AT Forum Volume 28, #3 April/May 2017
Categories: Newsletter, TOC
Number of OTPs Tops 1,500 For First Time Ever
By Alison Knopf
For the first time in the history of opioid treatment programs (OTPs)–federally regulated clinics that dispense methadone and other medications to treat opioid use disorders—there were more than 1,500 as of March, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).
“This is the first time it has gone past 1,500,” said Mark W. Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD). “I believe there will be a steady rise in OTP numbers and patients in treatment, over the next several years,” Mr. Parrino told AT Forum. “SAMHSA is doing a great job in managing new OTP applications.”
AATOD has an ambitious plan—to reach 2,800 OTPs by 2020—announced at last fall’s meeting in Baltimore (see http://atforum.com/2016/12/aatod-conference-recap/).
As of December 23, 2016, there were 1,482 OTPs—up 66 from a year earlier (1,416), which was up 53 from December of 2014 (1,363) (see http://atforum.com/2017/02/aatods-goal-doubling-number-otps-strong-samhsa-support/).
Still, SAMHSA isn’t the only player. It’s up to other agencies—the state, the Drug Enforcement Administration (DEA), and of course local communities—to complete the process of certifying OTPs. This process can be long and time-consuming—and costly (see http://atforum.com/2016/04/success-story-advocate-opens-first-otp-second-opens-spring/). But in the end, communities benefit.
And that may be another reason that the OTPs are increasing in number: communities may finally be overcoming their NIMBY (“not in my backyard”) fears. “The rate of growth of opioid treatment programs has traditionally been slow,” Melinda Campopiano, MD, chief of SAMHA’s Division of Pharmacological Therapies, told AT Forum. “This expansion in programs, approximately 100 in the last year, may indicate that communities and providers are recognizing the utility of the model, and acceptance of pharmacotherapy for opioid use disorders is increasing.”
Categories: Addiction, Heroin, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids, Prescription Drugs
Tags: AATOD, Addiction, DEA, Opioid Treatment Programs, SAMHSA
Amid Beltway Disarray, Field Sees Bright Spot in McCance-Katz Nomination
By Alison Knopf
President Trump, along with Republican members of Congress, is calling for a repeal of the Affordable Care Act (ACA)—which many believe jeopardizes treatment coverage. And there’s the otherwise general chaos reported in the White House.
Yet treatment for substance use is nevertheless going forward. Patients need help, and opioid treatment programs (OTPs) still work to help them.
One path forward at the Substance Abuse and Mental Health Services Administration (SAMHSA) is President Trump’s nomination of Elinore McCance-Katz, MD, to be assistant secretary for mental health and substance use in the Department of Health and Human Services (HHS). Dr. McCance-Katz will oversee agency policies involving substance use and mental disorders.
A strong supporter of medication-assisted treatment (MAT) for opioid use disorders, Dr. McCance-Katz was chief medical officer at SAMHSA from 2013 to 2015. While there she disagreed with some mental health directions taken by then SAMHSA administrator Pam Hyde, finding them to be unscientific.
The American Association for the Treatment of Opioid Dependence (AATOD) is hoping for a swift confirmation, but action may take weeks or months. Still, “We believe that this represents an enlightened nomination,” said AATOD president Mark Parrino, MPA.
Enthusiastic Endorsements for the McCance-Katz Nomination
“Dr. McCance-Katz is extremely knowledgeable in the field of addiction treatment,” Mr. Parrino said. “She has a unique set of experiences on the treatment and research side, in addition to holding federal and state policy positions. From our point of view, she has the necessary background to balance out the incredible challenges of treating opioid use disorders in the United States. We encourage a speedy Senate confirmation.”
The American Psychiatric Association (APA) also supports her nomination. “Dr. McCance-Katz has a wealth of experience in academic and public-sector settings in addressing mental health and substance use,” said American Psychiatric Association President Maria A. Oquendo, MD, PhD. “She is an accomplished physician, and the APA strongly supports her nomination.
Before joining SAMHSA, Dr. McCance-Katz was medical director of the California Department of Alcohol and Drug Programs. Since leaving SAMHSA in 2015, she has been professor of psychiatry and human behavior, as well as professor of behavioral and social sciences, at the Alpert Medical School at Brown University. She served also as chief medical officer for the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals.
Health Care Reform: What’s Ahead?”
