In January 2019, Governor Phil Murphy of New Jersey announced new strategies to strengthen the state’s response to the opioid epidemic. The announcement included a robust, statewide office-based addiction treatment (OBAT) program aimed at encouraging primary care providers who work with Medicaid beneficiaries to increase their capacity to address opioid and substance use disorder (SUD). The OBAT program is a product of months of stakeholder engagement and planning led by New Jersey’s Department of Human Services.
The Center for Health Care Strategies recently spoke with two physicians who participated in the planning of New Jersey’s OBAT program about their experiences treating addiction within primary and specialty care settings. Lynda Bascelli, MD, is the chief medical officer at Project H.O.P.E., a patient centered medical home offering integrated care for people experiencing homelessness in Camden, New Jersey, and Kaitlan Baston, MD, MSc, is the medical director of addiction medicine at the Urban Health Institute at Cooper University Health Care. This blog post provides insight into the benefits and challenges associated with providing medication-assisted treatment (MAT), particularly in primary care, and explores how states like New Jersey are supporting providers in doing so. The interview is a product of CHCS’ work with New Jersey to inform activities to improve health outcomes for Medicaid beneficiaries, made possible through support from the Robert Wood Johnson Foundation.
What sparked your interest to work with people with SUD?
L. Bascelli: When I started working at Project H.O.P.E., it became clear that many patients had SUDs. My job as a primary care physician is about helping people stay healthy and manage their chronic diseases, and SUD is just another chronic disease that needs to be managed. It also became clear that we weren’t going to make any progress with individuals whose blood pressure or diabetes was out of control unless we addressed the underlying SUD. In so many cases, the SUD is the acute life threatening illness. So, for somebody who is actively using heroin, it seems silly to just focus on how to best manage their blood sugar when they have this bigger issue.
K. Baston: My interest in working with people with SUD also came from a background in primary care. During my family medicine residency, I noticed that as primary care doctors, we weren’t doing a very good job taking care of patients with SUDs. That’s not because we didn’t care, it’s because we didn’t have great training. We would go in with great intentions to help a patient, but too often the patient would feel horrible, the doctor would feel horrible, the nurses would feel horrible. I kept thinking, there’s got to be a better way to do this. And then I did an addiction medicine rotation and saw a better way, and realized that we could not only build better skills and tools to manage SUDs, but in doing so, it would make everybody’s lives better.
What are the benefits to integrating SUD treatment into primary care?
L. Bascelli: Primary care is where patients show up first, for the most part. The more you try to send people elsewhere for help with mental health and/or substance use, the less likely they are going to be able to follow through with appropriate treatment. Doing as much as possible under one roof is your best chance at actually helping a patient. It is also easier to engage somebody in treatment when a trusted relationship is already established.
K. Baston: I also think it destigmatizes SUDs to say, “This is just part of your regular primary care.” So, the combination of having SUD treatment available in primary care, and the understanding that it is treated just like every other chronic disease is helpful for both patients and providers. Hopefully we’ll do that in the hospital system as well.
Patient Story: Offering Hope for the Future
“A couple of months ago, a person came in seeking help, but while he was waiting for his appointment, he overdosed in the bathroom. We ended up reviving him with Narcan. He walked out of the office that day with a prescription for buprenorphine. His mother had been waiting in the car, and she didn’t know what was going on. It was wonderful to be able to take care of him in the moment that he needed care, to send him off with a prescription that should prevent him from overdosing in the future, and to offer him hope. To see his mother’s face and how providing that treatment right there was affecting the family is just…it is overwhelming.” – Lynda Bascelli, MD
What are some of the biggest challenges related to integrating SUD treatment into primary care, and how can states help mitigate these barriers?
L. Bascelli: Get rid of prior authorization for SUD medications, which New Jersey recently did. I think that’s one of the very biggest barriers. Another big challenge is getting primary care providers to buy into the idea that this is part of their scope of practice. But, even when providers are interested, what holds them back is the administrative burden that comes with prescribing SUD medications. Primary care providers don’t have the resources to dedicate to that.
