Industry Insider - August 2016

Jul/Aug 2016

Vol. 2 No. 4

CARA: Cautious Optimism pg. 2

Recovery: A LongTerm Journey pg. 4

Testing Matters pg. 10

Industry Trends pg. 11

The Legal Beat pg. 12

The Rhythm of Recovery: Dr. Andrea G. Barthwell Leads the Way pg. 6

The Meadows Joins Forces with Sunspire Health pg. 3

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AmericanAddictionCenters.com

Jul/Aug 2016

Industry Insider

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Letter from the Editor

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n early June, Michael Botticelli, the director of Office of National Drug Control Policy (ONDCP), traveled to his home around Albany, New York to join leaders throughout New York State to host a community forum on prescription drug misuse and heroin use.

The discussion focused on evidence-based ways to prevent and treat the overdose epidemic. This was one of a series of forums across the country to continue the conversation that President Obama began in West Virginia in October, and recently highlighted during the May 14, 2016 weekly address about SUDs. Director Botticelli joined congressional, state, and local leaders and other advocates from New York State to discuss the ongoing efforts to address the opioid epidemic; and provided an overview of recent actions by the Obama Administration. It’s always a treat for those of us in this recovery space to meet with and listen to Mr. Botticelli, who has personally been in long-term recovery for more than twenty-six years.

A ubiquitous presence wherever the Insider travels, “he has encouraged the millions of Americans in recovery today to make their voices heard and confront the stigma associated with substance use disorders, which often keeps individuals from seeking and receiving treatment” (“Michael,” 2016).

As Director of the Office of National Drug Control Policy, Mr. Botticelli leads that administration in “its drug policy efforts, which are based on a balanced public health and public safety approach” (“Michael,” 2016). It’s a common refrain that the “Administration has advanced historic drug policy reforms and innovations in prevention, criminal justice, treatment, and recovery” (“Michael,” 2016), but I am struck this month by vignettes showing how much still needs to be done, and that is captured in our profile of one who knows a thing or two about federal responses to crises, the galvanizing Dr. Andrea G. Barthwell on page 6.

That was particularly poignant in a posting around the same time, with citations to very credible sources, entitled “Collaboration at Every Level: Solving the Country’s Opioid Crisis.” The post is by Mark Price, US public sector leader of the Deloitte Center for Health Care Solutions and Deloitte Consulting LLP. He states, The numbers are staggering. Drug overdose is now the leading cause of accidental death in the US, ahead of car accidents and suicide, and claimed 47,055 lives in 2014 alone. Six in ten of these deaths involved some type of opioid, including both prescription drugs and heroin. To put this into perspective, since 2000, the rate of overdose deaths involving opioids has more than doubled; it grew from 6.2 deaths per 100,000 Americans in 2000 to 14.7 per 100,000 in 2014.

But, it is more complicated than that. Three out of four Americans who are addicted to heroin were introduced to opioids through prescription drugs. This linkage adds to the complexity of the problem, as heroin use and opioid abuse impact different geographies, age groups, and genders, and deserve different approaches.

This problem has directly impacted organizations across the health care system as they struggle to manage the staggering costs. In 2012, the cost of inpatient hospitalizations related to opioid abuse reached $15 billion. This figure has nearly quadrupled since 2002.

For state government agencies, the first step is acknowledging that

this is not a regional issue but rather a nationwide problem and should be a legislative priority in each state (2016).

In Florida, where Counselor and the Industry Insider are headquartered, we get to see this first-hand through the prism of a disproportionate number of patients from across the country whose home states do not have the infrastructure in place to handle the demand.

As our esteemed “Legal Beat” columnist Jeffrey C. Lynne, Esq. says from the trenches of the zoning with which he deals on page 12, while opening a residential detox program may seem like “good business,” it is a medically necessary service to combat the overprescription of opioids. Outpatient detox programs also need to be accepted by local zoning authorities as necessary to treat those who may not be wholly “addicted,” but yet still need services. Overall, our community must come together to accept that South Florida can and must be a center of addiction treatment excellence. We cannot “zone out” treatment providers unless and until it is determined that a quarantine of such persons is medically and scientifically required, which of course, is absurd.

As Mark Price asserts, “States can play a role in increasing access to treatment options via public insurance programs, developing harm reduction strategies that include broader administration of naloxone, and investing in social programs that focus on prevention. States can also use their regulatory authority in the form of Medicaid demonstration waivers to tailor service delivery to meet their population’s treatment needs” (2016).

One scrambles for vestiges of hope where one can, and there may be some in this: “After years of relentless growth, the number of US opioid prescriptions in the United States is finally falling, the first sustained drop since OxyContin hit the market in 1996” (Goodnough & Tavernise, 2016). Surely it’s a little flash of a signal “that the long-running prescription opioid epidemic may be peaking, that doctors have begun heeding a drumbeat of warnings about the highly addictive nature of the drugs, and that federal and state efforts to curb them are having an effect” (Goodnough & Tavernise, 2016). Mobilizing to ensure that such a cascade of prescriptions never returns will surely be pivotal to all that Director Botticelli, Surgeon General Murthy, and company propose. n Sincerely,

Stephen Cooke Editor, Treatment & Recovery Industry Insider References Goodnough, A., & Tavernise, S. (2016). Opioid prescriptions drop for the first time in two decades. The New York Times. Retrieved from http://www.nytimes.com/2016/05/21/ health/opioid-prescriptions-drop-for-first-time-in-two-decades.html?_r=0 “Michael Botticelli.” (2016). Retrieved from https://www.whitehouse.gov/ondcp/botticelli-bio Price, M. (2016). Collaboration at every level: Solving the country’s opioid crisis. Retrieved from http://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/ health-care-current-may31-2016.html?id=us:2em:3na:hcc:awa:chs:053116#1

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Jul/Aug 2016

The Comprehensive Addiction Recovery Act: Still Moving, but Where is the Finish Line?

