Another hustle. “This is predatory.”

51T1SeT4LRL._SX345_BO1,204,203,200_Alcoholism and Drug Abuse Weekly (ADAW) posted an article that describes the system used by a Florida treatment program to fill beds with insured clients as an out-of-network provider. They want out-of-network admissions because they do not come with managed care restrictions. ADAW describes their approach as “not unusual for the field.”

The fact that virtually all Banyan patients have out-of-network insurance is by design — out-of-network insurance is the best kind from the provider’s point of view, as there are no cost limitations based on contracts. The main referral source is in Illinois, where Tim Ryan operates as Banyan’s Midwest regional outreach coordinator, a full-time salaried position. Ryan told us that he refers people with good insurance to Banyan, because that’s his job.

. . .

The vast majority of patients Ryan, who has no clinical credentials, refers to treatment have no insurance. He has a not-for-profit that, according to Banyan and Ryan, is independent of his work for Banyan, called the Man in Recovery Foundation. Through this, he attracts people who need treatment.

. . .

Ryberg [an industry consultant] grew up in the area of Chicago where Ryan is operating, and got sober there. He has heard about the Man in Recovery Foundation’s “outpatient groups,” which are used as recruiting mechanisms for patients. “In no way, shape or form does the job they do resemble a typical clinical outreach representative in the industry,” he said. “They’re not clinical, and they’re not sending clients to the appropriate level of care based on need. This is predatory.”

 

The Chicago Tribune ran a similar story months ago:

Ryan heads a Naperville-based nonprofit dedicated to aiding people with drug problems, but he also has a job marketing a $15,000-a-month rehab center in Florida. The line between those roles is blurry to some critics, who say it could create a conflict of interest.

. . .

The for-profit rehab, which opened in 2013, is one of hundreds of treatment centers in the state. Like many others, it follows the so-called “Florida Model,” in which patients receive therapy at a clinic but live in offsite apartments.

The arrangement allows patients to stay much longer than the typical 28 days of inpatient care, said John Lehman of the Florida Association of Recovery Residences. Low costs and substantial insurance reimbursements have turned such treatment centers into a lucrative business, he said, and many market their services far beyond the state’s borders.

That strikes a nerve with some Chicago-area rehabs — “I find it hard to believe that people need to leave this immediate area in order to get very effective and caring service,” said Pete McLenighan of Joliet’s Stepping Stones Treatment Center — but Banyan owner Joe Tuttle said leaving home can be good for someone seeking sobriety.

“We’re selling (the idea of) getting away from your environment,” he said. “If your friends are using, you’ll probably be using, too.”

Since joining Banyan 15 months ago, Ryan said, he has referred more than 100 people there, some of whom he met through his charitable work. Such an arrangement strikes some in the recovery community as problematic.

What’s the consequence of this?

“The sad thing is, someone sees a TV show [Ryan was recently on Steve Harvey] or a video [Ryan has several], and they make that call,” said VanDivier. “It’s an uninformed panic-stricken consumer out there, and that’s what these guys take advantage of.”

John Lehman, president of the Florida Association of Recovery Residences, told ADAW that lack of education among patients and family members is the systemic problem. “They go Google, and boom, they make a decision,” he said. “As an industry of ethical operators across the country, we should be building an infrastructure that supplants their SEO methods and gets them to a site that educates them on the levels of care, on the appropriate care for the individual, how you go about choosing a program,” he said.

That reference to SEO reminds me of this post and a conversation I had with a rep for program that had something like 6 boutique treatment sites and some ridiculous number of websites to market them.

What will the long term consequences be? It’s hard to know for sure, but I’m pretty certain that it will damage the reputation of all treatment providers (residential, in particular), damage the public perception of recovery, and give insurers reason to clamp down sufficiently indiscriminate manner that will make it more difficult for everyone to access higher levels of care.

