1. Addiction Resource Center’s Experience Implementing Medication Assisted Treatment 2007-2010 Eric Haram, LADC Director OPBH-Mid Coast Hospital Niatx Coach

2. Maine, OSA Goal 2005: To Increase Use of Available Addiction Medications OSA received a RWJ Grant in 2005 to improve the rate of diffusion for Medication Assisted Treatment. OSA received a RWJ Grant in 2005 to improve the rate of diffusion for Medication Assisted Treatment. Four Agencies were invited to participate. Mid Coast Hospital’s Addiction Resource Center was one. Four Agencies were invited to participate. Mid Coast Hospital’s Addiction Resource Center was one. OSA’s aim was to increase MAT at the participating agencies by 15% in order to increase treatment retention and improve outcomes OSA’s aim was to increase MAT at the participating agencies by 15% in order to increase treatment retention and improve outcomes

3. The Need 63% of treatment admissions in 2005 were for alcohol abuse 63% of treatment admissions in 2005 were for alcohol abuse 24% were for opiate abuse 24% were for opiate abuse Our focus was and is on these two categories for which there are FDA approved medications and which make up the majority of the patients seen in Maine’s treatment system Our focus was and is on these two categories for which there are FDA approved medications and which make up the majority of the patients seen in Maine’s treatment system

4. The Need State public health data estimates the current untreated opiate dependent volume in Maine to be 34,000 people with an estimated 2500 clients currently in treatment. State public health data estimates the current untreated opiate dependent volume in Maine to be 34,000 people with an estimated 2500 clients currently in treatment. These rates place the per capita rate of prescription and other opiate abuse in Maine at around 2%. These rates place the per capita rate of prescription and other opiate abuse in Maine at around 2%.

5. The Need ARC took a 4 month snap shot to trend volumes of clients seeking treatment for opiate dependence. ARC took a 4 month snap shot to trend volumes of clients seeking treatment for opiate dependence. Before MAT implementation 25% of opiate addicted clients made it to their first treatment session. Following implementation this number grew to 80%. Before MAT implementation 25% of opiate addicted clients made it to their first treatment session. Following implementation this number grew to 80%.

6. The Need Based on sample data, fewer than 10% of people admitted for alcohol abuse have been prescribed FDA approved medications. Based on sample data, fewer than 10% of people admitted for alcohol abuse have been prescribed FDA approved medications. In 2005, ARC was providing care for opiate addicts while only 19% were receiving medication, compared to 80% in 2010. In 2005, ARC was providing care for opiate addicts while only 19% were receiving medication, compared to 80% in 2010.

7. FDA Approved Medications for Addiction and Anti-Craving http://www.niatx.net/PDF/NIATx-MAT- Toolkit.pdf pgs. 45,46. http://www.niatx.net/PDF/NIATx-MAT- Toolkit.pdf pgs. 45,46. http://www.niatx.net/PDF/NIATx-MAT- Toolkit.pdf http://www.niatx.net/PDF/NIATx-MAT- Toolkit.pdf

8. Community Response-Business Case

9. Projected Volumes at ARC 2005

10. Actual Volumes 2007-2010

11. MAT Pts. as % of total new Pts 2007-2010

12. Diversion Diverted buprenorphine is not primarily used to get high; as a partial agonist of the mu opiate receptor, buprenorphine alleviates withdrawal and craving, but does not have the euphorogenic effects of other opioids. Diverted buprenorphine is not primarily used to get high; as a partial agonist of the mu opiate receptor, buprenorphine alleviates withdrawal and craving, but does not have the euphorogenic effects of other opioids. Patients regularly report that buprenorphine makes them feel “normal,” “like I never used.” Since buprenorphine strongly attaches to the opiate receptor and blocks other opioids, it does not have an additive effect with other drugs, and it even blocks their effects. Patients regularly report that buprenorphine makes them feel “normal,” “like I never used.” Since buprenorphine strongly attaches to the opiate receptor and blocks other opioids, it does not have an additive effect with other drugs, and it even blocks their effects.

13. Diversion Concern about diversion and misuse of buprenorphine must be seen in the context of rampant opioid diversion and misuse (see S. Okie, “A flood of opiates, a rising tide of death,” 2010, New England Journal of Medicine, 363:21. Concern about diversion and misuse of buprenorphine must be seen in the context of rampant opioid diversion and misuse (see S. Okie, “A flood of opiates, a rising tide of death,” 2010, New England Journal of Medicine, 363:21.

