For a quarter-century AT Forum has served as a source of support and encouragement for the opioid addiction community, as well as an advocate of medication-assisted treatment (MAT) and opioid treatment programs (OTPs). Much has changed during that time, and some things have come full circle.
Back in the early 1990s, methadone was the only medication for treating opioid use disorders (OUDs). The opioid of choice among users was heroin, and most heroin users were living in urban areas. The first issue of AT Forum noted that the typical upper daily limits of methadone at some OTPs were only 20 to 60 mg; many patients require higher doses.
OTPs often worked in isolation, and they felt it keenly. A treatment that had been a scientific breakthrough in the 1960s now had few supporters. Program staff members, their patients, policy makers, and the media sorely needed reliable information.
AT Forum stepped in to help meet that need.
The 1990s—The Beginning: Some Dark Days, Some Bright Spots
The first issue of the AT Forum newsletter offered a mix of patient advocacy, management guidance, news updates, and research articles—as the newsletter does today.
Susan Emerson—publisher of Addiction Treatment Forum (atforum.com) throughout its lifespan—recalls those early days.
In the early 1990s, the Internet was several years away from being widely available, so the public had limited resources for information or help about opioid addiction. “Patients and families called AT Forum with questions,” Ms. Emerson recalls; “questions about how to find methadone treatment programs, specific questions about treatment itself—questions they couldn’t find answers to anywhere else.”
Ms. Emerson remembers the stories that had an impact. Some involved persistent stigma and NIMBY (Not in My Back Yard); others showed progress being made in treating OUDs. But what stands out most in her memory is the difference the publication made in peoples’ lives.
“People thanked AT Forum, because patients and OTP staff members were seeing improvements in their patients. Effective methadone dosing levels, and comprehensive care—things that AT Forum played a role in bringing about—were helping patients get better.”
Dr. Dole’s Disappointments
In 1995, AT Forum featured an interview with Vincent Dole, MD, one of the developers of methadone maintenance treatment (MMT). It was now 30 years after Dr. Dole, Marie Nyswander, MD, and Mary Jeanne Kreek, MD, first published their research showing the effectiveness of methadone treatment.
But Dr. Dole was now less hopeful than he had been three years earlier, when AT Forum first talked with him. He was disappointed about the “endless moral and other types of objections” that have nothing to do with the scientific data, and surprised to find that “we still get the anti-methadone argument of substituting one addictive drug for another,” he said. “The fact that people, especially medical practitioners, would dismiss the data as unimportant simply staggers me!”
An Ominous Shift in Opioid of First Use: The Rise in Prescription Opioids
An important shift occurred in the mid-1990s: more heroin users chose a prescription product, instead of heroin, for their first opioid use. As the graph below shows, heroin use continued in a downtrend, and prescription opioids in an uptrend, until the 2000s, when a reversal began. Not shown in the figure: the lines crossed again in 2017, as heroin became once again the opioid of choice.
Adapted from Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826. doi: 10.1001/jamapsychiatry.2014.366. Published online May 28, 2014.
From 1992 to 2017: A Recap
Much has changed since AT Forum was introduced 25 years ago. Today, opioid-related deaths are reaching new highs. News about the escalating opioid crisis dominates media outlets—from newspapers to consumer magazines to broadcast media.
The makeup of the people who use heroin has changed. Heroin is no longer “an inner-city, minority-centered problem.” (JAMA Psychiatry 2014) The recent sharp rise in heroin use has been “greater among white individuals, unmarried respondents, males,” those with less education, and those living in poverty. Interestingly, heroin use may have become more socially acceptable among suburban and rural white individuals because its effects resemble those of widely available prescription opioids. (JAMA Psychiatry 2017)
Signs of progress. Along with the troubling news of increased heroin use, signs of progress have appeared along the way. Among them: Providers, government officials, corporate partners, and patient advocates have joined together to form a stronger community. In the treatment area, a choice of three medications gives health care providers options for treating OUDs. A fourth medication, naloxone, for treating opioid overdose, is now available without a prescription in many states, and has saved countless lives.
Today’s AT Forum articles cover topics such as these, as well as offering advice on other key aspects of addiction treatment—siting new facilities, adjusting drug therapy to conform to individual patients’ requirements, and meeting adolescents’ urgent needs for treatment programs, to name a few.
What Lies Ahead
Speculation calls for yet another change ahead in the opioid addiction community—a shift from heroin to fentanyl, carfentanil, and an opioid known as U-47700—as the upcoming choices of opioids of first use. Indications are that it’s quite likely to happen.
And if it does, AT Forum will be there to cover the news.
# # #
Funded by an unrestricted educational grant from Mallinckrodt Pharmaceuticals ever since its inception a quarter-century ago, AT Forum has published 300 news updates and nearly 100 newsletters.
It’s Official: Heroin Is Once Again More Popular Than Rx Opioids. AT Forum. October 24, 2017.
Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366. Published online May 28, 2014.
Madras BK. The surge of opioid use, addiction, and overdoses: Responsibility and response of the US health care system [editorial]. JAMA Psychiatry. 2017;74(5):441-442. doi:10.1001/jamapsychiatry.2017.0163. Published online March 29, 2017.