I don’t know anything about Tim Ryan or Banyan Treatment Center. But, I do know there are a lot of hustlers out there. Many of them are well-intentioned and want to do good and make a little money at the same time. Unfortunately, many of these people, for a variety of reasons (some financial, some personal) end up in ethically troubling places.

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Methadone retention

evidenceMAT advocates frequently accuse me of “cherry picking” articles that paint a distorted and negative view of MAT. The irony is that most of the articles I link to are pointed to as evidence of MAT’s effectiveness. I’m just looking deeper into what the article actually says.

BASIS just shared an analysis of a new article about methadone retention. I’m not going to comment, just highlight some of the content.

The article starts of with this introduction:

Did you know that methadone maintenance treatment (MMT), is one of the most effective treatments for opioid use disorders, especially when patients stay in treatment for at least 12 months?

What’s behind that link to “most effective treatments”? (Those are not intended to be scare quotes. Just trying to keep the source clear.)

The effectiveness of MMT is most apparent in its ability to reduce drug-related criminal behaviors. MMT had a moderate effect in reducing illicit opiate use and drug and property-related criminal behaviors, and a small to moderate effect in reducing HIV risk behaviors.

It’s important to note Looking beyond the abstract of that “most-effective treatments” meta-analysis, here’s a little more on the issue of methadone’s effects on criminal activity:

The inability of methadone maintenance intervention to produce a consistent and substantial effect on both drug-and non-drug related crimes, when considered together, suggests that treatment effects are restricted to those crimes that are associated with drug use, and that some opiate-dependent individuals may have a propensity to engage in certain criminal behaviors not directly related to drug use. Indeed, many studies report a negligible effect on non-drug-related crimes, while reporting a significant effect on drug-related crimes (e.g. Cushman, 1971; Jacobs et al., 1978; Bale et al., 1980), with one study noting an increase in non-drug-related crimes after admission to methadone maintenance treatment (Boudoris, 1976).

The “most-effective treatments” meta-analysis does have a line that speaks to the relevance of the retention article that BASIS is analyzing.

Findings from these analyses must be generalized with caution. The majority of studies included in the analyses examined the status of only those participants who remained in treat- ment throughout the entire period of assessment, and excluded those who left treatment during the intervention period. It is quite probable that those participants remaining in treatment throughout the assessment period represent a more  “successful” subset of participants.

Ok. Back to the BASIS analysis of the retention study. What were the retention findings?

Almost 50% of the patients were still in treatment 6 months after starting, and about 20% were still in treatment at 12 months.

 

 

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Recovery hustlers

51T1SeT4LRL._SX345_BO1,204,203,200_There’s more attention on addiction, treatment and recovery than there has ever been. It’s a good thing that brings some bad things. One of the bad things is the emergence of recovery hustlers. Some are exploiting it as an opportunity for profit and others are exploiting it as an opportunity for attention.

NPR just ran a story on big investors that are seeing big financial opportunities in addiction treatment, but is it good for patients?

Linda Rosenberg, president of the National Council on Behavioral Health, which represents non-profit addiction treatment programs, worries that private investors are too focused on the profitable inpatient beds and will neglect the services that help patients re-enter society.

“After rehab, you come back to your family and your family knows very little,” Rosenberg says. “You need a job, you need health insurance, you need medication-assisted treatment for addiction, you need counseling.”

She says there’s very little private investment in all that.

“I think that’s the biggest danger,” she says.

What’s the difference between a hustler and provider? Hustlers focus on profit over care.

I recently worked with a man who had been in one of these very expensive programs for months and said that, while in treatment, he expressed concern about his unemployment and insurance running out. They told his to not worry about that and to make recovery his priority. Once his insurance ran out, they discharged him. He was thousands of miles from home and relapsed on his way back. I contacted the program to see if they could offer him any help. They said they would not provide un-reimbursed services and suggested that he contact the alumni association for peer support. They said that they were trying to develop relationships with sober housing providers. I ended up putting him in touch with our intake staff to get on our scholarship wait list. He ended up going with Salvation Army because he could get in immediately. (Especially unfortunate, because he’s gay and not religious and his only option was a religious outreach.)

