Transcript Medications and Substance Abuse Treatment:

Yngvild Olsen, MD, MPH
Vice President of Clinical Affairs
Medical Director
Baltimore Substance Abuse System, Inc.
Workshop Outline
 Introductions and objectives
 Review basic principles
 Case scenario – Part 1
 Small group work
 Report out
 Practical issues
 Case scenario – Part 2
 Small group work
 Report out
 Baltimore Buprenorphine Initiative
 Wrap up with Case scenario – Part 3
Workshop Objectives
 Describe principles for thinking about incorporation of




medications
Provide framework for change as related to
incorporation of medications
Share practical tools that can apply to incorporation of
medications
Describe real-life successful models for integrating
medications
Interactive sharing of ideas, challenges and solutions to
incorporating medications into substance abuse
treatment
Questions for Consideration
 What does my program gain by incorporating
medications?
 What do individuals accessing services in my
program gain?
 What does my program risk by incorporating
medications?
 What are the costs and how does my program
sustain them?
 Others…………….
Principle #1: Change Happens
 Accept change as a reality and an
opportunity
“Nothing is permanent, but change”
Heraclitus 535-475 BCE
“It is not the strongest of the species that survive, nor the
most intelligent, but the one most responsive to change”
Charles Darwin 1809-1882
Grant to PAC Transition
 As of Jan 1, 2010, the Maryland Primary Adult Care
(PAC) Medicaid waiver program covers outpatient
addiction treatment
 Assessment
 IOP/OP
 OMT
 Significant transition from grant to Medicaid fee-for-
service funding mechanisms
Healthcare Reform
 H.R. 3590 Patient Protection and Affordable Care Act and
Reconciliation Bill H.R. 4872
 Implications for Substance Abuse Treatment
 Expands Medicaid eligibility to 133% of FPL
 SUD/MH services included in the basic benefits package
required in exchange and for Medicaid recipients
 All plans in exchange must adhere to Wellstone/Domenici
parity act provisions
Healthcare Reform
 Includes SUD/MH in chronic disease prevention
initiatives
 Includes SUD/MH workforce in health workforce
development initiatives
 Makes SUD prevention, treatment, and MH service
providers eligible for community health team grants
aimed at supporting medical homes
 Increases mandatory funding for CHCs
ONDCP National Drug Control Strategy 2010
Highlights
 Integrate Treatment for Substance Use Disorders into
Health Care, and Expand Support for Recovery
 Performance Contracting Pilot Project: $6.0 million for a
performance contracting pilot project to enhance overall
drug treatment quality by incentivizing treatment
providers to achieve specific performance targets.
 Outpatient providers who retain greater proportions of
patients in active treatment for longer time periods
 Payment supplements for treatment providers who connect
higher proportions of detoxified patients with continuing
recovery‐oriented treatment
Principle #2: Have a Method
 Use a systematic method for making changes to your program
 Individualize it
 Be flexible
 Acknowledge non-linear process of program change
 Examples
 NIATx model (www.niatx.net)

Transtheoretical models
(http://www.attcnetwork.org/explore/priorityareas/techtrans/tools/chan
gebook.asp)
TAP 31: Implementing Change in Substance Abuse Treatment Programs
www.samhsa.gov

Adaptive models
(http://www.drugabuse.gov/about/organization/despr/hsr/datre/DeSmetAdaptiveModels.html)
Common Change Principles
 Know, and involve, your population
 Including community, patients, and staff
 Culture, attitudes, and knowledge level
 Pick, and equip, at least one change agent or champion
in your program
 Given them appropriate authority and time
 Plan, do, reassess, revise – and repeat
Principle #3: Data is Your Friend
 Make it simple and relevant
 Know it
 Use it
 Update it
“Knowledge is power”
Sir Francis Bacon 1561-1626
Principle #4: Why and Why Not?
