Archive for the ‘Governmental solutions to addiction’ Category

Hurricane Harvey and Other Emergency Situations

 

Hurricane Harvey

 

 

 

 

 

We all felt heartbroken as we watched the plight of citizens of Houston and other locations deal with the latest weather emergency. I worry most about debilitated senior citizens, children, and animals, all of whom won’t understand what’s happening. I’ve prayed for all people affected by the storm, but that didn’t feel like enough, so I donated to an emergency relief fund.

I said special prayers for patients on medicated assisted treatment. By that I mean any patient who can’t get much needed medications during the flood for serious illnesses. That includes patients with diabetes, heart disease, depression, asthma, opioid use disorder, and many other illnesses.

After Katrina, my state pushed for all opioid treatment programs (OTPs) to formulate emergency planning for their patients for these situations. In New Orleans, patients on methadone (there weren’t many patients on buprenorphine in 2005) had no way to get their medication, and no way to contact their home clinic for confirmation of their dose if they were re-located to a new area with a new OTP. It was only one aspect of the giant disaster that was Katrina.

I thought about what our OTP would do if struck by weather so bad that the facility shut down.

We have a disaster plan, and we just updated it a few weeks ago, coincidently. It’s easier now, since we have a sister OTP located about an hour away. Since both are owned by the same company, sharing data should be simple. We use a server that stores data off-site and can be accessed off-site. Obviously, electronic data retrieval has grown much more sophisticated since Katrina in 2005.

Since my OTP has about nine times the number of patients as our newer sister program, we would need to transport medication to meet the needs of the extra patients routed there for their dose. I feel like that could be easily accomplished, though we’d have to get the approval of the DEA and follow protocols already arranged for these situations.

There are several other OTPs, all about forty-five to ninety minutes’ drive away, surrounding my work site. Patients living closer to those programs could be easily dosed at those facilities as well, if needed. I have a good relationship with the medical directors of those programs, and I feel sure they would go out of their way to help in an emergency. I know I would do the same if they suffered an emergency.

Office-based buprenorphine patients are a little easier. There’s a number of ways to accommodate these patients, since prescriptions could be called in to pharmacies in a pinch. I have records of my office-based patients’ phone numbers both on paper an stored electronically, so if my office can’t open I can still communicate with them for alternative arrangements, assuming phone systems are operable.

Several weeks ago, my fiancé (who also provides counseling for my office-based patients) and I drove to my office practice but forgot the keys to the front door. No problem, we thought, our health services manager, Daniel, will have his keys. Nope. He forgot too. OK, we thought, we can get the landlord, who has an office at the front of our building, will have a master key. Nope. She was out of the country.

It was a pleasant day, not too hot and still shady on the bench in front of my office door where I was sitting. While the other two went in search of another person who may have a master key, my first patient arrived. I explained the situation and asked him if he minded if we conducted the session outside. He thought that was a splendid idea, so we had a very nice fifteen-minute chat. He was doing well, as he has been for about ten years. I couldn’t do a drug screen, but I didn’t make that into an obstacle. At the end of our visit, he gave me his pharmacy’s phone number and I called in his prescription. By the time my second patient arrived, the others had found a key and we proceeded as usual.

In other words, creative solutions to problems can be easy. However, we do need to plan for how to handle situations such as floods, power outages, and other emergencies.

I spent some time on the internet trying to find something about how OTPs in Houston were handling the storm, and how their patients were faring, but so far, I can’t find anything. I hope someone in that area can tell the rest of the nation what happened, so we can better learn how to handle medical issues during emergencies. 

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Buprenorphine in the Primary Care Setting

 

 

 

 

 

I was asked to participate in a project to help primary care doctors provide buprenorphine in office-based settings. This grant, awarded to some very smart people at the University of North Carolina, uses the ECHO model to help physicians in the community become more comfortable with treating patients with opioid use disorder in their offices.

This ECHO model, originally conceptualized at the University of New Mexico, uses a hub-and-spoke model to connect experts at UNC and other locations with primary care doctors at their North Carolina locations. The ECHO model can help not only the physicians and physician extenders, but also nurses, social workers and other staff members who are a part of patients’ treatments, using teleconferencing.

Other hub-and-spoke models have placed physicians and the hub and patients at the spokes, so this is a little different. It’s also different from telemedicine, since the participants at the hub and spoke are all care providers, not providers and patients.

It’s a great program, and gives free continuing medical education hours to the physicians who participate, at the same time they get help with problematic situations in their practice.

Our group is prepared. We’ve done practice sessions and we’ve gotten comfortable with the technology (no small achievement for me!).

Now all we need are providers to participate.

We’ve had some interest, but of course would like to reach as many providers as possible. We had some brainstorming sessions about how to get more participants. We would like to reach primary care providers who have a waiver to prescribe buprenorphine, or who may be interested in prescribing.

As it turns out, many physicians who get the waiver to prescribe buprenorphine don’t end up prescribing, or only prescribe to a few patients. These providers could see more patients with opioid use disorder, and help our nation’s situation with the treatment gap.

This treatment gap is the number of people who need treatment compared to the number of people who are able to receive it. At present, experts estimate that only about 20% of people who need treatment for opioid use disorder actually get it. Of course, some of the remaining 80% aren’t yet interested in treatment, but many are desperate for help, and can’t access it.

Due to changes in the DATA 2000 law, physician extenders like nurse practitioners and physicians assistants will be allowed to prescribe buprenorphine to treat opioid use disorder, after they take a 24-hour course. Of course…many extenders in my area have been prescribing buprenorphine for years, off-label “for pain” with a wink and a nod, but the new law will allow them to be legitimate prescribers. This may expand the number of prescribers a great deal, and help to close the treatment gap.

