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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.”

12/11/2017 12:00 AM

Increasing death rates from opioid overdoses among whites have been widely documented, but less well-known is the increase in cocaine-related overdoses among blacks, as the National Cancer Institute reported last week in the Annals of Internal Medicine. Using complete U.S. death certificate data from the Centers for Disease Control and Prevention’s National Center for Health Statistics, Meredith S. Shiels, Ph.D., and colleagues compared data from 2000–2003 with data from 2012–2015. They found that total overdose death rates increased among blacks (6.1 to 9.0 per 100,000 person years), Hispanics (4.2 to 6.0) and whites (5.6 to 15.5). Broken down by age and race, however, increases were most pronounced for older blacks (men over 50 and women over 45).

Increasing death rates from opioid overdoses among whites have been widely documented, but less well-known is the increase in cocaine-related overdoses among blacks, as the National Cancer Institute (NCI) reported last week in the Annals of Internal Medicine. Using complete U.S. death certificate data from the Centers for Disease Control and Prevention’s National Center for Health Statistics, Meredith S. Shiels, Ph.D., and colleagues compared data from 2000–2003 with data from 2012–2015. They found that total overdose death rates increased among blacks (6.1 to 9.0 per 100,000 person years), Hispanics (4.2 to 6.0) and whites (5.6 to 15.5). Broken down by age and race, however, increases were most pronounced for older blacks (men over 50 and women over 45).

The most common contributor to overdose deaths in whites was opioids, but for blacks, cocaine was the largest contributor to overdose. Between 2012 and 2015, cocaine-related overdose deaths were almost as common in black men as deaths due to opioids in white men (7.6 vs. 7.9). Cocaine-related deaths declined between 2008 and 2011, and then increased between 2012 and 2015.

The largest recent increases in drug overdose deaths for blacks and Hispanics were due to heroin, although there were also increases due to other opioids, benzodiazepines and psychostimulants.

The researchers noted that “important public health measures have been initiated, particular in heavily affected areas” in response to opioid deaths among whites. But overdose deaths among blacks and Hispanics “are an important, long-term public health problem that is often overlooked.” Their results are probably underestimates, they said, because about 20 percent of deaths classified as unintentional overdoses miss a contributing drug.

Researchers urged additional research to understand the increasing rates of overdose among older black men and women. In addition, they say it’s essential to focus on preventing cocaine-related deaths, which disproportionately affect older blacks.

Harms of single-drug focus, racial disparity in coverage

The article, “Trends in U.S. Drug Overdose Deaths in Non-Hispanic Black, Hispanic, and Non-Hispanic White Persons, 2000–2015,” underscores two important problems in current drug policy, said H. Westley Clark, M.D., J.D., Dean’s Executive Professor at Santa Clara University: focusing on opioids only, and racial discrimination..

“A single drug focus belies the nature of drug problems,” Clark told ADAW. The Cures Act devoted $1 billion for the opioid epidemic, “but alcohol, cocaine and methamphetamine have been forgotten,” he said. “People dying because of alcohol, cocaine, methamphetamine or any other psychoactive substance are no less important than people dying from opioids.”

The report also brings to light a complaint that many blacks have been making, said Clark. “When African Americans die of drug overdoses, it gets ignored. When whites die of drug overdoses, the whole world listens, from politicians, Big Pharma, researchers and the FDA to the media. When African Americans die, it isn’t news,” he said.

Clark noted that blacks in the public health workforce are “particularly sensitive to the epidemiological reality” that the authors at the NCI, which is part of the National Institutes of Health (NIH), uncovered. “This report demonstrates why African Americans and other people of color in the public health workforce are essential to the public health paradigm,” said Clark. “I commend the NIH researchers for asking the question about race and drugs,” he said. “Their paper provides some of the answers. Now we need to do something. The public health effort should not be to focus on younger whites while ignoring older blacks.”

