1. Substance Abuse Treatment in the FQHC: Managing the Opioid Crisis
PCC Community Wellness Center
Amanda Brooks, LCSW, CADC
Director of Behavioral Health
Katherine Suberlak, LCSW
Chief Population Health Officer

2. Objectives
Explanation and justification for the integration of substance abuse treatment into the integrated primary care and behavioral health model
Understanding of State and Federal regulations for medication assisted treatment
PCC as an example of Integrated Model of Care
Tools for considerations of safety and risk management for treatment of the opiate dependent patient
Effective MAT options in primary care
Outcome measures and provider satisfaction
A case study

3. Opioid Overdose Deaths- United States, 2000-2014
Rudd R et al MMWR 2016

4. Nonmedical Use of Prescription Opioids and Heroin among Noninstitutionalized Persons 12 Years of Age or Older, 2002–2014
Original Data from the Center for Behavioral Health Statistics and Quality; slide from NEJM 374; 2

5. Mental Health Indicators
National Data for any mental illness, 2014
25.7% of individuals living below the Federal Poverty Level
5.5% have a co-occurring MH/SUD
Compared to 15.4% for those at 200% of the poverty level or higher
2.7% have a co-occurring MH/SUD
2014 survey data for treatment of reported mental illness
18.8% of the African American/Black respondents
26.3% of White respondents
accessed 4/15/16

6. Mental Illness & Substance Abuse Climate in Illinois
2004
˃1.2 million Illinois residents suffered from a Substance Use Disorder (SUD)
10 percent received treatment.
˃ 266,000 individuals with co-occurring MISA disorders
6 percent received care for both.
, Illinois decreased treatment capacity for SUD’s by 52%
number one treatment capacity decline in the United States
10% of illinois population had SUD, 2% had Co-occurring

7. Primary Care: Opportunity for Integration
As much as 70% of all behavioral health conditions are treated in primary care
66-74% of all depression management occurs in the primary care setting
As many as 2/3 of primary care providers had no access to specialty behavioral health care.
When referral sources were available, those that showed to a first appointment- 44% with a cold referral, 76% with a warm handoff to a specialty provider
12% of the non-elderly population are uninsured
22% of non-elderly population receive Medicaid
1 in 5 of the non-elderly population receive Medicaid
Seelert RK, Hill RD, Rigdon MA, et al. Measuring patient distress in primary care. Family Medicine 1999;31:483–7
Kolbasovsky A, Reich L, Romano I, et al. Integrating behavioral health into primary care settings: a pilot project. Professional Psychology: Research and Practice 2005;36:130–5

8. Federal Regulations for the Prescribing of Buprenorphine
DATA Waiver
Limited to MD providers
Must complete an 8hr approved ASAM training course, sit for online test, and submit application for change in DEA number
30 patients in the first year of attaining the Waiver
Increase to 100 patients after 1 year of prescribing
Comprehensive Addiction Recovery Act (CARA)- passed 7/21/16

9. Public Act 99-840 (HB1) Medicaid Coverage
Requires coverage of all FDA approved MAT, including methadone once federally approved
Removes all lifetime limits for MAT
Removes prior authorization requirements
Requires coverage of all antagonist medications
Applies Illinois mental health and substance use disorder parity requirements to Medicaid
Certain pharmacist training provisions for naloxone only must be completed prior to going into effect. : The law requires pharmacists to be trained before initiating a prescription for naloxone. Training in the use and administration of naloxone is also required for non-medical professionals prior to distributing naloxone to them. Many of the opioid antagonist provisions will not be implemented until this training is completed. Filling a prescription initiated by a doctor, nurse practitioner or physician assistant does not require any training.

10. Public Act 99-840 (HB1) con’t Drug overdose prevention
Authorizes pharmacist-initiated prescribing of overdose medication, (pending training).
Allows health professionals to prescribe overdose medications to persons not personally at risk for overdose,(pending training).
Protects health professionals from criminal liability for administering or prescribing overdose medications
Explicitly protects lay people from civil liability for administering overdose medications
Requires the state to train police, fire fighters, first responders and school personnel in the use of opioid antagonist medication, and have access to these medications in the course of their work (pending training).

11. Public Act 99-840 (HB1) con’t Other major provisions
Expansion of the Illinois Prescription Monitoring Program
Establishment of medication take back program for unused medications
Expands access to drug courts
Institutes drug education in elementary, middle, and high schools

12. Public Act 99-840 (HB1) con’t Private Insurance
Expands parity requirements to include coverage for opioid antagonists.
Expands parity requirements to include acute and crisis inpatient treatment such as medically supervised detox and stabilization.
Requires insurance plans to publish their SUD treatment and medication policies.

