By Alison Knopf
How will the election of Donald Trump as president of the United States, with far-ranging changes in administration officials and policy, affect opioid treatment programs (OTPs)? There are many questions about the future, with Mr. Trump having said little in terms of concrete plans.
Drug policy reform may take a turn away from the “we can’t arrest our way out of the problem,” with a return to punishment instead of treatment for drug offenders. If Sen. Jeff Sessions (R-Alabama) becomes the new Attorney General, this may be the direction taken.
Increased access to medication-assisted treatment for opioid use disorders (OUDs) may be in the future, and there are indications that a Trump administration would favor the pharmaceutical industry. And Vivitrol may be getting more of a boost, especially as treatment in the criminal justice system takes a bigger role.
The fact that OTPs are highly regulated could be a plus in the eyes of a Trump administration.
What’s Next for Medicaid Expansion, the ACA, and OTPs?
But the biggest question in many people’s minds is what will happen with health insurance. Medicaid expansion, which made it possible for many more patients to get treatment, is now up in the air due to questions about the future of the Affordable Care Act (ACA). What Congress will do, now that the House of Representatives, the Senate, and the White House are Republican-controlled, is a question.
“To a large degree, we are all in the dark,” said Jerry Rhodes, former CEO of CRC Health Group, and now chairman of BayMark Health Services. “There has been scant discussion or indication of policy on behavioral health and addiction issues from President-elect Trump.
“Mr. Trump did attend an opioid abuse summit in New Hampshire, where he was confronted with the extent of the problem.” And the involvement of Rudolph Giuliani as a close advisor to Mr. Trump “certainly gives pause to folks who have been in the field a long time, as they remember that as Mayor, Mr. Giuliani proposed shutting down the OTP clinics in New York City.”
Still, drug abuse is a nonpartisan issue, and there has been broad agreement among Republicans and Democrats that the opioid crisis needs to be addressed.
Field groups were already aligned to work with either administration, and are working as usual to make sure treatment is accessible.
Mr. Rhodes is concerned about the ACA. “Everyone is clearly aware of the promise to repeal and replace the ACA,” he told AT Forum. There are several Republican plans floating around, he added, noting that a consistent theme of these plans has been to limit further Medicaid expansion, or to outright eliminate expanded Medicaid populations. Other plans include “bare bones plans” and developing high-risk pools, he said.
While OTPs have benefited from Medicaid expansion, this has been on a state-by-state basis, noted Mr. Rhodes. “There have been significant variances among states on the Medicaid commitment, including some states not offering any Medicaid reimbursement for OTPs.”
Factors to Keep in Mind
When thinking about the future of OTPs, Mr. Rhodes recommends weighing several factors:
- Fundamental demand. “We are in the midst of a pandemic of opioid abuse,” he told AT Forum. “This has devastated communities in the Midwest, the Northeast, and New England, and now is a plague across all the country.”
Despite Mr. Trump’s lack of policy specifics, drug abuse was an important topic in the elections. “The new administration cannot ignore the issue,” said Mr. Rhodes. “I think that the facts supporting OTPs, their proven efficacy, and the cost and the outcomes are compelling. These facts hopefully will continue to weigh strongly in favorable policy.”
- Mental Health Parity and Addiction Equity Act (MHPAEA). This Act had strong bipartisan support in Congress, and has helped OTPs in policy and regulation, said Mr. Rhodes. “Despite the imposition of mandates, I don’t think there is any appetite to repeal or modify MHPAEA.”
- Comprehensive Addiction and Recovery Act (CARA). This legislation is supportive of evidence-based and cost-effective treatment options—all options favoring OTPs, noted Mr. Rhodes. CARA also has strong bipartisan support in Congress.
- Block grants. “Some of Mr.Trump’s inclinations on policy favor the use of federal block grants for entitlements and other funding and allowing the states significant latitude to disseminate funding as they see fit outside of federal mandates,” said Mr. Rhodes. Whatever happens here, “there would continue to be variability among the states, with some that continue commitments to OTPs, and some that don’t,” he said.
- Fortunately, stigma is diminishing as a factor in policy and regulation, Mr. Rhodes commented. “Many in law enforcement now favor treatment, not incarceration, as the critical intervention.”
“Everyone involved with OTPs should have heightened vigilance,” he added. “However, given the factors above, I think there is some cause for optimism that we will continue to see support for expanded OTP services.”
As AT Forum went to press, Congress was considering adding $1 billion over two years to treat the opioid epidemic.
Categories: 2016 Presidential Election, Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Medicaid, Opioid Treatment Programs, Stigma
By Alison Knopf
Double the number of opioid treatment programs—from 1,400 to 2,800—in the United States over the next three years: that was the main message from Mark Parrino, MPA, President of the American Association for the Treatment of Opioid Dependence (AATOD), and from the organization’s conference in Baltimore this fall. There were almost 1,800 attendees at the meeting, which held its customary open board meeting on the evening of October
Open Board Meeting
Great News: Mobile Vans Slated to Return
There was some really good news for the field at that meeting. The 30 board members and 175 attendees heard from Demetra Ashley, associate deputy assistant administrator of the Office of Diversion Control of the United States Drug Enforcement Administration (DEA). She told the group that the DEA is working to re-open the licensing of mobile vans next year.
Mobile methadone vans are connected to brick and mortar opioid treatment programs (OTPs), and their return would be great news for patients who have to travel far, or who lack transportation. According to Mr. Parrino, the DEA has gone through a “tectonic shift” over the past 18 months in several ways, including in their thinking about mobile vans.
