Addiction Treatment Forum

AT Forum Volume 29, #4 August 2018

	Opioid Bills in the Senate: Focus on Medicare and OTPs (Originally published earlier in August with an update on August 25, 2018)
	42 CFR Part 2 Faces Tough Going in Congress
	How New York Uses Its STR Funds to Enhance Treatment
	As the NAS Crisis Worsens, a New Study Offers Treatment Guidelines
	Research Report: In Appalachia, Pregnant Women With OUD Encounter Barriers to Treatment
	West Virginia Leads the Nation With Its Opioid Problems; But Could Change Be Coming?
	Events

Categories: Medication-Assisted Treatment (MAT), Newsletter, TOC

Opioid Bills in Congress: Focus on Medicare and OTPs – Updated August 25, 2018

By Alison Knopf

As the Senate gets ready to vote on opioid legislation, advocates urge people to contact their members of Congress to call for comprehensive coverage by Medicare for treatment for opioid use disorders. A demonstration project is not needed – we know treatment works. Seniors need it too. The House of Representatives, in H.R. 6, passed a bill calling for full coverage for Opioid Treatment Programs by Medicare. A comprehensive legislative fix – not a demonstration project – is what is needed.

Contact your member of Congress via the Advocates for Opioid Recovery (AOR) grass roots site: https://www.opioidrecovery.org/actnow/

For the infographic on Medicare coverage in Opioid Treatment Programs, go to: http://cdn.atforum.com/wp-content/uploads/Infographic_Aug-2018-FINAL.pdf

The Hill reported on August 23rd that opioids legislation is likely to come to the Senate floor the week after Labor Day (September 3rd). The article can be accessed at: http://thehill.com/homenews/senate/403278-senate-leaders-in-talks-to-wrap-up-august-session

Latest News: Senate set to vote on opioid response package next week – 9/6/18. The Politico article can be accessed at: https://www.politico.com/story/2018/09/06/senate-opioid-response-package-76253

The original article by AT Forum can be accessed at: http://atforum.com/2018/08/opioid-bills-senate-focus-medicare-otps/

Categories: Medication-Assisted Treatment (MAT), Newsletter

42 CFR Part 2 Faces Tough Going in Congress

By Alison Knopf

When the U.S. House of Representatives passed H.R. 6082 last June methadone patients worried that they would lose their confidentiality. The bill would remove a major portion of the protections of 42 CFR Part 2, the regulation requiring most substance use disorder (SUD) treatment providers to obtain patient consent before releasing their records, by allowing disclosures without patient consent for purposes of treatment, payment and health operations. See related article in this issue (Opioid Bills in the Senate: Focus on Medicare and OTPs originally released August 14, 2018).

The bill is now in the Senate Committee on Health, Education, Labor, and Pensions. For almost 10 years, opponents of CFR Part 2–electronic health record (EHR) vendors, at first–have desperately wanted SUD treatment records, including those about methadone treatment, to be in the patient’s electronic records.

Now, most treatment organizations, including the National Association of Addiction Treatment Providers and the American Society of Addiction Medicine, have joined in wanting to eliminate 42 CFR Part 2. So has the American Psychiatric Association. But the American Association for the Treatment of Opioid Dependence (AATOD), Faces and Voices of Recovery, and the Legal Action Center have steadfastly supported keeping the regulation.

Interestingly, some of the largest Opioid Treatment Program (OTP) chains have allied themselves with the anti-42 CFR Part 2 forces. This places the clinical operators of those OTPs at odds with the policy of the corporations that own them. The question of why companies would support something that would likely deter patients from seeking or staying in treatment is still not answered.

Revised Rule by SAMHSA

Last year, when the Substance Abuse and Mental Health Services Administration (SAMHSA) issued its final rule on the regulation, confidentiality protections were kept, but many changes were made that were hoped to assuage opponents (see http://atforum.com/2017/02/final-rule-42-cfr-part-2-retains-core-confidentiality-protections/). However, the agency couldn’t go any farther than that, leaving Congress to take up the matter.

The core protections are retained: that patients must consent to the release of their information, and that redisclosure is not permitted. This means that when the patient consents to having information released to a specified individual, the individual receiving the information may not redisclose it to a third party.

