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8/7/2017 12:00 AM

Confidentiality of substance use disorder (SUD) patient records is under attack again, less than a year after the Substance Abuse and Mental Health Services Administration finalized a rule to make it easier to share this information within health systems. This time, the opposition to consent provisions, which give the patient the right to say who gets his or her SUD information, comes not only from some in the insurance and mental health treatment community, but from some treatment providers themselves.

Confidentiality of substance use disorder (SUD) patient records is under attack again, less than a year after the Substance Abuse and Mental Health Services Administration (SAMHSA) finalized a rule to make it easier to share this information within health systems. This time, the opposition to consent provisions, which give the patient the right to say who gets his or her SUD information, comes not only from some in the insurance and mental health treatment community, but from some treatment providers themselves.

The main objection is to the consent provisions of 42 CFR Part 2, the SAMHSA regulation almost four decades old, which was recently changed to make it easier to exchange information within a health system.

But none of the opponents of consent is able to answer the two-part question: If a patient wants to give consent, why do you object to obtaining it? And if they don’t want to give consent, why are you taking that choice away from them?

The attack comes from two places: the Partnership to Amend 42 CFR Part 2, which includes the Hazelden-Betty Ford Foundation and the American Society of Addiction Medicine and is spearheaded by the Association for Behavioral Health and Wellness (ABHW), and a bill proposed by Rep. Tim Murphy (R-Pennsylvania) that would gut the law implementing 42 CFR Part 2 and is supported by that partnership. The ABHW is a membership organization of managed behavioral health care organizations and counts among its partners Alkermes (which makes Vivitrol), Indivior (which makes Suboxone) and Braeburn (which makes Probuphine, the buprenorphine implant). But Indivior and Braeburn are working on buprenorphine injectables as well.

The partnership and the bill want to align 42 CFR Part 2 with the Health Insurance Portability and Accountability Act (HIPAA), which does not require that a patient consent to release of his or her patient information, and allows for easy sharing within health care providers.

According to the partnership’s July 28 statement, 42 CFR Part 2 is “not compatible with the way health care is delivered”; it does not allow for integration of care, which can lead to risks to patients, “such as contraindicated prescription medicines and problems related to medication adherence”; and “obtaining multiple consents from a patient is challenging.”

Rep. Murphy’s bill, The Overdose Prevention and Patient Safety Act (H.R. 3545), would also place all SUD patient records under the much looser protections of HIPAA.

Both the proposed legislation and the coalition got support from the White House Commission on Combating Drug Addiction and the Opioid Crisis (see p. tk), released July 31, which also calls for 42 CFR Part 2 to be changed to HIPAA.

ASAM stance

“I used to work in an emergency department, and I was unable to get records from a methadone clinic,” said Corey Waller, M.D., chair of ASAM’s legislative advocacy committee. “Let’s say a patient is not doing well and asks for medications for pain — we’re putting them at risk for mortality,” Waller told ADAW, citing one of the most common reasons ASAM members cite for wanting to abolish consent provisions of 42 CFR Part 2.

Many of Waller’s patients are pregnant people with SUDs, so he understands the need for confidentiality. “There is no way that we want this entire thing to slip into HIPAA without some specific conditions,” he said. These conditions include “the capability to exempt these records from criminal proceedings except for a direct court order,” he said.

The main point of the 42 CFR Part 2 consent form is that it allows the patient to dictate who gets the information. This “to whom” part of the consent form is considered particularly onerous because it means a new form for every new person or organization.

And, said Waller, the problem is that the information should be as readily available as other health information. “I will find information about cancer, about diabetes, because it will be part of the normal record,” said Waller.

Finally, Waller doesn’t trust patients to disclose information on their own about their SUDs. “If a patient is diagnosed with a severe opioid use disorder, they’re not going to walk into an emergency room and tell them that,” he said. “Without the knowledge of what the patient has, they’re going to get bad treatment that puts them at risk.”

ASAM is in the process of writing a “global consent form,” said Waller. “With the release of Murphy’s bill, we’re starting to gear up for what it would look like,” he said.