But Support Seen as Lacking for Methadone and OTPs
Another issue at the open board meeting was the federal government’s observed lack of support for methadone and OTPs. “Don’t forget that OTPs exist,” board members told Kimberly A. Johnson, PhD, director of the Center for Substance Abuse Treatment (CSAT), the agency of the Substance Abuse and Mental Health Services Administration (SAMHSA) that, along with the DEA, regulates OTPs.
Ms. Johnson and Mitra Ahadpour, MD, DABAM, director of SAMHSA’s Division of Pharmacologic Therapies, were told that they were more focused on buprenorphine and Vivitrol than on methadone. They were also told that when they talk about “medication-assisted treatment,” nobody thinks they are talking about OTPs.
“If you really want to help us, then tell a state that they have to put block grant money into OTPs,” was the sentiment of some board members. Some state governors—such as Maine’s—are opposed to methadone, it was noted. What can SAMHSA do? Dr. Johnson said that SAMHSA can provide technical assistance (federalese for advice, assistance, and training) if a state is resistant. “What about local zoning boards?” she was asked. Dr. Johnson’s response: SAMHSA can’t get involved in local problems.
All of SAMHSA’s literature reflects advice that the three medications should be used, said Dr. Ahadpour. But OTPs have no challenges to the SAMSHA literature—“the problem is what’s on the ground,” said one. States can look at the SAMHSA literature, read about the three medications, and pick one—buprenorphine or Vivitrol—leaving out methadone and OTPs, but thinking they are still going along with SAMHSA. “AATOD Board members were saying that the literature is intact, but the action plan doesn’t follow,” as Mr. Parrino put it.
Perhaps one of the for-profit OTPs put it best: “If you want to see a targeted expansion capacity, you’re going to have to target funds.” However, it’s unlikely that public funds will be used to expand treatment in a private setting.
There was a distinct presence of office-based opioid treatment—the buprenorphine-prescribing physicians—at AATOD, “driven by the conference content, which transcends a unique interest in OTPs,” said Mr. Parrino. And AATOD itself does have some members who are DATA 2000 physicians, he said.
The basic concept of an OTP is not just treating many patients at a single site—there are buprenorphine clinics that do that. “What services do you provide—that’s what distinguishes you as an OTP,” said Mr. Parrino.
To get from 1,400 to 2,800 OTPs in three years will “compel federal authorities to focus on the impediments to opening new clinics,” he said. “You need to educate communities. You need to reverse the thinking that a treatment program in a community is a negative. We’re going to help your community save lives, we are going to help your families and your neighbors.”
This, in fact, was a central theme throughout the conference. People are dying from opioid overdoses, and America is clamoring for help, but whenever an OTP is proposed, the neighborhood doesn’t want it. “You can’t have it both ways,” Mr. Parrino said.
While there were clear issues brought up at the open board meeting, SAMHSA support for OTPs was present during the conference. Dr. Johnson spoke about the importance of treatment at one of the plenaries, and at the policy luncheon.
As the future of federal strategy plays out in the wake of the surprise election victory of Donald Trump, states and OTPs will be looking at how to best expand. In the meantime, the record attendance at AATOD—almost 1,800 people—shows that the commitment to treating opioid use disorders in OTPs is strong.
Categories: Addiction, Medication-Assisted Treatment (MAT), Methadone, Newsletter, OBOT, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: AATOD, Heroin, Methadone Treatment, Opioid Treatment Programs, Prescription Opioids, SAMHSA, Substance abuse treatment
A centerpiece of the American Association for the Treatment of Opioid Dependence (AATOD) is the award banquet, honoring leaders for their work in the field.
It was no surprise that Michael Botticelli, director of the White House Office of National Drug Control Policy (ONDCP), received the Friend of the Field award at the Baltimore Marriott Waterfront on November 1. Mr. Botticelli, in long-term recovery from alcoholism, has been a steadfast supporter of treatment, including medication-assisted treatment, during his tenure at ONDCP. He has also championed the use of naloxone to reverse opioid overdoses, and has worked to improve recovery support for people with opioid use disorders (OUDs).
The Nyswander/Dole “Marie” awards were established in honor of the two researchers who, along with Mary Jeanne Kreek, MD, pioneered the use of methadone in the maintenance treatment of OUDs. Dr. Kreek was also at the conference. Jerome H. Jaffe, MD, presented these awards to:
- Ray Caesar, LPC: The State Opioid Treatment Authority (SOTA) of Oklahoma, Mr. Caesar helped change regulations in the state to make it possible for more opioid treatment programs (OTPs) to open, played a key role in stigma reduction, and now works on Medicaid reimbursement.
- Spencer Clark, MSW: Under the leadership of Mr. Clark, North Carolina’s SOTA and Mental Health, Developmental Disabilities, and Substance Abuse Services Division have worked together to provide recovery support services and treatment to people in the state with OUDs.
- Alice Gleghorn, PhD: During her 20 years at the San Francisco Department of Public Health, Dr. Gleghorn worked to ensure access to MAT in several locations, including jails.
- Robert Kent: As general counsel for the New York State Office of Alcoholism and Substance Abuse Services (OASAS), Mr. Kent has provided support to OTPs during the state’s transition to Medicaid managed care, establishing OTPs as essential providers, and creating regulatory relief where necessary.
- Robert Lambert, MA: President and executive director of Connecticut Counseling Centers, Mr. Lambert helped create innovative intensive outpatient programs within OTPs; he also developed “Bridge to Recovery,” a peer-mentoring program.
- Richard Moldenhauer, MS: The Minnesota SOTA for the past 15 years, Mr. Moldenhauer is not afraid to take political risks, successfully advocating for OTP patients.