So why do providers, after getting the training to be able to prescribe buprenorphine, not end up prescribing?

A study done by Walley et al., published in the Journal of Internal Medicine, 2008, surveyed all 356 physicians in Massachusetts who were waivered to prescribe buprenorphine. The study was done in 2005, so that was relatively early in the history of office-based treatment. Out of that total, 235 responded to the survey. Of the 235 that answered the survey, 66% had prescribed at least once, and 34% had never prescribed buprenorphine.

Of the non-prescribers, around half said they would prescribe if some barriers were removed. Nearly a third of these doctors felt like they had insufficient office support. Other barriers, in rank of descending importance, were insufficient nursing support, lack of institutional support, insufficient staff knowledge, low demand for services, and payment issues. So this study showed physicians didn’t feel like they had the support staff that they needed.

Of the physicians who were already prescribing buprenorphine in their office-based practices, the biggest barriers, in descending order of importance, were payment issues, insufficient nursing support, insufficient office support, insufficient institutional support, and pharmacy issues.

Some additional tidbits of data emerged from this study. For example, psychiatrists were less likely to prescribe buprenorphine than were primary care physicians, and physicians in solo practice were more likely to prescribe than those in group practices.

I suspect it’s easier to implement changes to medical practice when you are the boss and the lone provider. In groups of physicians, it’s probably harder to change the status quo to take on new projects and ideas, even when more support staff are presumably available.

This trend, where many of the physicians waivered to prescribe buprenorphine don’t end up prescribing, or prescribe for very few patients, has continued through the last fifteen years.

A study from 2014 by Hutchinson et al., published in the Annals of Family Medicine, looked at 120 physicians in Washington State who received training in 2010 and 2011, to prescribe buprenorphine for opioid use disorder. Out of the 120 providers trained, 92 participated in the post-training survey. Of those providers, some were excluded because they were still in their residencies, or were prescribing buprenorphine before they took the course, leaving 78 physicians newly qualified to receive a waiver to start prescribing buprenorphine for opioid use disorder

Of these 78 physicians, only 64% actually applied for the waiver. Of these 50 physicians, only 22 actually ended up treating at least one patient with buprenorphine. In other words, only about a fourth of physicians who could start prescribing to treat opioid use disorder actually did so. Of these 22 physicians, half prescribed for only three or fewer patients.

Physicians in a practice where there was already another physician prescribing buprenorphine were significantly more likely to actually start prescribing than physician in practices where no other physicians prescribed. Younger physicians were more likely to prescribe buprenorphine than older physicians. Fewer than half of these physicians were willing to have their names listed on SAMHSA’s buprenorphine treatment locator site. (http://buprenorphine.samhsa.gov)

Another study by DeFlavio et al., Rural Remote Health, 2015, was done with an anonymous survey of all of Vermont’s primary care doctors. As it turns out, 10% were buprenorphine prescribers, while 80% said they saw patients addicted to opioids. The barriers that these physicians saw for buprenorphine treatment were inadequately trained staff, insufficient time, insufficient office space, and cumbersome regulations.

Interestingly, Vermont also used a “hub and spoke” model, where experts at the hub stabilize patients newly starting buprenorphine, and after stabilization they transfer to the “spokes” which are primary care providers who continue the prescribing for these patients. This model seemed to work well for the patients and physicians who participated.

As of today, SAMHSA’s website (https://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/physician-program-data accessed 6/6/17) says there are almost 38,000 physicians with waivers to prescribe buprenorphine from an office setting to treat opioid use disorder. Around 3200 have permission to treat up to 275 patients; nearly 9000 can treat up to 100 patients, and around 26,000 can treat up to thirty patients.

In other words, if all of these physicians were prescribing to their maximum, and were located in areas with the highest rates of opioid use disorder, we’d have enough manpower to treat all patients who wanted help.

But these providers aren’t at their maximum.

How can we convince these doctors to prescribe for more people? How can we recruit new providers, who will follow through with a commitment to treat people with opioid use disorder? How can we remove the barriers, which largely appear to fall under the category of insufficient support to give good care?

Some smart people have been working on this for some time, and we now have several models available to assist buprenorphine providers help patients with opioid use disorders.

“Collaborative Care Model,” also known as the Massachusetts model, uses nurse care managers to expand access to treatment. This model is based on how patients with other difficult chronic diseases are managed, such as diabetes and HIV infection. In other chronic illnesses, nurse care managers help the patient with day-to-day care management. This helps the physician know what is going on with the patient and gives the doctor much-needed support to manage the health of these patients.

Studies done on this model showed that patients did as well or better than patients managed only by physicians. This program expanded into community health centers, and the numbers of waivered physicians participating increased by 375%, though this was at a time when buprenorphine was first taking off anyway. The patients treated under this model also had significantly fewer hospital stays.

In this model, nurse managers were doing much of the medical management: doing inductions, doing follow-up on patients, and troubleshooting any problems the patients were having. Providers participating in the model mentioned that RNs can’t charge as much for the care they provide as physician extenders or physicians, so that’s a possible problem.

This year at the American Society of Addiction Medicine’s annual conference, Dr. Andrew Saxon spoke during a session which addressed how to engage practitioners to treat opioid use disorders. He treats patients in the Veterans Administration system, and describing an intriguing method that he called “academic detailing” that they use at the VA.

He said that pharmaceutical companies have already found a model that works, when it comes to getting doctors to prescribe new medications. These companies hire charming people to go to doctors’ offices to spend time talking with the physicians and physician extenders, explaining the new medication and giving them brochures with information.