Hazelden Betty Ford

Jennifer Lohse, vice president and general counsel for Hazelden Betty Ford, said that patients want to coordinate care with their primary physician. Under 42 CFR Part 2, the program “has to do a lot of paperwork” to give consents to coordinate care, said Lohse. Under HIPAA, “if a patient says I want you to coordinate care with my GP at home, we wouldn’t have to do paperwork,” she said.

Pressed for why it is so hard to obtain the consent, if the patients want to give it, Lohse did not have a good answer, beyond the paperwork.

Lohse did give two other examples of problems with 42 CFR Part 2. First, when people contact the program to find out if their insurance would cover treatment, the program would have to obtain consent before investigating this with the insurance company, she said. Second, in e-prescribing, the provisions banning redisclosure of the information take up too much space, she said. The electronic health record (EHR) won’t accept the redisclosure notice “because there are too many characters,” she said.

Legal Action Center

The Legal Action Center, which has been working on confidentiality regulations since the beginning, noted that if the health care field wants to share SUD patient information within a system without consent, SAMHSA provided for that in the final rule.

“There is a statute, and we are strongly opposed to eliminating Part 2 or folding it into HIPAA or anything else that would eviscerate the confidentiality regulations,” said Paul Samuels, director and president of the Legal Action Center. “We do not understand where this is coming from, given the fact that SAMHSA has recently amended the regulation to make it easier for substance use providers to share information with the rest of health care.”

The Legal Action Center has long held that it is important to facilitate effective communication between SUD providers and the health care system, but confidentiality is necessary “so that treatment records cannot be used to include great damage to the lives” of patients, he said. In addition, dismantling consent “would discourage those in need for care from coming forward to seek it.”

Samuels dismissed the concerns about checking patient benefits. “For decades now, SUD providers have been able to navigate issues involving patient applicants by either arranging to have a written consent, which has become even easier with digital technology, or by touching base with the insurer and asking what the coverage is under a certain plan.”

And SAMHSA has been issuing and will continue to issue subregulatory guidance on 42 CFR Part 2, as it stated in the final rule. “There are issues that still need to be worked out,” said Deborah Reid, senior health policy attorney with the Legal Action Center. If something needs to be changed to make e-prescribing easier, SAMHSA can provide guidance on that, she said. “It’s not as if the doors are shut,” she said. “It would be more helpful to ask SAMHSA to do some subregulatory guidance.”

AATOD, other providers

Neither the National Association of State Alcohol and Drug Abuse Directors (NASADAD) nor the National Association of Addiction Treatment Providers (of which Hazelden Betty Ford is a member) signed on to the partnership. Neither had a comment, either.

Mark Parrino, president and executive director of the Association for the Treatment of Opioid Dependence (AATOD), said that much of the support for revising 42 CFR Part 2 comes from software vendors (indeed, Netsmart is in the partnership) and insurance companies.

“But there is also a great deal of talk about integrating and normalizing patient care, regardless of what illness the patient is treated for,” said Parrino. “Then we come down to the reality of stigma and how much that affects patient care.” In his discussions with methadone patient advocates, he has heard many stories about patients who have “lost something when an individual or an organization finds out that they are a patient in treatment,” said Parrino. This even applies to patients in office-based opioid treatment with methadone, he said. “There are individuals who cannot get either life or disability insurance once it has been discovered that they are using buprenorphine in a DATA 2000 practice,” he said.

There are also many stories of women who have lost custody of their children simply because they were on methadone maintenance, said Parrino. “In such cases, Child Protective Service workers, who think they are doing well by the newborn, compel the mother to withdraw from methadone with universally negative results,” he said. “There are also many reports where judges are compelling the patient to end their treatment once they find out that the patient is using either methadone or buprenorphine.”

The possibility that their patient information will be disclosed may discourage patients from even seeking treatment, added Parrino. “They cross the threshold into treatment programs with some trepidation,” he said. “They hope that they will encounter a welcoming and therapeutic environment, with trained and compassionate personnel,” he added. “They also hope that they are not taking other risks, which may not be obvious at the time of patient admission. In order to keep the patients in treatment, it is important to ensure that their treatment remain confidential and they do not risk any potential exposure.”

