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6/23/2014 12:00 AM

It was an unusual meeting — a top legislator and a group of experts and officials sat around a horseshoe table for almost four hours on June 18 discussing possible regulatory changes to the Drug Addiction Treatment Act of 2000 (DATA 2000). The meeting, which was livestreamed, gave a glimpse into how a key lawmaker gets educated about a topic, while at the same time setting the course for change.

Sen. Carl Levin (D-Michigan) convened the forum along with Sen. Orrin Hatch (R-Utah). Both congressmen had also spearheaded the two laws allowing buprenorphine to be prescribed: DATA 2000, which limits physicians to 30 buprenorphine patients, and the 2006 amendment, which allows physicians to treat up to 100 patients after the first year of treating 30. The group was preselected to be in favor of buprenorphine expansion, with the exception of federal officials, who outlined pros and cons.

It was an unusual meeting — a top legislator and a group of experts and officials sat around a horseshoe table for almost four hours on June 18 discussing possible regulatory changes to the Drug Addiction Treatment Act of 2000 (DATA 2000). The meeting, which was livestreamed, gave a glimpse into how a key lawmaker gets educated about a topic, while at the same time setting the course for change.

Sen. Carl Levin (D-Michigan) convened the forum along with Sen. Orrin Hatch (R-Utah). Both congressmen had also spearheaded the two laws allowing buprenorphine to be prescribed: DATA 2000, which limits physicians to 30 buprenorphine patients, and the 2006 amendment, which allows physicians to treat up to 100 patients after the first year of treating 30. The group was preselected to be in favor of buprenorphine expansion, with the exception of federal officials, who outlined pros and cons and focused on diversion and other consequences caused by lack of adequate care, including drug tests and counseling, for patients.

Senator Levin opened the meeting by saying there were too few doctors certified to prescribe buprenorphine and stressed that the current opioid addiction problem makes it important to remove as many barriers to treatment as possible.

The forum was only about buprenorphine, and the witnesses had been told to prepare their opening remarks accordingly. The participants included Michael Botticelli, acting director of the White House Office of National Drug Control Policy (ONDCP); Nora Volkow, M.D., director of the National Institute on Drug Abuse; H. Westley Clark, M.D., director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA); Elinore McCance-Katz, M.D., chief medical officer of SAMHSA; Colleen LaBelle, program director with the office-based opioid treatment with buprenorphine program at Boston University Medical Center; Andrew Kolodny, medical director of the Phoenix House Foundation and president of Physicians for Responsible Opioid Prescribing; John Kitzmiller, M.D., a certified buprenorphine prescriber from Senator Levin’s home state of Michigan; and R. Corey Waller, M.D., a buprenorphine prescriber and founder of the Center for Integrative Medicine at Spectrum Health in Grand Rapids, Michigan, who was also representing the American Society of Addiction Medicine (ASAM). There were also buprenorphine patients who spoke.

After the prepared remarks, Senator Levin and the participants engaged in a colloquy that revealed some of the forces behind buprenorphine expansion, and the concerns about what will happen if in fact the “floodgates are opened,” as Botticelli put it.

Waivered physicians

Under the Harrison Narcotics Act of 1914, physicians are not allowed to prescribe narcotics to treat addiction, which is why opioid treatment programs (OTPs) — methadone is an opioid agonist — are so tightly regulated, allowing only dispensing and only under strict federal and state regulations. The 1914 law is also why DATA 2000 was needed, to allow buprenorphine — also an agonist — to be used in the treatment of opioid addiction. Under DATA 2000, physicians must receive eight hours of training to be “waivered” from the Harrison Narcotics Act, which is enforced by the Drug Enforcement Administration (DEA), and then they can prescribe Schedule III, IV or V controlled substances to treat addiction. Buprenorphine is Schedule III and is only indicated for addiction in this country. Methadone is Schedule II but can be prescribed for pain by any physician with a DEA license.

One theme that emerged was that there are barriers to treating buprenorphine even among the physicians who have been waivered. McCance-Katz said that the main barrier is a “lack of implementation tools.” After meeting with the Health Resources and Services Administration (HRSA) and the ONDCP, SAMHSA concluded that physicians need to understand the induction process better, need training for office staff on how to work with patients with addiction, and need more detailed information on documentation and billing for buprenorphine treatment.

