A van park outside Baltimore City Detention Center five days a week and provides on-demand access buprenorphine. This gold-standard medication is used to treat opioid addiction disorder. It has been proven to lower the risk of dying and prevent health complications associated with injecting. The Behavioral Health Leadership Initiative, also known as BHLI, is the non-profit that operates the service. It has been developing a low-threshold treatment model where people can leave their first appointment with a prescription. This means that there is no requirement for group attendance and abstinence from drugs. The organization pays pharmacy co-pays. In lieu of photo identification, Polaroid photos are attached to prescriptions. No appointment is necessary. Deborah Agus, executive Director of BHLI, stated that people just show up. We were as open-minded as possible, said Deborah Agus, executive director of BHLI. BHLI was forced to decline federal funding twice. BHLI rejected the grant money as part of a growing federal effort to provide much-needed funding for substance abuse disorder treatment. The Substance Abuse and Mental Health Services Administration (or SAMHSA) is a federal agency that has begun to make significant investments in substance abuse disorder treatment, as a way to meet the staggering death toll.The total grant amount of $5.5 billion was granted to substance abuse disorder patients for the fiscal year 2021. This is the largest ever given for treatment. However, some low-threshold providers and substance use disorder patients may not be able to access the funds due to the budget of the agency. Multiple health department officials and service providers told The Intercept that the grants' prohibitive requirements are to blame. They impose burdens on programs and re-traumatize highly vulnerable populations. Six officials from five states' health departments spoke out against the Government and Performance Results Act tool. This is required for SAMHSA-funded programs according to the GPRA, but was created at the agency's discretion. This controversial questionnaire is administered to patients by health workers before they can prescribe medication. It is intended to evaluate program performance. Officials claim that it hinders programs' ability to provide lifesaving treatment.One official from the state that received the most funding stated that the sentiment is not limited to those who were interviewed. Everybody is guilty of wishing they didn't have to or being pissed about it. The GPRA tool was described by four service providers, including Agus, the BHLI's executive director, five anonymous New York state officials who managed the SAMHSA Opioid Response grant, and an advocate for harm reduction officers working in state departments. In addition to obtaining detailed information about physical abuse, which includes quantifying highly stigmatized topics such as the frequency with which a patient engages in graphic sexual acts, the amount of criminalized behavior (including illicit drug use), and the number children taken from them by the authorities, the GPRA tool is also sought to provide details on the personal issues. According to an anonymous state official, the questions are not trauma-informed and are even trauma-producing.Photo by Sessi BlanchardAgus stated that there is no way for us to be no-barrier in taking this [SAMHSA] money. She cited the GPRA requirement, which was the only reason her organization rejected federal funding. Agus is working to close the so-called "treatment gap", which means that 8 out of 10 patients with opioid addiction in the United States had not received treatment in the past year at a rehabilitation or hospital. The problem is that buprenorphine is not easily accessible to patients. In 2020, 40 percent of all states did not have a single licensed physician to prescribe it. It is underutilized by those who can afford it, which poses a problem for the Biden administration's recent expansion of prescribing eligibility. Accepting the money would require BHLIs Baltimoreans to accept it. They will have to be pushed by BHLIs clients Baltimoreans, who are predominantly Black, disabled or unemployed; unstably housing; and sick and tired enough that they can tolerate an invasive interview lasting more than the 20-minute intake. Agus said that this is the maximum length [clients] can tolerate. The SAMHSA estimates that the tool takes 36 minutes. However, service providers and officials from state health departments say it can take 45 minutes to an hour. Although the administration of the tool takes time, an SAMHSA spokesperson acknowledged that it could be integrated into patient-centered healthcare in line with program goals. Agus said that clients really want to get treatment and feel better. But they also want it now, without any barriers. One official stated that GPRA tools should not be mandated in low-threshold settings. It is not practical to use low-barrier services. Laura Pegram, associate director of Drug User Health at the National Association of State and Territorial AIDS Directors, a group representing harm reduction programs in health departments, stated that it is impossible. We want bupe buprenorphine as quickly and easily as possible. However, the intensive GPRA renders [low-threshold] services unfundable. Some low threshold services have accepted SAMHSA funds despite these requirements. One East Coast program coordinator, who requested anonymity because of employment restrictions, stated that their case manager pushes for the fastest possible resolution. After all, that's all they have to do. The coordinator claimed it negates the purpose of low-barrier programs, which is a sentiment that Agus and Pegram also agree with. This contradiction has clearly had consequences. Some patients have stopped attending GPRA interviews. The provider