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Medication-Assisted TherapyVivitrol Pilot
NJ Division of Addiction ServicesOverview Overall DAS has a goal to develop a systemof care that consistently offers clients themeans to enter and sustain recoveryTo this end DAS promotes evidence basedpractices in the treatment of addictionsOne initiative in this area is the Vivitrol Pilotto support recovery needs of the high riskDUI offender
What is Vivitrol? Injectable form of NaltrexoneOnce monthly dosingFDA approved 2006Manufactured by Alkermes, Inc.An evidence-based practice - SAMHSATreatment Improvement Protocol #49:“Incorporating Alcohol Pharmacology intoMedical Practice”
BENEFITS OF INJECTABLENALTREXONE:–––––––Reduces cravingsDecreases impulsivityEnhances motivationImproves treatment adherenceEliminates daily adherence decisionsSingle injection is effective for four weeksRapid onset of therapeutic effect in the first 2days
Outcome MeasuresVivitrol Pilot Improved client outcomesDecreased recidivism DUIIReduced treatment costs per clientReduced treatment episodes for DUIoffenderIncreased capacity for new admissions
NJ Division of Addiction ServicesVivitrol Pilot Objective:– Provide an evidence-based interventionfor the alcohol dependent DUI offenderwho is at risk for further offenses– Survey, monitor, and report outcomesspecific to this high risk population
How We Are Spending DUII Resources2009 DUII Costs and Number of therDTXCosts10% clients use 50% of resources on STR50% of clients use 32% of resources on OTPDTX2.7Clients
NJSAMS DUII Clients Primary DrugPrimary 4.41613.8Opiate-Other70.42511032.4Other 00OxycontinTotalData source: NJSAMS April,2010 download
LOCs for DUII Funded STR Clients withMultiple ox-Free Standing Res16234.3Detox-Hospital Inpatient102.1472
DUII Funded STR Clients with MultipleAdmissions Of the 472 STR clients, 199 had multipleadmissions 47% of the readmissions were to STR and34.3% was to III.7D Detox Free StandingResidential
National Quality ForumVoluntary consensus standards-setting organizationthat addressed the need for performance measuresand other standards to improve healthcareIncludes:-consumer and patient groups-healthcare purchasers-healthcare providers and professionals-research and quality improvement organizations
National Quality Forum“Pharmacotherapy should be offered andavailable to all adult patients diagnosed withalcohol dependence”.“Pharmacotherapy, if prescribed, should beprovided in addition to, and directly linkedwith, psychosocial treatment/support.”2007 NQF consensus report on national voluntary consensus standardsfor the treatment of substance use conditions – Practice #9
Literature SurveyWhile previous studies have shown the benefit ofusing naltrexone as part of a combinedbehavioral intervention*, oral naltrexone, “hasnot been widely prescribed at least in partbecause of inconsistent adherence with oraltherapy.”*** Donnovan, D., Anton, R. F., Miller, W. R. et al. (2008). Combined pharmacotherapies andbehavioral interventions for alcohol dependence: examination of posttreatment drinkingoutcomes. Journal of studies on alcohol and drugs 69(1) 5.** Kranzler, H. R. (2006). Extended-release intramuscular naltrexone. Drugs 66(13) 1754.
Literature SurveyThe intramuscular administration ofnaltrexone offers less psychotherapeuticlimitations over its oral form and has ledresearchers to conclude that, “Vivitrol hasdemonstrated efficacy at decreasing heavydrinking among alcohol-dependent males.”Johnson, B.A. (2007). Naltrexone long-acting formulation in the treatment ofalcohol dependence. Therapeutics and clinical risk management 3(5) 741-9.
Literature SurveyAdditional study references regardingVivitrol, as well as extended-releasenaltrexone, can be found in SAMHSA TIP#49, “Incorporating AlcoholPharmacotherapies Into Medical Practice”and its accompanying “A Review of theLiterature” addendum.