The House of Representatives passed the American Health Care Act on May 3. This bill, which is supported by President Trump, would cut Medicaid by $882 billion. It would also repeal the most important provisions in the ACA applying to treatment for opioid use disorders, allowing states to opt out of essential health benefits, among them behavioral health services.
Many analysts expect states to drop the requirement to cover substance use treatment, the newest benefit covered by law. If passed by the Senate as is, then agreed to by conference committees, the Republican bill would immediately end subsidies for Medicaid expansion and the individual market.
In fact, President Trump recently suggested not waiting for the bill to become law, but ending subsidies for the individual market immediately, placing health insurance for low- and middle-income people at risk now. (Under the ACA, people who earn under 400% of the federal poverty level receive subsidies to buy health insurance.) Health insurance companies, uncertain of the future, are already dropping out of the individual market. That market serves everyone who doesn’t have health insurance through an employer or isn’t eligible for Medicaid or Medicare.
Three Medications: Options for Individual Needs
Finally, Tom Price, MD, Secretary of the Department of Health and Human Services (HHS), caused an uproar from the medication-assisted treatment community in remarks made in West Virginia disparaging methadone and buprenorphine and praising Vivitrol. HHS sought to downplay the controversy, noting that Dr. Price is committed to making the opioid epidemic a top priority, and views it as a public health problem.
Many advocates hoped that the arrival of Dr. McCance-Katz at SAMHSA would provide guidance to Dr. Price, an orthopedist.
AATOD’s April 27 blog states: We also need to be careful about advancing one addiction treatment medication at the expense of another. There are only three federally approved medications to treat opioid addiction. They all have value and they all should be used at different times in the experience of patient care depending on what the individual needs.”
Categories: Addiction, Donald Trump, Healthcare Reform, Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Addiction, Buprenorphine, Healthcare Reform, Methadone Treatment, Opioid Treatment Programs, SAMHSA, Substance Abuse Treatment
AATOD, Acadia, and 433 Others Protest Health Care Bill as Destructive to Opioid Treatment
By Alison Knopf
President Trump promised to repeal the Affordable Care Act (ACA), and although it took some negotiating, he got what he wanted from the House of Representatives on May 3. That’s when the House passed the American Health Care Act (AHCA), repealing key provisions of the ACA.
Many organizations in the treatment field, including the American Association for the Treatment of Opioid Dependence (AATOD), Acadia Healthcare, and 433 others, sent a letter immediately to House Speaker Paul Ryan and Senate Leader Nancy Pelosi objecting to the AHCA.
“We are very concerned that the AHCA’s proposed changes to our health care system will result in reductions in health care coverage, particularly for vulnerable populations including those suffering from substance use disorders and mental illness,” they wrote.
The letter noted that more than 20 million Americans have obtained coverage through the ACA. Many of these individuals couldn’t access treatment for substance use disorders until the ACA expanded Medicaid to low-income adults (in many states, only pregnant women and children had been eligible).
The letter cited the opioid overdose epidemic and the need for insurance reimbursement for medications to treat substance use disorders. The letter also noted that the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) provides parity of coverage for substance use disorders and mental illness, on the same level as other medications. It was the ACA that extended MHPAEA to the small and individual-group market, as well as to Medicaid expansion plans.
“Turning the Clock Back”
As authors writing in The New England Journal of Medicine recently noted, “Repeal of the ACA would dismantle these protections and turn the clock back to a time when most Americans were subject to restrictive and inequitable limits on coverage for medication treatment and other supplementary treatments for opioid use disorder.”
That letter concluded, “we implore you to keep in mind how your decisions will affect the millions of Americans suffering from substance use disorders and mental illness who may lose their health care coverage entirely or see reductions in benefits that impede access to needed treatment.”
“We Are Very Concerned”—435 Signatories
Among the signatories:
- Acadia Healthcare
- Addiction Policy Forum
- American Correctional Association
- American Academy of Addiction Psychiatry
- American Association for the Treatment of Opioid Dependence
- American Congress of Obstetricians and Gynecologists
- American Public Health Association
- American Psychiatric Association
- American Psychological Association
- American Society of Addiction Medicine
- Clean Slate Addiction Treatment and Rehabilitation Centers
- Faces and Voices of Recovery
- Facing Addiction
- Hope House Addiction Services
- Legal Action Center
- NAADAC – the Association for Addiction Professionals
- National Alliance for Medication-Assisted Recovery (NAMA)
- National Association of Addiction Treatment Providers
- National Association of Drug Court Professionals
For the full letter with the complete list of signatories, go to https://www.naadac.org/assets/2416/cwh-ahca-opposition-letter-05032017.pdf.
