Legislative Budget and Finance Committee

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1 Legislative Budget and Finance Committee A JOINT COMMITTEE OF THE PENNSYLVANIA GENERAL ASSEMBLY Offices: Room 400 Finance Building, 613 North Street, Harrisburg Mailing Address: P.O. Box 8737, Harrisburg, PA Tel: (717) Fax: (717) Web: SENATORS JOHN R. PIPPY Chairman JAY COSTA, JR. WAYNE D. FONTANA ROBERT B. MENSCH DOMINIC PILEGGI JOHN N. WOZNIAK REPRESENTATIVES ROBERT W. GODSHALL Secretary VACANT Treasurer STEPHEN E. BARRAR JIM CHRISTIANA H. SCOTT CONKLIN ANTHONY M. DELUCA A Performance Audit of Pennsylvania s Medical Assistance Transportation Program for Methadone Maintenance EXECUTIVE DIRECTOR PHILIP R. DURGIN Conducted Pursuant to Senate Resolution February 2011

2 Table of Contents Page Report Summary... S-1 I. Introduction... 1 II. Treatment Approaches for Opiate Addiction... 3 III. IV. Pennsylvania Medical Assistance Methadone Treatment Program Medical Assistance Methadone Maintenance Transportation Expenditures V. Appendices A. Senate Resolution B. HealthChoices Opiate Detoxification (non-methadone) Treatment Expenditures by County for CYs C. SCA Substance Abuse Treatment Expenditures by County for FY Through FY D. HealthChoices Methadone Treatment Expenditures by County for CYs E. Fee-for-Service Methadone Treatment Expenditures by County for CYs F. Medical Assistance Transportation Program County Profile Statistics FY Through FY G. Methadone Maintenance Transportation Clients as a Percentage of All MATP Clients H. Methadone Clinic Trips as a Percentage of all MATP Trips I. Methadone Clinic Transportation Expenditures as a Percentage of All MATP Transportation Expenditures J. Mileage Reimbursed Methadone Clinic Trips as a Percentage of All Methadone Clinic Trips K. Comparison of MATP Trips per Client and Methadone Trips Per Clients L. Comparison of Methadone Maintenance Transportation Statistics Between Counties With Methadone Clinics and Counties Without Clinics i

3 Report Summary Senate Resolution directed the Legislative Budget and Finance Committee (LB&FC) to conduct a performance audit of Pennsylvania s Medical Assistance Transportation Program for clients in methadone maintenance treatment programs. This included a determination of the annual Medical Assistance (MA) cost to the Commonwealth for methadone treatment and the length of time in treatment for persons receiving treatment. Regarding the transportation program, the resolution directed a determination of the annual cost of the MA transportation program for methadone maintenance treatment and the cost savings that could be achieved if individuals in the MA program for methadone maintenance treatment were required to receive treatment at the facility closest to the individual s residence. The resolution also directed a determination of whether there are effective narcotic treatment plans for drug addiction other than methadone maintenance and a review of other states initiatives and policies for their treatment programs, including options other than methadone for treating heroin addiction. Findings and Conclusions Methadone is the most frequently used medication for opioid addiction treatment. Opioids act on the brain and body by blocking the perception of pain but can also cause drowsiness, nausea, and a depressed respiration rate. Additionally, opioid drugs can induce a feeling of euphoria. Methadone is used to treat opiate addiction by acting on the same targets in the brain as opiates such as heroin and morphine and blocks the effects of the drug, suppresses withdrawal symptoms, and relieves craving for the drug. Methadone does not cause euphoria, intoxication, or sedation. Our review found the following: MA Expenditures for Outpatient Methadone Treatment, Not Including Transportation Costs, Totaled $48.8 Million in CY Outpatient methadone treatment is provided by Narcotic Treatment Programs (NTP) licensed by the PA Department of Health (DOH). 1 As of June 2010, Pennsylvania had 58 of these programs. See the map on page 17 for the distribution of these programs. Methadone maintenance treatment requires daily doses of methadone with the dosage to achieve optimum therapeutic effects varying 1 DOH has also approved three psychiatric hospital NTPs and six residential programs that use methadone for detoxification and rehabilitation. S-1

4 depending on individual needs. A long-term addict may need a larger dose than someone with a shorter addiction history. Methadone is dispensed in a liquid form taken orally at the NTP. In addition to the daily doses of methadone, individuals in methadone treatment are required to receive psychotherapy to assist in addressing the addiction. As shown below, in 2009 MA expenditures for methadone treatment were $48.8 million for 18,884 clients, or an average per client cost of $2,585. This includes both managed care and fee-for-service expenditures. In addition, Single County Authorities (SCAs) spent $7.0 million using other public funds in FY for methadone treatment. Medical Assistance Expenditures for Methadone Treatment CY 2009 Expenditures Clients HealthChoices Managed Care a.. $48,568,884 16,828 Fee-for-Service b ,877 2,056 Total... $48,809,761 18,884 a HealthChoices managed care expenditures and clients are based on procedure codes for methadone treatment in a licensed program, methadone take-home, and methadone maintenance. b Methadone FFS expenditures and clients are based on procedure codes for methadone treatment in a licensed program, methadone take-home, and methadone maintenance. Source: PA Department of Public Welfare. MA Transportation Program (MATP) Methadone Maintenance Transportation Expenditures Totaled $32.5 Million in FY Federal regulations require that the state Medical Assistance agency ensure that transportation is available for Medicaid recipients to and from medical providers. The Medical Assistance Transportation Program (MATP) is a cost-reimbursed, county-run program that is funded through a combination of state and federal Title XIX monies. The program uses MA funds to provide non-emergency transportation services to medical services for those clients who need transportation. This includes mass transit, paratransit (including taxis), and the use of a personal vehicle in the form of mileage reimbursement. County MATP offices are responsible for ensuring that customers are eligible for transportation services. This includes having a valid medical services eligibility card, residency in the county, declaration by the applicant of the need for transportation services, and substantiation by the county of that need. Once eligibility is S-2

