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6/13/2016 12:00 AM

It’s not a new story: in states where treatment capacity is limited and waiting lists predominate, Florida — where treatment providers are plentiful — has become the end destination for families desperate to get their loved ones into recovery. In this article, we focus on one such provider — Banyan Treatment Center — and its marketing methods, which are not unusual for the field.

Banyan has a residential treatment center in Pompano and a detoxification facility in Stewart, and it recently opened an intensive outpatient program in Naperville, Illinois. According to Eric Oakes, executive director, 95 percent of the patients in Florida have out-of-network insurance coverage. The other 5 percent are self-pay. “We don’t take Medicaid, we don’t have in-network contracts,” said Oakes, noting that very few Florida providers are in-network with insurance companies. The vast majority of patients go to Banyan with a primary diagnosis of opioid use disorder.

It’s not a new story: in states where treatment capacity is limited and waiting lists predominate, Florida — where treatment providers are plentiful — has become the end destination for families desperate to get their loved ones into recovery. In this article, we focus on one such provider — Banyan Treatment Center — and its marketing methods, which are not unusual for the field.

Banyan has a residential treatment center in Pompano and a detoxification facility in Stewart, and it recently opened an intensive outpatient program (IOP) in Naperville, Illinois. According to Eric Oakes, executive director, 95 percent of the patients in Florida have out-of-network insurance coverage. The other 5 percent are self-pay. “We don’t take Medicaid, we don’t have in-network contracts,” said Oakes, noting that very few Florida providers are in-network with insurance companies. The vast majority of patients go to Banyan with a primary diagnosis of opioid use disorder.

Insurance first

The fact that virtually all Banyan patients have out-of-network insurance is by design — out-of-network insurance is the best kind from the provider’s point of view, as there are no cost limitations based on contracts. The main referral source is in Illinois, where Tim Ryan operates as Banyan’s Midwest regional outreach coordinator, a full-time salaried position. Ryan told us that he refers people with good insurance to Banyan, because that’s his job. And in fact, this is an age-old marketing job for treatment programs — getting beds filled.

Some patients are referred to Florida, and some to the new IOP in Naperville, said Ryan. The IOP is a partial hospitalization program (PHP) that ultimately could treat up to 90 people but currently only has 20 housing beds, he said. “Some people don’t want to leave the state or are still living with Mom and Dad.” Only patients with “good policies” are referred to Banyan, he said. “It has to be PPO or cash pay,” he said.

PPO plans — which allow treatment out of network but frequently only pay a portion of that care as a way of encouraging patients to use in-network providers — are viewed as a kind of out-of-network plan. Treatment programs that do not collect the patient portion of the PPO coverage are subject to fraud charges.

Art VanDivier, executive director of La Hacienda in Texas, questioned Banyan’s business model of taking only out-of-network patients. “If you don’t have a contract, most insurance companies will say they’ll pay 50 percent of your rate,” VanDivier told ADAW. “Suddenly the rates become very high, and 50 percent of out-of-network is higher than an in-network contractor gets and the provider doesn’t even want to be in-network,” he said. “Insurance is cracking down on this because it’s an obvious abuse.” This is a “shaky business plan,” said VanDivier. “Is it illegal? Not technically. Is it unethical? You’re gouging the insurance company.”

It’s not unusual for a treatment provider to have a patient whose insurance doesn’t contract with the provider. “We all have those situations,” said VanDivier. “But to create a business that’s based on it? If I were an investor in that company, that would be scaring me to death, because managed care is going to come down on it. They’re keeping stats, and they know there’s money hemorrhaging.”

The vast majority of patients Ryan, who has no clinical credentials, refers to treatment have no insurance. He has a not-for-profit that, according to Banyan and Ryan, is independent of his work for Banyan, called the Man in Recovery Foundation. Through this, he attracts people who need treatment. “I put 300 people a month into treatment, but 98 percent have no insurance or have state insurance,” Ryan told ADAW. “I know how to maneuver the system whenever even if someone has state insurance, they can get treatment,” he said. “I know exactly where the beds are.” But, we pointed out, there are waiting lists all over the state. “I know when beds are opening up,” said Ryan.