In that NPR story, the president of a small multi-site provider share his experience of exploring a sale to a larger provider/investor.

And that’s exactly what Tamasi found.

When he met with the first group of investors, he learned they only wanted to buy Gosnold’s money-making programs — inpatient detox and rehab, “A detox setting or a rehab program, they have a much wider stream of where revenue can come from,” Tamasi tells Shots. “They’re covered by insurance, people are willing to pay for it if they have the resources to pay for it.”

The investors didn’t want the prevention programs, the long-term care or the school-based programs. They didn’t want to invest in the recovery managers that help people get back on their feet once they get out of rehab.

But Tamasi thinks those things are important, so he didn’t sell.

“They’re almost like investments that a community-minded provider would make in order to do the things that they think the community could use,” he says

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He’s a recovering addict. So why did his doctors give him opioids and leave him on his own?

wp17a759ca_05_06Seth Mnookin just published a must-read piece for anyone interested in the issue of recovery maintenance over the lifespan of people with a history of addiction.

Mnookin is in recovery from opioid addiction and recently required surgery for kidney stones.

That’s why, throughout the course of my 43-hour stay at MGH at the end of April and into early May, I told everyone I could — from the ER doctor who informed me that I’d need surgery, to the anesthesiologist who prepped me for the procedure — that I was in recovery from a substance use disorder.

And while my doctors all said they were aware of the issue, it still felt as if no one was listening.

. . .

“You know he has a history of addiction?” she asked the surgeon.

The reply surprised her: “No, I did not.” . . .

A few minutes later, still groggy from anesthesia, I was handed a stack of seven prescriptions. One was for 20 pills of oxycodone at 5-milligram strength.

When my wife and I talked about this later, we were nonplussed. On the very first page of the seven-page report generated before my operation, “substance abuse” was listed under “past medical history.” Three pages later, the first sentence of the “assessment/plan” for my care began, “Briefly, this is a 44 y.o. male with a history of … substance abuse (in remission).”

Despite that, I got no counseling before I checked out of the hospital that night. No one talked to me about the risk of relapse — or how to guard against it. No one offered to advise me as I began taking the powerful painkillers I would need to get through the next few days.

He warned doctors of his history of addiction, recruited recovery support from his family and still ended up physically dependent on opioids. His withdrawal was missed and he was offered more opioids to treat his discomfort. Fortunately, he declined the additional opioid prescription and it was a friend who is also in recovery from opioid addiction that pointed out that his discomfort was opioid withdrawal.

This happens every day. (I encountered similar care following an appendectomy last year.)

I’m glad Mnookin made it through this experience without a relapse.  Please read the whole article here.

  • Previous posts on Mnookin here and here.
  • Previous post on recovery maintenance and iatrogenic relapse here.

UPDATE:I shared with Mnookin my personal story of needing an appendectomy last year. Prior to surgery, I informally consulted an addiction specialist. That doctor suggested telling the doctors my history and asking for a few days worth of pain medication rather than their standard longer term prescription. He added something to the effect of, “They won’t listen to you, but try away.”

They didn’t listen. I came home with 120 hydrocodone. My wife asked the pharmacist if they could just dispense a few days worth. They were required to fill the prescription as it was written and could not dispense less.

I used 2 pills and had to dispose of 118.

In a tweet, Mnookin points out that a recent Massachusetts law allows pharmacists to dispense smaller quantities of opioids than prescribed.

This looks like a good target for advocates.

More info on the Massachusetts law here.

