Overcoming Barriers to MAT: Bridging the gap between research and treatment in Nevada

“Of the 2.5 million Americans 12 years of age or older with [opioid use disorders] OUDs, fewer than 128,000 [less than 0.05%] of those attending specialty treatment programs had treatment plans that included pharmacotherapy” (Molfenter et al., 2017, p.2).

For many people with opioid use disorder (OUD), the most effective treatment is the combination of counseling and medication assisted treatment (MAT) with medications such as buprenorphine methadone, or naltrexone. MAT, an evidence-based best practice, allows individuals with OUD to be healthy, productive members of society (Sofuoglu, DeVito, & Carroll, 2018). As part of a comprehensive treatment program, MAT has been shown to:

  • Improve survival
  • Increase retention in treatment
  • Decrease illicit opiate use
  • Decrease hepatitis and HIV seroconversion
  • Decrease criminal activities
  • Increase employment
  • Improve birth outcomes with perinatal drug users

(The Connecticut Certification Board, 2018)

Co-occurring disorders and comorbidity with communicable disease are common among individuals with OUD (Stoller & Stephens, 2016).   A multifaceted approach to treatment is needed to address the diversity of needs.

Buprenorphine and naltrexone are two Food and Drug Administration (FDA) approved MAT medications Buprenorphine works for both medically supervised withdrawal and maintenance. Naltrexone is a long acting medication that blocks the effects of administered opioid agonists and prevents return to opioid dependence after medically supervised opioid withdrawal.  Both medications allow patient and provider more flexibility with regards to dosage and structure of MAT than a traditional methadone clinic. Like methadone, buprenorphine and naltrexone are classified as controlled substances and governed by the federal Controlled Substances Act.

MAT that has been approved by FDA is currently supported by unprecedented federal funding and resources in response to the opioid crisis.  However, researchers have identified a significant gap between provider capacity to prescribe buprenorphine and naltrexone, and the number of individuals with OUD who are accessing medication assisted treatment (Abraham et al., 2015; Andraka-Christou, & Capone, 2018; Andrilla, Moore, & Patterson, 2018; Duncan, Mendoza, & Hansen, 2015; Haffajee, Bohnert, & Lagisetty, 2018; Molfenter, 2015; Valenstein-Mah, Hagedorn, Kay, Christopher, & Gordon, 2018).

Initial attempts to address the discrepancy between patient need and the application of MAT focused on increasing the number of providers who are DATA 2000 waivered.  (To become a MAT provider in the United States, clinicians must receive specialized training and be granted a waiver to prescribe MAT medication under the Drug Addiction Treatment Act (DATA) of 2000 (Substance Abuse and Mental Health Services Agencies (SAMHSA), 2018). Significant efforts were made to increase the number of patients each individual Data waivered provider can treat, and to increase the overall number of waivered providers.  Despite success in increasing both the number of prescribers and the number of patients each provider may serve, the average waivered physician is prescribing MAT medication under their allotted capacity, or not at all (Abraham et al., 2015;  Andraka-Christou, & Capone, 2018;  Andrilla, Moore, & Patterson, 2018;  Duncan, Mendoza, & Hansen, 2015;  Haffajee, Bohnert, & Lagisetty, 2018;  Molfenter, 2015; Valenstein-Mah, Hagedorn, Kay, Christopher, & Gordon, 2018).

When asked why they were not providing MAT at capacity or in general, providers cited barriers that included bureaucracy, lack of resources and education, and stigma toward the OUD population.  Researchers also asked what was working well in MAT. Providers who were successfully implementing MAT presented solutions to the barriers cited by colleagues (Andrilla, Moore, & Patterson, 2018; Valenstein-Mah, Hagedorn, Kay, Christopher, & Gordon, 2018).  Researchers have come to the following consensus regarding the barriers and solutions to prescribing MAT (buprenorphine, naltrexone). See Table 1.

