1. Baltimore Buprenorphine Initiative: A Case Study of System Change Robert P. Schwartz, M.D. Friends Research Institute Open Society Institute-Baltimore

2. Stakeholders & Leaders Baltimore City Health Department (BCHD) Joshua Sharfstein, M.D.; Marla Oros, R.N; Vanessa Kuhn Baltimore Substance Abuse Systems (BSAS) Adam Brickner; Bonnie Cypull, M.S.W. Baltimore Health Care Access (BHCA) Kathleen Westcoat; Tracey Kodek, Sadie Matarazzo Mid-Atlantic Community Health Center Association Rebecca Ruggles Treatment Providers Tracy Schulden, Wendy Merrick Maryland Medical Society Meena Abraham, M.P.H. Foundations Abell, Annie E. Casey, Bearman, Kreiger, Open Society Institute-Baltimore, & Weinberg

3. Heroin Addiction: The Problem Baltimore has a storied history of heroin addiction Most addicted individuals are not in treatment Treatment capacity is inadequate to meet demands

4. Buprenorphine Partial opioid agonist Effective in reducing heroin use Longer treatments at higher doses yield better outcomes Good safety profile Available by prescription since Fall 2002 Certain restrictions apply MD offices, community health clinics, drug-free outpatient treatment, hospital and STD clinics, needle exchange programs

5. Infuse the Health System Community Health Centers: 2002 – 2005 Started 90-day detoxes at 4 centers Resistance to longer-term treatment met by compromise Medical Society: 2003 -2004 Increase interest in obtaining the “waiver “ Educational sessions Surveyed members about barriers Hospital Outpatient Clinics: 2005 -2006 Expanded treatment into 4 clinics

6. Formulary Approval Buprenorphine was included in Maryland Department of Health’s drug formulary (2003) through the effort of CSAT, the State Health Department, Medicaid Program and Alcohol and Drug Abuse Administration Medicaid Program Primary Adult Care Program Ryan White Program

7. Change the Treatment System Baltimore Substance Abuse Systems (BSAS) 6 providers were offering 3- 10 day buprenorphine detox June 2005: Community Health Centers presented outcome data for their 90-day buprenorphine programs BSAS proposed change to a longer-term model August 2005: BSAS convened a provider roundtable Some resistant to change Thought their outcomes were good

8. Data Drives the Plan November 2005: New Health Commissioner BSAS presents short-term detox outcome data: Completion rate: 66% 90-day retention: 18% BSAS mandates future migration to longer-term treatment Continue provider roundtable Begin MD meetings Seeks to maximize use of public insurance coverage

9. Goal Reduce the city’s heroin-addiction problem Transform its buprenorphine treatment model from short- term detoxification to longer-term treatment Expand access to effective treatment build on the existing medical system utilize existing public health insurance Improve patient outcomes

11. Leadership for Change Health Department BSAS Provider Roundatable Physician Roundatable BHCA

12. Coordinating Committee: Change-Structure Key lead agencies: BCHD, BHCA and BSAS Each agency had clear role BCHD: recruit physicians, paid for waiver training BHCA: case management, benefits coordination, advocated with state and MCOs, drafted procedures BSAS: treatment, practice guidelines, shifted funding Each agency dealt with its strength Dealt with new issues as they arose Buprenorphine urine test, ID cards for benefits, drug testing for health center, bulk purchasing

13. Provider Roundtable: Preparing to Change Program directors and BCHD, BSAS and BHCA Decision-making by consensus Minutes distributed BHCA wrote protocols and forms for the providers All documents considered drafts Alleviated strain on providers and delay

14. Protocols Counseling and Medication Pharmacy relationships - Billing BHCA prepared patients for transfer Patient “passport” - MD to MD: Transfer criteria, drug testing, med/psych history, dose, recommended frequency of visits

15. Switch to Longer-term Treatment: July 2006 Contract SNAFU needs fixing September 2006: Provider pushback - BSAS doesn’t want to dictate to providers - Some providers resist longer-term therapy - Resist cross-site standardization, case managers, paper work - Resolved through leadership & consensus building BCHD & BHCA met with primary care providers

16. Outcomes 1,367 patients treated 33%: currently enrolled in treatment 25%: transferred to primary care Average of 163 days in drug program prior to transfer 57% retained in treatment at least 90 days Includes patients who wanted shorter-term treatment MTP retention (83%) short-term detox retention (18%) 83 % obtained health benefits 82 new MD “waivers”

17. Principles of Implementation

18. Keep Your Eye on the Big Picture City’s mission: treatment-on-demand Focus on the patient

19. Chose Intervention Wisely Scan national environment for evidence-based treatments NIDA Clinical Trials Network, local University researchers, ATTCs Can it impact a major problem? Can it be implemented in stages, if necessary? Can it be implemented with fidelity? Can it be brought to scale?

20. Effective Leaders Dedicated staff with allocated time Good interpersonal skills - collaborative Organized Respected lines of authority Provided technical assistance during change to all players

21. Good Communication: Internal Provider and MD Roundtables Regularly scheduled, rotated site w/food Respectful and incorporated feedback to build trust Flexible but persistent It became a priority for the providers BHCA prepared documents and organized meeting MDs began to play a more active role in these formerly “drug- free” treatment programs

22. Good Communication: External Get support from community leaders & key stakeholders - Mayor, Health Commissioner & Congressman wrote letters to hospital CEOs to get their plan to train MDs - Garnered support from legislators and judges Email list-serve updates Release summary reports Press conference Prepare for challenges at every step

23. Use External Experts Expert Advisory Group Expert MDs to consult with practitioners Dosing Counseling Prescribing practices

24. Diversify Funding Federal, state and local grants Health insurance: Medicaid and state programs Local and national foundations Redirect existing drug treatment money Special populations HIV Criminal justice Social Services

25. Use Meaningful Incentives Health Centers: free drug testing, patients with benefits, case management Drug Treatment Providers: increased funding, case management, discounted medications through bulk purchasing Physicians: BCHD paid for waiver and training Patients: better treatment, case management, health benefits

26. Lesson Learned One project can teach you about the strengths and weaknesses of the entire system