AT Forum Volume 25, #4 October/November 2014 Newsletter

Categories: 2014 October/November, Newsletter, TOC-News

Kade Appointed Acting Director of CSAT in Wake of Clark’s Retiring

KadeDaryl W. Kade, MA, has been appointed acting director of the Center for Substance Abuse Treatment (CSAT) for the Substance Abuse and Mental Health Services Administration (SAMHSA). H. Westley Clark, MD, former director, retired suddenly, effective October 3. Ms. Kade will be acting director until a permanent director is found.

Ms. Kade was director of SAMHSA’s Office of Financial Resources (OFR) before her October 10 CSAT appointment. At OFR she was responsible for SAMHSA’s budget, which totals more than $3 billion, and includes funding for block and discretionary grant programs and program management.

Prior to joining SAMHSA, Ms. Kade worked for the Office of National Drug Control Policy (ONDCP) as a budget and legislative analyst responsible for drug treatment and prevention programs. She joined ONDCP after working as a program analyst for the Office of Planning, Budget and Evaluation and the Department of Education.

She spent many years as a member of the New York State Assembly Ways and Means Committee, serving as deputy budget director from 1984 to 1987.

Categories: 2014 October/November, Newsletter
Tags: Government, SAMHSA

Increasing the Buprenorphine Patient Cap: Threat to Patient Care

home-featured-arrowOver the summer, steps have been taken to increase the “cap”—the number of patients a physician can treat—with buprenorphine/naloxone. The American Association for the Treatment of Opioid Dependence (AATOD), opioid treatment programs (OTPs), and other national organizations watched the proceedings with concern, because there is no validation of whether most office-based physicians are providing comprehensive care for their patients.

Under the Drug Addiction Treatment Act of 2000 (DATA 2000), which made it possible for physicians to treat opioid addiction with an opioid outside of an OTP, a single physician could have 30 patients on buprenorphine. The law was amended to allow physicians to have up to 100 patients after one year (DATA 2006). The American Society of Addiction Medicine (ASAM) says that the cap is unfairly keeping patients out of medication-assisted treatment.

As H. Westley Clark, MD, who until his retirement October 3 was director of the Center for Substance Abuse Treatment (CSAT) at the Substance Abuse and Mental Health Services Administration (SAMHSA), said at a June 18 congressional buprenorphine forum sponsored by Sen. Carl Levin (D-Michigan), “We are dealing with the issue of addiction, not simply a medication.” Dr. Clark added that the same concerns about diversion that led the original DATA 2000 law to cap patients at 30 are still present.

And even though buprenorphine has a safety profile that makes it unlikely for someone to overdose on that drug only—due to the “ceiling effect”—when combined with other drugs or alcohol, that safety profile might not be present; in particular, Dr. Clark cited benzodiazepines. The federal government never wanted to create “pill mills,” he said. But without pill counts, urine tests, and other aspects of treatment, especially in early treatment, it’s not clear that diversion would be prevented.

Lack of Comprehensive Treatment?

It’s not that expanding office-based buprenorphine is a threat to OTPs, so much as it is a threat to effective patient care. “It’s a threat to how comprehensive opioid addiction treatment should be provided to the patient, based on long-held research principles and clinical practice,” AATOD president Mark Parrino, MPA, told AT Forum. “On the one hand, you have OTPs providing comprehensive addiction treatment for patients.” OTPs are regulated by the State Opioid Treatment Authorities (SOTAs), as well as by SAMHSA and the Drug Enforcement Administration (DEA). “OTPs will continue to provide comprehensive services, but on the other side of the fence, with office-based buprenorphine, there’s very little oversight to guide therapeutic practices.” SAMHSA certifies office-based buprenorphine physicians, but leaves clinical practice up to the physician. This is far different for OTPs, who have many mandates from SAMHSA and the states. Everyone who dispenses and prescribes controlled substances is audited by the DEA, including OTPs and buprenorphine physicians.

Some OTPs don’t think there would be a problem with raising the cap from 100 to 150. But any more than that would be a problem. “My sense is this is a done deal,” said Jerry Rhodes, CEO of CRC Health Group. “I don’t know what the number will be, but the cap will be lifted.” While CRC is always in favor of increasing access to treatment, that isn’t what increasing the buprenorphine cap would do, he told AT Forum. “This isn’t increasing access to treatment, this is increasing access to medication,” he said.

