Baltimore Buprenorphine Initiative Adam Brickner bSAS President/CEO January 3, 2008

1. Baltimore Buprenorphine Initiative Adam Brickner bSAS President/CEO January 3, 2008

2. Overview • System Structure • Implementation Steps • Lessons Learned

3. System Structure: Three Agency Collaborative Effort • Baltimore Substance Abuse Systems, Inc. • Substance abuse treatment oversight • Baltimore HealthCare Access, Inc. • Health insurance assistance • Case management services • Baltimore City Health Department • Training and recruitment of physicians • Initiative oversight

4. System Structure :Three Pronged Approach • Step 1: • Buprenorphine induction at treatment program • IOP/OP services provided • Step 2: • Assistance with obtaining health insurance • Transition to primary care/medical system • Step 3: • Continued buprenorphine therapy in primary care • Ongoing counseling and case management

6. Implementation Steps:Substance Abuse Treatment System • Forming core group of Initiative coordinators • Choosing provider (s) • Hold regular provider roundtable meetings • Produce written policies and guidance • Oversight of buprenorphine providers • Swift response to unanticipated problems • Patient tracking

7. Implementation Steps:Preventing Medication Diversion • Begin with 1 week prescriptions • Increase duration of prescription once demonstrated capacity to use buprenorphine appropriately • Prescription and medication recall • Patients bring medication back for pill count • Urine testing • Test for continued opioid use and illicit drug use • Test for buprenorphine with instant dip stick test at least weekly after take-home prescriptions are started

8. Implementation Steps:Case Management • Case worker involved from treatment start • Special referral consent signed by patient • 1:150 • Help with obtaining necessary documentation • Help with health insurance application, application tracking, and MCO/PCP selection • Facilitate transition to primary care • Patient tracking

9. Implementation Steps:Transfer to Primary Care • Patient must meet transfer criteria • Case worker facilitates transfer to certified PCP • Makes appointment with selected PCP • Sends transfer summary to PCP before appointment • Assures transportation for patient • Sets up co-pay vouchers for patient if needed • Follow up on PCP visit with patient and PCP • Patient tracking

12. Implementation Steps:Primary Care • Buprenorphine and medical care provided by PCP • Continuation of OP treatment for 3 months post transfer • Subsidized urine testing • Patient tracking for 6 months post transfer • Co-pay voucher system set up with PCPs and pharmacies • Free training for all Baltimore physicians

13. Baltimore Burprenorphine Initiative: Results to Date (12/31/2007) • 701 entered the Initiative since 10/2006 • 392 (56%) have remained in treatment for 90+ days • 134 of 392 (34%) transferred to a PCP • 128 days is average LOS in primary care • 25 patients (19%) dropped out post-transfer

14. Lessons Learned (1) • Maintenance therapy presents philosophical shift • Provider as change-leader • Develop written protocols and procedures early • Use SAMHSA’s evidence based TIP 40 to develop protocols and procedures • Regular provider meetings ensure information exchange • Training of treatment providers and PCPs

15. Lessons Learned (2) • Case management extremely important - holds system together • Ensure open communication between all parties • Know MCOs’ coding and billing procedures • Set specific goals, expectations, and benchmarks

16. Lessons Learned (3) • Set up patient tracking system • Essential for case-management • Allows tracking of goals and benchmarks • Anticipate problems and seek solutions • Documentation requirements • Delay in insurance coverage • Medication purchasing and storage • Co-pay coverage • Urine testing • Clinical inconsistencies