April 2019 How Community Health Centers Are Addressing the Opioid Epidemic Case Study Robert M. Hayes • Joseph Squitieri, DO Last month, the United Hospital Fund (UHF) and the Milbank Memorial Fund released a report, The Ripple Effect: The Impact of the Opioid Epidemic on Children and Families, which made clear that the magnitude of the epidemic’s impact is much greater than realized—and that the epidemic’s impact on young children and adolescents whose parents are addicted has received little attention until now. The UHF report was based on extensive research, interviews, and a litera- ture review by UHF staff, as well as a 2018 meeting that brought together national and local experts in child development, addiction treatment, child welfare, and much more. The report also described innovative programs around the nation that address these issues. As we focus on the ripple effect, we want to keep in mind the entirety of the opioid epidemic. As a follow-up to the ripple effect report, we have selected a case study by Robert M. Hayes and Joseph Squitieri, DO, of Community Healthcare Network, a federally qualified health center in New York City, that examines two important dimensions of the opioid epidemic not explored in-depth in the first report: 1) the phenomenon of adolescents becoming addicted to opioids at home by trying a family member’s prescription and 2) the importance of providing medication- assisted treatment in primary care settings with integrated behavioral health services. Milbank Memorial Fund • www.milbank.org 1 Introduction The nationwide opioid epidemic is an intensely personal, human catastrophe. Behind the data are the men, women, and children who are the casualties of addiction, whether they are battling a substance use disorder themselves or are loved ones caught up in the ripple effect of addiction. Lives and families are destroyed and, too frequently, lost to this epidemic. Nearly 50,000 Americans died from opioid overdoses in 2017. That fact captures only part of the suffer- ing caused by addiction. Treatment works, but recovery is a hard road and rarely a straight one. The keys to success are a patient’s commitment to recovery and, critically, the flexibil- ity, comprehensiveness, and quality of treatment programs. Federally qualified health centers such as New York City’s Community Healthcare Network (CHN) are on the front lines of stemming the tide of the opioid epidemic. Several factors contribute to its success in treating patients addicted to opioids: funding, location in underserved areas, and lower drug costs for patients. Perhaps most important is that the medication-assisted treatment (MAT) program administered by CHN is integrated with comprehensive medical, behavioral, and social care. Proper medication is essential for patient treatment, but so too is the tight integration of the full range of supports a person needs to recover. The story of one young woman and the treatment she received at a CHN facility in the South Bronx shows what works. Asia’s Story Asia, now 26, became addicted to opioids while in high school in Florida. As a teenager, she lived with her mother, who had suffered a serious back injury. Her mother’s physician had liberally prescribed opioids, and pills were available in the bathroom shared by mother and daughter. Curiosity compelled Asia to help herself to her mother’s pills, she recalls. And then help herself some more. Asia’s best friend was already taking opioids recreationally, she recounted. And Asia saw her friend’s opioid use as positive—her friend spoke of a fun, good feeling. “My mom was sick on them, but it wasn’t like that at all for me,” Asia said. Soon she was hooked. Things went bad quickly. “I didn’t realize I was sick until months later when I started hav- ing withdrawal symptoms,” Asia said. “I didn’t understand, but then I started understand- ing. ‘Fuck, I need those pills.’” Asia feared telling her mother about her addiction. She did not want to admit to stealing the pills. Still living in Florida, she bought pills on the street. “They’re real easy to find. They are everywhere,” she said. Milbank Memorial Fund • www.milbank.org 2 Asia’s life began to spin out of control. She had more and more fights with family members to the point where she would sleep in her car. After nearly two years of using, Asia realized she needed help. She enrolled in her first Suboxone program in Florida, and it helped her withdraw from opioids—for a while. Suboxone, a prescription drug used to treat opioid addiction, is a medication that combines buprenorphine and naloxone. It helps relieve symptoms of opioid withdrawal and is at the heart of MAT programs. In Florida, a doctor prescribed Suboxone to treat Asia’s withdrawal symptoms, and she met, sporadically, with the prescribing doctor to check that she was receiving the right dosage. She received no additional support. Asia filled the prescriptions, followed the dosage as directed, and for a while that helped. Things were going well: Asia completed college, got a job, and credits the Suboxone treatment for supporting her stability. Then, as happens often with addiction, the course changed. Asia moved to New York to be with her father, but