AT Forum Volume 29, #3 April/May 2018
Categories: Newsletter, TOC
Has the Medicaid Expansion Issue Finally Been Settled? If so, What’s the Best Way to Make Expansion Work?
By Barbara Goodheart, ELS
Much has been written about the impact of Medicaid expansion on the opioid crisis and access to medication-assisted treatment (MAT). A group associated with amfAR, the Foundation for AIDS Research, has helped put the issue to rest.
Under lead author Alana Sharp, the group gathered data from all states, from 2011 to 2016—covering the years before and after expansion—to assess the effects of expansion.
Did Medicaid Expansion Worsen the Opioid Crisis?
More opioid prescriptions were written for Medicaid enrollees after expansion than before. The number written increased almost equally in expansion states and in nonexpansion states.
Expansion states saw a marked increase—more than 200%, the authors estimated—in prescriptions written for buprenorphine and naltrexone. In nonexpansion states, the increase in prescriptions written was far less— estimated at less than 50%.
Methadone prescribing dropped in all states, but the drop was greatest in expansion states.
Unlike buprenorphine and naltrexone, methadone is prescribed for pain as well as for opioid use disorder (OUD). This meant that investigators couldn’t separate the data to figure out what effect Medicaid expansion had on the number of methadone prescriptions written specifically for OUD.
The Answers
So, has Medicaid expansion worsened the opioid crisis? “No.”
Is Medicaid expansion helping patients with SUDs obtain opioid medications and treatment? Clearly the answer is, “Yes.”
Putting Medicaid Expansion to Work
Medicaid expansion can be a useful tool—but Medicaid itself must be “substantially strengthened” first. That’s the opinion of Keith Humphreys, PhD, the Esther Ting Memorial Professor of Psychiatry and Behavioral Sciences at Stanford University, expressed in an editorial in the same issue. Dr. Humphreys, who is a member of the Stanford Neurosciences Institute, works with policy makers to reduce the negative impact of substance use on public health and safety.
Regarding the amfAR team’s findings, Dr. Humphreys called them “a welcome indication that Medicaid can in fact contribute to resolving the most destructive epidemic that the United States has faced in decades.” The American Journal of Public Health published the amfAR article and Dr. Humphreys’ editorial in its May issue.
Testing—and Improving—Medicaid
States can use Section 1115 Medicaid waivers to shape some Medicaid provisions to their advantage. Medicaid expansion has been critically important for low-income adults in New York and three other states, according to an October 4, 2017 report from the Center on Budget and Policy Priorities. New York received $7.7 billion for adults in Medicaid expansion in federal fiscal year 2015, a Medicaid in New York fact sheet said.
In Pennsylvania, health leaders are reportedly “thrilled” by a dramatic drop in the state’s uninsured population. A 16-county area that includes Philadelphia has enrolled nearly 10,000 newly eligible people. (Enrollment updates are available on the waiver-tracker from the Kaiser Family Foundation; see References.)
Getting the Best Results From Medicaid Expansion
How can states get the most out of Medicaid expansion? Dr. Humphreys listed several requirements if Medicaid expansion is to reach its maximum effectiveness.
All states need to participate in the expansion
The map below shows 10 remaining holdouts—9 states and Washington, DC—as of May 24.
All Medicaid programs should cover the four levels of care specified by the American Society of Addiction Medicine (ASAM) (see citation in References).
The levels of care are standard outpatient, intensive outpatient, residential inpatient, and medical inpatient. Usually patients with OUD need more than just medication. At this writing, estimates indicate that only about a dozen state Medicaid programs cover all four.
Medicaid programs should cover—at higher rates—more services related to substance use.
States that do currently reimburse may be setting their rates too low, Dr. Humphreys said. Because current average rates are lower than those of other insurances, it’s difficult for patients to find providers. Dr. Humphreys believes that broader coverage would likely drop crime levels and cut transmission of hepatitis C virus (HCV) and HIV—probably resulting in fewer overdoses, and a healthier population of patients with OUD.
All insurance plans—not just Medicaid—need to find ways to reduce opioid overprescribing, misuse, and related problems.
Dr. Humphreys noted in his article the value of Medicaid in the response to the opioid epidemic—but he added that decisions “to not sufficiently expand its number of enrollees and the scope of its services” have limited Medicaid’s potential.
(As we were closing this issue, a spokesperson at ASAM alerted us to a new publication, Report to Congress on Medicaid and CHIP. This report includes a lengthy chapter with helpful information for opioid treatment programs: “Access to Treatment for Substance Use Disorders in Medicaid” [see Resources].)
AT Forum asked Dr. Humphreys what types of additional Medicaid expansion would be most useful. He referred us to a paper he coauthored on this topic, published in Health Affairs (see References).
The article noted that the failure of many states to cover all levels of care restricts treatment providers who are trying to make the best decisions for patients. For example, patients assessed as “needs close monitoring” are at high risk in states that fail to cover residential treatment, or level 3 residential, or level 2 intensive outpatient services.
The article also questioned the clinical guidelines used to decide on preauthorization policies and annual maximums, and those used to determine if access to “needed substance use disorder services are unnecessarily or inappropriately denied.”
A third key concern: lack of coverage of all four medications for opioid use disorders—something that’s necessary for effective treatment. They point in particular to methadone—“the medication covered by the fewest states”—despite the fact that methadone remains the “most efficacious and rigorously studied medication” for opioid use disorders.
What Comes Next?
Now that it’s clear that Medicaid expansion isn’t at fault for the opioid crisis, where does the real problem lie?
Dr. Humphreys has raised a possibility—one that he hopes a Senate hearing will explore—that what really has worsened the opioid crisis is not Medicaid expansion, but “our failure to expand Medicaid.”
Perhaps the Senate will take another look at the problem, with a fresh eye.
References
Sharp A, Jones A, Sherwood J, Kutsa O, Honermann B, Millett G. Impact of Medicaid expansion on access to opioid analgesic medications and medication-assisted treatment. AJPH. 2018;108(5):642-648. Epub April 4, 2018.
Humphreys K. How Medicaid can strengthen the national response to the opioid epidemic [editorial]. AJPH. 2018;108(5):589-590. Epub April 4, 2018.
Broaddus M, Bailey P, Aron-Dine A. Medicaid Expansion Dramatically Increased Coverage for People with Opioid-Use Disorders, Latest Data Show. Washington, DC: Center on Budget and Policy Priorities; February 28, 2018. https://www.cbpp.org/sites/default/files/atoms/files/2-28-18health.pdf.
Medicaid in New York. June 2017. Fact Sheet. The Henry J. Kaiser Family Foundation. http://files.kff.org/attachment/fact-sheet-medicaid-state-NY.
One Year in, Pennsylvania Medicaid expansion prompts celebration and new outreach. Elana Gordon, April 29, 2016. From a reporting partnership that includes WHYY, NPR, and Kaiser Health News. https://whyy.org/articles/one-year-in-pennsylvania-medicaid-expansion-prompts-celebration-and-new-outreach/.
Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? May 24, 2018. The Henry J. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/which-states-have-approved-and-pending-section-1115-medicaid-waivers/.
What are the ASAM Levels of Care? Continuum: The ASAM Criteria Decision Engine. Knowledge Base. May 13, 2015. https://www.asamcontinuum.org/knowledgebase/what-are-the-asam-levels-of-care.
Katch H. Medicaid Expansion is Critical for States Fighting Opioid Epidemic. Washington, DC: Center on Budget and Policy Priorities; October 4, 2017. https://www.cbpp.org/blog/medicaid-expansion-is-critical-for-states-fighting-opioid-epidemic.
Grogan CM, Andrews C, Abraham A, et al. Survey highlights differences in Medicaid coverage for substance use treatment and opioid use disorder medications. Health Affairs. 35:2016;12:2289-2296.
Resources
MACPAC. Penny Thompson, MPA, Chair. Chapter 4: Access to Substance Use Disorder Treatment in Medicaid. In: Medicaid and CHIP Payment and Access Commission. Report to Congress on Medicaid and CHIP. South Washington, DC. June 2018;80-112. https://www.macpac.gov/wp-content/uploads/2018/06/Access-to-Substance-Use-Disorder-Treatment-in-Medicaid.pdf. Accessed June 21, 2018.
Categories: Buprenorphine, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), naltrexone, Newsletter, Opioid Abuse/Addiction
Tags: Health Insurance, Medicaid, Medication-Assisted Treatment
SAMHSA Gives No Information on How Many Patients Are on Buprenorphine or How Well They Are Doing
By Alison Knopf
Opioid treatment programs (OTPs) must submit a plethora of information on their services to the Substance Abuse and Mental Health Services Administration (SAMHSA). Office-based outpatient treatment (OBOT) providers who prescribe buprenorphine must submit exactly nothing, it appears.
