Barbara Goodheart, BA, ELS
Final Rule For 42 CFR Part 2 Retains Core Confidentiality Protections
AATOD’s Goal of Doubling Number of OTPs Has Strong SAMHSA Support
$1 Billion For Opioids from Cures Act, But ACA Repeal Could Undercut the Benefits
- Legal Action Center: Free Toolkit Will Help Challenge Criminal Justice and Child Welfare Agencies Who Require Patients to Stop Taking Methadone and Other Medication-Assisted Treatment
Research Results: Opioid Agonist Treatment Versus Detoxification in Lowering the Costs of Crime
Virginians Vote: Support Treatment—Not Jail—For Drug Users
Fighting Stigma: Down With “Drug Users”; Up With . . . ?
Mallinckrodt Donates Drug Deactivation Pouches to Help Families Safely Dispose of Unwanted Pain Medications
By Alison Knopf
The final rule on 42 CFR Part 2, issued by the Substance Abuse and Mental Health Services Administration (SAMHSA) in January, essentially keeps the confidential protections that were in the proposed rule.
We talked with Karla Lopez, senior staff attorney at the Legal Action Center, about how the final rule affects opioid treatment programs (OTPs). She explained that the new rule maintains not only the core protections, but also the basic requirement that patients consent to having their information disclosed.
In addition, the new rule maintains the prohibitions on re-disclosure—meaning that when the patient consents to having information released to a particular individual, the individual receiving the information may not re-disclose it to a third party.
The rule requires that consent be given to a “specific name,” but the patient can agree to a “general designation” instead. “This allows for flexibility, which was the purpose of revising the regulation,” said Ms. Lopez. “But it still gives the patient the choice of whether they want the OTP to have that flexibility.”
OTPs and patient advocates were among the strongest supporters of retaining the privacy protections of 42 CFR Part 2. The challenge to these protections started with the electronic health record proponents who couldn’t understand the CFR rule.
Effectively, the rule kept OTP patient records out of a patient’s general electronic health record, and required the OTP to get the patient’s consent, in writing, to each person who would receive the EHR. SAMHSA, which promulgates the CFR rule, began making proposed changes in response to the electronic health issues. These issues, in turn, were in part coming from the federal government itself, which was backing universal electronic health records.
In the end, after many hearings and controversies, SAMHSA upheld the key protections of 42 CFR Part 2, which some critics had recommended scrapping completely. These critics claimed that stigma against patients in treatment for substance use disorders (SUDs) no longer existed. Among those who wanted to get rid of the privacy protections was The American Society of Addiction Medicine (ASAM). Standing firm in favor of keeping 42 CFR Part 2: The American Association for the Treatment of Opioid Dependence (AATOD).
The preamble as well as the text of the final rule make it clear that it is the responsibility of the treatment program—the OTP in this case—to explain the patient’s rights, said Ms. Lopez. She added that the final rule says the consent form “should be written in plain language.”
The final rule, like the proposed rule, makes it easier to add a generalized “to whom” section of the consent form, in terms of who gets to access patient information. But Ms. Lopez said protections are still there. “The new consent requirements are specific and stringent,” she said. For example, the consent form must indicate the “amount and kind of information that will be disclosed,” so patients know exactly what they are signing.
The patient does not have an option to allow disclosure of all personal health information, which is good, said Ms. Lopez. The generalized consent form still has an option limiting the consent to recipients who are treating the patient,” she pointed out. There can’t be that kind of disclosure to a health insurance company, for example.
Uncertain Future of ACA
The uncertainty about the future of the Affordable Care Act (ACA) under President Trump and the Republican Congress doesn’t affect the importance of 42 CFR Part 2, said Ms. Lopez; “42 CFR Part 2 long predated the ACA.” The incentives for electronic health records, which have become part and parcel of the ACA-driven health care system, were in fact from the HITECH (Health Information Technology for Economic and Clinical Health Act, signed into law in 2009), not from the ACA. The Act amended HIPAA (Health Insurance Portability and Accountability Act of 1996). The key reason for 42 CFR Part 2—patient confidentiality—is preserved, so that people are not afraid to seek treatment for SUDs.
In addition, patients are doubly covered in many states because of state laws that protect the confidentiality of personal health information regarding issues such as SUDs, sexually transmitted diseases, and HIV. The main reason for these protections is to encourage patients to seek treatment, with the goal of protecting public health.
