The document discusses Baltimore Substance Abuse Systems' (BSAS) efforts to address opioid addiction in Baltimore through expanding access to medication-assisted treatment (MAT) options like buprenorphine and methadone, improving coordination between behavioral health and criminal justice agencies, and developing a recovery-oriented system of care. BSAS aims to ensure high quality substance abuse prevention and treatment services in Baltimore through strategic planning, advocacy, and creating coordinated networks of community-based recovery services.

1. Treatment and
Recovery in America
April 10-12, 2012
Walt Disney World Swan Resort

2. Accepted Learning Objectives:
1. Define when and how medication-assisted
treatment methodologies for successful
recovery of opioid addiction should be used.
2. Explain how to improve access and quality of
care through strategic planning and
community-wide coordination with local and
state agencies.
3. Describe behavioral health issues faced by
individuals within the corrections system and
devise strategies to adequately address these
clinical needs after incarceration.

3. Disclosure Statement
• All presenters for this session, Dr. Elinore
McCance-Katz and Gregory C.
Warren, have disclosed no relevant,
real or apparent personal or
professional financial relationships.

4. Baltimore Substance
Abuse Systems, Inc.
Nuts and Bolts of
Medication
Assisted Treatment
and System
Coordination

5. Baltimore Substance Abuse
Systems, Inc.
BSAS is a quasi-public agency incorporated in
1990.
In 1995, BSAS became responsible for the
management of the publicly-funded substance
abuse treatment and prevention service system.
The Chair of the 27-member Board is the
Commissioner of Health.

6. Baltimore City’s Challenge
• Heroin addiction remains high
– Treatment capacity falls short of demand despite
expansion in treatment system
– Estimated 30,000 individuals with opioid
dependence
– ~4,000 methadone treatment slots
– Over 8,000 treatment admissions for opioids in FY
2008
• Consequences from heroin addiction are severe
– Crime
– Family and community disruption
– Medical complications
• 1 in 48 Baltimore City residents are living
with HIV and/or AIDS

7. , .
57%
arrested 71% Unemployed
in the 50% < $10,000 per yr.
past 2
years
Characteristics of Clients in
60% Baltimore City Programs
13%
male
Homeless FY 2010
77%
use Treatment
tobacco 45%
Episodes
less than a 12th
n = 21,000
grade education
70%
between 83% Black,
30-50 years 16% White
of age Less than 1% Hispanic

8. Neighborhood Factors
• 78% felt drugs was a major problem
• 31% felt neighborhood was safe to live
• 26% felt neighborhood was a good
place to find a job
• 59% felt living in the neighborhood
made it hard to stay out of jail

10. BSAS Vision and Mission
VISION
We envision Baltimore as a city with healthy people, thriving
families and safe communities.
Mission
Baltimore Substance Abuse Systems seeks to ensure that
Baltimore residents receive high quality and comprehensive
services proved to prevent and reduce substance abuse.
HOW WE WILL ACHIEVE THIS
We do this by planning, advocating for and helping to
create coordinated networks of community-based and
recovery focused services that build on the strengths and
resilience of individuals, families, and communities.

11. Concerns for the Future
• Do our citizens have access to care?
• Do our citizens receive quality care?
• Individualized, continuous, coordinated care is better than
disjointed, acute care which ignores the importance of the
family and community
• Cultural and clinical diversity of services are better than
“cookie cutter treatment”

12. Key Philosophical
Understandings
• Pain and suffering are powerful
motivators for change
• We need to be where people have
their motivational moments
• Medication assisted treatment
provides the time for counseling to
work

13. Recovery Oriented
Systems of Care (ROSC)
Networks of formal and informal services
developed and mobilized to sustain long-
term recovery for individuals and families
impacted by substance abuse.
“ The act of asking what the patient wants
instead of what will be done to the patient.”

14. Buprenorphine: 14
Methadone: 13

15. What is different about
buprenorphine?

16. Buprenorphine Formulations
Buprenex (for pain only)
Subutex (for opioid addiction only)
Suboxone (for opioid addiction only, with naloxone)

17. How long do people need to stay
on buprenorphine?
• Individualized
• Studies demonstrate that staying on
medication in combination with
counseling results in much better
outcomes than detox
• 50% relapse rate within a year among
patients who came off

18. Outcomes for Treatment As Usual
• Of 3,753 admissions to Level I treatment in
FY08, 51% retained for 90 days or more
• Of 11,013 treatment discharges in FY08, only
Prince George’s county had smaller change
in substance use
• Relapse rates high
– In methadone studies, 50-80% relapse within one
year after detoxification
– 91% of patients receiving buprenorphine for 4
months had relapsed to prescription
opioids within 2 months of taper*

