SC MAT ACCESS. Medication Assisted Treatment Academic Community Capacity Expansion for Sustainable Success Kathleen Brady, MD, PhD, VPR, MUSC

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1 SC MAT ACCESS Medication Assisted Treatment Academic Community Capacity Expansion for Sustainable Success Kathleen Brady, MD, PhD, VPR, MUSC

3 Overdose Death Rates from Opiates Most important sign of a SUD Marked increase from 1999 to 2014 by county

4 Opioid Prescriptions have started to Decrease but Opioid Fatalities are still Increasing OPIOID MME IN BILLIONS Opioid morphine milligram equivalents (MME) dispense fell by over 15% from Opioid OD Deaths US, Overdose Deaths: 52,404 Any Drug 33,091 Any Opioid Source: IMS Health, U.S. Outpatient Retail Setting

Heroin Price Has Decreased in Recent Years 4 out of 5 new heroin users started with rx opioids $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 $- "Retail" Price Per PureGram Emerging Illicit Synthetic

5 Heroin Price Has Decreased in Recent Years 4 out of 5 new heroin users started with rx opioids $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 $- "Retail" Price Per PureGram Emerging Illicit Synthetic Opioids Increasing reports of fentanyl laced - heroin and prescription pills. National Drug Control Strategy--Data Supplement Other synthetic opioids emerging i.e., Carfentanil.

6 HOW DID WE GET HERE?

OPIOID DEPENDENCE IN South Carolina Since 1999, rate of opioidrelated deaths has quadrupled In SC, 600 opioid-related deaths in 2015 In 2015, 1 RX for an

11 OPIOID DEPENDENCE IN South Carolina Since 1999, rate of opioidrelated 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

12 Opioid Prescribing JAMA, published online August 6, 2014

13 Opioid-Involved Overdose Deaths by County of Occurrence in 2015 SC DHEC, 2017

14 Medications Are Effective and Save Lives Medication Assisted Treatment (MAT) Opioid Agonist Treatments Decreased Heroin OD Deaths DECREASES: Opioid use Opioid-related overdose Criminal activity Infectious disease transmission And INCREASES Social functioning Retention in treatment But MAT is highly underutilized Baltimore, Maryland, Schwartz RP et al., Am J Public Health 2013.

15 Medication Assisted Treatment (MAT) in Opioid Dependence: Lifesaving!!!! Naltrexone Buprenorphine Methadone Antagonist Partial Agonist Agonist

16 Narcan Administration Counts by County, 2015 & 2016 SC DHEC, 2017

17 Methadone Treatment Centers, 2017

18 Buprenorphine Waivered Physicians by County, * 4 physicians did not provide valid county identifier SAMHSA, 2017

19 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

20 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

21 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.

22 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

23 SC MAT ACCESS An Overview of the Initiative Jenna McCauley, PhD

25 Methadone Pill, liquid, and wafer Taken once a day Combined with counseling & social support Receive medication under supervision of physician Buprenorphine Buccal film, sublingual tablet, film Taken once a day (at home) Combined with counseling & social support Receive mediation under supervision of physician, NP, or PA Length of treatment: Minimum 12 mos. Length of treatment: Minimum 6-12 mos. Only dispensed at SAMHSA certified Opioid Treatment Program (OTP) Can be dispensed in physician s office, community hospitals, health departments, OTPs, & correctional facilities

26 Academic Detailing Training & Support for MAT Delivery Interactive Web Resource

27 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

28 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

29 Training & Support for MAT Delivery

30 Training & Support for MAT Delivery

31 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?

32 Training & Support for MAT Delivery

33 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

34 Next Steps: Registration (with proof of training) Patient limits: (at least one year in each category) Record keeping requirements (ongoing) Staff training Prior authorizations and funding? Referral options for higher level of care

35 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

36 Training & Support for MAT Delivery

37 SC MAT ACCESS Project ECHO for MAT Success Louise Haynes, M.S.W.

39 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

40 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.

41 ECHO Model Led by expert teams Hub and spoke knowledge-sharing network Clinicians learn to provide excellent specialty care for patients in their own communities. Project Echo allows for the collaboration of: specialists at academic medical centers community-based primary care providers to co-manage patients with a broad range of conditions. Over time, primary care providers develop the competencies needed to effectively manage complex patients independently.

