On January 21, 2020 Wisconsin Society of Addiction Medicine President David Galbis-Reig, MD, DFASAM and Wisconsin State Representative John Nygren were able to speak at a press conference with the announcement of eliminating prior authorization for medication assisted treatment for opioid use disorder patients.

You can read more in the AP article here or the Wisconsin Health News article here.

Wisconsin Health News

Officials from the Department of Health Services expressed broad support for the latest package of bills from Rep. John Nygren’s Heroin, Opioid Prevention and Education Agenda but called for some modifications, during a Senate Committee on Health and Human Services hearing on Wednesday.

Earlier in the hearing, Nygren said he was open to changes.

“We’ve been working with DHS,” said the Marinette Republican. “These issues are some of the remaining pieces that we have been working on with our friends from the Pew Charitable Trusts to address the gaps in our system.”

Paul Krupski, director of opioid initiatives for DHS, said that a measure requiring the department to reimburse peer recovery coaches as a Medicaid benefit would, as written, have to be paid for with all state dollars. That’s because the federal government won’t provide matching funds for peer-provided services unless that individual is supervised by a licensed mental health professional, Krupski said. The bill proposes that they are supervised by another peer with certain training.

“With some changes, there may be opportunity to draw down federal matching funds and better preserve the existing workforce by either building upon our existing certified peer specialists infrastructure, or by providing DHS with additional oversight of the training and other requirements so that the department can align it with the existing infrastructure,” he said.

Nygren said that adding the supervision is “something we are willing to look at to make sure we maximize our federal dollars.” He said the state has seen a spike in peer recovery coaches because they are an effective tool in navigating the complicated system of addiction. 

Krupski also pushed back against legislation that would require the department to establish and maintain a registry of approved recovery residencies. Under the bill, DHS may not include a recovery residence in the registry if it excludes any resident solely on the basis that the resident participates in medication-assisted treatment. 

Krupski said that while DHS recognizes medication-assisted treatment as a “valid, evidence-based therapy,” many of the residencies do not accept individuals receiving the treatment.

“We must carefully consider the impact of creating a statewide registry of residencies which, as a prerequisite to receiving state or federal pass through funding, must not exclude a resident solely on the basis that they are participating in MAT,” Krupski said. “The Legislature will need to weigh the potential unintended consequences of eliminating state funding for current sober housing options that do not allow their residents to use MAT.”

Nygren said he would be open to an amendment phasing in the requirements.

“[DHS] has a concern about putting existing houses that may discriminate currently with someone on medication-assisted treatment out of business,” Nygren said. “That is not the goal of myself or anyone who supports this bill.”

Meanwhile, Krupski praised legislation that would allow for the Medicaid reimbursement of acupuncturists and increase the Joint Finance Committee’s supplemental appropriation by $1 million to boost payments for chiropractors and physical therapists. Gov. Tony Evers vetoed a similar measure in the budget that did not include reimbursement for acupuncture. 

“The Department supports efforts to reimburse providers for non-opioid and non-pharmacological pain management techniques,” Krupski said.

Other bills in the package would:

• Require DHS to study the availability of medication-assisted treatment for opioid use disorder in prisons and jails.
• Extend a sunset to 2025 for a law requiring prescribers to check a patient’s records in the state’s prescription drug monitoring program before issuing a prescription order.
• Repeal a sunset for a law that grants immunity from prosecution for certain controlled substance crimes and from having probation, parole or extended supervision revoked for possessing a controlled substance for those calling for help for another person suffering an overdose and overdose victims who complete a drug treatment program.
• Require the Medical Examining Board to issue guidelines on the best practices for treating neonatal abstinence syndrome.

Austin S. Kilaru, MD; Jeanmarie Perrone, MD; David Kelley, MD; Sari Siegel, PhD; Su Fen Lubitz, MPH; Nandita Mitra, PhD; Zachary F. Meisel, MD

Introduction

Pennsylvania experienced an 80% increase in emergency department (ED) visits for opioid overdose from 2016 to 2017.1 The engagement of patients with opioid use disorder (OUD) in treatment after hospital discharge is a key strategy in preventing subsequent opioid overdose.2,3 The Pennsylvania Department of Human Services established an incentive program to improve the rate of OUD follow-up treatment among Medicaid recipients.4 In the Opioid Hospital Quality Improvement Program, hospitals earned payment for designing and attesting to 4 distinct clinical pathways: (1) ED initiation of buprenorphine treatment, (2) warm handoff to community resources, (3) referral and treatment for pregnant patients, and (4) inpatient initiation of medication treatment. Payment of the full incentive ($193 000) was contingent on participation and attestation of all 4 pathways, with smaller incentives for partial participation.We evaluated participation in this program among hospitals.

