Many Residential Addiction Centers Don’t Offer Med Assisted Therapy, at Deadly Cost

When Quincie Berry was discharged from a rehabilitation facility on June 26, his caretakers weaned him off Suboxone (buprenorphine-naloxone).

The decision was made because no halfway houses would accept him if he was on opioid agonist treatment (OAT), said his mother, Jennifer Hornak, RN. (Hornak is considering pursuing litigation against the facility and requested it not be named in this article.)

Medication-assisted treatment (MAT) with OAT has been shown to reduce cravings, withdrawal symptoms, and death from overdose. MAT coupled with counseling is the standard of care for patients with substance use disorder.

Without it, Berry entered the halfway house unmedicated. Because he had been abstinent for months, his tolerance was far lower than it was when he entered rehab on May 10.

Not even a month after his discharge, Berry, a father of two, died from an overdose on July 23.

"He called when he was in the inpatient facility and told me, 'They are going to wean me off this because they're having some trouble finding a place to send me,'" Hornak told MedPage Today. "I believed he would be okay, that he was in a system that was intended for him to get better."

"He didn't want to die," she said.

Stories like Berry's are common in the addiction treatment field, specialists told MedPage Today. At many addiction treatment centers, follow-up care is rarely provided post-discharge, OAT certification is not required, and many are centered around a "12-step" program or similar abstinence-only treatment methods. Programs patterned after Alcoholics Anonymous can be lifesaving for some, but are not backed by research.

Historically, addiction treatment centers have been siloed from the medical field, largely due to stigma, said Michael Barnett, MD, of the Harvard T.H. Chan School of Public Health in Boston.

One study found that, in 2018, 82% of patients hospitalized at Boston Medical Center with opioid use disorder were rejected from post-acute care after discharge.

"Stigma against opioid use disorder and OAT kills people," Barnett told MedPage Today. "It kills people in the same way that if we had a stigma against insulin, and the only way to treat diabetes was through a strict diet and weight loss, people would die."

Barriers to Treatment

Stigma persists in the language of addiction medicine itself: "getting clean," implies people who use drugs are dirty; "addict" dehumanizes a patient with substance use disorder; and "medication-assisted therapy" implies that the treatment is optional, or simply substituting one drug for another.

"When we identify a medical treatment for diabetes, even though behavioral counseling for nutrition is really important and social support for people with chronic conditions is really important, we don't call insulin 'assistance,'" said Richard Saitz, MD, of the Boston University School of Medicine and Public Health.

"This name was to placate folks who had a belief and a philosophy rather than just saying this is a treatment that works and has been proven and we should make sure that anyone who has this disease has access to it," Saitz told MedPage Today.

In a "secret shopper" study published in JAMA last month, Barnett and co-authors called 368 residential programs across the country posing as a 27-year-old uninsured person who used heroin.

Just 29% of facilities offered callers OAT with continued maintenance, while 31% offered it only for detoxification, which has been shown to have poorer outcomes.

Altogether, 39% of clinics did not have OAT available, and 21% actively discouraged its use, most commonly by saying that it was "substituting one drug for another" or that it was addictive.

"If you think of addiction as a mental illness like any other, then these things we are finding seem absurd and unbelievable," Barnett said. "But in the context of the addiction field, the only way to be 'clean' is through abstinence and that is deeply rooted to the idea that people who have opioids in their system are somehow dirty."

Suboxone does come with a boxed warning about its potential for abuse and misuse. However, it is formulated to prevent misuse with a "ceiling effect," such that more frequent doses will not amplify potency. If it is crushed and then injected or snorted, the naloxone component blocks opioid receptors and induces withdrawal.

In order to prescribe buprenorphine, physicians need a waiver obtained after 8 hours of training and a fee. Methadone can generally only be prescribed in short-term doses and dispensed from special opioid treatment programs.

Although the Substance Abuse and Mental Health Services Administration (SAMHSA) has relaxed the guidelines for prescribing buprenorphine and methadone in the context of the COVID-19 pandemic, it is unclear whether these changes will remain after the state of emergency has ended.

