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3/13/2017 12:00 AM

Last month, the first-ever national deflection summit was held in Alexandria, Virginia, where experts from criminal justice, behavioral health and public policy convened to come up with strategies aimed at diverting, or deflecting, low-level drug offenders away from the justice system into treatment, before arrest. Also called prebooking diversion, deflection can help get people into treatment instead of incarceration. The two-day summit was sponsored by the International Association of Chiefs of Police.

Last month, the first-ever national deflection summit was held in Alexandria, Virginia, where experts from criminal justice, behavioral health and public policy convened to come up with strategies aimed at diverting, or deflecting, low-level drug offenders away from the justice system into treatment, before arrest. Also called prebooking diversion, deflection can help get people into treatment instead of incarceration. The two-day summit was sponsored by the International Association of Chiefs of Police (IACP).

Perhaps the best-known examples of “deflection” are the Police Assisted Addiction and Recovery Initiative (PAARI), which started in the Gloucester, Massachusetts, police department and now has many member police departments across the country, and Law Enforcement Assisted Diversion (LEAD), based in Seattle, Washington.

While law enforcement is eager to find treatment solutions instead of arrest and incarceration, the treatment field isn’t making it easy, said Jac A. Charlier, national director for justice initiatives at the Center for Health and Justice at TASC (Treatment Accountability for Safer Communities), which convened the meeting. “Police departments are willing to partner, but it’s behavioral health that has to get its act in gear,” Charlier told ADAW in an interview last week. “There are police departments all over that are ready to do this, but they don’t have a history of working together with behavioral health.” Charlier urged treatment providers to call him. “I will help you navigate the waters with the police,” he said.

One obvious barrier for treatment providers is funding. Police departments have direct government funding; treatment providers don’t. “In the United States, for the most part our community behavioral health system is nonexistent in terms of capacity,” said Charlier. Medicaid expansion has accounted for much of the increased access to treatment, but it’s still not enough, he said. “There are low rates of insurance, so therefore low access to treatment.” But the calls, when there are overdoses or other substance use–related problems, usually go to first responders, including police, he said. “We want to increase treatment access points through our first responders,” he said.

Charlier distinguishes deflection from diversion, which is a criminal justice term. He coined the term to make that distinction clear, and also to encompass the many terms used in the emerging field (Charlier, whose expertise is deflection, said there are nine terms, and noted that even PAARI and LEAD don’t use the same terminology). “Nothing is settled about this,” he said. “There are early adopters, there are experimenters, but I want to focus on deflection, which means moving away from the criminal justice system without ever having entered it.” Diversion often means entering, and then leaving, the criminal justice system. Deflection means using the criminal justice system as an access point to non-justice-related treatment. But that means making sure access is there.

“Behavioral health capacity is the holy grail of deflection and diversion,” said Charlier.

But as for funding, Charlier and his deflection colleagues have “no pretense to solving the problem,” he said. “We’re not going to crack that nut because it’s a federal issue.” But he sees little resistance from police on deflection. “The resistance is from behavioral health, not because they’re the bad guys, but because they have to worry about how they get paid,” he said.

The treatment view

C4 Recovery Solutions, an international not-for-profit focused on substance use, headed up the treatment side of the deflection meeting. “We tried to broaden people’s awareness that substance use is a multisystemic issue,” said Dee K. McGraw, director of education and event services for C4. At the West Coast Symposium on Addictive Disorders last summer, C4 convened a group focusing on first responders, she said. C4 senior advisor Lee Feldman took this to the next level, to address the problems of capacity.

“We’re looking at different kinds of financing, and models such as municipal bonds,” Feldman told ADAW. “There are also possible private-public funding mechanisms.” Key to the success of this, however, is community support. Just as a community is willing to pay taxes for a firehouse, it should be willing to support a treatment infrastructure, he said. “Communities have a need for treatment capacity, and it’s a community responsibility to create that capacity,” he said. “Some communities are looking at additions to the sales tax.”

