Expanding access to treatment for opiate addiction: Successes and Barriers

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1 Expanding access to treatment for opiate addiction: Successes and Barriers Miriam Komaromy, MD Medical Director, Turquoise Lodge Addiction Treatment Hospital, NM Department of Health; and UNM Project ECHO Addiction Treatment Program

2 Misuse of prescribed opioids is common.. SAMHSA Nat Survey Drug Use and Health 2005, 2006

3 % of 12 th graders reporting nonmedical use in past year, 2007 OxyContin Vicodin NIDA Monitoring the Future Study 2007

4 Unintentional overdose deaths involving opioid analgesics now exceed the sum of deaths involving heroin or cocaine Number of deaths 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Opioid analgesic Cocaine Heroin '99 '00 '01 '02 '03 '04 '05 '06 07 Source: National Vital Statistics system, multiple cause of death dataset, Len P aulozzi, CDC

5 New Mexico has a huge opioid addiction problem NM had the 2 nd highest drug-induced death rate in the US in 2005, 20.9 deaths per 100 K persons, compared to the US rate of NM counties were among the top 25 in the US for druginduced poisoning death The total unintentional drug overdose death rate in NM increased by 180% (5.6 to 15.5 per 100K ) During , the 196% increase in single drug category overdose death was driven by prescription opioids alone and heroin alone Shah NG, NM Epidemiology Report 2008 Shah NG, Addiction 2008

6 In response to the problems of opiate and alcohol addiction, and the highest rates of Hepatitis C infection in the US, we launched a program in 2006 to expand access to addiction treatment in our large, poor, rural state: Project ECHO

7 What is Project ECHO? Extension for Community Healthcare Outcomes Founded by Dr. Sanjeev Arora at the University of NM with an initial focus on expanding access to hepatitis C treatment The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas, and to monitor outcomes.

8 Project ECHO: methods Use technology to leverage scarce healthcare resources: tele / video conferencing with Primary Care Providers (PCPs) in underserved areas Case-based learning: PCPs present cases on weekly statewide teleconference, and receive feedback from specialists at UNM and other PCPs Disease management model improves outcomes by sharing best practices Learning loops help PCPs develop confidence and expertise of their own, become resources in their own communities Force Multiplier

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10 How does ECHO work for Addiction Treatment? Because of huge opiate problem in NM, focus has been on training PCPs to treat with buprenorphine Raise interest/awareness via grand rounds presentations around state 8-hour tailored Buprenorphine trainings in-person and via videoconference Weekly 2-hour telehealth conference since 06, includes counselors as well as medical providers

11 Observational data on Buprenorphine effectiveness Increasing use of buprenorphine in France associated with 1,2 Decrease in arrests for heroin (77% decline since 1995) Decrease in overdose deaths (81% decline since 1995) 1. Auriacombe 2004, Am J Addict; Lepere 2001, Ann Med Interne (Paris);152 Suppl 3.

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13 Buprenorphine treatment outcomes at 6 months Heroin users Pain pill users Methadone (data from literature review) Retention in treatment 67% * 77% 53-63% Abstinence (self-reported) 70% 73% 30 day illicit drug use (selfreported) 1.2 days 3-7 days *14% of pts reported they had already completed treatment by 6 months SAMHSA evaluation of the Impact of the DATA waiver program, Final Summary Report. March gov/for_final_summaryreport_colorized.pdf

14 Criminal Activity past 30 days in buprenorphine-treated patients (self- reported) Baseline After 6 months of treatment Street drug acquisition Drug dealing Prescription fraud Other crimes 13 days 16% 10% 10% 1.7 days 3% 1% 2% SAMHSA evaluation of the Impact of the DATA waiver program, Final Summary Report. March gov/for_final_summaryreport_colorized.pdf

15 RCT of buprenorphine 40 Heroin addicts Buprenorphine 8mg/day vs taper + placebo All received counseling, groups Followed for 1 year Retained at one year Buprenor -phine Placebo 70% 0 Died 0 20% Kakko et al, Lancet 2003

16 Buprenorphine vs Methadone Like Methadone Reduces IDU Retains pt in treatment Decreases craving Stops withdrawal Costs $ 5-13 per day Unlike Methadone. Low potential for OD No sedation Easy taper/detox Prescribed in MD office Offers access in small rural communities

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18 Ranking has increased from 13 th to 5 th in the US since the start of ECHO: buprenorphine providers per capita State Rank 2005 Physicians certified 2005 Rank 2009 VT ME DC 9 81 MA MD Physicians certified 2009 NM (*156 by ECHO) RI NY CT PA AK CSAT database of certified MDs 2005, 2009

19 Survey of ECHO bup prescribers: What has been the impact of prescribing buprenorphine on your clinical practice? Response choices from 0=strongly negative impact, 4=no impact, 5=somewhat positive, 7=strongly positive impact Question My ability to help opiate-addicted patients 6.5 My satisfaction with clinical practice 6.2 The clinic staff s satisfaction with our practice 5.6 My practice partners satisfaction with our practice 5.9 My ability to have a positive impact on my community 6.4 My interest in treating patients with opiate addiction 6.4 My interest in treating patients with other addictions 6.0 My professional reputation in my community 5.5 N=51, survey response rate 70%, 2010 Mean

20 Why do so few trained prescribers actually prescribe? Nationally, only ¼ of buprenorphinecertified physicians actually prescribe Only 1/3 of doctors we train actually prescribe buprenorphine Clinic administrators are often opposed to buprenorphine prescribing Why?

21 Huge reimbursement barriers for NM PCPs who wish to treat opiate addiction Medicaid/Saluds will pay for Suboxone prescribed by PCP (with Prior Auth) However, they won t pay PCP for the visit Optum Health will pay for Suboxone and for office visit, but only if it is prescribed by a psychiatrist There are very few Suboxone-certified psychiatrists in NM, and virtually none in rural areas Most poor New Mexicans are not covered by either of these programs, and can t afford >$400/month for Suboxone Contrast with Vermont

22 How to contact us Miriam Komaromy, MD Bonnie Kraybill Mount, RN Upcoming ECHO buprenorphine training: Albuquerque, Saturday January 22