The Care Alliance for Opioid Dependence

The Care Alliance for Opioid Dependence The Vermont Hub and Spoke Model John Brooklyn, MD Clinical Assistant Professor of Family Practice and Psychiatry University of Vermont College of Medicine Medical Director of Howard Center Chittenden Clinic Medical Director BAART St. Albans Hub

Vermont

Vermont 626,000 people in VT 49 th smallest of 50 states in population in US 45 th smallest of 50 states in area in US 75% Forests Largest city is Burlington at 39,000

History of Opioid Use Treatment in Vermont Methadone approved in US in 1972 Vermont opened 1st methadone clinic Opioid Treatment Programs (OTP) in 2002 with 100 slots By 2009 650 people enrolled in 6 OTPs Buprenorphine (BPN) approved for Office Based Opioid Treatment (OBOT) in 2003 2200 people in OBOT by 2009 Vt is #1 in US in per capita BPN prescriptions and waivered MDs

Hub and Spoke System Vermont's Blueprint for Health established a Chronic Care Initiative that designated Opioid Addiction as a chronic condition, like diabetes, heart disease, lung disease, etc. Idea floated of creating regional centers of addiction experts (HUBS) that would provide comprehensive services like any other specialty and would use all medications for opioid treatment- methadone, buprenorphine and naltrexone Office Based Opioid Treatment (OBOT) providers were linked in each county as SPOKES to HUBS Main goal is to prevent overdose and deal with the opioid crisis in the state in a systematic way

Hub and Spoke System Integrates substance use disorder into primary care and provides office based supports and a referral network for more complex cases Patients can start at a Hub and go to a Spoke for less care or can go from a Spoke to a Hub for more care Goal: No loss of treatment for Opioid dependence

Integrated Health System for Addictions Treatment Corrections Probation & Parole Family Services Spokes Nurse-Counselor Teams w/prescribing MD Residential Services Mental Health Services Spokes HUB Assessment Care Coordination Methadone Complex Addictions Consultation Spokes In Patient Services Substance Abuse Out- Pt Treatment Spokes Nurse-Counselor teams w/prescribing MD Pain Management Clinics Vermont Department of Health Medical Homes

1. Northwestern Hub HowardCenter Chittenden Clinic Chittenden, Addison & Grand Isle 2. Farwestern Hub BAART Behavioral Health Services Franklin & Grand Isle 3. Northeastern Hub BAART Behavioral Health Services Essex, Orleans & Caledonia 4. Central Vermont Hub BAART/Central Vermont Addiction Medicine Washington, Lamoille & Orange 5. Southwestern Hub Rutland Regional Medical Center Rutland & Bennington 6. Southeastern Hub Southeast Regional Comprehensive Addictions Treatment Center (Habit OPCO & Brattleboro Retreat) Windsor and Windham Vermont Population 626,562

SPOKES Linked to a regional HUB All buprenorphine prescribers in an office can participate as SPOKES Can be 1 doctor in private practice or group practice with many prescribers Can refer complex patients to the HUB for stabilization All SPOKES take advantage of the MAT teams in the region

SPOKES All community BPN providers were eligible to become SPOKES Allowed for enhanced services to be provided to offices with linkages to their regional HUBS if needed Goal was to provide enhanced services for better management of these patients with better outcomes

MAT Team MAT (Medication Assisted Treatment) Team is 1 FTE Case Manager and RN per 100 BPN patients and a prescribing physician Paid for by Federal matched health care dollars as part of Chronic Care Initiative What many BPN physicians had been asking for to help increase the number of patients they could serve May serve a few practices and not be on site

Hub or Spoke?? Triage tool needed Based on level of care needed rather than medication driven Helps physician decide where to best treat patient

CRITERIA FOR HUB AND SPOKE Treatment Need Questionnaire (TNQ) developed by Brooklyn and Sigmon 21 item checklist with scores up to 26 Lower scores predict good SPOKE outcomes Based on Addiction Severity Index (ASI) topicslegal, work, social, psychological, medical, drug use

TREATMENT NEED QUESTIONNAIRE Have you ever used a drug intravenously? 2 0 If you have ever been on medication-assisted treatment (e.g. methadone, buprenorphine) before, were you successful? YES 0 2 Do you have any legal issues (e.g. charges pending, probation/parole, etc)? 1 0 Are you currently on probation? 1 0 Have you ever been charged (not necessarily convicted) with drug dealing? 1 0 Do you have a chronic pain issue that needs treatment? 2 0 Do you have any significant medical problems (e.g. hepatitis, HIV, diabetes)? 1 0 Do you have any psychiatric problems (e.g. major depression, bipolar, severe anxiety, PTSD, schizophrenia, personality subtype of antisocial, borderline, or sociopathy)? 1 0 Do you ever use cocaine, even occasionally? 2 0 Do you ever use benzodiazepines, even occasionally? 2 0 Do you have a problem with alcohol, have you ever been told that you have a problem with alcohol or have you ever gotten a DWI/DUI? 2 0 NO

