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2/12/2018 12:00 AM

On Feb. 8, ADAW learned that Kimberly Johnson, Ph.D., director of the Center for Substance Abuse Treatment (CSAT) at the Substance Abuse and Mental Health Services Administration (SAMHSA), was leaving the office. She was to be replaced temporarily by Kathryn Power. The word was that SAMHSA head Elinore McCance-Katz, M.D., wanted her own team at SAMHSA, which is not an unusual situation. Johnson became CSAT director in 2016, after H. Westley Clark, M.D., retired. Kana Enomoto, former acting director of SAMHSA, has been on detail with the surgeon general’s office for several months.

1/28/2018 12:00 AM

Last week, Philadelphia became the first city in the United States to officially allow safe injection facilities, which will be operated by the private sector for people with opioid use disorders. The plan, led by the Philadelphia Department of Public Health and the Department of Behavioral Health and Intellectual disAbility Services, is just part of the all-encompassing strategy the city is taking, which includes increasing outreach to medication-assisted treatment, developing warm handoffs from emergency departments to treatment for overdose victims, increasing distribution of naloxone and providing housing without requiring sobriety.

Last week, Philadelphia became the first city in the United States to officially allow safe injection facilities (SIFs), which will be operated by the private sector for people with opioid use disorders. The plan, led by the Philadelphia Department of Public Health and the Department of Behavioral Health and Intellectual disAbility Services (DBHIDS), is just part of the all-encompassing strategy the city is taking, which includes increasing outreach to medication-assisted treatment, developing warm handoffs from emergency departments to treatment for overdose victims, increasing distribution of naloxone and providing housing without requiring sobriety.

Still, the safe injection sites were the biggest news. Called Comprehensive User Engagement Sites (CUES) in the city, they are hoped to reduce overdoses and improve health, and will include referral to treatment and social services, wound care, medically supervised drug consumption, and access to sterile injection equipment and naloxone. The services are provided in a walk-in setting.

“We cannot just watch as our children, our parents, our brothers and our sisters die of drug overdose,” said Thomas Farley, M.D., Philadelphia health commissioner. “We have to use every proven tool we can to save their lives until they recover from the grip of addiction.”

The SIF recommendation was one of many made by the city’s opioid task force, for which city officials visited Vancouver, British Columbia, and Seattle, Washington, in November 2017 to study similar facilities and efforts in those cities.

“Our visits to Vancouver and Seattle really hit home that establishing CUES is just one piece of the puzzle to address the opioid crisis,” said Eva Gladstein, deputy managing director of health and human services, in announcing the SIFs on Jan. 23. “Our efforts to prevent addiction, help people access treatment, prevent overdoses in other ways, increase housing resources and address public safety concerns are already underway and must continue to grow and strengthen.”

“Having Comprehensive User Engagement Sites — or CUES — as part of our continuum to treatment is just one of the ways in which we believe we can connect Philadelphians struggling with substance use disorders to lifesaving treatment,” said DBHIDS Commissioner David T. Jones. “Of course, we will explore all opportunities that can provide people with the support and services they need, but we are confident that this option is a crucial step in helping people live healthier and happier lives.”

The city is now actively encouraging organizations like community nonprofits or medical organizations to operate and fund one or more CUES. The city will not operate one, but will bring together key stakeholders to identify organizations that are interested in operating, funding or offering such a location.

The SIF program is going forward with the support of the newly elected district attorney, Larry Krasner.

Responses from field

Responses from the field were, overall, supportive of Philadelphia’s move, although some organizations did not respond to requests for comment.

The importance of making treatment available via SIFs is stressed by many in the field. What follows are responses to ADAW’s request for comments.

Maureen Boyle, Ph.D., chief scientific officer, Addiction Policy Forum: “While some worry that safe injection sites would increase drug use, the research shows the opposite. It shows that safe injection sites help keep people who inject drugs safe and create a trusting relationship with the healthcare systems. People who use these facilities are more likely to start treatment and stop using drugs compared to people who don’t.”

Gail Groves Scott, manager of the Substance Use Disorders Institute (SUDI) at the University of the Sciences in Philadelphia: “What works in a public health crisis? You need leadership and you need community-level interventions; this is what Philadelphia is doing by piloting safe sites. For those who say it’s radical, it’s not — we aren’t the first to do this, although we may end up being the first in the U.S. While it would be great to see the federal government be part of the solution, if they won’t, they need to at least stay out of the way. We know what the research tells us will work, yet we aren’t doing it. That tells me we need to work harder on educating policymakers. Upending the broken system we have takes funding, but the cost of this epidemic getting worse will be many billions of dollars more. The University of the Sciences was founded almost 200 years ago to train pharmacists, and now we are an interdisciplinary health sciences school. We think addressing the intersection of pain and addiction in a multimodel way will be key to the opioid crisis, and the SUDI is going to be laser-focused on making that happen, through education, research and policy advocacy.”

