INSTRUCTIONS AND PROTOCOLS FOR THE IMPLEMENTATION OF MEDICATION-ASSISTED TREATMENT FOR OPIOID/OPIATE DEPENDENCE

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1 201 Mulholland Bay City, MI P F Title: MAT Protocol Original Date: March 30, 2009 Latest Revision Date: December 16, 2013 Approval/Release Date: January 1, 2014 INSTRUCTIONS AND PROTOCOLS FOR THE IMPLEMENTATION OF MEDICATION-ASSISTED TREATMENT FOR OPIOID/OPIATE DEPENDENCE This document establishes technical and service requirements that must be incorporated into the design and delivery of all medication-assisted treatment services funded through Riverhaven Coordinating Agency. Medication-assisted treatment service providers are required to adopt these protocol guidelines in their entirety. INTRODUCTION: Opioid/Opiate addiction has been steadily increasing over the past several years, especially among adolescents and young adults as citizens in our communities have fairly easy access to such physician-prescribed Opioid/Opiate medications as oxycodone (Oxycontin), hydrocodone (Vicodin) and morphine. Traditional approaches to Opioid/Opiate addiction have historically included repeated cycles of sub-acute detoxification in a residential treatment setting followed by transfer to another level of care. With the introduction of Methadone Maintenance Treatment in 1968, a reliable and effective treatment for chronic, long-term Opioid/Opiate users became available. In the mid- 1980's, buprenorphine was introduced as an effective detoxification medication for Opioid/Opiate addiction. The enactment of the Drug Abuse Treatment Act 0f 2000 enables specifically trained physicians in the United States to prescribe certain approved forms of buprenorphine for the detoxification and/or treatment of Opioid/Opiate addiction. It is the intention of Riverhaven Coordinating Agency (RCA) that Medication Assisted Treatment (MAT) for Opioid/Opiate dependence be available to all persons once clinical eligibility has been determined via appropriate screening and assessment of the individual for clinical and medical appropriateness for MAT services. The following are the procedure codes, code definitions, rates of reimbursement and other elements of this service in the Riverhaven Coordinating Agency region. SPECIAL NOTE: Medication Assisted Treatment for Opioid/Opiate Dependence is intended to stabilize an individual and foster readiness to make continued treatment decisions. An individual currently abusing Opioids/Opiates and seeking treatment services may not be initially capable of making decisions regarding their continuing treatment needs. t all individuals are appropriate for MAT, although they may meet clinical and medical criteria. Riverhaven expects providers to assess and stage every client to determine their readiness for change as a means of ensuring that the provision of MAT services will best meet the needs of the client. Individuals identified as having a diagnosis of Opioid/Opiate dependence and who are in the preparation or action stage of change may be authorized for admission to MAT services. Individuals identified as having a diagnosis of Opioid/Opiate abuse or Opioid/Opiate dependence and are in the precontemplation or contemplation stage of change will not be authorized for admission to MAT services. Such individuals will be offered Early Intervention services. For more information on Early Intervention services, reference the Michigan Department of Community Health-Bureau of Substance Abuse and Addiction Services Treatment Technical Advisory #09 - Early intervention (available from: as well as Riverhaven s Early Intervention Protocol (available from:

