TREATING OPIOID USE DISORDER: SO MUCH MORE THAN MEDICATION
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Written by Mark W. Parrino, M.P.A. – AATOD President
May 1, 2020
Opioid treatment programs continue to respond to the evolving needs of our patients throughout the first wave of this epidemic. These developing responses can be viewed as inflection points or stages. The first stage, beginning six or seven weeks ago, represented the initial shock to the system with conservative decision making. This gave way to a more adaptive responses through more flexible policy making at federal and state regulatory levels in addition to changing program policy.
The second stage represented increasing adaptability as more take-home medication was provided in addition to curbside administration of medications and providing families or friends of patients with take-home medication, following patient consent.
Without any question, this epidemic has provided different challenges to the OTPs. On the one hand, if OTPs were overly conservative in providing take-home medication to patients, there would be increased risk of infection. On the other hand, if the OTPs provided too much additional medication to clinically unstable patients, there would be additional risk for potential overdose and diversion.
This is why we discussed this balancing in our Association’s initial guidance to our field, which was released on March 20, 2020.
There were the initial complications, including the assurance that there would be an adequate supply of medication as OTPs began submitting larger than normal orders of medication. Fortunately, this challenge was quickly resolved through the DEA and pharmaceutical manufacturers. There has been no interruption in the supply of needed medication for OTPs.
OTPs were also experiencing difficulty in obtaining personal protective gear and SAMHSA was extremely helpful in providing a letter on March 25, 2020, which helped free up some supplies. Additionally, the White House Office of National Drug Control Policy also provided a letter to the field on April 23, 2020 and that has also been helpful in getting protective equipment to OTPs since there continues to be challenges in obtaining masks and other protective equipment. I am grateful to have the support of these federal agencies in providing guidance to our field as OTPs remain open as essential medical facilities.
We are now facing a new, third stage and I anticipate that there will be greater reports of patient and staff infection and mortality. We will begin collecting such information over the next several weeks in conjunction with our policymaking partners. There will come a time where we will be better able to understand what went right and what did not, and we will come to know how OTPs acted in response to the needs of our patients.
The dust has yet to settle but it is important to acknowledge the incredible work of the staff working in OTPs in addition to expressing gratitude to the patients, who continue to put their trust into the work of our treatment programs during such an extraordinarily challenging time. I realize that some programs may have been slow to react to the initial shock of the first wave and I believe that that there has been an evolution of thoughtful responses. There will be many people to thank in the coming months as the initial phase of this epidemic comes to an end and AATOD will continue to provide guidance to the field as we learn more.
For the time being, I am deeply appreciative of the work of the OTPs and other substance use treatment programs throughout our country and other nations. I am also grateful for the coordination of the federal and state agencies, which have jurisdiction in these areas.
In good health,
Mark
Written by Mark W. Parrino, MPA – AATOD President
April 27, 2017
As many of our readers know, it has been impossible to pick up a paper or watch television news without hearing a story about the current opioid addiction crisis in America. President Trump recently appointed Governor Christie to be the head of the Commission, focusing on addiction and the opioid crisis. Additionally, HHS Secretary Price nominated Dr. Elinore McCance-Katz to serve as the Assistant Secretary for Mental Health and Substance Use in HHS. Both of these appointments are excellent and will be extremely beneficial to our field.
Congress approved the CURES funding package and SAMHSA is currently working with the states and grantees to utilize the first $500 million dollars of funding in 2017.
Some states have extremely innovative models, such as the Vermont Hub and Spoke model. While other states have been challenged in providing access to treatment for their state residents. We have just learned that the state of Mississippi is expanding access to OTPs in order to get the patients the care they need. In the past several years, a large number of Mississippi residents have crossed the border to access care in Alabama and Louisiana. This is welcome news and we are grateful for such a progressive turn in the state’s approach to treatment.
We also know that a number of Tennessee residents cross the border to access care in northwestern Georgia. This border crossing caused the Georgia legislature to impose a moratorium on opening new OTPs. This moratorium is expected to be lifted at the end of the current calendar year as the legislature wraps up its findings.
The Commissioner of Health for West Virginia, Dr. Rahul Gupta, recently expressed his interest in developing a comprehensive plan to reduce the number of opioid related deaths in his state. I recently wrote Dr. Gupta, urging him to lift the longstanding moratorium, which has prevented the development of new OTPs in West Virginia since 2008.
While we are in an age of conflicting interests and a growing sense of urgency in order to protect our citizens from the ravages of opioid addiction, we also need to be clear in following evidence based practices and effective policies. Regardless of the state you live in, we need a balance of well-coordinated efforts with prevention, treatment and enforcement. These have always been the three essential policy cornerstones for any effective policy in this field.
