Welcome to the September 2018 issue of the Addiction Treatment Forum newsletter. The newsletter started as a quarterly publication back in 1992. In 2014 we made the decision to publish on a bi-monthly basis to be able to report the news to our readers on a more timely basis.
With so much important news circulating about the opioid crisis, the increase in overdose deaths, and the urgent need to expand medication-assisted treatment, we have made the decision to begin publishing the newsletter on a monthly basis.
Thank you for your continued interest in Addiction Treatment Forum. We always encourage your feedback on topics of interest to the field.
By Alison Knopf
As the opioid crisis continues, opioid treatment programs (OTPs) are going to face big challenges in the workforce, experts say. “We’re going to face a lack of access, even in areas where there are a lot of programs,” said Zachary C. Talbott, a certified MAT advocate and member of the national board of directors of NAMA Recovery. Mr. Talbott owned and operated Counseling Solutions Treatment Centers from 2015 until they were acquired by BayMark Health Services in August of this year. “We need to add slots and we need to hire more staff,” said Mr. Talbott.
“We are a talent-poor industry in certain areas of the country,” he told AT Forum. “It is so difficult to train and to retain a quality workforce.”
One pitfall is the “warm-body syndrome,” when an employer has someone who is there, but isn’t competent to do the rigorous work entailed in OTPs. “It’s critical that our approach include nursing schools, social work schools, medical schools─to make sure everyone getting trained is competent in the medical treatment of substance use disorders,” he said.
Training, Not Turnkeys
And it’s incumbent on the OTP to provide training─this is not a “turnkey” operation.“ You can recruit a good doctor or counselor, but I have yet to find someone who knows about methadone,” said Mr. Talbott. “This is part of the reason there’s a reluctance to expand─it’s hard enough to find staff for our existing programs.”
When opening new clinics, directors can be difficult to find as well, because the director must know the state regulations, Mr. Talbott added.
In addition to Mr. Talbott, we talked with Joe Pritchard, CEO of Pinnacle Treatment Centers, and Peter Morris, group president of Acadia Healthcare, for this article, which focuses on the “clinical” (counseling) and “medical” (prescribing) sides of the OTP workforce.
National Consortium Targets Four Main Issues
Workforce development is one of the four main issues of focus by the National Consortium of Opioid Treatment Providers, a group consisting of Acadia, BayMark, Aegis, New Season, and Behavioral Health Group. (The other main issues are Medicaid coverage, Medicare coverage, and commercial insurance payers.)
“We know this is industry-wide, not just our organization,” said Mr. Morris. “Internally, we’ve looked at where we are in the market, and certainly at certain areas that have been problematic, with salary and benefits. We have added some benefits this year that we didn’t have before.”
Indeed, one of the first things Talbott’s Counseling Solutions staff were rewarded with when he sold to BayMark was comprehensive benefits, including health care, which he couldn’t afford to provide previously.
On the recruiting side, it’s important to respond immediately when a candidate expresses interest in working with a center, said Mr. Morris. Acadia has started using the same approach for job candidates as for patients: “We measure how many hours it takes to get back to patients and get them in for an admission,” said Mr. Morris. “We’re using that same approach with recruitment─you can’t let it sit for 24 hours in this competitive environment, you need to strike while the iron is hot.” In other words, if you say, “Come in next Tuesday for an interview,” the candidate may well have been hired somewhere else before then.
There is the possibility that physicians could be harder to find, because of buprenorphine being administered through office-based opioid therapy (OBOT) clinics, said Mr. Morris.
Pinnacle, like Acadia, has a full continuum of services, with everything from residential care to detoxification to sober housing to OTPs. This makes it easier to recruit prescribers, he said. “We utilize medications throughout the continuum, so someone can move seamlessly up and down the scale. This is what a lot of prescribers are looking for.”
Typical OBOT prescribers fall into two categories: the physician who wants to be able to prescribe buprenorphine only for patients in his or her own practice; and the prescriber who wants to “be part of the answer to the bigger problem, but doesn’t have the infrastructure to do that,” said Mr. Pritchard.
But gradually the prescribers are starting to realize that the medical side─the medication─is “just one part of the equation,” said Mr. Pritchard. “They see the patient, write the prescription, and it takes 15 minutes,” he said. “There’s no real continuity of care.”
