In response to the growing need for treatment options for opiate users, in May of 2011, Boulder County Public Health Addiction Recovery Center (ARC) and the syringe access program, The Works, developed a pilot project to treat opiate addiction for injection drug use (IDU) clients. IDU can be at higher risk for communicable diseases including hepatitis C, and HIV, and can engage in high-risk behaviors that contribute to public health concerns. The rates of opiate abuse, addiction, and death by overdose have risen dramatically in Boulder County, whose population of approximately 300,000 residents is also home to the University of Colorado. Death rates caused by poisoning (which is reflective of overdose, but can include other factors) have risen dramatically. Rates went up nearly six fold from 1.7/100,000 in 1990 to 9.8 in 2009.
Boulder County Public Health
Rapid Treatment Access and Retention of Young Opioid Addicts
In response to the growing need for treatment options for opiate users, in May of 2011, Boulder County Public Health Addiction Recovery Center (ARC) and the syringe access program, The Works, developed a pilot project to treat opiate addiction for injection drug use (IDU) clients. IDU can be at higher risk for communicable diseases including hepatitis C, and HIV, and can engage in high-risk behaviors that contribute to public health concerns. The rates of opiate abuse, addiction, and death by overdose have risen dramatically in Boulder County, whose population of approximately 300,000 residents is also home to the University of Colorado. Death rates caused by poisoning (which is reflective of overdose, but can include other factors) have risen dramatically. Rates went up nearly six fold from 1.7/100,000 in 1990 to 9.8 in 2009. The most recent Youth Risk Behavior Survey (YRBS) determined that of males attending high school in Boulder, 6.3% of 11th grade and 6.7% of 12th grade students had injected drugs. This is almost 3 times higher than the national average. With funding from the Colorado Division of Behavioral Health (DBH) for Medication Assisted Therapies (MAT), a two-day inpatient detox, medical treatment (including physician time and Suboxone), and weekly recovery skills groups were offered at no charge. Clients of The Works Program were linked to these services. Rocky Mountain Treatment Centers of Boulder (RMTCB) is a treatment facility specializing in opiate addictions, and has a Suboxone-certified physician on staff. Boulder County Public Health (BCPH) contracts with RMTCB, a private sector treatment program, to participate in this public-private partnership. Medication was provided at cost by Mental Health Partners (MHP, the community’s non-profit Mental Health Center) and their pharmacy. Suboxone, an opiate replacement similar to methadone (but considered more effective), has been shown to help reduce opiate use and increase periods of ‘clean’ time. While the ARC regularly treats IDUs that come in for treatment, this pilot intentionally targeted people who were coming in for syringe access services and were not currently in any treatment. Last year, the ARC treated 101 self-identified IDUs, of which 15 came directly from the Works Program. The target population was 15 IDUs, whose primary drug was heroin and who accessed needles on a regular basis.
Clients, who came in for syringe access services were told about the program and, if interested, referred to the ARC. They were then approached using Motivational Interviewing and strength-based interventions to explore Suboxone treatment options. In the first 6 weeks of operation, 15 clients were admitted to the program, all of whom were injecting opioids. Of the clients that were admitted, eight have remained in treatment for more than 90 days. These are impressive results for clients who had never engaged in treatment before, had not expressed interest in treatment prior to being offered the Suboxone option, and were unlikely to come into treatment via traditional methods.
The main goal and objectives for the program are:
GOAL: Offer medication-assisted therapy options to heroin users in the syringe access program.
Objective: Offer 90 days of Suboxone treatment and doctor follow-up to 15 clients referred from the Works program.
Strategy: Offer immediate access to a free 48-hour Detox episode, a weekly treatment group, and case management including individual counseling to 15 clients from the Works program for 180 days.
Strategy: Consistent and accurate communication and collaboration regarding client progress between the four collaborative partners, ensuring the best in client care. All the objectives were met. Of the 15 clients that were offered services, 8 reached 90 days of treatment.
Three main success factors and observations on the program include:
The ongoing relationship between the Works staff and its clients is critical. Because the program focuses on harm reduction principles, the ongoing relationship with clients allows program staff to assess who may be ready to hear about options for treatment and recovery.
