OUD. Examples include the Hub-and-Spoke model, which features OTPs as central to diagnosis and assessment and treating difficult patients, and Certified Community Behavioral Health Clinics (which are not allowed to dispense methadone).
The authors conclude by emphasizing that “efforts to expand access to comprehensive service delivery models that can address the substance use, mental health, and physical health co-morbidities of this population are urgently needed.”
Novak P, Feder KA, Ali MM, Chen J. Behavioral health treatment utilization among individuals with co-occurring opioid use disorder and mental illness: Evidence from a national survey. J Subst Abuse Treat. 2019 Mar;98:47-52. doi: 0.1016/j.jsat.2018.12.006.
Jones CM, McCance-Katz EF. Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug Alcohol Depend. 2019 Apr 1;197:78-82. Epub 2019 Feb 14. doi: 10.1016/j.drugalcdep.2018.12.030.
By Barbara Goodheart, ELS
In a report published in the July issue of Health Affairs, addiction specialist Jessica L. Gregg, MD, told the poignant story of a patient she called James. She’d met James when he was hospitalized with hallucinations and headaches caused by brain cancer. Dr. Gregg had been called in because James was also having symptoms related to heroin withdrawal.
The day the two met, James told Dr. Gregg that he’d had pain in his back and shoulder ever since a long-ago car accident, and injecting heroin relieved the pain almost immediately—as well as lifting his feelings of loneliness and isolation.
James said that he’d been treated with methadone earlier, for four years, after trying buprenorphine unsuccessfully. After an attempt to taper off methadone, he’d returned to heroin.
He looked back rather wistfully at his time on methadone, before he’d relapsed. While on methadone, he’d had a job. His sister had let him visit. He’d gotten to know his young nieces and nephews. “He had a life he liked, and he was proud of it.
“Now,” Dr. Gregg recalled, “facing the end of his life, he wanted to stop using heroin.” James asked Dr. Gregg if he could go back to methadone, and she agreed to arrange it.
Successful Treatment and Hospital Discharge Lead To—No Options
Triple therapy—radiation, chemotherapy, methadone—improved James’ condition, and he was soon well enough to be discharged from the hospital. His oncologist thought chemotherapy would allow James to live comfortably another year, perhaps even longer.
But James couldn’t manage the mandatory daily visits to the methadone clinic. Even if he could find a ride, he wasn’t well enough to stand in line waiting for his methadone dose. Nor was it likely he could leave the clinic in time for chemotherapy or radiation treatment.
And if nausea from chemotherapy or from the cancer itself prevented him from getting to the clinic, he’d have no way of getting his methadone dose.
Bottom line: once James left the hospital, the law offered him no alternative for methadone treatment.
James missed a chemotherapy appointment, then another. Then he missed radiation appointments. As Dr. Gregg described James’ downward course: “Then his cancer roared back to life, and he returned to our hospital confused, in pain, and dying.”
James was back on heroin, “sick, alone, and ready for hospice.”
His advanced stage of cancer qualified him for hospice care. That meant, Dr. Gregg explained, “his doctors could finally treat him with methadone—all he wanted in the first place.”
In what she called “the cruelest kicker,” Dr. Gregg underscored the option he had been given: treat his OUD with a medication he knew would work, or treat his cancer. If he chose not to treat the cancer, he would probably live only another month or so, but he would be eligible for hospice care—and methadone. “Not as a treatment for addiction, but as palliation,” Dr. Gregg stressed, “a way to ease pain and stress at the end of his life. He could even get methadone delivered to his home, “like a pizza.”
James, who had wanted to live, had chosen instead to die—to access methadone.
Why Did It Happen?
Dr. Gregg was left to ponder why. Why James had gone through what he did. Why there hadn’t been another way, a better way.
Her report cited some facts.
- Drug overdose is the leading cause of death in Americans younger than age 50
- For individuals with opioid use disorder, methadone cuts the risk of death in half
Given such facts, she commented, we might expect the government, and everyone involved in patient care, to be “frantically working” to increase methadone access.
Instead, many are blocking it.
Patients with opioid use disorder (OUD) are running up against barriers to access. Discrimination. Stigma. Laws and regulations. Dr. Gregg described desperate patients forced to choose between effective treatment for their OUDs—and other lifesaving services.
