Mar 4, 2017

Stuck Systems Slow Reforms

Over the past five years, advocates and organization leaders throughout the country have focused on the overdose epidemic. Have we made sufficient progress? What obstacles get in way of reform?

Nebraska’s former Director of Behavioral Health, Scot Adams, says healthcare organizations are just like people with addictions, in that they are stuck in denial. People in trouble must confront and overcome denial in order to change for the better. The systems that serve the public must also confront and overcome issues of denial if they are to fundamentally improve how they operate. Adams enumerates several aspects of denial embedded in healthcare systems. He writes:
Twenty-five percent of general hospital beds are filled with persons being treated for effects of substance abuse, like overdose, but not the core issue – addiction. And that goes further to include physical health care, with the standard practice at many emergency departments to “fix what’s in front of me” and ignore the rest. Or at best, refer it somewhere else. Value-based health care is helping this – however that is more the payer’s hot ticket right now and less the provider organizations that are still working as they were trained. They are paid to fix the broken arm, but not to drill down about the cause – a drunken fall.
Adams also blasts systems for tolerating “good ole denial.” He notes that this takes several forms. One creates a culture in which addictive behaviors appear normal because they are so prevalent. Another involves clinicians who avoid unpleasant or resistant clients. A third leaves medical professionals reluctant to identify dangerous behaviors because they don’t want to wrongfully accuse someone of being an addict or mentally ill. A fourth form of denial involves “old schoolers” in the addictions field who deny the value of medication-assisted treatment (MAT). Adams writes:
Some of these professionals have never been trained in the specifics of addiction and think it’s just another mental health malady to add to the treatment plan.
Public health and addiction experts have been calling out examples of embedded systemic denial and explaining how this produces barriers to effective care. When Dr. Jennifer Mooney of the Cincinnati Health Department recently testified about overdose trends before Cincinnati City Council, she said first responders face issues of inadequate training and a system that’s “really not congealed” in trying to help addicts. She said police “run into dead-ends a lot of times.” She said even though Hamilton County is “resource rich” with treatment options, including intensive outpatient care, 28-day programs and long-term residential programs, there’s not enough capacity for all the people who need help right now.

The terms “really not congealed” and “not enough capacity” are well taken, because few local treatment programs are specifically designed for opiates. The reason for the lag in evidence-based care for opiate addiction? Dr. Mooney cited “the comfort level of prescribing clinicians.”

Here is another example. In mid-2016, Dr. Christine Wilder, director of the UC Healthcare system’s addiction practice delivered a keynote address to an audience of over 200 advocates, clinicians, and funders at the Hamilton County Recovery Service Board’s annual meeting. In her remarks, she urged her audience to start delivering more medication assisted treatment. She told the audience she heard a colleague say he “just doesn’t like buprenorphine.” “Not like?” Dr. Wilder said. “Practicing medicine should not be like Facebook.”

Systemic denial pervades every element of community systems, hindering not only what happens in clinical offices, but also the level of effort and pace of reform. Resistance to change affects healthcare organizations, treatment funders, housing providers, residential care facilities, courts, prosecutor’s offices, and jails. It produces odd combinations of wishful thinking and weak action. Leaders might advocate publicly for solutions, but delay required approvals. Resistance to change is keeping systems weak, disconnected, underpowered, and fragmented. It is producing horrific results for clients despite the best efforts and intentions of clinicians and public servants.

Terry DeMio of the Cincinnati Enquirer recently reported on the efforts of some three dozen experts working in treatment systems and the criminal justice system in Kentucky and Ohio (along with dozens of ordinary community members) to help a young woman move past prostitution and addiction – unsuccessfully – over the course of four months. The article relates how, time after time, the young woman and her expert helpers encountered systemic barriers including limits on treatment, lack of secure housing, and medication treatment delivered without psychosocial support. The situation DeMio describes is not uncommon. Municipal Court judges see people with this set of problems every day.

What is left unsaid in DeMio’s article is the slate of treatment approaches and care models that are known to be powerful enough to address situations like these, but are not being deployed in our communities. Assertive community treatment (ACT) teams, trauma-informed care approaches, and integrated care models are well-documented and evidence-based. When solutions are implemented, delay is typical. Ohio declared an overdose emergency in 2011, but took six years to adopt American Society for Addiction Medicine’s evidence-based treatment protocols.

Those who know about evidence-based protocols and practices recognize the technical failures and stuck systems. They also know that the bodies of overdose victims are literally piling up. The Dayton, Ohio, Coroner’s office has run out of space to store bodies, and must rent cadaver storage space from funeral homes.

References

del Valle, L. (2017). Ohio coroner’s office running out of room because of overdose deaths. Retrieved February 10, 2017, from http://www.cnn.com/2017/02/01/health/ohio-coroner-overdose-deaths-trnd/index.html

DeMio, T. (2017) In hell: The fight to save one addict. Retrieved February 10, 2017, from http://www.cincinnati.com/story/news/2017/02/03/saving-dominique-the-fight-to-save-one-addict/91550636/

Ohio Psychiatric Physicians Association (2017) Ohio MHAS promotes ASAM guidelines for treatment of opioid use disorder. Retrieved February 10, 2017, from https://www.ooanet.org/aws/OPPA/pt/sd/news_article/133664/

Oss, M. (2017). Addiction & Hospital Utilization – The Endless Loop? Retrieved February 10, 2017, from https://www.openminds.com/market-intelligence/executive-briefings/addiction-hospital-utilization-endless-loop/

Rosemeyer, J. (2017). Cincinnati saw fewer heroin overdose deaths in 2016 than the year before. Retrieved February 7, 2017, from http://www.wcpo.com/news/cincinnati-saw-fewer-heroin-overdose-deaths-in-2016-than-2015

Image from Getty Images/iStockphoto Studio-Annika

Sep 11, 2016

Fighting heroin in Cincinnati with money we already have and volunteers who are ready to start

A huge crisis. A new treatment paradigm. Now what do we do?