The immediate admission and induction reduces the all-too-common pattern of heroin addicts not staying for a detox episode. The promise and follow through of the medication kept the clients engaged. The same people that engage them at the Detox center also facilitate the Recovery Skills group.
Clients who remain in the suboxone treatment program have a similar demographic: males between the ages of 19-30 years with less than 3 years of injection use and little or no treatment history. All of the clients in the program started abusing prescription pain killers during their teenage years, and then progressed to heroin use by injection.
The public health issues that are in play with IDUs are extensive. As identified in Healthy People 2020, there are three objectives that are directly tied to the focus of our program: Reduce the rate of HIV transmission among adolescents and adults (HIV-3), reduce new hepatitis C infections (IID-26), and reduce the proportion of adults reporting use of any illicit drug during the past 30 days (SA-13.3). BCPH recently underwent a three year assessment process that engaged local partners, reviewed data, and also determined the capacity of the local public health system. As part of this process, three focus areas were identified as being critical to improving the overall health within Boulder County: 1) healthy eating and active living, 2) mental health, and 3) substance abuse. The State of Colorado has also identified substance abuse as a priority for public health moving forward.
An additional challenge in Boulder County is the large number of college students in our community. As prescription drug abuse has risen over the last 10 years, we have seen a number of overdoses that have greatly impacted the community, creating awareness for a need to intervene. We have seen several cases where a young person becomes dependent on prescription pain killers, and then they run out of legal and affordable options to support their use. They may go to an urgent care clinic, or their primary care doctor, but before too long they are not easily accessing opioid medications. With heroin being much cheaper than pain killers purchased off the street, they move to the more stigmatized drug, heroin. As their tolerance grows, many youth begin injecting. There is also a stigma attached to IDUs in the community and even in the treatment world. IDU has a predictable downward cycle, and the use of syringes increases the risk of bad outcomes exponentially.
This program was created in response to an identified community need, with the most apparent need being immediate access to treatment. Motivation to change is not constant, and ambivalence is a common feeling among this population. In order to dramatically improve their situation, immediate and sustained improvement is critical. While a ten-day wait from initial contact to admission for treatment is heralded as highly successful, and often times the gold standard, we have been able to improve on that with a seamless, immediate admission and induction process. We began the program utilizing principles similar to the Strengthening Treatment Access and Retention–State Implementation (STAR-SI) program, that identifies a problem, sets an identified goal, implements a small pilot project and then the initial outcomes are evaluated. In 2003, the Network for the Improvement of Addiction Treatment (NIATx), began to work on reducing wait times for treatment and retention. The STAR-SI program was started in 2006, and has shown to be a scientifically sound. While there is only a small sample from which to work with, we believe it is a good start, and a place from which to move forward. As stated above, BCPH has been involved in a continuous public health improvement process to determine the priority focus areas in order to intervene and reverse worsening trends. This was an extensive process that included interviews with local community members, judges, law enforcement, medical professionals, non-profit organizations, schools, higher education, and the treatment community. Approximately 100 community stakeholders were engaged through 20 meetings in order to get their feedback on what public health priorities were important to them. This survey of our community drives our work, and substance abuse was identified as one of the top three focus areas we will emphasize over the next five years.
The practice addresses substance abuse in a number of ways. IDUs are a highly challenging population to treat. They are a priority population in the federal substance abuse block grant, for the state, and a focus of treatment in all programs that treat addiction. The project also attempts to work with a previously untapped client base that usually doesn’t enter treatment until there is legal involvement, and they are forced to get treatment. Getting them before they enter the legal system is a huge cost savings. Preventing the cost of a social service case being opened on a family is significant. By helping people engage in treatment before they are involved in other systems, we save money on the front end, and reserve those resources for other people.
Suboxone as a medication-assisted therapy is not new. Many programs have used it in the treatment of opioid dependent clients. What is new from our perspective is that we are actively engaging syringe access clients before they even ask for help, and providing immediate access to services and treatment. As a part of the exchange process, clients are engaging with people who use motivational interviewing techniques to look at their readiness for a discussion of a different life. When they show signs of interest, they are told about the program. From that point, they are directed to the Detox program, where a more detailed assessment takes place. If the client is ready, they admit into detox, and are induced with medications within 48 hours. Therefore, what is new is adding the concept of rapid access to a population of clients not consistently amenable to opioid treatments, to take advantage of the fleeting moment of motivation.