- Einat Peles, PhD: Research director at the Adelson Clinic for Drug Abuse Treatment & Research in Tel Aviv, Dr. Peles studies retention and hepatitis C in her clinic in Israel and at a “twin” clinic in Las Vegas.
- Kenneth Stoller, MD: Dr. Stoller’s Broadway Center for Addiction in Baltimore includes wraparound services that cover housing, primary health care, and other areas, making it a center of excellence. In addition, his research has advocated the cost-effectiveness of treatment in an OTP.
- Trusandra Taylor, MD: Dr. Taylor has worked in addiction medicine for more than three decades. In Philadelphia, where she served as a clinician and an expert in managed care, she took part in many workgroups and consensus panels at the federal level.
- Hoang Van Ke, MD: In Vietnam, which historically has treated SUDs as a moral problem, Dr. Van Ke has pioneered the work in MAT for OUDs, showing in 2008 that a methadone clinic pilot could be effective. Under his efforts, the number of clinics in Vietnam has grown from six in 2008 to 250, now serving more than 45,000 patients.
Brenda Davis, MS, received the Patient Advocacy Award, named for Richard Lane and Robert Holden, both recovering heroin users. Ms. Davis has been employed as a patient advocate for 20 years by NAMA Recovery, and she helped establish the MARS Project at the Mount Sinai/Beth Israel methadone program in New York City.
The awards banquet is supported through a grant from Mallinckrodt Pharmaceuticals.
Categories: Addiction, Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: AATOD, Addiction, Heroin, Methadone Treatment, Opioid Treatment Programs, Prescription Opioids, Stigma
By Alison Knopf
Produced by the American Association for the Treatment of Opioid Dependence (AATOD) under a contract with the Substance Abuse and Mental Health Services Administration, three white papers provide comprehensive models of how opioid treatment programs (OTPs) can ensure high-quality care and continuity of services.
We summarize the white papers in this issue, focusing on the hub-and-spoke model in Vermont. In this model, buprenorphine and office-based opioid treatment are integrated with OTPs, but OTPs perform all inductions and provide specialty care and consultation to the entire system.
The first white paper (56 pages) is called “Models of Integrated Patient Care Through OTPs and DATA 2000 Practices.” The first section of this paper discusses “Essential Elements of Vermont’s Hub and Spoke Health Homes Model,” and was written by Karen Casper and Anthony Folland of the Vermont Department of Health, Agency of Human Services. The second section, by Sue Storti, PhD, RN, is “Integration of Health Homes in Rhode Islands’ OTPs.” The third section covers “Integration of Health Homes in Maryland OTPs,” and was written by Vickie Walters and Angela Fulman.
The second AATOD white paper (34 pages) is “Integrated Service Delivery Models for Opioid Treatment Programs in an Era of Increasing Opioid Addiction, Health Reform, and Parity.” The first section of this publication was written by Kenneth Stoller, MD, and Mary Ann Stephens, MD, of the Department of Psychiatry and Behavioral Sciences, the John Hopkins University School of Medicine. It provides a model for how OTPs can work in conjunction with DATA 2000 practices. The second section was written by Allegra Schorr, President of the New York State Coalition of Medication-Assisted Treatment Providers and Advocates. It is concerned with how OTPs can work with primary health care services.
The third white paper (32 pages) is “Increasing Access to Medication-Assisted Treatment for Opioid Addiction in Drug Courts and Correctional Facilities and Working Effectively with Family Courts and Child Protective Services.” Douglas Marlowe, PhD, Chief of Science, Policy and Law of the National Association of Drug Court Professionals, wrote the first section of this paper, covering working with Drug Courts. The second section delves into working with correctional facilities, and was written by Sarah Wakeman, MD, of the Substance Use Disorder Initiative, Massachusetts General Hospital, and Josiah Rich, MD, MPH, director of the Center for Prisoner Health and Human Rights, Brown University. Pamela Peterson Baston, of Solutions of Substance, Inc., wrote the third section; it discusses how OTPs can work with Family Courts and Child Protective Services.
Categories: Addiction, Drug Courts & Criminal Justice, Healthcare Reform, Medication-Assisted Treatment (MAT), Methadone, Newsletter, OBOT, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs)
Tags: Addiction, Criminal Justice, Healthcare Reform, Methadone Treatment, OBOT, Opioid Treatment Programs
Health Homes in Vermont: Start Some Patients on Buprenorphine in OTPs, Transfer to OBOT (Part I in a Series of AATOD White Papers)
By Alison Knopf
The American Association for the Treatment of Opioid Use Disorders (AATOD) this year issued three landmark white papers on improving access to medication-assisted treatment (MAT) for opioid use disorders (OUDs). Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), the white papers can serve as guidelines for treatment providers addressing the opioid epidemic across the country.
The first white paper focuses on two main types of integrated care using health homes for opioid treatment programs (OTPs): the “hub and spoke” model in Vermont, and the models in two states—Maryland and Rhode Island.
Vermont’s model is widely viewed as the most progressive in the country, partly because of Gov. Howard Shumlin’s use of the Affordable Care Act (ACA) to expand medication-assisted treatment (MAT) with a combination of OTPs (hubs) and office-based outpatient treatment (OBOT) providers (spokes).
We focus in this article on the first white paper’s report on Vermont. “Models of Integrated Patient Care through OTPs and DATA 2000 Practices” is presented in three sections. The Vermont section was written by Karen L. Casper, PhD, and Anthony Folland, Clinical Services Manager, Vermont State Opiate Treatment Authority, Vermont Department of Health’s Division of Alcohol and Drug Abuse Programs.
