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1/1/2018 12:00 AM

2017 started with a combined sense of relief — $1 billion in federal funding over two years for the opioid crisis had just been approved by Congress and signed by President Obama — and of concern veering on panic, as opioid overdoses continued at an apparently unstoppable pace, and the new administration in the White House promoted policies that detracted from treatment: repeal of the Affordable Care Act, cutbacks to Medicaid and a growing sense of a return to a “war on drugs.”

2017 started with a combined sense of relief — $1 billion in federal funding over two years for the opioid crisis had just been approved by Congress and signed by President Obama — and of concern veering on panic, as opioid overdoses continued at an apparently unstoppable pace, and the new administration in the White House promoted policies that detracted from treatment: repeal of the Affordable Care Act (ACA), cutbacks to Medicaid and a growing sense of a return to a “war on drugs.”

Below is a run-through of ADAW’s coverage of that and other stories in 2017. This is not a complete list of stories; subscribers can access full texts of all of the articles from the 48 issues of 2017 — and those from previous years — online.

Opioid STR grants

The Substance Abuse and Mental Health Services Administration (SAMHSA) got out the funding opportunity announcement for the State Targeted Response to the Opioid Crisis Grants (Opioid STR) quickly, giving states until Feb. 17 to get in their application (see ADAW, Jan. 9). The $1 billion authorized by the 21st Century Cures Act, passed by Congress in December 2016 and signed by President Obama, is to be spent over the course of two years. The first year’s installment was distributed via checks in the spring (see ADAW, May 1). We outlined what each state planned to do with its funding, and how much each state would receive (see ADAW, June 19). We spotlighted New Jersey (see ADAW, Aug. 28) and Florida (see ADAW, Nov. 6); watch for more state spotlights on this grant program this year.

Marijuana legalization

The argument that wider access to marijuana could be fueling the opioid crisis has not been supported by science, and in fact a growing number of voices have been casting marijuana as more of a potential solution than a problem (see ADAW, March 6).

Marijuana use by adolescents is linked to long-term adverse psychiatric consequences, but whether that link is causal is not clear based on clinical research alone. Animal research suggests it may be causal (see ADAW, March 20).

Harvard psychiatrist John F. Kelly, Ph.D., says looking hard at the choices between prohibition and commercialization may help us arrive at a “sweet spot” (see ADAW, Sept. 11).

Three eminent physicians presented a compelling case for legalizing marijuana in the November issue of the American Journal of Public Health. The opinion piece, “The Physicians’ Case for Marijuana Legalization,” written by David L. Nathan, M.D.; H. Westley Clark, M.D., J.D.; and Joycelyn Elders, M.D., states that it’s time for federal law to change and make marijuana legal, and that the government should regulate it (see ADAW, Dec. 4).

Counseling

Methadone treatment patients who did not face mandatory counseling requirements or threats of administrative discharge fared no worse than patients in a more traditional opioid treatment program (OTP) structure, a randomized trial found (see ADAW, March 27).

Counseling is essential in substance use disorder (SUD) treatment, even with medications, interviews with experts, including the past president of the American Society of Addiction Medicine, show (see ADAW, April 24).

Is counseling necessary for patients on buprenorphine? David A. Fiellin, M.D., the researcher whose clinical trials got buprenorphine approved to treat opioid use disorders, said, “I think the issue is determining if outcomes are improved with counseling above and beyond physician management” (see ADAW, Oct. 2).

Buprenorphine

Data presented at the College on Problems of Drug Dependence show that a weekly injection of buprenorphine prevents withdrawal and blocks the euphoric effects of opioids. The medication is investigational. Braeburn Pharmaceuticals, the sponsor, plans to submit a new drug application for the product, called CAM2038, to the Food and Drug Administration in the near future. The study, “Effect of Buprenorphine Weekly Depot (CAM2038) and Hydromorphone Blockade in Individuals with Opioid Use Disorder: A Randomized Clinical Trial,” was published online June 22 in JAMA Psychiatry (see ADAW, June 26).

But Indivior’s weekly buprenorphine injection got the approval first. On Oct. 31, the advisory committee of the Food and Drug Administration (FDA) voted to recommend approval of Indivior’s RBP-6000, an experimental once-monthly injectable formulation of buprenorphine (see ADAW, Nov. 6). Indivior makes Suboxone, the buprenorphine strips that are administered orally.