Methods

This study was deemed to be exempt from review by the institutional review board at the University of Pennsylvania. Because this study was done with publicly reported data, no informed consent was required by the institutional review board.We conducted a cross-sectional analysis of all hospitals with an ED in Pennsylvania.We excluded pediatric, federal, and specialty hospitals. Participation in the program was publicly reported in January 2019.4 We obtained publicly reported data on hospital characteristics from the Pennsylvania Department of Health and county-level data from the Pennsylvania Open Data Portal.5,6 We used a multivariable logistic regression model with robust SEs to compare differences in characteristics of hospitals that fully participated with those that declined or partially participated.We report adjusted risk differences (ARDs) and corresponding 95%CIs. A 2-sided P < .05 was deemed to be statistically significant. Analyses were conducted using Stata, version 14 (StataCorp LLC). This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Read the full article which includes results, tables and discussion (plus references) here!

Submitted By David “Mac” Macmaster, CSAC, PTTS - Wisconsin Nicotine Treatment Integration Project (WINTIP)

Who is responsible for treating tobacco use disorders (TUD)?

Typically the programs created to treat substance use disorders, and TUD is by definition a substance use disorder—do NOT accept people with a sole or primary diagnosis of TUD for treatment.  For example, in Wisconsin TUD exclusion is confirmed in DHS75-86, the rule that governs substance use disorders in our state.  As far as I know the only state that has completely integrated TUD treatment in their statewide addiction services is New York State since 2008 under their rule 856. Other states like Wisconsin are seeking tobacco integration into behavioral health treatment services.

FACT: The American Society of Addiction Medicine (ASAM) includes Tobacco Use Disorder as a legitimate substance use disorder and provides intervention and treatment practices in their ASAM CRITERIA manual

FACT: The Diagnostic and Statistical Manuals that identifies psychiatric related disorders includes ”Nicotine Dependence and Abuse” as a substance dependence and abuse disorder in (DSM1V.) In 2015 (DSM1V) was updated to (DSM5) that includes “Tobacco Use Disorder” as a substance use disorder.

IMPRESSION: The Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Administration (SAMHSA) supports tobacco integration in behavioral health services.

FACT: Substance Use Disorder treatment providers do not identify tobacco use disorders as being within their scope of practice and do not accept those with TUD for SUD treatment

CONCLUSIONS:
Disease and death from tobacco in behavioral health populations can be reduced when:

1.  Substance Use Disorder providers expand their scopes of practice to include treatment of tobacco use disorder with the best practices they provide for treating other SUDs2.
2. Mental health providers diagnose and either treat TUD with smoking cessation evidence-based practices or refer those with TUD to SUD providers as an option when a TUD is confirmed through tobacco use assessments

The public health model of smoking cessation that has successfully reduced smoking in America from 42% to the current 15% was established by the Centers for Disease Control and Prevention (CDC.) The CDC created the Office of Smoking and Health (OSH) in 1965 and established single state Tobacco Prevention and Control (TPCP) agencies in every state.

One of the OSH mission objectives was, and is, address disparity populations that smoke more; develop more tobacco caused and related diseases, and die prematurely from tobacco than in the general population.  The Wisconsin Tobacco Prevention and Control Program has included behavioral health populations (substance use and mental health disorders) as disparity populations and included behavior and tobacco issues as a priority in Wisconsin’s TPCP’s strategic plan.

Smoking cessation has always been a priority for the CDC/OSH and TPCP services. The internationally accepted Clinical Practice Guideline for Treating Tobacco Use and Dependence provides evidence-based practices for treating TUD and establishes that these clinical practice guidelines are effective for smoking and tobacco cessation.

A review of evidence-based effective treatment practices for substance abuse disorders and a review of evidence-based TUD disorders reveals these practices are essentially identical. In other words, what works to achieve successful abstinence and harm reduction treatment outcomes for alcohol, opiates, cocaine and other substance use disorders also work for those with tobacco use disorders.

