So what’s the best approach? A recent study, published in JAMA Network Open, sought answers—and in doing so, underlined the importance of involving people with lived experience in policy decisions.

To come up with recommendations, the study consulted 38 experts: seven clinicians with personal lived or living experience of substance use disorder (SUD); 21 clinicians without experience of SUD; and 10 nonclinicians with experience of SUD. 

Eligible clinician experts were physicians, advanced practice clinicians, nurses, and social workers who had worked on a hospital-based addiction consultation team for at least four weeks in the past year. Personal experience of SUD was self-identified by experience of a hospitalization in the past 10 years, and meeting diagnostic criteria.

It was important that everyone was considered equally “expert,” according to lead author Joseph H. Donroe, MD, associate professor at Yale School of Medicine and a member of the Yale Addiction Medicine Consult Service. 

“Every expert opinion was equally powerful, no matter what their background was,” he told Filter.  

While the experts broadly agreed in most cases, there were significant differences between those with experience of SUD and those without on 10 of the recommendations.

The researchers used the Delphi process, which involves asking a group of experts questions anonymously to arrive at a consensus. The participants reached consensus on 84 recommendations.

There were three rounds of online surveys, the last of which included eight categories of recommendations, ranging from what should happen at the time of hospital admission to what should happen if substance use is suspected, the nature of the response and expected outcomes.

Looking at different potential approaches, participants recommended to always implement, sometimes implement, rarely implement, or never implement.

Recommendations on which consensus was reached included providing evidence-based SUD treatment, assessing and reassessing pain management, and treatment of withdrawal.

While the experts broadly agreed in most cases, there were significant differences between those with experience of SUD (whether or not they were clinicians) and those without on 10 of the recommendations.

For instance, none of the participants with experience of SUD (clinicians or nonclinicians) agreed that nonprescribed substances, if found on a patient, should always be stored in a locked place during hospitalization. But 70 percent of the clinicians without SUD experience recommended this.

Meanwhile, all but one of the clinicians without SUD experience said staff should always assess patients for SUD at the time of admission. But fewer than half (42 percent) of the clinicians and nonclinicians with SUD experience said the same.

In both cases, most participants with SUD experience said the policies should sometimes be implemented, depending on circumstances, and so “sometimes” was the consensus reached.

The caution of the SUD cohort is well-founded.

“The partnership breaks down, people get frustrated on both sides, and at its worst, patients leave the hospital. I’ve seen it go wrong so many times.”

“We frequently hear from people who use drugs that a primary reason they delay or avoid hospital care is knowing they will not receive withdrawal management,” Rebekah Joab, deputy director of litigation and legal services at the Legal Action Center, which advocates for health care access and harm reduction, told Filter.  

“When hospitals fail to provide withdrawal management and police and punish in-hospital use, too often the outcome is that people who use drugs don’t get health care,” she added. “Harm reduction belongs in hospitals as well as in the community: The goal should not be to stop a person’s drug use, but to ensure that they receive appropriate medical treatment.”

What happens in the hospital is “distrust,” Donroe acknowledged. “The partnership breaks down, people get frustrated on both sides, and at its worst, patients leave the hospital. I’ve seen it go wrong so many times.”

Many studies point to the link between a patient having SUD history and “discharge against medical advice,” now termed patient-directed discharge.

The new study focused on the consensus recommendations more than the differences. However, Donroe said, “It seemed from our data that people with lived experience were safeguarding their autonomy, their ability to participate in decision-making.”

While the clinicians all recognized the importance of patient safety, he continued, those without lived experience placed more weight on their perceptions of the safety of other patients, as well as patients with SUD. “There was a bit of tension there.”

Another example of an area with less consensus concerned involving the floor nurse in hospital substance use. For some of the physicians and advanced practice providers, it made sense to have the nurse involved, Donroe said. “But people with lived experience have been at the other end of it, and thought that maybe the nurse shouldn’t be involved.”

What about the anesthesiologist, who would surely want to know about what drugs the patient has been using, is tolerant to, or is withdrawing from?

“This is part of what makes this a nuanced and complicated issue,” Donroe said. “Every person you bring into the conversation should approach it with compassion. The situation can improve, or it can get a lot worse.”

Once there is a relationship with the patient, information about their drug use can be sought in a non-stigmatizing way, he continued. “It can be useful for the anesthesiologist to know what the tolerance will be. But don’t follow it up with anything punitive.”

To this end, he recommended that if use is established, providers ask the person about why they use drugs. “There are often reasons—pain, anxiety, withdrawal. The idea behind this paper is not to say anybody is condoning inpatient substance use, but that when it is identified or suspected, is there a way we can approach it that is compassionate?”

“Health records can turn into a rap sheet for people with a history of drug use, and hospital protocol for suspected inpatient use should include strict confidentiality.”

Jacqueline Seitz, the Legal Action Center’s deputy director of health privacy, also had takeaways from the study. “Among the consensus recommendations, it caught my eye that 89 percent of the experts agreed: When substances or supplies are found, patient confidentiality should be maintained, and providers should avoid linking evidence to the patient,” she told Filter. 

“But in practice, we frequently see hospitals recording the events surrounding suspected or actual in-hospital substance use,” she continued. “These notes can end up following a patient for the rest of their life, leading to future stigma and discrimination among providers with access to the electronic health record.” 

“Under current law, it can be challenging or impossible to amend erroneous information or restrict disclosures of stigmatizing or harmful information,” Seitz said. “Health records can turn into a rap sheet for people with a history of drug use, and hospital protocol for suspected inpatient use should include strict confidentiality protocols to avoid this criminalization of health information.” 

The American Hospital Association declined to comment on the study. But hospitals should be aware of their legal liability when it comes to treating patients who use drugs. 

“When decisions or policies are guided by stigma toward drug use, substance use disorder, or suspected use, it can lead to violations of anti-discrimination laws like the Americans with Disabilities Act,” Joab said. “For example, a violation is likely where a hospital applies restrictive security measures only to people with a history of substance use disorder. These anti-discrimination laws also prohibit the denial of health services to people currently using drugs —a protection that hospitals should consider when responding to or creating policies about in-hospital drug use.” 