Everyone should be concerned about patient care problems, but if the increase is to 150 patients, that would not be as worrisome, said Mr. Rhodes. “However, if you’re going to do a tripling or a quadrupling, then there’s a major concern, because you could see patients not getting good clinical intervention, and there would be diversion.”

ASAM logoASAM’s View

We asked ASAM for a source to discuss the cap with, and they recommended Kelly Clark, MD, who spoke at a September 22-23 buprenorphine summit sponsored by SAMHSA. She was medical director for Behavioral Health Group until the second day of the summit.

ASAM is supporting a trial of increasing the cap to 250 patients per physician for a year, and then going to 500 patients per physician, she told AT Forum.

But the current 8-hour training for buprenorphine-certified physicians is insufficient to treat higher numbers of patients, she said. So ASAM is advocating for a training program lasting at least 40 hours, according to her. In addition, training would have to cover aspects of addiction medicine, including motivational enhancement and drug testing. ASAM does not favor regulations that would require that these aspects of addiction treatment be performed, but physicians would have to be trained in them. ASAM will be issuing new medication-assisted treatment guidelines next spring, which would apply to methadone, buprenorphine, and Vivitrol.

One of the arguments against raising the cap is that most physicians with waivers aren’t even using them. ASAM ‘s Dr. Clark conceded that this is a problem, but said that one reason is that physicians don’t want to deal with the DEA. So ASAM is also recommending that buprenorphine practices be audited by SAMHSA rather than by the DEA. “We also know that there are a few doctors who are going over the 100-patient limit, which is problematic,” she said.


There’s no question that buprenorphine is diverted, and not just for people trying to stave off withdrawal, said ASAM’s Dr. Clark. “It’s diverted, and it’s diverted for people to use to get high,” she said. “We know the combination products are used intravenously.” This is a serious problem, because the naloxone was supposed to make it impossible for someone to inject the medication and have any euphoria. “But in reality, the naloxone is very short-lived in relation to the buprenorphine,” she said, adding that another problem is that buprenorphine has, in some cases, been a gateway drug leading to other drug abuse.

There have been cases in which patients were getting high doses of buprenorphine, and found to be diverting for profit what they didn’t need, according to ASAM’s Dr. Clark. In addition, some patients present histories in order to get buprenorphine, and then divert it. “The payers don’t want to be subsidizing diversion.” And it’s not only a matter of philosophy: payers are required by the DEA to monitor pharmacists who dispense controlled substances, she said.

The Number

Mid-summer there was a gathering in Boston with federal officials present that resulted in legislation being proposed by Sen. Ed Markey (D-Massachusetts), which would allow buprenorphine physicians to treat an unlimited number of patients. Senator Markey, whose bill would eliminate the cap completely, hosted the meeting.

SAMHSA says that legislation isn’t even necessary, that it has the ability to raise the cap without it. What the new number would be is unclear. In addition to the Markey bill’s “unlimited” number, other numbers being discussed are 250, 300, and 500 patients.

At the September 22-23 buprenorphine summit, it was clear that the logistics, and not the policy, of raising the cap was the agenda. At that summit, AATOD’s Mr. Parrino and other national association leaders were not allowed to speak. No OTPs were represented on the panel. There was a recurrent theme throughout the summit that more-effective care was offered to patients in DATA 2000 practices that had clinical and administrative support services. Illustratively, Anthony Folland, who serves as the SOTA from Vermont, discussed his state’s “hub and spoke” model, in which Vermont provides funds to have “embedded counselors” in DATA 2000 practices.

AATODMr. Parrino told AT Forum that without proper debate, everything that is known about addiction treatment may be set aside in the interests of showing some response to the opioid epidemic.

“I see this as the struggle for the heart and soul of what good treatment really is,” said Mr. Parrino. Yes, opioid addiction treatment needs to be made more accessible, in all parts of the country. But the policy debate about how to do that “has been overtaken by special interests, and that has replaced thoughtful policy deliberations,” he said. “Now people are in a panic, and the general feeling is that ‘we have to do something.’ When this turns bad, many of these decision-makers won’t be around to be held accountable.”