The rule requires that consent be given to a “specific name,” but the patient can agree to a “general designation” instead, which allows for the flexibility many people had wanted. But it still gives the patient the choice.

“I have always been concerned about the patient’s response, which is why we have advocated against this for such a long time,” said Mark W. Parrino, MPA, president of AATOD. “As you know, this has to go to the Senate and this will be our last bastion of defense,” he added. “Given the majority vote in the House, I cannot claim to be hopeful.”

“We don’t have any idea either how many patients are feeling the stress, but also are hearing stories that people are scared, and understandably so,” said Paul Samuels, president of the Legal Action Center, which has been advocating to save 42 CFR Part 2. Asked whether OTPs would be required to divulge patient information if the regulation changes, Mr. Samuels said, “We haven’t thought down the road here about what might happen in terms of the mechanics of this, in part because this is still in process.” The best-case scenario would be for the Senate version not to pass, he said. “This is a moving target which we’re still hoping we’ll be able to stop.”

The main message, Mr. Samuels said, is this: “In the middle of the nation’s worst opioid epidemic, we should be encouraging everyone to stay in treatment.” Mr. Samuels urges everyone who is concerned about patient privacy to contact their senators. And he urges patients not to taper. “Don’t get scared, don’t stop your lifesaving treatment; use your constitutional rights,” he said. “Members of Congress always pay attention to the phone calls and mail.”

Lawsuits by Patients

Westley Clark, MD, JD, Dean’s Professor at Santa Clara University, and former director of SAMHSA’s Center for Substance Abuse Treatment, said that treatment providers should not be surprised if the elimination of 42 CFR Part 2 comes back to hurt them. Patients whose confidentiality is breached will most likely sue for harms such as loss of custody, loss of a job, and all the problems that can happen when someone’s status as a methadone patient is revealed.

If the bill gets through the Senate, said Dr. Clark, “it won’t be long before the first lawsuits are filed against SUD treatment programs for reckless behavior in disclosing SUD treatment–derived information that winds up prejudicial to a person who sought treatment,” he said. “Then the SUD providers will begin to understand what they’ve gotten themselves into for the weak promise of integrated care.”

Westley Clark

“In addition, since HR 6082 permits the reporting of de-identified patient information to public health authorities without providing for who is going to pay for this capability,” said Dr. Clark. “State authorities could reasonably shift the cost to treatment programs by imposing new requirements for EHR as a part of SUD treatment program licensing,” he said, adding “this would force treatment programs to increase their costs in the middle of an opioid epidemic.”

Meanwhile, methadone patients are at risk. When they taper, they may relapse, and overdose, and die.

Costs to Programs

Eliminating 42 CFR Part 2 will also result in increased costs to OTPs, increased training requirements, and an increased risk for inadvertent disclosure, said Dr. Clark. “This isn’t simply about patients giving permission,” he said. “It is also about a more aggressive training program for staff. Given staff turnover in clinics, the possibility of errors goes up.”

For example, staff will have to be able to distinguish between self-pay patients and other patients, he said. Even H.R. 6082 recognizes this, when it states that the bill offers patients a “statement of the patient’s rights, including self-pay patients, with respect to protected health information and a brief description of how the individual may exercise these rights (as required by paragraph (b)I1)(iv) of such section 164.520.”

Support from TCA and NAADAC

Treatment Communities of America (TCA) and NAADAC, the Association for Addiction Professionals also oppose H.R. 6082 and changes to 42 CFR Part 2. “The bill represents a step back from the protections that patients in this very vulnerable population currently possess, and we believe the risks and harm that can be done to patients is greater than the purported benefits that would be gained were the bill to become law,” wrote Kathy Icenhower, PhD, president of TCA, in letters to Senate leadership July 2.

“Stigma related to addiction historically has been one of the most formidable hurdles to people with SUD seeking treatment, including the very real fear of negative consequences, and people with SUD understand how essential confidentiality and privacy are as they embark on a courageous journey into treatment and recovery,” she added.