There is a law against using telehealth for the first visit with a prospective buprenorphine patient: the Ryan Haight Act, enforced by the Drug Enforcement Administration and enacted to prevent diversion via online pharmacies. But in Utah, where buprenorphine prescribers are few and far between, providers want to get an exemption to this so that more patients can be treated (see ADAW, Aug. 21).

12-Step

Psychiatrist Marc Galanter, M.D., says the most severely ill individuals with addictions will not see their treatment needs met until facilities successfully integrate 12-Step counseling and medical staff expertise (see ADAW, May 8).

A study published in the Journal of Studies on Alcohol and Drugs found that an evidence-based 12-Step intervention can improve sponsorship rates for individuals with stimulant use disorders, and that sponsorship for this population can in turn improve drug use outcomes (see ADAW, June 19).

IMD

The prospect of eliminating the Institutions for Mental Diseases (IMD) exclusion, which bars Medicaid dollars for residential treatment in a facility with more than 16 beds, gave a boost to the treatment field. For residential treatment programs, this could be a game-changer (see ADAW, Aug. 21). In West Virginia, a Medicaid 1115 waiver overrode IMD exclusion (see ADAW, Oct. 16). Yet there is still uncertainty in terms of whether there will be waivers or IMD repeal (see ADAW, Nov. 20).

Prevention

Under federal law, states must direct at least 20 percent of the Substance Abuse Prevention and Treatment Block Grant toward primary prevention. This amounts to $371 million in FY 2017 (see ADAW, Feb. 13).

“We have the science” to prove prevention works, said Kana Enomoto, acting deputy assistant secretary of the Department of Health and Human Services (HHS), where she is in charge of prevention and treatment of mental health and substance use disorders. “We know what to do,” she said (see ADAW, April 3).

Drug Abuse Resistance Education, or D.A.R.E., the school-based substance use prevention program delivered by police officers, has changed into a completely different — and much improved — curriculum. The new D.A.R.E. is proven to work by randomized controlled trials (see ADAW, Aug. 14).

Federal opioids policy

On March 29, President Trump signed an executive order establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis (see ADAW, April 3). The initial eight-page report called for a national emergency to be declared, based on the number of opioid overdose deaths; this national emergency would have freed up funds (see ADAW, Aug. 7). However, President Trump said there would be no such emergency (see ADAW, Oct. 30). The final report included 56 items, but there was no advice about how to pay for these, beyond asking Congress for the money (see ADAW, Nov. 6).

Tom Price, M.D., then secretary of the Department of Health and Human Services, went to West Virginia along with Kellyanne Conway, special advisor to the president, to assess the opioid epidemic. When there, he disparaged medication-assisted treatment with methadone or buprenorphine, saying, “If we’re just substituting one opioid for another, we’re not moving the dial much” (see ADAW, May 15). H. Westley Clark, M.D., J.D., M.P.H., wrote an exclusive editorial for us on Price’s public disparagement of methadone and buprenorphine, as well as on Attorney General Jeff Sessions’ plans to prosecute drug crimes (see ADAW, May 29).

Buprenorphine

Despite calls to raise the “cap,” the number of patients a single prescriber can treat with buprenorphine, most buprenorphine prescribers are not treating anywhere near that limit, data from California, Maine and Ohio show (see ADAW, Nov. 13).

The lawsuit by 36 attorneys general against Reckitt Benckiser and Indivior, past and present manufacturers of Suboxone, for anticompetitive practices in violation of the Sherman Act and state laws is continuing (see ADAW, Nov. 13).

The FDA approved Sublocade, a once-monthly buprenorphine injection made by Indivior. The injection is indicated for adult patients who have been on a stable dose of oral buprenorphine for at least seven days (see ADAW, Dec. 11).

ACA repeal

Repealing the ACA, a process that Congress has begun and that was a key campaign promise of President Trump, would take treatment away from patients with opioid use disorders, and especially harm Medicaid expansion (see ADAW, Jan. 23, March 6).

Treatment programs that are committed to small self-pay residential models are insulated from the uncertainty of the health care system today (see ADAW, Jan. 30).

The first draft of the Republican bill to repeal and replace the ACA would have dramatically cut Medicaid, allowing the essential health benefits requirements to sunset from Medicaid expansion plans by 2020 (see ADAW, March 13). Efforts to pass this bill in the House failed, and the vote was canceled on March 23 (see ADAW, March 24). A planned vote on the Better Care Reconciliation Act, the Senate’s bill to repeal and replace the ACA, was delayed because there were not enough votes to pass (see ADAW, July 3). The push to repeal the ACA gathered steam after a narrow loss (see ADAW, Aug. 14), with a new bill that would put all federal health care spending into block grants. Linda Rosenberg, president and CEO of the National Council for Behavioral Health, summed up the bill this way: “It’s the same pig with different lipstick” (see ADAW, Sept. 25).