K. Baston: There are two challenges in trying to identify champions to treat SUD in primary care. The first is changing hearts and minds. There is a lot of fear when it comes to trying something new, especially in an already busy practice, and there is also fear of this population. The reality is that when somebody with an SUD comes in asking for help, it can be extremely rewarding. You get to see changes overnight — we have medications that when you give them to a patient it is literally night and day. The next week they look completely different, they’re happy, glowing, and able to get their lives back. It’s one of the most rewarding things you can do in your practice.
The other challenge, as Lynda said, is the administrative barriers, ranging from Drug Enforcement Administration requirements to insurance barriers to pharmacy lock-ins. All of these barriers perpetuate the fear and stigma of providing SUD treatment. I can prescribe as much oxycodone as I want, but if I want to treat people with an SUD, I’m limited. In New Jersey, the state recently got rid of prior authorization, although we do still have challenges of complying with each insurance carrier’s preferred formulary.
In general, how can primary care providers increase their capacity to support patients with SUD? What resources are available to NJ-specific providers?
L. Bascelli: We jumped in not really knowing what we were doing when we started prescribing pharmacotherapy for opioid use disorder, and took it slowly. I think the real turn for us came when we participated in Project ECHO for buprenorphine through a community health center in Connecticut. That helped us increase our capacity and to feel comfortable with prescribing and the uncertainty that we felt. Project ECHO offered us a structured touchbase every couple of weeks to talk about patients and get advice.
K. Baston: The state is supporting two university health care systems, Rutgers University in the north and Rowan-Cooper University in the south, to serve as Centers of Excellence to support primary care providers prescribing MAT. As part of the Centers of Excellence, we are building a warm line that will be available from 8:00 am to 8:00 pm where providers can speak with another provider for support around treating SUDs. We are also developing office support packages that detail county-specific resources, and we are working with the state to create a searchable database of local treatment providers, including specialists, behavioral health, and those with experience managing SUDs. At Rutgers, we are also starting an ECHO that is New Jersey-specific and focused on primary care providers prescribing buprenorphine. We will even have sessions that are specific for office support staff.
In Camden, Lynda and I started an informal, monthly breakfast club where we meet other providers and talk about what is what is new and exciting, what is challenging, all related to treating SUD. As the southern Center of Excellence, we are looking for local champions in other counties to start a similar breakfast club.
Patient Story: Helping Mothers-to-Be without Judgment
“Our perinatal program is extremely rewarding because we are taking care of women at such a vulnerable time. Women who are pregnant, who have been struggling with substance use disorders — they are the population with the most guilt and shame of anybody. It feels like everywhere they go, people just tell them they’re bad. They’re bad mothers. They don’t care. The reality is they care so much and are so motivated. When they come to our clinic, we tell them, ‘You’re so brave. I’m so glad you’re here. You clearly care so much. This is incredible. We’re here to help you. Everything’s going to be fine.’ And, we get them stable on medications. We have been doing this for so long now that we have several mothers who are having their second child with us. They come to our parenting groups and bring their kids who all play and are crawling around on the floor together. It’s just the most beautiful thing that we see — stopping the cycle and empowering women to do everything that they want to do in their lives.” – Kaitlan Baston, MD, MSc
What would you recommend to other primary care providers interested in supporting patients with SUD, but who aren’t sure where to begin?
L. Bascelli: Find someone to help who is already doing the work. We obviously are passionate about what we are doing and are eager to help other providers. My other advice is start with one patient. Start with someone who you know in your practice. It doesn’t have to be a big, perfect program when you get started. You just need to start with one patient and see how it goes.
K. Baston: When I was in residency, everybody had to have their waiver to graduate. But, it was still a mantra at the time that you shouldn’t go out and do it on your own. One of the graduates of my program, whom I thought of as a brave pioneer said, “Of course I’m going to do it on my own.” He surveyed his clinic staff, and everyone basically said, “We don’t want those patients. We’re worried about this. We can’t possibly do this.” So, he started with one patient and prescribed that person buprenorphine. Later on, he surveyed the clinic again and they said, “We love this patient. He is so great, so thankful.” And so, he slowly increased his panel from there. The majority of the clinic staff said that treating patients with SUD made their practice better, not worse.