The crisis often hits when a patient is released from the hospital and has nowhere to go, she explained. Nursing facilities can legally dispense methadone, but are deterred by federal regulations and stigma. Dr. Gregg has yet to find one that will dispense methadone for OUD patients.
Nor do homes await these patients after they leave the hospital. Sober-living homes, group homes, or recovery housing often will not accept patients taking methadone, arguing that they are not truly “drug-free” or not “really” in recovery.
And she zeroed in on the issue of methadone for pain versus methadone for OUD.
“If a patient is receiving methadone for pain, he or she can have it prescribed from any clinic and by any doctor, nurse practitioner, or physician assistant, with no additional requirements.” In contrast, laws about prescriptions for treating OUDs separate those patients, as if they’re “too dangerous, too out of control, or too different” to ever be treated in traditional clinical settings.
Dr. Gregg’s Recommendations
Dr. Gregg seeks sensible legal reform. She points to the SUPPORT Act as a useful step. (The SUPPORT for Patients and Communities Act of 2018 allows Medicare to pay OTPs for methadone.) Two things she would especially like to see, in addition: immediate methadone access for OUD patients in their own home, if they meet documented medical criteria; and treatment in primary care for patients who are on a stable dose of methadone.
Considering the frustrations that she and other caregivers have encountered in helping James—and so many other patients—and reflecting on patients’ “nearly miraculous determination to try again and battle this craving that is killing them,” Dr. Gregg observed, “we offer them obscene regulations, discriminatory practices, and impossible choices.
“Why—how—do the patients even try?. . . And why don’t we reward it by making treatment with a highly effective medication acceptable, and even commendable?”
Dr. Gregg isn’t certain that James would have avoided heroin if he’d been able to continue methadone treatment. He had “so many battles to fight.”
But there was something essential that she could say for certain: “James, and so many others who have died or are now dying, should have been given the chance.”
Gregg JL. Dying To Access Methadone. Health Aff (Millwood). 2019 Jul;38(7):1225-1227. doi: 10.1377/hlthaff.2019.00056.
By Alison Knopf
For months, the position of the American Society of Addiction Medicine (ASAM) on the move to deregulate the prescribing of buprenorphine for opioid use disorder (OUD) has been unclear. However, in a quiet move—a statement by Margaret A.E. Jarvis, MD, ASAM board member, in her testimony before the Congressional Bipartisan Opioid Task Force on July 23—the organization took sides—get rid of the “x-waiver.”
The x-waiver denotes a special permission from the Drug Enforcement Administration (DEA). The x-waiver is required under the Drug Addiction Treatment Act of 2000 (DATA 2000), which made it possible for buprenorphine to be used to treat OUD—only the second opioid ever allowed for this (the first and only other one is methadone). Having an x-waiver also means that prescribers are subject to DEA audits, in particular, looking at whether they are heeding limits on the number of patients per prescriber.
An opioid drug cannot be used for treatment of OUD except under special conditions. For methadone, those conditions are opioid treatment programs (OTPs) (which can also dispense buprenorphine). DATA 2000 and the x-waiver require prescribers to have training and to have a special registration with the DEA.
Because ASAM was crucial to the development of buprenorphine treatment—it provided the workforce of prescribers and the training involved—it had a vested interest in keeping the prescribing limited. But that has all changed.
Mainstreaming Addiction Treatment Act (Tonko Bill)
There is a bill under consideration in Congress: the Mainstreaming Addiction Treatment Act, introduced by Rep. Paul Tonko (D-New York), which would eliminate the separate DEA waiver for prescribing buprenorphine for treatment of OUD. But the ASAM endorsement of the Tonko bill comes with two conditions:
- Eliminate DEA regulations on medications in Schedules III–V that are based on the prescribing intent to treat addiction, including ending related routine DEA audits
- Require all prescribers of DEA-controlled substances to complete medical education on addiction
ASAM would like to see the training requirement for the x-waiver transferred to the DEA-controlled substance license. Everyone who prescribes controlled substances for anything—pain, anxiety, and so on—has this license.
OTPs have been concerned about the lack of comprehensive care in office-based opioid treatment, and particularly concerned about calls to have primary care—not addiction specialists—prescribe buprenorphine and even methadone for OUD.