Even if 42 CFR Part 2 did go away—and there is no indication that it will—health information exchanges (HIEs) would still have to protect sensitive health information, said Ms. Lopez. Finally, under the HITECH act, someone self-paying for treatment—as is the case in many self-pay OTPs—has the option to request that their information not be disclosed.
“SAMHSA worked really hard to get a lot of input over a number of years,” said Ms. Lopez. “It’s not an easy balance to strike. SAMHSA maintained core protections and made some significant changes that made things easier for researchers and for health information exchanges.”
(Researchers were pleased with the changes allowing them to use data sets without the impositions of 42 CFR Part 2, so they could better study the relationship between SUDs and other health issues.)
On the same day SAMHSA released the final rule, it released a supplemental notice of proposed rulemaking regarding how to share with contractors information that is protected under 42 CFR Part 2.
Final Rule Provisions
Provisions in the final rule, according to SAMHSA:
- SAMHSA will allow any lawful holder of patient identifying information to disclose Part 2 patient identifying information to qualified personnel for purposes of conducting scientific research if the researcher meets certain regulatory requirements. SAMHSA also permits data linkages to enable researchers to link to data sets from data repositories holding Part 2 data if certain regulatory requirements are met. These will enable more needed research on substance use disorders.
- SAMHSA will continue to apply Part 2 rules when a program is federally assisted and holds itself out as providing substance use disorder diagnosis, treatment, or referral for treatment.
- SAMHSA will allow a patient to consent to disclosing their information using a general designation to individual(s) and/or entity(-ies)(e.g., “my treating providers”) in certain circumstances. This change is intended to allow patients to benefit from integrated health care systems. This provision also ensures patient choice, confidentiality, and privacy as patients do not have to agree to such disclosures.
- SAMHSA has added a requirement allowing patients who have agreed to the general disclosure designation, the option to receive a list of entities to whom their information has been disclosed to, if requested.
- SAMHSA has made changes that outline the audit or evaluation procedures necessary to meet the requirements of a CMS-regulated accountable care organization or similar CMS-regulated organizations (including CMS-regulated Qualified Entities). This change will ensure CMS-regulated entities can perform necessary audit and evaluations activities, including financial and quality assurance functions critical to Accountable Care Organizations and other health care organizations.
- SAMHSA has updated and modernized the rule to address both paper and electronic documentation.
- SAMHSA will monitor implementation of the final rule and is working to develop additional sub-regulatory guidance and materials on many of the finalized provisions.
Supplemental proposal provisions:
- A new provision clarifying and limiting circumstances in which disclosures to contractors, subcontractors and legal representatives of lawful holders may receive and utilize Part 2 data for purposes of carrying out the lawful holder’s payment and health care operations activities.
- SAMHSA also seeks public comment on an abbreviated alternative statement for the notice to accompany disclosure.
- A new provision outlining CMS-regulated entities’ (e.g., ACO’s and QE’s) use of contractors, subcontractors and legal representatives to carry out audit and evaluation activities that are necessary to meet the requirements of a CMS-regulated program.
All Regulations on Hold
Both the final rule and the supplemental proposed rule were put on hold on January 20, when President Trump took office. The rule was supposed to take effect February 17, the effective date is now March 21.
It is not clear whether the final rule would then go forward as planned, or whether the administration would take additional actions, said Ms. Lopez. The impact on the supplemental notice of proposed rulemaking is unclear.
For the supplemental notice of proposed rulemaking regarding contractors and legal representatives, go to https://www.federalregister.gov/documents/2017/01/18/2017-00742/confidentiality-of-substance-use-disorder-patient-records.
Update on Final Rule
March 21, 2017 has been confirmed as the effective date the final rule as published in the Federal Register on February 16, 2017 and is available at: https://www.federalregister.gov/documents/2017/02/16/2017-03185/confidentiality-of-substance-use-disorder-patient-records-delay-of-effective-date
Update on Supplemental Notice
Comments must be received by 5 PM Eastern time on February 17, 2017
By Alison Knopf
Over the next three years, the number of opioid treatment programs (OTPs) in the country will double, from 1,400 to 2,800, pledges Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD).
Announced at last fall’s AATOD conference, the expansion plan certainly makes sense: the opioid epidemic has been increasing, and support for medication-assisted treatment (MAT) has been growing as well. And the Substance Abuse and Mental Health Services Administration (SAMHSA) wants to help.
The numbers are already going up. As of December 23, the United States had 1,482 OTPs, according to SAMHSA—up from 1,416 a year ago, and up from 1,363 in 2014.
Of the 168 applications SAMHSA received in 2016, 38 were hospital-based; the rest were freestanding. In 2015, there were 103 applications.