Insurance in Name Only?
A letter the American Society of Addiction Medicine (ASAM) sent to Congress on March 9 noted that repealing the ACA would be particularly painful for people who need addiction treatment, especially during the opioid epidemic. The result could be “insurers offering addiction treatment benefits in name only due to higher costs and/or less robust benefits.”
The letter also noted that Medicaid expansion had reduced the population of uninsured people hospitalized with addiction or mental illness from 20% in 2013 to 5% in 2015—illustrating why hospitals are so concerned about ACA repeal.
Undermining the Cures Act
The Cures Act, which President Obama signed in December 2016, thereby funding opioid addiction treatment by an additional $1 billion for two years, would be largely undone by the ACA. Before President Trump’s inauguration in early January, Richard G. Frank, PhD, wrote that repealing the ACA would erase the gains of the Cures Act.
Along with co-author Sherry Glied, PhD, Dr. Frank, formerly assistant secretary for planning and evaluation in the Department of Health and Human Services, noted that Cures was necessary to close an opioid treatment gap in which 420,000 people said lack of finances or service availability prevented them from getting treatment. Repealing the ACA would “increase that gap by over 50% with the stroke of a pen,” the coauthors wrote in The Hill on January 11.
‘Stemming the Tragic Toll’
“The Congress and the American people have come to realize that stemming the tragic toll of opioid misuse and addiction and serious mental illnesses takes funding as well as policy,” they wrote. “It would be a cruel sham for Congress to take an important, but modest, step forward in investing in treatment capacity, while withdrawing funds from the enormous recent progress made in addressing the needs for care of those with mental health and addictive illnesses.”
People with the greatest need for treatment would end up in prison or jail, instead, said Dr. Frank. “Without the foundation of that ongoing financial support, those in the eye of the opioid storm and those who live in society’s shadows due to serious mental illnesses will continue to die of untreated illness, and their communities will continue to pay for the jails, prisons and homeless shelters that serve as our de-facto service system for many with these conditions.”
Dr. Frank estimated that about 222,000 people with an opioid use disorder would lose some or all their insurance coverage under ACA repeal.
Virtually every single health care organization opposed the AHCA.
On May 24, the Congressional Budget Office (CBO) came out with its score on the AHCA (the House voted to pass it before the usual CBO rating because it was in a rush). The CBO found that the AHCA, especially the Medicaid reductions of $880 billion, would be disastrous for health care, and would lead to 23 million Americans’ losing coverage in a decade. For the CBO analysis, go to https://apps.npr.org/documents/document.html?id=3731724-CBO-Report-On-AHCA-As-Passed-By-The-House.
Debate on health care reform now moves to the Senate.
Categories: Addiction, Healthcare Reform, Medication-Assisted Treatment (MAT), Newsletter
Tags: Health Insurance, Healthcare Reform, Substance Abuse Treatment
SAMHSA Issues Opioid STR Grants
By Alison Knopf
On April 19, the federal Department of Health and Human Services (HHS) released the first round of funding for the two-year State Targeted Response (STR) to the Opioid Crisis grants: $485 million for the first year of the program. The funding went to the single state authorities (SSAs) in charge of the Substance Abuse Prevention and Treatment (SAPT) Block Grant. Funding was authorized by the 21st Century Cures Act, signed by President Obama on December 13, 2016.
On December 4 the Substance Abuse and Mental Health Services Administration (SAMHSA) announced the funding opportunity to the SSAs, all of whom are members of the National Association of State Alcohol and Drug Abuse Directors. Applications for funding were due February 17.
The funding in the STR grants must be used for treating opioid use disorders (OUDs).
Below are the states and territories with their award amounts.
