“In an opioid epidemic that is killing tens of thousands of people nationwide, finding and paying for addiction treatment remains a challenge for low-income Americans, particularly in the South and parts of the West.
The Affordable Care Act required Medicaid, the joint state-federal health program for the poor, to start paying for all available substance abuse treatments in 2014, a provision seen as a boon for low-income people who previously were not covered for addiction treatment.
But Medicaid coverage of the most widely used opioid addiction medication, buprenorphine, varies widely among states. Many doctors don’t want to treat Medicaid patients for addiction. And red tape can make it difficult for many Medicaid recipients with addictions to get effective treatment.”
Source: PBS.org – October 14, 2016
See related article: Policy Experts Clash over Medicaid’s Role in the Opioid Crisis available at: http://www.medpagetoday.com/Psychiatry/Addictions/60611?xid=nl_mpt_DHE_2016-10-07&eun=g380369d0r&pos=5
See related video: Matt Salo Explains Medicaid’s Role in the Opioid Epidemic available at: http://www.ajmc.com/interviews/matt-salo-explains-medicaids-role-in-the-opioid-epidemic
Categories: 2016-10-25, Addiction, Buprenorphine, News Updates, OBOT, Opioid Abuse/Addiction, Opioids
Tags: Addiction, Buprenorphine, Heroin, Prescription Opioids, Substance abuse treatment
So does anyone Care about Bears
Categories: Medication-Assisted Treatment (MAT)
Barbara Goodheart, ELS
Vermont’s Hub-and-Spoke System Could Be Model for OTPs
NIMBY: Even in an Opioid Epidemic, OTPs and Patients Fight an Uphill Battle
Patient Advocate Calls On Federal Government to Fight NIMBY
Health Policy Takes Aim at Two Epidemics—OUD in Pregnancy and NAS in Newborns
RI Health Homes Initiative: Improving Wellness for The Patient, And The Bottom Line for Medicaid
Marijuana Testing: Advice From SAMHSA and the Joint Commission
Categories: 2016 August/September, Newsletter, TOC-News
By Alison Knopf
In Vermont’s opioid treatment system, devised ingeniously by Gov. Howard Shumlin with Affordable Care Act funding more than five years ago, opioid treatment programs (OTPs) are the hubs, and office-based physicians prescribing buprenorphine are the spokes.
This hub-and-spoke system has solved two massive problems for office-based opioid treatment (OBOT) providers: 1) the OTPs are the experts in assessment, and decide along with the patient whether methadone in an OTP or buprenorphine in an OBOT setting would be better; and 2) the OTPs are the experts in induction with either medication—buprenorphine or methadone.
Many OBOT physicians without experience treating addiction have been unsure about how to perform this procedure and how to get new patients stable. Primary care physicians in particular are uncomfortable with having patients in withdrawal in their offices, and buprenorphine induction requires that the patient be in mild withdrawal, with logistics often calling for the physician to send the patient home, to return when in withdrawal.
ACA at Work
While the program would be ideal for other states, that might not be a realistic goal. In Vermont, the program is dependent on the health care reform infrastructure, Barbara Cimaglio, deputy commissioner of the state’s Department of Health, explained to AT Forum in an interview in September. “It’s heavily supported by Medicaid, and also by the private insurance companies in Vermont, which cover the hub bundle of services,” she said. “But there are elements of the model that would work well in other places.”
The hub-and-spoke model began with a hub in central Vermont whose role was to perform inductions and get people stabilized, she said. The state also developed buprenorphine regulations for Vermont that were stronger than the federal regulations (DATA 2000) for OBOT, requiring that an assessment be conducted to see if counseling would be necessary.
Now that the program has been off the ground for several years, Vermont no longer has the higher match rate for Medicaid. But the hub-and-spoke system is continuing at full speed ahead.
Every state has a different set of regulations, but it’s possible that an OTP or a chain of OTPs could do something similar to the hub-and-spoke model, said Ms. Cimaglio. “There could be a partnership between an OTP and a group of physicians, and they could form the same kind of model.”
Other states have not committed to the hub-and-spoke initiative, which is costly without the kind of waivers Vermont received from the federal Department of Health and Human Services.
Model is Ideal
In the meantime, Richard A. Rawson, PhD, is interested in assessing the hub-and-spoke model. Dr. Rawson grew up on a dairy farm in Vermont and graduated from the University of Vermont before going on to head UCLA’s Integrated Substance Abuse Programs (from which he is now retired). He reportedly plans to retire in Vermont. After spending decades setting up OTPs in California, he returned to Vermont and was astounded by the extent of the opioid problem there, he told the Valley News last month. Later this year, Dr. Rawson, in collaboration with the University of Vermont, will begin an assessment of the hub-and-spoke system.
Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), told AT Forum that the hub-and-spoke model is an idea that many OTPs could adopt. They could form partnerships with local physician groups, as Ms. Cimaglio also suggested, and then refer certain patients who would be suitable for OBOT with buprenorphine to those physicians.
And Mario A. Moreno Zepeda, spokesman for the Office of National Drug Control Policy, said that the administration supports “models that integrate care for substance use disorders with mainstream medicine, such as hub and spoke.” He added that many people still do not have access to effective, medication-assisted treatment.
OTPs themselves can dispense and give take-homes for either buprenorphine or methadone. OBOT physicians can dispense and prescribe buprenorphine.
Looking forward, Ms. Cimaglio said it’s time to leave the “traditional OTP” behind, moving towards what the Vermont-style hub could be: part of an integrated health care network. “There are a lot of opportunities for partnerships, with hospitals, with physicians,” she said.
Categories: 2016 August/September, Addiction, Heroin, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids, Prescription Drugs
Tags: Addiction, Buprenorphine, Medicaid, Methadone Treatment, OBOT, Opioid Treatment Programs
By Alison Knopf
Opioid treatment programs (OTPs) across the country have been engaged in battles to locate, in the case of new facilities, and to expand, in the case of already existing ones. The problem isn’t with federal regulators, who are mainly supportive of OTPs. Rather, the barriers come from the very communities where treatment is needed. This article will sum up some of the ongoing struggles, as well as some victories.
In Maine, where Gov. Paul LePage has been an outspoken opponent of OTPs—and methadone and buprenorphine—the opioid epidemic is among the worst in the country. Yet even the bullying behavior by the governor is not as significant as local opposition. Colonial Management Group (CMG), based in Orlando, Florida, has been trying to expand its patient capacity in Bangor. The company operates 64 OTPs, with two in Maine—the Penobscot County Metro Treatment Center in Bangor, and another in Rockland.
The Bangor City Council denied the application to treat more patients, and the company, no stranger to legal zoning battles, is considering whether to sue.
Penobscot Metro was seeking to expand the patient capacity from 300 to 500; CMG had recently spent $600,000 preparing for more patients, the Bangor Daily News reported. The state had already approved the expansion. Bangor has three OTPs, with a total 1,500 patients served.
The root of the problem is, as is so often the case, an ordinance. Local approval is required for expansion. The city council of Bangor decided there wasn’t a need for increasing the capacity. Instead, CMG should have opened new facilities elsewhere in Maine, so patients wouldn’t have to travel so far, according to the city council. (Another oddity of the addiction world is that politicians think they know how to treat it—unlike cancer or tooth decay.)
At the root of a possible legal defense, also usually true, is that the ordinance is discriminatory because it singles out patients with addiction, in violation of the Americans with Disabilities Act.
The case is reminiscent of what happened in Warren, Maine, where CRC Health Group (now Acadia) was trying to locate an OTP, and the town enacted an ordinance that restricted the location of OTPs and would have made it impossible for CRC’s site to open. CRC did sue, and the court ruled easily that the ordinance was a violation of the ADA. Warren agreed to settle the case by paying CRC $495,000. The OTP never opened.
This year, following a long legal battle, CMG was paid $350,000 by Monument, Colorado, part of a $900,000 settlement (the remainder to be paid by the town’s insurance agency), according to the Colorado Springs Gazette. The tiny town of Monument used all of its funds to pay the settlement, under which CMG would close its facility and never open again in Monument.
The residents opposing the facility claimed it would attract drug users. Last year, the town denied CMG a business license, and CMG sued. It settled, and is leaving. The victims: patients.
There is also the unsavory scenario of another treatment program contributing to the demise of an OTP. This happened in Louisville, Kentucky, where Baymark was edged out of a building complex by a competing treatment program that not only is not an OTP, but believes that medication should be tapered, not given on a maintenance basis.
BayMark had proposed opening the OTP, but the building owners, Brain Chase and Walter Crutcher, said instead that they would not allow BayMark to rent there. The main opponent of the OTP was Seven Counties Services, which rents 40,000 square feet in the two-story building, the Courier-Journal reported August 19. BayMark would have occupied 7,500 square feet.
This would have been BayMark’s first OTP in Kentucky. In Louisville, there is one OTP, run by the Metro Health Department (1,300 patients), and another, by the proprietary Center for Behavioral Health (300 patients).
Alabama, Tennessee, and More
This summer the Opelika, Alabama city went on record as opposing an OTP there, with the Mayor telling the Opelika-Auburn News, “We don’t want a methadone clinic in Opelika or Auburn, or Lee County.” CMG had filed a certificate of need. A lawyer has now been signed up to represent the city.
