expansion of m at in vermont: minding the crouching dragons!

Expansion of M AT in Expansion of M AT in Vermont: Minding the Vermont: Minding the Crouching Dragons!Crouching Dragons!

Peter Lee, MA. Chief of Clinical Peter Lee, MA. Chief of Clinical Services; ADAPServices; ADAP

Todd “The Dude” Mandell, M.D. Todd “The Dude” Mandell, M.D. Medical Director; ADAPMedical Director; ADAP

VermontVermont

VermontVermont

Clinical and Fiscal Creativity in a Tiny Clinical and Fiscal Creativity in a Tiny New England StateNew England State

Increasing Access to Treatment: High Increasing Access to Treatment: High PriorityPriority

Prescription opiate more common than heroin in those presenting for treatment

Vermont’s Service ExpansionVermont’s Service ExpansionFor Patients AND MDsFor Patients AND MDs

Back groundBack ground Vermont was rather late in joining the methadone Vermont was rather late in joining the methadone

treatment initiativetreatment initiative Buprenorphine release: Answer to the need?Buprenorphine release: Answer to the need?

Increased Access to Treatment and MD SupportsIncreased Access to Treatment and MD Supports First Methadone ProgramFirst Methadone Program Hybrid Bup TrainingsHybrid Bup Trainings Buprenorphine Induction CenterBuprenorphine Induction Center Coordination of Office Based – Medication Assisted Coordination of Office Based – Medication Assisted

TherapiesTherapies Finding more “slots” for methadone (options for Finding more “slots” for methadone (options for

treatment) Fancy financial footworktreatment) Fancy financial footwork

Vermont’s Service ExpansionVermont’s Service ExpansionFor Patients AND MDsFor Patients AND MDs

Prescription Monitoring ProgramPrescription Monitoring Program

Prescription Drug Abuse Work GroupPrescription Drug Abuse Work Group

Opioid Use in Vermont: At Crisis Opioid Use in Vermont: At Crisis LevelLevel

Increased demand for treatment through Increased demand for treatment through publicly funded programs for opiate publicly funded programs for opiate dependencedependence

Year – 2000Year – 2000 Requests -- 423Requests -- 423Year -- 2005Year -- 2005 Requests – 1,522Requests – 1,522

System of care for opioid-dependent pregnant System of care for opioid-dependent pregnant patients and their newborns began 5 years ago. patients and their newborns began 5 years ago. Number of deliveries and newborns cared by the Number of deliveries and newborns cared by the service increased by approximately service increased by approximately 50%50% each year. each year.

Opioid Use in Vermont: At Crisis Opioid Use in Vermont: At Crisis LevelLevel

Prescription opiate use on a dramatic risePrescription opiate use on a dramatic rise

Heroin is inexpensive and potent and availableHeroin is inexpensive and potent and available

Vermont’s First Methadone ProgramVermont’s First Methadone ProgramOpened October 28, 2002 with an initial Opened October 28, 2002 with an initial

census of 40census of 40Current Census: 207!Current Census: 207!

Burlington: The Chittenden Center

Arrival of buprenorphine for Arrival of buprenorphine for OBOTOBOT

Drug Addiction Treatment Act of 2000 Drug Addiction Treatment Act of 2000 Intended for a rather select populationIntended for a rather select population Eight hour training required (expensive to Eight hour training required (expensive to

attend, and required time away from attend, and required time away from practice and billing hours)practice and billing hours)

Arrival of buprenorphine for Arrival of buprenorphine for OBOTOBOT

Initially very limited numbers of patients Initially very limited numbers of patients allowed ie 30 per practiceallowed ie 30 per practice

On-line training rather isolating/non-On-line training rather isolating/non-interactiveinteractive

Vermont Bup practice guidelines posted Vermont Bup practice guidelines posted 20032003

Ten Factor Office Based Criteria Check ListTen Factor Office Based Criteria Check List

In general, 10 factors help determine if a patient is appropriate for office-basedIn general, 10 factors help determine if a patient is appropriate for office-basedbuprenorphine treatment. Check off “yes” or “no” next to each factor.buprenorphine treatment. Check off “yes” or “no” next to each factor.

