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Authors Posts by Jason Snyder

Jason Snyder

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In September 2023, the Substance Abuse and Mental Health Services Administration (SAMHSA) released a report, “Recovery from Substance Use and Mental Health Problems Among Adults in the United States.”

Although the definition and concept of recovery from addiction have been morphing for some time, the self-reported data contained in the report, coupled with SAMHSA’s definition of recovery, lays out starkly that what is considered recovery today is far different from what it has been considered historically. In some ways, it begs the question, then, “What is the purpose of addiction treatment?” What are the implications for addiction treatment providers, who for decades have operated with a mission of helping their patients stop their use of drugs and alcohol?

Using data from the 2021 National Survey on Drug Use and Health (NSDUH), SAMHSA’s report shows that 70 million adults aged 18 or older perceived that they ever had a substance use or mental health problem. For substance use specifically, of the 29 million adults who perceived that they ever had a substance use problem, 72 percent (or 20.9 million) considered themselves to be in recovery or to have recovered from their drug or alcohol use problem. (See SAMHSA’s press release.)

Of the 72 percent who considered themselves to be in recovery or to have recovered from their drug or alcohol use problem:

  • 65 percent reported using alcohol in the past year;
  • 68 percent reported using marijuana in the past year;
  • 60 percent reported using cocaine in the past year; and
  • 61 percent reported using hallucinogens in the past year.

Curiously, it doesn’t appear that respondents were asked whether they used illicit opioids in the past year. Encouragingly, substance use recovery was more prevalent among adults who received substance use treatment.

To the traditional addiction treatment provider and many in the recovery community today, recovery and drug and alcohol use cannot co-exist. One possible but unlikely explanation for the SAMHSA-reported data is that all of the respondents who identified as being in recovery but having used drugs or alcohol in the past year is that their recovery began within the last year.

This would presume that their definition of recovery includes abstinence. But this is not likely. Consider SAMHSA’s definition of recovery:

“Recovery is a process of change through which individuals improve their health and wellness, live a self-directed life; and strive to reach their full potential.”

No mention of abstinence from drugs and alcohol. What this means is that for millions of people, recovery can and does include moderated use of drugs and alcohol.

In 2004, SAMHSA’s Center for Substance Abuse Treatment said, “Treatment for substance use disorders is designed to help people stop alcohol or drug use and remain sober and drug free. Recovery is a lifelong process.” Twenty years later, it’s a far different message coming from SAMHSA.

As recently as 2019, the Pennsylvania Certification Board defined recovery as highly individualized, requiring abstinence from all mood and mind-altering substances, and may be supported by using medication that is appropriately prescribed and taken.

Talk about evolution and conflict.

When I began my recovery from substance use disorder (SUD) nearly 12 years ago, I went to treatment with the intention of stopping my drug use. I came to believe at that time from those who helped put me on this path, including those within the treatment facility as well as peers outside of it, that the foundational element of recovery was abstinence from all drugs. In fact, my first few years of recovery were so philosophically rigid that I even believed medications to treat opioid use disorder (MOUD) disqualified an individual from recovery.

I’ve drastically changed my views and beliefs since those early years, because I’ve seen the power of MOUD and, conversely, the grave danger anti-MOUD stigma poses. Sadly, though, many still believe the way I once did. I’ve held true to my own definition of recovery, which does include the foundational element of life without drugs or alcohol. But I am not so self-righteous as to believe that those who choose another path or definition of recovery should be discounted or forced to “recover” in a particular way.

For many in the treatment system and recovery community, abstinence remains a cornerstone of recovery. But for many other stakeholders in the broader addiction treatment ecosystem — payers, regulators, and policymakers in particular — although abstinence may once have been the goal for them, the purpose of treatment and definition of recovery have moved far afield of those historical tenets.

Nora Volkow, Director of the National Institute on Drug Abuse, said, “Healthcare and society must move beyond this dichotomous, moralistic view of drug use and abstinence and the judgmental attitudes and practices that go with it.”

