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Recovery Housing: Funding and Government Action

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On January 23, 2020

In General Information, Opioid Epidemic

By Cole Gordner

Over the last decade, recovery housing has proven to be an important tool in combatting the substance abuse crisis currently plaguing the United States. Recovery housing’s rise in popularity has brought new sources of funding, increased regulation, and greater efforts by the government to support its growth. This blog post briefly explores each of these areas with the goal of adding clarity regarding the funding, operation, and regulation of recovery houses. First, this post explains the role of recovery housing and explores the various avenues of funding available to the operators of such units through the federal and state governments, and via private foundations. It then explains the regulatory requirements that recovery houses must comply with if they accept federal funding or operate in Pennsylvania. Finally, this post will discuss some laws and initiatives currently being taken by the federal government and Pennsylvania to further promote the expansion and regulation of recovery housing.

Recovery houses are non-medical residences designed to support recovery from substance use disorders. They provide individuals struggling with addiction a safe space to form new and healthier social structures that reduce the possibility of relapsing into drug use. Recovery houses have proven themselves to be one of the most effective means of fighting addiction at the micro-level. Furthermore, they are cost-effective, as the reduction in illegal activity resulting from the success of these houses outweighs the costs of their funding. All of this has led to a proliferation of such houses throughout the nation in recent years. Along with this expansion has come a wider availability of funding for these homes, along with the federal and state governments taking a more active interest in their operation and regulation.

Limited funding for recovery houses is made available through a variety of both public and private sources. On the public side, the federal government and most states offer grants issued through an agency operating under departments of health. The federal government’s primary body for this is the Substance Abuse and Mental Health Services Administration (SAMHSA). Last year, SAMHSA issued millions of dollars’ worth of grants towards programs relating to recovery treatment and housing through their Access to Recovery (ATP) and Recovery Community Service Programs (RCSP). They have requested $89 million for FY2020 in order to continue funding these programs, along with grants for drug courts and other related services. The Secretary of Health and Human Services may also utilize Section 1115 of the Social Security Act to approve grants for “experimental, pilot, or demonstration projects that are found by the Secretary to be likely to assist in promoting the objectives of the Medicaid program,” which may include recovery housing services. Additionally, states may direct Medicaid funding to recovery services by exercising the Rehabilitation Services Option or applying for a waiver through Medicaid Section 1915(b).

Most states provide grants to operators of recovery housing similar to that of SAMHSA. For instance, Pennsylvania offers the Substance Abuse Prevention and Treatment Block Grant (SAPTB) through the Department of Drug and Alcohol Programs (DDAP). There are also a number of private foundations that offer to fund entities who are running recovery housing. The National Alliance for Recovery Residences (NARR) and the Robert Wood Johnson Foundation are two of the predominant organizations supporting recovery housing in the United States. In addition to grants, the NARR (who has affiliate organizations in nearly 30 states) offers insurance coverage to the operators of recovery houses.

As is always the case with the receipt of federal and state funding, recovery houses must comply with numerous regulatory requirements. Any recovery house that accepts federal funding must adhere to such laws as the Americans with Disabilities Act and the Fair Housing Act. Furthermore, operators of recovery housing must ensure that all in-house professionals and services rendered by these professionals comply with state regulations and that all local safety standards and ordinances are met.

Aside from funding, the federal government and Pennsylvania have been pursuing policies and enacting legislation that seek to promote access to recovery housing or regulate the operation of such housing. In 2018, President Trump signed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act into law. This act mandates the Secretary of Health and Human Services, along with other qualified individuals, to facilitate the development of best practices for operating recovery homes. Just this year, the U.S. Dept. of Agriculture (USDA) and the U.S. Dept. of Housing and Urban Development (HUD) partnered up to expand recovery housing in rural areas, which have been heavily impacted by the opioid crisis but sometimes aren’t able to provide recovery services similar to more densely populated, urban areas. The USDA and HUD are now selling single-family residences that are no longer being used by the government at a reduced price to non-profit organizations who will convert them into recovery houses. 

