Addressing Opioid Use Disorder in Vermont Barbara Cimaglio, Deputy - - PowerPoint PPT Presentation

Barbara Cimaglio, Deputy Commissioner, Alcohol and Drug Abuse Programs

October 2017

Addressing Opioid Use Disorder in Vermont

2002 2017

Today 2002 2004 2006 2008 2010 2012 2014 2016

First Methadone Clinic Opens (Chittenden Center)

2002

Buprenorphine Induction Hub Opened (CVSAS)

2004

Methadone in SE (Habit Opco)

2006

Patient Limits for Bup prescribers: 30 Year 1, then a max of 100

2006

PDMP (VPMS) data collection begins

2009

Hub and Spoke Model (Care Alliance)

2013

Safe Disposal of Unused Medication Rule

2013

Methadone in Rutland (West Ridge)

2013

Naloxone Pilot Begins

2014

Opioids for Chronic Pain Rule

2015

Acute Pain Prescribing Rules

2017

Buprenorphine Approved for MAT by FDA

2002

VT Prescribers use Buprenorphine

2003

Methadone in NEK (BAART)

2005

VT PDMP legislation passed

2006

Methadone in Central VT (BAART)

2008

MAT for Opioid Dependence Rules Enacted

2012

Opioids overtake alcohol as primary substance in treatment

2013

Good Samaritan Law Passed

2013

Mandatory PDMP/VPMS Registration

2013

VPMS Rule Updated

2015

MAT for Opioid Dependence Rules Updated

2016

Standing order for Naloxone at VT Pharmacies

2016

Timeline: Addressing Opioid Misuse and Addiction in Vermont

Vermont compared to National, Regional, and Best Practice Data

Perspective

Vermont Department of Health

The National Safety Council Categorized Vermont as One of Four States Making Progress in Strengthening Laws and Regulations Aimed at Preventing Opioid Overdose

Areas Assessed:

• Mandatory Prescriber Education
• Opioid Prescribing Guidelines
• Eliminating Pill Mills (VT doesn’t have

them but also doesn’t have legislation to eliminate/prevent them)

• Prescription Drug Monitoring Programs
• Increased Access to Naloxone
• Availability of Opioid Use Disorder

Treatment In Place Not in Place

Vermont Department of Health

Rate of Past Year Opioid Abuse or Dependence* and Rate of Medication Assisted Treatment Capacity with Methadone or Buprenorphine

Vermont Department of Health *Opioid abuse or dependence includes prescription opioids and/or heroin Source: AJPH 2015; 105(8):e55-63

Source: NSDUH 2003-2012 Source: N-SSATS 2003-2012

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All drug overdose deaths per 100,000 people decreased between 2013 and 2014

• 7.9%

73.9% 37.3% 18.8% 10.0% 4.5%

• 20.0%
• 10.0%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%

Percent change in deaths per 100,000 people 2013 to 2014

Vermont Department of Health

Source: CDC/ NCHS, National Vital Statistics System, mortality data. Includes opioids and other drugs

VT NH ME MA CT RI

7

New England Drug Overdose Deaths by State and Year

5 10 15 20 25 30

2010 2011 2012 2013 2014 Deaths per 100,000 Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont

Vermont Department of Health

Source: CDC/ NCHS, National Vital Statistics System, mortality

• data. Includes opioids and other drugs

8

Except for 2009, the Vermont Drug Overdose Rate per 100,000 is Not Statistically Significantly Different than the US

Vermont Department of Health

2 4 6 8 10 12 14 16 18 20 2009 2010 2011 2012 2013 2014

US VT

Source: CDC/ NCHS, National Vital Statistics System, mortality

• data. Includes opioids and other drugs

Vermont’s Death Rate Did Not Increase between 2013 and 2014

Vermont Department of Health

Source: CDC/ NCHS, National Vital Statistics System, mortality

• data. Includes opioids and other drugs.

Private Payer Average Cost per Person* with opioid use disorder in Vermont is lower than many other states

Average national private payer cost per person* with OUD in 2015 was

$63,356

Average Medicaid cost per person* participating in the Hub and Spoke system

• f care in Vermont in

2015 was

$16,402

Vermont Department of Health *All claims associated with the patient regardless of diagnosis Source: A FAIR Health White Paper, September 2016

Vermont has much higher access to buprenorphine both in the number of people receiving and the level of Medicaid Support

In Vermont, Medicaid funding is used by patients filling 68.1% of total buprenorphine prescriptions.

