e-Solutions February 2014
eSolutions: February 2014
Feature article: Medication Assisted Treatment: A Standard of Care
Grantee Feature: From Pilot to Practice: Medication Assisted Treatment in San Mateo County
Quick Tips: 5 training resources on MAT
Featured resource: SAMHSA’s Opioid Dependence Toolkit
An interview with Elinore McCance-Katz, MD, PhD, Chief Medical Officer, SAMHSA
Untreated substance use disorders are deadly. This should give us all pause.
We have a huge need in our country to treat mental health and substance use concerns, and we have a chronic shortage of specialty care programs with enough capacity to treat everyone with a substance use concern. It is our responsibility to expand access to this care in a way that allows greater choice of where individuals can receive treatment.
With the Affordable Care Act, the treatment of substance use disorders is now an essential benefit. Individuals with multiple complex healthcare needs, including mental health and substance use concerns, can be seen in integrated care settings and health homes.
We are going to see more and more integrated care. All healthcare providers, whether in primary care, mental health, or substance use treatment, will need to learn how to provide treatment for disorders they may not have historically treated. Providers who are not used to treating patients with certain types of problems may not feel confident about providing care. When that happens, the individual is less likely to get the care they need. Primary care providers especially will need to be ready to assess and provide treatment for clients who present with mental health and substance use concerns.
The Need for Medication Assisted Treatment
Medication assisted treatment (MAT) is a standard of care. There are a variety of medications that have been shown to be effective in treating substance use disorders and that can be used safely. Specifically, there are a number of FDA-approved medications for tobacco, alcohol and opioid abuse treatments.
MAT is an effective form of care, when medication is taken as prescribed, used properly, and the individual is engaged with other supports and services. With opioid use disorders, studies show that clients who get medical detoxification only have a greater than 90% relapse rate. On the other side, literature on methadone maintenance shows that these medications are quite effective. Methadone has been researched for many years, and there is no evidence that there are long-term serious health effects. Certainly there are side effects and some potential health concerns, but overall, people have tolerated it very well without serious health problems as a result.
We have to think about how effective the treatment is, what the alternative is if not treated, and where an individual is in their recovery. Individuals with chronic relapsing diseases should have access to MAT. It’s just the standard of care. We cannot diminish the importance of that.
For someone with a severe alcohol use disorder, withdrawal can be life-threatening. They are physically dependent on alcohol. Each time they relapse, they are at greater risk of life-threatening diseases. These are very serious considerations and concerns.
Substance use disorders are not simply treated by taking a medication. In fact, taking medications can be part of the problem. Just giving someone medication is not enough. Psychosocial interventions, counseling, and other services are absolutely necessary and will always be very important.
Integrated care providers are going to have to learn about how to use these medications. Many medications can be used within primary care. We’re going to see a spectrum of severity with clients in primary care. Some may need referral to specialty care and others can be treated at the primary care organization.
Challenges to Adoption
One challenge is simply encouraging providers to adopt the change. Many of these medications are fairly new. Some, such as methadone, have only been used in very specialized treatment settings. Integrated care settings have relatively low barriers to adoption of MAT. They have providers trained to address substance use and professionals on hand who can prescribe the medications.
In the substance use treatment field, there has been a focus on psychosocial treatments for many years. Every individual is different and has different needs. We have to confront the idea that abstinence-based treatment can be successful for everyone. Individuals with substance use disorders deserve care that involves an individualized treatment plan, and the support of their healthcare provider such that they receive all of the care needed to support them in recovery.
A big concern is always how providers are going to get paid. With time, we will see more ability for providers to get reimbursed for services that will include MAT. These issues will probably be addressed within states, and the Centers for Medicare and Medicaid Services (CMS) will provide ongoing guidance.
Learn more about MAT
If providers are unsure of how to provide MAT, they need to educate themselves. Primary care and behavioral healthcare providers alike should be trained on the recognition and treatment of substance use disorders. There are numerous trainings related to MAT available – for free – to providers. SAMHSA has two programs focused on creating a clinical support system for how to assess, how to make appropriate decisions on the use of the medications, and how to recognize problems with misuse, if they occur. Counselors, social workers, and other allied providers can all benefit from these trainings. (See the Quick Tips for more).
At this point, the use of MAT for individuals who have a history with a severe substance use disorder or have a chronic relapsing disease is really an ethical issue. These individuals need access to the treatments to help them recover. It is the right and ethical thing to do.
Medication assisted treatment (MAT) is the use of pharmacological medications, in combination with counseling and behavioral therapies, to provide a ‘whole patient' approach to the treatment of substance use disorders.
Robert Paul Cabaj, MD, Medical Director, San Mateo County Behavioral Health and Recovery Services
In 2012, San Mateo County’s Behavioral Health Director was visiting treatment centers in the community when he came across a wall full of photos. It was a gallery of all the clients who had died from alcoholism in the past two years.
Seeing and learning just how many individuals in the county had severe alcohol use, he tasked us with looking into how to better address these concerns. At the same time, we learned about an integrated care provider who had tested the use of long acting naltrexone at their center.
We decided to begin with a pilot initiative involving 10 clients. We focused on the use of long acting naltrexone for clients who were 18 or over, were misusing alcohol, had two or more emergency room (ER) visits over the past two months, and were not currently using opiates. Looking at data on ER use, we were able to quickly find 10 people willing to participate in the pilot. We trained nurses on how to give the injections and arranged for where the injections would be given.
