The use of medication-assisted treatment (MAT) therapies for substance use disorders is expanding. Additional funding for access was a key part of President Obama’s 2017 budget proposal, and the cap on the number of patients that waivered physicians can treat with buprenorphine was raised in July from 100 to 275. In addition, many treatment centers that previously rejected the use of medication in addiction treatment have begun incorporating MAT.
Deciding to add a medical dimension like MAT to an existing program is one thing; actually making the transition is another. The process involves overcoming a number of administrative, financial and cultural hurdles that could potentially derail the program. Implementing a MAT program requires executive-level support, education and training for staff, the addition of new staff (including waivered prescribers), patient outreach, new approaches to therapy, and in some cases, partnerships with other organizations.
“It’s always tricky trying to integrate a medical program and a non-medical program,” says Stuart Gitlow, MD, MPH, MBA, past president of the American Society of Addiction Medicine (ASAM) board of directors and executive director of the Annenberg Physician Training Program in Addictive Disease. “It’s really a change in the model. It would require changing policies, approaches, staff, everything.”
The road to MAT
The Hazelden Betty Ford Foundation has been a longtime proponent of group therapy, counseling and abstinence-based approaches without a medication component. In the early years, the organization even questioned whether offering coffee at 12-Step meetings was a good idea.
Now, the 70-year-old institution has begun offering both buprenorphine and naltrexone along with its 12-Step program, prompted by the scale of the opioid epidemic and the devastation it has caused among addicted patients.
“We started to see problems in our programs, especially residential treatment programs,” says Marvin Seppala, MD, chief medical officer at Hazelden Betty Ford Foundation. “Our admissions increased dramatically. People were bringing drugs into the treatment unit, and we were starting to see deaths early after discharge. There was an ethical imperative.”
In 2012, Hazelden approached the board of directors about implementing MAT.
“We showed them the data, and we got full support from the board, which is necessary for any kind of nonprofit going in this direction,” Seppala says. “If you don’t have leadership support, it’s not going to happen.”
Hazelden created a plan for the organization and began meeting with clinicians at its facilities to discuss their concerns. In addition to adding MAT to its programs, Hazelden also launched group therapy specifically for opioid disorder patients and is undertaking a study to help determine which medications work best for different types of patients.
Within two years, Hazelden found that the percentage of opioid patients who drop out of its 12-Step program and relapse fell from nearly a quarter to just 5%.
“They are our best group in terms of completion of treatment,” Seppala says. “That’s tremendous, because completion is a predictor of positive outcomes.”
The shift at Hazelden could help move the use of MAT forward at institutions that modeled themselves on its therapy approach, but there is still resistance to the use of medication by some practitioners—something Seppala says he encountered during the transition.
Choice of drug therapies
One of the first steps an organization should take is determining which MAT approaches fit with its mission and clientele. Not every provider can or will offer every kind of medication.
“We really had to evaluate our options,” says David Chernof of his previous experience in implementing MAT at Bridgeway Behavioral Health in Missouri (he is currently vice president of addiction services at Great Circle in St. Louis). “We weighed our options, and we determined that there were specific programs for methadone, and we didn’t want to get into that business because there were big barriers.”
Methadone is highly regulated and restricted to certain clinics that meet federal standards. But in Chernof’s experience, the state of Missouri played a role in the decision by offering a plan that would help cover the cost of naltrexone and buprenorphine.
Hazelden’s Seppala adds that some patients don’t want to use daily buprenorphine, so having injectable naltrexone as an option is valuable.
“We have about one-third of our patients that choose not to take meds, but to engage in a long-term program,” he says. “About a third take Suboxone (buprenorphine), and a little over a third take Vivitrol (naltrexone).”
If you have multiple facilities, another question to consider is where you would offer MAT services. Not every population will need the same type of drug therapy. The drug products must be secured at the location, and you must have the right medical staffing available to administer the medications.
And just because you offer MAT doesn’t necessarily mean you will immediately find success in increasing the number of patients taking those medications, experts say. The naltrexone program at Community Health Network in Indianapolis, for example, had just 15 patients in 2015—in a network that averages 19,000 outpatient client visits and 4,700 inpatient stays annually. According to Julie Maguire, nurse practitioner in psychiatry and behavioral health at the organization, physician buy-in was a challenge.
“There were some turf wars and fears about waiting room issues,” Maguire says. “Some felt they were inadequately trained or supported. There was fear of litigation.”