“Only a small number of physicians are electing to use medication-assisted treatment,” said Botticelli. There are more than 25,000 waivered physicians, of whom about 2,500 are allowed to treat up to 100. But most of the 20,000 aren’t treating anybody.

SAMHSA’s role

Prior to DATA 2000, the only treatment for opioid addiction was in methadone programs and the only office-based treatment was with naltrexone, said Clark. DATA 2000 made it possible for patients to get treatment “in the privacy of a physician’s office,” and SAMHSA certifies the physicians who prescribe it, as well as certifying OTPs. The Department of Health and Human Services (HHS) “is considering the need for changing the cap,” said Clark, noting that the lack of physician access in underserved areas is a problem.

What is needed, more than the lifting of the cap, is more physicians to prescribe buprenorphine, said Clark, noting that there are already 20,000 doctors who could treat up to 100, but who aren’t — they are sticking with the 30, and most of them aren’t even treating one patient.

Another theme was that of changing times, with some witnesses suggesting that the new treatment population for opioid addiction is people who got into trouble with prescription pain medication and who are better candidates for office-based treatment than for OTPs. “Before DATA 2000, people suffering from opioid addiction were disproportionately African American and Latino, from poor districts,” said Kolodny. “Nobody paid attention to them.” Now, however, he said many people get addicted to opioids by being overprescribed pain medication, and progress to injecting heroin.

Problems with expansion

Because the forum was geared toward the topic of expanding buprenorphine treatment, and the witnesses had been told to be prepared to discuss the barriers to such expansion, Senator Levin didn’t seek out comments about the problems with buprenorphine expansion, and in fact his questions and comments were all geared toward removing the barriers. But after Botticelli, Clark and Volkow explained some of the problems with unmitigated expansion, he pulled back slightly, concluding that should be undertaken but “with caution.”

In OTPs, one physician can be responsible for up to 300 patients. Senator Levin asked why the cap couldn’t be similar for buprenorphine.

At this point, Clark stepped in, reminding Senator Levin that in the process of passing DATA 2000, lawmakers were concerned about creating pill mills. “We are dealing with the issue of addiction, not simply a medication,” he said. “The risk of diversion, or of comorbidity with benzodiazepines, could go up,” he said. “While the system has tolerated the modest diversion that has occurred because of access issues, once that lack of access disappears and diversion goes up, then you have the backlash.”

LaBelle said that there are serious problems with getting rid of limits. Physicians with a lot of patients may become pill mills, and then get shut down, so there are hundreds of patients whose source of medication is cut off. “We have many places we can send patients so they don’t go into withdrawal,” said LaBelle.

“The concept of backlash by opening up the floodgates is not theoretical,” said Botticelli. “As buprenorphine expands, there’s been a backlash, even with the 100-patient limit,” he said, noting that even now states are imposing restrictions on buprenorphine.

Senator Levin, who seemed to equate OTPs with buprenorphine despite there being a strict regulatory system for OTPs, asked if there was a backlash against methadone too, and Botticelli said there isn’t because it’s already “so heavily regulated.” But the physicians prescribing buprenorphine have no such regulations, and may indeed only be handing out prescriptions. “What is the physician support?” asked Botticelli. “Are they doing urine testing, are they doing pill counts, are they ensuring patients are getting access to other behavioral therapies?”

Lack of access

Volkow said that 95 percent of buprenorphine diversion is due to lack of access to the medication — that people are buying it on the street to forestall withdrawal. Whether the same could be said for other opioids bought on the street is unclear. The implication is that if these users could have access to buprenorphine, the diversion wouldn’t happen. Only 5 percent is due to patients seeking euphoria.

Diversion of buprenorphine isn’t being used recreationally by people who are opioid-naïve, said Kolodny, who thinks buprenorphine should be more available.