In general, Tennessee is not a bright spot in the OTP world. But there is good news. After years of struggling, an OTP in Johnson City is finally near reality. Local citizens had tried to prevent the program from opening.
In West Virginia, there has been a moratorium on new OTPs for years. There is now a moratorium in OTP-friendly Georgia as well, although only for a year. There is only one OTP in Mississippi, where about 100,000 patients cross the border to access care in Louisiana and Alabama. Maryland came close to passing a bill that would require any new OTP to site in an industrial park, away from residential areas.
Prejudice Against OTPs
An oft-repeated criticism of OTPs is that they are “only in it for the profit,” and some people say that OTPs should be allowed to operate only if they are not-for-profit or publicly funded—ironically, these critics are in states that do not have any public funding for OTPs. Even progressive Illinois will start having Medicaid cover OTPs in January 2017, for the first time.
What’s going on? Many OTPs—and patients, including prospective patients, want to know the answer. Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), told AT Forum that NIMBY (Not In My Back Yard) is the major impediment to OTPs. “It has nothing to do with DATA 2000 (buprenorphine office-based practices) or any federal issues,” he said. “It’s the resistance to increase access to treatment for anyone who needs it.”
Mr. Parrino spoke with Michael Botticelli, director of the Office of National Drug Control Policy (ONDCP) about this—and other issues—recently. Mr. Botticelli’s idea was to conduct a state-by-state inventory identifying all the existing resources used to treat people with opioid use disorders, so that gaps in treatment can be identified.
Mr. Botticelli believes that OTPs are needed in those areas. But how will the OTPs be funded? The data will have to go to proprietary systems that will use them to target the areas of greatest need. On the other hand, there could be broader funding, as Vermont did, with public money to expand treatment.
The adversaries to OTPs, however, can’t be reduced to dollars—not when cities are willing to almost bankrupt themselves to pay to keep an OTP out. The main barriers are stigma and zoning restrictions, and unfounded fear.
And in terms of bordering states, there is the wish that patients would just go elsewhere if they need treatment, with little regard for how many hours patients have to drive.
There is also Stop Stigma Now (http://www.stopstigmanow.org/), which is urging patients and family members to be proud of their recovery, and plans to confront unfounded, erroneous information whenever it appears in print. Unfortunately, the confrontation will have to take place in many city council meetings before it will help OTPs open.
Categories: 2016 August/September, Addiction, Heroin, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioids
Tags: Buprenorphine, Heroin, Methadone Treatment, Opioid Treatment Programs, Prescription Opioids, Stigma
By Alison Knopf
Jocelyn Woods, MA, executive director of the National Alliance for Medication Assisted Recovery (NAMA-R), has a lot to say about NIMBY-ism. As the lead advocate for OTP patients, she shared her thoughts with AT Forum.
“Research was conducted decades ago showing that methadone reduces crime and public health problems,” she said. “Even more importantly, for the majority of methadone patients, if they were homeless, they find a place to live. They find work and begin to pay taxes, take care of their children, repair relationships with their family, and begin to live pretty normal boring lives.”
This transformation usually occurs within the first year of treatment, something Ms. Woods finds “pretty remarkable, considering that many have no work history, and legal entanglements that are often barriers.” They do it anyway. The reason, said Ms. Woods, is that most patients enter methadone treatment because they are “tired of the lifestyle, waking up sick in the morning and having to find a way to purchase drugs.” After a few months in treatment, they become stable on their medication, and see opportunities before them that they never had before.
They are not “loafers.” The struggle these new patients have before them is enormous. They will face discrimination in health care, education, employment, life insurance, family welfare and the court system, and criminal justice. “To succeed, you have to have a ‘never-give-up attitude,” said Ms. Woods. “There are a lot of very smart people being held back just because of the medication they are taking.”
It’s clear that society thinks it knows everything about opioid addiction and how to treat it, and that’s the problem, said Ms. Woods. “They don’t realize that they don’t know the answer.”
Ms. Woods would like the federal government, which itself does not espouse NIMBY, to “step up and create a massive public relations program to educate the public about opioid addiction and the effective treatments for it,” she said. “Only the federal government can do it right. But they’ve tried only campaigns that were ineffective and a waste of money.”
States also have a responsibility to make sure that adequate treatment is available for everyone who needs it, she said. “Both methadone and buprenorphine treatment is so inexpensive in comparison to the alternatives.”
In addition, the federal government’s aggressive campaign to discourage physicians from prescribing opioids for pain has had a very negative effect, said Ms. Woods. “We need to be smarter than that,” she said. “Limiting prescriptions to pain medication is not only imprudent, but self-defeating, because people will find a way to relieve their pain or they will commit suicide.”
