By Barbara Goodheart, ELS
We have lost our publisher, Sue Emerson. It happened on April 18, following a short illness. Just a year or so earlier we’d celebrated an important milestone—Sue’s 25 years as publisher of Addiction Treatment Forum.
Many of AT Forum’s readers didn’t know, or know of, Susan Caille Emerson. At one time Sue ran a “From the Publisher” column, but that was a while back. In recent years readers didn’t see her name on the publication unless they clicked on Contact Us. Yet Sue was the founder and sole owner of Clinco Communications, Inc., the company that publishes AT Forum.
When asked about her background, Sue liked to say she’d “come up through advertising.” She graduated from Michigan State with a BA in Advertising, then worked in media development for consumer-oriented accounts at BBD, Needham Harper & Steers, Tatham Laird & Kudner, and other agencies.
Next came more than 10 years in account management at business-to-business medical advertising agencies, among them Noble Arnold & Associates.
And then Sue moved on to Addiction Treatment Forum. She felt that her mission there was to serve as a source of support and encouragement for the opioid addiction community, and as an advocate for medication-assisted treatment in opioid treatment programs. The publication’s primary goal, she believed, was to report what has happened, what is happening today, and what may develop tomorrow, to help further success in treating opioid addiction.
The first newsletter was published in the summer of 1992, a quarterly print publication, eight pages long. In the Fall of 2011, it became electronic only. The schedule became bimonthly in 2014, then monthly in August 2018. Over the years Sue also expanded the AT Forum website, providing news updates, white papers, special reports, and brochures, helping to achieve AT Forum’s mission and goal.
During those years, according to Sue’s closest friend, Joy Jacoby, Sue enjoyed a busy life. She and her husband, Chuck, had no children, but traveled extensively, and enjoyed doing things together—boating, playing golf, and hosting parties. In talking with Joy several days ago, I remembered that I’d been on the phone with Sue a couple of times when Chuck knocked on her office door and delivered a nice lunch he’d prepared.
After losing Chuck nine years ago, Sue lived rather quietly. She spent much of her time in her upstairs office in her home in Vernon Hills, a northwest suburb of Chicago. She’d dine with friends twice a month, and holidays might see her picking up a takeout dinner at a nice restaurant, but otherwise Sue wasn’t into get-togethers or dining out or leaving her office very often. Usually she didn’t even travel to Chicago, an easy 35-mile train ride. Occasionally, though, an out-of-town friend visited Chicago, and Sue would take a cab into the city.
But she always took very seriously, and gladly accepted, her responsibilities to AT Forum, as she saw them: communicating with others in the addiction treatment field, learning from them, sharing her information and experiences. Spotting new trends, new ideas, new hopes for treatment. Getting to know people who were making, or would soon make, a difference in the field.
Despite her dislike for traveling, Sue regularly attended conferences of the American Association for the Treatment of Opioid Dependence (AATOD), no matter where the conferences were held. At those meetings Sue was the clear and obvious presence of AT Forum.
Above all, Sue cared about her readers, and communicated directly with them. The phone number listed in the newsletter rang in Sue’s office; faxes arrived there. She didn’t allow a secretary or answering service to intervene. An answering machine took over in her absence.
She cared most about readers who were seeking answers to questions about opioid addiction, especially those who had an addiction, or had a loved one who did; people who wanted personal advice about treatment, better treatment, better answers to addiction-related problems. When people called about places to go, resources to seek out—Sue listened, she offered suggestions, she helped.
She was deeply grateful for the differences AT Forum was able to make in peoples’ lives—yet she wouldn’t take credit personally. When we were drafting the 25th anniversary issue of our newsletter, Sue resisted all attempts to quote her at length, or to write about her contributions. But her pride shows in this brief quote she finally offered, about what AT Forum was able to accomplish:
People thanked AT Forum, because patients and OTP staff members were seeing improvements in their patients. Effective methadone dosing levels, and comprehensive care—things that AT Forum played a role in bringing about—were helping patients get better.