Vermont Department of Health Source: IMS Institute for Healthcare Informatics, September 2016

12

CDC Prevention Status Reports Ranking

Measure CDC Rating of Vermont Subsequent Action Requirement for timely data submission to prescription drug monitoring program Act 173 (2016) requires dispensers to report within 24 hours which is consistent with a “green” ranking. This will be implemented in 2017. Requirement for universal use of state prescription drug monitoring program VT has overly broad exceptions to use requirements.

Laws that applied only to limited classes of providers (e.g., only

• pioid treatment programs or pain clinics) or that had overly broad

exceptions (e.g., exempting prescriptions lasting 90 days or less), were not deemed as requiring PDMP checks in this report and were rated as red.

Act 173 (2016) requires licensing authorities to develop standards for acute and chronic pain. In order to be ranked “green”, prescribers must consult VPMS before initially prescribing opioid pain relievers and benzodiazepines, and at least every three months thereafter.

Vermont Department of Health

Source: CDC http: / / wwwn.cdc.gov/ psr/ ?state= Vermont 3/ 31/ 16

Research

Vermont Department of Health

14

Relationship between Nonmedical Prescription-Opioid Use and Heroin Use

 Increases in heroin use preceded efforts to address prescription

• pioid abuse and addiction

 Prescription monitoring programs  Law enforcement/regulatory  Abuse-deterrent formulations of prescription opioids  Public education campaigns  People engaged in the non-medical use of prescription opioids

rarely use heroin

 Primary causes in increase in heroin use & associated overdoses  Lower market prices  Higher purity for heroin Vermont Department of Health

Source: Compton WM., Jones CM, Baldwin GT. Relationship between Nonmedical

Prescription-Opioid Use and Heroin Use. N Engl J Med 2016; 374:154-163. http://www.nejm.org/doi/full/10.1056/NEJMra1508490

15

Higher doses of prescription painkillers increase risk of

• verdose

Vermont Department of Health

Source: AMDG 2015 Interagency Guideline on Prescribing Opioids for Pain

MED = Morphine equivalent dose

Evaluation

Vermont Department of Health

17

Retrospective System Evaluation

 Assessment of the Hub and Spoke system on:

 Clinical impact of the hub and spoke system

 Change in client functioning – substance use, mental health,

quality of life, living situation, employment, criminal activity

 Patient and family perception of services

 Interview process

 Access to Care

 Telephone survey of individuals waiting for services  Evaluation Cost: $199,200

 Timing: Began 8/2016. Results expected 1/2018

Vermont Department of Health

18

Proposed Prospective System Evaluation

 Differs from Retrospective Evaluation because

participants are recruited at admission to care with follow completed at 6 and 12 months thereby removing error related to client recall

 Clinical impact of the hub and spoke system  Change in client functioning – substance use, mental health,

quality of life, living situation, employment, criminal activity

 Expected Evaluation Cost: $1,500,000 plus

associated indirect rate (for UVM it’s approx. 50%)

 Currently seeking funds to allow this evaluation to be

completed

 Timing: Approximately 3 years to complete

Vermont Department of Health

19

DVHA/Blueprint Cost Analysis

 “Impact of Medication-Assisted Treatment for Opioid

Addiction on Medicaid Expenditures and Health Services Utilization Rates in Vermont” published in the Journal of Substance Abuse Treatment (August 2016)

 Highlights:

 Higher MAT treatment costs offset by lower non-opioid medical

costs

 MAT associated with lower utilization of non-opioid medical

services

 MAT suggested to be cost-effective service for individuals

addicted to opioids

 https://www.ncbi.nlm.nih.gov/pubmed/27296656

Vermont Department of Health

20

DVHA/Blueprint Data Linking

 Cost and service reporting for Medicaid hub and

spokes will be complete in December 2016

 Protocols and agreements are being developed to

link claims data with other data sources to determine impact of medication assisted treatment

• n:

 Corrections involvement  Employment

Vermont Department of Health

21

Results First

 VDH is reviewing the feasibility of completing a

cost/benefit analysis of medication assisted treatment

 Steps

 Create inventory of programs  Review which programs work based on independent

research

 Conduct cost/benefit analysis using actual Vermont costs  Use results to inform spending/policy decisions

 Cost/timeframe: tbd

Vermont Department of Health

22

Process Measure - Retention

 Retention in Treatment - Research indicates that most

addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best

• utcomes occur with longer durations of treatment.

