SC MAT ACCESSMedication Assisted Treatment

Academic Community Capacity Expansion for Sustainable Success

Kathleen Brady, MD, PhD, VPR, MUSC

Overdose Death Rates from OpiatesMost important sign of a SUD

Marked increase from 1999 to 2014 by county

1999 2014

Opioid OD Deaths US, 2000-2015

2015 Overdose Deaths:

52,404 Any Drug

33,091 Any Opioid266 260 253

242 234222250

300

200

150

100

50

0201020112012201320142015

OP

IOID

MM

EIN

BIL

LIO

NS

Source: IMS Health, U.S. Outpatient

Retail Setting

Opioid morphine milligram

equivalents (MME) dispense fell

by over 15% from 2010-2015

Opioid Prescriptions have started to Decrease

but

Opioid Fatalities are still Increasing

Heroin Price Has Decreased

in

Recent Years

4 out of 5 new heroin users started

with rx opioids

"Retail" Price

Per PureGram

$3,500

$3,000

$2,500

$2,000

$1,500

$1,000

$500

$-

National Drug Control Strategy--Data Supplement 2014. https://www.whitehouse.gov/sites/default/files/ondcp/policy-and-

research/ndcs_data_supplement_2014.pdf

Emerging Illicit

Synthetic Opioids

Increasing reports of fentanyl

laced - heroin and prescription pills.

Other synthetic opioids emerging

i.e., Carfentanil.

HOW DID WE

GET

HERE?

OPIOID DEPENDENCE IN South Carolina

› Since 1999, rate of opioid-related deaths has quadrupled

› In SC, 600 opioid-related deaths in 2015

› In 2015, 1 RX for an opioid was written for every adult in SC

› SC in top quartile for opioid prescriptions

› SC in lowest quartile re: access to medication treatment for opioid dependence

Opioid Prescribing

JAMA, published online August 6, 2014

Opioid-Involved Overdose Deaths

by

County of Occurrence in 2015

SC DHEC, 2017

Medications Are Effective and Save Lives

Medication Assisted

Treatment (MAT)

DECREASES:

• Opioid use

• Opioid-related overdose

• Criminal activity

• Infectious disease

transmission

And INCREASES

• Social functioning

• Retention in treatment

But MAT is highly

underutilized

Opioid Agonist Treatments Decreased Heroin OD Deaths

Baltimore, Maryland,1995-2009

Schwartz RP et al., Am J Public Health 2013.

Medication Assisted Treatment (MAT) in Opioid

Dependence: Lifesaving!!!!

+ + + + + +

+

+ + + + + + + + +

+ + +

Methadone

Agonist

Buprenorphine

Partial Agonist

Naltrexone

Antagonist

Narcan Administration Counts by County,

2015 & 2016

SC DHEC, 2017

Methadone Treatment Centers, 2017

Buprenorphine Waivered Physicians by

County, 2017

4

12

1

11

5

50

2

1

2

1

4

3

2

3

5

1

46

4

14

2

2

10

9

7

50

13

5

1

7

* 4 physicians did not provide

valid county identifier

1

SAMHSA, 2017

21st Century Cures Act

Enacted Dec 2016, included:

› Landmark mental health

reform bill

› Monies for states to fight

opioid epidemic

› PDMP

› Primary care involvement

› Train in best practices

› Prevention

SC MAT ACCESSSouth Carolina Medication Assisted Treatment

Academic Community Capacity Expansion for Sustainable Success

A Partnership between MUSC and

the Department of Alcohol and Other

Drug Services

Improve access to evidence-based

treatments for opioid dependence

throughout SC

Reaching Rural Areas to Address

the

Opioid Epidemic

Multiple rural counties

26 counties share 233 doctors

Many counties only 1-2 physicians

per 10,000

Can academic detailing spread

best practices?

Can telehealth be used for

specialized service delivery,

consultation and training?