Ryan, a former heroin addict who lost his 20-year-old son to a heroin overdose, just got out of prison two years ago. He does not refer patients to medication-assisted treatment (MAT) with methadone, and buprenorphine is only used in Banyan facilities for detoxification, said Oakes. The Naperville facility has Vivitrol, said Ryan.

Edward-Elmhurst Health, which has a substance abuse treatment program in Naperville, declined to be interviewed for this article.

The Florida Department of Children and Families (DCF) licenses and regulates substance abuse treatment facilities in the state. But the DCF “has no authority regarding provider marketing practices in Chapter 397, Florida Statutes,” said Jessica K. Sims, DCF communications director. The Office of the Attorney General (Pam Bondi) is responsible for enforcing the Florida Deceptive and Unfair Trade Practices Act and the civil provisions of the Racketeer Influenced and Corrupt Organizations Act, she told ADAW last week. “The State Attorney has enforcement authority over criminal cases,” she said.

Lack of MAT

The fact that the first-line recommended treatment for opioid use disorders includes medications — methadone, buprenorphine or naltrexone — is ignored in this Banyan philosophy — as it is in many rehabs, partly because of patient ignorance and mistrust. All counties in Illinois are experiencing a gap in capacity for treatment with buprenorphine or methadone, said Kathie Kane-Willis, director of the Illinois Consortium on Drug Policy at Roosevelt University. Methadone is still not covered under Medicaid in the state, she noted, adding that in 2017, it will be covered just as buprenorphine and Vivitrol now are. But there aren’t enough buprenorphine providers to meet the demand.

In addition, Illinois lost 50 percent of its publicly funded treatment capacity between 2007 and 2012, before the budget impasse in the state even started, noted Kane-Willis.

Of particular concern is the stigma against methadone and buprenorphine. “I just spoke to a mom who had lost her child to an overdose,” she said. The mother said she would never have allowed her child to be on buprenorphine. “I think this speaks volumes,” said Kane-Willis, who said Ryan is contributing to the attitude that buprenorphine and methadone aren’t really treatment, but just “trading one addiction for another.” This stigma has become worse, not better, over time — ironically during the same period in which the opioid epidemic itself has become worse. And family members are prey for rehabs that avoid these medications, like Banyan.

“Since folks really don’'t understand what treatment is and their only frame of reference is Intervention and Dr. Drew, they tend to look for inpatient programs because they feel that that is what treatment looks like,” she said. “We are working hard to make simple videos to reduce the stigma related to these life-saving medications,” she said. “People tend not to believe the science, which demonstrates the efficacy of these medications,” she said.

However, people are more likely to believe those with lived experience, said Kane-Willis. “I know this because of my own experience,” she said. “I can quote the science until I am blue in the face. However, when I mention my own lived experience, the conversation changes completely. When we were working on the override of the governor’s veto on the heroin crisis bill, I was talking about methadone, and the general consensus from the advocates was ‘We don’t like that.’ When I told them that I had used it in my recovery, the conversation changed, completely.”

“We really need more people to come out regarding their positive experiences with these medicines,” said Kane-Willis, although she sympathizes with the fact that stigma makes this difficult. “People are doing well and are stable living their lives — no one would know that they were once heroin users,” she said. “But I really do hope people do start sharing their stories, as we know that these medications are the most effective treatments for opioid use disorders.”

‘Predatory’ tactics

Because of the bias against MAT in many treatment programs, however, it is the “rehab” that is the focus of the Ryan-Banyan arrangement. Gerald “Jud” E. DeLoss, outside legal counsel for the Illinois Alcoholism and Drug Dependence Association (IADDA), shared his views on the arrangement between Ryan and Banyan with ADAW.

“First, state and federal consumer protection laws govern paid endorsers or references,” he said. “If an individual is paid by a third party to provide an endorsement of a particular product or service, then that individual should disclose the financial relationship/incentive to potential consumers because the payment impacts the credibility of the endorsement.”

