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N.C. efforts to reduce opioid dependency highlighted in national report

Two glass vials that say
Full Circle, based in Franklin, distributes naloxone kits along with fresh syringes, sterile water and toiletry items. Photo credit: Liora Engel-Smith.

By Yen Duong

In a national report subtitled “Leading-edge Practices and Next Steps,” the American Medical Association and consulting firm Manatt Health highlighted a North Carolina Medical Society initiative to support providers treating opioid use disorder.

Project OBOT, short for office-based opioid treatment, helps North Carolina providers get trained to prescribe medication-assisted treatment (MAT) to patients and eases roadblocks for patients beginning and staying on MAT.

Medication-Assisted Treatment

Medication-assisted treatment, or prescribing certain drugs along with behavioral therapy and other social supports, is the “gold standard of care” for treating opioid use disorder, per the Surgeon General.

To prescribe buprenorphine, the most common MAT, doctors must go through an eight-hour training for a waiver from the federal Substance Abuse and Mental Health Services Administration.

With waiver in hand, physicians can prescribe to 30 patients their first year. If they re-apply for the waiver annually, they can prescribe up to 100 patients in their second year and up to 275 patients in their third year.

The other two drugs approved for MAT are methadone, which must be administered under supervision at a federally approved center, and naltrexone, which requires patients to have not used opioids for seven to 10 days before starting.

“Project OBOT and the other community-based programs in the report show how state-based innovation can help end the epidemic,”  Dr. Patrice A. Harris, president of the AMA, said in an email. “Not all states have these types of innovations.”

shows about a half dozen long, thin kits with printed instructions on the outside on how to use the medication to reverse an opioid overdose
Naloxone injection kits assembled by the N.C. Harm Reduction Coalition include a vial of naloxone, a syringe and needle, instructions. Photo credit: Emily Davis.

“While we understand not all communities would be able to implement a Project OBOT, we wanted to provide the example of what not only is possible but what is showing promise to bring evidence-based care to patients.”

In May, the AMA, Manatt and the Medical Society released “Spotlight on North Carolina: Best Practices and Next Steps in the Opioid Epidemic.” The other “Spotlights” covered Pennsylvania, Colorado and Michigan, a “strong, representative set of states” due to their size, Medicaid coverage and scope of the opioid epidemic, emailed an AMA spokesperson. The AMA’s 18 month-long project analyzing the opioid epidemic culminated in the national report, released Sept. 9.

The reports commended North Carolina for taking steps such as increasing access to MAT, non-opioid pain management and widespread distribution of the overdose-reversing drug naloxone. In their publication, they also advocated for Medicaid expansion and continuing oversight of parity – insurance treating physical and behavioral health equally – during the transition to Medicaid managed care.

“The report provides practical guidance for policymakers, including insurance commissioners, Medicaid officials, legislators, governors, attorneys general and others working to end the opioid epidemic,” Harris wrote. “As a physician, I want to know what works so that I can provide the best care to my patients. This report identifies best practices to help policymakers take the same approach.”

Project OBOT

At the end of last year, 1,573 physicians in North Carolina, or fewer than 3 percent of Tar Heel doctors, had a SAMHSA waiver to prescribe MAT, according to the Project OBOT website. So far during its first year, Project OBOT has provided SAMHSA waiver training to 711 additional doctors.

“We have so many people in the state of North Carolina that would want to be in an MAT program, but we don’t have the providers to oversee it,” said Franklin Walker, the executive director of Project OBOT. “Number one, there’s not enough waivers. But number two, the most egregious problem is those that are waivered are only using it a small percentage.”

Walker said only 20 to 25 percent of waivered physicians end up using those waivers, due to patient compliance, added DEA scrutiny and other issues. To ease those issues, the initiative commissioned and distributes an electronic health record plug-in that manages MAT, as many  systems do not support MAT. The software also supports telehealth, increasing access for patients who live far from their MAT providers.