Martins SS, Sarvet A, Santaella-Tenorio J, Saha T, Grant BF, Hasin DS. Changes in US lifetime heroin use and heroin use disorder prevalence from the 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017;74(5):445-455. doi:10.1001/jamapsychiatry.2017.0113. Published online March 29, 2017.
For Additional Reading
To browse archived issues on the AT Forum website, go to http://atforum.com/newsletter-archives/.
Categories: Buprenorphine, Heroin, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids, Prescription Drugs
Tags: Heroin, Medication-Assisted Treatment, Methadone Treatment, Opioid Treatment Programs, Prescription Opioids, Substance Abuse Treatment
By Alison Knopf
In one respect, opioid treatment programs (OTPs) have an advantage over most areas of health care, when it comes to uncertainty about insurance in the future. If even the worst scenario came to pass (zero coverage for treatment, and that is unlikely), it wouldn’t be an unusual situation for OTPs. Unfortunately, OTP patients are used to paying out of pocket in many cases.
“It’s always been true, no matter what administration we’re under, that the most certain method of achieving sustained financial stability is a direct out-of-pocket payment, from patient to program,” said Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), in an interview with AT Forum. At the time of the interview, Congress was considering a tax bill that would have massive effects on health insurance, Medicaid, and Medicare.
The Fewer Payers, The Better
To the extent that they already have such patient-pay models, OTPs are insulated from insurance changes. “As a practical reality, the fewer parties you have in any payment scheme, the better,” said Mr. Parrino. “If you get a direct payment, there’s no delay. If you bill Medicaid, you’re going to wait weeks. If you bill Medicare, you’re waiting months.” (Some OTP patients are Medicare-eligible because of disability; AATOD is working to get Medicare coverage for patients based on age, as well.)
This is not to say that Mr. Parrino wants to see this happen. He, and AATOD, have worked tirelessly to have Medicaid and Medicare, as well as commercial insurance, reimburse programs and patients for OTP services.
Non-Medicaid States: No Access If You Can’t Pay
The comparison is stunning: 85% of patients in non-Medicaid states make out-of-pocket payments. And 85% of patients in Medicaid states have their treatment paid by Medicaid. “The implication is that those who can’t afford treatment simply don’t access care,” said Mr. Parrino. It’s also important for the Medicaid rate to be high enough to attract providers, he said.
Health care uncertainty has been pretty constant since President Trump, who vowed to repeal the Affordable Care Act, took office. Congress tried for repeal, but failed. Americans are signing up for health care, and, Medicaid expansion, it appears, will continue.
So OTPs with the self-pay model can expand their services to Medicaid—and patients covered by commercial insurance, and OTPs, as a public model, can continue to rely on Medicaid, ACA plans, and the Substance Abuse Prevention and Treatment block grant.
Categories: Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: AATOD, Addiction, Health Insurance, Medicaid, Opioid Treatment Programs, Substance Abuse Treatment
By Alison Knopf
The Substance Abuse and Mental Health Services Administration (SAMHSA) announced that the funding formula for the $1 billion Opioid State Targeted Response (STR) grant allocation formula will stay in place for the second year of the two-year program. SAMSHA made the announcement on October 30, to the relief of the state agencies that were not sure if they would need to write completely new applications for the next year.
Created by the 21st Century Cures Act, the Opioid STR grant program is focused on treatment for opioid use disorders, and has resulted in the expansion of medication-assisted treatment (MAT) and, in some states, widespread expansion of opioid treatment programs (OTPs). Keeping the formula in place means that the states that had already embarked on considerable investments in methadone and buprenorphine treatment can keep those initiatives going.
Year 2 Funding Based on a Formula; No Reapplication Needed
The second year of funding will be allocated according to a formula that takes into account the number of overdose deaths and people with an unmet need for treatment.
Importantly, states do not need to reapply. Many states requested that funding levels remain the same to ensure continuity of services to people needing treatment.
There was some concern after former secretary of the Department of Health and Human Services (HHS), Tom Price, MD, said this summer that the government would scrutinize the first year’s results before awarding a second year (see http://atforum.com/2017/08/expect-opioid-str-grant-money-scrutinized/).
“The work done by our partners in the states and territories has been central to our efforts to combat the trend of opioid abuse and overdose,” said Elinore F. McCance-Katz, MD, Assistant Secretary for Mental Health and Substance Use at HHS, in making the announcement. “Together, we will continue our work to advance the behavioral health of the nation by swiftly and directly addressing this public health crisis through evidence-based practices and programs.”
There is, so far, no plan to continue the funding beyond year 2.
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Addiction, Buprenorphine, Government, Methadone Treatment, Opioid Treatment Programs, Substance Abuse Treatment
By Alison Knopf
Arizona is using some of its Opioid STR (State Targeted Response) money, granted under the 21st Century Cures Act, to expand access to Opioid Treatment Programs (OTPs). Currently, one OTP has opened its doors 24/7 but the state’s plan is to have a total of five facilities—two of them OTPs, and three, crisis centers—able to help patients access treatment 24 hours a day, 7 days a week.
Crisis centers and crisis response teams provide emergency psychiatric services at the moment of need in order to stabilize individuals and engage them in a course of treatment. They see patients in emergency departments, and when they call the crisis line, said Heidi Capriotti, public information officer for the Arizona Health Care Cost Containment System (AHCCCS), which runs the program.
