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10/16/2017 12:00 AM

Thomas Andrew, M.D., was to retire from his position as chief medical examiner of New Hampshire on Sept. 11. He had to stay on to finish up some cases. Then on Oct. 7 came this headline from The New York Times: “As Overdose Deaths Pile Up, a Medical Examiner Quits the Morgue.” The story went on to discuss opioid overdose deaths throughout the country — a true and harrowing story, as are the deaths in New Hampshire. At the bottom of the story, New Hampshire was described as a place “where a backlog of autopsies has put the state at risk of losing accreditation.” At risk, but it did not lose accreditation. Still, this was followed by a section on the number of overdoses and cadavers in New Hampshire. Next came the Daily Mail, which on Oct. 9 wrote this headline and subhead: “New Hampshire’s chief medical examiner is retiring early amid overwhelming death toll from America’s worst drug epidemic” and “His office is now in danger of losing their National Association of Medical Examiners accreditation because of the number of bodies they have to analyze.” Next came Reason.com, which in its Oct. 11 rewrite of the Times story had this on top: “Bad Opioid Policy Is Killing So Many People That New Hampshire’s Medical Examiner Is Quitting His Job.”

It took 10 minutes to reach Andrew by phone. His retirement has nothing to do with the opioid epidemic, as he would have said if anybody had bothered to ask him. “I am most definitely leaving because I am done with my 20 years,” Andrew told ADAW last week. “We came close to losing accreditation because of the opioid crisis, but we passed; we were given full accreditation,” he said.

“I told my deputy that I was retiring in September 2017, and that was 15 years ago,” he said. “That was long before the opioid crisis began.”

If someone had bothered to ask him, Andrew would have explained his rationale for retiring. “I strongly feel, with any business, and especially any public agency, there is a leadership lifespan. I define that as 20 years. Even if you feel as if you have gas in the tank — and I do — any agency, particularly one like this, needs a new vision, a new set of eyes, new brains. Otherwise, bad things can happen, with complacency and staleness. My retiring is not a reaction to the current crisis.”

As for the new chief medical examiner — Jennie Duval, M.D. — “she’s ready to be chief,” said Andrew. “I have things I want to do.” In addition to pursuing a chaplaincy, Andrew will continue his forensic consulting business.

10/9/2017 12:00 AM

This summer, the Hazelden Betty Ford Foundation released a research paper embracing the concept of civil commitment for substance use disorders. The driving force is similar to that for suicidality: saving the life of a possible overdose victim. In issuing this paper, called “Involuntary Commitment for Substance Use Disorders,” Hazelden Betty Ford has opened a national dialogue among treatment providers on this controversial issue.

It’s controversial because some say that if addiction is indeed a disease, treatment should not be coerced, any more than treatment for cancer would be coerced. But according to the National Institute on Drug Abuse (NIDA), “treatment does not need to be voluntary to be effective.” In Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA states, “Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions.”

This summer, the Hazelden Betty Ford Foundation released a research paper embracing the concept of civil commitment for substance use disorders (SUDs). The driving force is similar to that for suicidality: saving the life of a possible overdose victim. In issuing this paper, called “Involuntary Commitment for Substance Use Disorders,” Hazelden Betty Ford has opened a national dialogue among treatment providers on this controversial issue.

It’s controversial because some say that if addiction is indeed a disease, treatment should not be coerced, any more than treatment for cancer would be coerced. But according to the National Institute on Drug Abuse (NIDA), “treatment does not need to be voluntary to be effective.” In Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA states, “Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions.”

In addition, civil commitment is used for mental illness when a patient is a danger to himself or others, and that is how it is being positioned for substance use disorders — or, more specifically, for opioid use disorders.

Related to the issue of patient control are efforts to do away with 42 CFR Part 2, the regulations protecting the confidentiality of SUD treatment records. Hazelden Betty Ford was also on the cusp of this controversy in aligning itself with the American Society of Addiction Medicine and others in removing this regulation, which requires that patients give written consent for their treatment records to be released (see ADAW, August 7).

Civil commitment laws in general provide only for residential, not ambulatory treatment. There are already laws in place allowing the commitment of someone with a mental disorder who is at risk of causing harm to himself or someone else. Now, some states are considering laws that would make commitment in some cases for opioid use disorders easier.