She called the Drug Enforcement Administration “out of control” in its shutdown of pain treatment centers “without considering what could happen next.” What happened was that many valid pain patients attending the clinic were in crisis. It didn’t take long for heroin dealers to step in.
“You cannot stop an epidemic by limiting pain medication or illicit opioids,” she said. “The only way to get it under control is to provide pain medication for those that need it, and addiction treatment for those that need it. And to do this NIMBY cannot be tolerated.”
Categories: Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids, Patient Advocacy, Prescription Drugs
Tags: Heroin, Methadone Treatment, Opioid Treatment Programs, Prescription Opioids, Stigma, Substance abuse treatment
By Barbara Goodheart, ELS
A comprehensive review article in Obstetrics and Gynecology summarizes troubling data on the epidemic of opioid use disorder (OUD) during pregnancy, and the subsequent sharp rise in the incidence of neonatal abstinence syndrome (NAS) (withdrawal symptoms in newborns). The article also evaluates recent policy decisions and discusses their implications.
Opioid treatment programs (OTPs) have a key stake in the policy proceedings. OTPs need to be aware that the massive increase in the incidence of OUD and NAS will almost certainly continue, so they need to be prepared. They also need to follow the changes in protocols. Policymakers’ decisions will have important implications for women who become pregnant during OTP treatment, and for pregnant women with an untreated OUD who are referred to an OTP.
Some recent health policy and legislative initiatives spurred by the opioid epidemic have benefited patients; others have harmed them; some have even involved criminal penalties.
Evaluating Health Policy
Treating OUD. Treatment options for OUD are medication-assisted treatment (MAT) with methadone or buprenorphine. Detoxification or withdrawal during pregnancy carries many disadvantages for mother and child, and the American College of Obstetrics and Gynecology (ACOG) and other major medical organizations do not recommend it.
In 20 states, according to a 2014 HHS publication on Medicaid coverage, Medicaid 2013 preferred drug lists did not include methadone—a distinct disadvantage to OTPs—yet Medicaid covers buprenorphine in all 50 states. The authors refer to this lack of Medicaid methadone coverage as “a missed opportunity to provide comprehensive drug treatment services for pregnant women.” They point to the HHS publication, which estimates that methadone yields $37.72 in benefits for every $1 in cost.
Some states impose restrictions on Medicaid eligibility and benefits, such as requiring prior authorization and limiting quantity and lifetime treatment.
Protecting Mothers and Infants
The report discusses several legislative plans, the most important being “Prenatal Drug Use and Newborn Health” (The Protecting Our Infants Act of 2015).
This major legislation, released as a document in February 2015, identifies program gaps and directs the Department of Health and Human Services (DHHS) to take several specific actions. DHHS was also to report back to Congress with evidence-based recommendations one year after the bill became law. The Protecting Our Infants Act was passed with broad bipartisan support; President Obama signed it into law November 25, 2015.
As for funding, Congress must allocate money before action can be taken. But comments from lawmakers prior to the signing suggest that funding will happen; a way will be found.
A Call to Arms
The article calls for medical societies to coordinate their professional guidelines and advise policymakers. It also calls for health care providers to act as gatekeepers, screening all pregnant patients for OUD, and helping, where appropriate, with referral and enrollment in medication-assisted treatment programs.
Will Physicians Become Simply Gatekeepers?
When recommendations and guidelines are in place, can physicians still choose the best treatments for their patients?
The Ohio Story: Doctors’ Ethical Dilemma
A situation in Ohio in 2011, reported in PLOS, raises concern.
Ohio state law obligated physicians performing a medication abortion—a nonsurgical procedure in which medications are taken to induce an abortion—to follow an obsolete protocol. The result: medication doses that were too high, causing “significant increases in medical interventions, side effects, and costs.”
PLOS noted that “laws like Ohio’s prohibit clinicians from practicing medicine based on the latest developments in clinical research . . . This law will continue to require physicians to provide care that may fall below the accepted standard of care, placing them in an ethical dilemma.”
Anti-choice issues were underlying the state’s actions, but this example clearly illustrates the power of state government to force physicians to use a protocol. This particular protocol happened to be obsolete. The situation would have been much worse if the protocol had been dangerous.
AT Forum contacted ACOG for their comments about the potential negative impact on patients when policy conflicts with medical evidence. “There should not be political interference with patient care and we have had success at the federal level working together with Congress and peer organizations to pass positive legislation that frames the issue of opioid use during pregnancy in the public health, as opposed to punitive, space,” said ACOG Vice President Hal C. Lawrence, MD. “However, the states are much more varied in their approach and some pass laws or set precedents penalizing pregnant women with OUDs.