Andrew Kessler, JD

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or more than a year you have been hearing and reading about landmark legislation in Congress that goes by the name of the Comprehensive Addiction Recovery Act (CARA). Authored in the senate by Senator Portman (R-OH) and Senator Whitehouse (D-RI), it is a true bipartisan bill with a wide breadth of support in the SUD advocacy community. Years in the making, CARA is approaching the finish line. Yet nothing is a given, especially in Washington, and especially in this environment.

Among other objectives, CARA would expand prevention and educational efforts—particularly aimed at teens, parents, other caretakers, and aging populations—to prevent prescription opioid abuse and the use of heroin. It promotes wider distribution of the overdose reversal drug naloxone to law enforcement agencies and other first responders, and expands disposal sites for unwanted prescription medications to keep them out of the hands of children and the elderly. More resources would be available to promptly identify and treat individuals suffering from SUDs in the criminal justice system.

There are benefits to the treatment community as well. CARA would launch an evidence-based prescription opioid and heroin treatment and intervention program to expand best practices throughout the country, as well as a medication-assisted treatment and intervention demonstration program. In addition to the provisions in CARA, we hope it will provide robust funding to several other areas that will aid in prevention, treatment, and recovery.

These include high-intensity drug trafficking areas, drug-free community grants, drug court grants, alternative treatment grants, and the National Health Service Corps.

The benefits to California would be immense.

As the bill focuses on opioid abuse, there are several regions of California that are struggling

with this epidemic. Recently, CNN reported on the problems of heroin overdoses plaguing the capital of Sacramento.

There is good news to share, and much to be encouraged by. When CARA made it to the Senate floor in March, it was the first standalone bill that addressed substance abuse to make it that far in the process in over four decades. It then passed the Senate in a nearly unanimous vote, 94–1, with only Senator Ben Sasse (R-NE) voting against the bill.

With the good news comes some bad news.

Congress to appropriate additional funding for the programs created by CARA. Challenges remain before CARA becomes law, the largest of which is passage in the House of Representatives. Speaker Ryan has hinted that he would like to see the House take up the bill. Even if there are enough votes to pass CARA in the House, the enemy is the calendar. 2016 will be a short legislative session, as a presidential election year keeps Congress away for almost three months in the summer and fall. In addition, due to the way oversight is structured in the House, it would need to pass through more committees than it did in the Senate.

The House has begun the process of considering the bill, and we can only hope the legislative language they produce is palatable to the the senate. CCAPP has advocated moving the bill quickly, and has contacted the offices of Majority Leader McCarthy and Minority Leader Pelosi to this effect.

If CARA does pass the house this year, CCAPP is part of an effort to fund the programs authorized within it in the current budget being created in Congress, which is FY 2017. If this does not happen, we will have to wait until FY 2018 until the programs are funded.

So let’s call the mood “cautious optimism.”

CARA has come so far that it is a source of great pride for the SUD community. The challenges to final passage—and implementation of its program—unfortunately remain very real and very difficult. n

“CARA has come so far that it is a source of great pride for the substance use disorder community.”

A tremendously important amendment to the legislation, filed by Representative Jean Shaheen (D-NH) would have provided $600 million in new funding, in order to fully fund the new programs authorized by CARA. The amendment, which was based on an earlier supplemental appropriation bill written by Rep. Shaheen last December, was tailored to fit the new programs created by CARA. Now, if CARA does indeed become law, the new programs created by it will have to compete for existing funds within the Department of Justice and the Department of Health and Human Services—not an easy task, especially in a fiscal environment as brutal as the current one. Representative Hal Rogers (R-KY), the chairman of the House Appropriations Committee and a long-time champion of addressing opioid abuse, has often said “A vision without funding is a hallucination.”

CCAPP will continue to work with members of

Andrew D. Kessler, JD, is founder and principal of Slingshot Solutions LLC, a consulting firm that specializes in behavioral health policy and Federal Policy Liaison for IC&RC. IC&RC promotes public protection by setting standards and developing examinations for credentialing prevention, substance use treatment, and recovery professionals.

Jul/Aug 2016

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Mergers & Acquisitions The Meadows Joins Forces with Sunspire Health

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eadows Behavioral Healthcare— also called “The Meadows”—a Wickenburg, Arizona treatment center and an industry leader for the almost forty years, is joining forces with Sunspire Health, a rapidly expanding provider of treatment for substance abuse and other co-occurring disorders.

The announcement was made in late May by Kohlberg & Company, a leading private equity firm, via the formation of Alita Care, LLC, which will serve as the parent holding company for The Meadows and Kohlberg’s existing portfolio company, Sunspire Health.

The Meadows and Sunspire will continue to operate as independent brands within Alita, while exploring ways to improve patient care through the sharing of best practices. Jim Dredge, CEO of Meadows Behavioral Healthcare, has accepted the position of CEO and will lead the combined company.

He stated,

will have the ability to serve patients across the country.

Clinical and day-to-day operations at both companies will not be impacted by the transaction, and both The Meadows and Sunspire will continue to focus on providing best-in-class treatment services for patients and their families.

A. J. Schreiber, CEO of Sunspire, who has been appointed vice chairman of the board of Alita, said, “Sunspire and The Meadows share common cultures and similar passions in providing industryleading treatment. We are very excited to be entering this phase of our company’s evolution under the Alita umbrella.”

Evan Wildstein, partner of Kohlberg, added, We are very pleased to further develop our investment in the behavioral health services sector, and look forward to

continuing to invest in both companies to support their strategic initiatives and bestin-class clinical offerings.

The Meadows is highly regarded as an industry leader, providing treatment for trauma and for people struggling with addiction, eating disorders, and related mental health conditions. The company’s programs include The Claudia Black Young Adult Center at The Meadows, Gentle Path at The Meadows, Remuda Ranch at The Meadows, The Meadows Outpatient Center, and a series of intensive workshops.