Resources for recovery and naloxone access

Concerned citizens can plug in their address to this Google map to find the nearest pharmacies that carry naloxone, the opioid overdose-reversing drug. Another map shows safe drug disposal sites and a third shows locations of some recovery support groups. For a local resource, call 211 or visit NC211.org

Earlier this summer, the initiative formed an independent pharmacy network to accept a special pharmacy benefit card for MAT, which can cut costs for self-pay patients in half from the going rate of $300-$500 per month, Walker said. Project OBOT also negotiated lower lab costs for patients in MAT treatment from the lab companies.

“I now don’t have to go back to the street to get my heroin because it’s cheaper than my buprenorphine, because we’ve just equalized the price,” Walker said of the pharmacy benefit cards, which have rolled out to about 50 patients. “I can stay in treatment because the medications are cheaper for me [… and] because I’ve got this doctor that has this telehealth software, so I don’t have to drive an hour to get to see the doctor.”

This year’s pilot program took place with the Granville, Vance and Pender County local health departments and a clinic in Raeford, a half-hour from Fayetteville. Walker hopes to expand the project with its pharmacy network and add more drugs that qualify under the benefit cards.

Read more: Forty-one N.C. counties classified as ‘high-risk opioid counties’

“Most opioid use disorder patients are not there just for opioids,” Walker said. “If we’re able to extend our formulary on our Rx card … through an independent pharmacy network that has agreed to sell these medications at a little bit of a discount to these patients, it’s just a win-win all over the place.”

Other suggestions in the AMA report

Both reports strongly recommended Medicaid expansion: “This is a major missed opportunity that could help North Carolina end the opioid epidemic within its borders,” the NC report read. The spotlight estimated that 150,000 North Carolinians who have substance use disorder would gain coverage after expansion.

“If we are going to continue to make serious headway against this epidemic, we also need to close the coverage gap as they have done in other states,” wrote Dr. Susan Kansagra of the N.C. Department of Health and Human Services Division of Public Health.

The five reports focused on six key areas:

  • Access to MAT, including removing prior authorization and keeping MAT affordable.
  • Continuing to ensure insurers treat mental health on par with physical health. Read more of our parity series.
  • Health care networks, which means making sure patients aren’t on long waiting lists and treatment workers can keep their jobs.
  • Managing pain with access to different kinds of pain care, including options such as physical therapy, yoga and chiropractic care
  • Naloxone access, both expanding it and coordinating care after its use
  • Evaluating, revising and improving policies and outcomes

Other recommendations included making sure that DHHS includes oversight of Medicaid managed care companies, and that the Department of Insurance continues to make sure that insurers treat mental and behavioral health on par with physical health.

Read more: DHHS needs to continue oversight with Medicaid managed care

An NCDOI spokesperson emailed that the department hired a consultant to help them with the work and stay in contact with other states’ insurance departments to talk about parity strategies.

North Carolina received praise for its naloxone program, as the state has distributed almost 40,000 units of the overdose-reversing drug, according to the AMA report, which also praised the North Carolina Harm Reduction Coalition. The HRC website says they’ve distributed over 101,000 units since 2013.

READ more: NC needle exchange programs succeed despite odds

All 44 agents of the DOI’s Criminal Investigations Division are trained in administering naloxone, a DOI spokesperson emailed.

The report warned against over-restriction of opioids, noting that as opioid prescriptions have decreased 33 percent since 2013, some patients have been unwillingly cut off from their medications. The authors encouraged states to maintain access to opioids for pain care, as well as support for non-medication pain care. For instance, Colorado’s Medicaid program increased payment rates for physical therapy and supports options such as occupational therapy and cognitive behavioral therapy.

Read more: Our three-part series on chronic pain: Hundreds of N.C. doctors say they’ve stopped prescribing opioids,  Uncontrolled Pain: the other side of the opioid crisis and Complex pain problems put patients in a bind]

“‘I’m prescribing yoga for my patients,’” Walker recalled one doctor telling him. “I said, ‘Fantastic.’ … We’re looking at crossovers, in terms of yoga, maybe acupuncture, anything that helps at this point, because it’s such a bad thing; it’s just an awful problem.”

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