The use of medication-assisted treatment (MAT) therapies for substance use disorders is expanding. Additional funding for access was a key part of President Obama’s 2017 budget proposal, and the cap on the number of patients that waivered physicians can treat with buprenorphine was raised in July from 100 to 275. In addition, many treatment centers that previously rejected the use of medication in addiction treatment have begun incorporating MAT.
Deciding to add a medical dimension like MAT to an existing program is one thing; actually making the transition is another. The process involves overcoming a number of administrative, financial and cultural hurdles that could potentially derail the program. Implementing a MAT program requires executive-level support, education and training for staff, the addition of new staff (including waivered prescribers), patient outreach, new approaches to therapy, and in some cases, partnerships with other organizations.
“It’s always tricky trying to integrate a medical program and a non-medical program,” says Stuart Gitlow, MD, MPH, MBA, past president of the American Society of Addiction Medicine (ASAM) board of directors and executive director of the Annenberg Physician Training Program in Addictive Disease. “It’s really a change in the model. It would require changing policies, approaches, staff, everything.”
The road to MAT
The Hazelden Betty Ford Foundation has been a longtime proponent of group therapy, counseling and abstinence-based approaches without a medication component. In the early years, the organization even questioned whether offering coffee at 12-Step meetings was a good idea.
Now, the 70-year-old institution has begun offering both buprenorphine and naltrexone along with its 12-Step program, prompted by the scale of the opioid epidemic and the devastation it has caused among addicted patients.
“We started to see problems in our programs, especially residential treatment programs,” says Marvin Seppala, MD, chief medical officer at Hazelden Betty Ford Foundation. “Our admissions increased dramatically. People were bringing drugs into the treatment unit, and we were starting to see deaths early after discharge. There was an ethical imperative.”
In 2012, Hazelden approached the board of directors about implementing MAT.
“We showed them the data, and we got full support from the board, which is necessary for any kind of nonprofit going in this direction,” Seppala says. “If you don’t have leadership support, it’s not going to happen.”
Hazelden created a plan for the organization and began meeting with clinicians at its facilities to discuss their concerns. In addition to adding MAT to its programs, Hazelden also launched group therapy specifically for opioid disorder patients and is undertaking a study to help determine which medications work best for different types of patients.
Within two years, Hazelden found that the percentage of opioid patients who drop out of its 12-Step program and relapse fell from nearly a quarter to just 5%.
“They are our best group in terms of completion of treatment,” Seppala says. “That’s tremendous, because completion is a predictor of positive outcomes.”
The shift at Hazelden could help move the use of MAT forward at institutions that modeled themselves on its therapy approach, but there is still resistance to the use of medication by some practitioners—something Seppala says he encountered during the transition.
Choice of drug therapies
One of the first steps an organization should take is determining which MAT approaches fit with its mission and clientele. Not every provider can or will offer every kind of medication.
“We really had to evaluate our options,” says David Chernof of his previous experience in implementing MAT at Bridgeway Behavioral Health in Missouri (he is currently vice president of addiction services at Great Circle in St. Louis). “We weighed our options, and we determined that there were specific programs for methadone, and we didn’t want to get into that business because there were big barriers.”
Methadone is highly regulated and restricted to certain clinics that meet federal standards. But in Chernof’s experience, the state of Missouri played a role in the decision by offering a plan that would help cover the cost of naltrexone and buprenorphine.
Hazelden’s Seppala adds that some patients don’t want to use daily buprenorphine, so having injectable naltrexone as an option is valuable.
“We have about one-third of our patients that choose not to take meds, but to engage in a long-term program,” he says. “About a third take Suboxone (buprenorphine), and a little over a third take Vivitrol (naltrexone).”
If you have multiple facilities, another question to consider is where you would offer MAT services. Not every population will need the same type of drug therapy. The drug products must be secured at the location, and you must have the right medical staffing available to administer the medications.
And just because you offer MAT doesn’t necessarily mean you will immediately find success in increasing the number of patients taking those medications, experts say. The naltrexone program at Community Health Network in Indianapolis, for example, had just 15 patients in 2015—in a network that averages 19,000 outpatient client visits and 4,700 inpatient stays annually. According to Julie Maguire, nurse practitioner in psychiatry and behavioral health at the organization, physician buy-in was a challenge.
“There were some turf wars and fears about waiting room issues,” Maguire says. “Some felt they were inadequately trained or supported. There was fear of litigation.”
Naltrexone programs can also be cumbersome and confusing, and some physicians were worried about what would happen if the patient couldn’t pay for the injectable treatment.
Maguire says the one potential solution came through establishing a partnership with an urgent care center.
“We are gaining momentum this way,” she says. “We have infusion clinics to take some of the burden. We’re partnering with more medical teams, and we have a MAT clinic in the works that will be staffed by credentialed medical providers part time that will work with a behavioral health team.”
The agency has also started a program to add MAT training to the therapist onboarding process, and to recruit and entice primary care physicians who have expressed interested in MAT, as well as recruiting residents.
Evaluate reimbursement plans
The level of support for MAT by state Medicaid agencies and private insurers varies from state to state. Any organization considering the addition of a MAT approach should evaluate the reimbursement options available for clients in their region.
Opioid-disorder patients might represent a different demographic and a different set of payers, so it’s important to determine both the expected patient volume and the financial viability of the program, experts say. At Bridgeway, Chernof says there was support from the state as well as from the pharmaceutical companies to help make sure clients could afford their medications. There was also a program in the local jails that ensured clients received their first treatment before release.
Additionally, the physicians prescribing the medications will need to know that they will receive appropriate reimbursement. In some cases, agencies have been able to partner with providers or other organizations to create a sustainable program.
