Innovative Approaches to Expanding Access to Medication-Assisted Treatment in primary care and community settings for people with opioid use disorder
Contributors: Diane Arneth, Paul Vitale, Barbara Zeller M.D.
The Surgeon General’s recent report on addiction in us clearly states that the best treatment for opioid addiction is long term medication assisted treatment (MAT) with opioid agonists or antagonists. It has been shown to reduce overdose deaths and improve treatment outcomes.
Over the last few years, Brightpoint Health and its subsidiary Community Health Action of Staten Island (CHASI) have forged a partnership and approach that provides a comprehensive portfolio of access to MAT for people with opioid use disorder.
Annually, Brightpoint Health provides primary care and behavioral health services for close to 40,000 patients across all five boroughs of New York City, and medical care coordination and case management for 8,000. As Brightpoint’s community-based subsidiary on Staten Island, CHASI provides close to 13,000 residents with health outreach, education, disease screening and prevention services; benefits screening and application assistance; medical care coordination, case management and navigation for low income people with chronic illness; emergency food and computer access; domestic violence survivor services, and comprehensive services for substance use, including a drug user “Health Hub” for active drug users and the 24 hour Next Step Resource and Recovery Center.
We are focused on shifting the thinking and approach of both primary care and community providers regarding the identification of substance use and the interventions at their disposal. At Brightpoint Health primary care clinics, all adult primary care providers are trained in harm reduction and are required to complete the 8 hour training to secure the Federal DEA waiver to prescribe and dispense buprenorphine. We have recently had a number of our Nurse Practitioners also complete the 24 hour waivered training required for that discipline. This not only creates multiple access points for all primary care patients to access MAT as needed, but also reinforces a culture which clearly messages that SUD treatment is within the purview and expectation of our primary care providers. This is of course based upon the provider assessment of need and appropriate level of care for each individual. Providers always have the option to refer the patient to a different level of care, e.g. inpatient detoxification or long term residential treatment, if indicated. The integration of MAT into primary care has been supported by a Buprenorphine Nurse Manager, piloted at clinics in Brooklyn and Staten Island, with plans to expand that model to others. The Nurse Manager serves as the subject expert and resource for the clinicians, the care coordinator for the patients receiving MAT, and the intermediary for insurance approvals and advocacy.
In March 2012, Brightpoint also created a unique partnership with a Bronx-based harm reduction provider, BOOM!Health, by co-locating a primary care clinic within their harm reduction space. In the space where active drug users traditionally received clean syringes, food, peer counseling and social support, they now had access to primary care, mental health services, HIV and HCV care and access to MAT. A co-located pharmacy on the site provided additional adherence support and prescription drug monitoring for these clients.
We also see an important role for us in the prevention of opioid addiction within our clinical settings. Recognizing that harmful illegal substance use can be related to chronic pain, in 2014, Brightpoint Health introduced a pain management program to serve its primary care and behavioral health patients which was patient-centered and addiction and harm reduction informed. This approach has resulted in better treatment of chronic pain, as well as reductions in the use of illegal substances. As part of this commitment to offering clinicians and patients the best tools with which to address their pain, Brightpoint has piloted the prescribing of medical marijuana as part of their pain management toolkit. Since the begging of the pain management program, we have provided 5,202 pain management visits, and in 2017 alone, served 467 unique patients through this program.
For patients requiring a more intensive level of care related to substance use, Brightpoint provides OASAS licensed Part 822 clinical services in Brooklyn and Staten Island. These clinics integrate MAT, including buprenorphine and vivitrol, into their standard of care for people with opioid use disorder as part of a comprehensive service plan that can include individual and group counseling, toxicology testing and vocational counseling. Patients who have completed their treatment and are stabilized on medication can continue in the program indefinitely on “Continuing Care” status, followed regularly by the medical provider, with access to a counselor as needed.
For persons actively using opioids and other drugs who are not interested in or able to stop using, CHASI operates a Health Hub, a place where active drug users can receive low threshold services, including harm reduction education, free HIV and HCV testing, syringe exchange, linkage to other services and peer counselling. The Health Hub was recently funded to add low threshold medical services to that menu, which will include MAT overseen by a Nurse Practitioner with training and experience in harm reduction who has completed the waiver training.
There is a commitment among the programs to work together to both increase access to MAT and to deliver the right access and services to each patient to ensure success. To that end, leaders of all 3 MAT programs – the clinic, the treatment program and the Health Hub – have been meeting regularly to develop an integrated marketing plan and an algorithm for patient referral among the programs as needed.
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In addition, in early 2017, CHASI opened the Next Step Resource and Recovery Center, a 24 hour a day, multi-service, community-based space where individuals and family members can get help related to their own or other’s harmful substance use. Staffed by licensed counselors and peer specialists trained as recovery coaches, Next Step offers 24/7 walk-in or phone crisis intervention, SUD information and education, short term counseling, linkage to all levels of SUD treatment, and recovery services and support. It also serves as the hub for the Richmond County District Attorney’s HOPE program, a diversion program for low level drug possession arrestees offering services rather than criminal justice involvement and NYC Department of Health’s RELAY program, a pilot peer-delivered opioid overdose intervention with the emergency department of a local hospital.