Medications and Substance Abuse Treatment Putting It Into

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.

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

WHO AM I?

WHO ARE YOU?

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/cha ngebook. asp) TAP 31: Implementing Change in Substance Abuse Treatment Programs www. samhsa. gov Adaptive models (http: //www. drugabuse. gov/about/organization/despr/hsr/da‐ tre/De. Smet. Adaptive. Models. 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/Maryland. HIVEpi. Profile 122008. pdf

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 21

Prescription Opioids Growing problem among adolescents and young adults* Allegany County ‐‐ 20% of 12 th graders reported ever having tried prescription opioids for non‐medical purpose Talbot County – 12% of 12 th graders reported currently using prescription opioids for non‐medical purpose Effectively treated with buprenorphine** *Maryland Adolescent Survey: 2007 http: //www. marylandpublicschools. org/NR/rdonlyres/852505 C 8‐ 7 FDB‐ 4 E 4 E‐ B 34 E‐ 448 A 5 E 2 BE 8 BC/18944/MAS 2007 Final. Report_revised 111808. pdf **Woody G. et al. JAMA 2008; 300(17): 2003‐ 2011

Outcomes for Treatment As Usual Of 3753 admissions to Level I treatment in FY 08, 51% retained for 90 days or more Of 11, 013 treatment discharges in FY 08, 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®™) 8 mg/2 mg tablet ‐‐ $6. 18 per pill ($371 per month for 16 mg daily) 2 mg/0. 5 mg 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 Vareniclinenot cover Vivitrol® ‐‐ $110 per month for up to 1 mg twice daily (Chantix®™) *MD Medicaid does

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, 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

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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

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%) Health. Choice 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 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) i. Award 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/tip 43_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)