“According to SAMHSA, there are profound negative consequences that can result from the disclosure of an individual’s substance use disorder treatment record, including loss of employment, loss of housing, loss of child custody, discrimination by medical professionals and insurers, arrest, prosecution, and incarceration. That is why provisions in H.R. 6082 that would eliminate a SUD patient’s current legal right and ability to consent to disclose their treatment information for ‘treatment, payment, and health care operations’ purposes is so concerning. Under the bill, this sensitive information would be allowed to be disclosed to and shared with health plans, health care providers, and other entities without the patient’s knowledge and consent. This is a tremendous reversal and erosion of the protections that SUD patients currently possess, and has the potential to do tremendous harm in the midst of an opioid epidemic already claiming the lives of over 50,000 Americans each year.”

You can sign a petition to support 42 CFR Part 2 and oppose H.R. 6082. Go to https://t.e2ma.net/webview/pq9oq/c2e88ffd677340796cee4f151e6427c8

Note: The original article AT Forum wrote about current pending legislation can be accessed at: http://atforum.com/2018/08/opioid-bills-senate-focus-medicare-otps/

Categories: Medication-Assisted Treatment (MAT), Newsletter

How New York Uses Its STR Funds to Enhance Treatment

By Alison Knopf

To use its more than $50 million in funding from the State Targeted Response (STR) to the Opioid Crisis, New York State first identified its highest need counties, then added access to treatment for opioid use disorders, mainly with medications. “The major thing we did on the treatment side was creating Centers of Treatment Innovation, or COTI,” Robert A. Kent, chief counsel for the state’s Office of Alcoholism and Substance Abuse Services (OASAS), told AT Forum.

We talked with Mr. Kent just as the two-year STR program was winding down, and just before the August 15 deadline for applying for the new State Opioid Response (SOR) grants.

STR grants were set up by Congress in 2016 as part of the Cures Act. They provided $1 billion to the states over two years to treat the opioid crisis.

Both STR and SOR grant programs are administered by the Substance Abuse and Mental Health Services Administration (SAMHSA). Both programs must be run by each state’s Single State Agency (SSA), the entity that governs the SAMHSA Substance Abuse Prevention and Treatment (SAPT) block grant.

Vehicles

Robert Kent

Enhancements to ambulatory services covering the patients in Opioid Treatment Programs (OTPs), as well as the patients in regular outpatient treatment (such as buprenorphine office-based opioid treatment, or OBOT), were key in all counties. “We tried to give them help in terms of mobile treatment capacity,” said Mr. Kent. While the federal Drug Enforcement Administration (DEA) has not yet issued the long-awaited guidance on mobile vans providing methadone, these vans can “do everything but the methadone,” said Mr. Kent. Some programs bought mobile treatment vans, while others used the funding to buy vans to transport patients from their homes to treatment, and back.

Assuming that the DEA will eventually issue the guidance on the mobile vans, the investment in the vehicles is viewed as a good one. Mobile vans, tied to brick-and-mortar OTPs, can greatly expand access to treatment. In many communities, they also avoid siting problems for OTPs.

“We didn’t use any of the money to open new programs, because we were told we couldn’t use it for building or buying property,” said Mr. Kent. However, there have been new OTPs opening in the state, without the STR money. “In the midst of all of this, we’ve been in expansion mode for OTPs.” Most recently, the Genesee Council on Alcoholism and Substance Abuse was set to open an OTP in Batavia in mid-August. The new OTP will be one of the Centers of Treatment Innovation.

Hub and Spoke

For the SOR funding, OASAS will continue what it did with STR, and will also look at ways of expanding the state’s “hub and spoke” project. The expansion will be based on widening the reach of OTPs by linking them to community-based prescribers in remote areas, via telehealth, said Mr. Kent.

Vermont first instituted the hub and spoke, with the hub as an OTP, and the spoke as a prescriber. The OTP assesses all patients, and treats those for whom an OTP is the best treatment. The spoke is the DATA 2000-waivered buprenorphine prescriber (or Vivitrol prescriber).

But in New York, procurement will be local, and each county can decide how it wants to set this up. “We’re going to issue a procurement, we want to see what is out there,” said Mr. Kent. “I think that there are local relationships that are different.”

Jails and Prisons

One area the state will focus on is medication-assisted treatment for the incarcerated population, said Mr. Kent. “We did get funding, and there was additional money to do some behind-the-walls treatment,” he explained. “We want to make sure there’s patient choice involved” in terms of medication–methadone, buprenorphine, or Vivitrol.

