By Alison Knopf
There are moves—important and funded ones—to support the expansion of medication-assisted treatment (MAT), but those moves apply mostly to office-based opioid treatment (OBOT) providers, not to opioid treatment programs (OTPs).
“I suspect that the OBOTs are already the beneficiary of increased access to MAT, since they keep expanding the number of providers, who can be DATA 2000 waived,” said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD). “To some extent, buprenorphine appears to be used as a harm reduction approach in expanding access to treatment,” he added.
However, the question is what constitutes treatment, after medications are used.
“Unintended Challenges” to Expanding Access to Treatment
In a paper published this winter (http://www.aatod.org/wp-content/uploads/2019/01/2019-Policy-Paper-5.pdf), Mr. Parrino cited “unintended challenges” that are developing as legislators and policymakers move to expand access to treatment for opioid use disorders (OUDs). One major barrier is developing a workforce. “Based on the history of OUD treatment, it is clear that comprehensive services are necessary for the majority of people in treatment, especially when treatment begins,” Mr. Parrino wrote. Methadone can help the patients become stabilized, but then the focus is what services are needed to continue recovery—which will differ from patient to patient.
However, said Mr. Parrino, it is “clear that increasing access to care and treatment requires quality of care assessments and monitoring, as well as continuous quality improvement at the provider/facility level.”
AATOD: “A Diverted Opioid Is Not a Therapeutic Opioid”
Medication diversion is another issue—but one that does not seem to trouble the harm-reduction community. “A number of public-health proponents have described the street diversion of buprenorphine as ‘therapeutic,’ because its use by individuals not in treatment amounts to an attempt at lay treatment of OUD,” said Mr. Parrino. However, he noted that injectable and depot formulations will restrict diversion.
“AATOD’s public position on this topic is that the diversion of any opioid at any time, and particularly during an opioid epidemic, is unwise. Our argument has always been that one cannot define a diverted opioid as being therapeutic.”
According to SAMHSA and the Drug Enforcement Administration (DEA), there are approximately 1,600 licensed and accredited OTPs in the United States, with an estimated 400,000-plus patients receiving treatment at OTPs. By 2017, SAMHSA had approved more than 45,000 DATA 2000 prescribers, but only half were prescribing any buprenorphine, a phenomenon attributed partly to low reimbursement by health insurance. “Comprehensive treatment protocols are critical as patients progress to maintenance therapy and recovery, especially in light of the focus on increasing access to medications, with or without support services, and the limited availability of support services,” said Mr. Parrino.
How Primary Care Providers Can Help
Sometimes, primary care allies itself with harm reduction in looking at reforming the OUD treatment system—basically, in getting rid of OTP regulations. As for the idea of methadone prescribed by primary care practitioners either for maintenance or detox, AATOD said such practices would be “countertherapeutic and dangerous.”
Citing the unintended consequences of prescription of methadone for pain—overdoses by patients who didn’t understand the long-term nature of the medication (and lack of prescribers’ education on the medication)—Mr. Parrino did, however, suggest that primary care practitioners, working in conjunction with OTPs, could help in treating fully stabilized patients.
OTP Hubs; Primary Care Extensions
In this model, the OTPs would be the addiction “hub” and the primary care practices their extension. “Linkage back to the hub site would provide accessibility to patients and providers for re-stabilization and increased recovery services and support as needed,” said Mr. Parrino. “Clearly, this model would need to be developed as treatment protocols are put into place to ensure safety and to protect patients from exposure to unintended danger. Additionally, it is worth considering the prospect that some entities, such as Johns Hopkins, may utilize pharmacies to treat even more stabilized patients, as they do when patients pick up medications to treat any other chronic disorder.
Harm Reduction Policies, AATOD, and OTPs
“I do not think that OTPs will change significantly through a harm reduction focus,” Mr. Parrino told AT Forum. “I know that a number of harm reduction policy groups would like to see the OTP regulations removed, to expand access to care. AATOD does not support this, and my recent paper explains why. The impediment to OTP expansion has been rooted not in the regulatory structure, but instead in zoning Board ordinances, community opposition, and occasional legislative moratoria on opening OTPs. I believe that West Virginia still has its moratorium in place.”
The Harm Reduction Coalition, however, does want to collaborate with OTPs. “Harm reduction programs also serve methadone patients. Harm reduction program staff should include methadone patients, and OTP staff include members of the harm reduction community,” said Daniel Raymond, deputy director of planning and policy for the Harm Reduction Coalition, based in New York City.
“Harm reduction advocates have attended and presented at AATOD’s conference, and OTP staff participate in our National Harm Reduction Conference,” Mr. Raymond told AT Forum. “We have a lot of common interests—not the least of which are struggles with NIMBY concerns—and among the broader SUD treatment field, OTPs were often the first to recognize the value and role of harm reduction. Ultimately, there are still far more OTPs than harm reduction programs, but the harm reduction community is clear on the value and role of methadone; indeed, in much of the world, methadone treatment is considered a central part of harm reduction.”
It should be noted that harm reduction forces are not the only ones who favor a deregulation of the system. The belief seems to be that if regulatory barriers are eliminated, access to treatment will be increased.
It’s important to add that harm reduction groups would like to see OTPs expanded—but that there is a basic lack of understanding that regulatory issues are not the real obstacle. The real obstacle is zoning boards and community groups.