Taking Action Summit: The ROADSS Model: Removing Barriers on the Road to Recovery
Thank you for joining this session,
The ROADSS Model: Removing Barriers on the Road to Recovery. My name is Michele Herman, and I would like to welcome participants who are joining through the virtual platform and those of you who are joining us here at Eastman School of Music. I am honored to introduce you to today's speaker. I've had the pleasure to work with Patrick for the past 14 years.
Patrick is the senior director of addiction services and a senior associate faculty member in the Department of Psychiatry at the University of Rochester Medical Center. This role includes general oversight of clinical operations, administrative functions, fiscal management of Strong Recovery, which is comprised of three clinics and multiple specialty programs, and oversight for 90 staff and faculty ranging from medical, supervisory, clinical, and support functions. Prior to taking responsibility for all addiction services in 2008, Patrick served as clinical coordinator of Strong Recovery Chemical Dependency and senior counselor and team leader in its methadone maintenance program.
On the steering committee for the UR Medicine Recovery Center of Excellence, Patrick focuses on substance use disorder, methadone treatment, and community relations. At the end of this presentation, we will have a Q&A period for both in-person and virtual attendees. For the virtual attendees, please use the chat option. Patrick?
- Thank you. Good morning again to everyone, and thank you for being at the conference and joining this session. So the ROADSS model is one of the projects of the UR Medicine Recovery Center of Excellence, and the focus, the goal of it, to put it simply, is to make the most effective treatment for opioid use disorder available, and as available to as many people who need them as possible. Which button advances?
Wait, did I just do it, or did you do that?
I'll advance for you, it's fine.
- Okay. Oh, wait, maybe it's working now. (audience laughs) We did all that on purpose, just to get a laugh out of you guys. So as you may have heard in other sessions, this Center of Excellence, we're focusing in certain counties in New York state and Ohio, West Virginia, and Kentucky.
They're Appalachian counties. There are 23 counties. But the project and the focus is disseminating information that can help reduce or eliminate opioid overdose and overdose deaths. However, the resources and the information that we have, they're available to everyone.
So just because our focus are those counties, the projects that we develop can be implemented in any state, in any county, in the country. We developed them that way, so that they're not only available to the Appalachian counties, even though those are our focus areas. So we've all been listening to a lot of the data, especially since the CDC recently released the preliminary data on drug overdose deaths for 2021 at 107,000-plus, number of deaths, which is just staggering. To kinda put it into perspective a little bit, we didn't get here just overnight.
This has been happening for decades. It's been developing to get us to this point over decades, starting with the rise in prescription opioid overdose deaths in the 90s, then the rise in heroin overdose deaths in 2010, and then the start and the rise of synthetic opioids like fentanyl in 2013, which, I'm hoping we've reached a peak and we can start making a downturn in this epidemic, especially when it comes to the overdose deaths. But if you look at, I especially use this slide because this is data from the CDC. When you look at, this is two decades, data for two decades, 500,000 people die from opioid overdose, just to give you kind of a picture of what the numbers are currently.
The current numbers the CDC released, about 85% of those are opioid overdose deaths. So for one year, it's almost 85,000 deaths. When we look at for two decades, it was 500, not that that's a good number, but it's just staggering to think about what the number is currently. What we know is, we had an epidemic that we weren't quite dealing with as effectively as we could, compounded by a pandemic that led to increases in use, and that's the result, what we're looking at.
The data we're currently looking at, that's the result. And again, in 2019, 70% of the drug overdose deaths were from opioids. We're now at 85%. We're going in the wrong direction.
So in looking at those numbers in Appalachian counties, Appalachian areas, it's even worse. When we look at the drug overdose deaths per capita in West Virginia where the numbers, the rates are the worst, the overdose deaths per capita is higher than any other state. And in rural counties, nearly 50% of rural Americans and 70% of farmers have been directly impacted by non-medical opioid use. And the overdose deaths in the Appalachian counties are 72% higher than in non-Appalachian counties.
So when we look at this data, the most effective treatments that we have should be available in those areas that are most impacted. It should be available everywhere. However, we have the opposite. And one more piece to look at, and I pulled this data around rural counties.