In the initial phase of the pilot, emergency room use practically disappeared, from an initial average of 5.8 visits per client in six months, down to 0.2 visits. This dramatic reduction shows an evident cost benefit. The cost of the medication may be high (for Medicaid clients, the medication costs around $750 per month, and exceeds $1,000 per month at retail), but if you can eliminate six ER visits in six months, you save more than enough to cover the cost of the medications. In addition to the reduction in emergency services, we have also seen a decrease in the drinking days of participants, and many participants have been able to switch to less expensive oral medication over time.
We knew we could expand the pilot with another payer source. In California, all counties have a health plan that coordinates local Medicaid (and in some cases Medicare). We met with them and showed them our pilot results, which led to expansion of the pilot to 16 clients.
All 16 clients in the initiative are now in stable living arrangements, some are employed, and some have been able to stop the medications and remain sober through traditional substance use treatment services (including 12 step programs).
Given these successes, we are working to move this from a pilot phase and into our mainstream operations. To do so, we will train more providers, particularly nurses, on the use of medication, and educate our clients and county partners on the impact of MAT. With Medicaid expansion, we are working with our health plan to have them cover the medication for clients enrolled in Medicaid.
We also want to extend the use of the full range of MAT interventions, including oral medications, and interventions to address tobacco use and opiate use. We looked into the information on these interventions and created a set of guidelines for both behavioral health and primary care providers to follow.
To support broad implementation across the county, we train psychiatrists and psychiatric nurse practitioners in integrated settings on the medication guidelines and offer the opportunity for them to consult one-on-one with a psychiatrist who has an addiction medicine background. We now have trainings specific to both the use of buprenorphine and pain management. We worked with medical students and psychiatric residents to update the clinical guidelines, and we developed grand rounds on pain management strategies for both primary care and behavioral health providers.
We are seeing increased interest and awareness of MAT. Centers across the county are required to use a version of SBIRT, and California’s Medicaid program (Medi-Cal) added substance abuse treatment, detoxification, and medication management as new benefits, and that has spurred interest in our guidelines and training from providers wanting to learn about how to implement MAT.
We also have a new health system task force on managing long-term opiate use. The task force consists of integrated clinics from throughout the county, and we are working to develop interventions which will work at each center, so we can have MAT available to everyone who can benefit from it.
Have an example of how your center implemented medication assisted treatment, or addresses clients with substance use concerns? Share your story, email firstname.lastname@example.org.
Offering medication assisted treatment requires your team members to understand substance use disorders and be comfortable addressing them with clients. The following trainings and educational materials can help team members at all levels learn more about substance use and medications to treat addictions.
- Check out SAMHSA's Providers Clinical Support System for Medication Assisted Treatment (PCSSMAT) and the American Psychiatric Association’s 2014 webinar series on MAT. Oriented toward prescribers, webinar topics include pain management, the psychology of AA, and treatment options.
- Dive into the Addiction Technology Transfer Center network’s series of online courses designed to help counselors and line staff better understand substance use and MAT.
- Review SAMHSA’s Treatment Improvement Protocol (TIP) guides related to MAT, including TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs, and TIP 49: Incorporating Alcohol Pharmacotherapies into Medical Practice.
- Listen to Recovery to Practice’s archived webinar on the use of medications in a recovery-oriented practice for guidance in talking to and working with clients regarding medication.
- Read the Getting Started with Medication Assisted Treatment toolkit from NiaTx.
More resources on MAT can be found on CIHS’ MAT web page.
SAMHSA's Opioid Overdose Toolkit prepares communities and local governments to develop policies and practices to help prevent opioid-related overdoses and deaths. The toolkit addresses issues for first responders, treatment providers, and those recovering from opioid overdose.
CIHS and the Annapolis Coalition on the Behavioral Health Workforce released Core Competencies for Integrated Behavioral Health and Primary Care, to shape workforce training, inform job descriptions, recruit ideal candidates, orient staff to the integrated care model, and complete performance assessments. Be sure to visit the workforce section of the CIHS website for up-to-date resources relevant to all parts of the integrated care team.
Applications are now being accepted for the Eugene Washington PCORI Engagement Awards (up to $250,000 each) to support patient-centered outcomes research efforts. View the archived webinar for more information on the program.
The Kaiser Family Foundation’s issue brief, Integrating Physical and Behavioral Health Care: Promising Medicaid Models, examines five promising approaches currently underway in Medicaid to better integrate physical and behavioral healthcare. The five approaches include universal screening, navigators, co-location, health homes, and system-level integration.
Population Health Implications of the Affordable Care Act summarizes a roundtable discussion from the Institute of Medicine on opportunities within the ACA to focus on population health improvement and outcomes.
A recent study in the Journal of Studies of Alcohol and Drugs found that asking a single question about drinking and a single question about drug use could indicate if a person was using substances in a risky manner, and whether the behavior was severe enough to merit referral to specialty treatment. The findings emphasize the importance of short screens in primary care settings.
Resources for the New Integrated Healthcare Workforce: Join us on March 6 to discuss the newly released set of core competencies for the integrated workforce, explore a provider’s perspective on workforce considerations, and share resources related to these competencies. CIHS’ workforce resources include job descriptions, workforce training, and recruitment and retention programs.
The Role of Peer Providers in Integrated Care Settings: As integrated care teams increasingly incorporate peer providers, employers are learning new strategies to effectively hire and support them in the workforce. On March 25, learn from a peer provider and her supervisor how their organization supports a strong peer workforce, and discuss practical issues such as job descriptions, the hiring process, supervision, billing, and training opportunities.