State |
Award Amount |
| Alabama | $7,967,873 |
| Alaska | $2,000,000 |
| Arizona | $12,171,518 |
| Arkansas | $3,901,297 |
| California | $44,749,771 |
| Colorado | $7,869,651 |
| Connecticut | $5,500,157 |
| Delaware | $2,000,000 |
| District of Columbia | $2,000,000 |
| Florida | $27,150,403 |
| Georgia | $11,782,710 |
| Hawaii | $2,000,000 |
| Idaho | $2,000,000 |
| Illinois | $16,328,583 |
| Indiana | $10,925,992 |
| Iowa | $2,728,077 |
| Kansas | $3,114,402 |
| Kentucky | $10,528,093 |
| Louisiana | $8,167,971 |
| Maine | $2,039,029 |
| Maryland | $10,036,845 |
| Massachusetts | $11,742,924 |
| Michigan | $16,372,680 |
| Minnesota | $5,379,349 |
| Mississippi | $3,584,702 |
| Missouri | $10,015,898 |
| Montana | $2,000,000 |
| Nebraska | $2,000,000 |
| Nevada | $5,663,328 |
| New Hampshire | $3,128,366 |
| New Jersey | $12,995,621 |
| New Mexico | $4,792,551 |
| New York | $25,260,676 |
| North Carolina | $15,586,724 |
| North Dakota | $2,000,000 |
| Ohio | $26,060,502 |
| Oklahoma | $7,283,229 |
| Oregon | $6,564,425 |
| Pennsylvania | $26,507,559 |
| Rhode Island | $2,167,007 |
| South Carolina | $6,575,623 |
| South Dakota | $2,000,000 |
| Tennessee | $13,815,132 |
| Texas | $27,362,357 |
| Utah | $5,537,458 |
| Vermont | $2,000,000 |
| Virginia | $9,762,332 |
| Washington | $11,790,256 |
| West Virginia | $5,881,983 |
| Wisconsin | $7,636,938 |
| Wyoming | $2,000,000 |
| Territory | Award Amount |
| American Samoa | $250,000 |
| Micronesia | $250,000 |
| Northern Marianas | $250,000 |
| Palau | $250,000 |
| Puerto Rico | $4,811,962 |
| Virgin Islands | $250,000 |
“Through a sustained focus on people, patients and partnerships, I am confident that together we can turn the tide on this public health crisis,” said HHS Secretary Tom Price, MD. “Opioids were responsible for over 33,000 deaths in 2015; this alarming statistic is unacceptable to me,” said Dr. Price. “These grants aim to increase access to treatment, reduce unmet need and reduce overdose-related deaths.”
Dr. Price’s subsequent comments did raise some questions about how the second installment of the funding will be handled. “I understand the urgency of this funding; however, I also want to ensure the resources and policies are properly aligned with and remain responsive to this evolving epidemic. Therefore, while I am releasing the funding for the first year immediately, my intention for the second year is to develop funding allocations and policies that are the most clinically sound, effective and efficient. To that end, in the coming weeks and months, I will seek your assistance to identify best practices, lessons learned, and key strategies that produce measurable results. Thank you for your collaboration and partnership as we move forward in this critical work together to help the millions of Americans hurt by this public health crisis.”
SAMHSA’s Center for Behavioral Health Statistics and Quality prepared an interactive medication-assisted treatment (MAT) map to help states identify their areas of greatest need for treatment for opioid use disorders. That map was not made public until May 10, but Kimberly Johnson, PhD, director of SAMSHA’s Center for Substance Abuse Treatment, told AT Forum about it in the last issue (see http://atforum.com/2017/04/samhsa-develops-maps-project-determine-where-otps-needed/.
For the interactive MAT map identifying underserved areas, go to https://www.samhsa.gov/data/mat_map.
Problems exist with the methodology used to develop the map. The map defines risk based on all substance use, not just use of opioids, and it looks at areas of high poverty as especially needy, without recognizing that even in wealthy areas there are poor people with opioid use disorders, H. Westley Clark, MD, Dean’s Executive Professor of Public Health at Santa Clara University, told AT Forum. He added, “I appreciate the complexity of the task presented to SAMHSA to come up with a useful algorithm to assist in making the decision on how to allocate the funding under STR.” Dr. Clark retired as CSAT director in 2014.
The Opioid STR grants are meant to “address the opioid crisis by increasing access to treatment, reducing unmet treatment need, and reducing opioid overdose related deaths through the provision of prevention, treatment and recovery activities for opioid use disorder,” according to SAMHSA. The term opioid use disorders includes misuse of prescription opioids and use of illicit opioids, such as heroin. The grants were to be awarded based on two factors: the unmet need for OUD treatment, and overdose deaths.
Also see the AT Forum story on how California plans to use its funding: http://atforum.com/2017/04/california-cures-act-80-million-expand-treatment-hub-spoke-system/.