On May 20, we asked SAMHSA, “How is office-based treatment with buprenorphine working, since the patient cap was increased from 100 to 275 in July of 2016? How many patients are getting treatment? What kind of treatment are they getting? Are doctors reporting anything?”
On May 23, SAMHSA responded: “The only MAT data we have would be from N-SSATS, and that doesn’t include private practitioners.” (N-SSATS is the National Survey of Substance Abuse Treatment Services.)
SAMHSA then provided this statement: “SAMHSA promotes access to medication-assisted treatment for opioid use disorder through training of providers (e.g., physicians, nurse practitioners, and physician assistants). For example, the 4,151 buprenorphine prescribers who have increased their patient limit from 100 to 275 represent the potential to treat up to 726,425 additional people with opioid use disorder. Starting with the 2019 National Survey on Drug Use and Health [NSDUH], SAMHSA is planning to include questions on the use of medication-assisted treatment among Americans for the treatment of opioid and alcohol use disorders.”
The Actual Number, Please; Not the Potential Number
We explained that we were asking about the actual number of patients being treated, not the “potential” number. “There is no mechanism for that,” was SAMHSA’s response. That’s why they’re going to use NSDUH, which self-reports—not from everyone, but from a selected sample. They extrapolate the information from the sample.
Either SAMHSA is getting reports from doctors and not telling anyone about it, or is not getting reports from doctors.
So, SAMHSA requires the waiver that allows providers to prescribe buprenorphine for treating opioid use disorder; SAMHSA allows doctors to prescribe to no more than 275 patients; and then SAMHSA collects no data from doctors on what they are actually doing: how many patients are being treated, whether they are going over the cap [the maximum they can prescribe to], whether they are referring patients for counseling, or testing urine for traces of drug use, or anything else.
It was only after we sent SAMHSA a link to their own reporting form (https://www.surveygizmo.com/s3/3854276/Mandatory-275-Waiver-Report/) that we got this response: “The purpose of those reports is to verify that people are either being provided with or referred to counseling. At this time, our Policy Lab is working to further analyze the incoming data and determine how it can be used.”
AATOD Responds
“SAMHSA would have been better positioned if they would have gone through with their last Federal Register notice, which would have collected data from the physician practices that wanted to treat over 100 patients,” said Mark Parrino, MPH, president of the American Association for the Treatment of Opioid Dependence (AATOD). “SAMHSA lost its opportunity to have any insight on what is happening in these practice settings.”
ASAM Responds
Kelly J. Clark, MD, president of the American Society of Addiction Medicine (ASAM), noted that significantly more physicians have requested a waiver to treat up to 275 patients than the Department of Health and Human Services (HHS) had anticipated. The final rule estimated that 1,150 physicians would request the waiver in the first year, and a total of 1,950 by the end of five years. As of May 22, there are 4,151 physicians with waivers to prescribe to up to 275 patients, as SAMHSA stated. “This is a significant increase in physician prescribing capacity,” said Dr. Clark.
The Required Data . . . Aren’t Available
Dr. Clark said that physicians with waivers to prescribe to up to 275 patients are required to report their average number of patients, by month, as well as other statistics. But these data are not, as SAMHSA said, available.
Clark added that mid-level practitioners are now prescribing buprenorphine as well as physicians.
As of May 18, a total of 11,491 nurse practitioners (NPs) and physician assistants (PAs) have registered for the free 24-hour training that ASAM offers, in collaboration with AANP and AAPA. Already, over half of those who have registered have completed the training, she said. ASAM is compiling the results of surveys of the NPs and PAs. “We want to learn more about their experience with the training, patient care and other educational needs.”
Categories: Buprenorphine, Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioids
Tags: Buprenorphine, SAMHSA
Profiles of Today’s OTP Leaders
By Alison Knopf
Plenty of opioid treatment program executives are leaders in the field, but their names don’t get out nearly enough. This article is meant to change that. The list of leaders isn’t exhaustive, but it includes some of those at the helm of the nation’s opioid treatment programs (OTPs).
AT Forum asked the leaders what they consider their main achievements, what they see as the field’s biggest challenges, and what specific reasons they have—if any—for their deep interest in the opioid treatment field.
Their stories clearly reveal their love of the addiction treatment field. Surprisingly, when they entered the field, several had no intention of making it a long-term career commitment. But they started in it, for one reason or another, and simply “fell in love” with it.
We have profiled the following OTP leaders:
Their stories are below.
Ann Jamieson
Ann Jamieson, MS, aged 46, is the Chief Operating Officer and Director of Professional Development for Maric Healthcare, a Tulsa, Oklahoma-based company operating OTPs across six states. Ms. Jamieson recently served as the Executive Director of Oklahoma Treatment Services, which runs seven OTPs in Oklahoma.
Ms. Jamieson received a BS in Psychology from Louisiana State University, and an MS in Counseling from Northeastern State University. She is licensed as a mental health and addictions counselor, and as a clinic supervisor.
When she was 25 years old, Ms. Jamieson started her career in opioid treatment—first, as a drug and alcohol counselor. Her passion for the field grew into a 21-year career, evolving from counselor to program director, then to many other leadership roles.
Under Ms. Jamieson’s leadership, the Oklahoma Association for the Treatment of Opioid Dependence (OKATOD) was established in 2010; she was elected its first president and AATOD delegate. Beginning in 2000, Ms. Jamieson was instrumental in expanding access to treatment, helping to open clinics in North Carolina, Oklahoma and Colorado. She continues to consult on CARF, regulatory compliance, and best practices for facilities within Maric Healthcare.
Ms. Jamieson has developed a series of trainings—approved by NAADAC—for CEU credits specific to substance use and unique to the needs of OTP providers and practitioners, and delivers training workshops across several states. As Director of Professional Development, she created an extensive set of initial and ongoing training programs for personnel at the OTPs managed by Maric Healthcare. These trainings have been vital to improving competencies of OTP personnel, and improving the quality of treatment and reputation of OTPs in many states.
Ms. Jamieson’s goals are to continue to improve the quality of treatment across Maric’s OTPs, and to engage in initiatives to improve opioid treatment throughout Oklahoma, working with OKATOD, and throughout the United States, working with AATOD.
“In the current climate of opioid treatment in the United States, it is essential that OTP leaders serve as gatekeepers and ensure that OTPs are providing no less than the highest quality of services to a population of patients that need this life-saving treatment,” concludes Ms. Jamieson. “In order to reach so many whose lives are at risk we have to battle a pervasive stigma that permeates our modality of treatment and serves as a strong accessibility barrier to treatment. This is what I strive for every single day.”
Jason Kletter
Jason Kletter, PhD, aged 47, is the President of BayMark Health Services, where he has worked for 25 years in operational, management, and executive roles. As his parents founded BAART (Bay Area Addiction Research and Treatment) in 1977, and added more programs, he grew up “hanging around” in the clinics, then working summers doing Medicaid billing through high school. His first clinic jobs in college included front-desk work, urine collection, then counseling and intakes. He assumed a leadership role in 1999 when BAART had 10 clinics in California.
He and his siblings grew BAART to 23 clinics in five states before partnering with Webster Capital, and then MedMark Treatment Centers. He then worked with the BayMark management team to grow the company to 167 locations in North America.
Dr. Kletter in 2010 led a successful campaign to block the effort by former Governor Schwarzenegger to eliminate Medicaid funding for addiction treatment services in California. He worked with the California Department of Health Care Services to adopt the hub-and-spoke model in the state, using the largest allocation of Opioid STR grant funding of any state to develop 19 hub-and-spoke systems.
Dr. Kletter earned his doctorate in organizational psychology in 2001. He serves as the President of the California Opioid Maintenance Providers (COMP), representing the state association with the largest group of opioid treatment programs in the country; and as a board member of the American Association for the Treatment of Opioid Dependence (AATOD). Dr. Kletter also Chairs the AATOD Legislative Affairs Committee.
The AATOD Nyswander-Dole awardee in 2015, Dr. Kletter works regularly with local, state, and federal government officials to advise on regulations, policy, funding, and health care trends. Dr. Kletter has served as advisor to the California State Department of Health Care Services on many committees, including the Narcotic Treatment Program Advisory Committee, The California Outcome Management System Workgroup, the Counselor Certification Advisory Committee, and the 1115 Waiver Advisory Group.
He has also participated in federal Substance Abuse and Mental Health Services Administration initiatives, advising on accreditation guidelines and evaluating training curricula for opioid treatment program physicians, as well as advising state legislators helping to craft sound policy into legislation. Dr. Kletter was appointed by California’s Governor Jerry Brown to the Lawyers Assistance Program Oversight Committee in 2013.
