Medications and Substance Abuse Treatment: Putting It Into Practice

1
Medications and Substance Abuse Treatment
Putting It Into Practice

• Yngvild Olsen, MD, MPH
• Vice President of Clinical Affairs
• Medical Director
• Baltimore Substance Abuse System, Inc.

2
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

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WHO AM I?
4
WHO ARE YOU?
5
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

6
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.

7
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

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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

9
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

10
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

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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

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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.or
  g/explore/priorityareas/techtrans/tools/changebook
  .asp)
• TAP 31 Implementing Change in Substance Abuse
  Treatment Programs
• www.samhsa.gov
• Adaptive models (http//www.drugabuse.gov/about/or
  ganization/despr/hsr/da-tre/DeSmetAdaptiveModels.h
  tml)

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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

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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

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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

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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?

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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?

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Potential Challenges to Integrating Medications

• Program culture and philosophy
• Counselor attitudes and knowledge
• Patient , family, and community attitudes about
  medications

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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

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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/DataStatistics/M
arylandHIVEpiProfile122008.pdf
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Risk for 2006 HIV IncidenceBaltimore City
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
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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.maryla
ndpublicschools.org/NR/rdonlyres/852505C8-7FDB-4E4
E-B34E-448A5E2BE8BC/18944/MAS2007FinalReport_revis
ed111808.pdf Woody G. et al. JAMA
2008300(17)2003-2011
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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 Georges 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/viewartic
le/722342
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What Does Your Program Look Like?
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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

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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

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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

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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
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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

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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

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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 programs 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 programs services.

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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?

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Program Goals and Medications

• Increase retention
• Improve counseling attendance
• Increase program completion rates
• Provide treatment options for patients
• Improve abstinence rates
• Others..

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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

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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

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Next Steps for Case Scenario

• Put together implementation plan
• Identify funding

37
Baltimore Buprenorphine Initiative
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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
  

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BBI Goals

• Expand treatment for heroin addiction
• Access funding from larger medical care system
• Increase retention in treatment
• Link patients with ongoing medical care

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Link from Treatment Program to Primary Care Is Key

• Initially 6 treatment providers
• In FY 2009 moved to 9 providers
• 56 continuing care physicians

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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

43
BBI Results

• Currently, 357 patients receiving full BBI
  services in treatment program
• Approximately 6 drop-out from continuing care

44
Number of Clients Still in Counseling after
Transfer
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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

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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.

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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

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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...........

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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
  Physicians 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

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Next Steps

• Your change team decides to next focus on the PAC
  enrollment process

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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/

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Resources

• Buprenorphine Information
• http//buprenorphine.samhsa.gov/bwns/index.html
• http//buprenorphine.samhsa.gov/bwns/tip43_curricu
  lum.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)