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By Jason Snyder, Director, SUD Treatment Services, BH Division and
Chris McKenzie, Community Relations Coordinator, Pinnacle Treatment Centers
October 15, 2025

Editor’s note: I asked my good friend Chris McKenzie, Community Relations Coordinator at Pinnacle Treatment Centers, to collaborate with me on a blog about what we both see as a gap between what research tells us about medications to treat opioid use disorder and the prevailing attitudes toward it in the treatment and recovery communities. We have shared our firsthand experiences here as Part I of a two-part blog. In Part II, we will discuss our suggestions for greater genuine acceptance of multiple pathways to recovery as well as address feedback we may get on Part I.

(Jason)

Several years ago, I met an individual in recovery from addiction who eventually went on to become a therapist. As our friendship and my own 12 step-based recovery from substance use disorder evolved, so did my position on medication to treat opioid use disorder (MOUD). His did not. Where once I was staunchly opposed, I was now beginning to embrace the idea, if for no other reason than the rising overdose death toll and the devastating stories of loss I continued to hear. I bought into the messaging that said we can’t treat someone who is dead.

My friend still failed to see the light.

“But the research shows it to be highly effective,” I ineffectively implored.

“Well, you need to show me this research, because I just don’t see it,” he replied.

In the end, it really didn’t matter what research I showed him, because that research did not match his reality. It could not overcome his perception, personal experience with individuals using MOUD, and definition of recovery, which was based on a belief that use of medication was nothing more than substituting one drug for another. And unfortunately, he is not an anomaly, at least within what I’ll call the traditional treatment system and recovery communities. For most of them, the gold standard is not MOUD. It is abstinence combined with a new way of life, despite what many within these very systems will publicly say.

What my friend saw — and what I sometimes see today – were individuals using MOUD who were living chaotic lives of polysubstance use, with no real ability to manage their own lives. This is what many in the lay public, health care and treatment systems, law enforcement, and legislature, to name a few, also see. And some of these groups have great power in influencing broader access to and acceptance of (or, conversely, opposition to) MOUD, including the ability to make laws that can limit it.

I believe it is fair to ask, “How is that recovery?” Actually, it may not be – yet. Often times, it can be a first necessary step on a path toward change. Consider SAMHSA’s definition: a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. For many, the start of the process can be chaotic. But if we believe in meeting people where they are and helping them along through a process of change, then we shouldn’t be condemning MOUD. In fact, for many, we should be genuinely encouraging it for whatever length of time necessary for the individual. Yet even under that scenario, not every case will be a success, just as it is not in every other medical and clinical discipline.

But many people lack the foresight or open-mindedness to see beyond their own experience and what’s in front of them right now. So, when these very people — families, friends, peer specialists, counselors, nurses, police, and lawmakers — who have had some negative experience with MOUD make blanket, disparaging statements about it, it has a ripple effect, eventually reaching the very people intended to be helped. In turn, it negatively influences their perceptions and willingness to try this way. And I’ve seen this very scenario end in death, when friends who could not stop using illicit opioids refused to use MOUD because of the stigma put upon them by others.

The danger in riding the high horse of judgment, condescension, and condemnation because others don’t recover like you or because others aren’t experiencing a transformation as you believe it should be is that you put their life in grave danger.

Does MOUD save more lives than abstinence? The research says yes.

Does medication transform the lives of those with SUD? In many instances, it absolutely does.

Does the transformed life that doesn’t align with a particular set of values have less worth than the one traditionally held up as an example of “recovery”?

If we truly believe the answer to the last question is “no,” then why do we still discourage or even demonize medication?

(Chris)

Jason raises two important questions: What is recovery and what is a valid way to get there? I would add one more: Why do we continue to place our own values on other people’s recovery? If we take a moment to reflect on how it might feel when someone does that to us, we might see things a little bit differently.

From my own experiences with substance use, I have learned the importance of examining my biases. The gap between research and reality is a clear case of bias. Recovery is not defined by another person, but is a deeply personal journey. That is why SAMSHA’s definition of recovery is purposely broad. Recovery is a process of change and that process can begin with something as small as a shift in mindset or the very first positive step, as defined by the individual. The individuality of recovery is what makes the definition so powerful, and so necessary.

Yet, this understanding is not always reflected in practice. I once interviewed for a job and was asked if I “worked a program.” I shared that I attended SMART Recovery meetings. The interviewer quickly told me that they only practiced one program at that organization, and it wasn’t SMART Recovery. In that moment, it felt as if every other pathway, including my own, was dismissed as invalid. If I, as someone with professional experience, felt those words like a sharp wound to my own recovery, I can only imagine how discouraging it must be for someone who is just beginning their recovery journey.

This narrow view extends to many places like recovery housing, treatment settings, and peer support programs, where certain approaches are upheld while others, like MOUD, are diminished or outright rejected. Research, once again, clearly shows that MOUD saves lives and this pathway, just as any other, is valid. When institutions or individuals impose these narrow definitions, they not only reinforce bias but also close doors for people who might otherwise succeed.