“We are working with the corrections medical people,” he said. The concern is that patients on methadone go “cold turkey” in jail, which is unnecessary and inhumane. “You have a person who was on methadone and ended up being incarcerated–the hard taper is really tragic,” he said. “We try to keep them connected to community-based OTPs.”

Buprenorphine Prescribers

Another concern for OASAS is the problem of getting DATA 2000-waivered physicians (buprenorphine prescribers) to prescribe for more patients. “Some people say we have to create more DATA 2000 prescribers, but that shouldn’t be our priority,” said Mr. Kent, noting that most buprenorphine prescribers do not prescribe anywhere near their “cap,” or patient limit. “Our priority is to get the ones we have, to prescribe to more patients.”

OASAS is using the ECHO model, a learning collaborative from the University of New Mexico, to expand the reach, by sending prescribers there for training. Then these physicians, who are interested in treating addiction, can return to New York and “cascade” what they learned to others. “If we get New York docs talking to New York docs, it’s the best way to get them to be engaged,” said Mr. Kent.

High-Risk Counties

The counties of highest need in year 1 of the STR grant were identified via three different data sets: the number of overdose deaths for the first cut, followed by the number of hospitalizations involving opioids, followed by the percentage of people leaving the county to get OASAS treatment services. For year 2, OASAS reassessed.

In year 1, OASAS identified 16 counties; in year 2, there were 35.

There are 20 providers in the 35 counties; six of them run OASAS-certified OTPs, and 14 have other outpatient treatment programs. OASAS also engaged in a partnership with the Research Institute on Addictions at the University at Buffalo to help high-risk counties provide services.

“People ask, where are the high-need areas? And I say, ‘The whole state,’” said Mr. Kent. Yes, New York City has a lot of treatment services. But it also has a lot of heroin and illicit fentanyl.

Sustainability From Insurers

What happens when the money–from STR and SOR–runs out? Insurance will pay for treatment–just as it does for treatment of medical and surgical diseases. “We had that in mind from the beginning,” said Mr. Kent. “We made these investments understanding that we were giving seed money.”

Treatment is reimbursable via the state’s Medicaid program and commercial insurance, now that the state has moved to Medicaid managed care. And reimbursement includes OTPs–under commercial insurance as well as under Medicaid. “Our state insurance department has issued circulars saying OTPs need to be part of your network,” said Mr. Kent. “They must cover the full range of substance use disorder services.”

Categories: Medication-Assisted Treatment (MAT), Newsletter

As the NAS Crisis Worsens, a New Study Offers Treatment Guidelines

By Barbara Goodheart, ELS

The incidence of neonatal abstinence syndrome (NAS) has been climbing steadily, according to a 2016 Morbidity and Mortality Weekly Report from the Centers for Disease Control and Prevention (CDC). The report, published August 12, indicated that the number of NAS cases rose from 1.5 per 1,000 hospital births in 1999 to 6 per 1,000 in 2013.

Yet guidelines for treating NAS have been lacking, according to a study in JAMA Pediatrics. The study, published online June 18, found that although several different approaches are being used, “no universal evidence-based pharmacological treatment strategy exists.” The article also noted that the FDA hasn’t approved any drug for treating infants who have NAS.

The authors of the JAMA Pediatrics study said that, without clear treatment guidelines, caregivers have typically chosen either methadone or morphine to treat their young NAS patients.

New Guidelines

Which medication—methadone or morphine—is better, and how to decide on an appropriate dose? Some studies have suggested basing the dose on the infant’s weight; others, on the severity of NAS, as assessed by the Finnegan Neonatal Abstinence Scoring System.

The JAMA Pediatrics team set out to answer the medication questions. They designed a treatment plan, then carried out what they believe is the first multisite, double-blind, randomized trial comparing the safety and efficacy of methadone and morphine in NAS. They published their results online June 18.

Study Summary

Study sites were eight U.S. newborn units housing 116 infants. The mothers had been treated during pregnancy with buprenorphine or methadone for an opioid use disorder, or with an opioid prescribed for chronic pain.

The 58 subjects in one study group were given morphine every four hours. The 58 in the other group were dosed every four hours with either methadone (given every eight hours, because of its longer half-life) or placebo (given four hours after the methadone, so caregivers wouldn’t know which medication they were giving). The starting dose was based on the infant’s weight and the severity score; successive doses were adjusted, based on how severe the symptoms The study ran from February 9, 2014 to March 6, 2017.