Recently in Pennsylvania, Governor Wolf signed SB 446 into law. This gave the DDAP the authority to license, certify, and regulate recovery houses within the state. From now on, any recovery home operating in Pennsylvania that either receives public funding or referrals from public institutions will have to acquire certification from the state and comply with their guidelines.

While the government has been taking some positive steps towards supporting and regulating recovery housing, there is still progress to be made. In 2018, the National Council for Behavioral Health released a policy paper focused on the development of recovery houses. In this document, they outlined a few initiatives that the government could pursue in order to increase the effectiveness of recovery houses and make them more uniform on a national scale. The federal government has begun work on creating a model of best practices through the SUPPORT legislation, which was one of the proposed initiatives. Moving forward, the National Council recommends that greater technical assistance should be offered by the government to recovery houses, and that the federal government should incentivize recovery housing operators to adhere to nationally recognized quality standards.

Bibliography:

https://www.thenationalcouncil.org/wp-content/uploads/2017/05/Recovery-Housing-Issue-Brief_May-2017.pdf

https://www.thenationalcouncil.org/wp-content/uploads/2017/05/Recovery-Housing-Issue-Brief_May-2017.pdf

https://www.samhsa.gov/sites/default/files/partnersforrecovery/docs/RSS_financing_report.pdf

https://narronline.org/supporters/partners-in-excellence-2/

https://narronline.org/wp-content/uploads/2014/06/Primer-on-Recovery-Residences-09-20-2012a.pdf

http://www.williamwhitepapers.com/pr/dlm_uploads/Recovery-Residence-Draft-Practice-Guidelines-SAMHSA-2019.pdf

https://www.samhsa.gov/newsroom/press-announcements/201902151000

https://www.governor.pa.gov/newsroom/governor-wolf-signs-legislation-regulate-recovery-homes/

https://www.healthvermont.gov/sites/default/files/documents/pdf/State%20policy%20guide%20for%20Recovery%20Housing_0.pdf

https://www.recoveryanswers.org/research-post/oxford-houses-offer-both-recovery-benefits-cost-savings/

http://soberhouse.com/guide/how-is-recovery-housing-regulated/

https://www.medicaid.gov/medicaid/section-1115-demo/about-1115/index.html

Measuring the Opioid Crisis: The Need for Standardized Cause-of-Death Reporting

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On August 14, 2019

In Cross Posts, General Information, Health News

[Cross-posted from the Petrie Flom Center at Harvard Law School’s Bill of Health Blog]

By J. Alexander Short

All too often, the modern opioid epidemic is reduced to numbers. Over 70,000 drug overdose deaths occurred in the United States in 2017. This marked a substantial increase from the more than 63,000 deaths reported in 2016. So many news articles, books, and even policymakers depend on these numbers as an accurate measure of the opioid crisis. However, can we rely on their accuracy?

Continue reading here.

Safe Injection Site Fights to Call Philadelphia Home

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On August 7, 2019

In General Information, Health News, Uncategorized

By J. Alexander Short

Dr. Thomas Farley, Philadelphia Health Commissioner, recently stated “[t]he opioid problem is perhaps the greatest public health crisis this city has faced in the last century.” The opioid crisis continues to wreak havoc in Philadelphia, where it takes nearly four times more lives than homicide. Safehouse Philly, a recently proposed safe injection site in Philadelphia, seeks to address this crisis in a politically controversial manner. The organization quickly drew ire from a U.S. Attorney who promptly filed a federal lawsuit against Safehouse. The opioid crisis is now taking center stage as federal courts in Philadelphia will soon determine the fate of safe injection sites in the United States. 

Safe injection sites, also referred to as supervised injection sites and overdose prevention sites, are facilities with medical supervision that allow intravenous drug users to administer their drug of choice in a safe and supervised manner. Dating back to 1986, the existence of safe injection sites now exist in many countries, including Canada, Australia, and several Western European countries. Despite this, safe injection sites remain a point of controversy in the United States.

Proponents of safe injection sites argue they offer many positives for society. One collateral effect of such sites is to reduce drug consumption on the streets or in other public places and promote safe disposal of drug paraphernalia. As opposed to a criminal or sanction-based approach to a public health problem like the addiction crisis, safe injection sites focus on a harm reduction model. In other words, acknowledging that behaviors like illicit drug use will occur, these health policies focus on the reduction of the harms associated with such behaviors.