So West Virginia is number three in the country as far as rural population, and they had one of the highest percentage changes in drug overdose deaths. And Kentucky, which is number eight most rural county in the country, they were at 18.25%. So the rate of changes increases is even higher in those counties compared to less rural areas. So what we have is, the most effective treatment is least available in the areas most impacted, and that's the goal of ROADSS, is that we have to make medications for opioid use disorder available in those areas, and there are effective ways that we can do that.
And looking at why we're focusing on medications for opioid use disorder, and just to describe a little bit, there are three FDA-approved medications for opioid use disorder. There's methadone, buprenorphine, and naltrexone. Methadone is an agonist medication, buprenorphine is a partial agonist, and naltrexone is an antagonist, so it blocks the effects of opioids, where methadone and buprenorphine, they occupy those receptors, and so they prevent withdrawal symptoms, and they reduce or eliminate cravings from substances and allow people to stabilize physically and lead normal lives. Methadone has been approved and used for treating opioid use disorder since 1972.
Buprenorphine was 2002, a little bit more recent. Can't remember and didn't look up when naltrexone became available, but it was prior to buprenorphine. But we have these three medications available, and it's extremely important that they are made available. And we can look at data, we can look at the research, we can look at the experts, the World Health Organization identifying that medication-assisted treatment is the most effective way to treat opioid use disorder, and I'll just quickly go back and just mention something, 'cause I will use certain terms interchangeably.
So medication for opioid use disorder or medications for addiction treatment, MAT, to me, it's the same thing. So if you see on the slide, I say MAT, it's medications for addiction treatment, or MOUD, I'm talking about the same thing, or if I mention opioid use disorder or substance use disorder, I'm essentially talking about the same thing. Because our focus is opioids and reducing opioid overdose and overdose deaths, you will likely a lot of times just hear me say opioids or opioid use disorder. But again, they're interchangeable.
Some of the approaches are the same. So, numerous studies around how medications for addiction treatment reduce opioid use, reduces criminal activity, overdose, decreases overdose and risky behaviors. So when looking at medications for addiction treatment, it's most effective when provided in combination with counseling and social supports, in a treatment center, any kind of treatment center setting, for substance use disorder or a healthcare setting, any kind of healthcare setting that is providing treatment for substance use disorder, that it's supervised and overseen by medical providers and a treatment team that is providing whatever the treatment needs are for the person being treated.
It's also important, and especially since we are at a stigma conference, and especially when we're talking about the rural areas, that the leaders, I mean, this is applicable anywhere, that the leaders of those areas, and I'm talking about leaders in healthcare, leaders in public policy, leaders in government, leaders in faith, in those communities, family members, are all aware of the effectiveness of medications, of MAT, because what we are fighting is the perception about these medications. It's also very important and most effective when people voluntarily go to treatment, when they are choosing to go to treatment, and we assist that process, not being forced to treatment, not the criminal justice model of forcing people to treatment.
It's also most effective when people have options. I actually did an interview earlier this morning and mentioned that it's important that people know that they have options. It's also important to know that there isn't a one-size-fits-all in substance use disorder treatment. There isn't one pathway to recovery.
There are different ways to do it. We just need to make all of the options available to people so that they can make that choice, and it's also okay if someone tries a certain treatment and it doesn't work and we help them try something else. That's also okay, 'cause part of the perception is that, and I have interactions with people
all the time to this day about this: "Well, they already went to treatment, and it didn't work." Okay, well they can try a different treatment. That's okay. It's not the only healthcare issue we have where, the first time, second time, or even however many times people try treatment, it doesn't work.
You just try something else. As long as there are options to try, then it should be available for people to try them. Let's see. So, I mentioned earlier that methadone has been used to treat opioid use disorder since 1972.
That is five decades of data that we have. We have two decades' worth of buprenorphine. It is the most researched and peer-reviewed medication there is for addiction treatment, methadone specifically, and it's the most stigmatized medication that we have available for treating people. But it's the most researched and peer-reviewed that has shown itself to be effective time and time and time again.
And I don't need the research to tell me that. I have been working in a methadone maintenance treatment program since 2001, and I have personally seen its effectiveness. I have personally seen the lives that it's been able to restore, the lives that it's been able to save. But the research is also important, and it's shown the effectiveness in reducing illicit use.
It's shown the effectiveness in retention in treatment, which, research has shown us that it is most important to retain people in treatment. It's also effective at reducing overdose and overdose deaths. These are just multiple research. There's countless of them available, and we can make 'em available to anyone who would be interested in looking at them.