It’s also time for a “census check” to see exactly how many patients are being treated in OTPs. “We haven’t done this [a census] since 1998,” said Mr. Parrino, who suspects that OTPs may now have more than 400,000 patients. “I have been told anecdotally by administrators that many have been admitting many more patients,” he told AT Forum. “Existing sites that were treating 300 to 400 patients are now treating 600 to 800.”
The AATOD board wants to know how many patients are in the OTP system, as well. In the last two years, increases for opioid treatment have come predominantly from DATA 2000 (buprenorphine prescribers), said Mr. Parrino.
SAMHSA Is Helping
SAMHSA wants the number of OTPs to grow, so it is actively reaching out to applicants, said Mitra Ahadpour, MD, DABAM, director of the division of pharmacologic therapies (DPT) at SAMHSA’s Center for Substance Abuse Treatment (CSAT). “We try from our side,” she told AT Forum in December.
“We had all these submissions, but some were just sitting there and nothing was happening,” she said. “So, we emailed people when information was missing, and if we got no response, we called them, saying this is the information we need.” The goal at SAMHSA is to process all these applications. “We know there is a crisis, we have it in the back of our minds every day that people need treatment.”
Why aren’t the applicants following up on their submissions? “I think sometimes they get busy, I am not sure why,” said Dr. Ahadpour. “It takes time from our side to put in this extra effort.”
After the SAMHSA application, the process of becoming an OTP includes obtaining approval from the state, from the accrediting body (Joint Commission, or Commission on Accreditation of Rehabilitation Facilities [CARF]), and from the Drug Enforcement Administration (DEA). The OTP process at SAMHSA is going very well, Dr. Ahadpour said, adding that it will continue to do so under the new administration. “The infrastructure has been built. I feel very happy for our division; we have put in the infrastructure.”
Smoothing the Process
Dr. Ahadpour has been working hard on innovations at DPT while helping OTPs get certified. First, she noticed that accrediting bodies have to submit a “humongous folder,” entirely on paper. “So what I’ve done for DPT these past five months is to make this an online process, and decreased the number of questions,” she said. “There is now a system in place to renew online.”
In addition, the DPT has a “great relationship” with the DEA, said Dr. Ahadpour. This wasn’t always the case, but now, “we have become close friends, always on the phone with each other.”
One issue SAMHSA has little control over, however, is NIMBY (Not In My Back Yard), the biggest barrier new OTPs face. This barrier is erected by local schools, neighbors, sometimes even law enforcement officials, who are not opposed to MAT—as long as the patients don’t come to their community.
This mindset, one would think, would be eliminated by a simple fact: many people with opioid use disorders who would benefit from a local OTP are already in communities where OTPs would be sited. Stigma against agonist medications, especially methadone, is fueled by ignorance.
At the AATOD conference, CSAT director Kimberley Johnson, PhD, promised to provide information to the states on how to increase OTPs through technical assistance grants that help identify key locations. Mr. Parrino noted that a board member at the open board meeting asked if SAMHSA could help with siting and NIMBY issues. Johnson’s response was: ‘Don’t expect us to come to zoning boards, but do expect us to help you in providing guidance to the states.’”
“This is something we’re looking into,” said Dr. Ahadpour. “The only thing I can do from my end is bring in more technical assistance.” She said that SAMHSA is listening to stakeholders. “One issue we heard from the AATOD board is that the OTPs and OBOT [office-based opioid treatment, or buprenorphine prescribing] need more cross training, and they need to train with primary care people, so they can work better with each other,’ she said. “We’re also hearing from all sides about the importance of all three medications,” she added, referring to methadone, buprenorphine, and naltrexone.
Ahead: Prioritizing, Identifying Sites, Doubling OTPs
Dr. Ahadpour brings a vitality to DPT that OTPs will appreciate. “I have a lot of ideas on what we can do,” she told AT Forum. “Not everything can be done today; we have limited resources, and we have to prioritize. We’re putting out an effort of more outreach, more education, more awareness. We’re trying to make sure the public understands better what MAT is all about, so they don’t say, ‘I don’t want it in my back yard.’”
SAMHSA is also working on maps to help identify optimal areas for new OTPs. And Dr. Ahadpour asked for help from stakeholders—the National Association of State Alcohol and Drug Abuse Directors, AATOD, and others.
SAMHSA’s application information doesn’t break down how many facilities belong to chains, and how many are individual OTPs. However, she noted that every new owner needs a new application.