 Keep asking the Why? questions
 Improves the process and the outcome
 Encourages critical thinking by everyone
 Helps articulate program messages
“Millions saw the apple fall, but Newton was the
one who asked why”
Bernard M. Baruch 1870-1965
 Ask the Why Not? questions
 Clarifies program vision
 Prevents stagnation
“I dream of things that never were, and ask why not?”
Robert F. Kennedy 1925-1968
Case Scenario: Part 1
 You are an administrator of an urban facility that has been
providing drug-free, outpatient substance abuse
treatment for 30 years. Sixty percent of the funding for
your organization comes from the state block grant. The
Governor of your state has recently announced that he
wants to double the number of individuals receiving
buprenorphine by the year 2012. Your state agency
enthusiastically supports this deliverable.
 How will your agency respond?
Questions for Case Scenario Part 1
 How will patients react to this?
 How will your staff react to this?
 What other issues do you need to consider?
 What are your next steps going to be?
Potential Challenges to Integrating Medications
 Program culture and philosophy
 Counselor attitudes and knowledge
 Patient , family, and community attitudes about
medications
Problem Solving
 Form change team with representation from key
stakeholder groups
 Gather and use data to identify critical measures to impact
 Patient surveys
 Staff surveys
 Relevant local and state data
 Outcomes for treatment as usual
 Ensure change team and others have sufficient
information on medications to make informed decisions
Baltimore City
 Heroin addiction remains high
 Treatment capacity falls short of demand despite expansion in
treatment system
 Estimated 30,000 individuals with opioid dependence
 ~4,000 methadone treatment slots
 Over 8,000 treatment admissions for opioids in FY 2008
 Consequences from heroin addiction are severe
 Crime
 Family and community disruption
 Medical complications

1 in 48 Baltimore City residents are living with HIV and/or
AIDS
http://www.dhmh.state.md.us/AIDS/Data&Statistics/MarylandHIVEpiProfile122008.pdf
Risk for 2006 HIV Incidence
Baltimore City
Heterosexual
24%
30%
6%
Injection Drug
Users (IDU)
Other
MSM/IDU
4%
36%
MSM
MSM= Men who had sex with men
MSM/IDU = Men who had sex with men & were injection drug users
Source: Maryland Dept. of Health & Mental Hygiene, AIDS Administration, October 4, 2007
21
Prescription Opioids
 Growing problem among adolescents and young adults*
 Allegany County -- 20% of 12th graders reported ever
having tried prescription opioids for non-medical purpose
 Talbot County – 12% of 12th graders reported currently
using prescription opioids for non-medical purpose
 Effectively treated with buprenorphine**
*Maryland Adolescent Survey:
2007http://www.marylandpublicschools.org/NR/rdonlyres/852505C8-7FDB-4E4EB34E-448A5E2BE8BC/18944/MAS2007FinalReport_revised111808.pdf
**Woody G. et al. JAMA 2008;300(17):2003-2011
Outcomes for Treatment As Usual
 Of 3753 admissions to Level I treatment in FY08, 51%
retained for 90 days or more
 Of 11,013 treatment discharges in FY08, only Prince
George’s county had smaller change in substance use
 Relapse rates high
 In methadone studies, 50-80% relapse within one year after
detoxification
 91% of patients receiving buprenorphine for 4 months had
relapsed to prescription opioids within 2 months of taper*
*Weiss R. et al. NIDA CTN Prescription Opioid Treatment Study.
http://www.medscape.com/viewarticle/722342
What Does Your Program Look Like?