So how do we move closer to true acceptance of multiple pathways to recovery, including the use of medications? In Part II of our blog, we’ll offer our suggestions. In the meantime, if you have any ideas about this or thoughts on the subject or the blog in general, let us know.

Email Jason or Chris with your thoughts, or start a conversation on LinkedIn.

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Message from Rep. Dan Williams’s Office:

HARRISBURG, June 24 – Bipartisan legislation introduced by state Rep. Dan Williams, D-Chester, that would help Pennsylvanians take advantage of new federal Medicaid rules that give patients and clinicians more telehealth options for behavioral health services passed the PA House today with overwhelming support.

“The longstanding and outdated ‘four walls’ requirement has limited Medicaid reimbursement to services within the physical walls of a clinic,” said Williams. “This only creates barriers to care, particularly in rural areas and regions experiencing mental health workforce shortages.”

The Centers for Medicare and Medicaid Services gave states the option to waive the requirement on Jan. 1. In response, the Pennsylvania Department of Human Services has submitted a State Plan Amendment to adopt this flexibility, which is currently awaiting federal approval.

House Bill 1590 would repeal state regulations that conflict with the new federal flexibility. Importantly, the bill would not change existing rules requiring in-person treatment hours for outpatient behavioral health clinics.

“Under this bill, Pennsylvania can fully implement the change, expanding access to behavioral health services and reducing care gaps for our vulnerable populations across the Commonwealth,” Williams said.

The bill now moves to the state Senate for consideration.

It is important to note that, at this time, OMHSAS is awaiting approval from CMS. To address the Federal Medicaid payment conditions in the Pennsylvania statute, there was a need for this legislation to permit services be covered under Medicaid, and HB 1590 would achieve this. It is also important to reiterate that this bill will not change outpatient behavioral health clinic rules requiring in-person treatment hours. The passage of this bill will address these conditions for outpatient clinics as well as the delivery of SUD services.

Both the CMS SPA approval and the legislation would be retroactive to January 1, 2025.

Until then, the completion of both the SPA and the legislation on 4 walls flexibilities will remain in place. RCPA is grateful to have partnered with OMHSAS, House legislators, and other stakeholder associations on the development of this bill. We will continue our efforts in getting the legislation to the Governor’s desk.

If you have any questions, please contact RCPA COO and Director of Mental Health Services Jim Sharp.

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By Jason Snyder, Director, SUD Treatment Services, BH Division
June 2, 2025

In the latest legislative run at involuntary substance use disorder (SUD) treatment, two Pennsylvania senators co-sponsoring SB 716 are looking to amend Pennsylvania’s Mental Health Procedures Act to include SUD and alcohol use disorder (AUD) by themselves as mental illnesses. Doing so would, under the law, subject those with the disorders to involuntary commitment in the same way mental health is today; that is, individuals with an SUD can then be forced into treatment against their will, mainly through a court-petitioning process, just as an individual in a mental health crisis can be involuntarily committed to psychiatric care today.

As to whether SUD and AUD are in fact mental illnesses, Sens. Laughlin and Williams appear to be on solid ground. The most recognized and credible medical association in the country, the American Medical Association, includes SUD as a mental illness, and the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies it as such. In fact, 34 states allow involuntary commitment for SUD, whereas all 50 allow involuntary commitment for a mental health issue.

But beyond that, the senators’ rationale is debatable.

Although we absolutely are still dealing with a continually evolving SUD epidemic, as of today, I would not call the epidemic unprecedented. In 2017, Pennsylvania was in unprecedented times with the highest number of annual overdose deaths ever seen at 5,456. Earlier in May of this year, the Centers for Disease Control released preliminary data that showed overdose deaths down 31 percent to 3,358 in Pennsylvania in 2024 over 2023. Had it not been for the Covid years, we may well have seen a continual annual decline from 2020 through today.

Even as fentanyl has replaced heroin and adulterants like xylazine and medetomidine have exacerbated the crisis, naloxone and warm hand-off protocols – both instituted broadly around 2016 – along with improved access to evidence-based treatment including buprenorphine; increased integration of peers; and other harm-reduction strategies, including fentanyl test strips, have all over time contributed to decreasing deaths. Most experts on the ground would say we need to do more of this, as it has proven over time to save lives.

Many of those same experts also oppose any effort to force people into SUD treatment. Research evaluating its effectiveness is mixed. In one review of studies assessing the outcomes of involuntary treatment, evidence did not overall suggest improved outcomes, with some of those reviewed studies suggesting potential harms. However, other studies do suggest some benefit to involuntary treatment. For example, one study found significantly reduced emergency department visits and unplanned hospital admissions for people who received involuntary treatment. Another study found that, when interviewed six months later, the majority of involuntarily admitted patients acknowledged that they needed treatment and felt positively about having been mandated to attend.