he too was addicted to opioids. Untreated, he died of an overdose. As a result of this trauma and, as is common for many with a substance use disorder, Asia stumbled in her recovery and reverted to using opioids. Before hitting bottom, she enrolled in CHN’s South Bronx nurse care manager model, which expressly incorporates the delivery of opioid use treatment services, including Subox- one, within a supportive, primary care environment. Physicians and nurse practitioners at CHN are trained and certified to prescribe Suboxone, and a specially trained nurse coordinates and manages a patient’s overall care. A full range of services—psychiatric care, therapy, nutrition, wellness, and care management—are pulled together, as needed, by the nurse care manager. “The nurse care manager model is effective for patients with opioid use disorder because it is focused on addressing and intensively following up on all of a patient’s concerns,” says CHN Nurse Care Manager Beth Zucker, BSN-RN. “Medical and psychological comor- bidities, along with social factors, are addressed, which builds on patients’ investments in treatment and leads to positive long-term outcomes.” Physicians and nurse practitioners at CHN are trained and certified to prescribe Suboxone, and a specially trained nurse coordinates and manages a patient’s overall care. Referrals to social work services often link a patient’s family members to care, both at CHN and, when needed, to other community-based resources specializing in child welfare, hous- ing, or employment. Zucker, who has worked in CHN’s program from its inception, empha- sizes the value of integrating a coordinator role within a program that takes place in a busy, often hectic, primary care environment. “It’s my job to make the patients’ and providers’ experiences with treatment fluid while continuing to address patients’ specific concerns.” Milbank Memorial Fund • www.milbank.org 3 Asia is now feeling confident that she is on “a good track,” despite dealing with persisting social stressors that threaten her stability. For that, she meets weekly with CHN’s deputy director of psychiatry, Joseph Squitieri, DO. She has a job offer, is off opioids, and credits the integrated nature of her care to her confidence in her success this time. Even with Asia’s current stability, family relations remain strained. She only occasionally speaks with her mother, who is unwilling or unable to offer emotional support. Relations with a once-close aunt are also difficult, but Asia’s paternal grandmother remains a consis- tent, nonjudgmental force in her life. “CHN definitely has helped me a lot with my mental health, with my addiction, with every- thing,” Asia says. “Everything you need is right there. I don’t need to go to different doctors and go all over the same story time after time. I do everything here.” When a Suboxone Treatment Program Is Embedded in a Community Health Center Federally qualified health centers such as CHN are unique resources in fighting the opioid epidemic. Like many health centers, CHN accepts all patients, regardless of insurance coverage or ability to pay. It prides itself on not turning anyone away. In addition, for uninsured patients, the federal 340B program operated by many safety net health care providers offers deep discounts on out-of-pocket costs for medications. CHN had spent decades building up primary care practices in New York’s most underserved communities. Over time, CHN integrated behavioral health, social work, nutrition, wellness, and care management into its medical practices. In 2016, CHN launched MAT programs, integrated with comprehensive medical, behavioral, and social care. CHN now offers its MAT program in Crown Heights and Williamsburg in Brooklyn; the South Bronx; and Long Island City and Jamaica in Queens. If a patient has Medicaid or other insurance, CHN bills for MAT services and visits like any other service. Programs such as CHN’s that add spe- cialized nursing or social work resources to MAT are launched with federal and state grants. CHN is moving toward financial sustainability with payments for patient visits. At a number of its sites, CHN pioneered two MAT models, each relying on Suboxone. One program is coordinated by an addiction social work manager, another by a nurse care manager. The clinical social work model has the advantage of more counseling and therapy, but less medical consultation between appointments. The nursing model fits neatly into primary care settings. The nurse takes medical and substance history and does vitals and labs (blood and urine). Both models are effective and, in all cases, the treatment programs involve supporting the patient’s overall care—medical, behavioral, and social. As the MAT programs grew, CHN’s nurse care managers were able to actively seek patients to enroll in the programs, both from within the CHN network of health centers and from other practices, with the goal of engaging individuals struggling to find footing in addiction treatment. Milbank Memorial Fund • www.milbank.org 4 By integrating MAT services into a community health center, where MAT services had not previously been offered, programs like CHN’s are able to work with patients