Factor Factor Yes Yes NoNo Does the patient have a Does the patient have a diagnosis of opioid dependencdiagnosis of opioid dependence?e? Is the patient Is the patient interested in office-based buprenorphineinterested in office-based buprenorphine treatmentreatment?t? Is the patient Is the patient aware of the other treatment optionaware of the other treatment options?s? Does the patient understand the Does the patient understand the risks and benefits risks and benefits ofof buprenorphine treatment and that it will address somebuprenorphine treatment and that it will address some aspects of the substance abuse, but not all aspects?aspects of the substance abuse, but not all aspects? Is the patient expected to be Is the patient expected to be reasonably complianreasonably compliant?t? Is the patient expected to Is the patient expected to follow safety procedurefollow safety procedures?s? Is the patient Is the patient psychiatrically stablpsychiatrically stable?e? Are the Are the psychosocial circumstances psychosocial circumstances of the patient stableof the patient stable and supportive?and supportive? Are Are resources available in the office resources available in the office to provide appropriateto provide appropriate treatment? Are there other physicians in the grouptreatment? Are there other physicians in the group practice? Are treatment programs available that will acceptpractice? Are treatment programs available that will accept referral for more intensive levels of service?referral for more intensive levels of service? Is the patient Is the patient taking other medications that may interacttaking other medications that may interact with buprenorphine, such as naltrexone, benzodiazepines,with buprenorphine, such as naltrexone, benzodiazepines, or other sedative-hypnotics? or other sedative-hypnotics?

ADAP’s efforts to increase access to MATADAP’s efforts to increase access to MATHybrid Bup TrainingsHybrid Bup Trainings

AAAP online training AAAP online training Hard copy sent to participants ahead of Hard copy sent to participants ahead of

timetime Facilitator “talks” participants through the Facilitator “talks” participants through the

online course; Vermont resources online course; Vermont resources providedprovided

ADAP’s efforts to increase access to MATADAP’s efforts to increase access to MATHybrid Bup TrainingsHybrid Bup Trainings

List serve of waivered MD’s hosted by List serve of waivered MD’s hosted by Vermont Medical SocietyVermont Medical Society

>80 MDs have obtained waiver through >80 MDs have obtained waiver through Hybrid Trainings with High satisfaction Hybrid Trainings with High satisfaction responses to questionnairesresponses to questionnaires

Demand Increases Even as Demand Increases Even as Resources IncreaseResources Increase

High number of calls to providers and ADAP High number of calls to providers and ADAP office requesting “A bup program”office requesting “A bup program”

Six month waiting list at the methadone Six month waiting list at the methadone program and many calls to providers and ADAP program and many calls to providers and ADAP requesting MAT including methadonerequesting MAT including methadone

Most waivered MDs:Most waivered MDs: Wary about doing inductionsWary about doing inductions Wishing to treat only those patients identified in their Wishing to treat only those patients identified in their

own practicesown practices Feel that Medicaid reimbursement is too lowFeel that Medicaid reimbursement is too low Feel that they do not have enough supportsFeel that they do not have enough supports

Demand Increases Even as Demand Increases Even as Resources IncreaseResources Increase

BUT Most waivered MDs:BUT Most waivered MDs: Wary about doing inductionsWary about doing inductions Wishing to treat only those patients identified Wishing to treat only those patients identified

in their own practicesin their own practices Feel that Medicaid reimbursement is too lowFeel that Medicaid reimbursement is too low Feel that they do not have enough supportsFeel that they do not have enough supports

WaiveredWaivered MD MD PrescribingPrescribing Patterns Patterns

0102030405060708090

100

1 to 10 11 to 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70

Number of Patients

Num

ber o

f MD

s Pr

escr

ibin

g

Number of MDs prescribing for 1 patient – 24

Number of Waivered MDs not prescribing for Medicaid patients - 50

Medication Assisted Treatment Medication Assisted Treatment Induction Center: July 2004Induction Center: July 2004

Response to the Community Heroin Task Response to the Community Heroin Task force and limited availability of methadoneforce and limited availability of methadone

Evidence based screening and Evidence based screening and assessment: MovingToward Informed assessment: MovingToward Informed Prescribing PracticePrescribing Practice