Even so, practical considerations within Pennsylvania’s addiction treatment system remain a big hurdle, and most treatment providers agree that involuntary commitment to SUD treatment is not only ineffective; in actuality, it is a burden on the system, staff, and other patients. And at this point, there are more questions than answers. To my knowledge, the senators have not consulted the broad provider community about the bill, the immense challenges it brings, or their ideas for alternatives.

In Pennsylvania’s last legislative session, Sen. Laughlin introduced SB 962, which would have established a new involuntary commitment process for those with SUD, especially those who overdose. In opposing that bill on behalf of our SUD treatment providers, we wrote a brief position paper in 2023, highlighting our concerns: the enormous burden placed on providers to manage an unfunded, complex involuntary treatment process; the perpetuation of stigma toward the disease of addiction by introducing the complexity and trauma of the judicial system to the treatment of a disease – not the commission of a crime; and little evidence that this approach reduces overdoses and death, not to mention the lack of locked SUD treatment facilities in the commonwealth and the potential disruption to the milieu of patients who do want to be in treatment.

As a provider representative, RCPA and its members still have those concerns today and continue to oppose the senators’ current efforts.

Yet I understand the anguish of families who live the active addiction of a loved one, and the exasperation, helplessness, and hopelessness of watching a downward spiral often end in death. My family, hoping that we were going to somehow wake up from the nightmare we were living, watched it with both of my brothers, who eventually died of drug overdoses.

So with involuntary commitment a non-starter for providers because of the complexity, ambiguity, and debatable outcomes, what more can we do for those in most danger of death who seem least likely to proactively seek treatment?

First, we must sustain and improve upon what is already demonstrating effectiveness at reducing deaths; namely, widespread distribution and availability of naloxone, improved access to evidence-based treatment (including buprenorphine and methadone), increased use of peers at multiple intercepts, and other harm-reduction strategies.

In opposing SB 962 during the last legislative session, RCPA proposed that finding the will to develop programs and policies that are proven to reduce overdose deaths and better engage those with SUD with the treatment system was preferable to a well-intended but misguided involuntary commitment law. Such policies and programs would include: enabling safe access to evidence-based medications to treat opioid use disorder including, for example, immediate buprenorphine induction by emergency medical personnel at the site or instance of overdose or access to low-barrier bridge clinics; providing meaningful, sustainable funding to specially train and embed certified recovery specialists at every potential touchpoint with overdose survivors; and reforming regulations and eliminating administrative burdens that act as barriers to treatment access.

As an example of what others are proposing as alternatives to forced treatment, APA, in its journal Psychiatric Services, recently suggested focusing on the highest-risk subpopulations for brief (72 hours or less) involuntary holds, as opposed to commitments, in hospitals to allow health care providers to engage them and begin to provide ongoing care management and peer support, as opposed to simply watching the individual walk away. Could something like this work?

Most in the treatment system and arguably all harm reductionists oppose involuntary commitment for SUD. With overdose deaths continuing to trend significantly downward, now seems like an even less opportune time for reintroduction of such a bill than in the past. But clearly, some in the legislature want to do more.

What alternatives to involuntary commitment would you suggest?

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A Review of the BH-HealthChoices Program as We Emerge from COVID
By Richard S. Edley, PhD, RCPA President/CEO

A lot has happened within the behavioral health Medicaid system over the last several years. The BH HealthChoices program, which started in the mid-90s, has certainly evolved over time – the implementation of supplemental services and reinvestment strategies, program expansion, and value-based payment structures, to name a few advances. It is a mature program that certainly has achieved the three original goals when the program was developed, which should be applauded:

  • Increase access;
  • Increase choice; and
  • Stem the escalating health care cost curve.

As a carve-out model, Pennsylvania BH HealthChoices has and continues to be a model that reflects the unique government and local structure of counties, compared to states that operate on a state run behavioral health system. As noted in our most recent position paper, a program such as BH HealthChoices should continuously look to improve. While the role of RCPA is, at times, to challenge primary contractors and BH-MCOs when indicated to best represent providers and those they serve, we have also been consistent in our support of the program.

COVID certainly was the largest challenge to date for the whole human services system and to the BH HealthChoices program. RCPA worked with DHS/OMHSAS, the primary contractors (counties), and the BH managed care programs to implement a range of alternative payment mechanisms to keep community programs alive at that time as we collectively went into uncharted waters. The recognition by the primary contractors and BH-MCOs of the need to rethink funding to maintain the solvency of providers was a feat that was unprecedented. In comparison, this approach was not routinely implemented on the PH-MCO (physical health) side of HealthChoices. Further, RCPA supported the simultaneous rapid movement into telehealth at this time. If there is any silver lining during this period, we learned quite a bit about the utility of both these initiatives.

