Key points made at the meeting of the American Association for the Treatment of Opioid Dependence (AATOD) in Baltimore last week were to double the number of opioid treatment programs (OTPs) from 1,400 to 2,800 in the next three years, decrease stigma that is directly preventing the opening of new OTPs and discouraging people from seeking treatment, and increase Medicaid reimbursements, including in the 16 states that do not allow Medicaid reimbursement for OTPs at all.
But underlying almost every speech was the fact of overdose deaths caused by heroin and, now, illicit fentanyl analogs. Speaking to the standing-room-only audience of almost 1,800 the first day of the conference, Lt. Gov. Boyd K. Rutherford of Maryland said that access to treatment, alternatives to incarceration and funding are key recommendations to treat the epidemic in the state.
Naloxone and Baltimore
Barbara J. Bazron, Ph.D., executive director of the state’s Behavioral Health Administration, said there have been more than 1,000 overdose deaths in the state as of September — an increase since last year. She blamed “wider availability of opioids and lack of access to treatment.” But she said no one agency can solve the crisis. Priorities of her administration are: (1) prevent opioid misuse, (2) expand treatment capacity, (3) prevent overdose deaths by distributing naloxone and (4) expand recovery supports in the community. Treatment providers will be required to utilize the state’s prescription drug monitoring program (PDMP) or they won’t get a license, she said. Naloxone training is free in the state; the medication is covered with a $1 copay in the public system and a $3 copay with preauthorization from commercial insurance, she said.
In Baltimore City in particular, where firebrand health commissioner Leana Wen, M.D., is spearheading naloxone, the medication is available to everyone — as in, everyone. She has written a standing order for the prescription for every resident. “I’ve used it hundreds of times in the ER to save lives,” she said. “I hear elected officials making arguments to the effect that making naloxone available will make people more likely to use drugs,” she said. “Some people say you’re just treading water if you give someone naloxone over and over.” She agrees that treatment is important, but the person needs to be alive first. “It’s important to save the person’s life right now,” she said.
And treatment isn’t easy to access. There aren’t enough slots. “I can’t tell you how many times in the ER I’ve turned away patients,” said Wen. “They know they need help. Some have learned to lie to me and say, ‘I’m suicidal,’ because they know I’m obligated to get a psychiatrist to see them, but in what world is it acceptable to encourage patients to lie to us to get the treatment they need?”
NIMBY and BANANA
Baltimore is trying to launch a “stabilization center” for patients who need treatment for substance use disorders (SUDs), because the emergency department isn’t the ideal place to get such treatment, said Wen. Patients would be diverted from the emergency department to the center, and paramedics would have protocols to divert someone who might be headed to the emergency department or even jail to this center, where there would be counselors and addiction specialists.
But the problem is where to put it. “We face incredible opposition to this in Baltimore City,” she said. “We received $3.6 million in capital costs so we could build it, but no matter where we turn, you know what happens,” she said. The NIMBY (Not in My Back Yard) and BANANA (Build Absolutely Nothing Anywhere Near Anyone) forces take over. They can’t site it.
Baltimore has a history of opioid use disorders, and of embracing methadone and, now, buprenorphine. But there is still bias against these agonists. “Many people will tell stories of how abstinence-only stories worked for them,” said Wen. “But I’m a doctor and a scientist and I have to use what the evidence shows us. Science shows a combination of medication-assisted treatment, combined with psychosocial services, combined with housing, which is also health care, is what works.”
More OTPs, comprehensive care
Mark W. Parrino, president of AATOD, said that the number of OTPs has to double over the next three years. “We should be going past 2,800 OTPs if we are going to fulfill the vision that OTPs are the essential hub sites to treat this illness,” he said. Noting that there are 16 states that do not have any Medicaid reimbursement, he said that changing this would help patients access treatment — and add to the number of OTPs. “We need both public funding and private investment,” he said.
Parrino also noted that there are only three medications — methadone, buprenorphine and naltrexone — that are approved to treat opioid use disorders. Methadone is only provided via OTPs, which provide comprehensive care, including counseling.
“We need to make sure that all of our partners, including those in DATA 2000 practices, make sure that patients get the care they need in addition to medication,” he said. Many office-based opioid treatment (OBOT) providers are only providing buprenorphine, with no counseling or drug testing.