“The opioid epidemic in the U.S. and Canada has wreaked havoc on peoples’ lives, families, and communities,” said Dr. Kletter. “Like the HIV epidemic of the 1980s, the current opioid epidemic has created widespread awareness about opioid use disorder. With that awareness has come a tsunami of opinions about how to treat opioid use disorder, and more broadly about how to solve the epidemic.
“Many of those opinions are science-based and innovative, but some are philosophically based and potentially harmful. Our field must remain vigilant in educating our communities, and especially policy-makers, at all levels, as often as possible, about opioid use disorder and the effectiveness of medication-assisted treatment.”
On the bright side, the attention has brought significant new resources to treatment, added Dr. Kletter. And he urged the field to advocate for funding and policies that support a continuum of evidence-based services. “This means meeting with State Opioid Treatment Authorities and state and federal legislators to steer current and new funding toward increasing access to medication-assisted treatment and, critically, evaluating the effectiveness of all funding for opioid use disorder.”
On “medication-assisted treatment,” or MAT, Dr. Kletter said this can be delivered in various settings, all of which have merit. “We know from many years of research that MAT has the greatest chance of helping people recover from opioid use disorder,” he said. “But it’s critical that we not conflate terminology—MAT has always been defined as the use of medication in combination with robust psychosocial support services.
“More recently, there are efforts to undermine that science, suggesting that medication alone is sufficient to treat opioid use disorder. Our field must continue to ensure the provision of high-quality, evidence-based practices, despite calls by some for diluting the quality of care provided in the interest of prescribing more medications.”
Robert C. Lambert
Robert C. Lambert, MA, aged 54, president and executive director of Connecticut Counseling Centers, Inc., began as an entry level counselor in the center’s Methadone Maintenance Treatment Program (MMTP). He told AT Forum that he signed on immediately after graduating with a bachelor’s degree in psychology, “because it was the only decent position in the counseling field available at the time.”
Mr. Lambert admitted he didn’t know much about methadone back then. “I fully intended to work as a methadone counselor for a year or two, to gain some experience, then move on to a ‘real’ counseling position,” he said. His goal was to become a clinical psychologist; in fact, at the time he had no real interest in addiction treatment.
“However, during that first year, I fell in love with the population I was treating, and never left.”
Among his accomplishments, Mr. Lambert, now a Licensed Alcohol and Drug Counselor with 31 years of experience in the field, created the Connecticut Certified Alcohol and Drug Abuse Counselor Training Program; helped establish a Master’s Degree Certificate Program in Addictions Counseling at Albertus Magnus College; and created and implemented the nationally recognized innovative MMTP based peer-mentoring program, Bridge to Recovery.
In 2012 his Bridge to Recovery program received the prestigious Substance Abuse and Mental Health Services Administration “Science and Service” award. This was followed in 2016 by the Nyswander-Dole (Marie) Award, presented to Mr. Lambert by the American Association for the Treatment of Opioid Dependence (AATOD).
Mr. Lambert also had a role in significantly expanding access to medication-assisted treatment (MAT) in Connecticut, where he chairs the Methadone Treatment Provider Group. Mr. Lambert is currently a member of the AATOD Board of Directors and is the Chair of the 2019 AATOD Conference Workshop Committee.
But he’s not resting on his laurels. His goals include expanding access to all approved medications for opioid use disorders, regardless of insurance coverage. This applies to OTPs as well, for OTPs must now embrace all FDA-approved medications, he said. In addition, “collectively, we need to keep the pressure on to achieve parity.”
Another goal is to eliminate or at least greatly reduce stigma, which is responsible for so many barriers to care, he said. To that end, Mr. Lambert has facilitated numerous regional and national forums on stigma and misinformation regarding MAT. He has also authored research on MAT related attitudes in the behavioral healthcare field and the effect of stigma on counselor expectations and patient outcomes in MAT.
Finally, Mr. Lambert emphasizes that during this current period of MAT expansion, programs must make sure that quality of care is consistent, and high. “The world is watching,” he said.
Christine Martin
Christine Martin, LMFT, CACII, aged 35, is director of clinical services for Center for Behavioral Health, North Charleston, South Carolina. She started working as an OTP counselor shortly after completing her Master’s degree program in marriage and family therapy.
“Initially, I didn’t envision staying in the field, but it wasn’t long before I found myself invested in the work and passionate about the population and the treatment modality,” she said. Eventually, she was given the chance to advance with Center for Behavioral Health, an organization with 22 OTPs across the country.
In 2016 Ms. Martin was elected president of the state OTP association, SCATOD (South Carolina Association for the Treatment of Opioid Dependence). With that role came representations of the state on the AATOD board. She is also the spokeswoman for the South Carolina OTPs with the state drug and alcohol authority.
“We secured contracts with our state authority during year one of the Opioid STR grant to cover methadone treatment for pregnant and postpartum women unable to pay,” she said. For year two, this will be expanded to cover services for all patients who are indigent or cannot pay. “Our year-two contracts will include funding for OTPs to implement, at their sites, Overdose Education and Naloxone Distribution (OEND) programs,” she added.
Ms. Martin’s primary, immediate goal is to get coverage for OTP services under SC Medicaid. South Carolina is one of a handful of states that does not cover methadone treatment and OTP services under Medicaid. “We are continuing to work with SC DHHS, and hope to see this accomplished within the next year,” said Ms. Martin. “I would also love to see better integration of medication-assisted treatment in our drug courts and incarcerated settings here in South Carolina.”
Ms. Martin believes that the most important thing for OTPs to do now, while funding is being increased because of the opioid epidemic, is to reach out and work with their State Single Authority (SSA)—the agency or person in charge of the Substance Abuse Prevention and Treatment Block Grant, and the STR grants. “I think it is essential that we give input into the use of these funds, and better coordinate and expand the capacity of our systems of care,” she said. “There are quite a few care coordination models emerging where OTPs are being utilized for their specialty expertise.”
Finally, Ms. Martin urges OTPs to embrace the peer recovery movement. She serves on the board of FAVOR Lowcountry, her local Recovery Community Organization. “I see great value in people being able to recover within a fellowship of peers and within their communities,” she said. “In a couple of the states where Center for Behavioral Health operates, we’ve been able to use STR funds to begin adding peer support to our service array.”
She would also like to see more patients who are in medication-assisted treatment getting certified or trained to become peer coaches or support specialists. “I think it is important to have medication-supported recovery represented in this movement.”
Stacey Pearce
Stacey Pearce, aged 43, Chief Compliance Officer at Alliance Recovery Centers, in Georgia, started working in an OTP in 1995 as a part-time receptionist. “It was one of three jobs to pay my rent and bills,” she said. “I never had intentions of working in substance abuse treatment, and didn’t think I would make a career of it. But I really enjoyed watching the changes people were able to make in their lives after entering medication-assisted treatment.”
She decided that she wanted to work in the field, and changed her college classes to reflect that.
Mrs. Pearce has developed good relationships with many people in state offices to identify and meet the needs of patients and providers in the state. Among her other accomplishments, she opened an OTP in an underserved area in 2002 at the age of 27; has been a CARF surveyor; has been an active and involved AATOD board member for more than a decade; received the Nyswander-Dole (“Marie”) award; and helped organize Methadone Treatment Awareness Day at the state capitol.
Her top goal currently is to get a bundled rate from Medicaid, to cover take-home medication. She also wants OTPs and office-based providers to have better relationships, so patients “can receive more coordinated care that suits their needs and enhances their recovery,” she said. “Higher-need patients can be treated in OTPs, and once they become stable, and lower need, they can transition to OBOT.”
Pearce also wants to decrease stigma within the Department of Family and Children Services, and to be able to coordinate better with patients when there are open cases.
Finally, she wants to have medication-assisted treatment in the state’s correctional facilities.
Ms. Pearce urges more collaboration among OTPs. “I think one of the missing pieces within the leadership of many OTPs is a sense of commitment to the field as a whole and a willingness to do things for the greater good,” she said. “Many people are inwardly focused and involved in what is going on in their clinic or their small area of the world and are missing the broader conversation. By not being involved in the providers organization or group in your state, and not attending the national AATOD conference, you are missing opportunities for growth and learning. All levels of clinic personnel need to be involved in things and attend educational opportunities, or the facility will become stagnant and out of touch.”
Allegra Schorr
Allegra Schorr, aged 56, is president of the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA). Ms. Schorr has over 25 years of experience in health care and substance use treatment services. An owner and vice president of West Midtown Medical Group, an OTP, Ms. Schorr also represents New York State as a board member of AATOD, and was chair of the 2018 national AATOD conference.
