By Alison Knopf
The Cures Act, signed in December 2016 by President Obama, gave $920 million over a two-year period to states to devote to opioid use disorder treatment. States submitted their applications for funding to the Substance Abuse and Mental Health Services Administration (SAMHSA), and are already making plans with what to do with their money.
California is getting $40 million a year for two years, and it’s going to use it to develop a hub-and-spoke model similar to that in Vermont. Jason Kletter, PhD, president of California Opioid Maintenance Providers, whose BAART clinics are providers in Vermont, told AT Forum how the project will work in California.
Cures Act Allocations Will Expand Access to Programs
States get a Cures Act allocation based on need, and in California, the money will be used to expand access to Opioid Treatment Programs (OTPs). OTPs will be the center of the system—the hub—and office-based opioid treatment (OBOT) will be the spokes.
“Hub and spoke is a great model to expand access, to get more doctors involved and more community prescribers,” Dr. Kletter said.
States had the benefit of SAMHSA’s maps (see related story), which helped indicate where treatment is needed. Of course, COMP already knows. And the problem in California is typical of the problem in New York—many programs in urban areas and none in rural areas. For Vermont, basically a rural state, the issue was that treatment was needed everywhere.
“We’ve got a density of programs in Los Angeles and very few in the north above Sacramento,” said Dr. Kletter.
Fewest Overdoses in Counties With OTPs
One national map—the so-called heat map published in the New York Times (https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html)—shows where overdose deaths are. This map can be compared to the SAMHSA map showing where OTPs are. “The counties with the most overdoses are the ones with no OTPs,” said Dr. Kletter. “That makes sense to us. It’s a striking visual to see those two maps side by side.”
Officials in California hope that Cures Act money will be used to develop programs where they don’t currently exist. The OTPs would help people move across the continuum of care—which is what often happens in reality. “When someone relapses, it’s important to get them back to a center of excellence, and keep them there until they are stable and doing well,” he said.
The hubs are OTPs that conduct assessments on new patients, stabilize them, and, if the patients are taking buprenorphine and determined a good fit for OBOT, they will go to the spokes. “If they’re taking methadone, they won’t be going out to the spokes, but if they’re taking buprenorphine they can be stepped down” said Dr. Kletter. Some patients being treated with buprenorphine will remain in the OTPs, due to needed extra services provided in that setting, just as is currently happening in Vermont.
“There isn’t a goal either way—keeping people in one setting or another,” said Dr. Kletter. “The goal is to get people to the right setting. If they’re stable and doing well, they should be in a less restrictive setting.” Patients taking methadone, as he mentioned, must remain in an OTP, due to federal regulations.
“I’m very proud of our state for using this money in this way,” said Dr. Kletter. “This Cures Act program is intended to be a rapid response to increasing access, and the hub-and-spoke model is a proven strategy for increasing access based on the strengths of the existing OTP system.”