The big news in NY is methadone in prisons, but who will bid?
Attendees of the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA) methadone symposium held last month at the Albert Einstein College of Medicine/Montefiore Medical Center in New York City were told that this fall’s debut of required methadone, buprenorphine, and naltrexone in state prisons and county jails is a “golden opportunity.” Mostly opioid treatment programs (OTPs) were interested, because it’s the methadone which falls under their exclusive purview. But Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD) referred somewhat ominously to the massive project, because for it to actually work would be “like pulling a rabbit out of a hat.”
On the positive side, the state legislature and the Office of Addiction Services and Supports (OASAS) support this 100%. “The concept is good,” said Mr. Parrino.
“There are a lot of challenges” to implementing the new law requiring that methadone (and other medications) be offered to everyone in state prisons, county jails, and under community supervision, admitted OASAS director Chinazo Cunningham, M.D. But she pointed out that New York is the pioneer in this important process. “Our learning experience will be what the country is looking towards,” she said.
When inmates leave prison or jail, if they go back to their regular street opioid use, they are likely to overdose, especially with the potent illicit fentanyl now being sold. Placing them on medication before release will help prevent that. In addition, when people are first admitted, if they are already in a program or already addicted to opioids, they will need medication to avoid painful and potentially lethal withdrawal.
The blind RFP
Allegra Schorr, president of COMPA, noted that the one barrier to methadone in prisons is a procurement one. The Department of Corrections and Community Supervision (DOCCS), which is in charge of the bidding process, wants only one OTP to be awarded the bid. This is going to be very complicated in a huge state with a sprawling prison system.
As for the jails, they are run by the counties, and that is even more problematic: jails are run by county sheriffs, and they are not all in agreement with providing addictive medications in their facilities. Jails can opt out if they don’t have enough funding in the county, said Schorr. State prisons have no way to opt out, because the funding is part of the state budget, said Schorr.
The initial thought was that DOCCS would get a medical director and get the prisons certified as OTPs, but “they couldn’t do it,” said Schorr. Rikers, the huge jail in New York City, has its own OTP, but this is outsourced to New York City’s Health + Hospitals Corporation.
Schorr was told that DOCCS only want one provider because it would be easier to contract with them. But there is no single OTP that could handle a project this big. In addition, a problem that is even worse is that the RFP is “blind,” meaning that there is no way for bidders to tell what they need to provide. “Our suggestion would have been to figure out how to collaborate and form a network” before issuing the RFP, which is on the DOCCS website, said Schorr. “If you were going to bid on this, you couldn’t possibly know what you were going to have to provide,” she said. “This could have been avoided if DOCCS had sat with us and worked this out ahead of time.
In any event, the problem isn’t the money – it’s there. The problem is the design. And in the end, this could end up being something nobody wants to bid on – a not infrequent occurrence with blind OTPs.
Stay tuned for more on the methadone-in-prisons story.
Other groundbreaking policies in New York include beefing up take-home dosing (see https://atforum.com/2022/07/methadone-reform-in-ny-part-1/) , funding up to 35 methadone vans (all must be linked to brick and mortar OTPs), opening new OTPs in regions where there are no OTP services, and integrating methadone OTPs into existing Part 822 outpatient programs. (Part 822 is New York lingo for the regulation applying to outpatient addiction treatment programs, which is now being tweaked to accommodate mental health, detoxification, rehabilitation, and methadone).
Dr. Cunningham also wants to make telehealth permanent for methadone and buprenorphine. She said it doesn’t make sense to allow the initial visit for buprenorphine to take place via telehealth, but not for methadone.
And she wants to make it possible for residential addiction treatment, nursing homes, and long term care facilities to store and administer methadone to patients.
Need for good care
Mr. Parrino is all in favor of expanding access to care. But his response is invariably, “what care?” If the care is going to be medication only, what about patients’ other problems, including psychiatric? How will this increased access be accomplished safely? He knows that bad federal policy will lead to a bad treatment outcome. He ran an OTP for 18 years. So it’s important for states and the federal policy maker – the Substance Abuse and Mental Health Services Administration (SAMHSA), to “stay connected.” At the AATOD conference in October, SAMHSA will be meeting with the State Opioid Treatment Authorities. “There has to be an alignment between the federal structure and the states,” he said.
In the 1970s, when Mr. Parrino was forming an association of OTPs, he learned how quickly communities can mobilize against a clinic. “Businesses that wouldn’t talk to each other magically found common ground when you were trying to open a program.”
SAMHSA and the SOTAs should certainly be on the same page. If treatment outcomes are bad, there will be more fodder for anti-methadone voices in the community to use against the new OTPs OASAS wants to see sited in the state.