Evaluation for appropriateness for Evaluation for appropriateness for medication assisted therapy and level of medication assisted therapy and level of care ie care ie methadone clinic or OBOT with methadone clinic or OBOT with bup bup

Medication Assisted Treatment Medication Assisted Treatment Induction Center: July 2004Induction Center: July 2004

Induction, stabilization and transition to Induction, stabilization and transition to waivered MDs in the communitywaivered MDs in the community

Challenges: “log jam” due to limit of 30 Challenges: “log jam” due to limit of 30 patients per practice and limited number of patients per practice and limited number of community MD’s accepting patientscommunity MD’s accepting patients

Question to consider: might some of the Question to consider: might some of the needs be met with expanded methadone needs be met with expanded methadone services?services?

Induction CenterInduction Center

Chittenden Center

Induction Center

Central Vermont Substance Abuse Services: MAT

As of August 1, 2007 399 patients have been evaluated

346 have been inducted onto bup

Challenges for transitioning Challenges for transitioning patients back to the patients back to the

communitycommunity Different approaches by waivered MDs:Different approaches by waivered MDs:

Zero tolerance to more flexibility ie with THCZero tolerance to more flexibility ie with THC Very liberal script writing – weeks or monthsVery liberal script writing – weeks or months Use of single agent medicationUse of single agent medication Inconsistent use of tox screensInconsistent use of tox screens Varied experience in management of addictionsVaried experience in management of addictions

The 8 hour training does not make an addiction specialist. The 8 hour training does not make an addiction specialist. How then do we help inform medication prescribing How then do we help inform medication prescribing practices?practices?

Challenges Con’tChallenges Con’t

Reports of diversion – usually “lateral” reinforcing Reports of diversion – usually “lateral” reinforcing need for more treatment need for more treatment

Non-static nature of drug availability and population Non-static nature of drug availability and population requesting treatment – Neighboring state drug requesting treatment – Neighboring state drug seizuresseizures

DOC reports that buprenorphine is one of the most DOC reports that buprenorphine is one of the most commonly discovered contrabands in the prisonscommonly discovered contrabands in the prisons

Bup is being crushed and put under envelope Bup is being crushed and put under envelope stickumstickum

Challenges Con’tChallenges Con’t

Reports of IV use of both preparations of Reports of IV use of both preparations of bupbup

Variable availability of counseling and other Variable availability of counseling and other treatment servicestreatment services

Number of OBOT patients allowed: Number of OBOT patients allowed: Changed to 30 per MD in a practice, then as Changed to 30 per MD in a practice, then as of 2007 MDs may apply for a waiver to treat of 2007 MDs may apply for a waiver to treat 100 patients.100 patients.

Surveillance: Continued and New Surveillance: Continued and New ConcernsConcerns

Increased calls to poison control re: prescription Increased calls to poison control re: prescription opiates and benzosopiates and benzos

Maine Benzo Abuse Study: Benzo Prescribing Maine Benzo Abuse Study: Benzo Prescribing information from Dept of Surviellance and information from Dept of Surviellance and Corrections recently receivedCorrections recently received

Note: Note: Buprenorphine is actually quite low on surviellance Buprenorphine is actually quite low on surviellance

from Poison Controlfrom Poison ControlBuprenorphine is quite safe on its ownBuprenorphine is quite safe on its own

Substance Abuse-Related QuestionsTop 10 Categories - Vermont

Northern New England Poison Center's SASRS Database

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2001 2002 2003 2004 2005 2006 2007

Opioids

Benzodiazepines/Benzodiazepine-like

Unknown Drug

Non-Opioid Analgesics without sedatives (aspirin, Tylenol®)

Antidepressants

Cardiovascular (Heart)

Skeletal Muscle Relaxants

Stimulants and Street Drugs

Antibiotics and Other Anti-infectives, Vaccines

Other Drug (Chemotherapy, Radiopharmaceuticals, Diagnostic,Hormones, Antidiabetic, Antithyroid)

County VT

Count

Year Quarter

Group Name

Substance Abuse-Related QuestionsTop 10 Opioids - Vermont

Northern New England Poison Center's SASRS Database

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2001 2002 2003 2004 2005 2006 2007