Pinnacle is recruiting medical staff, including nursing and primary care staff, from medical schools, and is also looking at residents in addiction and psychiatry as part of the hiring pool. “A lot of the doctors want to moonlight to make some money during residency, so we bring them in,” said Mr. Pritchard. “These are people who don’t want to just write a scrip─they want to be part of a more comprehensive practice,” he said. “These are the physicians we want to attract.” The opioid epidemic is headline news, and young medical students who are drawn to help, need to know where to work. OTPs are an ideal location.
According to Mr. Morris, the biggest hiring problem seems to be counselors, in particular in certain areas of the country like Massachusetts, where Acadia has 12 clinics. There is also competition in rural areas like West Virginia and Wisconsin.
“We try sign-on bonuses, which can be helpful,” he said. The new counselor gets half of the sign-on bonus when he or she first starts working, and the rest in a period of time. Acadia also uses referral bonuses in problem areas.
Another good place to find workers is job fairs, especially at local universities, said Mr. Morris.
Recruiting counselors is difficult because of the schedule, as well. It’s not as bad as it was years ago, when counselors and nurses had to be at work by 4 or 5 in the morning, said Mr. Pritchard. “It was a grueling schedule, but the world is changing, fortunately,” he said. “We schedule counseling appointments.”
While many patients must come in every day to get their medication, as they progress through treatment, they need fewer and fewer counseling sessions, he said. Still, it’s important for the staff to be available, as family meetings also take place. “It shouldn’t just be limited to 5 AM to noon, and then the place shuts down,” he said.
Pinnacle also does a lot of training, making sure counselors know that “getting off medication shouldn’t even be part of the discussion,” said Mr. Pritchard. Counselors are attracted to a milieu where there is comprehensive care, said Mr. Pritchard. “They like to feel that this isn’t a place where people get their medication and check in with me once a month, that this is true engagement.”
Once you have good staff, how do you keep them? Because of turnover, it’s important to constantly analyze the competition landscape─how much other workers in the area are getting paid─as well as the benefits package offered. Soft benefits like staff luncheons and team-building events also help retain employees.
“We foster local leadership to try to do something different, so we stand out from our competitors,” said Mr. Morris. “But that part of the equation is up to the local leadership; we have to train our local leaders.”
Facilities also must balance zoning requirements with the need to be part of mainstream health care─and indeed, OTPs are part of mainstream health care. But society still hasn’t come to terms with that. “We want to be on Main Street USA as much as possible,” said Mr. Morris. “We don’t want to be down the back alley─historically we’ve been thrown in that category of liquor stores and strip clubs, but we want to be good neighbors, and we are.” This attitude─and the environment─helps to attract and retain good workers, he said.
Categories: Addiction, Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Addiction, Buprenorphine, Counseling, Medication-Assisted Treatment, Methadone Treatment, Opioid Treatment Programs, opioids, Substance Abuse Treatment
By Alison Knopf
This summer, Bay Area Addiction Research and Treatment (BAART) sued the city of Concord, California after a three-year effort to site its methadone clinic there. Amitai Schwartz represented BAART and BAART’s owner, BayMark Health Services.
It is a classic case; everything seemed to be moving forward (with some hitches, of course), and after a few years a site was located. Then the neighbors heard about it. They protested, and local officials caved to the popular pressure.
The lawsuit requests an injunction against the city and anyone succeeding or working with it from prohibiting the use of the location─2152-58 Solano Way─as a methadone treatment clinic. It also requests costs and attorneys’ fees.
The city’s economic development office allowed the use of the facility at the location, and classified it as a medical office. However, city planners then reclassified it as a medical “clinic,” a use that is not allowed in a commercial and mixed-use zoning district.
BAART then went looking for other spots, found one that did allow a medical “clinic,” and began paying rent at the site in April. In November of 2017, however, NIMBY (not in my back yard) took over the official process, and residents didn’t want the facility near them. At the same time, the city’s economic development office decided the center should be a “social service facility,” which requires an additional permit.
BAART Appealed; Negotiations With the City Fell Apart
The lawsuit─like others involving NIMBY─is based on the state’s incorporation of the Americans with Disabilities Act (ADA). In the lawsuit, BAART charges the city with changing the classification of the facility, with the intention of violating the rights of people with disabilities. Under the ADA, patients seeking or in treatment at Opioid Treatment Programs (OTPs) have a protected disability.
BAART already has two other OTPs in Contra Costa County, where Concord is located. One of them, in Antioch, lost a legal fight to prevent the clinic from locating there in the 1990s.
