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1/30/2017 12:00 AM

The drug strategy of the Trump administration is going to look a lot like that under John Walters, head of the Office of National Drug Control Policy under President George W. Bush, ADAW has learned. The three key issues are prevention, treatment and border control. According to an administration official, speaking on background, “This administration is working to develop a comprehensive approach to addressing drug use and its consequences that will address preventing drug use before it starts, getting people who are struggling with substance use disorder the help they need and stopping the flow of illegal drugs into the country. We will provide further information in a timely manner as these policies are developed and implemented.”

The drug strategy of the Trump administration is going to look a lot like that under John Walters, head of the Office of National Drug Control Policy (ONDCP) under President George W. Bush, ADAW has learned. The three key issues are prevention, treatment and border control. According to an administration official, speaking on background, “This administration is working to develop a comprehensive approach to addressing drug use and its consequences that will address preventing drug use before it starts, getting people who are struggling with substance use disorder the help they need and stopping the flow of illegal drugs into the country. We will provide further information in a timely manner as these policies are developed and implemented.”

At the stroke of noon on January 20, President Donald Trump became the nation’s leader. But despite the swirling uncertainties about the future of the Affordable Care Act (ACA) and other questions, prevention and treatment of substance use disorders are still a part of the national drug control strategy.

There were initial concerns in the field because the ONDCP website had disappeared, but that’s because everything that was EOP (Executive Office of the President) had been replaced by the new White House. Michael Botticelli, the beloved ONDCP director who had championed recovery and, along with Gil Kerlikowske, President Obama’s first drug czar, a focus on treatment and away from the drug war, was also gone. But the programs are still there, as is the ONDCP itself, with Kemp Chester the acting director. Chester joined ONDCP as associate director for the National Heroin Coordination Group in October 2015. He retired from the Army, where he worked for 27 years; his last tour was at the Defense Intelligence Agency, working on counternarcotics. 

We asked Andrew Kessler, principal with Slingshot Solutions, about how the changes will affect the SUD field. “We are in a situation that is not unique to our field,” said Kessler, who lobbies on behalf of behavioral health providers. “A lot of people across government are very curious to see how this plays out.”

Kessler zeroed in on community policing as a key question going forward. Community policing is recommended for elimination from the Department of Justice budget by the Heritage Foundation in a report the Trump Administration appears likely to consider. However,  Sen. Jeff Sessions, nominee for Attorney General, has in the past been a big supporter of community policing – as is Kessler. “I think community policing can play a huge role in working with the treatment community on diversion programs, prevention programs, any number of programs,” he said.

SAMHSA leadership team

In addition, the leadership team at the Substance Abuse and Mental Health Services Administration (SAMHSA) consists of career officials with longtime experience in the programs of that agency (see organization chart, SAMHSA.pdf). As Kana Enomoto, deputy assistant secretary for mental health and substance use in the Department of Health and Human Services (HHS), told SAMHSA staff last fall, “SAMHSA’s work remains critical and behavioral health continues to be a top priority” (see ADAW, Nov. 21, 2016). The HHS assistant secretary for mental health and substance use will be appointed by President Trump. The move from SAMHSA administrator to the new position of HHS deputy assistant secretary, as well as the new position of HHS assistant secretary, were created by the Cures Act, which incorporated some changes to SAMHSA organization (see ADAW, Dec. 12, 2016, and Jan. 23).

Charles Curie, SAMHSA administrator from 2001 to 2006, gave us a sense of perspective about how the transition will work. “I know some of the people who are in acting positions at HHS — all have been in transitions before, all are highly competent, all SES [Senior Executive Service] with institutional knowledge, and are in a good position to inform stakeholders,” Curie told ADAW last week. For example, Acting Secretary of HHS Norris Cochran was at the Office of Management and Budget (OMB) when Curie was waiting to be confirmed as SAMHSA administrator. Cochran’s expertise is the health budget, and he has experience in Congress as well.

Curie, now a consultant in behavioral health, also has great confidence in the SAMHSA career officials — many of whom worked there when he was administrator. “These are very strong people,” he said. “Kana is an example of someone who is SES, key advisor on my team, and has demonstrated that she can work with a range of administrations.” A note on SES: it’s not based on seniority alone. A federal employee has to go through a review process, under which competence must be demonstrated. Also, Curie doesn’t think the title change is going to make much difference, noting that the SAMHSA administrator position always reported to the HHS secretary.