Methadone specifically has been very effective in helping individuals with other health issues like HIV/AIDS, in terms of adherence to treatment and how effective the treatment that they're receiving can be. And some of those are long-term studies that follow the patients for years and show that the improvement in the quality of life and reduction in use or elimination of use. There's also one particular study about criminal justice-involved individuals that shows injectable naltrexone, which is the antagonist medication I mentioned earlier, is also effective at preventing overdose events with individuals.
The key is that when it comes to opioid use disorder, people have a better chance if they're being treated with medication, with the medications that are approved for treatment in opioid use disorder and under the direction of a medical provider and a treatment team that can provide whatever those needs are, whatever the counseling needs and other social supports that an individual needs. So why is that? I mentioned that this medication's been around, specifically methadone, since 1972. It's been researched, peer-reviewed.
There's so much evidence out there about it. Well, part of the reason is because the myths about methadone are louder than the facts about methadone. And somehow, we have to get the facts to be louder. We have to get the facts out there about it.
So there's quite a few here that I'll mention. I included in the slides here that perception, that maybe it's better to just stop cold turkey. Well, no, stopping cold turkey increases your chance of relapse, increases the person's chance at overdose and dying from an overdose. That's the fact.
And part of that is, when someone stops cold turkey, and we have all the evidence of people in the criminal justice system that are forced to stop cold turkey, they are at their highest risk of overdose and overdose deaths, because your tolerance decreases, and they use the amounts that they were previously using, and it significantly increases the risk of overdose and overdose deaths. So another one is medication is just substituting one addiction for another. As I mentioned, these are FDA-approved medications that shown their effectiveness over decades, and they're not all the same, and that's why I mentioned earlier that options, it's important for people to have options.
For someone, maybe buprenorphine as a partial agonist works, and that's great, but for some people, that doesn't work. Then they need the full agonist medication. For some people, the antagonist medication works, and that's great, and again, all of those in combination with whatever treatment the person needs and whatever social supports that the person needs. And you'll hear me continue to repeat that, because in addition to the research that's available, that's what I also know and I've seen for now over two decades to be extremely effective in treating people.
So medications are a crutch that prevents true recovery from addiction. Well, research has shown that people who are treated with medication are less likely to use illicit substances. They do not experience the functional impairments that happens with the use of illicit substances. Of course there's the decrease in the risk of overdose, and there isn't that loss of control, because again, this is measured doses that are effective for eliminating the withdrawal, eliminating the craving, and allowing the person to physically stabilize and function normally.
Or that medications just simply aren't effective. That's self-explanatory. I think anyone who's interested in more of the details of the effectiveness of medications for addiction treatment, I would recommend SAMHSA. So SAMHSA has a series of treatment improvement protocols.
They're called TIP, and they all have a number associated with them. TIP 43 specifically focuses on medications for addiction treatment, tons of information about the effectiveness of medication. And I would truly recommend that. So when it first became available, buprenorphine, in Baltimore, immediately, there was a decrease by 37% of overdose deaths once buprenorphine became available and they started using it to treat people in Baltimore.
I think I skipped something here. So, here's one that it's not just with the general public, but sometimes with even health and human services providers, that it should not be used long-term for the treatment of opioid use disorder, when in fact, the opposite is true. It's a long-term treatment. It is indicated to be a long-term treatment.
It is not indicated to have a time period in it, "Oh, well, "you're gonna get this treatment for the next six months, "and then we have to taper you off," no. It can be indefinite. We have, (Patrick brushing lapel mic) oh, I'm sorry, we have patients in our program that have been there for as long as I've been there, so since 2001 and that were there prior to me getting there. And you know what?
They're leading their normal lives. They've never had an overdose event. They haven't used any illicit substances, and they're caring for their families. So it can be indefinite, and that's okay.
Actually, it's more than okay; it's actually a fact. It's indicated to function that way. More on that, that it should not be used long-term, so the National Institute of DruG Abuse that medication for addiction treatment is an essential component of an ongoing treatment plan, for people to take control of their health and their lives. SAMHSA indicates these three phases to treatment.
There's this beginning stage of stabilizing physically and introducing counseling and those social supports. Then there's a second phase of maintenance after people stabilize, and there can be, and this is very important.