But when Kolodny said that it’s difficult to overdose on buprenorphine, Volkow stepped in to correct him. The situation in Europe, where buprenorphine is used for pain, has proven that buprenorphine combined with benzodiazepines does result in overdoses, she said. Then, Senator Levin asked why buprenorphine can’t be used for pain, and Volkow described another way in which buprenorphine can cause overdose — it’s so slow-acting that when the pain doesn’t go away after the first pill, the patient may take another, and another. “The dose accumulates and it can result in overdose,” she said.

Other issues

The use of nurse practitioners (NPs) to increase buprenorphine prescribers was also discussed. Senator Levin asked if it made sense that nurse practitioners can prescribe opioids for pain but can’t prescribe buprenorphine for addiction. “No, it does not make sense,” said Kolodny. McCance-Katz noted that NPs can’t prescribe buprenorphine but can perform other addiction treatment functions.

The DEA works in conjunction with SAMHSA on certifying physicians, but Kolodny wants to eliminate the DEA visit to buprenorphine doctors, which he says discourages new physicians from signing up.

Waller said that his addiction patients are “treated terribly” in the general medical system, and he thinks that this shows the stigma and discrimination among physicians that is another barrier.

In fact, the physicians who treat 100 seem to be the ones who focus on addiction — which was not necessarily the way the system was set up. “So at 30 you’re not an addiction doctor but at 100 you are?” asked Senator Levin.

Patients prefer to go to the 100-cap physicians, because these are the doctors most enlightened about addiction. Asked how patients know whether a physician has 100 instead of 30 patients, Waller said that “it’s the word on the street.” Because buprenorphine combined with naloxone can’t be started until the patient is in withdrawal, induction is something that physicians familiar with addiction are more comfortable handling.

He noted that he stays in the high 90s in terms of patients but has primary care physicians that he hands stable patients over to so he can keep taking new patients.

Regulatory fix

Senator Levin asked whether there was authority to increase the patient limit, so that he and Senator Hatch did not have to go the legislative route. “We believe the secretary [of HHS] through regulatory exercise may be able to increase the limit,” said Clark, telling Senator Levin that “we are briefing her as we speak, and we will let you know.”

Waller said that ASAM would take on Senator Levin’s questions about what the hurdles are in insurance to buprenorphine.

Training

Senator Levin also asked whether it was possible for the SAMHSA website to indicate what physicians are prescribing buprenorphine, or who have openings available for patients. But McCance-Katz said physicians don’t want their names published — they don’t want to deal with the annoyance of phone calls.

“We would need staff and funds for that because the list would need to be maintained,” added Clark.

There was also a discussion about training not being more available, with Kolodny complaining that any doctor who wants to get trained should be able to get it for free. In fact, SAMHSA offers free training through its Physician Clinical Support System (PCSS), and two of the groups named in DATA 2000 don’t charge for training. The other groups, including ASAM, do charge, however, and Clark said that in at least one case, the revenue from these trainings is significant. Physicians must belong to the medical society that is providing the training.

Still, training is only $200. “That’s an impediment?” asked Senator Levin, incredulously. “A lot of doctors won’t do it,” said Kolodny. McCance-Katz noted that SAMHSA gets no money from the trainings, but that groups that provide them under DATA 2000 can charge if they want.

Clark said the problem is not the cost of the training, it’s the fact that doctors aren’t interested in treating addiction. “The issue is whether I want to be bothered with the patients,” he said. They don’t mind paying for the junkets they go to for Continuing Medical Education (CME), he said. Physicians have “no problem paying to take the family to an event for CMEs and spend the afternoon on the golf course,” he said. “But if I don’t want to be bothered with the patients, then two hundred dollars for eight hours of training is prohibitive.”

Kolodny criticized President Obama for not speaking about the issue of opioid deaths, and Senator Levin said the issue was a good one for Mrs. Obama to take on.

Stay tuned.

For the forum, which is now on YouTube, go to https://www.youtube.com/watch?v=dXpFFwC-nZQ.

5/26/2014 12:00 AM

In a May 16 blog focused on the upcoming three-day meeting on the National Longitudinal Study of Neurodevelopmental Consequences of Substance Use later this month, the directors of four institutes at the National Institutes of Health wrote about the likelihood that more adolescents will have easier access to marijuana in coming years. New designer drugs and e-cigarettes, which provide a way to ingest nicotine (and have health effects that are “barely understood”), increase even more the need to answer questions about the risks of long-term effects of these substances, according to the blog.