In North Carolina, the cost of incarceration per person per year is $40,000, noted Feldman. In the Charlotte area, counties are discussing the idea of moving some money from corrections to treatment, in cases of diversion. C4 is hoping to research the effectiveness of such programs.

“So far, the research is anecdotal,” said Feldman. “One sheriff might mention that if he has to continue building jail capacity because of opioids, he’ll need several million dollars.” Instead, that money could go to treatment. “The economic justifications are there, and the need is there,” said Feldman. “What’s missing is the research on the actual mechanisms — how do you take the capital expenditure for a new jail and move it over to pay for treatment?” There may be a requirement for legislation, he said. “This is a local issue."

Deflection also means a shift in the way people think about funding treatment, said Feldman. “In the past, funding treatment meant funding an addict or an alcoholic,” he said. “Here we’re talking about funding community safety. The ‘ask’ is different, and it’s an ‘ask’ that has not been made before.” The community — hospitals who keep seeing repeat patients whose substance use disorders aren’t getting better, law enforcement and taxpayers — needs to figure out what it needs, and pay for it, he said. “It’s the community that needs to raise the war chest."

There was consensus at the conference that behavioral health needs to be brought into the law enforcement discussion on deflection, said Feldman. “But the problem is, they want to deflect people to treatment, and nobody is bothering to ask whether the behavioral health community can do it,” he said. “The behavioral health system isn’t even a system — it’s a bunch of independent actors, and getting it organized isn’t going to be easy.”

C4 is working to create a repository of information communities can use to jump-start deflection efforts, said McGraw. “We’ve been to law enforcement trainings, but they each have their own way to do it; they all have different names,” she said.

There were about 60 people at the invitation-only meeting in Alexandria, which is hoped to lead to a “think tank” on deflection, said McGraw. “We need to figure out what deflection means. Is it one chance at treatment and that’s it? You need assessment instruments. You need to train the police officers to make these determinations.”

Civil citations

The Civil Citation Network (CCN), based in Tallahassee, Florida, offers counseling, education and community service in lieu of arrest, enabling clients to avoid a record. The clients pay for it themselves — the same $350 they would be required to pay for their own court costs if they were arrested — explained Tom Olk, founder of the CCN. Using the GAIN to assess clients, the CCN decides whether they need treatment; less than 8 percent do. Only about 100 of the 1,200 people who went through the CCN since 2013 have needed actual treatment, he said. The CCN is publicly funded.

People who don’t need specialty treatment are treated by CCN counselors using CBT, MI and trauma-informed care, using the curriculum from The Change Companies. “They have at least three therapeutic sessions,” said Olk.

“What we’re trying to do is provide the officer on the street with another option,” said Gregory A. Frost, president of the CCN, which was the third convener of the deflection conference. “If you don’t have a way to deflect that person, you either arrest them or you let them go. Our option is prearrest deflection.” The completion rate since 2013 is 83 percent, said Frost. CCN clients are first-time offenders and are required to sign a contract and to remain substance-free. They are drug-tested.

“Let’s not wait until this person has been arrested five times before they get the help that they need,” said Frost. “Let’s get this person the very first time they have a contact with law enforcement. We intervene early on before they get to the point of sitting in jail for the 10th time, before they are overdosing.”

But the CCN program is “not a free ride,” said Olk. “If they continue to use while they’re in our program, they risk going into the criminal justice system.” If they complete the program, however, they will not have any record, he said.

The two main substances involved in the CCN program are alcohol and marijuana. First-time misdemeanor offenders have a 45 percent rearrest rate within three years, said Olk. But the rearrest rate for people who go through the CCN program is only 7 percent.

Alcohol offenses that end up in the CCN are typically for open container or disorderly conduct charges, said Olk. Anyone caught driving under the influence is arrested and not eligible for the program. The CCN also gets non-drug-related cases, such as people who are hunting at night. “They don’t want to arrest people for hunting at night — we get cases like that,” he said. “We still drug-test them.”

