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.”     

HRC and DPA on where harm reduction is,where it's going

As “harm reduction” increasingly becomes less grassroots and more established in governmental and organizational bureaucracies, ADAW asked representatives of two major groups — the Harm Reduction Coalition (HRC) and the Drug Policy Alliance (DPA) — about the current and ongoing role of harm reduction.     

Addiction telemedicine comes into its own with COVID‐19

Telepsychiatry, telemental health, telepsychology, teletherapy — whatever you call it, it is now required in the era of the COVID‐19 pandemic. “We should be doing it immediately; the more, the better,” said Robert Caudill, M.D., a member of the American Psychiatric Association's Committee on Telepsychiatry. “It's exploded in the past week, obviously,” he told ADAW in a Zoom interview on March 23. But he thinks it should be the norm.     

As HIPAA changes loom,patients demand continued confidentiality for SUD records

In last week's issue, we wrote about the plans by the federal Department of Health and Human Services (HHS) to weaken the Health Insurance Portability and Accountability Act (HIPAA), citing regulatory burdens and the need for information‐sharing (see ADAW, Jan. 21). The plans, detailed in a request for information (RFI) issued Dec. 12, throw a wrench into the plans by the “make 42 CFR Part 2 like HIPAA” movement, which would erase the federal confidentiality regulation protecting substance use disorder (SUD) treatment records by watering it down to HIPAA standards. Now, with even HIPAA seeming too burdensome, the need is even greater to protect the consent provision of 42 CFR Part 2 — which is basically all that's left after the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed information‐sharing for the vague “health care operations” without consent last year (see ADAW, Jan. 8, 2018). Last week, H. Westley Clark, M.D., J.D., dean's executive professor at Santa Clara University and former director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration, made this abundantly clear in his comments to ADAW.     

Underage drinking and the role of parents

Last week's article on underage drinking and DWIs touched on the role of parents in helping to prevent both (see “Binge drinking in 12th grade predicts DWIs, blackouts and ‘extreme’ binge drinking,” ADAW, Feb. 3, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32610 ). The article was based on a study published in Pediatrics, co‐authored by Ralph W. Hingson, Sc.D., M.P.H., director of the Division of Epidemiology and Prevention Research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Last week, Hingson, who presented on underage drinking at the annual leadership meeting of Community Anti‐Drug Coalitions of America (CADCA), also explained more about the role of parents. “Parents do have an influence over whether and how much their children drink,” he told us. For example, if a parent binge drinks, their children will be twice as likely to binge drink — and to have alcohol use disorder.     

Lionrock prepared for the pandemic with video treatment

Lionrock Recovery has been providing videoconferencing for addiction recovery for a decade, so it was ready for the requirements under the pandemic for virtual support groups. Originally designed for people who wanted privacy and would not go to a physical treatment program, Lionrock's high‐definition videoconferencing, in groups and in individual therapy, is now essential. (Also see “HD videoconferencing offers a treatment alternative,” ADAW, Nov. 19, 2012; https://onlinelibrary.wiley.com/doi/epdf/10.1002/adaw.20354 .)     

NAATP guidebook not only for residential care

The National Association of Addiction Treatment Providers (NAATP) has released its draft guidebook for minimum standards for members (see ADAW, April 22, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32334 ). NAATP is not only for residential treatment providers, however. “Our position at NAATP is that we are a membership association for providers along the entire continuum and that, while residential holds an important place in our work and is our historical foundation, our membership is in no way limited to residential,” NAATP Executive Director Marvin Ventrell told ADAW last week. “Even apart from our membership, we intend our resources, including ethics and the guidebook, to reach and guide the entire continuum. It is true that some of the guidelines have application more or less relative to type of care, but as a whole it should be viewed as a provider guide, not just a residential provider guide.” We regret any confusion. The field — and prominent organizations within it — is changing.     

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.”     