Vermont Department of Health

50% 55% 60% 65% 70% 75% 80% 85% 90% 2012 2013 2014 2015 Percent Retained 90+ Days

90 Day Retention Rate for New Hub/Spoke Clients with Continuous Medicaid Enrollment by CY

Spoke Hub and Spoke Transfers Hub Total System

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CDC Grant Funded Ethnographic Evaluation of Opioid Hard Drug Users in Vermont

 Institutional Review Board approval and formative

research completed through July 2016

 Structured interviews of 300+ hard drug users

between three locations: Burlington, St. Johnsbury, Brandon completed August – October 2016

 After interviews are conducted, interviewees are linked

to services

 Draft report due Feb 2017.

Vermont Department of Health

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Patient level surveys of opioid use after surgery

 Dartmouth-Hitchcock researchers estimate that

patients need 43% of opioids prescribed after surgery (Sep. 2016)

 UVM is doing similar work. Data collection to end in

November 2016

Vermont Department of Health

Prevalence

Vermont Department of Health

26

Non-medical use of prescription pain relievers in Vermont

8 7 7 7 6 6 6 7 6 5 4 13 13 15 14 13 14 13 13 12 9 8 3 3 3 3 3 3 3 4 3 3 2 5 10 15 20 25 Percent of Vermont population reporting non-medical use of pain relievers in the past year by age in years. 12-17 18-25 26+

Source: National Survey on Drug Use and Health, 2003-2014

27

Vermont has one of the lowest rates of past year non- medical use of prescription pain relievers

 In 2013/2014 only two states had lower prevalence rates for

people age 12+ compared to 37 in 2010/2011. Number of states (and DC) with HIGHER prevalence rates of non-medical use of prescription pain relievers (NSDUH) by age group:

Vermont Department of Health

Age 2010/2011 2013/2014 Age 12-17 21 46 Age 18-25 7 38 Age 26+ 34 51 All (12+) 14 49

Vermont rates have decreased in all age groups between 2010/2011 and 2013/2014

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Lifetime Heroin Use of 9th – 12th Graders Has Decreased

3% 3% 2% 2% 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 2009 2011 2013 2015 Percent of Students

Vermont Department of Health

Source: Youth Risk Behavior Survey

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Percent of Adults Who Report Prescription Drug Misuse

Vermont Department of Health

9% 9% 7% 7% 8% 8% 6% 7% 1% 1% 1% 1% 1% 1% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 2007 2008 2009 2010 2011 2012 2013 2015

Percent of adults (18+) who report prescription drug misuse by frequency and year

Ever used Rx Drug w/o Own Rx Past 30 Days Rx Drug w/o Own Rx

Source: Behavioral Risk Factor Surveillance System

Changes in Prescribing

Vermont Department of Health

31

VPMS Patients meeting thresholds for proactive reporting

Sources: Vermont Prescription Monitoring System



Since 2010, the number of patients identified by VPMS’s as visiting multiple prescribers and/or pharmacists has declined steadily.

722 624 466 432 339 310

2010 2011 2012 2013 2014 2015

32

32

Number of Prescriptions by Drug Type and Year



Opioids account for approximately 48% of the controlled substances dispensed in VT on an annual basis. Sedatives account for approximately 26%.