42 CFR Part 2, the federal regulation protecting treatment records, may or may not apply. “Part 2 protects SUD treatment records that identify a patient as seeking or receiving services from a Part 2 program,” Seitz said. “It is possible in a hospital setting for an Addiction Medicine Consult team or an alcohol detoxification unit to meet the definition of a Part 2 program, but most of the emergency medical treatment provided in hospitals does not fall under Part 2.”

“Physicians have a lot of blind spots and it is important to include the people we help care for in the decisions that affect them.”

Hospitals are not relaxing places to be. They can produce anxiety in almost anyone. “From the standpoint of people with lived experience, it’s not uncommon for them to have trauma or incarceration in their past,” Donroe said. “When you take a person with a history of incarceration, and you say, ‘You cannot leave, we will bring you your meals, your medication, we will tell you what’s okay in your behavior,’ this will bring up past trauma.”

Changing the hospital environment is not easy, he conceded. “I’m part of the Yale Addiction Medicine Consult Team, and one part of why we did this study is to have this data and start evolving policy. Our next step is to evolve policies that are more partnering with patients. We’re not there yet. This is part of the process.”

“Since we began our consult service, there’s been a palpable transition in the way that hospital providers think about people with lived experience in a less stigmatizing way,” he added.

The clinicians involved in the study all had experience in addiction medicine, “in order to generate recommendations based on expertise with substance use disorders,” Donroe said. But many other “stakeholders who weren’t part of this conversation” will need to be involved in order to actually develop new policies, including hospital security and administration staff, as well as nurses.

Above all, Donroe emphasized, to find out what patients who use drugs need in order to have a beneficial hospital experience, providers must ask them.

“Physicians have a lot of blind spots and it is important to include the people we help care for in the decisions that affect them,” he said. Otherwise, the risk is that they will leave, despite being sick—or just not come at all.

Photograph via Pickpik

The post In-Hospital Drug-Use Study Shows Lived Experience Key to Better Policies appeared first on Filter.

Organizers and proponents of PDMPs—electronic databases that enable doctors and other prescribers, pharmacists and law enforcement to track prescribing of controlled substances—will undoubtedly want to add methadone prescriptions to these widely available records.

Whether states will agree—or instead side with methadone patients, who want their information kept private and OTPs, which generally take the same line—is uncertain. But a clear message came from the National Governors Association earlier this month: PDMPs can be money-makers.

On August 10, the American Association for the Treatment of Opioid Dependence (AATOD) issued recommendations, mainly related to consent, advising OTPs to make sure patients know what they’re “consenting” to in the release of their information.

OTPs should “check with [state authorities] to determine if they are expected to report patient data.”

SAMHSA’s final rule states: “OTPs are permitted to enroll in a state Prescription Drug Monitoring Program (PDMP) and are permitted to report data into the PDMP.”

AATOD interprets this change to “permit—but not require—OTPs to report data to the PDMP if required by state law and authorized by patient consent.” AATOD adds: “If a patient chooses not to provide a written consent, then the OTP cannot share information with the PDMP.”

But SAMHSA has opened the door for state regulations to remove that choice. It is therefore important, says AATOD, for OTPs to “check with their respective PDMPs or State Opioid Treatment Authority to determine if they are expected to report patient data. If it is determined that OTPs are not expected to report such patient data, then obtaining a written consent from the patient would not be necessary.”

AATOD’s guidelines state:

It is critically important for OTPs to inform their patients that:

* Once such information is provided to the PDMP, it cannot be taken back;

* PDMPs share information with law enforcement agencies with the exception of Indiana and Nebraska. Pennsylvania has limited authority to share patient information with state level law enforcement;

* PDMPs also share information with other healthcare and non-healthcare organizations, including Drug Courts, Medicaid Drug Utilization and Review entities, medical interns/residents, prosecutors, regulatory/licensing boards and state health departments to cite a few; and

* Patients are not required to consent to the disclosure.

SAMHSA’s new rule is in stark contrast with its previous policy. In 2011, SAMHSA told OTPs they should not put patient information into the PDMP, but rather should check the PDMP to see if patients were receiving any other medications which could conflict with the medication the OTP was dispensing.

The federal confidentiality law, at least for now, requires that patients give consent for release of their substance use disorder treatment information, regardless of whether states tell OTPs they must put information into the PDMP. States may interpret the rule differently, and some may not even require OTPs to obtain consent before putting patient data into the PDMP—even though the Legal Action Center interprets the rule to say they have to obtain it.

More likely—and especially where state policies exert pressure—patients will consent without knowing what they’re consenting to.

This is confusing to everyone, but the possibility is there that patients may not be given the opportunity to consent or refuse to consent. What is more likely in practice, however—and especially where state policies exert pressure on OTPs to obtain consent—is that patients will consent without knowing what they’re consenting to. Once in the PDMP, data won’t be removed. And it can be used by anyone.

PDMPs report to states’ governors, and the governors seem to love the possibilities of PDMPs. The National Governors Association has just released a toolkit extolling their value. It refers in glowing terms to possibilities for revenue generation by putting the information into Electronic Health Records (EHRs), with funding from Medicaid, for example; to opportunities to investigate patient “behavior;” and more.

Some further strategies espoused by the NGA toolkit include:

* Expand types of substances and overdose information tracked through the PDMP to identify potential overdoses or misuse of potentially addictive substances or dangerous drug combinations.

* Permit staff of prescribers and dispensers and providers who have no prescribing authority to access PDMP data to facilitate clinical decision support and care coordination across health care providers.

* Support use of PDMP data by public health authorities to identify hotspots, trends, and improve understanding of drug-related overdoses.

* Promote interstate data sharing for an improved picture of residents’ controlled substance prescription histories to identify potential doctor shopping and create opportunities for greater care coordination across state lines.

In some states, law enforcement is actually in charge of PDMPs—not the health department, which manages EHRs. Do you see where this is going?

Pain patients already know the harms of opioid scrutiny  But for methadone patients, it’s about more than potentially not getting medication. It’s about potentially losing custody of a child, losing a home, losing insurance, losing employment, losing freedom.

Discrimination against patients with substance use disorders, especially opioid use disorder, is widespread. Just ask all the doctors who say they need methadone data in the PDMP because they don’t trust their patients, who are “addicts,” to tell them the truth.

Photo via Pixnio/Public Domain

The post Methadone Patients’ Data Poised to Be Entered Into PDMPs appeared first on Filter.