We also need to be careful about advancing one addiction treatment medication at the expense of another. There are only three federally approved medications to treat opioid addiction. They all have value and they all should be used at different times in the experience of patient care depending on what the individual needs. Illustratively, Vivitrol (Naltrexone) represents an excellent medication for a former opioid addicted inmate, who has been in jail for some time and is about to be released. Many inmates generally have a fear of relapse upon release from long term incarceration even though they have not used opioids for some time. There are a number of correctional facilities that are using Vivitrol injections before the inmate is released. Once again, the key here is to ensure that the patient gets access to a referral so that they can continue their treatment with Vivitrol or other medications, which are deemed medically appropriate and effective. A number of correctional facilities are also working with treatment providers so that inmates with opioid use disorders get access to methadone and buprenorphine.
While methadone maintenance is still considered the “gold standard” of medications to treat this disorder, there are a number of people who have forgotten that it exists and do not factor it into their plan to treat this disorder. The state of Wyoming comes to mind as the recent recipient of a SAMHSA grant. A recent newspaper story indicated that such treatment providers do not believe that methadone is a safe medication to treat this disorder.
Buprenorphine is an excellent medication and access to such medication has increased through DATA 2000 practices. Once again, all of these medications should be used with effective and well-coordinated services.
Ultimately, there will be many discussions about what works best for patients and how the system should function in an integrated way. The only way we are going to get a handle in dealing with an epidemic that has taken 25 years to develop, is to be clear in setting realistic goals about what can be done.
Finally, financial and workforce resources also need to be available as treatment access increases.
Written by Mark W. Parrino, MPA – AATOD President
December 8, 2015
Focus on the Use of Medications to Treat Opioid Addiction
This has been an incredibly dynamic year with regard to the implementation of federal and state policies to increase access to treatment for opioid addiction.
In many respects, this activity is unprecedented. There have been daily media stories about increasing access to opioid overdose prevention toolkits, in addition to shifts in the characteristics of opioid addicted individuals in rural and suburban areas of the US. Presidential campaigns have also begun to focus on increasing access to treatment for opioid addiction.
President Obama recently met with Secretary Burwell and ONDCP Director Botticelli in West Virginia, discussing the need to increase access to the use of medications to treat opioid addiction, focusing on the three available medications – methadone, buprenorphine, and combination Naltrexone products.
There has also been greater policy alignment between ONDCP and DHHS, especially in providing clearer direction to criminal justice grantees with regard to utilizing Medication Assisted Treatment (MAT) for opioid addiction wherever it is needed as they receive federal grants. This is the first time such clear direction has been provided to grantees.
The FDA just approved intranasal Narcan, which will add to the availability of opioid overdose toolkits in saving lives.
AATOD will continue to work with our federal and state agency partners in increasing access to the use of medications to treat opioid addiction through evidence based methods. We also plan to increase the focus on how we can expand OTPs throughout the United States, overcoming many barriers to care, including zoning ordinances and moratoria in developing much needed OTPs. The focus will be how to increase the base of 1,400 OTPs to a far greater number over the course of the coming years.
We certainly support the increased use of such medications, such as buprenorphine and Naltrexone products, but there also needs to be an increased focus on the use of methadone as an effective maintenance medication for the treatment of opioid dependence.
AATOD is also working with states to increase the utilization of Medicaid reimbursement for medications and services provided through OTPs. At the present time, there are 17 states that do not offer any Medicaid reimbursement for OTP services.
We will keep you posted about future developments but wanted to provide an understanding of some of AATOD’s leading initiatives and how grateful we are to have the support of so many key federal agencies in increasing access to care through OTPs and other programmatic sources.
Please feel free to share your comments.
Written by Mark W. Parrino, MPA – AATOD President
October 22, 2013
We are in the final stages of conference planning and many of AATOD’s leading initiatives will be discussed during the course of this five day conference. Most of our associates have been following the announcements of this conference over the course of the summer. We will feature topics on Health Care reform and increasing access to Medication Assisted Treatment in the criminal justice system. I talked about these matters in my first blog.
There have been an increasing number of challenges to our system over the course of the past several years, and such efforts are intensifying. We continue to read stories about the difficulty of siting OTPs in many cities throughout the country based on negative perception and long standing stigma. Fortunately, many of our provider associates are challenging such long held perceptions and are setting legal precedent in several cities that are clearly using discriminatory tactics and preventing the siting of much needed OTPs. Our treatment system has also expanded significantly over the past ten years and a greater number of patients are entering treatment.