Jack Stein, Ph.D., director of the Office of Science Policy and Communications at the National Institute on Drug Abuse (NIDA): “NIDA supports conducting research on this strategy to address the opioid crisis and hopes that results will help shape related policies and practices.”

Daniel Raymond, deputy director of planning and policy at the Harm Reduction Coalition: “It’s a positive step forward. Philadelphia’s officials have clearly done their homework and thought this through. I hope their leadership sends a signal to other cities that this strategy is worth pursuing.”

Sheila P. Vakharia, Ph.D., policy manager for the Drug Policy Alliance: “It definitely sounds like it could be another great model after Vancouver’s Insite. Some people are using the acronym CUES to describe it because it would provide services along a continuum of care for people who visit it. At one end of the continuum, the most basic form of harm reduction will be provided — a place to safely inject using sterile equipment. However, I don’t know what the other end of the continuum might be. I haven’t heard details on what such a place in Philly would actually look like — what types of staff/professionals would be employed, whether support groups or formal treatment would be provided, or if medication-assisted treatment would be dispensed. It probably depends on funding and credentialing because more formalized treatment and prescribing may require more bureaucratic processes for licensing and accreditation.”

David Metzger, Ph.D., research associate professor and director of the HIV/AIDS Prevention Research Division in the Department of Psychiatry at the University of Pennsylvania: “In Philadelphia, there were 1,200 overdose deaths last year (80 percent were opioid-related, the majority involving fentanyl). This mortality is the most visible tip of a huge opioid abuse epidemic here. It’s estimated that there are 70,000 heroin users and 50,000 prescription opioid ‘misusers.’ So, currently there are hundreds of unsafe injection locations — public bathrooms, doorways, subway stations, abandoned buildings, even libraries). The safe injection facility being promoted in Philadelphia would begin with a single site, use private funds and provide immediate care for overdoses and injection-related infections and wounds. As recommended, it would also provide linkages to medication-assisted treatments (methadone, buprenorphine/naloxone and naltrexone) and other services. The public health impact of a single program will be limited. But as a demonstration project, it has great potential to provide a model for other neighborhoods and communities. Expanding access to medication-assisted treatment will be an important outcome.”

Charles O’Brien, M.D., Ph.D., vice chair of psychiatry at the University of Pennsylvania, and the founding director of the prestigious Center for Studies of Addiction: “My knowledge of the data on safe injection sites shows beneficial results from a harm-reduction perspective. My concern is that responsible authorities must not use this method as a substitute for treatment programs, which are more expensive. The safe injection sites might be used to attract people into treatment, which is much better for addressing the epidemic. Also, we must be sure that there are adequate numbers of treatment slots. As a member of the mayor’s commission on the opioid epidemic, I heard presentations on the Philadelphia programs and was favorably impressed. Also, the majority of members of the commission were in favor of safe injection sites. As for the U.S. as a whole, I think that we need more treatment slots and more trained clinicians. Also, we need all patients to be given a chance for medical treatment. We now know that there are both agonist and antagonist treatments that are effective. I don’t think that most patients are getting the best medication. Far too few are given the opportunity to benefit from extended-release naltrexone, which we now know gives them a chance for eventual abstinence rather than years on an agonist.”

Alex H. Kral, Ph.D, director of RTI’s Urban Health Program: “Treatment programs should definitely be involved. The state’s largest drug treatment provider (Healthright 360) signed on to California Assembly Bill 186, and the director of the California Society of Addiction Medicine provided testimony in Sacramento at the hearing. There should also be health screening and treatment. And yes, this is a public health intervention, one that should work with law enforcement. DA support is necessary but not sufficient.”

Jeff Deeney, an activist and social worker who works with drug users in Philadelphia: “The opioid task force approached me about this last year. I told them only if Krasner wins the DA race. I put them in contact with Krasner’s team, they went to Vancouver and looked at Insite, and Krasner won and got on board. The opioid task force brought the mayor on, and the city council came on board with the mayor. I’m doing this for my people.”

For the scientific review of evidence, go to http://dbhids.org/wp-content/uploads/2018/01/OTF_LarsonS_PHLReportOnSCF_Dec2017.pdf.

Bottom Line…

An experiment that will include treatment programs is moving ahead in Philadelphia — safe injection facilities, which will be privately run, where opioid users can receive a broad array of services as well as clean injection equipment and overdose rescues.

1/15/2018 12:00 AM

For our story on chronic pain patients being terminated from their opioids as a result of the opioid crisis (see p. 1), we put out a call on Twitter, where these patients are very active, and received many responses — too many to include here. The responses came via email, and we had a back-and-forth with the patients to focus on what their prescriber gave them as the reason for being discharged. These patients were not drug-seeking, except to the extent that they needed medications to stay out of pain.

