Shawn K. Hatch, ACSW, LMSW, CCS, CAADCMarquette General Health System

Maximum east-west distance – 320 miles

Maximum north-south distance – 125 miles

1700 miles of continuous shoreline with the Great Lakes

4,300 inland lakes and 12,000 miles of streams

2,156

36,628

6,780

16,427

8,860

11,817

67,077

26,168

9,601

24,029

37,069

8,485

7,028

11,113

38,520

*U. S. Census Bureau: 2010 Population of UP Counties

Morbidity and Mortality

Healthy BehaviorClinical CareSocial & Economic Physical Environment

The UP has a growing problem with opiate and prescription drug abuse.

National MichiganUP

Alc. dep. or abuse in past year 7.53 7.79 8.05Illicit drug dep or abuse in past year 2.82 2.88

3.07Dep. on or abuse of any illicit drug 9.07 9.41

10.00or alcohol in past year

Nonmedical use of pain relievers in past year among person aged 12 or older

National Michigan UP

5.00 5.63 5.29

MDCH, Mental Health & Substance Abuse AdministrationBureau of Substance Abuse & Addiction ServicesState & Substate Estimates of Substance Use in Michigan

2006-2008 National Surveys on Drug Use and Health

Traditional outpatient and residential treatment programs

Methadone . . . not available in the UP Green Bay, WI – 175 miles Muskegon, MI – 440 miles

Buprenorphine 4 physicians accepting new patients

Medication approved for the OP treatment of opiate dependence in 2000 (Drug Abuse Treatment Act of 2000). Set physician qualifications for prescribing.

FDA approved Suboxone/Subutex in 2002.

Partial Opioid Agonist Ceiling effect

Withdrawal & Craving

Suboxone 8 mg buprenorphine/2 mg naloxone

Subutex 8 mg buprenorphine▪ Primarily for pregnancy

Multiple reports of addicts snorting or using IV.

Amount of naloxone may not be enough for some individuals.

This is an abusable drug – like most, can be used for good or evil.

Prescribers must go through special training and are issued a separate DEA number.

Prescribers are limited to 30 patients for the first year. Can apply for a waiver and treat up to 100

after the first year. Many prescribers want this population

out of their office . . . . Prescribers still have limited knowledge of

addiction.

Yes It isn’t the “drug of choice” but it is

(significantly) better than nothing▪ The “high” experience▪ Expectancy▪ Relief from sick to not sick

Great to have on hand in case addict can’t score▪ Selling/trading for full agonist

Methadone is currently the “standard of care” for the pregnant opiate addict.

ACOG: Buprenorphine Versus Methadone Treatment for Opiate Addiction in Pregnancy: An Evaluation of Neonatal Outcomes, 2010 Lower NAS scores for the Subutex babies▪ 10.69 versus 12.5

Shorter LOS▪ 8.4 versus 15.7

Less than 50% of Subutex babies requiring treatment versus 73% of methadone babies

2006 142007 232008 172009 232010 45

Yes . . . . and noMaking the leap

June of 2007 – MGHS accepts first patient

Brief phone screen Quickly overwhelmed

Swamped with phone calls High “hassle factor”▪ Reports of “lost” or “stolen” meds▪ Requests for early refills▪ Refill requests . . . from jail

High volume of drop-outs and non-compliance

April of 2008 – Discontinued admissions 10 months and 29 patients

No denying how desperately this service was needed.

At this point, only one other physician prescribing in the UP.

We had a handful of patients who were doing well for the first time in their lives.

This posed an interesting and challenging question: How do we expand this classification of patients?

Prescribing physician left our organization

Dr. John Lehtinen agrees to prescribe.

Road trip

How do we manage a limited resource?How do we make this service available

to the best treatment candidates?How do we manage the “hassle factor”

and prevent burning out our staff and physician?

How do we maintain our integrity and credibility with local agencies, treatment providers, law enforcement, and most importantly, our patients?

Slowing down the process and looking for the best matches for the medication.

Rationale for the application: Completing and mailing the application would

require effort. The application would allow us a better

opportunity to screen applicants and potentially fill the limited treatment slots with those in the best position to benefit from buprenorphine.

Items from criteria in TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Dependence: History of treatment completion/compliance Not currently abusing benzos, sedative-

hypnotics, or barbiturates Not currently abusing alcohol Supportive living environment Supports for recovery

Dependence is limited to opiatesEmployedNo medical contraindications Indicated agreement to abide by

rules and expectations.

