By Alison Knopf
To use its more than $50 million in funding from the State Targeted Response (STR) to the Opioid Crisis, New York State first identified its highest need counties, then added access to treatment for opioid use disorders, mainly with medications. “The major thing we did on the treatment side was creating Centers of Treatment Innovation, or COTI,” Robert A. Kent, chief counsel for the state’s Office of Alcoholism and Substance Abuse Services (OASAS), told AT Forum.
We talked with Mr. Kent just as the two-year STR program was winding down, and just before the August 15 deadline for applying for the new State Opioid Response (SOR) grants.
STR grants were set up by Congress in 2016 as part of the Cures Act. They provided $1 billion to the states over two years to treat the opioid crisis.
Both STR and SOR grant programs are administered by the Substance Abuse and Mental Health Services Administration (SAMHSA). Both programs must be run by each state’s Single State Agency (SSA), the entity that governs the SAMHSA Substance Abuse Prevention and Treatment (SAPT) block grant.
Enhancements to ambulatory services covering the patients in Opioid Treatment Programs (OTPs), as well as the patients in regular outpatient treatment (such as buprenorphine office-based opioid treatment, or OBOT), were key in all counties. “We tried to give them help in terms of mobile treatment capacity,” said Mr. Kent. While the federal Drug Enforcement Administration (DEA) has not yet issued the long-awaited guidance on mobile vans providing methadone, these vans can “do everything but the methadone,” said Mr. Kent. Some programs bought mobile treatment vans, while others used the funding to buy vans to transport patients from their homes to treatment, and back.
Assuming that the DEA will eventually issue the guidance on the mobile vans, the investment in the vehicles is viewed as a good one. Mobile vans, tied to brick-and-mortar OTPs, can greatly expand access to treatment. In many communities, they also avoid siting problems for OTPs.
“We didn’t use any of the money to open new programs, because we were told we couldn’t use it for building or buying property,” said Mr. Kent. However, there have been new OTPs opening in the state, without the STR money. “In the midst of all of this, we’ve been in expansion mode for OTPs.” Most recently, the Genesee Council on Alcoholism and Substance Abuse was set to open an OTP in Batavia in mid-August. The new OTP will be one of the Centers of Treatment Innovation.
Hub and Spoke
For the SOR funding, OASAS will continue what it did with STR, and will also look at ways of expanding the state’s “hub and spoke” project. The expansion will be based on widening the reach of OTPs by linking them to community-based prescribers in remote areas, via telehealth, said Mr. Kent.
Vermont first instituted the hub and spoke, with the hub as an OTP, and the spoke as a prescriber. The OTP assesses all patients, and treats those for whom an OTP is the best treatment. The spoke is the DATA 2000-waivered buprenorphine prescriber (or Vivitrol prescriber).
But in New York, procurement will be local, and each county can decide how it wants to set this up. “We’re going to issue a procurement, we want to see what is out there,” said Mr. Kent. “I think that there are local relationships that are different.”
Jails and Prisons
One area the state will focus on is medication-assisted treatment for the incarcerated population, said Mr. Kent. “We did get funding, and there was additional money to do some behind-the-walls treatment,” he explained. “We want to make sure there’s patient choice involved” in terms of medication–methadone, buprenorphine, or Vivitrol.
“We are working with the corrections medical people,” he said. The concern is that patients on methadone go “cold turkey” in jail, which is unnecessary and inhumane. “You have a person who was on methadone and ended up being incarcerated–the hard taper is really tragic,” he said. “We try to keep them connected to community-based OTPs.”
Another concern for OASAS is the problem of getting DATA 2000-waivered physicians (buprenorphine prescribers) to prescribe for more patients. “Some people say we have to create more DATA 2000 prescribers, but that shouldn’t be our priority,” said Mr. Kent, noting that most buprenorphine prescribers do not prescribe anywhere near their “cap,” or patient limit. “Our priority is to get the ones we have, to prescribe to more patients.”
OASAS is using the ECHO model, a learning collaborative from the University of New Mexico, to expand the reach, by sending prescribers there for training. Then these physicians, who are interested in treating addiction, can return to New York and “cascade” what they learned to others. “If we get New York docs talking to New York docs, it’s the best way to get them to be engaged,” said Mr. Kent.
The counties of highest need in year 1 of the STR grant were identified via three different data sets: the number of overdose deaths for the first cut, followed by the number of hospitalizations involving opioids, followed by the percentage of people leaving the county to get OASAS treatment services. For year 2, OASAS reassessed.
In year 1, OASAS identified 16 counties; in year 2, there were 35.
There are 20 providers in the 35 counties; six of them run OASAS-certified OTPs, and 14 have other outpatient treatment programs. OASAS also engaged in a partnership with the Research Institute on Addictions at the University at Buffalo to help high-risk counties provide services.
“People ask, where are the high-need areas? And I say, ‘The whole state,’” said Mr. Kent. Yes, New York City has a lot of treatment services. But it also has a lot of heroin and illicit fentanyl.
Sustainability From Insurers
What happens when the money–from STR and SOR–runs out? Insurance will pay for treatment–just as it does for treatment of medical and surgical diseases. “We had that in mind from the beginning,” said Mr. Kent. “We made these investments understanding that we were giving seed money.”
Treatment is reimbursable via the state’s Medicaid program and commercial insurance, now that the state has moved to Medicaid managed care. And reimbursement includes OTPs–under commercial insurance as well as under Medicaid. “Our state insurance department has issued circulars saying OTPs need to be part of your network,” said Mr. Kent. “They must cover the full range of substance use disorder services.”