The transition

“In a transition, in the very early part of a new administration, you have a situation where prior to cabinet officials being confirmed and being in charge, you have senior executive career people who are in acting positions who are working with White House liaisons and counselors who are working for the new administration,” said Curie. These people are likely to be part of the HHS secretary’s new leadership team once the secretary is confirmed. (Tom Price, congressman from Georgia, is Trump’s nominee for HHS secretary.)

As for Medicaid and ACA changes, Curie cautions this is not a time to panic. “During a transition, where there’s been a major process to put into place, the assumption needs to be to continue with that process,” he said. For example, the treatment providers who have learned how to bill Medicaid and commercial insurance for services need to keep doing this, he said. “Any new process coming in is not going to be implemented quickly,” he said.

It’s still very early in the administration. More will be known when the secretary gets confirmed and when agency heads are put into place, said Curie. This doesn’t happen quickly. In Curie’s case, he was nominated in July 2001 — six months after the inauguration took place — and not confirmed until October.

Curie’s advice to new appointees is to “make sure what you are doing is aligned and transparent with what the White House wants,” he said. “Make sure stakeholders have had the opportunity to engage and have some ownership, and as you move forward, you can put new ideas on the table, facilitating trust for the administration.”

And everyone needs to “think about what is sustainable positive change, not just a quick win here or there,” Curie said. From his administration, he cited the Strategic Prevention Framework, Access to Recovery, the New Freedom Commission and the National Outcome Measures, all “readily embraced by the secretary and the White House.” Not all survived the Obama administration, which had other plans. But if the new drug strategy is any key, some of the same ideas — especially a focus on primary prevention — may come back.

ACA, parity and Medicaid/IMD

The National Association of Psychiatric Health Systems (NAPHS) is committed to three priorities as the Trump administration sets its policies: health insurance, parity for mental health and addiction, and increasing access for Medicaid patients by continuing progress in the Institutions for Mental Diseases (IMD) exclusion, according to President and CEO Mark J. Covall. “We recognize that there will be changes in the ACA, anything from total repeal to replacement, but we’re going to make sure that people have coverage however it plays out,” Covall told ADAW last week.

NAPHS will also “continue to preserve and protect the parity laws and regulations that are in place across the board,” said Covall. This includes those that apply to Medicaid as well as those that apply to the small business and the individual market, he said. “There’s strong bipartisan support for parity, and we’re going to keep the pressure on that one,” he said. Covall is co-chair of the Parity Implementation Coalition, and works with many partners on parity, including the Kennedy Forum and the American Psychiatric Association.

The IMD exclusion, under which Medicaid could not pay for treatment in a residential facility with more than 16 beds, was relaxed last year, allowing larger SUD and psychiatric facilities to obtain Medicaid payment for 15 days per calendar month (see ADAW, Aug. 1, 2016).  “We want to continue to break down the barriers to access, and a good example is the IMD exclusion, where we made some progress last year,” said Covall. “As part of that, we’re going to be very focused on Medicaid.”

The focus on Medicaid, as there is discussion of possibly changing the program to a block grant program, is an essential part of making sure there is health coverage for everyone, said Covall. “Maybe there will be changes — we’ll see,” he said. “But we want to make sure that individuals receiving Medicaid are protected.”

The interviews for this story were conducted before President Trump had been in office for even a week. The transition is still in transition. What is in place is what was in place before: a cadre of experienced staff at SAMHSA; an ONDCP in the process of developing a drug strategy that is not unlike those of the past; and plenty of funded programs and grants, laws and regulations. Above all, what remains regardless of politics: substance use disorders.

Bottom Line…

In the first few days of the Trump administration, we have learned that the new drug strategy will resemble that in place before Obama’s: primary prevention, treatment and sealing off the borders from illegal drugs.

1/23/2017 12:00 AM

One of the reasons for passing the Cures Act was to start to close an opioid treatment gap in which about 420,000 people said finances or lack of availability of treatment were the reasons they couldn’t get it. Repealing the Affordable Care Act would, Richard G. Frank, Ph.D., and Sherry Glied, Ph.D., write, “increase that gap by over 50% with the stroke of a pen.”

