Opioid Settlement Money Part 2

This blog entry is a continuation on some of the ideas presented in my last blog, mainly that the opioid settlement money being granted to each North Carolina county’s commissioners needs to be spent wisely.

The guidelines that our state government has put forth can be found in this pdf: https://www.ncacc.org/wp-content/uploads/2021/04/Opioid-Litigation-Settlement-Overview-202109.pdf

These plans include very reasonable ways to fight the opioid epidemic, embracing prevention, treatment, and plans for additional services. I have thoughts regarding a few specific topics.

Housing

Housing is a problem for many people with opioid use disorder in my area. There’s not enough low-income housing available in general, but people with substance use disorders have unique problems with housing. For example, if a person seeking recovery lives with other people who use drugs, as often happens, they encounter a constant trigger for relapse. They need to move, but where can they go?

We do have recovery houses in our area, but they don’t accept patients on methadone or buprenorphine. Last blog, I explained how some medical practices and facilities have been found in violation of the Americans with Disabilities Act (ADA) if they exclude people from services because they are on prescribed methadone or buprenorphine. I don’t know if this law applies to recovery houses, but the bottom line is that there are no recovery houses available in our area for people on medications for opioid use disorder. We need this is our area and around the state.

Over the past few years, our area’s homeless population has grown. I think there are several reasons for this, including a rise in methamphetamine use disorder, which often co-occurs with opioid use disorder. Methamphetamine use seems to lead to people getting kicked out of their housing. Also, our homeless shelter closed a few years ago, pressured by a community that didn’t want “those people” present in their community. Thankfully, a church opened a temporary homeless shelter, but people can only stay there for fourteen days per year.

Ironically, the closed shelter was located very near our OTP. Since that shelter closed, “those people” formed a tent city in the woods behind our OTP, at least during warm months. I’ve admitted some of them into treatment for their opioid use disorder, and at least they can get to our OTP daily since they live in our backyard. However, most also struggle with methamphetamine use and are triggered by others in this homeless camp. As most of my blog readers know, there’s no medication that has been proven to help patients with stimulant use disorder. We try our best to engage them in counseling, but they need safe housing.

At one point I estimate there were ten or fifteen people living there, though only a handful were our patients. Several churches in the area brought food to these patients regularly, and our OTP had clothing and blankets which we provided when we could.

In an ideal world, recovery homes for patients in treatment on medications for opioid use disorder would be wonderful.

Transportation

I’d like for our state to spend part of the opioid settlement money on the transportation of patients to treatment. The nature of our outpatient treatment program means patients must come for dosing and counseling daily, at least until they stabilize.

Transportation is a barrier to treatment for patients in our rural county. We have no public transportation for people without Medicaid. Thankfully patients with Medicaid can ride vans that bring them to and from our opioid treatment program to dose daily, but it’s not feasible for patients without Medicaid.

Since requirements were loosened for take home doses during COVID, patients can get take homes much earlier than in the past. But new patients starting methadone still need to come daily until they get to stable doses. Some patients take longer than other to get to a stable dose and stop using fentanyl and other opioids. If they miss days, it interferes with dose increases and they spend longer in induction, placing them at higher risk for a bad outcome.

I’d like for someone to invent dependable transportation for our patients.

Of course, a mobile unit would be ideal but so far there’s no talk of starting this at the OTP I work for. It could work well, particularly in rural areas.

Fund Treatment

Of course, the most obvious need in patients with opioid use disorder is funding to pay for treatment. As I talked about in my last blog, the opioid settlement money should pay for evidence-based treatment.

The state opioid response grant (SOR) has paid for treatment at opioid treatment programs for indigent patients. To qualify for the grant, patients need to have an income below a certain cut off and have no health insurance or Medicaid. This grant has been a lifesaver for many patients. We have around two hundred patients now getting their treatment paid for by this grant at the OTP where I work.