For many years The Meadows has employed some of the best known authors, speakers, and trainers in the addiction and behavioral health field as senior fellows—most notably Drs. Bessel van der Kolk, Peter Levine, Patrick Carnes, Shelley Uram, Claudia Black, and the late John Bradshaw. More recent

We are thrilled to be joining forces with Sunspire, whose patient-centric model and national footprint, combined with the forty-year history of clinical excellence at The Meadows, creates a compelling value proposition for patients and their families, clinical referral sources, and payers Combined, we will be able to offer expanded, full continuumof-care treatment to patients suffering from a wide crosssection of addictions and other behavioral health disorders, including eating disorders, sexual addiction treatment, and treatment specifically focused on young adults. Furthermore, with fifteen differentiated programs in eight states, we

Jim Dredge

AJ Schreiber

senior fellows include Terry Eagan, MD, Alex Katehakis, MFT, CSAT, CST, and Dan Griffin, MA. Sunspire operates a portfolio of independently branded treatment centers currently comprised of ten locations in California, Florida, Illinois, Massachusetts, Oregon, South Carolina, and Texas. Utilizing evidence-based clinical interventions and an abstinence-focused approach, Sunspire offers treatment for those living with SUDs, gambling addiction, sex addiction, and co-occurring mental illnesses.

Sunspire delivers improved patient outcomes by offering a full continuum of care and individualized treatment plans in intimate settings in residential and outpatient facilities across the nation. n Source: http://www.kohlberg.com/ ViewDocument.aspx?f=MMRS_Sunspire%20 -%20add-on%20-%20Meadows.pdf

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Jul/Aug 2016

What is Recovery?

John Lehman

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he science of addiction has expanded to include functional brain scans, medication-assisted treatment (MAT), and evidencebased interventions. While this emerging science is of great value in guiding clinical care, reducing stigma, and enhancing traumainformed care, it falls far short in preparing patients to manage a chronic condition as they return to their natural environment.

The professional addiction treatment community has long appreciated the need for community-based infrastructure to support client engagement upon exit from acute care. Aftercare plans prepare clients for their first steps in recovery.

Referral to outpatient treatment providers (OTP), recovery residences, and mutual aid networks are typical components of such plans. The primary objective is to connect patients to resources at the community level. Providers, payers, and the academic research community now identify recovery as something very different from treatment. Recovery is about doing life clean and sober. The Substance Abuse and Mental Health Services Administration (SAMHSA) published a pamphlet entitled SAMHSA’s Working Definition of Recovery wherein they define recovery as “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (2012).

The science of recovery gains momentum as well. In a 2012 monograph, William L. White, MA, thoroughly examines evidenced-based interventions and practices demonstrated to promote and sustain recovery: The emergence of recovery as an organizing paradigm for addiction treatment and the larger arena of behavioral health care underscores the need to measure both early recovery initiation and stabilization and the prevalence of long-term recovery maintenance. Such measurement is critical in evaluating addiction treatment as a system of care and monitoring broader dimensions of community health (White, 2012).

“Providers, payers, and the academic research community now identify recovery as something very different from treatment.”

The White House Office of National Drug Control Policy (ONDCP) and SAMHSA host recovery resource pages on their websites. Exploration of these sites reveals that the science of recovery points to effective community integration as a primary goal of recovery-oriented systems of care (ROSC). Science demonstrates that periodic assessment of an individual’s recovery capital offers a more reliable construct for predicting resilience and guiding interventions in support of resilience. According to William White and William Cloud, PhD, “Recovery capital is the breadth and depth of internal and external resource that can be drawn upon to initiate and sustain recovery from AOD problems” (2008). Since its publication, the peerreviewed Assessment of Recovery Capital: Properties and Psychometrics of a Measure

of Addiction Recovery Strengths, presented

by Teodora Groshkova, PhD, David Best, PhD, and William White is now available in five additional languages and recognized internationally as a reliable measurement of internal and external recovery resources necessary to sustain resilience (2013).

Further recovery research regarding recovery capital is underway. While funding remains a challenge, a significant barrier to recovery research lies in sustaining postacute care accessibility to research subjects. Many residential inpatient providers have expanded their platforms vertically to step-up clients through a series of outpatient programs, diminishing in intensity, to the ultimate destination of self-directed recovery. It is suggested that this vertical continuity of care provides greater stability and offers the additional benefit of extending

Jul/Aug 2016 outcome assessment. Alumni groups further extend outcome monitoring, however; this data skews results as participants are predominantly comprised of persons who remain tethered.

The bulk of clients disappear as they exit acute care into a vast cavern of anonymity. This is one driver of Dr. Best, professor of criminology at Sheffield Hallam University in the United Kingdom and associate professor of addiction studies at Monash University in Australia and his decision to continue his research with populations that reside in recovery-oriented, community-based housing platforms in the UK and Australia. These populations have remained sufficiently stable to meet the rigors of research protocols.

SHU-FARR REC CAP RESEARCH STUDY

Through an introduction facilitated by William White, the Florida Association of Recovery Residences (FARR) has recently contracted with Sheffield Hallam University to conduct a study into outcomes produced by the REC CAP recovery planning instrument. Approximately three hundred research subjects who reside in housing operated by six certified providers will engage in a six-phase study commencing June 1, 2016.

In an attempt to address the concerns that most standard instruments in the alcohol and other drug (AOD) field measure pathologies and are not suited to mapping long-term recovery journeys, the Assessment of Recovery Capital (ARC) was developed as a measure of recov-

Industry Insider

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“Self-direction is foundational to development of recovery resilience.” ery growth that could be repeated throughout the recovery journey. While the initial scale contained one hundred items—fifty pathology items and fifty strength items—feedback from clinicians was that this was too long and duplicated existing measures of deficit. Consequently a fifty-item instrument was developed and tested for validity and reliability, with the resulting paper published in Drug and Alcohol Review (Groshkova, Best, & White, 2013).

This measure is widely used in both academic research and recovery practice, and has already been translated into four languages other than English. The final scale consists of five five-item scales measuring personal recovery capital and five five-item scales measuring social recovery capital. While the ARC has been used in a range of treatment and recovery settings, recent work in the UK has seen this developed to include a scoring framework and training manual for workers, embedding the ARC within a larger package of measures called the REC-CAP that also looks at ongoing support needs and involvement in community recovery organizations.