The adjusted opioid prescription total indicates that fewer opioid prescriptions were dispensed in 2015 Source: Vermont Prescription Monitoring System

482,572 502,566 513,773 509,057 538,403 601,506 281,624 284,571 287,121 289,756 291,011 291,833 111,203 128,169 150,617 164,655 173,199 185,315 498,973

2010 2011 2012 2013 2014 2015

Total Number of Controlled Substance Prescriptions by Drug Type and Year

Opioids Sedatives Stimulants Adjusted Opioids

Note: The 2015 Annual Report reflects the first full year of VPMS data with tramadol reclassified from a Schedule V to a Schedule IV drug. Its inclusion in VPMS data due to this reclassification resulted in an increase of 82,992 opioid prescriptions being reported to VPMS 2015. Additionally, the White River Junction Veterans Affairs Medical Center began uploading to VPMS in March of 2015. It uploaded 19,541 opioid prescriptions in 2015. Had these two new data sources not been provided to VPMS in 2015, the number of opioid prescriptions would have decreased for the first time since 2010. (See the Adjusted Opioids trend line.)

33

33

Number of Recipients by Drug Type and Year



Opioids were dispensed to more recipients than any other drug type, followed by sedatives and stimulants.



The number of people receiving opioids has decreased since 2010

Source: Vermont Prescription Monitoring System

124,814 120,668 119,125 115,333 118,802 116,617 64,854 65,833 66,263 65,830 66,852 64,550 18,023 21,054 22,418 23,464 23,825 22,081

2010 2011 2012 2013 2014 2015

Total Number of Controlled Substance Recipients by Drug Type and Year

Opioids Sedatives Stimulants

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34

Number of Opioid Prescriptions per 1,000 Vermonters by Type

49 52 50 53 172 179 175 172

20 40 60 80 100 120 140 160 180 200

2015 Q1 2015 Q2 2015 Q3 2015 Q4

Buprenorphine (MAT) Analgesics (pain)

Vermont Prescription Monitoring System

35

35

Percent of Patients Receiving More than an Average Daily Dose of >90 Morphine Milligram Equivalents

69.3% 69.7% 70.7% 70.8% 12.5% 12.2% 11.8% 12.1%

0% 10% 20% 30% 40% 50% 60% 70% 80%

2015 Q1 2015 Q2 2015 Q3 2015 Q4

Buprenorphine (MAT) Analgesics (pain)

Vermont Prescription Monitoring System

36

36

Changes in Prescription and Recipient Totals by Drug Type

% Change – Prescriptions Change in # of Prescriptions % Change - Recipients Change in # of Recipients Opioids 25% 118,934

• 7%
• 8,197

Sedatives 4% 10,209 0%

• 304

Stimulants 67% 74,112 23% 4,058 Hormones 90% 5,481 50% 934 Cannabinoids 104% 750 75% 149 Changes in Prescription and Recipient Totals by Drug Type from 2010 to 2015

Sources: Vermont Prescription Monitoring System & U.S. Census



There were fewer opioid and sedatives recipients in 2015 than 2010 despite the increase in prescriptions associated with these drug types during the same time.



There were marked increases of both prescriptions and recipients in the stimulant, hormone, and cannabinoid drug types in 2015 than 2010.

Note: The 2015 Annual Report reflects the first full year of VPMS data with tramadol reclassified from a Schedule V to a Schedule IV drug. Its inclusion in VPMS data due to this reclassification resulted in an increase of 82,992 opioid prescriptions being reported to VPMS 2015. Additionally, the White River Junction Veterans Affairs Medical Center began uploading to VPMS in March of 2015. It uploaded 19,541 opioid prescriptions in 2015.

37

Opioid Prescription Total by Year and Clinical Application



Opioid prescriptions can be broken down into two broad categories based on their clinical application:



Analgesics are prescribed to treat pain



Opioids used in medication-assisted treatment (MAT drugs) are prescribed to help treat opioid addiction

All Opioids Analgesics MAT Drugs 2010 482,572 410,600 71,972 2011 502,566 415,846 86,720 2012 513,773 416,204 97,569 2013 509,057 405,953 103,104 2014 538,403 426,007 112,395 2015 601,506 470,008 131,494 Total Number of Opioid Prescriptions by Year and Clinical Application

Sources: Vermont Prescription Monitoring System

Note: The 2015 Annual Report reflects the first full year of VPMS data with tramadol reclassified from a Schedule V to a Schedule IV drug. Its inclusion in VPMS data due to this reclassification resulted in an increase of 82,992 opioid prescriptions being reported to VPMS 2015. Additionally, the White River Junction Veterans Affairs Medical Center began uploading to VPMS in March of 2015. It uploaded 19,541 opioid prescriptions in 2015.

