Integrating Primary Care by Using SBIRT

Very interesting video about how the Institute for Family Health is integrating primary care and substance abuse treatment. A patient speaks about her personal struggle with addiction and how she was able to change her life. A doctor also talks about using buprenorphine on patients fighting opioid addiction and dependence. The VP for Psychological Services and Community Affairs mentions SBIRT several times when talking about the Institute’s mechanism for integration. SBIRT stands for: Screening, Brief Intervention, and Referral to Treatment. Boston Medical Center was part of a grant with the Bureau of Subsidies Services that had doctors from BU train to do SBIRT. The program found several positive outcomes from the integration of primary care into addiction treatment.

Behavioral Health Care Cuts

Massachusetts' Sen. John Kerry, along with 12 other members of Congress, are currently debating a $1.2 trillion spending cut that could possibly include Medicaid. If this were to be the case, thousands of people living in Massachusetts who are currently receiving treatment for mental health or addictions disorder would be affected. Medicaid, which is responsible for paying for these services, has played an extremely important role for millions of Americans by providing critical support for people who suffer from mental illness and addiction. Medicaid allows these individuals the ability to overcome their illnesses and the potential to lead satisfying and productive lives.

The negative impacts that could result from such budget cuts include an increased demand for expensive emergency room care as well as increased strain on the criminal justice and corrections systems which are already overtaxed. In addition, cutting Medicaid just by 5% would result in tens of thousands of job losses and would cost the states $14 billion. The result of such large cuts would be a detriment to the recession we are already dealing with. The ultimate goal of outing inefficiencies that exist in our health care system needs to be done in a cost-effective and successful manner that does not threaten our network of behavioral health care services.

Congress' recommendations for controlling spending and reducing the deficit are due Nov. 23 so now is really the time to contact committee members and show support for preserving Medicaid.

A Conversation with Timothy Lepak, President and Cofounder of NAABT

It wasn't until I read a brief article on silobreaker.com that I learned about treatmentmatch.org. The article talked about how the website is leveraging their technology to help patients left without treatment after all 30 of Preventive Medicine Associates branches closed their doors. I thought it was really amazing to see the growing amount of support for these patients whose road to recovery was halted by a fraudulent act. What I really wanted to know was more about this free, online website that claims to have matched a total of 40,508 patients with 3,300 doctors nationwide as of this past Monday. I was lucky enough to have the opportunity to speak with Timothy Lepak, President and cofounder of the National Alliance of Advocates for Buprenorphine, which is responsible for treatmentmatch.org as well as two other websites

Can you tell me about what motivated you to start NAABT?

I had a friend who was addicted to heroine and opiates and no treatments worked for him; he couldn't quit. In 1999 he became involved in a study at Yale with buprenorphine and in a matter of weeks he went from talking about suicide to talking about starting classes in the fall. His cravings had subsided and he was really focusing on the positive things in his life. It wasn't until 2000 that made it even possible for doctors to prescribe buprenorphine because, since 1914, doctors were not allowed to prescribe any opiate drug to anyone who was addicted to opiates. When buprenorphine got approved, in late 2002, a lot of things started to happen. People were still dying and there were still older methods of treatment taking place there were changes taking place. At first, doctors were only allowed to treat 30 patients their first year and then 100 patients each year after that. We helped to get this rule changed by petitioning and bringing it to congress. It changed to 100 patients each year but that is still a problem. That's when we decided to start the website for people to become better educated on buprenorphine and the concept of addiction. There's a lot of stigma in the medical field in regards to addiction treatment. Many act like it's not as good of a medicine to practice. We try to educate people about addiction so we can get rid of this stigma. Once people understand it's no longer controversial. The question "how can you treat a drug addiction with a drug" slowly disappears and people realize that the medication helps these patients; they aren't just switching one addiction for another. Soon after NAABT began we saw the problem with people not being able to find doctors and we started treatmentmatch.org.

How exactly did treatmentmatch.org come about?

