Tuesday, September 23, 2014

Low-Cost High-Impact Measures to Reduce Opiate Addiction and to Assist Individuals in Recovery from Addiction 12 Measures in 12 Months

1. Increase access to Buprenorphine for Recipients of Medicaid
Background: See report p. 14
Problem: There are approximately 7 doctors in a tri-County region (Montgomery, Carroll, Frederick) who provide Buprenorphine (Suboxone) to patients who are not enrolled in an in-patient or out-patient rehabilitation program and who also accept Medicaid. Each doctor is only allowed to prescribe to 100 patients in recovery. According to one doctor, her practice turns away “3 people daily” who are seeking treatment. Addicts who are stabilized on Buprenorphine in a detox facility and are then discharged from that facility are not able to continue getting their medication. They are then at risk for withdrawal from the Buprenorphine and pose a very high relapse potential. It is a waste of taxpayer dollars to detox and stabilize these patients on an addictive medication, with a plan to taper these patients off of externally derived opiates under medical supervision, when there is no one to provide this medical supervision and nowhere for them to access treatment.

2. Ensure that Students Recovering from Addiction Receive Educational Accommodations pursuant to Americans with Disabilities Act (ADA)
Background: See report p. 34 – 35
Problem: Students with an Addiction Disorder and who are in recovery from a drug addiction are not recognized as having “a current physical or mental impairment that substantially limits one or more of that person’s major life activities” (Opiate Addiction: Maryland’s Hidden Epidemic, p.34) by county public school systems. Recovery from opiate addiction often requires a combination of inpatient and outpatient treatment, and symptoms resembling a diagnosis of “mood disorder”, including severe insomnia, anxiety, depression, lack of concentration, etc. persist for several months after the patient has stopped using opiates. Accommodations to ensure that the student’s educational needs are met during their treatment and recovery are mandated under federal ADA guidelines, but are not formally recognized within Maryland’s school systems. Addictive Disorder is not currently coded under 504 Plans or Individualized Education Plans (IEPs).

3. Mandate Health Insurance Providers to Expand Insurance Networks so that they are Equal to Patient Demand
Background: See report p. 18 – 22
Problem: If a patient is referred into treatment, according to medical criteria, by a licensed professional healthcare provider, and there are no beds available in the patient’s “insurance network”, then the insurer should be forced to expand their network, regardless of state boundaries and jurisdictional borders, so that the insurer has a sufficient number of providers to meet their patient demand for treatment.

4. Create an Insurance Parity Oversight Office to Document and Investigate All Consumer Complaints Regarding Parity Issues in a Timely Manner and Direct all Insurance Providers Operating Within the State to Notify all their Maryland Patients of its Existence
Background: See report p. 19 – 22
Problem: Often, the federal mandate ensuring that insurance providers pay for the treatment of mental health illnesses, including substance use disorders, on par with other medical and surgical conditions, is not enforced. This costs the state when privately insured individuals are forced to rely on public funding to pay for their treatment. It costs the consumer when they are forced to mortgage homes, cash out retirement and other savings accounts, or go deeply into debt in order to pay for their own treatment or the treatment of a minor child.

5. Mandate that all Treatment Providers (Assessment Services, Hospitals, In-Patient and Out-Patient Providers, Residential Half-Way Houses, and Suboxone Doctors) Provide Patients with a Written Treatment Plan and a Discharge Plan Even When the Patient Leaves Treatment Prematurely or When Discharged for Non-Compliance
Background: See report (particularly, Wrap-around services, Continuum of Care, and Maintenance Medication) p. 25 – 28
Problem: Many times the individual with an addictive disorder will receive treatment while in a treatment facility or program only until the patient is discharged from the program. Patients leave a program for many reasons –either because they completed the program, voluntarily left prior to the completion of treatment, were kicked out of treatment for non-compliance with program guidelines, changed insurance providers, or any number of reasons. Suddenly left without any treatment at all, and without any idea where to get the treatment they need and were receiving, the individual is at great risk for relapse, thereby undoing any treatment goals that were attained in treatment. This is particularly true for medication maintenance. If they are housed in a residential program, they must have a place to live and resources for maintaining and supporting their quality of life upon being discharged from the residential program. Too often, patients are discharged or leave prematurely without any follow up plans. This creates a disjointed and sporadic patchwork of treatment at best, and a quick return to addiction at worst.