TASC’s Charlier said the summit will create a “voice and vision” for deflection and increased access to treatment for people involved with the justice system. Treatment providers can email him at JCharlier@tasc-il.org or call him at (312) 573-8302.

Bottom Line…

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

3/6/2017 12:00 AM

Last week, amidst an unclear trajectory in Congress on repealing and replacing the Affordable Care Act (ACA), President Trump declared, “Nobody knew that health care could be so complicated.” He had just met with conservative governors, and the topic of health care was likely a key priority: the National Governors Association wrote to Trump on Jan. 24, less than a week after the inauguration, about the need to preserve health care for vulnerable populations, and the federal responsibility in doing so.

Last week, amidst an unclear trajectory in Congress on repealing and replacing the Affordable Care Act (ACA), President Trump declared, “Nobody knew that health care could be so complicated.” He had just met with conservative governors, and the topic of health care was likely a key priority: the National Governors Association wrote to Trump on Jan. 24, less than a week after the inauguration, about the need to preserve health care for vulnerable populations, and the federal responsibility in doing so.

One of Trump’s main campaign promises was to repeal the ACA, and congressional Republicans, now in charge, are set to do that. But doing so is, as the president indicated, complicated. In fact, nobody has come up with a clear plan to replace the 5,000-plus pages of the ACA, crafted carefully with an aim to providing health insurance for everyone. Addiction treatment in particular was affected by the ACA, which required addiction treatment to be covered by all health plans as an essential benefit, and expanded coverage via marketplace plans and Medicaid expansion. This leaves addiction treatment providers unsure about what lies ahead.

“I wouldn’t say anybody is making any major changes right now,” said Becky Vaughn, consultant on treatment for the Addiction Policy Forum. “They’re just on pins and needles.”

Ironically, it’s the states that chose not to partake of Medicaid expansion who will be hurt the least by ACA repeal, if it happens, because they never reaped any of its benefits, Vaughn told ADAW last week. “The [Substance Abuse Prevention and Treatment] Block Grant is still secure,” she said. But in the states that did expand Medicaid, there is “anxiety,” because providers in these states have been able to see more patients.

“We’re working with Congress to make sure they understand that whatever they decide to replace the ACA with, people can still access addiction services,” said Vaughn. “Our big goal right now is funding.” The Comprehensive Addiction and Recovery Act (CARA) needs to be fully funded to be implemented, she said.

The vehicle for funding is the budget process, said Vaughn. When the White House releases its budget request, many hope that it will reflect President Trump’s stated claim that he wants to expand treatment for those who need it. One way to do this would be to increase the Substance Abuse Prevention and Treatment Block Grant, she said. But the funding wouldn’t only be in the Department of Health and Human Services. “There’s also talk of more money in the Bureau of Justice Assistance to increase treatment options for the criminal justice population,” said Vaughn. “There are a lot of ways to do it.”

ACA is still the law

“We have no idea how any of this is going to unfold,” said Chuck Ingoglia, senior vice president for public policy at the National Council for Behavioral Health. “When I talk to Medicaid directors, they tell me ‘the law is the law, and until the law changes, we’re just going to proceed with what we know.’” It’s hard for treatment providers to prepare for the unknown, said Ingoglia. “Hopefully I’m not being Pollyannaish, but it does seem Congress is having a hard time putting together a plan that is portable,” he said.

For example, on Feb. 24 a draft of a bill was released that days later everyone backed away from. “We heard the president say he doesn’t like it, and then we hear congressional leadership say that was an early draft and they’re farther along,” said Ingoglia. “I think the longer they struggle, the more it’s unclear what will happen. Obviously, if they have their way, they want to get rid of the essential health benefits.” But now, those benefits are the law, and Medicaid directors are not backing away from requiring them, said Ingoglia. “I don’t know how you plan for something that is so unclear,” he said.