The South Carolina Telehealth Alliance

Statewide collaboration to expand

Telehealth services statewide

Headquartered at MUSC Center for

Telehealth: Dr. Jimmy McElligot

Provides guidance, assists with

strategic development, advises on

technology and standards

to develop an open-access net

Will assist with equipment/consultation

for SC MAT ACCESS

SC MAT ACCESS

An Overview of the Initiative

Jenna McCauley, PhD

Methadone Buprenorphine

Pill, liquid, and wafer Buccal film, sublingual tablet, film

Taken once a day Taken once a day (at home)

Combined with counseling & social

support

Combined with counseling & social

support

Receive medication under supervision

of physician

Receive mediation under supervision of

physician, NP, or PA

Length of treatment: Minimum 12 mos. Length of treatment: Minimum 6-12

mos.

Only dispensed at SAMHSA certified

Opioid Treatment Program (OTP)

Can be dispensed in physician’s office,

community hospitals, health

departments, OTPs, & correctional

facilities

Training & Support for

MAT Delivery

Academic

Detailing Interactive Web

Resource

Academic Detailing

• University or non-commercial based educational outreach to

physicians and their staff

• Face to face education

• Delivered by trained healthcare professionals

• Structured visits

• Topics

• Responsible opioid prescribing

• Risk mitigation strategies

• Screening, brief intervention, and referral to treatment (SBIRT)

• Becoming a MAT provider

Other Educational Trainings• Neurobiology and Epidemiology of Addictive Disorders

• Overview of the Opioid Epidemic

• Neurobiology, Epidemiology, and Treatment of Opioid Use Disorders

• Medication Assisted Treatment

• SBIRT Implementation

• Motivational Interviewing

• Practice Support

Training & Support for MAT Delivery

Training & Support for MAT Delivery

Pre-Implementation Needs Assessment:

• Strengths and resources of organization

• Personnel

• Fiscal

• Space

• Technology

• Relative weaknesses and needs of organization

• Workflow integration

• Who?

• When?

• Where?

• How many?

Training & Support for MAT Delivery

Waiver Training

• Drug Addiction Treatment Act of 2000 (DATA 2000)

• 8-hour training (16 hours for NPs) to qualify for a waiver to prescribe and dispense buprenorphine

• DATA 2000 Waiver options:

• Buprenorphine Waiver Training at the American Academy of Addiction Psychiatry

• American Society of Addiction Medicine Buprenorphine Course for Office-Based Treatment of Opioid Use Disorders

• Providers Clinical Support System for Medication Assisted Treatment Self-Study at the American Academy of Addiction Medicine

Next Steps:

• Registration (with proof of training)

• Patient limits: 30 100 275 (at least one year in each category)

• Record keeping requirements (ongoing)

• Staff training

• Prior authorizations and funding?

• Referral options for higher level of care

SC MAT ACCESS Website

• Resource for healthcare providers interested in:• Learning more about MAT

• Becoming MAT providers

• Receiving ongoing practice support for their delivery of MAT

• Online repository for:• Academic Detailing educational materials

• Trainings and presentations offered by our group across South Carolina

• ECHO consultation didactic seminars

• Practice support resources

• Promotes ongoing, bi-directional communication between South Carolina MAT-providers and the MUSC practice support team:• Online discussion forum

• Colleague Connections directory

• Consultation request form

• Updates and News

Training & Support for MAT Delivery

SC MAT ACCESS

Project ECHO for MAT SuccessLouise Haynes, M.S.W.

Although the ECHO model makes use

of telecommunications technology, it is

different from telemedicine.

ECHO

Extension for Community Healthcare Outcomes

• Founded by a professor of Internal

Medicine at the University of New

Mexico, Project ECHO started as a

clinic to treat underserved Hepatitis

C patients.

• The success of the model is due to

its simplicity and cost effectiveness.

• ECHO decreases provider isolation

and increases confidence.

ECHO Model

Hub and spoke knowledge-sharing networkHub and spoke knowledge-sharing network

Led by expert teamsLed by expert teams

Clinicians learn to provide excellent specialty care for patients in their own communities.Clinicians learn to provide excellent specialty care for patients in their own communities.

Project Echo allows for the collaboration of:

✓specialists at academic medical centers

✓community-based primary care providers

to co-manage patients with a broad range of conditions. Over time, primary care providers develop the competencies needed to effectively manage complex patients independently.

