05/24/17  Portland, Ore.

Opioid use – and misuse – is top-of-mind for many of America's healthcare providers. Since 1999 opioid overdoses have quadrupled, leading to over 30,000 deaths in 2015 alone. In 2014, the American Medical Association called on its members to come together to address the issue, claiming, "It is our professional and ethical responsibility as physicians to help bring this epidemic to an end." This led to the development of the Opioid Task Force.

Since 2014, physician groups and organizations have driven substantial change in how opioids are prescribed and managed, as well as supporting corresponding legislation. The task currently at hand is to address the health of nearly 2.5 million people in the United States who live with opioid substance use disorders or heroin addiction. 

Medication Assisted Treatment (MAT) is gaining popularity as a program to address these substance use disorders, and uses a combination of medication and behavioral health management. OHSU Family Medicine at Scappoose and at Richmond have both developed MAT programs that utilize teams of healthcare providers (physicians, nurse practitioners and/or physician assistants), behavioral health specialists, and nurse case managers with incredible success, and no sign of slowing down in growth and improvement.

Why Medication Assisted Treatment?

Medication replaces opioids within the patient's body. While taking the medication, patients maintain their opioid dependence, but "the difference between dependence and addiction is the body's needs versus the behaviors that surround the dependence," explains David Casey, M.S.W., C.W.S.A., C.A.D.C. II, of Family Medicine at Scappoose. "[MAT] stops the chaos of the drug and offers people a choice...We get to a point where we can manage their dependence as a physiological issue and start to address their behavioral health. Sometimes within three or four days, people are already turning their lives around." (Click here for a patient story from Scappoose.)

MAT programs at both Family Medicine clinics also credit their success to the strong collaboration between physical and mental health services. As soon as patients begin treatment, they are connected with behavioral health specialists with whom they work closely and frequently. As patients regain control of their lives, they come into the clinic less often.

Family Medicine at Scappoose makes use of group sessions; some look more like a deep therapy session, others emphasize recovery and development of life skills.

"I've seen people go from addiction to sustaining a low dose of medication and getting their kids back, their relationships back, finding work, and going into mental health treatment," says Rebecca Cantone, M.D., Medical Director of Scappoose's MAT program; "They learn to process what made them become addicted and get their lives back."

So why is MAT still uncommon practice? Unfortunately, in spite of its success in helping people reclaim their livelihood, MAT is not widely accepted in the recovery community. "[Narcotics Anonymous (NA)] and a lot of other treatment facilities don't consider someone 'recovered' unless they are abstinent," explains Casey, "so those who go to NA have to lie about being in the MAT program." This means patients cannot fully shed their dishonesty, which is an important part of recovery. The stigma also persists in the primary care setting, making it difficult to expand across other clinics.

Building a New Model of Care

Providing Medication Assisted Treatment takes a specific skill set and certification, and an interest in addiction management. Not all providers are eager to make MAT part of their practice, so very few clinics offer the service, and at those that do, not all of their providers participate.

At Family Medicine at Scappoose, Rebecca Cantone, M.D. and Bruin Rugge, M.D. were for a while the only two providers offering MAT. With a patient population spanning across Columbia, Tillamook and Clatsop counties, however, the clinic soon became overwhelmed by the number of patients requiring addiction services. Clatsop County alone has an opioid overdose death rate that is twice that of the rest of the state.

Family Medicine at Richmond was in a similar state with only three physicians, Nicholas Gideonse, M.D., Amanda Risser, M.D., and Brian Frank, M.D., providing MAT services.

Seeing a need for change, clinical and behavioral leadership developed a MAT treatment model for both clinics based on the latest research. The model utilizes behavioral health staff and registered nurses to take on the bulk of coaching, counseling, education, and medication management to take some of the pressure off providers and to allow for treatment of more patients. Treatment takes a tiered approach, moving people through phases based on their risk and progress. Initially, patients will come in two or more times per week for behavioral health appointments, and will reduce their visits over time as they gain control of their health and lives.

At Family Medicine at Richmond, Luke Jennings, R.N., M.S.N. takes on the role of counselor and registered nurse for many of the patients in the MAT program. "A lot of patients come in with co-morbidities to go along with their addictions, like diabetes or chronic pain. For those with chronic pain, we work on relaxation, strengthening, and learning to differentiate between pain and suffering. The goal," he explains, "is to free up providers to take on more MAT patients and to have time for their other patients as well."

In 2016, the Comprehensive Addiction and Recovery Act (CARA) made allowances for nurse practitioners (NPs) and physician assistants (PAs) to prescribe for MAT, which also allowed for more of Family Medicine's clinicians to join the team and share the growing number of patients.

Partnerships and Funding

Family Medicine at Richmond received federal dollars to fully launch their MAT program (story here). Family Medicine at Scappoose, along with partners, Columbia Pacific Coordinated Care Organization (CPCCO) and Greater Oregon Behavioral Health, Inc. (GOBHI), recently received a grant from Substance Abuse and Mental Health Services Administration (SAMHSA). Stemming from the belief that behavioral health is tightly connected to addiction and addiction treatment, the SAMHSA grant will allow Scappoose to create a specialized MAT program that will include a more intensive behavioral health component.

Expansion

With both clinics –and many others –maintaining lengthy waiting lists and receiving multiple applications each week, MAT programs need to expand across more primary care clinics. With that in mind, Family Medicine at Scappoose is –as part of the SAMHSA grant – developing a protocol that the clinic hopes to slowly roll out and offer to other community healthcare providers.

MAT is an optimal solution for many primary care providers because it is less complex to dispense than methadone, and does not take the expertise of a pain clinic to manage. "Providers tend to equate it to chronic opiate tapering, which can be a challenging experience," explains Brian Garvey, M.D., who will begin work at Scappoose in July, "so they're hesitant to work with [MAT] at first." MAT is different, however, and often once providers "start doing it, they realize how effective it is and how much of a meaningful difference it makes in peoples' lives."

Photo 1: Becca Cantone, M.D. is the Medical Director of the MAT program at Scappoose (OHSU/Jaime Cartales)

Photo 2: Aaron Winder, R.N. (left) and Becca Cantone, M.D. (right) work together with other teammates to coordinate care of MAT patients (OHSU/Jaime Cartales)