14. Diversion When the Director of Pharmacy at Mid Coast Hospital surveyed prescriptions filled through the hospital, he found that in 1995 there were no analgesics in the top ten drugs prescribed. By 2000 Vicodin was the fourth most common prescribed, in 2005 it was #2, and in 2009 it was the most commonly prescribed drug, with oxycodone in tenth place. When the Director of Pharmacy at Mid Coast Hospital surveyed prescriptions filled through the hospital, he found that in 1995 there were no analgesics in the top ten drugs prescribed. By 2000 Vicodin was the fourth most common prescribed, in 2005 it was #2, and in 2009 it was the most commonly prescribed drug, with oxycodone in tenth place.

15. Efforts to reduce impact of opiate addiction on public health and safety: Treatment Increased access to intensive treatment services by 500% 2006-2010. Increased access to intensive treatment services by 500% 2006-2010. Implemented Medication Assisted Treatment with Buprenorphine, 2007. Vivatrol/Naltrexone 2009. Implemented Medication Assisted Treatment with Buprenorphine, 2007. Vivatrol/Naltrexone 2009. Expanded services to Lincoln County, Damariscotta Office, 2009 Expanded services to Lincoln County, Damariscotta Office, 2009 Physician Leadership working with Maine DUR to assure access to FDA approved medications for withdrawal and craving. Physician Leadership working with Maine DUR to assure access to FDA approved medications for withdrawal and craving.

16. Efforts to reduce impact of opiate addiction on public health and safety: Pt. Adherence/Follow UP Twice weekly clinical huddles to review cases and develop timely interventions. Twice weekly clinical huddles to review cases and develop timely interventions. Rigorous use of Prescription Monitoring Database. Rigorous use of Prescription Monitoring Database. Random, observed UDS may include Buprenorphine levels. Random, observed UDS may include Buprenorphine levels. Random pill counts Random pill counts

17. Efforts to reduce impact of opiate addiction on public health and safety: Pt. Adherence ARC took a snapshot of 20 pt. pill counts conducted prior to attendance at group as a baseline measure of medication adherence. The second sample was with all patients using bubble packs. The adherence rates with bubble packs was double the baseline measure. ARC took a snapshot of 20 pt. pill counts conducted prior to attendance at group as a baseline measure of medication adherence. The second sample was with all patients using bubble packs. The adherence rates with bubble packs was double the baseline measure. ARC has requested that all participating pharmacies use bubble packing for Bup. only. As of Jan. 1, 2011 all participating pharmacies use bubble packs. ARC has requested that all participating pharmacies use bubble packing for Bup. only. As of Jan. 1, 2011 all participating pharmacies use bubble packs. 25% of the ARC MAT clients have random pill counts weekly. This rotates as planned in clinical huddles to assure monthly random counts for each pt. each month. 25% of the ARC MAT clients have random pill counts weekly. This rotates as planned in clinical huddles to assure monthly random counts for each pt. each month.

18. Efforts to reduce impact of opiate addiction on public health and safety: Community and Professional Education Provided NIDA/CTN endorsed training curricula to 125 participants in Maine since 2009. ( Rockland, Machias, Portland, Lewiston) 8 hour training sponsored by ATTC, Brown University and CCSME. Provided NIDA/CTN endorsed training curricula to 125 participants in Maine since 2009. ( Rockland, Machias, Portland, Lewiston) 8 hour training sponsored by ATTC, Brown University and CCSME. Published Guide for the Implementation of Medication Assisted Treatment, 2011, University of Wisconsin-Madison, Center for Health Enhancement Systems Studies. http://www.niatx.net/PDF/NIATx-MAT- Toolkit.pdf Published Guide for the Implementation of Medication Assisted Treatment, 2011, University of Wisconsin-Madison, Center for Health Enhancement Systems Studies. http://www.niatx.net/PDF/NIATx-MAT- Toolkit.pdf http://www.niatx.net/PDF/NIATx-MAT- Toolkit.pdf http://www.niatx.net/PDF/NIATx-MAT- Toolkit.pdf

19. Efforts to reduce impact of opiate addiction on public health and safety: Community and Professional Education Provided training for USM school of Nursing students. 2009, 2010 Provided training for USM school of Nursing students. 2009, 2010 Working actively with Maine DOC to examine barriers to inmates’ access to FDA approved medications for withdrawal and craving. Working actively with Maine DOC to examine barriers to inmates’ access to FDA approved medications for withdrawal and craving. CIT training annually. CIT training annually.