Repealing the Affordable Care Act (ACA) could undo the gains of the Cures Act, which gave $200 million to serious mental disorders and $1 billion to opioid use disorder treatment over the next two fiscal years, and go even further, taking billions away from treatment for substance use disorders (SUDs) and mental illnesses in years to come. The ACA, which builds upon the Mental Health Parity and Addiction Equity Act, gave many people health insurance who didn’t have it before, either through Medicaid expansion or subsidies of marketplace plans. Without the protections of the ACA, insurance companies could also single out people with pre-existing conditions to deny coverage. Rolling back the ACA will mean many people with mental illness and SUDs will end up in prison and jail instead of treatment, wrote Richard G. Frank, Ph.D., and Sherry Glied, Ph.D., in The Hill Jan. 11. Frank was formerly the assistant secretary for planning and evaluation in the Department of Health and Human Services, where he shepherded many initiatives through the regulatory process.

One of the reasons for passing the Cures Act was to start to close an opioid treatment gap in which about 420,000 people said finances or lack of availability of treatment were the reasons they couldn’t get it. Repealing the ACA would, Frank and Glied write, “increase that gap by over 50% with the stroke of a pen.”

Repealing just the mental and substance use disorder coverage provisions of the ACA would cut at least $5.5 billion a year from the treatment of people with mental and substance use disorders, leaving the Cures Act’s $500 million in 2017 and 2018 little more than a bandage, they write.

“The Congress and the American people have come to realize that stemming the tragic toll of opioid misuse and addiction and serious mental illnesses takes funding as well as policy,” they write. “It would be a cruel sham for Congress to take an important, but modest, step forward in investing in treatment capacity, while withdrawing funds from the enormous recent progress made in addressing the needs for care of those with mental health and addictive illnesses.”

Ultimately, people with the greatest need would end up in prison or jail, instead of getting treatment, they write. “Without the foundation of that ongoing financial support, those in the eye of the opioid storm and those who live in society’s shadows due to serious mental illnesses will continue to die of untreated illness, and their communities will continue to pay for the jails, prisons and homeless shelters that serve as our de-facto service system for many with these conditions,” Frank and Glied write. “Repealing the ACA — and its behavioral health provisions — would have stark effects on those with behavioral health illnesses,” they continue. “We estimate that approximately 1,253,000 people with serious mental disorders and about 2.8 million Americans with a substance use disorder, of whom about 222,000 have an opioid disorder, would lose some or all of their insurance coverage.”

And all four plans under discussion in Congress do not even mention Medicaid expansion. Five states that did expand Medicaid under the ACA would be particularly hurt when it comes to opioid use disorders.

Medicaid expansion in West Virginia

Also last week, Sen. Joe Manchin (D-West Virginia), along with other organizations from the state, announced the research by Harvard and New York University conducted by Frank and Glied that shows repealing the ACA would cut $5.5 billion per year from treatment and prevention of opioid use disorders. The removal of this funding would lead to increased deaths, homelessness and incarcerations and would adversely affect states with opioid challenges, according to Senator Manchin, whose state did take advantage of the Medicaid expansion provisions of the ACA. “Repealing the Affordable Care Act without a replacement will not only cause 184,000 West Virginians to lose their coverage, but would also cause those struggling with addiction to lose their treatment,” Senator Manchin said. “In West Virginia, half of the people in treatment would lose their coverage that was made possible through the Affordable Care Act. With our state leading the nation in drug overdose deaths, West Virginians cannot afford to have this critical funding ripped from them without a replacement ready. In order to beat this scourge on our society, we must use every tool and resource at our disposal and that includes the funding and consumer protections for individuals suffering from substance abuse disorders established by this law. While I recognize the serious flaws with the ACA, I will do everything in my power to protect the individuals, families, and communities in West Virginia who are struggling and ensure that they have the resources they need to combat this epidemic.”

Any cut of federal funding for SUD treatment “could literally kill members of my community,” said Judge William S. Thompson, circuit judge in the 25th Judicial Circuit (Boone and Lincoln counties). “We need to be expanding treatment dollars, not cutting them.”

Recovery Point West Virginia operates four residential recovery centers, and almost all patients are on Medicaid. ACA repeal would jeopardize health care coverage for the 250 individuals there now, said J. Matt Boggs, executive director. “Currently, 98% of Recovery Point clients are enrolled in Medicaid through the ACA expansion and have access to essential behavioral health and physical health services in our community,” he said.