Table 1. Prescribing MAT (buprenorphine, naltrexone) at Capacity in Nevada – Barriers and Solutions

BARRIERS

SOLUTIONS

Bureaucracy/ Regulatory Restrictions

  • Concerns about reimbursement
  • Cumbersome regulations
  • Perception of bureaucracy
  • Regulatory hurdles to obtain the waiver needed to prescribe buprenorphinein non-addiction specialty treatment settings
  • Restrictions imposed by the criminal justice system
  • Working with the Drug Enforcement Administration (DEA)
  • Policy pathway: Eliminate buprenorphine waiver requirements for those licensed to prescribe controlled substances.
  • Maintain appropriate recording practices.
  • Provide peer mentoring programs to guide new providers through the process.

Insufficient Resources

  • Inadequate office space
  • Lack of adequate time, time constraints in practice
  • Lack of resources
  • Coordinate with integrated opioid treatment and recovery centers (IOTRCs) and office-based opioid treatment programs (OBOTs).
  • Incorporate Project ECHO[1]/telehealth into provider training and care coordination.
  • Access state targeted funding to support MAT.

(“State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49–6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31–4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00–1.39, p=.049”. (Abraham et al., 2018,p.1)

 

Insurance and Reimbursement

  • Prior authorization or other insurance requirements
  • Inadequate reimbursement from private and public insurers
  • Liability fears
  • Policy pathway: Enforce insurance parity requirements.
  • Policy pathway: Increase insurance reimbursement for behavioral health care.
  • Policy pathway: Mandate insurance coverage of MAT and inpatient supervised withdrawal.
  • Policy pathway: Prohibit excessive insurance prior authorization requirements.
  • Policy pathway: Require coverage of evidence-based medication-assisted treatment as essential health benefit.
  • Implement the Patient-Centered Opioid Addiction Treatment (P-COAT) Model. See Table 2.

Motivation

  • Lack of [provider] interest
  • Lack of patient demand
  • Continue efforts to eradicate both internalized and externalized stigma related to the OUD population.
  • Increase support for, and coordination amongst, MAT providers.

Poor Care Coordination

  • Lack of mental health and psychosocial support
  • Establish linkages to behavioral health providers and other psychosocial supports/treatment.
  • Implement collaborative stepped care, and expert consultation.[2]
  • Policy pathway: Incentivize interdisciplinary cooperation.
  • Policy pathway: Provide financial incentives for care coordination across healthcare professional types-including behavioral health counselors and other non-physicians in specialty and non-specialty settings.
  • Implement the Patient-Centered Opioid Addiction Treatment (P-COAT) Model. See Table 2.
  • Provide prescriber recruitment bundles (PRBs) with organizational change model and Kickoff, training, and monthly coaching calls. PRB is currently being piloted in 70 Addiction Treatment Centers in three states.
  • Support collaborative systems such as Nevada’s Integrated Opioid Treatment and Recovery Center (IOTRC) model.

Stigma

  • Mistrust of people with addiction or buprenorphine
  • OUD population viewed as difficult patient population
  • Perception that treating OUD patients can be difficult
  • Reduce/eliminate the use of stigmatizing language by providers and the media.
  • Raise awareness via providers, that buprenorphine and methadone are evidence-based treatments.
  • Develop mentorship between individuals with OUD who are successfully using MAT and individuals who are discouraged from initiating MAT due social/self-stigma.
  • Render evidence-base and best practices more accessible to the community at large.
  • Promote MAT certification for those less likely to feel stigma towards individuals with OUD, e.g. peer recovery and support specialists.

