Drug Treatment and the Physician Community

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Drug-related convictions place a substantial burden on the criminal justice system and on society. The MD Magazine Peer Exchange “Medication-Assisted Treatment in Drug Abuse Cases: A Path to Success” features a panel of experts in the criminal justice field who provide insight on medication-assisted re-entry programs.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Phillip Barbour, master trainer with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jac Charlier, director for consulting and training, also with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jonathan Grand, MSW, LICSW, senior program associate at the Advocates for Human Potential in Sudbury, MA
• Joshua Lee, MD, MSc, associate professor in the Department of Population Health, and a research clinician at Bellevue Hospital Center, NYU Langone Medical Center, and the New York City jails

Peter L. Salgo, MD: We have this good experience with pilot programs. Your example in particular was really quite impressive. So, how do you get from this pilot program and leverage this into the rest of the country? They sound expensive. On the other hand, maybe they save money. What do you do? Anybody got a great idea there?

Jonathan Grand: Well, it’s fairly obvious that everyone is hearing about this now. And not only are they hearing about it, but the federal government is now finally starting to take the lead. We have two agencies: The Office for National Drug Control Policy, which works out of the White House, ONDCP, and the Substance Abuse Mental Health Services Administration, SAMHSA, which is really pushing medication-assisted treatment. And, let me give you a couple of examples of how it’s affecting us nationally.

They have just mandated that any drug program in the country that gets federal money, they must allow their clients to get medication-assisted treatment if they want. In the past, again, it was not a medical decision, it was a decision made by their administrative staff. And now the government is saying, “You’re not going to get funds if you don’t allow MAT.” So, there’s an example of how things are changing. President Obama now has a $1.1 billion proposal for medication-assisted treatment, expanded treatment, and lower cost for treatment. It’s moving in the right direction.

Peter L. Salgo, MD: It’s moving, but you’ve got to set up an infrastructure, right? It’s not like, ‘Okay, we’ve got the money here, but where are the clinics?’ Literally, define structure. What buildings are they in? What neighborhoods are they in? Who’s running them? Do you have people? How does all that come out of what we’ve got now?

Joshua D. Lee, MD, PhD: Yes, it’s a great point. Away from the specialized, more intense model, you could also spend time linking these populations, whether it’s opiate users in New Hampshire, people getting out of jail or prison, or criminal justice or opiate addiction in general to the existing mainstream medical system. That’s back to getting regular doctors to learn about these medications and use them more often in more people in their area, and think about treating opiate alcohol and other addictions as part of their practice. That might be gaining speed. There’s stuff happening within medicine in general about integrated care, primary care medical homes, and cannibal care organizations.

This is all an ACA alphabet soup. But, the general idea is that the more complex and expensive patients who have medical problems, substance abuse problems, or mental health problems, they really need to be managed by a team; interdisciplinary, collaborative, and prospectively. Not just waiting for Billy to show up in the ED drunk again, but really reaching out and doing stuff proactively to manage somebody’s care better. And those kind of models fit exactly with the kind of high risk, high need clients that come out of the criminal justice settings, and that use these medications.

Peter L. Salgo, MD: Let me just see if I heard it correctly. In the middle of all of that complex explanation, you talked about primary care physicians. And, I had this image flash into my mind of primary care physicians getting involved in MAT, administering the drugs. But, that also begs the question of, where’s the rest of the support? In other words, if you go to the primary care physician and you’re going to get these drugs, that’s fine. But, you told me you need psychological support, social support, community support. So, the poor primary care physician’s patient sounds like he’s out there hanging in the breeze unless you do more for him.

Joshua D. Lee, MD, PhD: And that’s how a lot feel.

Phillip Barbour: We spoke about this in the last session. There needs to be some kind of a referral linkage to those other behavioral health providers from the primary care physicians. And, then, the other thing that I wanted to touch on, too, that shouldn’t be ignored, is the work that Jac and I do around educating the judiciary on this medicated-assisted treatment. That needs to continue so that they don’t undermine something that, say, Josh has prescribed for his patient. That linkage to other behavioral health providers, so that they can get both the medication and the other treatment that they’re going to need, is going to be very important.

Peter L. Salgo, MD: Now you’re running right now under federal grants, if I heard you correctly, right? You’ve got to expand that, right? There’s got to be commercial insurance, there’s got to be affordable healthcare reimbursement. All of that has to come into play. We’ve got to go beyond the pilot studies, the pilot grants, and to roll this thing out.

Jac A. Charlier, MPA: That’s right.

Peter L. Salgo, MD: Who’s going to do that, you?

Jac A. Charlier, MPA: Here’s one of the things that comes up in the ACA world with Medicaid and managed care, for example. So, we talk about cost savings, right? This is a population that has a lot of health needs beyond addiction. The criminal justice population presents with many more health needs, both acute and chronic. Because by the time they hit the health system, there’s a lot more to be done. In the managed care world, I think what can be part of the solution of building it from a systemic standpoint is convincing every chief financial officer of every managed care corporation, not of a future savings, but of savings here and now. And that is a reality with this population. But, to build the case management into that, you have to convince the managed care companies, “Hey, by the way, by building this case management, you will eventually realize real-time savings right here, right now, because they’re going to cost you more.” The problem is “cost you more down the road”, to a chief financial officer in an organization, isn’t that important versus how much am I saving right now?

Peter L. Salgo, MD: Now you’re not talking about a standalone doctor’s office. Maybe those are going the way that they’ll go anyway.

Jac A. Charlier, MPA: The solution is systemic here between criminal justice, as Phil said. One of the things I want to reach out, while I have the opportunity, to the medical community and say: You, as professionals, come and educate us. Use organizations like AHP (Association for Healthcare Philanthropy), like TASC, and let us help you reach into the justice system as a well-respected profession, to educate us on the science and the medical part of MAT, because then we will have more of an uplift and do our part of it also.

Peter L. Salgo, MD: I can see this in the managed care community. I can see this in an HMO (Health Maintenance Organization), which has an established infrastructure. So, that’s an add-on. A MAT program would simply be another part of that infrastructure. But, again, maybe the poor private practitioner is not long for the system, because it’s very difficult for that poor woman or guy to reach out to all these other tentacles that you need.

Joshua D. Lee, MD, PhD: Yes, no doubt. So, the message of hope is that you can still just write a script. You can say, “Hello patient, you have an alcohol-use disorder. I’m putting you on a medication, you’re going to come back in a month. Take this, every day. If you don’t, don’t worry about, but we’re going to talk about that, we’ll work on that. See if it helps. The goal here is to reduce or quit drinking and not get into trouble anymore.” And that is a pretty simple treatment episode. It’s not much different than it looks like you qualify as depressed. We want to treat you with a medication. We do a lot of actual behavioral health in primary care already. This is very similar to that. And, it doesn’t have to be super complicated beyond that with some of the medications. Buprenorphine’s a narcotic, it’s a controlled substance. There are other issues when you’re starting a buprenorphine practice. We have kept that in a box for being special, because there’s some extra training that’s involved in buprenorphine prescribing, and there’s a limit to the number of patients you can have per prescriber. The federal stuff that might happen this summer would hopefully simplify some of that, but the message is: try it out, start prescribing.

Peter L. Salgo, MD: Vivitrol is the outlier, right? Because it’s not a control.

Joshua D. Lee, MD, PhD: You don’t need anything to get a certain drug.

Peter L. Salgo, MD: You can. It’s not a scheduled…

Joshua D. Lee, MD, PhD: Right, it’s not a control.