2,156 36,628 6,780 16,427 8,860 11,817 67,077 26,168 9,601 24,029 37,069 8,485 7,028 11,113 38,520 *U. S. Census Bureau: 2010 Population of UP Counties
Total population: 311,258 The UP holds 30% of the total land mass and 3% of the state population. Three largest cities in the UP* Marquette21,000 (Marquette County) Sault Ste. Marie14,000 (Chippewa County) Escanaba12,000 (Delta County) * 2010 U.S. Census
Healthy Behavior Clinical Care Social & Economic Physical Environment
The UP has a growing problem with opiate and prescription drug abuse.
NationalMichiganUP Alc. dep. or abuse in past year7.537.798.05 Illicit drug dep or abuse in past year2.822.883.07 Dep. on or abuse of any illicit drug9.079.4110.00 or alcohol in past year Nonmedical use of pain relievers in past year among person aged 12 or older NationalMichigan UP 5.005.63 5.29 MDCH, Mental Health & Substance Abuse Administration Bureau of Substance Abuse & Addiction Services State & Substate Estimates of Substance Use in Michigan 2006-2008 National Surveys on Drug Use and Health
Traditional outpatient and residential treatment programs Methadone... not available in the UP Green Bay, WI – 175 miles Muskegon, MI – 440 miles Buprenorphine 4 physicians accepting new patients
Medication approved for the OP treatment of opiate dependence in 2000 (Drug Abuse Treatment Act of 2000). Set physician qualifications for prescribing. FDA approved Suboxone/Subutex in 2002. Partial Opioid Agonist Ceiling effect Withdrawal & Craving
Multiple reports of addicts snorting or using IV. Amount of naloxone may not be enough for some individuals. This is an abusable drug – like most, can be used for good or evil.
Prescribers must go through special training and are issued a separate DEA number. Prescribers are limited to 30 patients for the first year. Can apply for a waiver and treat up to 100 after the first year. Many prescribers want this population out of their office.... Prescribers still have limited knowledge of addiction.
Yes It isn’t the “drug of choice” but it is (significantly) better than nothing ▪ The “high” experience ▪ Expectancy ▪ Relief from sick to not sick Great to have on hand in case addict can’t score ▪ Selling/trading for full agonist
Methadone is currently the “standard of care” for the pregnant opiate addict. ACOG: Buprenorphine Versus Methadone Treatment for Opiate Addiction in Pregnancy: An Evaluation of Neonatal Outcomes, 2010 Lower NAS scores for the Subutex babies ▪ 10.69 versus 12.5 Shorter LOS ▪ 8.4 versus 15.7 Less than 50% of Subutex babies requiring treatment versus 73% of methadone babies
June of 2007 – MGHS accepts first patient Brief phone screen Quickly overwhelmed Swamped with phone calls High “hassle factor” ▪ Reports of “lost” or “stolen” meds ▪ Requests for early refills ▪ Refill requests... from jail High volume of drop-outs and non-compliance April of 2008 – Discontinued admissions 10 months and 29 patients
No denying how desperately this service was needed. At this point, only one other physician prescribing in the UP. We had a handful of patients who were doing well for the first time in their lives. This posed an interesting and challenging question: How do we expand this classification of patients?
Prescribing physician left our organization Dr. John Lehtinen agrees to prescribe. Road trip
How do we manage a limited resource? How do we make this service available to the best treatment candidates? How do we manage the “hassle factor” and prevent burning out our staff and physician? How do we maintain our integrity and credibility with local agencies, treatment providers, law enforcement, and most importantly, our patients?
Slowing down the process and looking for the best matches for the medication. Rationale for the application: Completing and mailing the application would require effort. The application would allow us a better opportunity to screen applicants and potentially fill the limited treatment slots with those in the best position to benefit from buprenorphine.
