2017 started with a combined sense of relief — $1 billion in federal funding over two years for the opioid crisis had just been approved by Congress and signed by President Obama — and of concern veering on panic, as opioid overdoses continued at an apparently unstoppable pace, and the new administration in the White House promoted policies that detracted from treatment: repeal of the Affordable Care Act (ACA), cutbacks to Medicaid and a growing sense of a return to a “war on drugs.”
Below is a run-through of ADAW’s coverage of that and other stories in 2017. This is not a complete list of stories; subscribers can access full texts of all of the articles from the 48 issues of 2017 — and those from previous years — online.
Opioid STR grants
The Substance Abuse and Mental Health Services Administration (SAMHSA) got out the funding opportunity announcement for the State Targeted Response to the Opioid Crisis Grants (Opioid STR) quickly, giving states until Feb. 17 to get in their application (see ADAW, Jan. 9). The $1 billion authorized by the 21st Century Cures Act, passed by Congress in December 2016 and signed by President Obama, is to be spent over the course of two years. The first year’s installment was distributed via checks in the spring (see ADAW, May 1). We outlined what each state planned to do with its funding, and how much each state would receive (see ADAW, June 19). We spotlighted New Jersey (see ADAW, Aug. 28) and Florida (see ADAW, Nov. 6); watch for more state spotlights on this grant program this year.
The argument that wider access to marijuana could be fueling the opioid crisis has not been supported by science, and in fact a growing number of voices have been casting marijuana as more of a potential solution than a problem (see ADAW, March 6).
Marijuana use by adolescents is linked to long-term adverse psychiatric consequences, but whether that link is causal is not clear based on clinical research alone. Animal research suggests it may be causal (see ADAW, March 20).
Harvard psychiatrist John F. Kelly, Ph.D., says looking hard at the choices between prohibition and commercialization may help us arrive at a “sweet spot” (see ADAW, Sept. 11).
Three eminent physicians presented a compelling case for legalizing marijuana in the November issue of the American Journal of Public Health. The opinion piece, “The Physicians’ Case for Marijuana Legalization,” written by David L. Nathan, M.D.; H. Westley Clark, M.D., J.D.; and Joycelyn Elders, M.D., states that it’s time for federal law to change and make marijuana legal, and that the government should regulate it (see ADAW, Dec. 4).
Methadone treatment patients who did not face mandatory counseling requirements or threats of administrative discharge fared no worse than patients in a more traditional opioid treatment program (OTP) structure, a randomized trial found (see ADAW, March 27).
Counseling is essential in substance use disorder (SUD) treatment, even with medications, interviews with experts, including the past president of the American Society of Addiction Medicine, show (see ADAW, April 24).
Is counseling necessary for patients on buprenorphine? David A. Fiellin, M.D., the researcher whose clinical trials got buprenorphine approved to treat opioid use disorders, said, “I think the issue is determining if outcomes are improved with counseling above and beyond physician management” (see ADAW, Oct. 2).
Data presented at the College on Problems of Drug Dependence show that a weekly injection of buprenorphine prevents withdrawal and blocks the euphoric effects of opioids. The medication is investigational. Braeburn Pharmaceuticals, the sponsor, plans to submit a new drug application for the product, called CAM2038, to the Food and Drug Administration in the near future. The study, “Effect of Buprenorphine Weekly Depot (CAM2038) and Hydromorphone Blockade in Individuals with Opioid Use Disorder: A Randomized Clinical Trial,” was published online June 22 in JAMA Psychiatry (see ADAW, June 26).
But Indivior’s weekly buprenorphine injection got the approval first. On Oct. 31, the advisory committee of the Food and Drug Administration (FDA) voted to recommend approval of Indivior’s RBP-6000, an experimental once-monthly injectable formulation of buprenorphine (see ADAW, Nov. 6). Indivior makes Suboxone, the buprenorphine strips that are administered orally.