2 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 2 of 15 It is the expectation that clients seeking Opioids/Opiates for chronic pain issues will be referred to a primary care physician. Riverhaven Coordinating Agency does not fund the use of methadone or buprenorphine/naloxone for pain management. A clear diagnosis of Opioid/Opiate dependence must be present prior to any RCA funds being utilized for clients with chronic pain. Although Riverhaven Coordinating Agency realizes that Opioid/Opiate addiction may be an incurable brain disease that can last a lifetime, it is not the intention of Riverhaven to provide Block Grant funding for medication-assisted treatment indefinitely. It is our intention to provide intensive medication-assisted treatment to those clients with Opioid/Opiate dependence in order to enable them to reacquire the life skills as well as the degree of recovery to assume financial responsibility for their own treatment within three (3) years of their induction into treatment. Riverhaven Coordinating Agency realizes that this is ultimately a medical decision and that any rare exceptions to this 3 year time frame must be provided in detail to Riverhaven by the provider physician. SERVICE DEFINITION: According to the Treatment Improvement Protocol #43, as published by the U.S. Department of Health and Human Services (US HHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) the definition of Medication Assisted Treatment for Opioid/Opiate Dependence is:...any treatment for Opioid/Opiate addiction that includes a medication (e.g. methadone, buprenorphine, naltrexone) approved by the U.S. Food and Drug Administration (FDA) for Opioid/Opiate addiction detoxification or maintenance treatment. Medication Assisted Treatment for opioids/opiates using methadone must be provided in a licensed and state-regulated outpatient treatment provider (OTP), or for buprenorphine/naloxone, a physician's office or other healthcare setting, including an OTP. MAT is part of a broader continuum of care for substance use disorders that should include recovery supports, case management and outpatient therapy. The minimum required services for MAT are outlined in Federal regulations (42 Code of Federal Regulations [CFR], Part 8). The Michigan Department of Community Health-Bureau of Substance Abuse and Addiction Services has published Treatment Policies for both methadone and buprenorphine/naloxone. These Treatment Policies are identified in the reference section of this document and are available on the MDCH website. Outpatient Treatment Providers must inform clients of daily attendance requirements, mandatory counseling requirements, toxicology testing requirements and other program participation requirements outlined in this protocol document both at admission and throughout the course of treatment. Riverhaven Coordinating Agency requires that Medication-Assisted Treatment Providers offer at least the following services: General minimum service requirements for authorizing treatment for methadone-assisted treatment services: Comprehensive psychosocial assessment with an initial diagnosis of Opioid/Opiate dependency of at least one-year duration Coordination of care with all prescribing physicians, treating physicians, dentists and other health care providers Physical examination upon admission and as appropriate during the course of treatment Mandatory Four-month reviews to determine continued eligibility Daily attendance requirements for medication dispensing Must be used as an adjunct to Opioid/Opiate treatment which must include a counseling component Mandatory toxicology screening at intake and randomly during the induction period, to be conducted at a rate of no less than two per month. Beyond induction period, random toxicology screening to be conducted at a rate of no less than once per month; more if toxicology screening indicates possible relapse; toxicology screening must assay for Opioids/Opiates, cocaine, amphetamines, cannabinoids, benzodiazepines and methadone metabolites

3 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 3 of 15 Identification of co-occurring disorders and neuropsychological problems Counseling to stop substance abuse and manage drug cravings and urges Evaluation of and interventions to address family problems HIV and hepatitis C virus (HCV) testing, education, counseling, and referral for care Referral for additional services as needed. General minimum service requirements for authorizing treatment for buprenorphine/naloxone services: Comprehensive psychosocial assessment with an initial diagnosis of Opioid/Opiate dependency Coordination of care with all prescribing physicians, treating physicians, dentists and other health care providers Used as an adjunct to Opioid/Opiate treatment which must include a counseling component Physical examination upon admission Mandatory Four-month reviews to determine continued eligibility Mandatory toxicology testing at intake and randomly during the induction period, to be conducted at a rate of no less than two per month. Beyond induction period, random toxicology screening to be conducted at a rate of no less than once per month; more if toxicology screening indicates possible relapse; toxicology screening must assay for Opioids/Opiates, cocaine, amphetamines, cannabinoids, benzodiazepines and methadone metabolites Identification of co-occurring disorders and neuropsychological problems Counseling to stop substance abuse and manage drug cravings and urges Evaluation of and interventions to address family problems HIV and hepatitis C virus (HCV) testing, education, counseling, and referral for care Referral for additional services as needed. Special tes regarding the use of buprenorphine/naloxone as part of medication-assisted treatment for Opioid/Opiate dependence: Only the combination medication buprenorphine/naloxone (commonly known as Suboxone) is approved for use as part of medication-assisted treatment for Opioid/Opiate dependence. Buprenorphine/naloxone is not approved for pregnant women and should not be used as part of medication-assisted treatment for pregnant women. All physicians prescribing and/or dispensing buprenorphine/naloxone must have a waiver from the Substance Abuse and Mental Health Services Administration (SAMHSA) permitting them to prescribe and/or dispense buprenorphine/naloxone. Outpatient Treatment Provider's can provide several MAT options: Maintenance treatment combines pharmacotherapy with a full program of assessment, psychosocial intervention and support services; it is the approach with the greatest likelihood of long-term success for many clients. Maintenance treatment is typically indicated for the first two years of a methadone program. Medical maintenance treatment is provided to stabilize clients and may include long-term provision of methadone, buprenorphine or naltrexone with a reduction in clinic attendance and other services. A client may receive medical maintenance at an OTP after he or she is stabilized fully. A key feature of medical maintenance treatment is a reduction in clinic attendance as the client receives fewer ancillary treatment services once stabilized on medication. Medical maintenance treatment is typically indicated subsequent to the first two years of a methadone program. Riverhaven Coordinating Agency requires all potential clients seeking methadone-assisted treatment services to contact the Access Center for a pre-authorization screening and CareNet assessment for preliminary determination of MAT program eligibility. Such pre-authorization screening and assessment will typically include a brief client history, including any prior treatments, drug use and/or abuse history, presenting problems, provisional diagnoses, and an evaluation of Stage of Change. This pre-authorization work is not intended to replace a methadone provider s clinical and medical assessment process.

