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4/3/2017 12:00 AM

An open-label study of “neuromodulation with percutaneous electrical nerve field stimulation” — a device put on the ear to treat opioid withdrawal symptoms in which patients were told that it would make withdrawal less painful — has shown promising results. But it’s an open-label study in which the placebo effect could have a huge effect on reducing subjective symptoms of withdrawal, such as anxiety, aches, yawning and restlessness — four of the 11 measures on the Clinical Opiate Withdrawal Scale (COWS), which was used to assess the patients’ symptoms in the study. The other measures are more objective: pulse rate, sweating, pupil size, runny nose or tearing, gastrointestinal symptoms, tremor and gooseflesh skin. All 11 measures are assessed based on severity.

An open-label study of “neuromodulation with percutaneous electrical nerve field stimulation” — a device put on the ear to treat opioid withdrawal symptoms in which patients were told that it would make withdrawal less painful — has shown promising results. But it’s an open-label study in which the placebo effect could have a huge effect on reducing subjective symptoms of withdrawal, such as anxiety, aches, yawning and restlessness — four of the 11 measures on the Clinical Opiate Withdrawal Scale (COWS), which was used to assess the patients’ symptoms in the study. The other measures are more objective: pulse rate, sweating, pupil size, runny nose or tearing, gastrointestinal symptoms, tremor and gooseflesh skin. All 11 measures are assessed based on severity.

The pilot study, “Neuromodulation with Percutaneous Electrical Nerve Field Stimulation Is Associated with Reduction in Signs and Symptoms of Opioid Withdrawal: A Multisite, Retrospective Assessment,” found that the device resulted in 64 of 73 treated patients being successfully transitioned to extended-release (ER) naltrexone. Treatment program staff — not the researcher — recorded COWS scores on patients on day 1 before the device was placed and at 20, 30 and 60 minutes after the device was placed, and a subset of patients (33 of the 64 who returned) had COWS scores analyzed when they returned to the clinic on day 5 when the device was removed and they were placed on ER naltrexone. The study is published in the current issue of the American Journal of Drug and Alcohol Abuse.

The research was a retrospective study, led by Adrian Miranda, M.D., who is with the Department of Pediatrics, Division of Gastroenterology and Hepatology, at the Medical College of Wisconsin in Milwaukee.

The mean COWS score before the device was placed was 20. Twenty minutes later, it was 7.5, reduced further to 4.0 at 30 minutes, and 3.1 at 60 minutes. There were no rescue medications.

Proprietary technology

The abstract for the article cites the name of the device (the Bridge) in full capital letters seven times, and says that the patients were transitioned to medication-assisted treatment (MAT) without indicating that it was to ER naltrexone only, not to buprenorphine or methadone. One of the two authors (Arturo Taca, M.D.) is a consultant to Alkermes, which makes the only patented form of ER naltrexone — Vivitrol. Taca is medical director of INSynergy Treatment Program in St. Louis, Missouri.

The Bridge is cleared by the Food and Drug Administration (FDA) but not approved. Made by Innovative Health Solutions, a company based in Versailles, Indiana, the Bridge is featured on the website of Taca’s treatment program, as is Vivitrol. It costs $500.

The reason the Bridge was used only with Vivitrol was because of Taca’s practice, said Miranda. “I know as a practicing physician we all have preferences in what we use and what we believe in, and in this case, that’s how Dr. Taca practices,” he told ADAW. “This was not a study that was planned.”

“Alkermes is not involved with the Bridge in any capacity,” said Matthew Henson, Alkermes spokesman, in response to our query. “Dr. Taca is a paid speaker for Alkermes, but any work on the Bridge has been conducted without any involvement from the company.” However, Alkermes recognizes “that there is strong interest from the medical community in studying additional methods to help transition patients onto antagonist therapies and help patients manage opioid withdrawal symptoms,” he added.

Study details

The theory is that the device can alleviate pain “through stimulating peripheral cranial neurovascular bundles in the external ear that could potentially gain access to brain areas involved in fear, pain and nociception,” according to the article. The amygdala, in particular, plays a role in fear conditioning and pain processing, as well as in “processing the negative emotional state of withdrawal.”

