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HomeMy WebLinkAbout2016-08-08 16-290 Council Documents (4) ielrr Pbrtta d,ME si r Augusta ME tri Nfl P.Doifia Jr. Boston,MA I, ; .., Dim1c1 Nal; .3.�1r, Wash#ngtcm,tX August 3,2016 YIA TMAIL Hon. Sean Fateloth,Chair Bangor City Council 73 Harlow`Street BangorME E E}4401, RE °j,� 3 f,: r �� x ti exkg l t4 , g r lel: �,Uth t JCL from 300 to 500 w'— Clem 1.Fig Dear l Fairc1ath.and Members of tile CUY Council: This filing addresses several issues were raised at the August 1,2016 hearing and supplements the materials that were d with the Council in the Notebooks we distdbuted that time, We will also recap some of the key points that were discussed and provide some further perspective. Penobscot City Metro Toxament Center(`Metro")and we look forward participating in the August 8 continued hearing,and are most hopeful that approval will be forthcoming at this meeting. Among the many factors supporting approval: • Metro 44 been licensed and has been operating at its current site on Hogan Road for the past 11 years; • Metro has all required licenses,certifications and authorizations from the U.S. Drug Enforcement Agency(''DEA"),),the U.S.DHS SA H A and the Maine Department of Ihmtan Service, See Notebook,Tab 1, and multiple attachments; • State licensing laws provide that licensed clinics may treat up to 500 patients,and may expand their authorized slots to this 500 level Through a simple amenthnent process with Maine H S Division of Licensing.and Regultdoty Service& Metro has completed these steps. See DM-1S Licensing Regulations, 14-118 Cvlik Chapter 5,Regulations for Licensing and Certifyingof Substance Abuse Treatment Programs,at Section 19.8.43,and Notebook,ok,Tab 10,e-mail from Sarah Taylor dated June 16,2016; • State licensing regulations authorize licensed clinics to expand to 700 slots through waiver process set forth in the Licensing Regulations,Section 19.83. This waiver process was utilized by Discovery House in 13angor to expand its authorized slots from 500 to 700 in 2010,with the approval of the Bangor City Council following a public hearing,with one dissenting vote. Pteti Flaherty Bel,eau&PachitsI.LP Attorneys at Law One aty+Carder,Potts ME 04101 I PO 80x954C Portland,ME 041124546 I Tel 2071913000 I watte.prtttheutt 10801263.3 PRETI FLAHERTY August 3,2016 Page 2 Why Bangor and Why Not Another Location? At the hearing, Metro's witnesses presented extensive evidence to demonstrate the bases for its determination to expand the Bangor clinic from 300 to 500, and to show further that creation of a clinic in a different site was not a feasible alternative from many perspectives. Expansion of Bangor is Far Mare Economically and Financially Feasible than Development of a New Alternative Site First, James Scully,Director of Facility Operations for Colonial Management Group,the parent of Penobscot Metro,presented the attached chart,titled"Penobscot County Metro TC Expansion." This showed that:. • Metro has already invested$630,000 in the buiidout of the current facility,and an additional$20,000 in an improved security system. The annual operating cost increases for these improvements is$25,000; • Thus,Metro has a total investment of$675,000 in enhancements to its facility to handle the current census—and the potential expansion. These art now"sunk costs" that were incurred with the reasonable expectation that its expansion will be approved by all governmental entities; • As Metro ramps up to 350 patients,an additional counselor will need to be added to the eight it now has, at a coat$40,000 to$50,000; • Going from 350 to 400 patients will require an additional nurse,Treatment Services Coordinator,and an additional counselor,with accompanying annual expenses for these three positions of in the range of$120,000 to$145,000; • Going to 450 patients will require an additional counselor with an accompanying cost of$40,000 to$50,000; • Going from 450 to 5.00 will require yet another counselor at an additional cost of $40,000 to$50,000; • The aggregate total of these incremental additional staffing costs to go from 300 to 500 patients ranges between$240,000 and$295,000; • These incremental coats will be incurred gradually as Metro ramps up at a rate of between 8 to 16 new patients each month. In sharp contrast,developing a new clinic in another Maine location would require a total initial