Through her efforts, West Midtown Medical Group became the first opioid treatment program to dispense buprenorphine in an OTP setting in New York State. Most recently Ms. Schorr was appointed to the New York State Pain Management Steering Committee, formed as part of the State’s 2018-2019 Budget.
Ms. Schorr is a graduate of Sarah Lawrence College and expects to complete her Master’s of Science degree in Healthcare Management at Rutgers University-School of Health Professionals at the end of 2018.
Ms. Schorr’s father and uncles began managing Methadone Maintenance Treatment Programs in 1973. “I grew up around MMTPs and learned at an early age how methadone could help patients,” said Ms. Schorr. “After college, I worked on developing an HIV treatment program that would provide outpatient medical care for patients with HIV who were enrolled in the MMTP.” She submitted a certificate-of-need application for the MMTP to become certified as West Midtown Medical Group, a NYS Article 28 Diagnostic and Treatment Center—a comprehensive primary care facility with OTP and outpatient treatment for substance use disorders. (The MMTPs were Article 33 facilities.) The application was approved, and “my sister, cousins, and I became the owners of West Midtown Medical Group, located on West 35th Street in Midtown Manhattan.
“OTP leaders need to be alert to and speak out against stigma regarding MAT—and especially methadone,” said Ms. Schorr. On the other hand, “we need to hear legitimate criticism regarding our programs, and take positive steps to respond and improve things,” she said. “OTPs truly are essential hub sites and can provide leadership for the entire treatment field. The framework for OUD treatment in an OTP has enormous potential to offer integrated and coordinated care. Our leaders should think about how to utilize this structure to respond to our patients and our communities, and to turn the tide on the opioid epidemic.”
Ms. Schorr is also president of the Coalition of Medication-Assisted Treatment Providers and Advocates.
Nick Stavros
Nick Stavros, age 39, CEO of Community Medical Services, presided over the recent sale of the OTP platform to the private equity firm, Clearview Capital. The sale relieved the inactive owners of their equity in the company, and left Mr. Stavros as the largest individual owner. With Clearview leaving him at the helm as CEO, no operations are expected to change within the Arizona-based
Even though the OTP system began as a family business, Mr. Stavros did not grow up in the industry. “Five years ago, I didn’t know what methadone treatment was,” he told AT Forum. Prior to joining the company, he spent eight years in the military, and then left his position as an Infantry Captain and attended UCLA, where he earned an MBA. His parents, who founded the company in 1983, called him soon after and asked him to join the business to help them prepare the company for a sale. “This was in 2012,” he said. He was on the job for nine months, and found out that he had a strong passion for treating
So he changed course. Instead of prepping the company to sell to a larger organization, he decided he’d rather stay with it and partner with a private equity firm to buy out the other owners—family members and non-family members. “With the intention of staying with the company, I spent four years building a platform to grow from, to attract investors.” He partnered with Clearview Capital after meeting with numerous interested investors, because “they have an outstanding reputation in this space,” he said. “They’re pretty hands off and their values aligned most with
“I love what I’m doing,” said Mr. Stavros, asked why he is staying involved. “From an entrepreneurial perspective, this is an opportunity to build an amazing business. We are very patient-focused; We live by our values; I do a mission, vision, values presentation with every new employee and a weekly online town-hall meeting with the whole company. We make decisions based on our values and we are all impassioned by the uphill battle of our cause and by the tenacity of our patients in their recovery. There aren’t a lot of companies out there that continue to grow while staying true to their
Under his tenure, Community Medical Services has grown from 6-14 clinics in 4 states and from one Medicaid contract to more than 15. “Our goal was to be cash-flow neutral every year, investing every penny back into the company,” he said. “By the end of 2018, we’re going to be at 21 organic clinics and the private equity funds will allow us to potentially add on an additional 10-20 acquisitions. The goal is to be treating 60,000 patients by the end of 2022.” Currently, the program treats more than 5,000
There is still a shortage of slots nationwide. “One of the problems is that there is mostly just a consolidation taking place,” he said. “The growth rate of new OTPs isn’t coming close to paralleling the growth rate of the
Finally, Mr. Stavros seconded other leaders who said it’s important for OTPs to get involved in their communities and to seek out STR funds and other new forms of funding. “We are the largest recipient in the state of Arizona for STR funds,” he said. With those funds, the program has started the country’s first 24/7 OTP, a number of Medication Units, and a vibrant peer support
As with many other advocates in this space, Mr. Stavros has a personal connection to this field. His sister died from a heroin overdose when she was 21.
Zac Talbott
Zachary C. Talbott (“Zac”), aged 35, a native of Tennessee, is administrator and program director of Counseling Solutions Treatment Centers, based in Georgia. When he was at the University of Tennessee Knoxville College of Social Work, pursuing his Master of Social Work (MSW) degree, his addiction to prescription opioids and heroin spun out of control, leading to an academic dismissal.
After several years of “spiraling into the darkest places opioid addiction can take an individual,” as he puts it, Mr. Talbott found evidence-based treatment at an opioid treatment program (OTP). When he achieved a stable dose of methadone and took part in individual counseling, the “old Zac” quickly re-emerged. He then became involved in recovery advocacy, joining a Tennessee/Northwest Georgia Chapter of the National Alliance for Medication Assisted Recovery (NAMA), and serving on the national Board of Directors of NAMA until March of 2017.
Since he started his long-term recovery, Mr. Talbott has re-enrolled in the MSW program his addiction robbed him of years ago, and has opened two opioid treatment programs under the name “Counseling Solutions Treatment Centers”: Chatsworth, Georgia, in February 2016; and Brasstown (Murphy), North Carolina, in March 2017.
Mr. Talbott serves as program sponsor of both OTPs, and as program director of the OTP in Chatsworth, Georgia. He also co-founded, along with Sharon Dembinski—at the time, director of quality and clinical services for MedMark Treatment Centers—the Methadone (and buprenorphine) Discussion Group on Facebook.
As a “closed group,” where only approved members can see posts or make comments, the Methadone Discussion group has grown into the largest online community for Medication-Assisted Treatment (MAT) support and information, boasting more than 8,000 members. Most members are methadone and buprenorphine patients, but some are MAT providers and family and friends of MAT patients. Mr. Talbott was committed to ensuring that those enrolled in or considering MAT would always have a safe place to go; where credible information could be provided, and shared experiences in recovery would be a source of strength.
Mr. Talbott is a Certified Alcohol and Drug Counselor, Level II (CADC II), through the Alcohol & Drug Abuse Certification Board of Georgia (ADACBGA); a Certified Addictions Counselor, Level II (CAC II), through the Georgia Addiction Counselors Association (GACA); a Medication-Assisted Treatment Specialist (MATS), through the ADACBGA; an Internationally-Certified Alcohol & Drug Counselor (ICADC), through IC&RC; a Registered Addiction Specialist (RAS), through the Breining Institute; and a Certified Medication-Assisted Treatment Advocate (CMA), through NAMA Recovery. He currently serves on the Credentialing Committee and Board of Directors of the Alcohol and Drug Abuse Certification Board of Georgia (ADACBGA), and the Georgia IC&RC affiliate and addiction counselor credentialing body, as well as on the Board of Directors of the Southeastern Institute on Chemical Dependency (SICD).
Mr. Talbott has been a Recovery Month Planning Partner with the Substance Abuse and Mental Health Services Administration (SAMHSA) for the last four years. Despite his ability to successfully engage in medically supervised withdrawal, slowly tapering the dosage of his medication in transition to a medication-free state of recovery, he acknowledges that “one size does not fit all.” He believes firmly that our response to the opioid crisis must include public education that acknowledges long-term or even indefinite maintenance with methadone or buprenorphine may be necessary for some people, as it is for any other medication for any other illness. He remains passionate about evidence-based treatment approaches, and will always be, first and foremost, a patient advocate.
Mr. Talbott feels it is important that clinicians and medical professionals not lose their place in the leadership of an ever-merging field. Always remembering and acknowledging that opioid treatment programs first and foremost provide medical treatment and clinical care to an overly stigmatized and vulnerable population is critical to turning around the current opioid addiction and overdose epidemic. While he acknowledges that OTPs have a business component that is important to ongoing sustainability, he believes it is critical to ensure that physicians with expertise in addiction medicine, and counselors or clinical social workers with training in substance use disorders, remain in the leadership positions of companies that operate opioid treatment programs and office-based medication-assisted treatment clinics.
Dr. Mary Jeanne Kreek, one of the three founders of methadone treatment, alongside Doctors Vincent Dole and Marie Nyswander, inspired Mr. Talbott so deeply that her words remain his daily mantra. Dr. Kreek told him at the 2013 AATOD Conference in Philadelphia: “The love and care of patients is what everything we do and every decision we make should ultimately be about.”