Meanwhile, OTP patients who take methadone have been attracted to the more lenient take-home provisions for buprenorphine. So far, there is no federal proposal to change this disparity. Methadone is viewed as less safe than buprenorphine; in addition, methadone is Schedule II, while buprenorphine is Schedule III.
For Dr. Jarvis’ written testimony, go to https://www.asam.org/docs/default-source/advocacy/final-oral-margaret-jarvis-testimony-bipartisan-heroin-task-force-(7).pdf?sfvrsn=799e4dc2_2.
For the Mainstreaming Addiction Treatment Act, go to https://www.govtrack.us/congress/bills/116/hr2482
By Alison Knopf
A report out from the American Medical Association (AMA) this summer recommends closing the treatment gap to address the opioid epidemic. Buprenorphine was the main treatment focus. Noting that more than 66,000 physicians and other health care professionals now have a waiver to prescribe buprenorphine in-office for the treatment of opioid use disorder, the AMA said that additional work is required to remove stigma and reduce barriers to treatment.
Methadone is not mentioned per se in the report.
Removing prior authorization requirements for medication-assisted treatment (MAT) was a key recommendation, with the report commending the states that have done so, saying “Who’s Next?”
“We are at a crossroads in our nation’s efforts to end the opioid epidemic. It is time to end delays and barriers to medication-assisted treatment (MAT)—evidence-based care proven to save lives; time for payers, PBMs and pharmacy chains to reevaluate and revise policies that restrict opioid therapy to patients based on arbitrary thresholds; and time to commit to helping all patients access evidence-based care for pain and substance use disorders,” said Patrice A. Harris, MD, chair of the AMA Opioid Task Force and current president of the AMA. A psychiatrist, Dr. Harris added: “Physicians must continue to demonstrate leadership, but unless and until these actions occur, the progress we are making will not stop patients from dying.”
Here are the AMA’s recommendations:
- Remove inappropriate administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication-assisted treatment (MAT) for opioid use disorder (OUD).
- Support assessment, referral, and treatment for co-occurring mental disorders as well as enforce meaningful oversight and enforcement of state and federal mental health and substance use disorder parity laws.
- Remove administrative and other barriers to comprehensive, multimodal, multidisciplinary pain care and rehabilitation programs.
- Support maternal and child health by increasing access to evidence-based treatment, preserving families, and ensuring that policies are non-punitive.
- Support reforms in the civil and criminal justice system that help ensure access to high-quality, evidence-based care for opioid use disorder, including MAT.
Between the Lines: Methadone and OTPs Are Important
If you read between the lines, you can see the importance of methadone and opioid treatment programs, as methadone—along with naltrexone and buprenorphine—is included in MAT for OUD. And remember that OTPs can dispense buprenorphine as well—and preserve confidentiality, because a 2011 Dear Colleague letter from the Substance Abuse and Mental Health Services Administration tells OTPs to check the Prescription Drug Monitoring Program, but not to put prescribing information about their patients into it (http://atforum.com/documents/dearColl-pmp2011.pdf). This has made OTPs the last bastion of confidentiality in the substance use disorder treatment field.
That said, the AMA, which supported 42 CFR Part 2 in lobbying efforts last year, has reversed itself, allowing the organization to support weakening it in a vote by the House of Delegates this spring.
For the American Medical Association Opioid Task Force 2019 Progress Report, go to:
By Alison Knopf
A new program in New York has finally made it possible for methadone patients in the KEEP program at the New York City Rikers jail—the first behind-the-walls opioid treatment program (OTP) in the country—to continue their treatment if they are sentenced to incarceration upstate. The program, a partnership between NYC Health and Hospitals/Correctional Health Services, the New York State Department of Corrections and Community Supervision (DOCCS), and NYS Office of Alcoholism and Substance Abuse Services (OASAS), is expected to affect about 200 to 400 patients a year, said Jonathon M. Giftos, MD, clinical director of substance use treatment for NYC Health and Hospitals/Correction Health Services.
The new program, which takes effect July 1, applies to one upstate prison, in Elmira. This is the first time methadone will be allowed in state prisons. Buprenorphine is not included in the program. This means that patients on methadone in Rikers will no longer need to taper off the medication before going to Elmira, but instead can stay on it. This is a huge improvement.
