Acritical element to successfully treating opioid addiction and addressing the epidemic is offering a wide range of therapies. Due to the extreme dependence created by opioid use, Medication Supported Recovery is often necessary. For decades, Methadone; dispensed in an Outpatient Treatment Program (OTP) was the only option available for maintenance. While this remains an important and well-researched treatment, new trends in addiction show that multiple treatments are needed. As such, other medications are becoming available. One such medication, Buprenorphine, has become a well-known and effective treatment for opioid dependence.
Buprenorphine is an effective means of treatment and is known to be prescribed in primary care settings. However, the DEA limit on physicians’ patient case load size restrict wide spread use of Buprenorphine, also the absence of substance abuse counseling in this setting can be an ineffective model. OTPs were waived from the above limits; therefore, dispensing Buprenorphine in an OTP setting is very much needed as we continue to expand the use of this medication treatment to address the current opioid epidemic.
Prior to implementing any new modality of treatment, it is necessary to conduct the appropriate “pre-work.” This includes analyzing your current population as well as target populations that may be able to enter treatment if this modality was offered. VIP Community Services tracked incoming requests for Buprenorphine maintenance from self-referrals as well as referents to assess that there was a population in our community in need of this form of treatment.
Cost is another major driver as Buprenorphine is significantly more expensive than methadone. Medicaid reimburses the cost of the purchase in the New York State blended rate; however, a significant cost is required up front. It is important to assess your target population as this will help you determine the appropriate dosage amounts to purchase, as well as how quickly you will be enrolling clients and billing for services provided.
Space and client flow are other important aspects to be reviewed in the pre-implementation phase. Buprenorphine requires a separate inventory and space to house the medication. It also requires additional dispensing time as compared to dispensing methadone. Preparing for this different client flow is important to ensuring the ongoing operations of the clinic. VIP has designated areas for individuals who may be in withdrawal to rest comfortably through the induction process and encourage clients to adhere to a time for dispensing when client flow is less heavy.
Staff resources and staff training are additional factors to consider. Only Physicians are allowed to induce Buprenorphine, and the regular administration of Buprenorphine requires the nursing staff to watch a client while the film is placed under the tongue to be dissolved. Training and educating staff about the administration of Buprenorphine was another significant undertaking, which required repeated group and individual training session. It was important to help staff to understand which clients are well-matched for Buprenorphine treatment and the difference in service provision. Much of the individual services provided by staff are not reimbursed at an individual reimbursement rate. Having a written protocol in place definitely assisted with the orientation of staff.
The billing system for Buprenorphine is also different from methadone. Buprenorphine billing is a blended rate, individual services are not billed. Increasing the frequency of entitlement reviews is also of great importance. Due to the cost of purchasing Buprenorphine, prolonged lapses in a client’s Medicaid could have an immediate negative financial impact. It is recommended that Medicaid status be reviewed a minimum of weekly. In addition, VIP reviews revenue on a weekly basis to ensure that all billings are being collected and that all claims have been accepted. Finally, this allows us to review the costs associated with providing the service and ensure that the revenue is meeting the resources that have been expended.
Finally, evaluating your effectiveness is critical to program success. Programs should determine indicators early in the process that will measure how effective the program is. Retention, reduction in illicit substance use, and attendance are some initial factors. As the program develops, we will continue to measure other indicators of a holistic recovery, such as vocational engagement, family involvement, and other community engagement.
Implementing multiple treatment modalities to address the diverse populations entering care for opioid abuse is becoming increasingly important. It is critical that new treatment options are implemented in a manner that ensures their sustainability and success to continue opening access to treatment.
Debbie Pantin, LCSW, is Associate Executive Director; Doreen Thomann-Howe, LCSW, is Chief Program Officer; Ernst Jean, MD, is Medical Director; and Debbi Witham, LMSW Esq, is SVP Compliance, Policy, and Planning at VIP Community Services.