 

 

 

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Gabapentin misuse, abuse and diversion

From a new meta-analysis of gabapentin misuse:

Gabapentin has been presumed to have no abuse potential historically [19-23]; however, this review reports evidence to the contrary. Of the 11 population-based studies and 23 case reports included here, nearly one-third report gabapentin misuse/abuse for recreational purposes and epidemiological studies from the United States and United Kingdom estimate abuse rates between 40 and 65% just among individuals with a gabapentin prescription. Studies from the United Kingdom indicate that gabapentin has developed a prominent place as a drug of abuse; in Scottish prisons, gabapentin is among the top-requested prescription drugs of abuse [42]. However, the rise in popularity of recreationally used gabapentin is also occurring in the United States. Smith and colleagues [44] describe a near 3000% increase in the use of gabapentin to get ‘high’ from 2008 to 2014 among a cohort of 503 prescription drug users in the Central Appalachian region of the United States.

Motivations for misused gabapentin can be classified largely into three basic categories: recreational (e.g. get high or substitute for more expensive drugs), self-harm and self-medication (e.g. for pain or withdrawal symptoms from other substances). The majority of case reports involved individuals who had prescriptions for gabapentin, but took higher dosages than they were prescribed. Descriptive reports on gabapentin reveal an array of subjective experiences evocative of opioids (e.g. euphoria, talkativeness, increased energy, sedation), benzodiazepines (e.g. sedation) and psychedelics (e.g. dissociation). These effects do not appear to be specific to a particular dose, and may occur well within the therapeutic range. No pattern was observed in terms of dose taken or interactions between dose and motive or dose and effects achieved, which may be explained partially by the unpredictable pharmacokinetics and non-linear bioavailability of gabapentin [61]. To date, no carefully controlled human laboratory studies have been published that sought to examine and characterize the abuse potential profile of gabapentin in comparison to other prototypical drugs of abuse. Overall, further empirical research is obviously needed to evaluate and characterize gabapentin psychopharmacology and the risks associated with gabapentin use more clearly, especially among those using it recreationally.

. . .

Gabapentin is relatively inexpensive and, in fact, many individuals can acquire it free of charge or at a drastically reduced price under subsidy plans [63-65]. Further, due to its widespread off-label prescribing world-wide [8, 11, 12], it is relatively easy to receive gabapentin by prescription, as illustrated by physicians and the health-care system being the primary source of misused gabapentin in the United States and United Kingdom. These factors have enabled the market to be flooded with gabapentin and it has been referred to among the drug-using population as ‘a cheap man’s high’ (personal communication). It is important that prescribers recognize the current diversion of gabapentin and dispense judiciously.

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Differences in outcomes between people receiving and not receiving opioid substitution therapies

From a recent study comparing various health and quality of life outcomes for methadone and buprenorphine patients with  addicts who are not in treatment [emphasis mine]:

Polysubstance use profiles exhibiting a broad range of substance use were generally at increased risk of negative drug-related outcomes, whether or not participants were receiving opioid substitution therapies (OST), including thrombosis among OST receivers, injecting with used needles among OST receivers and non-receivers, respectively and violent criminal offences among OST receivers and non-receivers, respectively. An important exception was non-fatal overdose which was related specifically to a class of people who inject drugs (PWID) who were not receiving OST and used morphine frequently.

It’s not an easy read, but here’s more from the discussion section of the article [emphasis mine]:

Our findings provide novel evidence of the patterns of drug use and drug-related outcomes between regular PWID receiving and not receiving OST. Strikingly, in both groups a class emerged exhibiting broad-ranging polysubstance use which was at the greatest risk for most of the negative outcomes. While we must interpret the results from any complex model with caution (in our case there are known difficulties in LCA with regard to deciding upon the ‘best’ class enumeration), our results reinforce the growing idea of broad-ranging substance use as the polysubstance use profile with particularly negative consequences for the individual and society [2]. From a clinical perspective, among individuals who inject drugs and use a broad range of substances, those receiving OST were not found to have better outcomes in our naturalistic and cross-sectional study, suggesting that alternative intervention strategies may need to be found. This is in keeping with meta-analytical findings showing that those with polysubstance use disorders were among the least responsive to treatment [23], while a recent review suggests that further research is needed to conclude as to whether it is more effective to treat multiple substance problems concurrently or sequentially [2].