“Where emergency rooms may lack the staff or resources to stabilize a patient with opioid use disorder, specialized crisis response teams and facilities can help patients find licensed medication-assisted opioid treatment programs. These teams can literally facilitate that warm transfer, to make sure a patient doesn’t just walk out the door with a business card, but is taken to an opioid treatment program, if that’s their choice,” said Ms. Capriotti. “With expanded, 24-hour access to crisis and OTP services, patients with opioid use disorder have more access to immediate crisis intervention and treatment.”
Community Medical Services is the first facility to participate in the program, opening the doors of its Phoenix OTP 24/7 for the first time in October. The program will use the second year of its allocation of the two-year, $24-million Opioid STR grant to expand this program.
At Community Medical Services, all three medications are offered, CEO Nick Stavros told AT Forum. The clinic in Phoenix was the largest OTP in Arizona even before the expansion, with 900 patients.
Because of the expanded hours, there were 312 intakes in the first eight weeks. Most of these patients are taking methadone, he said, with only 12 on Suboxone and six on Vivitrol.
“With expanded hours at the opioid treatment center, Arizona is setting a national example, making access to medication-assisted treatment a priority. We are fighting the opioid epidemic on many fronts—through prevention, education, and treatment—and we are committed to ending the opioid epidemic in our state,” said Sara Salek, MD, AHCCCS chief medical officer, in a November 15 press statement announcing the program. Usually, OTPs are open from 4:30 AM to 11:30 AM, said Dr. Salek. This gives patients time to get medication before the start of the workday.
Intake Center for After-Hours Patients
The 24-7 clinic in Phoenix has a full-time staff: a physician, a nurse, and a peer counselor, working around the clock. There are currently 38 OTPs in the state of Arizona. The 24/7 OTP in Phoenix will end up transferring many of the people who come in after hours to one of the other facilities, said Mr. Stavros. “This is an intake facility for after hours,” he said. Patients can get inductions and then transfer to an OTP that is more convenient to them; only Phoenix has the after-hours admissions.
Most of the patients are on Medicaid, said Mr. Stavros. Arizona opted for Medicaid expansion under the Affordable Care Act. “We also have SAPT block grant funding, so if the patient doesn’t qualify for Medicaid, they have the option of being covered by the grant,” he said, referring to the Substance Abuse Prevention and Treatment block grant from SAMHSA.
Patients need treatment available at the moment they decide they’re ready for it—or they may never get it. And they need it fast. For example, one patient had gone to detox, but it wasn’t working. “She was out of detox for a week, and she started to relapse, and called her dealer,” Mr. Stavros said. “The dealer didn’t answer the phone, so she showed up at the clinic, and we started her on methadone.” She is now stabilized in treatment, re-connected with her family, and working two jobs, whereas she was unemployed upon entering treatment. For her, as for many patients, the key was to find a place in the middle of the night, with the lights on, when she was in the midst of a relapse, that could help her then and there.
Methadone or Buprenorphine
Next year, a second OTP—a nonprofit facility in Tucson—will expand its hours to 24/7. In addition, three crisis centers—not OTPs, but aimed at opioid treatment—will open in Prescott Valley, Kingman, and Tucson. Patients who seek help at these centers may be referred to an OTP; they will definitely be referred to medication services.
However, the three crisis centers will not necessarily be dispensing methadone, because they are not OTPs. One is a subacute crisis center, and two are hospitals.
In fact, the 24/7 concept isn’t new; hospitals can treat people with methadone for three days, giving them time for transfer to an OTP. But few hospitals—none that Mr. Stavros knows of—actually do this. Instead, they are starting people on buprenorphine. “Buprenorphine only works for a percentage of patients,” said Mr. Stavros.
“When the state received the Cures Act funding, they said they wanted to open five opioid centers of excellence,” said Mr. Stavros. “But only OTPs provide methadone. We see hospitals starting people on buprenorphine, but they are only kept on it for a few days, and then they relapse,” he added. “There has to be a solid, warm, handoff process, from emergency department to OTP, and I don’t think that’s happening.” But there is hope; Community Medical Services already has just such a warm hand-off going for pregnant patients who are seen at the hospital and referred to the OTP if they have an opioid use disorder along with a warm handoff process with a number of correctional health and inpatient treatment programs, and has received a number of new referrals into the 24/7 clinic via these sources.
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioids
Tags: Addiction, Buprenorphine, Medication-Assisted Treatment, Methadone Treatment, naltrexone, Opioid Treatment Programs
By Barbara Goodheart, ELS
They’ve been called a “growing and understudied population”—people who need treatment, yet find it hard to obtain or to pay for. So, many do without it. And, as time passes, they become increasingly vulnerable to physical and mental challenges.
Who are they? They’re older adults who have opioid use disorders (OUDs).
Recommendations from medical and government sources on what to do to help them—evidence-based guidelines, supportive policies, even general suggestions on making treatment available to this group—are sorely lacking.
Until very recently, this was the case with another demographic group—adolescents with OUDs. When we wrote about adolescents in our August/September newsletter, that situation was changing for the better. In fact, we found so many recommendations about making drug therapy available to this group that we couldn’t include all of them.
