Recovery Centers of King County

1. Recovery Centers of King County Buprenorphine Treatment Program AAP Providers Conference, April 19, 2013, Lynnwood, WA Patricia C. Knox, Ph.D.

2. Where do I sign up?

3. Program Design • Pharmacological treatment in conjunction with behavioral CD treatment • Six month Suboxone taper (max 16mg) starting with induction in detox, followed by 28 days of intensive inpatient and five months of outpatient treatment • Ultimate goal is Abstinence

4. Funding: DSHS • Patients enrolled were Medicaid eligible: TANF, ADATSA, SSI, Disability Lifeline, and Disability Lifeline – Extended. • DSHS paid for medication in treatment and for physician services. • Detox Subutex and Suboxone were not billed to DSHS.

5. Funding: King County • King County MHCADSD contracted with RCKC to provide Buprenorphine services. • Contract began in 2009 and has been annually. Fund source was County MIDD funds. • Funding was used for MD services: initial visit and med checks, and for UA’s and bus tickets.

6. Funding: King County • The contract objectives were: • To evaluate the acceptability and feasibility of buprenorphine detoxification with heroin dependent patients. • To evaluate the impact of buprenorphine on outpatient treatment retention following inpatient treatment by comparing retention of the project sample to historical norms. • To evaluate the impact of buprenorphine on repeat detoxification admissions by comparing readmission rates of the project sample in the 12 months prior to admission to the project.

7. Program Flow Overview Patient screened over the phone and has Medicaid funding Patient enters RCKC detox (4-5 days) 28-Day Intensive Inpatient Treatment Build behavioral skills and taper suboxone 5-12 Months of Outpatient Treatment

8. Program Flow: Screening During the screening call, we determine if the patient has funding ( TANF, ADATSA, SSI, Disability Lifeline, and Disability Lifeline – Extended) The RCKC screening form guides our staff member through appropriate criteria for admittance. Recent methadone and fentanyl use are exclusions for entering detox.

9. Program Flow: Detoxification • Upon admission, patients are transported to a nearby lab by RCKC and liver values are tested. • Detox stays for Suboxone patients are funded by RCKC. • After a health evaluation, patients are inducted unto Subutex with a starting dose of 16mg and detoxed for any additional substances. • The typical length of detox is 4-5 days.

10. Program Flow: Detoxification (cont) • Suboxone DBHR authorization completed and faxed • http://www.dshs.wa.gov/pdf/ms/forms/13_720.pdf

11. Program Flow: Intensive Inpatient • After successful detoxification, patients enter 28 days of intensive inpatient treatment. • Funding for Inpatient is provided by State. • For the duration of Inpatient, patients are maintained on a dose of 16mg of Suboxone.

12. Program Flow: Outpatient • After successful completion of IIP, patients begin outpatient treatment at our Central Seattle location. • Outpatient treatment lasts 5-12 months for Suboxone patients. • Patients receive priority admission • Assigned to Buprenorphine Group and additional appropriate groups (e.g. RPG, CCG …) • Rules for OP compliance include: • Weekly UDS tests • Mandatory Buprenorphine Group attendance • Positive UDS test for Buprenorphine

13. Compliance Protocol • Noncompliance • Relapse, missing group / individual session • Failure to attend 3 SS meetings weekly • Negative for Buprenorphine • Refusing a UA Verbal Warning Further Noncompliance Bupe. Group counselor and Program Coordinator meet and patient signs Behavioral Contract. Director, Physician and Research Coordinator notified via email Contract Violation Patient Discharged

14. Suboxone Tapering Schedule • The Suboxone taper begins in the 10th week. • Every two weeks thereafter, Suboxone dose is tapered by 2mg. • At week 24, the final taper goes from 2mg to 1 mg.

15. Program Challenges • Billing Issues • ADATSA funding and Medicaid Coverage (patients need Medicaid coverage for meds to be covered) • Coordination Problems: • Prescriptions only filled every two weeks • Only 8mg pills are covered: problems with taper • Population challenges: • Housing issues • Non-tapering Suboxone patients • Fear of discomfort with the taper

16. Program Observations for Success Readiness • To actively engage in 12-step program • To taper off the Suboxone • To actively participate in the Buprenorphine Group

17. Future Plans • Consider continuing the pilot and comparing a one year taper to six months taper. • Develop outpatient Relapse Prevention program specifically for these patients. • Work with State to streamline the prescription authorization system. • Incorporate alternative treatment methods for anxiety related withdrawal symptoms (i.e. mindfulness)

18. Happy, Joyous and Suboxone Free!!