estimates that interviews account for 80 percent of a first appointment. Others walk out when they learn they will need to undergo a long intake to receive medication to alleviate withdrawal symptoms. According to the coordinator, the intake in-house can be completed in five minutes. Contrary to what the SAMHSA spokespersons claimed, the coordinator stated bluntly that this document was not client-centered.This document is not client-centered.Patients who complete the questionnaire will be required to do more work even after their first visit. SAMHSA requires grantees, depending on their grant amount, to administer the tool three to four times for each client. Agus stated that the agency requires grantees to administer the tool three or four times depending on how much they receive. However, it is impossible to do so for clients who are not housed or living in poverty. A service provider in another part of the country who receives SAMHSA funds, but who asked to remain anonymous due to employment restrictions, confirmed that this is true. There are many clients who contact me and don't show up for their appointments. The GPRA is not completed because they have too many clients. Another service provider in the country, who requested anonymity due to employment restrictions, confirmed this reality. The grant grants are administered by the National Advisory Council for Substance Abuse Treatment of SAMHSA. Members of that council called it a pain in their necks in February 2018, and a burden on grantees March 2019. However, it doesn't have to be that way. The GPRA statute does not require agencies to collect specific data or use any tool for doing so. Corey Davis, lawyer and director of Harm Reduction Legal Network, explained that SAMHSA has a lot of discretion as to which data it requires grantees provide. Agus believes that the GPRA tool is counterproductive to the purpose of grants to end overdoses, and to support people in changing their relationships with drugs. She said that it is frustrating to have resources tied up when the goal is to provide the best programs.Screenshot: SAMHSAPrior to new patients in SAMHSA-funded programs being admitted, they must tell staff how many times they have been hit, slapped or kicked over the last month. The GPRA tool also asks patients if they have been hit, slapped, or kicked in the past month. It is unclear what purpose it serves in assessing the effectiveness of the substance abuse disorder treatment program. A state official said that they are not certain. However, they also said that this information is often harmful to patients. The spokesperson stated that the questions are used to determine how programs affect clients' social environments.You are using vulnerable populations as guinea-pigs to obtain information that is not available.Implementers of the tool are not unaware of its confusing purpose. You are using vulnerable people as guineas pigs to obtain information that doesn't exist, according Rachel Fitzpatrick (ex-assistant director for managing the SAMHSA Opioid Response grant at New York Office of Addiction Services and Supports). According to the SAMHSA spokesperson, specific information is provided along with other outcomes to Congress and other oversight agencies. In its 2020 consensus report, the National Academy of Sciences stated that the question regarding removing children from clients' custody is worded in a way that makes clients feel embarrassed or alienated from their service providers. In a note to the administrator of the tool, SAMHSA clearly states that illegal drug use is the reason that patients seek help. The framework for clients to recall their drug-related experiences is that each was a crime. Journalists, advocates, as well as the United Nations acknowledge that drug criminalization can lead to stigma. Sources believe that it could be shameful to bring up the subject in treatment settings. SAMHSA spokesperson stated that it is an indicator of possible change in client behavior as the result of treatment. Drug possession is a federal crime. It is not drug use per se. When asked about the reason, the spokesperson for SAMHSA was unable give a direct answer. Officials warn that if one client experiences a negative experience, it could discourage others from seeking assistance. Word of mouth spreads quickly. Officials stated that people will not pursue this if they think people believe it every time. SAMHSA has had issues with providers and officials who have sought a waiver from the GPRA tool. According to a report from the Government Accountability Office (a federal watchdog agency), the agency informed grant recipients in July 2020 that funds would be put on hold if they didn't comply with GPRA data collections. Two state officials claim that they were also told their grants could be at risk if they fail to use the GPRA tool. There is a disconnect between bureaucratic processes. One official said that the SAMHSA does not see the positive impact it is having. Another anonymous service provider said that SAMHSA staffers don't see the impact it has. The GPRA requirements are not easily circumvented by providers and officials. They have been calling for modifications to the tool. According to Tom Coderre (SAMHSA's current leader), the agency is currently revising its current tool. SAMHSA is committed to helping people find treatment for substance and mental disorders. We will continue to explore ways to improve efficiency and reduce the burden on people we serve. Fitzpatrick, a former New York official, wants to see the tool fully updated with trauma-informed best practice. An official from another state's health department recommended that it be simplified and made more useful by the community. People with lived experience should decide what is most important.The system doesn't adapt to provide care for people. This is absurd.