Naïveté and inconvenience

H. Westley Clark, M.D., executive professor of public health at Santa Clara University, blames Hazelden Betty Ford for taking the “convenient” route. “It appears that when a premier substance use disorder treatment program is willing to ignore potential harms that could result from inappropriate disclosure simply because it is inconvenient to press EHR vendors and others to modernize their information sharing, a sad state of affairs exists,” he said. “The issue isn’t patient unwillingness to share; it is that Hazelden doesn’t want to be inconvenienced.”

It is “strange that patient consent is viewed as a barrier to integrated care,” he added. “This suggests that whole-person care is not patient-centered care, but provider convenience.” Clark also criticized ASAM, Hazelden and the American Psychiatric Association for their decision to “engage in advocacy that would undermine patient autonomy and share decision-making.”

Without patient participation, there can be no whole-person care, said Clark, who was director of SAMHSA’s Center for Substance Abuse Treatment for most of the rulemaking. “There can be discrimination and harm, but no whole-person care,” he said.

“I am shocked at their naïveté,” said Clark of ASAM. “The notion that they can eviscerate 42 CFR Part 2 so that they can join the rest of medicine is an exercise in self-deception. Somehow they believe that they can minimize harm while disclosing personal information so that the rest of medicine is not inconvenienced ignores that their bread and butter turns on the trust that patients have in them.”

Once harm occurs, providers will bear the brunt of malpractice claims, and, ultimately, patients will be reluctant to enter treatment, said Clark. “If ASAM wants to abandon the object of its profits, then the members of ASAM will have to figure out how to interact with patients in a manner that does not result in patients being compromised,” he said.

Clark noted that 89 percent of people who meet criteria for needing treatment are not in treatment and do not seek treatment. “Once it becomes clear to all that substance use disorder treatment records could under HIPAA’s health care operations exemption be disclosed for administrative things like business planning, customer service, and training of non-health care professionals, there will be even less enthusiasm for medically oriented treatment,” he said. “In small to middle sized communities where privacy can easily be compromised, the current revised 42 CFR Part 2 protections are essential.” What is worse, Clark observed, is that the Murphy bill and the Partnership’s actions will decrease the perceived treatment choices for those with opioid use disorders, making social model treatment options the preferred choice, even when medication assisted treatments are indicated. “If we are in the midst of an opioid crisis, we should be reducing barriers to care, not constructing them.”



Criminal justice system

AATOD’s Parrino, who frequently cites patient interactions with treatment and the need for treatment to be welcoming, agrees. “Insurance companies and other groups that are beating the bushes to end the patient confidentiality protection offered to patients through 42 CFR Part 2, thinking that the protections will remain in effect with HIPAA, simply do not understand the differences between the two approaches,” he said. “Other than that, they are looking out for the interests of their members and companies but not the long-term interests of the patients.”

Finally, Samuels noted that by focusing only on disclosures within health care, ASAM and others are losing sight of all the other harm that could come to a patient without the protections of 42 CFR Part 2.

If law enforcement seeks patient records, HIPAA provides very little protection, Samuels added. There doesn’t need to be a court order specific to SUD records — it could be just a subpoena, search warrant or other power under law, he said.

The timing also seems to ignore the fact that Attorney General Jeff Sessions is promoting policies aimed at arresting and prosecuting drug users and purchasers. Unlike cancer and diabetes — or any other health care condition — only SUDs can lead people directly to prison. Do treatment providers want to deliver them there?

“SAMHSA has addressed health care,” said Samuels. “Let’s allow those recommendations to move forward. But to eliminate 42 CFR Part 2 would be opening access to records to arrest and prosecute patients.”

For the Murphy bill, go to https://murphy.house.gov/opioid-and-drug-addiction-crisis/the-overdose-prevention-and-patient-safety-act/.

Bottom Line…

A coalition of organizations opposed to 42 CFR Part 2, including ASAM and Hazelden Betty Ford, joins forces with Rep. Tim Murphy in proposing folding it into HIPAA.

6/29/2017 12:00 AM

Four not-for-profits have joined forces to fight for compliance for parity in addiction treatment and insurance — the National Center on Addiction and Substance Abuse, the Legal Action Center, the Partnership for Drug-Free Kids and the Treatment Research Institute. The first initiative of the group, called the Addiction Solutions Campaign (ASC), will be securing insurance coverage for addiction treatment, which consumers are assured under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Enforcement of the MHPAEA has failed to close the treatment gap, especially as the opioid epidemic is adding to the demand.