It was Sue’s determination and drive that helped her accomplish so much. When technology hit the medical communications scene, some time back, some people in marketing had trouble coping—especially people in Sue’s age group. Technology wasn’t easy for Sue, but she immediately grasped its potential. She saw the internet as a huge opportunity for patients and families to access more—and better—addiction resources. She realized that she could put the internet and its opportunities to even greater use if she personally stepped up to meet the new tech challenges. And so, when Twitter came along, Sue set up a Twitter account for AT Forum in February 2011, and personally managed all aspects of it. She did the same with Facebook.
A recent tally shows how effective her efforts were: Twitter: 3,070 tweets, 588 followers, 158 followings; Facebook: 1,155 likes, 1,280 followers. And 5,500 readers have signed up to be notified by email whenever AT Forum posts new content.
As time went on, Sue devoted more and more of her heart and soul to AT Forum. She spent most of her time in her office. I knew she was alone much of the time, so I sometimes sent her silly emails, little diversions, attempts at humor. She seemed to find them amusing. And when the working day was over—for her, that was often well into the evening—she would close the AT Forum computer files and click over to Words With Friends.
Just when you thought you knew her—and I’d worked with her for 12 years, so I thought I did—she’d startle you by doing something unexpected, often something thoughtful. A phone call—a gushing, “Wonderful article! Best you’ve ever written for AT Forum!” Another time, the mail brought a brief, sentimental note—with a very generous gift certificate for dinner for two.
Looking back at her long career at AT Forum, several things stand out. Sue carried the publication through a truly remarkable period: from the days when the only medication for opioid use disorder was methadone, routinely underdosed, to today, when buprenorphine and naltrexone are available as well, and adequate dosing of methadone is expected, even routine. Where we once had piecemeal treatments, we now have comprehensive care—meeting all the patient’s needs, not just needs directly related to addiction. Through it all, Sue’s intuition, born from her close ties with patients, guided her choice of coverage, so her readers had the stories—the information they needed—to keep up.
Especially notable, Sue’s era—and her influence—extended over one of the great sociomedical tragedies of recent times: the opioid crisis.
Sue covered all that, and more, guiding and encouraging her writers, putting to work the power of the press, supplying her readers with facts, with information they could trust.
And now, Sue is gone. It’s hard to realize that we’ve lost our publisher. We are devastated. But we know what we need to do, how to carry on. We will manage. She would have expected no less of us.
By Barbara Goodheart, ELS
A new review paper by Carlos Blanco, MD, PhD, and Nora Volkow, MD, nicely summarizes current and future management of opioid use disorder (OUD)—as one would expect from two outstanding researchers. Dr. Blanco is Director of the Division of Epidemiology, Services, and Prevention Research at the National Institute on Drug Abuse (NIDA), and Dr. Volkow is the Director of NIDA.
The first sections of the article cover screening, assessment, comorbid conditions, risk factors, prevention, and patient care. Concise charts present key points on withdrawal symptoms, drug therapy, management, models of care for medications, and interventions to improve the cascade of care.
Especially valuable is the second section, Future Directions, where the authors share a wealth of suggestions for prevention and treatment, arranged by topic.
High-priority needs include evidence-based prevention of opioid use disorders in adults and older youth, and clarification of associations between risk factors. Special targets for intervention are psychiatric comorbidities and broader environmental factors, such as policies and socioeconomic conditions.
Susceptibility to OUD seems to involve multiple genes, each having a minor influence. Some genes have already been implicated. The authors recommend studies with large sample sizes to help identify the effects of single genes, and clarification of the roles of genetic and environmental factors “in increasing the risk of [OUD] within and across racial or ethnic groups.”
Because reliable genetic biomarkers for methadone treatment do not exist, the authors suggest using network approaches to identify genes that work together in raising the risk of disease, or in influencing the response to treatment. The biomarker approach seems a promising one for uncovering new targets for drug therapy.
Many factors are involved in the opioid crisis; thus medications alone will not provide a complete answer. There’s a need for current treatments to become more available, and for new medications.
A promising strategy: develop medications that:
- Are more effective
- Help provide better, longer-lasting adherence
- Improve impulse control, reduce stress reactivity, and decrease conditioning to drug cues
- Strengthen the appeal of nondrug rewards
Also suggested: repurposing existing medications, developing strategies using transcranial magnetic stimulation and transcranial direct current stimulation, and clarifying the possible therapeutic role of marijuana and its components.