Then there was 2024, the year of MA “unwinding.” During COVID, many individuals joined Medicaid coverage while very few were ever removed. Under a federal directive, PA began to require re-enrollment of all persons on Medicaid during this year – leading to a disenrollment of individuals who perhaps could now receive coverage elsewhere (e.g., PENNIE) or did not qualify to remain on MA. No one argues that this should happen; but as with all other COVID and post-COVID initiatives, no one also quite knew how to predict what would actually be the result.

What did, in fact, occur is now well documented. OMHSAS and their contracted actuarial consultant simply missed their projections. They underestimated the number of people who would be removed from the rolls, and further underestimated the acuity of those that remained covered under BH HealthChoices. This double hit produced record losses for the programs and those primary contractors/BH-MCOs that are at financial risk for the programs. These losses were the result of the capitation payment being inadequate for the primary contractors while they were still required to support and pay providers for (the increased) medically indicated services.

It should be noted that there were similar losses of even larger numbers and proportion to the physical health system and those MCOs. The standard line from DHS and the governor’s office has been that those companies took the risk, and while it was a “bad” year, there have been good years (i.e., profit) and that is the nature of a risk agreement. This is perhaps true for the PH-MCOs that held funds during COVID, because the medical spend was greatly reduced due to members not seeking services. This same logic, however, has been attempted to be applied to the BH HealthChoices program.

Indeed, the BH managed care programs have built risk and contingency dollars over the years and that is what those dollars are there for when programs have losing years. The problem with applying the PH logic to the BH system goes back to the reimbursement strategy employed by the BH-MCOs and supported/encouraged by RCPA: alternative payments. Therefore, during COVID the BH-MCOs got as much of the dollars out as possible in advance to providers, to keep programs alive. These were not years of excess profit. Also, all primary contractors and BH-MCOs are capped at the amount of risk reserves that they can maintain, and have been capped at 3% max earnings in “good years.” These same organizations are on the hook for unlimited losses in the “bad” years. So the double-hit noted earlier really became a triple hit: high disenrollment, high remaining acuity, and the available dollars during COVID were spent.

What has also been well documented is the inadequacy of the mid-year capitation adjustment that was provided by OMHSAS to the primary contractors to “backfill” these losses. First, it was widely assumed that the adjustment would be for the full 12 months of 2024. Instead, it was only retroactive to July 2024, or six months. Second, the programs have estimated that across PA the capitation adjustment equated to about 17 cents on the deficit dollar. Based on the presentation of DHS that this was an unprecedented infusion of dollars into the BH system, many providers assumed this would equate to rate and program increases.

Moving into 2025, there is also some debate as to the adequacy of the increased capitation rates. Is the increase going to cover the utilization? Will utilization begin to come back to pre-COVID levels? These are clearly unknowns and RCPA has heard mixed reactions from the primary contractors and BH-MCOs. It is simply too soon to answer these questions. Based on this uncertainty, it is not surprising that many of the BH HealthChoices programs sent letters out to providers noting that they should not expect any program increases in 2025. While RCPA does not support that position, we clearly can understand it. What we would hope is that if 2025 begins to appear more positive financially, that these decisions can be revisited for the second half of the year. Several of the primary contractors have verified that this is their intent and have communicated this to providers.

At the same time, RCPA provider members have been increasingly vocal that in 2024 and into 2025, there appears to be increased scrutiny of the BH system by BH-MCOs, leading to an increase in denials of treatment requests. This feedback has been particularly apparent among SUD providers. RCPA took this very seriously, but also understood that such an assertion needed data, rather than relying solely on anecdotes. We did embark on our own data study and, due to the complexity, the results are still pending.

On April 24, 2025, however, OMHSAS preempted this effort and released a report to the Medical Assistance Advisory Committee (MAAC) on Denials, Grievances, and Complaints. The data does clearly reflect an increase in denials for some BH-MCOs in 2024, but not all. RCPA has to ask the question: what are the factors that led to this increased scrutiny and denials in some of the programs?

As with many issues, the answer to this question is again not so simple. While it is easy to make the correlation between financial losses and increased denials, BH-MCOs and primary contractors have noted several additional factors to consider, which RCPA also recognizes need to be discussed and understood:

  • The increase in denials is not across every BH-MCO and every program. Therefore, large generalizations should be avoided and there needs to be a better understanding of what might be happening within the provider network and region(s) of those BH-MCOs that did show increases. The data was also published in raw numbers, not as a percentage of all service requests, or as denials/1000, to account for membership sizes.
  • Could there be something related to the implementation of the ASAM criteria, which is mandated by law to be used for treatment decisions, on both the provider and BH-MCO that is driving this increase? BH-MCOs have asserted that there is a direct correlation between the increase in denials and the implementation of ASAM criteria. BH-MCOs have also noted that a small group of providers are driving the denial trends. 2024 was a learning period for all; therefore, could we project that denials will decrease when providers and BH-MCOs come to a better alignment?
  • Is there an increase because we are comparing COVID years (before the MA unwinding) to 2024? What were denial levels before COVID? During the public health emergency, OMHSAS issued mandates requiring the approval of all admission and continued stay requests for specific SUD levels of care, regardless of whether MNC was met. This mandate ended in 2024, which accounts for some of the increase in denials. Were 2024 denial rates actually below historical norms?

