Mind and Body

Did a recent research study by the Boston Fed need an expiration date?

Last week, BHDDH and the Department of Health were busy promoting a study – and a news story written about that study – that appeared to contain misleading, out-of-date information about medication-assisted treatment policies and practices in Rhode Island

Image courtesy of the New England Public Policy Center

The cover image of the research study published by the Federal Reserve Bank of Boston.

By Richard Asinof
Posted 1/11/21
A new research paper and a Boston Globe story about the study contained what appeared to be out-of-date, misleading information regarding the current landscape in Rhode Island regarding medication-assisted treatment. However, both the study and the story were widely disseminated by state health agencies, reinforcing stigma about such treatment, according to the state’s largest nonprofit provider of these services.
Will there be an effort to update the research paper to include more, better information about current practices regarding MAT? Why were behavioral health workers working in outpatient treatment centers not been given higher priority to receive their vaccinations? What is the position of the Governor’s Task Force on Overdose Prevention and Intervention on creating a pilot program for harm reduction centers/safe injection sites in Rhode Island? Why do R.I. Department of Health regulations forbid licensed social workers in Massachusetts from seeing telehealth patients in Rhode Island, if they are not licensed in Rhode Island, in the midst of a pandemic? What are the increases in alcohol-related substance use disorders in Rhode Island since the start of the COVID-19 pandemic? Why did it seem that there was an explicit bias in the research study that appeared to promote Gov. Gina Raimondo’s policies?
Misleading information can prove deadly. As the New York Times reported last week, “Reports of a highly contagious new coronavirus variant in the United States, published on Friday by multiple news outlets, are based on speculative statements made by Dr. Deborah Birx and are inaccurate, according to several government officials.”
The story continued: “The erroneous report originated at a recent meeting where Dr. Birx, a member of the White House coronavirus task force, presented graphs of the escalating cases in the country. She suggested to other members of the task force that a new, more transmissible variant originating in the United States might explain the surge, as another variant did in Britain.”
Further, the story reported: “Her hypothesis made it into a weekly report sent to state governors. Dismayed, officials at the Centers for Disease Control and Prevention tried to have the speculative statements removed but were unsuccessful, according to three people familiar with the events.”
At some point, the R.I. General Assembly may want to investigate the role that Dr. Birx played in promoting the reopening of schools in Rhode Island, working in close contact with the Raimondo administration, as she pushed out a CDC position that apparently had been “doctored” by White House officials.

PROVIDENCE – Amidst the chaos of the last week – an armed insurrection where a mob, urged on by President Trump, stormed the U.S. Capitol; the stunning election of two Democratic Senators from Georgia, enabling the Democrats to take control of the U.S. Senate; and the announcement that Gov. Gina Raimondo was joining the incoming Biden administration as Secretary of Commerce, as coronavirus pandemic crisis worsened in the state – the publication and promotion of a research paper by the New England Public Policy Center, the research arm of the Federal Reserve Bank of Boston, might seem a bit like a little black dot on the overwhelming sun of disruptive news flow.

The research paper, entitled “Medication-Assisted Treatment for Opioid Use Disorder in Rhode Island: Who Gets Treatment, and Does Treatment Improve Health Outcomes?” was written by Mary A. Burke and Riley Sullivan, and it was based upon an analysis of claims data from the All Payer Claims Database [which the state has rebranded as HealthFacts RI] to examine the relative success of Rhode Island’s efforts to promote medication-assisted treatment for opioid use disorder. [See link below to research study.]

The research study, which analyzed claims data from 2011 through 2019, was published in December of 2020, after it was “approved” by the HealthFacts RI Data Review Board.

On Thursday, Jan. 7, a broadcast email was sent by Tia Macek from the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals to a list of more than 100 people associated with the Governor’s Council on Behavioral Health, promoting the research report. Also attached was a story published on Tuesday, Jan. 5, in The Boston Globe, written by Edward Fitzpatrick, with the headline: “Report calls for boosting access to take-home medical treatment for opioid addiction.”

