Medically Assisted Treatment Overview
The opioid prescription problem exploded in the middle to late 90s and continued to get worse and worse in the early 2000s. As the pressure on doctors to slow down on the prescribing of prescription pain pills continued to grow the early signs of the heroin epidemic started showing up around 2005 and was directly linked to the indiscriminate and irresponsible use of opioid pain medications.
St. Louis and the Midwest at large were particularly vulnerable because Chicago was the distribution point for heroin smuggled in from Mexico. The heroin problem went undetected primarily due to the shrewd tactics deployed. Prescription opioid abuse was primarily within the White suburban community – age group 17 -30. Small time dealers targeted the same young whites, mostly male to not only switch to the cheaper heroin but also become small time dealers to sustain the habit. All this occurred under the radar of law enforcement.
Around 2007, Missouri drug courts and the Missouri Department of Behavioral Health became increasingly aware of the problem due to the rising incidents of overdoses and deaths. At this time Medication Assisted Treatment (MAT) was restricted primarily to methadone treatment and was the only medication funded by the state.
In 2008, the state of Missouri looked at broadening the scope of MAT to include all medications approved by the FDA for the treatment of addictive disorders. These included Naltrexone, Vivitrol, Suboxone, Acamprosate and Methadone. By early 2009, MAT was increasingly seen and promoted as a viable treatment option to improve treatment outcomes. The science behind MAT validated the its use.
The success factors for MAT are medical detox (as opposed to social detox) and offering patients anticraving medications that would prevent relapse along with treatment for psychiatric/dual diagnosis disorders.
The results of the program:
o Dramatic reduction in people leaving residential treatment against staff advice.
o Dramatic reduction in residential days – no more 28-days for everyone. Individualized treatment – the use of MAT gave many patients a chance for the first time to get well in their home and natural environment…Patients continued to receive MAT primarily buprenorphine and Vivitrol as they learnt to live in a landscape dotted with cues and triggers associated with drug use.
o Dramatic reduction in overdoses and deaths.
o Greater interest and involvement from the pt with regards to counseling, family, job, vocational training etc.
OVER COMING THE CHALLENGES AND THE LONG LASTING BENEFITS
The introduction and acceptance of MAT among the treatment community took time and effort. It took the partnership, open-mindedness and tremendous cooperation and willingness to work as a team. MAT brought together clinics and programs that in the past operated rather independently, sometimes as rivals. The Department of Behavioral Health, in conjunction with the guidance from Percy Menzies, was the main driver and catalyst. Drug courts increasingly accepted MAT as part of treatment.
Prior to the introduction of MAT the addiction field had not seen much if any use of medications in treatment outside of Methadone. As a result there was often times little to no need for physicians or other medical providers. Finding physicians and getting them to obtain DEA waiver to use buprenorphine and training them on detox protocols proved to be a real challenge. Physicians and medical staff were turned off by the idea of treating those who struggled with addiction.
To further complicate the issue other members of the mental health community and general community at large who now were being asked to be a part of the solution were set in the old way of doing things. Training social workers, counselors, therapists, probation and parole officers, drug court staff including judges on the benefits of MAT took time and a team effort. The results of the program spoke for themselves and clearly showed that integrated treatment is more effective than just self-help groups and social detox.
INTRODUCTION OF TELE-MEDICINE
Over the past 5 – 7 years the Heroin Epidemic has exploded on at a national level…in part due to the availability of the drug in the rural and underserved areas. Telemedicine was a natural offshoot of MAT, which now allows those in rural and underserved areas to receive the same level of medical and psychiatric care, essential for MAT.
Some of the Benefits of Telemedicine are:
o Ability to serve those who would otherwise not have access to care
o Allows states to overcome shortage of providers
o Forces all disciplines to work together which creates a holistic and comprehensive approach
Some of the Requirements for a successful Tele-Med Program are:
o Robust IT Infrastructure
o Knowledgeable and well trained medical staff (physicians and RN’s)
o Buy in from the staff and community being served
o Strong and Open Communication – regular staffing of clients
o Multi-Disciplinary Team/Approach – must bring the medical and psychosocial components of treatment together through an acceptance of common and evidence based modalities
WHAT ARCA CAN PROVIDE
1. Same day access to a provider for both MAT and PSYCH services
2. Robust and Timely documentation of appointments
3. Knowledgeable and reliable Provider(s) that are able to prescribe Suboxone and other MAT Medications
4. Provider(s) that are knowledge about the treatment of addictive disorders and the medications used for these diagnosis
5. Provider(s) that are knowledge about the treatment of dual diagnosis and other co-occurring mental health disorders
6. the possibility of e-script services and calling in of medications along peer support and nursing services.