“This is a challenge that we will continue to face, and physicians and others will need to continue to advocate at the state and federal levels to defend evidence-based approaches to treating OUD in pregnancy, and NAS,” Dr. Lawrence said.
Protocols and Product Labeling
What about protocols containing specific dosages? Some time ago, John McCarthy, MD, ABAM, who will chair a panel at the upcoming meeting of the American Association for the Treatment of Opioid Dependence (AATOD), developed a high-dose, split-dose methadone protocol for pregnant women. The protocol is still used in the California clinic he headed until recently. In a recent study, only 29% of newborns on his protocol required treatment of NAS, vs. published rates of 60% to 80% with other methadone dosages.
AT Forum asked Dr. McCarthy, “If an FDA protocol is published, will you and others no longer be able to use your protocol?”
“Our divided-dose protocol is not yet standard,” he said, “although the science supporting divided doses is very strong. Nor is our individualized dose range—20 mg/day to 415 mg/day—something that would go well with those who think less methadone is better, no matter how severe the mother’s withdrawal symptoms.” He added that it is hard to see a protocol actually going against pharmacokinetic science and restricting what physicians can do.
FDA Regulatory Powers
For clarification on regulatory issues, protocols, and the role of the U.S. Food and Drug Administration (FDA), AT Forum contacted Mark L. Hudak, MD, chairman of the department of pediatrics at Wolfson Children’s Hospital, University of Florida College of Medicine—Jacksonville.
As a former member of the American Academy of Pediatrics (AAP) Committee on Drugs, Dr. Hudak co-authored the clinical guideline, Neonatal Drug Withdrawal, the committee’s landmark 2012 report.
What we learned from Dr. Hudak was reassuring. The FDA labels for both methadone and buprenorphine include an indication for maintenance treatment of opioid dependence or addiction. The labels provide additional information about the potential effects of these drugs on the fetus, including the risk of NAS, but do not prohibit their use in pregnant women.
Dr. Hudak noted that the FDA has no authority to interfere with the doctor’s decision, with respect to treating the mother—and no intention of doing so. Congress has granted FDA regulatory authority over drug manufacturing and approval, but not over physician prescription of approved drugs to individual patients.
FDA Labeling and NAS
“In regard to babies experiencing opioid withdrawal, none of the medications we commonly use—morphine, methadone, buprenorphine, or phenobarbital—received label indications from the FDA to treat babies with NAS,” Dr. Hudak said.
In fact, he noted that the FDA label for methadone specifically states that “neonatal opioid withdrawal syndrome . . . should be treated according to protocols developed by neonatology experts.”
Lack of a Protocol Can Mean Changes in Treatment
When Dr. Hudak helped draft the clinical guidance document for NAS, many physicians did not follow a common protocol, so there was a wide variation in treatment within each hospital. Most physicians would use an opioid as a first-line treatment, but approaches differed on when to start treatment, what drug and dose to use initially, and how to escalate treatment and wean the baby. So when another physician took over the baby’s care, the treatment approach often changed.
A Protocol Can Offer Several Treatment Pathways
The AAP guideline recommended that each hospital treating babies with NAS adopt a common protocol.
“A protocol could offer several pathways, depending on a standardized evaluation and the baby’s response to treatment,” said Dr. Hudak. He explained that many more centers have now standardized their approach, and length of treatment and hospital stays are shorter.
“Protocols differ from one hospital to another, and clinical studies have not defined an optimal protocol, so it’s easy to see why no government body could have regulatory authority and tell physicians what drug to use in what patients at what time.”
Dr. Hudak recommended a protocol for everyone in his unit. “It offered several pathways, depending on evaluation and the baby’s response to treatment. The good news is that many more centers now standardize their approach.”
Another advantage: “With such a wide range of acceptable practices, it’s easy to see why no government body could have regulatory authority and tell physicians what drug to use, in what patients, at what time,” he said.
The Next Steps
Regarding OTP patients: under the code of federal regulations (42 CFR 8.12), OTPs must maintain current policies and procedures that reflect the special needs of pregnant patients. “Prenatal care and other gender-specific services . . . must be provided either by the OTP or by referral to appropriate healthcare providers.”
OTP patients will be included in new evidence-based recommendations. According to Dr. McCarthy, data from current studies indicate that these recommendations should include monitoring patients’ methadone dose throughout pregnancy, not just the third trimester.
Recommendations should also include dosage increases. “The pre-pregnancy dose of methadone is never effective,” Dr. McCarthy believes. To claim that it is pretends that metabolic changes do not occur. They do; usually the rate of metabolism rises progressively, and the methadone dose needs to be increased accordingly.”
Outlook: Mixed, but Hopeful
The rise in the incidence of OUD and NAS continues. But with Congress likely to fund The Protecting Our Infants Act, setting in motion a host of actions, specific evidence-based treatment and management recommendations for OUD and NAS should soon emerge.