The 54-page rule was published in the Federal Register on July 15, and takes effect on August 14. It follows along with the proposal, on which Filter reported last summer when the Substance Abuse and Mental Health Services Administration (SAMHSA), the agency which is supposed to protect patient confidentiality, outlined sweeping changes to the rule.

The confirmed changes allow for Opioid Treatment Programs (commonly referred to as methadone clinics) to input patient information into Prescription Drug Monitoring Programs (PDMPs), which can be accessed not only by medical professionals and pharmacists, but potentially by law enforcement.

Many patients are now likely to seek to taper off their medication.

Entering such information into PDMP databases was previously not allowed, under a 2011 “Dear Colleague” letter from SAMHSA’s Center for Substance Abuse Treatment, which regulates OTPs. Many patients believed—and still do believe—that if PDMPs find out they are on methadone, they will be penalized and discriminated against. The idea that this information will be used against them is highly plausible, given the widespread stigmatization of people on medications for opioid use disorder. As Filter has reported, many patients are now likely to seek to taper off their medication.

Finally, the new rule further expands the definition of who can receive an SUD patient’s information. When patients consent to the release of their patient information—including the fact that they were in treatment—potential recipients of that information now fall within a much broader category than previously of healthcare operations, care coordination and case management.

The rule has been issued over patients’ objections. Observers have seen it coming for a long time.

The new SAMHSA rule follows the March 27 CARES Act, meant to alleviate some of the problems of COVID-19, which had already gutted 42 CFR Part 2. In about eight months, the CARES Act provision requiring SUD patients’ one-time consent only for the widespread, irrevocable sharing of their treatment information, will take effect. This consent will be requested, presumably, at the vulnerable time when the patient is just entering treatment and is pressured to sign, just in order to get care.

Oddly, most treatment providers back the SAMHSA changes, perhaps because they want to go with the status quo, or to integrate with the rest of medicine and get out of the SUD silo. The American Society of Addiction Medicine and the National Association of Addiction Treatment Providers have long supported this.

A few organizations—the American Association for the Treatment of Opioid Dependence (OTPs), Therapeutic Centers of America, and the National Association of Alcohol and Drug Abuse Counselors  (NAADAC)—do not. Neither do patients, as their comments during last year’s public commenting period for the proposed rule-change demonstrated—despite “technical problems” conveniently and severely limiting public access to the comments.

The final rule has been issued over their objections. Observers have seen it coming for a long time.

“Will my treatment be confidential?” Substance use disorder patients would be well advised to know the answer before they ask.

Correction, July 21: This article has been edited to reflect more accurately the new rules around undercover agents and court disclosures.

Photo by Kevin Ku on Unsplash

The post SAMHSA Rule-Change Strips SUD Patients’ Privacy, Invites Police Intrusion  appeared first on Filter.

This license to operate as an official outpatient treatment center is going to make it possible for founder and CEO Justine Waldman, MD and her team to continue their low-threshold model of treating opioid use disorder (OUD) on a far better financial footing than before, with the new ability to bill for their full range of services.

That’s great for thousands of patients in Upstate New York, but the news represents something bigger still. Having covered substance use disorder treatment for 35 years nationally, I can say that this is not a typical OASAS license coming down the pike. Rather, it is the wave of the future.

“Harm reduction means we prescribe buprenorphine to our patients even if they’re not abstinent, even if they’re using benzodiazepines or alcohol or methamphetamine or other opioids,” Waldman told Filter. “We’re prescribing a medication that is hopefully going to save their lives. We want to keep them safe. If they’re doing transactional sex work, we ask if we can put them on PrEP. There is no punitive nature to our relationship with them.”

“Low-threshold” additionally means that counseling isn’t required (although it’s offered). And it’s this aspect of REACH’s work that makes the official seal of approval groundbreaking. This is the first clinic of its kind to receive such a license in New York. 

“We see ourselves as the safety net for all of rural New York.”

Ithaca is in Tompkins County, but REACH, which opened its doors in February 2018, currently treats patients from no fewer than 26 rural counties, reflecting the lack of similar services available elsewhere. Its numbers are astounding: 1,300 patients so far, with ten prescribers all waivered to treat up to 275 patients each. That means the clinic could have a total of 2,750 patients, and with telephone inductions now allowed, the patients can theoretically be anywhere in the state.

New York’s Behavioral Health Services Advisory Council Project Review Committee approved the license application at its June 26 meeting, and the license to operate as an 822 outpatient program, under article 32 of the Mental Hygiene Law, is set to be issued any day.

Longtime former OASAS general counsel Rob Kent championed REACH from the beginning, helping to push the agency toward official acceptance based on his belief in harm reduction. “When I first met the [REACH] folks at a conference, what I came away with was first, that they had a really good ability, based on their numbers, to reach people,” he told Filter. Many of the center’s patients had already tried other treatment programs, but they didn’t work. “These were people who really needed help, but they wanted to get it on their own terms,” he said. That is exactly what REACH offers.

However, REACH faced an uphill struggle to survive as a private medical practice, for which Medicaid only covers the prescriber and the medication.

“That system isn’t set up to pay for all the things Justine is doing,” explained Kent. “It wouldn’t pay for social workers, recovery coaches, counselors, peers and outreach workers and everything else, because private medical practices can’t bill for them.” In other words, the office-based opioid treatment (OBOT) model, with a private prescriber seeing the patient every month for a prescription, period, wouldn’t work here. With an OASAS license, in contrast, the clinic will be able to bill Medicaid for the many services it offers.

REACH has other sources of funding, certainly. It has a grant, for example, from the federal Health Resources and Services Administration (HRSA) to teach internal medicine residents about health equity at the Cuyahoga Medical Center. All residents rotate through REACH under the terms of this five-year grant.

OASAS also provided REACH with State Opioid Response funding to assist in the process of seeking licensure, and the center has another grant from Tompkins County to do COVID testing in the local homeless encampment, where treatment staff also do telemedicine inductions. “We do have a great testing site” for COVID, said Waldman.

But these piecemeal grants aren’t enough to sustain the full program long-term. The OASAS license and Medicaid MCO (managed care organization) rates are the only thing that will do that. To date, one third of REACH reimbursement has come from MCOs, and the rest from grants and research grants.