“We’re going to devote time and energy and resources” to doubling the number of OTPs by 2018, Mr. Parrino told AT Forum. “I’m not going to devote any more time on the buprenorphine cap—I don’t want to walk down that road again,” he added. “It was extremely time-consuming and ultimately not productive. I’m going to focus on the integration of service delivery.”
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs)
Tags: Heroin, Opioid Treatment Programs, Prescription Opioids, SAMHSA, Substance Abuse Treatment
By Alison Knopf
In December, the 21st Century Cures Act was signed by President Obama, providing $1 billion over two years to address opioid addiction. The law also provided $4.8 billion to the National Institutes of Health for research, such as for the “cancer moonshot.” However, the possibility that the Affordable Care Act (ACA) will be repealed creates great uncertainty about the future of treatment.
The $1 billion will be provided by the Substance Abuse and Mental Health Services Administration (SAMHSA) via grants to states. Under the Cures Act, preference would go to states with the greatest unmet need.
Medication-assisted treatment (MAT) is clearly the preferred type of treatment in the Funding Opportunity Announcement (FOA) of the grants. According to the FOA, “Funds may not be expended through the grant or a subaward by any agency which would deny any eligible client, patient or individual access to their program because of their use of FDA-approved medications of the treatment of substance use disorders (e.g., methadone, buprenorphine products including buprenorphine/naloxone, combination formulations and buprenorphine monoproduct formulations, naltrexone products including extended-release and oral formulations or implantable buprenorphine). Specifically, patients must be allowed to participate in methadone treatment rendered in accordance with current federal and state methadone dispensing regulations from an Opioid Treatment Program and ordered by a physician who has evaluated the client and determined that methadone is an appropriate medication treatment for the individual’s opioid use disorder….”
Applications for the funds are due from the states and territories by February 17, 2017.
The National Association of State Alcohol and Drug Abuse Directors (NASADAD) released an analysis of the Cures Act that explains how the opioid grant program will work. The single state authority (SSA) that manages the Substance Abuse Prevention and Treatment (SAPT) block grant will implement the grants. NASADAD members are the SSAs from each state.
According to the FOA, the Secretary of the Department of Health and Human Services (HHSwill give preference to states with an incidence or prevalence of opioid use disorders that is relatively higher than that in other states.
Grant activities may include:
- Improving State prescription drug monitoring programs (PDMPs).
- Implementing prevention activities, and evaluating those activities to identify effective strategies to prevent opioid addiction.
- Training health care practitioners (e.g. best practices for prescribing opioids, pain management, recognizing potential cases of addiction, referral of patients to treatment programs, and overdose prevention).
- Supporting access to health care services, including those services provided by federally certified opioid treatment programs (OTPs) or other appropriate health care providers to treat substance use disorders.
- Other public health-related activities, as the state determines appropriate, related to addressing the opioid crisis within the State. A State receiving a grant to address opioids must submit a report to the Secretary that includes a description of how grant funds were expended in the preceding fiscal year, a description of grant activities, and the ultimate recipients of amounts provided to the State in the grant. Grant funds will be subject to the same requirements as substance use disorder prevention and treatment programs under titles V and XIX of the Public Health Service Act.
The Cures Act also amends the Public Health Service Act, adding an Assistant Secretary for Mental Health and Substance Use within the Department of Health and Human Services. This person would be appointed by the President with the consent of the Senate, and replaces the administrator position of SAMHSA.
There would also be a Deputy Assistant Secretary for Mental Health and Substance Use, to be appointed by the Assistant Secretary. Currently, former SAMHSA administrator Kana Enomoto, MA, is the Deputy Assistant Secretary for Mental Health and Substance Use at HHS. The nominee for Department of Health and Human Services Secretary, Tom Price, MD, had not yet been confirmed at press time.
Cures also amends the Public Health Service Act to create a Chief Medical Officer. This person would serve as a liaison between the Administration and providers of mental and substance use disorder prevention, treatment, and recovery services.
Unlike some regulatory actions, which have been held up by the Trump administration pending review, Cures is a law and is not delayed.
For more information, go to http://nasadad.org/wp-content/uploads/2017/02/21st-Century-Cures-Section-by-Section.pdf
ACA ‘Repeal and Replace’?
President Trump campaigned on a promise to repeal the ACA, something Congress has been trying to figure out how to do. The problem is that many health care systems, as well as people, now rely on two key aspects of the ACA: Medicaid expansion, and the marketplaces with subsidies to help lower income Americans purchase health insurance. With some 30 million people insured under the ACA, it will be difficult for President Trump to keep his promise that nobody will lose health care at the same time that the ACA is repealed.