So a huge study is going to be done.

The institutes envision tracking a cohort of about 10,000 young people for a decade, beginning in late childhood. They would collect mental health, genetic and behavioral data on substance use, school achievement, IQ and cognition. The study would use brain imaging, which the institutes say is crucial. “The array of neuroimaging and genetic tools now available enables us to study the nature of the brain changes that arise from substance use and shed light on causal mechanisms, to a degree never before possible,” they write. The study should “identify neurodevelopmental pathways that link drug abuse with mental illness, and disentangle the effects of individual substances as well as characterize their combined effects.”

The study will start around age 10, before participants have started using substances.

“A study of this magnitude and scope will be costly, but understanding the impact of drugs, alcohol and tobacco on the developing brain has enormous potential to affect the health of current and future generations of young people,” according to the blog. “Fortunately, we are now in a position to provide confident answers to these research questions based on the most robust modern science.”

The authors are Nora Volkow, M.D., director of the National Institute on Drug Abuse (NIDA); George Koob, Ph.D., director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA); Alan Guttmacher, M.D., director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD); and Bob Croyle, Ph.D., director of the Division of Cancer Control and Population Sciences at the National Cancer Institute (NCI).

There is evidence from animal and human studies that exposure to marijuana — and other drugs — can affect the adolescent brain, the blog notes. “But there are many gaps in our knowledge, and no large prospective study has yet been conducted that has followed participants all the way from childhood — i.e., before the first use of substances — through to adulthood, employing neuroimaging tools to assess the effects of substance exposure on brain development while measuring a broad range of behavioral antecedents and outcomes,” according to the blog.

That’s the purpose of the longitudinal study, which has not even been designed yet — to study what the effects are of “occasional or regular use of alcohol, tobacco, and other drugs on the brains and lives of young Americans.”

The research community is now being asked to help design a study that would do just this. An expert panel workshop on May 27–28, which is open to the public, will develop recommendations on designs and “measures to assess developmental effects of substance exposure.” After this meeting, there will be, sometime this summer, a formal request for information (RFI) for input from the research community on the proposed design and measures. There will be a revised design, based on RFI input, via a symposium at the annual Society for Neuroscience meeting in Washington, D.C., in November.

For more about the meeting, go to http://addictionresearch.nih.gov/cran-initiative-neurodevelopmental-consequences-substance-use.

The initiative is part of the CRAN (Collaborative Research on Addiction at NIH) that was announced last year (see ADAW, December 23, 2013).

5/19/2014 12:00 AM

People with alcohol use disorders (AUDs), especially in cases of heavy or long-term drinking, are almost always advised to be abstinent. But randomized controlled trials (RCTs) have documented outcomes such as reductions in the number of heavy drinking days or drinks consumed as successes.

People with alcohol use disorders (AUDs), especially in cases of heavy or long-term drinking, are almost always advised to be abstinent. But randomized controlled trials (RCTs) have documented outcomes such as reductions in the number of heavy drinking days or drinks consumed as successes.

The official standpoint of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) is that the safest path for someone with an AUD is abstinence, said Robert B. Huebner, Ph.D., acting director of the NIAAA Division of Treatment and Recovery Research, who along with NIAAA Director George Koob, Ph.D., talked to ADAW on May 14 about the viability of treatment goals that fall short of abstinence.

“The safest course is to remain abstinent,” said Huebner. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) supports that, he said. Participants who were interviewed there years after their remission, who remained abstinent, were at much lower risk of returning to alcoholism than those who returned to low-risk drinking after remission, he said.

NESARC, a study of alcoholism and related disorders conducted by NIAAA researchers in two waves (2001–2002 and 2004–2005 on the same respondents), found that many people with AUDs reduce their drinking, even without any treatment.

“But there may be a proportion of patients who meet the criteria for AUDs and who can return to low-risk drinking,” said Huebner. “We need to be open-minded about this.”

There have been studies comparing patients over a two-year period, and finding that those who were low-risk drinkers were “not appreciably worse on a number of personal and social consequences,” said Huebner. “These are hints that there may be subgroups of alcoholics who are candidates for this.”

