By Alison Knopf
Over the next three years, the number of opioid treatment programs (OTPs) in the country will double, from 1,400 to 2,800, pledges Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD).
Announced at last fall’s AATOD conference, the expansion plan certainly makes sense: the opioid epidemic has been increasing, and support for medication-assisted treatment (MAT) has been growing as well. And the Substance Abuse and Mental Health Services Administration (SAMHSA) wants to help.
The numbers are already going up. As of December 23, the United States had 1,482 OTPs, according to SAMHSA—up from 1,416 a year ago, and up from 1,363 in 2014.
Of the 168 applications SAMHSA received in 2016, 38 were hospital-based; the rest were freestanding. In 2015, there were 103 applications.
It’s also time for a “census check” to see exactly how many patients are being treated in OTPs. “We haven’t done this [a census] since 1998,” said Mr. Parrino, who suspects that OTPs may now have more than 400,000 patients. “I have been told anecdotally by administrators that many have been admitting many more patients,” he told AT Forum. “Existing sites that were treating 300 to 400 patients are now treating 600 to 800.”
The AATOD board wants to know how many patients are in the OTP system, as well. In the last two years, increases for opioid treatment have come predominantly from DATA 2000 (buprenorphine prescribers), said Mr. Parrino.
SAMHSA Is Helping
Mitra Ahadpour, MD, DABAM
SAMHSA wants the number of OTPs to grow, so it is actively reaching out to applicants, said Mitra Ahadpour, MD, DABAM, director of the division of pharmacologic therapies (DPT) at SAMHSA’s Center for Substance Abuse Treatment (CSAT). “We try from our side,” she told AT Forum in December.
“We had all these submissions, but some were just sitting there and nothing was happening,” she said. “So, we emailed people when information was missing, and if we got no response, we called them, saying this is the information we need.” The goal at SAMHSA is to process all these applications. “We know there is a crisis, we have it in the back of our minds every day that people need treatment.”
Why aren’t the applicants following up on their submissions? “I think sometimes they get busy, I am not sure why,” said Dr. Ahadpour. “It takes time from our side to put in this extra effort.”
After the SAMHSA application, the process of becoming an OTP includes obtaining approval from the state, from the accrediting body (Joint Commission, or Commission on Accreditation of Rehabilitation Facilities [CARF]), and from the Drug Enforcement Administration (DEA). The OTP process at SAMHSA is going very well, Dr. Ahadpour said, adding that it will continue to do so under the new administration. “The infrastructure has been built. I feel very happy for our division; we have put in the infrastructure.”
Smoothing the Process
Dr. Ahadpour has been working hard on innovations at DPT while helping OTPs get certified. First, she noticed that accrediting bodies have to submit a “humongous folder,” entirely on paper. “So what I’ve done for DPT these past five months is to make this an online process, and decreased the number of questions,” she said. “There is now a system in place to renew online.”
In addition, the DPT has a “great relationship” with the DEA, said Dr. Ahadpour. This wasn’t always the case, but now, “we have become close friends, always on the phone with each other.”
NIMBY
One issue SAMHSA has little control over, however, is NIMBY (Not In My Back Yard), the biggest barrier new OTPs face. This barrier is erected by local schools, neighbors, sometimes even law enforcement officials, who are not opposed to MAT—as long as the patients don’t come to their community.
This mindset, one would think, would be eliminated by a simple fact: many people with opioid use disorders who would benefit from a local OTP are already in communities where OTPs would be sited. Stigma against agonist medications, especially methadone, is fueled by ignorance.
At the AATOD conference, CSAT director Kimberley Johnson, PhD, promised to provide information to the states on how to increase OTPs through technical assistance grants that help identify key locations. Mr. Parrino noted that a board member at the open board meeting asked if SAMHSA could help with siting and NIMBY issues. Johnson’s response was: ‘Don’t expect us to come to zoning boards, but do expect us to help you in providing guidance to the states.’”
“This is something we’re looking into,” said Dr. Ahadpour. “The only thing I can do from my end is bring in more technical assistance.” She said that SAMHSA is listening to stakeholders. “One issue we heard from the AATOD board is that the OTPs and OBOT [office-based opioid treatment, or buprenorphine prescribing] need more cross training, and they need to train with primary care people, so they can work better with each other,’ she said. “We’re also hearing from all sides about the importance of all three medications,” she added, referring to methadone, buprenorphine, and naltrexone.
Ahead: Prioritizing, Identifying Sites, Doubling OTPs
Dr. Ahadpour brings a vitality to DPT that OTPs will appreciate. “I have a lot of ideas on what we can do,” she told AT Forum. “Not everything can be done today; we have limited resources, and we have to prioritize. We’re putting out an effort of more outreach, more education, more awareness. We’re trying to make sure the public understands better what MAT is all about, so they don’t say, ‘I don’t want it in my back yard.’”
SAMHSA is also working on maps to help identify optimal areas for new OTPs. And Dr. Ahadpour asked for help from stakeholders—the National Association of State Alcohol and Drug Abuse Directors, AATOD, and others.
SAMHSA’s application information doesn’t break down how many facilities belong to chains, and how many are individual OTPs. However, she noted that every new owner needs a new application.
“We’re going to devote time and energy and resources” to doubling the number of OTPs by 2018, Mr. Parrino told AT Forum. “I’m not going to devote any more time on the buprenorphine cap—I don’t want to walk down that road again,” he added. “It was extremely time-consuming and ultimately not productive. I’m going to focus on the integration of service delivery.”