Opioids - Oxycodone (OxyContin®, Percocet®)

Opioids - Hydrocodone (Lortab®, Tussionex®, Vicodin®)

Opioids - Morphine (Avinza™, Kadian®, MS Contin®,Oramorph®)Opioids - Tramadol (Ultram®)

Opioids - Methadone (Dolophine®, Methadose®)

Opioids - Propoxyphene (Darvocet®, Darvon®)

Opioids - Hydromorphone (Dilaudid®, Palladone™)

Opioids - Codeine(Tylenol®, Fiorinal® or Soma® with codeine)

Opioids - Stomach Opioids (Loperamide, Diphenoxylate)

Opioids - Buprenorphine (Suboxone®)

County VT

Count

Year Quarter

Group NameSub Group Name

Safety Depends on the ContextSafety Depends on the Context

Vermont Medical examiner: Drug related deaths in Vermont Medical examiner: Drug related deaths in Vermont, half of 2007Vermont, half of 2007

48 Drug related deaths48 Drug related deaths37 Accidental related to either substance abuse or an 37 Accidental related to either substance abuse or an

accidental overdose of prescribed pain medsaccidental overdose of prescribed pain medsOxycodone, Methadone, Antidepressants, Fentanyl, BenzosOxycodone, Methadone, Antidepressants, Fentanyl, Benzos

7 Deaths from cocaine: 4 cocaine alone 3 in combination with 7 Deaths from cocaine: 4 cocaine alone 3 in combination with other drugsother drugs

8 Included ETOH8 Included ETOH 7 Suicides: all included prescription and/or OTC medications7 Suicides: all included prescription and/or OTC medications

More Context Issues:More Context Issues:

Medicaid Data: Benzos and bup from different Medicaid Data: Benzos and bup from different providers; several bup providers providers; several bup providers

Non-waivered MDs, PAs and APRNs prescribing Non-waivered MDs, PAs and APRNs prescribing

buprenorphine for “pain”buprenorphine for “pain”

MDs identified as being “easy” to get scripts for MDs identified as being “easy” to get scripts for bup frombup from

Are the right patients getting OBOT with bup? Are the right patients getting OBOT with bup?

How much does increased access contribute to How much does increased access contribute to diversion?diversion?

Surveillance: A Positive NoteSurveillance: A Positive Note

Medicaid: Reported a decrease in Medicaid: Reported a decrease in utilization of other medical services for utilization of other medical services for patients being treated with MATpatients being treated with MAT

Vermont has the highest number of Vermont has the highest number of waivered MDs per capita in the countrywaivered MDs per capita in the country

Vermont has the highest number of Vermont has the highest number of prescriptions for buprenorphine per capita prescriptions for buprenorphine per capita in the countryin the country

Where there are little fires, are Where there are little fires, are there Dragons?there Dragons?

Is patient/public safety being compromised?Is patient/public safety being compromised?1) Asking too much from MDs with 1) Asking too much from MDs with limited addictions limited addictions treatment experiencetreatment experience and from a system with a lack of and from a system with a lack of MAT experienced counseling?MAT experienced counseling?2) Contributing to the prescription meds used on the 2) Contributing to the prescription meds used on the street?street?3) Revisit of the question: Are the right people getting 3) Revisit of the question: Are the right people getting buprenorphine?buprenorphine?

BuprenorphineBuprenorphine

Let’s not demonize the Let’s not demonize the medication!medication!

There have to be scripts out There have to be scripts out there!there!