If an opioid-addicted patient wants medication, there are three choices, explained Mr. Parrino: medication in a DATA 2000 practice “where practitioners don’t have to do drug screens or provide counseling,” and patients visit once or twice a month; going to an OTP that has to follow guidelines and requires counseling and urine tests; the third choice is Vivitrol. An untreated patient is likely to choose a treatment intervention that is less-demanding with regard to medical care and compliance. This presents a potential threat to the stability of the entire treatment system.

In fact, SAMHSA has been under great pressure to respond to the opioid epidemic by raising the buprenorphine cap. ASAM, with support from the American Medical Association, agrees. The basic argument is that no physician treating any disease should have any limits on the number of patients they can treat.

It’s clear that SAMHSA is following the lead of Senators Levin and Markey by heading toward lifting the cap, and not talking about expanding access to OTPs. The “political energy” is behind lifting the cap. Whether that will be done by regulatory or legislative means is unclear, but both paths are now open to SAMHSA.

See related blog by Dr. Jana Burson – Office-based Opioid Addiction Treatment: Raising the One-hundred Patient Limit available at:

See related blog by Dr. Jana Burson – Expanding Access to Buprenorphine available at:

Categories: 2014 October/November, Buprenorphine, Featured, Methadone, Newsletter, OBOT, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs)
Tags: AATOD, ASAM, Buprenorphine, Government, Heroin, Methadone Treatment, Opioid Treatment Programs, Prescription Opioids, SAMHSA

“The Talk”—When Patients Want to Switch from Methadone to Buprenorphine

Most advocates in the field oppose the idea of a stable patient who is doing well on methadone switching to buprenorphine provided by an office-based physician. If treatment in an opioid treatment program (OTP) is working well, and the patient is in successful recovery, why jeopardize this by switching to office-based opioid treatment (OBOT), they reason.

“It shouldn’t be OBOT vs. OTP,” said Zachary Talbott, CMA, director of NAMA Recovery for Tennessee, and administrator of the Peer Recovery Network for the Medication Assisted Recovery Services (MARS) Project. Mr. Talbott and other peers and advocates are often turned to by patients who are thinking of leaving their OTP for what they believe is the better world of OBOT with buprenorphine.

But for patients who do want to switch, the Substance Abuse and Mental Health Services Administration (SAMHSA) does have protocols.

SAMHSA’s Advice on Making the Switch

“The key is, before the physician makes the switch, you have to reduce the amount of methadone,” said SAMHSA Medical Advisor Anthony Campbell, RPh, DO, who spoke with AT Forum for this article. “They taper the daily dose of methadone down to around 30 milligrams,” he said. That’s the lowest dose at which the patient is likely to be comfortable, and will work with buprenorphine. Dr. Campbell noted that 30 milligrams may even be too high for some inductions. There has to be some withdrawal before induction of buprenorphine. So ideally the physician can bring the methadone dose down low enough so that within 24 hours there will be withdrawal that will be treated with buprenorphine.

Usually the reason a patient wants to switch to buprenorphine is to get away from the clinic structure, he said.

Some OTPs have established a relationship with a buprenorphine physician in the community, said Dr. Campbell. “We tell them that if they’re going to release a patient from an OTP into OBOT, the treatment plan must be discussed ahead of time.”

But there still aren’t enough buprenorphine physicians to fill the need, and there are indications that physicians who don’t have a practice specializing in addiction don’t really want to treat these patients anyway. There are many physicians who have taken the training to prescribe and dispense buprenorphine, but who aren’t doing it. “We don’t know why,” he said. “The stigma of addiction still exists, even among the medical profession.”

Patient Advocates Question ‘Why Switch’?

When patients tell Mr. Talbott they want to switch from methadone to buprenorphine in OBOT, the first thing he asks them is, “Why?” The answer “may be because the patient is well-read on the issue, and is maintained on such a low dose of methadone that he or she thinks buprenorphine would work,” he said. But that’s not usually the case. Rather, the answer is “because they’re ticked off at their clinic, or they have only one clinic and there’s no competition, or they lost their take-homes, or they don’t like the state regulations.”