Also last month, the Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) estimated the budgetary effects of H.R. 3762, the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015. This act would repeal portions of the ACA.
The number of uninsured people would increase by 18 million in the first new plan year following enactment of the bill. It would increase to 27 million after elimination of the ACA’s expansion of Medicaid eligibility and elimination of subsidies for insurance purchased through the ACA marketplaces. The number of uninsured would further increase to 32 million in 2026.
Premiums in the nongroup market (for individual policies purchased through the marketplaces or directly from insurers) would increase by 20% to 25%—relative to projections under current law—in the first new plan year after enactment. The increase would reach about 50% in the year after the Medicaid expansion and the marketplace subsidies have been eliminated. Premiums would approximately double by 2026.
Repealing the ACA will cut treatment for substance use disorders so extensively that the Cures $1 billion will be little more than a bandage. Richard G. Frank, PhD, and Sherry Glied, PhD, wrote last month in The Hill that repealing just the coverage provisions for mental and substance use disorder in the ACA would cut at least $5.5 billion a year from the funds spent treating people with mental and substance use disorders.
The CBO and Frank-Glied estimates do not even include the more recent suggestions from Congress that the Medicaid program be changed to block grants, which would cap benefits and result in even less access to treatment.
For the CBO report, go to https://www.cbo.gov/publication/52371.
Categories: Addiction, Buprenorphine, Healthcare Reform, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Addiction, Buprenorphine, Methadone Treatment, Opioid Treatment Programs, Prescription Drug Monitoring Programs, Substance Abuse Treatment
Legal Action Center: Free Toolkit Will Help Challenge Criminal Justice and Child Welfare Agencies Who Require Patients to Stop Taking Methadone and Other Medication-Assisted Treatment
By Alison Knopf
A new toolkit from the Legal Action Center can help patients, especially those taking methadone, understand their rights when they are told that they must stop taking their medication in order to keep custody of their children or avoid incarceration.
Many times, these patients don’t have a lawyer, but even if they do, the lawyers could use help advocating for their clients’ rights to stay on medication received at opioid treatment programs (OTPs), Legal Director Sally Friedman told AT Forum.
“People don’t know what to do when they’re told to get off their addiction medication,” said Ms. Friedman. “If they’re lucky enough to have a lawyer, even their lawyers may not understand why ending medication-assisted treatment [MAT] is a problem,” she said. “We wanted to give patients a toolkit they could use and also hand to their lawyers.” (The toolkit includes a simple two-page handout for attorneys.) “Many people who call us don’t even have a lawyer, because once you’re sentenced to probation, you may lose your public defender.”
The beauty of this toolkit: it’s short and easy to read. And there’s clearly a need for it. “We field calls from all over the country, about people being forced off MAT by the child welfare system and the criminal justice system.”
OTPs can use the toolkit as well, said Ms. Friedman. “We have found treatment providers often don’t have the time to provide a comprehensive and convincing letter” about why their patients should be taking methadone, she said. “We’ve provided a template that treatment centers can use.”
Treatment centers that advocate for their patients to continue taking methadone face a Catch-22: child welfare and corrections officials don’t trust their motives, said Ms. Friedman. “They think this is just a moneymaker to keep people on medications.” That’s why it’s important to put clinical reasoning into the letter, even though it may be obvious to a medical professional.
“We try to get the point across to treatment programs, that they can’t assume the relevant players are educated about the basics of addiction or MAT,” Ms. Friedman explained. “Many of these players are hostile to MAT, and they need to be educated in a friendly manner. It’s not enough to say, ‘This person’s taking this medication, and that’s that.’ This isn’t persuasive, because the criminal justice or child welfare agency thinks ‘of course you want to keep them on the medication, because every time they come in you get paid.’” Ms. Friedman also noted that the judge or agency may view MAT as an unnecessary crutch.
The Legal Action Center’s toolkit has an online form people and providers can fill out when criminal justice or child welfare officials order individuals off MAT. The data collected through this form enables the Center track these practices nationwide. “We can’t represent people in their criminal and child welfare cases all over the country, but we’re communicating with important decision-makers,” said Ms. Friedman. The Legal Action Center is the only entity that is tracking this trend, she said, adding that the organization now has data from 32 states.
Another reason to complete the online form is that the Center is seeking a test case to challenge these practices. “We think that forcing people off MAT violates the Americans with Disabilities Act, but no court has ruled on this issue yet,” said Ms. Friedman. “We are very interested in bringing this legal challenge.”