The Opioid settlement money could be administered in a similar way, except I wish even patients with health insurance could get grant money. Right now, having health insurance disqualifies patients from the grant, but many of those patients can’t get their health insurance to pay for treatment. It’s not quite as bad for office-based buprenorphine treatment, but similar.

As I wrote about last blog, county commissioners need to take care not to give money to unproven treatment providers.

Just last week, WRAL in Raleigh ran a piece about a ten-million-dollar grant to combat opioid use disorder to a pastor running a non-profit organization called Hope Alive. Critics say this agency has no experience treating opioid use disorder. To make matters worse, WRAL did some research and found that this pastor served time for seven counts of embezzlement 1992 through 2004. [1]

Defenders of the grant decision say there’s no other providers of treatment in rural Robeson County, and the pastor’s criminal record was a very long time ago.

The last part of that I’ll agree with completely. Perhaps the pastor had a substance use disorder himself, leading to the criminal charges. Perhaps his past has made him a more effective person to lead a recovery service. I believe people can grow and change, or else I wouldn’t be working in this field.

But the first part…just because there’s no other programs in Robeson County doesn’t mean spending money on ineffective or unproven treatment will help anyone. Shouldn’t the treatment facility be vetted, to make sure it adheres to evidence-based treatment, before the state awards ten million dollars?

In order for agencies and programs to receive settlement money, there should be some standard process to prove that they use evidence-based programs or medications.

Treatment for incarcerated people

Our state’s county jails and state prisons don’t often offer medication-assisted medications to treat opioid use disorder in incarcerated people. They usually won’t continue treatment that a patient has been getting. There’s a pressing need for this to change. I was happy to see this added as a priority for how NC planned to spend the opioid settlement money.

Litigation around the nation has been decided in favor of people who were denied their usually prescribed medications of buprenorphine or methadone while incarcerated. I’m happy about this because the threat of a lawsuit motivates organizations to change quickly.

I wish the public knew how much suffering our patients endure in these county jails when they are denied their treatment medication. A patient dosing for months on methadone at 120mg could be locked up for unpaid traffic tickets and spend five days in jail going through hellish withdrawal. If a nurse can be found, the patient might be given their “detox protocol:” a single bedtime dose of clonazepam .5mg. Healthy adults usually don’t die from opioid withdrawal if dehydration is treated in a timely fashion with intravenous fluids. However, medically fragile patients can die from sudden and severe opioid withdrawal.

I’ve blogged about this before. I tell all my patients who have been through such an awful experience that they can contact the NC chapter of the American Civil Liberty Union, to ask about filing a lawsuit for being denied appropriate medical care. Such lawsuits have been won in other states.

But North Carolina’s plan looks farther than continuing legitimate medical care for people already in treatment. It also envisions screening of newly incarcerated people to start appropriate medications. That’s a wonderful idea. After all, we know that studies show reduced criminal activity in patients who start in treatment with buprenorphine or methadone, so it makes financial sense as much as medical sense.

The logistics of providing this care will be difficult, but some prisons already have such protocols. We can learn from them how to set up good programs that benefits incarcerated people with opioid use disorder and our communities.

  1. https://www.wral.com/church-nonprofit-with-zero-track-record-of-providing-drug-treatment-awarded-10-mil-from-state-to-combat-opioid-crisis/20072234/

2 responses to this post.

  1. Posted by bpmurraymd on January 20, 2022 at 2:52 am

    if there is one simple thing any state could do it is to continue treatment when our OTP patients are incarcerated ! it is definitely cruel and unusual punishment to force these patients to detox in jail. You are right : where are the local ACLU attorneys ? the second best thing would be
    to start treatment while patients are incarcerated — but that is another issue.

    Reply

  2. Posted by Alan Wartenberg MD on January 21, 2022 at 4:45 pm

    You want the Prison/Industrial Complex to do some rational, kind and cost effective? What are you? Crazy or sumpin’

    Reply

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