Robert Ryberg, managing partner with Peak Consulting Partners, an addiction treatment consulting company based in Colorado and Arizona, agreed. “I feel very strongly that someone’s integrity is in question when they don’t make their financial situation known to the client,” Ryberg told ADAW. “Tim and the entire group of Banyan folks, contract or not, are notorious for doing that,” he said. “I’ve had a lot of words with them about this.” Ryberg grew up in the area of Chicago where Ryan is operating, and got sober there. He has heard about the Man in Recovery Foundation’s “outpatient groups,” which are used as recruiting mechanisms for patients. “In no way, shape or form does the job they do resemble a typical clinical outreach representative in the industry,” he said. “They’re not clinical, and they’re not sending clients to the appropriate level of care based on need. This is predatory.”

The involvement of the not-for-profit Man in Recovery Foundation also concerned IADDA’s lawyer. DeLoss questioned “whether a not-for-profit foundation can legally or ethically refer business to a for-profit treatment center that employs the foundation’s leader,” he said. “It’s possible, but there are a whole host of tax-exempt issues that must be addressed.”

“These are predatory marketing tactics,” said Peter Palanca, executive vice president and chief operating officer of TASC, based in Chicago. “I don’t think there’s any question about that,” he told ADAW. “To prey on families who are scared to death, grasping at straws, terrified about their son or daughter dying” is wrong, he said. Ryan “has the credibility that a microphone gives someone,” said Palanca, who is on the board of the National Association of Addiction Treatment Providers (NAATP). “Large crowds are showing up for these presentations,” he said. Palanca recalls the days when he spoke about adolescent issues in the 1980s, and people would show up looking for care for their children — but the audiences were much smaller. And he was at the time linked to a specific program and identified himself as such. “I ran the first intensive adolescent outpatient program in Illinois,” he said. “We focused on kids who needed addiction treatment, and we were at that point in time where we would put every kid who came to us into IOP because there wasn’t anything else,” he said. “We quickly realized that it wasn’t the way to go.” Now, however, that is the scenario repeating itself.

DeLoss, who also represents treatment programs in Illinois and other states, also questioned the licensure, training or certification of Ryan. “There would likely be ethical if not legal restrictions on the use of a position of trust to refer clients to a specific treatment center,” he said.

In Illinois, treatment providers are already having difficulties contracting with certain health plans to become in-network, said DeLoss. “We believe that the limitations imposed by the plans may be violations of federal and state parity laws that prohibit plans from treating mental health/substance use disorder providers differently than medical/surgical providers,” he said. To the extent that there are waiting lists, it’s likely the fault of plans failing to contract with in-state providers to ensure sufficient coverage of areas of the state where there is a lack of capacity, he said.

“Finally, I am aware of treatment centers utilizing separate not-for-profit foundations to fund the travel of clients to out-of-state treatment facilities,” said DeLoss. These foundations are supported by the treatment centers, which pay for the transportation of patients, so the costs of treatment itself are similar to what they would be if treatment were delivered in Illinois. These arrangements would be prohibited if the patient has Medicare or Medicaid, under the anti-kickback law. State laws impose similar restrictions on private insurance, said DeLoss. “It is possible to structure such an arrangement legally but it is complex and an unsettled area of the law,” he said.

‘Switching hats’

“I have no problem with an individual being compensated as long as they are transparent,” said Bob Ferguson, founder of Jaywalker Lodge in Colorado. He said the transparency issue is paramount. “I am very careful when I walk into a room that people understand I am a full-time employee of Jaywalker Lodge, that I represent Jaywalker Lodge, that I’m not a licensed or trained counselor in any way, that I am not trained or equipped to make clinical recommendations, and that I do serve on the board of directors of nonprofits, including one called A Way Out, which provides treatment scholarships — and that those scholarships don’t go to Jaywalker,” he said. When a marketer is working for a program, that person “can’t switch hats,” he said. “I have no problem with anyone being employed for an organization as long as they represent themselves as such,” he said.

But “switching hats” is exactly what Ryan is doing — he is taking some patients for Banyan. Others — those without good insurance — are referred to other programs, to mutual support groups and to the Salvation Army.