Five new medication-assisted treatment (MAT) facilities have opened with funding through the ACA last year, said Louise Reese, chief executive officer of the West Virginia Primary Care Association. Young adults and pregnant mothers are among the patients getting this treatment, said Reese, adding that the new programs are providing MAT to about 700 patients, and already have long waiting lists. “West Virginia needs significant resources to reduce this serious epidemic and medication-assisted treatment is one of several important strategies to reduce addiction,” she said.

The Children’s Home Society of West Virginia cares for over 14,000 children and families annually, said Chief Operations Officer Mary White. “The expansion of Medicaid in West Virginia has benefited West Virginia’s most vulnerable children and families,” she said. Many of these families have been left homeless, and the number of children in foster care has been greatly increased — all because of the opioid epidemic, she said. “West Virginia’s Medicaid expansion has provided the additional resources to allow West Virginia child welfare providers to better care for and meet emergent needs,” White said.

Mark Drennan, executive director of the West Virginia Behavioral Healthcare Providers Association, said that Medicaid expansion under the ACA allowed his members to increase the number of patients to about 30,000 last year. “Prior to the ACA we served approximately 9,000 annually,” he said.

CBO report

Also last week, the Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) estimated the budgetary effects of H.R. 3762, the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015, which would repeal portions of the ACA. The law would have eliminated the ACA's mandate and subsidies but left market reforms in place. Now, the CBO has estimated the changes in coverage or premiums that would result from leaving market reforms in place while repealing penalties and subsidies. The report was prepared at the request of Senate Democrats.

In brief, the CBO and JCT estimate that enacting that legislation would affect insurance coverage and premiums primarily in these ways:

  • The number of people who are uninsured would increase by 18 million in the first new plan year following enactment of the bill. Later, after the elimination of the ACA’s expansion of Medicaid eligibility and of subsidies for insurance purchased through the ACA marketplaces, that number would increase to 27 million, and then to 32 million in 2026.
  • Premiums in the nongroup market (for individual policies purchased through the marketplaces or directly from insurers) would increase by 20 percent to 25 percent — relative to projections under current law — in the first new plan year following enactment. The increase would reach about 50 percent in the year following the elimination of the Medicaid expansion and the marketplace subsidies, and premiums would about double by 2026.

For the CBO report, go to https://www.cbo.gov/publication/52371.

Bottom Line…

Repealing the ACA, a process that Congress has begun and that was a key campaign promise of President Trump, would take treatment away from patients with opioid use disorders, and especially harm Medicaid expansion.

1/16/2017 12:00 AM

Last week, President-elect Donald Trump told reporters he considers any friendship with Russia an “asset,” and his fondness for the country — and, in particular, Russian President Vladimir Putin — is well-known.

But the two countries have very different approaches to opioid addiction. Russia bans methadone and buprenorphine treatment, and Putin closed all opioid treatment programs in Crimea after annexation, and Trump does not always listen to science. So we spent the past several weeks trying to find out what, if any, influence Russia and Putin could have on Trump’s thinking on treatment for opioid addiction.

Last week, President-elect Donald Trump told reporters he considers any friendship with Russia an “asset,” and his fondness for the country — and, in particular, Russian President Vladimir Putin — is well-known.

But the two countries have very different approaches to opioid addiction. Russia bans methadone and buprenorphine treatment, and Putin closed all opioid treatment programs (OTPs) in Crimea after annexation, and Trump does not always listen to science. So we spent the past several weeks trying to find out what, if any, influence Russia and Putin could have on Trump’s thinking on treatment for opioid addiction.

“Substitution therapy is against Russian law, just as it was in the United States between the 1920s and the late 1960s,” said George E. Woody, M.D., the University of Pennsylvania researcher on substance use who worked on the Russian Vivitrol study. He had been in a meeting in Moscow two months before we spoke to him in December, and said he saw no indication that the law would be changed.