4 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 4 of 15 GENERAL EXPECTATIONS: Block Grant Methadone-Assisted Treatment Waiting List Because of dwindling financial resources, Riverhaven Coordinating Agency (RCA) has implemented a waiting list for those clients wishing to receive methadone-assisted treatment services who would be funded through Block Grant. Census of Block Grant-funded clients must remain static in order to maintain compliance with dwindling Block Grant funds. As such, medication-assisted treatment providers can admit clients approved by RCA s Access Center, only when a treatment slot becomes available. Such admission slots become available only when existing clients funded through Block Grant are discharged from treatment services; whether due to program non-compliance, transfer to self-pay status, obtaining Medicaid, or successful program completion. RCA s Access Center maintains a Block Grant Methadone Waiting List. In order to be considered for placement on the Block Grant waiting list, a client must contact the Access Center for a full screening and assessment to determine appropriateness for this level of care. Those consumers funded through Block Grant and placed on the waiting list should 1) be encouraged to go to local Outpatient treatment services while they are on the waiting list, 2) be encouraged to apply for Medicaid, and 3) be told to contact the Access Center if they obtain Medicaid and are still interested in receiving methadone-assisted treatment services. Clients on the Block Grant waiting list will be admitted to methadone-assisted treatment services according to their current priority status on the waiting list. When an admission slot becomes available, The Access Center will make three attempts to contact the next client on the Block Grant waiting list (according to priority status) via telephone. If unable to make contact with client via telephone, the Access Center will mark that client as inactive in the Block Grant methadone waiting list database and move to the next client according to priority status and repeat the above process until a client is successfully contacted. Clients so contacted will be screened and a CareNet assessment will be conducted by the Access Center to ensure continued appropriateness for methadone assisted treatment. If approved, the client will be warm-- transferred to a methadoneassisted treatment provider of their choice to arrange for an admission appointment. At this time, the Access Center will mark the client as "inactive" in the Block Grant methadone waiting list database. Clients contacted will have 14 days from the date of initial contact to be admitted into methadone-assisted treatment services. After 14 days have elapsed, the methadoneassisted treatment provider will contact the Access Center indicating whether the client failed to present for admission. If the client fails to present at the methadone-assisted treatment provider within 14 days of initial contact by the Access Center, the provider will inform the Access Center. The Access Center mark that client as inactive in the Block Grant methadone waiting list database and move to the next client according to priority status and repeat the above process until a client is successfully admitted. If the client does present at the methadone-assisted treatment provider within 14 days, the provider will inform the Access Center of the client's admission date. The Access Center will then enter the client's admission date into the methadoneassisted treatment waiting list database. For additional details regarding the Block Grant waiting list process, see the "Methadone Wait List Process" flow chart located at the end of this document. Block Grant-funded clients meeting criteria for urgent priority population (pregnant intravenous drug users or pregnant drug users) and having completed a screening and CareNet assessment through the Access Center will be allowed direct admission into methadone-assisted treatment, if appropriate, and will not be placed on the Block Grant waiting list. Individuals funded through Medicaid will not be placed on the Block Grant waiting list. Such clients will be required to contact the Access Center for a full screening and CareNet assessment to determine clinical appropriateness for this level of care. Clients determined to meet eligibility criteria for this level of care will be directed to the provider of their choice.

