Medication-assisted treatment: an update from Missouri

April 28, 2015

Maureen Fitzgerald
Communications Coordinator, ATTC Network
Editor, NIATx

In the April 2015 NIATx E-news, Mike Boyle shared results of recent studies on use of medication-assisted treatment (MAT). Overall results suggest that a lot of work remains to be done in order for MAT to gain wide acceptance.

But MAT is firmly established in states like Missouri, which was among the first states to make a commitment to providing MAT.

Mark Stringer, Director, Division of Behavioral Health at the Missouri Department of Mental Health (DMH) says his state’s involvement with a NIATx program, Advancing Recovery (AR) helped build the foundation the MAT program that exists toda. Stringer also serves as the state's Single State Authority.

As a participant in AR, funded by the Robert Wood Johnson Foundation, Missouri started to offer naltrexone and acamprosate for alcohol use disorders in 2006. (See the new SAMHSA publication, Medication for Treatment of Alcohol Use Disorder: A Brief Guide.)  In 2009, the DMH (then known as the Divisions of Alcohol and Drug Abuse and Comprehensive Psychiatric Services) secured state funding for MAT, and it also made offering MAT a condition for state contracts and certification. 
 (Read more about how Missouri reduced barriers to the use of naltrexone and acamprosate for alcohol dependence in the NIATx publication, Getting Started with Medication-assisted Treatment.)

Stringer and Nora Bock, Director of Adult Community Treatment Services at the Missouri DMH, were both involved in the Advancing Recovery Project. I caught up with them recently to find about current use of MAT in Missouri, and what other states can learn from the Missouri experience.

Today, Missouri continues to require that providers either provide a variety of addiction medications or arrange to provide them by establishing a referral arrangement if they want to be contracted or certified with the state.

For Stringer and his team, it’s an ethical issue.

“We now have FDA-approved medications that are very effective for some people with an SUD, and our certification standards require that pharmacotherapy be made available where its appropriate and helpful,” says Stringer. “We owe it to our patients to offer them medication.”

Stringer sees acceptance of MAT as a process of evolution, comparing it to what happened when anti-depressants first became available. “There was a lot of resistance initially because mental health treatment at the time was based on talk therapy,” he comments. “Medication represents a new way of treating addiction as a disease.”

Have attitudes toward MAT in Missouri changed since the 2010 publication of Getting Started with Medication-Assisted Treatment?  Nora Bock thinks so.

“The message has been driven home for so long in Missouri that it’s becoming part of the vernacular, and clinicians and people in the community have had plenty of time to see successes with the various forms of MAT,” she says.

Stringer and Bock agree that client success with various forms of MAT has helped to change attitudes. 

Finding physician prescribers for medications such as buprenorphine is an ongoing challenge, but Stringer emphasizes the progress that’s been made in the last decade.
“When we first added offering MAT as a requirement, many of our substance use treatment providers did not have medical directors or physicians on staff. It’s been a struggle, but they really have come a long way,” he says. 

Patients have played a role in promoting use of MAT by asking their family physicians to obtain the DATA 2000 waiver, or asking them to prescribe naltrexone or acamprosate for alcohol use disorders.

Educating providers has helped with MAT adoption in Missouri, says Bock. The DMH offers an MAT website for providers that includes MAT videos, information on approved medications, and other helpful resources. Regional representatives from the Division of Behavioral Health also have regular discussions with agencies about removing barriers to MAT, and quarterly reports on MAT utilization show who is using medications and who is not.  Explains Bock, “The reports show use of MAT and if providers are using a variety of medications. Some may not yet have access to a Suboxone prescribing physician, but we expect them to provide other medications and to establish a referral relationship for prescribing.”

Stringer and Bock credit their participation in Advancing Recovery as essential to launching MAT in Missouri. “The grant award of $250,000 that we received was small by some standards, but it’s proven to be worth 10 times that in terms of change for our system,” says Stringer.

AR also helped the state identify the following elements for establishing and sustaining its MAT program:

1. Clear Expectations.  Says Stringer, “Our team set the expectation that in Missouri’s publicly funded behavioral health system, implementing MAT was not a question of if, but when. “

2. Provider relationships. Because DBH had a good relationship with providers, setting the MAT requirement did not create an adversarial relationship. “The feeling was and continues to be that we are all in this together,” says Stringer.

3. Funding. “One of the biggest obstacles to MAT is finding funding for it,” says Bock. 
"With the Advancing Recovery project, it helped that Mark asked for funding at the legislative level that we could dedicate to MAT,” she explains. “Getting state funding gave MAT more legitimacy, which in turn can help in changing attitudes.”

Funding for medications continues to be a challenge, however, and Missouri has addressed this by building relationships with other stakeholders.

 “Reaching out to other stakeholders and letting them know the effectiveness and potential costs savings is important,” says Bock. “Having a good relationship with the state Medicaid agency made it easier to have the addiction medications added to the Medicaid formulary.” 

Looking ahead, Missouri is pursuing funding via a SAMHSA grant to expand MAT for opioid dependence. Stringer and Bock also anticipate an increase in the use of addiction medications in mental health settings. 

“Even in agencies that offer both mental health and substance use disorder treatment, silos remain,” says Bock. “Some mental health providers know very little about what substance use disorder providers do, and vice versa. We’re really at the point of connecting the dots and emphasizing the appropriate treatment of co-occurring disorders.”

Stringer and Bock agree that one of the biggest challenges on the horizon is integration of SUD treatment with primary care. “There will always be a need for specialty addiction care,” says Stringer, “but we can help many people find recovery through sound office-, clinic-, and hospital-based practice that includes screening, assessment, counseling, medication, and support groups.”

Bock adds that in true integration, the door swings both ways. “Our specialty programs will only get stronger as they increase their medical capacity for providing not just medication- assisted treatment but also comprehensive care for the whole person.”

For more information about medication-assisted treatment and related ATTC Network resources for education and training, visit:
Your Doctor Understands Your Addiction
NIDA-SAMHSA Blending Initiative: Buprenorphine Treatment
Prescription Opioid Addiction Treatment Study (POATS)

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