Vermont MAT ServicesVermont MAT Services

050

100150200250300350400450500550600650700750800850900950

10001050110011501200

2003 2004 2005 2006 2007

Waivered MDs

Meth Patients

Bup Patients

Vermont Legislature Response* to Vermont Legislature Response* to Continued Treatment Needs: Continued Treatment Needs:

One-TimeOne-Time Funding to Funding toADAPADAP

&&OVHAOVHA

Increase Treatment Availability to MAT Increase Treatment Availability to MAT (Specifically Bup) (Specifically Bup)

and and Increase in Informed Medication PrescribingIncrease in Informed Medication Prescribing

* Senator Bartlett* Senator Bartlett

ADAP: Support and Coordination of ADAP: Support and Coordination of Treatment for Waivered MDsTreatment for Waivered MDs

$350,000$350,000Dispersement Plans:Dispersement Plans: 25K to pay for MD CMEs and a one time 25K to pay for MD CMEs and a one time

stipend to offset time away from practicestipend to offset time away from practice 315K Granted to the Howard Center to 315K Granted to the Howard Center to

provide care coordination to waivered MD provide care coordination to waivered MD practices (Coordination of Office Based- practices (Coordination of Office Based- Medication Assisted Therapies)Medication Assisted Therapies)

10K to FAMC for evaluation component 10K to FAMC for evaluation component of project of project

Office of Vermont Health Access Office of Vermont Health Access

(OVHA): Capitated financial incentive(OVHA): Capitated financial incentive $500,000$500,000

Dispersement Plans:Dispersement Plans: Calculated Percent increase above Calculated Percent increase above

Medicaid Medicaid reimbursement depending on acuity reimbursement depending on acuity of patientof patient

5% lump sum bonus incentive for each 5% lump sum bonus incentive for each increase in patient numbers by fiveincrease in patient numbers by five

10K match to FAMC to match ADAP’s 10K match to FAMC to match ADAP’s contribution for evaluation componentcontribution for evaluation component

Coordination of Office Based-Coordination of Office Based-Medication Assisted Therapies Medication Assisted Therapies

(COB-MAT)(COB-MAT)Care Coordination offered to all waiveredCare Coordination offered to all waiveredMDs. MDs. MandatoryMandatory if MD plans to participate in if MD plans to participate inincreased remuneration program.increased remuneration program.

One state wide coordinatorOne state wide coordinatorSix regional coordinatorsSix regional coordinatorsMAT Tool KitMAT Tool KitStart up date: December 1, 2006Start up date: December 1, 2006

COB-MAT RegionsCOB-MAT Regions

Chittenden Center Central Vermont Substance

Abuse Services: MAT

Mobile Methadone Programs

Newport and St Johnsbury

West Lebanon

New Hampshire

Coordination of Office Based-Coordination of Office Based-Medication Assisted TherapiesMedication Assisted Therapies

Development of MAT “Tool Kit” for officesDevelopment of MAT “Tool Kit” for officesProvision of education to MD office staff re: MAT, Provision of education to MD office staff re: MAT,

contracts, tox screens, legal obligations (ie for contracts, tox screens, legal obligations (ie for termination)termination)

Facilitation of transition of patients from Induction Facilitation of transition of patients from Induction Center to community Based, waivered MDsCenter to community Based, waivered MDs

Follow up on treatment plan to assess efficacy (not Follow up on treatment plan to assess efficacy (not treatment “cops”)treatment “cops”)

Distribute MD satisfaction questionnairesDistribute MD satisfaction questionnairesProvide data to state wide coordinatorProvide data to state wide coordinator

Coordination of Office Based-Coordination of Office Based-Medication Assisted TherapiesMedication Assisted Therapies

State Wide CoordinatorState Wide CoordinatorOversees regional coordinatorsOversees regional coordinatorsCollects data and works with research Collects data and works with research team at Fletcher Allen Medical Center for team at Fletcher Allen Medical Center for assessment portion of projectassessment portion of project

Fletcher Allen Medical Center Fletcher Allen Medical Center Research Team Research Team

Participating physicians: Participating physicians: 35 new MDs waivered since the one-time expenditure.35 new MDs waivered since the one-time expenditure.