5 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 5 of 15 Individuals who lose their Medicaid benefit while admitted to a methadone-assisted treatment provider will roll over to Block Grant funding; at which point, the three year benefit rule will begin. For buprenorphine/naloxone assisted services: clients receiving buprenorphine/naloxone assisted services will not be placed on a waiting list. Buprenorphine/naloxone assisted services are NOT an alternative to methadone-assisted treatment services. Therefore, if a client is assessed as needing methadone-assisted treatment services, they would not be placed in treatment with buprenorphine/naloxone. Clients can NOT receive buprenorphine/naloxone while on the waiting list for methadone-assisted treatment services. Block Grant Methadone-Assisted Treatment Co-Pays Riverhaven Coordinating Agency (RCA) will assist clients working on total abstinence or attaining remission to achieve financial self-sufficiency and total responsibility for their own medication. A client that has a financial investment in their recovery is more likely to be committed to their recovery; therefore, the following graduated co-pay schedule for methadone administration has been established: Beginning January 1, 2014, a modified graduated co-pay becomes effective for methadone dosing (Block Grant funding only). The co-pay shall be adjusted annually according to the below schedule. At admission, the below co-pay schedule will be communicated to each client funded through Block Grant, with documentation included in the client s record. Additionally, this modified co-pay structure must be communicated to each current client funded with Block Grant dollars so the client knows which co-pay tier they are in. Co-Pay 0-12 Months $0/day Months $2/day Months $4/day The provider will be responsible for collecting co-pays and billing Riverhaven accordingly. The provider will be responsible for making sure that all clients receiving Block Grant funding will be made aware of these changes both at admission and throughout the course of treatment. Clients that are able to show that they are making efforts to secure employment yet are still unable to pay for their co-pay amount may request a waiver of co-pay reduction through the provider. There must be documentation signed by the client included in the client file. The co-pay may be reduced or eliminated at the discretion of the methadone provider. Riverhaven expects the provider to begin working on a comprehensive recovery plan with EVERY client immediately upon admission and be able to show documentation of assisting the client with developing a comprehensive recovery plan, which includes but should not be limited to: building a recovery support network developing a relapse prevention plan achieving a stable living environment securing stable employment Progress will be measured by the documentation of active participation in substance use disorder treatment as evidenced by: Quantifiable evidence of progress toward goals and objectives on a collaborative recovery plan designed to address treatment, and promote recovery and self sufficiency.

6 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 6 of 15 Negative toxicology screens or evidence of engagement in strategies to address recovery. All agencies that provide methadone assisted treatment will be responsible for completing the Annual Assessment to determine if the client will continue in treatment and to update assessment information. An Annual Assessment is required in order to ensure that clients continue to qualify for CA-funded substance use disorder treatment services. Continuation of funding will be contingent upon client progress. Funding for methadone-assisted treatment services will terminate after a maximum of thirty-six (36) months of dosing for the majority of clients funded through Block Grant. The program providing methadone will be expected to work with the client to achieve a full tapering of the medication within a maximum of thirty-six months -or- the client will be expected to self-pay the full Block Grant supported methadone-assisted treatment services amount in order to remain active in the program. Extensions to 36 Month Limit for Block Grant Funding Providers may request an extension for Block Grant funded individuals seeking continued assistance with methadone dosing beyond the initial 36 months using the Methadone Assisted Treatment Extension Request form (available at Completion of this document does not guarantee that an individual will be approved for continued assistance in funding. Riverhaven will consider exceptions for those clients that have: 1. Evidence of attempts (successful or otherwise) of tapering of methadone dosing, under the supervision of the clinic physician, or compelling rationale for not tapering. 2. Either maintained, gained, or actively seeking employment (with documentation) during the 12-month period prior to extension review. 3. Achieved no less than 6 months of consecutive negative urine drug screens in the 6 months (or longer) immediately proceeding anticipated termination of Block Grant funding for methadone services. If a client presents as pregnant, an immediate exception will be approved. Clients presenting as pregnant will be expected to apply for Medicaid. Additional information regarding exception criteria is available in the RCA MAT Exception Requests document; available at (www.riverhaven-ca.org). Clients being funded through Medicaid for buprenorphine/naloxone or methadone may continue treatment according to their specific Medicaid benefit as long as medically and clinically appropriate. Failure to follow program rules, lack of continued clinical and medical appropriateness for treatment are reasons for program discharge, regardless of funding source. Behavioral Contracts It is the CA's expectation that all clients will be compliant with the rules of the medication-assisted treatment provider. Clients that are non-compliant will be subject to placement on behavioral contracts according to the below stipulations: One Hundred Eighty (180) Day Induction Upon admission, clients are expected to work toward the reduction of and eventually elimination of the use of other drugs (non-prescribed) or alcohol. Riverhaven Coordinating Agency recognizes that the induction period can be difficult for clients as they work to change behaviors that may have taken years to learn. RCA expects that the majority of clients entering medication-assisted treatment services may relapse until stabilized on an appropriately therapeutic dose of opioid replacement medication (either methadone or buprenorphine).