Numerous other federal agencies, academic medical centers, and even

interest, first with partner sites, then with a nationwide pilot by

42 Numerous other federal agencies, academic medical centers, and even other countries are in various stages of exploring or implementing Project ECHO. 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.

43 Currently ECHO model initiatives focus on multiple diseases and high need aspects of care throughout the country and internationally. Hepatitis C Behavioral Health Autism Child Abuse Sickle Cell Disease TB HIV Pain Transgender Health Maternal and Child Health Geriatrics Epilepsy Palliative Care Cancer

If we can leverage technology to spread best practices through case-based learning and

44 Medical knowledge is exploding, but it s often not traveling the last mile to ensure that patients get the right care in the right place at the right time. If we can leverage technology to spread best practices through case-based learning and mentoring of providers, we can move knowledge instead of patients to get better care to rural and underserved communities across the country.

South Carolina s ECHO Network Using telemedicine technology through the MUSC Center for Telemedicine, SC MAT ACCESS will identify medical providers in SC who are interested in joining

45 South Carolina s ECHO Network Using telemedicine technology through the MUSC Center for Telemedicine, SC MAT ACCESS will identify medical providers in SC who are interested in joining a mentoring network for supporting medication assisted treatment in community practices. Providers and MUSC experts in opioid treatment will be connected through telemedicine technology.

46 Before Project ECHO, fewer than a dozen clinicians in New Mexico were certified to prescribe Buprenorphine. Now nearly 300 clinicians in New Mexico are certified to prescribe buprenorphine the best-practice treatment medication for opiate addiction.

47 ECHO Plan for SC MAT ACCESS TEAM Team to attend training in New Mexico later this month. Model proposes a one hour weekly conference. The first half of the conference will be a case-based presentation by one of the practitioners followed by group discussion. The second half will include a brief presentation by the MUSC team on a relevant topic. Topics for the didactics will be chosen by participants and/or based on case material presented. The MUSC ECHO Coordinator will provide the liaison between participating practices and the MUSC team to schedule case presentation and didactics. Additionally, individual consultation concerning practice or patient-specific issues will be available. Practitioners can request a consultation through a link on the SC MAT ACCESS website, and there will be a response within 24 hours.

48 Sample Topics Introduction to Addiction Opioids Opioid Use Disorder (OUD) Medication Assisted Treatment for OUD Overview of Chronic Pain Non-Opioid Pain Medications Integrated Pain Care Screening for Depression, Anxiety and SUD Assessment of OUD Opioids Co-Prescribed with Other Meds Pain and Addiction in Pregnancy Alternative Treatments for Pain Fibromyalgia/Osteoarthritis Headaches/Complex Regional Pain Syndrome Motivational Interviewing SBIRT 12-step Facilitation Recovery Cognitive Behavioral Therapy Brady Brady Barth Brady Barth Barth McCauley Barth Barth Guille Guille Borchardt TBD TBD Killeen Haynes Haynes Haynes McCauley

ECHO trains primary care clinicians to provide specialty care services. This means more people can get the care they need.

49 People need access to specialty care for their complex health conditions. There aren't enough specialists to treat everyone who needs care, especially in rural and underserved communities. ECHO trains primary care clinicians to provide specialty care services. This means more people can get the care they need. Patients get the right care, in the right place, at the right time. This improves outcomes and reduces costs. South Carolina MAT ACCESS will use ECHO Model to enhance the state s capacity to provide care to citizens with opioid related problems. With a focus on primary care providers.

50 OUR TEAM IS EAGER TO HEAR FROM YOU! What challenges do you face in providing care to people with problems related to opioid use? What barriers do you face in your community? How could our project help to address those barriers?

51 For Additional Information Contact: Rachel Grater Program Coordinator II SC MAT ACCESS (843)

QUARTERLY PROVIDER MEETING MARCH 9, 2017 SUZANNE BORYS, ED.D.

2017 State Targeted Response to the Opioid Crisis Grants QUARTERLY PROVIDER MEETING MARCH 9, 2017 SUZANNE BORYS, ED.D. H.R.6-21st Century Cures Act The 21st Century Cures Act is a United States law enacted