Rosecrance comments

“I’m not familiar with what Banyan is doing or their business practices, and I’ve never met Tim Ryan,” said Rosecrance President and CEO Phil Eaton. But he recalled how the Rockford-based treatment program, which started more than 100 years ago as a mental health provider, began marketing addiction treatment in the 1980s. “We advertised in the Yellow Pages and trade magazines,” he told ADAW. “We had marketing staff who would talk to clinicians and hospitals that were in our catchment area — traditional, transparent relationship marketing.”

Now, however, treatment organizations around the country “overpromise and underdeliver,” he said. “There are SEOs and outfits that are middle men brokering referrals,” he said, noting that some organizations steal Rosecrance’s website and put their own 800 number on it.

Compared to the internet scams, having a real person like Ryan who has a commitment to recovery and tries to get people into treatment may be a step up. Banyan is a real treatment program, with its own website and Ryan clearly listed as a staff member.

Rosecrance has just survived a NIMBY (Not in My Back Yard) battle over a licensed 24-hour staffed recovery home (see ADAW, February 8, October 26, 2015). And Eaton is concerned about “getting lumped into the sober living effort where some guy has a house and no oversight,” he said.

Eaton is also concerned about the offers of Florida programs to fly patients there for free, and if the patient goes, the treatment program will forgive the copay (questionable legally, as DeLoss said). “We’re very concerned about the high costs of urine drug screens as well,” he said.

The National Association of Addiction Treatment Providers is working aggressively to rid the industry of these abuses in order to protect the integrity of the industry. “My concern is that consumers are getting swept up by these programs,” said Eaton, who has served on the NAATP board. “These are often organizations that are not accredited by the Joint Commission or CARF, that are unlicensed, that have skirted around zoning requirements and are often not accepted in the communities where they are.”

Uneducated, panic-stricken consumers

“The sad thing is, someone sees a TV show [Ryan was recently on Steve Harvey] or a video [Ryan has several], and they make that call,” said VanDivier. “It’s an uninformed panic-stricken consumer out there, and that’s what these guys take advantage of.”

John Lehman, president of the Florida Association of Recovery Residences, told ADAW that lack of education among patients and family members is the systemic problem. “They go Google, and boom, they make a decision,” he said. “As an industry of ethical operators across the country, we should be building an infrastructure that supplants their SEO methods and gets them to a site that educates them on the levels of care, on the appropriate care for the individual, how you go about choosing a program,” he said.

“My dad used to say, ‘Let’s check with the Better Business Bureau,’” recalled Eaton. “Now, I would tell consumers, go to the NAATP website and check the program out. Are they licensed? Are they accredited?”

Meanwhile, back at Banyan, Oakes defended Ryan and the arrangement. “He is primarily an ambassador for recovery,” he said. “He’s not a treatment broker. He runs the Man in Recovery Foundation, he speaks publicly and privately about trying to save lives from addiction, and if someone needs a treatment program and is willing to come to Banyan, that’s an option,” said Oakes. “If he can get someone clean in the rooms, that’s his primary goal,” he said. “If he can get someone to talk to him and put down the needle, he’s fine with that. His primary goal is not to serve Banyan.”

Banyan is not a member of NAATP.

Bottom Line…

A mix of a forceful speaker-marketer, family members uninformed about appropriate treatment and a for-profit Florida rehab is an example of the out-of-network business model at work.

5/30/2016 12:00 AM

A popular but little-researched model for self-treating alcohol use disorders is self-tapering. This involves people cutting back on their alcohol consumption. Typically, detoxification is accomplished by the use of benzodiazepines, either on an outpatient or inpatient basis; the benzodiazepines replace the alcohol in the body, and then are tapered in a controlled way.

A popular but little-researched model for self-treating alcohol use disorders is self-tapering. This involves people cutting back on their alcohol consumption. Typically, detoxification is accomplished by the use of benzodiazepines, either on an outpatient or inpatient basis; the benzodiazepines replace the alcohol in the body, and then are tapered in a controlled way.

Alcohol withdrawal can be life-threatening. Before the advent of benzodiazepines, one out of six alcoholics who went into severe withdrawal died, said George Koob, Ph.D., director of the National Institute on Alcohol Abuse and Alcoholism. We had asked him about self-tapering, which is promoted by HAMS: Harm Reduction for Alcohol, a self-described “support and informational group for anyone who wants to change their drinking habits for the better.” The group’s acronym, HAMS, stands for Harm reduction, Abstinence, and Moderation Support. We had sent the group’s tapering page (http://www.hamsnetwork.org/taper/) to Koob to review.

