We’re well into one of the worst opioid addiction epidemics in recent memory, and one would expect that opioid treatment programs (OTPs) would be rapidly expanding to meet the demand. But instead, it’s physicians’ office practices using buprenorphine to treat patients that seem poised for growth, although precise numbers are lacking.
Why aren’t more OTPs opening to meet the demand?
Siting an OTP is “completely different” from opening an office-based practice that dispenses and prescribes buprenorphine, explained Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD). The office-based practices are referred to as DATA 2000 practices, for the Drug Addiction Treatment Act (DATA). That was the 2000 law that allowed physicians to receive a waiver allowing them to treat opioid addiction with buprenorphine. Such practices can open almost overnight, compared to OTPs.
Doctors need only take an 8-hour training session and obtain certification from the Substance Abuse and Mental Health Services Administration (SAMHSA) to open DATA 2000 practices. And typically, physicians do not need to consult with state or county authorities before treating patients with buprenorphine as DATA 2000 practices.
The issue of opening a new OTP is quite different. No OTP can open its doors until it has a three-part regulatory approval, from the State Opioid Treatment Authority (SOTA), SAMHSA, and the Drug Enforcement Administration (DEA). The approval process requires what Mr. Parrino describes as “elaborate tracking” on the part of the new OTP.
And regardless of what those three regulatory authorities say, a community can still put up a huge battle that effectively prevents the OTP from finding a place to operate. It little matters that a region has a desperate need for treatment, with the only “nearby” OTP full to capacity─and that OTP may be a three-hour drive for citizens of the community. NIMBY (Not In My Back Yard) is still alive and well when it comes to OTPs.
Success in North Dakota
But successful new openings, while few and far between, are taking place. Nick Stavros, MBA, the CEO of Community Medical Services, is in the process of trying to open OTPs in North Dakota. This is a pioneering operation, with challenges in some cities.
“Our company is in a growth mode to meet the growing demand” in North Dakota, said Mr. Stavros. “We’ll be the first OTP in the state.” Community Medical Services was also the first in the state in Montana.
Officials in North Dakota admit that there is an opioid addiction problem. “Every single person we have talked to is very responsive to the need, and responsive to medication-assisted treatment (MAT),” said Mr. Stavros. They just have a “lack of information,” he said. “When you hear about methadone being involved in overdoses and diversion, the majority of the time the source of said methadone is pain clinics─but people associate the problems with OTPs.”
NIMBY
In North Dakota, Community Medical Services has a clinic in Minot that has provisional approval from both the state and SAMHSA. Staff has been hired, and already spent time training in Arizona with CMS’ existing OTPs.
But there’s a hitch from the local communities. It’s a one-year moratorium, expiring in the fall of 2015, on OTPs in the cities of Minot, West Fargo, and Mandan. It is a violation of the Americans with Disabilities Act (ADA) for the cities to impose these bans; in all cases in which OTPs have sued based on the ADA, the OTPs won. “We’re not considering that at this point, because everyone we’re talking to is being cooperative,” said Mr. Stavros regarding the prospect of filing a lawsuit.
Both the legislature and the state are in favor of OTPs in North Dakota. After Mr. Parrino talked to the state legislature, it voted to approve OTPs in the state for the first time. “It’s the cities who are having a problem─the city council, the mayor, the city manager, the police chief,” he said. They aren’t anti-treatment, they just want to gain a better understanding of the ramifications in their respective cities.
The main concern by cities is that they think an OTP “is going to bring addicts into the community,” said Mr. Stavros, noting that there has been negative publicity related to OTPs in the neighboring state of Minnesota. “To combat that, we’ve explained that we go to communities where there’s already a problem.”
Secondly, the OTP also uses buprenorphine and Vivitrol, which means those patients don’t have to go to the clinic daily, and won’t have to move in order to be nearby. The third point Mr. Stavros makes is that patients receive take-home privileges over time, and those patients will not have to come in on a daily basis.
Mr. Stavros’ clinic seems to have a degree of support from the police chief in Minot, who contacted police chiefs in Missoula and Kalispell, both in Montana, where Community Medical Services has established OTPs. “The police chief in Kalispell didn’t even know there was a methadone clinic there,” said Mr. Stavros. That’s a good thing, he added, because it shows that the program was operating just like any other medical office, without any problems.
Given the headache of NIMBY, some programs may think it’s easier to expand by adding slots at existing sites. But Mr. Stavros said just adding more patients comes with its own problems. “You see increased wait times, people can’t find a parking spot, they get agitated waiting for their services, staff gets overloaded. Any time an operation approaches 100 percent capacity utilization, things start falling apart …”
One of the best solutions─mobile methadone clinics─has been outruled by the Drug Enforcement Administration (DEA), said Mr. Stavros. “The DEA has supposedly said they’re not going to approve mobile methadone clinics, or that would be a great option for rural areas such as those in North Dakota where staffing and property are scarce.”
Where OTPs are Needed
At Community Medical Services, the expansion strategy is to go to places where there’s a need. So Mr. Stavros is optimistic about expansion in North Dakota. “It’s just a matter of time,” he said. “I’m completely confident it’s going to happen in time. It just pains us in the addiction treatment community that there are patients suffering while stakeholders are deliberating on how best to treat them.”