8/16/2018. California s MAT Expansion Hub and Spoke System: Provider and Consumer Perspectives. Agenda. No Wrong Door

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1 California s MAT Expansion Hub and Spoke System: Provider and Consumer Perspectives Gloria Miele, PhD, Learning Collaborative Coordinator, Hub and Spoke MAT Expansion Project Richard Rawson, PhD, Professor Emeritus, UCLA UCLA Integrated Substance Abuse Programs DHCS Statewide Conference, Garden Grove, CA August 21, 2018 Agenda Update on California s Hub and Spoke MAT expansion project The realities of providing MAT in community health and specialty treatment centers Provider and consumer perspectives on medication-assisted treatment Karl Kaplan, MD, Tarzana Treatment Center Gilmore Chung, MD, Venice Family Clinic and UCLA Health Priscilla Romero, Consumer Questions and discussion No Wrong Door 1

2 CA Hub & Spoke System Based on the Vermont Hub & Spoke Model Harnesses the strengths of specialty methadone NTPs and skills of physicians and advanced practice clinicians who prescribe buprenorphine in office-based settings. NTPs are the only entities that are allowed by federal law to provide methadone treatment for an OUD. Hubs NTPs act as Hubs, and serve as the regional consultants and subject matter experts on opioid dependence and treatment Provide care to clinically complex buprenorphine patients Manage buprenorphine inductions Support Spokes that need clinical or programmatic advice Spokes Spokes may be (1) a federally waivered prescriber, or (2) one or more federally waivered prescribers and a MAT team. Provide ongoing care for patients with milder SUD (managing induction and maintenance) and for stable patients on transfer from a Hub Monitor adherence to treatment Coordinate access to recovery supports Provide counseling 2

3 (typically a nurse) 8/16/2018 Required Services Professional medical, social work, & mental health services, onsite or by referral Access to FDA approved MAT for an OUD Access to subject matter expertise on opioid dependence and treatment for Spokes HIV and HCV testing and referral to services Case management Counseling Naloxone and training Local access to maternal addiction treatment Recovery and/or peer support services Use of the OBOT Stability Index and the Treatment Need Questionnaire tool Hub and Spoke MAT Team Panel Manager/Nurse Prescription management Call back procedure, counting films, calling pharmacies Management of drug testing Coordination of medical services with buprenorphine prescriber Help the physician educate and manage the panel of patients Behavioral Health Provider Brief Counseling or referral to more intensive services Group counseling Some clinical case management Intake of stable patients from Hub to Spoke Referrals to Hub for unstable patients Coaching to prescribers in managing patients clinical stability Hub and Spoke Interaction 3

4 California s Opioid Epidemic 2016 vs Availability of MAT Overdose Death Rates Data source: CDPH Vital Statistics Multiple Cause of Death Files via the California Opioid Overdose Surveillance Dashboard 4

5 Hub and Spoke Network Growth Aug 2017 Jun 2018 Statewide New H&S Patients Per Month by Medication (Preliminary)* Aug Sept Oct Nov Dec Jan Feb Mar Methadone Buprenorphine XR-NTX *Preliminary data: based 12 of 19 systems completing all required monthly reports Hub and Spoke Provider Survey Results Survey Respondents (n=149) 18% 34% 48% UCLA conducted surveys of all 212 known Hub and Spoke providers from May June surveys were completed in total: 72 Waivered Providers (MD, NP, PA, etc.) 51 MAT Team (RN, Counselors, Etc.) 27 Hub Leadership (directors, coordinators, administrators) 5

6 18% Survey Results: Knowledge and Attitudes MAT Team members agree/strongly agree that Methadone is just substituting one addiction for another. 16% I feel equally comfortable working with patients with OUD as I do working with other patient groups. Waivered prescribers disagree/strongly disagree that Icon made by Freepik from Survey Results: Primary Care Settings Waivered prescribers 35% agree/strongly agree that Treating patients with OUD in primary care settings could negatively impact the workload of clinic staff. 19% Waivered prescribers agree/strongly agree that Treating patients with OUD in primary care settings might drive away other primary care patients. Icons made by Kiranshastry Survey Results: Diversion and Tapering 1/4 59% Agree or Strongly Agree that patients who divert buprenorphine or other opioids should be discharged from care immediately. Among these respondents, only 59% agreed that they felt confident in their abilities to detect diversion behaviors Waivered providers who had never prescribed buprenorphine were more likely than those who had that to agree that all patients should be tapered off of buprenorphine as soon as possible (p <.05) 6