19. Business Case for BBI in 2006
• Baltimore needs more effective treatment
for opioid dependence
• Review of literature and studies by UMBC
– Medical costs are increased for patients
with drug abuse
– Opioid addicts on methadone consume far
fewer Medicaid resources than addicts who go
untreated
– Buprenorphine is economically viable alternative
in city with limited methadone treatment
capacity
19

20. Dept of Public Safety and
Correctional Services
• Maryland manages the Detention
Center
– 4,000 inmates
• Men have a LOS of 28 days
• Women have a LOS of 60 days
• Division of Correction
– 22,000 inmate population
• 12,000 released annually
• 9,000 are Baltimore City residents
– Over 70% have a diagnosis of Substance Abuse

21. OTP Interventions
• Maintain arrested OTP clients during Pre-Trial Status and
reconnect them to their OTP at release
• Detox heroin-addicted inmates with non-opioids or on
methadone
• Pregnancy protocol
• Buprenorphine conversion

22. Criminal History of Prison-based OTP Patients 1
Mean
Age first crime 13.8
Age first arrest 16.5
Age first incarceration 20.6
Lifetime incarcerations 9.1
Past 30 days crime 25.5
Past 30 days crime-profit 24.8
Criminal Income ($/past 8,057
30 days)
1 Kinlock, Schwartz Gordon (2005)

23. Treating Prisoners with Heroin
Addiction Histories
 Most detainees with histories of heroin addiction do
not receive drug abuse treatment while
incarcerated
 Such inmates typically become re-addicted within
one month of release
 Re-addiction is accompanied by the following:
 Increased criminal activity
 Unemployment
 High risk of HIV infection
 Greater risk of overdose death
 Incarceration

24. Offenders have more serious Substance
Use & Other Disorders
• Offenders Have Higher Rates of Psycho-Social
Dysfunctional Than the General Population
– Substance Use Disorders
– Mental Health and Somatic Health Disorders
– Educational Deficiencies
• CJ Populations: 4 Times Greater SA Disorders
NSDUH
2007

25. BBI Results
3,209 patients • Currently, 357
treated
patients receiving
full BBI services in
2,094 (65%) obtained or
had medical assistance
treatment
program
1,645 (79%) 449 (21%)
PAC Health Choice • Approximately
6% drop-out from
796 (38%) continuing care
transferred to
continuing care

26. bSAS and B-MAT: Results
• After controlling for baseline group differences, the B-MAT group
had less:
– Inpatient hospital admissions
– Inpatient days in hospital
– Outpatient hospital visits
– Emergency room visits
– Physician visits
• However, the only statistically significant differences compared to
M-MAT and Abstinence-based treatment was for physician visits
• The M-MAT group has more health problems while the B-MAT and
Abstinence groups have similar profiles
26

27. Factors to Improve Networkness?
Integration or Boundaryless Processes of SA & CJ
Agencies
Most Typical Activities:
• Share Information with  Average Number of
agencies Activities Integrated:
• Develop Client Eligibility  Drug Court=6.1
Across Agencies  Probation/Parole=4.5
• Written Program  Prison=3.2
Programs  Jails=3.7
• Joint Staffing of Program  Interagency integration is
• Modified Program to Meet associated with more use
Correctional and SA of EBPs, more holistic
Agencies services, and improved
outcomes
• Written MOU between
agency
Fletcher,
et
al,
in
press
;
Taxman
&
Perdoni,
2007

28. Project ACCESS
• Accountability
• Communication
• Collaboration
• Efficiency
• Security of Information
• Service focus

29. BSAS ACCESS
Supports BSAS, Vision, Mission and Goals
 EHRc Information Sharing supports continuity of care.
 EHRc Information Sharing furthers the goals of a ROSC
approach.
 EHRc Information Sharing frees up funding and staff so that it
can be applied to improved Quality of Care.
• EHRc Information Sharing expands, consolidates and improves the
quality of Public Health Data Repository.
• EHRc Information Sharing provides better quality and more complete
data for evaluation and outcome reporting.