Dr. Saxon started doing the same thing with VA doctors. Experienced providers make an appointment to speak with a doctor, and bring him or her information, perhaps bring lunch, and generally talk about the process and pleasures of treating opioid use disorders in an office setting. This one-on-one approach appears to work well, and the VA increased treatment availability a great deal using this approach.

The VA made a slick brochure, called “Opioid Use Disorder Provider Guide” which is a pretty good summary of information needed by providers starting to prescribe buprenorphine. Since it’s in the public domain, you can access this document at: https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Opioid_Use_Disorder_Educational_Guide.pdf

I think this academic detailing idea is a winner. It makes sense – pharmaceutical companies wouldn’t have used this method for years if it didn’t work.

To veer off-topic for a moment…it strikes me that I’ve been trying to “detail” local providers for five years, not to get them to prescribe, but just to get them to stop telling patients to get off buprenorphine and methadone. It would be a huge relief if local doctors encouraged these patients, rather than belittling them.

I exaggerate, of course. There are many physicians in my area who are great to work with, but I guess the more difficult doctors tend to stand out in my mind.

Maybe local doctors need detailing from a physician with credentials and/or clout. Perhaps I lack the credibility or personal charisma that makes other doctors listen to me. I’d like to enlist that kind of doctor to “detail” in my area.

Back to the topic at hand.

The VA isn’t the only agency that’s created guidelines.

The American Society of Addiction Medicine (ASAM) has had a similar document, composed by experts as a guide for prescribers: https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf

There’s also information published by SAMSHA (Substance Abuse and Mental Health Services Administration):

https://store.samhsa.gov/product/Medication-Assisted-Treatment-of-Opioid-Use-Disorder-Pocket-Guide/SMA16-4892PG

However, the last time I tried to download this one, there seemed to be a glitch.

So there’s plenty of information available for new prescribers, and there’s a nationwide support network called PCSS MAT, for Providers’ Clinical Support System. It’s an organization dedicated to training and mentoring medical providers in the treatment of opioid use disorders with medication-assisted therapies.

If you go to their website, (http://pcssmat.org/) you can access archived trainings about various topics relating to MAT. They have online modules, podcasts, and basic information. It’s possible to be connected with a one-on-one mentor with experience treating the disease. This helps the provider feel connected and supported, particularly with difficult issues that often arise.

So currently, there’s a ton of data and support for providers who want to treat patients with opioid use disorders, more than there’s ever been before.

With our ECHO UNC launch, providers can get specific recommendations for managing complex patients (with patient privacy protected, of course). Their staff can learn how to support the prescriber, and it’s all free, paid for under grant money. The prescriber can even earn continuing education credit hours, so it’s a win-win-win prospect for them.

I’ll keep my readers updated about how it’s going.

If you are a provider or know a provider who’d like to take advantage of this opportunity to learn, get help with issues that are vexing you, and get free credit hours for doing so, send me an email so I can connect you with the ECHO UNC hub. The technology is free and easy to use.

Price is “Not a Fan” of MAT

Guest Blogger for this week: Yoshi the Cat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Those of us working with patients with opioid use disorder felt apprehensive about what the new head of Health and Human Services (HHS), Dr. Tom Price, would say about medication-assisted treatment. Our wait ended last week, and according to news services, he’s “not a fan” of MAT.

Dr. Price, during a visit to West Virginia last week, said “If we’re just substituting one opioid for another, we’re not moving the dial much,” Price said of MAT, according to the Charleston Gazette-Mail. “Folks need to be cured so they can be productive members of society and realize their dreams.” [1]

He went on further to voice his support for faith-based addiction treatments.

As my regular readers know, medication-assisted treatments with buprenorphine or methadone are the most evidence-based treatment for opioid use disorder.

Damn. Just when we were enjoying the push for treatments proven by science to be effective, we get a new head of HHS who either doesn’t know what science shows us, or worse, doesn’t care. Either way, it’s particularly disheartening, since he’s a physician.

If he’s not a fan of MAT, it is doubtful that President Trump will be a fan.

I searched the internet, trying to find information on his record concerning other health-related issues.

Price, while serving as a Congressman from Georgia, voted against the Family Smoking Prevention and Tobacco Control Act. He has voted against Planned Parenthood funding, saying providing taxpayer money birth control pills violated religious freedoms. I scoured the internet for his views on Viagra, but couldn’t find anything. I would assume, given his views on birth control, that he’s also opposed to taxpayer funding of Viagra and similar drugs.

Commentators wonder if Price will support re-allocation of funds from MAT to the faith-based treatments he favors.

Then several days ago, our former Surgeon General Vivek Murthy posted comments on Twitter, encouraging people to look to science for answers. He tweeted, “Science, not opinion, should guide our recommendations and policies.” And also, “Decades of research have shown that the benefits of medication assisted treatment greatly outweigh the risks associated with diversion.”

I heard Dr. Murthy speak at this year’s American Society of Addiction Medicine conference. The man is smart, and I hope Dr. Price is listening. He could learn much from this younger physician.

Governor Chris Christie was tasked with leading a panel on opioid addiction by the White House, and his final report will be due October 1st of this year.

  1. http://www.businessinsider.com/hhs-secretary-tom-price-medication-assisted-treatment-suboxone-news-opioid-crisis-2017-5

Virginia Board of Medicine Changes Opioid Treatment Program Regulations

aaaaaafail

 

 

In a surprising turn of events, last week the Virginia Board of Medicine passed regulations applying to the prescribing of buprenorphine not only in office-based settings, but also in opioid treatment programs.