The Elderly and OUDs—Today and Tomorrow
An article by Brandi Cotton, PhD, and colleagues, in ps.psychiatryonline.org (citation below) depicts the current situation with elderly people in New York City, and postulates how the picture is likely to change. The age group 50 to 59 years is among the most populated in New York, and about 13% of the population is older than age 60. Some older New Yorkers have been in methadone maintenance treatment (MMT) since the mid-seventies.
These factors, along with the medical problems and coexisting conditions that typically accompany aging, will continue to make older people increasingly vulnerable to OUDs—not only in New York City, but across the country—and will increase the need for MMT.
Age-Related Medical and Financial Issues
Aging often makes patients more susceptible to the side effects of MMT, and may also bring some degree of cognitive decline. Patients may find it difficult to continue to adhere to MMT’s federal regulations and requirements, such as the need for on-site visits.
Costs are another issue. Transitioning to Medicare usually means higher expenses, because Medicare currently doesn’t pay for methadone when it’s used to treat OUDs. Nor do nursing homes, other long-term facilities, and home health agencies generally cover methadone for treating OUDs.
The very thought of becoming old and being opioid-dependent makes many patients anxious, the authors note; yet patients lack good options. They’re also anxious about discontinuing methadone treatment, or cross-tapering to buprenorphine or naltrexone—with “potential rebound pain, opiate withdrawal, and the prospect of relapse.”
The authors stress that as the government considers changing funding mechanisms, “providing access to MMT and addressing the unique treatment needs of older adults should be considered.” So far, the authors note, the needs of the elderly receiving MMT “have received minimal attention.”
The proportion of older patients receiving MMT is expected to rise. The authors believe it’s important to develop clinical guidelines to help providers and patients decide whether to taper or to discontinue MMT, and if to discontinue, when to switch to an alternative, and whether the taper should be slow or quick.
If continuing MMT is deemed the best clinical choice, it’s important to ensure that structural supports are in place for administering MMT under long-term care, or in skilled-nursing facilities.
Cotton BP, Bryson WC, Bruce ML. Methadone maintenance treatment for older adults: Cost and logistical considerations. ps.psychiatryonline.org. doi: 10.1176/appi.ps.201700137.
Bill White’s Blog: Challenges Older Adults Face During Recovery
A search for additional recommendations turned up little—until we found an interesting November 7 post by William L. White on the blog he co-authors with Randall Webber: http://www.williamwhitepapers.com/blog/2017/11/recovery-challenges-among-older-adults-bill-white-and-randall-webber.html.
|William (Bill) White, MA, Emeritus Senior Research Consultant with Chestnut Health Systems in Illinois, has a Master’s degree in Addiction Studies. Active in the field since 1969, he’s the award-winning author or co-author of more than 400 articles, research reports, monographs, and book chapters, and 20 books.
Randall Webber, MPH, a consultant and trainer at JRW Behavioral Health Services, is a faculty member at the Behavioral Services Center CADC School in Skokie, Illinois.
Bill White’s November 7 blog on older adults discusses several vulnerabilities that can disrupt the stability of long-term recovery in this age group—but then he turns optimistic about the future.
Vulnerabilities That Can Disrupt Long-Term Recovery
Listed below are the four root causes of vulnerabilities Bill White discusses in his blog. These underlying causes are responsible when adults develop problems related to drug or alcohol use in later life. They may also cause recurrences after patients have spent years in recovery—when recurrences may be fatal.
- Physiological factors. Age-related changes in the way the body metabolizes drugs and alcohol can cause drug interactions and troublesome symptoms. The onset of pain and sleep disturbances may lead patients to self-medication. This can make matters worse, for multiple medications can intensify the effects of drugs and alcohol for older people. On the other hand, if patients must discontinue important medications taken to support their recovery, problems related to drug or alcohol use are likely to recur.
- Emotional factors. Depression or anxiety are among common responses to losses—the loss of one’s own functional capabilities; the loss of friends and family members, because of death or relocation; a lack of meaningful activities; and a possible decline in one’s standard of living. These situations and others can eventually lead to self-medication with drugs or alcohol.
- Social factors. Social networks are disrupted when family members, friends, or sponsors relocate, retire, or die. New social groups—such as retirement communities—may favor heavy drug or alcohol use.
- Spiritual factors. Some people who lose connection with religion as they grow older drift into substance use or other forms of risk-taking. Some aging adults, Bill White notes, “fearing they are running out of time, commence risk-taking behavior similar to that seen in adolescence.” Some people feel they’ve fallen far short of their goals, and simply give up, “until some event or new relationship rekindles a zest for living.
Despite having written about these vulnerabilities, Bill White strikes an optimistic note as he closes his blog.
In an eloquent closing paragraph, he lists some advantages of aging that help enhance resilience and the quality of personal and family life in long-term recovery:
. . . Changes in lifestyle that improve physical and emotional health. A shift in focus from doing to being. Acceptance of imperfection and limitation. Letting go of past resentments. Seeking forgiveness and forgiving. Deepening gratitude for one’s blessings. More meaningful personal and family relationships. Discovering previously hidden resources within and beyond the self. The gift of time for pleasurable pursuits and quiet reflection.