She added that to do this, the Legal Action Center needs the cooperation of local counsel. “We could provide back-up assistance on the case, and may bring a separate lawsuit, but it’s critical that local defense counsel put necessary evidence in the record to support the person’s continued receipt of MAT.”
But the bottom line is that the lawyers who defend people need to be educated. “We have clients who have been charged with child neglect because they are taking methadone prescribed by their doctor,” said Ms. Friedman. Unfortunately, when their lawyer then agrees that they should just stop taking methadone, that leaves the patient in an untenable position.
“We need to educate the criminal defense bar and the family defense bar,” she said. “We need to educate all of the players in the criminal justice and child welfare system.”
For information about the toolkit, go to https://lac.org/mat-advocacy/
Note: A webinar on the MAT Advocacy Toolkit is scheduled for Thursday, February 16, 2017 from 3:00 PM to 4:30 PM. For additional information and to register go to: http://facesandvoicesofrecovery.org/news-events/event-calendar.html/event/2017/02/16/mat-advocacy-toolkit-webinar/148614
Categories: Addiction, Drug Courts & Criminal Justice, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Criminal Justice, Drug Courts, Methadone Treatment, Substance Abuse Treatment
By Barbara Goodheart, ELS
A recent study compared opioid agonist treatment (OAT) and detoxification in patients with opioid use disorders. The goal was to see which treatment approach is associated with costs of crime.
A team of six investigators, supported by a grant from the National Institute on Drug Abuse (NIDA), led the study. They published their findings last December in the online version of Addiction.
Included were more than 31,650 patients. Treatment took place in publicly funded facilities in California from the beginning of 2006 to the end of 2010. The median treatment time was 130 days; median observation time was 2.3 years.
- Median age at treatment admission: 32 years
- Men: 64.2% of the population
- Substances used (%): prescription opioids, 37.1; marijuana, 15.1; opiates that have not been prescribed, such as fentanyl,14.9; heroin, 6.6; alcohol, 4.7; stimulants, 2.0
- Some involvement with the criminal justice system: 43.2%
Costs of Crime: Justice System and Victimization
Justice system costs included policing, court, and corrections. Costs related to victimization included crime-specific medical expenses, cash losses, property theft or damage, and earnings lost due to injury, etc. The team was especially interested in the difference in crime costs during and after OAT, a time-unlimited (maintenance) treatment.
Costs were compiled in 2014 US dollars; see the full report for details.
Medications. Treatment in publicly funded programs “predominantly entailed” offering patients methadone, rather than buprenorphine, buprenorphine/ naloxone, or naltrexone.
Costs. Average daily costs of crime per person, over an assumed 1-year period—including treatment and post-treatment categories—were $113.
When investigators compared the costs of crime per patient during treatment, they found daily costs were $126 lower than after treatment for the group receiving OAT, and $144 lower than after treatment for those undergoing detoxification.
But the picture changed when they included length of treatment time—161 days for the OAT group, much longer than the 19 days for the detoxification group.
The bottom line: When totaling the costs of publicly funded treatment in California over a postulated 6-month time frame, the cost savings of crime per patient became clear: “enrolling an individual in OAT as opposed to detoxification would save $17,550.”
The table below shows how that figure was calculated.
Birnbaum HG, White AG. Schiller M, Waldman T, Cleveland JM, Roland CL. Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States. [Epub March 10, 2011]. Pain Med. 2011; Apr;12(4):657-667. PMID:21392250. doi: 10.1111/j.1526-4637.2011.01075.x.
Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care. 2016; Oct;54(10):901-906. PMID: 27623005. doi: 10.1097/MLR.0000000000000625.
Krebs E, Urada D, Evans E, Huang D, Hser Y, Nosyk B. The costs of crime during and after publicly funded treatment for opioid use disorders: a population-level study for the state of California. [Epub ahead of print December 15, 2016.] Addiction. doi: 10.1111/add.13729.
For related articles, read Virginians Vote: Support Treatment—Not Jail—For Drug Users* and Fighting Stigma: Down With “Drug Users”; Up With . . ?
Categories: Buprenorphine, Drug Courts & Criminal Justice, Heroin, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioids
Tags: Criminal Justice, Drug Courts, Heroin, naltrexone, Prescription Opioids, Stigma, Substance Abuse Treatment
By Barbara Goodheart, ELS
Treatment, not jail time—that’s what most people who misuse opioids should be offered, say Virginia voters. More than 6 out of 10 Virginians recently polled favored treatment instead of arrest and criminal charges for heroin users, and more than 7 out of 10 also chose treatment for prescription drug abusers.