“As an advocate, I’d say it’s fine, but let’s talk about it first,” he said, “You need to make sure patients first understand what is entailed.”

As for the rules and regulations that go along with OTP treatment, Mr. Talbott, who is an OTP patient, said, “I get it.” But it’s important to know what leaving the OTP means. “There’s a lot more to recovery than just putting up with the clinic system.”

Starting Over Again

For the patient who is not on a low dose of methadone, it’s important to understand how the transition to buprenorphine would work. First, the methadone dose would have to be lowered to around 30 milligrams. Second, even then, the buprenorphine might have the effect of displacing the methadone that is in the opioid receptor in the brain, causing withdrawal. Finally, if the patient wanted to come back to the OTP and resume methadone treatment, he or she would have to start all over, at the beginning, as if there had been no time in treatment already.

Patients in OBOT who fail drug tests risk being terminated from treatment, said Mr. Talbott, adding that in an OTP, such a patient may lose take-homes, but would continue in treatment.

The Ceiling Effect

Buprenorphine has a ceiling effect, and above that dose there is no increase in effect. So for patients who are tolerant to higher doses of methadone, and have been in treatment long term, it may be impossible to achieve an adequate dose of buprenorphine.

That doesn’t mean that even if you’ve been maintained on 100 milligrams of methadone for years, you can’t still taper down and switch to buprenorphine. But does it make sense for someone to leave the OTP, if treatment is working?

Treating the Biopsychosocial Aspects of Addiction

When younger patients ask Walter Ginter, CMA, project director of MARS, about switching from methadone to buprenorphine, he explains the difference: methadone is a treatment strategy, and buprenorphine is a harm-reduction strategy.

Addiction is a biopsychosocial disease, he explained. Methadone and buprenorphine treat the “bio” (biological) effects. In OTPs, peer services or 12-step provide the psychological support, and counseling provides the social support, said Mr. Ginter, who is the rare OBOT patient on methadone.

Difficulties of Switching Medication

It’s much easier to switch from buprenorphine to methadone than from methadone to buprenorphine, said Suzanne Ducate, MD, medical director of the Hartford Dispensary in Connecticut. Clinically and logistically, it’s tricky, because of getting the dose of methadone low enough to induce buprenorphine.

But from a business standpoint, for most OTPs, the biggest problem with buprenorphine is the cost. “It’s markedly more expensive than methadone, and there’s not much benefit in exchange,” she said. So most OTPs don’t dispense it. “The price difference is astronomical.” So if patients are going to come in for a daily medication to be dispensed, there’s no reason to use the more expensive buprenorphine, she said.

Also see:

For the protocols on induction of buprenorphine in patients on methadone, go to pages 52-54 of TIP 40 available at:

Categories: 2014 October/November, Buprenorphine, Featured, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Patient Advocacy
Tags: Buprenorphine, Methadone Treatment, Opioid Treatment Programs, Patient Advocacy

Research: Buprenorphine Treatment for Opioid Addiction: Opportunities, Challenges, and Strategies

Buprenorphine/naloxone has been available in the U.S. for both opioid treatment programs (OTPs) and office-based opioid treatment (OBOT) since 2003. While OBOT physicians can prescribe the medication, OTPs must dispense it. Costs and reimbursement problems have been the main barriers to its use in OTPs.

Although more than 15,000 physicians are certified to prescribe buprenorphine to patients, too few of them actually do. Yet the Substance Abuse and Mental Health Services Administration is currently considering increasing or eliminating the cap on the number of patients a certified office-based physician can treat (see related article in this issue).

An August 29 online article in the journal Expert Opinion on Pharmacotherapy discussed opportunities, challenges, and strategies related to the use of buprenorphine to treat opioid addiction. While the article focuses primarily on OBOT, sections of interest to OTPs include a discussion of which patients could be successful candidates for buprenorphine over methadone, and an assessment of alternative delivery models, such as a stepped-care model in a traditional methadone clinic.