A Hopeful Outlook for the Older Generation
Bill White writes that most older adults, including those in recovery, do manage to maintain their health and meet the challenges of the final stage of life, but that they need “specialized, developmentally appropriate prevention, early intervention, treatment, and recovery support services.” He expects to see remarkable breakthroughs aimed at the special circumstances and needs of older adults.
By Alison Knopf
Senior citizens are not immune from opioid use disorders (OUDs), but Medicare does not cover treatment in an Opioid Treatment Program (OTP). The American Association for the Treatment of Opioid Dependence (AATOD), Advocates for Opioid Recovery (AOR), and the Collaborative for Effective Prescription Opioid Policies (CEPOP), are trying to change this.
AOR and CEPOP sponsored a briefing at the U.S. Capitol Visitor Center in Washington D.C. on November 15. The meeting focused on increasing access to medication-assisted treatment, specifically with methadone and buprenorphine. While opioid briefings have become almost a daily event on Capitol Hill, this one was special in that it brought out the need for better access to OTPs.
- Seniors commonly take opioids for pain management; in 2016, one out of every three Medicare beneficiaries received at least one prescription opioid through Part D, Medicare’s insurance coverage for pharmaceuticals
- Prescription opioids have a high risk for misuse or abuse
- Symptoms of prescription opioid misuse or abuse may be hard to recognize in older adults, because they resemble some symptoms that may accompany aging, such as memory changes
- Methadone is covered by Part D only when prescribed for pain, not for treating OUD, because in Part D it cannot be dispensed by prescription at a retail pharmacy
- Methadone cannot be covered by Medicare Part D because it is administered through outpatient OTPs
Congress should immediately authorize Medicare coverage of all medications approved for treating OUDs–methadone, buprenorphine, and extended-release naltrexone. Currently, only in OTPs can methadone be dispensed to treat OUDs.
At the November 15 briefing, Angela Caldwell, MS, lead counselor and program coordinator at Montgomery Recovery Services, an OTP in Rockville, Maryland, described a case of an older patient whose insurance coverage was terminated when she became eligible for Medicare at the age of 65.
The solution wasn’t perfect. The program found a physician willing to continue treating her with methadone, but as a pain patient. However, the ways methadone is prescribed for chronic pain and for addiction are very different. For pain, dosing is by pill and split throughout a 24-hour period. For addiction, patients need to take only one liquid dose every 24 hours.
The patient under discussion had been maintained on 70 milligrams; the physician lowered her dose to 40 milligrams. “It wasn’t ideal, but it was the best we had to work with,” said Ms. Caldwell. “We need to treat this as a disorder.”
Ms. Caldwell went on to read a letter from a 66-year-old patient in the program, who has stayed off heroin for 23 years, thanks to the OTP. He attends group sessions at Montgomery Recovery Services, where he can share his fears. (He has severe depression and anxiety attacks.)
“My depression is multiplied tenfold since, when I turned 65, I was told I might not be able to continue my treatment,” he wrote. “I don’t want to guess what might happen to me.”
With Coverage, Services Increase
Mark Parrino, MPA, AATOD president, has been working with Congressional committees on Medicare Part B coverage. He said at the November 15 briefing that the increased access to treatment resulting from the expansion of Medicaid, and from the decision by states to allow Medicaid to cover treatment in an OTP, have made a huge difference in the opioid epidemic. He explained that when states add Medicaid reimbursement, the use of OTP services increases by 20%.
In states where Medicaid does not pay for OTPs, 85% of the patients make out-of-pocket payments, said Mr. Parrino. “If they can’t do that, they can’t get into treatment.” He added that in states that have robust Medicaid-OTP programs, like New York, California, and Pennsylvania, 85% to 90% of patients in OTPs are covered by Medicaid.
“This is not a criticism of treatment centers that do not use medications to treat opioid use disorders,” said Mr. Parrino. “But there are only 1,500 OTPs in this country. That is not a profound number, and it’s woefully inadequate to meet the increasing demand for services.”
Because of the addiction epidemic, some of the bias against OTPs is evaporating, said Mr. Parrino. “People are starting to say, ‘We need treatment in our community.’”
Medical Experts and Former Legislators Call for Coverage
Mary Bono, former representative from California, and founder of CEPOP, stressed that treatment with buprenorphine or methadone reduces the risk of death. “I’ve had employees who are in methadone treatment,” she said. “Congress has to get this done,” she said of Medicare coverage of methadone.
Patrick J. Kennedy, former representative from Rhode Island, and an outspoken proponent of treatment, called for funding. “We have great recommendations, but where is the money to implement them?” he asked. “Either this is a national emergency, or it isn’t.”
Frances Levin, MD, past president of the American Academy of Addiction Psychiatry, noted that the presence of fentanyl in almost all drugs sold on the street as opioids has drastically changed the situation for people who need treatment. “We are testing all patients, and most are coming up positive for fentanyl,” said Dr. Levin, who is also Kennedy-Leavy Professor of Clinical Psychiatry at Columbia University, and Chief of the Division on Substance Abuse at New York Presbyterian Hospital. “They didn’t even know they had taken it,” Dr. Levin said, referring to fentanyl.
