Obama and the TREAT Act

I just read an article in the Daily Beast that reads like a better version of something I would write about the value of medication-assisted treatment of opioid dependence.  I appreciate Christopher Moraff telling a story that has been untold far too long, and I hope the story raises questions across the country.
But I have something else on my mind that deserves a story of its own.  I am just a small-town psychiatrist in the Midwest, of course, and so I could be missing something.  I watch Veep and House of Cards, but I assume that the political games in those shows are grossly exaggerated.  I’ll offer a bit of background… but if you already understand why people opposed to increasing the buprenorphine cap are idiots, just skip the next few paragraphs.
The Recover Enhancement for Addiction Treatment Act, a.k.a. TREAT Act, is a Bill with bipartisan support written in response to the epidemic of opioid dependence in the US.  If enacted into law, the TREAT Act (among other things) would increase number of patients that a physician can treat with buprenorphine from 100 to 500 and allow nurse practitioners and other ‘mid-level prescribers’ to treat opioid dependence with buprenorphine medications. For newcomers, treatment professionals debate the wisdom of raising the cap on the number of patients treated by each practioner.  Some people argue against medication treatment entirely and claim that abstinence is the only legitimate goal when treating addiction, despite the fact that abstinence-based treatments rarely work.  ‘Rarely’ is in the eye of the beholder, I guess– but even the most optimistic promoters of abstinence-based treatments claim they fail only 70% of the time– within ONE YEAR.   Other addiction docs advocate using medications that dramatically cut death rates, in concert with counseling.  They demand the counseling despite no evidence– none– that counseling improves outcomes in medication-assisted treatments.  But arguing against counseling is like arguing against… milk, I guess.  Who can argue against milk?
Then there are the extremists like me who argue that addiction is an illness that should be treated like any other illnesses and managed with medications, sometimes over the course of a person’s life.  Maybe counseling is indicated, and maybe not– but the need for counseling should not stand in the way of obtaining a life-sustaining medication.  After all, do we withhold insulin from diabetics who don’t receive nutritional counseling?  We extremists point out that there is no ‘cap’ on patients who are prescribed opioid agonists– the type of practice that started this epidemic in the first place.  We point out that literally no deaths have been caused by buprenorphine in patients who were prescribed the medication.  In all of medicine, THAT is the medication that needs a ‘cap’?  Doctors can treat unlimited numbers of patients with cancers, pain disorders, or complicated surgical procedures, but can’t handle more than 100 of THESE patients?!
I don’t see the point of the other groups, so I won’t try to explain their thought processes– accept one example.  Some docs are Boarded in Addiction Medicine– a secondary certification that can be obtained after certification in primary care or psychiatry.  Full disclosure– I am not Board Certified in Addiction Medicine.  I am Board Certified in Anesthesiology and in Psychiatry, and I worked with narcotics as a pain physician and anesthesiologist for ten years.  And I have a PhD in neurochemistry.  From my perspective, I have enough things on the wall. But the docs who DID get boarded in addiction medicine are angry that they get nothing special for their efforts.  The law that created buprenorphine treatment was intended to increase addiction treatment by primary care practitioners.  But that’s sour grapes to the addiction docs, who want the sole right to treat more than 100 patients.  Never mind that 30,000 people die from overdose each year, and buprenorphine could save many of them.  The addiction-boarded docs are angry that they aren’t given special privileges.  Isn’t THAT a problem!
What does all of this have to do with President Obama?  A bipartisan group of members of Congress of worked on the Treat Act over the past 8 months.  Professional societies have come to compromises over the Bill.  According to Schoolhouse Rock, Congress creates laws and then if passed, the President signs them into law.  The President often pulls opposing factions together, encouraging them to get a Bill to his/her desk.  For most of President Obama’s term, about 20,000-30,000 young Americans have died each year– far more than the total number of Americans killed by war, terrorism, hurricanes, and other natural disasters combined.    Until a month ago, I’ve heard absolutely nothing from the US President– no calls to action, no pressure on lawmakers, no requests to call our congresspersons.  But as the TREAT Act was introduced in the Senate, President Obama announced that he will raise the cap by Executive Order.  A supporter of the President would say (I know, because I’ve heard them) that the important thing is that it got done– so who cares how it happened?
Readers of this blog know that I pretty-much dislike everybody… so it is no surprise that I’m not happy.  We have the TREAT Act sitting in Congress, needing a simple majority to be sent to the President’s desk and signed into law.  During an epidemic of overdose deaths, the support would not be difficult to find for most Presidents, even with an ‘obstructionist Congress’, as our President likes to call them.  A change in the law would be relatively PERMANENT, unlike an Executive order– which can be changed with a new President, or with a new set of political calculations by the same President.   And an Executive Order to change rules at HHS requires hearings for citizen comments, which take more time– time when more patients will die.  Shouldn’t President Obama have used the operations that other Presidents used for far-more controversial issues, and changed the law?  This temporary, delayed Presidential action will get kudos from articles like the one in the Daily Beast.  And Obama gets TV time and headlines to describe how he addressed the opioid epidemic, on his own– in spite of a ‘obstructionist Congress.’
What irks me the most, though, is that an Executive Order didn’t need to take seven years.  By 2010 the overdose epidemic was well-underway, and had already killed a couple hundred thousand young people.  Did President Obama need to wait until the TREAT Act was almost at his doorstep before taking ANY action to stem the surge in overdose deaths?  From the sidelines it looks like the deaths themselves didn’t provoke a response.  But the threat of bipartisan action during an election year?  I guess that’s another story!