As of June 30, 2007As of June 30, 2007

79 MDs were participating in the project79 MDs were participating in the project

Region 1 (Northeast Kingdom): 48 clients Region 1 (Northeast Kingdom): 48 clients

Region 2 (Chittenden County, and Northwestern Vermont): 61 clients Region 2 (Chittenden County, and Northwestern Vermont): 61 clients

Region 3 (Rutland and Central Vermont): 43 clients Region 3 (Rutland and Central Vermont): 43 clients

Region 4 (Southern Vermont): 10 clients Region 4 (Southern Vermont): 10 clients

Fletcher Allen Medical Center Fletcher Allen Medical Center Research Team Research Team

(Dr. Thomas Simpatico)(Dr. Thomas Simpatico)Establishment of data bases and collection Establishment of data bases and collection

formatsformatsWill be providing feedback regarding Will be providing feedback regarding

increases in access to treatment and increases in access to treatment and satisfaction satisfaction

Comparison of increasing access, use of Comparison of increasing access, use of capitated program and overall medical capitated program and overall medical service use of patients treatedservice use of patients treated

Phase I Results Phase I Results Program Participants Show:Program Participants Show:

Very low rate of arrest and incarceration:Very low rate of arrest and incarceration:Anecdotal reports indicate this may Anecdotal reports indicate this may represent a reduction represent a reduction when compared to when compared to pre-program arrest and incarceration pre-program arrest and incarceration rates. rates.

Variability in retention*:Variability in retention*:The tendency to drop out of the program The tendency to drop out of the program may correlate may correlate with identifiable and with identifiable and addressable issues including treatment addressable issues including treatment modality assignmentmodality assignment

Phase I Results Phase I Results

Variability in terms of:Variability in terms of:Illicit substance abuse and honesty Illicit substance abuse and honesty about it*about it*

* Potentially predictive concerns ie: matching * Potentially predictive concerns ie: matching treatment to patient needstreatment to patient needs

Phase I Results Phase I Results

There may be a relationship between attitude of There may be a relationship between attitude of physician, RCC, and program councilors with physician, RCC, and program councilors with positive treatment outcomes positive treatment outcomes

Phase I ContinuedPhase I Continued

“ “Positive relationships with their Positive relationships with their siblingssiblings””

Greater probability of remaining active Greater probability of remaining active throughout the sample period of the evaluationthroughout the sample period of the evaluation

Helpful in devising strategies and protocols that Helpful in devising strategies and protocols that would best match candidates for treatment with would best match candidates for treatment with particular treatment modalities (e.g. methadone particular treatment modalities (e.g. methadone vs. buprenorphine).vs. buprenorphine).

Phase I ContinuedPhase I Continued

IOP SurpriseIOP Surprise

IOP may be less effective for Bup patientsIOP may be less effective for Bup patients

This result may be a proxy for various factors ie:This result may be a proxy for various factors ie:A selection bias which places the most A selection bias which places the most

challenging clients in the more intensive challenging clients in the more intensive programming, thereby selecting a group programming, thereby selecting a group which which may have a natural inclination to fail may have a natural inclination to fail programming. programming.

Methadone ExpansionMethadone Expansion

Decrease travel to out of state Decrease travel to out of state methadone programs:methadone programs:

Use funding to increase in state Use funding to increase in state capacity!capacity!

Transportation to out of state Transportation to out of state methadone programsmethadone programs

Manchester NH Methadone Program

Greenfield, MA Methadone Program

Transportation of 11 patients to out of state clinics:

1) Huge travel expense

2) Tremendous time commitment for patients

Newer InitiativesNewer Initiatives


Prescription Drug Abuse Work Prescription Drug Abuse Work GroupGroup


Hopeful start up in the Spring ‘08 Hopeful start up in the Spring ‘08

Intention:Educational opportunitiesIdentification of patients in need of treatment

NO FISHING EXPEDITIONS!


Response to the Fentanyl Laced Heroin Related Deaths in Cook County IL, Camden NJ, and Philadelphia PA. 2006


Prevention State LabVermont Poison Control CliniciansMedical Examiner Public SafetyPMP Manager NH SMAStudent Assistance ProgramsBoard of Pharmacy


Goals:Education re: prescribing of controlled substances for MDs and non-MD practitioners

Education for non-medical clinicians

Prevention

Information repository for Vermont and neighboring states

Drug Disposal?

DreamsDreams

Enough treatment options for the treatment of opiate dependenceBuprenorphine and COB-MAT vs Methadone Programs

Decrease in high prescribing of narcotics and other substances that may be abused

Improved education to MDs and publicSurveillance through Poison Control and Prescription Monitoring

expansion of m at in vermont: minding the crouching dragons!

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