No carte blanche

NIAAA does not recommend that alcoholics return to low-risk drinking after they have recovered. “One has to be extraordinarily careful,” warned Koob. “A carte blanche that says everybody can return to low-risk drinking is not appropriate based on what we know,” he said. “There are many people who tried that and failed in disastrous ways.”

But that doesn’t mean patients who want to reduce their drinking should be told they have to accept abstinence. “If a patient has a goal of reduced drinking, we should not show them the door,” said Huebner. “We should engage them, and if necessary reevaluate it on a regular basis.” In some cases, he said, when patients experience the benefits of reduced drinking, they go on to abstinence.

“That’s why we take all comers,” said Koob. “If you reduce heavy drinking, that is so much better” than continuing heavy drinking. “You can have a goal of complete abstinence, and for most of my closest colleagues and friends who have alcoholism in their family, that’s the goal they advocate for their loved one,” he said. “But stigmatizing a slip can be devastating,” he said. “We have to have a more realistic view of behavior and pathological behavior.”

Letting the patient choose

Tom Horvath, Ph.D., is president of Practical Recovery, a for-profit corporation that provides treatment that allows patients to make their own choices about whether they want abstinence or moderation, with the exception of patients in residential treatment, who are required to abstain while they are there. “The fundamental problem in addiction is motivation,” Horvath told ADAW. “You can get clients to do something, but ultimately they’ll do what they want.” Outpatient clients are “free to moderate or abstain,” he said.

About half of the patients in Practical Recovery choose abstinence, said Horvath, adding that most have already attempted the moderation route. “By the time they get to treatment, they’re more inclined to have discovered that moderation isn’t working for them,” he said.

Practical Recovery is based in San Diego and has 12 residential beds, amounting to about 140 admissions a year, said Horvath. The outpatient program is mostly one-on-one — no groups — and there are a “few hundred” patients, he said.

Improving engagement

Offering moderation as an option helps both engagement and retention, said Horvath. “If the treatment threshold is very high, people don’t want to do it. So this is the come-as-you-are harm-reduction approach — just show up because we want to be in contact with you.” This gives the clinician the chance to start motivational interviewing, helping guide the patient.

Moderation is a good option “for people who can accomplish it,” said Horvath. “From a clinical standpoint, if you’re drinking 20 drinks a day, your chances aren’t great to lower that.” But the fundamental barrier, he said, is that people don’t want to be told they can’t have even one drink. “When I try to infringe on your freedom, you become highly motivated to prove me wrong,” he said. “Step 1 of AA doesn’t work.”

Horvath is also president of SMART Recovery, a not-for-profit organization that has abstinence-based self-help groups around the country that do not have the religious or anti-medication aspects of Alcoholics Anonymous.

“There is an enormous amount of research” on controlled drinking, said Horvath. “It is one of the most well-researched subjects in the field of addiction treatment, but it’s not much discussed outside of academic circles.” Many of the studies took place in the 1970s and 1980s when psychologists were grappling with addiction issues, he said.

Personalized medicine

Who is best suited for moderate drinking? That question is important to NIAAA, as is the whole concept of personalized medicine and tailoring treatment to the individual, based on genetics and other factors. “We are developing a nice repository of clinical trial findings,” said Huebner, citing Project MATCH, COMBINE and NIAAA’s Clinical Investigations Group (NCIG). “We ask whether the treatment goal is abstinence or a reduction in drinking.” Mining these databases for outcome data can provide insights into the viability of different treatment goals.

NIAAA officials stopped short of calling a return to low-risk drinking “harm reduction,” saying instead it is “health promotion.” But the label isn’t what’s important, they said. And they do not believe that people have to “hit bottom” before getting treatment. “We don’t agree with that approach,” said Koob of hitting bottom. “The earlier one starts a conversation about changing drinking behavior, the better.”

Early intervention is more likely to be done by the primary care physician than the specialty treatment provider, who usually doesn’t see patients unless they are very sick. “We are trying to facilitate the interaction between primary care physicians and the specialized treatment facilities,” said Koob. “That’s an area I’m going to be putting my nose into a lot more.”