Catastrophic plans

About 80 percent of the patients in Bradford Health Services, a private for-profit addiction treatment provider based in Alabama with programs in Tennessee, Arkansas, Florida and Alabama, are covered by health insurance, said Howard J. Bayless-Bonventre III, Bradford corporate director of development, in an interview last week. “The ACA established minimum benefits that every health plan had to provide, but a lot of the information that’s coming out of Washington right now will move us back to catastrophic plans,” he said. These plans have low premiums and high deductibles — they are not the ACA-type plans for which people under 30 can qualify for a “hardship exemption.” They are simply low-premium, low-coverage plans that people buy hoping that they won’t get sick. When they do, they have to pay — a lot more than they would have if they had bought full-coverage insurance. And since preventive care isn’t covered at all, they don’t get it. “We had this before,” said Bayless-Bonventre. “There were record numbers of bankruptcies for people who were left with medical bills they couldn’t afford.”

When people don’t have insurance, they tend to seek medical care in the emergency department, where “hospitals try to manage them and get them stabilized and out the door, or they end up in prison,” he said. “It’s disconcerting to hear that we’re going back to the old way that wasn’t working.”

Treatment providers will need to work with their insurance partners to navigate the future, said Bayless-Bonventre. “We’re hearing from our managed care partners that they’re also concerned,” he said. The problem with addiction treatment is that many people don’t realize that they need it or don’t want it. “People don’t wake up in the morning and say, ‘Oh, this is bad. I think I’ll go to treatment today,’” he said. “Their family or their job draws them in to look for options.” It’s easier to motivate people to get better when they have health insurance.

For most managed care companies, the ACA’s 10-percent cap on administration costs has been a deterrent, said Bayless-Bonventre. Most managed care companies want at least a 15-percent return — Medicare Advantage plans go to Congress every year to get that, he said. “Because so many plans have withdrawn, this has given fodder to those who say it isn’t working,” he said. In fact, however, the biggest utilization of health insurance is in the first five years of enrollment, he said. “We were getting to the end of that; we were seeing costs begin to decline and rates normalize,” he said.

Alabama did not opt for Medicaid expansion, so the $3 billion the state could have gotten for that went elsewhere. There is no demonstration project for Medicaid reform in the state. Bayless-Bonventre and other treatment providers had supported the state’s planned move to a regional care organization (RCO) system. “Because the Medicaid budget in Alabama is unruly, and we have no way to pay for it, we were hoping the RCO format would help,” he said. “But now, with the new administration, there are concerns that this won’t happen.”

Medicaid block grants

One factor that has nothing to do with ACA repeal is the introduction, by Congress, of the concept of Medicaid block grants — something that wasn’t even there before the ACA. Block grants are caps. Under Medicaid today, there is no cap — no matter how many people are eligible or how many people get sick, the Medicaid dollars will be there, making it an “entitlement.” While the ACA offered states the funding to expand Medicaid to people above the federal poverty level, and the single adults without children, a Medicaid block grant would sharply cut back on this coverage. “For the states that didn’t expand, anything they got would help them,” said Vaughn. These states may, for example, like the idea of the flexibility that comes with a block grant. “But in the states that did expand, a block grant would mean reduced funding,” she said.

But it’s hard to generalize, said Vaughn, who always notes that every state is different. In Oregon, for example, there is already a capitated system, so a block grant wouldn’t necessarily affect them. “They are already managing a fixed amount of money,” she said. “But in a state like New York that has done a fabulous job of making the best use of Medicaid expansion, there is a lot of concern.”

Going to Medicaid block grants — with the added “flexibility” for how the money is spent — could be deleterious to addiction treatment, said Bayless-Bonventre. “We’ve seen over the years that these are ways states either fund community-based programs they’re fond of, or they go into another politician’s pockets,” he said. “There have to be standards. You can’t peel government away from health. People should know all the aspects of an insurance plan.”