Barriers to Prescribing OBOT

The article identifies and discusses potential barriers that need to be overcome if OBOT with buprenorphine is to expand. The article divides the barriers into three categories:

Patient Barriers

  • Stigma related to substance use disorders and their treatment
  • Limits on length of treatment
  • High monthly copayment
  • Formulary restrictions

Physician Barriers

  • Legitimate concerns about buprenorphine misuse and diversion
  • Uncertainty about the role of medication in treating addictive disorders
  • Concerns about practice disruptions due to stigma and the complexity of induction in the office setting
  • Lack of access to addiction specialists and consultation resources

System Barriers

  • Lack of remuneration; inadequate financial support from Medicaid
  • Lack of institutional support

Overcoming Barriers

The authors recommend a multifaceted approach to overcoming barriers. The steps that they suggest include new buprenorphine formulations to minimize misuse, identification of appropriate patients, prescription monitoring programs (PMPs), medical education programs, and policy regulations.

Patient Selection

A key step in expanding access to buprenorphine treatment is identifying patients who are likely to have successful treatment outcomes. The authors believe that buprenorphine may offer advantages over methadone in patients with the following conditions:

  • Patients with HIV/AIDS. Buprenorphine is compatible with drug therapy to treat HIV/AIDS, and management of both conditions by the same physician improves outcomes. Concomitant use of buprenorphine and highly active antiretroviral therapy (HAART) does not appear to produce significant drug–drug interactions, or to require dose adjustments.
  • Patients with chronic pain and opioid use disorders. Practitioners can treat these patients with buprenorphine/naloxone, but optimal dosing strategies for pain (e.g., the amount and timing of medication) have yet to be determined. Sublingual buprenorphine is not FDA-approved for pain management.
  • Adolescents with severe opioid use disorder. When possible, first-line treatment for adolescents is psychosocial intervention, with a goal of abstinence.
  • Pregnant patients. Neonatal abstinence syndrome may be milder with buprenorphine than with methadone.

OBOT with buprenorphine isn’t the best option for some patients. Based on their research and clinical experience, the authors identified several patient characteristics associated with relative indications and contraindications for OBOT:

Factors Associated With a Good Outcome in OBOT Relative Contraindications to Buprenorphine
  • Addiction limited to prescription opioids
  • Strong motivation for office-based buprenorphine treatment
  • History of compliance and reliability
  • Stable housing and employment
  • Psychosocial support
  • Severe opioid addiction (e.g., long-term IV heroin use
  • Dependent on high-dose CNS depressants, especially IV
  • Previous treatment for opioid use disorders, with frequent relapse
  • Psychiatric comorbidities
  • High-risk environment for relapse
  • Severe opioid addiction (e.g., long-term IV heroin use
  • Dependent on high-dose CNS depressants, especially IV
  • Previous treatment for opioid use disorders, with frequent relapse
  • Psychiatric comorbidities
  • High-risk environment for relapse
  • Poor support system

The authors add that good office practice from the point of intake includes discussions and expectations about diversion, and the use of PMPs, urine drug screens, and pill counts. These steps will help protect patients and make misuse and diversion less likely. Links to counseling services and more-intensive treatment will facilitate additional care, when needed.

Delivery Models

In looking for ways to help patients access buprenorphine, the authors assessed three prescription models:

Nursing Care Management Modela primary care clinic with an experienced, skilled nurse clinical manager coordinating many aspects of patient care. This model provided good quality of care, but may be of limited use in a small office practice.

Centralized Buprenorphine-Induction Modela centralized induction clinic. After spending about 20 days in the induction clinic during the difficult buprenorphine-induction period, patients were transferred to a community clinic and pharmacy. If necessary, patients returned to the induction clinic for referral to methadone or residential treatment. The program was highly successful in a setting of extreme poverty. This model requires collaboration between the new clinic and pharmacy, and existing community facilities.

Stepped-care Modela traditional methadone clinic. In this model, patients started on buprenorphine/naloxone, and switched to methadone if needed. Of 48 patients followed, 20 changed to methadone and completed treatment. Outcomes—retention rate and urine samples free of illicit drugs—were virtually identical in the two groups. This model has the advantage of transforming an existing resource, a methadone clinic, to provide buprenorphine. The authors noted that methadone clinics could be nodes in a provider network that links with office-based providers.

Declaration of Interest: One of the authors of the article, T. R. Kosten, has been a consultant for Reckitt Benckiser, the company that markets Suboxone (buprenorphine/naloxone sublingual film).