7 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 7 of 15 During the induction period, it is RCA s expectation that medication-assisted treatment providers actively work with clients to address any program non-compliance issues in a positive manner to reduce the incidence of guilt and client drop-out that often accompanies recidivism. However, Following the initial 180 day induction period, clients who continue to test positive for the use of other drugs (nonprescribed) or alcohol will be placed on a 60 day behavioral contract. Clients showing little or no progress during this initial 60-day Behavioral Contract will begin a 60-day tapering of methadone, known as an administrative discharge. If at any time during the 60 day administrative discharge period the client begins to show progress, by achieving consecutive non-positive urine drug screens, the client may be placed on a new 60 day behavioral contract, at the discretion of the medication-assisted treatment provider. Clients continuing to produce positive urine drug screens during this second 60-day Behavioral Contract will begin a final 60-day tapering of methadone and be administratively discharged from the program. Documentation of the Behavioral Contract, client response, and detailed discharge reason must be included in the client's file. Clients being administratively discharged will not be allowed back into methadone-assisted treatment for a period of six months following the discharge. During the six-month waiting period, a client that has been administratively discharged from methadone-assisted treatment will be expected to participate in other treatment services, community support services, and any other appropriate services and be able to provide documentation of such. Following the six-month waiting period, the client wishing to re-enter medication-assisted treatment will be expected to contact the provider for a full re-assessment to determine eligibility for re-admission into medication-assisted treatment. Client participation in other treatment services, community support services, and any other appropriate services will weigh heavily in re-admission determination. Additionally, in order to be re-admitted into medication-assisted treatment, a client must sign a contract with the medicationassisted treatment provider stating all of the conditions of treatment listed below, under Conditions of Treatment and will be immediately placed on a probationary period of not less than 180-days. Conditions of Treatment The following conditions of treatment will be expected for all clients wishing to enter or re-enter medication assisted treatment. Discontinuation of the use of all illicit and non-prescribed drugs and alcohol. Regular attendance at the medication-assisted treatment provider for dosing (daily,until such time that the client meets criteria for take home dosages in the case of methadone, and as clinically and medically appropriate for buprenorphine). Attendance at all group and/or individual treatment sessions. Adherence to all program rules. Provide the name, addresses and phone numbers of all medical, dental, and pharmacy providers. Produce valid prescription or medication bottles with physician name on the label for all controlled substances within one week of admission. Prescribed medications may have to be changed in order to better coordinate treatment. Enrollment in one medication-assisted treatment program only. Evidence of continued work toward goals outlined in treatment plan. altered urine screens or non-compliance with drug testing. Regulatory Compliance All medication-assisted treatment providers must obtain client consent to contact other medication-assisted treatment providers within a 200 mile range to have the ability to regularly monitor for enrollment in other medication-assisted treatment programs. Evidence of such must be included in the client file.

8 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 8 of 15 Legally prescribed medication including controlled substances must be presented to the physician, who will decide whether these prescriptions are appropriate for the patient who is taking opioid replacement medications. Coordination of care with the prescribing physician is essential and expected. All medication-assisted treatment providers will require that clients provide a complete list of all prescribed medications. Legally prescribed medication including controlled substances must not be considered as illicit substances when the provider has documentation that it was prescribed for the client. Legally prescribed medications that are not being used as prescribed will be treated as illicit substances. Such information must be documented in the client file. Approved examples of documentation include copies of the prescription label, pharmacy receipt, pharmacy printout, or a Michigan Automated Prescription System (MAPS) report. According to Treatment and Recovery Policy #05: Criteria for Using Methadone for Medication-Assisted Treatment and Recovery, "Michigan law allows for individuals with the appropriate physician approval and documentation to use medical marijuana. Although there are no prescribers of medical marijuana in Michigan, individuals are authorized by a physician to use marijuana per Michigan law. For enrolled individuals, there must be a copy of the MDCH registration card for medical marijuana issued in the individual s name in the [client] chart or the prescribed medication log". A copy of the client's registration card must be included in the client chart. A MAPS report must be completed for individuals receiving either buprenorphine/naloxone or methadone prior to initial dosing. For clients receiving methadone, a MAPS report must also be completed prior to off-site dosing being approved. Offsite dosing is not allowed without documented coordination of care by the MAT provider's physician and the prescriber of identified controlled substances, which include, but may not be limited to: Opioid/Opiates, benzodiazepines, muscle relaxants. This coordination must be documented in the doctor s notes. Documentation must be individualized, identifying the client, the diagnosis, and the length of time the client is expected to be on the prescribed medication. It is recommended that MAPS be run, at a minimum, during every 120-day physician review on all individuals that are receiving medication-assisted treatment with either methadone or buprenorphine/naloxone. PROVIDER REQUIREMENTS: Medication-assisted treatment Providers must have an appropriate license issued by the State of Michigan and a contract with Riverhaven Coordinating Agency in order to be reimbursed for medication-assisted treatment and outpatient treatment through Riverhaven Coordinating Agency. The Michigan Department of Community Health, Behavioral Health and Developmental Disabilities Administration (MDCH/BHDDA) requires that: 1) The program must be identifiable and distinct with the agency s service configuration; and 2) The agency must offer or purport to offer MAT services as a separate and distinct program among any other program services that may be offered. Providers must base their program of services on the principles detailed in Treatment Improvement Protocol (TIP) 43, Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs and Treatment Improvement Protocol (TIP) 40, "Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid/Opiate Addiction". Individuals employed by provider organizations must be appropriately credentialed to provide the services described in this document (see Staff Credential Requirements below). After the initial year of methadone dosing, specific documentation must be included in the client file which evidences attempts at decreasing the dosage of methadone or tapering off of the medication (or adequate clinical/medical justification for not attempting to decrease or taper methadone dose), decreased problem severity, and the provider assisting the client in achieving employment along with other recovery goals that promote self sufficiency. In all re-authorization requests,