7 Results from Vermont Hub and Spoke The H&S Evaluation: Spoke Participant Themes Participation in MAT had profound benefits in many domains of patients lives. The spoke environment was a powerful positive influence on participants self-esteem and attitude toward treatment. Participants reported their relationships with their doctor was a very powerful and positive aspect of treatment. Receiving MAT at spokes was very similar to receiving routine medical care. Buprenorphine was viewed as very positive and important. Participants felt minimal stigma at spokes, but they reported they experienced stigma when they accessed medical services in the larger healthcare system. The H&S Evaluation: Conclusions Participation in MAT was associated with: a very large reduction in opioid use a substantial reduction in other drug/alcohol use, except cannabis. a substantial reduction in drug injection a large reduction in ED visits and overdoses. a slight increase in education/training activities, but not in days of employment. a 90% reduction in both days of illegal activity and contacts with police. a substantial decrease in family conflict and improvement in measures of mood. 7

8 The H&S Evaluation: Conclusions Participants treated in the hubs with methadone and those treated in the spokes with buprenorphine showed similar and positive responses to MAT in virtually all measurement domains. Participants in both settings viewed MAT positively and as very helpful to them. Spoke patients view their relationship with their MD as very valuable. Spoke patients rated their care as helping them to a greater degree in three of the four assessed domains. Family members/significant others (FM/SOs) were uniformly grateful and appreciative of the availability of treatment. FM/SOs expressed interest in being involved in the treatment but felt that such involvement was actively discouraged. They also identified other service deficiencies The H&S Evaluations: Closing Thoughts The Vermont Hub-and-Spoke System of Care for Opioid Use Disorders is an innovative and constructive public health response to the opioid epidemic of the 21 st century in the United States. The H & S system has markedly expanded access to MAT and improved participants lives. The services provided within this model have saved many lives and have allowed many Vermonters to discontinue opioid use and improve their lives. Patient perspectives from Vermont People with OUD are very positive about treatment in primary care settings They experience little stigma and feel they are treated like all the other patients They are treated with respect and receive individualized care 8

9 Community Health Center Involvement Kaiser Family Foundation Collected data on community health centers (CHCs)in conjunction with the Affordable Care Act Used data from questions on how centers are approaching the opioid crisis Online surveys mailed to all CEOs of federally funded community health centers in all 50 states and DC from early January to late February 2018 N= % (489) survey responses from 49 states and DC Most health centers have seen an increase in patients with OUD 9

10 Nearly half of health centers provide MAT CHCs are increasing number of waivered prescribers CHCs report capacity challenges 10

11 Next Steps Ensure More Prescribers are Available Make training and support more available Expert facilitator project Independent consultant provides onsite and tele/video conferencing with Spoke providers and teams CSAM Medical Education Research Fellowship Provide additional mentorship and education to prescribers Provide the Least Restrictive Level of Care Methadone buprenorphine naltrexone One size does not fit all Convenience for patients integration back into the community Work School Family Long-term costs for society 11

12 Pain and SUD Science and practice of treating pain in the context of opioid use disorder Series of conferences for primary care providers Clinical presentations and case discussion Oakland (9/18), San Bernardino (9/26), Fresno/Clovis (10/10) Combat Stigma Public education campaigns Upcoming webinar on Stigma and OUD, Sept. 6, 10am Hearing from people involved in different aspects of the treatment system Avoid stigmatizing language (addict, relapse, dirty vs. clean, etc.) Panelists Karl Kaplan, MD, Tarzana Treatment Center Gilmore Chung, MD, Venice Family Clinic and UCLA Health Priscilla Romero, Consumer 12

13 Questions and Discussion For more information, contact Gloria Miele, Ph.D Join our listserve! 13