At recent meetings of OTP medical directors in my state, we’ve had renewed discussions about how to provide primary care and psychiatric care to program patients.
Opioid treatment centers that are able to offer a wider array of services than just dosing with methadone show better patient retention in treatment and better patient outcomes. This means that the more services that are added, like psychiatric care, primary medical care, help with employment, and family counseling services, patients in those programs have better outcomes than patients in programs that offer only medication and individual counseling. This shouldn’t be a surprise; it makes sense to me. (1)
The problem is, of course, these extra services cost more to the treatment program. If you want to offer psychiatric services, a psychiatrist must be hired, usually on a contract basis, to be available during dosing hours. If the program’s medical director is a psychiatrist, that doctor has to be paid for the extra time it takes to provide the extra care. More commonly, patients are referred to other places for low-cost psychiatric help.
It’s the same with medical care. In order to offer any level of primary care, you have to hire a doctor, unless patients are asked to pay extra for this. Most patients can barely afford basic treatment, so extra expenses can’t be obtained.
At both of the programs where I work, I used to offer some level of primary and psychiatric care. I used to try to treat uncomplicated mental illness like depression and anxiety disorders, and non-chronic, low-intensity primary care illnesses. Of course I referred patients who needed ongoing medical or psychiatric care, but was able to provide them some level of care until they got an appointment, or were able to afford an appointment. I already knew their history of addiction and didn’t prescribe anything that would interact with methadone or buprenorphine, of course. It didn’t cost the patient anything to see me for these extra services, so it saved patients money. I saw six or seven such patients each time I worked at the clinic, and they didn’t necessarily need any appointment. It seems like a good thing all around.
But then came time for us to have our first CARF survey in one program.
Treatment centers want to be certified by the Commission of the Accreditation of Rehabilitation Facilities (CARF). CARF personnel are invited to facilities for a voluntary inspection. These OTPs hope to be given a sort of seal of approval by this agency. The CARF agency inspects mental health, substance abuse treatment, and physical rehabilitation facilities, as well as youth and family service facilities. Accreditation is important because it demonstrates the facility is providing good care.
Our CARF survey went fair in most regards. We got a one-year accreditation, and the CARF surveyors had good things to say about our clinic regarding our dedication to our mission to help our patients. They said great things about the staff enthusiasm and outlook. But they did not like how I was providing primary physical and mental healthcare. The CARF people supported the idea of providing primary care to patients, but they had many recommendations about how to do it. They wanted implementation of a few policies and procedures. This is what they recommended, verbatim:
F.2.a.(1) through F.2.b.(16)
It is recommended that ongoing documented training and education on medications be provided to the person served, family members, individuals identified by the person served, the team, and service providers. This ongoing training should include how the medication works; risks associated with each medicine; the intended benefits as related to the behavior or symptom targeted by the medication; side effects, contraindications, and potential implications between medications and diet/exercise; risks associated with pregnancy; the importance of taking medications as prescribed, including, when applicable, the identification of potential obstacles to adherence; the need for laboratory monitoring; the rationale for each medication; early signs of relapse related to medication efficacy; signs of nonadherence to medication prescriptions, including alcohol, tobacco, caffeine, illicit drugs, and alternative medications; instructions on self-administration, when applicable; wellness management and recovery planning; and the availability of financial supports and resources to assist the persons served with handling the cost associated with medications.
F.a.(1) through F.4.c.(3)
It is recommended that, when medications are prescribed for or provided to a person served (including those self-administered medications), an up-to-date individual record of all medications, including nonprescription and non-psychoactive medications, include the name of the medication; the dosage; the frequency; instructions for use, including the method/route of administration; and the prescribing professional. The program should provide ready access to the telephone number of a poison control center to the program personnel and the person served. Written procedures that address how the medication will be integrated into the overall plan of the person served should be available. There should be a process for identifying, responding to, documenting, and reporting medication reactions and actions to be followed in case of emergencies related to the use of medication.