Workforce Barriers

  • Inadequately trained staff
  • Lack of adequate [provider] education, lack of knowledge
  • Lack of [provider] confidence/ comfort level
  • Lack of institutional and clinician peer support
  • Leverage existing resources of Project ECHO and telehealth.
  • Mentorship (in-person or via project ECHO).
  • Enhanced MAT training and certification for providers and/or support staff
  • Policy pathway: Provide free and easy-to-access education for providers about opioid use disorders and medication-assisted treatment
  • Provide education in the stepped care model
[1] Project ECHO is an innovative health care delivery solution pioneered in New Mexico by Dr. Sanjeev Arora. Since its inception, Echo has been replicated at over 100 sites worldwide. The University of Nevada, Reno School of Medicine was an early adopter of Project ECHO, along with Washington state, and Chicago. ECHO is a simple telehealth linkage connecting university-based faculty specialists to primary care providers in rural and under-served areas to extend specialty care to patients with chronic, costly, and complex medical illnesses (University of Nevada, Reno School of Medicine, 2018: https://med.unr.edu/echo).

[2] “An adaptive stepped-care model … adjusts counseling intensity and medication prescribing and dispensing based on ongoing indicators of treatment response (e.g., toxicology screen results and percent counseling adherence). If there are indications of clinical destabilization (e.g., positive toxicology screen or decline in counseling adherence), counseling schedules can be intensified. When necessary, medication dispensing is shifted from the OBB to the OTP dispensary site. Conversely, as the patient stabilizes, counseling intensity is decreased and medication prescribing in the office-based setting is resumed,” Stoller & Stephens, 2016, p.9) (Abraham et al., 2015; Andraka-Christou, & Capone, 2018; Andrilla, Moore, & Patterson, 2018; Duncan, Mendoza, & Hansen, 2015; Hadland, Park, & Bagley, 2018; Haffajee, Bohnert, & Lagisetty, 2018; MacDonald, Lamb, Thomas, & Khentigan, 2016; Molfenter, 2015; Molfenter et.al 2017; Stoller & Stephens, 2016; Valenstein-Mah, Hagedorn, Kay, Christopher, & Gordon, 2018.)

Table 2. The Patient-Centered Opioid Addiction Treatment (P-COAT) Model (ASAM, AMA, 2018)

OPTION A: PAYMENTS FOR MEDICAL MANAGEMENT BY A 2000 PRACTITIONER

Opioid Addiction Team

  • A physician or other qualified healthcare professional with a waiver to prescribe buprenorphine under the Drug Addiction Treatment Act of 2000. This practitioner could bill for IMAT/MMAT payments to support medication assisted treatment and care management services for the patient.
  • A board-certified physician who specializes Addiction Medicine. This Addiction Specialist could bill for IMAT/MMAT payments to support medication assisted treatment and care management services for the patient
  • One or more physicians, psychologists, counselors, social workers or other qualified healthcare professionals who are licensed and certified to provide appropriate psychiatric, psychological, or counseling services to individuals with OUD and have contracts or collaborative agreements with the practitioner prescribing buprenorphine or naloxone services to deliver services to patients in a coordinated way
  • One or more nurses, social workers, pharmacists or other healthcare or social services professionals, who have the training and skills necessary to necessary to help individuals with OUD to address non-medical needs, and who have a contract or collaborative agreement with the practitioner prescribing buprenorphine or naltrexone to deliver services to patients in a coordinated way. Under Option B, these providers would be paid using existing billing codes or other payment methods that support their services.

OPTION B: PAYMENTS FOR MEDICAL MANAGEMENT BY AN ADDICTION SPECIALIST

Opioid Addiction Team

  • A board-certified physician who specializes Addiction Medicine. This Addiction Specialist could bill for IMAT/MMAT payments to support medication assisted treatment and care management services for the patient
  • One or more physicians, psychologists, counselors, social workers or other qualified healthcare professionals who are licensed and certified to provide appropriate psychiatric, psychological, or counseling services to individuals with OUD and have contracts or collaborative agreements with the practitioner prescribing buprenorphine or naloxone services to deliver services to patients in a coordinated way
  • One or more nurses, social workers, pharmacists or other healthcare or social services professionals, who have the training and skills necessary to necessary to help individuals with OUD to address non-medical needs, and who have a contract or collaborative agreement with the practitioner prescribing buprenorphine or naltrexone to deliver services to patients in a coordinated way. Under Option B, these providers would be paid using existing billing codes or other payment methods that support their services.

