COMPA symposium highlights issues of concern to NY OTPs on brink of expansion
Methadone reform is taking place in New York, which can serve as a model for other states. The first thing that happened was reimbursement for take-homes. The next was methadone vans. And this fall, a new law requiring prisons and local jails in New York state to provide all three medications for opioid use disorder (OUD) will take effect. In this case, as in many others, “all three medications” is code for methadone, because that is the only medication which can only be provided by opioid treatment programs (OTPs). Buprenorphine and naltrexone, the other two medications approved by the Food and Drug Administration to treat opioid use disorder (OUD), can be provided in physician offices, pharmacies, and other facilities.
Exactly how OTPs will help provide methadone to inmates under this new law was one of the many topics discussed at the June 13 symposium held at Albert Einstein/Montefiore Medical Center in New York City last month.
The symposium highlighted the ways in which New York State’s Office of Addiction Services and Supports (OASAS) is leading the way in methadone reform. OASAS is focusing on methadone vans – both mobile and stationery (in clinic parking lots), on merging opioid treatment programs (OTPs) and other addiction programs, on increasing take-homes, on providing methadone in prisons and jails, and on getting rid of stigma.
Some new information was revealed at the symposium, which was chaired by COMPA. OTPs stood up one after another and said that the increased take-homes allowed by SAMHSA under COVID-19 may have resulted in diversion. Drug-testing of new patients was also halted by COVID, and when it resumed again, OTPs found new patients coming in with methadone in their systems. How did it get there? Questions about the new take-home rules, in which less than stable patients could receive up to 2 weeks of methadone doses, arose, with OTPs rightfully concerned about their own liability. This is why they use clinical judgement to decide how many doses to give to what patients. As Mark Parrino, president of AATOD, pointed out, nobody has offered to indemnify OTPs in the event of a poor outcome. Fortunately, there have been no methadone overdose deaths, but there have been emergency room visits, he said.
However, OASAS commissioner Chinazo Cunningham, M.D. told AT Forum that as far as she knows, there is no diversion, and that she would need to see more than anecdotes to hear about this. It is a priority on the part of OASAS to increase take-homes, and Dr. Cunningham chastised the audience of mainly OTPs about why take-home doses are going down.
It’s no longer a matter of avoiding the spread of COVID, apparently. Now, the priority is one of cutting down on opioid overdose deaths, mainly from illicit fentanyl, and again rightfully, methadone treatment is seen as a way to do this.
So far there are 10 methadone mobile vans in New York, with more on the horizon. The state paid $200,000 per van, and OTPs complained, because they needed more money for them. “We know we underfunded the vans,” Cunningham said. One of the costs will be security, because all it will take will be for one van to be broken into, with methadone or buprenorphine stolen, to put a stop to the entire program.
By integrating OTPs into the existing Part 822 outpatient programs, there will be more locations providing methadone treatment, said Cunningham. However, this would not by itself solve the
NIMBY (Not In My Back Yard) problem with methadone. The symposium panelists said that education is needed to help reduce stigma, so that the communities where programs will be sited will understand that it is their own residents who need help.
Patrick Seche of the University of Rochester Medical Center was successful with this outreach approach in a community in upstate New York, where OTPs are sorely needed. “Everytime there was an opioid overdose, the local media would write about it,” he said. “Not just a number, so the community started to learn about the people involved, and I found that it changed the community’s acceptance.”
But the bottom line is ignorance. Mr. Parrino told a story about working with a legislator on OTPs, who told him flatly that methadone is a “devil drug.”
And Mr. Parrino noted that he has fought for years to make methadone more accessible to patients, getting rid of some of the regulations, and that it has been the federal government itself, and some states, which have less reasonable regulations than are allowed by the federal government. “I think they’re getting there,” said Mr. Parrino. “The issue of the mobile vans is a game-changer.”
Nevertheless, Mr. Parrino remembers the recent days when he had to fight against rules that clinics be open every day of the week, with no plan for how patients would get there. Then, in March of 2020, the new rules came down: “It’s okay to give 14 days [of takehomes] to unstable patients. It’s not like you’re changing the deck chairs on the Titanic. You’re changing the deck.”
The pandemic ushered in the new telehealth and take-home rules, but there are indications that some of these will be here to stay, at least in New York, where harm reduction has become a constant drumbeat of OASAS. And there are good things about some of these changes. “The advantage is that we have learned our patients are more robust than we thought,” said Mr. Parrino. Still, he is concerned, because changes have been so rapid. “I’m all for change but the system can only absorb so much at a given time,” he said.
It’s likely that this summer there will be recommendations that physicians be given prescription authority for methadone outside of OTPs, coming from NASEM. “We think this is unwise,” said Mr. Parrino. “I have to remind people of what happened in the past.” When physicians began prescribing methadone for pain, overdoses did occur, as is documented in five federal reports.
Now, the overdoses are mainly from illicit fentanyl. For new methadone patients, most now have very significant opioid tolerance, noted Mr. Parrino. They’re surviving, not overdosing. So they will need higher doses of methadone than may otherwise be expected – generally, 160 to 180 milligrams a day – said Mr. Parrino.
But take the state of West Virginia, which has a very high overdose rate, but still has only 9 OTPs – the same as there were 15 years ago. And in Wyoming, there are no OTPs. “In my opinion, this is criminal,” said Mr. Parrino. “No person who needs medical treatment should have to drive to another state to get it.” One would think health commissioners, alcohol and drug abuse directors, and other state officials would be pushing to open more programs, Mr. Parrino said.
See also Part 2: More on methadone in corrections, and other reforms in New York.