At a time when many governmental agencies are trying to figure out ways to keep people from dying from opioid overdoses, the Virginia medical board is more concerned with diversion and misuse of the life-saving medicine, buprenorphine.

Last Thursday, the Virginia Board of Medicine outlawed opioid treatment programs from giving buprenorphine monoproduct take home doses. All patients on the buprenorphine monoproduct have to be dosed on- site at the opioid treatment program, with directly observed dosing. If patients are willing to switch to the combination product, buprenorphine/naloxone, they will be allowed to continue their earned take homes.

I know why the Virginia Board of Medicine restricted the monoproduct; they are convinced people are misusing this medication, injecting it and selling it on the black market. To be sure, this does happen, and I agree that we must do what we can – within reason – to prevent medication misuse and diversion. But I doubt the members of the Virginia Board of Medicine know that opioid treatment programs already have diversion control programs in place, both for buprenorphine and for methadone, a more powerful opioid.

It appears that rather than open a dialogue with opioid treatment programs and their physicians, to get a better idea of how to help patients, the Virginia Board of Medicine unilaterally issued an edit that will adversely affect these patients.

People on the front lines, working at opioid treatment programs in rural areas, know that the medical board ruing will cause considerable hardship for patients who are in good recovery.

Patients have several options, and all of them present some complications that will have to be overcome. Patients can either chose to stay on the monoproduct and dose daily at their opioid treatment program, switch to the combination product and continue to get take home doses, switch to methadone and get take home doses, or drop out of treatment altogether.

Let’s look at each option.

This medical board appears to assume patients could just switch to the combination product, with no problem. But there is a problem – a big financial problem. I’ve looked carefully at the costs of the generic monoproduct compared to the generic combination product. In my area, there’s about a $120 per month difference between the two, at a dose of sixteen milligrams per day. That’s a best-case scenario.

Let’s assuming the opioid treatment programs were able to pass on only their direct increased cost of medication to the patients. An extra $120 per month to stay in treatment doesn’t sound like much to some people, but to uninsured blue-collar workers who make up the majority of opioid treatment program patients in rural areas, that extra cost is prohibitive. It’s enough to force patients out of treatment.

People fortunate enough to have money and insurance can pooh-pooh this all they want, but an extra $120 per month is unaffordable for many patients enrolled in opioid treatment programs.

What about the small but significant number of patients who say they don’t feel as well on the combination product as the monoproduct? The medical board members exhibit a stigmatizing and biased attitude when they assume all patients who request the buprenorphine monoproduct are intent on injecting and/or selling their medication.

I’m convinced some patients do absorb more of the naloxone in the combination buprenorphine/naloxone tablets than they are “supposed” to. People do respond differently to medications, with no bad intent. These patients can recover nicely on the monoproduct, with careful monitoring, and they don’t have the headache and vomiting sometimes seen with the combination product.

While I agree physicians need to take extra measures when prescribing medication which have value on the black market, we should already be doing this, both at opioid treatment programs and office-based buprenorphine offices.

At opioid treatment programs, we have diversion control plans, including frequent bottle recalls to assess for diversion in all patients, on buprenorphine or methadone. We sometimes check patients’ arms for track marks, particularly if they have a previous history of intravenous drug use.

According to the Virginia Board of Medicine, if patients can’t tolerate the combination product buprenorphine/naloxone, or if they can’t afford it, they can just dose each day at their opioid treatment program.

That position overlooks our patients’ realities too.  In rural areas, patients may drive an hour and a half one-way to get to their opioid treatment program. For a person who is doing well and who has earned a week of take homes, the sudden imposition of dosing daily means three hours out of their day, plus the extra expense of travel. That can be a deal-breaker for financially fragile patients, too.

Think how insulting it would feel for patients who have done well in medication-assisted recovery. Think of patients who have done well for many months, have passed drug screens, passed all bottle recalls, and who have become employed. They have recovered into responsible and productive members of society…only to have legislators decide they can’t be trusted to have take home medication.

What would your response be? I’m afraid I might react very badly.

Since dosing every day at the opioid treatment program isn’t an appealing option, and for patients who can’t afford the extra cost of the combination product, or who can’t tolerate the side effects, methadone is a viable option. It works well, and it’s been proven over the last sixty years to be an effective treatment.

It does have some disadvantages, though. There’s still quite a stigma against methadone, and it is harder to taper off of at some point in the future, if indicated. It has more medication interactions and is more dangerous during the induction phase. It’s possibly less forgiving when mixed with alcohol or benzos than buprenorphine.

It also has street value and can be diverted, which is why all OTPs have diversion control plans, which brings us back to the original reason why the medical board wants to outlaw buprenorphine take homes. If they want to outlaw buprenorphine take homes today – a drug much less likely to kill people than methadone – will they outlaw methadone take homes tomorrow? I think that’s highly likely.

Because buprenorphine is so much safer than methadone, SAMHSA dropped the time in treatment requirement for buprenorphine take homes. Their purpose in doing this was, I thought, to encourage more people with opioid use disorder to get into treatment, and consider using the safer drug, buprenorphine.

Virginia’s new requirement puts an end to any take home doses for the monoproduct while ironically continuing to allow take home doses for patients on methadone, a much heavier opioid more likely to cause overdose death when misused.

The last, and worst, option for patients who will be faced with the decision of what to do when their buprenorphine take home doses are revoked by the Virginia Board of Medicine is to leave treatment.

I really hope this doesn’t happen. One study (Zanis et al, 1997) showed an eight-fold increase in overdose death for patients who left treatment at opioid treatment programs.