Although there is a legal restriction against providing opioids to individuals who are opioid-dependent in Russia, buprenorphine can be prescribed for pain management for cancer patients, said Thomas Kresina, senior public health advisor in the Division of Pharmacologic Therapies of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA), who helps provide technical assistance to countries receiving PEPFAR (President's Emergency Plan for AIDS Relief) support related to substance abuse treatment and HIV. We talked to him instead of Kevin Mulvey, who is SAMHSA’s person in Kiev, and who was waiting to get approval from the embassy in Ukraine to speak to us. “I’m not clear if methadone itself is illegal in the Russian Federation, or if it could be used like buprenorphine in pain management, but all prescribers know it is illegal,” said Kresina. “Methadone is so stigmatized in the Russian medical community that I doubt anyone would use methadone for pain management.” As an aside, Kresina noted there is street methadone in Russia that is trafficked illegally there.

In fact, Russia never adopted agonist treatment, but the government does fund more than 25,000 inpatient beds for detoxification and treatment, Woody told ADAW. “These are free and have no apparent restrictions on length of stay or readmissions,” he said, noting that this is many more free beds than exist in the United States. “The problem is the high relapse rate after they leave, unless they are started on extended-release naltrexone, which is not widely available due to its cost.” Detoxification beds are widely available throughout the country, he said. Availability of extended-release naltrexone "is mostly confined to programs in Moscow and a few other places that have funds to purchase it." 

The last needle exchange in Moscow

“Why is there no methadone and buprenorphine in Russia, and why so much booze?” asked Anya Sarang, director of the Andrey Rylkov Foundation for Health and Social Justice, a grassroots organization for HIV and overdose prevention and the only group offering free needle exchanges in Moscow. “During the Soviet times there was a big opposition to the West and Western ideas, and the Russian narcologists were really against substitution treatment,” said Sarang, whom we reached via Skype in Amsterdam last month. There was some discussion of methadone in the 1990s, but no proposals that would allow for a clinical trial, she said. When Putin came to power in 2000, the ideology didn’t change. “There is no light at the end of the tunnel that Russia will change,” she said. However, there are some harm-reduction programs, first instituted in 1997–1998, involving needle exchanges and referral to testing for HIV, which is a very big problem in Russia. But by 2009 and 2010, the harm-reduction programs started getting clamped down on, and last year the Andrey Rylkov Foundation was labeled a “foreign agent” by the Russian government.

The Russian government never supported harm reduction financially, but before 2009, at least there was no open opposition, said Sarang. And there was initially some promise with government funding for HIV prevention. Asked why, she said “it’s the same reason why the programs weren’t funded in the first place — ideology and the conservative stance of the government.” And here’s the darker side: Officials don’t say it in Russia, but the common understanding is that the policy of the health ministry is to imprison injecting drug users, said Sarang. “People die of AIDS; we have a huge HIV epidemic and a rise of AIDS deaths,” she said. “We have no rehabilitation, and in prison, many people have HIV already, many get tuberculosis, and many die of AIDS.” In Russia, most people with HIV are drug users, she said. “We have to send some clients to Ukraine,” she said. “There’s no way for them to survive in Russia, but in Ukraine, they can get a combination of treatments.”

There is methadone in Ukraine, except in Crimea, which is no longer part of Ukraine but rather part of the Russian Federation since annexation. “The federal drug control service of Russia came and said all methadone programs would be shut down in Crimea,” said Sarang. “There were some attempts at negotiation with UNAIDS [Joint United Nations Programme on HIV/AIDS], but this was unsuccessful.” For a few months, as programs were shut down and patients didn’t receive help, there were deaths — 800, said Sarang. But propaganda kept this from the West. “The U.N. Special Envoy on HIV in Eastern Europe received an official note from the Minister of Health that this is all lies and that actually people used to die even before methadone was closed,” said Sarang. “There was a diplomatic scandal, and after that, all access to data has been shut down. There was no official kind of investigation around these deaths.”

‘Badly managed’ health system

People on the ground in Russia know that “the public health system is very badly managed,” said Sarang. “There is no area in public health where people don’t complain.” But all of the power is in Putin’s central administration, she said. Local authorities are afraid of being punished by the health department, she said. “Unless you are an activist organization like ours, you don’t do it,” she said. “The local administration says, ‘Yes, yes, I understand it is bad, we have an HIV epidemic, but we cannot do harm-reduction programs here.’”