Then again, could this report also be under-reflecting true denial rates? Several providers note that all of their grievances and appeals of denials are upheld. Therefore, it is not worth the significant administrative time to pursue this action, so alternatives are sought. This assertion, of course, is anecdotal and BH-MCOs do not agree that they have seen this trend. Since some of this may not be tracked in the data available, it highlights the importance of an ongoing discussion between all parties.

So what does this all mean? The evolution of the program, the COVID experience, and now the post-COVID data is important to understand. We don’t have all the answers, but this does set up an important set of discussions in the coming weeks/months:

  • What does the denial data mean and how do we best understand it?
  • Are there improvements we should be looking to for the BH program as it continues to evolve?
  • What is the financial experience in 2025? Have utilization and expenditures leveled out?
  • How do we ensure that what happened in 2024 is not repeated? Certainly it was a unique and difficult year, and while it might be a one-time event, is there anything learned from the experience? How do we ensure that the actuarial analysis moving forward takes into account any unique and recent utilization trends and data?

RCPA will continue to engage this dialogue with the primary contractors and BH-MCOs. But we also understand that the best way to approach these issues is ultimately in partnership with those organizations and OMHSAS.

In the coming weeks and months, we will continue to update the RCPA membership as we learn more. The BH-HC model has been and continues to be a success for the state, the counties, the providers, and most importantly, the members. As with past challenges, we are confident we can work with all stakeholders to navigate this current challenge and come out even better than we went into this period. We encourage providers to continue to bring to RCPA your experience in the coming months, so as to best inform the discussion and to continue to approve the program.

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By Jason Snyder, Director, SUD Treatment Services, BH Division

For as long as I’ve been active in the recovery community and addiction treatment system, the prevailing mentality around people who couldn’t “get it” – with “it” mostly meaning compliance with a program and an outcome of sustained abstinence – was that they just weren’t ready, or they just didn’t have enough willingness to do the things that are necessary to stop using drugs and begin to recover. That attitude is much more pronounced in certain recovery communities, much more nuanced in the treatment environment, but it’s an accepted way of thinking in both. It’s a kind of thinking that blames the individual for failing, as opposed to the system failing the individual.

But what if a large subset of individuals with substance use disorder (SUD) really can’t get it, with “it” not only being abstinence or reduced use, but, more consequentially, the cognitive demands of treatment – alertness, attention, cognitive processing, memory, and executive functioning? What if these individuals are neurologically incapable – even if only temporarily – of engaging in treatment for their SUD the way the treatment system expects them to, because they have either an acquired or traumatic brain injury from or driving their SUD?

Such a recognition by the broad treatment system, the subsequent implications for improved individualized treatment and, most importantly, actual modifications to SUD treatment could be huge.

Earlier this month, I had the opportunity to participate in what for me was an eye-opening summit convened by the Pennsylvania Department of Health and the Brain Injury Association of Pennsylvania. It focused in part on recognizing the significance and prevalence of brain injury among those with SUD, especially opioid use disorder (OUD), and identifying ways to better treat this population. Much of what was shared and stimulated my thinking on this came courtesy of the Addiction Technology Transfer Center’s “Traumatic Brain Injury and Substance Use Disorders: Making the Connections” toolkit.

Most of the discussion focused on acquired brain injury (ABI). Internal factors, including lack of oxygen to the brain due to an opioid overdose, result in ABI. Traumatic brain injury (TBI), on the other hand, results from an external force, such as a blow to the head, including those that result from physical abuse. Both ABI and TBI have significant implications for those in SUD treatment. Often subtle yet significant changes in memory, attention, and social behavior, for example, make it difficult to participate in treatment, and many leave without completing. With historic numbers of overdoses over the past 10 years, the connection between SUD and brain injury, especially ABI, has not gotten the commensurate discussion it needs.

Since 2015, Pennsylvania advocates have rightly made the widespread distribution of naloxone a top priority. In fact, that is the year I began working for the Pennsylvania Department of Drug and Alcohol Programs, and getting naloxone into the hands of first responders, especially police, was our top priority. The mantra then, as it is now, was we can’t treat someone who is dead. From there, the natural progression from administration of naloxone was to warmly handing off that person to treatment or recovery support. One of the biggest challenges, and therefore areas of focus, with the warm hand-off process has been finding more effective ways to intervene at that critical moment to prevent the individual from simply walking away from a near-death experience and continuing on as if it hadn’t happened.

What has received little attention over those 10 years is the fact that for many, regardless of whether they agreed to treatment or walked away, life would never continue as if the overdose hadn’t happened, because many who overdose experience permanent brain damage.