Protocols will be revised. The country’s OTPs and hospitals will put the new OUD protocols into practice. Patients who are pregnant will ultimately benefit—as will those patients’ unborn babies—and there is hope for new protocols to help newborns with NAS as well.
# # #
Hall ES, Wexelblatt SL, Crowley M, Grow JL, Jasin LR, Klebanoff MA, et al. A multicenter cohort study of treatments and hospital outcomes in neonatal abstinence syndrome. Pediatrics. 2014;134:e527–e534.
Hudak ML, Tan RC, Committee on Fetus and Newborn, American Academy of Pediatrics. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540-60. doi: 10.1542/peds.2011-3212. Epub 2012 Jan 30. PMID: 22291123. DOI: 10.1542/peds.2011-3212. http://pediatrics.aappublications.org/content/129/2/e540.long.
Krans EE, Patrick SW. Opioid Use Disorder in Pregnancy: Health Policy and Practice in the Midst of an Epidemic. Obstet Gynecol. 2016;128(1):4-10. doi:10.1097/AOG.0000000000001446.
McCarthy JJ, Leamon MH, Willits NH, Salo R. The effect of methadone dose regimen on neonatal abstinence syndrome. J Addict Med. 2015;9(2):105-110. doi: 10.1097/ADM.0000000000000099.
Opioid abuse, dependence, and addiction in pregnancy. Committee Opinion No. 524. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;119:1070-1076. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Opioid-Abuse-Dependence-and-Addiction-in-Pregnancy.
Substance Abuse and Mental Health Services Administration, Medicaid Coverage and Financing of Medications to Treat Alcohol and Opioid Use Disorders. HHS Publication No. SMA-14-4854. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.
Upadhyay UD, Johns NE, Combellick SL, Kohn JE, Keder LM, Roberts SCM. Comparison of outcomes before and after Ohio’s law mandating use of the FDA-approved protocol for medication abortion: A retrospective cohort study. PLOS. August 30, 2016. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002110.
White House Office of National Drug Control Policy. Epidemic: responding to America’s prescription drug abuse crisis. https://www.whitehouse.gov/sites/default/files/ondcp/policyand-research/rx_abuse_plan.pdf.
Zarkin GA, Dunlap LJ, Hicks KA, Mamo D. Benefits and costs of methadone treatment: Results from a lifetime simulation model. Health Econ. 2005;14 (11):1133-1150. doi: 10.1002/hec.999.
Categories: 2016 August/September, Buprenorphine, Heroin, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioids
Tags: Buprenorphine, Heroin, Methadone Treatment, Neonatal Abstinence Syndrome, Opioid Treatment Programs, Pregnancy, Prescription Opioids, Substance abuse treatment
By Alison Knopf
People with opioid use disorders are a small percentage of Medicaid enrollees, but they represent a significant percentage of costs in terms of emergency department utilization and repeat hospital admissions. By using opioid treatment programs (OTPs) as these patients’ “health homes,” the Centers for Medicare & Medicaid Services (CMS) is hoping that these costs can be cut—and at the same time, health care can be vastly improved for these patients. Health homes in OTPs are strongest in Rhode Island, where Rebecca Boss, the state’s lead in the project, completely buys into the OTP model.
The payment approach is key: Rhode Island uses a weekly bundled payment. The Rhode Island Opioid Treatment Program Health Home State Plan Amendment involves offering OTP patients the chance to have daily contact with clinical professionals.
Linda Hurley, MA, President/CEO of CODAC Behavioral Healthcare, based in Providence, has been involved with the health homes project from the beginning. Ms. Hurley describes OTPs as a “culture of healing,” not just for opioid use disorders, but in general. “It’s beyond the relationship between the patient and the therapist,” says Ms. Hurley. Whether it’s the nurse at the dosing window or the front desk person helping patients figure out insurance, the entire program is aimed at helping the patient get healthy. That’s why OTPs are an ideal setting for being a health home—a location where a patient can receive or be connected to all the health care he or she needs.
About five years ago, Rebecca Boss asked several OTPs, including Ms. Hurley’s, to talk about how to apply the health home concept. Ever since then, the group has met every Tuesday, every week. The group included OTPs, primary care, third party payers—all of the stakeholders—and they looked at barriers to access. The most important part of the health home paradigm is getting the other providers to treat the OTP patients. So the OTPs did help educate primary care physicians about the importance of working with these patients. At the same time, the OTPs learned a lot from primary care people, said Ms. Hurley.
