SC MAT ACCESS Medication Assisted Treatment Academic Community Capacity Expansion for Sustainable Success Kathleen Brady, MD, PhD, VPR, MUSC
Overdose Death Rates from Opiates Most important sign of a SUD Marked increase from 1999 to 2014 by county 1999 2014
Opioid Prescriptions have started to Decrease but Opioid Fatalities are still Increasing Opioid morphine milligram Opioid OD Deaths US, 2000-2015 equivalents (MME) dispense fell by over 15% from 2010-2015 2015 Overdose Deaths: 52,404 Any Drug 33,091 Any Opioid 300 266 260 253 242 234 222 OPIOID MME IN BILLIONS 250 200 150 100 50 0 201020112012201320142015 Source: IMS Health, U.S. Outpatient Retail Setting
Heroin Price Has Decreased Emerging Illicit in Synthetic Opioids Recent Years 4 out of 5 new heroin users started with rx opioids "Retail" Price Per PureGram $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 Increasing reports of fentanyl $- laced - heroin and prescription pills. Other synthetic opioids emerging National Drug Control Strategy--Data Supplement 2014. https://www.whitehouse.gov/sites/default/files/ondcp/policy-and- i.e., Carfentanil. research/ndcs_data_supplement_2014.pdf
HOW DID WE GET HERE?
OPIOID DEPENDENCE IN South Carolina › Since 1999, rate of opioid- related deaths has quadrupled › In SC, 600 opioid-related deaths in 2015 › In 2015, 1 RX for an opioid was written for every adult in SC › SC in top quartile for opioid prescriptions › SC in lowest quartile re: access to medication treatment for opioid dependence
Opioid Prescribing JAMA, published online August 6, 2014
Opioid-Involved Overdose Deaths by County of Occurrence in 2015 SC DHEC, 2017
Medications Are Effective and Save Lives Medication Assisted Opioid Agonist Treatments Treatment (MAT) Decreased Heroin OD Deaths DECREASES: Baltimore, Maryland, 1995-2009 • Opioid use • Opioid-related overdose • Criminal activity • Infectious disease transmission And INCREASES • Social functioning • Retention in treatment But MAT is highly Schwartz RP et al., Am J Public Health 2013. underutilized
Medication Assisted Treatment (MAT) in Opioid Dependence: Lifesaving!!!! Methadone Buprenorphine Naltrexone Antagonist Agonist Partial Agonist + + + + + + + + + + + + + + + + + + +
Narcan Administration Counts by County, 2015 & 2016 SC DHEC, 2017
Methadone Treatment Centers, 2017
Buprenorphine Waivered Physicians by County, 2017 2 7 46 7 13 2 1 12 4 2 2 1 3 4 50 10 14 5 1 9 1 4 5 1 5 3 2 50 * 4 physicians did not provide 11 valid county identifier 1 SAMHSA, 2017
21 st Century Cures Act Enacted Dec 2016, included: › Landmark mental health reform bill › Monies for states to fight opioid epidemic › PDMP › Primary care involvement › Train in best practices › Prevention
SC MAT ACCESS South Carolina Medication Assisted Treatment Academic Community Capacity Expansion for Sustainable Success A Partnership between MUSC and the Department of Alcohol and Other Drug Services Improve access to evidence-based treatments for opioid dependence throughout SC
Reaching Rural Areas to Address the Opioid Epidemic Multiple rural counties 26 counties share 233 doctors Many counties only 1-2 physicians per 10,000 Can academic detailing spread best practices? Can telehealth be used for specialized service delivery, consultation and training?
