Shatterproof on its rating pilot for SUD treatment programs

Shatterproof launched its rating system for addiction treatment programs with a $5 million pilot, the company announced in December, with funding coming mainly from insurance companies and grants (see ADAW, Jan. 14). The project began a year ago (see ADAW, Jan. 15, 2018) but is now moving forward. ADAW caught up with Sam Arsenault, director of national treatment quality initiatives for Shatterproof, last week about the project.     

‘Incentivizing Recovery’ follow‐up: White paper was a ‘first step’

Last week's issue featured the announcement of a new payment model for addiction treatment, a combination of capitated and bundled reimbursement that places the treatment provider at risk in the event of repeat admissions. Greg Williams, executive vice president of Facing Addiction with NCADD, described the rationale for the system: Treatment providers should not be paid if patients don't get well. Anne Marie Polak, senior director at Leavitt Partners and in charge of the “Incentivizing Recovery” project the organization is convening, described the basics of how the project works. None of the treatment organizations participated in the project, which resulted in the white paper released Sept. 7 (see ADAW, Sept. 17).     

Briefly Noted

Almost 70% of Americans think it's unlikely a driver will get caught for driving while impaired by marijuana, according to a survey released last month by the AAA Foundation for Traffic Safety. And 14.8 million drivers themselves report driving within an hour of using marijuana — and engaging in this activity within the past month. According to research, the impairing effects of marijuana occur within the first one to four hours after smoking, and marijuana users who drive while intoxicated are more than twice as likely to be involved in a crash. “Marijuana can significantly alter reaction times and impair a driver's judgment. Yet, many drivers don't consider marijuana‐impaired driving as risky as other behaviors like driving drunk or talking on the phone while driving,” said Dr. David Yang, executive director of the AAA Foundation for Traffic Safety. “It is important for everyone to understand that driving after recently using marijuana can put themselves and others at risk.” In the AAA Foundation survey, almost 14% of millennials report driving within one hour after using marijuana in the past 30 days; 10% of Generation Z reports doing this. “It's time to face the facts. Any driver who gets behind the wheel high can be arrested and prosecuted,” said Jake Nelson, AAA director of traffic safety and advocacy. “Law enforcement officials are getting more sophisticated in their methods for identifying marijuana‐impaired drivers and the consequences are not worth the risk.” AAA recommends all motorists avoid driving while impaired by marijuana or any other drug (including alcohol) to avoid arrest and keep the roads safe. Just because a drug is legal does not mean it is safe to use while operating a motor vehicle. Drivers who get behind the wheel while impaired put themselves and others at risk.     

Kelly at CCSAD: AA works,but most severe patients need treatment

On Sept. 6, as the remnants of Hurricane Dorian were heading for Cape Cod, the Cape Cod Symposium on Addictive Disorders' (CCSAD's) plenary speaker John F. Kelly, Ph.D., Elizabeth R. Spallin Professor of Psychiatry in the Field of Addiction Medicine at Harvard Medical School and the founder and director of the Recovery Research Institute, gave the 1,100 attendees — many of them representatives of the treatment field — some welcome news: 75% of people who once had a problem with drugs and alcohol are now in remission. “Think about that,” said Kelly, who has become a mainstay of the speaker circuit in the addiction field. “This disorder has a good prognosis, despite, sadly, the opioid crisis.”     

Feds charge Florida addiction doctor with billing fraud

Last month, the U.S. Department of Justice arrested Michael J. Ligotti, D.O., of Delray Beach, Florida, for billing Medicare and private insurance companies for $681 million in unnecessary urine tests. Ligotti owned and operated Whole Health, a private clinic, which offered addiction and other treatment programs, and he also was the “medical director” of more than 50 addiction treatment programs and sober homes.     

Shatterproof launches ATLAS, ‘Yelp’‐like tool for treatment

When it comes to treatment that is evidence‐based, nonprofit Shatterproof, funded mainly by insurance companies, is keeping patients informed in a “Yelp”‐like tool. The New York City–based organization formally launched its ATLAS (Addiction Treatment Locator, Assessment, and Standards Platform) in six states last week.     