6. Provide a Continuum of Care, Case-Management Services, and Wrap-Around Services
Problem: After an individual undergoes detox either in a treatment facility or in jail, they may face insurmountable challenges to staying clean when they are discharged. For instance, they may be homeless and jobless, they may have become alienated from their family, they may need psychiatric services, they may be under-educated, or they may require medical treatment for ongoing health issues. If they are unable to resolve these issues, they may return to former friends and eventually former using patterns, as their only means of survival. This is self-defeating and destructive. Any gains made in treatment are wasted when the recovering addict is unable to maintain a lifestyle that supports his or her recovery. Individuals in recovery must be supported to acquire a normal and healthy lifestyle, until they are able to maintain it independently.
“Recovery begins when the person who is addicted to drugs or alcohol decreases or stops using, attains health care, meaningful employment, stable housing and appropriate education, and maintains a system of support. There is no ‘endpoint’ for successful recovery. Those who are addicted need and deserve the staples of a stable life, including a job that provides for self-sufficiency, a safe place to call home, knowledge and skills and family, friends and companionship. Simply ‘getting off drugs’ is not the answer.” (Open Society Institute –Baltimore, 2011)
Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must also address associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual’s age, gender, ethnicity, and culture. Many patients require medical services, medication, family therapy, parenting instruction, vocational rehabilitation, and social and legal services. A continuing care approach often provides the best results, with the treatment intensity varying according to a person’s changing needs. (NIDA, 2009)

7. Enforce Patient Abandonment Laws
Problem: Abandonment occurs when the doctor severs his professional relationship with a patient who is in need of continuing healthcare. This could occur for a patient adhering to a Suboxone tapering protocol, and they are suddenly kicked out of treatment for a relapse or a missed appointment. They are still addicted to opiates, and therefore in need of continuing healthcare. Their inability to obtain Suboxone, puts them at risk for returning to their old methods of attaining opiates, rather than endure withdrawals. Similarly, if a dually diagnosed patient is started on a regimen of mood stabilizing drugs or antidepressants in treatment, they must have a psychiatrist or doctor to prescribe them when they leave treatment, regardless of whether they leave treatment early or not.

8. Recognize that Substance Use Disorder is a Mental Health Issue, not a Crime
Background: See report p. 15 – 18
Problem: Currently, when police officers encounter an individual with a Substance Use Disorder, they treat them like criminals, rather than as someone suffering from any other mental health diagnosis –schizophrenia, bipolar, Alzheimer’s disease, etc. A police officer checks for evidence of criminal behavior, such as drugs or paraphernalia. If there is none, the officer leaves without any further intervention. In some states, police officers can also make a referral to a social services agency. Virginia police officers file non-criminal reports to a local Community Service Board, which then provides outreach services to families or individuals at risk. (report p. 41 – 42)

9. Adopt Legislation Similar to the Florida Substance Abuse Impairment Act
Background: See Report p. 43 – 44
Problem: According to a recent article in Time.com (Szalavitz, 2012), overdose has now surpassed car crashes as the leading cause of accidental death. However, shooting a lethal injection of heroin into your bloodstream somehow does not seem as “accidental” as running off the road and hitting a telephone pole due to slippery road conditions. The State of Florida has put chronic opioid addiction in the same category as a suicide attempt by determining that the individual is imminently dangerous to self or others. This allows friends or family members of the addict to petition for involuntary admission to a facility providing assessment and/or treatment. The petition is filed when there is “a good faith reason to believe the person is substance abuse impaired and, because of such impairment, has lost the power of self-control with respect to substance use; and either has inflicted, or threatened or attempted to inflict, or unless admitted is likely to inflict, physical harm on himself or herself or another; or the person’s judgment has been so impaired because of substance abuse that he or she is incapable of appreciating the need for substance abuse services and of making a rational decision in regard to substance abuse services” (Clerk of Circuit Court –Okeechobee, Florida).
The Florida legislature passed the Act in 1993, recognizing “the growing trend of substance abuse across the nation, and the need for government to play a role in addressing the consequences of addiction upon society as a whole” (Ferrero, R., 2009). The law has been successful in forcing addicted individuals into treatment when they begin making suicidal comments or taking lethal doses of their drug of choice. It has also worked for addicts who are breaking the law in dangerous ways to get money for their addiction, or for those who have become violent toward family members when under the influence. It is a last resort for most families. Yet, for those who are convinced that the addict’s life is in danger, and getting him or her to consent to drug treatment has failed, it is the action necessary to get them the help that may save their life. The Act has been embraced by parents, desperate for a way to save the life of an addicted child. Prior to the law, some parents were forced to file criminal charges against their addicted child, as their only means of getting him the treatment he needed. There are no criminal penalties or criminal records associated with the Act, because it is considered a means for rehabilitation, rather than punishment.