^aMethadone or placebo.

The authors specified that the morphine used was diluted, commercial, preservative-free, neonatal morphine.

They explained that commercial methadone contains 15% alcohol as a preservative. Because alcohol could affect outcomes, the U.S. Food and Drug Administration (FDA) required preparation of a preservative-free methadone solution for this study, using methadone powder (Mallinckrodt Inc).

End Points

Primary: Length of hospital stay

Secondary: Length of stay attributable to NAS; Length of stay attributable to treatment for NAS

Key Findings

Methadone patients:

Shorter hospital stay (16 vs 20 days [for morphine patients])
Shorter hospital stay related to NAS (16 vs 19 days)
Shorter length of stay attributable to treatment (11.5 vs 15 days)

Bottom Line

Study infants given methadone had better short-term outcomes than those treated with morphine. Differences were modest, but statistically significant. The authors are continuing to assess longer-term outcomes.

Implications for Treatment

Formulations. The methadone used in this study resulted from extensive prestudy work to guarantee the stability, purity, and sterility of the preparation—an expensive, time-consuming process, according to the authors. They also said that drugs used for treating newborns are usually “adult formulations that contain preservatives that have not been proven to be safe and could affect neurodevelopmental outcome”—and they noted the need for a commercially available methadone solution—”preservative free and safe for newborns.”

The authors also commented on the preservative issue in terms of buprenorphine. They pointed out that in a recent study in the New England Journal of Medicine, Kraft and colleagues showed that buprenorphine, given under the tongue, was more effective than morphine in treating NAS. But the buprenorphine formulation used in the Kraft study contained significant enough amounts of alcohol to possibly ultimately limit the widespread use of the medication, according to the JAMA Pediatrics authors.

Other Measures. The authors pointed out that shortening the length of hospital stay—even modestly—could have important economic effects, given the thousands of NAS infants treated each year. An article in Pediatrics in March estimated that, adjusting for inflation, total hospital costs for NAS births covered by Medicaid jumped from $65.4 million in 2004 to $462 million in 2014, the most recent year with available data.

The authors called for a better understanding of the factors influencing the severity of NAS, and the differences in long-term safety of the treatment options. This, they believe, will “help refine best practices and reduce the societal and financial burden of NAS, while improving short- and longer-term outcomes in this highly vulnerable population.”

References

Centers for Disease Control and Prevention. Incidence of neonatal abstinence syndrome — 28 states,1999–2013. MMWR 2016;65:799–802. doi: http://dx.doi.org/10.15585/mmwr.mm6531a2.

Davis JM, Shenberger J, Terrin N, et al. Comparison of safety and efficacy of methadone vs. morphine for treatment of neonatal abstinence syndrome. A randomized clinical trial. JAMA Pediatr. 2018;E1-E7. Published online June 18, 2018. doi:10.1001/jamapediatrics.2018.1307.

Kraft WK, Adeniyi-Jones SC, Chervoneva I, et al. Buprenorphine for the treatment of the neonatal abstinence syndrome. N Engl J Med. 2017;376(24):2341-2348.

Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and costs of neonatal abstinence syndrome among infants with Medicaid: 2004-2014. Pediatrics. March 2018;141(4):e20173520. doi:10.1542/peds.2017-3520.

(Also see “When Mom Is Better Than Morphine: Shorten Stay and Decrease Costs For Babies With Methadone-Related NAS.” http://atforum.com/2018/04/when-mom-is-better-than-morphine-shorten-stay-and-decrease-costs-for-babies-with-methadone-related-nas/)

Categories: Medication-Assisted Treatment (MAT), Newsletter

Research Report: In Appalachia, Pregnant Women With OUD Encounter Barriers to Treatment

By Barbara Goodheart, ELS

Appalachia is an area long known for beautiful scenery, coal mining, and devastating poverty. And now the area around central Appalachia has become the epicenter of the opioid epidemic.

Four Appalachian states—Tennessee, Kentucky, North Carolina, and West Virginia—have been especially hard-hit in the epidemic. A team from Vanderbilt University in Nashville launched a study to investigate possible barriers to treatment in women with opioid use disorder (OUD). A report of their findings, summarized below, was published online June 27 in Substance Abuse.