Treatment

Vermont Department of Health

39

Pre and Post Hub and Spoke numbers served Pre Hub/Spoke - 2350

 OTP numbers served (4/2012): 650 (source: SATIS)  OBOT Medicaid served (4/2012): 1700 (Source: Medicaid Claims)

Post Hub/Spoke – 5792 (246% increase)

 Current OTP served (6/16): 3171 (Source: Hub Census Report)  Current OBOT Medicaid Served (6/16): 2621(Source: Blueprint

Spoke Report)

Note: In 2015, over 5000 individuals received at least one prescription for an anti- addiction drugs dispensed by pharmacies, the overwhelming majority of which were for buprenorphine products. Source: VPMS

Vermont Department of Health

40

The statewide number of people waiting for opioid use disorder treatment in hubs has trended downward over time; the number of people served in hubs has increased

500 1000 1500 2000 2500 3000 3500

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16

Number of People in Hubs and Waiting for Hub Services Over Time

In Treatment Waiting

Vermont Department of Health

Source: Alcohol and Drug Abuse Treatment Programs

41

The number of individuals using heroin at treatment admission is increasing faster than for other opioids/synthetics

1,000 2,000 3,000 4,000 5,000 6,000 7,000

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Number of people treated in Vermont by substance

Alcohol Marijuana/Hashish Heroin/Other Opioids All Others

Source: Alcohol and Drug Abuse Treatment Programs

42

The number of individuals using heroin at treatment admission has increased in the last five years

500 1000 1500 2000 2500 3000 3500

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Number of People Treated by Type of Opioid Being Used on Admission to Treatment

Heroin Other Opioids/ Synthetics Non-prescription Methadone

Source: Alcohol and Drug Abuse Treatment Programs

Primary Opioid of Abuse- Gender

200 400 600 800 1000 1200 1400 1600 1800 200720082009201020112012201320142015

Primary Substance by State Fiscal Year

Heroin Non-prescription Methadone Other Opiates/Synthetics

FEMALES MALES

Vermont Department of Health

200 400 600 800 1000 1200 1400 1600 1800 200720082009201020112012201320142015

Primary Substance by State Fiscal Year

Heroin Non-prescription Methadone Other Opiates/Synthetics

Data Source: SATIS

44

Age of Medicaid Recipients With at Least One Primary Opioid Diagnosis or Buprenorphine Prescription by CY

0% 10% 20% 30% 40% 50% 60% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Percent of Opioid Recipients in the Year 12-17 18-24 25-34 35-44 45-54 55+

Vermont Department of Health

Claims with Primary Opioid Diagnosis (304.00, 304.01, 304.02, 304.03, 304.7, 304.71, 304.72, 304.73, 305.5, 305.51, 305.52, 305.53, F11), procedure code H0020 or MAT prescriptions (Buprenorphine, Subutex, Suboxone, Vivitrol, Bunavail). Excludes Lab Claims. Excludes drug poisoning. Not adjusted for eligibility.

45

Average Age at Admit Over Time (SATIS)

27.7 27.8 28.2 28.5 28.4 28.5 29.3 28.9 28.5 29.1 29.6 29.1 29.5 28.7 28.9 28.8 28.5 28.9 29.0 29.7 30.9 31.5

25 26 27 28 29 30 31 32 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Primary Heroin Primary Rx Opiates

* * Vermont Department of Health *2014 significantly greater than 2004

Source: Alcohol and Drug Abuse Treatment Programs

46

Median Time to Treatment from Age of First Use

16 7 6 16 4 7 2 4 6 8 10 12 14 16 18 Alcohol Heroin Other Opioids

Years 2009-2011 2012-2014

Vermont Department of Health

Source: Alcohol and Drug Abuse Treatment Programs

47

Percent IVDU 2004-2014 (SATIS)

80.5% 81.9% 77.2% 73.1% 72.6% 75.7% 76.7% 74.8% 74.6% 76.5% 76.1% 18.5% 21.6% 24.8% 20.7% 21.6% 21.0% 23.3% 24.9% 25.7% 22.2% 23.2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Primary Heroin Primary Rx Opiates

