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HomeMy WebLinkAbout2016-08-08 16-290 Council Documents (14) August 1, 2016 • Penobscot Metro's Fulfillment of Criteria in Chapter 93 The following reviews the criteria set forth in Ch. 93, Bangor's Ordinance for Chemical Dependency Treatment Facilities. This summary lays out key points in Penobscot Metro's June 6, 2016 application that demonstrate fulfillment of the pertinent criteria, supplemented by more recent information in certain instances (waitlist, etc.). It includes additional material and references supplementing the handout we shared with the Council at its July 11 meeting. 93-5.A. The property is adequate to accommodate the proposed increase, including providing sufficient interior space to avoid patient queuing on sidewalks,parking area, and other areas outside of the facility. • Location at 659 Hogan Road—Maine Square Mall—close to Bangor Mall and other retail and service establishments; • 6,250 sq. ft. of first and second floor office space where facility has been for 11 years; • Significant construction upgrades involving investment of$600,000—construction upgrades now include sufficient office space to accommodate: • 11 counselors; • • Clinical supervisor; • Medical Director; • Separate office for Nursing Department; • Up to three rooms to provide for groups of our patients; • Drawings with room configurations and improvements will be shown to the Council; • Two more dosing windows to provide a total of 4 dosing windows to improve patient flow; • Ramp-up to 500 patients will be gradual, increasing by 8 to 16 patients per month; • 120 patients on typical day with 40% arriving before 8:00 a.m.; • Parking is sufficient under § 165 of Bangor Code per March 26, 2016 sign-offs of multiple Certificates of Occupancy; • Traffic flow has been coordinated; • • Dosing hours are from 5:15 a.m. to 11:30 a.m.; 10788359.3 III • Security personnel on duty at all times—two typically on duty. 93-5.B. The treatment program is able to hire and retain adequate numbers of qualified staff to meet applicable state and federal standards of care. • Over the past 11 years, Metro has been able to hire and retain needed professionals to meet all state and federal standards and regulations; • Have several medical and treatment professionals, including: • 8 substance abuse counselors; • 1 certified clinical supervisor; • 1 registered pharmacist; • 3 licensed physicians; • 3 dispensing nurses with registered nurse manager; • 3 security persons; • 1 Program Director; III • 20 full-time and part-time subcontracted employees; • Each of the treatment professionals meets all state and federal licensing requirements and practice respective disciplines; • Now have 8 counselors—will ultimately need at least 10 upon full ramp-up to 500; • Metro will hire 3 additional counselors upon receipt of approval so that regulatory ratio of at least one counselor to each 50 patients continues to be met—the standard in the regulations [other facilities have found it necessary to seek and obtain waivers to go to ratio of 150 clients to each counselor—but Metro has always been within the 50 to one standard—and 35 to one for counselors in first year]. 93-S.C. The applicant has demonstrated a need for increased services that cannot be reasonably met except by the increase in the permitted number of patients at its existing location. • Total census now 300 and has been 300 over the past few months; • Waitlist of 173 patients as of June 6; • Updated waitlist based on call backs over past 2 weeks—see update below under III93-6 review of fulfillment of this criterion; - 2 - 10788359.3 • • Three to five individuals contact daily seeking treatment; • Many on waitlist have been waiting over 120 days to be admitted; • Dr. Patel notes Public Health Epidemic: o May 2 Fox 22 Report on 2 deaths from dangerous batch of potent heroin; o Bangor Daily News reported on March 7th this year that 272 individuals had died in 2015 from heroin overdoses in Maine—a 31% increase from the previous year. Portland Press Herald July 8 article titled Planfor'social detax'center in Bangor generates debate contained the following: Maine is in the middle of an opioid epidemic, with 272 people dying of a drug overdose in 2015, the most ever. Meanwhile,people are clamoring for treatment, but there's skyrocketing demand and a limited supply. About 25,000 to 30,000 people want to enroll in drug treatment programs in Maine but do not have access, according to the U.S. Centers for Disease Control and Prevention. The state currently has a capacity to serve 4,300 opioid patients with medication-assisted treatment, according to an