My observation is that the tobacco programs do not diagnose tobacco use disorders (TUD) using DSM5 assessment criteria and do not make referrals to addiction/SUD treatment providers. This has been typical practice since the Tobacco Prevention and Control Programs were established.

SUMMARY
The opening question for this opinion article was:
Who is responsible for treating tobacco use disorders (TUD?)

Should the addiction/substance use disorder treatment providers treat TUD? Of course they should, but they aren’t. They can but they don’t.  Yet, these SUD providers have successfully integrated alcohol and other drugs and treat them at the same time. They have not gone out of business doing it. They can treat TUD. There is no evidence to the contrary.

Should the Tobacco Prevention and Control Programs treat tobacco use disorders? They already are. They call it cessation. They use a public health model that research reports is effective for many with tobacco use disorders.

However tobacco use disorders are on a continuum of severity. Public health smoking cessation is effective, but is not always enough for those with a severe TUD. They might be more successfully treated in substance use disorder treatment programs when access to addiction/SUD treatment becomes available.  Addiction treatment and smoking cessation programs provide two effective options for treating tobacco use disorders. Two viable options are better than only one.

I am motivated by this vision.

When we successfully integrate tobacco use disorder treatment and tobacco free recovery we will open the door to addiction treatment that has been closed too long.  In Wisconsin we have more than 3,500 alcohol and other drug counselors who have the skills to treat all the substance use disorders including TUD. We have social workers, therapists, doctors and many more that can improve treatment opportunities for those with TUD. This would be true in every state when access to tobacco use disorder treatment and tobacco free recovery support expands dramatically.  We would double, triple and provide even more opportunities for smoking cessation and tobacco free recovery.

Addiction treatment providers will discover they can readily treat patients with TUD harmoniously with other SUD’s. New York State and one of our Wisconsin programs have done it successfully for more than a decade.

Smoking cessation programs will have an option for Wisconsin residents with tobacco use disorders they haven’t had before. They can refer people to our established substance use disorder treatment programs.

It is time to integrate effective tobacco use disorder in our substance use disorder treatment and other behavioral health programs. It is time to lead and make this integration in behavioral health happen. Lives will be saved. That is why we created WINTIP in the first place.

__

Our Wisconsin Nicotine Treatment Integration Project (WINTIP) is a strong advocate for tobacco cessation, treatment, and tobacco free recovery support. WINTIP was created to integrate evidence-based Tobacco Use Disorder treatment in our Wisconsin behavioral health programs and services. Our strong advocacy for tobacco integration in behavioral health will make it easier for decision makers to finally assure this gap in tobacco treatment is closed for the good of those suffering from tobacco use disorders and their families.  Tobacco integration in behavioral health is the ethical and clinically responsible improvement in Wisconsin’s public health strategic plan we need to make.  There is no longer any viable excuse for not doing it.

Contact Information:
David “Mac” Macmaster
Managing Consultant – Wisconsin Nicotine Treatment Integration Project (WINTIP)
608-393-1556
creativerep@mac.com

December 5 - Wisconsin Medical Society Medigram

The Wisconsin Medical Society is excited to announce that WisMed Community – the new online community just for WisMed Members – will be live on Monday, December 9! This new member benefit will allow physicians to connect, collaborate and celebrate their successes.

Initially, there will be two community groups: WisMed Members (for general discussions about things like tips and recommendations) and Share a Success (for you to share the great work you or a colleague is doing to advance health care). More community groups will go live in the coming months including Advocacy in Action, so be sure to check back often.

Members will receive an email on Monday with information about how to get logged in and start connecting with colleagues. Please add connectedcommunity.org to your safe sender list so you stay connected.

Contact Anne Hauer with questions.

November 12, Wisconsin Health News

Wisconsin collected more than 30 tons of prescription drugs during a drug take back day last month, according to final numbers released by the Department of Justice last week.

Wisconsin collected a total of 60,472 pounds of drugs on Oct. 26. Across the state, 280 law enforcement agencies held drug take back events and collected medications from 476 drug disposal boxes.

The collected medications were transported to Indianapolis where they were incinerated.

Wisconsin had the second largest collection of any state in the nation, according to a report of preliminary numbers from the Drug Enforcement Agency.

November 12, Wisconsin Health News

Legislators are asking their colleagues to sponsor seven more bills that are part of a years-long effort to fight the opioid epidemic.

