When Gloucester, Massachusetts, police chief Leonard Campanello announced on Facebook last spring that he would accept drug users’ drugs and equipment and send them to treatment instead of arresting them for possession, treatment providers and patient advocates were full of praise. At the time, ADAW reported that a treatment program in Florida had sent a marketing person to Gloucester to request that patients with out-of-network coverage be referred (see ADAW, July 27, 2015). Now, however, the initiative is far more sophisticated, with local providers being included. But there aren’t enough local beds for inpatient care, and there are concerns as treatment providers ask why the police department is choosing what kind of treatment patients should get and where they should get it. In particular, buprenorphine and methadone maintenance, the two treatments with the longest history of evidence in the treatment of opioid use disorders, appear to be getting short shrift in favor of drug-free residential treatment. And most recently, Vivitrol has been touted by the Arlington Police Department, which robocalled 20,000 residents to attend a town meeting on the subject January 26.
On the other hand, the drug-free residential providers that are partnering with the police initiative, which has spread beyond Gloucester, speak favorably of the partnership, and are doing their best to accommodate the patients, some of whom have been promised “scholarships,” or free treatment.
MAT first-line treatment
For most patients with opioid use disorders, some form of medication-assisted treatment is the most efficacious, said Ken Freedman, M.D., director of the New England region of the American Society of Addiction Medicine. “There are exceptions, but for those who have been using opioids consistently, either methadone, buprenorphine or Vivitrol is preferred” over any other kind of treatment, said Freedman, who is a clinical professor of medicine at the Tufts University School of Medicine and chief medical officer at Lemuel Shattuck Hospital. Gloucester police Chief Campanello was going to be speaking at Lemuel Shattuck on February 1, said Freedman. “The bottom line is that the chief is promising immediate treatment, and there weren’t enough slots in Massachusetts, so they have to send people out of state,” he said.
However, Freedman was concerned about patients going to abstinence-based programs. “The percentage of success in drug-free rehab for opioid use disorders is quite low,” he said. “And for those who are on medication-assisted treatment and then come off it, the relapse rate is 85 to 90 percent.”
John Guilfoil, executive director of the Police Assisted Addiction and Recovery Initiative (PAARI), which was co-founded by Campanello and developer and activist John Rosenthal, has his own public relations company and is the spokesman for the Gloucester Police Department. “We have a network of more than 200 treatment centers,” Guilfoil told ADAW last week. So far, the Gloucester program has sent more than 400 people to treatment, he said. An additional 200 were sent to treatment by other police departments participating in the PAARI program. “We don’t know where” each person went.
“In order for a treatment program to become a partner with the PAARI organization, we first scientifically and medically vet it to make sure it’s backed by science,” he said. In addition, the treatment center has to “guarantee a certain number of scholarships,” he said.
The actual treatment may be decided by the police department and not the treatment provider; we received conflicting information on this. According to Guilfoil of PAARI, the police decide. “The police department does an intake on each person who comes in, and based on that, we will call a treatment center,” he said. And although the program is open to all kinds of addictions, he said, “almost everyone has been a heroin or an opioid addict.”
Some of the police departments that work with PAARI use methadone, buprenorphine and Vivitrol, said Guilfoil. However, the programs listed as partners on the PAARI website are all inpatient and abstinence-based, he said.
“The Gloucester Police Department and PAARI are unequivocal in their belief that people who make their living off the drug trade should be aggressively pursued, but we are in favor of the Good Samaritan laws,” said Guilfoil. “We fully acknowledge the great work that the district attorneys do.” However, he said that PAARI does not believe in arresting people who ask for treatment. “If you’re a police partner with the PAARI organization, that means you have made a decision to use your protected and well-known right to police discretion to put a person who asks for help into treatment and not be arrested,” he said. “If you come to any of the PAARI police agencies seeking help, you can rest assured that no police officer will arrest you and nobody will prosecute you. It’s no questions asked, nobody’s going to interrogate you, nobody’s going to be recording a conversation with you.”
The main provider getting referrals is Worcester-based Spectrum Health Systems, said Guilfoil. Spectrum CEO and President Charles Faris is on the PAARI board of directors.
Brendan Melican, Spectrum’s spokesman, told ADAW that 170 patients were referred to the program’s detoxification and residential program from the Gloucester Police Department. “We offer medication-assisted treatment as well,” he said. Spectrum has a comprehensive continuum of care, including an opioid treatment program that provides methadone, outpatient buprenorphine treatment, sober living and more. We asked how many of the 170 patients referred from Gloucester received either methadone or buprenorphine. He wasn’t sure, because Spectrum doesn’t track the referral source data. However, he said there are some patients who requested outpatient treatment with medications, although he didn’t know if the medications were methadone, buprenorphine or Vivitrol.
Lahey Health Behavioral Services, based in Danvers, is working with the Gloucester Police Department to embed a master’s-level clinician to provide triage, said Hilary Jacobs, vice president of addiction services. Jacobs, formerly the Single State Authority for Massachusetts, said there is “some agreement that while some people will require inpatient detoxification, that medication-assisted treatment beyond Vivitrol is a real option,” she said, noting that Lahey has an opioid treatment program (OTP) in Gloucester. “Our OTP has a good relationship with the Gloucester Police Department,” she said, although she did not know if anyone had been referred to the OTP from the police department.