So what does this mean for addiction treatment providers philosophically and operationally? If the purpose of addiction treatment is not necessarily to stop drug and alcohol use, what is it? One managed care organization in Pennsylvania recently talked about the purpose of addiction treatment in much the same way as SAMHSA defines recovery, addressing health, home, purpose, and community. This would seem to mean that providers are now expected to address not only addiction but mental and physical health, too, at least to some extent, as well as myriad social determinants of health. In fact, it is what payers expect providers to do today.

This is an attempt to integrate various human services and incorporate harm reduction into the addiction treatment system, and it is a sea change. The addiction treatment system was not built in this way. This is not to say that this movement is wrong, or that the treatment system is not evolving or cannot evolve along with the definitions of treatment and recovery. But to do so will require an ongoing cultural shift with which many in the treatment system — from the front line to the CEO office — struggle. It will also require a much broader systemic change than simply within addiction treatment organizations. Regulation, oversight, and payment structure must also change to reflect the changing expectations and demands placed on providers.

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Recovery Community Divided Over Pending Legislation That Would Radically Change SUD, Mental Health Peer Services in PA

Nothing about us without us.

That is the mantra that emanates from the recovery community any time policy decisions are being considered that would affect those seeking or already in recovery from substance use disorder (SUD) or mental health issues.

The thinking goes that no one knows the plight and the needs of the person seeking recovery better than those who have sought and found recovery themselves. The peer profession is based largely on this tenet. I can attest to the power of the peer. Without those with lived experience helping me early in my recovery and, in fact, to this day, my life likely would not have followed the path that it has.

“Nothing about us without us” is a spoken tie that binds, and often times it’s a rallying cry in an us-against-them mentality. It’s no different from any other special interest, including the addiction treatment providers who I represent, rallying their own against perceived threats from outside influences. It’s what we as advocates do.

But that tie is being tested with a yet-to-be-introduced bill – called Promoting Recovery, Opportunity, Professionalism, Ethics, and Longevity (PROPEL) – that would radically change the way peer services are provided in Pennsylvania. It is being tested because the bill lacks widespread support within the recovery community. Few in the recovery community had any hand in shaping it. In fact, from the many conversations I’ve had with those in the peer community, most had no idea this bill was even in the works. Many probably still don’t know it’s been written.

Licensing, Regulating, and Funding All Peer Organizations

Although the cosponsorhip memo describes the pending bill as a means to reduce overdose deaths by developing a sustainable funding stream for peer support services providers, it reaches far beyond funding. It does intend to create a sustainable, consistent revenue stream through Medicaid reimbursement for SUD and mental health peer services, though on the mental health side of the behavioral health equation, Medicaid reimbursement for certified peer specialist services (CPS) provided by peer organizations licensed by the state Department of Human Services has been a reality as a Medicaid state plan service for nearly 20 years. On the SUD side, DHS is seeking to add certified recovery specialist (CRS) services to the state plan. When a service is part of the state plan, behavioral health managed care organizations are required to pay for the service (As a point of clarification — in Pennsylvania, CPS’s have lived mental health experience and provide mental health peer services; CRS’s have lived SUD experience and provide SUD peer services. Whether we should continue to silo the two in the recovery and treatment worlds and beyond is an important discussion for another time).

This bill would change the current mental health peer organization licensure process, while creating new and separate licensure processes for mental health peer organizations and SUD peer organizations. Regulations to govern peer services would be promulgated and largely drive the licensure processes. The bill also conflates mental health drop-in centers, crisis centers and recovery community organizations (RCOs), a point of contention among operators of RCOs.

For RCOs – defined by SAMHSA through its Peer Recovery Center of Excellence as a nonprofit organization founded and led by people with direct lived experience with substance use challenges and recovery – funding has been much tougher to come by when compared with licensed mental health peer services providers. With the biggest source of funding for many RCOs being grants, a consistent, sustainable funding stream would be welcomed. But the challenges of licensure and regulation, which bring significant burden in the form of oversight and regular audits, has some in the recovery community, including those operating RCOs, concerned what it could mean to their survival and ability to be flexible and adapt to their community’s needs.

