By Alison Knopf
A host of changes in accreditation standards are coming for opioid treatment programs (OTPs) from the Joint Commission. The standards are based on the Substance Abuse and Mental Health Services (SAMHSA) guidelines, published in March of 2015, “Federal Guidelines for Opioid Treatment Programs” (http://www.samhsa.gov/newsroom/press-announcements/201503270300).
SAMHSA established the accreditation requirement in 2001 to help OTPs improve the quality of patient care, treatment, and services, delivered in the OTP setting.
AT Forum interviewed Megan Marx, MPA, associate director for behavioral health care accreditation at the Joint Commission, to learn the details about the accreditation changes. We discuss some of the most significant changes below.
Licensed Mid-level Practitioners to Write Medication Orders in OTPs
- The organization will have a federal exemption in place to allow mid-level medical practitioners to write medication orders in opioid treatment programs.
- The program’s telemedicine services do not expand the scope of practice of a health care provider or permit practice in a jurisdiction (the location of the patient) where the provider is not licensed.
- The program reviews the individual licensing, scope of practice, and supervision requirements of its state with regard to the duties of authorized health care professionals within the program, such as advanced practice nurses, physician assistants, and advanced practice pharmacists.
“Medication orders” in OTPs refers to determining dosages. This change, one of the key changes in the federal guidelines, would allow OTPs to submit an exemption request to SAMHSA for using mid-levels to determine methadone orders in states where this is allowed. Current SAMHSA guidelines do not allow mid-levels—nurse practitioners and physician assistants—to make medication orders for methadone.
“We reached a middle ground here,” explained Ms. Marx. “SAMHSA does have an exemption function written into the regulations. SAMHSA takes the very conservative view that the regulations prohibit mid-level prescribing. We went back and forth about that when we were drafting the guideline revisions [that came out last April]. Some folks do believe that the federal regulations allow this.” OTPs can start submitting their exemption requests immediately.
Interim Maintenance to be Reserved for Patients Cleared for Treatment
- To receive interim maintenance, the patient must be fully eligible for admission to comprehensive maintenance.
This standard is to ensure that patients aren’t placed in interim maintenance—methadone dosing without any additional services—unless they have already been designated “cleared for treatment,” said Ms. Marx. “SAMHSA wanted to be really clear about this.”
This standard does not mean that interim maintenance is the goal—rather, as soon as a slot is available, the patient should be moved into comprehensive treatment. “Nobody says it’s a good idea to do induction on interim maintenance. But if there is no other alternative, this is the way it needs to be done.”
A typical example would be an established patient who is moving, and wants to transfer to another OTP. If all programs are full, which is likely, interim maintenance will be an option.
Telemedicine to Support Physicians’ Decision-Making
- The program does not use telemedicine to substitute for a physical examination when one is needed. Telemedicine may be used to support the decision making of a physician, when a provider qualified to conduct physical examinations and make diagnoses is physically located with the patient.
“We’re seeing more use of telemedicine, in particular in places where there are geological challenges,” said Ms. Marx. Sometimes the patient is far away from the OTP, and this is an important alternative. “Our biggest challenge has always been the mountains—you can’t get over them when there’s snow in the way.”
Confirmation Drug Testing to Address Potentially False-Positive and False-Negative Results
- The program includes confirmation testing such as gas chromatography-mass spectrometry (GC-MS) or liquid chromatography-mass spectrometry (LC-MS) as part of its established procedures for addressing potentially false-positive and false-negative urine or other toxicology test results.
“This is SAMHSA’s language,” said Ms. Marx of the drug testing. It’s not clear whether the confirmation has to be done for all tests, however. “It could be that you need to wait until there’s a challenge” by the patient, she said.
Because the Joint Commission is a deemed accrediting body, it has to incorporate both the regulations and the SAMHSA guidelines into their standards, explained Ms. Marx.