He also urged all OTPs to check the PDMP databases in their states, so that they know what prescriptions their patients are getting. “If you are not checking the databases, you are not fulfilling your obligations,” he said, to applause from the attendees.
He also noted that there are significant challenges in states. “Maine has a governor who wants all OTPs closed because he doesn’t like the medication,” said Parrino, adding, “This is not a rational policy, but he’s not a rational person,” referring to Gov. Paul LePage. And in West Virginia, there has been a moratorium on new OTPs since 2007, when the state mistakenly thought methadone-related deaths were connected to OTPs (they weren’t; they were connected to pain clinics). When asked if the state planned to re-evaluate this policy since West Virginia is the epicenter of the opioid epidemic, their response was “no plans yet,” said Parrino. In Mississippi, there is only one OTP and patients have to be transported across state borders.
But Parrino said the biggest barrier to new OTPs is at the local level — zoning boards. And he had this message for the country: “American citizens cannot claim that we need to treat their sons and daughters and spouses, while simultaneously preventing OTPs from opening in their communities. You can’t have it both ways.”
Surgeon General Vivek Murthy, M.D., said he was surprised when he started to practice medicine at how many people had substance use disorders. He wasn’t trained in it, and doctors “tend to avoid what they’re not trained in.” Of course, this lack of training applies to many physicians, even now. Now there is a resurgence of heroin use, HIV and hepatitis C, and he is working to “Turn the Tide,” as his campaign is called.
Murthy recounted his travels to states “where I was told by people who should know better that methadone was the root of all evils.” One community told him methadone was “leading to more promiscuity and more women getting pregnant and their children born with NAS,” he said, adding that “nobody in the room stood up and said, ‘That is wrong; that is not scientific.’” In this environment, people with opioid use disorders don’t want to come forward to ask for help, because they are afraid they would lose their job, and even be “shunned by their doctors,” said Murthy.
The United Nations view
The international perspective came from Gilberto Gerra, M.D., chief of the Drug Prevention and Health Branch, Division of Operations, United Nations Office on Drugs and Crime (UNODC), based in Vienna, Austria. His presentation, replete with many citations from peer-reviewed publications, focused on drug dependence as a disease that can be treated. He noted that on April 19, when the disease of drug dependence was discussed at the UN in New York City, there was very little mention in the press (see our lead story, ADAW, April 25). But two days later, the climate change meeting was widely covered. Few people in the audience of treatment providers even knew about the meeting, based on the show of hands Gerra called for. The main reason it wasn’t covered was stigma, said Gerra.
In China, a law passed in 2008 encourages the development of community-based treatment, moving finally from the detention-camp model, said Gerra. But it’s taking hold slowly, because police and health officials in China have “divergent visions and do not cooperate,” he said. Police are rewarded for arresting more people, and health care is rewarded for treating more people. “These are not convergent targets,” said Gerra. But, he added, it’s still a move forward that was “unimaginable” a few years ago.
One key international move is toward eliminating waiting lists for treatment. In the highly regulated OTPs in the United States, however, this would not be possible. The only solution is expanding the number of OTPs.
There are still “crazy rules” in the system, said Gerra. “Did you fail after three detoxes? No methadone for you. Go detox again and fail.” And: “Are you HIV-positive? If you are not HIV-positive, no methadone. Please go out, infect yourself and come back.” Although these sound like jokes, they’re not, he said.
In Gerra’s view, the main barrier to treatment is ignorance. There are even people in some countries who think methadone is a “state drug,” and that switching from “street drugs” to “state drugs” is somehow being forced to do the government’s wishes.
This is why it’s so important for patients to be treated with dignity. “Do not say ‘enforced treatment,’” he said. “Treatment must be based on the consent of the treatment — this theory is still not applied in many countries.”
Gerra’s presentation ended with two slides — one of a quintessential American scene in an OTP with a patient being handed a dose of methadone through a hole in a glass window “like in a bank,” said Gerra. The other was of a patient and a treatment counselor sitting together. “I know there are many reasons why we give medication through a glass,” he said. “But in the ideal future, the treatment should be an empathic relationship, not discriminating against these patients.”
The number of OTPs needs to double in three years, says AATOD, but stigma and ignorance are standing in the way.