Further, in considering these two broad-ranging polysubstance use profiles, those receiving OST had the highest odds of participating in all three types of criminal activity, including violent offences. Although reverse causation must be considered (i.e. criminal behaviour resulted in apprehension and enrolment in treatment), this high level of criminal involvement was found despite having received treatment for at least the 6 months prior to interview. Along with the fact that receiving OST in the full sample was not associated with reductions in violent offences and drug dealing, and associated with increased property offences, our findings are inconsistent with an earlier Norwegian study which found that OST was beneficial in reducing drug-related criminal activity if injecting persisted [10]. The reason for this inconsistency is hard to identify and, as the study design is similar to ours, is unlikely to be attributed to methodological differences. Instead, we that suggest the profile of OST users may differ between Australia and the Netherlands, with OST in the former context not related to decreases in crime if injecting persists. When interpreting this result it must be remembered that due to the sample eligibility requirements our findings are not related to individuals who receive OST and stop injecting.

They did find protection from non-fatal overdose.

A potential benefit of OST was found in relation to non-fatal overdose. Those not receiving OST had greater odds of experiencing a non-fatal overdose in the previous month, with this increase attributed to morphine users, who were 80% more likely to experience non-fatal overdose when compared with all of the other polysubstance use classes combined. Thus, broad-ranging polysubstance use does not seem to play a role in this outcome. Rather, the heavy use of a single prescription substance (i.e. morphine) was associated with an increased risk of non-fatal overdose, after adjusting for covariates including the advanced age in this class.

I also posted a few years ago on another study finding buprenorphine maintenance was not associated with reduced criminal activity.

When confronted with these kinds of findings, practitioners and researchers are left with an important question: Is the problem me and my treatment? Are we not up to the task? Or, is the problem these patients?

It should be no surprise that they go with the latter explanation. Their conclusions, and the other commentary in the journal, suggest that the problem is those darn injecting poly-substance users. There just isn’t much hope for them.

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Health care’s most underpaid workers

100_4218-2-300x225Vox recently posted an article that frames patients as the health care system’s unpaid workers:

I’m not talking about the work of managing one’s health, the work that diabetics do to monitor their blood sugar or the healthy eating choices a doctor might recommend for an overweight patient. This can be a significant burden in its own right.

What I didn’t understand was the burden patients face in managing the health care system: a massive web of doctors, insurers, pharmacies, and other siloed actors that seem intent on not talking with one another. That unenviable task gets left to the patient, the secret glue that holds the system together.

For me, this feels like a part-time job where the pay is lousy, the hours inconvenient, and the stakes incredibly high. It’s up to me to ferry medical records between different providers, to track down a pharmacy that can fill my prescription, and to talk to my insurance when a treatment gets denied to find out why.

It’s amazing to me that this is the first time I’m reading this characterization of the role of the patient in their own care. It’s true in many areas of health care (as I learned personally last year) and addiction care is no exception.

Getting good care is a lot of work for the patient and requires a lot of time, energy, attention and self-discipline—scarce resources for a lot of patients.

The article does a great job framing just one of the challenges that addiction treatment patients face, especially if they receive care from a provider that does not offer an integrated and complete continuum of care. And, while I view the addiction treatment system as inadequate and deeply troubled, this challenges some of the grass-is-greener-on-the-other-side-of-the-health-care-fence thinking. We frequently hear statements like, “you would never see this with any other patient population.” To be sure, there’s a truth in these statements, but they may be giving the health care system too much credit.

Maybe we can take a little consolation in the idea that we’re not quite as alone as we may have thought in the challenges we face.

Maybe addiction care can play a role in improving health care in general.

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