5 confirmed, the county determines the least costly, most appropriate method of transportation available to meet the needs of the client. In addition, trips of less than ¼ mile will not be funded unless this client cannot travel the ¼ mile independently. In FY , MATP payments to the counties totaled about $131 million, or approximately 1 percent of the total Medical Assistance budget. Over the last three fiscal years, methadone maintenance transportation has been 38 percent of all MATP trips reported and 22 percent of the total transportation costs. Mileagereimbursed methadone maintenance trips averaged 25 percent of all methadone trips and 25 percent of the methadone maintenance transportation cost. DPW Recently Restricted Mileage Reimbursement to One of the Two Closest Clinics to the Client s Residence and No More Than 50 Miles One Way, With Estimated Cost Savings of $1.3 Million. DPW conducted a pilot project that restricted mileage reimbursement up to the distance of one of the two closest in-network Behavioral Health-Managed Care Organization s (BH-MCO) clinics from a client s residence, with a maximum reimbursement of 50 miles one way. The total cost savings realized by the two counties for the following month (January 2010) was $3,600, or about $200 for each of the 18 recipients. After completion of the pilot program, DPW issued a statewide policy change restricting mileage reimbursement up to the distance of one of the two closest innetwork BH-MCO clinics from a client s residence, with a maximum reimbursement of 50 miles one way. Prior to this policy, clients could be reimbursed for transportation to any NTP within a BH-MCO s network of providers. The policy does not restrict the ability of a client to receive services at the NTP of his choice, only the amount of mileage reimbursement to be paid to the client. To calculate potential savings statewide, DPW had each county determine the number and cost of their Medical Assistance recipient mileage reimbursement requests for methadone maintenance trips for the month of February For those trips that would be affected by the proposed change to the mileage reimbursement policy, the daily cost to reimburse for trips to currently selected clinics was calculated. Also calculated was the cost to transport these individuals to the closest and to the second-closest clinic. 2 Allegheny and Philadelphia were not included in the analysis because DPW believed they had relatively few mileage-reimbursed trips to methadone clinics. Based on subsequent data provided by the counties, mileagereimbursed trips in Philadelphia were only 4 percent of the total number of trips to methadone clinics in Allegheny submitted for more mileage reimbursed trips to methadone clinics than paratransit and mass transit trips combined. However, it is not clear from this data how many (if any) of these trips would be affected by the implementation of the policy. DPW believes that many of the trips in these two counties, if not to the closest or second-closest clinic, were well within the 50-mile one-way limit. S-3

6 The costs were projected annually and compared to one another. The cost difference between transportation to the currently selected clinics and to the secondclosest clinic was a cost savings of $1.3 million. An additional cost savings of approximately $500,000 was projected if reimbursement was limited to the mileage to the closest clinic. The operations memorandum issued does not restrict where a client may go for treatment but, rather, limits the mileage to be reimbursed to the client to the second closest clinic. DPW Implemented a Similar Policy for Paratransit Services Beginning January DPW issued a restriction for paratransit transportation services (including taxis) that is similar to that for mileage reimbursement. The policy, however, grandfathers the current clients so as not to disrupt their treatment. DPW calculates savings of approximately $560,000 by restricting paratransit transportation services to the second closest clinic. If restricted to the closest clinic, savings for paratransit services are projected to be $1.4 million. Clients Currently in Treatment Average 27.3 Months in Methadone Treatment. We surveyed 61 NTPs providing treatment to Pennsylvania MA clients. 3 The 33 providers who responded provide services to approximately 8,061 of the MA clients receiving methadone treatment in Pennsylvania. They reported an average time in treatment of 27.3 months for these clients. As reported by the providers, 2,657, or 33 percent, of their MA clients have been in treatment for less than one year and 2,714, or 34 percent, have been in treatment for one to three years. The longest average time in treatment was reported by a provider in Philadelphia at 52 months, and the shortest average time in treatment was reported as 9 months by two providers, one in Montgomery County and one in Lehigh County. Six providers reported that their clients average 36 months in treatment. Of the 8,061 MA clients receiving outpatient methadone treatment at these clinics, 314, about 4 percent, were reported to have been in treatment for over ten years. DPW HealthChoices data (Southwest, Southeast, and Lehigh/Capital zones) for clients in methadone treatment or entering methadone treatment in 2003 shows similar results; through CY 2009, clients were in treatment for an average of 26 months. A significant majority, 72 percent, was in treatment for less than three years, and 13 percent were in treatment for six or more years (the time frame was restricted to seven years in treatment). Since the data reflects a maximum length of treatment of seven years, the actual average length of treatment is likely to be longer than 26 months. 3 As on June 30, 2010, Pennsylvania had 58 NTPs. Three in Maryland serve Pennsylvania residents whose care is funded by MA. S-4