30. BSAS ACCESS
Health Information Strategic
Planning
 New ways to collect, share and use data to serve
client.
 Interoperable systems and smooth information flow.
 “Wherever you go, there you are”
• Better Quality data – reliable, consistent, complete.
• New partnerships and collaborations in evaluating and
applying meaningful data.
• Confidentiality and Consent

31. What providers tell us they want from their
Information Systems
(From focus group discussions, interviews and in depth needs analyses)
 A fully functional, modern and meaningful use certified
EHR
 Consolidation of Information Systems and elimination of
redundant applications
 Access to additional client data and interoperability with
other client data systems
• Pricing discounts and additional leverage associated with
forming an EHR (HIT) consortium
• Business practice and clinical practice management
Information Systems improvements
• HIT advisement – How to get CMS incentive payments and how
to avoid penalties

32. Draft - ACCESS Advisory Board
• Behavioral Health Treatment Providers (2)
• Consumers (2)
• BSAS CEO
• BSAS CIO
• DPSCS CIO
• Baltimore City CIO
• DHMH CIO
• BSAS Epidemiologist
• University of Maryland Law Clinic
• Health Care Access Maryland

33. Treatment Outcomes for the
Criminal Justice Population
Criminal Justice Populations
Drug Treatment Court Other Criminal Justice
N = 1,353 N = 2,745
Completion: 1,068 Completion: 1,687
Incarceration: 21 Incarceration: 71
Terminated: 264 Terminated: 987
Treatment Outcomes Drug Court Non-Drug Court
Drug use during treatment 13% 38%
Substance use at discharge 10% 25%
90 day retention in outpatient treatment (Level I) 63% 57%
Completion of outpatient treatment (Level I) 52% 34%
Continuity of care from ICF (Level III.7) to another LOC 73% 35%
% change in employment from admission to discharge 183% 52%

34. Treatment Outcomes for the
Criminal Justice Population
Criminal Justice Populations
Drug Treatment Court Other Criminal Justice
N = 1,353 N = 2,745
Completion: 1,068 Completion: 1,687
Incarceration: 21 Incarceration: 71
Terminated: 264 Terminated: 987
Treatment Outcomes Drug Court Non-Drug Court
Drug use during treatment 13% 38%
Substance use at discharge 10% 25%
90 day retention in outpatient treatment (Level I) 63% 57%
Completion of outpatient treatment (Level I) 52% 34%
Continuity of care from ICF (Level III.7) to another LOC 73% 35%
% change in employment from admission to discharge 183% 52%

35. Access:
The Patient-Centered, Clinical Case Management Approach
A Recovery Oriented System of Care Not Constrained by Walls
Offender Patient
NEEDS NEEDS
• Custody • Substance Abuse treatment
• Somatic Care • Mental Health treatment
• Substance Abuse Treatment • Somatic Care
• Mental Health Treatment • Housing
• Case Management • Entitlement Benefits
• Family Support Services
• Faith-Based Services
DPDS DOC DPP Health Dept./Community Services

36. Shared Critical Understanding
• Correctional Services is an expectation
of the public
• DPSCS is a part of Maryland’s public
health system
• Our success is measured long after our
offenders/patients leave

37. DPSCS and BSAS have a
Shared Challenge
Information must follow the offender/
patient and not reside and remain at
the institution for it to do the greatest
good.
The Patient-Centered Approach

38. The Benefits of a DPSCS/BSAS
Partnership
• BSAS will champion critical value added
linkages which will improve offender’s health
outcomes
• DPSCS/BSAS health information exchange
becomes a higher priority to CRISP
• Direct benefit to 9,000 returning Baltimore
City offenders annually

39. BSAS ACCESS
The Value Proposition
 Full-featured, meaningful use certified EHR for providers and
partners.
 Consolidation of multiple provider applications on a single
operating platform. (Replace UP and eliminate SMART data entry.)
 Information sharing between community resources and DPSCS.
 Steep discounts for high quality solution to providers and
partners.
• More efficient and cost effective clinical and practice management for
providers and partners
• BSAS consultation and assistance in securing Medicaid incentive
payments.
• Information sharing between BSAS provider network, mental health,
primary care providers, and other community resources.
• Primary source, comprehensive public health data repository.
• Comprehensive statistical evaluation
and outcome reporting

40. BSAS- ACCESS
Design & Implementation
• Secure, segregated installations on a common operating platform
• Custom module selection and configuration.
• Economies of scale and cost reductions
• Data sharing and information exchange
• Aggregate public health data

41. BSAS ACCESS
Patient Management Work Flow
Intake Administration
Client Referral / Client Scheduling and Releases
Walk-in AND Consent
DATA FROM OTHER
CONSORTIUM MEMBERS
Methadone (Other Meds) Clinical Case
EPrescription Management / Management /
Dispensing Documentation
Billing /Accounts
Standard Practice Compliance Reporting
Receivable/Financial
Management Management Reporting City, State, Federal

42. BSAS Health Information Exchange
DPSCS
OCMS BSAS
BSAS Methadon
Residential e
Programs
BSAS
BHCA
Outpatien
Entitlemen BSAS ACCESS t
t
Programs
Benefits
FQHC
DHMH GE
SMART Centricity
Health Health
Providers Departme
thru CRISP nt