Prohibiting Treatment Providers From Providing Peer Services

The bill’s supporters also say its intention is to protect the integrity of the individual peer professional. With this bill, all peer services would be co-opted by licensed peer support organizations, meaning no treatment providers – for-profit and nonprofit alike — could offer any type of peer services unless they contracted with a licensed peer organization. In fact, any for-profit company, whether clinical or otherwise, could not provide peer services. The rationale behind this piece of the bill, at least what has been communicated to me, is that peers are being made to do work well beyond or below their scope (e.g., fulfilling duties of behavioral health technicians as opposed to peer professional responsibilities), which sometimes forces peers into unethical situations. Proponents of the bill haven’t been shy about saying they have video recordings of peers sharing such stories.

Substance use disorder and mental health treatment providers, many of whom have been providing peer services within their organizations for years, would no longer be able to provide the services as they currently do. Instead, they would be required to enter into a contractual arrangement with a peer support services provider, defined as “an independent, nonclinical, nonprofit organization, including an RCO or mental health peer organization that is led and governed by individuals in mental health and substance use recovery that employs peer support specialists and provides peer recovery support services.” Such a requirement would make treatment providers – trained and educated experts in providing comprehensive services, including recovery services, to any client who is receiving services in their program – beholden to licensed peer support programs, add additional layers of administrative burden, and jeopardize access to peer services.

The bill would also remove any requirement of clinical supervision of peers for reimbursement, thereby removing what can be critical clinical judgement in certain cases where peers lack needed expertise to direct clients to immediate services they may need. In other words, a clinician would no longer be required to oversee a peer in order to receive reimbursement for the services. A peer supervisor would be adequate to be reimbursed for those services.

Paying Peers Commensurate to Their Value

There are some pieces of this bill that I wholeheartedly support. A lot of lip service gets paid to the value of peers, but we don’t see that translating into consistent funding or adequate rates. I would love to see an adequate, sustainable funding model for community-based peer organizations that recognizes the real value of the peer – putting our money where our mouth is, so to speak. And I would love to see peers be used with fidelity in all settings in the way they are intended. I think there is a way to bring all stakeholders together to discuss how to make this happen.

Considering the Optics

There are some pieces of the bill that are obviously concerning, too. Prohibiting treatment providers from providing peer services as they currently do is one. There’s also a small but concerning piece of language in the bill that enables peer services to be reimbursed “as a primary service for individuals with a mild, moderate or severe mental health disorder or substance use disorder and require no other diagnosis, condition or preauthorization.” Without clinical expertise to assess severity of the mental health or SUD issue, how the RCO will know whether an individual seeking services has a mild, moderate, or severe mental health disorder is unclear. But if it’s nothing more than self-diagnosis/self-referral, anyone could claim to have an SUD or mental health issue. Financial incentives have led many organizations astray. Any hint of potential fraud hurts any field, but an already stigmatized profession still regularly fighting for a seat at the table is especially vulnerable.

The recovery community has for years been fighting for credibility and respect, and it has made great strides in doing so. Yet I think many of its leading advocates will tell you there is still a long way to go. Although in my experience it’s rare that any group or movement has 100 percent agreement among itself, the treatment system included, the infighting we have already seen play out in public over this proposed legislation is not a good optic. Rather than elevating the profession, this splintered effort risks having the opposite effect.

I have a personal interest in this issue. I have colleagues and friends who are leaders of the recovery community. Any success I have had during my recovery is mostly because of my recovery community. I am also a CRS, although I have never practiced professionally as one. I have a professional interest, too. I represent treatment providers, many of whom have been providing stellar peer services for years, and I am on the board of the Pennsylvania Peer Support Coalition. In this spirit, I have had many conversations with various stakeholders on this issue, with the intention of eventually convening a large group of all stakeholders. If you want to be part of a broader discussion so that all voices are heard, please email me. I would love to hear from you.