The state has been helpful, said Dr. Giftos. “My experience with the state DOCCS leadership has been very positive,” he told AT Forum. “They are operationally very careful, and so they are making sure that there are clear protocols and contingency plans.”
So, yes, New York’s DOCCS is cautious, but the leadership is very much in favor of methadone for inmates. “It’s like a mission for them,” said Dr. Giftos. “They’re trying to make it work.”
What about custodial staff, though? These are the workers who actually interact with inmates, and who are most likely to have the view that methadone is “switching one addiction for another.” Dr. Giftos hasn’t spoken to custodial staff in state prison. But he works with them at Rikers, where they are not judgmental.
How the Project Came About
New York City has been discussing the importance of allowing patients who are taking methadone or buprenorphine to stay on their medication when being transferred to state facilities. The city “slowly influenced the state,” said Dr. Giftos. There has also been political pressure put on the state from public health advocates.
Up until 2017, methadone patients at Rikers who had a felony arraignment charge, and therefore faced the possibility of being convicted and having to go to a state prison, were tapered off their methadone. This was just on the “off chance” that they would be convicted, but it applied to every Rikers inmate who was taking methadone and facing that charge. In 2017, this was changed: regardless of arraignment charge, Rikers patients could stay on methadone (or buprenorphine), but if they were convicted, they would be tapered off either drug.
The state’s Elmire prison will now accept inmates on methadone, but only if their sentence is for two years or less. The reason for this time limitation, said Dr. Giftos, is that they wanted a pilot that captured patients at highest risk of overdose during the post-release period. The assumption was that patients with shorter-stay prison sentences would be most destabilized by a taper, and therefore would be at the highest risk of relapse and overdose after release.
However, there’s not much data to back up this theory. It’s true that someone who has been in recovery for five years has a much lower chance of relapse than someone in recovery for two years, but this is based on voluntary recovery, not forced “institutional remission,” a term based on the idea (which is not accurate) that drugs are not available in prisons, and therefore everyone there is not using.
How methadone will be dispensed in Elmira took a lot of planning, said Dr. Giftos. Unlike Rikers, which has a completely licensed and accredited OTP, Elmire doesn’t. The state prison system partnered with the state’s substance abuse services at OASAS to work with third-party OTPs, so that patients who are enrolled in KEEP at Rikers and want to stay on methadone can do so.
Here’s how it works. First, the methadone patients are moved to Downstate Correctional Facility, in Fishkill, where they receive five days of courtesy dosing from Lexington Center for Recovery, under Dr. Giftos’ methadone order.
After those five days, the patients are transferred to Elmira, where they begin to receive methadone from United Health Services (UHS), and the OTP. Even though they are not going to UHS for services, the patients are enrolled in the UHS OTP, and UHS doctors and staff deliver the methadone weekly to the Elmira facility.
One story that has never been told is that the pilot program for this was done in New York, where KEEP patients were medicated by Samaritan Village. “This was the first pilot where we worked out the logistics,” said Dr. Giftos. It was only for people who were going to get services for 120 days or less.
It is unclear why methadone, but not buprenorphine, was included in this Elmira project.
About 200 to 400 patients a year will be affected, now being allowed to continue their methadone when transferred from Rikers to Elmira, said Dr. Giftos.
The full OTP services will not be provided in Elmira—just the methadone. Any counseling and other services will be provided by correctional health staff.
But even having the methadone is crucial to patients. “I cannot tell you how many patients have said to me, ‘Methadone saved my life, I cannot believe that I have to come off this medication,’” before going to a state prison, said Dr. Giftos. And now, the gratitude that they have, just because they can stay on their treatment, it’s hard to describe,” he said.
“Lexington Center for Recovery is proud to be a partner in this endeavor to provide ongoing methadone treatment to those addicted to opiates within the New York State criminal justice system,” said Adrienne Marcus, PhD, executive director, Lexington Center for Recovery, Inc. Her statement was issued at the time of the announced plan, June 20.
But the plan falls short of what OTPs across the state wanted: full medication-assisted treatment for all incarcerated patients who need it.
