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4/25/2016 12:00 AM

Connecticut, spurred by opioid overdoses and the epidemic of opioid use disorders, as well as by the high proportion of inmates in state jails and prisons with a substance use disorder, is instituting a statewide policy to make sure everyone in treatment with methadone gets to stay on the medication upon incarceration. To medical experts, this is an obvious necessity: how can you withhold a legal prescription and essential medication from someone? But in the corrections systems across the country, there is a widespread belief that methadone (and buprenorphine) are “substituting one addiction for another,” and that withdrawing in jail or prison is the best thing that could happen to someone. The next step — after keeping someone on methadone who is already on it — is inducting people who are dependent on heroin or pills when they are incarcerated. And Kathleen F. Maurer, M.D., medical director of the state’s Department of Correction, started three years ago with both steps in mind.

Connecticut, spurred by opioid overdoses and the epidemic of opioid use disorders, as well as by the high proportion of inmates in state jails and prisons with a substance use disorder, is instituting a statewide policy to make sure everyone in treatment with methadone gets to stay on the medication upon incarceration. To medical experts, this is an obvious necessity: how can you withhold a legal prescription and essential medication from someone? But in the corrections systems across the country, there is a widespread belief that methadone (and buprenorphine) are “substituting one addiction for another,” and that withdrawing in jail or prison is the best thing that could happen to someone. The next step — after keeping someone on methadone who is already on it — is inducting people who are dependent on heroin or pills when they are incarcerated. And Kathleen F. Maurer, M.D., medical director of the state’s Department of Correction, started the initiative three years ago with both steps in mind.

The Connecticut program got started when a former corrections commissioner was told by the treatment community that patients on methadone needed to stay on methadone when incarcerated. “’You’re not doing right by our people’” was the message, recalled Maurer, who spent an hour describing the program to ADAW last week. “The commissioner told me to go to New York and see what they do, so we went,” she said. At Rikers, the jail in New York City, methadone has been given to inmates for years. “They said, ‘It’s inhumane not to give methadone,’” she recalled. At about the same time, the Connecticut Department of Mental Health and Addiction Services (DMHAS) was encouraging the corrections department to continue methadone treatment for patients already on it.

There are 15,400 inmates in Connecticut prisons and jails; 80 to 85 percent of them have a substance use disorder that requires treatment. The primary drugs of abuse are alcohol (31 percent of inmates), marijuana (30 percent) and opioids (25 percent) based on February 2016 data.

Praise from counselors

Counselors in the state, and experts from outside the state, have nothing but praise for the program, and hope it can go further by inducting everyone who wants methadone onto the medication — not just people already in treatment. “Since we support all paths to recovery, we strongly support the plan to expand methadone treatment in the prisons to help those who are opioid dependent upon incarceration,” said Jeffrey Quamme, executive director of the Connecticut Certification Board, which certifies addiction counselors and other professionals in the state. “Not only does it help the treatment system in the Department of Correction by adopting this evidence-based practice, we also believe that helping inmates avoid terrible withdrawal symptoms is not only humane, but lessens the burden on the correctional custodial staff and medical providers by avoiding having to respond to the issues associated with the symptoms of withdrawal,” Quamme told ADAW. “This is an absolute positive step forward for the Department of Correction.”

And Yngvild Olsen, M.D., medical director for the Institute of Behavior Resources in Baltimore and past president of the Maryland chapter of the American Association for the Treatment of Opioid Use Disorders, agrees. “The national resistance in the criminal justice system, both state and federal systems, against continuing patients who are on methadone when they get incarcerated is a travesty,” she told ADAW. “If it were diabetes and people were taking insulin and got incarcerated, no one would question the need to continue that medication.”

Even in prison systems, there is a need to ensure that people with diabetes have appropriate food, access to diabetes management and exercise, said Olsen. “The same thing should be there for people with an opioid addiction who take methadone as part of their treatment,” she said. And while there are correctional facilities where treatment behind the walls is being implemented, in most instances it does not include a medication, and when it does, that’s injectable naltrexone (Vivitrol), she said. “It’s the stigma against methadone” that is at play, she said.

Funding barriers

One problem for corrections departments treating people in jails and prisons is funding. While medical care has to be provided, medical vendors do not provide methadone, which is only provided by opioid treatment programs (OTPs), strictly regulated by federal and state governments. Another factor is Medicaid, which can’t be used for anybody in prison or jail. The two OTPs who are working with Maurer’s program now — the APT Foundation in New Haven and Recovery Network of Programs (RNP) in Bridgeport — are doing so for free, bringing in the medication for their patients or, in about half the cases, for other OTPs’ patients. The OTPs have contracts to do this — but there is no money involved.