This is why I highlighted that last part: so there can be a third phase at some point down the line where people can choose to taper off of the medication. But it is extremely important that that is done based on the person's need and that it is self-directed with the guidance of their healthcare provider. So not that it's being dictated by a judge or a probation officer or a family member or anything else that might apply pressure to someone to say, you need to get off this medication, no. But it can be done self-directed with the guidance of their medical provider based on their needs.
And again, research has shown that to be effective, but I don't need the research, because I've seen it to be effective. Now, that's a process that someone can go through that can be for a couple of years, or it can be a process that they can do within a year or over five years. Really, the timeframe really does not matter. It should not be rushed.
It should not be forced. It should not be influenced in any other way except for, that's the person's choice, and it meets their needs, and they work with their care provider to do that in an effective and safe way, because that's also something else that, if it's done too quickly, that can increase someone's risk of relapsing, which then increases their risk of overdose. So that self-directed process is extremely, extremely important. Another myth, that courts or the criminal justice system can determine someone's course of treatment.
We don't do that with any other medical condition, where a judge can tell you what the course of treatment you need for your diabetes or some other medical condition. It sounds ridiculous, right? But sometimes it happens with substance use disorders. So overdoses from methadone used for treatment are common and increasing.
No, it is not. Methadone is a very highly regulated medication, highly regulated, and a lot of times, incidents of overdose that may happen with someone that is being treated with methadone may involve other substances. Now, the combination with other substances can increase someone's risk for overdose. But it's not because they're being treated with methadone.
So requiring people to taper off medication helps them get healthier or healthy faster. Nope, it's the opposite. It's counterproductive to require someone to taper off medication if that is not their choice and it's not what fits their need, and it increases their risk. Some of these are repeating, but these are things that are out there.
And they're not out there just in the rural counties. They're out there everywhere. They're in this county. They're in the urban counties as well, just the stigma against medication.
Or medication should be, and especially methadone, should be avoided during pregnancy. No, actually, we need to actually push someone who has an opioid use disorder that is pregnant towards methadone treatment, because it stabilizes the level of opioids in their system and decreases repeated prenatal withdrawals for the fetus. It links the mother to prenatal care, or if it's needed, infectious disease clinics that can provide further treatment to them. It increases and improves the long-term health outcomes for the mother and the baby.
So when a pregnant woman comes into an opioid treatment program where methadone maintenance treatment is being provided, it's not just medication they're receiving. They're receiving care from medical providers and a treatment team that is also linking them to the other services that they need, for them and the baby. Furthermore, it decreases the severity of neonatal abstinence syndrome, and decreases the treatment time that the baby might require after it is born. So it's actually the most effective treatment that we can push a pregnant woman with an opioid use disorder to.
But again, the perception in the general public or in some sectors is the opposite. That's why I mentioned earlier that we need the facts to be louder than the myths. Right now the myths are louder that the facts. So, when we looked at and we were working on this project, this is not the total barrier, but here's a glimpse of it, based on the 23 counties I mentioned earlier that this project focuses on between New York, Ohio, Kentucky, and Virginia.
You remember those rates of, how the rates of overdose are much higher and the rates of increases are much higher in those counties? Well, so, here are the 23 counties in those four states that we are focusing our projects on. In 23 counties, there are five opioid treatment programs. The medication that can decrease, reduce, and I'm really being very modest in saying just over 50%, because it's much higher than that, that it can decrease the risk of overdose and overdose deaths that has been around since 1972, and researched and peer-reviewed more than any other medication for addiction treatment, in 23 counties, it's available in five.
So that means for someone, if that is the treatment, if that is the medication that would be effective for them, for some people, it requires traveling great distances to get the treatment. That's another area where I don't need to look up data for, because we have people in our clinics now that are traveling an hour and a half or more to come receive the care, not because that's what they choose to do, but it's the treatment they need, and it's the only option available to them. So that's opioid treatment programs. Making them more available to those counties is the goal.
ROADSS is, I don't know if I mentioned this earlier, so ROADSS, testing my memory here, so ROADSS stands for, it's Rural Opioids and Direct Support Services. The whole point is to make opioid treatment programs, especially methadone maintenance treatment, available directly in those areas, in those areas that are most affected by overdose and overdose deaths. What are opioid treatment programs? Opioid treatment programs, that's an outpatient clinic that is providing substance use disorder treatment, so an OTP for short.
