As state committee works on opioid addiction treatment rules, some advocate for easier access

As state committee works on opioid addiction treatment rules, some advocate for easier access

By CAROLINE BECK and MARY SELL, Alabama Daily News

MONTGOMERY, Ala. – A group working to establish additional guidelines and regulations for physicians who prescribe Buprenorphine to people with opioid drug addictions isn’t going to recommend a ban on cash payments, but alleges offices that deal in cash are at a higher risk of misuse and abuse of the drug.

Buprenorphine, under the brand name Suboxone is a low-grade opiate that is meant to block cravings for opioids, without the same level high as methadone. The group’s recommendations will eventually be sent to the Alabama Board of Medical Examiners to be approved for statewide implementation.

Originally, some members wanted to ban cash sites altogether, but the group appears to have settled on a warning to the state board that if treatment centers deal mostly in cash,  the board should allocate personnel and funds “commensurate with this increased risk.”

The wording was debated among the group members on Tuesday.

Group leader Dr. Brent Boyett said that he understands that physicians may think the guidelines created by the committee are too restrictive, but they have to be when dealing with a controlled substance like Buprenorphine.

“We want to provide a standard of care that is consistent among providers and I fully expect there to be arguments to loosen this and that but there needs to be some sort of guardrails in place for these very dangerous medications and Buprenorphine is a controlled substance that has potential abuse and potential diversion,” Boyett told Alabama Daily News.

Nicole Warden, the director of Substance Abuse Treatment and Development of the Alabama Department of Mental Health told Alabama Daily News that providers shouldn’t be punished just because they happen to accept cash.

“So many people with substance abuse disorders have destroyed their life before they actually get to treatment,” Warden said. “They don’t have credit history or the ability to open a bank account because a debit card costs money, so just that fact that they showed up for treatment and are able to give you $20 is huge.”

In May, the Alabama Legislature approved the creation of increased regulations on Buprenorphine. The bill outlines several areas to be addressed through new rules, including dosage and minimum requirements for counseling, behavioral therapy and case management.

Boyett helped Sen. Larry Stutts, R-Tuscumbia, draft the Buprenorphine bill. Boyett is an addiction medicine specialist and now leads the 17-member commission created by the legislation. Boyett, from Hamilton, is the founder of a treatment center with five locations in the state. He argues that increased counseling is key to beating addiction. He previously told Alabama Daily News that the group wanted to eliminate the “cash culture” of some clinics that prescribe Buprenorphine.

In response to Stutts’ law and the proposed new rules and guidelines, a new group, the Medical Assisted Treatment Association, formed to advocate for expanded access to addiction treatment, including Buprenorphine. 

Dale Agan is a board member on the new association. He’s a member of the Krulak Marine Alliance of Alabama, a non-profit group helping Marines and other veterans in distress, including suicide prevention efforts.

“There is a direct correlation between veterans who commit or consider suicide and who have a mental health or substance abuse issues,” Agan told Alabama Daily News.

Drug addiction treatment needs to be as easily accessible as possible, he said.

“Reducing services can cost lives,” Agan said.

He said the association plans to engage and education state leaders about treatment needs in the state.

“We’re not political people, our purpose is to create a unified voice and create best practices for addiction treatment,” Agan said.

He also said it’s reaching out to all Buprenorphine prescribers in Alabama. As of November, there were 781, according to the Substance Abuse and Mental Health Service Administration, part of the U.S. Department of Health and Human Services. Most are doctors, some are nurse practitioners and physicians assistants.

Dr. Gregory “Phillip” Jones is a prescriber and member of the new Medical Assisted Treatment Association.

“I continue to have concerns about some of motivations of some of the (rule-making committee) members and how this is going to affect citizens of the state,” Jones said. “I don’t want to be inciting, I just have strong reservations about where this is going.” 

Jones, an obstetrician and gynecologist, said policies should be based on best practices and data.

“Can any state show that eliminating cash (payments) helps outcomes?” he said.

In December, the deputy assistant administrator of the U.S. Drug Enforcement Agency’s Diversion Control Division wrote a letter in support of medication-assisted opioid treatment.

“The stigma that DEA does not support (medication-assisted treatment) is predicated on the belief by some that DEA unfairly targets (practitioners),”  Thomas Prevoznik wrote. “This is not the case. In fact, the overwhelming majority of practitioners act within the law and provide MAT as it is intended.”

Another concern for the working group Tuesday was the required number of visits for patients, especially those who are under Medicaid because it only allows 14 office visits per year.

Some in the group still worry that the mandated drug treatment visits will eat up the allotted Medicaid visits not leaving patients many options if they become sick with something else.

“What if the patient has diabetes, hypertension or other medical problems?” Dr. Boyde Harrison, one of the group members and a physician from Haleyville, told ADN.

But Boyett believes that having a required number of in-person visits the patient must undergo is the only way to hold them accountable to the treatment.

“There’s the reason it’s called medical assisted treatment, it’s meant to be a part of a comprehensive program,” Boyett said. “Otherwise we would put Buprenorphine in vending machines for people to access.”

The working group will meet again on Jan. 29 to go over its final draft proposal before it is sent to the Alabama Board of Medical Examiners.

Last month, the Associated Press reported on the use of Buprenorphine on the first day of treatment at clinics around the country.

Early research suggests the approach can change lives, the AP reported. But it will be a tough sell elsewhere: Nearly two-thirds of U.S. treatment centers don’t offer anti-addiction drugs and there’s resistance to easy access. 

The opioid crisis now kills more Americans than car crashes and is estimated to cost more than $500 billion a year, the AP reported. The epidemic is driving new treatment strategies for the 2 million Americans addicted to opioids.