9 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 9 of 15 information must be included regarding attempts made at lowering the dose or reasons that these attempts are not being made. Without such documentation, methadone-assisted treatment may cease to be funded. Throughout the course of buprenorphine/naloxone-assisted treatment, specific documentation must be included in the client file which evidences attempts at decreasing the dosage of buprenorphine/naloxone or tapering off of the medication, decreased problem severity, and provider assisting the client in achieving employment and other recovery goals that promote self sufficiency. Without such documentation, buprenorphine/naloxone-assisted treatment services may cease to be funded. STAFF CREDENTIALS AND PROGRAM SUPERVISION REQUIREMENTS: Medication Assisted Treatment for Opioid/Opiate Addiction services must be delivered by individuals in provider organizations who have been credentialed as a Certified Addictions Counselor or Certified Advanced Addictions Counselor, or an individual who has a registered Development Plan with the Michigan Certification Board for Addiction Professionals. Supervision of an identifiable MAT program within a licensed provider organization must be by an individual credentialed as a Certified Clinical Supervisor, or an individual who has a registered Development Plan for Certification as a Clinical Supervisor with the Michigan Certification Board for Addiction Professionals. MAT services must be provided under the supervision of a physician licensed to practice medicine in Michigan. The physician must be licensed to prescribe controlled substances. Within a methadone program, the physician must be specifically licensed to work at a methadone program. Methadone must be administered by an MD/DO, physician s assistant, nurse practitioner, registered nurse, licensed practical nurse, or pharmacist. A physician prescribing buprenorphine/naloxone must have completed all certification requirements mandated by the State of Michigan. INCLUDED SERVICES (CODES AND CODE DEFINITIONS): Medication Assisted Treatment (for Opioid/Opiate dependence) in an outpatient setting is intended for the purpose of 1) managing the effects of withdrawal from Opioids/Opiates or 2) stabilizing the client and providing maintenance treatment. Ancillary services such as individual counseling and therapy, group counseling and therapy, Recovery Supports and/or Case Management should be made available during a client's episode of care. Medication Assisted Treatment Utilizing Methadone or Buprenorphine: or "Medication Review" "Individual psychotherapy" "Group psychotherapy" "Individual psychotherapy - Half session" H "Individual Outpatient Counseling 15 min" H "Group Outpatient Counseling" T "Recovery Support Services" H "Case Management Services" H0020 Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed methadone program)" Covered services for methadone and pharmacological supports and laboratory services, as required by Federal regulations and the Administrative Rules for Substance Abuse Service Programs in Michigan, Include: Methadone medication Nursing services Physical examination Physician encounters (monthly) Laboratory tests

10 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 10 of 15 TB skin test (as ordered by physician) Opioid/Opiate-dependent clients may be provided medication assisted treatment as an adjunct to therapy. Provision of such services must meet the following criteria: Services must be provided under the supervision of a physician licensed to practice medicine in Michigan. The physician must be licensed to prescribe controlled substances, as well as 1) licensed to work at a methadone program, and/or 2) Approved to prescribe buprenorphine. The medication component of the substance abuse treatment program must be licensed as such by the state and be certified by the OPAT/CSAT and licensed by the Drug Enforcement Administration (DEA) as appropriate. Methadone must be administered by an MD/DO, physician s assistant, nurse practitioner, registered nurse, licensed practical nurse, or pharmacist. Service providers are required to document all services on the appropriate clinical form (i.e., Assessments on Assessment Forms, Individualized Treatment Plans on an appropriate form, contacts on progress note forms, etc.). All documents will be made a part of the permanent clinical record. It is expected that all MAT providers contracted with Riverhaven Coordinating Agency will offer many various services such as; individual and group counseling and therapy, recovery support, and case management. Riverhaven believes that there is great therapeutic value to the client to be included in group sessions with other clients. Riverhaven promotes the use of group counseling and therapy in Medication Assisted Treatment. All services provided must be documented clearly in the record of the person served. te: A client entering an MAT treatment serviceswith buprenorphine/naloxone will usually not require sub-acute detoxification services prior to admission to the outpatient program. It is expected that the majority of clients will enter directly into buprenorphine/naloxone-assisted treatment at the outpatient level without first receiving services through subacute detoxification. ELIGIBILITY CRITERIA: To be eligible for medication-assisted treatment services funded through Riverhaven Coordinating Agency, the intended recipient must meet clinical criteria as set forth in the American Society of Addiction Medicine Patient Placement Criteria (ASAM PPC-2R). Further, the intended recipient should be assessed for ability to benefit from medication-assisted treatment services, including the stage of change in which the client presents. Determination of eligibility for MAT services and determination of a level of care is done by the MAT provider, using a standardized assessment tool for alcohol and drug abuse/dependence. Individuals are afforded a choice of provider upon determination of appropriate level of care. Client choice must be documented in the client s permanent record. Persons presenting for treatment are admitted to treatment in the following order: 1. Pregnant injecting drug users. 2. Pregnant substance abusers. 3. Injecting drug users. 4. Parents whose children have been removed from the home or are in danger of being removed from the home due to the parents substance abuse. 5. All others. Admission procedures for medication-assisted treatment require a physical examination. This examination must include a medical assessment to confirm the current DSM diagnosis of Opioid/Opiate dependency, as identified in the screening process. The physician may refer the client to other care providers (dentists, PCP, or other health care providers) for further medical assessment as indicated.