A similar broadcast email, once again promoting both the report and the story, was sent out on Friday, Jan. 8, by Carol Stone at the R.I. Department of Health to members of the Governor’s Task Force on Overdose Prevention and Intervention, in advance of the Task Force’s scheduled virtual meeting on Wednesday, Jan. 13.

In The Globe story, Dr. Mary A. Burke, co-author of the study, provided her overview of the findings:

She explained that methadone can be more effective for some people, but it is a lot less convenient to use because people have to take it at clinics while buprenorphine is available by prescription and can be taken at home. Also, researchers say that buprenorphine has less potential for misuse than methadone, especially when mixed with naloxone with the brand-name formulation Suboxone.

“To get methadone, you have to show up in person every day and have people watch you take the medication,” Burke said. “Imagine if you had diabetes and you had to show up to get insulin every day – people would often miss and have health problems. So, it’s a huge barrier.”

Burke’s statement, however, is inaccurate and misleading – what she described is no longer the way that methadone is currently being dispensed in Rhode Island.

Further, the reporter from The Boston Globe appeared to be equally uninformed about the situation, taking what Burke said to be an accurate depiction, in effect serving as am apparent mouthpiece for wrong, misleading information.

Perhaps worse, state health agencies, by widely disseminating The Globe story and the research study, appears to be promoting misleading, inaccurate information about current policies around medication-assisted treatment in Rhode Island. The question is: Why?

Indeed, after persistent questioning by ConvergenceRI about the apparent inaccuracy of comments made by Burke, Darcy Saas, the deputy director of the New England Public Policy Research Center, who initially had championed the Globe story, changed her tune. In an email sent to ConvergenceRI on Friday, Jan. 8, Saas wrote: “We regret that the Globe article does not provide a full picture of the scope of Dr. Burke’s research report.”

Inaccurate, misleading and out of date
The problem with the research paper – and specifically, the quotes by Burke in the story, is that it does not reflect wholesale changes in MAT policies related to methadone distribution in Rhode Island, which were changed in response to the coronavirus pandemic, in order to reduce and prevent the potential for in-person transmission of the virus.

As ConvergenceRI reported six months ago [emphasis added] in July of 2020: Linda Hurley, the president and CEO of CODAC Behavioral Healthcare, the largest nonprofit outpatient provider for opioid treatment in Rhode Island, was recently featured in a July 15 story in Crain’s HealthPulse New York, written by Jennifer Henderson, talking about her organization’s focus on maintaining access to care during the COVID-19 crisis.

“The primary goal was to mitigate exposure to the virus,” Hurley told Henderson. To help do so, between April 1 and May 15, the organization provided nearly 160,000 doses of methadone to be self-administered outside of the clinic. The medication went to those who usually visited daily or several times a week, had been released early from prison, were in a homeless shelter or had been self-isolating.

Some 60 percent of the doses would not have been distributed outside of the clinic before the pandemic, Hurley said. However, less than 1 percent of the medication was not managed well, with people losing it or taking too many doses. [See link below to ConvergenceRI story, “A report from the front lines of telehealth.”

Translated, the alleged problems around methadone distribution cited by Burke in The Globe story have dramatically changed. Burke’s statements are out of date and misleading, in ConvergenceRI's opinion.

Further, in the July 20, 2020, story, in response to a question from ConvergenceRI about the most important things learned from the COVID-19 pandemic, Hurley said:

• One, that our field has been both over-regulated relative to methadone and under-regulated relative to the use of buprenorphine as a medicine for opioid use disorder.

Both of these conditions are very clearly the result of historic fears, bias and discrimination. In other words, stigma.

In Rhode Island, the relaxation of regulation and the ability of patients to self-manage their medications has not resulted in an increase in diverted medications in the community. This perception of those who come to us for care for substance use disorder is not supported by the facts. 

Importantly, we have learned that these regulations actually have become a barrier to care for many, many individuals.

• Two, we have learned that telehealth is an incredibly effective component of a menu of services for the treatment of substance use disorder and other behavioral health care disorders. We have learned that it is effective and has met with a great deal of patient satisfaction.

• Three, telehealth creates increased utilization that creates more revenue. Within the context of Rhode Island having one of the lowest Medicaid rates in New England [emphasis added] and the Mid-Atlantic states, this becomes even more vitally important.