Key to the success of the hub-and-spoke model is a revolutionary concept for OTPs: Instead of automatically beginning methadone treatment for all new patients, decide which patients are more appropriate for buprenorphine. The OTP would start those patients on buprenorphine, and when they are stable, transfer them to the care of general practitioners and other prescribers who are not in OTPs—“the spokes.”
Lower operating costs will offset the significantly higher cost of buprenorphine compared to methadone. And the decision about which medication to use will be based on the clinical needs of the patient. The coordination of care—the “health home” aspect—will be paid by a Medicaid waiver under the ACA.
Vermont and the ACA
Medicaid health homes were established by the ACA, under which states can reimburse agencies for care coordination. For OTPs, this means that the Centers for Medicare and Medicaid Services (CMS) can pay them extra to help patients manage physical and behavioral problems, in addition to their OUDs.
Collaboration between OTPs and DATA (Drug Abuse Treatment Act) 2000 practices that prescribe buprenorphine is an essential part of integrated care, all three papers suggest. In Vermont, this coordination is clear, with the OTPs serving as “hubs” and the DATA 2000 practices as “spokes.” The hub can refer patients to the spoke, and vice versa, so the patient can be in the most appropriate treatment.
Methadone and buprenorphine are the primary medications used in Vermont to treat OUDs. They are used in conjunction with counseling. Vermont’s “hub and spoke” initiative aims to improve care at reduced costs for the state’s health system.
This works, for several reasons. Buprenorphine use is expanded in both hubs and spokes; the system is flexible enough to allow patients to transfer between OTPs and OBOT programs, as clinically indicated; and creative payment methods support enhancements that hold the hub-and-spoke system together.
Hub OTP Services
Services hub-OTPs must provide to OBOT physicians include:
- Consultation services; for example, psychiatry, addiction medicine, expert management of co-occurring mental health conditions, and recovery support
- Comprehensive assessment and treatment recommendations, such as differential diagnosis, assessment of need for MAT versus other services, and use of methadone or buprenorphine
- Induction and stabilization services for initiating buprenorphine treatment, especially in complex cases
- Reassessment and treatment recommendations for patients who have relapsed after having been treated for substance use disorders
- Support for tapering off maintenance medication, including referral for more-intensive psychosocial support
- Support and consultation for recovery and rehabilitation services and assistance regarding treatment needs for substance misuse, in designing individualized recovery plans and coordination with human services, housing, employment, and other specialized services and support
Spokes must employ one full-time nurse and one full-time licensed clinician case manager for every 100 patients being treated with buprenorphine. Staff are hired or contracted by the state’s Blueprint for Health program. For OBOT practices with fewer than 100 patients—most of the practices, as of this writing—several practices can share the support staff.
The state’s Medicaid program pays for the six health home services authorized by the Affordable Care Act. The six
- Comprehensive Care Management: Activities undertaken to identify patients for MAT, conduct initial assessments, and formulate individual plans of care
- Care Coordination: Implementation of individual plans of care (with active patient involvement) through appropriate linkages, referrals, and coordination; also included is follow-up as needed with services and support across treatment and settings, and providers
- Health Promotion: Activities that promote patient activation and empowerment for shared decision making in treatment, support healthy behaviors, and support self-management of health, mental health, and substance abuse conditions; there is a strong emphasis on person-centered empowerment to promote self-management of chronic conditions
- Comprehensive Transitional Care: Care coordination services focused on streamlining the movement of patients from one treatment setting to another, between levels of care, and between health and specialty mental health and SUD service providers; the goal is to reduce hospital readmissions and to facilitate the timely development of referrals and transitions to other services
- Individual and Family Support Services: A flexible, intensive-to-moderate service and support package that increases family capacity, wellness, and functioning
- Referral to Community and Social Support Services: Help for patients to obtain and maintain eligibility for formal support and entitlements (e.g., health care, income support, housing, legal services) and to participate in informal resources to promote community participation and well-
Buprenorphine in OTPs
The success of the hub-and-spoke solution relies on expanding the use of buprenorphine in OTPs. This is a sea change for OTPs, previously exclusively methadone clinics. Now, OTPs can prescribe buprenorphine—and no other state uses as much buprenorphine as Vermont.
The first question is “How can this be cost effective?” Buprenorphine is much more expensive than methadone. The answer is simple. The patients won’t stay in the OTP. When an OTP starts patients on buprenorphine instead of methadone, the patients can be transferred to OBOT once they are stable.
For those patients, the high costs of OTP that are unrelated to the cost of methadone would be avoided. OTP clinicians would determine which new patients would be best for methadone treatment, and which for buprenorphine. So far, about one-third of patients move out of OTPs after stabilization on buprenorphine. Additional cost savings are also expected as a result of fewer unnecessary emergency department and hospital visits, as well as fewer social and legal costs.
While it may sound easy to be able to refer patients between OTPs and OBOT physicians, it isn’t. The first step involved developing a “referral culture” to replace the previous “capacity culture,” based on a fee-for-services billing model. If OTPs are paid by the patient, what is the incentive to refer to an OBOT? The state helped this process by paying for discharge planning and referral, and for requiring health home encounters as one of the reimbursement criteria.
The model also provides for the OBOT to refer the patient back to the OTP if necessary, which requires a sophisticated process for bidirectional movement—referrals from OTP to OBOT, and from OBOT to OTP.
Creative new uses of Medicaid include case rates, combined funding streams, and capacity-based payments, rather than fee-for-service. Vermont will collect federal matching funds ($90 for every $10 spent by the state) only for the hub-and-spoke costs directly linked to providing health home services. The remaining services are matched at the current federal-state rate of 50-50.