“It’s not a trivial undertaking,” said Koob of alcohol withdrawal. “You can have a severe hyperthermic reaction, which can be fatal, or seizures that can be fatal,” he told ADAW. “Very few people die of opioid withdrawal, but you can die from alcohol withdrawal.”

But that is the whole point of tapering, and the HAMS web page says as much: “Alcohol withdrawal is potentially fatal, so if you find yourself starting to experience significant alcohol withdrawal symptoms when you stop drinking then it is important to gradually detoxify from alcohol rather than quitting all at once ‘cold turkey.’” The page then lists recommendations for tapering, which include using beer (which has a lower alcohol content than wine or hard liquor), drinking just enough to keep the withdrawal symptoms (sweats and shakes) away but not enough to get drunk, and drinking fluids to replenish electrolytes.

Self-control

“Self-tapering can work, but it has to be under situations of tightly controlled access,” said Koob. “Someone has to help, because it takes an incredible amount of self-control, and we know that individuals with alcohol use disorders don’t have a lot of control.”

“I am not familiar with research on the efficacy of a controlled alcohol withdrawal taper versus a medication-assisted taper,” said Katie Witkiewitz, Ph.D., associate professor in the Department of Psychology at the University of New Mexico’s Center on Alcoholism, Substance Abuse, and Addictions. “When I have clients who want to quit drinking, I always recommend a medication-assisted taper under medical supervision,” she said. “Outpatient benzodiazepine treatment is typically sufficient for less severe cases — inpatient detox may be necessary for more severe cases with a history of seizures.”

However, she said that she “can see why an oral alcohol taper would be an attractive option, from a harm-reduction perspective.” But the lack of research to support an alcohol taper would make it problematic.

Kenneth Anderson, who founded HAMS in 2007 after he became disenchanted with Moderation Management, has his own model: he drinks 17 drinks one day a week, not driving and over the course of eight hours. He used to drink a bottle of whiskey — 17 drinks — four days a week. Now he’s down to one 17-drink day a week, which is a definite improvement. But still, it has the potential to create liver damage, said Koob.

“This phenomenon of harm reduction is reinforcing the fact that you can drink yourself to oblivion and get the high alcohol levels, which kill your liver cells,” said Koob. “I’d hate to see his liver enzymes,” referring to Anderson’s weekly 17-drink planned intoxication.

Anderson told us that he goes for regular physicals, and his liver tests are fine.

But Koob said that half of liver disease in the United States is caused by alcohol, and that there’s a shift to younger people getting it — even cirrhosis. At colleges, young people are drinking to the blackout stage, which is 12 to 15 drinks, he said. “It’s not a pretty picture,” Koob told ADAW. “Talk to any liver doctor, and you’ll find out they’re seeing younger and younger patients,” he said. “Anybody who is doing 17 drinks in a sitting should see what their liver enzyme levels look like.”

HAMS responds

Many people didn’t know that they could self-taper from alcohol using alcohol before HAMS, Anderson told ADAW last week. “Alcohol works as well as benzodiazepines” for detox, he said. Many people don’t want to go to medical detox because they don’t want it on their medical records, said Anderson.

“Regardless of how much you drink, some people have a predisposition” to liver disease, said Anderson. “It’s not dose-dependent,” he said.

Finally, tapering down one drink a day is too fast for many people, said Anderson. “If someone is determined, and they want to do the taper in four or five days, they could try it,” he said, adding that many people on the HAMS network, which has a Facebook page and other social media, contact him. “They’re highly motivated, or they wouldn’t be looking me up online.”

“We think people should support each other,” said Anderson. That’s why the social media sites for HAMS are so nonjudgmental — whether someone is in the hospital after a four-day binge or someone has decided to go back to AA (anathema to HAMS) because sobriety agrees with them. “I look out every day for the trolls and the spammers,” Anderson said. “I’m not there to tell people what to do. I’m there to offer people options. If you do one and it works, that's fine. If you make up your own approach, that’s fine.”

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.

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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