“I’ve been doing this for almost 30 years, and decade after decade I have to go out and provide information to a new group of doctors,” said Ms. Hurley. Listening to them at these Tuesday meetings, she learned a lot about the barriers patients face. “Historically, our patients have the least amount of resources to follow treatment recommendations,” she said. “They have a high no-show rate.”
Talking with the physicians “opened my brain and my heart.” She learned to reach out to them, and, importantly, to have a case manager from the OTP go with struggling patients to the primary care physician appointment. For example, one patient, in early treatment, went to the physician for an appointment, and was very intoxicated. There were families in the waiting room, but because the OTP’s case manager was there to meet the patient, disaster was averted. As it turned out, the patient didn’t actually have an appointment that day, and the practice was willing to give the OTP—and the patient—another chance. “He was exhibiting a symptom of his disease of addiction,” said Ms. Hurley.
The health home team at the OTP consists of a pharmacist, a physician and RN, a master’s level clinician, and two case managers. That team sees 150 patients in the OTP. In addition, each patient continues to have his or her regular treatment team.
One CODAC patient had been depressed, and had low self-esteem. But it wasn’t until the health home initiative that a case manager tried to find out more, and learned that the patient had a lot of dental pain. In fact, from a cosmetic perspective, the dental pain was compounded by the fact that she felt her teeth were unattractive. Through the health home, she got dental care. “All the Wellbutrin in the world wouldn’t have fixed this,” said Ms. Hurley, referring to the antidepressant, bupropion.
CODAC had to add to its facility to make room for the new program. Across the state, health homes in OTPs created 68 new jobs. “Rhode Island says health homes are here to stay—they like the outcomes,” said Ms. Hurley. Emergency department visits have gone down. And this is clearly related to the OTP patients’ understanding that they now have primary care physicians, that their personal physician is not the emergency department doctor.
Finally, the health home initiative ended up with the OTP community in Rhode Island banding together to create a health home leadership group, to make sure services offered from one OTP to another were comparable. “We went a step further,” said Ms. Hurley. “We pooled health home funds, based on the number of patients each entity had, and purchased three positions.” These positions were a health home coordinator, who set up metrics and an auditing tool; a software consultant; and a training coordinator.
The health home program in Rhode Island has been fully operational for two years.
Categories: 2016 August/September, Buprenorphine, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Heroin, Medicaid, Opioid Treatment Programs, Prescription Opioids
By Alison Knopf
In this day of medical marijuana in some states, and recreational marijuana as well, what is a treatment program to do when it comes to testing for the drug. We checked with the Joint Commission and with the Substance Abuse and Mental Health Services Administration (SAMHSA). Both say the same: test at admission, and from then on, it’s up to you.
The requirements for opioid treatment programs (OTPs) cited in the Joint Commission Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) do not specify that marijuana must be tested for, except at admission. Megan Marx-Varela, associate director of the Joint Commission’s behavioral health care program, replied to our question about this by citing Standard CTS 02.020.09, element of performance 4 (for OTPs), which states: “On admission the program tests the patient for opiates, methadone, amphetamines, cocaine, marijuana, and benzodiazepines. The need for testing for additional substances is determined by individual patient circumstances and local drug-use patterns.”
As for SAMHSA, in 2014, a Dear Colleague letter to OTPs noted that marijuana is still listed as a Schedule I controlled substance (and it still is in 2016). In accordance with federal law, SAMHSA still views marijuana as an illicit drug in all OTPs, regardless of the state they operate in. This means SAMHSA, as a federal agency, does not accept medical marijuana or recreational marijuana.
As for drug testing, however, marijuana testing is required only at admission.
Both SAMHSA and the Joint Commission specify that admission to an OTP requires running the following toxicology tests: opioids, methadone, buprenorphine, amphetamines, cocaine, marijuana, and benzodiazepines. SAMHSA states that if there is a history of prescription opioid analgesic abuse, “an expanded toxicology panel that includes these opioids should be administered.”
However, any additional testing, beyond admission, “is based on individual patient need and local drug use patterns and trends,” states SAMHSA.
Alcohol vs. Marijuana
We asked specifically what the difference is between recreational marijuana and recreational alcohol use in OTP patients. SAMHSA’s response: “Using methadone and alcohol together is particularly dangerous because of the interactions between the two substances. According to the National Institutes of Health (NIH), when used at the same time, alcohol can increase the risk of experiencing serious and life-threatening side effects from methadone.”
Using alcohol and methadone together “can create health concerns that are more severe based on the combined use of these two substances,” added SAMHSA. “Individuals who mix methadone and alcohol may be more likely to experience respiratory depression, irregular heartbeat, drowsiness, and coma.
We also asked about the effects of combining marijuana with methadone. “Illicit drug use, specifically cannabis, is common among opioid-dependent individuals and has the potential to impact treatment in a negative manner,” SAMHSA responded. “Studies demonstrate that rates of cannabis use were high during methadone induction, dropping significantly following dose stabilization.”
