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What We Are Reading This Wee

Much thanks to the American Health Lawyer’s Association (AHLA), for compiling today’s news for us:

Trump Opioid Plan Explicitly Favors Alkermes’ Vivitrol Over Other Addiction Medications.

In covering the White House’s recent national strategy to address the opioid epidemic, STAT (3/26, Facher) reports that when Alkermes CEO Richard Pops testified before a White House commission on the opioid crisis in September, he “stressed the importance of increasing insurance coverage for Vivitrol [naltrexone], but added that patients should be made aware of all available treatment options.” Administration health officials “themselves expressed doubts about the approach,” but a White House spokesman later confirmed that the strategy document referred specifically to naltrexone in its injectable form, which is made only by Alkermes and marketed as Vivitrol.

Draft Legislation Would Bolster FDA’s Powers In Opioid Fight.

The Hill (3/26, Roubein) reports Senate Health Committee Chairman Lamar Alexander (R-TN) on Monday released draft legislation “aimed at bolstering the Food and Drug Administration’s (FDA) capacity to respond to the opioid crisis.” One of the draft bills “would let the FDA require drug manufacturers to package certain opioids in set doses, known as ‘blister packs,’” that would reduce the volume of opioids prescribed and be easier to dispose of. The Hill reports other draft legislation “would ensure the FDA can spend the $94 million included in the spending bill passed last week to upgrade equipment at the border, boost laboratory capacity and improve the infrastructure to better seize illegal drugs at the border,” including fentanyl.

The Washington Times (3/26, Howell) reports Alexander also said that the FDA should use the new funding to improve its coordination with US Customs and Borders Protection.

American Dental Association Backs Seven-Day Limits On Opioid Prescriptions.

CBS News (3/26, Strickler) reports on its website that according to new research (PDF) published Monday in the Journal of the American Dental Association, dental prescriptions for opioids have been rising while opioid prescriptions have been declining nationwide. The American Dental Association “has now released a new policy saying they now support statutory limits of seven days for dental opioid prescriptions,” limits not currently embraced by the American Medical Association, “which has so far resisted opioid prescription limits.”

The Hill (3/26, Roubein) reports the new research “shows that 6.4 percent of all opioid prescriptions were written by dentists in 2012, but that rates increased slightly from 2010 to 2015.” ADA president Joseph Crowley said in a press release, “This new policy demonstrates ADA’s firm commitment to help fight the country’s opioid epidemic while continuing to help patients manage dental pain.”

The AP (3/26, Tanner) reports dental opioid prescriptions grew slightly “despite evidence that ibuprofen and acetaminophen work just as well for most dental pain.” The AP reports that according to a study published in the same journal, dentists “are the leading prescribers of opioids for U.S. teens and the largest increase in dental prescriptions from 2010 to 2015 occurred in 11- to 18-year-olds.”

The Washington Examiner (3/26, Leonard) also reports.

WE’VE SEEN THE ENEMY…. AND IS HE THE ADDICT?

The other day, I commented upon a local Facebook post about another treatment center being “raided.” I took exception to the term “raid” because the word evokes images of Seal Team Six taking out Osama Bin Laden, as opposed to what really happened, which was the serving of a search warrant by local law enforcement. When I made this statement, I began to be attacked by people who self identify advocates for recovering addicts as being on the wrong “side” of this issue, as if one must be either for treatment providers are you are against them, but you cannot be both. While I did not take it personally, this attack by the very same people whom I believed I was advocating for, which is anyone seeking ethical and effective treatment from substance use disorder as well as their service providers, did cause me to reflect upon the past seven years of my working and interacting with this entire subculture of our society.

(1) Is There Something Inherently Wrong With the Modern Addict?
What I believe to be true is that, for the most part, young recovering addicts who enter the treatment “industry” seem to have no inhibitions from cannibalizing their own kind. They prey upon their own, either because they know how to, or because they know of no other way to survive. They speak the same lingo and can easily lead the young addict to the slaughter house of relapse and without much prodding.

And we, as a society, have allowed it to get this way. We are the “adults in the room” yet blame the children for burning down the house.

This has caused the righteous indignation that I historically felt about discrimination against addicts to come into question. Maybe there is a reason, based in similar experience from those who came before me, that the addict simply is unable, on his or her own, to function within a society that lives by an apparently different set of norms and rules regarding how we are to treat one another.

