Background
The purpose of the Medication Assisted Treatment – Prescription Drug and Opioid Addiction (MAT-PDOA) project was to provide resources to help expand and enhance access to Medications for Opioid Use Disorder (MOUD) in rural communities. The program aimed to increase access to medication for individuals with Opioid Use Disorder (OUD) using an integrated hub-and-spoke model.
Healthcare Challenge
Compared to individuals with all other Substance Use Disorders (SUDs), individuals with OUD have the poorest response to traditional addiction treatment. Research has shown that overdose rates increase two- to six-fold after individuals leave addiction treatment and six- to 10-fold after individuals leave jails or prisons due to high relapse rates associated with OUDs and reduced tolerance. Prior to the project, each of the targeted communities experienced significant increases in overdose rates with subsequent increases in addiction treatment services. In the two years prior to project implementation, each community experienced a 50% to over 100% increase in fatal overdoses, fueled by low cost, but potent heroin and fentanyl. High attrition rates also contributed to long waiting lists due to patients with an OUD cycling through the treatment system.
Goals
The goals of the project were to: 1) increase the number of providers and settings that offer MAT; 2) create an integrated and coordinated continuum of care for individuals with OUD by standardizing MAT assessment and protocols, creating engagement protocols, and increasing the use of peers; 3) increase the quality of MAT services by implementing comprehensive training and quality indicators for providers; and 4) increase the sustainability of MAT services by implementing payment model reform and implementation support.
Implementation Approach and Findings
An integrated hub and spoke model was embedded within these communities using three overlapping components to rapidly identify, engage, and retain individuals in evidenced-based MAT treatment:
1) a super hub; 2) three regional hubs (one in each community); and 3) integrated spokes, including primary care physicians, substance abuse providers, mental health centers, emergency departments, peer supports, and the criminal justice system, among others.
Through this approach, the number of providers who obtained their x-waiver increased by 75% across the targeted counties. The number of certified recovery specialists (CRS) working with patients in these counties tripled. Over 550 community-based providers participated in training supported by the project such as Motivational Interviewing and Screening, Brief Intervention, and Referral to Treatment (SBIRT). Seventy-three percent of enrolled individuals reported an improved living situation. The number of enrolled individuals reporting depressive symptoms improved by 46%. Employment improved by 23% and financial need decreased by 37% among enrolled individuals. Only eight individuals reported an overdose during enrollment, compared to 149 prior to enrollment. Overdoses during the project period averaged 1.4 per person compared to 3.5 per person prior to the start of the project (among those reporting any overdoses).
Individually, each of the counties were also successful in making notable accomplishments during the project period. Through their partnership with UPMC Altoona, the Single County Authority (SCA) in Blair County was able to support the emergency department in starting the MAT induction process and improved the warm hand off process, almost increasing sixfold the number of individuals who accepted referrals to treatment from the emergency department. The SCA for Lycoming and Clinton Counties implemented a warm hand off process at all UPMC Susquehanna hospitals’ emergency departments. Through a collaboration with local universities and family medicine residency programs, they were able to increase the number of waivered providers in the two counties. Erie County providers implemented a team-based approach to provide integrated care for individuals receiving MAT by embedding a therapist and certified recovery specialist in primary care settings. The SCA for Cameron, Elk, and McKean Counties, which was added in the last year of the project, was able to restructure the warm hand off process with local emergency departments and increased the number of warm hand offs from previous years.
Note that before the Mainstreaming Addiction Treatment (MAT) Act in 2021, the US DEA required clinicians who wanted to prescribe medication for the treatment of opioid use disorder to complete training and registration process for the “x-waiver” which was named as such because upon completion of these requirements, an “X” was added to the clinician’s DEA registration.
Also note that SCA programs receive state and federal funding through the PA Department of Drug and Alcohol Programs (DDAP), Department of Human Services (DHS), and Office of Mental Health and Substance Abuse Services (OMHSAS) to plan, coordinate, and programmatically and fiscally manage and implement the delivery of drug and alcohol prevention, intervention, and treatment services at the local level.