Posts Tagged ‘mobile narcotic treatment programs’

Mobile Opioid Treatment Programs

Opioid overdoses killed 47,600 people in the United States in 2017.

Last spring, just before COVID demanded all our attention, a friend at our state opioid treatment authority emailed me a link to document titled, “Registration Requirements for Narcotic Treatment Programs with Mobile Components,” and asked what I thought of it. This was a new document – at that time – posted on the DEA’s website, under the Diversion Control Unit. The document described new rules for mobile opioid treatment programs (they call them NTPs, for Narcotic Treatment Programs).

The intention of the new proposal was to make it easier for treatment providers to meet demand in rural areas.

Sometimes I have an opinion about an issue before I get all the information, and the idea of a mobile OTP seemed dangerous and ill-advised. But after reading the DEA document, I’m convinced mobile opioid treatment programs could be great options, if done with proper care.

The DEA stated that it recognized the extent of the financial burden needed to open a brick-and-mortar opioid treatment program. Because of all the regulations, a new facility owner must pay rent on a building for a very long time before all the permissions and inspections are done by all regulatory bodies. That often ends up being more than a year. That’s a considerable outlay of time and money for new programs, and rural areas with few prospective patients are financially unattractive sites for new OTPs.

Mobile units are a way to fill the void.

This new proposal means mobile units can be operated as a “coincident activity” based out of a brick-and-mortar treatment program. The new rule proposes doing away with the present requirement that mobile unit need their own licensing and registration. This change makes it much cheaper to operate a mobile unit.

There are several caveats involved in creating a mobile OTP unit. For example, trailers won’t qualify. The unit must be a “conveyance,” that is, able to move on its own power. This conveyance would be subject to inspection just as brick-and-mortar opioid treatment programs are.

Medication must be stored securely, of course. Medications must be stored in a safe that is bolted to the floor or side of the vehicle and must be accessible only from inside the vehicle. Medication can’t be accessed from outside of this van or vehicle. Patients should not be able to step into the portion of the vehicle containing the safe with medications in it, so there must be some sort of door dividing the portions of the conveyance.

There must be an alarm system on the unit.

Records may be kept in paper or electronic forms while the mobile OTP is in service but must be stored inside the brick-and-mortar structure overnight.

Analysis of the proposed system indicated that opioid treatment programs will save money because of the reduction in start-up costs for mobile units that are under the auspices of existing brick-and-mortar programs. Mobile vans could reduce healthcare costs and reduce time lost from work for patients.

 At first, I thought the idea was a little goofy, but then I thought of all the ways such mobile units could be creatively used.

Incarcerated patients: Patients already on methadone or buprenorphine products could have their medications delivered and dispensed by the mobile OTP. Jail and prison staff wouldn’t have the headaches of storing and administering these medications, and inmates would be evaluated each day as usual. Or, depending on the stability of the patient and the willingness of jail staff, the patient could be dosed by staff on the mobile OTP, and enough daily doses left until the mobile OTP needs to return. With that method, jail staff would still have to store, track, and administer some doses.

The biggest benefit would be reduction of illness from enforced withdrawal from life-saving medication, and reduced risk of death after the patient is dismissed from jail, assuming the patient remains in treatment.

Rural patients: In areas too small to support a traditional opioid treatment program, mobile units would be able to treat patients more efficiently. I could imagine that arrangements could be made for the mobile unit to be at “X” location in a small community at a set time daily, for treatment of patients living in that area. Then the unit could be scheduled for another location in that rural area for later in the day. Patients would have to make sure they arrived at set times, but they would have far less distance to travel to a more traditional program. This would save them time and money, particularly in areas too rural for public transportation.

Outreach: Some communities are less likely to participate in treatment; for example, a minority community might hold negative opinions about medications for treatment of opioid use disorder. But if a mobile unit repeatedly traveled to that community, both treating patients and educating citizens, hopefully their concerns could be addressed. Healthcare workers could dispel misinformation and reluctance. Or perhaps immigrant communities with suspicions about treatment could be addressed in similar ways.

 A report released last fall described Massachusetts General Hospital’s success using mobile opioid use disorder treatment to reach vulnerable homeless populations in Boston, where overdose death rates were high. This program was called Community Care in Reach. This mobile unit reached homeless populations in the city who have special difficulties accessing healthcare.

Studies showed the homeless die of opioid overdose at a rate approximately twenty times the general population, proving the need for outreach to that population.

The mobile unit wasn’t an opioid treatment program, but it was staffed with primary care providers who diagnosed and treated patients with sublingual buprenorphine products. At the same time, the program dispensed naloxone kits to reverse opioid overdoses, and provided clean needles to people who were injecting drugs. This program, which started in 2018, logged nearly ten thousand patient contacts by late 2019. [1]

As I scoured the internet for information about established mobile OTPs, I found much more information about mobile units that provide buprenorphine treatment. I found less information about true opioid treatment programs on wheels, which provided both methadone and buprenorphine.

I found an article describing how mobile services for methadone maintenance tend to retain patients in treatment longer than typical fixed-site programs.  In this article from 1996 by Greenfield et al., mobile program patients were retained in treatment an average of 15 months, compared to around 4 months for traditional patients. [2]

This study was done in Baltimore, in the inner city. I wonder how much better retention would be for rural areas that have very little public transportation compared to cities.

I want owners of our opioid treatment program to invest in a mobile unit. We have rural counties to our north that have no opioid treatment programs within their borders. They have several office-based programs which prescribe buprenorphine products, but not every patient responds to this medication. Patients who need methadone for stabilization drive an hour or more to our program or drive over the border into Virginia for help. I think a mobile OTP could reach many patients in that area.

However, our nation’s system of healthcare as a business means the mobile OTP would have to make a profit, or at least break even. I have no idea if it would be financially attractive, but I know that with the revision of the DEA rules, it is less costly than in the past.

The whole aim of encouraging development of mobile dosing units is to increase access to treatment in this time of opioid epidemic, while still using appropriate controls to reduce diversion.