On August 9, 2018, the articles of incorporation for a new nonprofit organization were filed with the Pennsylvania Department of State. Only five pages long, the articles bear the recognizable signature of Ed Rendell, former Governor of Pennsylvania, Mayor, and District Attorney of Philadelphia. Since this filing, the embryonic nonprofit organization has quickly garnered national attention, raising a litany of health policy and legal issues. 

According to the Safehouse Philly website, the organization is a “privately funded Pennsylvania nonprofit corporation whose mission is to save lives by providing a range of overdose prevention services.” Safehouse will seek to meet this goal by providing four different services to “participants” of their services. First, Safehouse will offer a medically supervised consumption room for intravenous drug administration, providing sterile equipment, fentanyl test trips, emergency care for overdoses, and safe disposal of equipment. Safehouse additionally offers medically supervised observation rooms, presumably where participants will remain under medical supervision and in close proximity to emergency services. Safehouse will offer other medical services, such as wound care and on-site Medication Assisted Treatment (MAT). Finally, wraparound services such as social, medical, legal, and housing services will be provided to participants. 

The proposal of a tax-exempt safe injection site in Philadelphia was expeditiously met with opposition from the U.S. Department of Justice. On February 5, 2019, the U.S. Attorney in Philadelphia filed a lawsuit against Safehouse seeking declaratory judgment that the organization’s activities would result in violation of federal law – namely, section 856 of U.S. Code. That portion of the law prohibits anyone from “knowingly [maintaining] any place, whether permanently or temporarily, for the purpose of manufacturing, distributing, or using any controlled substance.” According to a letter written on November 26, 2018, Safehouse Philly “respectfully disagree[s] with the conclusion that [their] proposed consumption room would violate federal law.” 

This controversy raises a broader question relating to the role of safe injection sites in the opioid crisis. Clearly, there are benefits to the existence of safe injection sites. Safe injections allow those using intravenous drug to administer dangerous drugs in a clean, medically supervised space that allows for interaction with the healthcare system. This allows for an important point of contact for individuals with significant health risks directly and indirectly related to their substance use disorder. Additionally, by creating such a point of contact, the individual can be offered important wraparound services relating to housing, jobs, and treatment. 

Clearly, however, the implementation of safe injection sites are not without their share of controversy. As the Justice Department vowed in 2018, safe injection sites may be met with legal action. Then U.S. Deputy Attorney General Rod Rosenstein stated he is “not aware of any valid basis for the argument that you can engage in criminal activity as long as you do it in the presence of someone with a medical license.” This raises the basic question of what role policymakers ought to play when the law arguably prohibits something that helps ease the strain of a healthcare crisis. Is the role of healthcare professionals to save lives or to save lives so long as it is within the realm of the law?

Safehouse Philly raises another interesting point about how society ought to respond to needs unmet by the government. The opioid crisis is wreaking havoc on this country and the government, despite its efforts, is failing to properly respond to the needs of the country. Nonprofits often enjoy tax exempt status because they fill societal needs that are not properly addressed by the government. Safehouse Philly is taking this one step further and filling needs not only unaddressed by the government, but arguably forbidden by the government.

What happens when the government fails to respond to health crises? Or even more specifically, what happens when the law conflicts with the healthcare needs of its citizenry? These questions must be addressed in order for policymakers to effectively respond to this crisis. The fate of Safehouse Philly remains uncertain. However, what happens in Philadelphia may very well impact the future of safe injection sites throughout the country. 

10 Ways to Reduce the Risk of Opioid Misuse and Abuse

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On July 31, 2019

In General Information, Opioid Epidemic

By Travis Murray

The following are recommendations on methods and practices to limit the exposure of opioid and other habit-forming medications from misuse and abuse by one’s self or others. They are made by a licensed pharmacist, based on guidelines from the Food and Drug Administration. Do not start or discontinue taking any medications without first talking with your prescriber or pharmacist. Finding your local prescription drug take-back location in Pennsylvania can be located here.  