(Ultimately, after the year’s final issue was published on Dec. 18, the individual mandate requirement of the ACA was repealed as part of the tax bill passed just before Christmas. The effects of this, as well as other aspects of the tax bill, will be covered in ADAW this month.)

Vivitrol

Many people in Philadelphia, New York City and parts of New Jersey have noticed an ad blitz for Vivitrol on highway and subway billboards, as well as in magazines — “everywhere” was the consensus (see ADAW, May 22).

Sen. Kamala D. Harris (D-California) launched an investigation into Alkermes in relation to its marketing and lobbying on behalf of Vivitrol, citing in particular marketing to the criminal justice system, despite the fact that methadone and buprenorphine have better proof of efficacy, she said (see ADAW, Nov. 13).

Overdoses

While the number of overdose deaths from opioids continues to rise, there is no clear picture of who these victims are — beyond the fact that heroin and illicit fentanyl are replacing prescription opioids as the main cause. So we asked the federal Centers for Disease Control and Prevention (CDC), which tracks such deaths, the following: What do we know about who is overdosing? Have they been through treatment? Are they naïve users? Have they overdosed previously? The answer from the CDC is that they don’t know, but the states might (see ADAW, Sept. 18).

Now that illicit fentanyl, and not prescription opioids, is leading overdose deaths, the CDC is starting to change its approach. A strategy aimed at reducing opioid prescriptions, with the hope that this would translate to a reduction in opioid use disorders and overdoses, has not worked. We interviewed top officials at the CDC (see ADAW, Oct. 23).

Harm reduction

An article published in the American Journal of Preventive Medicine showed that supervised injection facilities can reduce the harms of opioid use, if not opioid use itself (see ADAW, Aug. 28).

Opioid treatment programs/methadone

OTPs are growing, as resistance to them — at least at the neighborhood level — gradually declines; some states, however, still set up barriers to treatment (see ADAW, June 12).

Anti-methadone stigma resulted in a moratorium on new OTPs in Indiana, but now — almost 10 years later — there are five new OTPs slated to open, with Medicaid funding and integration with larger health centers (see ADAW, July 24).

The American Association for the Treatment of Opioid Dependence, the membership organization of opioid treatment programs, the federally certified clinics that are the only places patients can receive methadone maintenance for an opioid use disorder, released a fact sheet on the use of methadone in the criminal justice system (see ADAW, Nov. 20).

Neonatal abstinence syndrome, pregnancy

A new draft report to Congress from SAMHSA suggests that Vivitrol, which is not recommended for pregnant patients, be researched as a way to prevent neonatal abstinence syndrome (NAS) (see ADAW, Feb. 6).

Infants born to mothers who are in treatment for opioid use disorders with methadone are sometimes born with NAS, a constellation of symptoms associated with opioid withdrawal. “An Initiative to Improve the Quality of Care of Infants with Neonatal Abstinence Syndrome,” published in Pediatrics, found that the best way to treat NAS is with the mother — rooming in and breast-feeding — which may eliminate the need for medications (see ADAW, June 12).

The Government Accountability Office has criticized HHS in a report prepared for the heads of congressional committees on the agency’s strategy for managing infants with neonatal NAS and on the Protecting Our Infants Act (see ADAW, Oct. 16).

Abuses in rehabs/sober homes

The president of the Florida Association of Recovery Residences says that with consumers receiving little information on how to identify high-quality care, many might come to believe the state is populated entirely by unethical operators (see ADAW, Feb. 6). Leaders in the recovery residence community want more states to follow the lead of the handful of states that have taken proactive steps to elevate sober living’s place in the continuum of care (see ADAW, May 22).

Elements of newly signed legislation in Florida suggest the state may be poised for tighter regulation of treatment and recovery support organizations and for more successful prosecution of wrongdoers (see ADAW, July 3).

The National Association of Addiction Treatment Providers, the membership association representing mainly residential rehabilitation facilities, is helping root out unethical business practices that are sullying the entire field (see ADAW, Aug. 7).

A hearing on Capitol Hill focusing on rehab and sober home abuses brought many of the problems to light (see ADAW, Dec. 18).

Alcohol

Many researchers are not clinicians, yet they are working on treatment interventions for alcohol use disorders, so a feature of the annual meeting of the Research Society on Alcoholism was “Everything You Ever Wanted to Know About Alcohol Treatment but Were Afraid to Ask: A Primer for Non-clinicians” (see ADAW, July 10).