NASADAD requests $250 million for Phase 4 stimulus

If there will be a Phase 4, as Rep. Nancy Pelosi (D‐California) has promised, of stimulus money to help America cope with the fallout from COVID‐19, the substance use disorder (SUD) treatment field hopes to get some of it this time. Publicly funded SUD treatment and prevention got nothing — nothing — from the $2 trillion CARES Act passed at the end of March (see “In case you haven't heard,” ADAW, April 3, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32684 ).     

Onslaught against 42 CFR Part 2 continues in Congress

With the opposition of the American Medical Association (AMA) last fall, any moves in Congress and the federal government to weaken the patient consent provisions of 42 CFR Part 2, the regulation protecting the confidentiality of substance use disorder (SUD) treatment records, were stopped in their tracks — and in the nick of time (see ADAW, Oct. 1, 2018; Oct. 15, 2018). But the groups promoting the complete abandonment of 42 CFR Part 2, replacing it with the Health Insurance Portability and Accountability Act, which itself is targeted for at least partial destruction (see ADAW, Jan. 21, Jan. 28, Feb. 25), are back. There's a new push to try to overhaul 42 CFR Part 2.     

Fiellin: Keep the prescriber training for buprenorphine

It seems that almost everyone wants to deregulate buprenorphine for opioid use disorder (OUD) — with proposed legislation focused on getting rid of the Drug Addiction Treatment Act of 2000 (DATA 2000) waiver altogether (see ADAW, Oct. 11, “Bill to deregulate buprenorphine raises concerns among OTPs,” https://onlinelibrary.wiley.com/doi/10.1002/adaw.32510 ).     

AUD medications and postsurgery opioids: The latest

Topiramate's use as a treatment for alcohol use disorder (AUD) is not a new idea, Bankole Johnson, M.D. (now of ondansetron fame; see ADAW, March 25, April 1), reviewed it many times (see ADAW, Oct. 15, 2007; Feb. 11, 2008; June 16, 2008; Nov. 3, 2008; June 7, 2010; Jan. 31, 2011; Feb. 24, 2014). But a comprehensive review published recently in the Journal of Addiction Medicine is concise. While not approved by the Food and Drug Administration for AUD, topiramate can be prescribed off‐label, and should be considered as a treatment for the condition, according to Ajay Manhapra, M.D., and colleagues in the article, “Topiramate Pharmacotherapy for Alcohol Use Disorder and Other Addictions: A Narrative Review.” Like ondansetron and other possible AUD medications, including those that are approved (like acamprosate and naltrexone), topiramate doesn't work for everyone. But pharmacogenetic testing may help identify those who are likely to respond, according to the review. In addition, there are early studies indicating it could be used to treat cocaine and nicotine use disorder, as well as behavioral addictions.     

Transitioning SOR to the SAPT BG: Why not?

It's time to think about transitioning the State Opioid Response (SOR) grants to the Substance Abuse Prevention and Treatment (SAPT) block grant, Robert Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD), told the House Energy and Commerce Committee at its March 3 hearing on opioid legislation. The STR and SOR grants went directly to single state authorities (SSAs) in charge of the SAPT block grants — NASADAD members — so this makes perfect sense. These are the officials who best know how funding should be spent in their states — on what substances, including alcohol. Instead of having a designated amount set up for opioids — although that was expanded to include stimulants as well (see “FY 2020 Appropriations: Stimulants added to SOR's $1.5 billion,” ADAW, Dec. 23, 2019, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32573 ) — each SSA should just have this funding added permanently to the block grant.     