estimate by the Maine Opioid Collaborative, a group that worked for more than a year to devise a statewide strategy on how to address the 111 opioid crisis. §93-5.D. The applicant is in compliance with all state or federal laws, rules or regulations regarding its opioid treatment program. • Metro has all required state and federal certifications, licenses, etc.; • Opioid Treatment Certification from U.S. DHHS Substance Abuse & Mental Health Services Administration; • Controlled Substances Registration Certificate from DEA; • Certificate of Licensure from Maine DHHS; • Three year accreditation from Commission on Accreditation of Rehabilitation Facilities; • June 16, 2016 e-mail from Sarah Taylor, Asst. Director of Maine DHHS DLRS confirming that DHHS will approve increase in slots following approval from City of Bangor. 93.5.E. The applicant is in compliance with all City codes and ordinances. . • Metro is now in compliance with all City Codes and Ordinances; - 3 - 10788359.3 • Recent construction complies with City requirements per March 26 Certificates of • Occupancy; • Certificates of Occupancy document fulfillment of parking and all related criteria set forth in City Code that are generally applicable to medical treatment facilities; • City fire inspections have been successfully carried out. 93-6. Geographic location allowed for consideration. Notwithstanding the provisions of§93-5 above, the City Council may consider the geographic locations of patients and potential patients and may deny the application if it determines that there is sufficient patient demand to warrant a treatment facility in an area geographically closer to current and potential future patients. • Geographic distribution of current patients shows 88%from Penobscot, Hancock and Waldo Counties Penobscot: 201 (67%) Hancock: 42 (14%) Waldo: 23 (7.33%) Piscataquis: 12 (3.99%) Washington: 5 (1.66%) Somerset: 5 (1.66%) • Aroostook: 4 (1.33%) Knox: 2 (.66%) Lincoln: 1 (.33%) • More than two-thirds of our current patients live in Penobscot County, and over 88% live in Penobscot and the adjoining two counties of Waldo and Hancock; • Notable regarding patient distribution by cities and towns are the following: Bangor: 62 Brewer: 12 Hermon: 11 Old Town: 14 Winterport: 10 Milford: 18 • See Tabs 10 and 11 for application for further breakdowns; • Over the past couple of weeks, Penobscot Metro staff reached out to all those on waitlist to seek residence information. Staff was able to reach 60 prospective patients who confirmed that they were ready to enter treatment at the clinic. They provided the following additional information regarding their residence: • -4 - 10788359.3 • Totals Prospective Patients Stating Ready to Enter Treatment-- Total of 60 Those stating residences—52 Those with no stated residence—8 Penobscot County Cities Bangor—22 Brewer—2 Old Town—3 Penobscot County Towns Corinth— 1 Eddington— 1 Howland— 1 Lincoln—3 Medway— 1 Milford—3 Millinocket—4 110 Total residing in Penobscot County—41 of 60 --68% --79% of those stating residence(41 of 52) Waldo County Belfast— 1 Winterport— 1 Hancock County Ellsworth—4 Bar Harbor— 1 Bucksport— 1 Piscataquis County Guilford— 1 Washington County Calais— 1 IIIMachias— 1 - 5 - 10788359.3 • Colonial Evaluation of Other Sites The parent of the Penobscot Metro Clinic, Colonial Management, is evaluating the potential for other clinic sites in Maine. • Particular consideration is being given to a site in Aroostook County with different locations being evaluated—Houlton or Presque Isle look most promising; • While Metro's current census includes only four patients from Aroostook County, Colonial is aware of significant treatment needs in Aroostook County and the barrier to treatment that travel distances pose—no doubt there are many others seeking treatment in Aroostook county and other points north of Bangor; • There is no timetable for Colonial's reaching a determination on additional clinic sites, but Colonial agrees with the importance of providing treatment sites closer to client's communities and is giving serious consideration to additional sites; • At the same time, Colonial has already made the investment and has carried out the needed construction to meet the current waitlist and currently identified need of prospective patients seeking treatment at its Penobscot Metro clinic. Methadone Treatment Background • In the attached Notebook,please see the material set forth under the following tabs: 4. Penobscot Metro Chart Comparing Maine DHHS Substance Abuse Regulations for Outpatient Treatment Programs with the Office of Substance Abuse Waiver and Proposed MaineCare Manual Regulations Subject to