Emergency departments have long been able to give patients methadone to treat opioid use disorder (OUD) for three days. But there are problems with that: partly that patients have to keep coming back to get it every day, and, mainly, that doctors “just haven’t been excited about doing it,” in the words of Linda Hurley, president and CEO of CODAC Behavioral Healthcare. “We need to get people to the OTPs [opioid treatment programs],” she told AT Forum.
Two recent bills – one in New York
(https://www.nysenate.gov/legislation/bills/2021/s4359/amendment/a) and one in Rhode Island (http://webserver.rilin.state.ri.us/BillText/BillText21/SenateText21/S0769A.pdf): focus on making sure that when someone ends up in the emergency department, typically with an opioid overdose, that there is a place to refer that patient to for treatment.
So far, emergency departments have used volunteers, often from treatment, to encourage OD survivors to seek treatment. “We tried to have volunteer peers,” explains Ms. Hurley. “Volunteerism is wonderful,” but for competence, people should be paid, she adds.
The best option would be taking a staff member from a treatment provider and putting them in the emergency department, said Ms. Hurley. This would bridge the gap between the emergency department, and the community.
In the end, however, the big question is who should be compensated for making these referrals, and how.
Rebecca Boss, formerly the SSA of Rhode Island, is now COO of CODAC. The new SSA was formerly a hospital president, with no experience in behavioral health or dual diagnosis, let alone treatment for OUD, so there is some concern. COVID-19 has put hospitals and general health care front and center, leaving the OUD problem – which is still raging – aside.
Relaxation of the take-home rules
CODAC is one of the providers which immediately went to telehealth when the pandemic started in March of 2020, and has continued to provide relaxed take-home schedules. but what about going forward?
When telehealth initially took hold, patients loved it, because it meant they didn’t have to go to the clinic as often to pick up medication. The purpose of the relaxed take-home rules was to reduce exposure to COVID-19, but a beneficial side-effect was convenience for patients. “We provided at least double the amount of take-home medications to be self-managed,” she told AT Forum.
Pushback against the relaxed rules came from payers, because of the increased utilization of services, said Hurley. But law enforcement, which initially was concerned about increased diversion, and also concerned that there would just be more methadone on the street. The authorities were relieved to find that in fact, this didn’t happen. “At the end of June 2020, I spoke with the RI State Police, and asked if there were any community safety issues,” said Hurley. “They told me there was no bump whatsoever on confiscated prescribed methadone, no bump in found bottles, no bump in medical examiner toxicology results, and nothing at all related to OTPs,” she said.
Patients are also not returning empty bottles too soon, she said. “We measure this every month.”
Still a place for OTPs
If telehealth takes over methadone treatment, does this spell the end of a need for OTPs? Absolutely not, said Hurley. “This is not the demise of OTPs,” she said. They still need to dispense methadone. Unlike buprenorphine, which OUD patients can get by prescription, methadone is not available by prescription (except for pain).
And in fact, methadone is more dangerous than buprenorphine, which has a ceiling effect, she said.
Counselors at CODAC have 50 patients each on their caseloads. Deciding who should get extended take-homes and who shouldn’t – within the broad rubric of the federal allowance of up to two weeks for “less than stable” and 28 days for everyone else – is up the the clinical expertise of the OTP. “We evaluated every single patient,” said Hurley. It wasn’t a matter of automatically giving all patients two weeks of take-homes. “This was a specialty evaluation requiring discernment,” she said. “That’s why we didn’t see a problem in the community. Every day, every other day, every three days – the take-home schedule was individualized.” Patients who came in every day and then went to every other day or every three days would be called on a daily basis. If the calls didn’t connect, the patients would then be required to come in every day.
“This is regulatory stigma at work,” said Hurley. “The vast majority of our patients want to use their medication. We have stigmatized our patients.”
It all comes back to who is competent to evaluate, refer, and treat people with OUD.
Hurley does not support primary care physicians to get an exemption to prescribe methadone for OUD, as former ONDCP director Michael Botticelli and others have advocated. That would not end well, she said. “The reason that there wasn’t a problem with methadone in the community is that the evaluations were done by OTPs, with the high level of confidence that doctors and counselors and nurses who understand this disease have.”
Decreasing competence in a misguided effort to increase access, despite the good intentions, with a medication like methadone is the wrong way to go, said Hurley. “The importance of competence of the evaluating entity is key,” she said. That means that the OTP should give patients a choice and offer all three medications – methadone, buprenorphine, and naltrexone – in treating OUD. “Your ability to discern what is going to work best for this patient counts.” Understanding substance use disorder as a biopsychosocial disease that impacts all of life is not the same as understanding diabetes or cardiovascular disease, she said.
New York bill
In New York, similar legislation sponsored by Senator Pete Harckham and his colleagues (S.4359A) was approved last month that would connect people with SUD to appropriate service providers. The legislation would ensure that people admitted to hospitals at risk or suffering from an addiction receive treatment options to help them.
“Requiring hospitals to point people who have experienced an overdose in the right direction, and also begin to offer them treatment, will save lives across the state,” said Senator Harckham. “This will result in a wider involvement in addiction services for healthcare providers, which is necessary to address the increase in overdoses we are experiencing.”
The legislation focuses on individuals after they have experienced an overdose or substance-related incident required hospitalization or emergency treatment. “There should be no wrong door to enter treatment,” said Senator Harckham. “If someone is admitted to the hospital for addiction, everything should be done to make sure that the individual is connected to services that can help them.”