At a time when the rest of the world is trying to engage people in medication-assisted treatment of opioid use disorder, and make it more attractive to patients at risk for dying, the Virginia Board of Medicine is throwing up barriers to treatment.

I have a suggestion. Why not use some of those millions Virginia extracted from Purdue Pharma in their lawsuit settlement, and pay part of treatment costs for your Virginia citizens with no insurance?

If Virginia feels it’s imperative to offer the buprenorphine/naloxone tablets for patients with opioid use disorder who are able to tolerate that medication, help them pay for it.

For patients who don’t tolerate the combination tablet, let opioid treatment programs to continue to do what we do best…care for complicated patients with opioid use disorder.. Let us continue to do bottle recalls and arm checks to assess for continued IV drug use in patients who have that history.

I suspect, if diversion data could be examined, we will find what we found with methadone ten years ago. The diversion then was fueled by patients at pain clinics, who had little or no oversight, not the opioid treatment programs with active diversion control programs.

If we find some opioid treatment programs have lax diversion control, address that through the channels already in place, rather than trying to invent something new.

But please don’t erect new barriers for patients seeking to recover from opioid use disorder. It will – literally – kill people.

Trump and the Opioid Grants: What Will Happen Next?

"Du-oh!"

“Du-oh!”

 

 

 

 

 

The front page article in the January 9, 2017 issue of Alcoholism and Drug Abuse Weekly is the jumping-off point for this blog entry. This excellent article outlines in plain language how the $ 1 billion Cures Act allocations were supposed to be used.

But on January 20, 2017, President Trump placed a sixty-day freeze on regulatory actions and executive orders that have been published but not yet taken effect. I scoured the internet to try to figure out if Obama’s Cures Act falls into this category. I’m still not certain it does.

The Cures Act, passed in late December as one of President Obama’s last actions had strong bipartisan support. Under this act, the Substance Abuse and Mental Health Services Administration (SAMHSA) is to administer funding for grants to each state. These grants are called State Targeted Response to the Opioid Crisis Grants, or Opioid STR for short.

The amount allotted to each state isn’t based on opioid overdose death rates, but rather on treatment gaps in each state. “Treatment gap” is a term for how many people need addiction treatment in a state compared to how many people are actually getting it. The bigger the gap, the more money that state will be allotted out of the $1 billion pot, to be disbursed over two years.

The states with the biggest treatment gaps are California, due to receive nearly $45 million, and Texas and Florida, both to receive around $27 million.

If dollars were spent based on per capita overdose death rates, the three top states would be West Virginia, New Hampshire, and Kentucky. This, of course, led to some criticism of the way money allocations were decided. Some people feel that the states that need money most desperately won’t get a big enough piece of the money pie.

As the ADAW article points out, some people feel the method of allocation is unfair to states where action has already been taken to treat substance use problems, out of their own state budget. By proactively treating problems, these states won’t qualify for as much of this federal money as states that ignored their opioid problem.

Other complaints are that states which decided not to expand Medicaid will now be awarded more than their share of this federal money, since their treatment gap is wider due to fewer citizens with substance use disorder who qualify for Medicaid to pay for substance use disorder treatment.

Probably no method of dividing the money can be perfectly fair to all states. I think the Cures Act does as good a job as is possible under the circumstances.

However, I am troubled by one aspect of this money distribution.

Each state can spend their federal money as they see fit.

In the ADAW article, H. Westley Clark, past director of SAMHSA’s Center for Substance Abuse Treatment, said, “State attitudes towards agonist medications will be a controlling factor.”

Oh dear. This could be bad.

States which have held a strong bias against methadone or buprenorphine as treatment for opioid use disorders may decide not to spend money on this evidence-based form of treatment.

But now, with President Trump’s sixty-day moratorium on new legislation, no one knows what will come to pass. There are so many uncertainties.

In the January 23, 2017 issue of ADAW, the front page article outlines how the repeal of the Affordable Care Act (ACA) could adversely affect the treatment of opioid use disorders. As we know, Trump campaigned on a promise to kill this healthcare Act. No one knows what he will decide to do, or how it will affect the 30 million people who have health insurance through the ACA now.

As the ADAW article points out, much of the gains in funding for treatment of substance abuse and mental health illnesses came from the ACA, and from the Mental Health Parity and Addiction Equity Act which preceded it. This last Act made it illegal for insurance companies to cover physical health problems while denying coverage for mental illness and substance abuse. Other laws made it illegal to refuse coverage for pre-existing illnesses. Denial of coverage for pre-existing conditions was common practice until relatively recently. When insurance companies could pick and choose who they wanted to insurance, patients who needed health insurance the most couldn’t get it.

Would canceling the ACA affect patients with substance use disorder who are already in treatment? Yes, of course, though I’m not sure to what degree. I know it would be more of an issue for my patients in office-based treatment with buprenorphine than for my patients enrolled at the opioid treatment program.

In the opioid treatment program setting, I don’t know of any patients with Obamacare who were able to get reimbursed for what they paid to our treatment program. These patients paid out of pocket even if they had insurance. I don’t know what the problem was, but I do know I had some bizarre conversations with physician reviewers. One physician said my patients with opioid use disorder, treated with methadone, needed to go a cheaper route, and get methadone prescribed in a doctor’s office. Of course, this is illegal, and has been since 1914, but that fact didn’t budge the reviewer.

Some of my office-based buprenorphine patients were able to enter treatment only because they got Obamacare. I would estimate I have eight to ten patients on Obamacare at present. They get reimbursed for the office visit and drug screening charges they pay to me, and get their medication paid for at the pharmacy, except for a co-pay.