While the SHU-FARR research study relies on subjects who reside in recovery housing certi-

fied to be compliant with National Alliance for Recovery Residences (NARR) quality standards and code of ethics, REC-CAP is applicable for use by Outpatient Treatment Providers (OTPs) and Recovery Community Organizations (RCOs).

Development and implementation of a viable recovery plan is, by necessity, reliant on the navigator’s knowledge of and access to community-based resources. Connecting persons with these resources is essential to the ROSC integration objective. Self-direction is foundational to development of recovery resilience.

Measurement of assets evidenced to sustain resilience allows individuals to appropriately redirect focus at periodic assessment intervals. Identification and definition of concrete actions in support of self-determined recovery goals can be better facilitated by navigators.

More information regarding this important research may be found at www.farronline.org/ recovery-outcomes. n John Lehman has led FARR to achieve its current role as state credentialing entity for voluntary certification of recovery residences. He sits on the NARR Standards & Ethics Committee, Florida ROSC BRSS TACS Policy Academy, and Florida Certification Board Advisory Council. He serves several nonprofit boards. A person in long-term recovery, John is the grateful beneficiary of quality addiction treatment and recovery support services. He is committed to enhancing the recovery landscape in Florida.

References Groshkova, T., Best, D., & White, W. L. (2013).

Assessment of recovery capital: Properties and psychometrics of a measure of addiction recovery strengths. Drug and Alcohol Review, 32(2), 187–94.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). SAMHSA’s working definition of recovery. Retrieved from http://store.samhsa.gov/ shin/content//PEP12-RECDEF/PEP12-RECDEF.pdf White, W. L. (2012). Recovery/remission from substance use disorders: An analysis of reported outcomes in 415 scientific reports, 1868–2011. Retrieved from http://www.williamwhitepapers.com/pr/__books/ full_texts/2012%20Recovery-Remission%20from%20 Substance%20Use%20DisordersFinal.pdf White, W., & Cloud, W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22–7.

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Jul/Aug 2016

Devoted to the Rhythm of Recovery: Andrea G. Barthwell, MD, DFASAM, Leads the Way Stephen Cooke

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r. Andrea Grubb Barthwell’s career has thrived by “standing in the place of her truth when the time was right for speaking that truth.”

There are few medical doctors more focused on finding innovative ways to bring care to individuals in need of treatment for substance use disorders (SUDs). Science-based messaging about the dangers of marijuana use and proper application of drug-testing in the United States are informed by her work and newsworthy pitches and papers. Her extensive knowledge of the provisions of the Affordable Care Act (ACA) and experience in creating best-in-class clinical practices have had a massive impact on this burgeoning field in the century so far. But the arc of Andrea G. Barthwell, MD, DFASAM’s career is what has brought her to this moment in the twenty-first-century approach to healing in recovery, to this place as one of the nation’s most revered experts on the prevention and treatment of SUDs. “Dr. B,” as she is known to so many across the treatment Dr. Barthwell testifies at the ONDCP-sponsored Northeastern Governor’s Summit on Drugs (c. 2004). Photo credit: ONDCP landscape, just has to know the strategies that promote and restore natural rhythms, and the role of sleep, nutrition, meditation, and exercise; she simply hasn’t stopped evangelizing on multiple SUD fronts since the century began. livering lectures in her home environments In December 2001 President George W. Bush nominated Dr. Barth- of Cook County and Chicago, IL to—withwell to serve as deputy director for demand reduction in the Office of out the usual clinical sophistication that National Drug Control Policy (ONDCP). The United States Senate con- colors her prolific work—“help parents get firmed her nomination on January 28, 2002 and, as a member of the ‘em through adolescence without using.”

President’s subcabinet, Dr. Barthwell was a principal advisor in the ExBut she also found new forums from ecutive Office of the President (EOP) on policies aimed at reducing the the multiple entreaties for her experience demand for illicit drugs. in creating best-in-class clinical practices, During her tenure, the Bush Administration widely publicized science- the proper application of drug-testing, and based facts about the dangers of marijuana use and the harms of le- especially the opportunities offered by parity. galization. Her commitment to that came after the ONDCP mission; Dr. “I started working on policy first and Barthwell continued her work identifying the legislation of marijuana as learned much that I didn’t know that has addictive and dangerous, and had a pivotal role as coauthor in crafting equipped me to help more now in the field, ASAM’s white paper on the legalization of marijuana. “Doctors have especially with how all has played out with something that is FDA approved, reliable, and tested to treat every ill- ACA and parity,” she said from her Chicago ness that people might claim will be better, or provide reduced suffer- office, in between another round of nationing, when using marijuana,” she reasserted recently. al conferences delivering her message. “I Dr. Barthwell acknowledges that proponents of medical marijuana worked with Congressman Patrick Kennedy have been successful in moving the supposed “public relations barom- and realized that, for the major targets of eter” in their direction, but she insists that there are better alternatives. ACA to reach their full power, we need the When bills began to be passed at the state level, she shifted her efforts full implementation of parity for it to have from teaching constituencies about the dangers of such legislation to real currency,” she added. inoculating parents against the incomplete messages that minimized The founder and director at Two Dreams the inherent dangers of the drug. She founded the Parents Academy Outer Banks, Dr. B developed lectures for with help from the Caron Foundation in Pennsylvania, and started de- clinicians in tandem with this, incorporat-

Jul/Aug 2016 ing the therapeutic model of her seminal North Carolina program. She also continued to ponder the eternal American question of “failure to launch” with other gifted clinicians as to “how we ‘walk’ the thirty-fiveyear-old who started using at age twelve to get him or her to evolve into adulthood through treatment.”

Dr. Barthwell serves on the board of the Institute on Global Drug Policy and the board of the International Council of Alcoholism and Addictions, and served as president of the Encounter Medical Group.