Four not-for-profits have joined forces to fight for compliance for parity in addiction treatment and insurance — the National Center on Addiction and Substance Abuse, Legal Action Center (LAC), Partnership for Drug-Free Kids and Treatment Research Institute. The first initiative of the group, called the Addiction Solutions Campaign (ASC), will be securing insurance coverage for addiction treatment, which consumers are assured under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Enforcement of the MHPAEA has failed to close the treatment gap, especially as the opioid epidemic is adding to the demand.

“At a time when effective treatment for opioid addiction in the U.S. is so desperately needed, lack of transparency is one barrier that can be immediately removed if insurers make information about covered services more transparent to consumers, and regulators demand this transparency before allowing plans to be sold,” said Paul Samuels, director and president of the LAC and spokesman for the ASC. “It is clear today that even as 144 Americans die every day from a drug overdose related death, we are still struggling to address an unprecedented epidemic of substance use disorders, and that the requirements of the Parity Act are still not being met,” said Samuels. “The current enforcement system is flawed and some families are paying the ultimate price. Families often don’t know what their coverage is, or how or where to complain.” In fact, enforcement of the MHPAEA has been dependent on “complaining,” with family members and patients having to notify regulators about violations, and engage in burdensome processes to get coverage, according to the ASC.

Specifically, the ASC recommends:

  • Plans should be required to submit their internal analyses to demonstrate that coverage is compliant with the Parity Law, including identification of all specific limitations on benefit scope or access to services, such as preauthorization requirements or ‘’fail-first” policies.
  • As part of review for parity compliance, regulatory agencies should evaluate the scope of prescription drug coverage for mental health and substance use disorder treatment and utilization management requirements.
  • Regulatory agencies should develop model contracts that fully describe substance use and mental health benefits, align standards with Parity Act requirements and inform consumers of their rights under the law.
  • Regulatory agencies should enhance the provider community’s capacity to identify potential Parity Act violations and advocate for plan compliance in network adequacy and rate-setting standards.

The National Center on Addiction and Substance Abuse, Legal Action Center and Treatment Research Institute analyzed documents from seven small-group, large-group and employer-sponsored plans in New York and Maryland. The research was funded by Indivior. For the executive summary of the report, go to https://drugfree.org/wp-content/uploads/2017/06/Executive-Summary-Parity-Final-6-20-17.-REV-6-15.pdf.

6/11/2017 12:00 AM

Infants born to mothers who are in treatment for opioid use disorders with methadone are sometimes born with neonatal abstinence syndrome (NAS), a constellation of symptoms associated with opioid withdrawal. The old way of treating these infants — and the current way in many institutions — is to put them in the neonatal intensive care unit (NICU) and treat them with gradually decreasing doses of morphine. But keep out of the NICU, standardize nonpharmacologic care and empower parents, and what do you get? A reduction in the percentage of infants treated with morphine from 98 percent to 14 percent, a reduction in average length of stay (ALOS) from 22.4 to 5.9 days and a decrease in costs from $44,824 to $10,289. That is what researchers at Yale New Haven Children’s Hospital discovered when they implemented novel “plan-do-study-act” cycles in 2010 in response to a dramatic increase in the number of infants born there who had been exposed to methadone in utero (a 74 percent increase from 2003 to 2009).

Infants born to mothers who are in treatment for opioid use disorders with methadone are sometimes born with neonatal abstinence syndrome (NAS), a constellation of symptoms associated with opioid withdrawal. The old way of treating these infants — and the current way in many institutions — is to put them in the neonatal intensive care unit (NICU) and treat them with gradually decreasing doses of morphine. But keep out of the NICU, standardize nonpharmacologic care and empower parents, and what do you get? A reduction in the percentage of infants treated with morphine from 98 percent to 14 percent, a reduction in average length of stay (ALOS) from 22.4 to 5.9 days and a decrease in costs from $44,824 to $10,289. That is what researchers at Yale New Haven Children’s Hospital discovered when they implemented novel “plan-do-study-act” cycles in 2010 in response to a dramatic increase in the number of infants born there who had been exposed to methadone in utero (a 74 percent increase from 2003 to 2009).