The 38% who identified themselves as Democrat or Independent supported treatment for opioid users more strongly than the 24% who called themselves Republicans.
Almost 90% of respondents—including 81% of Republicans and 92% of Democrats—expressed very strong support for community-based treatment programs for nonviolent offenders who were mentally ill, and said they should not be incarcerated.
These results are from the 2017 Public Policy Poll, a project of the Center for Public Policy, L. Douglas Wilder School of Government and Public Affairs, at Virginia Commonwealth University. The poll was conducted in partnership with the office of the Virginia Secretary of Public Safety and Homeland Security.
Participants in the poll were 1,000 Virginia residents who took part in telephone interviews in December. The margin of error was 4.1 percentage points. To access the Public Policy Poll results, go to http://www.wilder.vcu.edu/media/wilder/documents/2017_poll_Public_safety_FINAL.pdf.
Treat, don’t jail, drug users, poll says. By Jessica Samuels, Capital News Service. The Suffolk News-Herald. January 21, 2017. http://www.suffolknewsherald.com/2017/01/21/treat-dont-jail-drug-users-poll-says/.
*See related article in this issue on stigma-sensitive terms.
By Barbara Goodheart, ELS
There’s a movement afoot to banish short, snappy, offensive terms like “addict,” “drug users” and “abuse,” and replace them with terms unlikely to perpetuate stigma.
And it’s not only about stigma. It is more medically accurate to use “substance use disorder” because that is the language of DSM-5, and is the correct diagnostic term.
But that leaves us with longer, clunky terms like “substance misusers,” or “person with substance use disorder.” Somewhat difficult, you might say, to work into a headline.
Publications and Agencies Continue to Use Stigma-Causing Words
Contributing to the problem: It’s difficult to support the idea of avoiding stigma-causing words when government agencies continue to use them. An example: a recently published article reporting data from the National Survey of Drug Use and Health uses the term “abuse” in its title and its contents. (In this case the data were gathered during the 2013 calendar year—before the current brouhaha.)
And here’s an example where the CDC’s current website uses the words “abuse,” and “abused”:
Overdose is not the only risk related to prescription opioids. Misuse, abuse, and opioid use disorder (addiction) are also potential dangers.
- In 2014, almost 2 million Americans abused or were dependent on prescription opioids.
However, the former director of the Office of National Drug Control Policy (ONDCP) frequently urged people to stop using stigmatizing language, and many news stories followed this. Last month, before he left federal government, he issued a memorandum to all federal agencies to avoid use of stigmatizing language. See https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Memo%20-%20Changing%20Federal%20Terminology%20Regrading%20Substance%20Use%20and%20
The posting contains links to sources that offer information on terminology, along with a somewhat more tolerant attitude. One resource notes that some individuals who have substance use disorders “may choose to identify themselves with a different terminology.”
AT Forum and Stigma
This isn’t the first time AT Forum has grappled with the stigma question. In February 2016 we ran a series of four articles on the causes and consequences of stigma in opioid addiction, with suggestions from experts on minimizing its effects:
Yet many headline writers in the non-medical world see no problem with using completely inaccurate terminology, such as “addicted babies.” You will even hear elected officials using this terminology. It may take Congressional action, such as Rosa’s Law, which in 2010 decreed that “mental retardation” be changed to “intellectual disability” and that “mentally retarded individual” be changed to “individual with an intellectual disability” across all governmental agencies. It wasn’t long before the news filtered down, and this extremely stigmatizing language disappeared from the world of mental illness.
Mallinckrodt Donates Drug Deactivation Pouches to Help Families Safely Dispose of Unwanted Pain Medications
By Alison Knopf
Mallinckrodt Pharmaceuticals has purchased and donated more than 1.5 million drug deactivation pouches across the U.S., through collaboration with policymakers, community organizations, health care professionals, law enforcement personnel, and industry partners. The purpose of the initiative is “to ensure the responsible use of pain medication and to prevent unused medications from ending up in the wrong hands,” Rhonda Sciarra, senior manager of communications at Mallinckrodt, told AT Forum. Pouch distribution started last year in several states and has been managed locally with donation partners in local communities where donations have been announced.