Briefly Noted

A federal audit of opioid treatment programs (OTPs) — methadone clinics — in New York City found that of 115 random sample claims, 35 did not comply with Medicaid requirements, and that of 598 claims in a non‐random sample, 299 were billed in error. Extrapolating these errors, the federal Department of Health and Human Services (HHS) says the state improperly claimed at least $39.3 million in the federal share of Medicaid reimbursement, and owes that money back. Improper claims were mainly due to failure to record patients in the central registry, which exists to make sure patients aren't enrolled in multiple OTPs (18 of the 35 noncompliant claims). This was not an audit alleging fraud. Extrapolation as an accounting method for OTPs, where patients often come in every day, so that each patient has more than 300 claims a year, is questionable, but OTPs are used to this even in state audits. In other words, one OTP patient comes in six days a week, with six claims, and the database balloons. “You're extrapolating over our universe, and our universe becomes large because people come in for medication,” said Allegra Schorr, president of the Coalition of Medication‐Assisted Treatment Providers and Advocates, a New York–based membership organization, and board member of the American Association for the Treatment of Opioid Dependence. “When you're just trying to get money, this counts,” said Schorr. “They hit the lottery when it comes to an audit because of that extrapolation.” However, Schorr, who is also an owner and vice president of West Midtown Medical Group, a Manhattan‐based group that was the first OTP to dispense buprenorphine in New York state, stresses that compliance is always important. “It's critical that there is oversight,” she told ADAW. Meanwhile, the state is reviewing the audit and will respond. “The Office of Addiction Services and Supports (OASAS), in partnership with the NYS Office of Medicaid Inspector General, intends to review the specific findings of this audit cited by OIG [Office of Inspector General] to verify its accuracy and to determine an appropriate course of action,” said Evan Frost, spokesman for OASAS. “As a proactive measure, we will remind our OTP providers of their obligations to comply with state and federal laws and rules for providing and claiming Medicaid reimbursement and ensuring the quality of care for those receiving OTP services.” OA SAS regulates OTPs in the state. For the audit, go to https://oig.hhs.gov/oas/reports/region2/21701021.pdf     

Hill Day: The three big ‘asks’ from NAATP

At the “Hill Day” event that marked the end of the annual leadership conference of the National Association of Addiction Treatment Providers (NAATP), 120 association members went to the Senate and House of Representatives to make their case. “I felt it would be successful if we had 50 members who stayed the extra day and did the Hill visits,” Mark Dunn, NAATP policy representative, told ADAW of the May 8 visits. So he was thrilled that so many went.     

Names in the News

The American Association for the Treatment of Opioid Dependence (AATOD) will be presenting the 2019 Richard Lane/Robert Holden Patient Advocacy Award to Zachary Talbott at the organization's conference in October. Talbott was selected by his peers for the award. Nominations were announced last month (see ADAW, April 15, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32331 ). Talbott has opened and directed new opioid treatment programs, and had “compassionate advocacy of people with opioid use disorder,” as well as “fierce dedication to our patient population,” according to AATOD's May 1 letter to Talbott announcing the award offer, a copy of which was obtained by ADAW. Congratulations!     

Membership doubles,and NAATP plans more on ethics and outcomes for 2019

The National Association of Addiction Treatment Providers (NAATP) has culled its membership, removing members who don't comply with its ethics guidelines — mainly for marketing purposes. But rather than reducing its total numbers, this move has doubled membership, from 450 in the fall of 2015 to more than 900, NAATP Executive Director Marvin Ventrell told ADAW last week.     

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 ).     

Three Ecologies: Urban Metabolism and the Society‐Nature Opposition

This article is an intellectual history of two enduring binaries—society‐nature and city‐countryside—and their co‐identification, told through evolving uses of the concept of “urban metabolism.” After recounting the emergence of the modern society‐nature opposition in the separation of town and country under early industrial capitalism, I interpret “three ecologies”—successive periods of urban metabolism research spanning three disciplines within the social sciences. The first is the human ecology of the Chicago School, which treated the city as an ecosystem in analogy to external, natural ecosystems. The second is industrial ecology: materials‐flow analyses of cities that conceptualize external nature as the source of urban metabolism's raw materials and the destination for its social wastes. The third is urban political ecology, a reconceptualization of the city as a product of diverse socio‐natural flows. By analyzing these three traditions in succession, I demonstrate both the efficacy and the limits to Catton and Dunlap's distinction between a “human exemptionalist paradigm” and a “new ecological paradigm” in sociology.