case studies

Case Studies featured on this site highlight the success of the Mid-Atlantic Association of Community Health Centers, our FQHCs and various projects that we have worked on with a variety of partners.  The purpose of these case studies is in part to demonstrate the programmatic expertise MACHC holds as well as the reach of our health centers in various communities.  

Case Study #1: The Baltimore Buprenorphine Initiative (BBI)

A Case Study on the Mid-Atlantic Association of Community Health Centers (MACHC)  Efforts to Increase Service Capacity and Access to Long-Term Treatment for Individuals with Heroin Addiction:

Summary
The Baltimore Buprenorphine Initiative (BBI) expands 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 program has enhanced access to long-term buprenorphine treatment and health insurance and increased the number of trained and certified physicians and treatment programs.

Problem Addressed
Untreated heroin and opioid addiction leads to the spread of infectious diseases, medical complications, and death. Although new treatments are available and policies have changed to increase access to such medication, a lack of trained prescribing physicians and operating procedures limits access to care. For those able to access treatment, insufficient service capacity often shortens the duration of care.1,2,3,4,5

• Prevalence of heroin use and addiction: An estimated 3.7 million people have used heroin at some time in their lives, 314,000 in the past year.1 More than 10,000 Baltimore residents were admitted to drug treatment programs for heroin treatment in 2006.2
• Consequences of untreated heroin addiction: Heroin is highly addictive and its use spreads infectious diseases (such as HIV) and can cause medical complications and death.3 For example, approximately 150 people die each year in Baltimore from overdoses involving heroin.4
• Available, effective treatment: In 2002, the U.S. Food and Drug Administration (FDA) added buprenorphine to the list of approved medication for heroin and opioid addiction. Buprenorphine treatment in the form of a combination tablet of buprenorphine and naloxone has been found to be a safe and effective treatment. It has been shown to reduce cravings, heroin use, and the likelihood of overdose.5 Individuals who receive treatment for heroin addiction are less likely to be hospitalized or receive urgent care than those not in treatment.6
• Limited access to long-term treatment: Before 2000, medications for heroin addiction could only be dispensed in a traditional opioid treatment program (i.e., a methadone clinic). The Drug Addiction Treatment Act of 2000 expanded treatment options by allowing qualified physicians to dispense or prescribe approved medications in other treatment settings, including their own offices.7 Although this legislation was intended to promote access, the demand for heroin and opioid treatments still exceeds supply in many areas, including Baltimore, where physicians lack training for prescribing this medication, and community health providers lack experience and resources for providing this type of treatment.5 Although long-term treatment has been found to be most effective, service duration tends to be shortened when service capacity is insufficient.8

Background on Partnership
After the FDA's 2002 policy changes , the Mid-Atlantic Association of Community Health Centers (a primary care association), along with the Baltimore Health Centers, met with the Open Society Institute-Baltimore to discuss opportunities to increase the capacity and effectiveness of substance abuse services in Baltimore by engaging and mobilizing the existing community health care system. These stakeholders initiated a variety of early efforts to enhance access to buprenorphine treatment, including pilot testing of clinical protocols, provider training programs, and the development of new infrastructure to serve patients. These early efforts laid the groundwork for the creation of the BBI.

Planning and Development Process
Key steps in the planning and development process include the following:

• Assessment of system capacity: In 2002, Mid-Atlantic Association of Community Health Centers (MACHC) received a planning grant from the Open Society Institute-Baltimore (OSI) to conduct an analysis of substance abuse treatment in Baltimore. The assessment provided an in-depth understanding of the availability of services and how they were funded.
• Pilot efforts: With support from OSI, MACHC provided technical assistance to six community health centers over a period of 5 years to initiate or expand addiction services such as the administration of buprenorphine treatment. These efforts laid the foundation for BBI.
• Provider training: Medical providers were initially reluctant to incorporate substance abuse treatment into primary care settings. In 2004, a study was conducted by Med Chi, the Maryland Medical Society, to better understand the needs of physicians who were transitioning their practice to include buprenorphine treatment. Physicians reported the need for upfront and ongoing training, adequate reimbursement for services, better ties to substance abuse, mental health and community services, and support with administrative issues. A number of early training programs were developed to address these concerns and support physicians in their new role as continuing care providers. 
• City-wide effort launched: Building on the early efforts, the new Baltimore City Health Commissioner launched BBI as a city-wide effort in 2006, with a vision that embraced mobilizing the city's strong community health provider system and making medication available as part of the comprehensive services offered. Partnering with Baltimore Substance Abuse Systems, Inc. and Baltimore Healthcare Access, Inc., the three implementing agencies established clear roles for their collaboration. Baltimore City Health Department's role includes recruiting physicians to administer buprenorphine treatment. Baltimore Substance Abuse Systems, Inc. is responsible for providing guidance and overseeing contracts with the substance abuse treatment programs. Baltimore Healthcare Access, Inc. is involved in working with health insurers to expedite applications and coordinating care between substance abuse treatment programs and medical facilities

  ----------------------------
Foot Notes:

1 Substance Abuse and Mental Health Services Administration. Results from the 2003 National Survey on drug use and health: National findings. Rockville, MD: Office of Applied Studies, NSDUH Series H-25, DHHS Publication No. SMA 04-3964; 2004.
2 State of Maryland, Department of Health and Mental Hygiene, Alcohol and Drug Abuse Administration.  Outlook and outcomes for Maryland substance abuse prevention, intervention, and treatment, State of Maryland, 2006. Available at: http://www.maryland-adaa.org/content_documents/OandO/OandO2006.pdf
3 Institute of Medicine. Federal regulation of methadone treatment, First Edition. Washington DC:  National Academy Press; 1995.
4 Baltimore City Health Department Office of Epidemiology and Planning. Intoxication deaths associated with drugs of abuse or alcohol, Baltimore, Maryland January 1995 through September 2007. Baltimore, MD; January 2008. Available at: http://www.baltimorehealth.org/info/2008_01_24.IntoxicationDeaths.pdf
5 Baltimore City Health Department; Baltimore Healthcare Access, Inc. & Baltimore Substance Abuse System, Inc. The Baltimore buprenorphine initiative. Interim progress report.  Baltimore, MD; July 2007.
6 Center for Health Program Development and Management. University of Maryland, Baltimore County, Heroin Addiction Treatment Correlates in Maryland. March 12, 2007. Available at: http://www.hilltopinstitute.org/publications/Heroin_Addiction_Treatment_Correlates_in_Maryland-Revised_March_12_2007.pdf
7 Public Law 106-310
8 Baltimore Substance Abuse Systems, Inc. The Baltimore buprenorphine initiative. Second interim progress report. Baltimore, MD; June 2008.