While the nation affixes its attention to opioids, the prevalence of alcohol use and alcohol use disorder is showing striking increases, with disadvantaged groups most severely affected (see ADAW, Aug. 21).

The National Institute on Alcohol Abuse and Alcoholism has launched a new online resource to help people find treatment for alcohol use disorders (see ADAW, Oct. 16).

Doctors have identified “teachable moments” that could facilitate alcohol treatment (see ADAW, Oct. 30).

Medication-assisted treatment

Only one in four adolescents and young adults with opioid use disorders get naltrexone or buprenorphine (see ADAW, July 10).

The FDA said benzodiazepines are not cause to deny methadone or buprenorphine (see ADAW, Sept. 25).

A Norway study found Vivitrol is as effective as oral buprenorphine (see ADAW, Nov. 13).

The first head-to-head study comparing buprenorphine-naloxone with extended-release naltrexone in the United States has found both medications are equally successful at retaining patients six months later (see ADAW, Nov. 20).

Criminal justice reform

New training in New Jersey introduces police to strategies for engaging and helping individuals under the influence of alcohol and drugs, identifying those with substance use disorders who are in need of immediate treatment and destigmatizing addiction (see ADAW, Feb. 6).

President Trump is getting pushback from law enforcement on his tough-on-crime stance, with police, sheriffs and prosecutors calling for a focus on treatment and urging the administration not to repeat the mistakes of the past (see ADAW, Feb. 20).

Police and sheriffs want to “deflect” people who need treatment from the criminal justice system, but treatment needs to be there to receive them (see ADAW, March 13).

The Police Assisted Addiction and Recovery Initiative, which started in Gloucester, Massachusetts, now has more than 350 police departments across the country working with local treatment programs, including those that provide medications; we attended their first national conference (see ADAW, Dec. 11).

The pain dilemma

Studies show 3 to 26 percent of people on long-term Rx opioids for pain develop opioid use disorders (see ADAW, Feb. 6).

A report calls for treatment to be added when opioid prescriptions are cut (see ADAW, July 24).

Dependence or use disorder: which is which? This is a gray area for some pain patients (see ADAW, Aug. 28).

Stories of crisis’s forgotten victims — pain patients — are emerging (see ADAW, Sept. 25).

42 CFR Part 2

In a webinar so popular it had to be repeated multiple times, the Legal Action Center detailed how the final rule on 42 CFR Part 2, released in January (see ADAW, Jan. 23), has changed the consent language for the release of information about a patient’s SUD. We attended the July 25 webinar (see ADAW, July 31).

Confidentiality of SUD patient records is under attack again, this time from treatment providers themselves (see ADAW, Aug. 7). Headed by the Legal Action Center, more than 100 treatment and recovery organizations have joined a “Campaign to Protect Patient Privacy Rights” (see ADAW, Oct. 2). The Pennsylvania Recovery Organizations Alliance (PRO-A) is opposing weakening of the federal confidentiality regulation, 42 CFR Part 2. “When I walked into treatment, that was my first question,” said Bill Stauffer, executive director of PRO-A since 2012. “Would my treatment be confidential?” (see ADAW, Dec. 11).

Bottom Line…

This year’s news was dominated by the opioid crisis and attempts to repeal the ACA.

12/18/2017 12:00 AM

An analysis of Medicaid data from 2001–2007 paints a picture of missed opportunity in offering more comprehensive care that might have averted numerous opioid-related deaths. While the study’s lead author acknowledges that the study period predates a fentanyl crisis that has since changed the face of the opioid overdose threat, he believes some trends seen in the study, such as overdose risk among chronic pain patients recently initiating prescription opioids, remain prominent today.

An analysis of Medicaid data from 2001–2007 paints a picture of missed opportunity in offering more comprehensive care that might have averted numerous opioid-related deaths. While the study’s lead author acknowledges that the study period predates a fentanyl crisis that has since changed the face of the opioid overdose threat, he believes some trends seen in the study, such as overdose risk among chronic pain patients recently initiating prescription opioids, remain prominent today.

Commenting on a key takeaway from this research, Mark Olfson, M.D., M.P.H., professor of psychiatry at Columbia University Medical Center, told ADAW, “It’s clear that the great majority of people are presenting for care in the months preceding their death.”