Training Health Professionals
There aren’t enough adequate residency programs in addiction, and there’s a lag in treatment capacity. Because training programs might not solve the personnel shortage, perhaps trained providers who are not currently offering treatment could be persuaded to return to patient care. Helpful in accomplishing this could be “combatting stigma, enhancing institutional support, and increasing reimbursement rates.”
Little is known about OUD in older people, ethnic minorities, and adolescents, and about the possible connection between patient gender and OUD prevention or treatment outcomes. In contrast, much is known about treating pregnant women, including the beneficial effects of methadone or buprenorphine treatment during pregnancy.
The HEAL Initiative: Helping End Addiction Long-term
Congress last year allocated $500 million for the HEAL initiative—a program to improve pain management and other aspects of treatment, and to minimize reliance on opioids. Priority areas include using existing basic science data to identify new pharmacologic targets, and developing new medications, or finding new applications for those that exist.
The authors identify three major thrusts of the initiative:
- Improve medications for overdose reversal, and develop therapies for respiratory depression
- Optimize existing treatments
- Perform clinical trials to identify best practices for treating neonatal abstinence syndrome
The authors believe that the results of the HEAL initiative “should lead to important advances in the prevention and treatment of opioid use disorder.”
Blanco C, Volkow ND. Management of opioid use disorder in the USA: present status and future directions. Lancet. 2019;393(10182):1760-1772. Published online March 13, 2019. Epub 2019 Mar 14. doi: 10.1016/S0140-6736(18)33078-2.
Study: Medicaid Expansion Under ACA Can Increase Access to OAT—But Better Access May Be Within Reach
By Barbara Goodheart, ELS
When Medicaid expansion was enacted under the Affordable Care Act (ACA), expectations were that patients with opioid use disorders (OUDs) in specialty substance use settings in expansion states would have better access to opioid agonist treatment (OAT). Several studies have now shown that to be the case.
A new study provides additional verification—and offers suggestions for even better access.
The study team, led by Ramin Mojtabai, MD, PhD, of Johns Hopkins, found that OAT did indeed increase after expansion: Medicaid admissions rose markedly in expansion states, but not in nonexpansion states. The paper was published April 30 on ps.psychiatryonline.org.
Investigators used administrative data on 943,430 admissions from the Treatment Episodes Data Set-Admissions (TEDS-A) data base. (TEDS-A, managed by the Substance Abuse and Mental Health Services Administration [SAMHSA], monitors admissions to specialty programs that accept public funds, and gathers information from most facilities that treat substance use disorders.)
The TEDS-A patients were admitted to regular or intensive outpatient treatment in the 31 states and two territories that reported appropriate insurance and payment data. The study focused on ambulatory care settings—the primary site for specialty OAT. About 80% of patient admissions who had Medicaid insurance listed Medicaid as primary payment source.
Increase in Admissions (%)
|With Medicaid Coverage||Involving Use of OAT|
Continuing the analysis, but restricting it to expansion states, revealed the following:
Increase in Admissions (%) 2010-2016 With Use of OAT in Expansion States
|States that included methadone in OAT coverage||41.1 to 52.7|
|States that did not include methadone in OAT coverage||11.7 to 20.8|
- After expansion, the increase in OAT use was greater in expansion states than in nonexpansion states (in large part because of proportionally more Medicaid admissions)
- Medicaid insurance was “strongly associated with OAT use”—supporting the theory that the increase in the use of OAT after expansion resulted from the increase in admissions with Medicaid in expansion states
How Access Can be Further Increased
Noting that many patients did not access treatment, the authors commented that “insurance coverage alone may not be sufficient to ensure access to evidence-based treatments.” They suggested steps for helping these patients access treatment: outreach, reorganization of treatment services, and recruitment of staff that can prescribe OAT medications. (They did not provide details on these steps, but one example that comes to mind about recruiting staff is bringing back to active prescribing status some of the many practitioners who are qualified to prescribe buprenorphine, but are not doing so.)
Medicaid coverage empowers patients to choose better treatment programs and to select sites where OAT is easily available. Covering more patients under Medicaid would enable services to hire caregivers that have prescribing privileges; these caregivers could then offer OAT to more patients.
A better understanding of how Medicaid expansion increases access to OAT could suggest ways to provide even better access for more patients.