While serving in the EOP, she had been an active member of the White House Task Force on Disadvantaged Youth and the White House Domestic Violence Working Group. Prior to her presidential appointment, Dr. Barthwell was a member of the Food and Drug Administration’s Drug Abuse Advisory Committee and has served on the triad of advisory councils for CSAT, NIDA, and NIAAA. While her able staff carried that developmental framework further, Dr. Barthwell was trying to simultaneously find scientific methods to thwart the interlopers who had appeared on the US drug-testing landscape she knew so well. She stated, “ASAM had produced a white paper, but there were no guidelines identifying the frequency with which to use the clinical tool of urinalysis.”

Dr. Barthwell sought support from the medical and clinical groups with which she was held in high esteem, but with the raw honesty that characterizes her appraisal of the national scene, she found those in counseling who were benefitting from “what one might call ‘largesse’ in this area.”

She went ahead and authored a consensus statement to accelerate progress towards the solution, not asserting unequivocally that this was the right way, but wanting something tangible out there for ethical providers. She endeavored—and still does every day—to broaden the

Dr. Barthwell at “Solutions for a New Way Forward” panel discussion at Jersey Shore University Medical Center. Photo Credit: Thomas P. Costelo, staff photographer, Asbury Park Press.

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Dr. Barthwell at Forjando Liderazgo, the Buenos Aires, Argentina conference “Drug Dependence and its Consequences.” Also pictured are Mina Seinfeld de Carakushansky, president of BRAHA, and Dr. Roberto Baistrocchi, president of Forjando Liderazgo.

treatment community’s vision for effective settings for the use of urine drug testing, along the lines of policy recommendations from the American Society of Addiction Medicine (ASAM) and the National Center on Addiction and Substance Abuse (CASA) at Columbia University.

Her focus emanating from that is to supplement Department of Justice (DOJ) efforts to rid the industry of those who have been and are still engaged in fraud and abuse. She also found effective forums for this work at US Journal Training (USJT), where she is presenting at the next three conferences; in the pages of this publication, where the Industry Insider was honored to publish her report in “Testing Matters” with Dee McGraw at C4 Recovery Solutions; and where her unofficial role in reviewing the findings from each AXIS Conference is valued by all in attendance.

“I developed a USJT talk on ‘Progress, not Perfection: Principles of Process-Driven Care’ as a workshop, posing the question of how we move from a 1950s model of treatment, which allows people to discover that there is a disease, see that they have it, and plant the seed of recovery possibilities, to a more technology-based representation of what treatment can be in the twenty-first century,” Dr. Barthwell explained. The workshop framed what fascinates her in what the clinician can do on the NOW! (No Other Way!) within the treatment setting, allowing clinicians to work with personal integrity—a regular theme of Dr. B.’s—in efforts to provide excellent clinical care in a landscape of intense competition for the public’s attention.

“I have interviewed many who, following treatment, reported that its value was in getting them to accept the diagnosis and the remedy— Twelve Step work. But today, I’m seeking to develop a more clinically intensive program for the modern age that takes us beyond viewing our patients as mere students of the disease,” she added.

That approach is crystallized in her novel presentation of “Healing Rhythms” at USJT’s 27th Santa Fe Conference Integrating Spirituality, Mindfulness, and Compassion in Mental Health and Addictions in Santa Fe, New Mexico. “Every living organism has a natural rhythm. These rhythms are disrupted by illness, particularly drug and alcohol use. A drug can create false sleep. A drug can stimulate alertness. A drug can suppress appetite. Another can stimulate appetite,” Dr. B. explained.

This workshop explores the science behind living rhythmically, strategies that promote and restore natural rhythms, and the role of sleep, nutrition, meditation, and exercise in the twenty-first-century approach to healing oneself in recovery that is consistent with the way she lives.

Reflecting her commitment to merging science and practice, Dr.

8 Industry Insider

Jul/Aug 2016

Dr. Barthwell and Antonio Navarro Wolf, Colombian presidential candidate (c. 2004). Photo credit: ONDCP

Barthwell has landed this year back at what galvanized her in the wake of those ONDCP years to bring ACA and parity together. She is beautifully poised now to execute her ideas about effective treatment on multiple fronts; also developing software for clinical notes as a compass to a database that will shape in a sophisticated way what treatment can do in this age.

Outer Banks is where she gets to apply all the evidence- and experientially based medicine that she relishes. She founded the center in bucolic North Carolina with a self-pay arrangement, with scholarships available for a few who could not afford their treatment. However, when ACA became law she perceived that it provided a forum for party payment, while learning along the way a method for clinically responsive treatment in that framework. The result is that over 75 percent of the institution’s revenues are now derived from insurance.

Dr. Barthwell calls Two Dreams her “laboratory” for being able to execute her ideas about effective treatment, but that “lab” was robust enough to be applied as the basis for the program at The Manor, a luxury treatment center in Wisconsin at which the indefatigable doctor was appointed chief medical officer (CMO).

“Bringing a clinically luxurious program like The Manor online for a

fully responsive program was a welcome challenge. My ten years on the Banks underlie that therapy even though I didn’t realize that I was developing it as such at the time. As CMO I work with the clinical director on-site, with responses to their highly specialized needs like in North Carolina, but there we help people achieve understanding of their needs and self-care. The luxury is in the care,” Dr. Barthwell explained.

The additional goals at The Manor are to develop a sense of what their needs are in spirituality and health, with process at the heart of The Manor’s residential treatment program based on a lifetime of medical and personal experience perusing the marriage between evidenceand experience-based therapies.

Holistic in scope and carefully tailored to specific lifestyle demands, The Manor provides individualized addiction treatment that helps guests chart a course towards long-term recovery and the life they truly desire and have earned. This approach focuses on five domains of treatment: physical health, mental soundness, emotional maturity, spiritual resilience, and social awareness.

“The work done in recovery is mentally and emotionally demanding.

In my clinical experience, adding a layer of physical stress or deprivation to treatment does not improve outcomes. Rather, engaging with patients within their comfort zones—including elements of the lifestyle of which they are accustomed—encourages greater openness, which is key to the entire process,” Dr. Barthwell stated. “To engage in one’s comfort zone is a privilege we extend to every guest, in an intellectually stimulating and emotionally safe place,” she added.

