By Alison Knopf
Arizona is using some of its Opioid STR (State Targeted Response) money, granted under the 21st Century Cures Act, to expand access to Opioid Treatment Programs (OTPs). Currently, one OTP has opened its doors 24/7 but the state’s plan is to have a total of five facilities—two of them OTPs, and three, crisis centers—able to help patients access treatment 24 hours a day, 7 days a week.
Crisis centers and crisis response teams provide emergency psychiatric services at the moment of need in order to stabilize individuals and engage them in a course of treatment. They see patients in emergency departments, and when they call the crisis line, said Heidi Capriotti, public information officer for the Arizona Health Care Cost Containment System (AHCCCS), which runs the program.
“Where emergency rooms may lack the staff or resources to stabilize a patient with opioid use disorder, specialized crisis response teams and facilities can help patients find licensed medication-assisted opioid treatment programs. These teams can literally facilitate that warm transfer, to make sure a patient doesn’t just walk out the door with a business card, but is taken to an opioid treatment program, if that’s their choice,” said Ms. Capriotti. “With expanded, 24-hour access to crisis and OTP services, patients with opioid use disorder have more access to immediate crisis intervention and treatment.”
Community Medical Services is the first facility to participate in the program, opening the doors of its Phoenix OTP 24/7 for the first time in October. The program will use the second year of its allocation of the two-year, $24-million Opioid STR grant to expand this program.
At Community Medical Services, all three medications are offered, CEO Nick Stavros told AT Forum. The clinic in Phoenix was the largest OTP in Arizona even before the expansion, with 900 patients.
Because of the expanded hours, there were 312 intakes in the first eight weeks. Most of these patients are taking methadone, he said, with only 12 on Suboxone and six on Vivitrol.
“With expanded hours at the opioid treatment center, Arizona is setting a national example, making access to medication-assisted treatment a priority. We are fighting the opioid epidemic on many fronts—through prevention, education, and treatment—and we are committed to ending the opioid epidemic in our state,” said Sara Salek, MD, AHCCCS chief medical officer, in a November 15 press statement announcing the program. Usually, OTPs are open from 4:30 AM to 11:30 AM, said Dr. Salek. This gives patients time to get medication before the start of the workday.
Intake Center for After-Hours Patients
The 24-7 clinic in Phoenix has a full-time staff: a physician, a nurse, and a peer counselor, working around the clock. There are currently 38 OTPs in the state of Arizona. The 24/7 OTP in Phoenix will end up transferring many of the people who come in after hours to one of the other facilities, said Mr. Stavros. “This is an intake facility for after hours,” he said. Patients can get inductions and then transfer to an OTP that is more convenient to them; only Phoenix has the after-hours admissions.
Most of the patients are on Medicaid, said Mr. Stavros. Arizona opted for Medicaid expansion under the Affordable Care Act. “We also have SAPT block grant funding, so if the patient doesn’t qualify for Medicaid, they have the option of being covered by the grant,” he said, referring to the Substance Abuse Prevention and Treatment block grant from SAMHSA.
Patients need treatment available at the moment they decide they’re ready for it—or they may never get it. And they need it fast. For example, one patient had gone to detox, but it wasn’t working. “She was out of detox for a week, and she started to relapse, and called her dealer,” Mr. Stavros said. “The dealer didn’t answer the phone, so she showed up at the clinic, and we started her on methadone.” She is now stabilized in treatment, re-connected with her family, and working two jobs, whereas she was unemployed upon entering treatment. For her, as for many patients, the key was to find a place in the middle of the night, with the lights on, when she was in the midst of a relapse, that could help her then and there.
Methadone or Buprenorphine
Next year, a second OTP—a nonprofit facility in Tucson—will expand its hours to 24/7. In addition, three crisis centers—not OTPs, but aimed at opioid treatment—will open in Prescott Valley, Kingman, and Tucson. Patients who seek help at these centers may be referred to an OTP; they will definitely be referred to medication services.
However, the three crisis centers will not necessarily be dispensing methadone, because they are not OTPs. One is a subacute crisis center, and two are hospitals.
In fact, the 24/7 concept isn’t new; hospitals can treat people with methadone for three days, giving them time for transfer to an OTP. But few hospitals—none that Mr. Stavros knows of—actually do this. Instead, they are starting people on buprenorphine. “Buprenorphine only works for a percentage of patients,” said Mr. Stavros.
“When the state received the Cures Act funding, they said they wanted to open five opioid centers of excellence,” said Mr. Stavros. “But only OTPs provide methadone. We see hospitals starting people on buprenorphine, but they are only kept on it for a few days, and then they relapse,” he added. “There has to be a solid, warm, handoff process, from emergency department to OTP, and I don’t think that’s happening.” But there is hope; Community Medical Services already has just such a warm hand-off going for pregnant patients who are seen at the hospital and referred to the OTP if they have an opioid use disorder along with a warm handoff process with a number of correctional health and inpatient treatment programs, and has received a number of new referrals into the 24/7 clinic via these sources.