An innovative hospital, one of the largest in New York City, has successfully integrated buprenorphine maintenance treatment (BMT) into its established opioid treatment program (OTP), giving patients and health care providers new choices in therapy.*
A report published online October 17 in Psychiatric Services in Advance (ps.psychiatryonline. org) describes the new arrangement between the OTP and the medical practices that treat buprenorphine patients.
The authors had two goals: to identify the benefits of integrating BMT into an established hospital-based OTP, and to identify the institutional barriers involved in integration.
The authors summarized their clinic, hospital, and corporation experiences during integration efforts. They also described the characteristics of 735 hospital outpatients given take-home doses of buprenorphine from 2006 to 2013. Table 1 of the article recaps these characteristics.
Patients with opioid use disorders (OUDs) who have comorbid conditions or are at high risk of complications of therapy have several treatment options. In this study, integrated treatment allowed patients and caregivers to choose between methadone and buprenorphine, or made it possible for patients to transition between intensive structured care and either primary care or outpatient psychiatric care, as needed. Intensive structured care can include frequent, regular visits to a psychiatrist, or even inpatient treatment. And patients aren’t required to switch from buprenorphine to methadone.
*The NYC Health + Hospitals/Bellevue Opioid Treatment Program (OTP), operated by the Department of Psychiatry at Bellevue Hospital, consists of a team of clinicians who provide patients with MAT for opioid use disorders. The clinicians dispense methadone and buprenorphine within the clinic and provide a variety of ancillary medical and psychiatric services. OTP physicians have academic appointments at the NYU Langone School of Medicine.
NYC Health + Hospitals/Bellevue is located at 462 First Avenue, New York, NY.
The opportunity to integrate buprenorphine into an OTP offers a new treatment option that better serves patients who have differing clinical needs and different levels of social support.
Early Barriers to Integration
Initial barriers included regulations, cost issues, cultural and professional issues, the basics of dispensing medications, and issues involving professional and cultural resistance.
In particular, cost issues and software-compatibility issues limited the OTP’s medication choices:
- Placing a tablet under the tongue and making certain it had been swallowed took more time than giving patients methadone, a liquid
- Buprenorphine toxicology tests were difficult to get, and analyzing the results took longer than analyzing other test results
- Cost differences and compatibility issues with the methadone-dispensing software and hardware meant that only the tablet formulation of buprenorphine could be used
Some early reimbursement issues were especially challenging. The article noted that although Medicaid historically reimbursed urban OTPs for methadone treatment for heroin users, patients addicted to prescription opioids tended to consult office-based buprenorphine providers. Usually these providers were in private for-profit practices, and some patients had to pay out of pocket. At first, these early barriers probably discouraged OTPs from adding buprenorphine to their medication list.
The Regulatory Situation Improves
In 2011, the New York State Office of Alcoholism and Substance Abuse services (NYS OASAS) granted the OTP a clinic-wide waiver, allowing it to dispense buprenorphine under conditions consistent with the Drug Addiction Treatment Act of 2000 (DATA 2000). OASAS also modified the requirement that new patients attend the clinic no less than six days a week to receive buprenorphine.
In 2013, additional changes greatly improved the regulatory situation. OTPs could now provide up to one month of buprenorphine take-home doses to appropriate patients, without waivers. The new guidelines also allowed integration—both medications could be dispensed in the same clinic—to replace colocation—separate clinical practices, and disjoined medical record-keeping.
Today’s rules and procedures for buprenorphine reimbursement can be complicated. And Medicaid reimbursement varies by state. For example, New York State Medicaid reimburses for BMT if treatment takes place within an OTP, but some other insurance plans may not.
And Medicaid now reimburses for individual services on an ambulatory patient group basis, the authors point out, which “better accounts for medication differences and other variations in care.” Previously, Medicaid used weekly flat reimbursement rates per patient, no matter how intensive the services. Patients receiving BMT needed to bill for more payment to cover the higher cost of buprenorphine.
How Integrating Buprenorphine Into OTPs Benefits Patients
- OTPs have built-in structures for serving large numbers of patients with OUDs
- Under integration, physicians can treat more patients (OTP-enrolled buprenorphine patients aren’t included in buprenorphine-patient limits)
- Integrated on-site services—medical and psychiatric care, and vocational training—may improve patient compliance
- Integrated programs may improve confidentiality protection (some clinics guard only the health information that is protected in the clinic)
- Adding BMT to OTPs promotes recovery and patient choice
The authors call for further research to address two issues: 1.) Does integrated BMT have any effect on patient relapse, retention, and dropout rates? 2.) Is it necessary to document changes in access to treatment that result from the integration?
Another innovation at OTPs could be just around the corner: The authors note that buprenorphine integration supports continued advances “that may include the introduction of extended-release naltrexone (Vivitrol) as a third treatment option.”
In closing, the authors refer to buprenorphine integration as “a model for other OTPs” that will facilitate partnerships among primary care and mental health clinics. Such partnerships will enable OTPs to “better serve diverse patients with varying clinical needs and with varying levels of social support.”
Polydorou S, Ross S, Coleman P, et al. Integrating buprenorphine into an opioid treatment program: Tailoring care for patients with opioid use disorders. Psychiatr Serv in Advance (doi: 10.1176/appips201500501. [Epub ahead of print October 17, 2016.]