The original study used Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for opioid dependence, rather than Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for opioid use disorders, even though the subjects were enrolled in 2015 and 2016. DSM-5 was released in 2013. The decision was made by the clinics, apparently, said Miranda. “For the purpose of this study, it doesn’t make that much of a difference,” he said. However, dependence under DSM-5 is not necessarily pathological: a patient on a therapeutic dose of methadone or buprenorphine for the treatment of opioid use disorders would not have a diagnosis. “It’s a valid point,” Miranda conceded.

The subjects had a history of dependence on heroin or other opioids, including prescription opioids, methadone and buprenorphine/naloxone. The clinics were in St. Louis, Missouri (27 patients); Liberty, Indiana (13); Florence, Kentucky (12); Anchorage, Alaska (9); Rising Sun, Indiana (6); Richmond, Indiana (2); Dayton, Ohio (2); and Indianapolis, Indiana (2). Six of the clinics were private, and all were chosen because the Bridge had been used as the standard care in the initial treatment of opioid withdrawal.


COWS scores rated from 0 to 48, and were mild (5–12), moderate (13–24), moderately severe (25–36) or severe (more than 36). Immediately before Bridge placement, 53 of the 73 patients (72.6 percent) were in the moderate withdrawal range, 16 (21.9 percent) in the moderately severe range and four (5.4 percent) were in the mild range. None were in the severe range.

During the five-day period, no antipsychotic, opioid or benzodiazepine medications were given, but 28 patients (38 percent) received an oral antiemetic — typically Zofran. Nobody was drug-tested during the time they were home, so it is unknown whether they were using drugs at this time, Miranda said.

“The authors don’t deconstruct the COWS to see which symptoms respond to neuromodulation,” said H. Westley Clark, M.D., Dean’s Executive Professor of Public Health at Santa Clara University. For example, 38 percent of the subjects needed an antiemetic. “That subjects needed an antiemetic suggests that certain autonomic responses are not amenable to neuromodulation,” said Clark, who we asked to comment on the study. “By focusing on the scores alone we don’t know enough about the appropriate needs of the patient.”

When asked about the specific symptom responses rather than total COWS scores, Miranda said that data was unavailable. “We heard from the company [Innovative Health Solutions, which makes the Bridge] that there were all these reports from people saying how amazing this was,” he told ADAW. “But the scores were collected prospectively,” he said, adding that that part of the study was analyzed by Taca. “You’re not going to be able to get that data now,” he said. In the future, there will be a double-blind randomized controlled trial of the device, said Miranda, adding that he would not be involved in that.

The study noted that many of the COWS measures are objective and therefore cannot be feigned.

Most patients were sent home after Bridge placement and relief of withdrawal symptoms, after the first hour. Patients were told that the “Bridge is not a cure, but rather a tool to treat the pain associated with” opioid withdrawal, and instructed to follow up within one to five days depending on the clinic, and to leave the device on for the entire five-day period.

All patients (64 of 73) who returned to the clinic on day 5 and received their first dose of naltrexone were considered to be successfully transitioned.

The mean age of the subjects was 32.9, and 65 percent were male. Ninety percent of the subjects had been using opioids for at least two years, and the mean length of drug use was 70 months.

A subset of patients — 33 — also had withdrawal scores recorded five days after the device was placed and prior to transitioning to naltrexone.

The article noted that the uncontrolled, retrospective study design and small sample size were limitations. The study design also did not include long-term follow-up.

Placebo effect?

“Placebos are known to be effective in reducing symptoms, including pain,” said Miranda. “The only way to know for sure is to do a randomized controlled trial using a sham device.” There is another device that doesn’t provide continuous current, but turns off every two hours, said Miranda. That device anecdotally does not reduce withdrawal symptoms, he said.

But he stressed that it’s important to separate the placebo response from a real effect. We recalled the story of PROMETA, which had promised treatment for methamphetamine during that epidemic but after many years and finally a randomized controlled trial was found to be no more effective than placebo (see ADAW, Nov. 21, 2011; April 18, 2011; July 17, 2006; July 28, 2008). “In the addiction field, so much stuff has come out with everyone looking to make a quick buck, and there’s a big piece of the pie people want to get,” he said. “But I’m not promoting this company or this product, and I know the people doing it — they’re trying to do it the right way. They’re trying to show the science before they go to the FDA for approval.”

