Societal Considerations of Drug Addiction and Treatment

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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

Jonathan Grand: If the primary care physician wants to be helpful in this area, he or she has to do some homework. He or she has to know some of the resources in the community where you can refer your patients to. One of the things that we have in the RSAT, the Residential Substance Abuse Treatment, we have a website, www.rsat-tta.com. And it has all sorts of information. But, on the home page, we have the United States on there. And if you click on a state, it tells you whether it’s a Medicaid extension state, whether the Medicaid is available for treatment. It tells you how to apply for Medicaid, how your patient can apply for Medicaid, and whether they’re eligible for Medicaid. It tells you what substance use disorder services are available in different cities and towns in the community, and that’s for all the 50 states. So, you have to do some education of your own if you want to be helpful to your patient. Now, God knows, you can’t be spending days and weeks on it. But, if you just know where some of the resources are, you can be incredibly helpful to your patients.

Peter L. Salgo, MD: Something else you said struck me, and it struck a real chord. I was asked to speak to a group of HMO CFOs (Chief Financial Officers). And one of these CFOs said that he was not going to put statins in the formulary. This was a long time ago. And, statins lower your cholesterol, lower your heart attack rate. I asked him why. I was incredulous. And, he said, “Well, because I can’t make my third quarter, they’re expensive.” I said, “But, 3 years from now you’re going to crash and burn as all these people go for open heart surgery, and get their CATs and all this angina workup.” It sounds like you’re saying the same thing, except, the turnaround time on that return on investment is quite quick. Am I wrong?

Joshua D. Lee, MD, PhD: Totally. In terms of social cost, an untreated heroin user is a big chunk of money. It’s jail, it’s overdose death, it’s emergency rooms, it’s hospitalizations, it’s ICUs for their endocarditis. So, if you can control that, use and bring them into treatment, that has a cost, but, generally, the overall spend goes down immediately. That’s the point.

Peter L. Salgo, MD: And, if you’re in HMO, and you’re working on a capitation, it’s not a fee-for-service model. It’s, “Oh, he’s got endocarditis, I’m going to get more money,” or it’s, “Oh, he’s got endocarditis, my capitation just got chewed up.”

Joshua D. Lee, MD, PhD: Well, you’re talking about the governor here. It’s like, your state Medicaid budget is going to be driven by this kind of dynamic, do you want to have a lower budget or not? If so, then treatment pays.

Peter L. Salgo, MD: What do you do about the social side? As this spreads, as this concept becomes accepted in the criminal justice system and in the medical system, pretty soon you’re going to have these MAT facilities everywhere—if it works, if things work out the way I hear you want them to. They’re going to be in the suburbs, they’re going to be in rural communities, and you’re going to be hearing people around these facilities say, “Whoa, whoa, not here, don’t bill that here, I don’t want these people here.” How do you push back against that?

Jac A. Charlier, MPA: The only one that’s a facility, though, is methadone, right? Everything else, that’s the only thing. And, that does not need to stay that way, that could change.

Peter L. Salgo, MD: Wait a minute. That’s a bit disingenuous, because if you’ve got a private practitioner and he’s got 50 patients, or she’s got 50 patients a week coming in for one of these drugs, these are drug addicts. That’s going to become known.

Jac A. Charlier, MPA: Well, are you talking about that they’re paying cash, or you mean that everything’s legit and above board? They’re paying cash. I’ll give you it, and you’re going to have the squad car sitting there soon.

Peter L. Salgo, MD: No, but if there’s an MAT-affiliated practice, whether it’s an HMO, whether it’s a private practitioner, the communities are going to know that this is a place where addicts are coming for treatment. And, my experience is they don’t like that. Am I wrong?

Joshua D. Lee, MD, PhD: No, those are some issues. It’s a not-in-my-backyard mindset, and that’s one reason why methadone clinics are not in North Dakota. They are in New York City. They can’t just grow along with the opiate epidemic, which maybe they should, arguably, but people don’t want that kind of stuff.

An example, of how it does all work together, is we have a large population of opiate-use disorder clients on these medications in a primary care clinic here in New York City at a public hospital. If you look at it from a satellite view, you can’t tell what’s happening. And, then, you come down to the hospital super block, you can’t really tell what people are there for. You would have to go to this one area of the waiting room where I have my clinic. Yes, if you really started to profile these patients, look a little different than your average primary care patient: younger, more men. But, within the context of the day-to-day of the hospital’s workweek and people coming in the lobby, it is a big facility. Granted, it’s indistinguishable from people arriving for any other type of treatment. And, the point is, they’re already addicted to their pills, so they’re doctor shopping. That guy’s already in your practice. He’s in six other people’s practices.

Or the heroin users, they’re in your emergency room with their overdose or their infection. They’re in and out of some treatment somewhere or detox, but they just haven’t been linked to the medications yet, for instance. A lot of what we’re doing, in terms of the churn of daily treatment still doesn’t involve the medications.

Peter L. Salgo, MD: So, what you’re actually saying—and I’ll let you actually address this—is they’re there anyway. These people are in your community. And, at the moment, they’re not getting treated, so they are at risk for all of this criminal justice involvement. If they start going to the physician in that community to get treated, the risk drops. Is that fair? They’re there anyway. It’s not as if you’re drawing them in.

Phillip Barbour: Right. And, I think also what happens, too, is the way that they get there is different. Right now addicts are getting into treatment usually by way of the criminal justice system or something like that. A few volunteer, but the majority of them are mandated. But, going to a private physician isn’t as stigmatizing as it has been in the past. And, the other thing, too, all you have to do is watch in the news. In any community, every day, they’re dealing with this problem. So, to know that I have a couple of doctors in my community who are there to try to address this problem, from a medical point of view, I think it is going to change the conversation. Maybe I’m too much of an optimist, but that’s how I see it.

Peter L. Salgo, MD: But, if you’re in New Hampshire and you’re aware of this issue, and suddenly a doctor comes up and says, “I can help,” that’s a different kettle of fish, isn’t it? That may be welcomed in a drug community.

Phillip Barbour: I think so.

Jac A. Charlier, MPA: Oh, absolutely. The medical profession is, again, viewed very favorably. The MD provides a little bit of leadership with its name, right; provides leadership people will listen to. It’s like a judge. When a judge speaks, right or wrong, people listen to that.

Peter L. Salgo, MD: Yes, but the judge can put them in jail.

Jac A. Charlier, MPA: Right. I’d listen, too. I’d say, “You’re always right judge.” We should not forget in the democracy, in which we live, the power of citizens, individual citizens, to affect change. And, leadership, that can come from a medical community on that by setting the example, by working for policy, by just going out and doing it, that’s very, very real and cannot be undermined.