“Right now we’re anxious to get OASAS certification,” said Waldman. “We see ourselves as the safety net for all of rural New York.”

Access to medication can’t now be conditioned on compulsory counseling.

“In the harm reduction world most of this [funding] is tin cup—and that’s not a sustainable model,” Kent said. “Harm reduction is part of the continuum of OASAS treatment. Why don’t they work toward getting into a system that pays for services that they provide?”

So Kent and his colleagues at OASAS rewrote the licensing regulations over the years, in such a way that access to medication can’t now be conditioned on compulsory counseling. “Let them get it, when they’re ready,” is Kent’s attitude.

Waldman would like to be able give higher doses of buprenorphine—32 milligrams are required for many patients. “If we were in New York City I might go up to 32 milligrams, but there’s already enough problems giving 24, because providers think that contributes to diversion.” she said. The program does give a few patients 32 milligrams, “but we don’t do it as a norm.” The OASAS license doesn’t have a bearing on this issue.

In light of relaxed regulations due to the pandemic, telemedicine has become increasingly important to REACH’s operations, as its associate medical director, Elizabeth Ryan, MD, recently described for Filter.

“We’re trying not to have people come in,” said Waldman. She was speaking to Filter via Zoom, which gave some illustration of her warm personality. She had various pet birds on her shoulders and hopping around on a bed behind her, where a black cat was sleeping peacefully.

For REACH, the OASAS licensure will bring peace of mind. For other providers pursuing low-threshold, harm reduction models of care, it brings new hope.

Image via Pixabay

The post Why an OASAS License for a Low-Threshold Bupe Provider Is So Significant appeared first on Filter.

Filter talked to Denise Paone, EdD—director of research and surveillance for the Bureau of Alcohol and Drug Use Prevention, Care and Treatment at the New York City Department of Health and Mental Hygiene—the day the home deliveries began. She estimates that over a two-month period, about 1,000 individual patients will receive home deliveries, for a total of 1,300 deliveries—although this number may rise if necessary.

There are 30,000-plus methadone patients in New York City. Patients’ opioid treatment programs (OTPs, often known as methadone clinics) determine who is eligible, based on criteria set up by the city and the OTPs together. Only those deemed able to receive two weeks of take-home doses safely will get deliveries—the rest will still have to attend their OTP.

For eligible patients, the OTP must make the referral to the city by 3 pm on the day before the delivery is to be made. “The OTP tells us that this individual person needs their methadone tomorrow,” said Paone. “There are a lot of details to set up.”

She said that the system—involving couriers employed by the city, chain-of-custody documents and “guest dosing” protocol for patients whose “home” OTP is not their nearest—is basically the same as the one used for deliveries to Isolation Hotels. But the methadone is delivered directly to the patient, at curbside outside of their residence, instead of to a nurse, as at the Isolation Hotels. All of the delivered methadone doses are in liquid form.

“The person will know we’re coming because we’ll call first,” said Paone. “They’ll come downstairs with a face mask on. We put the lock box down, and we confirm their identity.” The lock box with the methadone inside is in a bag so it is not obvious, she said.

Last week there were six teams of health department employees delivering methadone to patients in Isolation Hotels across four boroughs (OTPs can handle Staten Island deliveries on their own, said Paone). By next week, as deliveries to private homes increase, there will be 10 teams.

Although it’s unlikely that the city will be continuing home deliveries forever, the program may encourage some longer-term changes in the methadone rules.

“We have a very comprehensive chain of custody” for the methadone, said Paone. The medication gets signed out from the clinic to the courier. “At the end of the day, OASAS [the state agency with jurisdiction over OTPs] has a full accounting.”

She further commented on why many New York City methadone patients are not eligible. “Right now the protocol is that the person has to be on 14 days [of take-home doses] or more” to get the deliveries,” she said.

Paone did, however, note that the OTPs “really have bumped people up” to getting more take-homes in these circumstances. Patients who still have to go into their OTP have been told by the city and state about social distancing protocol and requirements for staggered visiting times.

Although it’s unlikely that the city will be continuing home deliveries forever, the program may encourage some longer-term changes in the methadone rules.

“I think we would be in favor of seeing some changes to the regulations in general post-COVID,” said Paone. “The best way to do that is through the data, and we’re thinking about what kind of study we can do. We don’t have it worked out yet, but this is a critical moment.”

So far there has been no negative feedback from the DEA or the police, she added. “We have not had any pushback. And we really recognize the importance of doing this right now. It was slower than people wanted.”

Experts have praised the move. “You have to commend New York for exploring an innovative way to meet the needs of patients in that jurisdiction who are on medication-assisted opioid use disorder treatment, especially during the current pandemic,” said H. Westley Clark, MD, JD, former director of SAMHSA’s Center for Substance Abuse Treatment. He emphasized that the model should be evaluated “for administrative issues that might surface,” but added that “the willingness of all, including the patients and programs, to explore a new avenue for treatment access is clearly important.”

The effort, Clark told Filter, “sets the stage for exploring alternatives to the existing model of care, fostering better patient centered service delivery.” 

“External events like the COVID-19 pandemic provide us with the need and necessity to explore options and modifications of the existing system of care,” he continued. “I also think that this represents an effort to treat people with OUDs with dignity and respect by tailoring strategies that meet their unique needs. My hope is that such efforts will not cease as the pandemic wanes. I also realize that others call for more sweeping change and that those calls may have merit, but while those calls are being addressed, the current project of courier deliveries is a step in the right direction.”

Meanwhile Rob Kent, until last month longtime general counsel for OASAS, told Filter: “It is a victory for patients who need methadone to support their recovery. It is a great and necessary patient-centered step in the middle of this pandemic and one I hope survives the pandemic and becomes a permanent practice. It is also a good step in support of mobile methadone which hopefully becomes a reality soon! The important thing is to track the data to show the real impact of this and other flexibility offered (extended take homes, telephonic bupe initiation) to show it worked without harm to patients and should be continued.”