Some of these patients have high deductibles, and still have to pay out of pocket for part of the year, but once they meet the deductible, have their opioid use disorder treatment paid for.

We’ve had the usual difficulties with prior authorizations with these patients, but it’s been no more difficult than patients with traditional insurance.

What would happen to my patients with Obamacare if it suddenly disappears? I assume most couldn’t afford treatment and would drop out. Data about patients who leave treatment for any reason shows relapse rates in the 85-90% range, so most of these people would go back to active addiction. I’ve become very attached to these patients, and this idea breaks my heart.

About a month ago, I was talking to Kristina Fiore, a reporter for the Wall Street Journal, who has done some outstanding reporting on the nation’s opioid use disorder epidemic. She called me for some background information for an article she was researching. Near the end of our conversation, she said something to the effect that everyone is always talking so negatively about our present opioid addiction situation, and she needed to know about reasons for optimism.

I thought about what she said for a few moments. Then I told her the only positive thing I saw was more money being released for desperately needed treatment.

Now, even this one positive aspect feels very uncertain.

 

 

Harm Reduction versus Abstinence Only

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I’ve heard the harm reduction versus abstinence -only debate about addiction treatment many times, not only at addiction medicine conferences, but also in my own head. In the past, I thought abstinence from all addictive drugs was the only true recovery from addiction. As I’ve aged, I’ve traveled far into the harm reduction camp, having seen people with addiction die from their disease when perhaps more could have been done to save them.

A wise mentor of mine once said try not to argue with people who aren’t actually in the room with you, so I’ve committed the debate to writing.

Following is an imaginary debate between two addiction treatment professionals. One professional believes harm reduction measures are worthwhile because they can keep drug users alive and healthier, even if they never completely stop using drugs. The other professional feels harm reduction cheats a drug user out of full and happy recovery, which she believes is seen with complete abstinence from all drugs.

First, they chat about needle exchange:

HR: I fully support needle exchange programs. They have been proven to reduce transmission of infectious diseases, including HIV and hepatitis. Why wouldn’t we want to help people avoid getting these potentially devastating diseases?

AO: Because giving out needles sends the wrong message. It says we are OK with people injecting drugs, and that we are willing to make it easier for them to do so. Appearing to condone drug use in any way sends the wrong message to young adults, who may be considering using drugs for the first time. Stigma towards drug users can be harmful, but perhaps stigma serves a good purpose if it discourages people from doing dangerous things like injection drug use.

HR: Studies do not show needle exchange increases the likelihood that people will start using drug intravenously. Easily available clean needles are not enough to convince a person to start injecting drugs. Besides, even if you have little compassion for the drug user, for every case of HIV we prevent with needle exchange, we save our society countless dollars in medical care. That’s just one disease. When you consider the health burden and medical costs of transmission of hepatitis C, it’s even more reasonable.

Even the ultra-conservative Mike Pence, the former Governor of Indiana and our future Vice President, changed his mind on needle exchange after an outbreak of HIV occurred in a rural community among people injecting opioids.

Besides being morally right, needle exchange makes financial sense.

AO: No, it doesn’t. It sends a message to drug users that we’ve given up on them. It says we don’t think they will ever be able to live without injecting drugs. In a way, it infantilizes them. By making drug use easier, we may cheat them out of trying to become clean and sober.

AO and HR move to the topic of medication-assisted treatment of opioid addiction with methadone and buprenorphine:

HR: First of all, medication-assisted treatment (MAT) is harm reduction only so far as all treatment should reduce harm. MAT is a good treatment in itself, and isn’t necessarily just a stop on the journey of recovery.

I fully support medication-assisted treatment. We have fifty years of studies that show people who are addicted to opioids are less likely to die if they enroll in methadone maintenance or buprenorphine maintenance. It is one of the most heavily evidence-based treatments in all of medicine, and it is endorsed by many professional agencies, such as the Institute for Medicine, Substance Abuse and Mental Health Services Administration, the World Health Organization, and the American Society of Addiction Medicine.

We have study after study showing how opioid addicted people have a better quality of life when on medication-assisted treatment with methadone. We have more information about methadone because it has been use in the U.S. much longer than buprenorphine, which was approved by the Food and Drug Administration in 2002, after the Drug Addiction Treatment Act of 2000 was passed.

Opioid-addicted people enrolled in methadone treatment are more likely to become employed, much less likely to commit crime, and more likely to have improved mental and physical health. They receive addiction counseling as part of the process of treatment.

We think buprenorphine has the same benefits, though there have been fewer studies than with methadone. We do know the risk of opioid overdose death is much lower when an opioid addicted person is treatment with buprenorphine, too.

Because medication-assisted treatment is so effective, it should be considered a primary treatment of opioid addiction, and not only a harm reduction strategy.

AO: With MAT, opioid-addicted people may be harmed more than if they continue in active addiction. It is no different from giving an alcoholic whiskey. Methadone is a heavy opioid that’s difficult to get off of. The opioid treatment programs that administer methadone don’t try to help these people to get off of methadone, because they make more money by keeping them in treatment. These patients are chained to methadone with liquid handcuffs forever. It’s also expensive over the long run, and patients have to agree to many restrictions put on them by state and federal governments.

HM: Methadone and buprenorphine treatments are not like giving an alcoholic whiskey, because the unique pharmacology of these medications. Both medications have a long half-life, and when patients are on a stable dose, they feel normal all day long without cravings for illicit opioids. This frees them from the unending search for drugs that occupies much of their days. Instead, they can concentrate on positive life goals.