In Colorado, BCPH has the only approved syringe access program in the state. Approval came earlier this year, but Boulder has been running the program without official consent for years, a decision supported by the current and former BCPH Executive Directors and supported by handshake agreements with local District Attorneys who agreed not to prosecute syringe access workers, program volunteers and participants. The Works program was officially approved earlier this year by the state after a legislative change.
This practice differs from other programs in our provision of immediate access to treatment. Our Detox has the ability to prescribe withdrawal medications to ease the painful symptoms that opioid addicts fear more than anything else. To tell an addict that they will be feeling better no later than 48 hours if they allow us to help them is powerful. There are many great programs that offer similar treatment or services. The distinctive element of our program is the immediate admission. The idea that there is hope within 48 hours, and that the clients will spend that 48 hours in a supportive environment, with palliative medications as indicated, is a powerful motivator for even the most ambivalent person. Most of them have tried to quit many times, only suffering defeat and failure by using again. This approach differs from traditional treatment that waits for the client to come to services, rather than making aggressive outreach to clients who are perceived as not amenable to treatment, providing immediate access to services which will engage and retain these oft-times reluctant clients. In looking at a number of websites, and talking with colleagues from the Harm Reduction Coalition, we believe that this is a new approach to engaging clients that are not actively seeking treatment. The different aspect of our pilot has been the speed at which clients receive their care, and intentionally targeting an untapped population in our community.
Role of Stakeholders/Partners
The role of the stakeholders in this process is critical. The Works program actively engages clients about the possibility of the Suboxone program, and refers them to the Intensive Services Program at the ARC. The ARC staff engages the client in a discussion of the specific details of the program, and sets up their Detox episode if they are ready. ARC staff guides the clients through the Detox; staff assesses their withdrawal on the COWS protocol, completes their intake assessment while in Detox, and transports them to RMTCB at the end of their 48 hour withdrawal. After the meeting with RMTCB, ARC staff transport the client to the MHP pharmacy to pick up their Suboxone. They have been assigned a therapist by this time, have attended the Recovery Skills Group, and have follow-up appointments scheduled at RMTCB.
The primary stakeholders in this collaboration are the ARC and the Works program, two divisions within BCPH. Our community partners are RMTCB, an outpatient opiate treatment program that utilizes Suboxone as a treatment modality, and Mental Health Partners, with their generous use of their pharmacy to purchase the medication at cost. The support of the Colorado Department of Behavioral Health to fund the medication and physician time for this project and to actively support our efforts helps give the program credibility statewide. Ultimately the primary stakeholders are Boulder County community members who benefit from reducing the spread of infectious disease and the reduction of addiction to opiates in the community. The local health department (BCPH) houses both The ARC and Works, and the two Program Managers had a discussion of the possibility of trying something new to engage the clients that were utilizing syringe access. Due to past collaborations of BCPH with RMTCB, and BCPH and MHP having decades of history collaborating on projects, it was easy to set up a meeting to discuss the idea, and develop a protocol and action plan. With solid support from the division managers of the two BCPH divisions, we were able to implement the program in a short period of time.
BCPH is intentional in our collaborations. From the ARC being a part of the Integrated Treatment Court program that was awarded a SAMHSA Science and Service Award in 2008, to the inclusive process by which we came up with our public health improvement plan (PHIP), collaboration is an integral part of who we are as an agency and county. Collaboration and Teamwork, and Effective Communication are two performance standards that all employees are held accountable for. We believe in good intentions from our collaborative partners, and when things get difficult, our default position is to believe that no matter what the obstacle, we will work our way through it. Another aspect of our collaboration is the shared belief that people can and do recover from addiction. We believe in the concept of longer and longer periods of sobriety, and in unconditional positive regard for the people in our care. A positive belief in the goodness of all people, combined with the same belief about positive intentions with our partners, provides the atmosphere where recovery and quality service provision thrives.