Items from criteria in TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Dependence: History of treatment completion/compliance Not currently abusing benzos, sedative-hypnotics, or barbiturates Not currently abusing alcohol Supportive living environment Supports for recovery
Dependence is limited to opiates Employed No medical contraindications Indicated agreement to abide by rules and expectations.
Already being treated with Suboxone and successful Active in substance abuse treatment Treatment goal of abstinence Has resources to pay for treatment and medication Not in collections with us “Clean” MAPS Application is complete
Buprenorphine screening questionnaire MGHS Personal Data form Releases of Information to the PCP and current substance abuse professionals, as applicable Treatment contract* Patient and family information about buprenorphine Summary of substance use
Program Requirements: Attendance at all scheduled appointments Attendance at a substance abuse program ROI’s to all physicians and counselors/therapists Abstinence from alcohol and drugs
Patient Responsibilities: Store medication properly Take as prescribed Pill counts Drug testing Notify office if medication lost or stolen Notify of relapse Payment for services
Application is sent to caller. Returned applications are “scored” Review by Committee Higher scoring applicants are contacted to schedule appointment with physician and for induction; assuming no medical contraindications. The score sheet – no magic number or total score for automatic admission
Receive letter with specific treatment recommendations and an invitation to meet with addiction physician in consideration of other treatment options. Receive instructions regarding how to access services for his/her circumstances, i.e., location, treatment history, funding source, etc. Encouraged to contact us for second review if treatment recommendations are followed through.
Prescribing Physician Director of Clinical Services Clinical Supervisor Clinician
Provides forum to review program policy, discuss clinical challenges, and advocate for candidates. Takes “heat” away from prescribing physician.
Between August of 2009 and March of 2011 more than 350 applications were distributed.
50/50 split between males/females Average distribution rate has been 18 per month Nearly half (170) of the 350 applications were completed and returned to the Review Committee 28% of those who have returned applications have been admitted for buprenorphine treatment.
Average age 29.8 Age: 171% 18-3061% 31-4028% 41-508% 51-651% Race 91% Caucasian 9% Native American Sex Male46% Female54%
June 2007 – April 2008 (10 months) 29 patients admitted 22 of original 29 were discharged 20 of the 22 were discharged by October of 2009, however, nearly half were gone within the first 4 months of treatment 13 dropped out 7 discharged “at staff request” 2 completed
August 2009 – March 2011 (19 months) 48 patients admitted 7 discharges 5 dropped out 2 discharged “at staff request” Retention rate went from 24% to 85% Significant reduction in the “hassle factor” Able to more than double admissions without additional staff resources Currently have 76 patients enrolled in the program.
Pregnancy The only exception to the application process The application process would delay treatment Acknowledgement that our focus has shifted to treat the pregnant addict and provide the best possible start for the baby. ▪ Limited window to engage the patient in treatment and recovery.
Non-compliance with counseling Late entry into pre-natal care and treatment Shame Use of other drugs/continued drug use Poor support system Poverty Distance from physician (from all over UP) “Hostage” until birth Case coordination between OB/NICU and prescribing physician Pregnancy to access program.
High volume of pregnant addicts seeking treatment with buprenorphine 43 since December of 2010; 40 pregnant at admission The return of the “hassle factor” Incentive to comply ▪ About 25% compliance but improving. Better outcomes from NICU Shorter LOS and less severe withdrawal
How significant problem of opiate addiction is in the UP Buprenorphine isn’t for everyone The application process is an effective way to manage a valuable and limited treatment resource Support group didn’t fly. How long should someone be on buprenorphine? A controversial and individualized question.
Counseling need to start before the buprenorphine and the longer the better We need to continually “take our own inventory” regarding attitudes, beliefs, biases, regarding buprenorphine treatment and patients. We still have much to learn.... More challenging and stimulating opportunities lie ahead....
Shawn K. Hatch, ACSW, LMSW, CCS, CAADC Director of Clinical Services, Behavioral Health Marquette General Health System Shawn.Hatch@mghs.org (906) 225-3214