I live in Cincinnati, where over 300 people have overdosed this past week. People have been calling this a “bad batch” of heroin, but overdoses have also ramped up across southern Ohio, West Virginia, Kentucky, and in Ohio’s other big cities. This is not a “bad batch.” It’s a product evolution, and it is coming to your town soon.

Fortunately, our community response systems have reached a tipping point on policy. Police here are offering immunity to people who turn in their drugs and ask for treatment. Medication assisted treatment is supported as the norm. Earlier this week, I spoke at a Cincinnati City Council committee meeting to offer my take on what might help. I used to be an outlier on policy, advocating for harm reduction and medication treatment in a community that favored nonmedical 12-step approaches and abstinence based care. This week, people were nodding their heads as I spoke, and I was nodding in agreement as treatment program leaders spoke.

To put it bluntly, we have reached a Kumbaya moment on addiction policy. Naloxone, medication assisted treatment, and community support programs are mainstream concepts now. People agree that we need a system that provides these things. What we need now is action. This creates new issues — implementation issues. How fast can we implement a new systems paradigm? Where will the money come from? Where will workers come from?

Fortunately, in Ohio, the money and protocols are already in the system. Certain reforms that have already been worked out must be implemented several months sooner than planned. Ohio has been in the midst of a behavioral health finance redesign for several years. These reforms are scheduled to kick off in mid-2017. The redesign process will move the state’s behavioral health system much closer to a “pay-for-performance” finance model. It also adds coverage for some new services, including peer support. Given the overdose emergency we are facing today, it should be possible to pilot the new payment system immediately in the places where overdoses are raging. In practice, this means training up existing staff, and upgrading payment systems to use new billing codes. It won’t cost more to implement reforms early. Because every dollar invested in medication assisted treatment saves around $5 in other healthcare system costs, the question is not “how much more we need to spend.” The real questions are “how much do we want to save?” and “how fast can we start?”

Who is going to do the work? Cincinnati already has the human resources to implement reforms at scale. We have about 1250 primary care physicians in Hamilton County, where the City of Cincinnati is located. If just ten percent of them took on 30 medication assisted treatment patients each, they could stabilize 3,750 people this year. Next year, federal regulations will allow each of these doctors to expand their caseloads, and serve 100 patients each, for a total of 12,500 people. That is the entire population that needs treatment in Hamilton County today, stabilized in just two years.

Our region is fortunate to have sufficient healthcare infrastructure to implement the new paradigm. We have four large hospital systems, a dozen or more Federally Qualified Health Centers, and several networks of behavioral health providers. These provider systems already negotiate rates and treatment protocols with public and private insurance systems. If provider systems step up their game, they can work together to create what are called Accountable Care Organizations (ACOs) and Special Needs Plans (SNPs). These are legal structures and insurance arrangements that support collaboration and help finance the work. It takes leadership and some technical skill to put this together, but the models to accomplish this exist.

Like other communities in America, Cincinnati has no shortage of willing volunteers. Church groups and community organizations are looking for ways to address the social needs of people in recovery. Our hospital systems at the center of the new treatment paradigm already manage volunteers. The missing ingredient is action.

Feb 25, 2016

Mercy for Addicts

Pope Francis has recently declared a Jubilee Year of Mercy  If we care to give mercy a try, we can start with our brothers, sisters, and neighbors who are suffering and dying from addiction.

In the last few years we have learned that people who use heroin and other opiates are risky, traumatized, disordered, and distressed. They have pain, addiction, immaturity, and mental illness all mixed together. They are in deep trouble. They need rescue. They need treatment, safety, and support, not lectures, punishment, and scorn. They need mercy.

We can heal the sick, and offer treatment to everyone who needs it. Northern Kentucky treatment agencies receive 40 calls a day from people seeking admission to care. We can say yes to everyone who calls, and if half show up, that’s 20 people every day, 100 every week, 5000 in a year. That is everyone at risk of overdose death in Northern Kentucky, brought to treatment in one year. It is not that costly to fund that surge of treatment.

Most people who use opiates stabilize quickly with medication and day treatment, but they require support to recover long term. We can show these people mercy, and support them as they make progress in their lives. We can house the homeless, feed the hungry, and offer comfort to the afflicted. Treatment groups can team up with churches and volunteers to help people stay in treatment. Ordinary human trouble disrupts treatment. Guest rooms, church dinners, safe recreation, and basic friendship help people overcome loneliness, rejection, transportation issues, and relationship trouble, the top barriers to retention in treatment.

Don’t forget jobs. When people emerge from drug use they tend to be poor and unemployed. We can give alms to the poor by combining jobs with support. This is another way for volunteers and co-workers to pitch in.

A minority of people have great trouble stabilizing, even with treatment. They may be too immature, too traumatized, or just too far out of control. Many of the people in this last group become prisoners for their own safety. Some are in jail, others are in secure facilities. We can show these people mercy too, by offering them treatment and connecting them with community support as soon as they are ready.

Mercy is good public policy. It aligns with effective medical care for addiction. Why are we so stuck in suffering? Perhaps mercy is our greatest challenge.

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This post previously appeared in the Cincinnati Enquirer and Cincinnati Community Voices