For our story on chronic pain patients being terminated from their opioids as a result of the opioid crisis (see p. 1), we put out a call on Twitter, where these patients are very active, and received many responses — too many to include here. The responses came via email, and we had a back-and-forth with the patients to focus on what their prescriber gave them as the reason for being discharged. These patients were not drug-seeking, except to the extent that they needed medications to stay out of pain.

  • A patient in Massachusetts is being forcibly tapered from opioids because she is a medical marijuana patient. Her doctor said the Drug Enforcement Administration (DEA) would “take his license if he continues to prescribe my low dose of opioids.” The marijuana helps to keep her opioid dose low, she said.
  • A patient who had been getting opioids from a pain management clinic was told that the clinic had to close because of the Centers for Disease Control and Prevention (CDC) guidelines. “They no longer had a business model that could break even,” she said, and all patients and staff were given a month. She moved in order to try to keep access to care, but still had to be driven 10 hours a day once a month for the past three years.
  • A patient in Texas had been on 40 milligrams of OxyContin three times a day, but a year ago, the insurance company, United Healthcare, notified the pain specialist that it would no longer cover that medication. She was forced to switch to Xtampza, and then, state regulations forced a second change to Opana. Ultimately, she lost insurance and was forced to change to methadone. Each time there was a change, the dosage was reduced. She has “a good doctor who honestly tries, drug tests regularly for any sign of abuse, but he follows every regulation and recommendation to the letter.” The patient’s husband says the doctor is “literally law-abiding my wife to death.”
  • One patient with chronic pancreatitis — Lauren Deluca, who is the founder of the Chronic Illness Advocacy & Awareness Group Inc. — was told by her primary care provider that “I will not lose my license for you or anyone else,” and that she had detoxed almost all of her opioid patients off the medications. The doctor did prescribe 5 milligrams but said she would never do it again. “I only got this because I literally begged,” the patient said. When she went to pain management clinics, she was also told that opioids would not be provided. Apparently, one doctor had summed her up as a pill seeker, and said the most likely reason for the chronic pancreatitis was long-term opioid “abuse.”
  • A patient in Maine who was forced to taper from opioids by her pain management physician of nine years was told he was afraid of the DEA and the medical board. This started three years ago, when the doctor told her he didn’t think she should be tapered. “In hindsight, I believe he was coached to placate his patients and that he was given step-by-step instructions as to how to mitigate his patient’s emotional responses in order to alleviate his stress,” the patient told us. When it became apparent that the CDC guidelines were going to become the law in Maine, he continued to lower her dose, to 100 MME by last July. “At my last visit, he told me that just because I have intractable pain it doesn’t give me the right to opioid pain medications for the rest of my life,” she said. “He now believes a dose over 100 MME is ineffective in abating pain. He also said he cringes every time he writes an opioid prescription and asks himself why he even bothers.”
  • “I lay in bed with a heating pad and just cry.” This is from Rebecca Dauber, who has chronic pancreatitis and has been a pain patient for 16 years. “Without the pain relief I get from taking Vicodin, I don’t have quality of life,” she said. “There is a huge difference between being addicted and being dependent. I don’t need them to get high; I depend on them to have some relief so I can have a somewhat normal life.” She was told that the reason her medication was being cut off was her insurance company, Amerihealth Caritas. She lives in Pennsylvania, and cannot afford to pay out of pocket for the medication. “We have signed pain contracts with our primary care doctors, pain management doctors agreeing that we only get our pain meds from them,” said Dauber. “We go through urine testing as if we are druggies, treated like drug seekers if we end up at an ER and then we are turned away from the ER because it’s all in our heads, yet we are doubled over from pain, crying and passing out because of the amount of pain we are in.”
  • A 60-year-old patient with spinal stenosis/sciatica and osteoarthritis on disability since 2012 was abruptly terminated from her opioids. Her primary care doctor’s reasoning: opioids were “no longer indicated or effective for long-term chronic pain.” The pain specialist she was referred to gave her Tramadol and Zanaflex prescriptions, but the primary doctor discontinued them. The primary care doctor then told her Lyrica, a STIM implant, and a laminectomy were her only options. When taking the opioids for pain control, she could walk up to three miles a day and manage activities of daily living. Last year, she had surgery for pain relief, but it only worked temporarily. Now she is back on crutches, and is forced to take Lyrica off-label, which has “horrid side effects” and is expensive. She believes that the primary care physician was doing what she was told by the business office. “My life is at a standstill. I can’t drive myself much or have my grandkids overnight anymore. My core strength is gone — can’t exercise at all. Life really stinks right now,” she said. She lives in rural Iowa, where it’s hard finding a new primary care physician; this patient had the same doctor for 25 years.