Categories: Addiction, Newsletter, Opioid Abuse/Addiction, Opioids
Tags: Government, Heroin, Prescription Opioids, SAMHSA, Substance Abuse Treatment
Research Results: Lowering the Risks of Death for Patients Receiving Methadone or Buprenorphine
By Barbara Goodheart, ELS
Evidence is growing that two key factors help determine the risks of death in patients being treated for opioid dependence: which medication the patients are—or have been—taking, methadone or buprenorphine; and whether the patients are currently in or out of treatment.
A new study that has delved into these two factors suggests ways of lowering patients’ risks of death—especially during times of highest risk (defined below).
The study was published in BMJ April 26 under the title, “Mortality Risk During and After Opioid Substitution Treatment: Systematic Review and Meta-Analysis of Cohort Studies.”
Study Details
| Group | Patients with opioid dependence |
| Objective | Compare risks of death from all causes during and after methadone or buprenorphine treatment
Characterize trends in risks of death after treatment begins and after it ends |
| Data Sources | Literature search |
| Periods Covered | Time in or out of treatment with methadone or buprenorphine, 1974 to 2016 |
| Patient Population | Methadone: 122,885 patients, treated 1.3 to 13.9 years
Buprenorphine: 15,831 patients, treated 1.1 to 4.5 years |
| Daily Dose | Methadone, 47 mg to 116 mg; buprenorphine, 10 mg to 12 mg |
Study Findings
Treatment with either methadone or buprenorphine lowered the risk of death to less than one-third of what would be expected without treatment.
Phases of Treatment
Induction and Treatment. The risk of death with methadone was initially high during the four weeks of induction. Risk dropped from its high point during the four weeks, eventually stabilized, then remained unchanged during the rest of treatment.
This did not happen with buprenorphine. Instead, the number of deaths remained stable during induction and throughout the rest of the treatment period. The authors commented, however, that findings with buprenorphine are preliminary; buprenorphine treatment probably reduces deaths, but further studies are needed for verification.
Treatment Cessation. With both medications, cessation of treatment clearly was a danger period. The authors noted: “The mortality risk in the four weeks immediately after cessation of either treatment is high . . . ” [emphasis added]. This increased risk could be due to patients’ return to heroin, after having lost their tolerance to its toxic effects. Other factors could be involved, such as patients being out of contact with therapists who might have guided them back into treatment, although the authors did not mention this specifically.
| Key Periods for Lowering the Risks Of Drug-Related Deaths:
Methadone:
Both drugs:
With methadone: focus on preventing drug-related deaths during the first four weeks; with both drugs: focus on the first four weeks after patients discontinue therapy. |
Implications of the Findings
The authors recommended using clinical strategies and public health measures to mitigate risks during periods of high and highest risk. They also suggested modifications in study design that could yield additional data.
Authors’ specific recommendations:
- Carefully assess patients’ opioid tolerance before treatment begins; use the information to establish a safe induction dose
- Monitor for mental and physical problems during induction; consider adjusting the dosage accordingly
- Prevent patients from using illicit opioids (they did not elaborate on how to accomplish this)
- Educate patients about the risk of overdose and the use of naloxone
- Consider using buprenorphine for induction, then transitioning to methadone
- Look for ways to improve patient retention
- Coordinate the exchange of information between health care professionals, social and legal services, and patients
- Have both medications widely available worldwide, to “reduce the social harm associated with opioid use”
The Dangers of Cycling
Patients who cycle—go in and out of treatment—face a high risk of death, possibly because they are repeatedly exposed to high-risk periods. The specific risks could involve fatal overdose, but this has not been proven.
Limitations and Comments
Despite the potential importance of their findings, the authors cautioned that further research is needed. Specifically, such studies would be directed toward several methodological shortcomings the authors encountered in the indexed studies. These shortcomings, which may have impacted their estimates, include a loss to follow-up and a lack of studies in low- and middle-income countries.
BMJ published three comments contributed by outsiders not involved in the study. Two concerned the study design. The third, by Richard Saitz, MD, MPH, amounted to a critique of the article’s title. (The linked editorial in BMJ also included a gentle criticism of the article’s use of the term “opioid substitution treatment,” pointing out, as did Dr. Saitz, that the preferred term is “opioid agonist treatment.”)
Our Comment: Dr. Saitz is editor of the Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine. He’s also no stranger to these pages. Dr. Saitz often speaks out against stigma, and last year we quoted his writings several times in our four-part series on that topic. So we weren’t surprised to see his comment accompanying the current paper.