There was another problem in Connecticut: the public health code doesn’t allow methadone to be dispensed in prisons or jails. “We went to the deputy commissioner of public health and asked to do this, because it’s the right thing to do,” said Maurer. “They were skeptical at first.” But they relented, and she herself wrote the language authorizing the Department of Correction to provide methadone in jail — not as an OTP. That got put in a bill that the state legislature passed, and allowed the Department of Public Health to license corrections to have a community provider to come into the facility. “We do not have, and did not want to have, a full-blown clinic in our facility,” said Maurer, noting that jails are not big and are all overcrowded, and do not have computer systems to manage patient charts (“everything is paper and pencil for now,” she said).

APT from New Haven did get funding initially, from the Substance Abuse and Mental Health Services Administration via a technical assistance grant. APT did education for corrections staff, which was essential. “Our custody officers and even medical people were uninformed and opposed to methadone. But the warden, Jose Feliciano, became “very invested in this,” said Maurer. “It was our job to make sure everybody understands that this is a disease,” she said, adding that the warden has been one of the strongest role models in spreading this message.

Role of OTPs

Despite not being paid, OTPs want to be involved. “They’re doing this because they don’t want to see their patients lost,” she said. Several years ago when RNP in Bridgeport heard about it, it wanted to get in as well, even without funding. “The person who runs RNP told me he’d been trying to get into correction facilities for 10 years,” recalled Maurer. When his patients got arrested, he told her, “’You detox them, you don’t give them methadone, then you send them out with nothing, and they’re lost, they don’t get back to me,’” she said. “I told him, ‘I hear you. If it takes money to do this, I can’t do it because we don’t have any. But if we can do it without money, call me tomorrow.’” He called her, and together they set up the logistics.

Medicaid pays $4,000 a year for patients in an OTP, but right now APT and RNP are providing counseling twice a month for free in the corrections program, as well as dispensing the methadone.

The OTPs are also responsible for re-entry — when inmates leave prisons and jails. Many inmates go to halfway houses, and this is a problem because technically they are not allowed to leave them for the first two weeks.

Finally, the OTPs should be paid, said Maurer. “We originally had funding from DMHAS. They were going to share the cost, and they put in $35,000 a year; we put in the other $35,000,” said Maurer. However, the Department of Correction only put in money for the first year; the second year, only the DMHAS portion was paid. And now there is no money.

“I just lost 3 out of 10 staff to layoffs,” said Maurer of the correction medical office. The layoffs were not proportional on the custody side: out of 6,000 custody officers, 40 were laid off. So the idea of expanding the program to induction, putting new patients on methadone, is particularly problematic. Maurer hopes to get more space for inmates on methadone by doing more diversion; working with prosecutors, judges, public defenders and OTPs, she wants to “provide diversion to treatment for people who come in with nonviolent crimes that are drug-related,” she said. “We are incarcerating people because they are sick.” So far, 100 offenders have been diverted to treatment, with a success rate of 75 percent, she said. This diversion program has funding from the Public Welfare Foundation.

Regulatory burden

Olsen said that the large contracts with medical corrections systems usually leave out methadone and, to a great extent, buprenorphine. “They say it’s too much of a regulatory burden,” said Olsen. “For me those arguments need to be looked at through a different lens. Correctional systems have to understand that opioid treatment is effective.”

And while buprenorphine does not have the same regulatory burden, corrections systems are usually opposed to it because the film is so easy to divert, Olsen and Maurer said.

Finally Olsen noted that people do die from opioid withdrawal in jail — whether they were on methadone or on illicit opioids — mainly from dehydration and electrolyte imbalances. Withdrawal means almost constant diarrhea and vomiting, as well as other symptoms. It can last for a week. While it technically hasn’t been viewed as life-threatening — compared to the seizures of alcohol or benzodiazepine withdrawal — it can be, said Olsen. “There have been many recent examples of even young people who have experienced complications of opioid withdrawal and died as a result,” she said.

Bottom Line…

Connecticut is expanding a program that would provide methadone to all inmates currently in treatment with the medication, and hopes to expand it to induct inmates dependent on any opioids but not yet in treatment.

4/18/2016 12:00 AM

Asking patients to be their own advocates when their treatment is interfered with by law enforcement is a tall order. But frequently, patients — especially those who are in treatment with methadone or buprenorphine — are left to their own devices when they are caught up in any kind of criminal investigation. Ultimately, they may be denied medication and go through withdrawal in jail, lose custody of their babies temporarily or permanently or be ordered off of medication by a judge.