Project Echo allows for the collaboration of:

✓specialists at academic medical centers

✓community-based primary care providers

to co-manage patients with a broad range of conditions. Over time, primary care providers develop the competencies needed to effectively manage complex patients independently.

Since its launch in 2003, the

ECHO model has continued

to draw interest, first with

partner sites, then with a

nationwide pilot by the U.S.

Department of Veterans

Affairs, and more recently,

with a global chronic pain

management program with

the Department of Defense.

Numerous other federal

agencies, academic medical

centers, and even other

countries are in various

stages of exploring or

implementing Project ECHO.

Currently ECHO model initiatives focus on

multiple diseases and high need aspects of care

throughout the country and internationally.

Hepatitis C

Behavioral Health

Autism

Child Abuse

Sickle Cell Disease

TB

HIV

Pain

Transgender Health

Maternal and Child Health

Geriatrics

Epilepsy

Palliative Care

Cancer

“If we can leverage technology to spread best practices

through case-based learning and mentoring of providers,

we can move knowledge – instead of patients – to get

better care to rural and underserved communities across

the country.”

“Medical knowledge is exploding, but

it’s often not traveling the last mile to

ensure that patients get the right care

in the right place at the right time.”

Using telemedicine technology through the MUSC Center for

Telemedicine, SC MAT ACCESS will identify medical providers

in SC who are interested in joining a mentoring network for

supporting medication assisted treatment in community

practices.

Providers and MUSC experts in opioid treatment will be

connected through telemedicine technology.

South Carolina’s

ECHO Network

South Carolina’s

ECHO Network

Now nearly 300 clinicians in New Mexico are certified

to prescribe buprenorphine—the best-practice

treatment medication for opiate addiction.

Before Project ECHO, fewer than a dozen clinicians

in New Mexico were certified to prescribe

Buprenorphine.

ECHO Plan for SC MAT ACCESS TEAM

• Team to attend training in New Mexico later this month.

• Model proposes a one hour weekly conference.

• The first half of the conference will be a case-based presentation by one of the

practitioners followed by group discussion. The second half will include a brief

presentation by the MUSC team on a relevant topic.

• Topics for the didactics will be chosen by participants and/or based on case

material presented. The MUSC ECHO Coordinator will provide the liaison

between participating practices and the MUSC team to schedule case

presentation and didactics.

• Additionally, individual consultation concerning practice or patient-specific issues

will be available. Practitioners can request a consultation through a link on the SC

MAT ACCESS website, and there will be a response within 24 hours.

Sample Topics

Introduction to Addiction Brady

Opioids Brady

Opioid Use Disorder (OUD) Barth

Medication Assisted Treatment for OUD Brady

Overview of Chronic Pain Barth

Non-Opioid Pain Medications Barth

Integrated Pain Care McCauley

Screening for Depression, Anxiety and SUD Barth

Assessment of OUD Barth

Opioids Co-Prescribed with Other Meds Guille

Pain and Addiction in Pregnancy Guille

Alternative Treatments for Pain Borchardt

Fibromyalgia/Osteoarthritis TBD

Headaches/Complex Regional Pain Syndrome TBD

Motivational Interviewing Killeen

SBIRT Haynes

12-step Facilitation Haynes

Recovery Haynes

Cognitive Behavioral Therapy McCauley

People need access to specialty care

for their complex health conditions.

There aren't enough specialists to

treat everyone who needs care,

especially in rural and underserved

communities.

ECHO trains primary care clinicians

to provide specialty care services.

This means more people can get the

care they need.

Patients get the right care, in the right

place, at the right time. This improves

outcomes and reduces costs.

South Carolina MAT ACCESS will use ECHO Model to enhance the

state’s capacity to provide care to citizens with opioid related

problems. With a focus on primary care providers.

OUR TEAM IS EAGER

TO

HEAR FROM YOU!

What challenges do you face in providing care to people with problems related to opioid use?

What barriers do you face in your community?

How could our project help to address those barriers?

For Additional Information Contact:

Rachel Grater

Program Coordinator II

SC MAT ACCESS

grater@musc.edu

(843) 792-5380