In criticizing the term “opioid substitution treatment,” Dr. Saitz points out that, unlike heroin, opioid agonists such as methadone reduce mortality and produce no euphoria or endocrine derangements. And people do not use the agonists compulsively.
A better term than substitution, Dr. Saitz suggests, would be “opioid agonist treatment.” Or more generally “medication treatment. Or medication for addiction treatment. Or just buprenorphine and methadone.”
* * *
RESOURCES
Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550 http://dx.doi.org/10.1136/bmj.j1550.
Manhapra A, Rosenheck R, Fiellin DA. Opioid substitution treatment is linked to reduced risk of death in opioid use disorder [Editorial]. BMJ. 2017; Apr 26;357:j1947. doi: 10.1136/bmj.j1947. http://www.bmj.com/content/357/bmj.j1947.
Saitz R. Time to avoid inaccurate terms in this field: it’s not substitution, it is opioid agonist treatment. http://www.bmj.com/content/357/bmj.j1550/rr.
Categories: Addiction, Buprenorphine, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioids, Overdose
Tags: Buprenorphine, Methadone Treatment, Overdose
Poll: The Public Speaks Out About Opioid Misuse
By Barbara Goodheart, ELS
Results of a Poll Released by the American Psychiatric Association (APA) -May 1, 2017
To get some perspective on this story, let’s picture a teenager who has a painful backache and accepts some hydrocodone (Vicodin) capsules from a friend. When those are gone, other friends share pills that they’ve been prescribed or they’ve obtained illicitly. Soon the teen has another problem—she’s unable to stop taking the hydrocodone.
Responses to the APA Poll
Now let’s look at the APA poll in light of the teenager’s story.
She took a prescription drug—an opioid—without a prescription
According to 87% of those who responded to the APA poll, that’s “bad.”
Breaking down the numbers, it’s “really bad,” say 55%; “somewhat bad,” 32%; “not that bad,” 10%; and “not bad at all,” 3%.
Clearly, most respondents judged such misuse pretty harshly. The two responses directly below indicate that very few respondents committed this type of “bad” behavior themselves; perhaps that’s why they were such severe judges.
- 1% of respondents have misused or been addicted to opioids or prescription painkillers
- 10% have taken an opioid or prescription painkiller without a prescription
Respondents were aware of others whose behavior was similar.
- 27% know someone who is or has been addicted to opioids or prescription painkillers
- 39% of all respondents (and 46% of millennials) said it would be extremely or somewhat easy for community members to obtain illegal opioids
- 69% “understand how someone accidentally gets addicted to opioids”
Despite their seemingly harsh judgment of illicit opioid use, respondents showed some empathy when it came to understanding behavior that can lead to addiction. They knew that obtaining illegal opioids wasn’t usually difficult, and they were acquainted with someone who had become addicted—a situation that may tend to create understanding and acceptance.
Other topics covered in the APA survey include what areas policymakers should prioritize in working with the opioid crisis (eg, access to treatment, stricter punishments, prescription limits); and whether the country is headed in the right direction in addressing the opioid crisis.
The complete APA survey results are available at: https://www.psychiatry.org/newsroom/apa-public-opinion-poll-annual-meeting-2017.
Categories: Addiction, Newsletter, Opioid Abuse/Addiction, Opioids, Prescription Drugs
Tags: Heroin, Prescription Opioids, Substance Abuse Treatment
Report from NASADAD – ONDCP to State Directors: Increase Access to Treatment
By Alison Knopf
Single state authorities (SSAs) are on the front lines of the opioid epidemic. They’re in charge of overseeing the Substance Abuse Prevention and Treatment (SAPT) block grants, as well as the $1 billion in opioid treatment funds to be provided over the next two years by the 21st Century Cures Act. A key task: make sure everyone who needs treatment gets it, Richard Baum, acting director of the Office of National Drug Control Policy (ONDCP), told attendees of the National Association of State Alcohol and Drug Abuse Directors (NASADAD) at its annual meeting, held in Indianapolis May 25-28.
“In 2015, 8.4 million people needed treatment for drug addiction, yet 4 out of 5 didn’t receive it,” said Mr. Baum, citing the 2015 National Survey on Drug Use and Health. “This has to change,” he added. The Substance Abuse and Mental Health Services Administration (SAMHSA) conducts that survey, and administers the SAPT block grant—as well as the $1 billion in grants from the State Targeted Response to the Opioid Crisis (STR Opioid Grants) that come from the 21st Century Cures Act.