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The newly established Pennsylvania Certification Commission for Addiction Professionals (PCC AP) is now offering certification and training for clinical supervisors and counselors who provide clinical treatment services in licensed substance use disorder (SUD) treatment facilities. Historically in Pennsylvania, the Pennsylvania Certification Board (PCB) has provided these certifications and trainings.

PCC AP, which also offers SUD and mental health peer certification, is affiliated with the Pennsylvania Association of Addiction Professionals and the National Association of Addiction Professionals (NAADAC). Both PCB and PCC AP/NAADAC offer certifications and training beneficial to those in the SUD field.

PCC AP aligns with Pennsylvania regulations and is currently providing a test-exempt period from February 1, 2024, to December 31, 2024. During this time, field licensure or certification holders can obtain PCC AP certification without a test, including certification for peers, counselors, and supervisors.

Detailed information about each certification level, including application processes and fees, can be found on the NAADAC website. Additionally, an FAQ page is available.

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Registration for the Pennsylvania Association of Area Agencies on Aging’s (P4A) 2024 Aging and Behavioral Health Conference is now open. The conference agenda will equip behavioral health practitioners and professionals with essential tools and knowledge regarding mental health and substance use disorders affecting older adults. The conference is set for May 29 – 30 at the Best Western Premier Hotel & Conference Center in Harrisburg. The deadline for registration is Friday, May 17. You can register and find details regarding the conference here.

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Pennsylvania state Reps. Maureen Madden (D) and Jim Struzzi (R) last week issued a bi-partisan co-sponsorship memo seeking support among their colleagues for a bill that will force the Department of Human Services (DHS) to take a more active role in Pennsylvania’s Opioid Use Disorder Centers of Excellence (COE) while forcing consistency and eliminating interpretation among the five behavioral health managed care organizations (BH-MCO).

RCPA has been working to address multiple components of COE inconsistency, including: interpretation of COE definition; compliance with COE requirements; and policies, procedures, and payment models being implemented by the commonwealth’s five BH-MCOs.

RCPA, on behalf of its SUD treatment provider members that operate COEs, has repeatedly asked DHS to enforce consistency in the COE program from MCO to MCO. Despite DHS considering the COEs overall to be a “wild success,” they have refused to take any action to ensure the success continues in the transition to managed care. In the past several months, RCPA and provider members that operate COEs have testified in front of the House Democratic Policy Committee and the House Human Services Committee on the disjointed and burdensome transition of the COEs into Pennsylvania’s Medicaid state plan. You can read RCPA’s testimony or watch the Human Services hearing.

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The Pennsylvania Department of Drug and Alcohol Programs (DDAP) has issued Licensing Alert 05-2024 to provide and organize guidance on the interpretation and implementation of regulatory licensing requirements for staff education, training, and supervision, as well as client-to-staff/counselor ratios for drug and alcohol treatment providers.

DDAP has issued individual licensing alerts over time that focus on specific regulation topics. This licensing alert organizes previous relevant active licensing alerts, as well as provide additional guidance for Chapter 704 staffing regulations.

Licensing Alert 05-2024 is available online.

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Folders with the label Applications and Grants

The Pennsylvania Department of Drug and Alcohol Programs (DDAP) announced the availability of $6.5 million in funding to expand drop-in center services for individuals with substance use disorders (SUD) across Pennsylvania.

Drop-in centers provide a safe, judgment-free place for people to receive daily essentials, engage with staff to learn about the possibility of recovery and treatment options, and, when ready, get connected to those services. They also provide harm reduction and recovery support services.

Eligible applicants, including existing community organizations, single county authorities, and DDAP-licensed treatment providers, can find the grant application online. Approximately eight grants of up to $750,000 will be awarded.