7 The Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services, develops Treatment Improvement Protocols (TIPs) as best-practice guidelines for the treatment of substance use disorders. TIP 43 reported that studies showed that, [p]atients who stayed in treatment a year or longer abused substances less and were more likely to engage in constructive activities and avoid criminal involvement than those who left treatment earlier, although all patients benefited from treatment, for instance, through less exposure to and transmission of infectious diseases. 4 The Center for Disease Control reported in 2002, however, that the majority of MMT [methadone maintenance treatment] patients leave before 1 year, either because they drop out, the clinic encourages them to leave, or they are discharged for not complying with program regulations. Most of those who discontinue MMT later relapse to heroin use. A study released in 1991 found that 82 percent of the patients who left treatment relapsed to intravenous drug use within one year. 5 This same study found that approximately 30 percent of the patients who successfully completed their detoxification and rehabilitation remained free of intravenous drug use at the time of follow-up. All 33 providers responding to our survey indicated that they develop treatment plans for their clients that address recovery from all illicit drug and alcohol addiction. Only two of those providers, however, require the plan of recovery to include tapering off of methadone. Other providers indicated that tapering off of methadone is offered to patients as an option when it is clinically appropriate. One provider noted that their program believes opiate addiction to be a brain disease (see SAMHSA & AATOD) which may require continuous Medication Assisted Treatment, and, therefore, does not require the patient to taper off methadone. Several Treatment Options Are Available for Opiate Addiction Treatment, But Effectiveness Depends on the Needs of the Client. Several treatment options are available for persons who suffer from opiate dependence, but no single approach to addiction treatment has been found to be appropriate for all patients. Studies have found that an informed decision about the best method for detoxification must be made after considering the patient s general health condition, psychological state, external support available to the patient, and length of time addicted. The treatment options available include: 4 Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Ball, J.C., and A. Ross. The Effectiveness of Methadone Maintenance Treatment, Patients, Programs, Services, and Outcome. New York: Springer-Verlag, S-5

8 Detoxification. 6 Detoxification may involve drug-free treatment or the use of medications. A drug-free method of detoxification is known as sudden withdrawal, or quitting cold turkey. This method typically leads to withdrawal syndrome, which is a long and painful process and can result in permanent damage to the cardiopulmonary system and the central nervous system. For these reasons, opiate dependency treatment requires appropriate and responsible medical care. Detoxification with the use of medication is known as medicallysupervised withdrawal and is utilized mainly to transition into or out of a maintenance program over a short period of time. Medically-supervised withdrawal safely manages the acute physical symptoms of withdrawal associated with stopping drug use. Medications such as methadone and buprenorphine are used to treat symptoms during the detoxification process but are discontinued after a short time. Buprenorphine. 7 In October 2002, the FDA approved buprenorphine, which is a synthetic opioid, for use in treating opiate addiction. Unlike methadone, which is a Schedule II drug, buprenorphine is a Schedule III drug and can be administered in an office setting by a physician who has been certified by the U.S. Department of Health and Human Services SAMHSA. While also available through opioid treatment programs, patients may receive buprenorphine by prescription from their physician and receive a month s supply from their pharmacy. This drug, however, does not work for everyone as its effects are often weak. Like methadone, buprenorphine reduces cravings and prevents withdrawal symptoms. Naltrexone. 7 Naltrexone is considered to be highly effective in treating opioid addictions. However, it can precipitate withdrawal in patients who have not been abstinent from short-acting opioids for at least seven days and have not been abstinent from long-acting ones, such as methadone, for at least 10 days. 8 Naltrexone has no narcotic effect and there are no withdrawal symptoms when a patient stops using it. It also does not have abuse potential. Despite its potential advantages, it has had little impact on the treatment of opioid addiction in the United States primarily because of patient compliance issues. Most studies have indicated very high 6 Some practitioners do not recognize detoxification as formal treatment since it is not necessarily accompanied by counseling. Rather, it is viewed as stabilizing the client with the intent to transition the client to a recognized level of care for counseling and long-term sobriety. 7 Suboxone, a combination tablet of buprenorphine and naltrexone in a ratio of 4:1 milligrams respectively, was approved by the FDA in October 2002 for the treatment of opioid dependence. Suboxone is covered under the MA program through a federal drug rebate agreement with the Centers for Medicare and Medicaid Services. DPW reported that, statewide, 3,306 clients were treated with Suboxone from May 2010 through October 30, Short-acting and long-acting refer to the half-life of a drug, i.e., how quickly the drug becomes effective and how long it remains effective in the body. Short-acting medications are generally prescribed at intervals of every 3-4 hours, and long-acting medications generally remain effective for at least 8 to 72 hours. S-6