It is recommended that, as the organization prescribes medications, it implement written procedures that include compliance with all applicable local, state or provincial and federal laws and regulations pertaining to medications and controlled substances, including on-site pharmacy services and dispensing. Written procedures should include the active involvement of the persons served, when able, or their parents or guardians, when appropriate, in making decisions related to the use of medications; the availability of a physician, pharmacist, or qualified professional licensed to prescribe for consultation 24 hours a day, 7 days a week; documentation and reporting of observed and/or reported medication reactions and medication errors; and a review of past medication use, including effectiveness, side effects, and allergies or adverse reactions. Written procedures should include the identification of alcohol, tobacco, and other drug use; use of over-the-counter medications; use of medications by women of childbearing age; use of medications during pregnancy; special dietary needs and restrictions associated with medication use; necessary laboratory studies, tests, or other procedures, when applicable; documented assessment of abnormal involuntary movements at the initiation of treatment and every six months thereafter for persons served receiving typical antipsychotic medications; when possible, coordination with the physician(s) providing primary care needs; and review of medication use activities, including medication errors and drug reactions, as part of the quality monitoring and improvement system.
F.6.a. through F.6.f.
If the organization provides prescribing of medications, it is recommended that it implement written procedures that include screening for common medical co-morbidities using evidence- or consensus-based protocols; evaluation of co-existing medical conditions for potential medications impact; identifying potential drug interactions, including the use of over the counter or homeopathic supplements; documentation or confirmation of informed consent for each medication prescribed, when possible; continuing a prescribed medication if a generic medication is not available; and continuity of medication use, when identified as a need in a transition plan for a person served.
It is recommended that, as an organization that provides prescribing of medications, it demonstrate, to the extent possible, the use of treatment guidelines and protocols to promote state-of-the-art prescribing and ensure the safety of the person served. It is also recommended that a program of medication utilization evaluation include measures of effectiveness and satisfaction of the person served.
F.8.a. through F.8.e.(2)
As an organization that provides prescribing of medications, a documented peer review should be conducted at least annually on a representative sample of records of persons for whom prescriptions were provided in order to assess the appropriateness of each medication as determined by the needs and preferences of each person served and the efficacy of the medication. It should be used to determine if the presence of side effects, unusual effects, and contraindications were identified and addressed and if necessary tests were conducted and used to identify the use of multiple simultaneous medications and medication interactions.
F.9.a. through F.9.c.
It is recommended that information collected from the peer review process be reported to applicable staff, used to improve the quality of the services provided, and incorporated into the organization’s performance improvement system.
I was overwhelmed. I’m a relatively intelligent person, but I’m still fuzzy on exactly what they mean. Here are some of my concerns:
-I already record a full history and physical on each patient, and have a record of all medications each patient takes. But apparently the way I’m doing this isn’t adequate, and I’m left to wonder what the specifics of their recommendations would look like.
-Get a signed informed consent in order for me to write a prescription? This is not generally done in primary care. Maybe if I were administering chemotherapy…but I was prescribing things like penicillin for an infected tooth. I’m not sure what the justification for this is in a methadone clinic population.
-Apparently I need to give each patient a written summary of all side effects of a prescribed medication. I don’t do this in primary care, because the pharmacy does all of that. Each time a prescription is filled, they give a long sheet of possible side effects. What’s the rationale for redundancy?
When faced with the task of complying with all of these recommendations, the owners of this clinic said forget it. They told me to prescribe only the methadone and buprenorphine, and when I saw other medical problems, provide a referral to doctors in the community. That way, the opioid treatment center won’t be penalized by CARF for not implementing…well, the byzantine recommendations above. I still don’t know exactly what CARF meant. Maybe I should say I don’t know what their recommendations would look like in real life.
Not providing any primary care took pressure off of me, but our patients were left with less medical care than they already have, which is little. It’s really hard to “coordinate care” for patients who have no insurance and no money. Yes, I know there are free clinics available in many areas, but they only provide a limited amount of care and follow-up. And specialty care is unattainable.
At our next CARF survey a year later, our program got good marks from CARF, and a three-year accreditation, instead of only one year. Without requirements around primary care to meet, it was simple.
CARF does a needed service, but in many matters I think it’s important to pull back to see the whole picture. Plus, drop the jargon and use words that make sense, please. It’s similar to the paperwork requirements for Medicaid – most of this paperwork is probably needed in some form or fashion, but I’ve seen the repetition. Leave counselors time to counsel.
Regulations are important. But don’t make the regulations so obscure and onerous that most clinics stop providing any extra care because of the difficulty meeting these requirements.
I’d love to see my state’s methadone authority work with the CARF organization. Maybe together they could issue new guidelines for primary care in opioid treatment programs that make sense. Then programs may be more likely to offer extra services.
(1) McLellan AT, Arndt IO, Metzger DS, Woody GE, O’Brien CP. The effects of psychosocial services in substance abuse treatment. JAMA 1993;269(15):1953-59