Historically, discrimination against the addict and alcoholic was said to be based upon wrongful stereotype, conjecture, and anecdote, without any basis in fact. So, when I was approached by a treatment center to represent its interests when it was experiencing discrimination by a local government, I took on the representation, notwithstanding what I had “heard” about addicts and people seeking recovery. Granted, I tend to have this insatiable need to fight social injustice that is inherently in my blood. I was “that” kid on the playground who would go and beat up the bully for picking on the little kid. I couldn’t help myself. The rage of watching others passively allow injustice was too much to bear.

But now, after working for a significant portion of my legal career with a multitude of treatment centers and sober living providers of all sizes, I have come to believe that the 21st Century “addict” may be different in kind than its predecessor.
From my experience, this is not your “father’s alcoholic.” I am talking about a new breed of American who was born after 1980, generally referred to as the “Millennials” whom, while there is nothing inherently wrong with them, they were born into a society that formed their worldview that instant gratification is an entitlement and work ethic is for a bygone era. Throw in a drug that reinforces this “reality” and there is a recipe for disaster.

Moreover, these more modern-day young adult addicts seem unable (or unwilling) to care for themselves. Pimping themselves out to treatment centers and sober homes in exchange for access to their parent’s insurance card benefits fits nicely into this narrative. They overwhelmingly do not appear to want to change their situation. For those who think they do, if they can’t get recovery on an iPhone via two-day Amazon Prime shipping, it’s too much work and effort. Easier to hide inside the warm blanket of heroin.

Potentially worse is the stain this select group has placed upon the more generally accepted “Young People in Recovery” movement. The irony, perhaps, is that young addicts in collegiate recovery may not be “addicts” after all, but rather people who misused drugs, got educationally sidetracked, and needed a little tough love. However, they want to distance themselves, understandably, from the nuisance that the “stereotypical” modern day young addict has caused. As a result, I have seen internal discrimination amongst addicts themselves, often stemming from those who come from families of financial means and stable support systems. However, these success stories seem to relish in all the notoriety and recognition of being sober but then seem to socially discriminate against others who did not win the same genetic gene pool lottery.

(2) Where is Addiction Medicine?
Where are those who practice “addiction medicine”
And where have they been all these years?

Understand two things: first, addiction “medicine” is by all accounts a very recent trend. Historically, few to no medical practitioners flocked to addiction medicine as healthcare. Second,
few but for the most altruistic have wanted to work with the addicted population. They have been viewed as untreatable, unable to follow socialized norms, and generally prone to impulsive behavior that is contraindicated for positive outcomes. The modern day young is less likely to take responsibility for their own recovery journey. They are surprised that there is no “cure” or pill to take to make it all go away (yet). To recover, they need to want it. No one can do the work for them.

But this is why their predecessors were statistically more successful. It was the fellow alcoholic who created a “recovery community” for others of their kind to heal. They picked themselves up and did it on their own and did not rely on others to do it for them. The early rejection by American society of providing treatment for the alcoholic caused the creation of Alcoholics Anonymous, 12 step programs, as well as recovery residences. This noble movement allowed many in our society to go on to lead successful lives.

Today, “treatment centers” have proliferated because addicts and their families have been told this is the first stop in recovery and certainly something that insurance will pay for. While that is not a misstatement, there is very little available education for the behavioral healthcare consumer in the 21st-century to be able to make an informed decision on how to viably reach their own recovery. Likewise, they are the only ones who are willing to work with addicts as a provider of services. Recovery is otherwise free in America. Yet we tend to blame treatment providers for trying to do well by doing good.

This does, however, get somewhat complicated when the relatively newly recovered addict decides they have found their calling and either goes to work for or open their own treatment center. Their ability to adhere to acceptable societal behavior has been somewhat compromised by years of living in an altered state of heroin or other drugs. Once relieved of that medicated burden, some seem to still live by a different code, by their own set of ethics, of right and wrong, morals and immorality. Not all. In fact some of the greatest treatment providers themselves have had a long-term history of addiction. But there are enough misbehaving actors in this space to cause a significant problem and burden upon the public.