9 drop-out rates from naltrexone therapy because naltrexone does not provide the effects of opiates or assist patients with the lingering effects of withdrawal. Drug-free Treatment. According to the National Institute on Drug Abuse (NIDA), the most effective drug-free behavioral approach to addiction treatment, is a therapeutic community residential program lasting from 6 to 12 months. These programs serve patients with long histories of drug dependence, involvement in serious criminal activities, and seriously impaired social functioning. The focus of the therapeutic community is the resocialization of the patient to a drug-free, crime-free lifestyle. Other drug-free, behavioral approaches can include residential and outpatient approaches including, for example, contingency management therapy and cognitive-behavioral interventions. These types of programs often also involve individual or group counseling and work best for patients who are abusers of drugs other than opiates or are opiate abusers for whom maintenance therapy is not recommended, such as those who have stable, wellintegrated lives and only brief histories of drug dependence. In Pennsylvania, 685 drug and alcohol treatment facilities are licensed by the DOH to provide addiction treatment services, with a capacity of approximately 80,725 clients. These facilities include outpatient, partial hospitalization and inpatient non-hospital. MA coverage for opiate detoxification (non-medication assisted treatment) in the State Plan for Medicaid provides for 42 opiate detoxification clinic visits during a 365-day period for the purpose of outpatient, ambulatory opiate detoxification. The plan further allows payment for inpatient drug/alcohol services in a general hospital with certain limitations. 9 As shown below, in CY 2009, $3.0 million in MA funds were expended to serve 1,401 clients in inpatient treatment. 10 HealthChoices Opiate Detoxification (Non-Methadone) Treatment Expenditures Year Expenditures a Clients b Expenditure/Client a $ 3,027,548 1,401 $ 2,161 a Based on provider type/provider specialty/encounter category 01/010/02 (inpatient facility, acute care hospital, and inpatient drug and alcohol detox) and provider type/provider specialty/procedure code/modifier 03/184/H0014/HG (alcohol and/or drug services; ambulatory detoxification-opiate detox visit for administration and evaluation of drugs for ambulatory opiate detoxification). b Based on client s residence by HealthChoices zone. Source: Pennsylvania Department of Public Welfare. 9 Payment is limited to days that are certified by DPW during which the individual with a drug/alcohol diagnosis is a patient in a drug/alcohol unit approved by the DOH. This includes detoxification services. 10 These figures do not include the non-hospital detoxification that is not included in the state plan. As reported by DPW, the non-hospital detoxification is the lion s share of detoxification activity. Non-hospital residential rehabilitation and detoxification are frequently used for opiate users but also for a variety of other addictions, e.g., cocaine, methamphetamine, barbiturates, and alcohol. S-7

10 The table below shows the SCA expenditures for the past three fiscal years for substance abuse treatment (excluding methadone treatment). In each year, about half of the individuals were treated in outpatient drug free treatment. 11 SCA Substance Abuse Treatment Expenditures* FY Through FY Fiscal Year Hospital Detoxification... $ 475,428 $ 539,395 $ 592,048 Non-Hospital Detoxification... 6,293,873 6,455,188 6,262,693 Hospital Treatment & Rehabilitation , ,127 98,810 Non-Hospital Treatment & Rehabilitation... 45,176,334 35,651,396 31,063,397 Halfway House Treatment... 4,151,203 3,029,010 2,806,018 Partial Hospitalization... 2,830,712 2,568,283 2,247,758 Intensive Outpatient... 7,999,681 7,180,941 8,807,087 Outpatient (Drug Free)... 25,675,575 25,712,733 24,526,335 Total... $92,745,592 $81,327,074 $76,404,148 *This includes all addiction treatment, including opiate addiction treatment, but is not specific to opiate addiction treatment. This does not include expenditures for outpatient maintenance programs (NTPs) which are reflected on a separate table. Source: PA Department of Health SCA expenditure information. Recommendation DPW should consider developing best practice guidelines for its methadone treatment providers to help ensure that transportation service reimbursements are appropriate. Ensuring that the MA program only pays for legitimate, qualified transportation services is difficult. Several providers have developed various guidelines and procedures to help minimize potential abuses. These procedures include: requiring clients to show their previous month s bus pass before receiving a new pass, or randomly asking clients to produce their bus pass (to help prevent selling passes), limiting the number of staff members who can fill out reimbursement forms, and using a unique stamp on the reimbursement forms and instructing transportation agencies to only process reimbursement forms that have this stamp. We recommend DPW discuss these and other procedures with their methadone treatment providers and develop best practices guidelines for their providers. 11 In FY , 30,719 total clients were treated in these programs with 15,552 in outpatient drug free; in FY , 26,357 total clients were treated in these programs with 12,376 in outpatient drug free; and in FY , 33,389 total clients were treated in these programs with 18,271 in outpatient drug free treatment. The Client Information System (CIS) is more aligned to the matrix of licensing activities and approaches whereas the collection of expenditures is aligned to the levels of care defined in the Pennsylvania Client Placement Criteria making it difficult to provide accurate client numbers for each treatment option cited on the expenditure table. S-8