Dr. Barthwell’s holistic message is resonating with clinicians, politicians, and police departments around the world. Last month she appeared on a Scientific American Opioid Addiction Panel in Neptune, New Jersey with Governor Christie, and her manic schedule continues with speaking engagements, not to mention lifetime achievement awards.

She’s far from finished.

“When healing from the chaos of alcoholism and other dependencies,” Dr. Barthwell continued, “we seek peace, social connection, gentle guidance, and serenity. The truth needs to be told, within the rhythms of recovery, within the rhythms of life.” She will go on delivering that message from her life’s work to all who will listen. n

Pictured left to right: Scientific American publisher and panel moderator Jeremy Abbate; New Jersey Governor Chris Christie; Chief Leonard Campanello, chief of police of Gloucester, MA; Behshad Sheldon, CEO of Braeburn; and Dr. Barthwell.

One of the world’s leading addiction treatment centers, headed by internationally renowned Addictionist, Andrea Grubb Barthwell, MD, DFASAM.

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10 Industry Insider

Jul/Aug 2016

Testing Matters Lab for Sale by Owner Brian P. Crowley

I

n last month’s issue I wrote about the state of urine drug testing in behavioral health and many of the changes that I foresee happening in the coming six to twenty-four months. My team and I conducted an extensive amount of research into how these changes will begin to affect the health care landscape. Our conclusion for drug testing is this: the lab business as they know it is dead. Many such providers did not really utilize drug testing as a true clinical tool, but primarily as a revenue booster to artificially inflate profits for potential acquisition or to expand their programs. From a business perspective this makes sense in the short term. However, in the long term this approach was essentially pulling the trigger on yourself in a game of Russian roulette with payers. As we all know, the gun went off.

For now, let’s drill down into more detail about what providers needs to be asking themselves and the prospective lab sellers when considering an acquisition. We will look at the internal and external things to consider, starting with the internal.

1. THE BOOKS

Take a look at the books to see the monthly income from what accounts and for what kind of testing. Are these testing menus and frequencies sustainable under the new 2016 guidelines?

2. COSTS

Take a look at their test menus and ask for samples of testing protocols that other providers utilize. The key here is to ensure that the lab is not overtesting or overbilling, now or over the last three years. Providers who didn’t check this out with their labs are now getting pulled into legal battles and are guilty by association.

3. CONTRACTS

Are there sales agreements with reps and referrals partners? If so, are they W2s or 1099?

These need to be structured in accordance with very specific federal and state guidelines. Does the lab have any interlab agreements? If so, then you need to ensure that these agreements

are meeting the guidelines. The most common violation is a lab will bill for a test that it outsourced to another lab for a more complex test and then proceed to bill a payer directly for a test the other lab did. This creates a problem with most state statutes because a lab can only bill for a test it is actually licensed to test for.

of audits when reimbursements were 70 to 100 percent more than they are today, it was okay to be vague. Not so now. Without this level of due diligence, you can find yourself thinking you have a business when you really don’t.

4. SCOPE OF PRACTICE

This area is seeing dramatic change in that the old ways of recycling the AR account every week or two is simply not effective any more.

Providers need to employ data-centric reporting tools that get billing encounters coded correctly the first time around and then has “touch-controls” built into its system so you can track in real time what your biller is doing to move you forward, and more importantly, what the payer is doing. The days of waiting for payer denials and EOBs are over. This should now be happening in milliseconds.

A lab is supposed to employ a limited scope of practice under its license; meaning it educates it clients on best practices, performs tests, and furnishes results. Anything beyond this needs specialized legal structuring between the lab and other entities or it can be seen and has been proven in court to be “incentivisation” of providers by a lab. Health care is extremely tricky when it comes to “schmoozing” providers and their staff. You can thank Big Pharma for its abuse of this and the reactionary laws which can lead to criminal and civil charges.

7. BILLING INTEGRATION AND COLLECTIONS

5. TECHNOLOGY

8. EXISTING CUSTOMER BASE

6. TESTING PLAN AND PROTOCOLS

9. MARKET CHANGE

Nothing bogs down a lab more than a poor lab information management system (LIMS).

Selecting the right system to give you basic reports is a must, but with the trends of data analytics and work process flow improvements becoming more popular, you really do need a system that’s capable of these functions or at the very least has the ability to interface easily with other third party systems that can. Second to this are the instruments themselves and their capacity, accuracy, and turnaround times.

Now let’s take a look at some external issues.

Does your center have written testing protocols that ensure controls with documentation of medical necessity in your electronic health records (EHRs)? A complete breakdown of frequency of drugs testing under residential, IOP, OP, and so on will need to be calculated and compared against payer historical allowances to give you a good insight into what are the actual type and number of tests that your facility will be testing for. This goes back to establishing clear costs. Before the payer tsunami

Reputation management is essential in our business and guilty by association is still a big problem. This is probably the biggest potential exposure a provider may have when buying an existing lab, as many labs took on accounts that may have skeletons in the closet. An assessment of these accounts to better understand the billing and tests trends is money well spent.

Going forward, every account should have in its service contract a clause that commits them to an audit process to ensure they follow their agreed testing protocols.

The drug testing market is still very much in flux as the laboratory industry debates with the federal government over fee schedules and questionable lab structures. Politics is very much in play with this business and having good intelligence is worth every penny, even though expensive. When building your business model, we highly recommend a series of what we call “what if” scenario analyses to predict how well the business will perform under adverse changing conditions.

Industry Insider 11

Jul/Aug 2016 10. NEW SERVICES

Many of the labs currently only offer toxicology. As payers require a full comprehensive continuum of care, the need to provide testing for blood, STDs, and physical ailments will require your lab to be able to do this in-house or outsource it to another lab. However, as payers are already testing bundled payment models in some states, the probability of bundling lab services into overall treatment services is on the way. This will create problems and opportunities for labs, depending on where they are today.