Well we noticed how difficult it is to find an appropriate doctor and one that is available. A good match is very hard to find because you need to consider issues like insurance and whether or not the doctor can treat your other ailments. There are still only 20,000 doctors able to prescribe buprenorphine and they are each limited to 100 patients a year. I've heard stories of doctors who've had patients die on the wait list. Another reason for the website is to encourage the patient to follow through with seeking help. When someone is finally ready to seek treatment they're usually in pretty bad shape and it's not easy to pick up the phone and call up a doctor only to hear a rejection. It's a horrible experience. So the website works like an online dating service except it connects doctors and patients. When patients register they state how far they are willing to travel for treatment. Then emails go out to doctors in those areas notifying them of the new patients seeking treatment. This way the patients are only hearing positive responses. The system works 24/7 so even at two in the morning a patient can get a response. It's like a lifeline going out to the patient.

Click here for a map of patients currently looking for treatment.

What are some problems affecting office-based addiction treatment?

Since the government started limiting and rationing the treatment of buprenorphine prices started going up. Now it's like the highest bigger gets the spot. Doctors can keep raising their prices until they are getting just enough patients. Some doctors are charging up to $400 cash only, instead of going through insurance, because of these limits. Limiting access is what's causing the diversion and the government's answer is to try and limit everything even more. Last year the DEA released a statement that they are going to show up announced to the offices of every buprenorphine doctor in the country. This lead a whole bunch of doctors who were involved in fraud to just up and leave their practices. This has resulted in a decrease in the rate of new doctors practicing and an increase in the rate of patients dropping out.

How do you get doctors to sign up with treatmentmatch.org?

Every month the District Attorney sends me a list of certified doctors. I send the doctors an email about getting on our system. Once they've filled out the paperwork they can select to be on a public locator or they can check a box that allows them to get direct emails notifying them when a patient signs up.

How do you get patients to sign up?

We do public service announcements on the radio, the subway, billboards, online advertisements, and we even display signs in pharmacies. But mostly we get patients through word of mouth. When people first reach out for help that's the time that people need to be there for them. The next time might not happen for months, or years, or it might never happen. This system is 24 hours and they can reach out whenever they want, not just between business hours. As of today we have 40,508 patients and 3,300 doctors nationwide. Just in the past 12 hours there have been 36 patients contacted. We've connected to about 80% of the patients who've signed up. Most of the ones we haven't reached out to yet are in rural areas where there are not as many doctors.

How is primary care being integrated into the addiction treatment offered by treatmentmatch.com?

We set up our system so that primary care is an integral part of treatment. The doctors we are connecting these patients to work in office-based practices. We list clinics as well but we really feel that the office-based environment is so much better. It also takes away the stigma in the sense that you are not standing in line for methadone treatment along with other methadone addicts; that can be very demoralizing. The way the government has treated the delivery system is inefficient. Whereas if you go to a doctor's office and are treated like you would be for any other condition it is much better for the patient and they have a positive experience that way. It makes more sense to go to a doctor who can also refer patients to further counseling or other treatment. Detox places have such poor success rates. It makes sense that detox would be ineffective considering what we now know about addiction; taking the drugs away doesn't help and it certainly explains why relapse rates are so high.

TreatmentMatch.org Reaches Out to Help Displaced Patients

In lieu of Dr. Punyamurtula Kishore's arrest and immediate closure of his dozens of addiction clinics across the state of Massachusetts, online service TreatmentMatch.org extends its services. The website serves as a free online resource to addicts suffering from opioid addiction. According to the website itself, 86 patients have been contacted and matched up with physicians just in the last 72 hours. The website is available 24/7 to connect people seeking treatment for addiction with treatment providers in an anonymous and confidential manner. Certified physicians can go onto the website and draw from patients in their area when they have an opening for an appointment. This eliminates the need for patients to call multiple physicians hoping to simply land one appointment. For patients who may not have access to a computer or to the internet, a counselor or advocate can sign on to the website and submit an application on the patient's behalf.

