Baltimore City has one of the most severe heroin addiction problems in the United States. This is evidenced by the number of admissions to substance abuse programs, emergency department visits, and deaths from heroin overdoses. More than 10,000 Baltimore City residents were admitted for heroin treatment in fiscal year 2006. Some of the medical consequences of opioid dependence are the spread of HIV, hepatitis C, endocarditis, and osteomyelitis. Long-term dependence on opiates also contributes to the worsening of other chronic conditions such as diabetes, hypertension, and asthma. Further consequences of untreated opioid dependence are premature death, increased crime, and destroyed families. Despite increased substance abuse treatment in Baltimore during the last decade, the availability of treatment remains inadequate to meet the increasing need for substance abuse treatment in the city.
To respond the significant treatment gap and to address Baltimore’s high rate of overdose deaths, the Baltimore Buprenorphine Initiative (BBI) was implemented in October 2006 by the Baltimore City Health Department. Two events, namely the passage of the Drug Addiction Treatment Act of 2000 and the approval by the U.S. Food and Drug Administration (FDA) to add buprenorphine to the list of approved medications for heroin and opioid addiction, made it possible for Baltimore to expand the existing treatment system and to implement the Baltimore Buprenorphine Initiative. The Drug Addiction Treatment Act of 2000 removed barriers to treatment access by allowing qualified physicians to provide buprenorphine in settings other than traditional opioid treatment program (i.e., methadone clinics), such as physician offices. The approval of buprenorphine in the form of a combination tablet of buprenorphine and naloxone, allowed for a new yet proven safe and effective medication to be used for the treatment of heroin addiction. The medication has been shown to reduce cravings, heroin use, and the likelihood of overdose, urgent care needs, and hospitalizations. The Baltimore Buprenorphine Initiative took advantage of this new treatment avenue and created an integrated system of care that aims to expand access to long-term heroin and opioid addiction treatment by developing partnerships between medical facilities, substance abuse treatment centers, and social service agencies and by building service capacity through training and certification of physicians to administer buprenorphine treatment. The Initiative has created access to evidence-based long-term buprenorphine treatment and has implemented a system of care that serves more than 1,000 patients per year. Significantly from 2007 to 2008, the heroin-related overdose death rate in Baltimore City has decreased by 39 percent.
In October 2008, the Agency for Healthcare Research and Quality awarded the Innovative Practice award to the Baltimore Buprenorphine Initiative. The goals and objectives of the program are as follows: Goal 1: Increase access to buprenorphine treatment for opiate addicted individuals in Baltimore City.• Objective 1: Develop a system of care for uninsured opiate addicted patients that provides a continuum of care starting in the publicly funded drug treatment system and continues to medical management in the community. • Objective 2: Expand the number of publicly funded outpatient substance abuse treatment slots that provide counseling and buprenorphine treatment. • Objective 3: Develop a range of treatment options, including residential treatment, low threshold outpatient treatment, and low threshold primary care treatment, to respond to individual patient needs for buprenorphine treatment. • Objective 4: Develop targeted outreach and treatment options for special populations, including HIV-infected patients, women engaged in prostitution, patients with co-occurring disorders and patients receiving needle exchange services.
Heroin addiction is a major public health issue in Baltimore City. Estimates show that between 40,000 and 60,000 individuals in Baltimore use heroin, yet the availability of treatment remains inadequate. Heroin addiction contributes to high rates of HIV infection, crime, unemployment, and other health related comorbidities that create additional public health and social costs for the city. With the implementation of the BBI, the city was able to create a new system of care for opioid addicted individuals who otherwise would have limited, if any, access to needed treatment services. Addressing substance abuse and its related effect on public safety has been a major priority of state and local leaders for the last several years. In 2006 when the BBI was initiated, Mayor Martin O’Malley identified the need to address the high rates of crime in Baltimore City and its related causes as one of his top priorities. Data from police records and the criminal justice system indicate the strong relationship between crime and substance use, particularly heroin. The increasing formation of gangs and youth violence in the city was also one of the Mayor’s top concerns. Data from the Department of Juvenile Services and police records again indicated that the drug market was a major factor contributing to the rise in youth violence and crime.