It takes only four to six minutes of a lack of oxygen to the brain to cause permanent brain damage, which can forever affect a person’s ability to understand, retain and recall information, express themselves, think critically, or solve problems. Those who sustain a brain injury are at risk for future overdoses.

In North America, approximately 23 percent of all intravenous drug users will experience a non-fatal opioid overdose per year. Further, there are estimated to be as many as 40 non-fatal overdose events for every fatal overdose among people who inject drugs.

Sadly, I can’t tell you how many people I’ve met who have been reversed multiple times. In fact, research shows that people who have had at least one opioid overdose are more likely to have another, which can compound any impairment or injury.

But it’s not only those who have overdosed who may have a cognitive impairment. Amount and duration of substance use can also result in neurologic and cognitive effects, meaning many people – perhaps the majority – who enter the treatment system have some level of difficulty with cognitive and behavioral function. Research suggests 80 percent of those seeking services for co-occurring mental health and SUD are living with the effects of brain injury.

Yet we as a treatment system often expect these same patients to sit quiet and still in hours-long group therapy sessions, pay attention, and not be disruptive. We expect them to be on time for group. We expect them not to miss their individual sessions. We expect them to follow through and comprehend. Those who don’t are often labeled as not ready for treatment. They haven’t reached their bottom yet.

Of course, there must be some measure of accountability on the patient’s part. But to set expectations for those with a brain injury in the same way we would for someone who does not have one is setting them up for failure.

To be fair, without assessing a person for a brain injury, clinicians may not even realize there is an issue. Without understanding the serious implications of brain injury on a person’s ability to engage in therapy, there may be no perceived need to change the way treatment is being provided. Instead, the lack of knowledge and understanding leads to incorrect assumptions about the patient as the reason the treatment isn’t working, not the reverse.

By beginning to effectively and comprehensively screen for brain injury; training clinicians, peers, regulators, and payers on the prevalence and implications of brain injury; and modifying the way treatment and recovery supports are provided for these individuals, the SUD treatment system can significantly improve treatment outcomes.

It will take collaboration with regulators, especially to remove regulatory barriers, as well as collaboration with payers to consider potential alternative payment models, to accommodate the therapeutic needs of those with a brain injury.

Quality individualized treatment should be more than rote alignment with ASAM criteria. It should effectively recognize neurologic limitations – both those acquired as a result of overdose and those caused by trauma – and appropriately modify treatment for those with such limitations. Otherwise, the behavioral health system will continue to misread and mislabel what arguably is a majority of its patients.

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By Jason Snyder, Director, SUD Treatment Services, BH Division

There are many stakeholders in the broad substance use disorder (SUD) landscape who are nervous about how US Department of Health and Human Services Secretary Robert F. Kennedy Jr. will steer policy. But from a treatment perspective, given his beliefs and experiences, he could drive significant improvement in the way those Americans who suffer most severely from SUD are treated.

In January, after President Trump took office and nominated Kennedy to be secretary, many SUD treatment providers and advocates, along with several media outlets, immediately raised concerns. Pointing predominantly to the 45-minute documentary Kennedy made as part of his early campaign for the presidency, some advocates feared that if he was confirmed as secretary of HHS, he would use his personal experience and preferences to unduly influence the country’s SUD treatment policy away from evidence-based treatment, including the use of medications like methadone and buprenorphine.

In “Recovering America – A Film About Healing Our Addiction Crisis,” Kennedy, who is in long-term recovery from heroin addiction, featured “healing farms” – a form of therapeutic communities – as successful models for treating SUD. Therapeutic community is a treatment approach built on the premise that for recovery to occur, a change in lifestyle and social and personal identity is vital. He said that if he was elected president, he would open hundreds of healing farms across the country.

Of course, he did not become president, but he was confirmed as secretary of HHS in February.

Kennedy’s support of healing farms is not the only concern of some advocates. The pathway to his own recovery – a 12-step program – and his staunch support and continued participation in that program, which many criticize for its abstinence-only philosophy, including its rejection of medications to treat SUD, is also a red flag.

An Opportunity to Improve What Already Exists

But Kennedy actually has an opportunity to leverage his experience and philosophies in a way that improves the predominant residential treatment model in place today for those with the most severe and advanced disease. This does not mean a wholesale shift toward healing farms or even therapeutic communities (though in a world of individualized care and personal choice, there can be a place for these types of treatment models). It should, however, include policy that forces increased funding of residential treatment settings, in order to provide adequate lengths of stay and meaningful integrated mental and physical health and recovery support services throughout the continuum – including, when necessary, skilled nursing facilities that accept patients whose treatment includes narcotic medication, and appropriate, safe, and accessible recovery housing. A stronger continuum of care for those suffering the most severe SUD can enable social connectedness, sense of community, belongingness, and meaning and purpose. Not only are these foundational goals of therapeutic communities and values Kennedy holds in high regard; they are also key tenets of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) working definition of recovery. As HHS secretary, Kennedy oversees SAMHSA.