Categories: Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Opioid Treatment Programs
Ann Jamieson
Ann Jamieson, MS, aged 46, is the Chief Operating Officer and Director of Professional Development for Maric Healthcare, a Tulsa, Oklahoma-based company operating OTPs across six states. Ms. Jamieson recently served as the Executive Director of Oklahoma Treatment Services, which runs seven OTPs in Oklahoma.
Ms. Jamieson received a BS in Psychology from Louisiana State University, and an MS in Counseling from Northeastern State University. She is licensed as a mental health and addictions counselor, and as a clinic supervisor.
When she was 25 years old, Ms. Jamieson started her career in opioid treatment—first, as a drug and alcohol counselor. Her passion for the field grew into a 21-year career, evolving from counselor to program director, then to many other leadership roles.
Under Ms. Jamieson’s leadership, the Oklahoma Association for the Treatment of Opioid Dependence (OKATOD) was established in 2010; she was elected its first president and AATOD delegate. Beginning in 2000, Ms. Jamieson was instrumental in expanding access to treatment, helping to open clinics in North Carolina, Oklahoma and Colorado. She continues to consult on CARF, regulatory compliance, and best practices for facilities within Maric Healthcare.
Ms. Jamieson has developed a series of trainings—approved by NAADAC—for CEU credits specific to substance use and unique to the needs of OTP providers and practitioners, and delivers training workshops across several states. As Director of Professional Development, she created an extensive set of initial and ongoing training programs for personnel at the OTPs managed by Maric Healthcare. These trainings have been vital to improving competencies of OTP personnel, and improving the quality of treatment and reputation of OTPs in many states.
Ms. Jamieson’s goals are to continue to improve the quality of treatment across Maric’s OTPs, and to engage in initiatives to improve opioid treatment throughout Oklahoma, working with OKATOD, and throughout the United States, working with AATOD.
“In the current climate of opioid treatment in the United States, it is essential that OTP leaders serve as gatekeepers and ensure that OTPs are providing no less than the highest quality of services to a population of patients that need this life-saving treatment,” concludes Ms. Jamieson. “In order to reach so many whose lives are at risk we have to battle a pervasive stigma that permeates our modality of treatment and serves as a strong accessibility barrier to treatment. This is what I strive for every single day.”
Categories: Medication-Assisted Treatment (MAT), Newsletter, Opioid Treatment Programs (OTPs)
Jason Kletter
Jason Kletter, PhD, aged 47, is the President of BayMark Health Services, where he has worked for 25 years in operational, management, and executive roles. As his parents founded BAART (Bay Area Addiction Research and Treatment) in 1977, and added more programs, he grew up “hanging around” in the clinics, then working summers doing Medicaid billing through high school. His first clinic jobs in college included front-desk work, urine collection, then counseling and intakes. He assumed a leadership role in 1999 when BAART had 10 clinics in California.
He and his siblings grew BAART to 23 clinics in five states before partnering with Webster Capital, and then MedMark Treatment Centers. He then worked with the BayMark management team to grow the company to 167 locations in North America.
Dr. Kletter in 2010 led a successful campaign to block the effort by former Governor Schwarzenegger to eliminate Medicaid funding for addiction treatment services in California. He worked with the California Department of Health Care Services to adopt the hub-and-spoke model in the state, using the largest allocation of Opioid STR grant funding of any state to develop 19 hub-and-spoke systems.
Dr. Kletter earned his doctorate in organizational psychology in 2001. He serves as the President of the California Opioid Maintenance Providers (COMP), representing the state association with the largest group of opioid treatment programs in the country; and as a board member of the American Association for the Treatment of Opioid Dependence (AATOD). Dr. Kletter also Chairs the AATOD Legislative Affairs Committee.
The AATOD Nyswander-Dole awardee in 2015, Dr. Kletter works regularly with local, state, and federal government officials to advise on regulations, policy, funding, and health care trends. Dr. Kletter has served as advisor to the California State Department of Health Care Services on many committees, including the Narcotic Treatment Program Advisory Committee, The California Outcome Management System Workgroup, the Counselor Certification Advisory Committee, and the 1115 Waiver Advisory Group.
He has also participated in federal Substance Abuse and Mental Health Services Administration initiatives, advising on accreditation guidelines and evaluating training curricula for opioid treatment program physicians, as well as advising state legislators helping to craft sound policy into legislation. Dr. Kletter was appointed by California’s Governor Jerry Brown to the Lawyers Assistance Program Oversight Committee in 2013.
“The opioid epidemic in the U.S. and Canada has wreaked havoc on peoples’ lives, families, and communities,” said Dr. Kletter. “Like the HIV epidemic of the 1980s, the current opioid epidemic has created widespread awareness about opioid use disorder. With that awareness has come a tsunami of opinions about how to treat opioid use disorder, and more broadly about how to solve the epidemic.
“Many of those opinions are science-based and innovative, but some are philosophically based and potentially harmful. Our field must remain vigilant in educating our communities, and especially policy-makers, at all levels, as often as possible, about opioid use disorder and the effectiveness of medication-assisted treatment.”
On the bright side, the attention has brought significant new resources to treatment, added Dr. Kletter. And he urged the field to advocate for funding and policies that support a continuum of evidence-based services. “This means meeting with State Opioid Treatment Authorities and state and federal legislators to steer current and new funding toward increasing access to medication-assisted treatment and, critically, evaluating the effectiveness of all funding for opioid use disorder.”
On “medication-assisted treatment,” or MAT, Dr. Kletter said this can be delivered in various settings, all of which have merit. “We know from many years of research that MAT has the greatest chance of helping people recover from opioid use disorder,” he said. “But it’s critical that we not conflate terminology—MAT has always been defined as the use of medication in combination with robust psychosocial support services.
“More recently, there are efforts to undermine that science, suggesting that medication alone is sufficient to treat opioid use disorder. Our field must continue to ensure the provision of high-quality, evidence-based practices, despite calls by some for diluting the quality of care provided in the interest of prescribing more medications.”
Categories: Medication-Assisted Treatment (MAT), Newsletter, Opioid Treatment Programs (OTPs)
Robert C. Lambert
Robert C. Lambert, MA, aged 54, president and executive director of Connecticut Counseling Centers, Inc., began as an entry level counselor in the center’s Methadone Maintenance Treatment Program (MMTP). He told AT Forum that he signed on immediately after graduating with a bachelor’s degree in psychology, “because it was the only decent position in the counseling field available at the time.”
Mr. Lambert admitted he didn’t know much about methadone back then. “I fully intended to work as a methadone counselor for a year or two, to gain some experience, then move on to a ‘real’ counseling position,” he said. His goal was to become a clinical psychologist; in fact, at the time he had no real interest in addiction treatment.
“However, during that first year, I fell in love with the population I was treating, and never left.”
Among his accomplishments, Mr. Lambert, now a Licensed Alcohol and Drug Counselor with 31 years of experience in the field, created the Connecticut Certified Alcohol and Drug Abuse Counselor Training Program; helped establish a Master’s Degree Certificate Program in Addictions Counseling at Albertus Magnus College; and created and implemented the nationally recognized innovative MMTP based peer-mentoring program, Bridge to Recovery.
In 2012 his Bridge to Recovery program received the prestigious Substance Abuse and Mental Health Services Administration “Science and Service” award. This was followed in 2016 by the Nyswander-Dole (Marie) Award, presented to Mr. Lambert by the American Association for the Treatment of Opioid Dependence (AATOD).
Mr. Lambert also had a role in significantly expanding access to medication-assisted treatment (MAT) in Connecticut, where he chairs the Methadone Treatment Provider Group. Mr. Lambert is currently a member of the AATOD Board of Directors and is the Chair of the 2019 AATOD Conference Workshop Committee.
But he’s not resting on his laurels. His goals include expanding access to all approved medications for opioid use disorders, regardless of insurance coverage. This applies to OTPs as well, for OTPs must now embrace all FDA-approved medications, he said. In addition, “collectively, we need to keep the pressure on to achieve parity.”
Another goal is to eliminate or at least greatly reduce stigma, which is responsible for so many barriers to care, he said. To that end, Mr. Lambert has facilitated numerous regional and national forums on stigma and misinformation regarding MAT. He has also authored research on MAT related attitudes in the behavioral healthcare field and the effect of stigma on counselor expectations and patient outcomes in MAT.
Finally, Mr. Lambert emphasizes that during this current period of MAT expansion, programs must make sure that quality of care is consistent, and high. “The world is watching,” he said.