Limitations of Other Studies
The Authors’ Take. The research team expressed some uncertainty about the findings of other studies—such as the use of OAT “may have increased”—and they cite the fact that those studies “were mainly based on drug utilization and pharmacy data, the number of providers able to prescribe OAT, or service-level data.”
Our Take. But no study is perfect. We see a limitation in the current study, because of the TEDS-A data base. TEDS-A does not include information from medical offices, where most buprenorphine patients receive their medication.
After reading other published studies in the field, we find it difficult to evaluate overall the effects of expansion. Here’s why: The studies use a variety of data bases; admission criteria vary; patient populations differ; dates used to define “expansion states” vary; state Medicaid programs vary—some do not cover methadone—and so forth.
But every study contributes some information to the knowledge base. And, as publication of studies on OAT access continues, we’ll have a clearer picture of the reasons behind the effects of expansion.
The authors of the current study close with this summary: “Although Medicaid expansion and other ACA provisions try to improve financial access to OAT, optimal use of OAT calls for reorganization of services and health system reforms to make these treatments more readily available.”
Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M. The Affordable Care Act and opioid agonist therapy for opioid use disorder. Psychiatr Serv. Ps.psychiatryonline.org. Apr. 30, 2019. doi: 10.1176/appi.ps.201900025
This study was supported by a grant from the National Institute on Drug Abuse.
By Alison Insinger
Despite years of attempting to do away with the regulation that protects the confidentiality of substance use disorder (SUD) treatment records—with almost all treatment organizations piling onto the bandwagon—the insurance industry has still not managed to do so.
The regulation, 42 CFR Part 2, has been chipped away at, allowing various exceptions, such as for the vaguely defined “healthcare operations.” And the federal government is now supporting getting rid of it as well, as are some—but not all—members of Congress.
Supporters of the Confidentiality Regulation Speak Up
The loudest supporter of the regulation is the American Medical Association, which last fall stopped the measure from getting through Congress, with an important letter making it clear that—as opioid treatment programs (OTPs) well know—patients would probably not want to go to treatment if they didn’t have control over who had access to their records (see AT Forum tk).
In fact, this was the very reason for the institution of the regulation more than three decades ago—the late Bob Newman saw that police would follow patients into OTPs in New York City. This was obviously untenable, during what was then a heroin epidemic, because it discouraged patients from seeking treatment.
We are in the midst of another opioid epidemic, and it is not the time to discourage patients from seeking treatment.
But yet, led by the electronic health record (EHR) industry, this is still the case. Congress is now taking up new initiatives to get the measure passed.
Opponents Fight Back
The “Partnership to Amend 42 CFR Part 2” is led by Pamela Greenberg, the same person who heads the Association for Behavioral Health and Wellness, a membership organization of behavioral health insurance companies. The partnership includes the American Society of Addiction Medicine and the National Association of Addiction Treatment Providers, and it supports the Overdose Prevention and Patient Safety Act, issued this spring in the House, and the Protecting Jessica Grubb’s Legacy Act introduced this spring in the Senate.
The identical bills would accomplish what similar bills—which failed last year due to the AMA’s intervention and the constant opposition by AATOD, the Legal Action Center, and Faces & Voices of Recovery—would have done—replace 42 CFR Part 2 with HIPAA, but include “protections against the use of addiction records in criminal, civil, or administrative proceedings,” according to the Partnership. What the bills would not allow, however, is the essence of 42 CFR Part 2, which is that SUD treatment providers cannot release patient information to anyone without specific written consent by the patient.
Part 2: Protection, or Endangerment?
Speaking for ASAM, R. Corey Waller, MD, said: “Today, patients suffering with addiction are often caught within a siloed system where—depending on where they receive care—doctors may lack critical patient information—creating life-threatening blind spots. As currently written, Part 2—which applies only to substance use disorder treatment in select healthcare settings—endangers the very lives it intends to protect. ASAM applauds the introduction of the Overdose Prevention and Patient Safety Act and the efforts of Congressional leaders to bring Part 2 into the 21st Century. Allowing patient information related to substance use disorder to be safely integrated into the rest of the health care system will save lives.”