A few examples of donations
- This past October Mallinckrodt, based in Staines-upon-Thames, England, with its U.S. headquarters in St. Louis, Missouri, provided more than 60,000 pouches to families in West Virginia. Under this statewide initiative, announced by U.S. Sen. Joe Manchin (D-West Virginia), each of the state’s 55 counties will receive 1,000 pouches for families to use. Free distribution has been coordinated by Sen. Manchin’s office, working with each county sheriff’s office and with local law enforcement, drug prevention coalitions, and senior centers.
- More than 100,000 drug deactivation pouches have been provided to community organizations in the greater Washington, D.C. area. The pouches will be distributed to families throughout the D.C. area through local community coalitions. All told, when the 1.5 million pouches are completely distributed, more than 50 million unused prescription opioid pills will have been destroyed and prevented from being diverted.
- Mallinckrodt also provided 160,000 drug deactivation pouches to families across seven states, the Midwest, and Central Appalachia, through a partnership with 800 Walmart store pharmacy locations.
Mallinckrodt Commended for Drug-Disposal
Mallinckrodt announced its comprehensive donation in June 2016, saying it would purchase and donate the Deterra drug deactivation pouches.
“Substance abuse is arguably the greatest public health crisis facing the U.S. today,” said CADCA (Community Anti-Drug Coalitions of America) Chairman and CEO Gen. Arthur T. Dean. “Addressing our nation’s misuse of pain medication requires collaboration and commitment from every sector. We commend Mallinckrodt for their efforts to make drug disposal safer and easier for patients, and we welcome the opportunity to collaborate with Mallinckrodt and others on these types of industry-led initiatives.”
Prior to June 2016, Mallinckrodt had already made about 500,000 pouches available to providers, patient groups, and other stakeholders through partnerships with organizations such as CADCA, The Jed Foundation (a not-for-profit promoting behavioral health for college students), and ACT Missouri (a not-for-profit drug and alcohol awareness program).
The pouch distributions are part of Mallinckrodt’s comprehensive vision to advance patient safety, including investment in the expanded use of opioid abuse-deterrent technology. The company supports developing tamper-resistant/abuse-deterrent technologies, and regulatory standards that stand behind these technologies.
Other elements of this comprehensive effort include:
- Strongly advocating for establishing a state-wide Prescription Drug Monitoring Program (PDMP) in the state of Missouri, the lone state without such a program, and improving the integration of federal and state prescription drug monitoring programs across the country
- Developing and sharing best practices for monitoring suspicious orders, at both the manufacturing and supply-chain stages—an area whereMallinckrodt is an industry leader
- Improving stakeholder education for patients, providers, and the public, including providing education initiatives that have been validated by measurable outcomes
- Enhancing drug take-back and addiction-rehabilitation programs
Pouches Render Chemicals Safe for Landfills
The medication deactivation pouches manufactured by Minneapolis-based Verde Technologies deactivate prescription drugs and make their chemical compounds safe for landfills. Chemically neutralizing unused prescription opioids also prevents them from being susceptible to theft, diversion, and misuse.
After placing medications in the pouch and adding tap water, the user can seal the pouch and throw it away with household trash. The pouches are completely biodegradable, providing an environmentally responsible way to deactivate and dispose of drugs.
“As a company focused on the health and well-being of our patients and communities, Mallinckrodt has long been a strong advocate of addressing the complex issues of opioid misuse and abuse that cause so much harm to families,” said Mark Trudeau, Mallinckrodt President and Chief Executive Officer. “We share the concerns of parents across the nation, and believe that providing patients with a safe, environmentally responsible way to dispose of unused medications is critical in this fight against prescription drug abuse,” added Mr. Trudeau.
A national survey of adults who used prescription opioids showed that nearly 6 out of 10 had or expect to have leftover opioids, indicate findings published online June 13, 2016 in JAMA Internal Medicine. As evidence of the escalating opioid misuse problem in the United States, nearly 68% of those who used prescription pain relievers nonmedically in 2012-2013 got them from friends or relatives, according to the 2013 Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on Drug Use and Health.
Preventing opioid misuse and diversion is a national priority that requires the active engagement of all stakeholders. Through its actions, Mallinckrodt is taking positive steps to help prevent drug abuse by making prescription opioids less accessible for nonmedical uses.
American Counseling Association (ACA) Annual Conference and Expo
March 16-19, 2017
San Francisco, California
American Academy of Pain Medicine (AAPM) 33rd Annual Meeting
March 16-19, 2017
National Association of Psychiatric Health Systems Annual Meeting
March 20-22, 2017
National RX Drug Abuse & Heroin Summit
April 17-20, 2017