Ohio's new 'pill mills'?

As Ohio struggles to contain the fallout from a still-raging epidemic of drug addiction, some experts worry that too many of the state's opioid-treatment clinics follow a business practice like that of the "pill mills" that fueled the crisis: They deal in cash.

"When you see exponential growth in a clinical service, then there probably is a huge margin in terms of profit. It's called capitalism," said Dr. Ted Parran of St. Vincent Charity Medical Center in Cleveland. "But when capitalism calls for asking for cash from desperate addicts, then you have to worry about whether the appropriate services are being provided."

The proliferation of office-based opioid-treatment providers who require payment upfront is especially troubling in a state where public officials champion Medicaid coverage as key to expanding access to treatment.

In a study released in June, Parran and other researchers surveyed active buprenorphine prescribers in Ohio — Suboxone is the most-common brand name for the synthetic opioid medication widely prescribed in Ohio and elsewhere to treat addiction to heroin and other opioids — and found that nearly half of those who responded said they did not accept insurance for office-based therapy.

Addicts know the landscape well. And they know that being cash-poor isn't necessarily a deterrent to becoming a patient at a cash-only practice.

"I caught on to the whole Suboxone thing," said Kyle Berry, a recovering addict from Grove City who used to obtain prescriptions for the drug.

Suboxone also is a popular street drug, one that state reports on drug-abuse trends say is "highly available for illicit use." Berry saw that a prescription could be a means to other ends.

Drug dealers happily front the money for so-called "cash-n-carry" clinic visits in exchange for a share of the Suboxone, he said. Or, addicts sell it themselves, typically $15 to $20 for one of the "film strips" or pills.

Berry said he wasn't cut off when he failed the urine tests that prescribers are supposed to use to check for the presence of buprenorphine and other drugs. No one called him in for a pill count, and he wasn't questioned about the proof-of-counseling documents that he forged multiple times.

"The doctors poorly regulate it," he said. "And if I bring somebody else in, that's 25 bucks off."

Parran, who was one of the first doctors to prescribe Suboxone in Ohio after it was approved for use in 2002, said that more study is needed to determine whether the cash model increases the risk of overprescribing and misuse as he and others suspect.

There's little in the medical literature addressing the cash-only phenomenon that seems common in Ohio and other parts of the Midwest, he said. His study, which largely compiled billing practices from 2014 and 2015, likely is one of the first efforts to do a statewide survey.

"The last big surge of cash clinics that we saw in the U.S. were the cash clinics for pain management," Parran said, referring to the so-called pill mills that took off more than a decade ago and finally, after the region was awash in opioid addiction, led to a state crackdown. "You start having deja vu all over again."

Used properly as part of a comprehensive recovery program, Suboxone can help drug users get off of heroin or opioid painkillers without the excruciating effects of withdrawal. Those who sell or buy it on the street, however, might take it only sporadically, to supplement or substitute for heroin and stave off being "dope sick."

Burt Dhira, CEO of central Ohio's Phoenix Recovery Center, said the cash practice represents "the worst concern I have right now. It's ruining patient care more than anybody knows. The only person who benefits is the owner."

Where Medicaid reimburses his clinic $42.99 for a patient visit, cash providers might receive $300 to $500, he said. Some people with Medicaid coverage get prescriptions for more Suboxone than they need — insurance can cover the pharmacy cost even if the office visit isn't billed — and then sell it.

"It becomes an income for them," Dhira said.

Berry, now in a long-term recovery program through the abstinence-based ministry the Refuge, is among several addicts in central and southern Ohio who The Dispatch interviewed about their experiences with cash-only treatment providers.

While street diversion and abuse also happen when Suboxone is obtained through providers who work with insurers, the addicts said that oversight seemed more likely to be lax at offices that require cash.

The accounts compare with reports from the Ohio Substance Abuse Monitoring Network, which collects data on drug-abuse trends through focus groups with active and recovering drug users, treatment professionals and law enforcement.

In the network's January report on the Columbus region, treatment providers said that Suboxone clinics have mushroomed. "The trend that I am seeing is that these people aren't even offering treatment in these 'pop-up shops.' ... That is creating a bigger problem than I think the system was ready for."

New regulations

A new Ohio law set to take effect Oct. 31 requires offices in which a prescriber is treating more than 30 patients for opioid dependence with a controlled substance such as Suboxone to be licensed by the state Board of Pharmacy.

The board will be able to conduct inspections to look for adherence to treatment standards, and it is adding staff as duties expand both on the opioid-treatment and medical marijuana fronts, said Cameron McNamee, the board's director of policy and communication.

"Certainly, the whole purpose of the licensure is to try and remove the criminal element from this practice," he said. "If you're doing everything well and properly, you shouldn't have any problem. We don't want to be a barrier to people wanting to do this."

But the new Ohio regulation doesn't speak to the matter of cash.

Republican state Sen. John Eklund of Geauga County's Munson Township, author of the bill Gov. John Kasich signed into law in January, said he was unaware of particular problems at cash clinics.

The medical director for the Ohio Department of Mental Health and Addiction Services, Dr. Mark A. Hurst, has concerns about patients getting comprehensive treatment, including drug screens and counseling. Still, he cautioned against painting cash clinics "with all the same brush."

As an opioid, Suboxone is a federally controlled substance, but federal officials don't see diversion of the medication onto the streets as a big national problem. At least not yet.

"I wouldn't say it's something a grand part of our assets are being diverted to," Melvin Patterson, a spokesman at U.S. Drug Enforcement Agency headquarters in Washington, said, contrasting Suboxone with drugs such as heroin and Fentanyl.