Patients transitioning to ER naltrexone seem “like a logical target population,” because the battery life of the device — five days — coincides with the time required for opioid abstinence before starting the medication, the article stated. (In fact, Vivitrol labeling calls for seven days of abstinence, but Miranda told us that most clinicians feel five days is adequate.) However, there is no reason that other patients undergoing withdrawal wouldn’t benefit from it, in any setting, the article concluded, noting that “it seems reasonable to consider that removing the fear of experiencing severe symptoms associated with opioid withdrawal may motivate and encourage more individuals to seek treatment in the future.”

None of the subjects was under criminal justice supervision, which is interesting, as many Vivitrol programs are aimed at this population.

A final note: Once it was written, instead of referring generically to MAT, the study should have always referenced only naltrexone for clarity. “I think it is a bit disingenuous to conflate MAT with XR-naltrexone alone, particularly since one of the authors is paid by Alkermes,” said Clark. “While withdrawal per se is not compelling with buprenorphine, it could be possible to facilitate the induction with buprenorphine or methadone using neuromodulation, even if the current study did not address this use,” he said. “This would have been an agnostic approach.”

Clark is not opposed to the concept of neuromodulation. “I like technology,” he told ADAW. “If neuromodulation holds promise, then great! But we need to consider the unintended consequences of what we recommend and to explore factors that extend out from our recommendations,” he said. “We need to acknowledge what we don’t know.”

Bottom Line…

A new device may — or may not — reduce opioid withdrawal symptoms.

3/13/2017 12:00 AM

Last month, the first-ever national deflection summit was held in Alexandria, Virginia, where experts from criminal justice, behavioral health and public policy convened to come up with strategies aimed at diverting, or deflecting, low-level drug offenders away from the justice system into treatment, before arrest. Also called prebooking diversion, deflection can help get people into treatment instead of incarceration. The two-day summit was sponsored by the International Association of Chiefs of Police.

Last month, the first-ever national deflection summit was held in Alexandria, Virginia, where experts from criminal justice, behavioral health and public policy convened to come up with strategies aimed at diverting, or deflecting, low-level drug offenders away from the justice system into treatment, before arrest. Also called prebooking diversion, deflection can help get people into treatment instead of incarceration. The two-day summit was sponsored by the International Association of Chiefs of Police (IACP).

Perhaps the best-known examples of “deflection” are the Police Assisted Addiction and Recovery Initiative (PAARI), which started in the Gloucester, Massachusetts, police department and now has many member police departments across the country, and Law Enforcement Assisted Diversion (LEAD), based in Seattle, Washington.

While law enforcement is eager to find treatment solutions instead of arrest and incarceration, the treatment field isn’t making it easy, said Jac A. Charlier, national director for justice initiatives at the Center for Health and Justice at TASC (Treatment Accountability for Safer Communities), which convened the meeting. “Police departments are willing to partner, but it’s behavioral health that has to get its act in gear,” Charlier told ADAW in an interview last week. “There are police departments all over that are ready to do this, but they don’t have a history of working together with behavioral health.” Charlier urged treatment providers to call him. “I will help you navigate the waters with the police,” he said.

One obvious barrier for treatment providers is funding. Police departments have direct government funding; treatment providers don’t. “In the United States, for the most part our community behavioral health system is nonexistent in terms of capacity,” said Charlier. Medicaid expansion has accounted for much of the increased access to treatment, but it’s still not enough, he said. “There are low rates of insurance, so therefore low access to treatment.” But the calls, when there are overdoses or other substance use–related problems, usually go to first responders, including police, he said. “We want to increase treatment access points through our first responders,” he said.

Charlier distinguishes deflection from diversion, which is a criminal justice term. He coined the term to make that distinction clear, and also to encompass the many terms used in the emerging field (Charlier, whose expertise is deflection, said there are nine terms, and noted that even PAARI and LEAD don’t use the same terminology). “Nothing is settled about this,” he said. “There are early adopters, there are experimenters, but I want to focus on deflection, which means moving away from the criminal justice system without ever having entered it.” Diversion often means entering, and then leaving, the criminal justice system. Deflection means using the criminal justice system as an access point to non-justice-related treatment. But that means making sure access is there.

“Behavioral health capacity is the holy grail of deflection and diversion,” said Charlier.

But as for funding, Charlier and his deflection colleagues have “no pretense to solving the problem,” he said. “We’re not going to crack that nut because it’s a federal issue.” But he sees little resistance from police on deflection. “The resistance is from behavioral health, not because they’re the bad guys, but because they have to worry about how they get paid,” he said.