11 I. Introduction Senate Resolution directs the Legislative Budget and Finance Committee (LB&FC) to conduct a performance audit of Pennsylvania s Medical Assistance Transportation Program for clients in methadone treatment and maintenance programs. Please see Appendix A for a copy of Senate Resolution Scope and Objectives Statement 1. To determine the annual cost to the Commonwealth for methadone treatment, including both the Medical Assistance and Single County Authority programs. 2. To determine the length of time in treatment for persons receiving treatment. 3. To determine whether there are effective narcotic treatment plans for drug addiction other than methadone maintenance. 4. To determine the annual cost of the Medical Assistance Transportation Program for methadone treatment and maintenance to the federal government, the Commonwealth, and counties. 5. To determine the cost savings that could be achieved if individuals in the Medical Assistance program for methadone treatment and maintenance were required to receive treatment at the facility closest to the individual s residence. 6. To review other states initiatives and policies for their treatment programs, including options other than methadone for treating heroin addiction. Methodology We met with Department of Public Welfare (DPW) staff in the Office of Mental Health and Substance Abuse Services and Office of Medical Assistance Programs to discuss their responsibilities for methadone treatment and Medical Assistance transportation services for methadone treatment clients. We also reviewed DPW policies and guidelines related to these services. To determine the use of Medical Assistance Transportation Program (MATP) services by methadone clients, DPW staff requested data from the county MATP offices. MATP data is not usually maintained by the type of medical service for which it is provided. This data was not audited by DPW or our staff. 1

12 We met with Department of Health (DOH) staff in the Division of Drug and Alcohol Program Licensure and the Bureau of Drug and Alcohol Programs to discuss their responsibilities regarding program licensing and practices. We reviewed DOH regulations related to program standards. We met or spoke with the staff of provider associations and staff of clinics providing methadone treatment in Pennsylvania. We spoke with members of the Pennsylvania Psychiatric Society. We surveyed the other states Medicaid programs to determine their use of Medicaid funds to pay for methadone treatment and transportation services to methadone treatment. We surveyed 58 providers of outpatient methadone treatment services in Pennsylvania and 3 in Maryland who receive reimbursement for Medical Assistance services provided to Pennsylvania residents. We received responses from 33 providers, a response rate of 54 percent. We identified the providers from information supplied by the Pennsylvania Association for the Treatment of Opioid Dependence and facility licensing information supplied by the Departments of Public Welfare and Health. Since the focus of our study was Medical Assistance costs for methadone treatment for drug addiction and Medical Assistance costs for transportation to methadone treatment, we did not include information on methadone treatment for pain management and included only limited information concerning inpatient methadone treatment for drug addiction. Acknowledgements We thank the Secretaries of the Departments of Public Welfare and Health and their staff for their assistance with this project. We also acknowledge and appreciate the excellent cooperation and assistance provided by the numerous Narcotic Treatment Programs who responded to our survey, met with us, or participated in telephone interviews. In addition, we thank the Pennsylvania Community Providers Association and the Drug and Alcohol Service Providers Organization of Pennsylvania who provided us with ongoing assistance with this report. Important Note This report was developed by Legislative Budget and Finance Committee staff. The release of this report should not be construed as an indication that the Committee or its individual members necessarily concur with the report s findings and recommendations. Any questions or comments regarding the contents of this report should be directed to Philip R. Durgin, Executive Director, Legislative Budget and Finance Committee, P.O. Box 8737, Harrisburg, Pennsylvania

13 II. Treatment Approaches for Opiate Addiction Background Information Opioids are a class of drugs derived from the opium poppy. They are primarily prescribed by physicians for pain relief and include drugs such as morphine, codeine, and oxycodone. Heroin is a semi-synthetic form of opioid made from natural opiates. Generally, opioids act on the brain and body not only by blocking the perception of pain, but can also cause drowsiness, nausea, and a depressed respiration rate. Additionally, opioid drugs can induce a feeling of euphoria. When prescribed by a physician and taken as directed, opioids can be used in a safe and effective manner. However, opioids can be easily abused, and long-term use can lead to physical dependence and addiction. The most recent National Survey of Drug Use and Health (2005) showed that 1 in 8 Americans has a drug problem. Twenty-seven million Americans are addicted to either illicit drugs or alcohol. The most common substances abused after alcohol, are cocaine, heroin, and prescription drugs used for non-medical purposes. This survey also showed that 379,000 Americans aged 12 and older used heroin in 2005, including 108,000 who used the drug for the first time. Annual admissions to substance abuse treatment for primary heroin use increased from 228,000 in 1995 to 254,000 in The Pennsylvania Department of Health (DOH) estimates that, in Pennsylvania, approximately 18,120 individuals are heroin users. Methods of Treatment for Opiate Addiction Several treatment options are available for persons who suffer from opiate dependence including sudden withdrawal, medically supervised detoxification, rapid detoxification, and treatment in narcotic treatment programs, which may include long-term methadone maintenance treatment. The U.S. Food and Drug Administration (FDA) has approved three medications for the treatment of addiction: methadone; buprenorphine; and naltrexone. 1 No one approach to addiction treatment has been found to be appropriate for all patients. Studies have found that an informed decision about the best method for detoxification must be made after considering the patient s general health condition, psychological state, external support available to the patient, and length of time addicted. Below is information about each of these treatment methods. 1 On October 12, 2010, the FDA approved Vivitrol to treat and prevent relapse after patients with opioid dependence have undergone detoxification treatment. Vivitrol is an extended-release formulation of naltrexone administered by intramuscular injection once a month. It blocks the effects of drugs like morphine, heroin, and other opioids and was approved in 2006 to treat alcohol dependence. 3

