Transcript Research Poster 36 x 60 - D - Ncadd-NJ

New Jersey Medication Assisted Treatment Initiative (MATI):
Twelve Month Outcomes
Jude Iheoma, Ph.D. 1; Robert Culleton; Ph.D. 1; Suzanne Borys, Ed.D. 1;
Charles Neighbors, Ph.D. 2; Sarah Dauber, Ph.D. 2 ; Gerod Hall Ph.D. 2; MerriBeth Adams, Ph.D. 4, Jon Morgenstern, Ph.D 2 3
1 Division of Mental Health and Addiction Services (DMHAS) of the State of New Jersey; 2 The National Center on Addiction and Substance Abuse
(CASA) at Columbia University; 3 Department of Psychiatry, Columbia University Medical Center;
4 The National Council on Alcoholism and Drug Dependence: New Jersey.
INTRODUCTION
The Bloodborne Disease Harm Reduction Act (P.L.
2006, c.99) was signed into law by Governor Jon
Corzine on December 19, 2006. This law made
New Jersey the 50th state in the nation to enact
what is commonly called “Needle Exchange”
policy. The law requires the Department of Health
and Senior Services (DHSS) to establish a
demonstration program that would permit up to six
municipalities to operate a sterile syringe access
program in accordance with the provisions of this
act. In addition, the law appropriates $10,000,000
from the General Fund annually to the Department
of Human Services (DHS), Division of Mental
Health and Addiction Services (DMHAS), for
inpatient and outpatient drug abuse treatment
program slots and outreach. Underlying the
impetus for funding is that novel systems reengineering and intervention strategies are needed
to combat the numerous obstacles to engaging
and retaining high risk IV drug users in treatment.
The Division of Mental Health and Addiction
Services of the State of New Jersey (NJ-DMHAS)
developed a pilot demonstration project entitled
“The Medication Assisted Treatment Initiative”
(MATI). This innovative project is designed to
provide medication assisted treatment and
supportive housing to the indigent, non-insured
syringe exchange program population without
access to treatment via mobile medication units
and office based services. The program has been
in progress for 41 months at six community and
two supportive housing sites across New Jersey.
A total of 3,225 clients, with a mean age of 42, of
whom 36% were female, were served.
METHOD
MATI Program Eligibility: (1) Household income at or below 350% of the Federal
Poverty Level; (2) Resident of New Jersey; (3) History of injection drug use; (4) Test
positive for opiates; (5) Proof of identification; (6) Not currently enrolled in Opioid
Replacement Therapy; and (7) Uninsured.
Evaluation Participants: Participants were N = 542 individuals enrolled in opioid
replacement treatment and counseling across the six MATI sites in New Jersey. See
Figure 1 for site characteristics and Table 1 for demographic characteristics.
Study Procedures: Program clients were offered the option to participate in the
evaluation by their intake counselor or case manager upon treatment program entry. If
interested and eligible, potential participants met with a research assistant located at
either the office base clinic or stationed on the mobile medication unit. Eligibility criteria
for the evaluation study included: ability to read in English at least at an 8th grade level,
current enrollment in treatment, and provision of informed consent. Participants were
rescheduled if they were intoxicated at the time of the interview. Clients agreed to be
interviewed once every six months for 18 months, provide at least one collateral
contact, and provide urine toxicology results for objective data verification. Each
interview lasted approximately 90 minutes. Participants were informed that data from
the evaluation was confidential and completely separate from their treatment.
Measures: Addiction Severity Index (ASI; McLellan et al., 1992); the Treatment
Services Review (McLellan, Alterman, Woody & Metzger, 1992); AIDS Risk Assessment
Scale (Simpson et al., 1994); and a measure created by our team examining treatment
access and barriers to care.
Data Analysis: Study participants were stratified according to referral source (needle
exchange or self-referral) or the opiate medication prescribed at baseline (methadone
or suboxone) for purposes of comparing differences in baseline characteristics and
outcomes at twelve months (see needle exchange vs. self-referral and Methadone vs.
Suboxone tables). Of the 542 evaluation participants, 417 completed a 12-month
follow-up interview and are included in the outcome analyses presented.
SITE CHARACTERISTICS
Paterson (N=105; 19%)
Received NE Services = 89%
Percent Suboxone = 23.1%
Newark (N=94; 16%)
Received NE Services = 66%
Percent Suboxone = 22.8%
Trenton (N=75; 14%)
Received NE Services = 4%
Percent Suboxone = 31.5%
EVALUATION AIMS
The National Center on Addiction and Substance
Abuse (CASA) at Columbia University is
evaluating this pilot program at all six
demonstration and two supportive housing sites by
conducting interviews with a sample of 542
mobile medication unit clients and 71 supportive
housing clients over an 18 month period.
Administrative records will also be used to
examine differential outcomes between those
enrolled in MATI and traditional Methadone
programs using a matched sample design.
This poster presentation will focus on 12 month
recovery outcomes based on the opiate
medication prescribed at baseline, as well as
whether participants were referred from needle
exchange or self-referred.