  • A patient in Maryland who had been with the same pain management provider for four years is now being cut back. Prior to pain management, the patient obtained the opioid prescription for six years. The primary care physician sent her to pain management “because he knew the crackdown was coming.” She had been on the same dose of methadone — 60 milligrams divided in three doses daily, plus 30 milligrams of oxycodone for breakthrough pain. She is now down to 40 milligrams of methadone daily. She has pain from scar tissue from bile duct surgeries, spinal stenosis, osteoporosis, failed back and neck surgeries, and a cyst on her lower spine. The pain physician gave the patient two reasons for cutting her back: that she was on too high a dose, and so the physician could “sleep better.”
  • One patient was cut off from her opioids abruptly; she had vomiting and diarrhea that was so bad she needed to be hospitalized for rehydration. (This is the likely response of all chronic pain high-dose patients who were abruptly cut off, but most told us that the memory of the withdrawal was overshadowed by the resurgence of pain.)
  • A patient in California who takes Tramadol and Flexeril for back pain and sciatica was laid off last year, losing her job and health insurance. When she finally got coverage again, she had to go through a list of plans. Eventually she got back on health insurance, but the wrong primary was assigned, and she can’t get in to see any doctor. “I have yet to see a PCP under Health Net because they first assigned me to the wrong primary and it took 3 months to get to the correct one, and she is backlogged on appointments,” she said. “Our entire health system is a mess; people can’t get in to see their doctors, and when they do they are just basically told to take Tylenol and put ice on it.”
  • A patient who had severe spinal injuries from a motor vehicle accident in 2000 “tried everything,” including surgeries. “I accept I will never be the same again but that doesn’t mean I have to die a horrible painful death.” After she was on opioids in a pain clinic setting — 180 milligrams of oxycodone a day, which enabled her to function well — the clinic reduced her to 60 milligrams, “which I’m still trying to adjust to,” she said. The reason for the tapering was the CDC guidelines, she said. Tapering has resulted in her pain going from an average of 4 to a minimum of 8 on the pain scale. “I never had a bad test, never went to the ER. I was a model patient,” she said.
  • From Canada: a patient who needed morphine for ovarian hyperstimulation syndrome was forcibly tapered off it, halving her dose on a weekly basis over a period of four weeks, leaving her in “bedridden agony” for the condition, which would take several months to resolve. The reason, according to her doctor: “We’ve created too many opioid addicts from overprescribing, and it is our responsibility to make sure that does not happen to you.”
  • A 54-year-old patient in Florida with fibromyalgia, osteoarthritis, herniated discs and an injured spine from a car accident had been taking 120 Lortabs a month. Her physician referred her to a pain physician, who wanted her to have spinal injections, but she had a bad reaction to the first one. She went to a second pain physician, recommended by her chiropractor, and was promptly told that she could have hydrocodone, one month of one low-dose pill per day. Her new doctor would not prescribe anything. She is now using Kratom, which helps. “I never considered complaining, but I definitely blame the CDC guidelines,” she said. “He said he doesn’t prescribe pain meds — too much risk.”
  • Even people without chronic pain, but with low-level pain that is treated well by opioids, are being affected. Last year when Victoria got rear-ended in her new car, she paid out of pocket for a chiropractor, deep tissue massages and acupuncture. There was some whiplash and lower back pain, but not severe. A few months later, she was given low-dose opioids. When she went back for a follow-up, the doctor said he was going to have to cut her dose. She is now afraid that she “looks like a junkie” and hasn’t gone back out of fear of getting refused more medicine. She doesn’t need it; she has saved some, which she did not take, but she is worried that there will be a flare-up that ibuprofen won’t fix. After stretching every day, paying out of pocket for acupuncture and massages, the pain isn’t that bad, she said. “And I do have some left, so I can’t be an addict!” she said.
In Case You Haven’t Heard
2/5/2018 12:00 AM

One of the possible ways to reduce opioid overdoses is to limit the availability of opioids, but federal researchers have embarked on another route: figure out if patients really are in pain. The National Institutes of Health (NIH) has announced five short- and long-term research initiatives to “help end the opioid crisis.” Four deal with drug development to treat pain. The fifth involves developing methods to objectively measure pain in patients — not in animals (the old rat tail in the cold water test won’t work here) but in humans. We wondered how one could objectively measure pain, so we went to Michael E. Schatman, Ph.D., editor-in-chief of the Journal of Pain Research and director of research and network development at Boston Pain Care, to find out. “There exist no objective measures of pain, nor will there ever be such a measure,” he told ADAW. “How does one measure something as subjective as pain objectively?” For more on the public-private partnership from the NIH, go to https://www.nih.gov/research-training/medical-research-initiatives/opioid-crisis/public-private-partnership.

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

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

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

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

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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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