As a result, the Mayor and now Governor of Maryland tasked the Baltimore City Health Commissioner to find a solution. The health commissioner identified buprenorphine as an evidence-based treatment modality to increase access to substance abuse treatment for opioid addiction. The system of care developed by the BBI facilitates increased access to treatment for opioid addicted individuals by maximizing funding streams in the substance abuse treatment and medical care systems. Through the BBI, uninsured patients are now able to receive buprenorphine treatment in publicly funded outpatient treatment clinics. During their stay, these patients are assisted in obtaining health insurance benefits by a team of treatment advocates. Most patients qualify for health insurance benefits that enable them to transfer to a continuing care physician in the community once they are stable. Patients who transfer are able to have their buprenorphine treatment reimbursed by third-party payors and their slot in the substance abuse treatment clinic opens up to another uninsured patient, thus expanding access to care. As part of the program design process, we conducted a review of best practices and model programs in other cities. We also conducted a review of the literature on office-based buprenorphine treatment.
Based on these reviews, we determined that Baltimore needed to create a new model of care to address the public health issue. This practice is very different from the way other public health departments have tried to implement city-wide buprenorphine treatment programs. The integration of the publicly funded treatment system with the medical care system is a unique model of service delivery. The other cities reviewed attempted to expand buprenorphine treatment through the medical system only and most of the efforts came across barriers to gaining large scale buy-in and participation by community physicians. In addition, other cities encountered numerous other barriers, such as insurance reimbursement issues, difficulty with induction in office-based settings, difficulty in establishing linkage to counseling and behavioral health services, and difficulty in coordination of care. The BBI reviewed these issues from other cities and attempted to address these problems in the model of care designed. By initiating induction of complex, unstable addicted patients in the traditional substance abuse treatment system, which has the experience and commitment to treat this population, community physicians are able to focus on buprenorphine maintenance therapy with stabilized patients. Including a strong case management model wi
Agency Community RolesThe local health department has been the lead agency to direct the development and implementation of the practice. The Baltimore City Health Commissioner played a key role in championing the development, funding, and expansion of the BBI. The health department convened the partnership between Baltimore Substance Abuse Systems, Inc. and Baltimore Health Care Access, Inc. to collaborate in designing the BBI. As the practice was developed, the health department played an instrumental role in designing the system, recruiting physicians, developing policy and procedure, advocating policy and funding in support of the BBI, and evaluating outcomes. The health department continues to play a role in oversight and program expansion.
There are several important stakeholders and partners that have been engaged in the planning and implementation of the BBI: • Baltimore Substance Abuse Systems, Inc. (BSAS). As the lead agency for the delivery of publicly funded substance abuse treatment and prevention services in Baltimore City, BSAS has been a major partner in the BBI to oversee the contractual relationship with participating outpatient substance abuse treatment providers. • Baltimore Health Care Access, Inc. (BHCA). The quasi-public agency in Baltimore City that provides advocacy and outreach to support participants in Maryland’s managed Medicaid, SCHIP, and other publicly funded health programs, BHCA has also been a major partner in the BBI. BHCA hires a team of treatment advocates who are assigned to participating outpatient treatment programs to assist patients in obtaining health insurance, other social services, and transferring to a continuing care provider. • Med-Chi. Maryland’s state medical society has been an ongoing partner with the BBI. Med-Chi works with the BBI to expand training and professional development opportunities related to buprenorphine treatment. • City hospitals. All of the acute care hospitals in Baltimore City are working with the BBI to increase the number of staff physicians and residents who are certified to prescribe buprenorphine. Several hospitals are also partnering to provide buprenorphine maintenance treatment in their ambulatory clinics. • Community health centers. All of the federally qualified community health centers in Baltimore City are active partners with the BBI. They have all agreed to train their medical staff to become certified to prescribe buprenorphine and all centers are participating as continuing care sites for the BBI. • Treatment providers. The eight outpatient treatment providers that serve BBI patients are integral partners in the practice. They provide buprenorphine induction and maintenance services along with outpatient counseling. • HIV specialty clinics. The Johns Hopkins Moore Clinic, the University of Maryland Evelyn Jordan Center, and the Baltimore City Health Department HIV clinic work collaboratively with the BBI to refer patients for buprenorphine treatment and accept patients for buprenorphine maintenance as a component of HIV primary care services. • Baltimore City Needle Exchange Program. This program works closely with the BBI to refer patients and provide support. • Power Inside. This community-based agency provides outreach to commercial sex workers on the street and in the Women’s Detention Center and refers women to buprenorphine treatment in the BBI. • Maryland Alcohol and Drug Abuse Administration. The state agency for substance abuse treatment in Maryland has been a major supporter of the BBI and has led advocacy efforts to expand funding. The health department organized two important bodies to foster collaboration. The Buprenorphine Coordinating Committee was developed from the start of the practice to bring together three large agencies, the health department, BSAS, and BHCA, to design and implement the BBI.