Others said that addiction patients weren’t treated fairly because they were being separated out from other patients. “It’s past time for health parity for persons with substance use disorders,” said Kevin Scalia, executive vice president of Netsmart, an EHR company. “Separating a person’s substance use treatment records from the rest of their medical record denies them fully-informed diagnosis and treatment from their doctors, increasing the chance of unintended prescribing errors, dangerous drug interactions and over-utilization. This common-sense bill aligns 42 CFR Part 2 more closely with HIPAA to enable integrated care, while adding increased anti-discrimination and patient privacy protections.”
In the meantime, patients say they would not go to treatment if they didn’t have control over their information.
For more coverage of 42 CFR Part 2 and OTPs, see
By Alison Insinger
The key to keeping methadone and opioid treatment programs (OTPs) in the sights of appropriators is the phrase “all three medications” when referring to “MAT” (medication-assisted treatment) to treat opioid use disorder (OUD). That’s because there are only three medications approved by the Food and Drug Administration to treat OUD—methadone, buprenorphine, and naltrexone—and only one of them can be dispensed only by an OTP—methadone. That point will be key to remember as funders in Washington move forward with continued increases in treatment funding for OUD.
Appropriations—the process by which Congress funds programs in the federal government—went well in the House of Representatives for substance use disorder in May. Next stop: The Senate.
House Funds Many SAMHSA Items
On May 8, the House Appropriations Committee approved the fiscal year 2020 Labor, Health and Human Services, Education, and Related Agencies bill on a vote of 30 to 23, which includes funding for the Substance Abuse and Mental Health Services Administration (SAMHSA) and other agencies within the Department of Health and Human Services, as well as the Departments of Labor and Education and other agencies.
Below are selected items from the bill:
- In total, the draft bill includes $189.8 billion in discretionary funding, an increase of $11.7 billion over the 2019 enacted level and $47.8 billion over the President’s 2020 budget request.
- $140 million to support CDC’s efforts to reduce new HIV infections by 90% in 10 years.
- The bill funds SAMHSA at $5.9 billion—$115 million above the 2019 enacted level and $179 million above the President’s budget request.
- Substance use treatment: $3.8 billion, an increase of $14 million, including continued funding for opioid use disorder prevention and treatment, and three new behavioral health programs to enhance treatment efforts.
- State Opioid Response (SOR) grants: $1.5 billion “for carrying out activities pertaining to opioids undertaken by the State agency responsible for administering the substance abuse prevention and treatment block grant” (level funding compared to FY 2019 and the President’s request).
- $50,000,000 of the $1.5 billion for SOR shall be made available to Indian Tribes or tribal organizations.
- 15% of the remaining amount shall be for the States with the highest opioid-related mortality rate .
- Substance use treatment within SAMHSA: $3.751 billion, “an increase of $14 million, including continued funding for opioid prevention and treatment, and three new behavioral health programs to enhance treatment efforts.”
- National Institute on Drug Abuse (NIDA): $1,489,237,000 ($70 million above FY 2019; $193 million above President’s request).
- National Institute on Alcohol Abuse and Alcoholism (NIAAA): $551 million ($25 million above FY 2019; $99 million above President’s request).
- Centers for Disease Control and Prevention (CDC)—Injury Prevention and Control: $697,559,000 ($49 million above FY 2019; $69 million above President’s request).
- CDC—Chronic Disease Prevention and Health Promotion: $1,073,121,000 ($114 million cut compared to FY 2019; $122 million above President’s request).
Importance of Payment
In a policy paper issued earlier this year (see http://atforum.com/2018/12/aatod-policy-methadone-buprenorphine/ for an advance review), AATOD president Mark Parrino made it clear that the biggest problem is lack of reimbursement. “Unless payors recognize that there is a need to reimburse treatment wherever patients receive care for their OUD, there will be no way out of this public health crisis,” the paper stated, noting that 11 states still do not provide Medicaid reimbursement for OTPs. However, soon, Medicare beneficiaries will be able to receive reimbursement for OTP services (see http://atforum.com/2019/04/cms-samhsa-visit-otps-bundled-rate/). Medicare reimbursement was a huge success for AATOD and for OTPs, which saw patients having to drop out of treatment when they turned 65 and lost Medicaid.