“Relatives and loved ones of an individual with a substance use disorder often feel helpless and disempowered when that individual is unable, due to an impaired brain, to make the rational decision to undergo and complete addiction treatment,” the report states. “Involuntary commitment laws for substance use disorder might be a way to initiate the treatment these individuals need to avoid death and ultimately re-establish productive and healthy lives.” The report goes on to say that “according to some,” there is a need to protect privacy and freedom of people with SUDs, and that treatment should always remain a choice, “even if the ability to choose is compromised.”

“We have no official position either pro or con” on civil commitment, said Jeremiah Gardner, spokesman for the treatment chain. “The laws on this matter vary greatly. They are inconsistent and lack established best practices and robust research.” But because so many people are dying from overdoses, it’s time to discuss options. “Our only position is that, in light of the opioid crisis, there ought to be a national dialogue around this issue so that such questions can be discussed and studied.”

Faces & Voices of Recovery also is not ready to make a statement on civil commitment. “Our Public Policy Committee has mixed views on it right now,” Executive Director Patty McCarthy Metcalf told ADAW last week. “We hope to have a consensus statement after our next meeting later this month.”

Who pays?

In addition to the concerns about privacy and self-determination for patients, there are practical questions, such as who pays for treatment under civil commitment? What if the patient has no insurance? Does insurance even have to abide by a court ruling that a patient needs, say, 30, 60 or even 90 days in residential treatment? “Good questions,” said Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP), which is currently reviewing the civil commitment issue.

In fact, the opioid epidemic puts the residential treatment field in a painful dilemma. Science says that the best treatment for opioid use disorders is with medication. Three are approved — methadone and buprenorphine, both opioids themselves, and naltrexone, an opioid blocker — but most residential programs have a bias against opioids, considering treatment with them not to be true abstinence. Still, they see the potential to help many patients who need treatment. And some see nothing but the potential to fill beds, giving rise to some of the seamy scenarios in the addiction treatment field that have filled the headlines — and which NAATP and respected facilities like Hazelden Betty Ford are seeking to distance themselves from.

Current laws

There are laws that allow for involuntary commitment of people with an SUD, alcoholism or both in 37 states and the District of Columbia, but the laws are rarely used, according to the report. In five of these locales, mental illness specifically includes substance abuse and alcoholism, making commitment the same as for individuals with psychiatric disorders. The other 33 states have separate statutes for substance use, to prevent criminal defendants from pleading an insanity defense if they committed a crime while under the influence. In 13 states, involuntary commitment for SUDs is not allowed.

States require an evaluation by a physician prior to commitment. Some states require proof that the person previously refused voluntary treatment, or was recently admitted on an emergency basis.

Most states allow a family member, medical professional or the treatment program to petition the court to get the patient committed to SUD treatment. In some states, even police officers can do this.

Parents who lost children to overdoses are a driving force behind these laws. In Kentucky, Casey’s Law, which took effect in 2004, was spearheaded by Charlotte Wethington, whose son died in 2002 from an overdose.

More questions than answers

How long should a civil commitment last? Some say it must be at least 90 days, but about a third of the states allow for only 30 days or less. Only in Kentucky can an individual be committed to treatment for up to a year.

Asserting that most people with SUDs also have co-occurring mental disorder, the Hazelden Betty Ford paper states that “treatment must be comprehensive and not rely solely on medications or any one therapy.”

The Hazelden Betty Ford Foundation has a program that combines medication — either buprenorphine or naltrexone — with the 12 Steps, which utilizes evidence-based practices, including 12-Step facilitation, cognitive behavioral therapy, and motivational interviewing. Residential treatment can help patients step down to outpatient treatment, the report states.

Section 35 in Massachusetts

One state does have a civil commitment law that is sending people to treatment. In Massachusetts, the treatment providers must contract with the state to be Section 35 facilities. High Point provides treatment for women in its New Bedford complex, and for men at its Brockton campus. Both facilities are unlocked. Treatment starts with detoxification.

“We have a very robust civil commitment process in Massachusetts,” said Vicker V. DiGravio III, president and CEO of the Association for Behavioral Healthcare. A combination of the state, Medicaid and commercial insurers pay for treatment under Section 35, as the civil commitment statute is called. The statute allows treatment up to 90 days, but “only allows patients to be detained as long as they are deemed to be a risk to themselves or others,” he told ADAW. “If the presentation warrants it, you start in a 24-hour detox, then a 24-hour stepdown and then you go into residential,” he said. Even if they are not deemed a risk, many patients then choose to continue in treatment voluntarily, he said.

