Comments on SAMHSA recovery housing guidelines

Below are my comments for SAMHSA in response to their request for comments on your proposed recovery housing guidelines. The deadline is 5pm today. Send your comments, whatever they are.

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To whom it may concern:

I am writing in response to your request for comments on your proposed recovery housing guidelines.

I commend your efforts to provide guidance for recovery housing. Recovery housing is a long-neglected and critical element in the treatment and recovery support continuum.

I strongly urge guidelines that maintain options for recovery housing where agonist MAT substances are excluded.

I offer the following as a rationale for this request.

First, there has been relatively little research on the diversion of opioid agonists in the US. The research that exists suggests that diversion is common.

For example, Walker, Logan, Chipley & Miller (2018), in the peer-reviewed journal The American Journal of Drug and Alcohol Abuse, found misuse of buprenorphone to be very common. One of the authors summarized their findings as follows:

Buprenorphine is an opioid that, like other opioid drugs, can produce effects such as pain reduction, a pleasurable “high,” sleepiness, physical dependence and addiction. It has become a street-trafficked drug. . . . Some claims for buprenorphine products have proven not to be true. People bluntly report ability to get a “high” within clinically approved doses despite early claims otherwise. Buprenorphine is commonly diverted and abused, despite early claims that the drug would not lend itself to such patterns. Most of the research studies by developers and marketers carefully selected subjects who only had opioid use disorder, mostly those only with prescription opioid-use disorder and, rarely, those only with heroin-use disorders. In contrast, this study looks at the real-world conditions and experiences collected on 1,674 people who report themselves as having a history of disordered use of many different drugs (including alcohol) and who have recently engaged in a recovery program to become abstinent from all substances that cause a “high,” or which mask unpleasant emotions.

Key Findings for those reporting prior use of buprenorphine products in the prior 6 months:

• 4.2% had only obtained buprenorphine by legal prescription
• 60% had only obtained buprenorphine by illegal means
• 35.9% had obtained buprenorphine by both illegal and illegal means
• 10% had overdosed with buprenorphine while taking other drugs or alcohol
• No matter how obtained, 56.1 % to 81.2% report getting a good “high” on buprenorphine
• Efficacy: 25.2% = helped 31.5% = no effect 43.3% = made problems worse

This is supported by this week’s, Department of Justice charges against Indivior for “deceiving health-care providers and health-care benefit programs into believing that Suboxone Film was safer, less divertible, and less abusable than other opioid-addiction treatment drugs”

Secondly, while there is a large evidence-base for the effectiveness of agonists in reducing illicit opioid use, overdose deaths, criminal activity, and disease transmission, those outcomes only partially overlap with the goals of most recovery housing programs. Most recovery housing programs seek abstinence from alcohol and commonly misused drugs—licit and illicit.

Hettema and Sorensen (2008), in the peer reviewed journal International journal of mental health and addiction, reported the following:

While much of the stigma against the use MMT does not seem grounded in evidence, some important arguments against the integration of MMT and residential treatment have been put forth. Residential treatment programs are faced with a complex context for their clinical decision making (Zemore & Kaskutas, 2008). Unlike methadone clinics, in which the behavior of one client has little effect on others, patients within residential treatment programs are highly dependent on one another. Here the behavior of one individual can have a huge effect on the overall environment and, consequently, what may be beneficial to one client may be harmful to the community as a whole.

The proposed guidelines themselves discuss the potential for diversion and misuse and outline actions provides can consider to manage these risks. If mandatory, this would be a considerable burden to place on providers and many residents.

Thirdly, the guidelines call for access to FDA approved medications. It’s worth noting and considering that legally prescribed medication played a key role in raising the opioid problem to the current crisis level and has helped sustain it. It’s also worth noting that legally prescribed, FDA approved medications can include opioids, benzodiazepines, muscle relaxers, and many other frequently misused drugs.

Finally, if large portions of recovery housing residents have misused agonist medications, isn’t it reasonable for residents to think of a “safe” recovery environment as one that excludes those commonly misused medications?

It is undoubtedly true that agonist patients do not have adequate access to recovery housing. One could explain this gap by accusing housing providers of stigmatization and discriminating. Another way to explain this gap is that agonist treatment providers have failed to deliver this kind of recovery support. Seen this way, the problem is not that many providers prohibit opioids, rather that there is a need to establish recovery housing that allows agonist medications.

The need for both agonist-friendly programs and opioid-free programs is clear. By all means, encourage and support the establishment of agonist-friendly recovery housing programs. However, please do so in a manner that assures we do not pit the needs of one group of patients/residents against the other.

Thank you for your consideration.

 

Sincerely,

Jason Schwartz

 

References:

Hettema, J. E., & Sorensen, J. L. (2009). Access to Care for Methadone Maintenance Patients in the United States. International journal of mental health and addiction, 7(3), 468–474. doi:10.1007/s11469-009-9204-6

Robert Walker, TK Logan, Quintin T. Chipley & Jaime Miller (2018) Characteristics and experiences of buprenorphine-naloxone use among polysubstance users, The American Journal of Drug and Alcohol Abuse, 44:6, 595-603, DOI: 10.1080/00952990.2018.1461876

White, W.L. & Torres, L. (2010). Recovery-oriented Methadone Maintenance. Chicago, IL: Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health and Mental Retardation Services and Northeast Addiction Technology Transfer Center.