Charles A. Buscema, MD

man holding briefcase with money

Opiate addiction, distinctly a healthcare problem, has grown into a national epidemic, the bounds of which have not yet been completely realized. HHS has stated that 3-4 % of the American population uses opiates on a daily basis, and 2 million Americans have a diagnosis of Opioid Use Disorder. Approximately 89% of patients in methadone clinics, began opiate use due to prescriptions for pain from physicians (NIH). There are over 130 opiate overdose deaths per day in the country, and over the last two decades, 300,000 Americans have died secondary to opiate overdoses. Yet, until very recently, the Drug Enforcement Administration in Washington, has not responded to this crisis in a manner that was commensurate with a national healthcare crisis. The Drug Enforcement Administration allowed manufacturers to produce more and more opioids for a decade, even as deaths from the crisis spiked, the Justice Department’s inspector general said in a report released this month (USA Today). Diversion control was not investigated or enforced, physicians who prescribed inordinately large quantities of opiates were not suspended from practice, and drug manufacturers who produced large amounts of addictive drugs were not cited nor fined. Remember these companies made huge profits at the expense of the American public health.

Pharmaceutical giants like Purdue Pharma, the company that introduced OxyContin in 1996, made billions in sales, and was responsible for tens of thousands of deaths. They recently settled a billion-dollar suit from State Attorney Generals and families of those people who died. In August of 2019, an Oklahoma Judge ordered Johnson and Johnson to pay 572 million dollars for their role in the opioid crisis. In the past three years, the DEA said, it has cut production for the seven types of opioids most frequently abused. Opioid prescriptions have dropped by about 30 percent since President Donald Trump took office, the department (HHS) said recently (USA Today, October 2019).

The question that needs to be answered is, who bears the responsibility for the lack of governmental response to a national emergency. As an analogy, if a JetBlue 737 Airbus, crashed every day in this country, claiming 130 passenger lives, how long would it take the FAA to ground all these commercial aircraft, until the nature of the problem was discovered and remediated. There is insufficient oversight presently.

The DEA receives their mandate for action from policies written by the political ruling class in Washington. Diversion control, that is, the monitoring of opiates prescribed for a patient (that ultimately ends up in the hands of another person), is their mandate. State and federal politicians must address the inactivity of governmental agencies, to prevent abuses that contribute to a controllable opiate epidemic. The federal government must be diligent in prosecuting providers, healthcare organizations, manufacturers and retailers, who commit fraud and abuse in an organized and systematic manner (National Institute of Health).

With the emergence of the opiate crisis, detoxification and rehabilitation became a booming business venture particularly in South Florida, Arizona, Texas, and California. The warm weather and beachfront accommodations attracted urban-based addicts from the Northeast, the Midwest, and other focal points of opiate trafficking. These facilities quickly became big businesses, with large price tags, amounting to $2500 per day for inpatient detoxification and $30,000 per month for rehabilitation. Patients were isolated from their families, and not allowed to use cell phones or leave the premises for 30-90 days. The amount of actual medical treatment by a professional (MD/APRN) gradually diminished, to about 20 minutes per week. Filling the void were paraprofessional staff, caseworkers, group leaders, massage therapists, and technicians. Patients often lived in residences that were prime beachfront property, and were allowed to watch movies, walk the beach, socialize, and dine by a gourmet chef in the evening. Elite facilities were replete with Olympic size swimming pools, indoor water falls, low patient-staff ratios, and plenty of optional items that were non-contributory for recovery. Rather, these facilities were not engaged in the transition to permanent recovery, but rather to short-lived recovery and eventual relapse. In some cases, they did not offer the patients medication-assisted treatment (MAT), which diminishes relapse from 75% to 30% in the first year following treatment. The cost of partial hospitalization (PHP) was so high, and the treatment results so marginal, that third party reimbursement entities (i.e. insurance companies) began reduction of the length of stay and the amount of reimbursement per month. As this process has continued, multiple conventional rehabilitation facilities have closed their doors, no longer able to survive financially in the traditional, high cost mode of operation. Their overhead expenses eclipsed their income.