Also, even after an opioid- addicted person stops using opioids and endures the acute withdrawal, he will usually feel post-acute withdrawal. This syndrome, often abbreviated PAWS, can cause fatigue, body aches, depression, anxiety, and insomnia. It’s unpleasant. Many people in this situation crave opioids intensely. We think this occurs because that person’s body no longer makes the body’s own opioids, called endorphins.

Endorphins give us a sense of well-being, and without them, we don’t feel so good. When humans use opioids in any form, our bodies stop making endorphins. In some people, it takes a very long time for that function to return. In some cases, it may never return. We can’t yet measure endorphin levels in humans, so this is a just theory, but one borne out by years of observation and experience.

Methadone and buprenorphine are both very long-acting opioids. Instead of the cycle of euphoria and withdrawal seen with short-acting opioids, these medications occupy opioid receptors for more than twenty-four hours. It can be dosed once per day and at the proper dose, it eliminates craving for opioids, and eliminates the post-acute withdrawal, which is so difficult to tolerate.

We often compare opioid addiction to diabetes, because in both cases, we can prescribe medication to replace what the body should be making.

And yes, methadone is difficult to taper off of, but most of the time it is in the patient’s best interests to stay on this medication, rather than risk a potentially fatal relapse to active opioid addiction. Some patients are able to taper off of it, if they can do it slowly.

Do you think of a diabetic who needs insulin as being “handcuffed” to it? Do you think the doctor who continues to prescribe insulin is just trying to make money off that patient? Why is it wrong to make money from treating addiction, but not other chronic diseases?

AO: What about all of the former opioid-addicted people, now in 12-step recovery, who are healthy and happy off all opioids? Why are these people doing so well, even though they had as severe an addiction to opioids as the patients in opioid treatment programs?

HR: We don’t have all the answers to this question. One form of treatment, even medication-assisted treatment, won’t be right for every patient. Maybe the support that a 12-step group can provide got these people through the post-acute withdrawal. We don’t have much information about these recovering people, obviously due to the anonymous nature of that program.

If these people feel OK off all opioids, that’s great. They don’t need medication. But don’t prevent other people who do benefit from medication-assisted treatment to be helped with methadone, and buprenorphine.

Besides, not all opioid-addicted people want to go to 12-step meetings. Do treatment professionals have the right to insist everyone go to these meetings, even if patients don’t like them?

AO: Medications cheat patients out of full abstinent recovery. Methadone and buprenorphine blunt human emotions, and make it impossible to make the spiritual changes necessary for real recovery. Methadone and buprenorphine are intoxicants, and they prevent people from achieving the spiritual growth needed for full recovery. You keep these people from finding true recovery, and condemn them to a life of cloudy thinking from these medications.

HR: Various people assert patients on maintenance methadone and buprenorphine have blunted emotions and spirituality, but there’s no evidence to support that claim. How can you measure spirituality? If spirituality means becoming re-connected with friends and loved ones and being a working, productive member of society, then studies show that methadone and buprenorphine are more likely.to assist patients to make those changes.

Physically, studies show patients on maintenance methadone and buprenorphine have normal reflexes, and normal judgment. They are able to think without problems, due to the tolerance that has built up to opioids. They can drive and operate machinery safely, without limits on their activities. Contrary to popular public opinion, patients on stable methadone doses are able to drive without impairment.

However, if that patient mixes drugs like sedatives or alcohol with methadone, they certainly can be impaired. That’s why patients should not to take other sedating drugs with medication-assisted treatments.

People with opioid use disorder are far more likely to make significant and healthy life changes if they feel normal, as they do on medications like methadone and buprenorphine. If they chose abstinence, many times they feel a low-grade withdrawal for weeks or months, and this makes going to meetings and meeting life’s responsibilities more difficult.

Remember: dead addicts can’t recover. Far too many opioid- addicted people have abstinence-only addiction treatments rammed down their throats. Most of these patients aren’t even told about the option of medication-assisted treatment, which is much more likely to keep an opioid drug user alive than other treatment modalities.

Too often, people addicted to opioids cycle in and out of detoxification facilities over and over, even though we have forty years of evidence that shows relapse rates of over 90% after a several weeks’ admission to a detox facility. We’ve known this since the 1950’s, and yet we keep recommending this same treatment that has a low chance of working. And then we blame the addict if he relapses, when in reality he was never given a treatment with a decent chance of working!

Medical professionals, the wealthy, and famous people are treated with three to six months of inpatient residential treatment, and they do have higher success rates, but who will pay for an average opioid user to get this kind of treatment? Many have no insurance, or insurance that will only pay for a few weeks of treatment. For those people, medication-assisted treatment can be a life-saving godsend. It isn’t right for every opioid-addicted person, but we do know these people are less likely to die when started in medication-assisted treatment. After these people make progress in counseling, there may come a time when it is reasonable to start a slow taper to get off either methadone or buprenorphine, but first we should focus on preventing deaths.

AO: Given the time, money, expense, and stigma against methadone and buprenorphine, it should be saved as a last resort treatment. If an opioid-addicted person fails to do well after an inpatient residential treatment episode, then MAT could be considered as a second-line treatment. Let’s save such burdensome treatments for the relapse-prone opioid-addicted people.

HR: It seems disingenuous to claim stigma as a reason to avoid MAT when you are the one placing stigma on this treatment.

I could go on for many more pages, so let’s stop here. You get the idea.

In the past, harm reduction and abstinence were considered opposing views. I’ve heard some very smart people say this is a false dichotomy, and that in real life, these views are complementary.

I like this newer viewpoint.