The treatment view

C4 Recovery Solutions, an international not-for-profit focused on substance use, headed up the treatment side of the deflection meeting. “We tried to broaden people’s awareness that substance use is a multisystemic issue,” said Dee K. McGraw, director of education and event services for C4. At the West Coast Symposium on Addictive Disorders last summer, C4 convened a group focusing on first responders, she said. C4 senior advisor Lee Feldman took this to the next level, to address the problems of capacity.

“We’re looking at different kinds of financing, and models such as municipal bonds,” Feldman told ADAW. “There are also possible private-public funding mechanisms.” Key to the success of this, however, is community support. Just as a community is willing to pay taxes for a firehouse, it should be willing to support a treatment infrastructure, he said. “Communities have a need for treatment capacity, and it’s a community responsibility to create that capacity,” he said. “Some communities are looking at additions to the sales tax.”

In North Carolina, the cost of incarceration per person per year is $40,000, noted Feldman. In the Charlotte area, counties are discussing the idea of moving some money from corrections to treatment, in cases of diversion. C4 is hoping to research the effectiveness of such programs.

“So far, the research is anecdotal,” said Feldman. “One sheriff might mention that if he has to continue building jail capacity because of opioids, he’ll need several million dollars.” Instead, that money could go to treatment. “The economic justifications are there, and the need is there,” said Feldman. “What’s missing is the research on the actual mechanisms — how do you take the capital expenditure for a new jail and move it over to pay for treatment?” There may be a requirement for legislation, he said. “This is a local issue."

Deflection also means a shift in the way people think about funding treatment, said Feldman. “In the past, funding treatment meant funding an addict or an alcoholic,” he said. “Here we’re talking about funding community safety. The ‘ask’ is different, and it’s an ‘ask’ that has not been made before.” The community — hospitals who keep seeing repeat patients whose substance use disorders aren’t getting better, law enforcement and taxpayers — needs to figure out what it needs, and pay for it, he said. “It’s the community that needs to raise the war chest."

There was consensus at the conference that behavioral health needs to be brought into the law enforcement discussion on deflection, said Feldman. “But the problem is, they want to deflect people to treatment, and nobody is bothering to ask whether the behavioral health community can do it,” he said. “The behavioral health system isn’t even a system — it’s a bunch of independent actors, and getting it organized isn’t going to be easy.”

C4 is working to create a repository of information communities can use to jump-start deflection efforts, said McGraw. “We’ve been to law enforcement trainings, but they each have their own way to do it; they all have different names,” she said.

There were about 60 people at the invitation-only meeting in Alexandria, which is hoped to lead to a “think tank” on deflection, said McGraw. “We need to figure out what deflection means. Is it one chance at treatment and that’s it? You need assessment instruments. You need to train the police officers to make these determinations.”

Civil citations

The Civil Citation Network (CCN), based in Tallahassee, Florida, offers counseling, education and community service in lieu of arrest, enabling clients to avoid a record. The clients pay for it themselves — the same $350 they would be required to pay for their own court costs if they were arrested — explained Tom Olk, founder of the CCN. Using the GAIN to assess clients, the CCN decides whether they need treatment; less than 8 percent do. Only about 100 of the 1,200 people who went through the CCN since 2013 have needed actual treatment, he said. The CCN is publicly funded.

People who don’t need specialty treatment are treated by CCN counselors using CBT, MI and trauma-informed care, using the curriculum from The Change Companies. “They have at least three therapeutic sessions,” said Olk.

“What we’re trying to do is provide the officer on the street with another option,” said Gregory A. Frost, president of the CCN, which was the third convener of the deflection conference. “If you don’t have a way to deflect that person, you either arrest them or you let them go. Our option is prearrest deflection.” The completion rate since 2013 is 83 percent, said Frost. CCN clients are first-time offenders and are required to sign a contract and to remain substance-free. They are drug-tested.

“Let’s not wait until this person has been arrested five times before they get the help that they need,” said Frost. “Let’s get this person the very first time they have a contact with law enforcement. We intervene early on before they get to the point of sitting in jail for the 10th time, before they are overdosing.”

But the CCN program is “not a free ride,” said Olk. “If they continue to use while they’re in our program, they risk going into the criminal justice system.” If they complete the program, however, they will not have any record, he said.