Private equity

The ACA, with its promise of insured patients and its requirement that all insurance cover addiction treatment, was also an allure to investors, who have invested in facilities. “What most people are worried about now is the idea that there won’t be an essential benefit that includes mandatory coverage for addiction treatment,” said Vaughn. But there are other opportunities, such as employers who need treatment for their workers, and are self-insured, she said. She noted that she was advising an investment group trying to decide on whether to open a 50-bed facility in Arizona, which would be entirely focused on insured patients. In this case, there was a fallback — a large employer that was self-insured needed such an option.

Bayless-Bonventre of Bradford said it’s too soon to see how investors will respond. “I don’t think we’re going to see a response until we see some actual plans in writing,” he said. “There was a jump when parity and the ACA passed — they saw growth opportunities in this area of health care that wasn’t adequate.”

Once there is an actual plan from Congress, he expects there to be an indication from investors on where they are heading on addiction treatment.

Criminal justice system

The two biggest pieces of the ACA for Treatment Alternatives for Safe Communities (TASC), which focuses on treating people with mental illness or substance use disorders (SUDs) in the criminal justice system, is Medicaid expansion and the requirement that addiction treatment be covered as an essential health benefit. “Being able to access mental health and substance use services as an alternative to incarceration, and as a way to avoid an arrest by getting treatment when they need it, is key,” said Maureen McDonnell, national director for health care initiatives at TASC, which is based in Chicago.

“We are trying to understand what the landscape might look like,” McDonnell told ADAW. “Our state, like others, has many waivers and contracting provisions that are already in place,” she said. “We are continuing to work on those while other changes take place. In the immediate short term, our clients still have coverage, and we’re going to take advantage of that.”

But there are great concerns that cutting treatment funding will just lead to more prison and jail terms for people with addictions. “When there’s a reduction in the amount of substance use and mental health care that’s available in the community, we see detention and incarceration go up,” said McDonnell. In 2009, when there was a 35 percent reduction in treatment services in Illinois due to the state’s budget, jails and prisons had increased numbers. “This is what happens, and we know this will be a likely outcome if treatment is cut,” said McDonnell. States and Congress have focused on bipartisan criminal justice reform over the last 10 years, she said. “Over the last five years, there has been an increase by local police departments and sheriffs in creating alternative pathways” by diverting people to treatment instead of arrest and incarceration, said McDonnell. “Dialing back on Medicaid expansion will reverse that,” she said.

Insurance viewpoint

The Association for Behavioral Health and Wellness (ABHW), the advocacy organization for managed behavioral health organizations — insurance companies that sell premiums to cover substance use disorders and mental illness — wants the gains of the ACA to continue. “It is hard to predict what the repair or replacement of the ACA will look like,” Pamela Greenberg, ABHW president and CEO, told ADAW last week. “Many gains have been made over the years for substance use disorder coverage — parity, inclusion in the essential health benefits and expanded Medicaid coverage, to name a few,” she said. “ABHW is advocating for the preservation of these gains in whatever legislation moves forward.”

Greenberg noted that many employers purchased insurance that covers SUDs and mental health before the ACA, and said she suspects that they will continue to do so even if it is repealed. “Understanding that substance use disorders are diseases like cancer and diabetes has increased over the years and the desire to stop the opioid epidemic and treat individuals with opioid addiction is a top priority for the nation,” she said. But the sticking point is Medicaid and the individual market — people who are not covered by employer health plans. “The real unknown is whether or not there will be enough funding in the Medicaid program for states to maintain the coverage for behavioral health disorders that they currently have and whether or not the individual market will be structured in a way that comprehensive health care benefits are affordable,” she said.

Advocacy

Whatever ACA reforms pass Congress, it’s important to make sure that parity implementations and compliance requirements in the Cures Act are implemented, as well as keeping mental health and substance use disorder treatment at parity as required under the Mental Health Parity and Addiction Equity Act, said Carol McDaid, principal with Capitol Decisions.