Addiction Recovery Act of 2015

With appreciation to the good folks at BDSI, makers of Bunavail:
Here is the latest news concerning the Comprehensive Addiction Recovery Act of 2015 (aka Heroin Crisis Act):
It has easily passed Committee and is headed to the Senate floor next week.  If approved, the bill is scheduled to go into effect this year. Here are some new highlights:

  • The proposed funding was originally $80 million. It may go to $1.2 billion with a proposal of $600 million in emergency funding (note that this article says ‘billion’, but that is a typo.  Other sources confirm $600 million.
  • Mid-level providers are looking to be added to those who can treat opioid-dependent patients
  • Language addressing regulations around the current marketing, manufacturing and prescribing of prescription opioids (pain meds)

This funding (including any emergency monies) would directly impact every state. Additional federal funding would not only mean additional education and treatment services but could also mean more affordable access to medicated assisted treatment.

The Cap

Each physician who prescribes buprenorphine for opioid dependence can treat only 30 patients at a time during the first year as a certified prescriber. After a year, physicians can apply to have the limit increased to 100 patients. I have been at the 100-patient limit for some time, in part because of the shortage of providers willing to undergo training and go through the paperwork to get certified.
At the same time, there are no limits at all on the number of patients who can be treated by doctors with high-potency opioids, and no limits or regulations on the types of conditions that can be treated using narcotics. It is no surprise that I receive several calls per day from people who ask for help, who I am forced to turn away.
The 100-patient cap, combined with the shortage of doctors, results in one of the few areas of true health care rationing, and it is only appropriate that the rationing hit drug addicts– those viewed as society’s least deserving. I realize that some people see ‘inability to pay’ as a form of rationing, and I understand the point. But inability to pay has at least a theoretical solution—if not an actual solution if enough hoops are jumped through. For opioid dependence, the patient cap is an absolute restriction, with no grievance or appeal process for those left out.
I feel for the patients who call asking for help, and for the parents who sometimes call in place of the child-addict. If I am the first person called, the callers are surprised and angry at being turned away. Here they finally got up the nerve to ask for help, and the person on the end of the line won’t DO anything?! More often, though, my name was found halfway down a long list of telephone numbers from poorly-updated web directories of Suboxone doctors, and disappointment can be heard in the voice of the caller before the entire question is asked: are YOU accepting any new people?
The good part of the cap, I suppose, is that it reduces the opportunity for unscrupulous practices to become ‘Suboxone mills’, turning out addict after addict with easy prescriptions but without adequate education, follow-up, and counseling. I buy into this argument, but at the same time, I wonder why the concern over unscrupulous practices focuses so intensely over those who treat addiction? Should there not be equal concern over the number of patients that a neurosurgeon can care for?
Now that we have urgent care centers in supermarkets, is there no limit to the capacity for the doctor in the meat department to provide adequate care and follow-up for the patients who stop by? Or is it OK if a general practice doctor decides to schedule 20 patients per hour, so that each patient receives a bare minimum of focused care with no time for preventative medicine?
But we think differently about THOSE doctors—those who work in the clean world of treating asthma and ulcers and hemorrhoids—than we do about the docs who work with drug addicts. With the former, there is an assumption that the doctors are good people who will know their own limits and do the right thing—even as any trip to the doctor points out the folly of that assumption. And the latter group of doctors—those who stoop to treating addiction—are assumed to be incapable of determining, by themselves, the appropriate number of patients who can be safely seen in their practices. The expectation of bad practice comes from negative attitudes toward those with addictions, with doctors guilty by association. In short, the medical specialty of addiction treatment suffers the same negative stigma as do the addicts themselves.
Given these attitudes, I do not expect the shortage of buprenorphine prescribers to end anytime soon.