Much media coverage of opioid overdoses has focused on young white people, many of them in suburbia. The question, said Clark, is why it has taken so long for the disparity in overdose reporting to come to light.

Surgeon general’s report

Clark recommends 2016’s Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health as a framework for a comprehensive strategy that relies on science, prevention, treatment and recovery. Clark, one of the science editors of the report, noted that it “recognizes neurobiologically that psychoactive substance use operates for different people in different ways, but that there is a need for a comprehensive focus.”

The comprehensive strategy recommend by the surgeon general’s report “would allow resources to be used where they are needed,” said Clark. “A population-based prevention strategy would recognize the unique needs of those communities where African Americans live, just as a similar strategy would address the public health needs of the non–African American communities.”

As Congress considers additional funding for substance use issues, it “should look for solutions that address the broader epidemic, not just those aspects of the epidemic that affect white people,” said Clark. “The Congressional Black Caucus and its Health Braintrust should mobilize its colleagues on the Hill to make sure that future legislation addressing drug use includes provisions dealing with the drug use landscape, so that the deaths of African-American drug users due to cocaine are not ignored by public policy.”

For the surgeon general’s report, go to https://addiction.surgeongeneral.gov/.

11/13/2017 12:00 AM

When Elinore McCance-Katz, M.D., assistant secretary for mental health and substance use at the Department of Health and Human Services (HHS), told the House Energy and Commerce Committee that changes were coming for 42 CFR Part 2, the regulation governing confidentiality of substance use disorder treatment records (see ADAW, Oct. 30), she was referring to the Supplemental Notice of Proposed Rulemaking (SNPRM). The SNPRM was published in the Jan. 18 Federal Register, along with the final rule on 42 CFR Part 2 issued by HHS under President Obama Jan. 18 (see ADAW, Jan. 23).

When Elinore McCance-Katz, M.D., assistant secretary for mental health and substance use at the Department of Health and Human Services (HHS), told the House Energy and Commerce Committee that changes were coming for 42 CFR Part 2, the regulation governing confidentiality of substance use disorder (SUD) treatment records (see ADAW, Oct. 30), she was referring to the Supplemental Notice of Proposed Rulemaking (SNPRM). The SNPRM was published in the Jan. 18 Federal Register, along with the final rule on 42 CFR Part 2 issued by HHS under President Obama Jan. 18 (see ADAW, Jan. 23).

Under 42 CFR Part 2, individual consent in writing is required before an SUD treatment provider receiving any federal funds can release information about a patient. The final rule kept the essential protections of consent. The SNPRM, however, creates an abbreviated alternative statement for the notice to accompany disclosure, and opens up disclosure to anyone involved in the vague term of “health care operations.”

Nobody is sure exactly what the supplemental rule will say. “It could fundamentally change how Part 2 operates,” said Paul N. Samuels, director and president of the Legal Action Center, in an interview last week.

The Legal Action Center has been at the forefront of 42 CFR Part 2 advocacy since before the rule was first promulgated in 1975. This summer, the Legal Action Center formed a coalition to protect patient privacy after the Partnership to Amend 42 CFR Part 2 was formed — a partnership that includes the American Society of Addiction Medicine (ASAM) and the Hazelden-Betty Ford Foundation (see ADAW, Aug. 7).

The Substance Abuse and Mental Health Services Administration (SAMHSA) said throughout the final rule issued last January that it would release subregulatory guidance. “We think it would be helpful for that guidance to be released,” said Karla Lopez, senior staff attorney with the Legal Action Center. “As far as we know, they’re still planning to do that,” she told ADAW.

And in fact, 42 CFR Part 2 has a very limited scope — providers who put themselves forward as treating SUDs. It does not apply, for example, to emergency department personnel who treat someone for an overdose; one myth is that these personnel are not allowed to disclose information about the patient to family members.

“We at the Legal Action Center are talking to whoever we can to find out what the specific concerns are that people have,” said Samuels. “We have worked closely with treatment providers on these issues for decades, and from our experience with them, treatment providers have routinely told us that obtaining consent at admission is not only possible, but to our understanding, it’s standard.”