There is a law against using telehealth for the first visit with a prospective buprenorphine patient: the Ryan Haight Act, enforced by the Drug Enforcement Administration and enacted to prevent diversion via online pharmacies. But in Utah, where buprenorphine prescribers are few and far between, providers want to get an exemption to this so that more patients can be treated (see ADAW, Aug. 21).
Psychiatrist Marc Galanter, M.D., says the most severely ill individuals with addictions will not see their treatment needs met until facilities successfully integrate 12-Step counseling and medical staff expertise (see ADAW, May 8).
A study published in the Journal of Studies on Alcohol and Drugs found that an evidence-based 12-Step intervention can improve sponsorship rates for individuals with stimulant use disorders, and that sponsorship for this population can in turn improve drug use outcomes (see ADAW, June 19).
The prospect of eliminating the Institutions for Mental Diseases (IMD) exclusion, which bars Medicaid dollars for residential treatment in a facility with more than 16 beds, gave a boost to the treatment field. For residential treatment programs, this could be a game-changer (see ADAW, Aug. 21). In West Virginia, a Medicaid 1115 waiver overrode IMD exclusion (see ADAW, Oct. 16). Yet there is still uncertainty in terms of whether there will be waivers or IMD repeal (see ADAW, Nov. 20).
Under federal law, states must direct at least 20 percent of the Substance Abuse Prevention and Treatment Block Grant toward primary prevention. This amounts to $371 million in FY 2017 (see ADAW, Feb. 13).
“We have the science” to prove prevention works, said Kana Enomoto, acting deputy assistant secretary of the Department of Health and Human Services (HHS), where she is in charge of prevention and treatment of mental health and substance use disorders. “We know what to do,” she said (see ADAW, April 3).
Drug Abuse Resistance Education, or D.A.R.E., the school-based substance use prevention program delivered by police officers, has changed into a completely different — and much improved — curriculum. The new D.A.R.E. is proven to work by randomized controlled trials (see ADAW, Aug. 14).
Federal opioids policy
On March 29, President Trump signed an executive order establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis (see ADAW, April 3). The initial eight-page report called for a national emergency to be declared, based on the number of opioid overdose deaths; this national emergency would have freed up funds (see ADAW, Aug. 7). However, President Trump said there would be no such emergency (see ADAW, Oct. 30). The final report included 56 items, but there was no advice about how to pay for these, beyond asking Congress for the money (see ADAW, Nov. 6).
Tom Price, M.D., then secretary of the Department of Health and Human Services, went to West Virginia along with Kellyanne Conway, special advisor to the president, to assess the opioid epidemic. When there, he disparaged medication-assisted treatment with methadone or buprenorphine, saying, “If we’re just substituting one opioid for another, we’re not moving the dial much” (see ADAW, May 15). H. Westley Clark, M.D., J.D., M.P.H., wrote an exclusive editorial for us on Price’s public disparagement of methadone and buprenorphine, as well as on Attorney General Jeff Sessions’ plans to prosecute drug crimes (see ADAW, May 29).
Despite calls to raise the “cap,” the number of patients a single prescriber can treat with buprenorphine, most buprenorphine prescribers are not treating anywhere near that limit, data from California, Maine and Ohio show (see ADAW, Nov. 13).
The lawsuit by 36 attorneys general against Reckitt Benckiser and Indivior, past and present manufacturers of Suboxone, for anticompetitive practices in violation of the Sherman Act and state laws is continuing (see ADAW, Nov. 13).
The FDA approved Sublocade, a once-monthly buprenorphine injection made by Indivior. The injection is indicated for adult patients who have been on a stable dose of oral buprenorphine for at least seven days (see ADAW, Dec. 11).
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 (see ADAW, Jan. 23, March 6).
Treatment programs that are committed to small self-pay residential models are insulated from the uncertainty of the health care system today (see ADAW, Jan. 30).