Most importantly, we have been permitted to prove that our patients are courageous responsible individuals who have come together with us as their medical providers and their communities in order to help to navigate together through this pandemic.

Out of date data
The other major problem, it seems, is that the research paper was based on claims information that ended in December of 2019, more than a year ago, using data that was already, by definition, backward looking.

For more than four years, the state of Rhode Island has been pushing the use of HealthFacts RI, the All Payer Claims Database, as an important tool to develop health policy. But, in talking with both data scientists and physicians working on the front lines, there have been numerous questions raised about the serious limitations if not flaws in applying such data. For instance, the claims only account for procedures that were approved and paid for by insurers, and do not include any data about claims that were denied – often by third-party firms in charge of authorization.

And, judging from the documents cited in the appendix, many of the sources for information were published academic papers about medication-assisted treatment. There apparently were no in-person interviews to verify what was actually happening on the ground.

What the Fed said
ConvergenceRI reached out to Dr. Mary Burke, whom had been interviewed by ConvergenceRI about her work previously. [See link below to ConvergenceRI story, “To measure quality of life as an economic indicator.”]

ConvergenceRI shared the July 2020 story and asked the following questions:

1. Were you aware of the changes in [MAT] distribution that had occurred [in response to the pandemic]?
2. Who were the sources interviewed for the research paper and when were the interviews conducted?
3. Who paid for the research paper? How directly did you work with the R.I. BHDDH in preparation of the research paper?

Darcy Saas, the Deputy Director of the New England Public Policy Research Center, responded promptly in an email:

Thank you for reaching out to us. We’re glad to hear of your newsletter, and happy that you saw the Globe’s coverage of our new report.

I wanted to first note that this body of work was completed by Boston Fed staff; this isn’t commissioned work.

Also, reading your questions, I wonder if you saw Page 41 of the full report. I’m sharing below because it addresses some of your questions.

The report and findings were based on analysis of the HealthFactsRI data. The full report was reviewed and formally approved in December by the Rhode Island All Payer Claims Database Data Release Review Board.

[Editor’s Note: ConvergenceRI reached out to the R.I. Department of Health to get a roster of who sits on the APCD Data Release Review Board; no response has yet been received.]

Here is the excerpt from Page 41 provided by Saas, which was taken from the last three paragraphs from the very last page [emphasis added] of the written report, under the final chapter entitled: “Policy Implications.”

In June 2019, one of the largest providers of MAT in Rhode Island began offering telehealth video conferencing options in an attempt to remove some of the barriers to buprenorphine treatment, including stigma and transportation.

In March of 2020, in response to challenges in accessing treatment during the onset of the COVID-19 pandemic, the federal government suspended a law that required patients to have an in-person visit with a health-care provider before they could be prescribed MAT.

Through the end of the declared public health emergency, patients are temporarily able to initiate treatment over the phone without in-person or video appointments.

Telehealth-delivered MAT was found to be effective in small-scale studies before the pandemic, and patients were more likely to remain in treatment uninterrupted [Ho and Argáez 2018].

Further evidence is needed to understand patient outcomes in larger samples and for those initiating treatment via telehealth.

In addition to the recent relaxation of telehealth regulations, the volume of medications – including both methadone and buprenorphine – that patients are able to take home was expanded during the pandemic. This shift prioritizes the goal of retaining patients in treatment for OUD over the risks of misuse and diversion of the medications.

While approved as a temporary measure occasioned by the pandemic, this policy experiment could lead to longer-lasting changes in allowed take-home doses moving forward, if it is shown that the revised rules increased treatment retention without resulting in substantial increases in misuse and diversion [del Pozo and Rich 2020].

Also, officials in Burlington, Vermont, and Philadelphia, Pennsylvania, recently announced they would not enforce penalties for the possession of diverted buprenorphine, on the rationale that some people are using diverted supplies to self-treat in lieu of going to a doctor and risking infection with COVID-19 [del Pozo, Krasner, and George 2020].

