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5/23/2016 12:00 AM

Where is the $1.1 billion the White House keeps talking about? Not in any bills currently under consideration on Capitol Hill. In fact, the 18 drug-related bills passed by the House of Representatives during the week ending May 13 included no appropriations at all.

From the beginning, the $1.1 billion was more public relations than reality. The $1.1 billion was announced by the White House days before President Obama’s budget request to Congress was actually released (see ADAW, February 8). At the time, the White House, via the Office of National Drug Control Policy (ONDCP), said most of the money would go towards medication-assisted treatment (MAT) to treat the opioid epidemic. However, when the budget request was released February 9, that money was nowhere to be found (see ADAW, February 15).

Where is the $1.1 billion the White House keeps talking about? Not in any bills currently under consideration on Capitol Hill. In fact, the 18 drug-related bills passed by the House of Representatives during the week ending May 13 included no appropriations; any amendments that included funding were voted down.

From the beginning, the $1.1 billion was more public relations than reality. The $1.1 billion was announced by the White House days before President Obama’s budget request to Congress was actually released (see ADAW, February 8). At the time, the White House, via the Office of National Drug Control Policy (ONDCP), said most of the money would go toward medication-assisted treatment (MAT) to treat the opioid epidemic. However, when the budget request was released February 9, that money was nowhere to be found (see ADAW, February 15).

The ONDCP and the Department of Health and Human Services (HHS) called the funding “mandatory,” meaning it would not come from appropriations and that Congress would have to figure out another way to come up with the money. That was what led the field back in February to call the $1.1 billion “smoke and mirrors” and a “gimmick.”

This month, the White House has ratcheted up its message — via a stakeholder meeting in the White House itself, Twitter chats and even a May 14 national radio address by President Obama joined by Macklemore — about the need for funding. During the same week that advocates were scurrying to follow House bills, ONDCP Director Michael Botticelli called a stakeholders meeting to ask advocates to help in getting the $1.1 billion out of Congress. Of course, advocates have been asking for money for the opioid crisis for years. For the White House to tell them they were not doing enough was, in the view of some advocates, just a “guilt trip.”

The ‘guilt trip’ on advocates

Speaking on background, some advocates told ADAW that it was “politically inept” for the White House, in the last months of its administration following an opioid epidemic that has been building for years, to now beg for assistance with Congress and even to chastise them for not doing enough. “What do they think we’ve been doing?” said one. 

With no guidance from the White House on how to offset the $1.1 billion, advocates are at a loss for what to tell their Capitol Hill contacts. “You cannot pass a bill off the House floor that is not paid for,” said one. “Congress has the power of the purse, and to tell them to do this did nothing but annoy appropriators. This was DOA from day one.”

It's important to note that the White House was bound by the spending caps agreed to with Congress, so it could not simply add money to the budget.

While advocates appreciate the White House effort to get additional funding, they do not appreciate being told to “get this $1.1 billion when there’s no vehicle,” said one. The administration could have submitted a supplemental emergency request for the money, as it did for Zika — for which it got $600 million. “If you’re going to offer money, have a path forward. You can’t do it on messaging alone.”

Another advocate said that ONDCP well knows that the opioid epidemic has been “a long time coming, and now we’re in the last year of the presidency, and we’re getting lectured about the need to step up our game?”

Support for administration

Others, however, do blame Congress. “This is a chicken and egg question,” said Daniel Raymond, policy director of the Harm Reduction Coalition. “The White House started the conversation, and I would like to think that if Congress had shown any interest or inclination to take it up, the administration would work on mechanisms and offsets,” he told ADAW, noting that the House refused to even hold a budget hearing. “For myself as an advocate, my job is to tell Congress and the administration what I think is needed and how the lack of resources are hurting people,” he said. “It’s not my job to figure out offsets, it’s not my job to come up with the exact language — that’s between Congress and the administration.” It’s not the fault of the White House that Congress has fought back all kinds of budget requests. As for the flurry of House bills two weeks ago, Raymond said he liked them, “but it feels like smoke and mirrors.”

“The federal funding piece for this year is one of the most complicated pictures we’ve seen in some time,” said Robert Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD). There was a proposal in the Senate to provide $600 million through a mechanism of emergency supplemental appropriations for the opioid problem as part of the CARA discussion. “It was real, it was tangible,” said Morrison. It passed by a 48-47 vote on the Senate floor, but didn’t meet the 60-vote threshold.

Morrison doesn’t believe in saying anything is impossible. “The appropriation process is difficult to predict — you keep going until the ink is dry,” he told ADAW. “For anyone to say that they know the exact algorithm for what’s going to lead us to an end product, I would call their bluff.”

A veteran Capitol Hill observer — and former lobbyist — Morrison said messaging is a very common and important approach by all White House administrations. “They’ll say it’s up to Congress,” he said. But he acknowledged that this time it’s more difficult, because the mechanism is “mandatory,” requiring legislation and offsets.

Still, Botticelli’s relentless insistence that substance use disorders are a health problem, not a criminal problem, is a major victory. “We have one of the best ONDCPs ever now,” said Morrison. “What a different problem to have — a strategy problem about trying to get more dollars, whereas before it was about trying to fix very problematic proposals on the budget side.”

It’s getting late

The timing was also mentioned by Andrew Kessler, principal of Slingshot Solutions. “While this effort by the White House shows commitment to treating opioid abuse, there are political realities that place some real hurdles in the way of the $1.1 billion in mandatory funding becoming reality,” Kessler told ADAW. “Not only are we dealing with a short election year calendar and a fiscally conservative Congress, we are also competing with other vital public health interests, such as the Zika virus and the Flint water crisis.”

There is also the Comprehensive Addiction and Recovery Act (CARA), which was passed overwhelmingly by the Senate but the House didn’t even take up (see ADAW, May 2). “A large part of the advocacy community have spent a large part of the last year advocating for CARA,” said Raymond. “We’re in the final quarter, everybody agrees it will get signed into law, and suddenly we don’t have any money attached.”

As one lobbyist said, the aim now is to get funding for whatever compromise bills come out of the House and Senate. “This isn’t partisan, it’s just good policy.”

The ONDCP responded to our multiple requests for an interview with this statement from spokesman Mario Zepeda: “The administration looks forward to working with Congress on securing funding to provide families and communities with the support they need for prevention and to ensure that treatment is available to those who seek it.”

Bottom Line…

Advocates, somewhat disgruntled by a White House “guilt trip” telling them they haven’t been doing enough, still stand strong behind the need for funding.

5/9/2016 12:00 AM

Press reports last week widely cited William Mauzy, the lawyer for the self-professed “nationally recognized leader” in addiction treatment Howard Kornfeld, in stories about the death of Prince last month. The lawyer’s moves were clearly intended to help his client, Kornfeld, in the midst of a law enforcement investigation into the death of the singer. Since treatment for substance use disorders is supposed to be confidential, we asked Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP), who is a lawyer, about the situation.

“I see no value in a physician disclosing this information,” Ventrell told ADAW. “It is at best unprofessional. I know if someone such as Prince had been planning to be treated at one of NAATP’s premier provider members, they would not have disclosed this. As for the lawyer disclosing his health care client’s information, I find it equally unprofessional at best.” Mauzy is a criminal lawyer based in Minnesota; Kornfeld is from California.

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.

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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  • 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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