additional investment of approximately$860,000,with sub-elements of$300,000 to $350,000 in development of the site and buildout of an appropriate site with the required security systems and so on,along with the furniture, and related technology and supplies. The annual 108012633 PRETI FLAHERTY August 3,2016 Page 3 operating costs would be an additional$100,000 and the initial clinic startup staff for a 200 patient capacity would be approximately$500,000. Lack of Sufficient Demonstrated Need or Critical Mass in Other Sites Where Current Patients and Waitlist Patients Reside Second,there is no alternative site that is superior,or even remotely close to Bangor,in terms of geographic access to the numbers and residences of patients now being treated or on the waitlist. No other site would provide sufficient critical mass of patients to make the site cost- effective. The information presented by Lisa Davis and James Harrison at the hearing,included at Tab 3 of the Notebook,showed that among the 60 patients who have expressed again that they are ready to enter treatment,41 of these 60 reside in.Penobscot County,and of these,28 reside m Bangor,Brewer and Old Town. It was suggested at the hearing that alternate locations might properly consider county seats or other significant cities or towns. The Tab 3 chart shows that there is one patient from Belfast seeking treatment at Metro,and four from Ellsworth. There are four patients from Millinocket. The Metro patients currently receiving treatment at the Bangor facility are predominantly from Penobscot County—201 out of 300,with a significant portion of these coming from Bangor(62),Brewer(12),Hermon(11), Old Town(14),etc. The above analysis demonstrates that another location does not make sense from several 1 perspectives—it would not be economically feasible, it would not permit Metro to realize the benefits of the investment it has already made in the Penobscot facility,and it would not be more geographically convenient for those on the waitlist or those currently receiving treatment. Me adone and Crime See Tab 7 in the attached Notebook,the NIDA Document,20 Questions, Question 4,Part B-20—Does methadone maintenance treatment reduce criminal activity? This response is provided: Yes. Patients are less likely to become involved in criminal activity while in Methadone maintenance treatment: • Patients who remain in Methadone maintenance treatment for long period of time are less likely to be involved in criminal activity than patients in treatment for short periods. • The availability of Methadone maintenance treatment in a community is associated with a decrease in that community's criminal activity,particularly theft. 10801263.3 I t FRETI FLAHERTY ! August 3,2016 Page 4 This NIDA Guide reviewed 24 studies and found that there was"an overall small- medium effect . . . of the impact on Methadone maintenance of criminal activity. A large effect size . — was seen in those studies that investigated the efficacy of Methadone maintenance treatment in reducing drug-related criminal behaviors." In another study cited by NIDA,there was a 70.8%decline in crime days within the four month methadone maintenance treatment period. See pages B-20 and 13-21 for further details. See, also Tab 9: i9, Addiction Research Report,Use of a"Microecological Technique"to Study Crime Incidents Around Methadone Maintenance Treatment Centers,Boyd et al., Department of Psychiatry,University of Maryland,Baltimore, February, 2012. (DocID No. 10736922). This Study concluded that"Methadone treatment centers,in contrast to convenience 1 stores,are not associated geographically with crime." We appreciate that witnesses appearing at the hearing recited their personal_experiences, and conveyed strongly held views. But their examples provided no objective broad-based data, and did not assert that the perpetrators were current or former patients of Metro,or of any other Methadone program, Media one and Societal and Economic Costs fron0Lack of Treatment I See Tab 7 in the attached Notebook,the NIDA Document,20 Questions, Question 18, Part 13-55-59—Are there cost benefits to methadone maintenance treatment. This reviews extensive research and notes"Research has demonstrated that Methadone maintenance treatment is beneficial to society,cost effective,and pays for itself in basis economic terms." I A 1991 NIDA Study of the yearly costs to maintain an opioid addict in New York determined relative economic costs to be: $43,000 for an opioid addict untreated and on the street(crime-related costs and security); $34,000 in prison, $11,000 in a residential program;and $2,400 in a Methadone maintenance program. 