In developing standards, the Joint Commission always considers the liability of the OTP. “We want everyone to be able to provide care, and not worry about whether they will be sued,” said Ms. Marx. “Ultimately, we hope physicians and other providers working with patients who are in an OTP are receiving the best care and services possible.”
Naloxone and Naltrexone to be Added for Patients Leaving Treatment
Naloxone and the availability of opioid antagonist therapy—naltrexone—has been added for the benefit of patients who withdraw from treatment.
- The program advises patients of the risks of relapse following withdrawal and offers a relapse prevention program that includes counseling, naloxone, and opioid antagonist therapy.
“Anytime you see naloxone written into the federal guidelines, that’s all new,” said Ms. Marx. As for naltrexone, the OTP just has to “know where it is accessible and who is available to provide it.”
Forced Withdrawal After Pregnancy to be Curtailed
- The program provides medically supervised withdrawal after pregnancy only when clinically indicated or requested by the patient.
“Forced withdrawal after pregnancy happens too often,” said Ms. Marx. Tennessee is a good example of this. The new standard makes it clear that OTPs can’t force patients to withdraw—even if the state tells them to,
Neonatal Abstinence Syndrome Education to be Provided for Mothers
- The program educates mothers about neonatal abstinence syndrome, its symptoms, its potential effect on their infants, and the need for treatment should it occur.
Next year the Joint Commission will expand this standard to include educating all women of childbearing age, not just mothers (including pregnant women), said Ms. Marx. “This was the language that SAMHSA came out with in the guidelines, but we thought it should go farther,” she said. “You never know when someone may become a parent, so at some point when they do become pregnant, they should be aware of neonatal abstinence syndrome.”
(Women in methadone maintenance treatment are generally urged to breastfeed their babies, which reduces neonatal abstinence syndrome. In addition, the babies can be given medication, then gradually weaned, to avoid discomfort.)
MAT or Counseling (or both) Offered for Alcohol-Use Disorders
- The program provides medication-assisted treatment for alcohol use disorders, when appropriate, as well as counseling interventions for patients with a need for treatment.
“This is an acknowledgement of the fact that patients come to us with all sorts of issues and challenges and disorders that need to be treated,” said Ms. Marx. “SAMHSA is trying to be more inclusive of medication-assisted treatment in the larger picture.” Medications approved for the treatment of alcoholism include naltrexone (also approved for the treatment of opioid use disorders, but contraindicated in patients taking opioid agonist medications methadone or buprenorphine).
Benzodiazepine Monitoring; Querying the PDMP
- The program periodically queries the prescription drug monitoring program (PDMP) throughout the course of each patient’s treatment (for example, quarterly) and, in particular, before ordering take-home doses as well as at other important clinical decision points.
- The program counsels patients known to be using benzodiazepines, even by prescription, as to their risk and provides them with overdose prevention education and naloxone.
Note: For an evidence-based strategy to address benzodiazepine use among OTP patients, refer to Management of Benzodiazepines in Medication-Assisted Treatment: Final Report on the Development of Clinical Guidelines http://my.ireta.org/sites/ireta.org/files/Best%20Practice%20Guidelines%20
for%20BZDs%20in%20MAT%202013_0.pdf prepared by the Institute for Research, Evaluation and Training in Addictions, with Support from Community Care Behavioral Health Organization.
Querying the PDMP is important because the patient may be getting prescriptions for medications that could interact with methadone, said Ms. Marx. “If you’re doing this in whatever fashion—quarterly or semiannually—chances are there won’t be any surprises.”
It’s important because there are still some physicians who may prescribe benzodiazepines. “A lot of providers are still very uncomfortable about treating both an opioid addiction and a disorder requiring benzodiazepines, because of the risk of overdose, and the liability.”
The standards take effect July 1. For the standards, which are issued electronically prior to publication, go to http://www.jointcommission.org/assets/1/18/Prepub_BHC_OTP.pdf. Accessed March 31, 2016.