So an OTP is able to provide all three of the FDA-approved medications for opioid use disorder. So dispenses methadone, can dispense buprenorphine, can prescribe injectable naloxone although that's not really done as much, but it can, and it's available. So it makes all of the medications available to people. Because what's happening currently now, most of the treatments that are available exclude methadone.
Currently, to provide methadone maintenance treatment, you have to be an OTP. You have to be a licensed OTP. So in addition to the treatment, in addition to the medication, there's comprehensive treatment that is provided: counseling, for some programs, case management, for some programs, health home might be available, or for some programs, if they don't provide some of those additional social supports directly, they can link people to those kinds of programs. In some programs, mental health treatment may be available.
There are providers who can assess and provide other medications that someone might be in need of, including psychotropic meds. So OTPs function in a wide range of ways, and it's not just about the medication, because again, it creates the opportunity to link people to medical care, to address co-occurring medical conditions they might have, to address co-occurring mental health disorders that they might have. And it also can link people to, provide opportunities for them to receive vocational training, return to work, return to school, any of those social aspects of life. So when I say OTP, that's what I'm talking about: comprehensive treatment.
And the ROADSS model really is taking, essentially, ROADSS is not creating anything. It's taking really three effective, three very effective things and combining them. One is OTP, so an opioid treatment program. The second is hub and spoke model that some of you I know are very familiar with.
So hub and spoke is Vermont's model for treating substance use disorder, where you have a central hub that is providing high-intensity treatment. They're more comprehensive, and usually that includes an OTP. They're providing comprehensive treatment. Again, all of the approved medications are available to people.
They're strategically located regionally, with multidisciplinary teams that can provide treatment to people. So you think of, in their model, a hub as more sort of the larger specialty SUD program, and then the spokes are smaller entities that provide the less intensive treatment. And maybe if you think, I mentioned that SAMHSA, the phases of SAMHSA, they use more of the phase two kind of treatment. They're providing that maintenance treatment after someone stabilizes.
A lot of times, there are PCPs locations that are spokes to a central hub. I think a lot of them actually are PCPs. Some can be community agencies. So that is a model within their state where, that's the approach to treating substance use disorder, and it's been very effective.
If you look at it, it increased access, significantly increased access, and despite the fact that their model is a higher cost model than what's happening anywhere else that's not using the hub and spoke, it's still cost-effective. And part of that is because when we provide the effective treatment, we are impacting, and that's true just for substance use disorder treatment in general, that we are impacting other high costs, co-occurring conditions that people have, because if they're not in care, it's not only the illicit use or the increase in overdose, but their physical health is not being taken care of, which then leads to high-cost hospital visits or ED visits, those sorts of things that we can prevent by having people in substance use disorder treatment.
So, it's OTP, hub and spoke, and then the third is what's called a CCBHC. A CCBHC is a certified community behavioral health clinic. What it essentially is is a very comprehensive behavioral health clinic model that treats both substance use disorder and mental health disorders. And some of the components of what makes up a CCBHC includes sort of focusing on the whole person, being person-centered, high levels of care coordination and integrated treatment.
The services are kind of delivered with this idea of a behavioral health home, because we are treating both mental health and substance use disorders. So when we look at, there are nine required core services of a CCBHC. So it include crisis services. It includes person-centered treatment planning, screening, assessment, and risk assessment, the outpatient mental health and substance use disorders, primary care screening and monitoring for physical health, psychosocial/psychiatric rehab services, which, in a lot of cases, especially for substance use disorder-based CCBHCs, focuses on vocational and educational services for patients.
Peer support services and family counseling is also one of the required, as well as targeted case management. So it's a very comprehensive model. Again, does everyone receive all of those services? No, it's person-centered.
It's available for the patients who need them. Some patients may receive all of these services. Some patients may receive just one of these services, or two, or three; it doesn't matter. We assess what the patient's needs are, and these services are available to be provided to them.
And it's even better when a CCBHC clinic includes an OTP. That's the idea with the model, that, because CCBHCs, being an integrated and comprehensive model, emphasizes recovery, wellness, trauma-informed care, and of course that behavioral health integration. So the combination of an OTP that is a CCBHC offers, for what's currently available, it offers the most comprehensive model for treating opioid use disorder. Now, we won't be able to establish CCBHCs with an OTP everywhere.
I'm realistic that that can't happen. However, we can, when we take CCBHC and combine it with an OTP and take that hub and spoke concept, we can make it available everywhere. And here's just kind of an infographic of what ROADSS is. So just to explain what ROADSS is, it's a comprehensive clinic.