Spoke payments are based on the average monthly number of unique patients in each health savings account for whom Medicaid paid a buprenorphine pharmacy claim during the most recent three-month period, in increments of 25 patients.
Most MAT funding is through Medicaid, but some patients have third-party insurance. Medicare will pay for treatment in spokes, but not in hubs.
Footnote: The total number of people receiving MAT services through the hub-and-spoke system since the program’s inception has increased by more than 50%. The hub system has significantly increased caseload—from 650 patients in 2012, to 2,723 in 2015. The spokes have not grown as fast as the hubs: from 1700 patients to 2143 during the same period.
Categories: Addiction, Heroin, Medication-Assisted Treatment (MAT), Newsletter, OBOT, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids, Prescription Drugs
Tags: Buprenorphine, Heroin, Methadone Treatment, Opioid Treatment Programs, Prescription Opioids, Substance abuse treatment
How OTPs Can Integrate Care With Other Health Care Providers (Part II in a Series of AATOD White Papers)
By Alison Knopf
The second white paper issued this year by the American Association for the Treatment of Opioid Dependence (AATOD) focused on coordination of care. Essential steps include integrating service delivery between opioid treatment programs (OTPs) and DATA (Drug Addiction Treatment Act) 2000 practices, and between OTPs and primary and behavioral health services.
In “The Opioid Treatment Program as a Hub for Coordinated Care,” Kenneth B. Stoller, MD, and Mary Ann C. Stephens, PhD, write about the ways OTPs can provide more services. Sometimes this amounts to counseling and consultation only. It’s a new paradigm.
OTPs can be key in accomplishing the goals of coordinating care for a high-need population. OTPs are open 6 to 7 days a week; they provide medication, counseling, and other services; have frequent staff contacts; and offer medical services.
One way OTPs can help DATA 2000 providers: make counseling and wrap-around services available to patients who are receiving their prescribed buprenorphine, but no other services. Offering ancillary services can be helpful, particularly “for providers with little experience,” the paper notes. Vermont’s hub-and-spoke model is the best example of coordination between OTPs and DATA 2000 providers.
Another model of coordination is that of Collaborative Opioid Prescribing (CoOP), a bottom-up care coordination model Dr. Stoller developed at Johns Hopkins. It’s more localized than Vermont’s model, uses a single OTP as a hub, and links the OTP with primary care, psychiatric, or office-based buprenorphine care.
Psychiatric providers and pain-treatment providers are ideal collaborators for OTPs. Many OTP patients have mental health conditions, and many have pain. Frequent contact between OTP staff and patients can give support to psychiatric providers. The OTP staff can perform several functions: help monitor psychiatric symptoms; improve outcomes, by observing the patient taking psychiatric medications; and deliver therapeutic messages, such as developing a positive self-regard and using effective coping skills—all during routine encounters.
The OTP can also be an expert consultant to pain physicians, not only for OTP patients, but for pain patients who might be having problems with substance use disorders, with opioids or other substances. OTPs are also experts in the pharmacology of opioid analgesia.
Methadone or buprenorphine are the recommended treatments for pregnant women with opioid use disorders. Obstetric providers are key to improving access to treatment for patients who need specialized care to improve outcomes for mother and child. Also recommended are wraparound services, including housing, parenting classes, and more.
Coordinating with primary care physicians is yet another model, probably one of the most difficult. When a physician has a patient with a substance use disorder, getting that patient to an OTP could help not only with the drug use but with other problems that are difficult for primary care personnel to manage, such as HIV.
In addition to medical providers, payers are key collaborative players in OTPs. If the OTP will be furnishing only counseling (as when a prescriber provides buprenorphine only), the OTP must be able to bill for the counseling—and be paid for it. In general, provider payment for time spent in care coordination is not allowed; reimbursement models for care coordination need to be encouraged.
Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA) of New York State, Inc., and vice president of the West Midtown Medical Group, wrote about how to transform co-located physical health care in an OTP model to a fully integrated model. The infrastructure and expertise for this is now in place.
The New York story required close coordination with the state, as part of both Medicaid redesign and a local waiver. The goal is the “triple aim”—enhancing the patient’s experience, improving the health of populations, and reducing per-capita health care costs. OTPs can accomplish this by coordinating with the complete health care system.
For more on New York’s program, go to http://atforum.com/2015/06/success-new-york-medicaid-to-reimburse-otps-for-buprenorphine/.
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Methadone, Newsletter, OBOT, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Buprenorphine, Heroin, Methadone Treatment, Opioid Treatment Programs, Pregnancy, Prescription Opioids
Criminal Justice System: The Need to Educate the Courts, Corrections, and the Child Welfare System (Part III in a Series of AATOD White Papers)
By Alison Knopf
The American Association for the Treatment of Opioid Dependence (AATOD) issued three white papers this year that focus on methadone and buprenorphine treatment for opioid use disorders (OUDs). The papers were funded by the Substance Abuse and Mental Health Services Administration (SAMHSA).
This white paper, the third in the series, shows how opioid treatment programs (OTPs) and DATA (Drug Addiction Treatment Act) 2000 prescribers can work with drug courts, correctional facilities, probation and parole systems, family courts, and Child Protective Services (CPS). Because obtaining treatment for patients going through the criminal justice system is beset by myths and ignorance on the part of the many nonmedical authorities involved, perhaps one of the most important roles OTPs and buprenorphine prescribers can play is to educate.