The two main substances involved in the CCN program are alcohol and marijuana. First-time misdemeanor offenders have a 45 percent rearrest rate within three years, said Olk. But the rearrest rate for people who go through the CCN program is only 7 percent.

Alcohol offenses that end up in the CCN are typically for open container or disorderly conduct charges, said Olk. Anyone caught driving under the influence is arrested and not eligible for the program. The CCN also gets non-drug-related cases, such as people who are hunting at night. “They don’t want to arrest people for hunting at night — we get cases like that,” he said. “We still drug-test them.”

TASC’s Charlier said the summit will create a “voice and vision” for deflection and increased access to treatment for people involved with the justice system. Treatment providers can email him at or call him at (312) 573-8302.

Bottom Line…

Police and sheriffs want to “deflect” people who need treatment from the criminal justice system, but treatment needs to be there to receive them.

3/6/2017 12:00 AM

Last week, amidst an unclear trajectory in Congress on repealing and replacing the Affordable Care Act (ACA), President Trump declared, “Nobody knew that health care could be so complicated.” He had just met with conservative governors, and the topic of health care was likely a key priority: the National Governors Association wrote to Trump on Jan. 24, less than a week after the inauguration, about the need to preserve health care for vulnerable populations, and the federal responsibility in doing so.

Last week, amidst an unclear trajectory in Congress on repealing and replacing the Affordable Care Act (ACA), President Trump declared, “Nobody knew that health care could be so complicated.” He had just met with conservative governors, and the topic of health care was likely a key priority: the National Governors Association wrote to Trump on Jan. 24, less than a week after the inauguration, about the need to preserve health care for vulnerable populations, and the federal responsibility in doing so.

One of Trump’s main campaign promises was to repeal the ACA, and congressional Republicans, now in charge, are set to do that. But doing so is, as the president indicated, complicated. In fact, nobody has come up with a clear plan to replace the 5,000-plus pages of the ACA, crafted carefully with an aim to providing health insurance for everyone. Addiction treatment in particular was affected by the ACA, which required addiction treatment to be covered by all health plans as an essential benefit, and expanded coverage via marketplace plans and Medicaid expansion. This leaves addiction treatment providers unsure about what lies ahead.

“I wouldn’t say anybody is making any major changes right now,” said Becky Vaughn, consultant on treatment for the Addiction Policy Forum. “They’re just on pins and needles.”

Ironically, it’s the states that chose not to partake of Medicaid expansion who will be hurt the least by ACA repeal, if it happens, because they never reaped any of its benefits, Vaughn told ADAW last week. “The [Substance Abuse Prevention and Treatment] Block Grant is still secure,” she said. But in the states that did expand Medicaid, there is “anxiety,” because providers in these states have been able to see more patients.

“We’re working with Congress to make sure they understand that whatever they decide to replace the ACA with, people can still access addiction services,” said Vaughn. “Our big goal right now is funding.” The Comprehensive Addiction and Recovery Act (CARA) needs to be fully funded to be implemented, she said.

The vehicle for funding is the budget process, said Vaughn. When the White House releases its budget request, many hope that it will reflect President Trump’s stated claim that he wants to expand treatment for those who need it. One way to do this would be to increase the Substance Abuse Prevention and Treatment Block Grant, she said. But the funding wouldn’t only be in the Department of Health and Human Services. “There’s also talk of more money in the Bureau of Justice Assistance to increase treatment options for the criminal justice population,” said Vaughn. “There are a lot of ways to do it.”

ACA is still the law

“We have no idea how any of this is going to unfold,” said Chuck Ingoglia, senior vice president for public policy at the National Council for Behavioral Health. “When I talk to Medicaid directors, they tell me ‘the law is the law, and until the law changes, we’re just going to proceed with what we know.’” It’s hard for treatment providers to prepare for the unknown, said Ingoglia. “Hopefully I’m not being Pollyannaish, but it does seem Congress is having a hard time putting together a plan that is portable,” he said.

For example, on Feb. 24 a draft of a bill was released that days later everyone backed away from. “We heard the president say he doesn’t like it, and then we hear congressional leadership say that was an early draft and they’re farther along,” said Ingoglia. “I think the longer they struggle, the more it’s unclear what will happen. Obviously, if they have their way, they want to get rid of the essential health benefits.” But now, those benefits are the law, and Medicaid directors are not backing away from requiring them, said Ingoglia. “I don’t know how you plan for something that is so unclear,” he said.