Vermont Department of Health

Source: Alcohol and Drug Abuse Treatment Programs

Other State Data

Vermont Department of Health

49

Drug-Related Fatalities Involving Opioids

41 61 50 69 61 76 38 47 37 45 25 32 9 9 20 34 34 5 5 6 12 18 29 2010 2011 2012 2013 2014 2015 Total number of accidental and undetermined manner drug-related fatalities involving an opioid (categories not mutually exclusive) Total opioid Rx opioid Heroin Fentanyl

Source: Vermont Department of Health Vital Statistics System

50

For every 1 fatal opioid overdose in VT there are:

2 3 5 18 64 113 235 1,482

infants born exposed to opioids emergency department visits for opioids community opioid reversals EMS overdose calls needle exchange members people receiving at least one MAT service for OUD nonmedical rx opioid users people receiving at least one rx for analgesics

Vermont Department of Health

51

Naloxone

333 566 471 600 589 815 664 732 51 184 264 426 434 618 938 1038

Jan-Mar 2014 Apr-Jun 2014 Jul-Sep 2014 Oct-Dec 2014 Jan-Mar 2015 Apr-Jun 2015 Jul-Sep 2015 Oct-Dec 2015

Number of doses dispensed to clients by client type, quarter and year

New Returning 8 32 31 51 68 85 145 102

Jan-Mar 2014 Apr-Jun 2014 Jul-Sep 2014 Oct-Dec 2014 Jan-Mar 2015 Apr-Jun 2015 Jul-Sep 2015 Oct-Dec 2015

Number of reports of naloxone use in response to a perceived overdose incident

Source: Vermont Department of Health Naloxone Pilot Program

52

Needle exchange members

1,612 2,072 2,802 3,749 4,315 4,860

1,000 2,000 3,000 4,000 5,000 6,000

2010 2011 2012 2013 2014 2015

Total number of syringe exchange members by year

Vermont Department of Health

53

Burlington “Drug Take Back” Results

84.7 92.8 90.1 72.2 91 15.3 7.2 9.9 27.8 9 10 20 30 40 50 60 70 80 90 100 Apr 2012 Sep 2012 Oct 2013 Apr 2014 Apr 2016

Percent

Nonscheduled Scheduled

Vermont Department of Health

Examples of press and data dissemination

Recognition

Vermont Department of Health

55

Vermont Recognition

 Association of State and Territorial Health Officials

• Maximizing Public Health Partnerships with

Medicaid to Improve Health case study.

http://www.astho.org/Health-Systems-Transformation/Medicaid-and-Public-Health-Partnerships/Case-Studies/Vermont-MAT- Program-for-Opioid-Addiction/

 NYT: Vermont Tackles Heroin, With Progress in

Baby Steps http://www.nytimes.com/2015/02/26/us/as-vermont-tackles-heroin-addiction-progress-is-

measured-in-baby-steps.html

 Boston Globe: In Rutland, Vt., a rare glimmer of

hope in battle against opioid addiction

https://www.bostonglobe.com/metro/2015/10/26/rutland-makes-gains-opioid- battle/0xJPia7xu1mQDI3jpFUPVK/story.html

Vermont Department of Health

56

Data Dissemination

 AIDS Education & Training Center Southeast: “Hub and Spoke:” Vermont’s

Framework for Medication Assisted Treatment for Opioid Addiction http://www.seaetc.com/events/event/hub-and-spoke-vermonts-framework- for-medication-assisted-treatment-for-opioid-addiction/

 Journal of Substance Abuse Treatment: Impact of Medication-Assisted

Treatment for Opioid Addiction on Medicaid Expenditures and Health Services Utilization Rates in Vermont http://www.ncbi.nlm.nih.gov/pubmed/27296656

 American Assoc. for the Treatment of Opioid Dependence, Inc.: Integrated

Service Delivery Models for Opioid Treatment Programs in an Era of Increasing Opioid Addiction, Health Reform, and Parity http://www.aatod.org/wp-content/uploads/2016/07/2nd-Whitepaper- .pdf

Vermont Department of Health

57

For additional Information

Vermont Department of Health Division of Alcohol and Drug Abuse Programs

Website: http://www.healthvermont.gov/adap/treatment/opioids/index.aspx For questions about the slides contact Anne Van Donsel Anne.VanDonsel@Vermont.gov

Vermont Department of Health