Asking patients to be their own advocates when their treatment is interfered with by law enforcement is a tall order. But frequently, patients — especially those who are in treatment with methadone or buprenorphine — are left to their own devices when they are caught up in any kind of criminal investigation. Ultimately, they may be denied medication and go through withdrawal in jail, lose custody of their babies temporarily or permanently or be ordered off of medication by a judge.

Even drug courts have a reputation for being opposed to methadone and buprenorphine, and order patients off of medication-assisted treatment (MAT). The Substance Abuse and Mental Health Services Administration (SAMHSA) put a stop to that last year for those few drug courts that receive federal funds (see ADAW, Feb. 16, 2015).

There is a disconnect in many jurisdictions between the clinicians — opioid treatment programs (OTPs) and office-based opioid treatment providers — and the courts and law enforcement. “Criminal justice and child welfare officials commonly usurp the role of doctor and order individuals off MAT,” said Sally Friedman, legal director for the Legal Action Center. “Patients and programs can use the Legal Action Center’s tools to educate these officials,” Friedman told ADAW. “Their lawyers can also call the Legal Action Center for help.”

Last week, the Legal Action Center issued a groundbreaking report urging drug courts to endorse MAT (for excerpts from recommendations, see sidebar). Produced with the Center for Court Innovation and the New York State Unified Court System, the report, “Medication-Assisted Treatment in Drug Courts: Recommended Strategies,” specifically calls for counseling and other services, in addition to medication. The report contains familiar information for medical professionals, but material that will be educational to many in law enforcement — including Child Protective Services, which in most jurisdictions is run by law enforcement.

What MAT staff can do

Intervening once your patient is involved with the criminal justice system is important, but you can make it easier by paving the way — by interacting with criminal justice people in your area in general, and on behalf of all patients.

Shirley Mikell of NAADAC, the Association for Addiction Professionals (NAADAC), a social worker whose past experience includes working in an OTP, recommends that clinicians treating substance use disorders (SUDs) offer to discuss their work at law enforcement conferences. “There are conferences for judges, and for drug courts, and if there’s one in your region, you can ask to do a presentation,” she said. “Sometimes they’re very receptive.”

Similarly, if there is a regional conference that is sponsored by clinicians — social workers, marriage and family therapists, addiction counselors — invite the judges to attend, said Mikell.

Frequently criticized for staying within their own circles, SUD treatment providers should reach out to law enforcement, even if they think it’s intimidating. In fact, it’s rewarding, said Mikell. In addition, if you do present at a criminal justice conference, you’ll find a good audience, she said. “When they’re in a mix of their own people, they hear better,” she said.

Inviting law enforcement officials to your treatment program — during non-patient hours — is a good way to educate them as well. But even if they are not willing to physically come to the program, you can prepare a presentation and leave it for them on a thumb drive, said Mikell. “Develop something like a pamphlet that talks about patient responsibilities and counselor responsibilities,” she said. “We are therapists, we are supporting the clients, but we also want to be salespersons.”

Who should actually do the presentations at conferences — marketing or clinical people — depends on the personal styles involved, said Mikell. “There are marketing people who are not good trainers, and may not be the best people to present,” she said. “The most effective person might be the counselor who also has some training skills, who can present the information with passion,” she said. “You need to search your staff — it might be a nurse — it’s the person who has enough charisma to maintain the attention of the audience.”

Judges do have an emotional side to them, said Mikell, but she added that the presentation has to have substance and facts. “They don’t want a lot of fluff,” she said. “And you have to keep your message clear. No one wants to hear that they’re doing something wrong.”

Bottom Line…

Treatment professionals need to step out of their comfort zone to communicate with law enforcement on behalf of their patients.

4/11/2016 12:00 AM

Dialectical behavior therapy (DBT) is a treatment for borderline personality disorder, but patients with substance use disorder (SUD) can benefit from it, according to treatment professionals. We have been hearing more about this lately, so we made some calls to investigate.

Dialectical behavior therapy (DBT) is a treatment for borderline personality disorder, but patients with substance use disorder (SUD) can benefit from it, according to treatment professionals. We have been hearing more about this lately, so we made some calls to investigate.

As a treatment for SUD alone, there is no research supporting the use of DBT. But there is research supporting the use of DBT in treating SUD and comorbid personality disorders. Two treatment professionals we interviewed say incorporating it with other types of treatment is useful, mainly because so many people with SUDs have comorbid disorders.

Hazelden Betty Ford

The Hazelden Betty Ford Foundation uses DBT in individual and group sessions, said Joseph Lee, M.D., medical director of the youth program. “We use DBT all the time,” he said, adding that it is used for all ages.