“As SSAs, you are among our most important partners in addressing substance use, and, particularly, the ongoing opioid epidemic,” Mr. Baum said. “I know you’re working hard to turn the tide on this epidemic, and I’m excited to learn more about what you’re doing.”
One problem is that people aren’t being referred to treatment by the health care system, said Mr. Baum, noting that there are “critically low levels of treatment engagement and access to treatment.” In fact, in 2014, one-third of all referrals to any kind of treatment for substance use disorder came from the criminal justice system, and fewer than one in five came from the health care system.
MAT Saves Lives
Mr. Baum urged the use of medication assisted treatment (MAT) and prescription drug monitoring programs (PDMPs). “I know I’m preaching to the choir, but prescriber training, PDMPs, and MAT can literally save lives,” he said. “We need every prescriber to have the training they need, and to check their state PDMP. And we need to make sure people who need MAT can access it. As SSAs, you are in the unique position to help increase prescriber training and the use of PDMPs in your states, and to improve access to treatment.”
Mr. Baum, who has been at the ONDCP for 20 years, had just briefed stakeholders on the White House budget request. That request would fund the agency for fiscal year 2018, despite attempts by the Office of Management and Budget to eliminate it.
“My experience has taught me a lot about our nation’s drug problem and the devastating consequences of drug use,” he said. “I’ve seen the incredible commitment of people inside and outside of government who are working tirelessly to make life better for people affected by addiction.”
‘Pro-treatment’ White House
Mr. Baum went on to call the Trump Administration “a pro-treatment administration,” listing the 21st Century Cures Act funding (signed into law by President Obama in December of 2016). This infusion of funding is very important to the states. Mr. Baum also noted that the ONDCP is developing a new National Drug Control Strategy, with input from SSAs and others.
And he touted President Trump’s new Commission on Combating Drug Addiction and the Opioid Crisis, headed up by Gov. Chris Christie of New Jersey, as the group that will “figure out the best path forward for solving this problem.” Mr. Baum is executive director of the Commission, which will issue a report that “will help set our national drug policy priorities for the next four years.”
Among other challenges facing the country is the illicit fentanyl increasingly being found in street drugs. Fentanyl is a synthetic opioid, more powerful than heroin. Its various analogues are so strong that even a small amount can cause an overdose.
Frequently, the fentanyl analogues are pressed into counterfeit pills, he said, “which means many people who are ingesting these synthetic opioids are not even aware of it.” Many states have “improved their post-mortem toxicology screenings to determine whether fentanyl or its analogues were involved in an overdose death, so we can better track the supply of these drugs and their full impacts,” said Mr. Baum.
ONDCP to Public Safety and Public Health Officials: Work Together
Public safety departments must work with public health officials in addressing the opioid epidemic, according to the ONDCP. Mr. Baum referred to the importance of police, courts, prosecutors, and judges in helping to “turn the tide on this epidemic.” In particular, he praised first responders for saving lives by reversing overdoses with naloxone. “But the intervention can’t end with reversing an overdose,” said Mr. Baum. “We’ve got to help people break this cycle.”
One of the key challenges is “how to get more people to come forward for treatment,” said Mr. Baum, adding, “we want your help and advice on what will work. ”The justice system should be able to offer people treatment and monitoring. “We need to expand access to medication-assisted treatment in correctional settings, which we’re seeing happen in Rhode Island, Kentucky, and other states,” he said. “And we need to make sure they have the proper controls to deliver it safely.”
Drug courts and corrections officials also have a role to play in making sure people have access to MAT when they leave incarceration, or when they enter a program designed to keep them out of jail or prison.
Mr. Baum urged the SSAs to “work with your governors” on such innovations.
Categories: Addiction, Healthcare Reform, Heroin, Medication-Assisted Treatment (MAT), Medication-Assisted Treatment (MAT), Newsletter, Opioid Abuse/Addiction, Opioids, Prescription Drugs
Tags: Government, Medication-Assisted Treatment, Methadone Treatment, Opioid Treatment Programs, SAMHSA, Substance Abuse Treatment
When Facing NIMBY, Be Transparent: The Lesson From Buffalo, NY
By Alison Knopf
Not in my back yard (NIMBY)—that’s how to best describe the feeling in local neighborhoods where residents say they support treatment for substance use disorders, but—not near the school, not near their house, and so on.
