September 25, 2014

An Introduction to Medication Assisted Treatment and the Hub and Spoke System

Posted in Residential, Substance Abuse and Mental Health Services tagged , , , , , at 7:08 am by Lund

What is medication assisted treatment ?

Medication assisted treatment (MAT)is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of opiate addiction. Research shows that when treating substance use disorders, a combination of medication and behavioral therapies is most successful. Medication assisted treatment is clinically driven with a focus on individualized patient care.” SAMSHA, www.dpt.samsha.gov. MAT is most effective in those who have suffered from continual relapses.

What medications are commonly used in MAT?

The medications most commonly used by clients at Lund’s residential treatment facility are methadone and buprenorphine. According to the Vermont Department of Health, the majority of MAT patients receive buprenorphine prescribed by a physician in a medical office setting. methadone, unlike buprenorphine, is a highly regulated addiction treatment medication and is only provided in specialty clinics.

Methadone is a medication for people dependent on opiates, who have often battled addiction for a long time and are taking high doses every day to avoid withdrawal. Methadone can be very dangerous medication if used outside of medical monitoring and federal regulations are very strict to ensure safety when using methadone. More people die each year from illegal use of methadone than any other medication. Methadone is dispensed daily at a clinic and those pursuing this course of treatment must visit the Chittenden Clinic daily to receive their dose.

Buprenorphine is an alternative course of treatment for opiate addiction, appropriate for those who have enough maturity, discipline and stability to participate in an office based program. Buprenorphine is a partial agonist which makes it a safer medication with less chance of overdose.

What is the Hub and Spoke method of substance abuse treatment?

Prescription drug abuse is the nation’s fastest-growing drug problem. Vermont is ranked the 34th worst of all the states in the non-medical use of pain relievers and for the first time ever, treatment admissions for opiate addiction surpassed that of alcohol addiction. In addition, drug diversion continues to be a problem for many reasons. In response to this problem, The Agency of Human Services (AHS) in collaboration with community providers proposed a coordinated, systemic response to the complex issues of opiate and other addictions in Vermont, now referred to the Hub and Spoke model, or “Care Alliance for Opioid Addiction.”

Although this initiative initially focused on creating capacity in the system for adequate medication assisted treatment for the increasing numbers of individuals with opiate addictions, it also created a framework for integrating treatment services for other substance use disorders and co-occurring mental health disorders into a medical home model. In addition, this treatment approach is proposed to help reduce recidivism in people who have been incarcerated and enhance outcomes for families where addiction is an identified problem for child welfare.

Very large waiting lists for methadone indicated insufficient treatment capacity and fewer providers have been willing to prescribe buprenorphine for new patients. With more Vermonters seeking treatment for opiate addiction every year, this difficulty of access to MAT is a problem. The Hub and Spoke system reaches more people and provides more MAT options for patients. It also offers increased supports directly to physicians in medical office settings, assisting them in effectively managing and treating patients.

This helpful diagram from the Vermont Department of Health illustrates the Hub and Spoke system

This helpful diagram from the Vermont Department of Health illustrates the Hub and Spoke system

What is a Hub?

A Hub is defined by AHS as “a specialty treatment center responsible for coordinating the care of individuals with complex addictions and co-occurring substance abuse and mental health conditions across the health and substance abuse treatment systems of care.” www.healthvermont.gov/adap/treatment

A Hub is designed to do the following:

♦ Provide comprehensive assessments and treatment protocols.

♦ Provide methadone treatment and supports.

♦ For clinically complex clients, initiate buprenorphine treatment and provide care for initial stabilization period.

♦ Coordinate referral to ongoing care.

♦ Provide specialty addictions consultation and support to ongoing care.

♦ Provide ongoing coordination of care for clinically complex clients.

What is a Spoke?

A Spoke is defined by AHS as “the ongoing care system comprised of a prescribing physician and collaborating health and addictions professionals who monitor adherence to treatment, coordinate access to recovery supports, and provide counseling,

contingency management, and case management services” www.healthvermont.gov/adap/treatment

Spokes can be:

♦ Blueprint advanced practice medical homes

♦ Outpatient substance abuse treatment providers

♦ Primary care providers

♦ Federally qualified health centers

♦ Independent psychiatrists

What does this look like here in Chittenden County?

The HowardCenter’s Chittenden Center Clinic is the Hub for Northwestern Vermont including Chittenden, Franklin, Addison and Grand Isle Counties.  The Chittenden Clinic has two locations – one at the University Medical Center and the other on San Remo Drive in South Burlington. The Spokes consist of 200 prescribing physicians in a variety of medical and behavioral health outpatient settings. Lund recently became a Spoke.

How did Lund become a Spoke?

In order to become a Spoke, Lund needed to add a Medical Director to our existing substance abuse treatment program. Dr. William Grass is the current Medical Director. His responsibilities include tending to the general and mental health needs of clients, acting as a consultant to the nursing team and to the clinicians and monitoring and evaluating urine test results. A crucial part of his work is evaluating and managing medication assisted treatment for our residential and community clients Dr. Grass is at Lund one day a week and also runs his own private psychiatry practice where he has practiced as a spoke physician for several years. Dr. Grass sees the benefits of MAT in Lund’s treatment program but as one part of a wider approach , “Life skills and parenting education are also an important part of treatment. MAT expands access to this sort of treatment in a population of people where opioid use disorder may be more prevalent than in the general population. Through the Hub and Spoke system, we’re able to expand access in a specific population of people. Healthy families mean a healthy future and that is important.

Lund’s residential and community treatment leadership team began conversations with Vermont’s Blueprint staff, who oversee Spoke implementation for Chittenden County, early in 2014. As a formal Spoke provider, Lund now receives funding from Vermont Health Access to deliver the comprehensive health services to clients receiving Spoke services, which optimizes treatment and health outcomes.

Having Dr. Grass on staff expands the medical team. Lund’s nurse, Jessilyn Dolan, is glad to have him on board, “Our clients’ medical needs have increased and become more complex over the last few years and it is very useful to have him to consult with. It is also really helpful to have a prescribing physician on staff so that if there is a time crunch with a new resident coming in who needs medication or a medical emergency, we have him to call on.”

Is MAT for everyone?

Not all people who have struggled with opiate addiction use medication assisted treatment. Having Dr. Grass on staff allows for him to consult with treatment teams and assess each client’s treatment plan and help decide whether MAT might be beneficial. As of the writing of this article 42% of clients at our residential treatment center are participating in MAT.

Medication is just one part of Lund’s treatment approach and is not appropriate for everyone.  Lund offers a comprehensive approach that includes clinical and psychiatric services, health care, education and case management to pregnant and parenting young women, their children, and other key family members. Our therapists, teachers and caseworkers not only assist women in their recovery from substance abuse or mental health issues, they help them identify their strengths and maximize their potential by offering parenting education, as well as life skills and job training.

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