The Study

Between April and May of 2017, the Vanderbilt team conducted a phone survey of opioid agonist treatment (OAT) providers, opioid treatment programs (OTPs), and providers of buprenorphine outpatient services, in the four Appalachian states.

They wanted to learn if insurance and pregnancy status had become barriers to treatment for women in states especially hard-hit by the opioid epidemic.

Primary outcomes – providers’ acceptance of insurance and providers’ treatment of pregnant women

Secondary outcome – patient wait time

Exposures – type of insurance, and pregnancy status

Results

It became clear to the team that some women seeking treatment were coming up against barriers—even stigma. Some barriers varied by location; others by type of payment; still others by type of treatment: methadone or buprenorphine. Two groups were especially affected: pregnant women, and women who wanted to pay using insurance instead of cash.

Medicaid acceptance ranged from 83% in West Virginia to only 14% in Tennessee.
Every OTP surveyed, and most buprenorphine providers (89%), accepted cash payments.
Costs related to treatment varied considerably: Treatment intake cost $20 to $175; methadone treatment, $49 to $160 weekly; buprenorphine treatment, $35 to $245 weekly.
About half the OTPs accepted pregnant women who had Medicaid or private insurance; slightly more than half the buprenorphine providers did.

Otherwise, comparing OTPs and buprenorphine providers, OTPs treated pregnant patients more favorably, as the table below shows.

	Opioid Treatment Programs	Buprenophine Providers
Accept new patients	97%	83%
Accept pregnant patients	90%	53%
Treat pregnant patients	91%	75%
Wait times for treatment (nonpregnant patients)	1 day	7 days
Wait times for treatment (pregnant patients)	0 days	3.5 days

Conclusions

Even though the area was disproportionately impacted by the opioid epidemic, many OTPs and buprenorphine providers didn’t accept any insurance, and buprenorphine providers treated a smaller percentage of women who were pregnant.

The research team had noted earlier the effectiveness of opioid agonist therapies in OUD, especially for pregnant women, and had emphasized that “improving access to OAT is an urgent public policy goal.”

On viewing the results of their survey, the Vanderbilt research team had two suggestions to help bring this about.

First, enhance access to treatment by prioritizing improvements in provider training. For example, obstetricians could be trained to become buprenorphine prescribers. Second, improve providers’ acceptance of insurance by raising reimbursement rates.

The study was funded by a grant from the National Institute on Drug Abuse, National Institutes of Health.

Under the NIDA grant, Stephan Patrick, MD, and his team at Vanderbilt created an infographic summarizing the study results. To download the infographic go to: https://www.vumc.org/health-policy/files/health-policy/public_files/OTPinfographic_Final%5B2%5D.pdf.

# # #

Reference

Patrick SW, Buntin MB, Martin PR, et al. Barriers to accessing treatment for pregnant women with opioid use disorder in Appalachian states. Subst Abus. 2018;Jun 27:1-18. PMID:29949454. doi:10.1080/08897077.2018.1488336 [Epub ahead of print].

Categories: Newsletter

West Virginia Leads the Nation With Its Opioid Problems; But Could Change Be Coming?

By Barbara Goodheart, ELS

It’s a lovely state, nestled in the tree-covered Appalachian mountains—but West Virginia, the state hardest hit by the opioid crisis, faces serious problems. According to the state’s Opioid Response Plan, West Virginia has seen its opioid overdose rate quadruple since 2010, reaching 52 per 100,000 inhabitants. Far behind is second place Ohio, with an overdose rate of 39.

West Virginia is not just out in front with its opioid problems, it’s way out in front.

A Dismal Past

Of all the states, West Virginia has taken the highest per-capita economic hit from the opioid crisis. In March the American Enterprise Institute (AEI) ranked it first in the country in total opioid-related expenses per person: $4,378. West Virginia spends the largest share of its gross domestic product (GDP)—12.03%—on opioid-related problems, according to a January report of the AEI. As the table below shows, that’s more than twice as much as any other state.

Cost of the Opioid Epidemic As a Share of State GDP (%) Five Highest States

So it’s no surprise that in a recent year, the AEI spotlighted West Virginia as home to 14 of the 30 counties in the nation with the highest per-capita opioid-related costs.