There is so much confusion and misinformation that clarification is constantly needed. While the Association for Behavioral Health and Wellness, the organization leading the Partnership to Amend 42 CFR Part 2, calls the 42 CFR Part 2 rule “antiquated” and wants it to revert to the Health Insurance Portability and Accountability Act (HIPAA), the main concern seems to be with the technology (paper vs. digital). Unfortunately, stigma is as pervasive now as ever, and there is nothing antiquated about a patient not wanting his or her SUD treatment records made public.

And the Legal Action Center supports the need for integrated care. “We support whatever mechanisms can facilitate communication, as long as the core protections of Part 2 remain,” said Samuels. “We are very worried that reducing or removing Part 2 protection will scare many people away from entering the lifesaving treatment they need,” he told ADAW.

‘Inconvenience’ to EHRs

Opposition to 42 CFR Part 2 seems to be focused around electronic health records (EHRs). For more than 25 years, there were no complaints against the regulation, but in 2010, the EHR industry began to recognize that consents in writing could not easily fit into their systems. Since then, 42 CFR Part 2 has been under siege, with various arguments being used, including a call by some ASAM representatives to know about what patients are taking methadone. The American Association for the Treatment of Opioid Dependence and patient advocates have been the staunchest supporters of 42 CFR Part 2.

H. Westley Clark, M.D., who was responsible for the interpretation of 42 CFR Part 2 as director of the Center for Substance Abuse Treatment at SAMHSA, thinks the opioid epidemic is being used “as cover for business interests.” Clark, who is now Dean’s Executive Professor of Public Health at Santa Clara University, frequently describes 42 CFR Part 2 as an “inconvenience” to businesses like EHR vendors. “With regard to 42 CFR Part 2, only anecdote and passion are offered as justification for eviscerating fundamental interests of those who come seeking assistance from those with established interests,” he told ADAW last week. “Software vendors, the health care industry and professional associations know that the evidence for sweeping away the protections of 42 CFR Part 2 is scant,” he said. “The demand to include the boundless exception to 42 CFR Part 2 found in the health care operations rubric is evidence of the lack of respect for those with substance use disorders and the disregard for patient welfare and public safety.”

How will a clinician respond when a patient asks “Is my treatment confidential?” is an important question no one is asking, said Clark. “Those in the know will artfully say, ‘Yes, to the fullest extent of the law,’ capitalizing on an insincere twist and knowledge of, and the unwillingness to explain, the unlimited possibilities that the rubric ‘health care operations’ offers,” he said. “We may have to wait until people are harmed by social exclusion, whisper and rumor. Worse yet, we may have to wait to see how many people truly value their privacy by refusing treatment rather than expose themselves to the vagaries of the health care operations exception. This, the middle of an opioid epidemic, when treatment should be welcoming, not discouraging.”

The President’s Commission on Combating Drug Addiction and the Opioid Crisis (see ADAW, Nov. 6) also wants to move in the direction of opening up 42 CFR Part 2, Clark noted. “In addition, the hunt is on for those on methadone,” he said. However, many OTPs are “off the grid,” in terms of EHRs, he said.

“We remain very concerned that many of the electronic health networks do not seem to be compliant with Part 2,” said Samuels. “The law requires that Part 2 be followed, and technology should follow the law,” he said. “We need to protect patient confidentiality.”

The Overdose Prevention and Patient Safety Act (H.R. 3545) would specifically align 42 CFR Part 2 with HIPAA, by allowing sharing of SUD records. The original sponsor, Rep. Tim Murphy (R-Pennsylvania), is no longer in office after a scandal (see ADAW, October 23). The lead Democrat sponsor is Rep. Earl Blumenauer (D-Oregon).

SAMHSA expects to release the supplemental final rule in early winter, ADAW has learned.

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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