Her group does outreach every night, usually near pharmacies where people buy the eyedrops to dilute heroin with, said Sarang. “We see maybe 10 to 30 people a night, give them syringes, condoms, health information, rapid testing for HIV, counseling and legal aid,” she said. Her work is currently funded by the Global Fund to Fight AIDS, Tuberculosis, and Malaria, but taking foreign funding puts the group at financial risk. “We are the last advocacy and, to be honest, quite loud organization,” she said.

AATOD and ASAM

Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD), is more concerned about who is going to head the Office of National Drug Control Policy (ONDCP) than about any connection between Russia and Trump. “If it’s a person who takes a dim view of medication-assisted treatment, that would be troublesome,” he told ADAW last month. “I can’t imagine that Trump would take any particular position to diminish OTPs, unless he has an adviser like a Giuliani type.” (Rudolph Giuliani, originally thought to be a contender for attorney general, tried to shut down OTPs in New York City when he was mayor.)

Could Trump shut down OTPs? “No, he can’t,” said Parrino. “You can’t shut down OTPs, and you can’t require patients to go on Vivitrol.”

Parrino said he couldn’t even imagine that someone would issue a directive to “de-operationalize OTPs or require them to change medication.” Ultimately, he asked, why do it? “It would be too insane,” he said, “even if Trump doesn’t understand the science.”

However, Parrino does think the Trump administration would be interested in eliminating the regulation limiting the number of patients a physician can treat with buprenorphine.

For the American Society of Addiction Medicine (ASAM), lifting the patient cap is indeed a hopeful sign of a Trump administration.

And Vivitrol is likely to be favored by many in the United States who do not like agonists, having the same biases that are seen in Russia.

Vivitrol

Indeed, Vivitrol, first approved in the United States to treat alcohol use disorders, was tested in Russia as a treatment for opioid use disorders. As Daniel Wolfe of the Open Society Foundations pointed out in The Lancet six years ago, Russia was one of the few places in the world where it would have been ethical to conduct a randomized controlled trial with Vivitrol and not include a comparison to the two medications proven to be effective for opioid use disorders (see ADAW, May 9, 2011). It would not have been ethical to give patients Vivitrol compared to nothing in a place where medications that work were available. To this day, that fact has created questions in the treatment community about the real effectiveness of Vivitrol. The criminal justice community, which has a bias against agonist medications, does approve of Vivitrol.

And while Vivitrol meets the ideological needs of the criminal justice system, some policymakers in the United States, and the Russian government, it’s expensive, doesn’t work unless people keep getting the shots and has questionable effects on craving (see ADAW, March 7, 2016).

The global view

While politics shouldn’t guide science, policymakers have their own ideas. And, unfortunately, they often consult themselves instead of scientists when it comes to addiction, say medical officials. “Often policymakers are unaware of or ignorant about addiction,” said Gregory Bunt, M.D., president of the International Society of Addiction Medicine, the global counterpart of ASAM. “HIV prevalence has more than quadrupled and the opioid epidemic is raging out of control in Russia,” said Bunt, who is a clinical assistant professor in the Department of Psychiatry at the New York University School of Medicine. He noted that ignorance among policymakers is not limited to Russia. “It’s also true in the United States,” he said.

Incarceration is not treatment, and both the United States and Russia have a long way to go on that, although access to evidence-based treatment is much more accessible in the United States, said Bunt. “We need to increase access to treatment,” he said.

At the United Nations conference last spring (see ADAW, April 25, 2016), it was understood that treatment must be a priority, said Bunt. Vladimir Poznyak, M.D., Ph.D., the head of substance abuse management for the World Health Organization, has laid out a manual for the U.S. State Department that clarifies that addiction is a treatable disease. “The problem we identified is that the amount of resources devoted to interdiction, prosecution and corrections far surpasses the amount of resources devoted to treatment,” said Bunt. “The problem can’t be solved by the criminal justice system only. But treatment providers understand that under various governments, they have to work within the system. That’s true in the United States and it’s true in Russia.”

So who supports the regime in Russia that is leading to an increase in HIV, AIDS and addiction? “I talk to my circle of people and they say there is 99 percent support of Putin in Russia, but I don’t know anybody who supports Putin in Russia,” said Sarang. “Maybe somebody is happy, but we just don’t know these people.”

Bottom Line…

It’s too soon to say what a Trump presidency will mean for methadone and buprenorphine, but the anti-agonist Russian model has proven disastrous for that country in terms of addiction and HIV/AIDS.

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
    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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