The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that there were 22,000 pediatric opioid poisonings in the country from 2006-2012. The following are a list of practical ways to properly store and dispose of prescription medications that could be improperly used by others. 

  1. Keep Medication in Original Prescription Vial

If you receive a prescription opioid medication, make sure to keep it in the original prescription bottle from the pharmacy. Medications should never be placed in vials that do not match the correct labeling. In the past, patients have admitted that they recycle old prescription bottles, or worse, combine multiple medications in the same vial. This increases the risk of the taking the wrong quantity or frequency of the medication or for caretakers to mistakenly give excessive doses of the opioid medication. This is important for all prescription medications. 

  1. Keep Medication Out of Children’s Reach

If you have children at home, make sure that the medication is properly stored out of reach. The medication should be in the prescription vial with a child proof cap. Keeping the opioid medication vials in a locked cabinet may be appropriate.  

  1. Dispose of Unused Medications Properly

If you have an opioid prescription that is no longer necessary, do not keep it in the house, “just in case.” There is a direct correlation between length of opioid use and the increased the risk of dependence and addiction. Opioids in the house also presents the opportunity for other inhabitants or visitors to use or sell. Many local municipal buildings take back prescription drugs at no cost. Often courthouses and police stations take back prescription drugs for destruction, and there are often DEA-approved drug take back days at pharmacies. Controlled substances should not be placed in the regular trash. If a drug take back is inaccessible in your area, the medications can be flushed or destroyed by mixing with coffee grounds or cat litter and water. Once the drug is dissolved and deactivated, the mix can be placed in a plastic bag, sealed, and discarded in the regular trash. 

  1. Never Share Prescription Medications

Like any prescription medication, never share it with anyone else. This medication was prescribed to you by a doctor for a specific indication and it was deemed safe for you specifically by a pharmacist. Besides being a federal crime to share narcotics, opioids can be addictive, have side effects, and have many drug interactions. 

  1. Dispose of Fentanyl Patches Properly

Topical fentanyl patches are highly lethal to children and must be disposed of carefully, especially since children have died thinking that used patches, which still contain this potent opioid, are stickers. When removing a fentanyl patch, the patch should be folded in half with the sticky sides together and flushed down the toilet. Fentanyl patches have also been known to fall off. If you are wearing one, be sure to feel for it multiple times a day, as a fallen patch presents the opportunity for children or pets to become exposed. Never apply to heat to a medication patch as well. 

  1. Take your Medication Exactly as Prescribed and Instructed

  Never take a medication more frequently or at larger doses than prescribed to you. If your pain is uncontrolled, it is important for your doctor to know and to appropriately manage. Never chew or crush long-acting opioid medications such as extended-release morphine, oxymorphone, or oxycodone as this increases the risk of toxicity. 

  1. Avoid Operating Vehicles and Consuming Alcohol While on Opioids

Do not drive or operate machinery until you know how opioids affect you. Opioids affect everyone differently and most people will notice a level of impairment while taking them. Do not drink alcohol while taking opioids and do not start taking any over-the-counter or new medications without your doctor or pharmacist knowing. You are protecting yourself and the safety of others.

  1. Know the Signs and Symptoms of an Opioid Overdose

Signs of an overdose include a decreased breathing rate, pinpoint pupils, and unconsciousness. Prior to unconsciousness, overdosing victims may experience tiredness, dizziness, confusion, and vomiting. Death can occur from decreased oxygen to the brain and asphyxiation from vomit. It is also recommended that someone you live with or takes care of you has access to and knows how to use naloxone in the case of an overdose. 

  1. De-Identify Prescription Vials When Discarding Them

Unfortunately, prescription opioids are valuable on the black market, so it is best for as few strangers to know as possible that you take opioid prescriptions to protect yourself from those who may wish to obtain it illegally from you. Labels on empty vials that contain personal information and the name of an opioid medication should be ripped off and blacked out before throwing them away. 

  1. Talk with your Family and Healthcare Providers 

Emphasize the risks and consequences of taking opioids with children. 70% of opioids used for nonmedical purposes are obtained from family and friends. Speak with your doctor and pharmacist about other options to control your pain and plans to de-escalate from opioids, if possible. You should not start any new medications without talking with your doctor or pharmacist first. 