The trend for the treatment of AUDs is for more integration between specialty treatment and primary care, said Huebner. “Both can learn from each other, and working together they will have a more effective approach,” he said.

Quality of life

And insurance companies, while they may prefer the abstinence approach, don’t require it, and welcome any treatment that can improve health outcomes. John P. Emerick, M.D., chief medical officer of New Directions Behavioral Health, told ADAW “the model we use is abstinence.” But that doesn’t mean the insurer doesn’t pay for treatment if the patient isn’t abstinent. “We provide coverage for treatment of people who are dependent on or abusing alcohol,” Emerick said. So, for example, New Directions would pay for treatment with medication, such as Vivitrol, and if the main effect was to reduce drinking, that would still be worthwhile.

“The abstinence model is based on AA, and there are people who don’t like AA because of the spiritual aspect,” said Emerick. The bottom line: reducing drinking also reduces health consequences.

“There is a dose-response relationship between reducing heavy drinking days and a lot of things — health, work life, family life,” said NIAAA’s Huebner. “Reducing drinking improves the quality of life.”

Whether a patient chooses abstinence or controlled drinking, medications like acamprosate or naltrexone, or others (except for disulfiram, which cannot be used for controlled drinking) can help, said Koob, who called attention to the study published in the Journal of the American Medical Association last week showing that naltrexone and acamprosate are underutilized in the treatment of AUDs, and that both medications reduce drinking. “We want to make it clear that there are multiple ways to eliminate an excessive alcohol problem,” he said. “They’re not all abstinence.”

Bottom Line…

The safest goal for someone with an alcohol use disorder is abstinence, but even reduced drinking has health, personal and societal benefits, and can be an easier way for patients to engage in treatment.

From the field
12/20/2012 12:00 AM
Advocates call for mental health treatment, gun control in wake of tragedy in Newtown.

(Editor’s note: On December 14, 20 elementary school students and six school teachers and administrators were shot and killed by a troubled young man, Adam Lanza, who also killed his mother and himself.)

Now is the time for the substance use and mental health community to act together to help end the violence and self-mutilation we as a nation encourage. The victims, their families and all of our children and communities must be comforted. Substance use and mental health clinicians are often at the forefront helping in the aftermath of these too frequent massacres.

We can resolve to change this social environment of destruction. Below is a letter from the behavioral health community to President Obama, congressional leadership, members of Congress and state government officials. Will you sign on? Will you send this or your own letter to your member of Congress, governor or state legislator? Will you help recruit others — people in recovery, families caring for a loved one struggling with substance use or mental illness, counselors and leaders of behavioral health programs — to send letters and call their congressional delegations, governors and state legislators?

As people touched by the tragedies in Connecticut, Arizona, Colorado and too many other communities, as people who are touched by the destruction of untreated alcohol, drug and mental health problems, we must act together to end these killings.

We must all be part of the solution — by showing the faces, voices and resolve of people affected by mental illness and addiction to end this violence and repair our communities. Mental health and substance use are not the causes of the violence, but we can help with solutions.

Dear Mr. President, Mr. Speaker and Members of Congress:

As people who have direct, lived experience with mental illness and addiction, as family members caring for our loved ones with these illnesses, as counselors and healthcare workers and as leaders of behavioral health programs, we all call on you, the leaders of our nation, to begin with us a road to recovery from these tragedies. We grieve for the innocents murdered in Newtown. These are our children, our neighbors, our families, our friends. There can be no greater tragedy in a society than losing its young, its own future, so needlessly and so senselessly. Such actions strike at the very heart of who we are and who we hope to become.

So we must grieve. We grieve for the families who lost their children, for the families of their teachers who were killed, for the entire Newtown community and for America itself. Yet, we owe them all much, much more than just our tears. They also deserve our action to identify and implement solutions.