Catastrophic plans

About 80 percent of the patients in Bradford Health Services, a private for-profit addiction treatment provider based in Alabama with programs in Tennessee, Arkansas, Florida and Alabama, are covered by health insurance, said Howard J. Bayless-Bonventre III, Bradford corporate director of development, in an interview last week. “The ACA established minimum benefits that every health plan had to provide, but a lot of the information that’s coming out of Washington right now will move us back to catastrophic plans,” he said. These plans have low premiums and high deductibles — they are not the ACA-type plans for which people under 30 can qualify for a “hardship exemption.” They are simply low-premium, low-coverage plans that people buy hoping that they won’t get sick. When they do, they have to pay — a lot more than they would have if they had bought full-coverage insurance. And since preventive care isn’t covered at all, they don’t get it. “We had this before,” said Bayless-Bonventre. “There were record numbers of bankruptcies for people who were left with medical bills they couldn’t afford.”

When people don’t have insurance, they tend to seek medical care in the emergency department, where “hospitals try to manage them and get them stabilized and out the door, or they end up in prison,” he said. “It’s disconcerting to hear that we’re going back to the old way that wasn’t working.”

Treatment providers will need to work with their insurance partners to navigate the future, said Bayless-Bonventre. “We’re hearing from our managed care partners that they’re also concerned,” he said. The problem with addiction treatment is that many people don’t realize that they need it or don’t want it. “People don’t wake up in the morning and say, ‘Oh, this is bad. I think I’ll go to treatment today,’” he said. “Their family or their job draws them in to look for options.” It’s easier to motivate people to get better when they have health insurance.

For most managed care companies, the ACA’s 10-percent cap on administration costs has been a deterrent, said Bayless-Bonventre. Most managed care companies want at least a 15-percent return — Medicare Advantage plans go to Congress every year to get that, he said. “Because so many plans have withdrawn, this has given fodder to those who say it isn’t working,” he said. In fact, however, the biggest utilization of health insurance is in the first five years of enrollment, he said. “We were getting to the end of that; we were seeing costs begin to decline and rates normalize,” he said.

Alabama did not opt for Medicaid expansion, so the $3 billion the state could have gotten for that went elsewhere. There is no demonstration project for Medicaid reform in the state. Bayless-Bonventre and other treatment providers had supported the state’s planned move to a regional care organization (RCO) system. “Because the Medicaid budget in Alabama is unruly, and we have no way to pay for it, we were hoping the RCO format would help,” he said. “But now, with the new administration, there are concerns that this won’t happen.”

Medicaid block grants

One factor that has nothing to do with ACA repeal is the introduction, by Congress, of the concept of Medicaid block grants — something that wasn’t even there before the ACA. Block grants are caps. Under Medicaid today, there is no cap — no matter how many people are eligible or how many people get sick, the Medicaid dollars will be there, making it an “entitlement.” While the ACA offered states the funding to expand Medicaid to people above the federal poverty level, and the single adults without children, a Medicaid block grant would sharply cut back on this coverage. “For the states that didn’t expand, anything they got would help them,” said Vaughn. These states may, for example, like the idea of the flexibility that comes with a block grant. “But in the states that did expand, a block grant would mean reduced funding,” she said.

But it’s hard to generalize, said Vaughn, who always notes that every state is different. In Oregon, for example, there is already a capitated system, so a block grant wouldn’t necessarily affect them. “They are already managing a fixed amount of money,” she said. “But in a state like New York that has done a fabulous job of making the best use of Medicaid expansion, there is a lot of concern.”

Going to Medicaid block grants — with the added “flexibility” for how the money is spent — could be deleterious to addiction treatment, said Bayless-Bonventre. “We’ve seen over the years that these are ways states either fund community-based programs they’re fond of, or they go into another politician’s pockets,” he said. “There have to be standards. You can’t peel government away from health. People should know all the aspects of an insurance plan.”

Private equity

The ACA, with its promise of insured patients and its requirement that all insurance cover addiction treatment, was also an allure to investors, who have invested in facilities. “What most people are worried about now is the idea that there won’t be an essential benefit that includes mandatory coverage for addiction treatment,” said Vaughn. But there are other opportunities, such as employers who need treatment for their workers, and are self-insured, she said. She noted that she was advising an investment group trying to decide on whether to open a 50-bed facility in Arizona, which would be entirely focused on insured patients. In this case, there was a fallback — a large employer that was self-insured needed such an option.