The first draft of the Republican bill to repeal and replace the ACA would have dramatically cut Medicaid, allowing the essential health benefits requirements to sunset from Medicaid expansion plans by 2020 (see ADAW, March 13). Efforts to pass this bill in the House failed, and the vote was canceled on March 23 (see ADAW, March 24). A planned vote on the Better Care Reconciliation Act, the Senate’s bill to repeal and replace the ACA, was delayed because there were not enough votes to pass (see ADAW, July 3). The push to repeal the ACA gathered steam after a narrow loss (see ADAW, Aug. 14), with a new bill that would put all federal health care spending into block grants. Linda Rosenberg, president and CEO of the National Council for Behavioral Health, summed up the bill this way: “It’s the same pig with different lipstick” (see ADAW, Sept. 25).
(Ultimately, after the year’s final issue was published on Dec. 18, the individual mandate requirement of the ACA was repealed as part of the tax bill passed just before Christmas. The effects of this, as well as other aspects of the tax bill, will be covered in ADAW this month.)
Many people in Philadelphia, New York City and parts of New Jersey have noticed an ad blitz for Vivitrol on highway and subway billboards, as well as in magazines — “everywhere” was the consensus (see ADAW, May 22).
Sen. Kamala D. Harris (D-California) launched an investigation into Alkermes in relation to its marketing and lobbying on behalf of Vivitrol, citing in particular marketing to the criminal justice system, despite the fact that methadone and buprenorphine have better proof of efficacy, she said (see ADAW, Nov. 13).
While the number of overdose deaths from opioids continues to rise, there is no clear picture of who these victims are — beyond the fact that heroin and illicit fentanyl are replacing prescription opioids as the main cause. So we asked the federal Centers for Disease Control and Prevention (CDC), which tracks such deaths, the following: What do we know about who is overdosing? Have they been through treatment? Are they naïve users? Have they overdosed previously? The answer from the CDC is that they don’t know, but the states might (see ADAW, Sept. 18).
Now that illicit fentanyl, and not prescription opioids, is leading overdose deaths, the CDC is starting to change its approach. A strategy aimed at reducing opioid prescriptions, with the hope that this would translate to a reduction in opioid use disorders and overdoses, has not worked. We interviewed top officials at the CDC (see ADAW, Oct. 23).
An article published in the American Journal of Preventive Medicine showed that supervised injection facilities can reduce the harms of opioid use, if not opioid use itself (see ADAW, Aug. 28).
Opioid treatment programs/methadone
OTPs are growing, as resistance to them — at least at the neighborhood level — gradually declines; some states, however, still set up barriers to treatment (see ADAW, June 12).
Anti-methadone stigma resulted in a moratorium on new OTPs in Indiana, but now — almost 10 years later — there are five new OTPs slated to open, with Medicaid funding and integration with larger health centers (see ADAW, July 24).
The American Association for the Treatment of Opioid Dependence, the membership organization of opioid treatment programs, the federally certified clinics that are the only places patients can receive methadone maintenance for an opioid use disorder, released a fact sheet on the use of methadone in the criminal justice system (see ADAW, Nov. 20).
Neonatal abstinence syndrome, pregnancy
A new draft report to Congress from SAMHSA suggests that Vivitrol, which is not recommended for pregnant patients, be researched as a way to prevent neonatal abstinence syndrome (NAS) (see ADAW, Feb. 6).
Infants born to mothers who are in treatment for opioid use disorders with methadone are sometimes born with NAS, a constellation of symptoms associated with opioid withdrawal. “An Initiative to Improve the Quality of Care of Infants with Neonatal Abstinence Syndrome,” published in Pediatrics, found that the best way to treat NAS is with the mother — rooming in and breast-feeding — which may eliminate the need for medications (see ADAW, June 12).
The Government Accountability Office has criticized HHS in a report prepared for the heads of congressional committees on the agency’s strategy for managing infants with neonatal NAS and on the Protecting Our Infants Act (see ADAW, Oct. 16).
Abuses in rehabs/sober homes
The president of the Florida Association of Recovery Residences says that with consumers receiving little information on how to identify high-quality care, many might come to believe the state is populated entirely by unethical operators (see ADAW, Feb. 6). Leaders in the recovery residence community want more states to follow the lead of the handful of states that have taken proactive steps to elevate sober living’s place in the continuum of care (see ADAW, May 22).