1 Proven Efficacy of Methadone Treatment and Supporting Documentation i The Notebooks we distributed.at the hearing contained several tabs providing extensive information regarding Methadone treatment,Methadone treatment versus Suboxone treatment (Buprenorphine);course of treatment, etc. i These tabs are the following: 1 6 New England Journal of Medicine,July 28,2016,Treatment of Opioid-Use 1 i Disorders,Marc A. Schuckit,M.D., (DocID No. 10793409) I http://wmv.nejni.org/doi/full/10.1056/NEJIN4a1604339?query=TOC 10501263.3 PRET].FLAHER1Y August 3,2016 Page 5 7. NIDA(National Institute for Drug Abuse)International Program—Methadone Research Web Guide—Part B—Questions and Answers Regarding Methadone Maintenance Treatment Research(DocID No. 10747358) httpst/Avww.drugabuse.gov/sites/defvlt/files/pdf7partb.pdf 8, U.S.])HHS Substance Abuse and Mental Health Services Administration (SAMHSA) Website Summary of Materials Regarding Methadone and Related Treatment http:Mvww.satrOsa.govhnedication-assisted-treatment a. Methadone Treatment—What is Methadone,flow Does Methadone Work,etc. (DocID No. 10747302) http://www.samhsa.govitnedication-assisted-treatmentitreattnenthnethadone b. Medication and Counseling Treatment and Opioid Treatment Programs(OTPs) (DocID No. 10747334) c. Medication Assisted Treatment(MAT)--Buprenorphine Options,Among Others (DoolD No. 10747345) d. Buprenorphine—How Buprenorphine works, etc.(DocID No. 10747331). The NEM Article stated as follows at p. 363 with respect to Methadone Treatment: The effectiveness of methadone maintenance is well established, and this drug is listed among "essential medications" by the World Health Organization. 11,45 Maintenance programs decrease mortality by approximately 50%among persons with opioid-use disorders, decrease acquisition of 111V infection and hepatitis, decrease crime and illicit-substance use, improve social functioning, and increase the rate of retention in rehabilitation programs. 15,50,54,55 Methadone and Suboxone—Comparisons and Alternatives Several of the Councilors raised questions regarding relative merits of Methadone treatment versus Suboxone(with principal component Buprenorphine)as alternative treatment modalities for Medication Assisted Treatment(MAT). Some speculated that the two treatments were,or might be,functionally equivalent and wondered whether significant numbers of patients who were receiving Methadone treatment could easily be transferred to Suboxone. Mr. Harrison and Ms.Davis pointed out that the Bangor Metro clinic is licensed and authorized to provide solely Methadone treatment. They noted that MaineCare coverage is provided for Methadone,and that many physicians were not interested in attaining federal Buprenorphine certification for a wide range of reasons. 10801263.3 MET!FLAHEIVIT August 3,2016 Page 6 Dr.Weisman stressed that she had significant experience in both types of Medication Assisted Treatment(MAT), and the determination of which medication made sense for a particular patient was a clinical determination based upon a wide range of circumstances. She noted that methadone had a well-documented 70 year history of safety and effectiveness,and was more appropriate for longer term IV drug users,the"heavy hitters"who suffer from heroin addiction,whereas Suboxone often made sense for those"light-weights"at the earlier stages whose addiction arose from prescription drugs. For further background,we call to your attention in this regard Tab 7 in the Notebook, the NIDA document,20 Questions—question 19,Part B-67-69—How Do Buprenorphine and Methadone Compare? Among the findings noted at the bottom of Part B-67 were as follows: • Buprenorphine given in flexible doses appeared statistically significantly less effective than Methadone in retaining patients in treatment. • There was no advantage for high-dose Buprenorphine over high-dose Methadone in retention. Together,this testimony and the additional filings we have made demonstrate that the documented need for additional Methadone cannot be satisfied by transferring these patients to Buprenorphine for a variety of