It doesn't have to be a CCBHC. I'm presenting a CCBHC because that's the model we have, and that's the most comprehensive and available model that you could design, but it doesn't have to be a CCBHC. It can be an OTP, a central OTP, that then can serve a larger area. How that can be done is that central OTP has auxiliary clinics in those areas.
Now, those auxiliary clinics can be in two forms. It can be a mobile unit or a mobile methadone unit that is going to areas where the treatment is needed, or it can be in partnership with a healthcare provider or a human service provider in that area where what's called a medication unit can be established.
So the difference between the two: so a central OTP can provide all of the counseling, prescribe the medication, dispense the medication, have the providers available to treat patients, as well as provide consultation to other providers in the rural or less populated areas, of course has the financial oversight and operational oversight for the auxiliary sites. So the auxiliary sites focus on dispensing medication, and through telehealth, all of the comprehensive services, peer support, counseling, can be available to people being treated, whether it's the mobile unit or a med unit that's being treated, because those services are linked to a more comprehensive central clinic, is the idea.
And again, this graphic is showing buildings for the auxiliary units, but again, because sometime last year, the DEA approved mobile methadone units, that that can be mobile. So it can be mobile, or it could be a combination of mobile and med unit, depending upon the area, because if it's too far out, a med unit would be more effective than a mobile unit trying to travel two, two and a half hours to get to people. So, it also depends on the geography and distance from central clinic to where the service needs to be established. So what does this model do?
It reduces that travel time for people. It increases access, because everyone can't travel that far to receive treatment, and by partnering with other organizations in the area, it can reduce some of the stigma or at least the stigma that keeps people from treatment. For example, if the partnership with a central comprehensive clinic is with a primary care provider, well, that's a setting where people are going to to get all kinds of care. It's not labeled as a substance use disorder treatment, but with this kind of setup, you can get substance use disorder within that setting.
So people don't have to worry about walking through the doors of a specialty substance use disorder program, because again, we're not there yet to where the facts are louder than the myths, so then we have to find ways to create constructs where people don't feel the weight of that stigma keeping them from accessing care. And the other point I wanna make with ROADSS is that the central OTP, or ideally, CCBHC with an OTP, can have multiple mobile units or med units, again, depending on the area. So it's designed to be that it could be just one auxiliary clinic, or multiple auxiliary clinics.
If all of us that have central OTP programs are doing this, we can cover every area that needs the treatment available to 'em. So this is quickly just an example of what this could look like. Again, this doesn't have to be the model that someone follows, but again, it's just to give you an idea of a central program having just a more comprehensive, multidisciplinary treatment team and structure, and an auxiliary clinic being a more reduced version of that that's again focusing on providing those services that must be done directly in the med unit or mobile unit, and again, through telehealth, the rest of the comprehensive services can be available to patients.
So this model is available on our UR Medicine Recovery Center of Excellence website, just to give an idea to any organizations who may be interested in trying to implement this. It's just to give an idea. Of course any organization would design this in the way that fits them better. It doesn't have to be exactly the model that we have.
It's just the idea or the concept that we want people to adopt. So by implementing this kind of model, we will increase access, and we will decrease the risk of overdose and overdose deaths, because it would make the most effective medication widely available to people who need them. Now, just to mention quickly, what are some of the barriers sometimes, maybe if an organization is even willing to do this? It's not easy, and I do understand that.
It's not easy to establish an OTP, and it's not easy to operate an OTP, and I'll very quickly give you an idea as to why. To operate an OTP, you essentially need four licenses. You have to have a DEA license specifically for that OTP. You have to have a SAMHSA license.
You have to have a state, whatever your state is, their operating certificate, whatever processes your state has established, and it has to be accredited, has to be accredited by one of the three federal accreditation organizations for healthcare facilities. So it administratively can be a burden, but there are a lot of us that have experienced operating OTPs, and part of the goal of this project is to provide support to organizations that are either looking to establish an OTP and adopt this model, or that already has an OTP and would like to then establish auxiliary clinics as part of that OTP.
You know, either/or. We know that the support is needed. There is also as part of the project a financial pro forma that we, again, established just to give an idea of a model of what some of the costs associated with this might be so organizations could get a sense, but again, that can vary. That will vary by region, area of the country, kind of organization, hospital-based versus community-based.