Published online Nov. 28 in the American Journal of Psychiatry, the study points to several factors that could have contributed to the heightened overdose risk in the Medicaid population, from the presence of dangerous prescription combinations of opioids and benzodiazepines to an overall absence of care integration between addiction service providers and other health professionals.

Olfson also points out, however, that there can be too narrow a focus on data around fatal overdose. He says analyses that are now underway, using the same data set, are examining patients who experienced a nonfatal overdose in order to identify prominent risk factors for later death from overdose or other causes.

Details of study

The study sought to outline health service utilization among Medicaid beneficiaries — a group at high risk of death from opioid overdose — in the month and year prior to an opioid-related death. Data from 45 states covering the 2001–2007 period were examined, with the research team looking only at individuals ages 64 and under at the time of death. The drugs contributing to the deaths that were examined in the analysis included heroin, prescription opioids, other natural and semisynthetic opioids, and synthetic opioids other than methadone.

The researchers compared outpatient service visit patterns and alcohol and drug use disorder diagnoses between individuals with and without chronic pain not associated with cancer. They also looked at pharmacy claims data for filled prescriptions for opioids, benzodiazepines, antidepressants, antipsychotics and mood stabilizers in the month and year before death.

The researchers identified 13,089 opioid-related deaths in the data set, with most victims being non-Hispanic whites between the ages of 35 and 54. While 42.2 percent of the victims had been diagnosed with a substance use disorder in the 12 months preceding their death, only 12.3 percent received such a diagnosis in the last month of life, and only 4.2 percent received an opioid use disorder diagnosis. Many of the overdose victims were engaging in polysubstance use, Olfson said.

Around two-thirds of the fatal overdose victims filled an opioid prescription during the last 12 months of their life, and around half filled prescriptions for both an opioid and a benzodiazepine. More than one-third of the victims filled an opioid prescription in the last month of life. Study authors wrote that “those with chronic pain diagnoses were significantly more likely to fill prescriptions for opioids, benzodiazepines, and both opioids and benzodiazepines, as well as antidepressants, antipsychotics and mood stabilizers during both time periods.”

The researchers also found that in the 12 months prior to death, 8.1 percent of fatal overdose victims with a chronic pain diagnosis experienced a nonfatal opioid overdose. Those numbers make it clear that while it is important to identify treatment opportunities for overdose survivors, doing that alone will not have a far-enough reach across the population of at-risk individuals.

The prevalence of substance use disorder diagnoses and filled prescriptions in the population with chronic pain “may provide opportunities for detection of overdose risk and early intervention,” Olfson and colleagues wrote. They added that the clinical management of chronic pain should incorporate a detailed mental health history and periodic assessments to mitigate potential risk of opioid overdose.

The researchers added that it appeared from the data that most victims who had received a substance use disorder diagnosis in the month prior to death had received no substance use services in the last 30 days of life. It was beyond the scope of this analysis to determine whether that lack of services was more of a reflection of coverage and access deficiencies or other barriers to care.

The researchers cited as a limitation of the study the fact that the data are from a period before fentanyl and its analogs altered patterns in opioid-related deaths. Olfson acknowledges that pain-related deaths likely were more prominent during the 2000–2007 period than they would be when looking at current data, which would reflect a rising number of deaths from heroin and synthetics.

More comprehensive care

Olfson says that based on the morbidity and mortality risks that the population with chronic pain faces, the linking of electronic records to allow for closer communication among health providers (which has been happening in more health systems) could serve to benefit these patients. He said the magnitude of the difference between health care usage patterns for persons with and without chronic pain in the study was somewhat surprising.

He now is examining data for individuals in this Medicaid data set who survived an opioid overdose, in order to attempt to identify risk factors for later death from overdose or other causes. “Many of these patients have other medical vulnerabilities,” said Olfson.

He also hopes to be able, as part of this overall work, to analyze similar but more recent data that would reflect more timely trends.

Bottom Line…

Medicaid data from 2001–2007 illustrate the need for more coordinated care to avert risk of fatal opioid overdose, especially in the subpopulation with a chronic pain diagnosis.

12/18/2017 12:00 AM

The focus of attention by members of the Committee on Energy and Commerce’s Subcommittee on Oversight and Investigations last week wasn’t news to the treatment field. There are unethical sober home operators who for at last five years have been profiting off the miseries of people with addiction, and treatment programs flying under the radar that deliberately overbill for unnecessary drug tests, steal patients from other programs with bait-and-switch internet marketing tactics, pay patient brokers and more. The Dec. 12 hearing, “Examining Concerns of Patient Brokering and Addiction Treatment Fraud,” did shed light on these issues for many of the subcommittee members, however, who were not familiar with the abuses beyond what they had read recently in the mainstream press, and were not aware of the extent to which the treatment field and others are working to make changes. Treatment representatives from Florida and California, where abuses have been most pronounced, presented testimony, as did law enforcement officials.