13. Integrated Care Model at PCC: Patients With Mental and Behavioral Health Care Needs: 2010 and 2014
Timeline Overview:
2007 BHC embedded in primary care
2011 Implement MAT (Suboxone) at 1 location
2014 Expanded MAT to 2nd Location
July 2016 Opened Chemical Dependency Clinic (CDC)
Growth 4 → 10 DATA Waiver Prescribers
100 patients currently receiving MAT (17% of identified opioid dependent patients)
Diagnosis
Patients With Diagnosis: 2010
Patients With Diagnosis: 2014
Alcohol Related Disorders 49
566
Tobacco Related Disorders
169
2,402
Other Substance Use Related Disorders 59
590
Depression and Other Mood Disorders
624
3,102
Other Mental Disorders
1,688
2,803
1000% SUD, 500% Depression

14. Comparison of Prevalence and Treatment
PCC
National Data
12-mo prevalence, needing treatment for AODA disorder
5.5%*
9.35%
Prevalence of Opioid Use Disorder (adults) 3%
0.35%
Opioid Treatment
16.6%
20%
Alcohol Treatment
Unknown
40%
1075 patients with active opioid use disorder in problem list
NIDA, 2011
*anticipate that as SBIRT screening that includes tobacco screening is integrated more universally, number will increase

15. SBIRT is… Unique opportunity for primary care providers to:
A comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders.”
(SAMHSA)
14,500 patients were eligible, screened ~2500 = 20%
>50% screening of patients 18 and over for AODA use
>50% receive appropriate intervention
Unique opportunity for primary care providers to:
Educate patients as to the link between their medical condition(s) and substance usage
Identify and intervene with those not seeking substance treatment
Link health care services and alcohol and drug treatment services
Increase access to clinically appropriate care for non dependent as well as dependent persons in a general healthcare setting.
Intervention is determinant of the severity of use
No intervention
Brief Intervention
Brief Treatment
Referral to Treatment

16. Integrated Pathway to Recovery
Asses-sment
Universal SBIRT
AUDIT and DAST
Self Referral at continuity clinic
Chemical Dependency Clinic
→Individual & Group Counseling
→Integrated BH session at each MAT apt
→Rapid Utox at each MAT apt
→Repeat SBIRT every 6 mos
Maintenance
Treatment
→Daily Integrated BH & DATA Waiver prescriber visits for 1 week
→COWS
Induction
Medical Assistant completes universal screening of alcohol and SUD for patients over 18
CDC accepts direct access, walk-ins, referrals from hospital partners ED & FMS
Exclusionary criteria – benzo use, alcohol use disorder
Contract done at Assessment

17. Treatment Effectiveness as Compared to Other Chronic Disease
Goal of treatment is to return to productive functioning
Reduces drug use by 40-60%
Drug treatment is as successful as treatment of diabetes, asthma, and hypertension
Strongest predictor of recovery is retention in treatment
According to several studies, drug treatment reduces drug use by 40 to 60 percent and significantly decreases criminal activity during and after treatment. For example, a study of therapeutic community treatment for drug offenders demonstrated that arrests for violent and nonviolent criminal acts were reduced by 40 percent or more. Methadone treatment has been shown to decrease criminal behavior by as much as 50 percent. Research shows that drug addiction treatment reduces the risk of HIV infection and that interventions to prevent HIV are much less costly than treating HIV-related illnesses. Treatment can improve the prospects for employment, with gains of up to 40 percent after treatment. (Note: Although these effectiveness rates hold in general, individual treatment outcomes depend on the extent and nature of the patient’s presenting problems, the appropriateness of the treatment components and related services used to address those problems, and the degree of active engagement of the patient in the treatment process.)
Use of MAT shown to
Increase treatment retention
Decrease overdose deaths
Decrease infectious disease transmission
Decrease criminal activity
Only 10% of patients with OUD in addiction treatment programs were receiving MAT
Cochrane analysis found that methadone had higher rates of treatment retention when flexible dosing used;
When high dose bup compared to high dose methadone, no difference in treatement retnetion (may suggest that the doses we use are too low)
Methadone and bup have similar rates of concurrent opioid use as measured by UDS
N Volkov et al, NEJM :
Knudsen et al. J Addition Med Dec; 6(4):
McLellan, et al. JAMA, 284: , 2000

18. Medication Assisted Treatment for Opioid Use Disorders
Buprenorphine (Suboxone, Subutex)
Partial opioid agonist (has ceiling effect- safer for overdose risk)
FDA approved for OUD since 2002 and able to be prescribed in outpatient settings with DATA waiver (Primary care, etc)
Strong evidence (in combination with behavioral therapy)
Naltrexone (Vivitrol)
Opioid antagonist
FDA approved in 2010
Evidence not as good for OUD (as compared to methadone or buprenorphine)- more for overdose risk
Methadone (not currently available for use FQHCs)
Full opioid agonist
Available since 1970s
Only available in certified programs, strict administration regulations
Strong evidence (in combination with behavioral therapy) Original slide by Dr. Elizabeth Salisbury-Afshar

19. Tools for considered use
Alcohol Use Disorders Identification Test (AUDIT)
Drug Abuse Screening Tool (DAST)
(ASSIST)
Clinical Opiate Withdrawal Scale (COWS)

20. AUDIT

21. DAST

22. ASSIST (Nicotine portion)

23. COWS

24. Resources

25. Quality Metrics: Benchmarking
Provider Report Card
SBIRT completion
Utox at each MAT appointment
Treatment Contract
COWS completed at induction
75% of patients in Suboxone program will have a documented controlled substance agreement
Hospital readmissions within 30 days
Readmissions to partner hospital will be ≤16%
SBIRT
70% of patients age 18 and over receive an SBIRT
70% of those screening positive receive the appropriate intervention

26. Future Quality Considerations
Appointment compliance
Buprenorphine present in urine screen
Medical Indicators
Decreased A1c
Asthma control test
Blood pressure
Hepatitis C

27. PCC: A case example of substance abuse treatment integration

28. Questions/Comments
We believe, literature shows 25%