She added that even patients who are tolerant to opioids can still overdose on fentanyl. “It’s 50 times stronger than morphine,” she said. “Clinicians are finding that even two naloxone kits aren’t necessarily enough” to reverse a fentanyl overdose.
The funding needed to reverse the opioid epidemic—$15 billion a year, according to Mr. Kennedy—isn’t likely to materialize any time soon, said Ms. Bono. “There isn’t going to be enough funding, so we have to spend our money wisely. Medicare coverage for methadone is a no-brainer.”
Mr. Parrino recommends that Medicare Part B cover federally approved medications utilized in an OTP in addition to all the comprehensive services, which are offered through OTPs.
The briefing, which was streamed on Facebook, was moderated by Brianna Ehley of Politico.
A fact sheet from the briefing is available at: http://www.atforum.com/pdf/AOR-HILL-BRIEF-FACT-SHEET-FINAL.pdf
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids, Pain
Tags: AATOD, Buprenorphine, Government, Medicare, Methadone Treatment, naltrexone, Opioid Treatment Programs, Pain, Prescription Opioids, Seniors
By Alison Knopf
The practice of ending treatment if patients test positive for benzodiazepines was discouraged in no uncertain terms by the Food and Drug Administration (FDA) last fall. Then, FDA commissioner Scott Gottlieb, MD, issued a powerful twofold statement: Combining benzodiazepines and other central nervous system depressants is known to be dangerous, but kicking people out of medication-assisted treatment (MAT) is worse.
Dr. Gottlieb added that MAT “should not necessarily be denied to patients taking these other medications,” because the “dangers associated with failing to treat an opioid use disorder can outweigh the risks of co-prescribing MAT and benzodiazepines.” MAT, he said, “is one of the major pillars of the federal response to the opioid epidemic in this country.”
A Strong Supporter of MAT
Dr. Gottlieb has emerged as one of the strongest supporters of MAT in this administration. He said that “patients receiving MAT cut their risk of death from all causes in half, according to the Substance Abuse and Mental Health Services Administration,” and that “many patients with opioid use disorder might abuse other substances, or have a coexisting chronic condition, such as a mental health disorder.”
On September 20, the FDA issued a Drug Safety Communication indicating that co-administering methadone or buprenorphine with benzodiazepines “can pose serious risks, including difficulty breathing, coma, and death.” However, while the advisory asks providers to be aware of these risks, it says that it’s more important, in the case of opioid use disorders, to keep patients on their methadone or buprenorphine, than it is to stop treatment, when patients would not be under any care, and could end up overdosing.
Labeling Changes are Coming
Changes will be made in labels of methadone and buprenorphine to decrease the practice of combining these medications with CNS depressants, while acknowledging that these medications might be co-administered with benzodiazepines.
“The new labeling recommends that health care providers develop a treatment plan that closely monitors any concomitant use of these drugs, and carefully taper the use of benzodiazepines, while considering other treatment options to address mental health conditions that the benzodiazepines might have been initially prescribed to address,” said Dr. Gottlieb.
For the FDA’s Drug Safety Communication, go to https://www.fda.gov/Drugs/DrugSafety/ucm575307.htm
Categories: Buprenorphine, Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs)
Tags: Addiction, Benzodiazepines, Buprenorphine, FDA, Methadone Treatment, SAMHSA
By Alison Knopf
On November 1, the White House released the long-awaited final report on the President’s Commission on Combating Drug Addiction and the Opioid Crisis. The report contains some good news for opioid treatment programs (OTPs)–if the recommendations can be turned into reality.
The 138-page report includes strong support for medication-assisted treatment (MAT), including the use of methadone, buprenorphine, and naltrexone, the three medications approved by the Food and Drug Administration (FDA) for treating opioid use disorders (OUDs).
Here are some key points.
- Treating the whole person: The report urges that effective treatment must meet “the needs of the whole person to be successful,” and goes on to recommend a model that OTPs fit perfectly. Citing research by the National Institute on Drug Abuse (NIDA), the report urges that treatment models should “incorporate behavioral, psychosocial, and pharmacological elements,” and be “tailored to the individual client.” The services should include 1) a complete evaluation for OUDs as well as other substance use disorders (SUDs), and psychiatric and medical disorders; 2) access to MAT; and 3) simultaneous access to psychosocial treatment.
- Importance of MAT: Medication-assisted treatment for OUDs “is associated with decreases in opioid use, opioid-related overdose deaths, criminal activity, and infectious disease transmission, while improving social functioning and retention in treatment.”
- Insurance and reimbursement: Less than half of privately funded SUD treatment programs offer MAT, and only a third of patients with OUDs at these programs receive MAT, the report says.
- Medicare: There are complex barriers for Medicare patients seeking MAT, the report notes. Methadone is covered under Medicare’s Part D program when prescribed for pain, but not when part of an OUD program. “Some MAT reimbursements are part of a bundled payment for inpatient care, but it has come to the attention of the Commission that bundled payments can be a barrier to providers offering an array of services and medications.”
- Corrections: There is very limited use of MAT in prisons and jails, and when it does exist, it is usually limited to maintenance for pregnant women, and detoxification for everyone else. In one study, most jail personnel did not support methadone treatment, and some custodial staff have negative attitudes about addiction and about inmates with addiction, in particular, heroin addiction. There is a general assumption that people who overdose get what they deserve. The report noted that progress has been made, but that there is a long way to go.