11 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 11 of 15 Ongoing methadone-assisted treatment authorization is dependent in part upon the results of the bi-monthly physician review. It is the expectation that total withdrawal from methadone will be attempted within the initial three-year period or that the client will self-pay at the two-year point. General eligibility guidelines to consider when authorizing treatment for medication-assisted treatment services: Methadone Assisted Treatment Services Client meets criteria for a diagnosis of Opioid/Opiate dependence. Client has been Opioid/Opiate dependent for a minimum of one year. Is 18 years of age or older. A client under 18 years of age is required to have had at least two documented unsuccessful attempts at short-term detoxification and/or drug-free treatment within a 12-month period to be eligible for maintenance treatment with the exception of a pregnant woman for which detoxification is not recommended. There must be no acute, serious, and unmanaged medical problems that would require hospitalization and stabilization of the medical issue prior to assisting the client with substance use disorder treatment. Other drug/alcohol use will be considered. Other drug use is not necessarily a reason to deny methadone-assisted treatment. If clinically appropriate (alcohol), send client to detox before admitting to medication assisted treatment. Concurrent illnesses can be stabilized and maintained on an outpatient basis. psychiatric illnesses that need to be addressed that could complicate treatment. (Untreated, unmedicated, unmanaged psychiatric issues or psychiatric issues that the Methadone-assisted treatment facility is not equipped to handle). Client must agree to and fully participate in Coordination of Care efforts with primary care physicians. Client is in immediate danger of continued using behavior without the treatment. Sufficient, safe, and supportive living environment (or client agrees to work toward obtaining). Client exhibits moderate to severe withdrawal or potential moderate to severe withdrawal. Client is pregnant and has a documented Opioid/Opiate dependency in the past and may continue to engage in active use during the pregnancy. Client is not seeking Methadone dosing for pain management (for pain management, refer to PCP or pain clinic, etc.). Buprenorphine/naloxone Treatment Services Client meets criteria for a diagnosis of Opioid/Opiate dependence. Drug-free treatment has been attempted and failed. Is 18 years of age or older. There must be no acute, serious, and unmanaged medical problems that would require hospitalization and stabilization of the medical issue prior to assisting the client with substance use disorder treatment. Other drug/alcohol use will be considered. Other drug use is not necessarily a reason to deny buprenorphine/naloxone-assisted treatment. If clinically appropriate (i.e. alcohol), send client to detox before admitting to medication assisted treatment. Concurrent illnesses can be stabilized and maintained on an outpatient basis. psychiatric illnesses that need to be addressed that could complicate treatment. (Untreated, unmedicated, unmanaged psychiatric issues or psychiatric issues that the medication-assisted treatment facility is not equipped to handle). Client must agree to and fully participate in Coordination of Care efforts with primary care physicians. Client is in immediate danger of continued using behavior without the treatment. Sufficient, safe, and supportive living environment (or client agrees to work toward obtaining). Client exhibits moderate to severe withdrawal or potential moderate to severe withdrawal. Client is pregnant (only permissible with documented evidence that prescribing physician deems buprenorphine/naloxone to be appropriate for pregnant client). Client is not seeking buprenorphine/naloxone dosing for pain management (for pain management, refer to PCP or pain clinic, etc.).