I have worked with our provider associates and state agencies in the US during the course of my career to increase access to care wherever it is needed. I have also participated in many fierce public meetings where people challenge our treatment of patients and our use of medications to treat chronic opioid addiction. The basic premise remains as true today as it did almost 50 years ago, as methadone was being used as a maintenance agent for the first time in Rockefeller University. Patients should be able to remain in treatment as long as they benefit from the use of such medications. This point has been made repeatedly throughout the literature and evidence-based clinical practices.
It is the responsibility of each and every OTP in the United States to educate members of the surrounding community, whether such individuals include local merchants, drug courts, police departments, or any group that the OTP needs to work with on behalf of preserving the care for our patients.
We also believe that patient advocates are critical to these educational efforts and to work in conjunction with treatment providers and other entities at the county or state level who wish to promote the treatment for chronic opioid dependence.
In one sense, OTPs have a curious advantage in needing to be compliant with balanced federal and state regulatory requirements so that patients receive a range of treatment services in addition to medication.
I hope to see many of our provider associates at our conference in Philadelphia so that they can benefit from the training opportunities and the policy information which are essential to guide the future strategic development of our system of care. We can never be complacent in working with community groups in any part of the country. As always, we welcome any comments you may have about these perspectives.
Written by Mark W. Parrino, AATOD President
December 6, 2012
This represents our first blog. More will follow based on initial responses. You are free to make comments, which can be added to our website. This represents a slightly more informal way of communicating what AATOD is doing in representing the collective interests of our field. AATOD released its most current Five Year Plan in 2012. Three of the most prominent issues affecting the existing system and the future of or field are Health Care Reform; work with the Criminal Justice System; and prescription opioid use and addiction.
Health Care Reform
We continue to work with our associates who comprise the Coalition for Whole Health and the Legal Action Center in preparing for the implementation to Health Care Reform in 2014. There are concerns about impediments to getting reimbursement for Medication Assisted Treatment for opioid addiction through OTPs and DATA 2000 practices. At the present time and according to SAMHSA data, there are approximately 310,000 patients in OTPs, with the majority (300,000) utilizing methadone. It is estimated that there are over 350,000 patients receiving buprenorphine through DATA 2000 waived practices in the US. This number varies depending on the source of data.
We are also working with individual states through Board member chapters of AATOD to improve access to care through Medicaid reimbursement at the state level. This is especially challenging for a number of states given restrictive state budgets. It is tragic that individuals who are making laws in state legislatures have not read the basic information, which provides a foundation of how we provide treatment to chronic opioid addicted individuals through OTPs and DATA 2000 practices.
Criminal Justice System
AATOD is also working with partners in the Criminal Justice system, as articulated in AATOD’s 2012-2016 Five Year Plan. We understand that there are shifting attitudes towards the use of various medications in the Criminal Justice system. There are a number of educational initiatives that are designed to counter such issues and we are grateful for the publication of a groundbreaking report by the Legal Action Center concerning the “Legality of Denying Access to Medication Assisted Treatment in the Criminal Justice System and the recently published RSAT (Residential Substance Abuse Treatment) Training Tool “Medication Assisted Treatment for Offender Populations”(Bureau of Justice Assistance, DOJ).
The Power of Patient Recovery
From our point of view, it is critical to work with patient advocates and families of patient advocates in educating legislative bodies and the public about what we do. While we have extremely powerful data to support our work, it may also come down to the emotional stories of patients and their families. One experience that comes to mind occurred during a hearing about the use of methadone maintenance treatment in Maine in 1995. From my memory, the most influential presentation came from someone who was not on the hearing docket. A woman rose from the audience and asked if she could be heard. At that point, there were two methadone detoxification programs in Bangor, Maine. The hearing was to determine if such programs were to be given maintenance status and the result would lead to opening additional facilities in the future to respond to the needs of patients. The woman was extremely clear. She was married to a patient in one of the two detox programs. Her husband was a fisherman and had been in treatment for several months. She explained to the panel that her two young daughters had new clothes as a result of the fact that money was being saved for the first time in many years. The apartment was clean and there was food in the refrigerator. Her request of the hearing panel was to ask if they could find a way to allow people like her husband to remain in treatment as long as he benefited from such care.
As legislators and regulatory officials continue to challenge the use of Medication Assisted Treatment for opioid addiction, this kind of story needs to be told by patients and their families in different states.
If these challenges are not forcefully made, we will lose the struggle of being able to provide access to Medication Assisted Treatment for opioid addiction. While the promise of Health Care Reform is great, we must be careful not to let other parties undermine the very point of increasing access to care for millions of Americans who desperately need treatment.
Mark W. Parrino, M.P.A.
AATOD President
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