Here are the eligibility criteria for the NYC methadone home delivery program, as provided by the New York City health department:  

∙       Individuals diagnosed with COVID-19 or have symptoms of COVID-19

OR

Individuals referred by the Medical Director of the Opioid Treatment Program (OTP), with the following criteria as guidance:

Aged 65+ AND OTP willing to provide a minimum of 14 days of medication AND have any of the following health conditions*:

o   Lung disease

o   Moderate to severe asthma

o   Heart disease

o   A weakened immune system

o   Obesity

o   Diabetes

o   Kidney disease

o   Liver disease

o   Cancer

 *Depending on the capacity, the Health Department may revise the guidance in the future

Photo via PxFuel/Public Domain              

The post NYC Begins Home Methadone Deliveries. Will It Have Lasting Impact on the Rules? appeared first on Filter.

New York state’s Office of Addiction Services and Supports (OASAS)—in conjunction with the New York City Department of Health-Mental Health (DOHMH), the NYC Department of Homeless Services (DHS), and the private Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA) of New York—has rolled out the “NYC OTP Methadone Delivery System.”

This started on April 20, with methadone delivered to New Yorkers in DHS Isolation Hotels, OASAS spokesman Evan Frost told Filter.

Deliveries will be conducted by a combination of OTP staff and drivers employed by the NYC health department.

Filter was first informed of this development by Allegra Schorr, president of COMPA, who said the move was spurred by Filter’s report on the problem, published on March 26. Schorr was quoted in that report as noting that the federal government would allow “doorstep delivery,” but only if it were done by OTP staff. She said that OTPs didn’t have the capacity to do this, and that “We’re going to need some outside agency like the National Guard.”

Rather than the National Guard, deliveries will instead be conducted by a combination of OTP staff and drivers who are employed by the NYC health department, managed by state and city health authorities and the OTPs themselves.

The system will be rolled out in two phases: The first, which has already begun, is getting methadone delivered to patients who are in the hotels set up for homeless people who need to be isolated. The second, due to start before the end of this week, will consist of deliveries to private residences.

This will be done via the protocol of “guest-dosing,” combined with a “designated other” who will serve as the courier. Here’s how the first phase of deliveries works.

The patient is assigned to a hotel—a real hotel, now converted to an Isolation Hotel reserved specifically for homeless people who are, or might be, COVID-positive. There are currently five such hotels in the city. The patient’s “home” OTP may be far from the hotel. So the patient authorizes a “designated other”—a courier, who is an employee of the city’s Department of Health—to pick up their methadone from a “guest” OTP.

After the patient signs an authorization and consent, the medication will be routed through from the home OTP to the guest OTP. The authorized courier will then bring the methadone from there to the patient’s hotel, and deliver it to a nurse—all of the Isolation Hotels have nurses. The courier and the nurse will witness the transfer in a chain-of-custody document.

The courier will bring one week’s worth of doses at a time, which will then be placed in the patient’s lockbox—all patients will be provided with a lockbox in which to keep their methadone. (Schorr said she was impressed by the quality of the lockboxes purchased by the city.)

Nobody will stay in the hotels more than 14 days, as that is the length of time stipulated for quarantine or isolation. Patients will then either leave the hotels to return to shelters, or, if they need to, go to the hospital.

There are currently about 30 homeless patients—either living on the streets or in shelters—entering the city’s OTP system every week, said Schorr. There are a total of 64 OTPs in New York City serving 30,000 patients. Of these, eight are authorized to provide guest dosing.

Home deliveries will start next, operating along similar lines but obviously required to deliver methadone to a much larger number of locations. Patients in private residences who are unable to obtain their medication due to quarantine or isolation, or who are experiencing symptoms of COVID-19 will be eligible, Frost told Filter.

Schorr, who is also owner and vice president of West Midtown Medical Group, a Manhattan-based treatment program that dispenses methadone and buprenorphine, said she is on calls more than once a day with the city working on this new system.

“This is brand new, basically in response to your article,” she said. “We’re looking at something far beyond our capacity, with the pandemic hot spot and the numbers of patients [in isolation] that we have.”

The federal government had already temporarily revised its guidelines, allowing all patients deemed stable to get 28 days of take-home methadone doses, and “less than stable” patients to get 14 days. However, it’s up to the OTP to decide who is placed in these categories.

The courier system, which involved coordination between City Hall and several city and state agencies already dealing with a huge health crisis, is a welcome way to help methadone patients navigate current circumstances. The overdose crisis continues regardless, making it vital that isolated patients get their daily medication rather than going into the street in search of something else to stave off withdrawal. 

Photograph of an MTA van in Brooklyn by Adam E. Moreira via Wikimedia Commons/Creative Commons 3.0.

The post NYC Rolls Out Courier System to Deliver Methadone to Isolated Patients appeared first on Filter.

The $2 trillion stimulus bill rapidly hammered out by Congress was unprecedented in scale and impacts American life in all kinds of ways, so the insertion of this one little amendment may not seem like a big deal. But to patient advocates in the substance use disorder (SUD) treatment field, it is.

The first question many people ask when they go into substance use treatment is whether it will be confidential. Treatment programs now will have to say, no.

The CARES Act does not simply turn over all substance use disorder treatment records to the general Health Insurance Portability and Accountability Act (HIPAA) governing healthcare records. But it does mean that once a patient gives initial consent for disclosure of information, the patient then loses control of it.

Under the CARES Act, there is no way to segment the reason the information might be used in future.

You typically consent to release of your SUD treatment records upon admission to a program. This is required in order for the program to be paid by insurance. But under the CARES Act, there is no way to segment the reason the information might be used in future.

The three possible uses of this information that the Cares Act permits are: treatment, and obviously, you would want treatment providers to know you are being treated; payment, which is also a necessity unless you want to pay for it yourself; and then, healthcare operations. This last category is troublingly broad, and could result in disclosure to all kinds of people and entities beyond what a typical patient would wish.

Potential negative consequences are severe. Your divorce outcome could be affected, you could lose custody of your child, you could lose your job, or you could lose your freedom and go to jail. Down the road, many years from now, you could need cancer treatment and an insurance company could use your SUD history against you to deny payment. The stigma applied to addiction and the illegality of drug use mean that the possibilities are endless. Finally, there is such a thing as just wanting privacy.

Before CARES, there were rules against redisclosure. That is no longer the case. HIPAA will apply after the first consent, and the patient will have no control over how the information is redisclosed. And although the CARES Act says patients can revoke consent in writing at any time, exactly how that could happen once your information is in the electronic health record is unclear.