10. Purchasers of Treatment Services Should “Reward Results” –Successful Outcomes for Patients
Background: See report p. 31 – 34
Problem: Currently, there is no mechanism for measuring how effective a treatment provider is at providing treatment and there is no oversight to ensure that consumers and taxpayers are getting what they are paying for. A national panel of experts, convened for the purpose of addressing treatment quality for substance use disorders, concluded that, “treatment for substance use disorders is woefully inadequate and underfunded. …When patients get poor results, in part because they got poor care, arguments for expanded resources are undermined.” (Join Together –A Project of the Boston University School of Public Health, 2003)
“Quality is an especially important concern in areas where the criminal justice system or the welfare system is coercing persons to participate in treatment. Nothing could be more futile than to make treatment participation a condition of liberty or economic support but offer only inadequate and unhelpfully aversive treatment. …Far too often, social agencies, lacking expertise, assume that providers are delivering quality care. They take at face value provider explanations for client failure that blame the client, when in fact, poor treatment quality may have failed to meet the client’s needs. …Given the severe consequences that they may impose when clients relapse or leave treatment, social agencies have a high duty to focus on quality.” (Join Together –A Project of the Boston University School of Public Health, 2003) Although many providers receive public funding, these funding agencies impose essentially no requirement for measuring performance or results by providers.
Substance use disorders are the nation’s number one health problem and lie at the root of many other societal problems. Improving quality of treatment is as important as improving access to treatment. “Our recommendations sum to a single phrase: Reward Results.” (Join Together –A Project of the Boston University School of Public Health, 2003)

11. Support Community Coalitions
Background: See report p. 38 – 40; 44
Problem: All too often, agency administrators, treatment providers, or policy advocates have absolutely no experience with how their systems of treatment really work. They have never actually attempted to use the system which they created and are implementing. Therefore, they may be unaware of what the needs in the community really are, as well as gaps that exist in their treatment system. Collaboration between county agencies and treatment providers has been well established. However, the voice for the consumers and their families has been deafeningly silent. Participation by grassroots community organizers is essential for providing input into substance abuse policy and practice. People who have progressed to the stage of recovery, and their families, often have essential insight into what did and did not work for them –their personal stories are frequently compelling and persuasive. Join Together, a Project of the Boston University School of Public Health, urges policy makers to “provide funding, resources, and in-kind support to local community groups who are working to alleviate substance abuse in their community”.

12. Adopt SAMHSA’s Comprehensive Community Mental Health Services Program for Children and Their Families and Include Substance Use Disorder
Background: See report p. 40
Problem: According to SAMHSA, most children between the ages of 9 and 17, diagnosed with an “emotional disturbance”, “do not get the care they need because services are either too expensive or unavailable”. Similarly, most children of the same age, with a diagnosed substance abuse problem, do not get the help they need for these same reasons.
The Comprehensive Community Mental Health Services Program for Children and Their Families promotes a coordinated, community-based approach to care for children and adolescents with serious mental health challenges and their families. Although this program serves youth with mental health, rather than substance abuse issues, the organizational design can be easily replicated for substance abuse patients. The community-based service brings together everyone in a child’s life to formulate a plan –a “system of care”. “The different child-serving systems, such as child welfare, juvenile justice, and education, need to speak to each other.” The goal is to avoid fragmentation and ensure a coordinated network of care for the patient. The program was voted one of the “top 50 innovations in government” by Harvard University’s Ash Institute for Democratic Governance in 2009. (SAMHSA, 2009)
“Before this program, community-based services didn’t really exist,” explains Diane Sondheimer of SAMHSA. “Still today, if parents can’t get mental health treatment for their kids, they may have to give up custody to the state. The child may even be sent out of the community –or even out of state –to receive care.”…“The SAMHSA program is designed to transform the way mental health services and supports are delivered, allowing communities to provide coordinated treatment in the least restrictive way possible.” The child and family participate in the team, instead of simply being the recipients of services. A system of care is not limited to traditional mental health services. Community organizations may also offer services such as respite care, tutoring, vocational counseling, legal services, peer and family groups, and therapeutic recreational activities.
The program has had enormous success. Emotional and behavioral problems dropped significantly or stayed stable for 89% of children 2 years after entering a system of care. Suicide attempts also dropped significantly, with attempts among children age 14 to 18 dropping by more than half within 6 months and by more than two-thirds after 18 months. The percentage of children attending school regularly increased from 74% to 81% 6 months after entering the program. Arrests fell by more than half, from 27% to 11% at 18 months. This resulted in a cost savings of $829 per youth. (SAMHSA, 2009)

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