Other Issues
 Program policies on medication management
 Dispensing vs. only prescribing
 Clinical policies on medication recalls, pill counts, etc
 Laboratory testing
 Resources needed
 Additional staff
 Medication costs
 Supplies and equipment
 State and federal regulations and licensing requirements
Factors to Consider In Medication
Management Policies
 Risk of medication diversion
 Medication safety and side effect profile
 Staff input
 Existing policies
 Urinalysis testing
 Approach to positive urines
 Approach to late or missed payments for services
 Program behavior policies
Dispensing vs. Only Prescribing
 Pros of Dispensing
 Better control over patient adherence
 More control over medication
 Additional, potentially reimbursable, contacts with patients
 Cons of Dispensing
 Need more equipment
 More paperwork for labeling and tracking medication
 Cost of purchasing medications
Medication Costs
 Buprenorphine (Suboxone®™)
 8mg/2mg tablet -- $6.18 per pill ($371 per month for 16 mg daily)
 2mg/0.5mg tablet -- $3.35 per pill
 Naltrexone
 Oral (Revia®™) -- $170 per month for 50 mg per day
 Injectable (Vivitrol®)* -- $700 for once monthly injection
 Acamprosate (Campral®™) -- $360 per month for 666 mg thrice daily
 Topiramate (Topamax®™) -- $240 per month for 200 mg per day
 Buproprion SR (Zyban®™) – $300 per month for 150 mg twice daily
 Varenicline (Chantix®™) -- $110 per month for up to 1 mg twice daily
*MD Medicaid does not cover Vivitrol®
Resources Needed
 Physician to prescribe medication
 Physician coverage for vacations and emergencies
 Malpractice insurance
 Nurse to dispense and/or administer medication if
physician does not
 Supplies and equipment
 Appropriate storage of medications, if dispensing
 Bottles, caps, labels, label printing software, if dispensing
 POC buprenorphine urinalysis testing kits
Regulation and Licensure Requirements
 DATA 2000 allows qualified, office-based physicians to
prescribe approved medications for treatment of opioid
dependence
 Sublingual buprenorphine currently is only medication approved
for this purpose
 Nurse practitioners are currently not allowed to prescribe
buprenorphine
 Practices subject to regular DEA visits
 To prescribe SUD medications physicians need
 Active state medical license
 Current state controlled substances license
 Current Federal DEA license
Case Scenario – Part 2
 You have convened a change team for your program, led by a
seasoned clinical supervisor who previously worked for many years
in a methadone program. Others on the change team include a
former client who now volunteers at your program, the mother of a
former client who died of an overdose shortly after leaving
treatment, one of your intake counselors, a billing specialist, the
program accountant, and an interested member of your Board.
 The change team has gathered and reviewed information on the
program’s population (see handout)
 Based on this data and more information on different evidence-
based treatment options, the change team recommends pursuing
adding buprenorphine into the program’s services.
Questions For Part 2
 What outcomes could you and the change team
consider impacting with the addition of
buprenorphine?
 How do you get buy-in from other staff?
 How will the program handle a mix of patients on
buprenorphine while others are not?
 Where would you look for resources for
implementation?
Program Goals and Medications
 Increase retention
 Improve counseling attendance
 Increase program completion rates
 Provide treatment options for patients
 Improve abstinence rates
 Others…………………………………………..
Buy-In and Mix of Patients
 Listen to staff concerns
 Start small
 Have clear program and clinical policies for selection and
management of patients on buprenorphine
 Model behavior
 Measure impact and celebrate successes
 Consult with peers
Resources
 Grant funds
 State
 Local government
 Foundations
 SAMHSA/CSAT
 Third party payers
 Bill for all reimbursable contacts
 Ensure patients enrolled in all entitlements they are eligible for
 Look at payer mix
 Partner with a community health center or local physician
practice
 Partner with another treatment program
Next Steps for Case Scenario
 Put together implementation plan
 Identify funding
Baltimore Buprenorphine Initiative
Business Case for BBI in 2006
 Baltimore needs more effective treatment for
opioid dependence
 Review of literature and studies by UMBC