The South Carolina Telehealth Alliance Statewide collaboration to expand Telehealth services statewide Headquartered at MUSC Center for Telehealth: Dr. Jimmy McElligot Provides guidance, assists with strategic development, advises on technology and standards to develop an open-access net Will assist with equipment/consultation for SC MAT ACCESS
SC MAT ACCESS An Overview of the Initiative Jenna McCauley, PhD
Methadone Buprenorphine Pill, liquid, and wafer Buccal film, sublingual tablet, film Taken once a day Taken once a day (at home) Combined with counseling & social Combined with counseling & social support support Receive medication under supervision Receive mediation under supervision of of physician physician, NP, or PA Length of treatment: Minimum 12 mos. Length of treatment: Minimum 6-12 mos. Only dispensed at SAMHSA certified Can be dispensed in physician’s office, Opioid Treatment Program (OTP) community hospitals, health departments, OTPs, & correctional facilities
Academic Training & Support for Interactive Web Detailing MAT Delivery Resource
Academic Detailing • University or non-commercial based educational outreach to physicians and their staff • Face to face education • Delivered by trained healthcare professionals • Structured visits • Topics • Responsible opioid prescribing • Risk mitigation strategies • Screening, brief intervention, and referral to treatment (SBIRT) • Becoming a MAT provider
Other Educational Trainings • Neurobiology and Epidemiology of Addictive Disorders • Overview of the Opioid Epidemic • Neurobiology, Epidemiology, and Treatment of Opioid Use Disorders • Medication Assisted Treatment • SBIRT Implementation • Motivational Interviewing • Practice Support
Training & Support for MAT Delivery
Training & Support for MAT Delivery
Pre-Implementation Needs Assessment: • Strengths and resources of organization • Personnel • Fiscal • Space • Technology • Relative weaknesses and needs of organization • Workflow integration • Who? • When? • Where? • How many?
Training & Support for MAT Delivery
Waiver Training • Drug Addiction Treatment Act of 2000 (DATA 2000) • 8-hour training (16 hours for NPs) to qualify for a waiver to prescribe and dispense buprenorphine • DATA 2000 Waiver options: • Buprenorphine Waiver Training at the American Academy of Addiction Psychiatry • American Society of Addiction Medicine Buprenorphine Course for Office-Based Treatment of Opioid Use Disorders • Providers Clinical Support System for Medication Assisted Treatment Self-Study at the American Academy of Addiction Medicine
Next Steps: • Registration (with proof of training) • Patient limits: 30 100 275 (at least one year in each category) • Record keeping requirements (ongoing) • Staff training • Prior authorizations and funding? • Referral options for higher level of care
SC MAT ACCESS Website • Resource for healthcare providers interested in: • Learning more about MAT • Becoming MAT providers • Receiving ongoing practice support for their delivery of MAT • Online repository for: • Academic Detailing educational materials • Trainings and presentations offered by our group across South Carolina • ECHO consultation didactic seminars • Practice support resources • Promotes ongoing, bi-directional communication between South Carolina MAT-providers and the MUSC practice support team: • Online discussion forum • Colleague Connections directory • Consultation request form • Updates and News
Training & Support for MAT Delivery
SC MAT ACCESS Project ECHO for MAT Success Louise Haynes, M.S.W.
Although the ECHO model makes use of telecommunications technology , it is different from telemedicine.
ECHO Extension for Community Healthcare Outcomes • Founded by a professor of Internal Medicine at the University of New Mexico, Project ECHO started as a clinic to treat underserved Hepatitis C patients. • The success of the model is due to its simplicity and cost effectiveness. • ECHO decreases provider isolation and increases confidence.
ECHO Model Led by expert teams Led by expert teams Hub and spoke knowledge-sharing network Hub and spoke knowledge-sharing network Clinicians learn to provide excellent specialty care for Clinicians learn to provide excellent specialty care for patients in their own communities. patients in their own communities. Project Echo allows for the collaboration of: Project Echo allows for the collaboration of: ✓ specialists at academic medical centers ✓ specialists at academic medical centers ✓ community-based primary care providers ✓ community-based primary care providers to co-manage patients with a broad range of conditions. Over to co-manage patients with a broad range of conditions. Over time, primary care providers develop the competencies time, primary care providers develop the competencies needed to effectively manage complex patients independently. needed to effectively manage complex patients independently.
Since its launch in 2003, the ECHO model has continued to draw interest, first with partner sites, then with a nationwide pilot by the U.S. Department of Veterans Affairs , and more recently, with a global chronic pain management program with the Department of Defense. Numerous other federal agencies, academic medical centers, and even other countries are in various stages of exploring or implementing Project ECHO.
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