Categories: Medication-Assisted Treatment (MAT), Newsletter, Opioid Treatment Programs (OTPs)
Christine Martin
Christine Martin, LMFT, CACII, aged 35, is director of clinical services for Center for Behavioral Health, North Charleston, South Carolina. She started working as an OTP counselor shortly after completing her Master’s degree program in marriage and family therapy.
“Initially, I didn’t envision staying in the field, but it wasn’t long before I found myself invested in the work and passionate about the population and the treatment modality,” she said. Eventually, she was given the chance to advance with Center for Behavioral Health, an organization with 22 OTPs across the country.
In 2016 Ms. Martin was elected president of the state OTP association, SCATOD (South Carolina Association for the Treatment of Opioid Dependence). With that role came representations of the state on the AATOD board. She is also the spokeswoman for the South Carolina OTPs with the state drug and alcohol authority.
“We secured contracts with our state authority during year one of the Opioid STR grant to cover methadone treatment for pregnant and postpartum women unable to pay,” she said. For year two, this will be expanded to cover services for all patients who are indigent or cannot pay. “Our year-two contracts will include funding for OTPs to implement, at their sites, Overdose Education and Naloxone Distribution (OEND) programs,” she added.
Ms. Martin’s primary, immediate goal is to get coverage for OTP services under SC Medicaid. South Carolina is one of a handful of states that does not cover methadone treatment and OTP services under Medicaid. “We are continuing to work with SC DHHS, and hope to see this accomplished within the next year,” said Ms. Martin. “I would also love to see better integration of medication-assisted treatment in our drug courts and incarcerated settings here in South Carolina.”
Ms. Martin believes that the most important thing for OTPs to do now, while funding is being increased because of the opioid epidemic, is to reach out and work with their State Single Authority (SSA)—the agency or person in charge of the Substance Abuse Prevention and Treatment Block Grant, and the STR grants. “I think it is essential that we give input into the use of these funds, and better coordinate and expand the capacity of our systems of care,” she said. “There are quite a few care coordination models emerging where OTPs are being utilized for their specialty expertise.”
Finally, Ms. Martin urges OTPs to embrace the peer recovery movement. She serves on the board of FAVOR Lowcountry, her local Recovery Community Organization. “I see great value in people being able to recover within a fellowship of peers and within their communities,” she said. “In a couple of the states where Center for Behavioral Health operates, we’ve been able to use STR funds to begin adding peer support to our service array.”
She would also like to see more patients who are in medication-assisted treatment getting certified or trained to become peer coaches or support specialists. “I think it is important to have medication-supported recovery represented in this movement.”
Categories: Medication-Assisted Treatment (MAT), Newsletter, Opioid Treatment Programs (OTPs)
Stacey Pearce
Stacey Pearce, aged 43, Chief Compliance Officer at Alliance Recovery Centers, in Georgia, started working in an OTP in 1995 as a part-time receptionist. “It was one of three jobs to pay my rent and bills,” she said. “I never had intentions of working in substance abuse treatment, and didn’t think I would make a career of it. But I really enjoyed watching the changes people were able to make in their lives after entering medication-assisted treatment.”
She decided that she wanted to work in the field, and changed her college classes to reflect that.
Mrs. Pearce has developed good relationships with many people in state offices to identify and meet the needs of patients and providers in the state. Among her other accomplishments, she opened an OTP in an underserved area in 2002 at the age of 27; has been a CARF surveyor; has been an active and involved AATOD board member for more than a decade; received the Nyswander-Dole (“Marie”) award; and helped organize Methadone Treatment Awareness Day at the state capitol.
Her top goal currently is to get a bundled rate from Medicaid, to cover take-home medication. She also wants OTPs and office-based providers to have better relationships, so patients “can receive more coordinated care that suits their needs and enhances their recovery,” she said. “Higher-need patients can be treated in OTPs, and once they become stable, and lower need, they can transition to OBOT.”
Pearce also wants to decrease stigma within the Department of Family and Children Services, and to be able to coordinate better with patients when there are open cases.
Finally, she wants to have medication-assisted treatment in the state’s correctional facilities.
Ms. Pearce urges more collaboration among OTPs. “I think one of the missing pieces within the leadership of many OTPs is a sense of commitment to the field as a whole and a willingness to do things for the greater good,” she said. “Many people are inwardly focused and involved in what is going on in their clinic or their small area of the world and are missing the broader conversation. By not being involved in the providers organization or group in your state, and not attending the national AATOD conference, you are missing opportunities for growth and learning. All levels of clinic personnel need to be involved in things and attend educational opportunities, or the facility will become stagnant and out of touch.”
Categories: Medication-Assisted Treatment (MAT), Newsletter, Opioid Treatment Programs (OTPs)
Tags: Medication-Assisted Treatment, Opioid Treatment Programs
Allegra Schorr
Allegra Schorr, aged 56, is president of the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA). Ms. Schorr has over 25 years of experience in health care and substance use treatment services. An owner and vice president of West Midtown Medical Group, an OTP, Ms. Schorr also represents New York State as a board member of AATOD, and was chair of the 2018 national AATOD conference.
Through her efforts, West Midtown Medical Group became the first opioid treatment program to dispense buprenorphine in an OTP setting in New York State. Most recently Ms. Schorr was appointed to the New York State Pain Management Steering Committee, formed as part of the State’s 2018-2019 Budget.
Ms. Schorr is a graduate of Sarah Lawrence College and expects to complete her Master’s of Science degree in Healthcare Management at Rutgers University-School of Health Professionals at the end of 2018.
Ms. Schorr’s father and uncles began managing Methadone Maintenance Treatment Programs in 1973. “I grew up around MMTPs and learned at an early age how methadone could help patients,” said Ms. Schorr. “After college, I worked on developing an HIV treatment program that would provide outpatient medical care for patients with HIV who were enrolled in the MMTP.” She submitted a certificate-of-need application for the MMTP to become certified as West Midtown Medical Group, a NYS Article 28 Diagnostic and Treatment Center—a comprehensive primary care facility with OTP and outpatient treatment for substance use disorders. (The MMTPs were Article 33 facilities.) The application was approved, and “my sister, cousins, and I became the owners of West Midtown Medical Group, located on West 35th Street in Midtown Manhattan.
“OTP leaders need to be alert to and speak out against stigma regarding MAT—and especially methadone,” said Ms. Schorr. On the other hand, “we need to hear legitimate criticism regarding our programs, and take positive steps to respond and improve things,” she said. “OTPs truly are essential hub sites and can provide leadership for the entire treatment field. The framework for OUD treatment in an OTP has enormous potential to offer integrated and coordinated care. Our leaders should think about how to utilize this structure to respond to our patients and our communities, and to turn the tide on the opioid epidemic.”
Ms. Schorr is also president of the Coalition of Medication-Assisted Treatment Providers and Advocates.
Categories: Medication-Assisted Treatment (MAT), Newsletter, Opioid Treatment Programs (OTPs)
Tags: Medication-Assisted Treatment, Opioid Treatment Programs
Nick Stavros
Nick Stavros, age 39, CEO of Community Medical Services, presided over the recent sale of the OTP platform to the private equity firm, Clearview Capital. The sale relieved the inactive owners of their equity in the company, and left Mr. Stavros as the largest individual owner. With Clearview leaving him at the helm as CEO, no operations are expected to change within the Arizona-based company.
Even though the OTP system began as a family business, Mr. Stavros did not grow up in the industry. “Five years ago, I didn’t know what methadone treatment was,” he told AT Forum. Prior to joining the company, he spent eight years in the military, and then left his position as an Infantry Captain and attended UCLA, where he earned an MBA. His parents, who founded the company in 1983, called him soon after and asked him to join the business to help them prepare the company for a sale. “This was in 2012,” he said. He was on the job for nine months, and found out that he had a strong passion for treating addiction.
So he changed course. Instead of prepping the company to sell to a larger organization, he decided he’d rather stay with it and partner with a private equity firm to buy out the other owners—family members and non-family members. “With the intention of staying with the company, I spent four years building a platform to grow from, to attract investors.” He partnered with Clearview Capital after meeting with numerous interested investors, because “they have an outstanding reputation in this space,” he said. “They’re pretty hands off and their values aligned most with ours.”
“I love what I’m doing,” said Mr. Stavros, asked why he is staying involved. “From an entrepreneurial perspective, this is an opportunity to build an amazing business. We are very patient-focused; We live by our values; I do a mission, vision, values presentation with every new employee and a weekly online town-hall meeting with the whole company. We make decisions based on our values and we are all impassioned by the uphill battle of our cause and by the tenacity of our patients in their recovery. There aren’t a lot of companies out there that continue to grow while staying true to their values.”