The education won’t be easy, because widespread prejudices against agonist medications are common in the criminal justice field. Many people are in prison or jail, on probation or parole, or have lost custody of their children—all because they were unable to access medication-assisted treatment (MAT). (Sometimes, especially in the case of CPS, it is because they are in MAT that they lose parental rights.)
This third white paper has three sections. The first section is about drug courts, written by Douglas B. Marlowe, JD, PhD, Chief of Science, Policy & Law with the National Association of Drug Court Professionals (NADCP).
The second section, by Sarah Wakeman, MD, medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital; and Josiah D. Rich, MD, MPH, professor of medicine and epidemiology at Brown University, and Director of the Center for Prisoner Health and Human Rights, focuses on how to improve access to pharmacotherapy within the criminal justice system. It zeroes in on several models.
The third section, by Pamela Peterson Baston of Solutions of Substance, Inc., discusses how OTPs and DATA 2000 practices can work with CPS and family courts. Termination of parental rights has been an unnecessary tragedy for many families, and it could be ameliorated by better training of CPS and courts, so that they understand how treatment works.
Part 1: Drug Courts
In 2010, the board of directors of NADCP issued a unanimous resolution directing drug courts to keep an open mind about MAT. It stated explicitly that drug courts should not have blanket prohibitions against MAT. (Some drug courts still do have a blanket prohibition.)
In 2013, NADCP said that drug courts should not prohibit offenders who are in MAT with methadone from participating in the court. Drug courts that do not follow this are operating below the recognized standard, said Dr. Marlowe. They may not be able to get certain drug court funds.
Beginning in 2015, the Bureau of Justice Assistance (BJA) required drug courts receiving federal funding to attest in writing that they would not deny eligible candidates access to the program because of an individual’s use of an FDA-approved medication for the treatment of an SUD. Nor would participants be required to taper off such medications as a condition of graduating from the program. (This mandate applies only to drug courts receiving BJA or SAMHSA funding.)
If a drug court is not receiving federal funding, and the prosecution offers its own medical evidence suggesting a medication isn’t necessary, the judge will need to make a ruling on the matter after listening to medical evidence from both sides. In this relatively circumscribed set of cases, medical experts will be required to provide the drug court with a convincing rationale for using or not using MAT, based on the facts of the case.
“Unfortunately, many physicians are unaccustomed to having their medical decisions questioned by laypersons, and even competent physicians can have a difficult time explaining their decision-making process to nonmedical professionals,” said Dr. Marlowe. Still, physicians need to be prepared to make this explanation to the judge, he said.
The best way to get drug courts to support MAT is to educate the drug court when there isn’t a specific case in question, he said. “Staff will need time to reflect on the issues, deliberate with fellow drug court team members, and convince colleagues from their respective agencies to reconsider entrenched practices.”
But, despite best efforts at education and outreach, some drug courts may continue with blanket prohibitions against methadone or buprenorphine. Drug courts are courts, and are required to receive evidence from scientific experts if the subject matter of the controversy is beyond the common knowledge of laypersons.
In a contested case, a medical expert should be prepared to explain why the circumstances justify using a relatively riskier or more complicated medication regimen. “Judges simply need a rational basis for following an expert’s recommendation,” he said. “Refusing to answer such questions or giving vague or patronizing responses interferes with the judge’s decision-making function and may cause the physician’s recommendation to be discounted and the prescription denied.”
Most drug court programs last between 18 and 24 months. Yet some drug courts require that participants be tapered from medication as a condition of graduation; this should not be the case. Still, the courts do want to know that the physician has considered tapering, and has developed either a tapering plan or a continuing-care plan.
“Physicians should give careful thought to this matter and be prepared to explain how they will decide whether and when to taper a medication regimen,” Dr. Marlowe wrote. “Specifically, what clinical signs and symptoms will the physician look for in deciding whether a taper is advisable? Are there clinical features in the case that might lead the physician to extend a maintenance regimen for a lengthier period of time, conduct a taper in a slow and stepwise manner, or maintain the patient on the medication indefinitely?”
These questions will, of course, seem odd to OTPs. After all, if a patient is doing well in treatment, why would you consider a taper? But the intent, said Dr. Marlowe, “is to help judges understand how and why competent physicians make such decisions.” By this education, a drug court judge can “assess the basis for a medical recommendation in a contested case and articulate a rational reason for accepting or rejecting the recommendation.”
In 2011, The Legal Action Center noted that about 65% of people in prisons or jails have a substance use disorder (SUD). Many are addicted to opioids. Denying them access to MAT violates the Americans with Disabilities Act, if denial is based on a blanket policy or made without individual evaluation. But this argument has rarely been invoked, as inmates continuously face a lack of treatment.
The bottom line—if OTPs and other MAT providers can’t establish a foothold in drug courts, they won’t be able to do so elsewhere in the criminal justice system, said Dr. Marlowe.
Part 2: Methadone, Buprenorphine, and the Criminal Justice System
Anyone who is detained or incarcerated should be screened for OUDs during initial intake. Those already taking buprenorphine or methadone should continue with their medication. Those who test positive for an opioid during screening but are not currently receiving a medication should be offered medical treatment for withdrawal symptoms, and assessed for further treatment.
Most barriers to MAT in prisons and jails are philosophical, but logistical challenges exist as well.
One model successfully implemented at the Rhode Island Department of Corrections was to partner with an OTP. In this model, doses of methadone that are individualized, measured, and labeled for each patient are delivered daily to the correctional facility. The methadone is picked up at the control desk and passed through multiple security checkpoints, counted, recorded, and ultimately placed in locked storage.
Inmates are administered methadone by the correctional nursing staff and observed during and after dosing. Nurses communicate each patient’s response and any side effects to a physician, who may adjust the dose as needed. The benefit of this model is that the Department of Corrections doesn’t need to become an OTP.