CONTACT
NJDMHAS: Jude Iheoma,: [email protected]
CASA: Charles Neighbors: [email protected]
NCADDNJ: MerriBeth Adams: [email protected]
Poster Design & Printing by Genigraphics® - 800.790.4001
BASELINE CHARATERISTICS
Plainfield (N=102; 19%)
Received NE Services = 21%
Percent Suboxone = 23.2%
Camden (N=84; 16%)
Received NE Services = 70%
Percent Suboxone = 35.1%
Atlantic City (N=84; 16%)
Received NE Services = 44%
Percent Suboxone = 48%
MOBILE UNIT
DISCUSSION
Sample Demographics
Male
60%
Ethnicity: Hispanic/Latino
White
25%
Black
58%
Less than HS/GED
65%
Homeless or temporary housing
Days used heroin in past 30, mean (SD)
32%
The MATI program is one of the first to implement a multi-method approach to engage
and retain high risk IVDUs in opioid replacement treatment. The majority of individuals
were referred from needle exchange programs highlighting that programs that
structure inter-agency cooperation can produce successful referrals to care.
36%
Most participants had extensive treatment histories and reported obstacles to
obtaining treatment in the general categories of personal motivation, financial,
difficulties and long waitlists. These reasons highlight that the goals of the program
were well-suited to this population. Of those who had been to treatment in the past,
>80% reported that it was easier to obtain treatment through the MATI program.
24 (11)
The 12-month follow-up data reveal how the strategies employed influenced positive
outcomes.
12- MONTH OUTCOME OVERVIEW
Days Heroin Use in the Past 30 days
•
•
•
•
69% decrease in the prevalence of heroin use
Heroin use declined by approx. 20 days per month averaging across all participants
In New Jersey the average user spends about $200 per day on heroin
20 day reduction in use is equivalent to ~ $5 million reduction in spending on heroin in 1 year
Times Injection Drug Use in the Past 30 days
How does providing treatment on demand to uninsured populations impact long-term
outcomes?
• At 12-month follow-up, MATI clients demonstrated reduced heroin use,
decreased injection drug use and needle sharing, decreased illegal activity and
days detained or incarcerated, and reductions in Emergency Room use.
• 78% decrease in the prevalence of injection drug use
• 72% decrease in the prevalence of needle sharing
• These positive outcomes were associated with significant cost savings.
Illegal Activity for Profit in the Past 30 days
• 70% decrease in the proportion of clients engaged in illegal activity
• Averaging across all participants, involvement in illegal activity decreased by approx. 8 days
• When averaged across all MATI clients, we estimate an approx. savings of $9 million in crime victim
costs and $45 million in criminal justice system costs
Were there baseline differences in client characteristics or differences in 12-month
outcomes between needle exchange and self-referred clients?
• At baseline, needle exchange clients were more likely to be male and have
Days Detention or Incarceration in the Past 6 months
• 29% decrease in the prevalence of detention or incarceration
• Averaging across all participants, detention or incarceration decreased by about 4 days
• Incarceration costs are $27,500 per person per year
• When averaged across all MATI clients , we estimate an approx. reduction in costs of $730,000 over
12 months
•
•
•
•
19% decrease in the proportion of clients visiting the ER
Each ER visit averages $900
Averaging across all participants, ER use declined by approximately 0.42 days
When averaged across all MATI clients, there is an approx. cost savings of $450,000
use or illegal activity were found.
• At 12 months, participants referred from needle exchange had higher rates of
• At baseline, Suboxone clients used cannabis more often, used needles less
Needle Exchange
N = 298
Self-referral
N = 107
Any heroin use in the past 30 days
28%
28%
Any injection drug use in the past 30 days
14%
17%
Any illegal activity for profit in the past 30 days
13%
10%
Any detention or incarceration in the past 6 months
16%
11%
Any ER visits in the past 30 days
31%
22%
METHADONE -vs- SUBOXONE
Methadone
N = 286*
• At 12 months, no meaningful differences between the groups on substance
Were there baseline differences in client characteristics or differences in 12-month
outcomes between Methadone and Suboxone prescribed clients?
NEEDLE EXCHANGE -vs- SELF-REFERRAL
Outcomes at 12 months
unstable housing, were less likely to have a chronic medical problem, and
reported less heroin use compared to self-referred clients.
detention/incarceration and ER use compared to those self-referred.
Days Presenting to the Emergency Room in the Past 30 days
Outcomes at 12- months
FIGURE 1: Participants were well-represented across sites. Four of six sites had
associated needle exchange programs (4 colored boxes). When these programs were
combined, over 65% of the individuals in treatment received services at the needle
exchange, and 60% were directly referred to treatment from needle exchange.
Approximately 30% of the sample (N=158) received Suboxone. All sites except
Newark had a mobile unit.
Lynn Kovich, Assistant Commissioner
Suboxone
N = 124
Any heroin use in the past 30 days
27%
31%
Any injection drug use in the past 30 days
13%
17%
Any illegal activity for profit in the past 30 days
11%
15%
Any detention or incarceration in the past 6 months
14%
18%
Any ER visits in the past 30 days
29%
30%
*Note that participants were assigned to medication groups based on the type of medication they were
prescribed upon admission to the MATI program.
often, and were more likely to experience serious depression compared to
Methadone clients.
• At 12 months there were no meaningful differences between the groups on
outcomes .
• It is important to note that there were some participants in each group who
switched medications between the baseline and 12-month interviews.
• The same pattern of results was found when limited only to those participants
who did not switch medications after baseline.
• The Suboxone sample is just as or more severe than the Methadone sample,
which is contrary to previous research that presents buprenorphine and
Suboxone patients as more stable than their Methadone counterparts.
When taken together the results reveal that overall program goals of referring
disenfranchised opioid dependent IVDUs to treatment directly from needle exchange,
providing treatment on demand to uninsured populations, and offering a choice of
opioid replacement therapies are largely being achieved.
Outcome data suggest that the MATI program is associated with positive outcomes for
participants and significant savings in criminal justice costs and costs associated with
emergency room use.