SAMHSA had previously been pressing for loosening of patient confidentiality and already has two rulemaking proposals on 42 CFR Part 2 in process, as Filter has reported. One would allow law enforcement to search records for patients on methadone. The other would radically change the regulation, allowing methadone patient information to go into the Prescription Drug Monitoring Program (PDMP), as well as making other changes in confidentiality to appease the insurance industry. As of March 31, SAMHSA did not know, according to press spokesman Christopher Garrett, whether it would drop its 42 CFR Part 2 rulemakings in light of the CARES Act.

The new regulations from the CARES Act will not take effect for 12 months, but they’re coming. Advocates are deeply concerned.

“Revocation of data from those systems … would be technically improbable.”

“Once that information is available for any purpose under treatment, payment and health care operations contexts, it has already been shared with different contractor systems and potentially hundreds of individuals,” Danielle Tarino of Young People in Recovery told Filter. “Revocation of data from those systems, which then may continue to share data absent a prohibition on redisclosure, would be technically improbable. I have yet to come across a technical solution, protocol or even a strategy that could support this type of activity.”

The CARES Act stops short of saying methadone patient data can go into the PDMP—in fact, it says the “sense of Congress” is that it shouldn’t. However, maybe SAMHSA will decide to ignore the “sense of Congress.” SAMHSA has already made it clear that it wants methadone patient data in the PDMPs. 

One result of COVID-19 is that telemedicine, including for both methadone and buprenorphine, will become a lot more common. While the CARES Act doesn’t specifically link 42 CFR Part 2 and telemedicine, there are many questions about how these online platforms are compliant with confidentiality. (Some, like doxy.me, are compliant with HIPAA.)

But HIPAA-compliant or not, there is just not going to be much enforcement of patient confidentiality, said Tarino, who used to work for SAMHSA. “The new lightened regulatory situation implies that there will be low prosecution and acceptances made amidst the COVID-19 crisis and provisioning of telehealth services,” she said. “That said, there still exists an ethical issue, and obligation of providers to ensure the protection of confidentiality and privacy via cyber services, to the best of their ability. In my opinion, that includes informed patient consent, or, at a minimum, conversation that is open and honest, when utilizing non-HIPAA compliant technologies.”

What would informed consent look like? These are the guidelines that Megan Marx-Varela, MPA, director of integrated care at Oregon Recovery and Treatment Centers (and formerly in charge of SUD treatment accreditation at the Joint Commission) told Filter she developed: 

When meeting with patients for the first time via telehealth or telephonic connection please read the following statement to each patient:

“At this time, in accordance with federal guidelines on ‘social distancing,’ as well as state and/or local government bans or guidelines on gatherings of multiple people, your treatment program has elected to offer most treatment services via telehealth or via telephone. This is not how services are usually provided. 

The federal government recognizes that we are currently experiencing a public health emergency and it is in the best interests of our patients and our staff to observe federal, state and local guidelines to prevent the spread of disease.  During this time your treatment program may not be able to obtain your written consent for disclosure of your substance use disorder treatment records. 

As a result, it is possible that patient identifying information held by your treatment program may be disclosed to medical personnel, without your consent, to the extent necessary to meet a bona fide medical emergency.  

It is important for you to know that your treatment program is responsible for determining whether a bona fide medical emergency exists for the purpose of providing needed treatment, and they are required to document certain information in their records after a such a disclosure is made.” 

WHAT DOES THIS MEAN

Essentially this means that patient identifying information about them may be released to medical personnel by the treatment program, without their permission, if the patient is experiencing a medical emergency. Typically, we would be required to obtain written consent from patients before we would provide patient identifying information, however, we may be unable to collect written consent while we are providing services via telehealth or telephone.  

DOCUMENTATION (very important)

Please document that you have reviewed this information with the patient in the patient’s chart stating: “Reviewed COVID-19 Public Health Emergency Response and 42 CFR Part 2, disclosure of patient identifying information without consent for medical emergencies.” 

If you really think that healthcare providers and authorities only want people’s substance use disorder treatment information for healthcare purposes, consider this: In August 2019, 32 Attorneys General banded together to call for the elimination of 42 CFR Part 2. Why would these powerful prosecutors want this? 

Because under 42 CFR Part 2, a court order is required to obtain people’s SUD treatment information. Under HIPAA, no such court order is required. Things are going to take a bleak turn for vulnerable patients across the nation. 

Photo of a methadone clinic by Helen Redmond

The post SUD Patients’ Confidentiality a Quiet Victim of the CARES Act appeared first on Filter.

The department’s modeling is renowned, and while the figure remains unofficial, it tallies with the mayor’s prediction that half of all New Yorkers will eventually contract the virus.

So how will those 15,000 patients who won’t be able to go to the clinic get their methadone? And what will they do if they can’t? 

Amid the crisis, the Substance Abuse and Mental Health Services Administration (SAMHSA) has issued revised temporary guidelines allowing opioid treatment programs (OTPs) to give stable patients 14 or 28 days of take-home doses—putting the onus on OTPs to decide who is “stable.”

OTPs can also be held liable if anything goes wrong; federal agencies are by definition indemnified. So SAMHSA’s move—while welcome—in a sense just passes the buck while that legal situation remains. It’s causing OTPs great concern given SAMHSA’s eight-point criteria and the potential of methadone, like any opioid, to be involved in fatal overdose, either of the patient or of another person to whom it’s sold or given. Schorr’s facility is trying to strike a balance between giving more take-homes, but not a universal 14 or 28 days. For example, patients who have been coming in daily will be given take-homes on a staggered schedule, every two or three days. This is what most OTPs across the country are currently doing.

Patients’ getting take-homes can help. But even if they are all permitted to receive them—which they will not be—that does not help people who cannot go to clinics due to isolation for coronavirus.

SAMHSA has instituted provision for “doorstep delivery” of methadone to isolated patients, but is asking OTP staff to do this. This will not be possible for the numbers of patients projected to need this service.

“The system is not set up for delivering methadone to 15,000 patients,” said Schorr. “We’re going to need some outside agency like the National Guard.”

Photo via Needpix/Public Domain

The post Estimated 15,000 NYC Methadone Patients to Be Isolated. How Will They Get Meds? appeared first on Filter.

But what Nicole described was worse than what happened to me. (People with a trauma history may not wish to read the description that follows.)

Nicole, who asked that only her first name be used, was going through airport security on her way home to Baltimore with her partner (who was in another line, so unable to assist) on January 14 at about 5:30 pm.