Earlier this year, the Bipartisan Policy Center released a report tracking federal funding of the opioid crisis (for the report, go to https://bipartisanpolicy.org/library/tracking-federal-fundingto-combat-the-opioid-crisis/), which focused on states that relied on SAMHSA’s STR and SOR grants. It’s also important to expand Medicaid, the report noted.
For the AATOD policy paper, go to http://www.aatod.org/wp-content/uploads/2019/02/2019-Policy-Paper.pdf
For the full text of the House HHS/Labor/Education appropriations bill:
The Senate will take up appropriations this summer. Vigilance will be required to make sure that OTPs and methadone are kept in appropriators’ mindset, so that comprehensive care is available for patients who need it, especially in the early stages of their treatment.
By Alison Insinger
Does for-profit status connote anything at all about the quality of treatment, about how well patients are cared for, about the responsibility of the program to the community, or about whether the program requires self-pay or takes insurance? It does not. “What I have found in my dual experience, as a patient advocate and as a provider, is that there are good and bad in both profit and not-for-profit OTPs,” says Zachary Talbott, MSW, MATS, who until recently was with BayMark Health Services.
Some for-profit (otherwise known as proprietary) opioid treatment programs (OTPs) are self-pay only—these are likely to operate in states that don’t allow Medicaid to pay for treatment. Not-for-profit OTPs that operate in those states are also usually self-pay only.
Comparing OTPs: What Matters Is the Staff
“To my knowledge, there are no head-to-head comparisons for OTPs, but it’s not as if not-for-profits are the holy Grail,” said Mr. Talbott, noting that salaries of chief executives at not-for-profits like the American Red Cross are astronomical.
“We need a balance of different models,” said Mr. Talbott. “As someone who has opened and owned and worked in for-profit programs, it’s best to have various models.”
There are some funding opportunities that are open only to not-for-profits. This was not true of the SAMHSA Opioid STR funding, which could go to for-profit OTPs, if the recipient state agreed to allocate the funding to OTPs. But it is true of some grants that come from SAMHSA, and some that come from other public funders.
What really matters—the heart of any OTP—is the staff, said Mr. Talbott. “This is true of any program, public or private, profit or not for profit,” he said. “Who is the program director, and what is the organizational culture within the same larger entity?”
Mergers and acquisitions have driven most of the OTP growth over the past decade in OTPs. Mr. Talbott’s programs—Counseling Solutions Treatment Centers— were acquired by BayMark last year, and while they are for-profit, there were no signs that they cut corners on treatment.
But sometimes the acquisitions make for hugely different programs within the same company. For example, there are two OTPs that are drastically different in reputation, located within two hours of each other, acquired and currently operated by the same entity. The staff working there—of which a majority came with the programs—are the reason for the differences.
It is important for executives at for-profit chains to be aware of where problems from rapid expansion can lead, if good training isn’t involved.
Spending—and Justifying It
If you are a small independent OTP—for-profit or not—and you want, for example, to send some staff to the AATOD conference, you could, without worrying that your profit margins will be a bit down for that quarter. Once you are part of a big program, with bean counters, you may have to justify every dollar you spend.
A whole other category in the for-profit sector is the private equity situation, which is growing throughout all of health care, including OTPs. “I think the jury is still out, on what private equity means for our field,” said Mr. Talbott. “I hope it means something positive.”
Training Quality Staff Is Essential
But regardless of whether the funding comes from private equity or a private investor or a mammoth not-for-profit that decides to invest in OTPs, it takes time to train and develop quality staff. This is particularly true in OTPs, and it’s why expansion can’t take place overnight.
“This is a niche treatment,” said Mr. Talbott. “We strive for therapeutic presence—for patients to know that they’re in a safe place, a place where they are cared for.” He’s one of the first ones to call for expanding treatment, but as Mark Parrino (AATOD president) himself pointed out, if methadone treatment is expanded before quality staff can be recruited and trained, it may fail.
Mr. Talbott left BayMark on good terms in May. Someone who credits his own long-term sustained recovery from opioid use disorder to methadone treatment himself, and an advocate, he started Counseling Solutions Treatment Centers in Chatsworth, Georgia and Brasstown, North Carolina, in 2015 and 2016, respectively. For more stories about him in AT Forum, go to