Li X, Shorter D, Kosten TR. Buprenorphine in treatment of opioid addiction: opportunities, challenges and strategies. Expert Opin Pharmacother. 2014;15:2263-2275. doi: 10.1517/14656566.2014.955469.


For Additional Reading

Hutchinson E, Catlin M, Holly C, Andrilla A, Baldwin L, Rosenblatt RA. Barriers to primary care physicians prescribing buprenorphine. Ann Fam Med. 2014;12(2):128-133.

Categories: 2014 October/November, Buprenorphine, Featured, Medication-Assisted Treatment (MAT), Methadone, Newsletter, OBOT, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs)
Tags: Buprenorphine, Heroin, OBOT, Research

Primary Care Clinic Next to Opioid Treatment Program Provides Stigma-free Care

home-featured-dr-patientIn Texas, people in the uninsured and indigent population die on average 29 years sooner because they don’t have access to primary care, says Allison Greer, BBA, vice president with the Center for Health Care Services (CHCS). A San Antonio-based community mental health center that runs an opioid treatment program (OTP), and an outpatient mental health center in a different location in the county, CHCS has just added a primary care clinic right next to the OTP.

The primary care clinic, called the Dianna M. Burns Bank M.D. CenterCare Clinic, was made possible by federal 1115 waiver funding. This waiver, from the Centers for Medicare and Medicaid Services, allowed the Texas Health and Human Services Commission to expand Medicaid managed care while providing incentive payments for health care improvements for uninsured patients.

Texas did not expand Medicaid. Under managed care, health care costs are controlled by a middleman, usually a private insurance company. The waiver sent $103 million to CHCS, and one of the 11 projects it funded was the primary care clinic next to the OTP.

The clinic is the safety net—the program of last resort—for Bexar County in Texas. Seventy percent of the patients have no insurance at all—not even Medicaid. Because Texas didn’t expand Medicaid, single men who are poor, without children, and without health care coverage predominate as patients.

The CHCS received $8.3 million for the primary care clinic, which Ms. Greer describes as a “turnkey” deal. “We were able to build the clinic right next to the Restoration Center, so we didn’t need zoning, and we didn’t have any of the requirements you usually have when you build a health care facility,” she told AT Forum. Opened just this summer, the integrated care clinic is meant to lower hospital costs by discouraging treatment in the emergency department.

No Stigma, No Judgmentalism

There’s no stigma for OTP patients when they go to the primary care clinic, which is a welcome feeling for someone on methadone, said Christi Mott, spokeswoman for CHCS. The population is almost completely indigent, partly due to the lack of Medicaid expansion in the state. One of the few benefits they have is substance use disorder (SUD) treatment, and now, a primary care clinic that caters to their needs. “It’s a beautiful thing.” And because the primary care clinic is embedded in the Restoration Center, staff in both the OTP and the center know each other. Staff in primary care have worked in the Restoration Clinic, so they are non-judgmental, Ms. Mott told AT Forum. “It’s very comfortable for patients to go there.”

Physicians and caseworkers are taking the OTP patients “by the hand” to the primary care clinic, said Ms. Mott. “They’re explaining that it’s not good to over-utilize emergency departments. The main health conditions our patients experience are diabetes, cardiovascular disease, and skin cancers.”

Coordinated Pregnancy Care

For pregnant patients in the Restoration Center OTP, the focus is on getting them proper prenatal care in addition to methadone, so that the baby doesn’t have to spend months in the neonatal intensive care unit, said Ms. Greer. They can access this care at the primary care clinic, CenterCare. Women in that program don’t risk losing custody. “They can keep their babies, because they’re not addicted to opioids.” There are currently 63 women in the pregnant program, and 600 patients overall in the OTP.

CenterCare Staff and Facility

The facility has four exam rooms. In addition to primary care, the clinic provides checkups for women and babies.  “We’re also talking about bringing in a pediatric specialist once a week,” Ms. Mott said. And it’s Texas, where many people—especially those without shelter—are exposed to the sun, so skin cancer is common. “If one of our doctors sees something that looks cancerous, that patient gets a referral to a specialist.”

There is also a care coordinator on staff, and a benefits coordinator who helps link patients to benefits. The majority of the patients are uninsured, but CHCS gets a combination of funding from the state, which has a generous SUD benefit, and from the county.