Bayless-Bonventre of Bradford said it’s too soon to see how investors will respond. “I don’t think we’re going to see a response until we see some actual plans in writing,” he said. “There was a jump when parity and the ACA passed — they saw growth opportunities in this area of health care that wasn’t adequate.”

Once there is an actual plan from Congress, he expects there to be an indication from investors on where they are heading on addiction treatment.

Criminal justice system

The two biggest pieces of the ACA for Treatment Alternatives for Safe Communities (TASC), which focuses on treating people with mental illness or substance use disorders (SUDs) in the criminal justice system, is Medicaid expansion and the requirement that addiction treatment be covered as an essential health benefit. “Being able to access mental health and substance use services as an alternative to incarceration, and as a way to avoid an arrest by getting treatment when they need it, is key,” said Maureen McDonnell, national director for health care initiatives at TASC, which is based in Chicago.

“We are trying to understand what the landscape might look like,” McDonnell told ADAW. “Our state, like others, has many waivers and contracting provisions that are already in place,” she said. “We are continuing to work on those while other changes take place. In the immediate short term, our clients still have coverage, and we’re going to take advantage of that.”

But there are great concerns that cutting treatment funding will just lead to more prison and jail terms for people with addictions. “When there’s a reduction in the amount of substance use and mental health care that’s available in the community, we see detention and incarceration go up,” said McDonnell. In 2009, when there was a 35 percent reduction in treatment services in Illinois due to the state’s budget, jails and prisons had increased numbers. “This is what happens, and we know this will be a likely outcome if treatment is cut,” said McDonnell. States and Congress have focused on bipartisan criminal justice reform over the last 10 years, she said. “Over the last five years, there has been an increase by local police departments and sheriffs in creating alternative pathways” by diverting people to treatment instead of arrest and incarceration, said McDonnell. “Dialing back on Medicaid expansion will reverse that,” she said.

Insurance viewpoint

The Association for Behavioral Health and Wellness (ABHW), the advocacy organization for managed behavioral health organizations — insurance companies that sell premiums to cover substance use disorders and mental illness — wants the gains of the ACA to continue. “It is hard to predict what the repair or replacement of the ACA will look like,” Pamela Greenberg, ABHW president and CEO, told ADAW last week. “Many gains have been made over the years for substance use disorder coverage — parity, inclusion in the essential health benefits and expanded Medicaid coverage, to name a few,” she said. “ABHW is advocating for the preservation of these gains in whatever legislation moves forward.”

Greenberg noted that many employers purchased insurance that covers SUDs and mental health before the ACA, and said she suspects that they will continue to do so even if it is repealed. “Understanding that substance use disorders are diseases like cancer and diabetes has increased over the years and the desire to stop the opioid epidemic and treat individuals with opioid addiction is a top priority for the nation,” she said. But the sticking point is Medicaid and the individual market — people who are not covered by employer health plans. “The real unknown is whether or not there will be enough funding in the Medicaid program for states to maintain the coverage for behavioral health disorders that they currently have and whether or not the individual market will be structured in a way that comprehensive health care benefits are affordable,” she said.


Whatever ACA reforms pass Congress, it’s important to make sure that parity implementations and compliance requirements in the Cures Act are implemented, as well as keeping mental health and substance use disorder treatment at parity as required under the Mental Health Parity and Addiction Equity Act, said Carol McDaid, principal with Capitol Decisions.

“I think we really all have to think about a multipronged approach,” said Bayless-Bonventre. “We have to push our elected officials to not forget that constituents need these services, to work with them to understand this need, a policy that supports all Americans.”

“The most important thing is to explain what ACA repeal would mean for patients, to help the policymakers understand how important Medicaid expansion is to access to treatment,” said Ingoglia. “We had all the focus last year on CARA and the opioid epidemic — the last thing we need is cutbacks.”

McConnell of TASC said there has been so much investment in taking advantage of the ACA, building substance use treatment systems. “Some plans are just getting under way, to broaden access,” she said. “This is a much bigger health issue” than just addiction, she said. “There’s a lot of advocacy going around this, over losing basic protections,” she said.

Bottom Line…

Repealing the ACA — something Trump and Congress have promised to do — could have devastating effects to treatment for substance use disorders, which saw many newly insured patients as a result of the law.

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: 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:

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

    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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