What have we done?NIAAA and CSAT:––Recommended a “naturalistic” studySuggested survey tools: –COMBINEOffered technical assistance throughout the pilot
What have we done?Florida Advancing Recovery Partnership (Vivitrol): Achieved positive client outcomes related to: Continuation of substance abuse treatment Increased independent living Improved employment and Decreased recidivism (2/3) 64% decrease in cost compared to priortreatment
What have we done? Florida Advancing Recovery PartnershipVivitrol:–––Positive consumer satisfactionImproved compliance with other medicationsDetox included in initial pilot: Clients refused medicationDetox staff needed additional trainingWidening scope to include residential programs provedmore successful to client participation
What have we done?Site visits with Agencies currently providing:DrenkPreferred Behavioral HealthMt Olive Counseling ServicesBergen Regional (next week)
What have we done?Vivitrol Training at the Medical DirectorsMeetingScheduled training for all medical staff:November 10, 2010 at DHS
What have we done?Client Phone Interviews:Soreness in injection site“Benefits outweigh the negative”Reduced cravingFearful of losing funding for VivitrolClient tested: no effects of alcoholfelt sober
What have we done?Surveyed DUII outpatient agencies to assessreadiness:1/3 expressed readiness or currently providing1/3 interested, technical assistance requested1/3 indicated no interest
DAS IDP Vivitrol PilotDesignDUII NetworkVivitrol Subnetwork
Vivitrol Network Requirements Agree to pilot termsA Physician or a New Jersey certifiedAdvanced Practice Nurse employed by theMedication Assisted Treatment /VivitrolNetwork approved provider.All counseling services must be provided inaccordance with DAS and DCA regulation.
Network Agency Requirements Patient Education PacketPatient Consent–– PilotMedicationPatient Survey and reportingClient charts for monitoring review
Network Agency RequirementsClient consent and participation:Informed and voluntaryMay leave pilot at any time:––medication will no longer be fundedcontinued treatment may be fundedSuccessful treatment completion:may continue medication with one one-hour face toface session monthly until medication iscompleted
Network Agency RequirementsSubmit policy and procedures regarding pilotparticipationSubmit policy and procedures regardingmedication assisted therapySubmit affiliation agreements with continuingcare providers
Network Agency RequirementsOpen account with wholesale medicaldistributor DAS will provide list (18 distributors) DAS reimbursed through DUII
Network Agency RequirementsWhat additional requirements doyou recommend?
Vivitrol Service PackageSix month maximum enhancement to existingtreatment costs per client: 4,235 - medication - (five units each) 208 - medical services:– 1 20 minute initial physician visit– 5 ten minute medicationmonitoring/injection visits– 3 Liver Functioning Tests
Vivitrol Service Package continued 144 Case Management:– One hour Orientation: Patient information regarding both pilotand medication, and completion ofconsent and survey-30 minutes for linkage to outpatient(residential)– up to six additional 15 minute sessionssurvey completion and follow up(outpatient)
Vivitrol Service PackageWhat additional services do yourecommend?
DAS Vivitrol PilotPatient Eligibility Criteria 100 voluntary participantsAlcohol Dependent DiagnosisAge 21 and upDriving Under the Influence Initiative (DUII)eligible
Patient Eligibility CriteriaDo you have any other suggestionsregarding patient eligibility?Do you think DAS should equallyallocate resources among 1st, 2ndand multiple offenders?
Induction At discharge from residential setting–– Within one weekIncludes linkage to outpatient settingNew admission in outpatient setting–Within two weeksAll subsequent doses will be administered inoutpatient settings
InductionDo you suggest any otherconsiderations for the inductionprocess?
POTENTIAL FOR COST SAVINGS
Current DUII UtilizationThe average second and multiple offenderper client cost*:––residential and outpatient treatment services: 10,836 per yearresidential only treatment: 10,808 per year* Per NCADD Billing Data for FY2010
MICHAEL’S LAWTHIRD OR SUBSEQUENT OFFENDER:shall be sentenced to imprisonment for aterm of not less than 180 days in acounty jail or workhouse, except that thecourt may lower such term for each day,not exceeding 90 days, servedparticipating in a drug or alcoholinpatient rehabilitation program
MICHAEL’S LAW COST TO NJPer client 9,450 for 90 days incarceration 6,120 for 90 days lt residential tx 15,570 total cost without enhancementsOR: 18,900 for 180 days incarceration 1,152 minimum 16 weeks outpatient 20,052 total with minimum treatment Per client cost 8,508 includes Vivitrol, IOP, OP
Total Pilot Costs 458,700. Estimated cost of medication for all clients 423,500 (5 units of medication per client)Estimated cost of medical services at networkprovider agencies 20,800Cost of Case Management at network provideragencies- 14,400
Questions/Feedback
Bergen Regional (next week) What have we done? Vivitrol Training at the Medical Directors Meeting . Scheduled training for all medical staff: . First injection at detox discharge offers the client awaiting a referral to the next l\ vel of care offers a benefit and incenti