The Restoration Center has no waiting lists—at 600 patients a month it’s one of the smaller methadone centers in the city. “We have a little capacity,” said Ms. Greer.

Categories: 2014 October/November, Featured, Heroin, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Prescription Drugs
Tags: Medicaid, Methadone Treatment, Opioid Treatment Programs, OTP Patients, Prescription Opioids, Stigma, Substance abuse treatment

Attracting New Patients to Your Opioid Treatment Program: The Importance of Word of Mouth and Referrals

shutterstock_144253762In many parts of the country, how to market to attract new patients to opioid treatment programs (OTPs) is a moot point. There are waiting lists lasting for months. The demand for treatment is such that the only programs that are able to grow are those in urban areas like New York City and Baltimore.

In places where there are plenty of slots and lots of competition, marketing is particularly important.

It’s important to reach out to new patients, especially with the existence of the Affordable Care Act and parity, which together are making treatment more accessible to younger, insured, employed patients.

To market to new patients, it’s important to understand what keeps your current patients happy, and what they need, said Jerry Rhodes, CEO of CRC Health Group, in an interview with AT Forum. “There’s a patient-focused ethic within CRC,” he said, adding that the organization monitors and evaluates patient satisfaction, so it’s a critical driver of business for the Cupertino, California-based chain. While addressing patient needs and desires may be difficult to translate into advertising, it’s still a critical element: “Patients talk, and they know which programs do what,” said Mr. Rhodes.

For example, ease of access—few barriers to care—is important to patients, and they’ll know whether your facility has it or not, just from talk on the street.

Another element that distinguishes OTPs from other kinds of programs is geography: patients looking for OTP services want something local. In areas where they have more than one option, the facility most likely to be able to accommodate their needs is the one they will choose.


CRC, which is for-profit, has various types of facilities, including the residential high-end programs which are in the extremely competitive market for patients. OTPs are different—competition may not be as fierce. But it’s still important to make sure that the prospective patients are getting the right information. “Younger people are using the Internet, which is a font of misinformation,” said Mr. Rhodes. But you can’t ignore Internet marketing—you need to use it well. “There’s overall consumer ignorance about the treatment options available,” he said.

At non-profit OTPs, patient satisfaction translates into marketing. “We’re a non-profit OTP, so we don’t market ourselves,” said Suzanne Ducate, MD, chief of the medical staff at the Hartford Dispensary in Connecticut. “Most of our patients come from word of mouth.”

However, new patients also come from referral sources. “We have good relationships with other state agencies, with local hospitals,” Dr. Ducate told AT Forum. The vast majority of the 4,000 Hartford Dispensary patients were referred by these sources, she said.

Stigma From Families

One of the specific barriers for younger patients is their families, said Dr. Ducate. “There’s a lot of stigma attached to medication-assisted treatment, and younger patients tell me that their families believe they’re just substituting one drug for another.” But with so many patients failing at inpatient treatment for opioid addiction, and overdosing after they are discharged, that standard is starting to change.

Hazelden, formerly a drug-free stalwart, changed its policy in 2012. It added buprenorphine to its treatment regimen when it realized that so many patients were relapsing and overdosing. Other former drug-free programs have followed suit. However, they do not generally ascribe to “maintenance” on a long-term basis, and rather view buprenorphine as a temporary medication that the patient can taper from within a few months.

Inpatient Methadone Induction

Inpatient methadone induction may be a better solution for some patients, according to Dr. Ducate and Mr. Rhodes. Although it had been standard across the country for patients to be detoxified on an inpatient basis, and then sent to drug-free treatment, this has resulted in so many failures that officials are reconsidering.

For example, the Connecticut Department of Mental Health and Addiction Services now allows inpatient programs to treat patients with methadone. “Then they refer them to us,” said Dr. Ducate.

CRC also provides and promotes inpatient methadone maintenance, which can help patients in the induction phase before transfer to an OTP.

Some OTPs have groups just for young people, said Dr. Ducate, noting that this kind of support can be helpful. When young people can bond and be guided about the value of medication-assisted treatment, it can help them resist pressure from their families to “get off” methadone. Groups for family members can be helpful as well.

