Tag Archives: Opioids

Modernizing Addiction Medicine Requires Medical Professionals

I wrote back in October 2016 (“Primary Care Doctors Staying Out of Addiction Treatment”) about how primary care doctors have shied away from taking their place on the front lines of preventing addiction and helping patients who find themselves in its grasp, and have posted more recently on the science being pumped out by the government and academia that addiction is a brain disorder and should be medically treated as such.

However, there remains a core old school dispute over the “right” way to address the current opioid epidemic and SUD overall, as was recently addressed in a December 29, 2018 NY Times article, “In Rehab, Two Warring Factions: Abstinence vs. Medication” We seem to currently remain be at a stalemate of sorts.

While there can be no doubt of the efficacy of AA and other Fellowships in recovery from SUD, the outcome-based measurements from abstinence stem back to mostly alcoholism studies; success with heroin (dating back to the 1970’s) remains “hit or miss.”  This is likely due, in part, to the “hijacking of the brain” that opioids has over its victims, contrasted with the psychological and biological impacts of other substances.

My response to this highly-charged discussion has always come down to a simple truth: we are still not in a position to medicalize addiction treatment without a sufficient medically-trained workforce.

And why don’t we?

It is because our society has shunned and stigmatized people with mental health issues and certainly ostracized (and jailed) people with SUD.  People seeking professions in psychiatry themselves were relegated to “second class status” in medical school, and that small population stayed away from “addiction medicine” overall.

Even the scant few who were inclined to become involved in addiction medicine found that the science was woefully lacking (due to no federal funding or private grants for such science and research) and the reality that brain science requires higher levels of brain scanning technology (fMRI, etc.) to understand how the brain and addiction impact one another.

Simply stated, there was no money, science, nor glory, in addiction medicine, and therefore a large population of medical professionals have stayed away.

However, in response to this workforce shortage, on December 27, 2018, the National Health Service Corps (NHSC) under the umbrella of HHS, launched the “Substance Use Disorder Workforce Loan Repayment Program” to provide eligible health care clinicians with student loan repayment assistance in exchange for their service on the front lines of the opioid crisis in underserved communities. As a result, it is anticipated that more patients who need help with substance use treatment will  have access to highly qualified clinicians.  Clinicians accepted to the program may receive up to $75,000 for three years of full-time service at a health care facility that has been designated by HRSA as an NHSC-approved substance use disorder site.  A part-time service option, with a maximum award of $37,500, is also available.

In the interim, even extremely populated states like Texas are finding that they are facing a shortage of SUD providers due to a shortage of professionals (which is also due, in part, the insurance carriers’ gamesmanship in reimbursement and violations of the Parity Act).

While this loan forgiveness program may not jumpstart the immediacy of need for a robust SUD workforce that is so desperately needed, it absolutely is a start in the right direction.

Report: Physician opioid prescriptions are higher with lower medical school rank

Physicians prescribing the most opioids tend to have attended lower-ranked medical schools, according to a recent report by the National Bureau of Economic Research.

In fact, many graduates of highly ranked schools did not write any opioid prescriptions. Researchers also noted that doctors of osteopathy (DOs) wrote a higher number of opioid prescriptions on average than medical doctors (MDs). They found that this prescribing behavior was consistent across various physician specialties, locations, and patient types.

Training was likely the most important factor for differences in prescribing behavior, according to the report. They found that differences in opioid prescribing patterns between graduates of higher- and lower-ranked medical schools were smaller when physicians received training on pain management. The rank of a physician’s medical school mattered less than the type of training he or she received.

Policymakers and physician educators could offer pain management training to help combat opioid addiction. For example, at the urging of the White House, in March of 2016, more than 60 medical schools agreed to incorporate the Centers for Disease Control’s pain management guidelines in their curriculum.

Background: Researchers used prescriber data from QuintilesIMS, which included background information from the American Medical Association and medical school rankings from US News and World Report’s, “Best Medical Schools: Research Rankings.”

Related: One in 12 US physicians received opioid-related payments – largely honoraria or speaking fees – from manufacturers of opioid drugs between 2013 and 2015, according to new research published in the American Journal of Public Health. In total, drug makers paid over $46 million to 68,177 physicians. Researchers compared this with payments for non-steroidal anti-inflammatory drugs, also used to treat pain, and found that total payments for NSAIDs were much less, around $13 million.

The majority of payments to physicians were for honoraria or speaking fees. Researchers excluded payments tied to research. They studied data from the Open Payments database. CMS requires pharmaceutical companies disclose payments to physicians and posts the data publically.

(Sources: Molly Schnell and Janet Currie, “Addressing the opioid epidemic: Is there a role for physician education?” National Bureau of Economic Research, August 2017; Scott Hadland, Maxwell Krieger, et al., “Industry payments to physicians for opioid products,” American Journal of Public Health, September 2017)

Opioid Emergency, Deductible Waivers,… and Methadone?

On May 3, 2017, the Governor of the State of Florida signed Executive Order Number 17-146 declaring that the opioid epidemic threatens the State with an emergency and that, as a consequence of this danger, a state of emergency exists. Also, in the executive order, the Governor directed the State Health Officer and Surgeon General to declare a statewide public health emergency, pursuant to its authority in section 381.00315, F.S. On June 29, 2017, the Governor signed Executive Order Number 17-177 to extend the state of emergency declaration.

The Department of Children and Families (DCF) was recently awarded a two-year grant to address this opioid epidemic.

Many Floridians involved in this discussion were excited that expansive use of Medication-Assisted Treatment and other modalities would be used to address the growing epidemic within underserved populations using a medical model, rather than exclusively through traditional counseling treatment.

However, what appears to be occurring, though more information still needs to be obtained, is that DCF will use these funds in part to expand onlyMethadone Medication-Assisted Treatment services in needed areas of the state as part of a comprehensive plan to address the opioid crisis. We do not believe this includes Suboxone or Vivitrol.

This also does not appear to help the majority of Floridians who may have insurance but cannot cover the costs of treatment due to treatment plans that continue to demand exorbitant co-pays and deductibles for SUD treatment. Stated otherwise, you either have SUD or do not. The economic decision of whether to pay a deducible becomes secondary.

While Florida does allow a statutory “deferral” of payment of deductibles in order to obtain payment, this allowance has been sometimes abused in the past with faux attempts to collect the deductible after-the-fact.

Florida mandates “balance billing” which means the provider MUST use all reasonable methods to collect on the balance. The fees for services are published and provided in advance as required by DCF rule, so the patient and their family know or have access to know what they are getting themselves into.

Ironically, perhaps, the “bad” providers who “forgive” the debt are alleged to have committed “Patient Brokering” for “inducing” a patient to treatment under the guise of waiving the co-pays and deductibles.

The “good” providers that follow the law and make every reasonable attempt to collect on the deductibles are called “heartless” or “ruthless” for “taking advantage of a family who is otherwise suffering a health tragedy.”

This law certainly must be changed.

For now, DCF has to revise the licensure requirements since methadone programs were the only type of service provider issued licenses based upon a needs assessment.  DCF has determined there is a critical need for more methadone medication-assisted treatment providers.

This rule makes changes to permanent Rule 65D-30.014 F.A.C., which is attached for reference, relating to licensure requirements for methadone medication-assisted treatment programs.