In Kennedy’s documentary, he walked the streets of San Francisco and showed footage of Philadelphia’s Kensington neighborhood. Living in the age of fentanyl and xylazine, the individuals from these streets who make it to treatment are typically homeless, have extreme physical comorbidities, and have suffered unimaginable trauma and mental illness. In other words, they are the most ill. Yet, in Pennsylvania, we often see an aggressive push by payers to quickly move them from the highest levels of care, where patients whose acute biomedical, emotional, behavioral, and cognitive problems are so severe that they require primary medical and nursing care, to lower levels of care well before their clinicians believe they are ready.

Many policymakers, pundits, and payers will point to the high cost and lack of evidence to support such lengths of stay in residential settings. But any argument that the research does not support long-term residential treatment should be carefully scrutinized, in particular because little research exists that examines outcomes for those with the most severe SUD. If Pennsylvania policymakers and payers have such data, they should bring it forward.

Ensuring and Improving Access to Medication

What is indisputable is the fact that medications to treat opioid use disorder not only reduce overdose deaths, but they also increase engagement and retention in treatment, increase abstinence from opioid use, and improve other quality-of-life metrics.

But Kennedy’s position on several other issues has advocates concerned about his position on medications like buprenorphine and methadone.

From within the mental health and SUD advocacy world, one of the strongest endorsements Kennedy received ahead of his confirmation was from his cousin Patrick Kennedy, a former US Congressman from Rhode Island and staunch SUD and mental health advocate who has been in recovery 14 years. Patrick Kennedy’s treatment and recovery path included the use of buprenorphine and naltrexone, as well as medications to address mental health.

In a 2016 story in the Seattle Times, Patrick Kennedy said, “We’re hogtied because many of those influencing addiction policy in this country come from the 12-step culture, which says abstinence is the only true form of recovery. We’re losing a lot of people on the altar of that type of rigid ideology.”

Even closer to home, Robert Kennedy experienced the death of his younger brother David, whom he described as his best friend. David Kennedy was 28 years old when he died in 1984. My younger brother Todd was 28 years old when he died in 2005 from a heroin overdose. Less than two years later in September 2007, my 25-year-old brother Josh, the youngest of my parents’ three children, died of a drug overdose. I have often said that my parents, both of whom I am grateful to still have today, would much rather have their two dead sons alive and using buprenorphine or methadone, with a chance to define their own lives and recovery, than lying side by side in a graveyard in Cambria County, PA. I can’t imagine that Robert Kennedy feels any different about David – that if there was something that could have been done to give him another day and a shot at recovery, he would have staunchly supported it. In preserving and enhancing access to medications, Kennedy has the opportunity to give to parents, siblings, and other family members and loved ones what he and I no longer have.

Walking the Tightrope

In my work, a key component of advocacy on behalf of SUD treatment and those who need it is an ability to put aside my own recovery path, and acknowledge and support other pathways that I might not choose but can nonetheless be effective. In fact, this is in large part what a professional peer does. And for Kennedy, as evidenced by his documentary, the peer is an indispensable, integral part of the recovery process; not just in the healing farm setting, but in justice-system diversion programs as well, for example.

Related to my recovery from SUD, if you want the type of life I am striving to live and want to know what I do, I am willing to show you. My professional role, however, does not include forced imposition of my personal philosophies on you. To find such a balance requires open-mindedness, which is also a bedrock principle of the Alcoholics Anonymous (AA) program Kennedy lives. The challenge with open-mindedness is applying it in all of life, not just within the parameters we choose to live. In doing so, we potentially attract others to that lifestyle.

Kennedy obviously is not simply an advocate or a well-known “old-timer” in a local area of AA meetings. He is the top policymaker for HHS and SAMHSA. From the highest, most influential platform he has ever had relative to his recovery, he can strike the right balance.

With a better funding approach, Kennedy can infuse aspects of a treatment modality and recovery support program that has worked for many, including himself, into the system we have in place today. In doing so, he can improve treatment broadly for those with the most severe SUD, and support and advance the integral, life-saving role medications play, all while serving as a role model for what recovery may look like for some.

For the sake of all of those who are still suffering from this disease, including families, I hope he can do it.

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Interested in learning more about how to integrate psychedelic therapy into your future services?

BrainFutures and the University of Berkley’s Collaborative for Economics of Psychedelics are hosting a “Provider Roundtable: Integrating Psychedelic Therapies into Healthcare” on April 1 at 12:00 pm EST/9:00 am PST!

The Roundtable will share findings from a new white paper on opportunities and challenges in scaling psychedelic therapy post-FDA approval. You can read the white paper here, and don’t forget to register for the Provider Roundtable to discuss solutions on April 1.