The goal was to reduce the ALOS by 50 percent — a goal the interventions far exceeded.

There were 287 methadone-exposed infants in the study, including 55 from the baseline period (2008 to 2010) and 44 from the post-implementation period (2015 to 2016). There were no adverse events, and no infants were readmitted for treatment of NAS.

Other institutions had successfully reduced ALOS after implementing a weaning protocol for morphine and standardizing the scoring of the Finnegan Neonatal Abstinence Scoring System (FNASS), which assigns a numerical score to 21 subjective clinical signs of NAS. It is usually used in an NICU, but there is no evidence that infants with NAS require management in an NICU, and in fact, it makes rooming-in out of the question, which itself is a nonpharmacologic intervention for NAS.

The researchers at Yale “set out to change the paradigm of how we approached the management of infants with NAS,” decreasing ALOS by not using morphine. They used the interventions with all infants with NAS, but only analyzed results for those born at least 35 weeks’ gestation and whose mothers took methadone daily for at least one month before delivery, because they “considered this population to be the most likely to develop signs of withdrawal.” Infants with significant comorbidities were excluded.

During the pre-intervention period, all infants at risk for NAS were admitted directly to the NICU after birth, and infants were monitored using the FNASS. Infants were initially managed in the NICU, with those with scores justifying medication getting morphine. Then, at the discretion of the neonatologist, they were either discharged or transferred to the inpatient unit. At day 5 of life, infants who received no morphine were discharged; infants receiving morphine were discharged one day after the medication was stopped. The second year of the pre-intervention period, the researchers noted an increase in the number of infants with NAS and identified four key drivers that could reduce ALOS: nonpharmacologic interventions, simplified assessment of infants, decreased use of morphine and communication between units.

The interventions

Over the next five years, the researchers developed and implemented eight interventions aimed at reducing the ALOS of infants with NAS.

  • Standardized nonpharmacologic care
  • Prenatal counseling of parents
  • Transfer from well-baby nursery (WBN) to the inpatient unit (with the mother)
  • Development of novel approach to assessment
  • Morphine given as needed
  • Empowering messaging to parents
  • Spread of change concepts to NICU

Nonpharmacologic interventions: Nonpharmacologic interventions included being placed in a low-stimulation environment with dimmed lights, muted televisions and reduced noise. Parents were continuously available to their infants; parents were strongly encouraged to room-in, to feed their infants on demand and to tend to their infant if crying. Staff were trained to view nonpharmacologic interventions as equivalent to medications — “when increased intervention was warranted, the approach was to increase the involvement of the parents before using pharmacologic treatment.” In conjunction with the well-baby nursery, clinicians encouraged breast-milk feeding of all infants for whom there were no contraindications (illicit drug use or HIV).

Prenatal counseling: The parents were given informational handouts several weeks before delivery, and told that they would be expected to stay with their infant throughout hospitalization. They were also able to ask questions, which the outpatient care coordinator would answer.

Empowering messaging to parents: On the inpatient unit, the parents were told that the most important treatment would be measures to comfort the infant, and that these measures should be performed by the mother or father (or other family member). Parents were told that they needed to be present at the hospital as much as possible. Nurses and doctors focused on supporting and coaching parents.

Novel approach to assessment: Instead of using FNASS scores for babies on the inpatient unit (these scores were still used in the WBN and the NICU), the researchers developed their own assessment focused on three parameters: the infant’s ability to eat, to sleep and to be consoled. If the infant couldn’t breastfeed or take at least one ounce from a bottle, or sleep for more than an hour, and took 10 minutes or more to be consoled when crying, nonpharmacologic interventions were maximized. If these didn’t work, morphine was either started or increased.

Morphine as needed: Instead of using rapid morphine weans on a schedule, the researchers modified their approach to give morphine as needed. “We noticed that signs of withdrawal were not always consistent throughout the day,” the researchers wrote. “In addition, sometimes we were unable to provide optimal nonpharmacologic care, such as when no parent, family member, or volunteer could be present.” If the maximal nonpharmacologic interventions were not effective, the infant would get one dose of morphine. If the infant was sleeping well, eating well and consolable within 10 minutes, additional doses of morphine were not administered.

