Tag Archives: opioids

Funders sometimes force grantees to provide services they don’t want to: FQHCs and Medication Assisted Treatment (MAT)

We often remind clients that those with the gold make the rules. Accepting a government grant means the applicant must sign a grant agreement, in which the applicant agrees not only to provide wherever services were specified in the proposal, but also abide by a myriad of regulations and laws. While many applicants will tussle with a funder over the budget, there’s rarely any point in trying to modify the boiler plate agreement—just like one can’t modify Apple or Facebook’s Terms of Service.

In addition to the specific terms of the grant agreement, grantees quickly become subject to other influences from the funder—when the Godfather makes you an offer you can’t refuse, you know that eventually you’ll be told to do something you’d otherwise not much want to do. While a federal agency is unlikely to place a horse’s head in a nonprofit Executive Director’s bed, the grantee might end up having to provide an unpalatable service.

A case in point is HRSA’s relatively recent (and divisive) endorsement of Medication Assisted Treatment (MAT) for treating opioid use disorder (OUD). Since HRSA is the primary FQHC funder, it is essentially their Godfather and has great influence over FQHCs. In the past few years, HRSA has strongly encouraged FQHCs to provide MAT. The CEOs of our FQHC clients have told us about HRSA pressure to start offering MAT. It seems that, even after several years of cajoling, only about half of our FQHC clients provide MAT, and, for many of these, MAT is only nominally offered. Other clients see offering MAT as a moral imperative, and we’ll sometimes get off the phone with one client who hates MAT and then on the phone with another client who sees not providing MAT as cruel.

“MAT” generically refers to the use of medications, usually in combination with counseling and behavioral therapies, for the treatment of substance use disorders (SUD). For OUD, this usually means prescribing and monitoring a medication like Suboxone, in which the active ingredients are buprenorphine and naloxone. While Suboxone typically reduces the cravings of people with OUD for prescribed and street opioids (e.g., oxycontin, heroin, etc.), it is itself a synthetic opioid. While MAT replaces a “bad opioid” with a “good opioid,” the patient remains addicted. Many FQHC managers and clinicians object to offering MAT for OUD, for a variety of medical, ethical, and practical reasons:

  • Like its older cousin methadone, as an opioid, Suboxone can produce euphoria and induce dependency, although its effects are milder. Still, it’s possible to overdose on Suboxone, particularly when combined with alcohol and street drugs. So it can still be deadly.
  • While MAT is supposed to be combined with some form of talking or other therapy, few FQHCs have the resources to actually provide extensive individual or group therapy, so the reality is that FQHC MAT patients will likely need Suboxone prescribed over the long term, leaving them effectively addicted. We’re aware that there’s often a wide gap here between the real world and the proposal world.
  • Unless it’s combined with some kind talking therapy that proves effective, MAT is not a short-term approach, meaning that, once an FQHC physician starts a patient on Suboxone, the patient is likely to need the prescription over a very long time—perhaps for the rest of their life. This makes the patient not only dependent on Suboxone, but also dependent on the prescriber and the FQHC, since few other local providers are likely to accept the patient and have clinicians who have obtained the necessary waiver to prescribe it. Suboxone users must be regularly monitored and seen by their prescriber, making for frequent health center visits.
  • As noted above, prescribed Suboxone can, and is often, re-sold by patients on the street.
  • Lastly, but perhaps most importantly, most FQHC health centers prefer to look like a standard group practice facility with a single waiting room/reception area. Unlike a specialized methadone or other addiction clinic, FQHC patients of all kinds are jumbled together. That means a mom bringing her five-year old in for a school physical could end up sitting between a couple of MAT users, who may look a little wild-eyed and ragged, making her and her kid uncomfortable. Since FQHCs usually lack the resources for anything beyond minor paint-up/fix up repairs, there is simply no way around this potential conflict.

Given the above, many FQHC CEOs remain resistant to adding the challenges of MAT to the many struggles they already face. Still, the ongoing pressure from HRSA means that most FQHCs will eventually be forced to provide at least a nominal MAT program to keep their HRSA Program Officer at bay. The tension between a typical mom and her five-year old against a full-fledged behavioral and mental health program is likely to remain, however. Before you leave scorching comments, however, remember that we’re trying to describe some of the real-world trade-offs here, not prescribe a course of action. What people really want in the physical space they occupy and what they say they want in the abstract are often quite different. You can see this in the relentless noise around issues like homeless service centers; everyone is in favor of them in someone else’s neighborhood and against them in their own neighborhood. Always pay attention to what a person actually does over a person’s rhetoric.