What is sure to happen is that payers will only pay a minimal rate for tests. This will require providers to be highly optimized and offer a full scope of testing services. Otherwise these

lab services will be carved out of the bundled rate and providers will end up eating a significant cost that patients will not be liable for if the provider has an agreement with the payer.

It’s a catch-22 situation that requires careful thought and planning now. Otherwise, providers will find themselves with a lab business that is not sustainable and they still owe the equipment vendors money.

CONCLUSION

The short answer is yes, it still does make sense to get into the lab business, even after the recent significant reductions in drug testing reimbursements and frequency. However, as one of my favorite attorneys would say, “it de-

pends” on several matters that need thorough investigation prior to making any significant investment, as it only makes sense at certain volumes, under certain levels of care and only with certain testing protocols in place. n Brian P. Crowley is founder of Integra Enterprizes. He has experience in the business of behavioral health, specifically drug testing, strategic business, and leadership development. He is chairman of the FBHA, Committee on Laboratory Services.

Industry Trends Media Attention: A Blessing and a Curse Michael Walsh, MS, CAP, BRI-I

W

hen looking at industry trends, there are so many directions to consider when formulating a column. Opiate deaths and questionable treatment programs seem to get the lion’s share of coverage, but these two issues both mask the crux of the substance abuse epidemic and also fail to accurately portray the problem, solutions, and the many people and programs working tirelessly in relative silence against a constant wave of negative publicity, sensational if inaccurate headlines, and a general lack of understanding.

The current issues dominating the headlines have been both a blessing and a curse. For those of you reading this who have spent decades helping people recover, this is probably both a frustrating and exciting time. For years many of us have worked to bring the issues of substance abuse and treatment into mainstream media. I spent years traveling and speaking about these issues and most people outside “the industry”

barely gave us a second thought.

Now the media attention has been more and more frequently focused on addiction. However, in my opinion too much time is spent on “the problem” and not nearly enough time and attention has been directed at the solution.

Research, prevention, and education must continue and be taken ever more seriously. However, with every minute that passes without addressing proper treatment, recovery, and reentry for addicts—especially the young generation that continues to fill programs locally and nationally—we enable a generation to continue dropping out and dropping in to treatment as a lifestyle choice. Without providing long-term care and help with resocialization we are essentially putting a Band-Aid on a hemorrhage!

Recently a good friend of mine went through our treatment program. He had been through treatment in 1992 and was essential to my entering recovery a few years later. He returned to graduate school and became a successful businessman, husband, and

father. After an unfortunate serious health scare he relapsed, finally reached out for help, and entered treatment for the second time in his life at fifty-four years of age. After a few weeks of treatment we spent a Sunday together and he looked at me and said, “Treatment has changed since 1992.”

I know it has in many ways, but I asked him what he meant by that and his response was disturbing.

He said that for many of his fellow clients treatment seems to have become a lifestyle choice! Similar to people who become comfortable going to prison, it seems some people have become comfortable going to treatment.

My opinion is that without the payers, politicians, business community, and treatment industry working together to reform the current system and provide an adequate length of stay, proper care, and aftercare services, this trend will continue. I am involved in C4 Recovery, a nonprofit board involved in a long-term treatment program with the Turkish government, which provides months of

treatment and a job upon graduation. This is an innovative and aggressive research project which we believe is showing great promise.

It’s unfortunate that we had to go outside the US to get the cooperation needed from government officials, professionals, and the public to create this opportunity for addicts seeking recovery. We live in the greatest country on Earth; why aren’t we using common sense and available resources to create these opportunities at home? n Michael Walsh, MS, CAP, BRI-I, is currently executive director and COO at HARP Treatment Center on Singer Island, FL. Former president/CEO of The National Association of Addiction Treatment Providers (NAATP), he holds a master’s degree in substance abuse counseling and is a certified intervention professional. As a certified addiction professional, he has extensive knowledge, experience, and understanding of the treatment industry from preadmission through the intervention, admissions process, case management, referent relations, client services, and aftercare coordination for patients.

12 Industry Insider

Jul/Aug 2016

The Legal Beat Residential Recovery Homes and Their Local Impact Jeffrey C. Lynne, Esq.

O

n one of the largest drinking holidays in our nation, Cinco de Mayo, I could not pass up writing about the current state of affairs in South Florida relating to the socalled “sober home epidemic.”

The Sun Sentinel wrote an editorial starting with the words “Sober houses have become a plague upon some South Florida cities,” without ever explaining what actual problems exist (2016).

While I find this to be entirely journalistically irresponsible, it simply underscores the “acceptance” our society has that addicts are to be

rejected as second-class citizens and “obviously” reprehensible.

Many are aware that Congresswoman Lois Frankel asked representatives from the Department of Housing and Urban Development (HUD) to come to South Florida this week to see for themselves the “disaster” that has occurred as a result of sober houses. I am not really sure what she saw, because no one with any real knowledge of the problem was invited.

Yes, they have anecdotes. They have stories about people wandering the streets. They have tales of needles being found on beaches

and in parks where kids play. Welcome to the urban jungle. Welcome to America in 2016. Welcome to the largest epidemic in our nation’s history.

But how we are handling it is similar to declaring that we have a problem of homeless people wandering our streets and sleeping in our parks, but without trying to understand why that is. Elected officials are trying to address the perceived effect, but have not spent any time trying to understand the cause. This is not because they are bad people, but because it takes true leadership to be brave enough

to look constituents in the eye and ask, “Who is leading who?”

Granted, there are real-world effects that sober homes have in communities as a result of being perceived as undesirable. The Fair Housing Act (FHA) and the Americans with Disabilities Act (ADA) do not eviscerate the gut reaction to the presence of sober homes that most people seem to have and have had for generations. But today, even amongst the most enlightened and educated of us, we continue to tolerate the stigma as if it is true and self-evident.

On the other hand, the point of

Jul/Aug 2016 the ADA was to provide an equal playing field. When that playing field begins to tip to the point where its effects are no longer in alignment with its purposes, we need to have a candid and frank discussion to determine where that balance point is.