TREATMENT NEED QUESTIONNAIRE Are you motivated for treatment? 0 1 Are you currently going to any counseling, AA or NA? 0 1 Do you have 2 or more close friends or family members who do not use alcohol or drugs? YES 0 1 Do you have a partner that uses drugs or alcohol? 1 0 Is your housing stable? 0 1 Do you have a reliable phone number? 0 1 Are you employed? 0 1 Do you have access to reliable transportation? 0 1 Did you receive a high school diploma or equivalent ( complete 12 yrs of education) 0 1 NO

TREATMENT NEED QUESTIONNAIRE Total possible points is 26 Scores 0-5 excellent candidate for office based treatment Scores 6-10 good candidate for office based treatment Scores 11-15 candidate for office based treatment by board certified addiction physician in a tightly structured program with supervised dosing and on site counseling or HUB Scores 16-26 HUB program

Learning Collaborative Designed to increase training of addiction medicine in community OBOT providers, MAT teams and other staff Separate for Hubs and Spokes Curricula designed by Dartmouth College with VT physician experts input 6-8 sessions,1.5 hours in length, spread over a year

Learning Collaborative Sessions covered Drug screening Dealing with behavioral issues Effective treatment of cocaine, benzodiazepines, and alcohol use disorders Need for dose adjustments and induction protocols Integrating regular medical and psychiatric care into the office visit Overdose, HIV and hepatitis education

GOVERNOR PHIL SCOTT, STATE AND LOCAL OFFICIALS ANNOUNCE VERMONT CAN PROVIDE OPIATE ADDICTION TREATMENT AND CARE UPON REQUEST 14 September 2017

VT Department of Health Department of VT Health Access Hub Census and Waitlist: June 2018 Region # Clients # Buprenorphine # Methadone # Vivitrol # Receiving Treatment but Not Yet Dosed # Waiting Chittenden, Addison 978 293 685 0 0 0 Franklin, Grand Isle 350 157 193 0 0 0 Washington, Lamoille, Orange 491 169 322 0 0 0 Windsor, Windham 655 150 505 0 0 0 Rutland, Bennington 407 87 302 1 17 0 Essex, Orleans, Caledonia 758 199 558 1 0 0 Total 3639 1055 2565 2 17 0 Note: The Franklin/Grand Isle location opened in July 2017. Some clients are transferring from the Chittenden/Addison hub to the FGI hub. Vermont Department of Health Source: Alcohol and Drug Abuse Treatment Program

The statewide number of people waiting for opioid use disorder treatment in hubs has trended downward over time; the number of people served in hubs has increased Number of People in Hubs and Waiting for Hub Services Over Time 4000 3500 3000 2500 2000 1500 1000 500 0 In Treatment Waiting Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jan- Apr- Jul- Oct- Jan- Jan- Apr- Jul- Oct- Apr- Jul- Oct- Jan- Feb- Mar Apr- May Jun- Jul- Aug-Sep- 17- Nov Dec- Jan- Feb- Mar Apr- May Jun- 14 14 14 14 15 15 15 15 15 16 16 16 17 17-17 17-17 17 17 17 17 Oct -17 17 18 18-18 18-18 18 In Treatment 175121522499252025732656276228202906300531043116328530743273327131143086314831933260328532893304365334033439368936793639 Waiting 513 384 431 516 389 615 419 462 343 375 313 218 145 162 133 106 104 95 110 90 92 60 64 58 20 15 0 2 0 0 Vermont Department of Health Source: Alcohol and Drug Abuse Treatment Programs

Agency of Human Services Spoke Patients, Providers & Staffing: June 2018 Region Total # MD prescribing pts # MD prescribing to 10 pts Staff FTE Hired Medicaid Beneficiaries Bennington 11 5 5.2 257 St. Albans 22 8 10.1 444 Rutland 20 7 5.15 351 Chittenden 82 15 14.5 606 Brattleboro 12 4 3.19 134 Springfield 6 2 1.55 50 Windsor 12 5 3.0 229 Randolph 6 4 1.7 129 Barre 21 6 6.45 292 Lamoille 16 7 3.8 150 Newport & St Johnsbury 11 2 2.0 101 Addison 12 4 1.25 115 Upper Valley 3 1 0.5 17 Total 234* 70 58.39 2875 Table Notes: Beneficiary count based on pharmacy claims August October, 2017; an additional 287 Medicaid beneficiaries are served by 35 out-of- state providers. Staff hired based on Blueprint portal report 11/22/17. *6 providers prescribe in more than one region.