14 Detoxification. 2 Detoxification may involve drug-free treatment or the use of medications. A drug-free method of detoxification is known as sudden withdrawal, or quitting cold turkey. This method typically leads to withdrawal syndrome, which is a long and painful process and can result in permanent damage to the cardiopulmonary system and the central nervous system. Withdrawal symptoms typically begin within 12 hours of not using the drug and peak after two to four days. The symptoms include: nausea, anxiety, diarrhea, abdominal pain, insomnia, chills, sweating, sniffling, sneezing, weakness, and irritability. Untreated and unmonitored, it can result in death for unhealthy patients. For these reasons, opiate dependency treatment requires appropriate and responsible medical care. Detoxification with the use of medication is known as medically-supervised withdrawal and is utilized mainly to transition into or out of a maintenance program over a very short period of time. Medically-supervised withdrawal safely manages the acute physical symptoms of withdrawal associated with stopping drug use. Medications such as methadone and buprenorphine are used to treat symptoms during the detoxification process but are discontinued after a short time. However, according to a report by the National Conference of State Legislatures, detoxification alone has not been proven to be as efficacious as other forms of treatment such as methadone maintenance for producing long-term abstinence. Longterm methadone maintenance treatment is generally the method of choice for treating opioid addictions. 3 Currently, research is being conducted using approaches like rapid detoxification under general anesthesia and subcutaneous naltrexone implantation. Rapid detoxification is performed under general anesthesia with intubations for six to eight hours. During this time, a combination of drugs, usually naltrexone and clonidine are administered to the patient. This is said to be a painless way to withdraw from opioid addiction. However, AddictionSearch, 4 a clearinghouse of resources relating to addiction treatment and recovery, reports that the procedure can lead to risk of death, psychosis, increased stress, delirium, attempted suicide, abnormal heart rhythm, and acute renal failure. Methadone. Methadone is the most frequently used medication for opioid addiction treatment. Methadone is a long-acting medication that is recognized by both the FDA and the National Institute of Drug Abuse (NIDA) as safe and effective in treating opioid dependence when combined with appropriate counseling and other treatment. Methadone acts on the same targets in the brain as heroin and morphine and blocks the effects of the drug, suppresses withdrawal symptoms, and relieves craving for the drug. Methadone does not cause euphoria, intoxication, or 2 Some practitioners do not recognize detoxification as formal treatment since it is not necessarily accompanied by counseling. Rather, it is viewed as stabilizing the client with the intent to transition the client to a recognized level of care for counseling and long-term sobriety. 3 Treatment of Alcohol and Other Substance Use Disorders: What Legislators Need to Know, NCSL, January (accessed November 1, 2010). 4

15 sedation. According to the American Association for the Treatment of Opioid Dependence, methadone maintenance treatment reduces the use of illicit drugs, reduces criminal activity, reduces needle-sharing and thus reduces HIV/AIDS infection and transmission, and is cost-effective. It also states that patients on methadone maintenance treatment are more receptive to behavioral treatment. 5 Methadone is provided in various forms, including oral solution, tablets, liquid concentrate, powder, and diskettes. In the United States, methadone used to treat addictions is almost always administered orally in liquid form. To be effective, methadone is typically administered once per day in doses ranging from 60 milligrams to 120 milligrams. Methadone is only available through state and federally regulated programs. Drawbacks of methadone treatment include increased risks of respiratory depression, death from overdose, changes to normal heart rhythms, and difficulty with withdrawal from methadone. Buprenorphine. 6 In October 2002, the FDA approved buprenorphine, which is a synthetic opioid, for use in treating opiate addiction. Unlike methadone, which is a Schedule II drug, buprenorphine is a Schedule III drug and can be administered in an office setting by a physician who has been certified by the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA). While also available through opioid treatment programs, patients may receive buprenorphine by prescription from their physician and receive a month s supply from their pharmacy. This makes the actual treatment administration easier and less costly, which encourages patients to continue in treatment. This drug, however, does not work for everyone as its effects are often weak. Like methadone, buprenorphine reduces cravings and prevents withdrawal symptoms. Unlike methadone, however, there is less danger of death from overdosing on buprenorphine and side effects such as a suppressed respiratory system. Buprenorphine can be used on a daily or less-than-daily basis. Intervals between dosing can be extended by doubling or tripling the daily dose to permit alternate day or three-day-per-week dosing, which is possible because larger doses do not increase side effects but do lengthen the duration of the drug s effects. Buprenorphine is available in sublingual (dissolved under the tongue) tablets. The typical maintenance dosage is between 24 milligrams and 32 milligrams daily. Naltrexone. 6 Naltrexone is considered to be highly effective in treating opioid addictions. However, it can precipitate withdrawal in patients who have not been 5 The Institute for Research, Education and Training in Addictions also reports similar data. See Recovery- Focused Methadone Treatment: A Primer for Practice Today in Pennsylvania, October Suboxone, a combination tablet of buprenorphine and naltrexone in a ratio of 4:1 milligrams respectively, was approved by the FDA in October 2002 for the treatment of opioid dependence. Suboxone is covered under the MA program through a federal drug rebate agreement with the Centers for Medicare and Medicaid Services. DPW reported that, statewide, 3,306 clients were treated with Suboxone from May 2010 through October 30,