Homeownership may be one of the highest ideals we aspire to in our nation. It built our nation’s middle class. With homeownership comes stability, increased interest in the promotion of . . . schools and churches, and “recognition of the individual’s responsibility for his share in the safeguarding of the welfare of the community and increased pride in personal achievement which must come from personal participation in projects looking toward community betterment” (Ewing v. City of Carmel-by-the-Sea, 1991).

A home is often a family’s most significant economic asset and investment. Home marketability and values can depend in part upon the condition of the housing stock, land uses on adjacent property, and proximity to other desirable land uses such as schools and shopping centers. The significant taxes generated by real estate are also cornerstones of the Florida economy.

While it is unlawful to discriminate against a sober home in a neighborhood, a potential purchaser cannot be forced to buy a property near or next to one. Overcoming this prejudice is mostly a function of educating the public on what a good sober living residence is, and what it is not. Many argue that there are currently no controls in place to determine how to distinguish the good from the bad, and the voluntary certification process offered by the Florida Association of Recovery Residences (FARR) is not enough.

What they fail to recognize is that there are also no controls in place to determine if any neigh-

bor is a good neighbor or a bad neighbor, so often this argument tends to be prejudice disguised as rational concern. The reality is also that there is likely to be more drug misuse and other undesirable activities occurring in a typical home in a gated community than in a sober home. Further, unlike lowermiddle-class people who generally cannot otherwise afford a house in higher-end neighborhoods, sober home providers have been able to pierce that invisible ceiling using the FHA and the ADA. This socioeconomic class warfare harkens back to the days of the “white flight” phenomenon after schools were desegregated in the 1950s.

Notwithstanding, there is a legitimate question of saturation or overconcentration of sober homes. However, rather than examining this question with the best interests of the person in recovery in focus (as the law requires), the sentiment by elected officials seems to be, “If we can’t get rid of them, we can at least thin the herd.”

By providing and requiring mandatory separation distances between such homes, as the argument goes, we support the “integration mandate” of the ADA, which encourages the integration of people with disabilities into “normal” society. But that begs the following questions: • •Does spreading out recovery residences throughout a city benefit or hinder the recovery process?

• •Does a specific concentration of recovery residences “change the character of a neighborhood” and transform into a “group home” neighborhood to the detriment of all involved?

• •I s an arbitrary distance of, let’s say, one block between such homes, something the law allows us to simply all agree upon, or do we need an impartial, third-party to study the issue and present solutions?

These seem to be the ques-

tions that everyone is asking, but no one is willing to really look in to because we are scared of the answer.

On a personal level, I find it interesting that cities will spend tens of thousands of dollars on zoning studies for redevelopment of specific corridors, or on traffic impact studies to determine what to do with certain roadways, but when it comes to the housing question presented by sober living, we are willing to go with existing, preexisting gut notions of “right” and “wrong” to pass laws. That alone is reason that HUD and DOJ are not likely to give cities the “relief” they are asking for.

However, the answer doesn’t matter anyway. In order to be effective, we need to have equal partners in the public health system to ensure that such homes deliver what is promised when it comes to the implementation of the behavioral health services to its residents. But we don’t.

What we do have as partners are the recovery residences and treatment providers themselves. However, cities must be willing to unclench their fists in order to first shake a hand. The greater recovery community has, time and again, offered itself as a willing partner to find a way to provide the necessary treatment and concurrent housing services to people in recovery within a safe and stable community. They, too, do not want (and can’t afford) to see neighborhoods become destabilized, as such an occurrence equally undermines what they too need in order to help their clients through their personal journey of coming back from the brink of extinction.

But let’s not forget that this is easier said than done. There is a reason the Civil Rights Act, the FHA, and the ADA were each passed, and it was not because local residents were enlightened and progressive enough to see past their own prejudices and eliminate irrational fear to be inclusive. It is because, at our core, we Americans

Industry Insider 13 govern ourselves from a base of fear. It is a natural human reaction, meant for self-preservation and protection.

While FDR wrote that “the only thing to fear, is fear itself,” he also wrote that “we must scrupulously guard the civil rights and civil liberties of all citizens, whatever their background; we must remember that any oppression, any injustice, any hatred, is a wedge designed to attack our civilization” (“Quotations,” 1940).

While our homes and neighborhoods are right to receive the highest protections our nation can afford, each of us must look past the narrowness of our self-interested fear and towards fundamentally changing how we perceive people in recovery so that we may collectively and collaboratively purge the real cancer from our communities.

But, law and public policy will not allow that to begin with the effective internment of people with addictions into ghettos. And we should not be reactionary to only fix the effect of sober homes, but rather take the time and resources to address the cause. n Jeffrey C. Lynne opened his own Delray Beach, FL law firm in 2010 and merged it with fellow land use attorney Michael S. Weiner and commercial litigator Laurie A. Thompson to form Weiner, Lynne, and Thompson, PA. As a result of his work with substance use disorder (SUD) treatment and housing providers, Mr. Lynne has forged a reputation as a leader in defining the role played by SUD treatment within our communities; he has led discourse about the need and right to provide safe, affordable housing for those in treatment in addition to those established in recovery.

References Ewing v. City of Carmel-by-the-Sea. (1991). Retrieved from http://www. sjsu.edu/urbanplanning/docs/ URBP229Materials/Ewing.pdf “Quotations” (1940). Retrieved from https://www.nps.gov/frde/learn/ photosmultimedia/quotations.htm Sun Sentinel. (2016). Empower cities in sober house fight. Sun Sentinel. Retrieved from http://www.sun-sentinel.com/ opinion/editorials/fl-editorial-sober-homeslois-frankel-20160504-story.html

Feed Your Mind, t Soup Cream of Carro Thyme d an in m Cu with 1 cup chopped onions 2 tablespoons r unsalted butte 1 sprig fresh thyme 2 cups chopped carrots en 1½ cups chick stock ½ teaspoon ground cumin ½ cup heavy cream Salt Freshly ground black pepper 2 teaspoons

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