Making the case for MAT

October 28, 2013

Michael Boyle, Associate Researcher
Center for Health Enhancement Systems Studies

Despite their proven effectiveness, medications for substance use disorders are still not widely prescribed. Results of the National Treatment Center Study conducted in 2009–2010 revealed that 62% of publicly-funded providers did not offer a single medication for the treatment of a SUD. I don’t think much has changed since the study was published. I’d like to offer a few factors for treatment organizations to weigh when considering whether or not to offer medications for substance use illnesses (a term that I prefer, as opposed to substance use “disorders.”)

The National Quality Forum (NQF) is a public-private partnership that develops consensus measures for a variety of health conditions. In 2007, the NQF released 11 standards for treating substance use illnesses. Four of the standards highlight the importance of using medications as a component of treatment for detoxification, opiates, alcohol, and nicotine. The standards are titled “voluntary,” but the aim is to encourage payers to establish contracts and provide reimbursements only to organizations that implement them.

Treatment organizations can meet the NQF standards for medication-assisted recovery (with the exception of using medications for detoxification) by referring to providers who can prescribe. For organizations that lack resources to employ medical staff who can prescribe medications, developing a relationship with a local Federally Qualified Health Center may be a viable option, particularly in states that are expanding Medicaid coverage. Another benefit of linking with an FQHC is that people in treatment for a substance use illness can also receive primary care.

And failure to offer FDA-approved medications for a substance use illness may result in lawsuits for malpractice.

That’s one idea that came up a recent TweetChat (#attcbridge) on the Fall 2013 issue of The Bridge, an electronic journal published by the ATTC. This issue of The Bridge focused on the consumer’s and family role in expanding medication-assisted treatment (MAT). I joined my fellow contributing editors and others to share our thoughts on this topic, in 140 characters or less on the TweetChat.

(You can follow the TweetChat conversation on the ATTC Network homepage.)

Tweeting about the legal implications of not offering approved medications for substance use disorders brought up parallels to primary care. A doctor who diagnoses hypertension but doesn’t tell the patient about effective medications—or offer a prescription—is asking for legal trouble if the patient later suffers a stroke. The medical record leaves a trail that will most likely result in a lawsuit.

There’s also a business case for offering medication-assisted recovery, using Suboxone in particular. For years, even patients with limited financial resources have been seeking medication at private-pay methadone clinics. These same patients would be willing to pay for medication and the related physician and counseling visits that help them repair relationships, obtain employment and housing, and basically get their lives back. Family members are often willing to help pay for effective treatment for their loved ones. And patients also see a cost benefit, as the medication and related treatment costs are less expensive than opiates.

These are just a few factors that I urge organizations and clinicians to consider when making decisions about using the medications now available to help their patients manage a substance abuse illness.

Share your thoughts with Mike in comments section that follows!

Michael Boyle is an Associate Researcher at the Center for Health Enhancement Systems Studies at the University of Wisconsin–Madison and provides consulting services. He was formerly President and CEO of Fayette Companies, a behavioral health organization located in Peoria, Illinois, and is the Director of the Behavioral Health Recovery Management project. Boyle recently served on a National Quality Forum committee charged with defining an episode of continuing care for a substance abuse treatment encounter. He has authored several articles and book chapters. His current activities include integrating mental health, addiction and primary care services, implementing evidence-based clinical practices within recovery oriented systems of care, and exploring the development and use of electronic technologies to support behavioral health treatment and recovery.


Understanding the Right Customer

October 2013

Jay Ford, Ph.D.

Executives at Procter and Gamble learned some powerful lessons when seeking to expand their customer base to India. Their experiences highlight the importance of two  NIATx principles: understanding the customer and getting ideas from outside the field. The P&G story highlights the importance of understanding the right customer.