Number of Medicaid Beneficiaries treated in spokes over time Region 9/13 12/13 3/14 6/14 9/14 12/14 3/15 6/15 9/1 5 12/15 3/16 6/16 9/16 12/16 3/17 6/17 9/17 12/17 3/18 6/18 Bennington 131 151 164 173 185 219 229 246 233 240 259 238 236 229 239 239 236 230 St. Albans 236 249 269 262 284 326 376 363 363 339 383 385 390 382 402 384 390 404 Rutland 206 242 251 253 234 244 245 256 259 267 274 300 223 253 282 304 223 327 Chittenden 352 408 314 357 382 402 400 420 434 474 528 514 553 596 573 513 553 516 Brattleboro 237 238 208 230 220 208 176 170 146 141 153 144 138 145 150 138 138 132 Springfield 41 54 57 41 55 50 52 52 67 57 77 77 55 53 73 54 55 50 53 50 Windsor 56 62 73 82 93 122 121 130 146 158 175 206 197 161 229 212 197 205 220 227 Randolph 78 91 103 110 112 99 95 100 93 83 83 107 130 145 97 89 130 108 111 119 Barre 198 201 210 212 234 245 254 251 231 302 317 301 268 273 263 254 268 248 Lamoille 117 125 134 135 127 134 137 139 147 154 155 157 145 151 217 239 145 228 Newport & St. Johnsbury 98 98 97 100 100 89 86 87 94 98 98 97 90 95 97 92 90 96 Addison 8 17 25 32 49 64 66 71 75 87 77 74 60 65 77 86 112 113 Vermont Department of Health Upper Valley 9 5 6 6 5 7 8 34 13 Source: 12 DVHA/Blueprint 17 34 for 16 Health22 19 Total 1,750 1,919 1,888 1,972 2,051 2,179 2,225 2,284 2,2 2,389 2,584 2,621 2,535 2,572 2,694 2,600 2535 2646 85 2807 2866 262 436 357 554 137 238 207 98 264 445 355 589 136 280 170 99

Number of Spoke Prescribers Over Time Region 9/14 12/14 3/1 5 6/15 9/15 12/1 5 3/16 6/16 9/1 6 12/1 6 3/17 6/17 9/17 12/1 7 Bennington 7 9 9 11 10 10 11 10 11 9 10 10 11 11 10 11 St. Albans 11 12 12 12 10 13 16 15 15 15 13 14 15 16 25 22 Rutland 9 10 8 9 10 10 13 13 12 12 16 18 12 20 16 19 Chittenden 30 27 27 30 30 31 38 53 71 70 78 78 71 82 79 79 Brattleboro 16 18 18 18 13 13 12 11 10 10 13 10 10 12 12 11 Springfield 5 4 5 6 2 2 2 3 4 4 3 4 4 4 6 6 Windsor 3 5 5 7 7 7 8 7 9 6 8 9 9 10 11 11 Randolph 8 6 4 4 7 4 6 5 6 7 7 6 6 7 5 5 Barre 19 17 14 14 18 17 15 20 21 19 19 21 21 19 18 19 Lamoille 7 8 7 6 7 6 7 9 10 9 12 15 10 14 17 16 Newport & St. Johnsbury 9 9 8 8 8 8 8 10 11 14 15 13 11 03/1 8 6/18 11 10 11 Addison 4 5 4 5 6 6 5 4 5 5 4 5 5 7 12 11 Upper 3 2 4 2 3 3 4 5 4 4 5 Valley 5 3 4 3 Total 128 133 123 131 126 126 140 160 187 180 196 203 187 212 225 224 Some providers prescribe in more than one region Note: Prior to 9/14, spokes were tracked by number of providers rather than number of prescribers so are excluded from this report Vermont Department of Health

Spoke Growth Prescribers and Spoke Staff FTEs Hired 300 250 200 150 100 50 0 Spoke MAT Prescribers in VT 10 Patients 1,837 114 38 7.6 Spoke MAT Prescribers in VT 2,646 212 63 63.9 3,000 2,500 2,000 1,500 1,000 500 0 Medicaid Benefiaries 26

MAT per capita 625,000 Vermonters 80 % over 18 yrs old 6505 on MAT from Medicaid Data 20-30% Commercial insurance in Spokes not accounted for 860 Total MAT estimates are 7365/500,000 adults is 1.47% of the TOTAL adult population of the state on MAT Estimate 2-3% may have OUD

Costs Impact of Medication-Assisted Treatment for Opioid Addiction on Medicaid Expenditures and Health Services Utilization Rates in Vermont published in the Journal of Substance Abuse Treatment (August 2016) Highlights: Higher MAT treatment costs offset by lower non-opioid medical costs MAT associated with lower utilization of non-opioid medical services MAT suggested to be cost-effective service for individuals addicted to opioids 6-7% cost savings by 2014 by treating OUD in the Hub and Spoke Vermont Department of Health

MAT and Non-MAT per Capita Rate of Health Care Expenditures, Excluding Opioid Use Disorder Treatment Costs $18,000 $16,000 $14,000 $12,000 $10,000 $15,579 $15,387 $13,874 $13,820 $13,937 $13,083 $12,259 $12,532 $12,008 $9,542 $9,345 $8,864 $9,225 $8,835 $8,774 $8,514 $8,082 $7,938 $8,000 $6,000 2008 2009 2010 2011 2012 2013 2014 2015 2016 Non-MAT Treatment MAT Treatment

MAT in jails Allowed since 2004 for up to 30 days Pilot in 2014 allowed treatment up to 90 days at few prisons if on MAT at incarceration-mtd or BPN H468 allowed on July 1, 2018 initiation of MAT/BPN for inmates pre-release with community follow-up at hub or spoke

The other major outcome. The most important one.. Vermont Department of Health

Contact info John Brooklyn, MD Johnr.brooklyn@gmail.com jbrookly@uvm.edu