16 abstinent from short-acting opioids for at least seven days and have not been abstinent from long-acting ones, such as methadone, for at least 10 days. 7 Naltrexone has no narcotic effect and there are no withdrawal symptoms when a patient stops using it. It also does not have abuse potential. The FDA approved the use of naltrexone for maintenance treatment in Despite its potential advantages, it has had little impact on the treatment of opioid addiction in the United States primarily because of patient compliance issues; most studies have indicated very high dropout rates from naltrexone therapy because naltrexone does not provide the effects of opiates or assist patients with the lingering effects of withdrawal. Drug-Free Treatment. Many drug-free, behavioral approaches to addiction treatment are available, with the most effective, according to NIDA, being a therapeutic community residential program lasting from 6 to 12 months. A therapeutic community is a highly structured program for patients with long histories of drug dependence, involvement in serious criminal activities, and seriously impaired social functioning. The focus of the therapeutic community is the resocialization of the patient to a drug-free, crime-free lifestyle. Other drug-free, behavioral approaches can include residential and outpatient approaches including, for example, contingency management therapy and cognitive-behavioral interventions. Contingency management therapy uses a voucherbased system where patients earn points based on negative drug tests, which they can exchange for items that encourage healthy living. Cognitive-behavioral interventions are designed to help modify the patient s expectations and behaviors related to drug use and to increase skills in coping with life stressors. These types of programs often also involve individual or group counseling and work best for patients who are abusers of drugs other than opiates or are opiate abusers for whom maintenance therapy is not recommended, such as those who have stable, wellintegrated lives and only brief histories of drug dependence. Treatment Options in Pennsylvania In Pennsylvania, 685 drug and alcohol treatment facilities are licensed by the DOH to provide addiction treatment services, with a capacity of approximately 80,725 clients. These facilities include outpatient, partial hospitalization and inpatient non-hospital. See Table 1 and Exhibit 1 for more information on the types of facilities licensed by DOH. Approximately 20,000 of these clients can be served in outpatient maintenance, i.e., methadone maintenance, programs. MA coverage for opiate detoxification (non-medication assisted treatment) in the MA State Plan provides for 42 opiate detoxification clinic visits during a 365- day period for the purpose of outpatient, ambulatory opiate detoxification. The plan 7 Short-acting and long-acting refer to the half-life of a drug, i.e., how quickly the drug becomes effective and how long it remains effective in the body. Short-acting medications are generally prescribed at intervals of every 3-4 hours, and long-acting medications generally remain effective for at least 8 to 72 hours. 6

17 further allows payment for inpatient drug/alcohol services in a general hospital with certain limitations. 8 As shown on Table 2, in CY 2009, $3.0 million in MA funds were expended to serve 1,401 clients in inpatient treatment. 9 Appendix B shows the expenditures and clients served in inpatient treatment by county for CYs See Finding III for information specific to methadone treatment. Table 1 Capacity of Drug Addiction Treatment Licensees* As of November 2010 Activity Capacity Intake, Evaluation and Referral Inpatient Non-Hospital Detoxification a Inpatient Non-Hospital Drug-Free... 6,027 Inpatient Non-Hospital Transitional Living Inpatient Hospital Detoxification a Inpatient Hospital Drug-Free Psychiatric Hospital Partial Hospitalization Drug-Free... 2,284 Partial Hospitalization Other Chemotherapy Outpatient Detoxification a Outpatient Maintenance... 19,967 b Outpatient Drug-Free... 47,300 Outpatient Other Chemotherapy... 2,998 80,725 * These numbers are updated continuously and are entered on the DOH s Data Collection Report form when a facility requests a change in capacity and one is granted. Not all licensees provide all treatment services. a Detoxification is considered by practitioners to provide stabilization for a client to proceed to treatment rather than a treatment service itself. b Capacity for Outpatient Maintenance (Narcotic Treatment Programs) are point-in-time based on the most recent inspection. These numbers are maintained manually by DOH. Source: Pennsylvania Department of Health. 8 Payment is limited to days that are certified by DPW during which the individual with a drug/alcohol diagnosis is a patient in a drug/alcohol unit approved by the DOH. This includes detoxification services. 9 These figures do not include the non-hospital detoxification that is not included in the state plan. As reported by DPW, the non-hospital detoxification is the lion s share of detoxification activity. Non-hospital residential rehabilitation and detoxification are frequently used for opiate users but also for a variety of other addictions, e.g., cocaine, methamphetamine, barbiturates, and alcohol. 7