Barriers to collaboration can be many, but when personal relationships exist, we have each other’s contact numbers on our cell phones, and trust each other to make good decisions; everything else is a matter of working it out. When one of us did exchanges in Berkeley before moving to Colorado, there was an idea from the harm reduction folks that it was not the clinician’s job to engage clients in any discussion of their behavior. The philosophy behind this is understandable, as we do not want to scare clients off by advocating for treatment when they are not ready. In the Works program, it is never pushed on a client to consider treatment programs. In the IV drug using community, BCPH has a stellar reputation for confidentiality and trust. Because of that built reputation, the Works and ARC staff is able to raise the option of treatment in a way which is perceived as supportive, not controlling or punitive. The ARC is an iconic program in Boulder. It started in a portable trailer in 1973, and has developed into a program that is now respected across the state and country. The Works program, too, has a long history of respecting clients and offering services to a marginalized population. At BCPH, we believe in the inherent value of every person that walks through the doors of our programs. We look for any chance to share a story of hope and redemption for those that choose to engage with us. Our collaboration is built on mutual respect, common cause, and a desire for people to live life to the fullest.
In order to implement the project, a confluence of factors came together. BCPH has supported a syringe access program, The Works, since 1989, long before these programs were approved at the state and federal level. The Intensive Services program had been coordinating for several years with the HIV/STI program that coordinates both the syringe exchange and HIV/Hep C testing program which lent itself to a level of familiarity and trust between the staff of the two programs. The availability of Medication Assisted Therapies funding from the state had initiated the collaboration between the ARC and Rocky Mountain Treatment Center of Boulder, and again, positive work relationships and trust had been built. These relationships proved to be the foundation of the willingness of each party to contribute what each had to offer, without possessiveness about clients or program identity. Although the concept itself was simple, (to provide a suboxone protocol to injecting, opiate-addicted clients), the implementation required a lot of detail work and the ability to iron out bumps along the way. Numerous conversations and joint discussions were held to develop a protocol and the agreements that allowed the work to flow easily.
The time frame was accelerated, as we had access to funding which was required to be spent by the end of the fiscal year, and we had other performance targets of admitting IDU’s as a priority population in the same short time frame. The program was conceptualized and implemented in a period of about two months, and then was carried over into the next fiscal period, where we now have a full year to adjust and improve the process, while seeking additional funding streams.
Process & Outcome
Offer 90 days of Suboxone and doctor follow-up to 15 clients referred from the Works program. The State of Colorado uses the DACODs system to capture all sorts of information related to clients in treatment. Some of the markers we are held accountable for in order to receive our treatment dollars are:
Number of clients in Treatment more than 90 days.
Time between first contact and admission to treatment.
Number of days using primary drug of choice in the last 30 days.
Identifying the primary, secondary, and tertiary substances abused.
Improvement on four measures of psychosocial stability; housing status, employment, family functioning and mental health issues
Time between first contact seeking treatment and admission to program.
Number of days within the last 30 client has used at the time of discharge In evaluating the success of the clients enrolled in this project, we will be able to utilize these data points to track longer-term outcomes than we currently have, as these data are collected at admission and at discharge from their treatment services, and our clients are still active in the treatment process.
GOAL: Offer medication assisted therapy options to IV heroin users in the syringe access program.
Objective 1: Offer 90 days of Suboxone and doctor follow-up to 15 clients referred from the Works program. Strategy 1: Offer immediate access to a free 48-hour Detox episode, a weekly treatment group, and case management including individual counseling to 15 clients referred from the Works program for 180 days. The main data we use for evaluation in the State of Colorado are captured in the Drug and Alcohol Combined Outcome Data ( DACODs) system. It is a statewide assessment tool that captures the relevant data related to substance abuse treatment. Our objective was to offer 90 days of Suboxone and doctor follow-up to 15 clients referred from the Works program. This is a relatively small sample we were working with, and at the outset we were not sure what outcomes to expect. We knew that the perceived desire for treatment services hovered around 20% in the syringe access program, and that anecdotally, few of the referrals from the WORKs to the ARC detox had ever followed through.