The bottom line for OTP marketing: if you help your patients navigate their care, despite stigma, making it easy for them to get treatment, word will get out.

Categories: 2014 October/November, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction
Tags: Heroin, Methadone Treatment, Opioid Treatment Programs, OTP Patients, Prescription Opioids, Stigma, Substance abuse treatment

Upcoming Webinars and Conferences/Meetings


“Treatment Options for Opioid Dependence: A Role for Agonists vs. Antagonists” American Psychiatric Association (APA)
Tuesday November 18 @ 12:00 pm – 1:00 pm EST
Register at: 

The Joint Commission Best Practices and New Standards in Medication-Assisted Opioid Treatment
Wednesday December 03, 2014 – 01:00 PM – 02:00 PM (CST)
Register at:


eventsConferences & Meetings


Eleventh Annual COMP Training and Educational Symposium
Thursday, November 13, 2014
Los Angeles, CA 90012
Click here for the agenda and registration form

Society for Neuroscience 2014 Annual Meeting
November 15-19, 2014
Washington, DC

American Public Health Association (APHA) 142nd Annual Meeting and Exposition
November 15-19, 2014
New Orleans, Louisiana

Association for Behavioral and Cognitive Therapies (ABCT) 48th National Convention
November 20-23, 2014
Philadelphia, Pennsylvania


American Academy of Addiction Psychiatry Annual Meeting
December 4-7, 2014
Aventura, Florida

Categories: 2014 October/November, Education, Events, Newsletter, Uncategorized
Tags: Conferences and webinars, Substance abuse treatment

News & Updates – October 14, 2014; Issue 207





Categories: 2014-10-13, News Updates, TOC

Research Report: Increasing Addiction to Prescription Opioids Fuels Rise in Heroin Overdose Deaths

heroin and injectionOverdose deaths from prescription drugs have continued to rise, and so have fatalities from heroin use. The two are interconnected, federal health experts warn.

As prescription opioid use has gone up, the population of people addicted to them has also expanded. For many addicts, the journey from pharmaceutical fixes to street remedies like heroin is all too common. A new report from the Centers for Disease Control and Prevention (CDC) demonstrates this relationship.

The CDC studied deaths related to overdose in 28 states and from 2010 to 2012; heroin deaths doubled in all of those states. “While the majority of prescription opioid users do not become heroin users,” the CDC reported, “previous research found that approximately 3 out of 4 new heroin users report having abused prescription opioids prior to using heroin.”

The CDC added that two factors are causing the increase in heroin overdoses: an increase in heroin supplies “and widespread availability of prescription opioids and increasing opioid addiction rates.”

“Reducing inappropriate opioid prescribing remains a crucial public health strategy to address both prescription opioid and heroin overdoses,” CDC Director Tom Frieden said in a statement. “Addressing prescription opioid abuse by changing prescribing is likely to prevent heroin use in the long term.”

See related article and data at:

Source: - – October 7, 2014

Categories: 2014-10-13, Heroin, News Updates, Opioid Abuse/Addiction, Prescription Drugs, Research/Surveys
Tags: Heroin, Injecting Drug Users, Overdose, Prescription Opioids

State Policies Can Influence Patient Access to Effective Heroin Treatment

Pg4_map“State policies can influence the number of physicians licensed to prescribe buprenorphine, a drug that can treat addiction to heroin and other opioids in outpatient settings, according to a new RAND Corporation study.

Studying county-level numbers of physicians approved to prescribe buprenorphine, the study found a significant link between the number of approved physicians and both specific state guidance regarding the use of buprenorphine and the distribution of clinical guidelines for buprenorphine treatment. The findings are published online by the Journal of Substance Abuse Treatment.

“State officials who are concerned about increasing opportunities for people to receive treatment for addiction to heroin and other opioids should know that there are policies they can adopt that appear to help increase access to these services,” said Dr. Bradley D. Stein, the study’s lead author, a practicing psychiatrist and a senior scientist at RAND, a nonprofit research organization.”

Related article available at:

Source: – October 7, 2014

Categories: 2014-10-13, Buprenorphine, Heroin, News Updates, News Updates, Opioid Abuse/Addiction, Research/Surveys
Tags: Buprenorphine, Heroin