The focus of attention by members of the Committee on Energy and Commerce’s Subcommittee on Oversight and Investigations last week wasn’t news to the treatment field. There are unethical sober home operators who for at least five years have been profiting off the miseries of people with addiction, and treatment programs flying under the radar that deliberately overbill for unnecessary drug tests, steal patients from other programs with bait-and-switch internet marketing tactics, pay patient brokers and more. The Dec. 12 hearing, “Examining Concerns of Patient Brokering and Addiction Treatment Fraud,” did shed light on these issues for many of the subcommittee members, however, who were not familiar with the abuses beyond what they had read recently in the mainstream press, and were not aware of the extent to which the treatment field and others are working to make changes. Treatment representatives from Florida and California, where abuses have been most pronounced, presented testimony, as did law enforcement officials.

It’s essential to root out the bad actors, said Douglas Tieman, president and CEO of Caron Treatment Centers. “It has become clear that many are putting profits ahead of the lives they’re supposed to be saving,” he told lawmakers. Patients and family members call an 800 number thinking they are talking to a treatment provider, but they’re talking to a marketer, he said. “It’s more like shopping for a time share,” he said.

“Patients and their well-being must be the top priority,” said Pete Nielsen, CEO of the California Consortium of Addiction Programs and Professionals. “Sober living is not nor has it ever been the same as residential inpatient treatment,” he said. “It is its own entity with different standards and goals.” Cooperative housing does offer a bridge to independent living, he said.

‘The Florida shuffle’

Many so-called sober homes in Florida are “nothing but flophouses,” said Dave Aronberg, state attorney for Palm Beach County — the only county in Florida that has a task force aimed at addiction treatment and sober home fraud. In what he referred to as “the Florida shuffle,” a patient gets a free one-way plane ticket to Florida, goes through treatment covered by insurance and, needing a place to live, is referred to a sober home. When those benefits are exhausted, the individual leaves the sober home. If the patient relapses, however, the patient gets treatment again, so rogue providers make sure drugs are accessible in those sober homes to ensure relapse and continued profits, he said. Seventy-five percent of private-pay patients in Florida centers come from out of state, said Aronberg. The Palm Beach County task force, formed last year, has so far resulted in 41 arrests, he said.

Alan S. Johnson, chief assistant state attorney and head of the Palm Beach County Sober Homes Task Force, said he wants the anti-kickback statute, which currently applies only to federally funded services by Medicaid and Medicare, to apply to the private sector. Noting that Florida has a patient-brokering statute, he said that the biggest problems are coming from “rogue actors in the treatment industry.”

Accreditation itself is no guarantee of quality, said Johnson. “There are some really bad places that we arrested that were accredited,” he told lawmakers. Parents from all over the country who are worried about their children in treatment in Florida call him, “but we can’t recommend a particular place,” he said. He does, however, recommend sober homes that are certified by the Florida Association of Recovery Residences, he said. “They’re not flophouses,” he said.

The scope of the problem

Rep. Diana DeGette (D-Colorado) wanted to know the scope of problems, such as patient brokers, unnecessary urine tests and billing for treatment that is not provided. “I’d like to know how a presumably licensed treatment facility can get away with this,” she said. “I don’t have any idea how extensive the problem is.” She pressed Johnson for numbers.

“We can’t put a number on it,” said Johnson. Of the 41 arrests in the last year, DeGette asked, how many were for different individuals or treatment centers? There were 12 treatment facilities, and sober homes, involved in the 41 arrests, he responded. “We look at it as a hub and spoke, with the hub providing treatment, and the spokes being sober homes,” said Johnson.

DeGette asked Nielsen how many rogue actors there are in California. “It’s hard to be able to boil down what’s actually happening,” he said. “They look like they’re good actors, but they’re rotten to the core.”

Asked why California doesn’t license or certify outpatient facilities, Nielsen replied, “That’s a very good question.” He noted that the state doesn’t even require a license for a drug and alcohol counselor to do private practice, “so anyone can hang up a shingle.” However, being in network with an insurance company is a good sign, he said. “We’re finding in California that it’s the out-of-network providers that are the real problem,” he said. 

Indeed, Florida treatment providers who seek out-of-state patients specifically look for those with out-of-network coverage.