Under his tenure, Community Medical Services has grown from 6-14 clinics in 4 states and from one Medicaid contract to more than 15. “Our goal was to be cash-flow neutral every year, investing every penny back into the company,” he said. “By the end of 2018, we’re going to be at 21 organic clinics and the private equity funds will allow us to potentially add on an additional 10-20 acquisitions. The goal is to be treating 60,000 patients by the end of 2022.” Currently, the program treats more than 5,000 patients.
There is still a shortage of slots nationwide. “One of the problems is that there is mostly just a consolidation taking place,” he said. “The growth rate of new OTPs isn’t coming close to paralleling the growth rate of the epidemic.”
Finally, Mr. Stavros seconded other leaders who said it’s important for OTPs to get involved in their communities and to seek out STR funds and other new forms of funding. “We are the largest recipient in the state of Arizona for STR funds,” he said. With those funds, the program has started the country’s first 24/7 OTP, a number of Medication Units, and a vibrant peer support program.
As with many other advocates in this space, Mr. Stavros has a personal connection to this field. His sister died from a heroin overdose when she was 21.
Categories: Medication-Assisted Treatment (MAT), Newsletter, Opioid Treatment Programs (OTPs)
Tags: Medication-Assisted Treatment, Methadone Treatment, Opioid Treatment Programs
Zac Talbott
Zachary C. Talbott (“Zac”), aged 35, a native of Tennessee, is administrator and program director of Counseling Solutions Treatment Centers, based in Georgia. When he was at the University of Tennessee Knoxville College of Social Work, pursuing his Master of Social Work (MSW) degree, his addiction to prescription opioids and heroin spun out of control, leading to an academic dismissal.
After several years of “spiraling into the darkest places opioid addiction can take an individual,” as he puts it, Mr. Talbott found evidence-based treatment at an opioid treatment program (OTP). When he achieved a stable dose of methadone and took part in individual counseling, the “old Zac” quickly re-emerged. He then became involved in recovery advocacy, joining a Tennessee/Northwest Georgia Chapter of the National Alliance for Medication Assisted Recovery (NAMA), and serving on the national Board of Directors of NAMA until March of 2017.
Since he started his long-term recovery, Mr. Talbott has re-enrolled in the MSW program his addiction robbed him of years ago, and has opened two opioid treatment programs under the name “Counseling Solutions Treatment Centers”: Chatsworth, Georgia, in February 2016; and Brasstown (Murphy), North Carolina, in March 2017.
Mr. Talbott serves as program sponsor of both OTPs, and as program director of the OTP in Chatsworth, Georgia. He also co-founded, along with Sharon Dembinski—at the time, director of quality and clinical services for MedMark Treatment Centers—the Methadone (and buprenorphine) Discussion Group on Facebook.
As a “closed group,” where only approved members can see posts or make comments, the Methadone Discussion group has grown into the largest online community for Medication-Assisted Treatment (MAT) support and information, boasting more than 8,000 members. Most members are methadone and buprenorphine patients, but some are MAT providers and family and friends of MAT patients. Mr. Talbott was committed to ensuring that those enrolled in or considering MAT would always have a safe place to go; where credible information could be provided, and shared experiences in recovery would be a source of strength.
Mr. Talbott is a Certified Alcohol and Drug Counselor, Level II (CADC II), through the Alcohol & Drug Abuse Certification Board of Georgia (ADACBGA); a Certified Addictions Counselor, Level II (CAC II), through the Georgia Addiction Counselors Association (GACA); a Medication-Assisted Treatment Specialist (MATS), through the ADACBGA; an Internationally-Certified Alcohol & Drug Counselor (ICADC), through IC&RC; a Registered Addiction Specialist (RAS), through the Breining Institute; and a Certified Medication-Assisted Treatment Advocate (CMA), through NAMA Recovery. He currently serves on the Credentialing Committee and Board of Directors of the Alcohol and Drug Abuse Certification Board of Georgia (ADACBGA), and the Georgia IC&RC affiliate and addiction counselor credentialing body, as well as on the Board of Directors of the Southeastern Institute on Chemical Dependency (SICD).
Mr. Talbott has been a Recovery Month Planning Partner with the Substance Abuse and Mental Health Services Administration (SAMHSA) for the last four years. Despite his ability to successfully engage in medically supervised withdrawal, slowly tapering the dosage of his medication in transition to a medication-free state of recovery, he acknowledges that “one size does not fit all.” He believes firmly that our response to the opioid crisis must include public education that acknowledges long-term or even indefinite maintenance with methadone or buprenorphine may be necessary for some people, as it is for any other medication for any other illness. He remains passionate about evidence-based treatment approaches, and will always be, first and foremost, a patient advocate.
Mr. Talbott feels it is important that clinicians and medical professionals not lose their place in the leadership of an ever-merging field. Always remembering and acknowledging that opioid treatment programs first and foremost provide medical treatment and clinical care to an overly stigmatized and vulnerable population is critical to turning around the current opioid addiction and overdose epidemic. While he acknowledges that OTPs have a business component that is important to ongoing sustainability, he believes it is critical to ensure that physicians with expertise in addiction medicine, and counselors or clinical social workers with training in substance use disorders, remain in the leadership positions of companies that operate opioid treatment programs and office-based medication-assisted treatment clinics.
Dr. Mary Jeanne Kreek, one of the three founders of methadone treatment, alongside Doctors Vincent Dole and Marie Nyswander, inspired Mr. Talbott so deeply that her words remain his daily mantra. Dr. Kreek told him at the 2013 AATOD Conference in Philadelphia: “The love and care of patients is what everything we do and every decision we make should ultimately be about.”
Categories: Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs)
Tags: Medication-Assisted Treatment, Opioid Treatment Programs
States Are Legalizing Nonprescription Syringe Sales in Pharmacies; How Well Is That Working?
By Barbara Goodheart, ELS
Nonprescription sales of syringes in pharmacies are being met with some enthusiasm, some resistance, and a tinge of stigma. But they offer an accessible, affordable, reliable way to lower the risks of HIV/AIDS and infectious hepatitis, and, if managed well, they can help control health care costs and save lives.
Attitudes—and Consequences
Some people sincerely question the wisdom of selling syringes (cylinders with hollow needles attached) to people who inject drugs (PWIDs). They see it as granting permission to continue misuse. Others think that people who misuse drugs “should suffer the consequences.” Those consequences are substantial; they include blood-borne infections and painful illnesses. As the data below show, they also include soaring medical costs—clearly impacting society as well.
Greatly boosting the medical costs are the sheer numbers involved. CDC data show that at least 3.5 million people in the U.S. are infected with hepatitis C virus (HCV). The C. Everett Koop Institute estimates the total lifetime costs for those currently infected with HCV could reach $9 billion. But if 80% develop chronic liver disease, the total costs over a lifetime would be “a staggering $360 billion in today’s dollars.” Adding medical costs, and all costs for other types of infectious hepatitis, along with costs for HIV/AIDS, boosts total expenditures to unbelievable levels.
Beyond those costs are other serious consequences that cannot be measured—broken ties with loved ones, untimely tragedies. Most of us know of a young person who had much to offer, but instead tragically succumbed to a drug overdose.
Stigma: The Not-So-Good News
Local stigma is a common problem, and California is no exception. California pharmacies have been selling nonprescription syringes since 2012—and The New York Times has identified areas where PWIDs face severely limited treatment options. An official blames local stigma— “county supervisors who don’t want a treatment program located in their area.”
Syringes for Diabetic Patients—But Not for PWIDs
A study in the International Journal of Drug Policy points to areas of stigma in California’s Central Valley. A purchase trial found that only one in five PWIDs were able to buy syringes, despite legalization. The study also found that only about 29% of pharmacists and staff would sell to PWIDs—but 79% would sell to patients with diabetes.
Pharmacists turned down people they thought might be PWIDs, based on appearance. Some participants donned conservative clothes and covered their injection scars, but were refused syringes nevertheless. Their attempts to buy, they said, were “embarrassing and stigmatizing,” and “forced them to ‘out’ themselves as drug users.” Some PWIDs who heard these reports didn’t even bother to try purchasing syringes.
Methadone Stigma
Stigma is no stranger to people taking methadone, participants learned. Methadone treatment was even “more stigmatized than injecting drugs,” they said, noting that many local sober living homes barred methadone patients.
Amanda, a study participant, said:
. . . if you get on methadone, you are just as bad as any junkie heroin addict, so you might as well just do the heroin because then nobody knows you are at a methadone clinic . . .
[We] hated people who were on methadone and talked crap about them, because, for whatever reason, we thought we were so much better.
