Addiction Treatment Changes Following Pressure from New Federal Rules

October 3, 2016
Photo: Thinkstock.

Photo: Thinkstock.

By Robin Urevich

Drug treatment professionals have long preached abstinence from all drugs—including medication aimed at managing addiction. But those who oppose medication-assisted treatment must face an inconvenient truth, say addiction medicine specialists like Richard Rawson, a psychologist who recently retired as co-director of the UCLA Integrated Substance Abuse Program: Scientific studies show medication saves lives.

“From a harm reduction perspective, it’s a no-brainer,” Rawson said, noting that 50,000 people die annually from heroin and prescription painkiller overdose, approaching the number of American military personnel who died in Vietnam.

The two camps have battled for years, but now medication assisted treatment is clearly in the ascendancy, although it can be difficult to access. The Obama Administration strongly backs it. Now the state of California has bet on it as well, by participating in a federal program that will pay higher reimbursement rates for programs offering a full range of treatments, including medications where appropriate.

The Food and Drug Administration has approved several drugs for treatment of opiate and alcohol abuse, but none for methamphetamine or cocaine addiction.

The Drug Medi-Cal Organized Delivery System is a five-year pilot program run by the state Department of Health Care Services that tests whether a range of evidence-based treatment options based on criteria established by the American Society of Addiction Medicine will help addicts achieve long-term recovery while saving health care dollars.

California counties can opt into the program, which is designed to provide coordinated care so that substance users get psychiatric and medical treatment while they recover. Participating treatment facilities must offer medication, along with proven therapies, like cognitive behavioral therapy, trauma informed treatment and relapse prevention.

The pilot poses challenges to existing treatment programs, many of which were established by religious or charitable organization decades ago when traditional medicine offered no solutions for substance abuse. Consequently, many programs are based on personal belief or faith, not science, and for decades, had held fast to the notion that abstinence is the only way to recover from addiction.

Now, faced with a deadly wave of heroin and prescription painkiller abuse, along with obsolescence if they refuse to alter their beliefs, and scientific evidence of the effectiveness of medication, many programs have begun to evolve.

A sign of the times is the name change underway at one of Southern California’s major treatment centers, Social Model Recovery Systems.

The group’s Jim McConnell, a 30-year industry veteran, says his group’s very identity is out of date.

“A few months ago, we got board approval to spend a big chunk of change to modernize our name,” he said.

McConnell said early in his career he’d learned that only total abstinence would help addicts, but he’s altered his thinking since his group participated in a county pilot program to test Vivitrol, a long-acting injectable drug that reduces cravings for opioids.

“The studies I’ve seen and personal stories I’ve had shared with me about the value of craving reduction has been nothing short of miraculous. Vivitrol has really opened my eyes…meds have a place at the table.”

Vivitrol is a long-acting medicine that blocks the effects of opiates and alcohol.

Still, McConnell said medications are by no means his first line of defense. Instead, he’d rather use an abstinence based 12-step program.

Abstinence-based industry giants like the Hazelden Betty Ford Center have also changed their view of meds. Even Drew Pinsky, of the Celebrity Rehab reality TV show, who’s famously disparaged medication assisted treatment, has moderated his views, said Michael Bloom, a drug and alcohol counselor who owns the Pasadena Recovery Center where Pinsky filmed his show.

“You throw up your hands,” Bloom said. “You see so many overdoses….you see something that’s working. If some of us had our druthers, we wouldn’t want it that way, but you can’t argue with success.

Bloom added that medications can be a slippery slope.

“There’s a real argument for abstinence-based. You’re really getting off of having something to keep you going.”

But even as opinions on medication-assisted treatment are changing, patients still have limited access to it. Anna Lembke is a psychiatry professor at Stanford university who heads the Stanford Addiction Medicine Dual Diagnosis Clinic.

“The Affordable Care Act states that mental health and addiction need to be reimbursed on a par with physical health. We are supposed to be providing coverage,” Lembke said.

“But in reality what insurers are doing is making it so difficult, creating so many loopholes in getting Suboxone.”

Suboxone is one of a handful of newer drugs—Vivitrol is another—used to treat opiate addiction. It’s taken while a patient is in withdrawal and suppresses craving and debilitating symptoms. But unlike Vivitrol, it contains a both a partial opioid that tricks the brain into feeling satisfied without the euphoria associated with heroin or painkillers, and naloxone, which blocks the high that users would get from full opioids like oxycontin or heroin.

Methadone has long been available, but it’s undesirable for many users because it’s only usually accessible in freestanding clinics, which users must visit for a daily dose.

Lembke said that insurers often require prior authorizations for Suboxone –one or two page forms including diagnosis and other methods the patient has tried. The process can take up to two weeks. Meanwhile, Lembke said her patients risk dying from overdoses if they fail to make it through withdrawal and resort to heroin instead.

Some physicians opt out of treating addicts altogether because of the bureaucratic hurdles, she said.

Suboxone isn’t harmless; it can be diverted and sold illegally on the street, but that doesn’t diminish its effectiveness as a tool for treating addiction, Lembke said. It’s also far more harmful than other pharmaceuticals that are sold illegally, like Fentanyl, Rawson said.

The system is rife with hypocrisy, Lembke noted. If she wanted to prescribe highly addictive opiate pain relievers like Oxycontin, insurers would raise no objection.

“It’s a real conundrum,” Lembke said. Insurers don’t usually make moral judgments, and they pay for far more expensive medications and procedures, she said.

“It comes down to that addiction has not been welcome in the house of medicine. There isn’t an infrastructure in medicine to treat addiction.”

That may change, if programs like California’s Drug Medi-Cal Organized Delivery program are successful. The first counties— Santa Cruz, Santa Clara and San Mateo—are set to launch their programs in the fall. The UCLA Integrated Substance Abuse Program will evaluate its results and report to the state.

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