 

Any form of treatment should reduce harm. If a patient achieves abstinence from drugs, then that’s the ultimate reduction of harm. Also, harm reduction principles can help keep drug users alive, giving them the opportunity to change drug use patterns later in life. As I’ve said above, dead addicts don’t recover. Let’s give people more choice and more opportunities to transition out of drug use, if that’s what they desire.

 

Let’s do a better job of working together in the coming year!

Access to Buprenorphine Will Expand; News About CARA

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Last week, the Department of Health and Human Services (HHS) announced it was raising the limit on the number of patients each doctor can treat for opioid use disorder with buprenorphine, from the present cap of 100 patients to 275 patients. However, each doctor must first meet criteria and complete an application procedure to be approved for this higher limit.

Initially, HHS wanted to increase the limit to 200 but for some reason ended up with 275. It’s still an arbitrary number, and opioid use disorder remains the only disease to have patient enrollment limits legislated for physicians.

HHS still wants physicians to meet extra requirements before they are approved to accept 275 patients, as I blogged about in my May 8, 2016 post:

  • Have professional coverage for after-hours emergencies.
  • Provide case management services
  • Use electronic medical records
  • Must use that practitioner’s state prescription monitoring program
  • Accept third-party insurance
  • Have a plan to address possible diversion of prescribed buprenorphine medication
  • Re-apply for permission to treat up to 275 patients every three years
  • Supply yearly reports about their practice and their buprenorphine patients

For some of the reasons I names in my May 8th blog, at this time I’m not planning to request permission to treat more than 100 patients.

This measure by HHS is a good and positive thing, and will help more desperate people get treatment. Just because I have a few objections to several HSS’s requirements doesn’t mean other doctors will feel the same way. I expect many physicians treating opioid use disorder will undergo the procedure to expand their patient limit.

 

Meanwhile, both the House of Representatives and the Senate passed the Comprehensive Addiction and Recovery Act (CARA) as of last week, and the bill is going before the President for his signature.

This bill, considered weak by some members of the House, contained only a fraction of the requested money to treat addiction. However, other advocates for addiction treatment say even a weak bill is better than none.

CARA’s content addresses the following:

Expand availability of naloxone to law enforcement and first responders, in order to quickly reverse opioid overdoses and prevent deaths. I think our own Project Lazarus helped get this ball rolling many years ago, and I’m so grateful my OTP has had support from them to give our patients naloxone kits!

Expand education and prevention efforts toward teens, parents, and aging people to prevent drug abuse and promote treatment and recovery.

Encourage states to improve their prescription monitoring systems. I hope some of that money will be directed to interoperability, meaning it will be easier to access a neighboring state’s prescription monitoring program. I also hope the Veteran’s administration will start reporting their data about prescribed controlled substances, too.

Prohibit the Department of Education from rejecting financial aid for people who have had past drug offences. I didn’t know people with drug offences on their record were denied governmental financial aid. If we want people to improve themselves and their life situations, why would we deny help for them? So this measure in CARA is great.

Expand resources to identify and treat incarcerated people with substance use disorders using evidence-based treatments.

Great idea, about forty years late.

Expand drug disposal sites to keep leftover meds out of the hands of children.

Just a question I’ve always had…Of all the tons of medication which have been collected at these disposal sites, has anyone ever studied how much controlled substances are collected?

Launch a “medication assisted treatment and intervention demonstration program.”

Not sure exactly what this will look like, but good luck with all of that.

I feel like I’ve beaten my head against the brick wall of prejudice and stigma against MAT in my community for four years. All I have is a headache…and resentment towards the medical community. I’d be very happy if someone else wants to take over for a while.

Launch a program to promote evidence-based treatment of opioid use disorder.

Well, yeah. it needs to happen. Actually it needed to happen about fifteen years ago, but whatever.

Director money towards law enforcement, to get people with substance use disorders help, rather than incarceration. CARA wants law enforcement to be able to work with addiction treatment services.

I indulged a private snicker at that last one. What a change from only a few years ago.

About six years ago, I was trying to educate people about medication-assisted treatment of opioid addiction. I thought I could help educate law enforcement personnel about addiction treatment, since they encounter it so much. I used the internet to find a journal for law enforcement.

I wrote to the editor, offering to write an educational article for their publication about opioid addiction treatment. My hopes weren’t especially high, but I wanted to give it a shot.

I was surprised when the journal’s editor took the time to call me in person. I was so excited!

Then the editor started talking to me like I was a naughty child. He asked what made me think it was appropriate to waste his time with such a query letter. He said I should have known better than to think any of his readers would be interested in the kind of thing I was offering to write, and he was calling to see what kind of person would be so unwise as to think otherwise.

I was stunned. I regret my reaction to him. I was so taken aback that I started apologizing to him, and said I was so sorry for bothering him and wasting his time.

In reality, he behaved like an asshole. If he didn’t want to waste time, he could have passed on the urge to call me to tell me how stupid he thought I was.

I wish I would have stuck up for myself in that conversation. I like to think I would handle it differently today.

Anyway, now, six years later, the government earmarked money to help law enforcement learn about opioid use disorder treatment.

While writing this article, I’ve come to realize I have bitterness towards people in law enforcement, medical fields, judicial, etc…when they denigrated my efforts to educate them about medication-assisted treatment for opioid use disorder.

I don’t want this bitterness. It’s too hard on me. It’s a weight that interferes with my enjoyment of life, and I’m going to release it.

The tide has begun to turn. We have legislation addressing the terrible opioid addiction problem we have, and money earmarked to help the problem. I want to be able to work with people who may have said bad things about medication-assisted treatment of opioid use disorders in the past. I want to work with those people without feeling resentment and without indulging in sarcasm.