Some examples of services provided by drop-in centers include but are not limited to:

  • Harm-reduction for substance use by incorporating overdose prevention and legally permissible harm reduction efforts into existing services;
  • Addressing social determinants of health through the provision of daily essentials;
  • Access to care and case management systems;
  • Access to free healthcare including wound care, Hepatitis C/HIV testing, reproductive healthcare, and dental care;
  • Referrals to SUD level of care assessments, treatment, including medication for opioid use disorder, behavior health resources, case management services, benefits services, and legal services;
  • Survival resources such as shelter and warmth or cooling;
  • Public restrooms, shower, and laundry facilities;
  • Clothing and hygiene product distribution;
  • Mail services;
  • Professionally facilitated support groups which offer education, emotional and social support, practical help, and more; and
  • Advocacy and other supportive services required to navigate complex issues impacting special populations.

DDAP is placing a focus on health equity as a part of this grant opportunity. Applicants must include a description of their current engagement with diverse populations, including communities of color, LGBTQ+ individuals, persons with disabilities, and those residing in rural and urban settings, and provide detailed information about how the project will engage and provide access to these diverse populations.

All applications must be submitted electronically by 12:00 pm on Friday, April 12, 2024. Applications will be competitively reviewed and scored based upon the applicant’s adherence to the funding announcement guidelines and a timely submission to DDAP.

Funding for these grants is provided from the opioid settlement funding that was appropriated to DDAP by the General Assembly for the 2023/24 fiscal year.

Questions regarding the grants and the application process should be forwarded via email.

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The Pennsylvania Department of Drug and Alcohol Programs (DDAP) is conducting a survey on regulatory reform that will help guide its work in this area. The survey is available online, and responses are due by close of business March 28, 2024. Regulations governing licensed addiction treatment providers under DDAP’s authority can be found in the Pennsylvania Code and Bulletin. If you have any questions, please contact Cynthia Beidler.

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As Pennsylvania pushes to legalize recreational marijuana, recent research suggests doing so could have harmful effects for adolescents, including a potential increase in suicide.

The study, “Cannabis use disorder, suicide attempts, and self-harm among adolescents: A national inpatient study across the United States,” examined the association between cannabis use disorder (CUD) and suicide/self-harm in a large, nationally representative sample of hospitalized adolescents. It found that adolescents with CUD were 40 percent more likely to experience a suicide attempt or self-harm.

Although the inpatient study does not directly tie an increase in adolescent suicide to legalization of recreational marijuana, there is an association between marijuana legalization and the increased risk of cannabis use disorder among adolescents. As more adolescents experience CUD, then, the potential for more suicides also increases.

In his 2024-2025 Budget Book, Governor Shapiro, acknowledging that all of Pennsylvania’s neighboring states except West Virginia have legalized recreational marijuana, says now is the time for the commonwealth to do so as well. His budget proposes legalization of adult use marijuana effective July 1, 2024, with sales within Pennsylvania beginning January 1, 2025.

The governor’s plan estimates about $14.8 million in revenue in the industry’s first year of operation, with more than $250 million in annual tax revenue expected once the industry is established.

In its review of the inpatient study, the Recovery Research Institute (RRI) suggests policymakers develop policies and funding structures that appropriately educate the public about the risks of cannabis use, and support those who are currently using, as a way to potentially help reduce the public health burden of cannabis use and suicidal behaviors among adolescents.

For treatment providers, RRI points out that cannabis use was uniquely associated with suicidal behaviors among adolescents being treated in an inpatient setting over and above well-known risks such as depression. Furthermore, those with both CUD and depression were at an even greater risk, concluding, then, that it is likely helpful to conduct thorough screenings for each of these issues if an individual presents with one of them.

The governor has proposed millions of dollars to address Pennsylvania’s growing mental health needs. With legalization of recreational marijuana seemingly inevitable in the commonwealth’s near future, even more resources will be needed to address the inevitable substance use disorder (SUD) and mental health issues Pennsylvanians of all ages will likely face following legalization. With a quarter of a billion dollars expected in eventual annual revenue from legalized marijuana, a significant portion of that sum must be committed to SUD and mental health treatment providers.

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