- Linkage to treatment after overdose: Patients hospitalized with an OUD should receive methadone induction in the hospital, followed by “direct linkage to an opioid treatment program,” the report states. Post-overdose engagement in treatment with buprenorphine or methadone can also be facilitated by hospitals. Buprenorphine, recovery coaches, and an opioid urgent care facility adjacent to a hospital are also recommended by the report.
The report does not come with any funding, and many of the recommendations are not feasible without added money. President Trump left this consideration up to Congress, but is not asking for any specific increases. Still, it is an important document; one that stakeholders should refer to, going forward.
For the final draft report, go to https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-3-2017.pdf.
Categories: Donald Trump, Drug Courts & Criminal Justice, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioids, Overdose
Tags: Addiction, Criminal Justice, Government, Health Insurance, Medicare, Medication-Assisted Treatment, Overdose
By Barbara Goodheart, ELS
An article in our August-September newsletter on the rise in adolescent opioid-related deaths included recommendations from several government and medical sources—virtually all of them suggesting expanding access to medication to treat adolescents with opioid use disorder (OUD).
If passed, legislation introduced in the US Senate on November 1—the YOUTH Act—would do exactly that.
The YOUTH Act
The Youth Opioid Use Treatment Help (YOUTH) Act, introduced by Senators Gary Peters (D-MI) and Shelly Moore Capito (R-W.Va), would 1) renew a current substance abuse program at the Substance Abuse and Mental Health Services Administration (SAMHSA), and 2) set up a demonstration program (see chart below) to help expand access to medication for adolescents.
“The opioid epidemic has devastated communities across the country, and it’s tragic that hundreds of thousands of young people suffering from opioid addiction are struggling to get the care they need,” Senator Peters said in a news release issued from his office. “This bipartisan bill would help hospitals and other health care providers expand lifesaving addiction treatments and care to adolescents and set them on a path toward recovery.”
“The opioid epidemic has had devastating effects on our state, especially when it comes to our West Virginia teens and young adults,” Senator Capito pointed out in a news release. She talked about the loss of an entire generation to the drug crisis, and added, “we have to take bold action to put an end to this tragic trend. The bipartisan YOUTH Act will help children and young adults access the resources they need to both treat and prevent addiction.”
|How Would Demonstration Programs Work?
Senate bill S.2055 and House bill H.R.5956, if enacted (which seems likely), will appropriate $5 million to award grants to eligible research entities. The grants would fund demonstration programs for treating adolescents and young adults with opioid use disorders (OUDs).
Targeting adolescents and young adults, the programs would—
Both bills also define the entities eligible to receive grants.
Initial funds would be granted for demonstration programs lasting not more than 3 years, with renewals based on yearly reviews and approvals.
Authorizations and Responsibilities
The YOUTH Act demonstration program would grant specified authorizations to the Agency for Healthcare Research and Quality (AHRQ), one of 12 Agencies within the US Department of Health and Human Services. AHRQ supports research to help improve the quality of health care.
Under the YOUTH Act, the AHRQ would:
- Provide grants to hospitals, local governments, and other entities, to increase adolescents’ access to MAT
- Identify and test ways to overcome barriers to access
- Provide resources on MAT training and implementation
The legislation would task AHRQ with several responsibilities, among them:
- Receive regular progress reports from grantees
- Report to Congress on the availability of MAT for young adults and adolescents, the effectiveness of current treatment and prevention programs, the unintended consequences of programs, and ways to ensure that MAT is available to young people who need it
Endorsing the YOUTH Act are: American Academy of Pediatrics, American Congress of Obstetricians and Gynecologists, American Psychiatric Association, and National Association of County and City Health Officials.
Adolescent Opioid-Related Deaths Are Soaring; We Can’t Wait “Until Things Get Worse”! http://atforum.com/2017/10/adolescent-opioid-related-deaths-are-soaring-we-cant-wait-until-things-get-worse/.
Capito, Peters Introduce Bill to Expand Access to Opioid Addiction Treatment for Adolescents. https://www.capito.senate.gov/news/press-releases/capito-peters-introduce-bill-to-expand-access-to-opioid-addiction-treatment-for-adolescents.
Johnston LD, O’Malley PM, Miech RA, Bachman JG, Schulenberg JE. 2017. Monitoring the Future: National survey results on drug use, 1975-2016: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan.
Substance Abuse and Mental Health Services Administration (2017). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. HHS Publication No. (SMA) 16-4984, NSDUH Series H-51. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/.
NIDA Launches Tools for Assessing Adolescents’ Risk of Opioid Use Disorder, Opening the Door to Medication-Assisted Treatment
By Barbara Goodheart, ELS
The National Institute on Drug Abuse (NIDA) has launched two online screening tools—BSTAD and S2BI—to assess the risk of substance use disorder in adolescents aged 12-17—and the timing couldn’t be better.
With the introduction and expected passage of the Youth Opioid Use Treatment Help (YOUTH) Act, practitioners who treat adolescents will welcome evidence-based, scientifically validated tools that provide a diagnostic assessment in less than two minutes, and open the door to treatment for those who need it.