Problems With Marijuana
SAMHSA offered the following evidence of the harms of marijuana, including citations.
Approximately 9% of people who experiment with marijuana will become addicted to it; among those who start using the drug in their teens, the number goes up to about 1 in 6, and among daily users to 25-50%. (Lopez-Quintero C, Perez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011; May 1;115(1-2):120-130. doi: 10.1016/j.drugalcdep.2010.11.004. Epub 2010 Dec 8.)
Early (animal) studies show that early THC exposure can weaken the dopamine system in the reward areas of the brain—an effect that, in humans, would explain why early and chronic marijuana use may increase the likelihood of developing other substance use disorders later in life. Agrawal A, Neale MC, Prescott CA, Kendler KS. A twin study of early cannabis use and substance use and abuse/dependence of other illicit drugs. Psychol Med. 2004; Oct;34(7):1227-37.) “This potential risk factor could further complicate the treatment course among those already struggling with substance abuse disorders,” stated SAMHSA.
Marijuana significantly impairs coordination and reaction time and is the illicit drug most frequently found to be involved in automobile accidents, including fatal ones. The recognition of this effect along with known methadone induced sedation is a major concern among OTP clients that drive. (Brady JE, Li G. Trends in alcohol and other drugs detected in fatally injured drivers in the United States, 1999-2010. Am J Epidemiol. 2014; Mar 15;179(6):692-9. doi: 10.1093/aje/kwt327. Epub 2014; Jan 29.)
The takeaway from all of this information: you do not have to test OTP patients for marijuana once they are admitted, but you may want to provide education about the deleterious effects of combining marijuana with methadone. Even more important, however, you may want to bring up alcohol–which just about nobody tests for because it doesn’t show up in urine tests. SAMHSA and the Joint Commission wisely leave testing decisions up to clinicians.
References, and for Further Reading
SAMHSA 2014 Marijuana Dear colleague letter. http://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/dear_colleague_letters/
Federal Guidelines for Opioid Treatment Programs. http://store.samhsa.gov/product/PEP15-FEDGUIDEOTP.
Scavone JL, Sterling RC, Weinstein SP, Van Bockstaele EJ. Impact of cannabis use during stabilization on methadone maintenance treatment. Am J Addict. 2013;Jul-Aug;22(4):344-351. doi: 10.1111/j.1521-0391.2013.12044.x.
Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs: Chapter 9. Drug Testing as a Tool. https://www.ncbi.nlm.nih.gov/books/NBK64151/.
Categories: 2016 August/September, Addiction, Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: alcohol, Buprenorphine, marijuana, Methadone Treatment, Opioid Treatment Programs
American Academy of Addiction Psychiatry (AAAP) Annual Meeting and Symposium
December 8-11, 2016
Bonita Springs, Florida
The Evolution of Addiction Treatment Conference
February 2–5, 2017
Los Angeles, California
New York Society of Addiction Medicine (NYSAM) Annual Medical-Scientific Conference
February 3-4, 2017
New York, New York
National Association for Court Management (NACM) 2017 Midyear Conference
February 5-7, 2017
Over 30 new conferences and meetings have been added to the website and are available at: http://atforum.com/events/
Categories: 2016 August/September, Newsletter
Tags: Addiction, Drug Courts
MEDICATION-ASSISTED TREATMENT & OPIOID ABUSE/ADDICTION
- New SAMHSA Rule Helps Finalize Move to Provide More Medication-Assisted Treatment to People with Opioid Disorders
- Funding Bill Includes $37 Million for Opioid Crisis
- Costs of US Prescription Opioid Epidemic Estimated at $78. 5 Billion
- Research Results: Widespread Use of Prescription Drugs Provides Ample Supply for Abuse
- Research Results: Physician Capacity to Treat Opioid Use Disorder With Buprenorphine-Assisted Treatment
- Exclusive: Obama Administration to Launch New Effort On Heroin Crisis
- There’s an Effort to Save the Drug Kratom from DEA Extinction
- New Research Summary: Opioid Dependence Leads to ‘Tsunami’ of Medical Services
LINKS TO ADDITIONAL NEWS OF INTEREST
- Opioid Addicts Get Second Chance in Denver Jail – 9/29/16
- Opioid crisis in rural areas may be tackled through telemedicine – 9/27/16
- Methadone users’ misconceptions about HCV hinders treatment – 9/26/16
- Where Hillary Clinton and Donald Trump stand on the opioid epidemic – 9/24/16
- Unused Dental Surgery Prescriptions May Help Fuel Opioid Epidemic – 9/23/16
Categories: 2016-09-30, News Updates, TOC