The case was filed in United States District Court for the Northern District of California, and is called BAART Programs, Inc., BayMark Health services, Inc., and Addiction Research and Treatment, Inc. vs. City of Concord and Andrea Ouse (who changed the designation to “social services facility” after residents protested the siting).
“Under California law it is unlawful to discriminate because of disability or the perception that a person is disabled,” the lawsuit states. “The patients who would be treated at the BAART clinic are disabled within the meaning” of state code.
For a Contra Costa County report that found more treatment is needed, go to http://www.cc-courts.org/civil/docs/grandjury/1806_The_Opioid_Crisis.pdf.
Categories: Addiction, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Addiction, Heroin, Medication-Assisted Treatment, NIMBY, Opioid Treatment Programs, opioids, Prescription Opioids, Stigma, Substance Abuse Treatment
By Barbara Goodheart, ELS
Under federal law, newly enrolled methadone patients must attend a methadone program six days a week, so caregivers can watch as patients are dosed.
But here’s the problem: Because many new methadone patients don’t have an opioid treatment program (OTP) nearby, this need for daily attendance markedly affects adherence. In fact, 20% to 50% of patients report poor or partial adherence during the most critical time of treatment—the first month, when patients face the highest risk of death.
That’s the subject of a study published this month in Journal of Substance Abuse Treatment.
The study’s authors, most of whom are affiliated with Washington State University, assessed the relationship between spatial access to the only state-funded OTP in Spokane County, Washington, and adherence to treatment during the crucial first month.
Authors’ Hypothesis—Treatment adherence is lower in new patients who live farther from the OTP.
The 892 patients received their first month’s treatment sometime between February 2015 and December 2017.
Effects of Distance
In the crucial first month of treatment:
- Patients living between 5 and 10 miles from the OTP were just as likely to miss doses as those living less than 5 miles away
- Patients living more than 10 miles away were more likely to miss methadone doses than patients living within 5 miles
- Patients living more than 10 miles away were younger, on average, than those closer; these younger, farther patients were considered possibly at higher risk of not adhering to treatment—and thus at higher risk of death
Time in Therapy
In the first three months, patients were required to complete 12 sessions of cognitive or behavioral therapy. After three months, take-home doses could be considered for those with good adherence. Also, mandatory attendance for therapy dropped to once monthly.
Median age was 34 years. The older the patient, the less the likelihood of missed doses. For every year of greater patient age, missed doses dropped 2%.
The authors commented that previous studies suggest that lower income, higher medication costs, and transportation barriers may influence nonadherence, affecting Medicaid patients, such as those in this study.
Day of the Week
Patients were most likely to miss Saturday and Sunday doses. The staff provided Sunday take-home doses only until 2 PM Saturday.
The research team found that during the first month of treatment, “significant positive associations” existed between the number of doses patients missed and the distance patients traveled to the OTP.
The authors stressed the importance of regular attendance, and the need to “improve the spatial availability of OTPs” for patients scattered throughout the area.
Methadone treatment is known to reduce or eliminate drug use, risky sexual behavior, criminal behavior, and deaths. But many OTP patients lose these benefits early, because no OTP is nearby. Evidence points to the first month as being key.
COMMENT: The authors have provided valuable data showing that the legal need to observe patients’ daily dosing may affect compliance. They’ve also raised important issues for further investigation.
In the meantime, laws have been passed limiting the availability of prescription opioids, and other investigators have suggested different approaches to the opioid problem, described below.
Rosenblum et al. Writing in The Journal of Environmental and Public Health, these authors recommended flexible take-home policies, mobile methadone maintenance services, and methadone medical maintenance—methadone provided by an office-based physician, or a pharmacy. Good ideas, all awaiting implementation. But the awaiting continues: The study was published seven years ago, the opioid crisis continues to surge, and the obstacles remain.
Saitz and Daaleman. Early this year an article in The Annals of Family Medicine urged making methadone treatment part of primary care. The authors said it would be impossible for the country to adequately respond to the current epidemic “without addressing it in primary care and there is no question that the time to do it is now.”
Samet et al. An article in the July issue of New England Journal of Medicine also called for primary care availability—specifically, by asking Congress to update laws. Regulating methadone prescribing in primary care would reduce barriers, the authors said, and would “extend the benefits of a proven, effective medication to people throughout the country.”
Given the variety of approaches to the opioid crisis—restricting opioid prescriptions, constructing more OTPs, allowing primary-care prescribing—what’s the best way to proceed?