The bills began circulating for co-sponsorship last week.

They’re part of the Heroin, Opioid Prevention and Education Agenda, a series of 30 bipartisan bills that have passed the Legislature.

Rep. John Nygren, R-Marinette, noted that recent data show overdose deaths declining in Wisconsin. He said that they've worked with healthcare professionals, the recovery community and law enforcement on addressing the issue.

“The HOPE Agenda is not a silver bullet solution to our statewide drug epidemic, but I am proud that we are continuing to take steps in the right direction,” Nygren said in a statement.

The bills would:

• Increase a supplemental appropriation for the Joint Finance Committee by $1 million over the biennium to up Medicaid rates for physical health services, like chiropractic care and physical therapy. The Department of Health Services would have to request the release of the funds from the Joint Finance Committee. The bill also directs DHS to submit a plan to the federal government to create a Medicaid benefit for acupuncture. 
• Repeal a sunset for current law that grants immunity from prosecution for certain controlled substance crimes and from having probation, parole or extended supervision revoked for possessing a controlled substance to those calling for help for another person suffering an overdose. It also ends a sunset for a law granting immunity from prosecution or having probation, parole or extended supervision revoked for a controlled substance to overdose victims, if they complete a drug treatment program.
• Extend a sunset for a law requiring prescribers to check a patient's records in the state’s prescription drug monitoring program before issuing a prescription order. Under the bill, the requirement would end on April 1, 2025, rather than April 1, 2020. The bill would also require the Controlled Substances Board to conduct a quarterly review of the program through Oct. 30, 2025, rather than through Oct. 30, 2020.
• Require the Medical Examining Board to issue guidelines on the best practices for treating neonatal abstinence syndrome.
• Require DHS to create a Medicaid benefit for peer recovery coach services. Also mandate that the department establish and maintain a program to coordinate and continue care following a substance use overdose.
• Require DHS to create a registry of approved recovery residences. DHS couldn’t include any recovery residency that excludes those participating in medication-assisted treatment programs. The legislation also bars disciplining state employees who are using controlled substances as a recommended part of their medication-assisted treatment.
• Require DHS to study the availability of medication-assisted treatment for opioid use disorder in prisons and jails. The agency will then have to propose a pilot project to the Joint Finance Committee to make all approved mediations for substance use disorder treatment available in at least one prison or county jail. The plan allows county jails to enter into an agreement with an ambulance service provider or doctor to obtain a supply of the anti-overdose drug naloxone and allows jailers to receive the training to administer the medication. The bill also grants legal immunity for administering naloxone.

November 6, Wisconsin Health News

A new Medicaid benefit for residential substance use disorder treatment could go into effect Feb. 1, pending approval of a final plan submitted to the Joint Finance Committee. 

The Centers for Medicare and Medicaid Services signed off on the plan last month. The committee will take a passive review process to the plan, meaning it'll go into effect unless members decide to meet.

DHS has begun pre-implementation outreach and communication activities about the program.

The benefit would cover short-term residential services in facilities that have been excluded from federal reimbursement because they're institutions for mental disease. 

October 28, Wisconsin Health News

More than 5,000 people contacted a state helpline connecting those seeking help with addiction to community resources during its first year.

The Addiction Recovery Helpline, a 24/7 hotline managed by 211 Wisconsin under a contract with the Department of Health Services, offers help to individuals with challenges related to drug use.

“Too often people delay seeking treatment for a substance use challenge simply because they don’t know where to begin,” DHS Secretary-designee Andrea Palm said in a Friday statement. “The Wisconsin Addiction Recovery Helpline is a good first step."

The helpline began taking calls on Oct. 22. In its first year, 5,594 contacted it.

Operators facilitated 11,940 referrals as people can call the line more than once and can be referred to more than one service.

Assessment, detoxification and residential treatment services were the most referred services. 

2019, WISAM Announcement

Michael Miller, MD, DFASAM, founding member of the Wisconsin Society of Addiction Medicine and past president of ASAM, receives the McGovern Award at the ASAM 51st Annual Conference. View video here.

This video is being shared from the ASAM 50th Annual Conference. You're invited to view more of The ASAM 50th Annual Conference on ASAM’s e-Learning Center here: https://elearning.asam.org/products/asam-50th-annual-conference-innovations-in-addiction-medicine-and-science-2019-85-cme.