“I had on a short black skirt—a skort—with an elastic waist,” she told Filter. The TSA agent, a woman, was conducting the search at the direction of another, male agent. Nicole was instructed to place her hands on her head. The woman reached with her gloved hand inside Nicole’s skort, then inside her panties.

“’We have to pat down and make sure there’s nothing there,’ they told me,” she said, quoting the man talking to the woman. “I thought it would be a quick swipe,” Nicole said. “But next thing I knew, her hand was in my underwear, and she felt around.”

“They said, ‘We have to feel inside,’” Nicole recounted. “My hands are still on my head. They asked me to open up my legs more. They asked, ‘Do you have anything in your vagina?’”

She recalled thinking, “My goodness, I’m 47.”

The TSA agent then inserted her gloved finger into Nicole’s vagina. Nicole said that this assault happened in full view of other passengers.

Afterwards, “She nonchalantly wiped off her glove.” She then placed the wipe in a machine, presumably to detect a banned substance (not drugs, as I previously discovered, but potential explosives).

As a transplant patient, Nicole is on an immunosuppressant and said she was terrified that the glove wasn’t clean.

Like me, Nicole was paralyzed and frozen. What happened after she complained made it worse.

Nicole, a musician, is also on oxygen. Her nasal cannula was on the X-ray belt at the time. She broke her arm badly a couple years ago and has eight screws and a plate in it. Yet after her scan, it was her vagina they were interested in.

Like me, Nicole was paralyzed and frozen. She initially tried to “laugh it off.” But after reading Filter’s articles, she said, she realized that she had a right to be upset. And she complained to the authorities.

But what happened after she complained made it worse. “I called [the Orlando police] after I read your article,” Nicole said. “I told the police officer there was penetration. He told me I watched too much television. The police officer said, ‘This didn’t happen to you, you’re making this up.’”

Nicole, like me, realized that there must be a video of the incident, and that it would be easy to find. “I have flaming red hair, I have oxygen.”

But the police officer, she said, told her that she would have to return to Orlando from her home in Baltimore if she wanted to press charges: ’’You have to fly down here and single her out in a lineup,’” he said, referring to the TSA agent.

Nicole added that the officer threatened her. “He said I would go to jail if it’s a false accusation.”

Ultimately, she called a rape crisis line. That was the first place where she received solace. The psychologist there talked with her for more than an hour.

When she got off the phone, she was “changed,” Nicole said. “It was comforting and validating. I felt guilty calling because I thought this was really for someone who has been raped, and in my mind I was in this weird category.”

But it hit her how she would have reacted if the same had happened to her 17-year-old daughter. “That’s why my reaction was so extreme. I knew it was wrong. But I stood there and submitted to it. That’s why I knew that I needed to talk to someone. I knew boundaries were being crossed.”

Nicole now feels “a million times better” than before. She cried a lot after her experience—and after complaining to the police—but no longer does, she said.

She and I compared descriptions of the TSA agent in our cases, and are certain that it was two different people. But the idea that the culture of Orlando TSA enables this is perhaps even more disturbing than the notion of a single predatory agent.

“I think they were torturing me for no reason.”

I asked Rory Fleming, a lawyer who writes regularly for Filter, about how Florida law would regard the attacks reported by Nicole and me.

Although I called my own molestation “sexual assault,” it turns out that Florida law defines this extremely narrowly. Groping someone’s crotch or squeezing their breasts apparently does not qualify.

“The honestly shocking part of this is that [in Florida] it’s a first-degree misdemeanor for a first offense and it’s not a sex crime,” said Fleming of my case. “’Sexual battery’ is the Florida statute’s euphemism for rape. There are sexual misconduct charges that address this type of conduct, but only when it involves a minor or ward (with very specific criteria like psychologist/patient).”

My experience does not fit the definition of sexual battery, which includes penetration with an object (such as a finger), said Fleming.

Nicole’s experience does, however.

A common retort against complaints like ours is that by flying, people consent to TSA agents’ contact–but this is “within certain acceptable, consensual bounds,” said Fleming.

“I think they were torturing me for no reason,” said Nicole.

Like me, she has contacted her Senator to seek answers. In her case, that’s Sen. Chris Von Hollen (D-Maryland), and she said that his staffer “was beyond helpful.” No concrete progress has yet been made, however.

Nicole filed her complaint with the TSA on February 12. On February 17, she received the following email reply—clearly a cut-and-paste job—with an ad for TSA pre-check embedded. Paying $85 seems to be the going rate to avoid the possibility of being attacked. (The “concentrator” refers to Nicole’s portable oxygen machine, which was disconnected from her and on the X-ray belt at the time.)

The last line of the email just about sums up the agency’s total indifference.

The TSA Contact Center has forwarded your message of concern to the Transportation Security Administration in Orlando. 

In your message you stated that you had concerns about the way you were screened at the security checkpoint.

 TSA Officers are screening for weapons and items related to explosives.  The AIT body scanner scans for everything above the skin.  Its computer compensates for normal clothing.  If the computer detects a potential threat it will display the alarmed area on the monitor at the exit of the scanner.  The TSA Officer will then pat down the area to resolve the alarm.  After a groin area inspection, the Officer will test their hands for explosives.

 If you could not disconnect from the concentrator, then a full pat down would have been performed.  Any time you are subject to a pat down, you may ask the officer to change gloves.  Also, you may ask for a private screening.

 TSA Pre-check has no age restrictions.  Travelers who are 12 and under are allowed in Pre-check with an eligible parent or guardian.  The fee for a background check is $85.00.  Pre-check eligibility lasts for 5 years.

 The following link refers to the age limit. 

https://www.tsa.gov/travel/frequently-asked-questions/there-age-restriction-apply-tsa-precheck

 Application for TSA Pre-check can be found on our home page: www.TSA.GOV

 Should you feel that you need assistance through screening, TSA has a program called TSA Cares.  The program is a help line to assist travelers with disabilities and medical conditions going through the security process.  Travelers may call TSA Cares toll free at 1-855-787-2227 or e-mail TSA-ContactCenter@tsa.dhs.gov 72 hours ahead of their flight.  TSA Cares will request information from your itinerary.  They will send a message to all of the airports involved with your travel.