This is certainly sad commentary, for it has been over 50 years where others who came before them fought in the trenches to secure insurance benefits to cover mental health and addiction coverage “on par” [Parity] with medical insurance coverage, culminating in the Patient Protection and Affordable Care Act of 2010 (i.e., “Obamacare”). This law flooded the healthcare marketplace with funds to pay for this overwhelming demand for care. But the one problem persisted – the lack of supply of healthcare professionals to deliver “treatment.”

(3) What Role Do Addicts’ Parents Play?
Many of the parents of young addicts are amazing and resilient. They have withstood things that I hope to never experience. They are inspirational, motivational, and eloquent. They are venerable advocates who championed a cause long before it was politically popular. But today, there is also a vast and vocal minority who actively troll Facebook, LinkedIn, and other chatroom groups, espousing their experience and “expertise” in identifying the “good” from the “bad.” They are quick to point the finger to a failed healthcare system; to an abusive drug treatment industry; to callous insurance companies; and to a society that has other priorities. They tend to blame everyone but refuse to step in front of a mirror and acknowledge that they are part of the problem and not part of the solution. As a result, the ability to identify a trusted parent advocate from one who simply is self-interested or may have their own behavioral disorder has become difficult at best.

(4) Law Enforcement – Friend or Foe?
After years of not comprehending the magnitude of the damage that was being caused to people seeking recovery, law enforcement agencies now have been provided with the political and economic support to effectuate positive change. But conducting “raids” as the press likes to call them only entrenches societal viewpoints that the addict is a dangerous criminal, prone to illegal and mischievous behavior, that requires the kicking down the doors of treatment centers in full Special Ops gear, simply to take away a few boxes of papers. Being a former prosecutor, I understand that law enforcement does not discriminate between criminals. Everyone is guilty until proven innocent. But just when we finally come to universally accept that alcoholism is a disease, we now have been provided a new face of “all addicts” as a white-collar criminal that the public is more than willing to digest as it fits their pre-existing narrative.

As for those in government signed with the obligation to regulate treatment centers, they have been underfunded and understaffed since their inception, not to mention that their core competency is child welfare services and not regulating multibillion-dollar healthcare industry. Every other healthcare modality is governed and regulated by a state department of health. But not addiction treatment. We continue to fail to recognize the impact that this decision has had upon society and then turn around and rather easily blame the addict as the root cause of all of these problems.

(5) Elected Representatives – Helping the Cause or Causing the Pain?
With some notable exceptions of rather exceptional public servants, many local elected officials readily spend their time and taxpayer money to perpetuate a false narrative. They pretend to want to “regulate the industry” for “the benefit of a vulnerable class of citizens” when it’s inherently obvious their goal is to rid their communities of people in recovery as well as anyone who would provide services to that population. They spend the same taxpayer dollars to take out advertisements and billboards, stroking fear that their children will “come home in body bags” if sent to Florida for recovery. They host “town hall” meetings to listen to the fears of their constituents, only to reinforce the false belief that sober homes are inherently dens of prostitution and drug use. They choose to conveniently ignore the facts, that good providers tend to have the best homes in any neighborhood, bring a much-needed workforce to their jurisdictions, provide a willing army of community volunteers, and supply a rather significant number of consumers of local goods and services, including parents who stay in local hotels and patronize local businesses when visiting their children. As I stated before, when the facts do not fit their narrative, they tend to create pseudo-facts to feed into otherwise really acceptable discrimination.

(6) So, Where Does This Leave Us?
Overall, its seems as if advocating for the addict, their service providers, and for society as a whole has become
a zero-sum game. There are apparently sides to be taken in a battle of “us” versus “them.” There have been and always will be addicts amongst us. There will always be drug providers (be it at the street level, at the liquor store, the marijuana dispensary, or those who have medical degrees and write prescriptions for pills). There will always be prejudice. There will always be a lack of sense of community when fear and mistrust is involved. The addicts and their families want to blame the healthcare industry. Society wants to blame the treatment industry. They want to blame anyone but themselves. We want to blame them as being morally inferior and mentally weak. They have a comprehensive and robust report from the U.S. Surgeon General, unequivocally identifying addiction as a national disease. We have an independent Grand Jury investigation, Sober Homes Task Force Report, and extensive local investigative reporting from a multitude of press outlets, The Palm Beach Post in particular, identifying an overwhelmingly fraudulent industry that seems to have an insatiable appetite for consuming its own class of people.