Caron in‐network with Aetna

Caron Treatment Centers is an in‐network provider for Aetna, effective Oct. 1, the Pennsylvania‐based program announced last week. “The COVID‐19 pandemic is taking a toll on the mental health of Americans,” said Doug Tieman, CEO and President of Caron Treatment Centers. “Unfortunately, isolation and anxiety make addiction worse, and we are already seeing a spike in substance use and substance use disorders. It's imperative that families have access to affordable, high‐quality, life‐saving treatment programs and support services.” The expansion of in‐network insurance relationships is among several recent moves by Caron to make treatment more accessible. Caron is also an in‐network provider with Highmark and the Blue Card program, which covers persons entitled to benefits as a member of any other Blue Cross and/or Blue Shield plan licensed by the Blue Cross Blue Shield Association, Independence Blue Cross, AmeriHealth Administrators, Independence Administrators, UPMC, Blue Cross Blue Shield, Employer Groups of Penn Medicine and Tower Health. “Accessing quality substance use disorder treatment has always been difficult for many families,” continued Tieman. “With more than 20 percent of the treatment sector reducing or closing services and programs as a result of the pandemic, it's even more difficult. This in‐network agreement with Aetna allows their members to access Caron at a time when they are needed the most.”     

Briefly Noted

Last month, the American Society of Addiction Medicine (ASAM) released a plan for advocacy, focusing on strengthening the addiction treatment workforce and standardizing the delivery of treatment. “We need comprehensive solutions to address such a complex problem,” said Paul H. Earley, M.D., ASAM president, in releasing the plan. “With the Advocacy Roadmap as our guide, ASAM will continue to advocate for equitable access to and coverage for evidence‐based addiction treatment services, increased funding for addiction research, and better education among professionals and the public to challenge the stigma and discrimination surrounding individuals with addiction.” Noting that there are still challenges in the field of addiction treatment, Earley said progress has been made, adding that “ASAM remains dedicated to treating addiction compassionately and effectively and, by doing so, saving lives.” There are 6,000 physician members of ASAM. For the “roadmap,” go to https://www.asam.org/docs/default‐source/advocacy/asam_report_feb2020_final.pdf?sfvrsn=f73f51c2_2 .     

Briefly Noted

Last week, Safehouse, a Philadelphia nonprofit that will open a supervised injection site in the city (see ADAW, Oct. 15, 2018), has hired an executive director, Jeanette Bowles, Ph.D. According to radio station WHYY, Bowles will help with fundraising and finding a site. “I believe in it so much,” Bowles said. “We see this working in other places, and the evidence supports it so strongly, that we don't have progress in public health without some controversy and scrutiny accompanying it.” Whether the Department of Justice will allow the site to operate remains unclear. “I've joined the team that respectfully disagrees with the Justice Department,” Bowles said. “Sitting in the office and doing the work separate from the community has never been my approach or style,” she said. “Being embedded with the community and developing those relationships and having my feet on the ground has always been most important to me. That's how the best public health work is done, through building bridges with community members.” Bowles earned a bachelor's degree from Temple University; obtained his master's in social work from the University of Pennsylvania; did postdoctoral work at the University of California, San Diego; and for her Drexel dissertation focused on opioid overdoses in the Kensington section of Philadelphia. The city, in giving the go‐ahead for the injection facility, said it would have to be run by a private nongovernmental entity.     

In the states

The Coalition of Medication‐Assisted Treatment Providers and Advocates of New York State (COMPA) issued support and further encouragement to New York legislators last week for the passage of a package of bills to combat the opioid addiction epidemic by increasing access to medication‐assisted treatment (MAT). “We applaud the Senate and Assembly passing A2904 Quart/S4808 Harckham, which eliminates prior authorizations for all MAT medications for commercial insurance policies,” said Allegra Schorr, president of COMPA. “This will increase access to treatment and reduce barriers for delivering care.” She added, “We urge the passage of A7246 Rosenthal/S5935 Harckham, which provides critical access to all medications to vulnerable Medicaid populations during this opioid crisis. Moreover, in order to ensure that all New Yorkers can access care, we urge the state to implement the policy outlined in A833 Rosenthal/S2161 Bailey that would establish a patient‐centered MAT program for incarcerated individuals in jails and prisons, and COMPA supports A972A Rosenthal/S4643A Harckham, which would prohibit copays during the course of treatment at an opioid treatment program.” COMPA is a nonprofit membership organization dedicated to treating addiction through the use of pharmacotherapy as a part of a comprehensive biopsychosocial approach to treatment. COMPA's program members include both opioid treatment programs and office‐based opioid treatment providers. COMPA is the New York state member program of the American Association for the Treatment of Opioid Dependence.     