OPTION C: PAYMENTS FOR COMPREHENSIVE SERVICES FROM AN OPIOD ADDICTION TEAM

Under Option C, a single organization would serve as the Opioid Addiction Team, and it would employ or contract with the necessary personnel to prescribe medications, deliver psychiatric, psychological or counseling services, address non-medical needs, and provide care management services for individuals with an OUD. This organization would receive “bundled payments” (Comprehensive IMAT/MMAT Payments) designed to cover all of those services, and it would fit the bill for those services using current billing codes.

Potential Barriers Associated with Implementation of the P-Coat Model:

  • General barriers to MAT prescribing listed in Table I
  • Time and Resources to support the implementation of the P-COAT model

Solutions to Potential Barriers Associated with Implementation of the P-Coat Model:

  • Solutions provided in Table I
  • Current federal policy and funding support for evidence-based best practice in the Treatment and Management of OUD

 

Table 3. Number of DATA 2000 Practitioners Potentially Accepting New Clients, per Nevada County

County

Number of DATA 2000 Practitioners

Carson City 4
Churchill 1, Additional provider(s) not currently accepting new clients, at capacity
Clark 215, Additional provider(s) not currently accepting new clients, at capacity
Douglas 2
Elko 4
Esmeralda 0
Eureka 0
Humboldt 1
Lander 0
Lincoln 0
Lyon 1
Mineral 1
Nye 1
Pershing Additional provider(s) not currently accepting new clients, at capacity
Storey 0
Washoe 38, Additional provider(s) not currently accepting new clients, at capacity
White Pine 0

For a listing of individual providers lists by county, CASAT OnDemand Resources and Downloads

Because the most effective treatment for OUD is a combination of counseling and MAT, it is imperative that the existing barriers to MAT be addressed. Providers can use the solutions proposed by current providers and additional materials and links in the CASAT OnDemand Resources and Downloads section to offer people with OUD the most current and effective approaches indicated by the latest research.

NEVADA SPECIFIC RESOURCES FOR MEDICATION ASSISTED TREATMENT (MAT)

Integrated Opioid Treatment and Recovery Centers (IOTRCs) in Nevada, funded by Nevada’s State Targeted Response to the Opioid Crisis (STR) Grant

STR IOTRC current providers: (Watch this site for new awardees to be announced soon.)

Center for Behavioral HealthCenter for Behavioral Health will be provided funding to expand services to meet the IOTRC certification for all five Nevada locations in Clark County and Washoe County. Medication Assisted Treatment for rural and frontier patients will be provided using telemedicine.

The Life Change CenterThe Life Change Center will be provided funding to expand services to meet the IOTRC certification for the locations in Sparks and Carson City. Medication Assisted Treatment for rural and frontier patients will be provided using mobile services across Lyon, Storey, Churchill, and Douglas Counties.

Vitality UnlimitedVitality Unlimited will be provided funding to expand services to meet the IOTRC certification at their Elko location. Elko is considered a frontier county in far Eastern Nevada. Medication Assisted Treatment is provided on-site and through telemedicine services. 

Certified Community Behavioral Health Clinics (CCBHCs) in Nevada:

Finally, for real time information on available residential beds in Nevada, call the 24/7 SAPTA Substance Use Assistance Duty Officer. For emergency placements, please call (775) 784-8090 or (800) 273-8255 to reach the officer on duty.  For all other non-emergency inquiries, please call our main line at (775) 684-4190.

DATA 2000 WAIVERED PROVIDERS IN NEVADA AND THE UNITED STATES

For a complete listing of providers nationwide, or to locate providers in other states, the Substance Abuse and Mental Health Services Agencies (SAMHSA) maintains inventories on two of their websites:

SAMHSA Buprenorphine Treatment Practitioner Locator: Find physicians authorized to treat opioid dependency with buprenorphine by state.

SAMHSA Opioid Treatment Program Directory: Find opioid treatment programs by state.

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