The best example of this model of “runaway capitalism” applies to the addiction treatment industry, i.e. the rehabilitation paradigm, as it has been utilized. Patients receive long initial stays which generate high costs to the patient, and to the insurance companies, and ultimately the taxpayers. Although recovery is the intended goal, relapse happens, and when the relapse occurs, the insurance resets, to provide another costly round of inpatient/outpatient rehabilitation. This cycle will be repeated as many times as is permitted by the payer. It does not occur randomly, but rather frequently.

Medication assisted treatment facilities, either inpatient or outpatient, will eventually surpass their conventional counterparts in performance. Outpatient MAT programs are actually more cost effective, since all of the esthetic and gratuitous components have been eliminated, leaving the pure treatment of opioid use disorder as the only common denominator. The effective use of medications for opioid addiction such as Suboxone, Sublocade, and Vivitrol is well substantiated in peer-reviewed scientific publications. Medications, in combination with behavioral therapy, group therapy, and an abstinence program, form the basis for a holistic approach. Reduction in the relapse rate, return to productive activities such as employment, and diminished cost to the consumer, to the taxpayer, and to the healthcare industry are all realized with MAT.

Medication assisted treatment is the antithesis of the profit model, because the medications which downregulate the reward center of the brain, reduce opioid cravings, which constitute the basis of relapse. Most of the ensuing costs are therefore eliminated, and following detoxification, the patient can receive all of the necessary services, from home, as an outpatient.

There will be active resistance to this MAT model from the “Establishment within the Industry”, 12 STEP abstinence disciples, and businesspersons who now control costs in the marketplace. The abstinence contingent believes, erroneously, that all that is needed is the commitment to the 12 STEP approach for sobriety. That is only effective in a minority of opiate use disordered patients. However, the majority of this population requires chemical stabilization of their brain disorder, which is analogous to stabilizing high blood glucose with insulin in diabetes mellitus. Combining MAT with abstinence models would result in optimal recovery rates. Once the stigma for treatment with medications in opiate use disorder is dispelled, and the statistics reveal comparative success with these techniques (from the scientific community), this will become the preferred modality of addiction treatment in the United States.

This is but a synopsis of the intricate web of graft, excess, and corruption which has plagued the healthcare industry and the rehabilitation of addicted individuals, resulting in diminished treatment efficacy, higher costs, and substandard results. When opiate addiction is treated for the purpose of generating a profit, rather than placing the clinical needs of the patient as the primary goal, overdoses and death result in its wake, due to often preventable treatment failures.

Dr. Charles A. Buscema is CEO and Medical Director of Alternatives For You, in Palm Beach Gardens, Florida, an outpatient MAT facility which operates under the mandate of the Federal Suboxone Program for Opioid Dependence. This is a pioneer facility in utilizing the principles of Medication Assisted Treatment on an outpatient basis. The outpatient office addresses the issue of detoxification and rehabilitation from opioid medications principally with buprenorphine and also the stabilization of any underlying co- occurring psychiatric disorders which interfere with the transition process.

Dr. Charles A. Buscema graduated from the six-year biomedical program, affiliated with the Albany Medical College of Union University, in 1974, with a B.S. in Biology and an M.D. degree.

Dr. Buscema was appointed the first Chief of Psychiatry at St. Peter’s Hospital in Albany, N.Y. in 1980, a position that he held for almost ten years. In 1983 he achieved board certification in the specialty of General Psychiatry from the American Board of Psychiatry & Neurology. In 1995, Dr. Buscema graduated from a two-year Forensic Fellowship at SUNY Upstate Medical University; subsequently, in 1999, he was named Associate Director of the Forensic Residency at SUNY Upstate and in June 2001, he was certified in the subspecialty of Forensic Psychiatry by the American Board of Psychiatry and Neurology. Dr. Buscema was Acting Clinical Director of Central New York Psychiatric Center from 1998-2000, and was subsequently named Director of Psychiatry of CNYPC and all of its prison satellite units, a position that he held from September 2000 until February 2003. Dr. Buscema has authored & presented numerous forensic & correctional topics to a wide array of audiences nationally, and has published a book with co-author Dr. William Glazer, (July 2002, McMahon Medical Publishing Inc., New York, N.Y.), titled “Treating Schizophrenia in the Correctional Setting: The Forensic Algorithm Project 2002”. This clinical practice guideline is the first published algorithm for the treatment of schizophrenia in the correctional environment and is being utilized by state health care delivery systems throughout the country.