Briefly Noted

Clayton Stafford died after using Vivitrol, and his family is suing Alkermes, the manufacturer, saying that the medication doesn't adequately treat addiction, compared to buprenorphine and methadone, and that the manufacturer knew this. In the lawsuit, California‐based law firm Lieff Cabraser alleges that Stafford, his parents and his treatment providers were misled into thinking Vivitrol was an appropriate treatment for his opioid use disorder. “Clayton Stafford's tragic death could have been avoided,” notes Lieff Cabraser partner Fabrice N. Vincent, who filed the lawsuit on behalf of the Stafford family. “The well‐reported defects in Vivitrol made Clayton's overdose a near‐foregone conclusion, and had the Staffords received accurate information about Vivitrol's risks and effective deficiencies from Alkermes, they would never have consented to its use by Clayton.” Naltrexone doesn't work to treat addiction and cravings, but just to block the effects of opioids, according to the lawsuit (and many others agree with this). “Because the patient's addiction is not adequately treated, the patient requires indefinite Vivitrol use to merely block the euphoric effects and keep the patient from seeking opiates,” Vincent said. “Patients therefore remain highly likely to relapse despite indefinite use of Vivitrol.” The lawsuit also makes note of Alkermes' direct‐to‐consumer marketing campaign, which extended into influencing the criminal justice system to use Vivitrol. Stafford had been mandated to use Vivitrol. Last year, the Food and Drug Administration issued a warning letter to Alkermes stating that its advertising did not state that stopping Vivitrol can lead to relapse and overdose, as is clearly stated by the label and package insert (see “FDA warns Alkermes about OD risk on Vivitrol ads,” ADAW, Dec. 16, 2019, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32566 ).     

MAP adds peer recovery as insurance benefit

MAP Health Management is getting health care plans to cover peer recovery as a health care benefit, but it hasn't been easy. “You're talking to a guy who's been thrown out of more health insurance plan offices than anyone you've ever met,” said Jacob Levenson, founder and chief executive officer of MAP, in an interview with ADAW last month. The early response from insurance companies was “You want us to pay addicts to talk to addicts?” recalled Levenson.     

NJ governor approves medical cannabis for OUD

Last week, Gov. Phil Murphy announced that New Jersey would remove prior authorization for Medicaid for medication‐assisted treatment (MAT) and would approve opioid use disorder as an eligible indication for medical marijuana. The moves, among several announced Jan. 23 in the state's efforts to combat the opioid epidemic, would increase access to treatment. Last year, more than 3,000 individuals in the state died from overdoses. “The opioid epidemic continues to devastate families and communities across our state,” said Gov. Murphy. “As we combat this crisis, it is critical that we use data‐driven, evidence‐based strategies to support individuals suffering from addiction and help them get on the path to recovery.”     

Briefly Noted

It's not every day that a nationally known “rehab” offers methadone. Recovery Centers of America (RCA) has opened its second medication‐assisted treatment (MAT) clinic — Bravo Medical — that does just this. “MAT is a vital tool in the battle against opioid addictions,” said Melissa Bishop, RCA national director of MAT, last week. “But many people are still afraid to learn more about it because of the stigma attached to this form of treatment.” The public is invited to tour the clinic on Oct. 16 from 12–2 p.m. At this event, families of loved ones from the southern New Jersey and Philadelphia area can tour the Somerdale, New Jersey, facility; see how medication is administered; and learn about the effectiveness of MAT. RCA offers MAT at its inpatient treatment centers and at stand‐alone MAT facilities such as Bravo Medical and the Trenton Healthcare Clinic. RCA offers methadone and buprenorphine. New Jersey State Medicaid is accepted at Bravo Medical and the Trenton Healthcare Clinic.     

