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Medications and Substance Abuse Treatment: Putting It Into Practice

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Yngvild Olsen, MD, MPH Vice President of Clinical Affairs Medical Director Baltimore Substance Abuse System, Inc. Buy-In and Mix of Patients Listen to staff concerns ... – PowerPoint PPT presentation

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Title: 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

3
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

8
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

11
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

12
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)

13
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

14
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

15
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

16
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?

17
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?

18
Potential Challenges to Integrating Medications
  • Program culture and philosophy
  • Counselor attitudes and knowledge
  • Patient , family, and community attitudes about
    medications

19
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

20
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
21
Risk for 2006 HIV Incidence Baltimore 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
22
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
23
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
24
What Does Your Program Look Like?
25
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

26
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

27
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

28
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
29
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

30
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

31
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.

32
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?

33
Program Goals and Medications
  • Increase retention
  • Improve counseling attendance
  • Increase program completion rates
  • Provide treatment options for patients
  • Improve abstinence rates
  • Others..

34
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

35
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

36
Next Steps for Case Scenario
  • Put together implementation plan
  • Identify funding

37
Baltimore Buprenorphine Initiative
38
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

39
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
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41
Link from Treatment Program to Primary Care Is Key
  • Initially 6 treatment providers
  • In FY 2009 moved to 9 providers
  • 56 continuing care physicians

42
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
45
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

46
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.

47
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

48
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...........

49
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

50
Next Steps
  • Your change team decides to next focus on the PAC
    enrollment process

51
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/

52
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)
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