Elements of newly signed legislation in Florida suggest the state may be poised for tighter regulation of treatment and recovery support organizations and for more successful prosecution of wrongdoers (see ADAW, July 3).
The National Association of Addiction Treatment Providers, the membership association representing mainly residential rehabilitation facilities, is helping root out unethical business practices that are sullying the entire field (see ADAW, Aug. 7).
A hearing on Capitol Hill focusing on rehab and sober home abuses brought many of the problems to light (see ADAW, Dec. 18).
Many researchers are not clinicians, yet they are working on treatment interventions for alcohol use disorders, so a feature of the annual meeting of the Research Society on Alcoholism was “Everything You Ever Wanted to Know About Alcohol Treatment but Were Afraid to Ask: A Primer for Non-clinicians” (see ADAW, July 10).
While the nation affixes its attention to opioids, the prevalence of alcohol use and alcohol use disorder is showing striking increases, with disadvantaged groups most severely affected (see ADAW, Aug. 21).
The National Institute on Alcohol Abuse and Alcoholism has launched a new online resource to help people find treatment for alcohol use disorders (see ADAW, Oct. 16).
Doctors have identified “teachable moments” that could facilitate alcohol treatment (see ADAW, Oct. 30).
Only one in four adolescents and young adults with opioid use disorders get naltrexone or buprenorphine (see ADAW, July 10).
The FDA said benzodiazepines are not cause to deny methadone or buprenorphine (see ADAW, Sept. 25).
A Norway study found Vivitrol is as effective as oral buprenorphine (see ADAW, Nov. 13).
The first head-to-head study comparing buprenorphine-naloxone with extended-release naltrexone in the United States has found both medications are equally successful at retaining patients six months later (see ADAW, Nov. 20).
Criminal justice reform
New training in New Jersey introduces police to strategies for engaging and helping individuals under the influence of alcohol and drugs, identifying those with substance use disorders who are in need of immediate treatment and destigmatizing addiction (see ADAW, Feb. 6).
President Trump is getting pushback from law enforcement on his tough-on-crime stance, with police, sheriffs and prosecutors calling for a focus on treatment and urging the administration not to repeat the mistakes of the past (see ADAW, Feb. 20).
Police and sheriffs want to “deflect” people who need treatment from the criminal justice system, but treatment needs to be there to receive them (see ADAW, March 13).
The Police Assisted Addiction and Recovery Initiative, which started in Gloucester, Massachusetts, now has more than 350 police departments across the country working with local treatment programs, including those that provide medications; we attended their first national conference (see ADAW, Dec. 11).
The pain dilemma
Studies show 3 to 26 percent of people on long-term Rx opioids for pain develop opioid use disorders (see ADAW, Feb. 6).
A report calls for treatment to be added when opioid prescriptions are cut (see ADAW, July 24).
Dependence or use disorder: which is which? This is a gray area for some pain patients (see ADAW, Aug. 28).
Stories of crisis’s forgotten victims — pain patients — are emerging (see ADAW, Sept. 25).
42 CFR Part 2
In a webinar so popular it had to be repeated multiple times, the Legal Action Center detailed how the final rule on 42 CFR Part 2, released in January (see ADAW, Jan. 23), has changed the consent language for the release of information about a patient’s SUD. We attended the July 25 webinar (see ADAW, July 31).
Confidentiality of SUD patient records is under attack again, this time from treatment providers themselves (see ADAW, Aug. 7). Headed by the Legal Action Center, more than 100 treatment and recovery organizations have joined a “Campaign to Protect Patient Privacy Rights” (see ADAW, Oct. 2). The Pennsylvania Recovery Organizations Alliance (PRO-A) is opposing weakening of the federal confidentiality regulation, 42 CFR Part 2. “When I walked into treatment, that was my first question,” said Bill Stauffer, executive director of PRO-A since 2012. “Would my treatment be confidential?” (see ADAW, Dec. 11).
This year’s news was dominated by the opioid crisis and attempts to repeal the ACA.