To begin our recovery, we recommend that you provide federal assistance to:

  • Immediately double the capacity of public mental health and substance abuse programs. Funding for community mental health and substance use treatment services has been cut dramatically. As a result, only a third of those with moderate mental illness and two-thirds of those with severe illness ever receive any care. Families simply cannot get badly needed care. The Affordable Care Act must be implemented fully, and mental health and substance use care must be fully integrated into good medical care.
  • Immediately implement school- and community-based programs to promote mental health, to prevent mental illness and substance abuse and to provide early interventions for those exhibiting these conditions. Prevention and early intervention strategies can strengthen children’s mental health and resiliency, prevent or lessen the burden of illness and help them and their families to recover from trauma. Further, teachers must be taught how to identify troubled children and to guide them into effective supports before these children get into trouble.
  • Immediately begin teaching students at all levels to recognize the signs of mental illness and addiction, and to seek help when needed. Few young people get even a single hour of education about mental illness or addiction, its signs or its treatment. We can’t expect people to step forward or to seek help for a family member when we don’t even provide them the rudimentary tools to do so. We must begin to do so.
  • Immediately ban assault rifles and large-capacity clips. Possession of these weapons is a fundamental public health problem. They are designed for the battlefield, not our closets. They are used to kill people senselessly and needlessly. In Newtown, an assault weapon was used to kill 20 young children just starting their lives and six of their heroic teachers. Enough!

Yes, we must grieve for the innocents, just as we grieved recently for those lost in Tucson, Aurora and Portland. But this time, our grieving must have a direction and purpose to galvanize action. As people who know firsthand the tragedies of mental illness and addiction, and the triumphs that are possible, we all call on you to take immediate action.

Our nation expects nothing less of all of us.

From the Field
10/1/2012 12:00 AM

We have seen a recent uptick in one-sided reporting by media outlets that are either misinformed about the successes and difficult challenges of the treatment field, have no interest in balanced reporting on these important issues or are using old and outdated information. CRC Health Group, in particular, the nation’s largest provider of behavioral health and addiction treatment services, has been the subject of a disproportionate number of these reports. And while this increased attention on addiction and treatment would be welcome if it were to raise awareness about this devastating disease, the unfortunate reality is that these media inquiries are spurred by our nation’s upcoming presidential election, CRC’s exaggerated connection with one of the candidates and the continued stigmatization of addicts and treatment.

We have seen a recent uptick in one-sided reporting by media outlets that are either misinformed about the successes and difficult challenges of the treatment field, have no interest in balanced reporting on these important issues or are using old and outdated information. CRC Health Group, in particular, the nation’s largest provider of behavioral health and addiction treatment services, has been the subject of a disproportionate number of these reports. And while this increased focus on addiction and treatment would be welcome if it were to raise awareness about this devastating disease, the unfortunate reality is that these media inquiries are spurred by our nation’s upcoming presidential election, an exaggeration of CRC’s connection with one of the candidates and the continued stigmatization of addicts and treatment.

Some recent media articles have attempted to politicize what CRC does and have accused CRC of “putting profits ahead of patients.” This is just not true. The truth is, having for-profit, investor-owned treatment centers is a positive thing for our country. Unlike many nonprofits or single-owned facilities, we have the geographic breadth and financial stability that enable us to continue to provide these necessary services, even in challenging economic times. As a result of our structure and access to capital, our programs are more insulated from state and local budget cuts or economic downturns. Our structure also allows us to invest significant dollars on patient quality, even when the general economic environment is stagnant.

Some journalists have chosen to focus on anecdotal — and dated — reports of incidents in our facilities and falsely extrapolate to a conclusion of declining quality. But the reality is that the addiction treatment field is increasingly dealing with more medically complex and highly compromised patients. While very unfortunate, incidents do happen within this field of healthcare, one that treats a population of people who are at the ends of their ropes, in the depths of their despair: troubled teens, patients with alcohol and drug abuse addiction, co-occurring mental health and drug and alcohol issues, sometimes suicidal, most in denial, and many untruthful to themselves, their families and us about preexisting medical and mental health conditions.

Some media have chosen to focus their criticism on incidents that occur outside of our facilities, when patients, under the supervision of doctors, take their methadone or buprenorphine home for administration of doses, despite the safeguards that we put in place such as lockboxes and patient accountability checks and contracts. Our mission is to help these individuals, but sadly, we cannot report 100 percent success. No treatment provider can.