Affordability of Naloxone in Pennsylvania

By

On July 24, 2019

In General Information, Naloxone, Opioid Epidemic

[The Addiction Legal Resource Team is proud to unveil a three-part series on Naloxone, a drug that reverses the effects of an overdose. While the role of Naloxone as a tool to combat the opioid crisis is undisputed, this series does not intend to address every aspect of the drug. Instead, the ALRT is releasing three different pieces that will explore how this drug may be used as a tool to fight the opioid crisis. This is the final post in that series.]

By Travis Murray

In response to the opioid epidemic in the Commonwealth, the Physician General of Pennsylvania issued a standing order for people to purchase naloxone from pharmacies in 2014 that was laid out in a Dear Pharmacist Letter.  Naloxone is a prescription medication indicated for the reversal of opioid toxicity. Naloxone works quickly to reverse overdose symptoms, but repeated doses of naloxone are often necessary. The standing order’s goal was to decrease opioid-related deaths by increasing naloxone accessibility. However, in the years since the standing order has been in effect, the price has risen sharply. Those without medical assistance or private insurance may have to pay out-of-pocket drug costs or rely on emergency services or limited free naloxone distribution days. 

Drug Cost

Narcan® and Evzio® are the only two branded naloxone agents on the market for the reversal of fatal opioid toxicity.  Narcan® is available in an easy-to-use intranasal spray, and Evzio® is an auto-injector, making both easy to administer by an individual to unconscious overdose victims. By mandate, both the naloxone nasal spray and the injection are covered without a prior authorization for recipients of Pennsylvania medical assistance (MA). However, people who are not policy-holders are not covered. Therefore, if an MA patient indicates at any time in the pharmacy that the naloxone is for someone else, the pharmacist may be unable to bill the insurance for the medication. Then, if the person wishes to purchase naloxone, he or she must pay out-of-pocket, and prices can range from hundreds to thousands of dollars per dose. For some patients, this may not be enough naloxone to keep the patient alive until emergency services arrive. While chemical dependence and addiction can affect any person, especially those with environmental and genetic risk factors, opioid deaths affects those with lower socioeconomic status disproportionately. Without insurance, a major population that would require access to naloxone may be unable to purchase the medication. 

This standing order has seen an increase in naloxone purchases in Pennsylvania, both by private citizens and municipalities, but has unintended consequences of payers insuring non-policy holders and the state is likely trying to limit paying for people who are not covered. For pharmacists, it raises an ethical question of knowingly dispensing and billing a medication to a person who will use the medication on another person. Regarding the high prices of branded naloxone, pharmacy benefit managers (PBMs) have contributed to increased prices for naloxone and many other prescription drugs. PBMs, in theory, are a middleman between drug manufacturers and Medicaid plans and other payers to negotiate and create health formularies, often via rebates. Most PBMs charge administrative fees that get passed on to the insurers and pharmacies that fill the prescription. Pharmacies do not independently contract with insurance plans and often accept these plans or risk forfeiting patients. High drug prices are essential for drug companies to be able to generate a profit from its investment in creating the product. In the end, individuals who wish to purchase the medication and do not have insurance or medical assistance could be unable to afford it.

Solutions to Accessibility Issues

Community pharmacies are trying to make the medication more accessible to patients by dispensing the significantly cheaper generic naloxone solution for injection. The naloxone solution in the syringe is actually safe for intranasal use, and pharmacies have been dispensing them without needles for this route. Some states have taken approaches with other life-saving medications to control costs that may have some applicability. Recently, Colorado limited the maximum price for vials of insulin. Other states have taken PBMs head-on and pushed for their abolition for their responsibility in soaring prescription drug costs. Ohio’s Attorney General has sued OptumRx and CVS Caremark. Pennsylvania has a bill currently in the works to bring payment transparency among PBMs, managed care organizations, and pharmacies in PA General Assembly HB-569. Sometimes even the best intentions can have unintended consequences, and naloxone is not immune to the plague of rising drug costs. Years out from generic formulations of Narcan® and Evzio®, there is much to be done to make naloxone more readily accessible and to protect pharmacists from difficult ethical situations. 

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