Assembly member Linda B. Rosenthal, chair of the Assembly Committee on Alcoholism and Drug Abuse, said, “Our obligation to provide basic, life-saving health care to New Yorkers is the same on both sides of a jail cell wall,” and commended New York City for this expansion.
However, the assembly member wants more, as do OTPs in the state. “I am fighting for legislation at the state level to ensure universal access to MAT, and to guarantee that all correctional facilities have robust MAT programming,” she said.
Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA), cited “fiscal reality” when it comes to having an OTP in every jail and prison in the state. “Ideally it would be great to have the full Rikers program in all facilities, but we recognize that that’s a very expensive model,” she told AT Forum. “I don’t think we’re going to be able to achieve that, because the costs are so high.”
But using the Elmira dosing model gets Schorr’s full support. “We’re able to get medication into the facility and into the patients, and that’s something we haven’t done before,” Ms. Schorr said.
She sees this program as “an important first step.” It’s only for people who have been identified as having an opioid use disorder and are already taking methadone. Other people in the inmate population, including some in Elmira, would benefit from methadone, but won’t get it because they aren’t from the Rikers OTP. “But we have to start somewhere,” she said.
In Rhode Island and Connecticut, OTPs behind the walls are a reality. But those states are both small, and have the benefit of a unified system, said Ms. Schorr. “I understand, as a provider, that this is not something you can just roll out. There has to be a thought process, a learning curve.”
The budget needs to include funding for OTPs in prisons. “I think we have to push the governor on this,” said Ms. Schorr. Some advocacy organizations seem to want to give up on the opioid crisis. “I don’t even know what to say about that,” she said. “The Assembly didn’t manage to pass the bill, and that’s a real disappointment. It should have passed. Then we would have something to bring to the governor.”
In the meantime, changing the correctional system in New York won’t happen overnight. “Having talked to them, I can see it’s like turning an ocean liner,” said Ms. Schorr.
By Alison Knopf
Many people have questions about the role of counseling in methadone maintenance treatment, sometimes suggesting that nothing is needed but the medication itself. The Substance Abuse and Mental Health Services Administration (SAMHSA), which certifies opioid treatment programs (OTPs), has long recommended counseling be part of treatment in an OTP. While SAMHSA does not “require” this in buprenorphine treatment provided outside an OTP, there are concerns that providing no counseling shortchanges the patient.
Many patients may not want counseling, and indeed, if they are long-term patients who are stable, they probably don’t need it. But new patients do.
What is it? According to SAMHSA, recommended focuses are:
- Providing support and guidance, especially to eliminate substance misuse
- Monitoring other problem behaviors
- Helping patients comply with OTP rules
- Identifying problems needing referral and extended services
- Identifying and removing treatment barriers
- Providing motivational enhancement
But standard components are basic:
- Identification of problems needing immediate attention (eg, homelessness)
- Help locating and joining mutual-help groups
- Education about addiction and effects of substance abuse
- Education about relapse-prevention strategies
- Information about stress- and time-management techniques
- Assistance in developing a healthy lifestyle (eg, exercise, good nutrition, smoking cessation, avoidance of risky sexual behaviors)
- Assistance in joining socially constructive groups (eg, community and faith-based organizations)
- Continuing education on health issues (eg, HIV/AIDS, hepatitis)
Types of Group Counseling in MAT
- Psychoeducational groups
- Skill-development groups (eg, relapse prevention, stress management, substance use cessation)
- Cognitive–behavioral groups
- Interpersonal-process groups
- Support groups
In fact, counseling, including helping patients find a place to live, is what differentiates OTP treatment from office-based outpatient treatment (OBOT). And many medical experts feel that OBOT patients deserve more than medication alone. Those with experience in the field already know that medication alone doesn’t work. There is no “magic pill.”
Facing Addiction in America: The Surgeon General’s Spotlight on Opioids, notes that individual counseling is better than group counseling. “Most studies support the use of individual counseling as an effective intervention for individuals with substance use disorders as part of MAT.” The report added that “Group counseling should primarily be used only in conjunction with individual counseling or other forms of individual therapy. Despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems.”
However, charging the patient for counseling, if insurance doesn’t pay for it, may be a growing trend, especially among proprietary OTPs. Perhaps counseling could be reserved for patients who need it, and individualized. But the likelihood of new patients needing it the most is great.
