On February 8, 2016

Tobacco ban at opiate treatment centers backfires

By Elizabeth Hewitt

During the first two weeks of the year, fewer than half of the 41 beds at Maple Leaf Farm, a residential opiate treatment facility in Underhill, were full. For a facility that usually has a waiting list of 34 and a wait of two weeks to get a bed, that’s unusual.

The sudden drop in clients at Maple Leaf Farm coincided with the implementation of a Vermont Health Department policy requiring residential drug treatment centers to be tobacco-free. Intended as a step toward improving public health and the wellbeing of clients, the anti-smoking policy instead deterred patients from receiving treatment for opiate addiction at the center.

While Maple Leaf Farm Executive Director Catey Iacuzzi sat in a committee room one morning earlier this month for testimony on opiate addiction services, she received emails notifying her that two clients had left the program because they were not allowed to light up at the facility.

The smoke-free policy was a long time coming. The Health Department began crafting it about two years ago. The goal: to make treatment facilities tobacco-free, in the same way that hospitals and other health services offices are, according to Deputy Commissioner Barbara Cimaglio.

Initially, the department planned to have the state’s residential treatment centers go tobacco-free by July 1, 2015, but the facilities asked for a six-month delay, so it went into place at the beginning of this year.

There are “a lot of myths” about tobacco use and addiction treatment, Cimaglio said Tuesday. Many people believe someone can’t give up smoking while also going through treatment for drug addiction. But research shows that’s not true, Cimaglio said. The department drew on scientific research in crafting the policy and looked to similar in policies in other states, especially New York, for guidance, she said.

She said the department adopted the tobacco-free policy with the intention that quitting smoking could be part of a patient’s treatment plan.

“It isn’t intended to be punitive,” Cimaglio said. “It’s intended to help the patients see that tobacco is a serious problem.”

When patients come into a program, they won’t be expected to quit cold turkey, she said. They’ll have access to nicotine patches and gum, and clinicians can refer them to other support services, like the Vermont Quit Line, Cimaglio said.

Initially, Iacuzzi supported Cimaglio and Health Commissioner Harry Chen in the move to cut down smoking in residential treatment facilities as a matter of public health. But the implementation of the policy has played out differently than the research suggested.

Staff at Maple Leaf Farm spent the first few weeks of the year chasing down tobacco-dependent clients to enforce the new policy, she said. Maple Leaf Farm is one of four residential treatment centers in Vermont and handles almost 800 patients annually, with an average treatment length of about two weeks.

With the ban in place, clients were going to great lengths to get a cigarette, Iacuzzi said. She saw one patient crouched behind one of the buildings on the facility’s campus to get a smoke. Some clients who were smokers left the program because quitting was too daunting; others never even began the program because of the ban, she said. Meanwhile, the policy was frustrating for nonsmokers who felt the focus of the opiate addiction program was distracted by the tobacco crackdown.

“It felt like we were the cigarette police, and we weren’t able to focus on other needs,” Iacuzzi said Wednesday.

Making the decision to go into treatment for opiate addiction is already stressful, Iacuzzi said. Clients experience intense anxiety and fear while going through withdrawal, she said. When patients were told they couldn’t smoke, it magnified that fear.

“The level of anxiety went through the roof when it was already at the roof,” Iacuzzi said.

Iacuzzi said she still supports the intent of the tobacco-free policy and would like patients at Maple Leaf Farm to get more information about the health risks of smoking and get support to quit. But, she said, there needs to be consideration of the different levels of risk associated with opiate and tobacco use.

“Someone tonight could die from an opiate overdose,” Iacuzzi said. “They’re not going to die tonight from tobacco use.”

In light of the concerns from some providers, the department is working with the state’s residential facilities to offer support during the rollout of the policy.

Health Department officials spoke with treatment providers this week about the issue. For the moment, the department isn’t requiring that the tobacco-free policy be enforced. Lawmakers on the Senate Health and Welfare Committee scheduled testimony on the policy for Friday, Jan. 29.

Though the policy is eased for the moment, Cimaglio said the department still hopes to bring treatment centers in line with the tobacco-free policy in Vermont’s other health centers. The policy is still in its early days, she said, and it will take time to challenge the perception that quitting smoking is not compatible with other substance addiction treatment.

“This is the right thing to do for public health,” Cimaglio said.

In the meantime, enrollment numbers at Maple Leaf Farm have bounced back since the facility stopped cracking down on smoking, according to Iacuzzi. It is at full capacity.

Iacuzzi said she is aware of one patient who had dropped out who has been back in touch to get some form of services. But when patients drop out of the program, it becomes difficult to keep in touch with them or track their wellbeing, Iacuzzi said.

“There’s a handful of clients that I’m worried about,” she said.

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