In 2008, executives at Gillette, which is now a division of Proctor and Gamble, wanted to increase its market share in India among men who shave. The prior introduction of a new shaving product in 2002 initially failed. At that time, they introduced a new razor with a bar to unclog hairs that collect in the razor. Market testing among Indian students at the Massachusetts Institute of Technology indicated that the new product was a big improvement. However, the introduction into the market was a complete failure. Why? The answer was simple:  the lack of running water.  Most men in India shave with a cup of water, which rendered the new razor useless. Alberto Carvalho, Vice-President of Global Gillette called it an “Another ‘aha’ moment’." Simply stated, they had not taken the time to understand the needs of the right customer.

So in 2008, Gillette was ready. They sent 20 staff to India. Once there, they conducted “walk-throughs” with their customers, spending over 3,000 hours watching men shave under many different circumstances and situations. They also conducted focus groups, another powerful tool to help understand the customer. Armed with this knowledge, they were able to develop and introduce new products in the market. Efforts to understand the needs of the right customer have resulted in an 11.8% increase in market share. To learn more about Gillette’s story, I encourage you to read the recently published article about their experience.

The implementation of the Affordable Care Act will change the market place for behavioral healthcare organizations. Through Health Information Exchanges, many more people with new  access to behavioral health care will will be seeking services. These people will become your new customers. The Gillette story highlights the importance of understanding their needs. 

Applying the first NIATx principle: Understand and Involve the Customer takes on a new meaning now. A walk-through conducted now should focus on understanding the needs of the right customer. Several California providers recently told me about how the new Health Information Exchanges present opportunities for them to provide care for different populations. As a result, they are taking steps to understand customer needs to show them--as well as new payers--that their services result in quality outcomes.

The choice is yours. You can repeat Gillette’s failed experience of 2002 or you can follow the approach they took in 2008 to clearly understand the needs of the right customer. What approach will you chose? 

What new customers will your organization be serving in the near future?  How will you know that you're  providing quality services for the right customers? Share your thoughts with the ATTC/NIATx Service Improvement Blog!

Assistant Scientist
Center for Health Enhancement Systems Studies/NIATx 
University of Wisconsin-Madison

Inspiring Change through SBIRT: Start with the “Why”

October 2, 2013

Catherine Ulrich Milliken
Director, Addiction Treatment Program
Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

I recently saw a fantastic  Ted Talk by Simon Sinek on how great leaders inspire action.   I was struck by the notion that people don’t buy what you do, they buy why you do it. What is your cause?  Your purpose and belief? How are they reflected in what you do?
As The Dartmouth Hitchcock Medical Center Addiction Treatment Program (DHMC-ATP) staff began to work on strategic planning for the next year, we recognized the need to clarify our “why.” In doing so, we realized that we must do more to address the entire SPECTRUM of substance use from a preventative, health promotion orientation.
Like treatment providers across the country, DHMC ATP has seen in increase in the number of pregnant women in need of substance abuse treatment. According to SAMHSA (2012), 5 percent of pregnant women are current illicit Drug Users. Between 2000 and 2009, maternal opioid use at time of delivery increased more than four-fold, with a 35% increase in healthcare expenditures for neonatal abstinence syndrome (Patrick et al., 2012). The incidence of opioid-related neonatal abstinence syndrome has increased nearly three fold (Chopra et al., 2009). These facts combined demonstrate that opioid use during pregnancy is a growing problem of great public health significance—and one that the staff at the medical clinics and hospital our center is affiliated with is facing.
Our program identified the need to integrate SUD treatment providers into settings where we can affect change with those who may be at risk for developing substance use disorders, and at the same time, welcome medical professionals into our setting to provide care for our patients.