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By Jason Snyder, Director, SUD Treatment Services, BH Division

As I watched Pennsylvania Governor Josh Shapiro give his budget address last Tuesday, it occurred to me that the light Pennsylvania government had brightly shined on the addiction epidemic for nearly the past 10 years has greatly dimmed.

In a speech of nearly 11,000 words, not one of them was “addiction.” Not one mention of treatment. No mention at all of an overdose death epidemic. Over the course of a 90-minute budget address, Gov. Shapiro, a man who likes to “get stuff done,” did not even attempt to take credit for overdose death numbers that are trending downward. He didn’t acknowledge them at all.

Granted, the Pennsylvania Department of Drug and Alcohol Programs (DDAP) continues to release pots of opioid settlement and federal money, including State Opioid Response (SOR) funding, into the behavioral health ecosystem, though not all of it is available to DDAP-licensed treatment providers. Counties also continue to spend opioid settlement dollars from multiple sources, including a national settlement with the three largest pharmaceutical distributors that netted more than $1 billion for Pennsylvania.

In arguing that everyone else is legalizing adult-use recreational marijuana, so Pennsylvania should, too, the governor ignores the evidence of the harms of marijuana, including a link between legalized adult recreational marijuana and an increase in adolescent suicides, as well as the broader implications for addiction treatment such that not one dime of the $536,000,000 in estimated Fiscal Year 2025/26 revenue is proposed to be directly allocated to DDAP. Although it appears recreational legalization is inevitable at some point, failing to acknowledge its potential to harm some Pennsylvanians is disingenuous.

Dig a little deeper into the budget, and it looks no brighter for addiction treatment providers.

Behavioral HealthChoices — the name for Pennsylvania’s Medicaid managed care program for behavioral health — currently is in a financial crisis. Pennsylvania counties and behavioral health managed care organizations (BH-MCO) are reporting to be significantly underfunded due to a Department of Human Services’ (DHS) actuarial error made in calculating the effects of the unwind of the Medicaid rolls post-Covid. The underfunding is affecting the counties’ abilities to meet contractual obligations to provide behavioral health services. In other words, the $6.3 billion comprised of state and federal dollars in the current fiscal year (2024/25) budget (see p. 104 of 372 of DHS’s budget book) for Behavioral HealthChoices capitation — capitation being a form of payment based on a complex formula that determines an amount of money needed per Medicaid recipient per month — is not enough money to pay for addiction and mental health treatment for everyone who wants and needs it.

Although we see an 18 percent increase in the HealthChoices capitation line item that amounts to $660 million in state dollars in the governor’s proposed executive budget, significant questions are still unanswered and even bigger concerns remain.

For example, we do not know how much of the 18 percent increase is earmarked for Behavioral HealthChoices, which is concerning because the Physical HealthChoices program also is underfunded, and the Physical HealthChoices program is a significantly higher expenditure. Estimates suggest that the Behavioral and Physical HealthChoices systems combined need an additional $2.5 billion (state and federal combined) in the current calendar year, which is partly funded by two separate fiscal year budgets, to meet their obligations to Pennsylvania’s most vulnerable. There is a $230,000,000 supplemental payment in the proposed budget, which would help to address the immediate need for additional funds in the current fiscal year, but we are hearing only a small percentage of this is for the HealthChoices issue.

As a result of the underfunding and uncertainty, BH-MCOs and primary contractors have announced to addiction and mental health treatment providers that they will not receive any increases in reimbursement rates in 2025, despite escalating provider costs. At the same time, in certain regions of the Commonwealth, addiction and mental health treatment providers are beginning to report increasing challenges in getting appropriate treatment authorized (e.g., decreased lengths of stay, increased denials). Although anecdotal, RCPA will continue to have these discussions and look to substantiating data.

The current HealthChoices crisis has been building since early 2024 and has caused much anxiety. So far, the proposed 2025/26 budget only exacerbates the worry. Add in the federal Medicaid and grant funding uncertainty coming out of Washington, DC following recent executive orders that potentially put funding streams like the Substance Use Prevention, Treatment, and Recovery Services Block Grant and SOR dollars at risk, and the calamity grows exponentially. Right now, we are looking at a real possibility of ongoing behavioral health service cuts that would be akin to rationing of care.

At this point, I am left with a few fundamental questions. How is $6.3 billion not enough to provide behavioral health services — addiction and mental health treatment — to Pennsylvania’s Medicaid population? How could the state have been so wrong on its calculations? How sustainable is a behavioral health system that needs at least upwards of $7 billion per year? Does the legislature have an appetite for such a system?

And, perhaps most importantly, what are the implications for the future of addiction treatment and the sustainability of the system as we currently know it? Beyond the funding crisis, the field continues to beg for relief from administrative burden and crushing oversight, pleas that have amounted to shouting into the void.

With DHS’s budget hearings coming up in early March in front of the Senate and House Appropriations Committees, I would expect the legislature to also be asking these same questions. Stay tuned.

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By Jason Snyder, Director, SUD Treatment Services, BH Division

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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