Another model, adopted by a handful of jails, is being directly licensed as an OTP. New York’s Riker’s Island program, called the Key Extended Entry Program (KEEP), is a jail-based methadone maintenance program that has been treating detainees since 1987.
Still another model is a buprenorphine treatment program. The medication is not a liquid, but it is taken sublingually, so the nursing staff needs to watch while the medication dissolves under the tongue. This can take up to 10 minutes for each patient, potentially causing staffing pressure.
The post-release period is particularly high risk, due to possible overdose. Recovery coaches could help connect patients to treatment. And all prisoners with a history of an OUD should receive overdose education and a naloxone rescue kit when leaving a correctional facility.
Part 3: Family Courts and Child Protective Services
Most substantiated child abuse and neglect cases involve substance abuse by a parent or guardian. And although most CPS resources are consumed by these cases, few child welfare systems in the country give priority to identifying parental SUDs early on.
Many missed opportunities for early identification and intervention exist in the CPS system. But Ms. Baston argues that there are even more in the SUD treatment system. People in treatment can lose their children to CPS. One study found that among parents who had a child that was removed by CPS, 29% of those in outpatient programs, 53% of those in residential programs, and 80% of those in OTPs had their parental rights terminated.
It is recommended that SUD treatment programs pay more attention to the children of their patients, and to parenting skills. “While not all parents who use opioids, alcohol, or other drugs mistreat their children, such use can adversely impact attachment, relationships, and family dynamics and significantly affect the likelihood the children will have traumatic experiences in childhood,” writes Ms. Baston.
Ms. Baston also notes that myths and prejudice about methadone during pregnancy, and actions by courts and CPS that counter evidence-based strategies, have created a “toxic and potentially deadly treatment and recovery environment.“ Parents involved with CPS are rarely offered MAT. One study found that only 24% of heroin users in a child welfare sample had been referred for methadone treatment, despite evidence of methadone’s effectiveness in treating heroin addiction.
In many parts of the country, women are forced to choose between going into or staying in treatment with methadone, and being reunified with their children. “We can and must do better,” said Ms. Baston. “But even the best evidence-based approaches cannot work in a vacuum. As long as MAT and other SUD treatment systems and child welfare systems avoid formal collaboration, parents dually affected by opioid and other SUDs and child maltreatment will continue to suffer the consequences, as will their children.”
So, just as with drug courts, it is incumbent upon OTPs to educate CPS. Because of the opioid epidemic, “community stakeholders that have previously not worked together are now feeling collaboration as a mandate, rather than an option,” said Ms. Baston. Cross-system collaboration among CPS, OTPs, and DATA 2000 providers is vital for the health of families.
Categories: Addiction, Drug Courts & Criminal Justice, Medication-Assisted Treatment (MAT), Methadone, Newsletter, OBOT, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Addiction, Drug Courts, Heroin, Opioid Treatment Programs, Prescription Opioids, SAMHSA
By Alison Knopf
The U.S. Surgeon General’s report on alcohol and drugs—the first ever devoted to this topic—should be a reference document for every opioid treatment program (OTP) and treatment provider in the country.
The report, released November 17 by the Office of the Surgeon General, Vivek H. Murthy, MD, MBA, is comprehensive, accurate, and written by the brain trust of the addiction treatment research community. It took 18 months to write. Editors included H. Westley Clark, MD, JD, dean’s executive professor of public health at Santa Clara University.
The report includes 76 mentions of methadone, 90 mentions of buprenorphine, and 56 mentions of naltrexone, but only eight mentions of extended-release naltrexone—with some mentions citing the use of naltrexone in treating alcohol use disorders. As is fitting with a scholarly publication, brand names (eg, Vivitrol, extended-release naltrexone) are not mentioned. It’s telling that the main medications cited for treating opioid use disorders (OUDs) are opioid agonists.
Timely Information on Opioid Use
While all substance use disorders (SUDs) are discussed in this 428-page report, the pages on OUDs are particularly timely, given the current epidemic. For example:
“Long-term methadone maintenance treatment for opioid use disorders has been shown to be more effective than short-term withdrawal management, and it has demonstrated improved outcomes for individuals (including pregnant women and their infants) with opioid use disorders. Studies have also indicated that methadone reduces deaths, HIV risk behaviors, and criminal behavior associated with opioid drug seeking.”
This report should be read repeatedly online. In digital form, it is technically superb, easily searchable. For reference, this should be the go-to resource for everyone, handed out to patients and clinicians, family members and administrators. It includes chapters on neurobiology, treatment, recovery, prevention, and other topics.
Finally, it’s easy to read. Hold on to this through the next year or two. The Surgeon General has two more years to serve the administration, guiding the science on addiction policy. With this report to share, nobody can question the evidence behind medication-assisted treatment. For more information—and the full report—go to https://addiction.surgeongeneral.gov/.
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction
Tags: Addiction, Buprenorphine, Government, Heroin, Methadone Treatment, Prescription Opioids, Substance abuse treatment
By Barbara Goodheart, ELS
An innovative hospital, one of the largest in New York City, has successfully integrated buprenorphine maintenance treatment (BMT) into its established opioid treatment program (OTP), giving patients and health care providers new choices in therapy.*
A report published online October 17 in Psychiatric Services in Advance (ps.psychiatryonline. org) describes the new arrangement between the OTP and the medical practices that treat buprenorphine patients.
The authors had two goals: to identify the benefits of integrating BMT into an established hospital-based OTP, and to identify the institutional barriers involved in integration.