In 2019, a bill titled the "Mainstreaming Addiction Treatment Act," which would remove restrictions on buprenorphine prescribing, was introduced in Congress. The Centers for Medicare & Medicaid Services also recently allowed OAT and MAT provided at opioid treatment programs to be reimbursed.

Still, fewer than 10% of primary care providers have obtained the buprenorphine waiver, and 40% of U.S. counties do not have a single waivered provider. Of providers who are waivered, only about half are actually prescribing buprenorphine.

In SAMHSA's 2018 National Survey of Substance Abuse Treatment Services, 33% of about 14,000 addiction treatment facilities that responded offered buprenorphine. Among SAMHSA-certified opioid treatment programs that responded to the survey, 10% offered methadone, buprenorphine, or both.

"There are no other medicines that have the level of training and barriers associated with it at the federal level," Barnett said. "It really makes no sense because buprenorphine is not a higher risk medication than other medications that we give physicians a free license to prescribe, most notably ... opioids."

Abstinence Only Models

Many addiction treatment programs are not evidence-based and rely heavily on religious philosophies instead, said Bill Kinkle, a former nurse and paramedic who has struggled with addiction himself for the past decade.

He has plenty of first-hand experience, having been admitted to 32 centers over a 10-year period. He told MedPage Today that many are run by folks who are in recovery themselves and have designed programs based on what worked for them.

Kinkle's first stay at Cirque Lodge in Provo, Utah, required him to participate in group prayer, beg for forgiveness, and turn his will over to a higher power, who would free him from his addiction, he said.

Cirque Lodge describes itself as an "abstinence-based and recovery oriented facility with a foundation upon the 12-step program developed by Alcoholics Anonymous."

"I could not comprehend how that was medically relevant," Kinkle said. "I was ultimately discharged. They said I was toxic to the community because I didn't believe in God."

Kinkle said he believes he would have recovered faster if he had OAT as an option, or if he had some form of social support to walk him through his options.

After being discharged from Cirque Lodge, he was charged $42,000 for his stay, which bankrupted his family, he said. Before being admitted, he had been homeless, and he returned to the streets. In 2009, he lost his nursing license and started using again.

"Just because of the deep shame that comes with addiction, I kept it very quiet, didn't seek help, and tried to manage it on my own," Kinkle said. "That's what led me to losing my job and career and becoming homeless so quickly. I didn't feel like I could talk to anyone."

As a nurse, Kinkle could not get his license reinstated or practice while on OAT. Instead, he was required to provide monthly progress reports to the state board of nursing, detailing time dedicated to a 12-step program, including attending three meetings a week, having a "sponsor," "working the steps," and speaking regularly at meetings, he said.

"I pushed back every month saying these 12 steps were detrimental to my recovery," Kinkle said. "They told me that was very concerning to them and they saw that as a warning of relapse."

For years, Kinkle continued to try residential treatment facilities and adhere to the abstinence-only plans. He said in subsequent treatments he "learned how to assimilate" and they gradually got better.

"As you struggle with addiction, every time you get really beat down, so when you enter these places, you're at a low," Kinkle said. "That really lowers the threshold of being a little more open to try different things even though they seem ridiculous, like believing in God, or spending more time with horses to cure your addiction, or stuff like that, that is really common."

As a nurse, Kinkle could not get his license reinstated or practice while on OAT. Instead, he was required to provide monthly progress reports to the state board of nursing, detailing time dedicated to a 12-step program, including attending three meetings a week, having a "sponsor," "working the steps," and speaking regularly at meetings, he said.

"I pushed back every month saying these 12 steps were detrimental to my recovery," Kinkle said. "They told me that was very concerning to them and they saw that as a warning of relapse."

For years, Kinkle continued to try residential treatment facilities and adhere to the abstinence-only plans. He said in subsequent treatments he "learned how to assimilate" and they gradually got better.