Section 35 is not the same as Section 12, a Massachusetts law under which patients with mental illness (not an SUD) can be held for 72 hours against their will based on a medical professional’s determination. In most cases, this involves suicidality. There doesn’t need to be court involvement for Section 12. A court order is required for Section 35. Gov. Charlie Baker proposed two years ago that Section 12 be extended to SUDs (see ADAW, Nov. 16, 2015).

If a patient wants to leave a Section 35 program, he can, said DiGravio. “The program can’t physically restrain someone from leaving,” he said. 

For the Hazelden Betty Ford report, go to http://www.hazeldenbettyford.org/education/bcr/addiction-research/involuntary-commitment-edt-717.

Bottom Line…

Hazelden Betty Ford has started a national dialogue about civil commitment for opioid use disorders.

9/25/2017 12:00 AM

For years, the treatment programs providing mainly residential care for patients with substance use disorder have had a marketing quandary: how much money to spend on internet advertising in the competition for patients. This month, Google made an important policy change that dramatically alters that landscape, making it more likely for programs that do not spend a lot of money on ads to compete on a level playing field, because the ads are now highly restricted. So far, Google has only done this for payday loans and locksmiths, both groups that have reputable and disreputable organizations — just like rehabs. All three groups serve consumers who are desperate — for money, to get into their houses or cars, or for addiction treatment.

For years, the treatment programs providing mainly residential care for patients with substance use disorder have had a marketing quandary: how much money to spend on internet advertising in the competition for patients. This month, Google made an important policy change that dramatically alters that landscape, making it more likely for programs that do not spend a lot of money on ads to compete on a level playing field, by restricting the use of words used to sell addiction treatment. So far, Google has only done this for payday loans and locksmiths, both groups that have reputable and disreputable players — just like rehabs. All three groups serve consumers who are desperate — for money, to get into their houses or cars, or for addiction treatment.

“We found a number of misleading experiences among rehabilitation treatment centers that led to our decision, in consultation with experts, to restrict ads in this category,” said a Google spokeswoman last week. “As always, we constantly review our policies to protect our users and provide good experiences for consumers.”

The news was broken by The Verge and The New York Times on Sept. 14.

Nobody is happier about this than the National Association of Addiction Treatment Providers (NAATP). “What this says to me is they are hearing that the abuses that can occur in addiction treatment marketing are so egregious that they are analogous to the kinds of harm and victimization of people in the payday loans and locksmith businesses," said Marvin Ventrell, executive director of NAATP, which has an ethics code that includes marketing. “If one of the benefits is that when you search for a specific provider, you’re more likely to find that one and not be misdirected, that’s a major win,” he said. (Providers have used “bait and switch” methods to attract patients who don’t know which program they are actually calling.)

AdWords

The restrictions levied this month apply only to the Google “AdWords” program — paid ads that show up at the top of searches, not on “organic searches” that do not involve paid ads, but rather manipulation of search engine optimization (SEO). But the AdWords policy could expand into restrictions. And it’s not clear how long the AdWords restrictions will remain, or how far Google will go with further restrictions. Google actually verifies which locksmiths are reputable now so that people don’t end up with thieves instead; whether it could do this with treatment centers is unlikely.

Of course, there is nothing illegal or unethical about advertising, paying for ads or having good websites. “It’s unfortunate that ethical providers who market under a legitimate competitive marketing program will suffer some restrictions,” said Ventrell. “But the greater good is served by the regulatory measure.”

While the payday loan system — in which people pay a huge fee in order to cash their paychecks instead of deposit them and have to wait for them to clear — seems “highly suspect” on its own, “there is nothing wrong with the locksmith industry, and nothing wrong with doing good addiction work,” he said. “To the contrary, it’s a lifesaving service.”

“Google is actually listening to our industry, and that’s the result of advocacy,” said Ventrell.

Just because a marketing scheme is unethical doesn’t necessarily mean that the treatment program itself is not good, said Ventrell. But it’s up to NAATP to make sure its members are ethical. It’s up to the accreditation agencies — the Joint Commission and CARF — to make sure quality care is being provided. “But at the end of the day, the things we value — quality of staff, longevity of program, description of services, membership in NAATP — if you did a mathematical analysis, I believe you would find a strong correlation between those things and quality. But yes, you could, in theory, have shoddy business practices and good care.”