In the Lahey system, as elsewhere in the state, inpatient beds are always full, Jacobs told ADAW. She said there is a statewide initiative for patients who are in inpatient detoxification to be offered expedited treatment in OTPs with methadone.
One of the problems with abstinence-based rehabilitation programs that was highlighted in a January 25 New York Times story about the Gloucester initiative is relapse and overdose. One patient who had been through multiple rehabs through Gloucester overdosed and died. Campanello said the police department would mourn the loss of the young woman.
Jacobs of Lahey hopes that the master’s-level clinician to be embedded in the Gloucester Police Department may be able to help with aftercare. “But I don’t know if it’s fair to lay the blame with police departments,” she said. “Treatment programs need to provide aftercare.”
Mylene Krzanowski, executive vice president of regional advancement at Caron Treatment Centers, confirmed that Caron has allotted three beds a year for scholarships for the Gloucester Police Department. “I think it’s an interesting concept,” said Krzanowski of the PAARI initiative. “We’ve always seen a number of patients coming from the criminal justice system,” she said, noting that the practice started with Caron’s founder. “Dick Caron visited the local jails when people were being released, and many times people came into treatment that way.”
Patients in Massachusetts do have insurance coverage but, because of the bed shortage in the commonwealth, cannot access treatment locally, she said.
Caron’s provision of scholarships to Gloucester is consistent with the center’s longstanding position of providing scholarships for people who can’t afford treatment, said Krzanowski. However, in the case of the Gloucester agreement, the scholarships are “given out at the discretion of the police chief,” she told ADAW.
Buprenorphine and methadone
Massachusetts is home to CleanSlate, which provides outpatient treatment for addiction, including buprenorphine treatment. There are always slots able to be filled, with offices across the commonwealth and more opening shortly, and CleanSlate president and CEO Amanda Wilson, M.D. approached the Gloucester Police Department about getting referrals. Ultimately, she was not well-received. “I had two phone calls with the police chief,” she said. “The first went well. In the second, he said I had to talk to the [PAARI] board to get the OK.” That phone call with the board made it clear that “they had the strong opinion that patients shouldn’t be put on medications,” Wilson told ADAW. “To their credit, they’re not putting people in jail — that’s a step forward.” But she is concerned that nonmedical people are making decisions about “what’s appropriate care,” she said. She also felt that they thought her defense of buprenorphine maintenance was motivated by self-interest.
The PAARI board also was concerned that the CleanSlate clinics are not open 24 hours a day, 7 days a week, and would not be able to take patients who walk into the police department during off-hours. However, Wilson was able to arrange with residential facility Phoenix House to accept patients via the ambulance that works with the Gloucester Police Department. Phoenix House Medical Director Andrew Kolodny, M.D., had agreed not to detox these patients, and to hold them on buprenorphine if necessary until the CleanSlate clinic opened. “I want to give full credit to Andrew Kolodny for agreeing to that,” said Wilson. But still, the board said no to CleanSlate referrals.
Janice Kauffman, founder and president of the Massachusetts Methadone Treatment Providers Association, told ADAW that the police should not be making medical decisions. Kauffman, who is also vice president for addiction treatment services at the North Charles Foundation, a Cambridge-based OTP, agreed that the police department is “doing a good thing by diverting people from going to jail and offering them treatment instead.” However, she is concerned about Gloucester relying on abstinence-based treatment, and even more concerned about the Arlington Police Department’s push for Vivitrol. “The police are taking the role of being diagnosticians,” she said. “All Vivitrol does is block the receptor sites; it doesn’t do anything to treat addiction.” She is concerned about what will happen once patients are no longer on Vivitrol. “I’m also very concerned that the police are saying a narcotic antagonist is the treatment of choice for people who have any opioid dependence disorder,” she said. “They’re not giving any credence to methadone, which has been around for 50 years, and there’s evidence to support Suboxone [buprenorphine] as well.”
OTPs require treatment — counseling and drug testing — in addition to dispensing the medication, she noted. As for inpatient, she asked about aftercare. “You go to Florida and you get treatment, then you go back home, and there’s a high rate of relapse,” Kauffman said.
Kauffman, who has been working in the opioid addiction treatment field since 1973, said that treatment requires more than a 30-day inpatient stay. “It’s a total lifestyle change,” she said. “And people have co-occurring psychiatric disorders, chronic pain, a full range of issues.”
“We’re all in this together,” said Wilson, referring to MAT as well as abstinence-based providers. “But I think that we have not succeeded in getting people to understand that medication-assisted treatment is the gold standard now for opioid use disorders.” The public perception is that “if you send someone away for four weeks, then when they come back they’re going to be just fine.”
Wilson hopes that before patients are referred by the police department to abstinence-based rehab, they are seen by a “physician provider who could evaluate them for their medical illness.” If they are going to detoxification, they should have a “warm hand-off” to treatment afterward. “The police should not be making medical decisions,” Wilson said.
For more information about PAARI, including a list of participating treatment providers and the board members, go to http://paariusa.org.
Some police departments are espousing treatment instead of incarceration, but seem to prefer that the treatment for people with opioid use disorders be in abstinence-based residential rehab instead of with outpatient methadone or buprenorphine.