Briefly Noted

At last week's annual conference of the National Association for Behavioral Healthcare (NABH), the increase in managed care figured prominently as causing a significant barrier to access to treatment. “The issue that is front and center is access to care, the problems that people are having getting necessary care, and not being able to access the right care at the right time,” NABH President and CEO Mark Covall told ADAW. In addition, the continuum of care has been severely impacted by managed care, he said. “Managed care companies are restricting care to crisis care only,” he said. This means that the longer‐term care needed for recovery when patients emerge from a crisis is not being covered. There are no clear legislative or regulatory fixes yet, said Covall, speaking by phone from the busy meeting. As an organization, NABH “will continue to be proactive and reach out to managed care companies,” he said. “We hope the collaboration that is desperately needed will be a two‐way street.” NABH members have reported that “it has been exceedingly difficult to get patients the care they need, and our members are saying that it's hurting patients, and this is not acceptable.” Last week, NABH launched Access to Care, an initiative “that will send our message to policymakers, regulators, payers and patient advocates that only true access to care can lead to recovery.”     

Briefly Noted

Last month, the federal Food and Drug Administration (FDA) warned that combining gabapentin or pregabalin with central nervous system (CNS) depressants such as opioids could result in serious breathing problems for patients with underlying respiratory problems, or in the elderly. New labeling will be required on gabapentin and pregabalin, the FDA said. There is less evidence supporting such a risk in otherwise healthy people, the FDA said in the Dec. 19, 2019, warning. Gabapentin, first approved in 1993, is not a controlled substance. It is approved to treat various conditions, including seizures, nerve pain, fibromyalgia and restless legs syndrome. Pregabalin, first approved in 2004, is Schedule V on the Controlled Substances Act, the lowest‐risk category of controlled substance. “With the evolution of the opioid crisis, getting ahead of new concerns or addressing those that are already evident requires examining signs of misuse and abuse as soon as any signal emerges,” said Douglas Throckmorton, M.D., deputy director for regulatory programs in the FDA's Center for Drug Evaluation and Research, in announcing the warning. “Reports of gabapentinoid abuse alone, and with opioids, have emerged and there are serious consequences of this co‐use, including respiratory depression and increased risk of opioid overdose death. In response to these concerns, we are requiring updates to labeling of gabapentinoids to include new warnings of potential respiratory depressant effects.” Drug manufacturers are also being required to conduct clinical trials to evaluate the abuse potential of all gabapentinoids, particularly when combined with opioids, said Throckmorton. The downside is that prescribers could inadvertently increase opioid use by not using these medications, Throckmorton acknowledged, saying “we do not want to unintentionally increase opioid use by turning prescribers away from this class of pain medications.” For more information, go to https://www.fda.gov/drugs/drug‐safety‐and‐availability/fda‐warns‐about‐serious‐breathing‐problems‐seizure‐and‐nerve‐pain‐medicines‐gabapentin‐neurontin .     

Psychodynamic therapy for SUD: Counselor's view

First of all, psychodynamic psychotherapy as treatment for substance use disorder (SUD) works. Ian McLoone, lead therapist with the Alltyr Clinic in Minneapolis, knows that firsthand — he's in recovery from heroin addiction and is in it himself. And despite the fact that addiction therapists aren't taught psychodynamic theory or psychoanalytic psychotherapy in graduate school, where cognitive behavioral therapy (CBT), motivational interviewing (MI) and, to a lesser degree, 12‐Step facilitation are stressed, he became interested in it mainly because of his employer, Mark Willenbring, M.D., a psychiatrist and former medical director of the National Institute on Alcohol Abuse and Alcoholism. We talked to McLoone for this story as a follow‐up to our article on the self‐medication hypothesis of addiction, for which we interviewed its developer, Ed Khantzian, M.D. (see “Psychodynamic psychotherapy: When it helps people in recovery,” ADAW, June 22, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32756 ).     

Briefly Noted

We asked Jerry Rhodes, former top executive at CRC (now Acadia) and a leader in opioid treatment program management, what he thinks of methadone as a medication to be used in primary care to treat opioid use disorder (OUD), as some people — including former Office of National Drug Control Policy Director Michael Botticelli — recommended last year (see ADAW, July 16, 2018). “I take issue with that,” said Rhodes. “Methadone is a dangerous drug in an unregulated environment,” he told ADAW. Buprenorphine is prescribed this way, but “buprenorphine is a relatively safe drug, and methadone isn't,” he said. A veteran of many battles over methadone, including the near‐elimination of opioid treatment programs, Rhodes told ADAW that “you don't give unfettered access to methadone” to patients with OUD. “Be careful what you wish for” is his advice. This has the potential to cause harm, he said. “Only people who don't understand the history of its utilization would recommend this.”