The word “methadone” strikes particular fear in these neighborhoods, so opioid treatment program (OTP) sponsors spend a great deal of time and effort on educating communities. Sometimes it works, but more often than not, it seems, it doesn’t.
Of course, when a locality enacts a zoning ordinance designed to keep treatment out, and the sponsor sues, based on the Americans with Disabilities Act, the locality always loses. It is against the law to discriminate against patients with substance use disorders who are seeking treatment.
But communities may now be waking up to the fact that it is their own residents who need this treatment. As the opioid overdose epidemic continues to take lives and terrify family members, more people realize that medication-assisted treatment (MAT), the accepted phrase for methadone, buprenorphine, or naltrexone treatment for opioid use disorders, is actually something they need in their back yard.
‘Mythbusting’
But OTPs need to be open about what they are doing, and must meet with residents to clarify what they do—in the words of one health commissioner, to “mythbust.”
Recent and successful efforts in Amherst, New York—near Buffalo—are a case in point. Amhurst is where Catholic Health wants to open a new OTP, called Sisters Amherst Health Center. The town supervisor, Barry Weinstein, knows he can’t prevent the clinic from opening, but he can force it, eventually, to move, by creating zoning rules, Spectrum News in Buffalo reported April 25.
One of the chief complaints expressed by residents is a lack of transparency—Catholic Health did not meet with residents during the 18-month process of opening. The Amherst Town Board voted to change the zoning rules. However, Erie County Health Commissioner Gale Burstein, MD, was the lone dissenting vote, and defended the clinic.
“There are a lot of perceived beliefs about the type of person that seeks care at these sites, but we really need to mythbust, we really need to beat stigma, and these types of restrictions are just fueling the fire for these stigmas and these discriminatory attitudes (toward) people suffering from chronic disease,” Dr. Burstein, a pediatrician, said.
Still remaining is a certificate of need (New York requires this) and a certificate of occupancy from the building department, a process Mr. Weinstein said would take six to ten weeks.
Meeting With the Residents
On May 2, Catholic Health met with Amherst residents. The meeting was held at the organization’s current OTP, and residents were impressed. “Catholic Health was very professional and they explained everything,” said Amherst resident John Radzikowski, WGRZ reported. “They knew they made mistakes by not telling the community.”
“We did have good dialogue, heated discussion, good discernment, which is what we’re all about,” said Mark Sullivan, Catholic Health Chief Operating Officer. “And I think there’s a lot of takeaways from both groups.”
In fact, Catholic Health had communicated about the OTP. On April 21, Joe McDonald, president and CEO of Catholic Health, wrote an op-ed about the topic. “It seems every day we see another story about the devastating opiate crisis plaguing our community,” he wrote. “To deal with this crisis responsibly, it’s time to remove the fear associated with substance abuse treatment centers, including those that offer methadone and other medication-assisted treatment.”
He noted that the OTP will offer counseling, treatment, and primary care, as well as medications. The location is zoned commercial, and faces a busy highway. The back of the building looks like any medical office, he said, adding that Catholic Health installed a privacy fence to prevent traffic from exiting the parking lot onto a road that has homes on it.
“With this, and other improvements we will make, the neighbors should actually experience less disruption on their street than when the site was an auto parts store,” wrote Mr. McDonald. “We recognize, however, it’s not the appearance of the building that has neighbors concerned. They are worried about safety and security around the site. For those unfamiliar with these types of treatment centers, they are highly regulated by the state Department of Health and Office of Alcohol and Substance Abuse Services. To ensure safety, regulations include onsite security, treatment by appointment only, and a strict no-loitering policy.”
He concluded: “Catholic Health has a long-standing mission to serve those in need, and we cannot turn our backs on this crisis or those who are suffering. Thankfully, the one thing we can all agree on is the need for this specialized care to serve the residents of Amherst.”
It now looks as if this OTP is soon going to join the growing number of OTPs nationwide.
Categories: Addiction, Medication-Assisted Treatment (MAT), Methadone, Newsletter, Opioid Abuse/Addiction, Opioid Treatment Programs (OTPs), Opioids
Tags: Methadone Treatment, NIMBY, Opioid Treatment Programs, Substance Abuse Treatment
Upcoming Events
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