18 Exhibit 1 DOH Division of Drug and Alcohol Program Licensure Definitions of Treatment Facilities Inpatient hospital - the provision of detoxification or treatment and rehabilitation services, or both, 24 hours a day, in a hospital. The hospital shall be licensed by the Department (of Health) as an acute care or general hospital. Inpatient non-hospital - a non-hospital, residential facility, providing one or both of the following services: treatment and rehabilitation or detoxification. The client resides at the facility. Inpatient non-hospital transitional living - the provision of supportive services in a semiprotected home-like environment to assist a client in his gradual reentry into the community. No formal treatment (counseling/psychotherapy) takes place at the facility. This is a live-in/work-out situation. Outpatient - the provision of counseling or psychotherapeutic services on a regular and predetermined schedule. The client resides outside the facility. Partial hospitalization - the provision of psychiatric, psychological, social and other therapies on a planned and regularly scheduled basis. Partial hospitalization is designed for those clients who would benefit from more intensive services than are offered in outpatient treatment projects, but who do not require 24-hour inpatient care. Psychiatric hospital - the provision of detoxification or treatment and rehabilitation services, or both, 24 hours a day, in a psychiatric hospital. The psychiatric hospital shall be approved as such by the Department of Public Welfare. Freestanding treatment facility - the setting in which drug and alcohol treatment services take place that is not located in a health care facility. The majority of drug and alcohol facilities take place in a freestanding treatment facility. The term does not include a mental retardation facility except to the extent that it provides skilled nursing care. The term does not apply to a facility which is conducted by a religious organization for the purpose of providing health care services exclusively to clergymen or other persons in a religious profession who are members of a religious denomination. Source: Pennsylvania Department of Health. 8

19 Table 2 HealthChoices Opiate Detoxification (Non-Methadone) Treatment Expenditures CY 2007 Through CY 2009 Year Expenditures a Clients b Expenditure/Client a $1,861, $1, ,887,381 1,329 2, ,027,548 1,401 2,161 a Based on provider type/provider specialty/encounter category 01/010/02 (inpatient facility, acute care hospital, and inpatient drug and alcohol detox) and provider type/provider specialty/procedure code/modifier 03/184/H0014/HG (alcohol and/or drug services; ambulatory detoxification-opiate detox visit for administration and evaluation of drugs for ambulatory opiate detoxification). b Based on client s residence by HealthChoices zone. Source: Pennsylvania Department of Public Welfare. Table 3 shows the SCA expenditures for the past three fiscal years for substance abuse treatment, excluding methadone treatment discussed in Finding III. As shown on the table, non-hospital treatment and rehabilitation and outpatient drug free treatment account for approximately 75 percent of these expenditures in each year. See Appendix C for SCA substance abuse treatment expenditures for the past three fiscal years by county. In each year, about half of the individuals were treated in outpatient drug-free treatment. 10 Treatment Programs in Other States We surveyed the other states to identify which options to treat opiate/heroin addictions are included in the state s Medicaid program. Six of the states responding indicated that four treatment options are covered by Medicaid, including methadone, buprenorphine, and naltrexone medications, as well as residential detoxification services. Nebraska indicated that it provides for detoxification only; it does not pay for maintenance treatment. Arkansas, Louisiana, and South Carolina do not pay for any opioid addiction treatment with Medicaid funds. 10 In FY , 30,719 total clients were treated in these programs with 15,552 in outpatient drug free; in FY , 26,357 total clients were treated in these programs with 12,376 in outpatient drug free; and in FY , 33,389 total clients were treated in these programs with 18,271 in outpatient drug-free treatment. The Client Information System (CIS) is more aligned to the matrix of licensing activities and approaches whereas the collection of expenditures is aligned to the levels of care defined in the Pennsylvania Client Placement Criteria making it difficult to provide accurate client numbers for each treatment option cited on the expenditure table. 9

20 Table 3 SCA Substance Abuse Treatment Expenditures* FY Through FY Fiscal Year Hospital Detoxification... $ 475,428 $ 539,395 $ 592,048 Non-Hospital Detoxification... 6,293,873 6,455,188 6,262,693 Hospital Treatment & Rehabilitation , ,127 98,810 Non-Hospital Treatment & Rehabilitation... 45,176,334 35,651,396 31,063,397 Halfway House Treatment... 4,151,203 3,029,010 2,806,018 Partial Hospitalization... 2,830,712 2,568,283 2,247,758 Intensive Outpatient... 7,999,681 7,180,941 8,807,087 Outpatient (Drug Free)... 25,675,575 25,712,733 24,526,335 Total... $92,745,592 $81,327,074 $76,404,148 *This includes all addiction treatment, including opiate addiction treatment, but is not specific to opiate addiction treatment. This does not include expenditures for outpatient maintenance programs (NTPs) which are reflected on a separate table. Source: PA Department of Health SCA expenditure information. Massachusetts, which covers the four available options under Medicaid, reported that there are 14,000 people in methadone treatment at any given time. It also reported that buprenorphine is the second most costly drug on the Medicaid formulary, and few people use Naltrexone. According to the questionnaire response, 66 percent of the clients in detoxification programs are opiate dependent, and their recidivism to that level of care is sometimes related to the fact that they were not appropriately referred to medication-assisted treatment. Virginia s response indicated that it expanded Medicaid coverage to opioid treatment just over two years ago. Virginia indicated that fewer than 5 percent of the patients in opioid treatment receive buprenorphine, with the other 95 percent receiving methadone. Montana s response indicated that approximately 75 percent of the people receiving opioid addiction treatment with Medicaid funds use methadone; 15 percent use buprenorphine; 1 percent use naltrexone; and 9 percent are in residential detoxification. Please see Exhibit 2 for more information. 10

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