Evidence shows that DBT reduces hospitalizations, self-injurious behaviors, emergency room visits and suicide attempts, said Lee. “Even if you’re a bean counter in an insurance company, you would want these services available,” he said. And even though DBT “became popular because of borderline personality disorder, the model is applicable to patients who may not meet the criteria fully,” he said.

Another reason that DBT is appropriate is that there are so many similarities between borderline personality disorder and SUDs, said Lee, a psychiatrist. “We know that a significant portion of people with SUDs have personality disorders that resemble borderline personality disorder,” he said. In addition, personality disorders make people more likely to be addicted, he said. “Both populations — people with SUDs and people with borderline personality disorders — have much greater rates of suicide and self-harm, and greater problems with emotional regulation and coping with stress,” he said.

DBT is a form of cognitive behavioral therapy, utilizing strategies to deal with impulses. There is also a mindfulness component, which can make the spirituality aspects of treatment easier to comprehend, said Lee.

Raleigh House of Hope

At the Raleigh House of Hope in Denver, Colorado, Osvaldo Cabral, director of operations of the Awakenings Recovery Program, created a model using traditional DBT, but reworking some skills to make a better fit with SUD treatment. “The core therapeutic work is focused on emotion regulation coping skills,” Cabral told ADAW.

He gave two examples showing how he altered DBT to be useful for SUD treatment.

  • One patient had tried to commit suicide by shooting herself in the mouth, prior to entering SUD treatment. “She did pull the trigger and she was badly disfigured and spoke through the side of her mouth,” said Cabral. Using traditional DBT, the therapists used the skill of “comparisons” in which patients compare themselves to others dealing with similar issues (in SUD applications, a patient might say “at least I just drank and didn’t use heroin,” for example). In the case of the woman who shot herself, after she came to the DBT group, she said, “‘I’m so glad we had that group, because some of the people in here are really messed up,’” Cabral recalled. “We were shocked because she had recently tried killing herself, was disfigured, couldn’t talk very well, and was using comparisons as a way to be judgmental and detach from others.” So instead, the skill of “comparisons” got changed to “count your blessings,” which is more in the spirit of the purpose of the skill, as well as being more in line with 12-Step philosophy, said Cabral.
  • Another patient — 36 years old when he came to treatment — had severe emotional dysregulation and had used substances since the age of 11. “He did not have any other coping skills and had difficulty relating to others because of his intense cognitive distortions,” said Cabral. “We practiced the skills used in the integrative model of DBT and 12-Steps,” he said. It turned out that the DBT-related skill of “contributing” was actually the 12-Step service work, and that the DBT concept of radical acceptance was the 12-Step concept of surrender. “Through the use of distress tolerance and the interpersonal effectiveness skills, the client was able to lower the intensity of his emotions and allow the frontal lobe to kick in and proceed in a rational, adult manner in the face of conflict,” said Cabral. Both DBT and 12-Step principles were used to strengthen his recovery; the patient has been in recovery for four years and is an active member of his fellowship, as well as a sponsor.

Cabral and his colleague, Bari Platter, both received intensive training on DBT at the Linehan Institute. They will be presenting on DBT at the annual meeting of the National Association of Addiction Treatment Providers in Fort Lauderdale, Florida, in May.

Research

Federal experts told ADAW that while DBT is a proven treatment for borderline personality disorder, there is no research on its use for SUDs alone.

“The original research on DBT was for suicide prevention and borderline personality disorder,” said Kim Johnson, Ph.D., director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA). “There is a version that was designed to be used with people who have SUDs, but the purpose was for co-occurring disorders,” she said. “I haven’t seen DBT by itself as an SUD treatment.”

And from the National Institute on Drug Abuse: “DBT has a strong evidence-base for patients with borderline personality disorder but has not been studied with substance use disorders alone. There was a recent review that looked at four small studies and found that it is effective in reducing substance use, suicidal/self-harm behaviors, and improving treatment retention for patients with this co-morbidity. However, we are not aware of any studies that looked at DBT for SUD alone.” For the abstract of the review, go to http://www.ncbi.nlm.nih.gov/pubmed/25919396.

Lee agreed that using research-based treatment is particularly important as the SUD field faces increased scrutiny.

“The ‘I’ve been sober for 20 years and I know you’ is complete bunk,” said Lee. “So we struggle with standardization and raising the bar for professionalism.” But on the other end of the spectrum, in general, there can be barriers with costs and certification. “The goal is to keep fidelity to the model,” he said, adding that there are modules and tools that can be used even if the provider is not certified in a particular technique.