That's not to say that Suboxone diversion isn't a big problem in pockets, Patterson said. To fight it, the DEA has scores of specialized squads looking for shady clinics that might be exacerbating the opioid crisis instead of fighting it, he said.

To be able to prescribe buprenorphine, doctors must undergo training and register with the DEA. Advocates say that many communities don't have nearly enough practitioners willing to obtain that federal waiver and bring addicts onto their patient loads.

"I think a large part of it is a lack of understanding about the treatment of patients with addiction," said Dr. J. Craig Strafford, a buprenorphine prescriber who sees patients at the Wilmington office of Groups Recover Together, a growing chain of Suboxone clinics built on the cash model.

Some cash-only clinic providers contacted or visited by The Dispatch did not return calls or declined to be interviewed. Others said they hope to begin working with Medicaid and other insurers. Those who spoke out said they provide good oversight, care and service to Ohioans struggling with opioid addiction, many of whom live in rural areas with few treatment options.

During an unannounced visit to Clinic 5 on the Northwest Side of Columbus, patients — many of them in work clothes or with children — sat in the waiting room and on the front porch. Clerks at the reception window sent them one by one for counseling or to see a doctor. In the front office, operators of the clinic said they were eager to speak out about the importance of well-run, cash-only clinics in ensuring patient access to treatment. Pushing out unscrupulous operators is vital, they said.

They agreed to schedule an interview after they'd had some time to prepare, but then a reporter's call was not returned.

The new licensing law requires opioid-treatment offices, like pain-management clinics, to be owned and operated solely by one or more doctors authorized to practice in Ohio. The board can, however, waive that requirement, so it's not yet known how many of those that ultimately obtain licenses will be doctor-owned.

At A.M.C. (Addiction Medicine Care), a treatment clinic with offices in Columbus and Nashville, Tennessee, the owner is a businessman "with a passion for this," the office manager said. She said the clinics opened with a fee-for-service model in 2011 because insurance reimbursements were low. "We are in the process of transferring over to insurance," D'Anna Rodriguez said.

Groups Recover Together opened its first office in 2014 in New Hampshire. The for-profit company has more than 30 locations in Ohio and four other states and continues to grow, now treating some 2,000 patients a week.

The clinics are brightly painted, with art and contemporary furnishings. For $250 a month, patients receive a weekly group therapy session and a monthly check-in with a doctor. Prescriptions are written weekly, and only if the patient comes to group therapy, Strafford said.

The chain's founder, Dr. Jeff DeFlavio, wanted to develop his treatment model and assess its efficacy before working with private and public insurers, said Josh Davis, Groups Recover Together's area leader for southwestern Ohio. He said the company expects to begin accepting one insurer this month and hopes to soon take Medicaid, the health insurance program for the poor that many of its cash-paying clients already have.

Other options

If Zac Wooten got his full 30-day prescription filled — 60 strips of Suboxone — he said he might keep back five for personal use. "Some people have kids, and that's how they feed them," he said of Suboxone sales. "Me, I was just trying to feed my habit."

The Grove City-area resident paid for his first clinic visit a few years ago with cash from his parents, who desperately wanted to help him escape a habit that started with painkillers after a football injury and progressed to heroin. He discovered that it wouldn't be difficult to obtain Suboxone and keep using.

"To me, it's a lot like the pill mills," said Wooten, 28 and now also a resident in the Refuge recovery program. "They would give you $50 for referrals."

Dr. Jeannette Ann Moleski, a family physician in Hudson, in northeastern Ohio, who has largely turned away from prescribing Suboxone, said in remarks prepared last week for the Ohio Department of Medicaid that the medication has become street currency.

For too many addicts, "Their primary use is not 'treatment' but as a way to ward off symptoms of withdrawal until the next shipment of heroin or Fentanyl hits the streets," she said.

At Hopewell Health Centers, a behavioral health and primary-care provider with multiple locations in Appalachian Ohio, patients seeking addiction treatment don't receive buprenorphine. Hopewell prefers Vivitrol injections, which block the effect of opioids, and other non-addictive medications, to help patients transition from drug dependence.

That doesn't prevent doctors and therapists from spending "a lot of time mopping up after Suboxone," said Kate Jiggins, Hopewell's medication-assisted treatment project director. "I put it like that because that's just the facts."

Abruptly stopping buprenorphine also can cause withdrawal, and addicts say the symptoms are even more severe than with heroin.

Travis, a 23-year-old recovering addict from Columbus, doesn't knock Suboxone. "It's definitely better than some of the drugs out there. You can take it and still be a functioning human being," Travis said, asking that his last name not be printed for fear of repercussions from making his drug history public.

But despite the medication's potential, the allure of sales and illicit use always seemed to win out. "I never really took the Suboxone I got, to be honest," Travis said. "With the cash, it's just all messed up. Ever since I turned 18, that's how I paid my bills."

One Suboxone prescriber told Travis he had failed his urine test, a finding that could have kept him from getting another prescription. As Travis braced for the news, the doctor instead made a request: "He asked for a $50 payment."

Parran, the study author, said Suboxone remains an important and effective drug in the fight against addiction, but one whose use requires much scrutiny. The state's new licensing mechanism is "a step in the right direction" but likely doesn't go far enough, he said.

"Honestly, it's the highest-risk prescribing, that's still legal, that you can be doing," Parran said. "The reality is, you are prescribing an opiate on a go-to basis to an opiate addict, and then you're asking them to behave sober."

rprice@dispatch.com

@RitaPrice

mschladen@dispatch.com

@martyschladen

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