“I think we really all have to think about a multipronged approach,” said Bayless-Bonventre. “We have to push our elected officials to not forget that constituents need these services, to work with them to understand this need, a policy that supports all Americans.”

“The most important thing is to explain what ACA repeal would mean for patients, to help the policymakers understand how important Medicaid expansion is to access to treatment,” said Ingoglia. “We had all the focus last year on CARA and the opioid epidemic — the last thing we need is cutbacks.”

McConnell of TASC said there has been so much investment in taking advantage of the ACA, building substance use treatment systems. “Some plans are just getting under way, to broaden access,” she said. “This is a much bigger health issue” than just addiction, she said. “There’s a lot of advocacy going around this, over losing basic protections,” she said.

Bottom Line…

Repealing the ACA — something Trump and Congress have promised to do — could have devastating effects to treatment for substance use disorders, which saw many newly insured patients as a result of the law.

1/30/2017 12:00 AM

The drug strategy of the Trump administration is going to look a lot like that under John Walters, head of the Office of National Drug Control Policy under President George W. Bush, ADAW has learned. The three key issues are prevention, treatment and border control. According to an administration official, speaking on background, “This administration is working to develop a comprehensive approach to addressing drug use and its consequences that will address preventing drug use before it starts, getting people who are struggling with substance use disorder the help they need and stopping the flow of illegal drugs into the country. We will provide further information in a timely manner as these policies are developed and implemented.”

The drug strategy of the Trump administration is going to look a lot like that under John Walters, head of the Office of National Drug Control Policy (ONDCP) under President George W. Bush, ADAW has learned. The three key issues are prevention, treatment and border control. According to an administration official, speaking on background, “This administration is working to develop a comprehensive approach to addressing drug use and its consequences that will address preventing drug use before it starts, getting people who are struggling with substance use disorder the help they need and stopping the flow of illegal drugs into the country. We will provide further information in a timely manner as these policies are developed and implemented.”

At the stroke of noon on January 20, President Donald Trump became the nation’s leader. But despite the swirling uncertainties about the future of the Affordable Care Act (ACA) and other questions, prevention and treatment of substance use disorders are still a part of the national drug control strategy.

There were initial concerns in the field because the ONDCP website had disappeared, but that’s because everything that was EOP (Executive Office of the President) had been replaced by the new White House. Michael Botticelli, the beloved ONDCP director who had championed recovery and, along with Gil Kerlikowske, President Obama’s first drug czar, a focus on treatment and away from the drug war, was also gone. But the programs are still there, as is the ONDCP itself, with Kemp Chester the acting director. Chester joined ONDCP as associate director for the National Heroin Coordination Group in October 2015. He retired from the Army, where he worked for 27 years; his last tour was at the Defense Intelligence Agency, working on counternarcotics. 

We asked Andrew Kessler, principal with Slingshot Solutions, about how the changes will affect the SUD field. “We are in a situation that is not unique to our field,” said Kessler, who lobbies on behalf of behavioral health providers. “A lot of people across government are very curious to see how this plays out.”

Kessler zeroed in on community policing as a key question going forward. Community policing is recommended for elimination from the Department of Justice budget by the Heritage Foundation in a report the Trump Administration appears likely to consider. However,  Sen. Jeff Sessions, nominee for Attorney General, has in the past been a big supporter of community policing – as is Kessler. “I think community policing can play a huge role in working with the treatment community on diversion programs, prevention programs, any number of programs,” he said.

SAMHSA leadership team

In addition, the leadership team at the Substance Abuse and Mental Health Services Administration (SAMHSA) consists of career officials with longtime experience in the programs of that agency (see organization chart, SAMHSA.pdf). As Kana Enomoto, deputy assistant secretary for mental health and substance use in the Department of Health and Human Services (HHS), told SAMHSA staff last fall, “SAMHSA’s work remains critical and behavioral health continues to be a top priority” (see ADAW, Nov. 21, 2016). The HHS assistant secretary for mental health and substance use will be appointed by President Trump. The move from SAMHSA administrator to the new position of HHS deputy assistant secretary, as well as the new position of HHS assistant secretary, were created by the Cures Act, which incorporated some changes to SAMHSA organization (see ADAW, Dec. 12, 2016, and Jan. 23).