NAATP’s new initiative

The hearing came just as the National Association of Addiction Treatment Providers (NAATP) is moving ahead with its Quality Control Initiative, in which it will not allow any members who don’t abide by ethical marketing and billing.

On Dec. 7, NAATP announced that it will implement its Quality Initiative, which will ultimately result in a winnowing of the membership.

Under a revised code of ethics, NAATP will define “prohibited acts including service misrepresentation, patient brokering, leads buying and selling, deceptive web presence, deceptive directory call aggregation, insurance billing abuse, payment kickbacks, and licensing and accreditation misrepresentations.” Any provider utilizing these will not be allowed to be a member. Providers who do comply may use the NAATP logo on their websites, and patients searching for treatment can be guaranteed that these providers are following the code of ethics.

Four categories of providers

Reached after the hearing, Tieman, who helped draft the NAATP initiative, told ADAW that even though the abuses have been going on for many years, many people — including treatment providers — didn’t know about it. “I thought those were outliers,” he said of the rogue providers. But in fact, the lines are blurry, with the bulk of not-for-profit providers falling under the category of not knowing they were doing something wrong, or the second category of doing it simply because they think everyone else is doing it and they need to do it in order to compete. Both of these categories can be brought around to ethical marketing and billing by education, said Tieman.

The third category is the for-profits that say that marketing and billing tactics “may or may not be wrong, but legally they’re defensible, and we’re going to go ahead and do it,” said Tieman. “This is where I put most of the private-equity” organizations, he said.

It’s important to note that the first three categories are based on marketing and billing issues, not clinical issues. All three types of programs provide excellent care. But the fourth group, which engages in “human trafficking,” are “the sociopaths of our industry,” said Tieman. These groups do not provide good care, and only exist to make money.

The “sociopaths” are probably not NAATP members anyway, but the private-equity organizations that provide good treatment may still not want to follow the new ethics guidelines. “Whether or not they will be swayed is unclear,” said Tieman of the private-equity-owned centers. These centers, which include giants such as Recovery Centers of America and American Addiction Centers, “might just decide there’s no real value in being a member of NAATP,” said Tieman.

NAATP Executive Director Marvin Ventrell agreed that Tieman’s categories are “representative of what goes on out there,” he said, and he says the largest chunk of the treatment industry is in the second and third categories. The “sociopaths” (the fourth category) and the “clueless” (the first category) are both “significant minorities,” he said.

“The two middle categories are both concerns,” said Ventrell. The second category, programs that think that have to market aggressively in order to compete, are one concern. And the well-resourced private-equity groups are an issue as well, “not because there are so many of them, but because they have a lot of power, they have a big footprint and the public sees them and gets an impression from them,” said Ventrell.

NAATP wants to address quality violations and push treatment to the “best levels of care seen in our country,” said Ventrell. “By approaching those two middle groups, we can do that.” This may mean NAATP, an association that charges membership dues based on facility size, gets smaller. That’s fine with Tieman and Ventrell. “We are perfectly prepared to lose revenue as a result of this,” said Ventrell. “It has been my view that that has always needed to be done. We’re now at that point.”

The Quality Control Initiative will result in several hundred facilities getting the “seal of approval,” said Tieman. “The value of this is that it will completely eliminate the fourth category — the fly-by-nighters,” he said. “And for the third group, we hope to be able to define ethical behavior.” That group can then choose to comply or not.

Saving smaller quality programs

The internet has radically changed the treatment field. Caron, for example, is a $100-million-a-year nonprofit, which last year gave away $10 million in charity care. But it also spent $12 million on marketing, said Tieman. That’s $10 million more on marketing than it spent five years ago. “We’ve been around 60 years, and never advertised before,” he said. “I would rather have spent that $10 million on charity care. But the board said, if you don’t have some presence in our key marketplaces, people won’t know about Caron.”

The real tragedy, said Tieman, is the small 40-bed programs that provide great treatment, are very affordable and will go under because they don’t have millions of dollars to spend on marketing, and therefore have patients “stolen from them every month” through brokering and other tactics. “Our main reason” for the quality initiative is to help these local providers “who are doing great work,” he said. Patients should be able to go to these programs, which are local, “instead of being sent a plane ticket to Florida.”

Bottom Line…

Treatment programs are cleaning up the industry, as Congress sheds a light on abuses.