All of those things vary. Again, it's to just give an idea for people to work with. So I think some of this info Michele might share, but if interested, all of the information about ROADSS is available on the Center of Excellence website. You can make contact with our project team, and we can work with you if it is something that you're interested in implementing.
All right, and I think we'll go to Q&A.
We are gonna go to Q&A. So is there anybody in the crowd that has, in person here, that has some questions for Patrick?
- Hi, Patrick, just a couple questions. Recently, the buprenorphine assessment no longer has to be done in person. It can be done via telehealth. Is that true for methadone now as well, or is that still waiting to happen?
- Yeah, methadone is still in-person.
- It's still in person, okay. And the mobile units, you said the DEA authorized those last year? Is the road clear for that? (man laughs) "The road clear for that."
- Oh, yeah. (all laughing) I like that. (all laughing) Yes, the road is clear for that. If you have an OTP, so organizations that already have an OTP can apply for a DEA license for, it's actually, you don't even need a new license.
There's a process that the DEA has for a mobile unit, and then there's a state process as well for establishing that. But the road is clear, and you can do it. And you can do it, 'cause previously, there were only a couple of states who were able to do it through some sort of loophole with the DEA, and they weren't allowing any other states to do it, but now it's available for any states to do it.
- Thank you. We have one from online. You know, there's a lot of concern in regard to the potential of a fatal interaction with individuals who are on MOUD as well as taking benzodiazepines. Could you speak a little bit to maybe offer some guidance for clinicians as they navigate that balance between the two medications?
- Yeah, I think it's, I mentioned a multidisciplinary team, so I think it's important, the partnership between the medical providers and nurses and counselors that are working in the treatment program to work together around how that risk can be reduced or how it can be monitored and work with the patient to reduce that risk. I don't think it's something that a counselor can do alone. You have to work with your medical providers to help reduce that risk.
- Hi, I learned at the summit that methadone was extended from 14 to 28 days for take-home medication and I am wondering how that has impacted your OTP or OTPs and the people you serve.
- Impacted in what way, just in general?
Yeah, just having the ability, like you had mentioned, there's limited OTPs, and there are areas that they don't exist, so with this extension from 14 days, are there any, in what ways I guess in general have you noticed an impact with that?
- So, other than it's provided patients a bit more flexibility, so the extension to the number of take-home someone can have was a result of the pandemic, obviously trying to reduce the number of people coming into a clinic so that we could manage it safely, our COVID protocol safely. So it's provided more flexibility, especially for patients who are in that maintenance phase that have stabilized, are not using illicit substances. It decreases their number of visits to the clinic. We haven't seen any overwhelming adverse effects of it.
Yeah, I think, she didn't have the mic, so the question was, do I think it's something that will continue? Yes, I think, and Rob Kent yesterday from ONDCP in his presentation mentioned that the federal agencies, so ONDCP, SAMHSA, DEA, are all working together in looking at, not sure if it will be the exact same as what the emergency waivers are, but definitely, the ability for increased take-homes I think will be permanent.
- We're gonna grab one from our virtual platform, and that is, how has the emergence of fentanyl impacted MAT, and particularly methadone treatment?
- You know, I think one impact is that we've certainly experienced in the last few years more overdose deaths in patients that we're treating as a result of the rise in synthetic opioids, especially fentanyl, again, because people are at different stages of treatment and their recovery, we're just seeing more patient deaths, which is really sort of increasing the urgency in making the treatment more available.
Somebody else had a question.
- I think center of the room.
- We're from Raleigh County, West Virginia, so a lot of the patients that we see are in those underserved counties that are on your map. We have several who travel upwards of two hours to get to our office, but we do family practice and incorporate office-based medication as a treatment with buprenorphine. There are still so many barriers, so I think with methadone, like what you guys have done, it's amazing, but we run into so many additional barriers with buprenorphine. Prior pandemic, we tried to do some pop-up clinics in those areas, and they were working well, and of course, we had to stop that when we couldn't do group visits anymore.
But I feel like West Virginia as a whole has really legislated themselves into this number-one position that we're in.
- I agree. (all laughing) - So not really a question.
- But we don't know how to fix that.
- Yeah, we're not a member of the good ol' boys club. (all laughing) - You know what, I would love to connect with you and connect you to Rob Kent and his colleagues.
We would love that.
Yes, absolutely, we need it.