All told, the estimated economic hit of the opioid epidemic to West Virginia’s economy is almost unbelievable: $8.8 billion a year, according to Rahul Gupta, MD, Commissioner and State Health Officer, West Virginia Department of Health and Human Resources.

What’s Behind West Virginia’s Problems?

Some people blame unemployment for illicit drug use; others point out that it’s just as likely that heavy drug use leads to unemployment.

Investigators recently began really looking into the opioid problem. Notable among recent reports: An Opioid Response Plan for the State of West Virginia, compiled by experts, with input from the public.

The Plan’s 12 high-priority recommendations cover key topics—from prevention to early intervention, treatment, overdose reversal, recovery, and family support. The Plan was presented to Governor Jim Justice on January 30.

A Candid Summary

The Response Plan doesn’t blame unemployment for West Virginia’s woes. In fact, the word “unemployment” appears nowhere in the plan’s 27 pages. Instead, in a section on treatment expansion—termed “a critically important initiative”—the report includes a remarkably candid summary of West Virginia’s problems:

Unfortunately, West Virginia has some of the most burdensome regulations on the provision of substance use disorder treatment that includes medications. These restrictions include a moratorium on new programs that use methadone and extra state rules that limit the prescribing of buprenorphine. These policies may reflect, in part, a history of public opposition to the use of medications for treatment, which is reflected in some of the public comments. This opposition may be the result of a vicious cycle. The historical underfunding of treatment with medications has made it difficult for high-quality programs to thrive. . . (p 16)

The Opioid Response Plan went out for a public hearing, and for review and comments. Suggestions from an expert panel were incorporated.

Full Speed Ahead

Things moved with a speed rarely seen in government endeavors. Listed below are some highlights.

Mid-January—Statewide screening of treatment needs in Medicaid patients began, with brief intervention, and referral to treatment (SBIRT). Methadone treatment, with counseling, was available as an opioid withdrawal strategy. Also included: a naloxone awareness and distribution initiative.

February—West Virginia became the first state to approve treatment of neonatal abstinence syndrome through Medicaid. Also, Gov. Jim Justice announced a partnership between the Department of Health and Human Resources (DHHR) and West Virginia University for developing pilot projects for combatting drug problems at the county level.

April—West Virginia awarded a $263,000 grant to Prestera Center to establish a quick response team (QRT) program. The program calls for medical, law enforcement, and mental health specialists to contact people within 72 hours of an overdose to try to get them into a treatment program. Officials hope to set up a QRT in every major city in the State.

June—The Opioid Reduction Act became effective, limiting opioid prescriptions, requiring documentation by providers, and allowing patients to decline in advance any opioid treatment.

An Impressive Start

What West Virginia has accomplished so far—in less than a year—is truly impressive.

Although success won’t come easily for the state, those who created the Opioid Response Plan, using a combination of evidence and compassion, believe there is reason for hope.

They admit that the steps they take will require “rising above the stigma against substance use disorder.” Yet they clearly believe that, as they phrase it in the Conclusion to their Opioid Response Plan, “recovery—for individuals, for their families, for their communities, and indeed, for our state, is within reach.”

* * *

(See a related story in this issue, “Research Report: In Appalachia, Pregnant Women With OUD Encounter Barriers to Treatment.”)

References

Opioid Response Plan for the State of West Virginia. January 2018. https://dhhr.wv.gov/bph/Documents/ODCP%20Response%20Plan%20Recs/Opioid%20Response%20Plan%20
for%20the%20State%20of%20West%20Virginia%20January%202018.pdf, Accessed August 26, 2018.

Brill A, Ganz S. The Geographic Variation in the Cost of the Opioid Crisis. AEI Economics Working Paper 2018-03. March 2018. https://www.aei.org/wp-content/uploads/2018/03/Geographic_Variation_in_Cost_of_Opioid_Crisis.pdf. Accessed August 26, 2018.

Brill A. New State-Level Estimates of the Economic Burden of the Opioid Epidemic. AEI, January 16, 2018. http://www.aei.org/publication/new-state-level-estimates-of-the-economic-burden-of-the-opioid-epidemic/. Accessed August 26, 2018.

Categories: Medication-Assisted Treatment (MAT), Newsletter