Charles Curie, SAMHSA administrator from 2001 to 2006, gave us a sense of perspective about how the transition will work. “I know some of the people who are in acting positions at HHS — all have been in transitions before, all are highly competent, all SES [Senior Executive Service] with institutional knowledge, and are in a good position to inform stakeholders,” Curie told ADAW last week. For example, Acting Secretary of HHS Norris Cochran was at the Office of Management and Budget (OMB) when Curie was waiting to be confirmed as SAMHSA administrator. Cochran’s expertise is the health budget, and he has experience in Congress as well.

Curie, now a consultant in behavioral health, also has great confidence in the SAMHSA career officials — many of whom worked there when he was administrator. “These are very strong people,” he said. “Kana is an example of someone who is SES, key advisor on my team, and has demonstrated that she can work with a range of administrations.” A note on SES: it’s not based on seniority alone. A federal employee has to go through a review process, under which competence must be demonstrated. Also, Curie doesn’t think the title change is going to make much difference, noting that the SAMHSA administrator position always reported to the HHS secretary.

The transition

“In a transition, in the very early part of a new administration, you have a situation where prior to cabinet officials being confirmed and being in charge, you have senior executive career people who are in acting positions who are working with White House liaisons and counselors who are working for the new administration,” said Curie. These people are likely to be part of the HHS secretary’s new leadership team once the secretary is confirmed. (Tom Price, congressman from Georgia, is Trump’s nominee for HHS secretary.)

As for Medicaid and ACA changes, Curie cautions this is not a time to panic. “During a transition, where there’s been a major process to put into place, the assumption needs to be to continue with that process,” he said. For example, the treatment providers who have learned how to bill Medicaid and commercial insurance for services need to keep doing this, he said. “Any new process coming in is not going to be implemented quickly,” he said.

It’s still very early in the administration. More will be known when the secretary gets confirmed and when agency heads are put into place, said Curie. This doesn’t happen quickly. In Curie’s case, he was nominated in July 2001 — six months after the inauguration took place — and not confirmed until October.

Curie’s advice to new appointees is to “make sure what you are doing is aligned and transparent with what the White House wants,” he said. “Make sure stakeholders have had the opportunity to engage and have some ownership, and as you move forward, you can put new ideas on the table, facilitating trust for the administration.”

And everyone needs to “think about what is sustainable positive change, not just a quick win here or there,” Curie said. From his administration, he cited the Strategic Prevention Framework, Access to Recovery, the New Freedom Commission and the National Outcome Measures, all “readily embraced by the secretary and the White House.” Not all survived the Obama administration, which had other plans. But if the new drug strategy is any key, some of the same ideas — especially a focus on primary prevention — may come back.

ACA, parity and Medicaid/IMD

The National Association of Psychiatric Health Systems (NAPHS) is committed to three priorities as the Trump administration sets its policies: health insurance, parity for mental health and addiction, and increasing access for Medicaid patients by continuing progress in the Institutions for Mental Diseases (IMD) exclusion, according to President and CEO Mark J. Covall. “We recognize that there will be changes in the ACA, anything from total repeal to replacement, but we’re going to make sure that people have coverage however it plays out,” Covall told ADAW last week.

NAPHS will also “continue to preserve and protect the parity laws and regulations that are in place across the board,” said Covall. This includes those that apply to Medicaid as well as those that apply to the small business and the individual market, he said. “There’s strong bipartisan support for parity, and we’re going to keep the pressure on that one,” he said. Covall is co-chair of the Parity Implementation Coalition, and works with many partners on parity, including the Kennedy Forum and the American Psychiatric Association.

