expanding access to treatment for opiate addiction ......expanding access to treatment for opiate...
TRANSCRIPT
Expanding access to treatment for opiate addiction: Successes and Barriers
Miriam Komaromy, MDMedical Director,Turquoise Lodge Addiction Treatment Hospital, NM Department of Health; and
UNM Project ECHO Addiction Treatment Program
SAMHSA Nat Survey Drug Use and Health 2005, 2006
Misuse of prescribed opioids is common…..
% of 12th graders reporting non-medical use in past year, 2007
0 2 4 6 8 10 12
VicodinOxyContin
NIDA Monitoring the Future Study 2007
Unintentional overdose deaths involving opioid analgesics now exceed the sum of deaths involving heroin or cocaine
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
'99 '00 '01 '02 '03 '04 '05 '06 07
Nu
mb
er o
f d
eath
s
Source: National Vital Statistics system, multiple cause of death dataset, Len P aulozzi, CDC 2010
Opioid analgesic
Cocaine
Heroin
4
New Mexico has a huge opioid addiction problem
NM had the 2nd highest drug-induced death rate in the US in 2005, 20.9 deaths per 100 K persons, compared to the US rate of 11.2. 2 NM counties were among the top 25 in the US for drug-induced poisoning deathThe total unintentional drug overdose death rate in NM increased by 180% 1990-2005 (5.6 to 15.5 per 100K ) During 1990-2005, the 196% increase in single drug category overdose death was driven by prescription opioids alone and heroin alone
Shah NG, NM Epidemiology Report 2008Shah NG, Addiction 2008
In response to the problems of opiate and alcohol addiction, and the highest rates of Hepatitis C infection in the US,
we launched a program in 2006 to expand access to addiction treatment in
our large, poor, rural state:
Project ECHO
What is Project ECHO?
Extension for Community Healthcare OutcomesFounded by Dr. Sanjeev Arora at the University of NM with an initial focus on expanding access to hepatitis C treatmentThe mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas, and to monitor outcomes.
Project ECHO: methodsUse technology to leverage scarce healthcare resources: tele / video conferencing with Primary Care Providers (PCPs) in underserved areasCase-based learning: PCPs present cases on weekly statewide teleconference, and receive feedback from specialists at UNM and other PCPsDisease management model improves outcomes by sharing best practices“Learning loops” help PCPs develop confidence and expertise of their own, become resources in their own communitiesForce Multiplier
How does ECHO work for Addiction Treatment?
Because of huge opiate problem in NM, focus has been on training PCPs to treat with buprenorphineRaise interest/awareness via grand rounds presentations around state8-hour tailored Buprenorphine trainings in-person and via videoconferenceWeekly 2-hour telehealth conference since ’06, includes counselors as well as medical providers
Observational data on Buprenorphine effectiveness Increasing use of buprenorphine in
France associated with 1,2
– Decrease in arrests for heroin (77% decline since 1995)
– Decrease in overdose deaths (81% decline since 1995)
1. Auriacombe 2004, Am J Addict;13.2. Lepere 2001, Ann Med Interne (Paris);152 Suppl 3.
1202000
564
Buprenorphine treatment outcomes at 6 months
Heroin users Pain pill usersMethadone(data from literature review)
Retention in treatment 67% * 77% 53-63%
Abstinence (self-reported) 70% 73%
30 day illicit drug use (self-reported)
1.2 days 3-7 days
*14% of pts reported they had already completed treatment by 6 months
SAMHSA evaluation of the Impact of the DATA waiver program, Final Summary Report. March 2006. http://buprenorphine.samhsa.gov/FOR_FINAL_summaryreport_colorized.pdf
Criminal Activity past 30 days in buprenorphine-treated patients(self- reported)
Street drug acquisition
Drug dealing
Prescription fraud
Other crimes
Baseline13 days 16% 10% 10%
After 6 months of treatment
1.7 days 3% 1% 2%
SAMHSA evaluation of the Impact of the DATA waiver program, Final Summary Report. March 2006. http://buprenorphine.samhsa.gov/FOR_FINAL_summaryreport_colorized.pdf
RCT of buprenorphine
40 Heroin addicts Buprenorphine 8mg/day vs taper + placeboAll received counseling, groupsFollowed for 1 year
Kakko et al, Lancet 2003
Buprenor-phine
Placebo
Retained at one year
70% 0
Died 0 20%
Buprenorphine vs Methadone
Like Methadone…• Reduces IDU• Retains pt in
treatment• Decreases
craving• Stops withdrawal• Costs $ 5-13 per
day
Unlike Methadone….• Low potential for OD• No sedation• Easy taper/detox• Prescribed in MD
office• Offers access in
small rural communities
Ranking has increased from 13th to 5th in the US since the start of ECHO: buprenorphine providers per capita
State Rank 2005 Physicianscertified 2005
Rank 2009
Physicians certified 2009
VT 1 31 1 160
ME 2 41 2 241
DC 9 81
MA 6 100 3 877
MD 10 82 4 749
NM 13 21 5 258 (*156 by ECHO)
RI 4 20 6 127
NY 7 292 7 2156
CT 3 67 8 382
PA 8 185 9 1200
AK 6 17 10 62
CSAT database of certified MDs 2005, 2009
Survey of ECHO bup prescribers:What has been the impact of prescribing buprenorphineon your clinical practice?
Question MeanMy ability to help opiate-addicted patients 6.5
My satisfaction with clinical practice 6.2
The clinic staff’s satisfaction with our practice 5.6
My practice partners’ satisfaction with our practice 5.9
My ability to have a positive impact on my community 6.4
My interest in treating patients with opiate addiction 6.4
My interest in treating patients with other addictions 6.0
My professional reputation in my community 5.5
Response choices from 0=strongly negative impact, 4=no impact,5=somewhat positive, 7=strongly positive impact
N=51, survey response rate 70%, 2010
Why do so few trained prescribers actually prescribe?
Nationally, only ¼ of buprenorphine-certified physicians actually prescribeOnly 1/3 of doctors we train actually prescribe buprenorphineClinic administrators are often opposed to buprenorphine prescribingWhy?
Huge reimbursement barriers for NM PCPs who wish to treat opiate addictionMedicaid/Saluds will pay for Suboxone prescribed by PCP (with Prior Auth)However, they won’t pay PCP for the visitOptum Health will pay for Suboxone and for office visit, but only if it is prescribed by a psychiatristThere are very few Suboxone-certified psychiatrists in NM, and virtually none in rural areasMost poor New Mexicans are not covered by either of these programs, and can’t afford >$400/month for SuboxoneContrast with Vermont
How to contact us
Miriam Komaromy, [email protected]
Bonnie Kraybill Mount, [email protected]
Upcoming ECHO buprenorphine training:Albuquerque, Saturday January 22