clinical,practical, economic and regulatory reasons. Methadone aid FQHCs L.D. 1213 in 2013 Some members of the Council suggested that greater access to Medication Assisted Treatment rmArl generally,and to Suboxone treatment in particular,could be enhanced if Maine's federally qualified health centers(FQHCs)were required to undertake to provide Suboxone treatment As noted at the hearing,efforts were made in this direction in the State Legislature,and we understand that the Bangor delegation and Council supported these efforts, which have not thus far been successful. The primary vehicle for these efforts was held in L.D. 1213,"An Act to Reduce Costs and Increase Access to Methadone Treatment." This bill was advanced in 2013 and a hearing was held on May 13,2013. The proposal was not,however,supported by the trade association for FQHCs,the Maine Primary Care Association. All 20 FQHCs are members of this Association. Attached is the testimony of Vanessa Santarelli, CEO. This testimony noted several concerns at the bottom of page 1 and top of page 2,including: • The-need to provide supportive treatment and resources,including counseling services; • FQHCs would have to apply to the Federal Centers for Medicare and Medicaid Services for change in scope; W8012613 FRET]FLAHERTY August 3, 2016 Page 7 • "There is also a great deal of upfront upgrades to facilities that they would need to absorb and they[FQIICs]are already operate[ski on the narrowest of margins);" th The testimony noted further that"there are certain facility and security changes that would need to be made before CMS would allow you to move forward. For example, storing Methadone requires security enhancements that our health centers currently don't have in place because of the risk of theft." The Maine Primary Care Association concluded its testimony by urging that the Committee report bill out"ought not to pass." Documentation of Compliance with State and Federal Laws and Inspections At the hearing, Councilor Ra,Idacci sought documentation to further demonstrate that Metro was in compliance with pertinent state and federal laws and that it was satisfying relevant inspection requirements. Metro's June 9,2016 Application(Tab 1 of Notebook)stated as follows,with the referenced documents also attached as part of this original filing: 93-5.D. The applicant isin compliance with all state or federal laws,rules or regulations regarding its opioid treatment program. Metro is fully compliant with all applicable state and federal requirements. We have attached the opioid treatment program certification from the US.Department of Health &Human Services, Substance Abuse and Mental Health Services Administration; Controlled Substance Registration certificate from the U.3, Department of.histice, Drug Enforcement Administration; Certificate of Licensure from the State of Maine, Department of Health&Human Services. Also attached is a summary of the three-year accreditation survey outcome conducted by the Commission on Accreditation of Rehabilitation Facilities (CARP'International), an accrediting agency for opioid treatment programs. Copies of current licenses, certificates, and accreditation documents are attached at Tabs 3-7. [these are references to the Tabs to the Application itself—within Tab 1 of the Notebook], The Maine DIMS Licensing Regulations, 14-118 CMR Chapter 5,Regulations for Licensing and Certifying of Substance Abuse Treatment Programs,at Section 19.82.2.1,state that in order to he licensed as an OTP in Maine,a clinic must demonstrate compliance with: Federal Certificate. 42 CFR Chapter 1, Subchapter A,Part 8, as amended, including but not limited to,possession of a current, valid certificate from the Substance Abuse and Mental Health Services Administration within the U.S. Department ofHealth and Human Services(SAMHSA), which shall be the demonstration of compliance with Sections 303(g)(v of the Controlled 105012633 1 1. PRETI FLAHERTY August 3,2016 Page 8 Substances Act(21 United States Code(USC)Section 823(g)(1)), as amended, to dispense opioid drugs in the treatment of opioid addiction. This will depend upon the OTP obtaining accreditation from an accreditation body that has been approved by SAMHSA; and Elsewhere in these Regulations,the Commission on Accreditation of Rehabilitation Facilities (CARP International),is recognized as the accreditation body approved by SAMHSA for