 At Orlando, we place your request on our assistance schedule.  On the day of your departure we assign you a Passenger Support Specialist, who is a TSA Officer.  If you had provided contact information, the Specialist will call you a couple of hours ahead of your departure time.

The Specialist will arrange for a meeting place in the airport.  When you meet you may address any concerns you may have about the screening process.  The Specialist will then escort you through the security checkpoint.  

We regret that your experience was less than satisfactory.

 Sincerely,

 William Kretchik

Program Assistant

TSA Orlando (MCO) Customer Support Representative

Photo of Orlando International Airport by elisfkc via Wikimedia Commons/Creative Commons 2.0.

The post Second Woman Reports Sexual Assault by TSA in Orlando appeared first on Filter.

After I wrote about this for Filter, numerous people called and emailed me with support. Some wanted me to fly right back to Florida and press charges. Some wanted me to get trauma counseling. A number of women just thanked me.

Since then, I have been trying to obtain the video of my October 23 “pat-down,” to no avail. It’s been frustrating, to say the least.

So I was gratified to see this week that that one woman is suing the TSA for this kind of behavior. The traveler, who was passing through Asheville Regional Airport in North Carolina is charging civil battery, among other things, for an unacceptable search. It’s not a criminal case, but she describes it as a sexual assault, in which the agent reached under her shorts to “fondle” her genitals for her sexual gratification. The flyer, who is from California, filed in United States District Court for the Western District of North Carolina and is represented by California attorney Jon Corbett, who has made a name for himself going after the TSA’s tactics.

Could I sue? Maybe. But would it be worth it to me, or to any lawyer taking it on contingency? Hardly likely. Even if I started legal proceedings in New York, they would end up in Florida, with a lot of travel involved. It would be prohibitively expensive, with little prospect of adequate money at the end of the process (yes, I asked my lawyer). The agent in my case clearly violated TSA’s own protocol in conducting searches. But I was still left wondering if this would be considered a crime. And I wanted the video.

“Closed Circuit Television is often the property of the local airport authority and only available for 14 to 30 days.”

When I inquired last fall to the TSA about getting the video via FOIA, Elaine Pancake, TSA Orlando customer service manager, responded: “You will receive notice within 1-3 business days of receipt. The notice will contain a tracking number for your request.”

I did not receive a tracking number when I filed my FOIA request with the TSA in January (within the three-month time limit). Rather, I received this, less than a day after filing my request: “Closed Circuit Television (CCTV) is often the property of the local airport authority and only available for 14 to 30 days. We recommend reaching out to the airport authority directly to request any CCTV footage. You can typically find the airport authority’s contact information on the airport’s website.”

The airport authority in this case is the Greater Orlando Aviation Authority (GOAA). Rod Johnson, assistant director of public affairs for GOAA, told me that I could file a FOIA with his agency for the video. However, “We don’t oversee the TSA so we have no recourse” when it comes to agent behavior, he said.

Could I have called the police from the TSA scanning area where I was being assaulted? Yes, and they would be allowed in, he said, noting that GOAA has a contract with the Orlando Police Department.  

So how should a passenger respond if they feel they have been sexually assaulted by a TSA agent? “I would recommend they contact the TSA,” said Johnson. What? Really? “Either that or you call the police department.”

There have been “no other issues with this, not that I’m aware of” said Johnson. But he was very helpful —much more so than the TSA—with instructions about how to file a FOIA with GOAA. I spoke to him on February 12 and started the process then.

When I belatedly contacted the local police department, Sergeant David Baker of the public information office emailed a response to my query: “If you feel you were the victim of a crime, you can contact the Orlando Police Department at 321-235-5300 or come to our headquarters to file a complaint. Since the airport is in the City of Orlando, we investigate allegations of crimes that violate Florida State Statute, regardless of who may employ the alleged violating party.”

He added: “Anyone who believes that they are the victim of a crime at the Orlando International Airport can contact the Orlando Police Department and their allegations will be thoroughly investigated.”

Sergeant Baker also sent me a link to the statute defining “sexual battery” in Florida. The definition is limited to oral, anal or vaginal penetration. I guess walking up to someone on the street and squeezing their breasts or fondling their crotch or buttocks is some other kind of crime. It certainly should be a crime.

But the Florida Department of Law Enforcement, asked which statute covered sexual assault, sent me a link to the same statute.

As a New York resident, I have also complained to NY Senator Charles Schumer. I filed my privacy notice by mail (you have to send a release before a member of Congress will investigate your complaint against a federal agency) right after the assault occurred. However, Sen. Schumer’s office didn’t receive it until late January, because of a new system in which all mail first goes to Washington, DC to be checked for explosives, etc.

It finally got to Susan Orlove, an impressive case worker in Sen. Schumer’s office who can handle everything from Medicare to Social Security to, now, the TSA. I told her that I want the video and an apology. She has contacted the TSA and said that she will keep me informed.

The episode left me asking questions about my own conduct. Why was I such a terrible reporter that I didn’t get the agent’s badge, or note the type of scanner used, or even thinking of calling the police? The reason is that I froze. It’s known as the freeze response, what psychiatrists and psychologists call dissociation.

I vividly remember what that agent looks like, however. Psychologist Christine Blasey Ford explained this phenomenon of memory to the nation in 2018—“indelible in the hippocampus”—in reference to what Bret Kavanaugh, now a Supreme Court justice, did to her as a teenager.

The TSA has become what author Bruce Schneier calls “security theater.” And it’s hurting people.

The TSA was created in response to 9/11, when it was feared that nobody would get in a commercial airplane again if nothing was done about the prospect of deadly hijackings. Now, however, the TSA has become what author Bruce Schneier calls “security theater.” And it’s hurting people.

That agent has continued to appear in my dreams—and she has not fared well there, trust me, facing punishments worse than anything I could come up with while conscious. I don’t for a minute think she represents the entire TSA, but that she is allowed to do this to people is unconscionable.

I think of other women, of my daughter. I may be dismissed as an old lady who allowed herself to get “felt up” by the TSA and then complained about it, but I trust my senses. One friend said the only solution is to wear steel panties. I can just imagine what the scanner would do to that one. 

Image of TSA flag via Wikimedia Commons/Public Domain. 

The post How the TSA Has Stonewalled My Follow-Up to Being Sexually Assaulted appeared first on Filter.