 Medical costs are increased for patients with drug abuse
 Opioid addicts on methadone consume far fewer
Medicaid resources than addicts who go untreated
 Buprenorphine is economically viable alternative in city
with limited methadone treatment capacity
38
BBI Goals
 Expand treatment for heroin addiction
 Access funding from larger medical care system
 Increase retention in treatment
 Link patients with ongoing medical care
40
Link from Treatment Program
to Primary Care Is Key
 Initially 6 treatment providers
 In FY 2009 moved to 9 providers
 56 continuing care physicians
Transfer process
 Criteria for transfer
 Patient compliant with medication and counseling
 Patient opioid-free; reduced other drug use
 Patient responsible with take home medication and
prescriptions
 Patient has insurance
42
BBI Results
3,209 patients
treated
2,094 (65%) obtained or had
medical assistance
1,645 (79%) PAC
449 (21%)
HealthChoice
796 (38%)
transferred to
continuing care
•Currently, 357
patients receiving
full BBI services in
treatment program
•Approximately 6%
drop-out from
continuing care
Number of Clients Still in Counseling after
Transfer
Retention in Counseling After Transfer to Continuing Care
30 Days Retained in Counseling Post Transfer
% of Patients Retained in
Counseling
100%
100%
89%
83%
76%
80%
60%
40%
20%
0%
91-120 Days
121-150 Days
151-180 Days
> 180 Days
Number of Days in Treatment Upon Transfer
44
Achievements
 4 times as many buprenorphine slots in Baltimore
from 112 slots in 2008 to 506 slots in 2009
 Four-fold increase in physicians trained to provide
buprenorphine from 50 to 200
 Patients receive buprenorphine within 48 hours of
first treatment appointment
45
Achievements
 Innovative Practice by Agency recognition by federal
Agency for Healthcare Research and Quality 2008.
 National Association of County and City Health
Officials (NACCHO) Model Practice Award 2009.
 Network for the Improvement of Addiction Treatment
(NIATx) iAward for Innovation in Behavioral
Healthcare Services 2010.
46
Sustaining Efforts
 Medicaid Primary Adult Care expansion
 Buprenorphine Medicaid Workgroup
 Increased Medicaid substance abuse service
reimbursement rates
 BBI Clinical Guidelines – Revise for PAC billing
 Recruiting for additional continuing care physicians 47
Case Scenario – Part 3
 Your change team, in consultation with a local physician





experienced in buprenorphine, puts together a comprehensive
implementation plan that convinced the state agency to award
you with additional grant funds, enough to support 17 patients.
The implementation plan calls for dispensing buprenorphine
to new patients, outlines protocols for how to transition
patients to prescription, includes medication inventory and
tracking forms, and a diversion plan.
Your program partners with a local pharmacy, and contracts
with a mental health agency to provide the services of a
buprenorphine-certified psychiatrist 4 hours twice a week who
is willing to dispense.
You obtain all the necessary supplies, equipment and licenses.
Staff are trained and identify eligible patients.
Patients begin receiving buprenorphine...........
6 months later…………
 The demand for buprenorphine has been overwhelming
 Patients are not getting PAC as quickly as you expected
 Clinical supervisors are wondering what to do with patients
who continue to use cocaine or benzos
 BUT……..
 You just got your first check from Maryland Physician’s Care
for $20,000 and even got paid by Aetna for one patient
 Your treatment incompletion rate has gone from 50% to 39%
 You are getting many more self-referrals
 Staff morale has improved
Next Steps
 Your change team decides to next focus on the PAC
enrollment process………
Resources
 Healthcare Reform
 http://www.healthreform.gov/
 http://www.healthreform.maryland.gov/
 http://www.lac.org/index.php/lac/342
 http://www.saasnet.org/drupal-6.6/taxonomy/term/18
 ONDCP Drug Control Strategy Information:
http://www.whitehousedrugpolicy.gov/strategy/
Resources
 Buprenorphine Information
 http://buprenorphine.samhsa.gov/bwns/index.html
 http://buprenorphine.samhsa.gov/bwns/tip43_curriculum.pdf
 http://buprenorphine.samhsa.gov/bwns/presentations.html
 Dispensing Regulations
 COMAR Title 10, Subtitle 19 (10.19.03)
 COMAR Title 10, Subtitle 13 (10.13.01)
 Federal DEA Controlled Substances Act Title 21, Chapter 13,
Subchapter 1, Section C
(http://www.justice.gov/dea/pubs/csa.html)