The Stanford Approach: Modeling Tools Provide Assessments
A team from Stanford University used sophisticated modeling tools to assess the benefits and harms of various responses to the opioid crisis. They found that policies that expand addiction treatment or mitigate addiction’s harmful effects, such as overdose and infection, are “immediately and uniformly beneficial.” And they lack negative consequences, such as increasing heroin-related deaths. The team published its findings this month in the online edition of The American Journal of Public Health.
As for policies that decrease the supply of prescription opioids—they can reduce prescription-related deaths, but could also increase heroin-related deaths, as some people seek heroin as a substitute for prescription opioids. It’s possible, the team believes, that eventually “some such policies may avert enough new addiction to outweigh the harms.”
What, then, is the best policy? It seems there’s no perfect answer. The Stanford team suggested “a portfolio of interventions,” but these would include reducing the prescription opioid supply, probably increasing heroin use temporarily. It would also deprive some patients with chronic pain of a medication they legitimately need.
Opening more OTPs, as the Washington State team recommends, wouldn’t have that disadvantage, and the data indicate it would optimize treatment outcomes.
Amiri S, Lutz R, Socias ME, McDonell MG, Roll JM, Amram O. Increased distance was associated with lower daily attendance to an opioid treatment program in Spokane County Washington. J Subst Abuse Treat. 2018;Oct;93:26–30. doi:10.1016/j.jsat.2018.07.006.
Rosenblum A, Cleland CM, Fong C, Kayman DJ, Tempalsky B, Parrino M. Distance traveled and cross-state commuting to opioid treatment programs in the United States. J Environ Public Health. 2011; article ID 2011;948789. Epub 2011;July 6;doi:10.1155/2011/948789.
Saitz R, Daaleman TP. Now is the time to address substance use disorders in primary care. www.annfammed.org/content/15/4/306.full. Ann Fam Med. 2017;(July);15(4):306-308. doi:10.1370/afm.2111.
Samet JH, Botticelli M, Bharel M. Perspective: Methadone in primary care — One small step for Congress, one giant leap for addiction treatment. N Engl J Med. 2018;379:7-8. doi:10.1056/NEJMp1803982.
Pitt AL, Humphreys K, Brandeau ML. Modeling health benefits and harms of public policy responses to the US opioid epidemic. Am J Public Health. Epub ahead of print August 23, 2018:e1-e7. doi:10.2105/AJPH.2018.304590.
Categories: Addiction, Heroin, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids, Overdose, Prescription Drugs
Tags: Heroin, Methadone Treatment, Opioid Treatment Programs, Overdose, Prescription Opioids, Substance Abuse Treatment
By Alison Knopf
California technically doesn’t have waiting lists for opioid treatment programs (OTPs). When a program is full, the operator can ask the state for an increase in slots. If the request is granted—and it usually is—the program then pays for the extra slots in a new license.
This flexibility is very helpful to OTP providers. “We adjust our capacity up or down each year,” said Jason Kletter, PhD, president of BayMark Health Services. “If I only have 200 patients, I’m not going to pay for a license for 500,” said Dr. Kletter, who is also president of California Opioid Maintenance Providers (COMP), a membership organization of OTPs in the state.
“We’ve never had a problem with waiting lists in California,” Dr. Kletter told AT Forum. “BayMark is at only 73% capacity.”
“Narcotic treatment is a Drug Medi-Cal benefit in California ,” said Thomas Renfree, interim executive director of the County Behavioral Health Directors Association. “And because Drug Medi-Cal is an entitlement program, this does not allow for waiting lists for narcotic treatment.” If an OTP has more patients than it can handle in a clinic, new patients are entitled to treatment elsewhere.
Counties in Charge
But that doesn’t mean the transition happens smoothly for everyone. In California, under the terms of the 1115 Waiver for the Drug Medi-Cal Organized Delivery System, said Mr. Renfree, counties act as managed care plans for their residents, which authorizes the county to select the network of providers with whom the county will contract to provide services to its residents. At the same time, each county is responsible to ensure that every eligible beneficiary has timely access to all covered services when medically necessary, including narcotic treatment. Each county is also financially responsible for services provided to its residents, whether in county or out of county.
Under ordinary conditions, if one clinic is at capacity, it asks the county for additional capacity, which refers that request to the state, as indicated above.