12 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 12 of 15 Provider will communicate to the client the importance of full participation in coordination of care efforts with the primary care physician(s). Client must have access to transportation (as they will be required to present at the facility on a daily basis). Client is assessed in either the Preparation or Action Stage of Change. Provider will communicate to the client the importance of full participation in coordination of care efforts with the primary care physician(s). Client must have access to transportation. Client is assessed in either the Preparation or Action Stage of Change. As each client is unique and presents with individual concerns, the Coordinating Agency encourages contact with us and/or the Access Center to discuss exceptions on a case-by-case basis. AUTHORIZATION PARAMETERS For medication assisted treatment using methadone, a maximum of 120 days of H0020 activity may be requested in an initial authorization in the CareNet system pending approval by either Riverhaven Coordinating Agency or the Access Center. Providers may request additional days at the rate of 120 additional days per reauthorization request provided appropriate and clear justification exists. A reauthorization will not be approved unless the provider has entered every toxicology report for the client into CareNet prior to the reauthorization request. Additional services such as medication reviews, drug screens, and actual dosing may vary depending on the service provider. However, all clients must contact the Access Center to complete an initial assessment prior to admission into a methadoneassisted treatment program. Providers will be required to complete an annual re-assessment for continuing care and will enter re-assessment information into CareNet. For medication-assisted treatment using buprenorphine/naloxone, a maximum of twenty (20) outpatient units, within a oneyear period, in any combination of 90834/H0004 (Individual Outpatient) and 90853/H0005 (Group Outpatient) activity may be requested in an initial authorization in the CareNet system. Providers may request additional units per reauthorization request provided appropriate and clear justification exists. The Access Center supervisor, or a representative, will review any service requests beyond the twenty initially requested units. Case management and Recovery Support services may also be requested. IMPLEMENTATION GUIDANCE: The U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, has issued treatment improvement protocols (TIPs) to assist with the implementation of these services. Treatment Improvement Protocol #43 (TIP-43), Medication-Assisted Treatment for Opioid/Opiate Addiction in Opioid/Opiate Treatment Programs ", Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (http://www.atforum.com/siteroot/pages/addiction_resources/mat-tip_43-mmt_guidelines2005.pdf) Treatment Improvement Protocol #40 (TIP-40), Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid/Opiate Addiction", Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (available from Substance Abuse Treatment/Recovery Policy # (TP-5), Criteria for Using Methadone for Medication - Assisted Treatment/Recovery", Michigan Department of Community Health, Bureau of Substance Abuse and Addiction Services (available from

13 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 13 of 15 Substance Abuse Treatment/Recovery Policy # (TP-3), Buprenorphine", Michigan Department of Community Health, Bureau of Substance Abuse and Addiction Services (available from Additional resources used in the development of this treatment protocol include: Michigan Medicaid Provider Manual (available from American Society of Addiction Medicine Patient Placement Criteria-2R (available from =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- As always, Riverhaven Coordinating Agency welcomes the opportunity to take into account your experience and input, and together to expand our partnership for the benefit of individuals with substance use disorders who require our services. Should you have any comments or suggestions for improving this protocol, please contact Riverhaven Coordinating Agency at

14 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 14 of 15 Methadone Wait List Process Client presents to AMS requesting methadone treatment Client presents to Provider Agency requesting methadone treatment AMS explains rules and expectations associated with participation in methadone treatment program Client is warmtransferred to AMS Does Client understand rules and expectations? Client is referred to Methadone Provider for immediate admission to Treatment Does Client agree to rules and expectations? Does Client have Medicaid? Is client Pregnant AMS sends client Medicaid Application AMS provides Screening and Assessment Does Client meet clinical criteria for methadone treatment? Client is placed on methadone waiting list Client referred to appropriate non-methadone services See page 2 for processing a client through Wait List Date: 08/11/2011 Version: 1.0 Effective Date: 09/01/2011

15 Riverhaven Coordinating Agency MAT Protocol for Opioid/Opiate Dependence - Page 15 of 15 Medication-Assisted Treatment Services Behavioral Contract Process Flow Client begins 180 Day medication induction At 180 Days Has Client shown improvement? Continue treatment services Client Past 180 Day medication induction Client is placed on 60 Day Behavioral Contract Is Client Following All Program Rules? After 60 Days on Behavioral Contract Client is Discharged from Treatment Has Client shown improvement? Behavioral Contract is ended and Client continues treatment services Continue treatment services as normal Client is Discharged from Treatment After 60 Days on Second Administrative Discharge Client is Placed on 60 Day Administrative Discharge After 60 Days on First Administrative Discharge Has Client shown improvement? Improvement suggests a reduction in use/abuse of illicit substances, increased engagement in treatment services and increased motivation to change. Date: 02/28/2012 Version: 2.0 Effective Date: 12/01/2013

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