who have not been reached by traditional treatment services. Stigma is reduced because CHN is not a substance use disorder clinic. A community health center sees all types of patients, includ- ing those seeking primary care, wellness, counseling, and nutrition services. There is no “scarlet letter” that says drug user. In addition to referrals and word-of-mouth outreach, significant portions of CHN’s patients have come from other programs that treat opioid addiction, such as New York City metha- done clinics and public and private hospital systems. Some are already patients at CHN, receiving primary care and other services there. Some are referrals for MAT, and those referrals frequently decide to get all treatment with CHN, including primary care and behavioral health. This, however, is not required. CHN will coordinate care with outside service providers for patients who prefer to get only Suboxone treatment with CHN and maintain their primary and/or behavioral care with existing providers. MAT, along with CHN’s complementary Opioid Overdose Prevention Program, has helped clinicians and staff see addiction more clearly as a chronic disease. The programs also give access to treatment resources that allow for improved diagnosis and recovery. The prevention program allows CHN to receive free supplies of naloxone (Narcan) to provide to patients and their loved ones, along with basic education about signs and symptoms of an overdose and how to administer Narcan. It also provides information for patients and fami- lies about the benefits of MAT for opioid dependence. MAT, along with CHN’s complementary Opioid Overdose Prevention Program, has helped clinicians and staff see addiction more clearly as a chronic disease. Several policy changes would increase the effectiveness of the MAT program at CHN and other community health centers. These reforms include reducing prior authorizations and insurance denials for medication and removing the requirement for 24 hours of training for busy nurse practitioners to prescribe Suboxone (notably, they do not need special training to prescribe opioids). The battle against the opioid epidemic will be a long one, with many more conflicts requir- ing many more weapons. MAT, integrated carefully into a robust, comprehensive primary care center, is one potent tool for saving the lives of many opioid users. Milbank Memorial Fund • www.milbank.org 5 The Authors Robert M. Hayes Robert M. Hayes has served as president and CEO of Community Healthcare Network since 2015. He has deep experience in leading mission-driven organizations that advocate for and deliver direct services to people in need, both locally and nationally. Hayes founded and led the National and New York Coalitions for the Homeless and, as an attorney, established the right to shelter in New York for homeless men, women, and children. More recently, Hayes served as president of the Medicare Rights Center and was senior vice president for health quality at University American Corp. Hayes is a McArthur Foundation Fellow and has been awarded honorary degrees by 11 colleges and universities. Joseph Squitieri,DO Joseph Squitieri, DO, is deputy director of psychiatry at Community Healthcare Network in the South Bronx. He completed his medical degree at New York College of Osteopathic Medicine and his psychiatry residency training program at St. Vincent’s Catholic Medical Center, where he served as chief resident in his last year. Dr. Squitieri has special training and experience in group therapy and the use of TeamSTEPPS, the Agency for Healthcare Research and Quality’s evidence-based tools, in acute care psychiatry to improve teamwork and patient safety. Milbank Memorial Fund • www.milbank.org 6 About the Milbank Memorial Fund The Milbank Memorial Fund is an endowed operating foundation that works to improve the health of populations by connecting leaders and decision makers with the best available evidence and experience. Founded in 1905, the Fund engages in nonpartisan analysis, collaboration, and communication on significant issues in health policy. It does this work by publishing high-quality, evidence-based reports, books, and The Milbank Quarterly, a peer-reviewed journal of population health and health policy; convening state health policy decision makers on issues they identify as important to population health; and building communities of health policymakers to enhance their effectiveness. The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan analysis, study, research, and communication on significant issues in health policy. In the Fund’s own publications, in reports, films, or books it publishes with other organizations, and in articles it commissions for publication by other organizations, the Fund endeavors to maintain the highest standards for accuracy and fairness. Statements by individual authors, however, do not necessarily reflect opinions or factual determinations of the Fund. © 2019 Milbank Memorial Fund. All rights reserved. This publication may be redistributed digitally for noncommercial purposes only as long as it remains wholly intact, including this copyright notice and disclaimer. Milbank Memorial Fund • www.milbank.org 7