Amanda and her husband eventually enrolled in methadone treatment, but she wished they’d done so sooner, instead of letting their daughter live elsewhere, “because she had heroin addicts her whole life as parents.”
Choices
What motivates some PWIDs to head for a pharmacy to purchase syringes, instead of sharing or reusing syringes on hand—their own, or others’—as many PWIDs do?
Perhaps they are aware of their risks, and ready to accept advice and help. Some may be standing on the brink—almost ready for treatment—waiting for someone to offer a hand.
The Pharmacist Is In
Enter the pharmacist. He or she is among the most trusted and knowledgeable sources patients approach for health care information.
In some states it’s standard to require pharmacists to provide information to people buying syringes. Pharmacists in California are called upon to offer guidance about testing and treatment for HIV and hepatitis, and to provide safe disposal of sharps. Some pharmacy programs give links to support groups and detailed help about entering treatment programs.
To date, more than half the states offer nonprescription sales of syringes in pharmacies. Some states have a counseling agreement resembling California’s.
The Bottom Line
The pharmacy staff’s interactions with customers can have far-reaching effects. Pharmacists who are nonjudgmental and understanding can do much more than provide helpful information and safe syringes; they can help PWIDs take those difficult first steps, perhaps even opening the door to treatment.
A Note To Our Readers—
This article certainly isn’t meant to encourage readers to use illicit drugs. But we do want to spread the word that, for drug users not in treatment, access to clean syringes can lower the risk of contracting or spreading HIV and viral hepatitis. Moreover, the opportunity to contact a pharmacist or other health care provider for advice may increase the likelihood that a person who is using drugs will consider treatment.
Sue Emerson, Publisher, Addiction Treatment
References
Edlin BR, Eckhardt BJ, Shu MA, et al. Toward a more accurate estimate of the prevalence of hepatitis C in the United States. Hepatology. 2015;62(5):1353-1363. (Free PMC Article.) doi: 10.1002/hep.27978.
The C. Everett Koop Institute. Dartmouth Medical School. Hepatitis C: The Facts: The Epidemic: Associated Health Costs—United States. http://www.epidemic.org/thefacts/theEpidemic/USHealthCareCosts.
Del Real JA. Needle by needle, a heroin crisis grips California’s rural north. The New York Times. May 8, 2018. https://www.nytimes.com/2018/05/08/us/california-heroin-opioid.html.
Paquette CE, Syvertsen JL, Pollini RA. Stigma at every turn: Health services experiences among people who inject drugs. Int J Drug Policy. 2018;(57)104-
Resources
Meyerson BE, Davis A, Agley JD, et al. Predicting pharmacy syringe sales to people who inject drugs: Policy, practice and perceptions. Int J Drug Policy. 2018;56:46-53.
HIV and Injection Drug Use. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. November 2016. https://www.cdc.gov/hiv/pdf/risk/cdc-hiv-idu-fact-sheet.pdf.
Categories: Addiction, Heroin, Newsletter, Opioid Abuse/Addiction, Opioids
Tags: Hepatitis C, Heroin, Methadone Treatment, Stigma
Methadone Patients Don’t Feel “Disabled,” But They Do Have a Protected “Disability” Under the ADA
By Alison Knopf
Patients in opioid treatment programs (OTPs) are protected under the Americans with Disabilities Act (ADA). This means that an employer can’t refuse to hire them just because they are in treatment with methadone. It means that towns can’t enact anti-OTP ordinances that make it impossible to site facilities. Do these things still happen? Yes, but the ADA protects against it.
That’s the legal reason for calling yourself a person with a disability if you’re a methadone patient. But there’s another reason—a very powerful human one: many methadone patients don’t see themselves as “disabled” and don’t want to be labeled as such. In fact, they see themselves for what they are: proudly able and proud of their recovery.
“I understand the sensitivity in approaching this,” Mark W. Parrino, MPH, president of the American Association for the Treatment of Opioid Dependence (AATOD), told AT Forum. “Patients who are stable do not want to have the label ‘disability’ attached to them. But,” he said, “it’s a matter of law for good reason,” noting that the label protects patients against discrimination.
Mr. Parrino compared the use of the word “disability” to the use of “client” instead of “patient.” Some programs use the word “client,” believing that it is less stigmatizing than the word “patient,” he said. But he pointed out that the National Alliance for Medication Assisted Recovery (NAMA) prefers “patient,” “because a patient has rights.”
All About Perception
Individuals with other disabilities don’t like the word either because they do not perceive of themselves as “disabled.”
“When you look at the literature on disability, it becomes clear that the perceptions of other people impose the biggest limitations on those with disabling conditions,” said Ellen Weber, vice president with the Legal Action Center.
In fact, perception is a key principle of the ADA. “It’s the perception of others that creates limitations, rather than the individual’s health condition,” said Ms. Weber. Under the ADA, anyone who is perceived as having a mental or physical impairment—even if they do not in fact have one—is still protected against discrimination.
“Because decision makers, as well as the general public, have biases, are uninformed about the ability of individuals with physical and mental impairments, and have prejudicial views, the ADA is needed,” said Ms. Weber. “But that doesn’t mean that because you’re protected by this law, you consider yourself to be disabled.”
There’s another definition of disability, used by the Social Security Administration, which will support people who are unable to work (and thanks to a bad decision by Congress, people with substance use disorders are ineligible, if that is their primary disability).
The ADA has a completely different standard. For the ADA, in the employment context, a reasonable accommodation must be made to allow someone to do his job. “So for a person with a substance use disorder, if that person has to take some time off in order to go to treatment, just like any other medical appointment, that’s a reasonable accommodation,” said Ms. Weber.
The Patient’s Perspective
“I understand the patient’s perspective,” said Mr. Parrino. “A legal term is different from a personal sense, in which a patient might ask, ‘What do you mean, I’m disabled?’”
Walter Ginter, CMA, project director for the MARS Statewide Network, and a patient advocate, sympathizes, but stressed that the ADA is essential. “I understand why patients do not want to be considered disabled—they want to be viewed like everyone else in society,” he told AT Forum. “But the fact is, methadone and buprenorphine patients aren’t like others. We have a chronic disease that for some bizarre reason can only be treated in OTPs or federally licensed DATA 2000 practices,” he said, which is itself a handicap, in his view.
“As long as the government is going to handicap us in a way that they do not handicap people with any other chronic disease, the least, and I mean that, the least, the government can do is make up for this discrimination by giving us the minimal protections available to other persons, under the ADA.”
Categories: Addiction, Heroin, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Addiction, Heroin, Methadone Treatment
OTPs in Florida: Needs-Assessment Changes Underway
By Alison Knopf
Florida Governor Rick Scott signed HB 21 in March, providing more than $65 million to support opioid treatment. This included $16.5 million for medication-assisted treatment for opioid use disorders, and $14.6 million for enhancements to the substance use disorder system of care, according to David Frady, spokesman for the Department of Children and Families (DCF). “DCF is absolutely committed to ensuring an adequate service network for individuals in crisis and in need of substance abuse services,” Mr. Frady told AT Forum. “Governor Scott and the Florida Legislature have increased substance abuse treatment funding every year since 2013, and DCF will continue to pursue additional funding opportunities to enhance the services provided to individuals struggling with addiction.”
The new funding, along with federal grants, such as the Opioid STR grant, will provide additional treatment for opioid use disorders.
In addition, Section 397.427, Florida Statutes, requires DCF to conduct a needs-assessment for establishing providers of medication-assisted treatment services for opiate addiction, said Mr. Frady. DCF is updating the Methadone Needs Assessment rule.
The STR grant will not fund any new OTPs, said Mr. Frady. Most of it is allocated to methadone and buprenorphine maintenance programs.
For the draft of the new Methadone Needs Assessment rule, go to:
http://www.dcf.state.fl.us/publicnotices/20180514/DRAFT%2065D-30%20014.pdf
http://www.dcf.state.fl.us/publicnotices/20180514/DRAFT%20CF-MH%204038.pdf
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioids
Tags: Buprenorphine, Medication-Assisted Treatment, Methadone Treatment
Events
National Commission on Correctional Health Mental Health Care Conference
July 14-16, 2018
Los Angeles, California
Contact: http://www.ncchc.org/upcoming-conferences
Community Anti-Drug Coalitions of America (CADCA) Mid-Year Training Institute
July 15-19, 2018
Orlando, Florida
Contact: http://www.cadca.org/
New England School of Best Practices in Addiction Studies
August 27-30, 2018
Waterville Valley, New Hampshire
Contact: http://www.neias.org/
29th Annual National Prevention Network (NPN) Prevention Research Conference
August 28-30, 2018
Boston, Massachusetts
Contact: http://www.npnconference.org
Categories: Events, Newsletter