Maybe we are all wrong, that the march towards decriminalization and deinstitutionalization of the addict has been a social experiment mistake? Maybe addicts need to be isolated from society for their own good? Perhaps the “integration” mandate of the Americans with Disabilities Act really did not take into consideration that the disabled in a wheelchair may really be different in kind than the disabled on heroin? Maybe we do need to re-open and re-examine the ADA, not to discriminate, but because there now is clearly a different set of facts that requires a different modality of response?

While I subscribe to the inherently American values of individualism and self-responsibility, we must put aside philosophical differences and recognize the clear science that the modern opioid epidemic is a terrorist that hijacks the mind, body and spirit. Even without the misuse of substances, what is true for all Americans is that greed is the most tolerated yet the most destructive addiction of them all.

We cannot demand that someone do something about “those addicts” but then refuse to provide the necessary funding, resources, infrastructure, housing, and services to care for this population, and we can therefore neither blame the addicts nor the treatment provider. We are the adults in the room. We cannot blame the unsupervised children for playing with matches and burning down the house.

If the disease of addiction is truly a public health crisis, rather than the now debunked theory that it is a moral failing, we appear to be left with only one choice – double our efforts, buckle down, and fix this system once and for all. Not later, not when it is more politically palatable. Now. We no longer have the luxury of time.

When Rehab Might Help An Addict — But Insurance Won’t Cover It

Growing up in the Philadelphia suburb of Warrington, Anthony Fiore checked all the boxes for a typical American guy. He’d go to the gym, play video games and watch football — in his case, the Eagles. His mom, Valerie Fiore, was proud of him.

 

“Anthony was very intelligent,” she says. “He breezed through his high school, Central Bucks South — he never studied. He aced his SATs. He got right into Penn State’s main campus.”

But before he could get to Penn State, the powerful painkiller Oxycontin got hold of him. Soon afterward, he moved on to heroin.

In May 2011, Anthony tried a 21-day rehabilitation stint in Florida. About a year later, he checked in to another facility, but only for 11 days. By the third attempt at inpatient rehab, Anthony said he really wanted to get help and would stick it out.

“That was a 21-day treatment. And that’s when I had Premera Blue Cross,” Fiore says. She begged the staff at the rehab-center to keep treating her son at their facility for longer than 21 days. “And that gentleman said to me, ‘Your insurance will not cover any more.’ ”

The family couldn’t afford to foot the bill for a longer stay, Valerie Fiore says. So Anthony left that facility in November 2013. Six months later, he was dead of a heroin overdose.

http://www.npr.org/sections/health-shots/2015/08/16/430437514/when-rehab-might-help-an-addict-but-insurance-wont-cover-it?utm_campaign=KHN%3A+First+Edition&utm_source=hs_email&utm_medium=email&utm_content=21342701&_hsenc=p2ANqtz-8nDHd_K7FhS5cUlWGzPw1oulSmLR0ZOUnhHZGpr8yCR0DjiIiQbeBDhSQ9K185ZYNC24r3-kXjjsWYqaJwWj7Npqh6ew&_hsmi=21342701

 

In heroin fight, White House will push treatment

“As heroin overdoses and deaths soar in many parts of the nation, the White House plans to announce Monday an initiative that will for the first time pair public health and law enforcement in an effort to shift the emphasis from punishment to the treatment of addicts.”

http://www.washingtonpost.com/politics/in-heroin-fight-white-house-tries-to-break-down-walls-between-public-health-police/2015/08/16/f63d63c2-4425-11e5-8ab4-c73967a143d3_story.html?hpid=z1&utm_campaign=KHN%3A+First+Edition&utm_source=hs_email&utm_medium=email&utm_content=21342701&_hsenc=p2ANqtz–fuNLAIiUFgTk7Q3tDGpCLDs5NXorIzGwpooxIBQzAg_vBWEZ3-Y9e78Q0DPeqIOj1IMSyNdqyH4eVpLuYizY8OoavDg&_hsmi=21342701

Telemedicine and Treatment Centers: Again Excluded from Modern Health Care?