NIH opioid research grants are here; expect opioid treatment RFPs to come soon

In his review of Dreamland: The True Tale of America’s Opiate Epidemic” and in his post on the “New grant wave for Medication Assisted Treatment (MAT),” Isaac noted that the heroin and prescription drug addiction epidemic crisis is likely to generate new grant programs. Since then, the crisis has in some ways been getting worse, not better, especially in politically sensitive parts of the country. The federal response has so far been slower than we expected, but the NIH just released a trio of research grant RFPs focusing on “Marijuana, Prescription Opioid, or Prescription Benzodiazepine Drug Use Among Older Adults.” Those grants are under the NIH R01, R03, and R21 categories.

The only surprising thing about these RFPs is how long they’ve taken to hit the street. Every time you see a news article or watch a TV exposé about the opioid epidemic, the likelihood of federal action rises. And every time you see such an article or video, you should be thinking about how it will affect your own proposals.

For example, SAMHSA just released a new RFP for a very old program: “Targeted Capacity Expansion-HIV Program: Substance Use Disorder Treatment for Racial/Ethnic Minority Populations at High Risk for HIV/AIDS (Short Title: TCE-HIV: High Risk Populations).” Someone ought to tell SAMHSA that brevity is a virtue in program titles, but apart from that I’ll note that, if I were writing a TCE-HIV proposal, the needs assessment would be filled with data about opioid use. We have collectively known about the dangers of sharing needles for decades, but the present opioid issue gives new urgency to old problems.

New grant wave forming for Medication Assisted Treatment (MAT)

A new grant wave is forming. An unexpected and shocking epidemic of heroin and prescription opioid addiction has erupted across America and the federal response is going to be a huge increase in funding for treatment and related services.

We’ve already seen signs of the grant wave in HRSA’s Substance Abuse Service Expansion program, which was designed to focus on “Medication-assisted Treatment in opioid use disorders.” Last week, the Obama Administration proposed a new $1 billion heroin treatment initiative involving pass-through grants to the states, which will in turn issue RFPs to local treatment providers, most of which will be nonprofits.

The new Obama initiative is to fund more medication-assisted treatment (MAT). Unlike the old methadone approach, MAT combines behavioral therapy with more modern medications to treat substance abuse disorders. While the Obama initiative is clearly aimed at treatment providers, peripheral grants are sure to become available for ancillary services like outreach, engagement, education and case management, most of which can be implemented by virtually any human services nonprofit.

Unlike many of President Obama’s proposals, the MAT grant initiative is likely to gain strong and quick bipartisan support in Congress, because vast stretches of rural America, as well as many suburbs and cities, are being overwhelmed by heroin, prescription opioid addiction, and concomitant ODs, often in the seemingly most unlikely of places. This includes over 400 ODs in New Hampshire in 2015. This bucolic state is not usually associated with a 22-year old woman overdosing in a squalid Nashua alley.

Listen to this heart-wrenching NRP story about how a middle aged and middle class New Hampshire makeup artist’s step daughter died. The makeup artist specializes in “painting” the presidential candidates that inundate NH every four years; she’s made-up everyone from Bernie Sanders to Mario Rubio this year. Each candidate has gotten an earful of the the addiction/OD crisis while captive in her chair.

In addition, almost every Democratic and Republican presidential candidate, with the possible exception of Hillary Clinton, seems to have been personally touched by the addiction and/or OD of a child, another relative, or a friend. It’s like Traffic writ large. Carly Fiorina and Chris Cristie regularly tell OD anecdotes as part of the their stump speeches, while Bernie and the now-out-of-the-race Rand Paul take a libertarian stand that prefers treatment over legal sanctions regarding substance abuse disorders.

When Bernie and Rand somehow agree on a major domestic policy issue, you know that the problem transcends politics. The US long-ago lost its 40-year “War on Drugs.” After over four decades of draconian law enforcement and incarceration that disproportionately affects communities of color, the net result is that heroin is actually cheaper than ever—the Washington Post reports that a bag of heroin costs less than a pack of cigarettes in much of America! High cigarette taxes are part of the reason, but heroin is not taxed. Taken together, these trends point to the need for nonprofits to be nimble enough to catch this cresting grant tsunami.