Due to the public health concerns around communicable disease and an increase in local opioid use, we were willing to give an innovative approach a try. In 2010-2011, we served 101 IV drug users. Within this 101, we had people that used cocaine, methamphetamine, crushed prescription pills, heroin, and combinations of these intravenously. Due to the intentional identification of this specific subgroup from the Works program, who were not in treatment at the time, we increased the number of this priority population by 15%. 15 Works clients were referred; 8 of them have remained in treatment for more than 90 days. The benchmark from the State of Colorado for all substance abuse clients admitted to treatment services is to maintain at least 80% for 90 days. By achieving maintaining half of these more challenging opiate clients, we were impressed. The Works program annually does a survey of their client base and rarely sees more than 20% of the clients state that they are interested in receiving treatment services, so the engagement of over half of these clients referred is significant. Another objective was to offer immediate admission to Detox, and medication induction no later than 48 hours after admission. The studies show that the quicker people can access treatment, the better the outcomes. This makes sense intuitively, but the hard science supports the intuitive sense. For example, the Special Connections program targets pregnant women who are using substances during their pregnancy. They are admitted within a day of the contact with the ARC, and all efforts are made to meet with them that day. This effort reduces the risk of babies born dependent on substances, and a host of other medical concerns. Using the same model of quick access, the clients from the Works program come to us and are admitted immediately into the Detox, and induced no later than 48 hours at RMTCB. For people that are in the middle of the addictive cycle, the ability to immediately give them hope and tangible steps to take is critical. We have done exactly that in this program.
Objective 2: Offer 90 days of Suboxone and doctor follow-up to 15 clients referred from the Works program. Strategy 2: Consistent and accurate communication about client progress between the four collaborative partners, ensuring the best in client care. From the start, the aim was to provide consistent and accurate communication about client progress between the four collaborative partners, ensuring the best in client care. This was actually easy for us, since we have such solid working relationships within the community, and at BCPH. It is time consuming to set up meetings, to go to collaborative partnership gatherings, or to include others in meeting common goals and objectives. But, the end result, as in this case, was a relatively smooth operation that was built on all the effort we had put toward collaboration in the past. By intentionally including others in shared projects, and no one worrying about territoriality or who may get the credit, the greater good is served, and the process works more smoothly.
One communication example is illustrative of the relationship we have within the group. The Intensive Services Program Manager, Widd, received a call from the Director of RMTCB, Wes, about a client who is in the program. As a part of being able to get the Suboxone for free, he was given UA’s at RMTCB before he was given another prescription. Wes called Widd saying he had some good news, and some bad news. Our shared client tested positive for Suboxone in his system, and had no other opiates. Widd responded that this was wonderful news. It meant the client had taken his Suboxone and not diverted it, and he was not using heroin. Wes then asked Widd if he was ready for the bad news. He said the client tested positive for benzodiazepines, cocaine, meth, and alcohol! In true harm reduction fashion, we encouraged the client to reduce the use of ALL substances as well as positive feedback for not using heroin. Another part of our success is that the overarching philosophy of treatment approaches of our programs use is very similar. There is a shared value which places client self-direction as paramount. The details are easy when there is a shared vision, a belief that helping people reduce their use, and a genuine sense of caring and commitment to our relationships. Process analysis for the project is done through ongoing assessment of the program strategies and the client progress involved in the services. Feedback from staff and the clients are used in real time to adjust the strategies. For example, initially, clients were allowed to provide their own transportation between the detox and the suboxone induction appointment. However, bitter experience showed that the clients did best when a case manager accompanied them to this appointment.
The Works, ARC, RMTCB, and MHP are committed to treating this at risk population in creative and cutting edge ways. The success of the first pilot group has inspired us to move forward with this on an ongoing basis. The commitment from each of the stakeholders is solid. When DBH heard about the project, and the identified group, they increased the available funding to pursue this work. With the state requiring priority population admits (including IDU) as the highest priority in treatment, this helps them achieve their state goals. BCPH has put together new focus groups on substance abuse and mental health as part of our Public Health Improvement Plan, which will help keep the momentum going for this program. BCPH is already in negotiations with other funding streams to seek support for the medication piece of the project. With the continued support of the community, we expect this program to grow.
The decisive point of the sustainability of this program lies in the cost of the medication. The monthly cost for the Suboxone is around $450. Using existing infrastructure, the programs involved were able to coordinate and stretch to support the clients with free or low cost services, and through a state pilot for Medication Assisted Therapies, we were able to cover the cost of the medication for the first fifteen clients. We are actively soliciting support from a variety of sources to assist financially in this promising practice.