The authors summarized their clinic, hospital, and corporation experiences during integration efforts. They also described the characteristics of 735 hospital outpatients given take-home doses of buprenorphine from 2006 to 2013. Table 1 of the article recaps these characteristics.
Patients with opioid use disorders (OUDs) who have comorbid conditions or are at high risk of complications of therapy have several treatment options. In this study, integrated treatment allowed patients and caregivers to choose between methadone and buprenorphine, or made it possible for patients to transition between intensive structured care and either primary care or outpatient psychiatric care, as needed. Intensive structured care can include frequent, regular visits to a psychiatrist, or even inpatient treatment. And patients aren’t required to switch from buprenorphine to methadone.
*The NYC Health + Hospitals/Bellevue Opioid Treatment Program (OTP), operated by the Department of Psychiatry at Bellevue Hospital, consists of a team of clinicians who provide patients with MAT for opioid use disorders. The clinicians dispense methadone and buprenorphine within the clinic and provide a variety of ancillary medical and psychiatric services. OTP physicians have academic appointments at the NYU Langone School of Medicine.
NYC Health + Hospitals/Bellevue is located at 462 First Avenue, New York, NY.
Transitions in OTP Care:
Integrating BMT into an OTP
Intensive Primary Care
Structured or Outpatient
The opportunity to integrate buprenorphine into an OTP offers a new treatment option that better serves patients who have differing clinical needs and different levels of social support.
Early Barriers to Integration
Initial barriers included regulations, cost issues, cultural and professional issues, the basics of dispensing medications, and issues involving professional and cultural resistance.
In particular, cost issues and software-compatibility issues limited the OTP’s medication choices:
- Placing a tablet under the tongue and making certain it had been swallowed took more time than giving patients methadone, a liquid
- Buprenorphine toxicology tests were difficult to get, and analyzing the results took longer than analyzing other test results
- Cost differences and compatibility issues with the methadone-dispensing software and hardware meant that only the tablet formulation of buprenorphine could be used
Some early reimbursement issues were especially challenging. The article noted that although Medicaid historically reimbursed urban OTPs for methadone treatment for heroin users, patients addicted to prescription opioids tended to consult office-based buprenorphine providers. Usually these providers were in private for-profit practices, and some patients had to pay out of pocket. At first, these early barriers probably discouraged OTPs from adding buprenorphine to their medication list.
The Regulatory Situation Improves
In 2011, the New York State Office of Alcoholism and Substance Abuse services (NYS OASAS) granted the OTP a clinic-wide waiver, allowing it to dispense buprenorphine under conditions consistent with the Drug Addiction Treatment Act of 2000 (DATA 2000). OASAS also modified the requirement that new patients attend the clinic no less than six days a week to receive buprenorphine.
In 2013, additional changes greatly improved the regulatory situation. OTPs could now provide up to one month of buprenorphine take-home doses to appropriate patients, without waivers. The new guidelines also allowed integration—both medications could be dispensed in the same clinic—to replace colocation—separate clinical practices, and disjoined medical record-keeping.
Today’s rules and procedures for buprenorphine reimbursement can be complicated. And Medicaid reimbursement varies by state. For example, New York State Medicaid reimburses for BMT if treatment takes place within an OTP, but some other insurance plans may not.
And Medicaid now reimburses for individual services on an ambulatory patient group basis, the authors point out, which “better accounts for medication differences and other variations in care.” Previously, Medicaid used weekly flat reimbursement rates per patient, no matter how intensive the services. Patients receiving BMT needed to bill for more payment to cover the higher cost of buprenorphine.
How Integrating Buprenorphine Into OTPs Benefits Patients
- OTPs have built-in structures for serving large numbers of patients with OUDs
- Under integration, physicians can treat more patients (OTP-enrolled buprenorphine patients aren’t included in buprenorphine-patient limits)
- Integrated on-site services—medical and psychiatric care, and vocational training—may improve patient compliance
- Integrated programs may improve confidentiality protection (some clinics guard only the health information that is protected in the clinic)
- Adding BMT to OTPs promotes recovery and patient choice
The authors call for further research to address two issues: 1.) Does integrated BMT have any effect on patient relapse, retention, and dropout rates? 2.) Is it necessary to document changes in access to treatment that result from the integration?
Another innovation at OTPs could be just around the corner: The authors note that buprenorphine integration supports continued advances “that may include the introduction of extended-release naltrexone (Vivitrol) as a third treatment option.”
In closing, the authors refer to buprenorphine integration as “a model for other OTPs” that will facilitate partnerships among primary care and mental health clinics. Such partnerships will enable OTPs to “better serve diverse patients with varying clinical needs and with varying levels of social support.”
Polydorou S, Ross S, Coleman P, et al. Integrating buprenorphine into an opioid treatment program: Tailoring care for patients with opioid use disorders. Psychiatr Serv in Advance (doi: 10.1176/appips201500501. [Epub ahead of print October 17, 2016.]
Categories: Buprenorphine, Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs)
Tags: Buprenorphine, Heroin, Opioid Treatment Programs, Prescription Opioids, Substance abuse treatment
The Evolution of Addiction Treatment Conference
February 2–5, 2017
Los Angeles, CA
New York Society of Addiction Medicine (NYSAM) Annual Medical-Scientific Conference
February 3-4, 2017
New York, New York
National Association for Court Management (NACM) 2017 Midyear Conference
February 5-7, 2017
American College of Psychiatrists (ACP) Annual Meeting
February 22-26, 2017
The American Society of Addiction Medicine (ASAM) 48th Annual Conference
April 6-9, 2017
New Orleans, Louisiana