Legislators Must Strive to Better Understand Our Treatment System to Ensure That Marylanders Have Solutions That Work for Them
Individuals who have problems with substances represent a complex population with a hugely diverse set of needs. Yet treatment practitioners and public policy experts at times seem to be striving to come up with a single solution, as if there is a magic bullet that will suddenly heal all of the multi-faceted causes at the root of addiction. They talk about “the gold standard” in treatment care and shift funding from one solution du jour to another, with little analysis or measurement of what has been successful and what has not.
Rarely are the individuals with the problem educated about all the options, along with side effects and success rates, and presented with choices for their own medical and/or behavioral condition. More often, treatment seems to be chosen for them, based on what is convenient or profitable, rather than what is effective or fiscally responsible. It can be difficult to find coordinated care with the range and type of services necessary to achieve optimal outcomes for individuals with an opiate dependence problem. The result can be an over-reliance on single elements of care –counseling or medication or supportive housing, dependent upon whatever service a particular provider is able to get paid to deliver –and lasting for only as long as that particular provider is able to get paid for delivering it.
Debates rage over whether the problem is a medical disease or mental health disorder or a chosen behavior, whether the solution lies in long-term abstinence-based residential treatment or medication-assisted treatment, whether the treatment should be short-term or long-term or opiate-based or non-opiate based, and which psycho-social therapies, if any, work best. Potentially viable alternative treatments, backed by a wealth of promising scientific data, without the funding to get the blessing of the FDA, or to pay for high-profile marketing and lobbying campaigns, are ignored at best and maligned at worst, and ultimately kicked to the way-side of the care compendium. In the end, it is the practitioners who stand to profit by promoting whichever brand of rhetoric supports their bottom line, who are able to control the messaging that shapes public policy and ultimately influences the options available to consumers of ‘substance-use disorder’ services. The consumers themselves, with lived experience and personal insight into what is helpful and what isn’t, are rarely consulted.
These are unnecessary and unhelpful debates. If we expect to begin to lower Maryland’s skyrocketing addiction and overdose death rate, we must begin to look toward science to drive the solution and not the vested interests that have traditionally been seated at the right hand of the policy table. We must begin to give more weight to facts than to bottom-line profits. Instead of discussing which modality is superior, the debate must evolve into how to make best use of ALL options.
While legislators have been quick to jump on initiatives that absolutely do help solve the problem –making Naloxone widely available, protecting ‘Good Samaritans’ from criminal charges when calling for help during an overdose, and ensuring that ‘addicts’ have access to clean needles to prevent the spread of deadly communicable diseases, they have been reluctant to delve into the area of TREATMENT REFORM, instead relying on the provider community to call their own shots, and create a treatment system which largely serves their own needs. Rarely do they question the positions espoused by those wearing Ph.D. hats with a string of impressive letters following their names on business cards, signifying credentials considered sacrosanct and beyond the refute of mere mortals with undergraduate degrees or less, despite the fact that it is these same business owners whose whopping salaries are reliant upon a steady flow of people with substance problems coming to them for their specific brand of ‘solution’. All but a few legislators have spent the time to understand our treatment system and its inherent ‘quality of care’ –or lack thereof, and to attempt to tackle this proverbial ‘elephant in the room’.
Delegate Howard, Anne Arundel County, introduced a bill in 2016 that was signed into law in May 2017 –The Recovery Residence Residential Rights Protection Act, which mandates state regulated treatment providers (most notably detox providers) to refer all patients into a ‘next level of care’ with referrals to ALL necessary services outlined in their assessment. So, for instance, if a patient’s assessment shows that an individual needs housing, GED and job support services, and psychological counseling, the regulated provider is mandated by law to ensure that the patient knows exactly where and how they will access these services when they are discharged. Despite passage of this critical and hugely influential law, the Behavioral Health Administration has failed to enforce it, and ‘discharges to nowhere’ continue to be the norm in many of our Maryland treatment programs.
Howard introduced a companion bill during the past session which mandates providers to begin discussing discharge planning based on ‘assessed’ needs within 72 hours of a patient’s admission to treatment –to allow enough time to plan a successful and smooth discharge. The bill was opposed by those who believed it was too onerous for the treatment industry to be expected to ensure that their patient is able to access the services that are necessary for their recovery and ultimately their survival upon being discharged from their program. Anyone who has ever been in residential treatment for opioid dependence is fully aware that ‘life after opioid detox’ is so much more complex than simply ‘taking your meds’. Is it any wonder that people have difficulty recovering from a hugely debilitating condition, regardless of whether it is rooted in a medical, mental, or behavioral cause, when there is opposition to a bill that mandates treatment providers to assist their patients with obtaining services which are necessary for their recovery?
Similarly, Delegate Morhaim, Baltimore County, forayed into the world of treatment reform with a bill that would have added ‘opiate use disorder’ to the conditions treatable with medical cannabis. While the legality of this treatment already exists and is protected under recently passed legislation outlining the conditions under which medical cannabis can be prescribed — including ANY condition that is currently treated with a prescription opioid –which would include opioid dependence treated with methadone or buprenorphine (both opioid replacement therapies used to treat heroin addiction), treatment providers have been less than slow to offer it as an alternative therapy to their patients, claiming that marijuana is a drug of abuse (apparently selectively forgetting that methadone and buprenorphine are harm reduction therapies with high abuse potential as well). In fact, owners of methadone clinics (wearing their Ph.D. hats) actively opposed the bill in 2017, claiming that the plethora of studies showing the efficacy of medical cannabis in alleviating both short-term and long-term symptoms of opiate withdrawal were insufficient to warrant an inclusion on the ‘treatable conditions’ list, particularly since the FDA has not given medical cannabis its blessing as a solution for opioid dependence. Of course, FDA inclusion remains unlikely since the pharmaceutical industry seems to be the only player with the millions of dollars it costs to undergo the process for attaining FDA approval for any new medication.
Likewise, representatives from the methadone industry opposed Delegate Beitzel’s (Garrett and Alleghany counties) bill that would fund a study on the efficacy of ibogaine, a naturally occurring root that has shown so much success in curing opiate addiction that it is standard therapy in Mexico, Canada, Brazil, and some European and Asian countries. They opposed it –claiming there have been deaths related to treatment –apparently overlooking the fact that methadone continues to hold the dubious title of having the highest death rate of any opiate on the market even when used for treating heroin dependence and comes with a ‘black-box warning’ for increased risk of respiratory depression and fatal cardiac arrhythmia.
Obviously, for those whom methadone has been a life-saving treatment for heroin dependence, these risks were and are worth taking, and their successful recovery is a tribute to the efficacy of this particular treatment modality …for them. But when we have methadone providers / business owners influencing state and local policy by holding important positions within supposedly unbiased state health agencies and garnering the ear of our elected officials simply because they can muster huge lobbying budgets, it is akin to relying on Perdue Chicken Farmers to create and dictate our state’s environmental policy. It is simply an unethical way for our state government to do business.
Hopefully, as consumers, elected leaders, and policy makers become more aware of the solutions that science supports, rather than the solutions that profit supports, we will begin to make some headway with reducing the ever-spiraling increases in overdose deaths and rates of addiction in our beloved state. We must begin to value lives over profits, and we must begin to create policy which reflects those values. We must support what works, rather than allow what doesn’t. To determine what works, we need to focus on measurable outcomes, and allow those impacted to determine what is important to measure and what is not. Treatment goals need to be more about assisting people to develop happier and more meaningful lives and assisting them to make the choices that work best for them, and not just about whether they are still alive at the end of the day.