Telemedicine in Florida (and nationally) is finally getting the due attention it deserves. Last year, the Florida Legislature tried to pass a bill during its annual session (March thru May) to approve of the use of remote video conferencing to supplement or replace regular doctor visits, in whole or in part. While the bill failed for other reasons, many believe this year’s legislation (currently filed as Florida House Bill 545 (2015) and Florida Senate Bill 478 (2015)) has a good opportunity to pass. A copy of the current staff of the Senate Committee on Health Policy is attached.

Legislatures in six states have introduced legislation that will force private insurance to cover telemedicine services at the same level they cover in person medical care, the American Telemedicine Association recently said (www.americantelemed.org/docs/defaultsource/policy/2015atastatelegislationmatrixEF9F3AD41F02.pdf?sfvrsn=16).

Unfortunately, the legislation in Florida, as proposed, does not specifically authorize the use of telemedicine by entities licensed pursuant to Ch. 394 (Mental Health) or Ch. 397 (Substance Abuse Treatment).

As proposed in Florida, only “Telehealth Providers” may utilize and therefore bill for telehealth services. Those are classified as persons who provide “health care and related services using telehealth and who are licensed under chapter 457; chapter 458; chapter 459; chapter 460; chapter 461; chapter 463; chapter 464; chapter 465; chapter 466; chapter 467; part I, part III, part IV, part V, part X, 25 part XIII, or part XIV of chapter 468; chapter 478; chapter 480; 26 parts III and IV of chapter 483; chapter 484; chapter 486; 27 chapter 490; or chapter 491, or certified under part III of chapter 401.”

While clinicians and other qualified professionals which fall under a specified Ch. 397 may qualify, I question whether substance abuse treatment providers themselves will be allowed to use this technology.

In Florida, the “devil is in the details,” i.e., the rulemaking that will follow from the Florida Department of Health. However, we anticipate those rules to be substantially similar to what has been adopted in other states.

We anticipate, once rulemaking begins, that various stakeholders will get involved to ensure that substance abuse/mental health is allowed to utilize this important technology, specifically in the aftercare and post-discharge process.

For more recent information, see the article from the SunSentinel: “More will visit doctors by teleconference under proposed state law.” http://bit.ly/1MvQBZa

Read more here:
SB 478 (2015) – Telehealth – Staff Report 1
SB 478 (2015) – Telehealth
More will visit doctors by teleconference under proposed state law – Sun Sentinel

It Takes Vision to Fight NIMBY

From the article: “Northeast treatment chain builds community relationships; expects openings this year” by Gary Enos, Editor, Addiction Professional Magazine, http://www.addictionpro.com/print/article/northeast-treatment-chain-builds-community-relationships-expects-openings-year

As Recovery Centers of America’s (RCA’s) concept of neighborhood-based addiction treatment and recovery support continues to take shape, the architects of what is designed to become a major Northeast treatment chain also are running up against some traditional community unrest about their plans.

“At the last zoning meeting I attended, we explained that if you don’t think the [addiction] issue exists here, within a 15-mile radius of this location there are 562 AA meetings every week,” said Chief clinical officer Deni Carise, PhD.

Prominent Philadelphia-area real estate developer J. Brian O’Neill spearheaded the initial $200 million investment that in 2014 created RCA, seeking to realize his vision of creating addiction treatment sites that rival the quality and hospitality of facilities that treat other illnesses such as cancer. As someone who has specialized in converting brownfields into attractive commercial and residential communities, O’Neill is hardly deterred by the “Not in My Back Yard” sentiment that can be pervasive in communities that are eyed for addiction treatment enterprises, says Carise.

Carise says she is excited about the prospect for developing neighborhood facilities where 12-Step meetings and family support services can be delivered alongside primary treatment. Planners in the for-profit organization are looking into establishing a “coffee house” concept at the sites, where members of the recovering community could congregate and where patients may be able to earn credits by completing work hours.

My comment: Wow. Progressive thinking. Embracing the Recovery Community. Acknowledging present realities. Sounds a lot like Delray Beach. Except, we endeavor to cast off and reject the notion that the Recovery Community is both an economic engine as well as a spiritual movement. As a native South Floridian, I think the difference down here is that people are still amazed when I tell them I am a second-generation Floridian and in my 40’s as most people I know are transient themselves, having moved here from other places. Yet they bring with them the “Not In My Back Yard” mentality, as if their slice of Florida is theirs and theirs alone.