This list of certified physicians was created by the Substane Abuse and Mental Health Services Administration (SAMHSA). According to a SAMHSA employee, who prefers to remain anonymous, not all of the certified physicians choose to be put on the list; some choose not to because they already have a full load of patients to treat and this can oftentimes be an exhausting process for the patients searching for openings. Click here to view the actual list of certified treating physicians.

According to prnewswire.com, there have been over 40,000 patient-physician connections made by TreatmentMatch.org. The website is run by the National Alliance of Advocates for Buprenorphine Treatment (NAABT), which is a non-profit organization that encourages the use of buprenorphine to treat opioid addiction. The opioid medication is a drug that activates specific receptors in the brain that mimic the full opioid effect commonly associated with heroin, oxycodone, methadone, hydrocodone, and morphine. Buprenorphine also has full properties of an antagonist, which is a drug that blocks opioids by attaching to the receptors themselves without actually activating them. Antagonists block full agonist opioids and do not cause any kind of opioid effect. Acting as a partial agonist while having the full properties of both agonists and antagonists allows buprenorphine to activate the opioid receptors in the brain to a lesser degree. This allows for some of the opioid effect but also suppresses the heavy withdrawal symptoms and cravings.

To learn more about this online source visit www.naabt.org.

New Services Offered to Addicts Affected By Clnic Closings

The closure of the 30 medical branches that make up Preventative Medicine Associates has resulted in Gosnold, a treatment center on Cape Cod, offering services for the patients affected by the closings. Gosnold is the largest provider of addiction and mental health services in the Cape Cod area and offers primary care, inpatient rehabilitation, transitional care, and residential treatment. The treatment became available on October 3rd and since then a Gosnold physician and several counselors are available to see patients in Gosnold's Centerville clinic.

President and CEO of Gosnold, Raymond V. Tamasi, said that the closures have created a state of emergency for addicts in treatment. He hired Dr. Robert Friedman, medical director of the Sandwich branch of Preventative Medicine Associates to work three days a week at first to help the patients displaced by the closures. Interestingly, Friedman's Sandwich clinic was closed back in August, which was 2 whole months before the entire larger organization, Preventative Medicine Associates, collapsed a couple weeks ago. Friedman was interviewed by the Cape Cod Times back in early September on his clinic's reaction to the abrupt shut down of their clinic and how Kishore randomly layed off three employees during their lunch hour.

Tamasi expects over 100 patients from Preventative Medicine Associates to take advantage of the newly available services. Gosnold will also be expanding its services to include the use of the injection drug vivitrol that eases the withdrawal symptoms of patients by blocking opiate receptors in the brain. The drug significantly reduced the craving symptoms associated with drugs like heroin and oxycodone. Gosnold will expand these services to accommodate the new patients permanently, says Tamasi. Gosnold must now find a way to take on these new patients who need counseling and other services which are not easily covered by insurance. Tamasi released a statement to the Cape Cod Times saying, "We do what we can by going to the community (for fundraising) and applying for grants."

The website for Preventative Medicine Associates does not address the organization's current state of affairs and attempts to contact Dr. Kishore were unsuccessful. Patients displaced by the closure of PMA clinics are instructed to call Gosnold at 800-444-1554 for outpatient care.

Statewide Crisis Threatens Addiction Clinics

The last of the 30 addiction treatment centers across Massachusetts that make up Preventative Medicine Associates was shut down last week after Dr. Punyamurtula Kishore was arrested for allegedly running a Medicaid fraud "kickback" scheme. Kishore owns and manages the 30 medical branches that altogether make up a larger corporation known as Preventative Medicine Associates. According to State Attorney General Martha Coakley, Kishore carried out an intricate scheme to funnel a drug screen business in his laboratories and send the bills directly to MassHealth to cover the service fees. Drug screens billed to the MassHealth generally cost about $100 to $200. Kishore's scheme involved approximately $500,000 in taxpayer funded testing which really puts the potential damage into perspective.

The aftermath of Kishore's arrest has created a state of panic for both patients and employees. When he stopped receiving reimbursements from the state, Kishore started shutting down clinics without any notice and stopped paying employees. After his arrest last week nearly all of his clinics were shut down in addition to their supply of the anti-addiction drug Vivitrol. Since Kishore was the predominant prescriber and supplier of the drug, thousands of heroin and OxyContin addicts are now left without a prescription.