This committee actively meets regularly to continue their collaboration.
Costs and ExpendituresFY 07 Start-up costs: Nurse consultant,- $20,000; Cost-benefit studies, $50,000; Online training, $5,000; Printing, $500; Meetings and presentations, $1,000; Baltimore Health Care Access, $80,000; MIS development , $15,000; Total start-up, $171,500; In-kind costs: Medical direction, $15,000; Administrative support, $12,000; Office supplies, $5,000; Space, computer, telephone, office furniture, $8,000; Staff from other agencies, $48,000; Total In-kind: $88,000; Implementation costs FY 09: $2,847,000.
ImplementationTo accomplish goal 1, we developed a system of care working with Baltimore Substance Abuse Systems, which is the local substance abuse authority, the Baltimore City Health Department and Baltimore Health Care Access, Inc. We enhanced capacity in outpatient treatment programs by funding medical staff and medication to support adding buprenorphine treatment to outpatient substance abuse services. We dedicated additional Single State Agency funding and Baltimore City general funds to support expansion. We also hired nurse a consultant to coordinate program development and implementation. We organized a Treatment Provider Roundtable to facilitate ongoing collaborative program design and training.
To achieve goal 2, we contracted for online training and promoted training to physicians through a variety of mechanisms. We developed physician training and support materials conducted office-based trainings.
To accomplish goal 3,we hired nurse and physician consultants to develop BBI Clinical Guidelines and Protocols and a quality improvement plan. We implemented trainings on protocols and developed tracking systems to monitor outcomes.
To accomplish goal 4, we developed case management systems to support health insurance access for patients. We advocated at state and city levels to expand funding to support BBI.
To accomplish goal 5, we assessed reasons for variations in outcomes. We developed alternative treatment options And implemented evidence-based treatment practices.
To achieve goal 6, we developed tools and systems to support transfer.
To achieve goal 7, we hosted training for providers and required state approval.
Accurate data entry is an essential component for tracking patients. To track the number of BBI patients in the BSAS Utilization Program database, a mechanism to identify the buprenorphine patients needed to be developed. Dedicated staff for data collection are also essential. Training providers who enter the data is important to ensure that there is consistent and accurate interpretation of the data fields. BSAS added several data fields to the BSAS Utilization Program database to allow for data tracking and as a result, additional training was necessary with providers to assure accuracy. There is a need to recruit and market the training course to physicians to promote participation.
Involvement by senior public officials and legislators in the recruitment efforts were instrumental in bringing attention to the need and attracting support. The initial focus was on hospital and community health center physicians in an effort to obtain a higher level of receptivity given the potential for a shared sense of purpose in responding to the public health issue. An outreach campaign was conducted to physicians that included presentations at medical staff meetings, one-to-one meetings with physicians, and attendance at professional association forums. The health commissioner personally attended numerous medical staff department meetings at hospitals and health centers to promote the training and to encourage participation. A system for support in registering and enrollment was developed to simplify the process for busy physicians and to facilitate increased interest in the training. The data demonstrated the need to provide additional support to encourage physicians to complete the training within the designated three-month time frame and to follow through on completing the waiver application.
There is sufficient stakeholder commitment to continue the practice. The BBI is committed to evidence-based practice and seeks to expand this modality. To date the BBI has demonstrated positive results and as a result, ADAA has expanded funding to the BBI and has used the BBI model to expand services across the state. Through the efforts mentioned above, the BBI has strong committed partners that are dedicated to the long-term sustainability of the BBI. The BBI will continue to use data to demonstrate positive results that will be used to sustain and leverage other and additional resources.
The Health Commissioner and BSAS President are actively involved in advocating at the state and local levels for sustained and expanded funding for the BBI. Efforts are underway currently to advocate for an expansion of the Primary Adult Care program to include substance abuse treatment as a covered benefit, which would greatly expand access to buprenorphine treatment through the BBI.