Expect some staff resistance
Even though there is ample evidence that MAT works, there are still behavioral health professionals that are philosophically opposed to the use of medication in substance abuse treatment. Some treatment professionals who are in long-term recovery themselves might believe their experiences without MAT are the ideal for all who seek recovery. You should plan accordingly to address those concerns and be prepared to make staffing changes if necessary.
At Bridgeway, Chernof says the transition was fairly smooth because the company already had a medical director and a nursing staff at its modified medical detox program. There was some staff resistance to overcome, which required training and education so that clients would get the most unbiased opinion on the best course of treatment.
“Our feeling was that we weren’t going to offer medication to be used by itself,” Chernof says. “It was going to be used in conjunction with traditional therapy. If patients stopped therapy, they couldn’t receive medication through us anymore, and that was a big piece of creating a comfort level for the staff.”
In some cases it’s a matter of resistance to change overall.
“The biggest likely obstacle is in the stigma that lies within the field,” Gitlow adds.
In one example from the National Council’s MAT Learning Community program, Advantage Behavioral Health in Athens, Ga., the largest public provider of behavioral services in Northeast Georgia, rolled out a naltrexone program with clients in residential treatment. According to a presentation covering the agency’s participation, leaders used health analogies to challenge beliefs. For example, some diabetic patients can manage their disease by adjusting their diet, while others have to use insulin.
Education and training are critical, and staff should be presented with the available evidence to help them understand how beneficial a MAT approach can be for opioid patients. Sometimes the evidence comes in the form of first-hand experiences in daily practice.
At Hazelden Betty Ford, Seppala once received a four-page e-mail from a counselor adamantly describing why the organization shouldn’t offer MAT.
“But she became a remarkable proponent,” Seppala says. “She came up and thanked me for doing this, because it has worked so well for our patients.”
Clinicians who simply won’t support MAT might need to be replaced. Gitlow takes a harsh view of providers that oppose the use of new medications like naltrexone and buprenorphine.
“A no-drug stance is stupid,” he says. “It’s antithetical to the practice of medicine to not treat a chronic medical disease that has been demonstrated to respond to these treatments.
“It’s time to bring in people who are going to apply evidence-based science and treatment to individuals who are addicted,” he continues. “Psychotherapy and 12-Steps and everything that goes along with that is also critically important, but you can’t do that without [additional treatment tools] and expect to get the best possible outcomes.”
Gitlow also points out that MAT and abstinence programs should not be thought of as mutually exclusive.
“Abstinence means abstinence from addictive drugs or those that a person is using to get high,” he says. “Using Suboxone following medical orders is an abstinence-based model. If they are sober, they are abstinent.”
Finding a prescriber
One major challenge, particularly in some rural communities, is finding a doctor that is willing to prescribe addiction medications. There may be no waivered physician in a given area, or those that are waivered may not be able to expand their patient load. Some doctors are resistant to prescribing the drugs because of concerns about the clients they will attract, reimbursement issues, or administrative challenges.
“There are maybe 5,000 doctors in the country who specialize in addictive diseases, and most are full or working full time,” Gitlow says. “So if you are a new facility and looking for a physician, they may very well be full or not interested or available. It’s very difficult to find extra doctors or excess capacity. The increase [in the waiver cap] hasn’t done a great deal to change that yet.”
Receiving a waiver for buprenorphine is fairly straightforward. Physicians will require a Drug Enforcement Agency certificate and state controlled substance license. Once physicians take the required training and apply, they can be certified for up to 30 patients for one year. After that, they can request to increase that level to 100 and then to 275. As of October, federal officials report more than 1,600 prescribers had registered for the 275 patient load level.
Hazelden Betty Ford was already staffed for MAT at its residential sites and had waivers in place before implementing the MAT program.
“In our outpatient settings, we had to hire physicians, and that’s a real limitation because outpatient is a low-margin facility and has a smaller volume of patients,” Seppala says. “If you only have three or four people [in the program], you can’t have a doctor sitting there all day long.”
In Florida, Hazelden found an outside physician who was willing to take its patients and prioritize them for appointments. In West Los Angeles, there is a part-time psychiatrist who works with Hazelden two half-days per week.
For programs that do not already have a medical director or a medical detox component, bringing in a physician can mean an upending of the existing order.
“A doctor tends to look at the practice of medicine as being multi-specialty,” Gitlow says. “It’s a team, but it’s a physician-led team. That’s a big deal: the idea of having a physician lead the team as opposed to a social worker, which is the case at many organizations. The physician’s liability is on the line, so the doctor has to be the one making decisions.”
In some cases, organizations can partner with other providers. At Bridgeway, for example, the company’s buprenorphine program was floundering. Chernof identified community mental health center that had recently lost its prescriber. The agencies came to an agreement so that the community mental health center would refer clients to Bridgeway’s doctor, and they would pay for the medication and physician/nurse time, and then Bridgeway would pay for the group therapy.
“That worked, and it expanded to include Vivitrol as well,” Chernof says.
Transitioning to a MAT model is not necessarily easy, but the benefits to the patient population—particularly as the opioid crisis grows—can make an enormous difference. Cultural and philosophical obstacles remain, but a well-planned approach can help integrate medical and abstinence programs to the benefit of patients.
“MAT offers a faster transition to the early stages of change, because you have that support,” Chernof says. “Medication offers relief for those withdrawal symptoms, and you build on that with talk therapy. When you remove the medications, they have the skills to keep moving forward to sobriety.”
Brian Albright is a freelance writer based in Ohio.
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- Why new buprenorphine caps may not increase utilization
- The federal government has a dedicated site with resources to address the opioid crisis here.