Public Hearing on July 11 (DocID No. 10786804) 5. Penobscot Metro Typical Patient Scenario (DocID No. 10786567) 6. New England Journal of Medicine (NEJM Article), July 28, 2016, Treatment of Opioid-Use Disorders, Marc A. Schuckit, M.D., (DocID No. 10793409) http://www.nejm.org/doi/ful1/10.1056/NEJMral604339?query=TOC 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) https://www.drugabuse.gov/sites/default/files/pdf/partb.pdf 8. U.S. DHHS Substance Abuse and Mental Health Services Administration (SAMHSA)—Website Summary of Materials Regarding Methadone and Related Treatment http://www.samhsa.gov/medication-assisted-treatment • a. Methadone Treatment—What is Methadone, How Does Methadone Work, etc. (DocID No. 10747302) - 6 - 10788359.3 • http://www.samhsa.gov/medication-assisted-treatment/treatment/methadone b. Medication and Counseling Treatment and Opioid Treatment Programs (OTPs) (DocID No. 10747334) c. Medication Assisted Treatment(MAT)—Buprenorphine Options, Among Others (DocID No. 10747345) d. Buprenorphine—How Buprenorphine works, etc. (DocID No. 10747331) NEJM Article Overview The NEJM Article stated as follows at p. 363 with respect to Methadone Treatment: Methadone Maintenance Approaches Maintenance treatment with methadone, an oral mu agonist, has been widely used and intensively studied worldwide. In the United States, methadone is offered only through approved and closely monitored clinics that initially require almost daily patient participation in order to receive the drug, although some take-home doses are usually allowed for patients who adhere to program guidelines. • To be eligible for methadone maintenance,patients must have a current opioid- use disorder with physiologic features or have high risks associated with relapse (e.g., during pregnancy). In addition,patients cannot be currently participating in another maintenance program and cannot be especially vulnerable to methadone- related medical complications (e.g., they cannot be dependent on a depressant drug or have severe respiratory or cardiac disease). Dangers associated with methadone include overdose if the dose is increased too quickly during the initial stages of treatment and a potential prolongation of the QT interval on electrocardiography that can contribute to cardiac arrhythmias with doses higher than 100 mg per day. 44-46 Patients must understand their roles and responsibilities as well as the benefits that the program can and cannot offer. Methadone maintenance treatment occurs in approximately three phases (Table 5).47 The induction and early stabilization phase (beginning at week 1 and continuing in week 2) begins with initial oral doses of 15 to 30 mg, increasing by 10 to 15 mg every 3 to 5 days to 50 to 80 mg per day. During the late stabilization phase (at approximately weeks 3 to 6), doses are increased as tolerance develops and craving decreases. The most effective dose is 80 to 100 mg per day. 47-50 • - 7 - 10788359.3 . Patients who receive more than 100 mg per day must be closely monitored for side effects. 44,46,50 The maintenance phase begins at approximately 6 weeks, with doses adjusted to avoid drug-related euphoria, sedation, or opioid craving. Methadone clinics must be open on weekends in order to meet the needs of most patients, 51 and weekend take-home doses are based on the patient's progress in treatment and determination that he or she is unlikely to divert medications to other persons. The length of the maintenance phase, which depends on the patient's progress in treatment and his or her motivation, can last years to a lifetime. 1 Tapering off methadone is individualized and may take weeks or months. 26 During and after tapering, close contact with the patient should be maintained because discontinuation of maintenance carries high risks of relapse to the use of illicit drugs and overdoses that may lead to death. 11,52,53 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 HIV 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 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 reviews extensive research and notes; "The availability of methadone treatment in a community is associated with a decrease in that community's criminal activity, particularly theft." See, also Tab 9: 9. 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 stores, are not associated geographically with crime." . - 8 - 10788359.3 • Methadone and Societal and Economic Costs from Lack of Treatment See Tab 7 in the attached Notebook, the NIDA Document, 20 Questions, Question 18, Part B-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." 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. i • - 9 - 10788359.3