Already being treated with Suboxone and successful

Active in substance abuse treatmentTreatment goal of abstinenceHas resources to pay for treatment

and medicationNot in collections with us“Clean” MAPSApplication is complete

Buprenorphine screening questionnaire

MGHS Personal Data form Releases of Information to the PCP and

current substance abuse professionals, as applicable

Treatment contract* Patient and family information about

buprenorphine Summary of substance use

Program Requirements: Attendance at all scheduled

appointments Attendance at a substance abuse

program ROI’s to all physicians and

counselors/therapists Abstinence from alcohol and drugs

Patient Responsibilities: Store medication properly Take as prescribed Pill counts Drug testing Notify office if medication lost or stolen Notify of relapse Payment for services

Application is sent to caller.Returned applications are “scored”Review by CommitteeHigher scoring applicants are

contacted to schedule appointment with physician and for induction; assuming no medical contraindications.

The score sheet – no magic number or total score for automatic admission

Receive letter with specific treatment recommendations and an invitation to meet with addiction physician in consideration of other treatment options.

Receive instructions regarding how to access services for his/her circumstances, i.e., location, treatment history, funding source, etc.

Encouraged to contact us for second review if treatment recommendations are followed through.

Prescribing PhysicianDirector of Clinical ServicesClinical SupervisorClinician

Provides forum to review program policy, discuss clinical challenges, and advocate for candidates.

Takes “heat” away from prescribing physician.

Between August of 2009 and March of 2011 more than 350 applications were distributed.

Marquette 46%

Delta19%

Dickinson12%

Baraga 5% Houghton 4% Menominee 4% Schoolcraft 3% Iron 2% Chippewa 1% Ontonagon 1%

Gogebic n=2 Luce n=1 Mackinac n=1 Alger n=2 Wisconsinn=2 Lower Pen.

n=1

50/50 split between males/femalesAverage distribution rate has been

18 per monthNearly half (170) of the 350

applications were completed and returned to the Review Committee

28% of those who have returned applications have been admitted for buprenorphine treatment.

Average age 29.8 Age:

17 1% 18-30 61% 31-40 28% 41-50 8% 51-65 1%

Race 91% Caucasian 9% Native American

 Sex Male 46% Female 54%

June 2007 – April 2008 (10 months) 29 patients admitted 22 of original 29 were discharged 20 of the 22 were discharged by

October of 2009, however, nearly half were gone within the first 4 months of treatment 13 dropped out 7 discharged “at staff request” 2 completed

August 2009 – March 2011 (19 months) 48 patients admitted 7 discharges

5 dropped out 2 discharged “at staff request”

Retention rate went from 24% to 85% Significant reduction in the “hassle

factor” Able to more than double admissions

without additional staff resources Currently have 76 patients enrolled in

the program.

Pregnancy The only exception to the application

process The application process would delay

treatment Acknowledgement that our focus has

shifted to treat the pregnant addict and provide the best possible start for the baby.▪ Limited window to engage the patient in

treatment and recovery.

Non-compliance with counseling Late entry into pre-natal care and

treatment Shame Use of other drugs/continued drug use Poor support system Poverty Distance from physician (from all over

UP) “Hostage” until birth Case coordination between OB/NICU and

prescribing physician Pregnancy to access program.

High volume of pregnant addicts seeking treatment with buprenorphine 43 since December of 2010; 40 pregnant

at admission The return of the “hassle factor”

Incentive to comply▪ About 25% compliance but improving.

Better outcomes from NICU Shorter LOS and less severe withdrawal

How significant problem of opiate addiction is in the UP

Buprenorphine isn’t for everyoneThe application process is an

effective way to manage a valuable and limited treatment resource

Support group didn’t fly.How long should someone be on

buprenorphine? A controversial and individualized question.

Counseling need to start before the buprenorphine and the longer the better

We need to continually “take our own inventory” regarding attitudes, beliefs, biases, regarding buprenorphine treatment and patients.

We still have much to learn . . . . More challenging and stimulating

opportunities lie ahead . . . .

Shawn K. Hatch, ACSW, LMSW, CCS, CAADCDirector of Clinical Services, Behavioral HealthMarquette General Health SystemShawn.Hatch@mghs.org(906) 225-3214