In a study of “open access” treatment with methadone maintenance, reducing barriers to treatment led to a tripling of the patient census and elimination of the waiting list, with all patients getting same-day treatment. There were no ill effects on the program’s financial stability. Facilities conducting the study include the APT Foundation, a not-for-profit opioid treatment program (OTP) clinic in New Haven, Connecticut; the University of Wisconsin/Madison; and Yale University School of Medicine.
The study was conducted using records of APT patients entering treatment between July 2006 and June 2015.
Phase I
For the first phase, APT used a rapid-cycle change model developed by the Network for the Improvement of Addiction Treatment (NIATx). In this model, a NIATx coach did a “walk-through” of the clinic with clinic staff, looking for barriers to treatment at the intake procedure. The change team identified multiple barriers involving waiting time and access, and developed a plan for eliminating those barriers. They made these changes:
- Modified tuberculosis testing procedures
- Changed verification of addiction procedures
- Discontinued the back-balance payment requirement and the upfront administrative, physical examination, and tapering fees
- Changed the admission fee structure
Phase 2
Phase 2 followed shortly thereafter, and consisted of looking for barriers to access, to retention, and to increases in capacity. Among the changes being made concurrently with Phase 2 were walk-in evaluations, same-day treatment initiation, and the initiation of “drop-in” groups.
Long waiting time, patient financial fees, and methadone underdosing were identified as barriers to treatment access and retention.
Study Design
For this study, the researchers looked at the primary outcomes of the changes made: census (number of patients enrolled in treatment), waiting time (number of days between face-to-face appointment and first methadone dose), retention (the number of patients in treatment longer than 90 days), illicit opioid use (based on drug testing), patient mortality, and program financial stability (net income and state block grants as proportions of total revenue).
Results
Between 2006 and 2015:
- Census increased 183%, from 1,431 to 4,051 patients
- Waiting time decreased from 21.3 days to 0.3 (same day)
Financial stability is a complex picture. State block grant dollars fell 14% from 2006 to 2015. Put another way, state block grant dollars fell as a proportion of revenue from 49% to 24%. During that time, net operating margin rose from 2% to 10%, and total revenue increased. The rise in revenue resulted from greater patient volume, increased efficiency (such as streamlining intake procedures), and expansion of coverage for methadone maintenance treatment through the Affordable Care Act.
Interim methadone treatment is an option, but not one that most OTPs like, because ultimately it means discharging patients. The open access model shows that it is possible to treat more patients, and to start them on treatment the first day they show up for care.
Some changes were simple. For example, replacing the individual counseling sessions with “drop-in” groups was popular among patients. Likewise, making patients “pay up” before getting treatment was an easy barrier to eliminate.
Findings and Recommendations
“Findings here provide a framework for scaling up MAT both in the United States and internationally,” the authors wrote. OTPs traditionally operate with the idea that the number of patients has to be fixed. When demand for treatment rises, patients are turned away or put on waiting lists. It’s common for patients to have to wait a month for treatment in the United States.
With lethal fentanyl on the streets, it’s vital to get people into treatment when they ask for it. It’s also humane.
(Note: Kimberly Johnson, PhD, former director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration, had previously run NIATx. It’s telling that one of her favorite stories from her time at CSAT occurred when she visited a methadone clinic in Africa, and found that the clinic treated everyone who wanted it. No barriers existed.)
Madden LM, Farnum SO, Eggert KF, et al: An investigation of an open-access model for scaling up methadone maintenance treatment [Epub ahead of print February 17, 2018]. Addiction. doi: 10.1111/add.14198.