Greg Williams’ discoveries

Greg Williams, co-founder of Facing Addiction, contacted Google about its policy last fall, when he was working with then-Surgeon General Vivek Murthy, M.D., on the release of the Surgeon General’s Report on Alcohol, Drugs, and Health. “We originally started talking to Google not about ads, but about searches,” he said. “We thought that if you are doing a search for addiction, you should be able to get a sidebar, the way you do for cancer or diabetes, that included a reference to the Surgeon General’s report,” he said.

“That discussion fizzled, but we were concerned enough to hire a contractor who looked at our website,” he said. “Our not-for-profit name — Facing Addiction — was being purchased by many marketers,” he said. “When you typed in Facing Addiction, you had to scroll three pages down to get us,” he said. “There were 20 different treatment centers first.”

The SEO consultant told Williams that Google offers $10,000 grants to nonprofits. “They give you $10,000 a month in a Google grant for free, but it comes with one catch — you can’t bid higher than a two-dollar cost per click,” he said. “Our consultant literally could not spend more than $4,000 a month.” The reason was that the bid for Facing Addiction — the name of Williams’ organization (and of the Surgeon General’s report) — was $80 per click. “We couldn’t bid on it because we were limited to the $2,” he said.

After some research, Williams found out that the top-four highest-cost clickable words are in the addiction field. “Why is this? Partly because nobody knows how to find a good treatment center,” he said, adding that another problem is that good credible information on the disease isn’t easily available with quick Google searches.

So Williams met with Google again this spring. “The core question is, how do we know what is good versus what is bad? How do we participate in this market in an ethical way?" Williams said. “Google asked, ‘Aren’t there some good rehabs?’ And we said, ‘Of course there are.’”

Williams had talked to Ventrell and others before he brought this issue to Google. “We said, ‘We don’t know what’s good and bad, but we know that the evidence is that people should get care as close to their natural living environment as possible.'” The Google marketing was fostering the searches for treatment, even when combined with a geographical preference, because in fact a Florida-based treatment provider could make it look as if it was in New York City — and then send the patient a plane ticket to Florida. “That really started to help Google frame this pay-per-click movement,” said Williams.

Williams said this won’t be a panacea. “Programs will find other ways,” he said. “But what I’ve heard is for ethical providers and ethical marketers, this will level the playing field. They can’t buy each other’s names.”

Finding patients via the internet

Jim Peake, a marketing consultant who specializes in websites and SEO in the treatment field, said that nonprofit, education and government sites carry the most weight with Google. “Inbound links matter to them,” he said. “If I have an inbound link to NAATP, to SAMHSA, to Alcoholism & Drug Abuse Weekly, that will have more credibility and make for a higher rating,” he said. “Those links are pure gold.”

The Google policy is going to adversely affect treatment programs who have spent millions on AdWords, said Peake. “Now you see the guys who have bet the farm on paid advertising, and they’re going to feel the sting,” he said. But he thinks Google will suffer too. “I think AdWords revenue just for the addiction space is between $50 and $100 million a month,” he said. “This is just my guess. But that’s why I don’t think this will last more than two to four weeks.”

American Addiction Centers, which this month spent $85 million to buy AdCare (see ADAW, Sept. 18), is one of the companies that has deep investments in internet advertising. After Google announced its AdWords policy change restricting addiction ads, American Addiction Centers adjusted one website to include more government and organization links to enhance credibility, making it look as if the entire website was about publicly funded treatment and NASADAD and SAMHSA.

“We don’t fully know what this means yet,” said Ventrell of the Google change. “We’ll see how this develops. Marketers and firms who are very sophisticated about playing the online game are already ahead of the game in terms of avoiding the restrictions in the new rule,” he said. “For example, even though ads may disappear, they can still use SEO to get on top of searches, to the disadvantage of small- to medium-budget centers, which represent most of the field.”

For more information about Jim Peake, go to www.addiction-rep.com.

For more information about NAATP’s ethics code, go to https://www.naatp.org/resources/addiction-treatment-provider-ethics/code-ethics.

For NAATP’s press release on the Google changes, go to https://www.naatp.org/resources/news/google-restricts-addiction-ads/sep-15-2017.

Bottom Line…

The internet marketing for patients that has characterized so much of the dark side of addiction treatment has been put to a stop — at least temporarily — by Google.

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
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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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