purposes of demonstrating fulfilhnent of the State regulations. The June 9 Application attached the 18 page CARF report for survey dates of September 17-18,2016,and issued a Three-Year Accreditation through November 30,2018. Among the"strengths"that CARP noted at page 2: The program facility is currently being expanded and renovated This is in response to the increased need for services in the community The Survey Summary went on to state: On balance, Penobscot County Metro Treatment Center provides compassionate and professional opioid treatment services in the Penobscot County area of Maine. Services are provided in clean and welcoming offices that are conveniently located Staff members work well together and collaboratively with other organizations in the community. The commitment to provide quality services can be seen throughout the organization. The organization has a few areas for improvement, including ensuring that data collected are related to objectives established in the strategic plan-and collecting additional information for the assessment that includes efficacy of current or previously used medication, gender expression, and history of witnessed trauma Leadership has expressed a commitment to address the recommendations noted in this report. Colonial Management Group, LI)dba Penobscot County Metro Treatment Center has earned a Three-Year Accreditation Leadership and staff members are commended for this achievement and encouraged to continue applying CARP standards. The 16 pages that follow review multiple facets of the clinic and determine that all accreditation standards have been met. Responding to the request for reports of prior inspections,we attach the CARP Report of an inspection carried out October 18-19,2012 that resulted in a three year accreditation through November of 2015. Many strengths were noted at pages 2-3 and else' here in the Report. At page 3 it is noted: The organisation provides excellent outpatient opiate treatment services and has support and satisfaction with the services provided. 1o8oi2is3.3 PRETI FLAHERTY August 3,2016 Page 9 For ease of reference,both CARF Reports are attached to this filing. ADA Recap Finally,pertinent provisions of the Americans with Disabilities Act("ADA")and multiple court decisions compel the approval of the expansion of treatment slots from 300 to 500, Multiple federal court decisions have determined that local zoning ordinances that purport to impose any stricter standards on methadone clinics than those that are generally applicable to other medical facilities and clinics amount to prohibited"facial discrimination"under the ADA. In the Notebook,at Tab 13,we shared the Recommended Decision of Federal Magistrate Rich dated March 31,2014 in CRC Health Group, Inc. v. Town of Warren(DocID 10764260). This reviewed several prior court decisions pertinent to this review. We now attach the decision of the Third Circuit Federal Court of Appeals,New Directions Treatment Services,490 F.3d 293(3d Cir.2007)and call to your attention,among its provisions;. • Extensive discussion of the safety and efficacy of methadone treatment at pp.3-4; • Review of highly regulated nature of the treatment,p 4; • Discussion of unproven connections to alleged criminal behavior,and determination that methadone patients do not pose significant risks,p. 13. The Pennsylvania statute under review banned the establishment of methadone clinics within 500 feet of schools,churches and residential properties,unless the local municipality determined to waive the ban after a public hearing with notice and opportunity for participation by affected property owners. The Third Circuit held that the statute was facially discriminatory in violation of the ADA and the federal Rehabilitation Act,and noted that provisions in the statute that give municipalities the power to waive the ban in no way altered this holding. Conclusion Based on Metro's fulfillment of each the several criteria set forth in Ch. 93,we respectfully urge the Council to approve Metro's application and permit it to provide treatment to those urgently seeking treatment.See Notebook,Tab 2. 10801263.3 PR.En FLAHERTY August 3,2016 Page 10 We look forward to working with Council to achieve this at your meeting on August 8. Sincerely, Aor p Holly P.Doyle Jr. Holly E. Lusk JPD/rte Enclosure cc: Norman Hein:tam,City Solicitor(via e-mail) 106012633