The media often fails to mention that the overwhelming number of patients do experience significant success. Journalists rarely interview any of the number of referrals provided by CRC who have positive experiences. Instead, the articles rely extensively on “survivor” organizations that criticize youth treatment or drug and alcohol programs across the board, critics with no firsthand knowledge of the events they purport to describe, and the selective republication of erroneous information from earlier media articles.

It is a fact that treatment organizations are prohibited by law from discussing specific cases or patient care, while other sources and family members making allegations have no such restraints. The occasional article that does mention such privacy regulations does so in a way that implies that treatment providers hide behind this language so as not to have to publicly discuss patient incidents. In actuality, these regulations are to protect our clients, every individual who enters our doors to get the treatment they so desperately need, who can take some comfort in this time of great distress knowing that their confidentiality is assured and trusting that it will never be revoked.

Several journalists who have written about CRC and treatment began their reporting with biased perspectives, specifically soliciting only critics of treatment programs to be sources.

CRC treats 30,000 people every day, yet this is just the tip of the iceberg when considering this nation’s treatment gap of people who need but do not receive treatment is over 20 million. We need more, not fewer, treatment options. When the media criticizes one provider because that sells newspapers or increases web hits, ignoring all of the positive aspects of treatment and lambasting our outcomes research, they are perpetuating the stigmatization, condemnation and discrimination of the entire treatment industry, with likely ramifications on millions of lives.

From the Field
8/20/2012 12:00 AM

Lately, much has been written about the state of the addiction field’s workforce challenges. Are there sufficient young people entering the field to replace those retiring? As a person relatively new to the field, I am optimistic based on a recent experience in which I had the good fortune to interact with a talented group of young adult leaders just beginning their training to assist others into recovery.

I had the opportunity to assist in the training of 50 young adults and their supervisors who were learning to coach youth and young military service members and veterans in recovery. The three-day event was organized by the Altarum Institute to support a federal Access To Recovery (ATR) grant that allows five counties in California to enhance their capacity to assist young people into recovery. The grantee, the California Department of Alcohol and Drug Programs (ADP), hosted the event, which took place in Los Angeles.

Claire Sallee, the outreach and training coordinator for ADP, developed the idea for the event and was among the facilitators. In welcoming the participants, she stressed that we were developing a learning community of recovery coaches and that her colleagues in Sacramento were excited to bring the concepts of recovery coaching to the providers of the Los Angeles area.

As a newly trained recovery coach, I was impressed with how quickly the workshop participants warmed to the basic tenets of recovery coaching. Most of these young people were recently hired, and while many were in recovery themselves, only a few had formal training in delivering alcohol and drug services.

The master trainer, John de Miranda, CEO of Stepping Stone of San Diego, had developed a variety of learning activities designed to provide basic skills in recovery coaching methodologies. My job was to support the participants as they struggled with new ways of thinking about how to help their “coachees.”

I believe that a major factor in the learning process for the workshop participants was sustained when they split into groups and replicated a one-on-one coaching environment. I was impressed to observe their efforts as they assisted and guided their coachees in the process of outlining recovery goals and ways to achieve them. The focus was on developing improved life skills but with a very definite recovery orientation.

This group of young adults was highly motivated and very energetic, thus making it a very pleasant experience for all involved. I really enjoyed watching the very diverse students interact with one another with great skill, enthusiasm and compassion. By the end of day three, it was obvious that this group had exceeded all of the trainers’ expectations for the workshop. As JayJay, one of the participants, stated, “Coaching is very different from my other job duties — at first I didn’t know how to distinguish the different roles of coach, counselor and sponsor but in the end of our practice sessions I got it! I’m very jazzed about adding recovery coaching to my other skills.”

I felt very connected with and proud of these young people. If, in fact, those who have come before are in the process of “passing the baton,” I believe that it is safe to say that the legacy of the previous generation of treatment and recovery workers is in good hands.

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  • Meet the Editor

    Alison Knopf
    Editor

    Alison Knopf is a professional journalist who began covering the addiction field in 1984 as founding editor of Substance Abuse Report. She has been the editor of Alcoholism & Drug Abuse Weekly since 2005.
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