The How: Relationship building

As part of a medical center that includes ob-gyn clinics and a hospital, ATP could easily identify partners to work with on meeting this need. Building upon existing provider relationships between the Geisel School of Medicine Department of Psychiatry and DHMC Maternal-Fetal Medicine, we came to a shared “why.” We all believe in healthy moms and healthy babies and strive to provide caring and thoughtful evidence-based, integrated, cost effective care.
Together, we agreed to implement SBIRT into the OB/GYN clinics at Dartmouth Hitchcock Medical Center. ATP staff drafted a one-page proposal and convened a meeting with stakeholders from DHMC Maternal Fetal-Medicine to pitch expanding care for pregnant women beyond traditional treatment—to include a specialty clinic for pregnant women at the ATP, as well as screening and brief intervention in the OB/GYN clinics. We also applied for an auxiliary grant to help fund contingency management in the clinic and consultation and training for the SBIRT initiative and are hopeful we will receive funding.
From this shared vision, the DHMC ATP developed a Specialty Clinic for Pregnant Women, which opened in July 2013. The clinic provides individual, group, and medication-assisted substance treatment as well as on-site access to psychiatric care, and soon to include obstetric care, and case management services. As they say, “If you build it, they will come,” and they have! To date we have a group of approximately ten women participating in group, individual and medication-assisted substance abuse treatment. We are averaging two new evaluations per week and will need to plan for expansion in the near future. We have the “T” in SBIRT and by demonstrating our commitment to this shared vision, are working implementing the “SBI” in the DHMC OB/GYN clinics. Women are most excited and looking forward to “one-stop-shopping:” receiving prenatal care and substance abuse treatment in one clinic.

Adding who, what, when and where: Process improvement

The implementation process is no small feat, but could not have gained momentum had we not secured buy-in with a shared “why.” By building upon existing relationships, we identified project champions from each department and formed a change team, following the NIATx process improvement model.
We have decided to use the NIATx rapid-cycle change process with PDSA (Plan, Do, Study, Act) Cycles in our efforts to implement SBIRT. PDSA cycles allow the change team uses quickly test the effectiveness of potential solutions generated from barrier assessment and process mapping  exercises.
One of the first barriers our change team identified wasyou guessed it—reimbursement for SBIRT services. New Hampshire has not yet expanded Medicaid or released the reimbursement codes. Other barriers we identified include workflow and training issues across systems. Our next change team meeting will tackle ways to address these barriers, and decide which one to target in our first change project. We will also choose our screening tools and develop a process map of the workflow.
Then it’s off to Kansas City for the SBIRT Training of Trainers, (October 14-16) offered by the National Screening, Brief Intervention & Referral to Treatment ATTC. From this training, I hope to bring home tools to address training issues and help the team move forward with planning our first PDSA Cycle of SBIRT.
As we continue on our journey of implementing SBIRT into the OB/GYN clinics at the Dartmouth Hitchcock Medical Center, our change team invites you along for the ride and welcomes your feedback, experience, and wisdom!  Look for an update on our progress in a future blog post.
We hope you find this blog helpful as you consider implementing SBIRT across settings. Below are some other useful resources on SBIRT:
Catherine Ulrich Milliken, M.S.W., LICSW, MLADC, LCS, is the Program Director for The Dartmouth Hitchcock Medical Center Addiction Treatment Program and an instructor in Psychiatry at the Geisel School of Medicine at Dartmouth. Previous academic appointments included University of Southern Maine, University of New England, and University of New Hampshire. She has worked passionately to improve the care and treatment of women's mental health and substance issues for the last 15 years. Before working at Dartmouth, she was the Director of Outpatient Services at Crossroads for Women, which provides gender‐specific and trauma‐informed outpatient programs and services for substance abuse and mental health, as well as residential rehabilitation and halfway house services for substance abuse in Portland, Maine. During that time, she also saw clients in private practice, specializing in adult psychotherapy, substance use and women's issues and worked with clients struggling with HIV and AIDS diagnoses. She conducts training on the basics of chemical addiction, tools for leading groups, exploring the relationship between substance abuse and child maltreatment, and women's treatment concerns, among other areas.  

Do you have questions or comments for Catherine?  Post them here, or e-mail Catherine at:


 SAMHSA, 2012

Patrick SW, Schumacher RE, Benneyworth BD, et al. “Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009," JAMA. 2012 May 9;307(18):1934-40. doi: 10.1001/jama.2012.3951. Epub 2012 Apr 30.

 Chopra, M.P., et al., “Buprenorphine medication versus voucher contingencies in promoting abstinence from opioids and cocaine.” Exp Clin Psychopharmacol, 2009. 17(4): p. 226-36.