The IMD exclusion, under which Medicaid could not pay for treatment in a residential facility with more than 16 beds, was relaxed last year, allowing larger SUD and psychiatric facilities to obtain Medicaid payment for 15 days per calendar month (see ADAW, Aug. 1, 2016).  “We want to continue to break down the barriers to access, and a good example is the IMD exclusion, where we made some progress last year,” said Covall. “As part of that, we’re going to be very focused on Medicaid.”

The focus on Medicaid, as there is discussion of possibly changing the program to a block grant program, is an essential part of making sure there is health coverage for everyone, said Covall. “Maybe there will be changes — we’ll see,” he said. “But we want to make sure that individuals receiving Medicaid are protected.”

The interviews for this story were conducted before President Trump had been in office for even a week. The transition is still in transition. What is in place is what was in place before: a cadre of experienced staff at SAMHSA; an ONDCP in the process of developing a drug strategy that is not unlike those of the past; and plenty of funded programs and grants, laws and regulations. Above all, what remains regardless of politics: substance use disorders.

Bottom Line…

In the first few days of the Trump administration, we have learned that the new drug strategy will resemble that in place before Obama’s: primary prevention, treatment and sealing off the borders from illegal drugs.

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.

From the Field
9/19/2016 12:00 AM

Opioid addiction is a disorder of brain structure and function. It is an illness. And the most effective treatment for this illness is medication. And as with any illness, the medication that should be used is the one that proves most effective for that patient. And yet, there are those that argue we should limit the medications we use to fight this epidemic of opioid addiction and death.

We’re dying out there. Look at the number of overdoses that have occurred in the last month to heroin and to fentanyl- or carfentanyl-laced heroin. If something, anything, can be used to save lives, then please, let’s put ideology aside and let’s do that. When used as a medication, prescribed by a physician, diacetylmorphine — prescription heroin — stabilizes brain function and allows the person to become well, stay well and, most importantly, stay alive. And this treatment is for those that are refractory to the other medications used to treat this medical condition. Methadone and buprenorphine don’t work for them. So, because those treatments failed, should we just discard the people?

According to the NAOMI study, the countries that have established heroin treatment programs — Switzerland, the Netherlands, the United Kingdom, Germany, Spain, Denmark, Belgium, Canada and Luxembourg — have all reported positive results for those individuals who are refractory to methadone and buprenorphine treatment.

It sounds radical, the provision of heroin to those addicted to heroin. But do understand, a drug is just a drug. It just does what it does. This controversy over using heroin as a treatment to control opioid addiction — it’s not about the data. It’s not about the research. It’s about stigma, ideology and people protecting their turf.

In a previous ADAW issue, Robert Lubran, then with the Substance Abuse and Mental Health Services Administration, stated, “It’s not difficult to find individuals who will prefer access to heroin over methadone maintenance treatment” (see ADAW, Aug. 31, 2009). He seems to believe this is a bad thing. I do not. If we can get more people into treatment, if heroin treatment will do that, how many lives can we save? And every life is someone’s son, it is someone’s daughter, and we would not only be saving them but also their mothers and fathers from the devastating loss of their child. We should be doing everything we can to keep them alive. And, yes, that includes treatment with diacetylmorphine.

The NAOMI studies show that, for those refractory to methadone or buprenorphine, heroin-assisted treatment is effective, with retention rates of about 88 percent. But there seems to be a problem. The acceptance of this form of treatment is opposed by some in the treatment field.

This is not a game. This is not a “my treatment is better than your treatment” contest. This is about saving lives. Heroin can produce addiction, or it can be used to stabilize (with medication) an addiction. It is how we use it that determines its effects. In this epidemic, we have an obligation to do everything we can to save lives. If the use of heroin-assisted treatment will do that, and the data show that it will, then please, put the ideologies aside, put the financial interests aside, push back on the stigma and let’s do everything we can to reduce the harm of this epidemic to those who suffer from this disorder of brain structure and function we call opioid addiction. Because every death, every loss, is someone’s son or daughter, and their lives are precious too.

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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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