Restricted Access to SUD Meds and the Lack of Informed Consent

by Ian McLoone

A recent study by Abraham, et al., published in the March Journal of Studies on Alcohol and Drugs, finds that patients receiving treatment at publicly-funded programs have significantly less access to potentially life-saving substance use disorder (SUD) medications like buprenorphine, disfulfiram, acamprosate, and naltrexone. Buried in the report, however, is the shocking statistic that a full 56.4% of the programs (publicly- or privately-funded) prescribed no medications whatsoever. Clearly, there are a whole lot of consumers not being informed of their full array of choices when it comes to managing their treatment.

The study analyzed nearly 600 treatment programs throughout the country - data originally part of the National Treatment Center Study – and looked for differences in physician access and SUD medication access. The authors found that 10.9% offered access to one medication, while 32.7% offered more than one medication. Fewer than 5% of programs offered access to all of the above medications.

The authors note that nearly 2/3 of all specialty SUD treatment programs in the US are publicly funded, relying on government block grants and state contracts for the money needed to provide treatment, while private funding tends to come from private insurance and self-paying patients.

When divided into publicly-funded and privately-funded categories, private programs were almost 15% more likely to have a physician on-staff and nearly 10% more likely to employ master’s-level counselors. And while publicly-funded treatment programs were almost 14% less likely to prescribe buprenorphine, only 32.5% of all programs offered the medication. Only 20.6% of programs offered disulfiram, 27% offered tablet naltrexone, 27% offered acamprosate, and a slim 13.1% of programs offered injectable naltrexone.

Among other findings, programs with a more professional workforce were positively correlated with the number of SUD medications offered, and programs with a physician on staff were more likely to offer higher numbers of SUD medications than programs with no access to physicians.

These findings beg the question: why are evidence-based practices so rare and why is this tolerated in addiction treatment but not in other professional treatments? (What if over half of American cardiologists prescribed no medications to their patients?) Sure, public programs offer fewer scientifically-supported therapies – but even people who are spending a fortune of their own money are often getting poor care. When patients are not informed of the full array of treatment options, the lack of informed consent becomes an ethical – and likely legal – issue.

I Challenge You to Find a Better Deal in Integrated Addiction & Psychiatric Treatment

First, my apologies for the drought in blogs lately. The last few weeks have been among the busiest in my life. Feels like internship all over again! Ian McLoone has been helping me with blog writing, and I haven't even had time to quickly look them over before publishing.

Busy is good to an extent, of course. The good news is that Alltyr is catching on, with very little marketing. Granted, being mentioned (with a very appreciated link) in Jane Brody's column, and the publication of Inside Rehab have propelled things along rather quickly, and to some extent it caught us off guard. But the new office in the 1st National Bank Bldg in St. Paul, MN is great. I love the building! Built in 1931, with lots of wonderful marble, and marvelous metalwork around the elevators. And, get this, planters with orchids all over the main level. In St. Paul, "the main level" is confusing. If you drive through downtown St. Paul, it looks like a kind of abandoned city on the street level. There's not much there except bus stops and the new light rail stops. Thing is, all the action occurs one story up, on the Skyway Level. Most buildings in downtown St. Paul and Minneapolis are connected to skyways. Skyways are connections between buildings 1 floor up from the street. So when I go to work there, I park in the heated garage in the building, leave my coat in the car, take the elevator to the skyway level. Here is where there are restaurants and delis, dry cleaning places, hair stylists, food courts, etc.

In addition to the office space, there are great amenities, including conference and training facilities at no extra charge and a modern workout facility, all included in the rent. And, we are in front of one of the new light rail stops, so it will be very easy to get here.

There are several suites on our current floor, which we are looking at for clinic expansion. My goal is to open a full -service SUD clinic in the fall of 2013. We are also talking to providers of sober housing. The idea is to create a comprehensive, state-of-the-art system of care that is based on 21st Century science, compassion and common sense.

We are also in discussions with local health plans, who are very interested in what we are doing. Remember, they are paying a lot for repeated useless residential and IOP rehabs. For example, a local nationally known provider charges about $30,000 for a 28-day residential rehab. I don't know what kind of discount the health plans get, but let's say they are paying $20,000 for it. Another prominent provider in the area charges $10,000 cash up front for a very pedestrian IOP with no housing. Alltyr's intensive services package, which includes a comprehensive evaluation by a physician (not a counselor), 10 1-hour psychotherapy and medication management visits, plus 25 30-minute therapy and medication visits over the course of a year, is only $4800, discounted from $5400 if purchased separately. Sober housing I'm going to estimate high at $1200 per month. So, for under $7,000, Alltyr Clinic will provide treatment services for a year plus 1 month supervised sober housing.  And with results that are guaranteed to be superior, because Alltyr's program includes completely integrated psychiatric treatment and uses all available treatment modalities.

I challenge you to find a better deal anywhere.

White House Announces Brain Mapping Initiative

Whew! Long drought! I was caught a bit off guard by the response to Jane Brody's column about Inside Rehab, which generated a lot of inquiries and new patients for Alltyr! All good things, plus opening the new office in downtown St. Paul and many other activities have left me a bit overwhelmed. Today's blog is written by Ian McLoone, a graduate student at the University of Minnesota Master of Professional Studies in Integrated Behavioral Health. Ian has been working with me learning about clinical work, as well as helping with Alltyr Clinic and other activities. He's going to be a regular contributor to Substance Matters.

MW

White House Announces Brain Mapping Initiative

President Obama announced on Tuesday plans to invest more than $100 million to develop and fund technology to map the human brain. The project, titled “Brain Research through Advancing Innovative Neurotechnologies”, or BRAIN Initiative, aims to improve our understanding of the human brain and, according to the White House, “uncover new ways to treat, prevent, and cure brain disorders like Alzheimer’s, schizophrenia, autism, epilepsy, and traumatic brain injury.”

Being hailed as the next Human Genome Project, the ambitious initiative will direct $50 million to the Defense Advanced Research Projects Agency (DARPA), $40 million to the National Institutes of Health (NIH), and another $20 million to the National Science Foundation (NSF). In addition, several private sector foundations and institutes have pledged significant contributions, each with specific goals in mind.

Cori Bargmann of Rockefeller University and William Newsome of Stanford University will lead the NIH working group. They will be tasked with creating specific plans, goals, a time frame, and cost estimates for the project moving forward. Of course this begs the question: what goals or plans would blog readers like to see addressed in this process? Is this initiative too ambitious, or not ambitious enough, given its size and scope? Leave your comments after the jump.