BSTAD—The Brief Screener for Alcohol, Tobacco, and other Drugs, is easy for patients to self-administer, and S2BI—Screening to Brief Intervention—is administered by providers, using a tablet or computer. NIDA’s website encourages clinicians to consider using the self-administration option—BSTAD—to save time.
Both BSTAD and S2BI question patients about the frequency of substance use during the previous year, then triage patients into one of three risk levels: no reported use, lower risk, and higher risk.
When used in pediatric primary care settings, both diagnostic tools have been shown to accurately identify adolescents with and without substance use disorders. Both are available for use without charge.
Screening May Help Open the Door to MAT
Screening has many advantages, but here’s the most important one: By quickly identifying young people who need help, screening opens the door to appropriate treatment—either brief intervention, or referral for treatment programs, such as medication-assisted treatment (MAT). If, as anticipated, the YOUTH Act passes, funds will become available to provide MAT for young patients who need treatment—medication and counseling—to have a chance for a normal life.
Adolescence often is the time when substance problems begin—but it’s also when problems respond best to treatment. That’s why the American Academy of Pediatrics and the World Health Organization recommend screening all adolescents for substance use. The new online tools, BSTAD and S2BI, will provide practitioners with handy, time-saving ways to do just that.
NIDA. 2017, November 1. NIDA launches two adolescent substance use screening tools. Retrieved from https://www.drugabuse.gov/news-events/news-releases/2017/11/nida-launches-two-adolescent-substance-use-screening-tools. December 15, 2017.
Categories: Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioids
Tags: Addiction, Heroin, Medication-Assisted Treatment, Prescription Opioids
By Alison Knopf
Last fall, West Virginia got its Medicaid 1115 waiver approved, allowing, among other things, Medicaid to pay for treatment in opioid treatment programs (OTPs). The state’s decade-old moratorium against any new OTPs still exists, however, and state officials don’t expect that to go away, even though the addition of Medicaid reimbursement will probably make treatment demand surge.
West Virginia is hard hit by the opioid epidemic. Cindy Beane, commissioner of the state’s Bureau for Medical Services in the Department of Health and Human Resources, said there are no plans to eliminate the moratorium.
Waiver Grants Additional Initiatives
Other initiatives granted by the waiver: payment for peer recovery services, and payment for residential treatment in programs with more than 16 beds. There is actually no need for a waiver for Medicaid to pay for treatment in an OTP; the Center for Medicare and Medicaid Services has no rule against it. This was a state decision by West Virginia, first to ban Medicaid payment for OTPs, and now to allow it.
“I commend the state for taking this step forward and getting methadone covered under Medicaid,” said Peter Morris, division president for Acadia Healthcare, which operates seven of the nine OTPs in West Virginia.
Morris does expect the demand for treatment to increase due to Medicaid, but the programs can’t create new facilities because of the moratorium. And he is sure there is already pent-up demand.
A lifelong resident of Rhode Island, where he was with Discovery House before joining Acadia almost three years ago, Mr. Morris said that his former state has about 5,000 patients out of a total population of about 1 million people. West Virginia’s population is almost twice that size, but is only treating 5,500 patients, of whom 4,900 are in Acadia OTPs. So he knows that there are thousands of patients who need treatment and aren’t getting it. In addition, West Virginia is much larger geographically than Rhode Island, meaning that patients have to travel an hour or more in some cases to get to treatment in West Virginia.
“There’s definitely a demand for more sites in West Virginia, just from a population-based standpoint,” said Mr. Morris, who is based at Acadia headquarters in Tennessee. “We have patients driving long distances to get to our clinics.”
In other states, when a facility gets too big, Acadia would try to locate a new facility in an area that would be convenient for many patients, said Mr. Morris. For example, if there are 1,000 patients in one program, and 200 live in a zip code that’s 45 minutes away, that would be a good zip code for a new OTP, said Mr. Morris. “With the moratorium, we can’t use that strategy in West Virginia.”
How many patients could the existing Acadia OTPs add? “It’s hard to tell without having a crystal ball,” said Mr. Morris. “We have a couple of smaller programs, other clinics with 800 patients, a couple with 1,000.” Adding many more patients “could lead to fiscal constraints,” he said. “Very broadly, we could not treat another 4,900 patients—maybe a couple thousand.”
Converting to Medicaid
Of the 4,900 patients currently in treatment, about 50% would convert from self-pay to Medicaid, based on Acadia’s experience elsewhere in the country, said Mr. Morris. When Indiana started taking Medicaid in September, about half of the patients converted, he added.
Medicaid rates have not been finalized, but Mr. Morris expects the bundled rate in West Virginia to be about $105 per week. This is good news, he said. “The focus over the last 12 months has been getting Medicaid coverage.”
New York Society of Addiction Medicine (NYSAM) Annual Medical-Scientific Conference
February 2-3, 2018
New York, New York
American Association for the Treatment of Opioid Dependence, Inc. (AATOD) 2018 Conference
March 10-14, 2018
New York City at the Marriott Marquis
National Rx Drug Abuse and Heroin Summit 2018
April 2-5, 2018
ASAM Annual Conference
April 12-15, 2018
San Diego, California