Many of his former employees and patients are making sense of a series of strange events that have occurred over the last few months. Not only were employees' checks bouncing back from their banks, but collection agencies were calling looking for payments, phone services had been shut off and the staff even had to borrow needed supplies from other doctor's offices.


Massachusetts Department of Public Health is expressing concern about the possibility of patient relapses stemming from the lack of Vivitrol. The state is currently in the process of searching for ways to provide the patients of Kishore's clinics with Vivitrol.

**Here's an interesting article on Kishore's methods of primary care and addiction treatment published before his arrest in September.

Healthcare in 2010

Implementation of the Wellstone/Domenici Mental Health Parity and Addiction Equity Act went into effect on April 5, 2010. This included several provisions that made access to important mental health and addiction treatment more readily available. It also required many health plans to cover addiction and mental health services which now included various other health conditions. For advocates of addiction treatment the implementation of parity was an enormous milestone. These laws are what require insurance agencies to provide the coverage necessary for the treatment and healthcare services of substance use and mental health patients. President Obama also signed into law the "Patient Protection and Affordable Care Act" which would help to improve coverage for access to treatment, prevention programs, and post-recovery services. The new federal healthcare law will expand coverage to millions of uninsured Americans and approximately 95 percent f the population.

Benefits from the Provision:

• Mental health and substance use disorder will both be included in basic benefits packages
• Plans within the health insurance exchange must adhere to all Wellstone/Domenici Parity Act provisions.
• Those enrolled in Medicaid will receive sufficient coverage
• SUD/MH (Substance use disorder/mental health) will be part of chronic prevention initiatives
• SUD/MH now part of health workforce development initiatives
• SUD treatment and prevention and MH service providers will be eligible to apply for community health team grants
• Americans below 133 percent of federal poverty level will have expanded Medicaid coverage

25 million Americans suffer from alcohol and drug abuse and only 4 million get the help and treatment they need. Something's wrong with the access to proper care and treatment for addiction patients if less than 16% of them are getting adequate help. Federal health care reform has now written mental health and addiction services into the federal parity law as well as into the health care law. The key push is to integrate behavioral health with primary health care. Today I spoke with Connie Peters, Vice President for Addiction Services at the Association for Behavioral Healthcare about the ongoing push for change in the realm of addiction treatment and addiction services. The lack of integration between primary health care and speciality behavioral health care is a prevalent part of the way health care systems are run in this country. The passage of the Affordable Care Act (ACA) has the potential to profoundly change this system.

ACA places an emphasis on two kinds of integrated care models. These are patient-centered medical homes and accountable care organizations (ACOs). Accountable care organizations are basically a group of coordinated health care providers who provide health care services to a group of patients. They are accountable for the quality, cost and overall care of patients assigned to them. There is plenty of evidence that link the importance of targeting integration efforts where patients will be interacting most directly with the health care system itself. Doctors need to do a better job of addressing and providing treatment for the medical needs of mental health and addiction patients. The ACA has already authorized $50 million in 2010 and additional funds all the way to 2014 for the Substance Abuse and Mental Health Services Administration (SAMHSA) to cover a type of grant called "co-location grants" to fuse services for mental illness and other medical conditions with the community-based behavioral health setting. There is also another initiative that would provide funding for the improvement of federally qualified health centers, which would mean they would provide behavioral health care in addition to the traditional means of treatment.

While the ACA continues to promise improvement in the areas of mental health, addiction and the infusion of primary health care, there are still several obstacles halting the process. One concern is that the prospect of lower numbers of uninsured people who need access to health care will tempt the government to cut direct financing. This is particularly likely considering the cuts to discretionary, or "optional", spending that the government agreed upon in the recent debt-ceiling deal. Nonetheless it remains to be seen just how health care laws will bend and reshape to improve the quality of health care though better integration methods and expanding coverage.