The “dose-and-go” model doesn’t allow for counseling.
Finally, thinking of counseling as relating to psychological issues only is incorrect. Methadone isn’t a treatment for depression, and it’s not a treatment for HIV. By the time most patients show up at an OTP for treatment, they have many problems. Or they may be doing well and just need the medication. Someone needs to assess that.
For more information, go to
By Alison Knopf
Two people died after a shooting at the highly respected Man Alive opioid treatment program (OTP) in Baltimore on July 15—the shooter, and one other man. “Fortunately, these kinds of incidents are rare,” noted Mark W. Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD). In fact, the late Ira Marion, who was the beloved advisor to AT Forum for years, was shot (and survived) by a disgruntled employee in 1988 (https://www.nytimes.com/1988/05/18/nyregion/bronx-drug-adviser-shoots-supervisor-and-kills-himself.html). In a similar incident, a patient killed a clinic employee, then committed suicide (https://www.nytimes.com/1977/09/03/archives/clinic-aide-killed-by-patient-who-then-kills-himself.html).
Man Alive was the second OTP in the country.
Possibly the best news about the Baltimore incident is that there was no news. It could easily have become another “NIMBY” story. As it is, reports from police sources suggesting that the shooter was seeking methadone could not be corroborated.
But the incident did have ramifications for REACH Health Services, the OTP across the street, which had to take Man Alive patients that week. Yngvild Olsen, MD, medical director of REACH, talked about how this process went.
Incident Command Structure
REACH was there for the Man Alive patients. Eventually about 350 to 400 of the patients visited REACH for their medication every day that week. “We used an incident command structure,” Dr. Olsen told AT Forum. Some staff from Man Alive came over to help.
As for methadone logistics, REACH is fortunate. “We have a fairly healthy stock of medication, and we have the space for it,” Dr. Olsen said.
There was a registration station for Man Alive patients. “We had to have dose confirmation from their records, and we were able to print out a list of all their records,” Dr. Olsen said. “We could put together EMR profiles,” he added (referring to electronic medical records—an electronic collection of medical information, stored on a computer). After printing the list, a nurse practitioner and Dr. Olsen entered orders at another station.
The Staff Joins Forces
How did REACH staff handle a doubling of patients—not to mention a crisis—with likely trauma, and possible chaos—that week?
Dr. Olsen credits the four nurses. “They did a fantastic job the entire week,” she told AT Forum.
Monday—the day of the shooting—staff, along with Dr. Olsen, spent several hours, after dosing, creating EMR profiles. These were for the patients who, understandably, had not shown up at Man Alive after hearing what had happened.
“So, on Tuesday, it was extremely smooth sailing,” said Dr. Olsen.
Donuts, Take-Homes, Time Off; “Whatever You Need”
The Substance Abuse and Mental Health Services Administration (SAMHSA), which regulates OTPs, called Man Alive shortly after the shooting “and said, ‘whatever you need,’” said Dr. Olsen. Man Alive director Karen Reese wanted to be able to let her staff have the rest of the week to “decompress,” Dr. Olsen added.
At REACH, “we decided to provide take-homes on Wednesday for the rest of the week, except for those cases in which patients were so unstable we were afraid for their safety,” said Dr. Olsen. Something many people not in the OTP field may not realize: dispensing take-homes takes a lot more time than observed dispensing.
Another issue: that week was the hottest all summer. “We brought in fans, donut holes, water,” said Dr. Olsen.
It was a “community effort” involving staff and patients, she said. The second day—Tuesday—there were more than 900 patients.
Dr. Olsen said that the media “tried to get a negative story” out of this. “At the end of the day, there was no story,” she said. And she commended the Baltimore Sun for an “accurate and very supportive editorial.” For that editorial, go to https://www.baltimoresun.com/opinion/editorial/bs-ed-0717-methadone-clinic-shooting-20190716-vnftdmvvwrelpcjw73jfxkkc2a-story.html
Lessons to be learned: Having an “incident command structure” in case an incident occurs is a good idea for all OTPs. “Be prepared,” said Dr. Olsen. “Hospitals have this now, leadership that is trained in leadership command.”