SIDEBAR

Sober homes, ADA and FHA

Alan S. Johnson, chief assistant state attorney and head of the Palm Beach County Sober Homes Task Force, hopes Congress can “explore a way to make the states more comfortable with being able to require sober home certification.” Florida does not mandate sober home certification “because they are afraid of violating the ADA or the FHA,” he said, referring to the Americans with Disabilities Act and the Fair Housing Act. Aronberg stated that these two federal laws prevent the regulation or inspection of sober homes.

However, we checked with Sally Friedman, legal director of the Legal Action Center, who said the Palm Beach County prosecutors are incorrect. “It is not true that the ADA and FHA prevent the regulation or inspection of sober homes,” she told ADAW. “They prevent discrimination based on disability. Jurisdictions may enforce nondiscriminatory housing codes and safety standards. When they don’t, they allow residents to be placed in unsafe living conditions and create quality-of-life issues for neighbors. This failure to enforce problematic operations foments NIMBY [not in my back yard] responses.”

In Case You Haven’t Heard
1/1/2018 12:00 AM

Life expectancy is down in the United States as a result of the opioid epidemic, the Centers for Disease Control and Prevention announced just before Christmas (see https://www.cdc.gov/nchs/products/databriefs/db293.htm). On the same day, in the American Journal of Public Health, a commentary called opioid overdoses one of the three “diseases of despair” that are killing Americans at a younger rate, alongside alcohol-related disease and suicide. That commentary, by Nabarun Dasgupta, Ph.D., M.P.H.; Leo Beletsky, J.D., M.P.H.; and Daniel Ciccarone, M.D., M.P.H., can be read at http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2017.304187. The bottom line: poverty, poor health, lack of opportunity, racism and despair are all inextricably linked as “root causes” of overdoses, according to the authors. Depressing news to end the year, but inspiring for people who want to make changes in 2018.

In Case You Haven’t Heard
10/10/2016 12:00 AM

The Office of National Drug Control Policy (ONDCP) is asking everybody to change their language when talking about addiction. Actually, they prefer substance use disorder. They also say to stay away from words like “dirty,” “abuse” and “dependence.” All good. After all, even the Diagnostic and Statistical Manual of Mental Disorders no longer uses “abuse” or “dependence” (to describe a pathology), and only the worst kinds of people use the word “dirty” to describe a urine test that is positive for drugs. The ONDCP is even asking for comments on this, in what must be the most frustrating time of the year for substance use disorder treatment advocates who have been trying to pry pennies from Congress for the worst opioid epidemic the country has ever seen. If you want to comment, here’s the draft: https://www.whitehouse.gov/ondcp/changing-the-language-draft. We would like to put in a plug for a change that has been due for some time: “medication-assisted treatment.” What does that even mean? In the field of substance use disorders, we have medications approved for alcohol use disorders (acamprosate, naltrexone) and for opioid use disorders (methadone, buprenorphine, naltrexone). The ONDCP and, increasingly, Congress use “medication-assisted treatment” to mean treatment for opioid use disorders. There’s a huge difference between methadone, which is only dispensed in opioid treatment programs; buprenorphine, which, like methadone, is an agonist (or partial); and naltrexone, which most of the time means the patented extended-release version: Vivitrol. Now “MAT” is in the lexicon — of legislation and regulation — and nobody knows what it means. So can we stop using the phrase “medication-assisted treatment” and just call it medication?

In Case You Haven’t Heard
10/3/2016 12:00 AM

As syringe programs, safe-injecting facilities and harm reduction in general enter the mainstream, what does “harm reduction” even mean anymore? Does it still mean encouraging drug users to get treatment? We asked the policy director of the Harm Reduction Coalition these questions. He is concerned about drug users being left behind as the field gets more mainstream. “Harm reduction has always been grounded in reaching and engaging people who use drugs to support their health needs, including overdose and HIV risk but also substance use itself,” Daniel Raymond told ADAW last week. “So I hope that we’re moving towards building deeper relationships with the treatment and recovery communities so that we can support each other and create a stronger continuum of care.” Raymond also wants to see “more engagement with health care, housing and criminal justice/re-entry,” he said. “Harm reduction philosophy and strategies have a lot to offer and share with these sectors. More broadly, we’re looking at addressing the broader structural issues like stigma, trauma, homelessness and mass incarceration that intersect with substance use and multiply vulnerability and harm.” For more on Raymond’s concerns about mainstreaming the harm reduction agenda, see his piece on the Midwest Harm Reduction Institute’s annual conference, published last week: https://medium.com/@danielraymond/holding-space-for-the-unredeemed-harm-reduction-and-justice-1d70ca675f25#.pbn8uqhcy.

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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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