"As you struggle with addiction, every time you get really beat down, so when you enter these places, you're at a low," Kinkle said. "That really lowers the threshold of being a little more open to try different things even though they seem ridiculous, like believing in God, or spending more time with horses to cure your addiction, or stuff like that, that is really common."

Kinkle experienced sexual abuse in his childhood and is a victim of adult rape. He became an EMT at 17 before he was mentally mature enough, in his opinion, to handle experiencing so much death firsthand. He worked in a busy academic emergency room as a nurse for 15 years and experienced secondary trauma there.

This trauma he later identified as something that predisposed him to develop substance use disorder, he said.

In the 2018 SAMHSA survey, 40% of clients had backgrounds of trauma, 26% had experienced sexual abuse, and 26% had experienced domestic violence.

"If you think about it, people who suffer from substance use disorder are people who generally have a horrific mental health or trauma background," Kinkle said. "They are people you really need to be delicate with in how you do counseling and therapy, and you have these untrained people tinkering around in their brains. You can really hurt somebody."

Fighting Stigma

In April, Kinkle was feeling the stressors of the pandemic and felt he was in a dangerous place for relapse, so he and his addiction medicine doctor decided Suboxone would be a good safety plan. Prior to this spring, he had been abstinent for two and a half years to try and get his license reinstated.

But when he reported his decision to the nurse monitoring program in Pennsylvania, he was immediately discharged, he said.

In Pennsylvania, the Professional Health Monitoring Program (PHMP) coordinates care for professionals with substance use disorder, if requested by the state board in the reinstatement process. The PHMP refers nurses to the Pennsylvania Peer Nurse Assistance Program (PNAP), an independent organization that monitors nurses throughout the process.

Laura Humphrey, of the Pennsylvania Department of State, told MedPage Today in an email that the PHMP permits licensees to be on MAT while being monitored, and that there is no requirement they wean off of MAT to practice.

However, the PNAP is an abstinence-based program that requires 12-step meeting attendance. The organization does not monitor nurses on Suboxone or methadone, its executive director, Joann Megon, RN, told MedPage Today in an email.

"PNAP is forcing me to choose between taking a medication that very well could save my life or continuing to white knuckle through the program and get my license back," Kinkle wrote in his blog. "So long as I survive, that is."

Many state physician and nurse monitoring programs use abstinence-based models for healthcare providers with disciplinary action related to substance use, often with the reasoning that cognitive side effects linked to OAT could affect patient care.

But the data establishing that association has been criticized as weak, said Kevin A. Fiscella, MD, MPH, of the University of Rochester.

"Quite frankly, it's cherry picking because there are a lot of medications that are prescribed that have potential psychotropic effects," Fiscella told MedPage Today. "If you take Benadryl, people can show up to work the next day with motor impairment."

Overall, it is difficult to ascertain which state monitoring programs offer OAT, and most programs are not transparent about their policies, Fiscella said.

"Certain programs may allow [OAT] for a transition period, or for very selective patients under very selective conditions," Fiscella said. "It's not universally sanctioned and seen as one option for treatment."

Kinkle, who is currently working as a case manager at an outpatient OAT clinic in Philadelphia, advocates for patients seeking recovery and people who use drugs. He openly shares his story as a public speaker to nurses, doctors, and other healthcare professionals, and recently blogged about his decision to go on Suboxone.

"A lot of people feel a lot of shame about that, which is one of the reasons I wanted to be open about it," Kinkle said. "Here I was, two-and-a-half years abstinent. I chose to go on the medication, and that's okay."

For Berry, MAT had worked in years prior. It wasn't his first time in a residential care facility, nor his first time taking Suboxone. The best treatments for him took place in facilities that had a lot of services: medication, but also therapy, support groups, and things like yoga to keep him busy, Hornak said.

"People with substance use disorder need access to this medication, maybe for short-term, maybe for long-term, or maybe for the rest of their lives," Hornak said. "They should not be discriminated against."

https://www.medpagetoday.com/special-reports/exclusives/88870