- Because I think it is something that the Office of National Drug Control Policy needs to take on. Just one perfect example you shared. You had pop-up clinics that were effective, and you had to stop. In the middle of a pandemic where we're seeing staggering increases in overdose deaths, you had to stop an effective approach to making treatment available to people.
And we also have issues, pharmacies won't fill the prescriptions. "We have limits, we have limits." Okay, well, the attorney general needs to do something about that.
- Won't fill buprenorphine prescriptions?
No, they max out, so they get red flagged by the distributor, which all stems back to the Oxycontin issue, blah, blah, blah.
But buprenorphine is lumped under opioids. So they say, well, we can only provide this percentage of opioids, and they consider buprenorphine the same as Percocet or whatever. So pharmacies simply won't fill anymore. They say they can't get any more.
- That is mind-boggling.
- And when we bring this up to the medical director, Dr. Becker from Medicaid, he says, every time we ask him about something or he feels we're challenging him, he says, "Well, you're red-flagged." I'm like, okay, well, red flag me then.
You're red-flagged for providing treatment?
- Well, no, he said it's because of our prescriptive practices, because we have so many patients. We have between three and 400 patients. We're four providers. The administrative burden is so big.
We could see so many more people, but the administrative burden is overwhelming. So that's why we don't have more patients, because we're a primary care practice too. So if you come to us for treatment, if you need primary care, we take care of that too. But Dr.
Becker is a major, major barrier to Medicaid patients in West Virginia. If they have BlueCross, we can get the services for them. If they have Medicaid, you have to go through Dr. Becker.
Dr. Becker actually told me, what, three weeks ago, we were trying to get a patient's dose to continue at 24 milligrams, because he became unstable at 16 during the pandemic. Dr. Becker refused to approve that.
He actually said, "Medicaid does not have to pay "for any of these medications. "We just do it because it's the right thing to do." So I told him The Support Act would beg to differ, and he said, "Well, I'm unfamiliar with that document." And I said, "Well, we sent you a copy, "but I'll send you another."
He literally said, "Well, your practice is red-flagged." I said, "Red flag me then!" (all laughing) - So I would love to connect with you. I would love to connect with you after this and really get you connected to ONDCP, because it's criminal.
And you know, what you mentioned in terms of, that you can provide the treatment if they have BlueCross but if they have Medicaid, you're talking about, this is a health inequity issue.
You're absolutely right, and when we bring that up, he said, "Well, I don't have anything to do with private insurance." That's true, he is discriminating against an entire segment of society.
And he doesn't have a problem with that. You know what's really frightening? He just told me that he is teaching a fellowship for nurse practitioners at Marshall University. That's scary to me, scary.
- Definitely would love to connect with you after this session.
- So we kinda had the same issue pop up that they're talking about, and it was a little bit of miscommunication. The pharmacies themselves could elect how much suboxone they wanted to purchase and distribute in their community. So we were the healthcare system, so what the MAT clinics did is they come to our large healthcare system and say, "We are gonna be doing this many participants," and so our pharmacies within our hospitals just stocked more of the medication. And so, it was more of their choice and their carrying how much of the medications, but they initially told us very similar things, that it was DEA regulation and it was this regulation, and it was not that.
Once you got down and got through all the BS, it was their personal preference.
- I know we had one more question online I wanna make sure that we get to. Sorry. Do you have any advice for a community who has providers that do not want the general public to know that they prescribe methadone or other MOUD medication?
- The providers don't want the public to know they can prescribe?
Yes. I think the fear is that they will be kind of overrun or that the providers themselves will be stigmatized by their peers.
- Yeah, my advice would be, and this is a model of a recent program that we established, is for those providers to work with the specialty treatment programs in their area to help with management of whatever volumes they might get. And it's kind of a little bit similar to hub and spoke, where specialty clinics can maybe deal with patients who are maybe a little bit more unstable or not quite at that stable phase, and so for those providers to then get patients linked to them that are a little bit more stable. I think partnering with the specialty substance use disorder programs might be the best way to help with that.
And we've gone a little over time, so if you have additional questions, please feel free to email the Recovery Center of Excellence. Our email address is on the main platform as well as on many of the flyers around. So Patrick, thank you so much.
- Thank you. (audience applauds)
Patrick Seche, MS, CASAC
Senior Director of Addiction Services & Senior Associate, Department of Psychiatry, University of Rochester Medical Center