But Alex Dodd, CEO of Aegis Treatment Centers, said there’s a glitch in this system. “We talk to the county and say the clinic is at capacity, we need your support for additional capacity,” Mr. Dodd told AT Forum. For example, in the Aegis OTP in Modesto, which has historically been full, new patients would historically have been referred to an Aegis clinic across the county border. However, under the Medicaid waiver, counties are not required to pay for treating patients from other counties, because each county gets a set amount for its Medicaid beneficiaries. Stanislaus County and Aegis are working together to open a new clinic in Ceres.
In fact, Stanislaus County, where Modesto is located, has a county-run program, and Aegis refers patients there if its clinic is at capacity, said Mr. Renfree. But what if the county-run program itself is at capacity or the patient wants to be in an Aegis program? “If the client wants to stay with Aegis and doesn’t want to go to the county-run clinic, they may request to receive services in the contracted Aegis facility across the border, he said. Stanislaus County understands that it is not good medical practice to disrupt patient care if the beneficiary has a good relationship with a particular clinic, and it is key to maintain continuity of treatment.
Building New Clinics
Another problem comes from NIMBY (not in my back yard)—not from the behavioral health policy makers, but from local supervisors. “The first thing you try to do is use your existing facility to accommodate the increase in capacity,” said Mr. Dodd. “But sometimes the clinic runs out of physical capacity, in which case you have to build a new clinic somewhere.” Aegis is currently trying to do this in two counties: one is being supportive, and the other is “dragging its feet,” he said.
Why would a county drag its feet about a new OTP during an opioid epidemic, especially when the investment is going to be borne entirely by a private company? “The main reasons we have found historically are stigma-related,” said Mr. Dodd. “If the board of supervisors is not in favor of treatment, they respond to political pressure.”
California has 19 grants categorized as State Targeted Response to the Opioid Crisis (STR) grants; Aegis is administering six of them. “By and large, this program is well done,” said Mr. Dodd. “But the biggest thing the government could help with next is a public awareness campaign to spread the word about treatment to patients and families. If it were up to me, I’d have a big advertising campaign.”
And Mr. Dodd would like to see more leadership from the governor’s office. When Howard Shumlin, then governor of Vermont, gave his state-of-the-state speech in 2014, “the only thing he talked about was the opioid epidemic,” recalled Mr. Dodd. “Unless there is that political leadership, unless number one says this is a big problem, the public servants are not going to take that direction.”
The big push using STR in California has been on a hub-and-spoke system, in which OTPs are the hubs and office-based opioid treatment (OBOT) prescribers are the spokes And in fact, aside from adding OTP capacity in the north, the biggest focus has been in expanding the spokes, said Dr. Kletter. The same is likely to be true of the new State Opioid Response (SOR) grants.
The STR grants have helped bring visibility and therefore support to the need to expand OTPs, especially north of San Francisco, where Aegis is using STR money to begin setting up programs, and where the relatively small and very rural counties have united. BAART (the predecessor to BayMark) tried to set up an OTP in Humboldt County about 25 years ago, recalled Dr. Kletter, but the county didn’t want it then. “Now, the STR grant gives some money to share with local communities, which garners support from those communities,” he pointed out.
The biggest problem facing OTPs is not funding: it is stigma and NIMBYism. There’s a segment of the population that will never be convinced to support a local OTP, said Dr. Kletter, “especially when they think their property values and safety are threatened.”
How to get past that? Community meetings are one way, but this can mean facing groups that are as friendly as “pitchfork mobs,” he said. Maybe the only solution would be to attach strings to funding, in which localities would have to agree to treatment programs to get their Medicaid dollars.
In the meantime, the main actors in OTP expansion are the private for-profit chains, in California as in the rest of the country. If these programs have plans for expanding and want to grow new clinics to meet the demand, they are going to need support, not only in funding, but in public awareness from government leaders. California’s regulatory system is flexible enough to allow new programs, and the law requires treatment on demand for Medicaid patients; advocates hope the momentum from federal STR and SOR grants continues to advance the needs of OTP patients.
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Addiction, Buprenorphine, Medication-Assisted Treatment, Methadone Treatment, Opioid Treatment Programs, Substance Abuse Treatment
The Evolution of Addiction Treatment Conference
January 24-27, 2019
Los Angeles, CA
National Association for Court Management 2019 Midyear Conference
February 10-12, 2019
Little Rock, Arkansas
American College of Psychiatrists (ACP) Annual Meeting
February 20-24, 2019
National Association for Court Management (NACM) 2019 Annual Conference
July 14-18, 2019
Las Vegas, Nevada