The level IV NICU housed infants with NAS in rooms with as many as 12 infants. There was no ability for parents to room-in, and the environment was not low-stimulation. “We discontinued the practice of directly admitting infants at risk for NAS to the NICU after birth in an effort to keep the mother-infant dyad intact,” the researchers wrote. Instead, these infants were taken to the WBN, where FNASS scores were measured, and if the score was 8 or more, the babies were transferred to the inpatient unit, where the mothers could room-in and nonpharmacologic measures were initiated as soon as possible for all opioid-exposed infants, whether they had withdrawal signs or not.

Results

There were 287 infants who met inclusion criteria between January 2008 and June 2016. The ALOS decreased from 22.4 days during the baseline period to 5.9 days in the post-implementation period. In 2010, the nonpharmacologic interventions were standardized; in December 2011, the babies started being transferred directly to the inpatient unit so they could room-in; in January 2014, the novel assessment approach on the inpatient unit began; in June 2014, implementation of prenatal counseling and rapid morphine weaning began; and in June 2015, rapid morphine weaning was replaced by as-needed morphine dosing and empowering messaging to parents began. Overall, the proportion of infants treated with morphine decreased from 98 percent to 14 percent, and the average cost of hospitalization decreased from $44,824 to $10,289.

For those infants transferred from the WBN to the NICU, only 6 percent (2 of 35) received morphine. The proportion of infants who took most of their feeding from breast milk increased from 20 percent to 45 percent. The proportion of infants admitted directly to the NICU decreased from 100 percent to 20 percent. No patient admitted to the inpatient unit required transfer to an ICU. There were no seizures and no readmissions within 30 days.

Implications

The changes in treatment of NAS — to less medical and more parental involvement — went far beyond the researchers’ goal of a 50 percent reduction in ALOS. The eight plan-do-study-act cycles led to an improvement in ALOS, well below that reported in any other published studies, and “we are confident that our interventions directly resulted in the changes observed,” they wrote.

“One of our study’s strengths was the inclusion of all methadone-exposed infants, which allowed us to fully measure the impact of our interventions,” they wrote.

Many studies define NAS as receiving pharmacologic treatment — in other words, only babies who received morphine count as having NAS. But that definition makes it impossible to draw conclusions about the effectiveness of nonpharmacologic interventions, the researchers note. “The use of medication to treat clinical signs should not be the sole factor used to define the syndrome,” they wrote. “Although we applied our interventions to all opioid-exposed infants, we focused our evaluation on the subset of opioid-exposed infants most likely to develop withdrawal, regardless of the eventual treatment received.”

Because methadone is a long-acting opioid, infants exposed to it are more likely to have signs of withdrawal than those exposed to short-acting opioids or buprenorphine, the researchers wrote. “By initiating intensive nonpharmacologic interventions for all methadone-exposed infants from the time of birth and before the presentation of clinical signs of withdrawal, we were able to intervene earlier and to prepare parents for their critical role in treatment,” they wrote. “We believe this strategy contributed greatly to our success.”

The researchers also said there has never been validation of starting or changing pharmacologic treatment for NAS based on FNASS scores. In addition, it’s impossible to obtain an FNASS score without disturbing and unswaddling the baby, which increases the likelihood of high scores in terms of tremors, tone and cry. “Our approach encouraged providers to focus on a small number of clinically relevant factors to assess the need for treatment with morphine,” they wrote. “Ideally, all infants should feed well, sleep well, and be easily consoled. We determined that if infants with NAS met these goals, then treatment was successful irrespective of the FNASS score.”

When less is more

A decade ago, all infants with NAS were admitted straight to the NICU, where rooming-in was not permitted and the only nonpharmacologic intervention was swaddling. In this setting, 98 percent of the babies exposed to methadone required morphine. By changing the milieu, the intervention changed an entire system, to one in which parents were not only allowed to visit their baby but encouraged to be the most important part of their baby’s treatment. “This approach employed the power of the maternal-infant bond to treat NAS,” the researchers wrote.

By changing the paradigm, the researchers reduced the use of morphine, the ALOS and costs.

The study, “An Initiative to Improve the Quality of Care of Infants with Neonatal Abstinence Syndrome,” is in the current issue of Pediatrics and was funded by the National Institutes of Health, and the researchers reported they had no conflicts of interest to disclose.

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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