Issues and Impacts Related to Opioid Treatment Programs in Florida

1. Issues and Impacts Related to Opioid Treatment Programs in Florida Agency for Health Care Administration Briefing Friday, March 16, 2012 Holly Hills, Ph.D.

2. Overview • Three areas of investigation were undertaken in FY 10-11: • Analyses examining costs • An examination of the role of pain • An evaluation of factors that impact treatment retention

3. Population Changes • There has been a shift in “Primary Problems” among those entering MAT. • A comparison of two cohorts of individuals entering MAT, demonstrates a shift over the five-year period with regard to the primary problems prompting admission to treatment, from illicit drugs (i.e., heroin, cocaine/crack) in 2002-2003 to prescription drugs (Oxcodone, Hydrocodone / Acetaminophen) in 2007-March 2008.

4. Most Frequently ReportedPrimary Problems Figure 1: Most Frequently Reported “Primary Problems” Prompting Admission to MAT for Opioid Dependence in 2002-2003 (N=537). * This includes codeine, Dilaudid, morphine and any other non-prescription drug with morphine-like effects.

5. Most Frequently ReportedPrimary Problems Figure 2: Most Frequently Reported “Primary Problems” Prompting Admission to MAT for Opioid Dependence in 2007-2008 (N=465). * This includes codeine, Dilaudid, morphine and any other non-prescription drug with morphine-like effects.

6. Cost Impacts • Analysis of service costs, demonstrated a cost offset related to emergency room costs for those engaged in MAT and this offset increased as time in treatment increased: • $69 at 90 days • $95 at 180 days • $399 at 365 days

7. MAT and Pain • Approximately one-half of those entering MAT in 2007-2008 had been prescribed opioids for pain: • Among the 412 persons admitted to MAT in 2007-2008 that had not been previously admitted in years 2002-2007, more than half (n=214) received a prescription for opioids due to a diagnosis of illness or injury in the five years prior to entering MAT.

8. Physical Health and MAT • Of the 4,239 individuals who sought MAT through Medicaid in years 2002-2008, 3,713 individuals had co-occurring physical health problems: • 1265 were diagnosed with ‘Lumbago’ (low back pain resulting from a variety of illnesses or injuries) • 912 were diagnosed with abdominal pain • 900 were diagnosed with back pain

9. Improving Outcomes • Greater numbers of psychotherapeutic counseling sessions were associated with retention in treatment: • Associated with a decrease in the odds of dropping out of treatment before 90 days • Associated with a decrease in the odds of treatment drop out before 180 days • Associated with a decrease in the odds of dropping out of treatment before 1 year

10. Policy Recommendations • Greater engagement with, and training of, primary and specialty care physicians, led by substance abuse treatment providers, is necessary to provide education as to the risk of extended or excessive prescription of narcotic painkillers especially to those with a history of substance use disorders.

11. Training Physicians: Resources • Since 2003, the AMA has offered a 12-module continuing medical education (CME) series on pain management. • The AMA has certified more than 20,000 physicians upon successful completion of these online courses. • In February 2011, the AMA created an online CME called “Prevention of Prescription Drug Misuse and Diversion” which provides an overview on prescription drug abuse information for patient education.

12. Policy Recommendations • Many prescriptions for opioids could not be associated with a diagnosis. • Policies related to associating a diagnosis with any billed interaction should be evaluated, as tracing the history of prescriptions and prescriptive practice would be made more interpretable.

13. Improving Outcomes • Psychotherapeutic counseling is associated with treatment retention and better long term outcomes. • Utilization of allowable funding categories to support greater psychotherapeutic interventions should be targeted to those most vulnerable to treatment drop out – individuals that identify significant stressors or histories of polysubstance dependence.

14. Investigations in FY 2011-12 Three studies have been initiated: An evaluation of client satisfaction with the treatment experience An examination of professional use of buprenorphine Analyses of administrative data examining the diagnosis and treatment of co-occurring disorders

15. Recommendations for Research: FY2012-2013 • Evaluation of opioid prescription practices among primary and specialty care physicians • Evaluation of the specific types of psychotherapeutic interventions offered to clients in OTP care • Development of a whitepaper / policy forum to identify and remedy impediments to adoption of innovation / buprenorphine variants

16. Recommendations for Research: FY2012-2013 • Implementation of physician training programs to improve identification of SA/SD history and modified prescriptive practice • GIS study investigating MAT clients’ access to treatment sites

17. Recommendations for Research: FY2012-2013 • Adoption of Innovation: • Modified clinical strategies to encourage treatment engagement • Improved integration of primary care into OTP settings • Improving pain management in MAT populations