“We don’t get into the certification thing” with Linehan, he said of Hazelden Betty Ford. “But we do use a manual, which is widely available, to keep fidelity as much as possible.” In addition, some of the Hazelden Betty Ford psychologists have been trained separately in DBT.

(For an abstract of an article about using DBT for SUDs written by DBT founder Marsha M. Linehan, Ph.D., and focusing on the 12 Steps, go to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797106. Emails and phone calls to Linehan and Behavioral Tech, which is owned by Linehan and sells the training for DBT, were unreturned.)

From the Field
4/11/2016 12:00 AM

On February 9, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a proposed rule that made changes to the Confidentiality of Alcohol and Drug Abuse Patient regulations (42 CFR Part 2). The purported goal was to modernize regulations that had not been updated since 1987. After more than 40 years, it is unquestionably time to modernize these outdated rules while still maintaining privacy (especially as it relates to law enforcement, employers, divorce attorneys or others seeking to use the information against the patient).

In addition to having broader coverage for treatment of substance use and mental health disorders, in large part due to the Affordable Care Act and the Mental Health Parity and Addiction Equity Act (MHPAEA), we now utilize patient-centered medical homes that integrate patient care and quality measures that require follow-up after hospitalization and care coordination. Today integrated and coordinated care is expected as the new norm for delivering best-practice, whole-person care. Additionally, we have electronic health records and stringent federal privacy and security regulations that were not in place when 42 CFR Part 2 (referred to as “Part 2”) was enacted. The Part 2 regulations were appropriate for a different time. The regulations now hinder safe, effective, high-quality substance use treatment. The proposed rule makes many steps in the right direction, yet it still leaves barriers to coordinated, integrated health care for some people seeking treatment for substance use disorders.

Part 2 is the federal regulation governing the confidentiality of specified drug and alcohol treatment and prevention records. These regulations limit the use and disclosure of patients’ substance use medical records from certain substance use treatment programs. The Part 2 regulations were originally authorized by the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 and the Drug Abuse Prevention, Treatment, and Rehabilitation Act of 1972. These laws were consolidated in 1992 by the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act (PL 102-321). Based on these laws, Part 2 sets out protections against unauthorized disclosure of substance use records as a way to encourage people to seek treatment. The regulations were established to assure people with substance use problems that their information would not be shared without their very specific consent, other than under several circumscribed conditions detailed in the regulations.

Patient privacy is important, and it needs to be balanced with providing access to the same standard of care afforded to individuals with a medical illness. After all, isn’t this why we fought so hard for the MHPAEA? Doctors ask for a list of your medications, your allergies, your medical conditions and your previous surgeries for a reason: to ensure individualized quality health care without injury or harm to their patients. Don’t individuals with a substance use disorder deserve the same protections? Shouldn’t a doctor prescribing pain medications know whether or not his or her patient is being treated for an opioid addiction? Shouldn’t a primary care provider know that his or her patient has cirrhosis of the liver?

The proposed rule applies to federally assisted programs. These outdated standards do not apply to patients with substance use disorders seeking care outside of these programs. People being treated in non–Part 2 programs have their records protected in the same way medical and mental health records are protected, by the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) regulations. Hopefully, SAMHSA will truly modernize Part 2 in the final rule and ensure that a treating provider has all of the necessary patient records to properly treat his or her patient and allow for the sharing of patient information for services like care coordination without a signed authorization. If the final Part 2 rule mirrors HIPAA, for treatment, payment and health care operations, patients will have privacy protections, quality care and the benefits of whole-person integrated care. This can be accomplished while maintaining the Part 2 prohibitions on sharing information with law enforcement and for other non-treatment-related purposes that might inhibit people from accessing care.

To quote the Centers for Medicare & Medicaid Services when they announced their initiative supporting improving connectivity for behavioral health and Medicaid providers, “doctors and other clinicians need access to the right information at the right time in a manner they can use to make decisions that impact their patient’s health.”

In Case You Haven’t Heard
4/11/2016 12:00 AM

Is West Virginia looking at yet another barrier to treatment with methadone or buprenorphine? According to a “treatment fee” proposal by U.S. Sen. Joe Manchin, a tax on prescription opioids could be used to fund treatment. The government currently charges no tax, he said. His proposal would be one penny per milligram for every milligram purchased. However, this proposal might backfire if it ever comes to pass, unless it exempts methadone and buprenorphine, both opioids, and both used in SUD treatment.

Coming Up
4/11/2016 12:00 AM
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    Alison Knopf
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    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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