Rhode Island has made much progress in helping a large share of patients to access high-quality treatment for OUD, including MAT. At the same time the state continues to struggle with elevated overdose rates. Although this combination of facts might seem discouraging, our findings suggest that in Rhode Island, MAT appears to be working to significantly reduce overdose risk, provided patients have taken the medications recently. In sum, the evidence argues strongly for policies that would focus on improved treatment retention and not just initiation.

ConvergenceRI responded to the email by Saas as follows:

Thanks, Darcy, for your responses; but it doesn’t address the basic question I asked: the data in the research paper appears to be inaccurate, reflected in the quotes by Mary Burke in the Globe story; the fact that it was “reviewed” and formally approved by the review board of Health Facts RI doesn’t address the problems with the inaccurate data; if the your research paper was based upon APCD data, re claims data, which is backward looking, may help to explain the problems.

Drawing conclusions from APCD data can be problematic; thanks for your prompt response.

Saas, in turn, responded: We regret that the Globe article does not provide a full picture of the scope of Dr. Burke’s research report, which on Page 41 discusses the policy changes you describe in your article that allow for expanded telehealth options for buprenorphine and increased take-home doses of methadone.

We kindly request that you refer to the research report as opposed to the Globe to access our full findings and related discussion.

Translated, after initially praising the Globe story, Sass changed her position, saying that she regretted that the Globe story did not provide a full picture of scope of the research report, asking that ConvergenceRI refer to the research report as opposed to the Globe story.

What Hurley had to say
ConvergenceRI also reached out to CODAC’s Hurley to get her response to both the Globe story and to the research paper, given that she is at the center of the storm when it comes to policy changes around administering medication-assisted treatment.

ConvergenceRI: The report and its findings, as reported by The Globe, seem terribly out of date, as if it were written before the changes implemented in response to the pandemic. Is that accurate?
HURLEY: Yes. As part of the COVID -19 risk mitigation re: exposure, much more medication was provided to our patients for self-medication management and self-administration. Patients do not have to “come to the clinic daily” for observed administration [emphasis added].

ConvergenceRI: In particular, what was inaccurate in the Globe story, regarding the current practices for MAT?
HURLEY: CODAC and other OTPs [outpatient treatment programs] created methods to decrease risk and provide increased support for our patients. So, CODAC began curbside dosing, delivering medication to homes, nursing homes and other living spaces for quarantine, providing medication to those in the early release program at the DOC [Department of Corrections], providing medication to temporary shelters for the homeless in quarantine, etc.

These methods of delivery and expanded take-home status are examples [that debunk] the community mythology that methadone equals daily trips to clinic. Individuals can receive up to 28 days of medication for self-administration.

ConvergenceRI: I found it curious that BHDDH was promoting the report and the story, which contained such “errors,” without any attempt to correct them in the memo sent out. How harmful is it to perpetuate wrong information about access to methadone, for instance?
HURLEY: Not addressing the science of this disease and the medications is a further demonstration of the stigma – the fear, bias and discrimination – that our communities hold.

Inadequate compensation and over-regulation of methadone are financial and regulatory stigma. Further, substantiating myths about care builds upon the cultural stigma, which is the primary barrier to individuals not accessing treatment. It is not about inadequate access to buprenorphine.

ConvergenceRI: I have heard that there are additional millions in new federal money going to R.I. BHDDH. Have you heard that? Where do you think the money should go?
HURLEY: We truly need dollars to support care for the sickest of our Rhode Island residents. Our patients have the highest percentage of co-morbidities, of co-occurring mental health issues, and lowest access to social determinants for wellness.

Treatment providers who hold the expertise for this highly complex disease need dollars to expand care, both for programming and capital expansion.

Second-class citizens?
In a follow-up phone conversation, Hurley raised the issues around poor reimbursement rates from health insurers, which in her opinion undercut and crippled the policies promoting continued expansion of behavioral health services. She said she had hoped to be able to provide updated data on the numbers of clients who had received methadone in 2020 under the new distribution policies begun in response to the COVID-19 pandemic.

Instead, Hurley explained, much of her time during the past week had been focused on attempting to coordinate vaccinations for her staff, which had apparently not been given priority under the state’s initial vaccination schedule.  [The good news is that vaccinations are scheduled to occur beginning in two weeks.] Stay tuned.


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