2010 Methadone Needs Assessment Report Substance Abuse Program Office Florida Department of Children and Families June 2010 Darran Duchene State Methadone Authority Introduction and Purpose The Narcotic Addict Treatment Act of 1974 allowed methadone, a synthetic narcotic, to be used in the detoxification and maintenance treatment of opiate addicts. Methadone maintenance treatment involves administering a constant therapeutic daily dose of methadone following stabilization together with medical, rehabilitative, and counseling services. Methadone provides recovering addicts support – carefully monitored support – to assist them in their successful treatment. In Florida, the need for new methadone maintenance treatment services is determined through a formal assessment. The statutory authority for conducting needs assessments is found in section 397.427(2) (a), Florida Statutes, which provides that: M edication assisted treatment service providers may be established only in response to the Department’s determination and publication of need for additional medication assisted treatment services. The purpose of the needs assessment is threefold: 1) to determine the need for new opioid treatment programs, also referred to in this document as full clinics; and 2) to develop additional Medicaid service capacity/indigent coverage for methadone maintenance; and 3) to determine the need for satellite opioid treatment programs/clinics. The two types of clinics and eligibility criteria are outlined below: New Opioid Treatment Programs/Full Clinics – Stand -alone medication assisted treatment programs that offer methadone induction and maintenance services for individuals with a history of abuse/dependence on heroin or opioid medications. These programs require a new license from the Department of Children and Families, registration of the “narcotic treatment program” with the federal Drug Enforcement Agency (DEA), and registration with the federal Center for Substance Abuse Treatment (CSAT) within the Substance Abuse and Mental Health Services Administration (SAMHSA). For each region of the state showing a need for expansion of opioid treatment programs, prospective providers must submit a competitive application to the State Methadone Authority (SMA). Only providers selected via the competitive process will be approved for licensure and registration. The process for submitting applications is outlined at the end of this document. Satellite Opioid Treatment Programs/Clinics – Medication assisted treatment programs that function under the auspice of a currently licensed methadone maintenance program. Pursuant to 65D-30.0014, Florida Administrative Code, changes to be adopted in Fall 2010 allow for existing methadone providers to establish a program at a location separate from the full clinic, provided the size of 2010 Methadone Needs Assessment Report Page 2 the satellite clinic does not exceed 25 percent of the full clinic’s capacity (e.g., if the full clinic can serve 200 patients, the satellite clinic can serve up to 50 additional patients). For each region of the state showing a need for additional satellite opioid treatment programs, prospective providers must submit a request to the SMA. Upon approval, the provider shall be responsible for filing appropriate registrations with the DEA and CSAT-SAMHSA. This process shall use a “first come, first serve” basis; if the number of providers interested in establishing satellite clinics exceeds the number identified as “need” in this document then a competitive process similar to the full clinic option will be employed. Needs Criteria Methadone maintenance programs in Florida and across the United States have historically focused on individuals addicted to heroin. In recent years, the state has seen a tremendous increase in the abuse of prescription opioid medications which has, in turn, created a need for additional, effective treatment options, including methadone and buprenorphine. The popularity and availability of prescription pain medications has been accompanied by an alarming increase in their abuse. Several factors may contribute to this phenomenon in that: 1) they are highly addictive; 2) they are increasingly available and a profit can be made from their sale on the street; 3) they are promoted heavily in the media, prompting patients to more frequently request them from their physicians; 4) they are even more deadly when combin ed with other readily available substances such as alcohol; 5) inter-physician and inter-pharmacy controls may be insufficient; and 6) more information is available to guide the misuse of these drugs (e.g., addicts can get information from the Internet about washing the slow-release coating off oxycontin tablets before grinding them into a powder, cooking them down, and injecting them). Florida currently has more than 800 physicians certified by CSAT to provide buprenorphine for the treatment of opioid addiction. However, for individuals without insurance or the financial means to self -pay, buprenorphine can be cost-prohibitive. Methadone maintenance, which has been proven effective for several decades, is one of the primary treatment regimens endorsed by the Department of Children and Families’ Substance Abuse Program. Thus, this needs assessment solely identifies the need for additional methadone maintenance programs in Florida. Several different types of data were used in the determination of need. Data was reviewed and analyzed for each of the Department’s six regions (Northeast, Northwest, Central, Southeast, Southern, and Suncoast). For the 2010 needs assessment, the Department was primarily concerned with improving the geographic availability of services within each region, while considering other key factors driving the need for service capacity: 1) heroin -caused deaths; 2) oxycodone/hydrocodone-related deaths; 3) opioid -related arrests; 4) travel hardships; and 5) opioid-related hospital emergency room admissions. 2010 Methadone Needs Assessment Report Page 3 Table 1: Data Sources for Methadone Needs Assessment P RIM ARY DATA SOURCE Medical Examiners Medical Examiners Local Law Enforcement Methadone Clinics Hospitals/Emergency Rooms Emergency Rooms Bureau of Economic & Business Research TYP E OF DATA AGENCY Heroin deaths Hydrocodone & Oxycodone deaths Opiate arrests FDLE FDLE FDLE Geographic Location/Travel hardship (>50 miles) Opiate hospital admissions and emergency room visits Opiate Overdoses Estimates of Florida population DCF AHCA AHCA OEDR The data used in the assessment were provided by state-licensed and accredited methadone programs, the Florida Department of Law Enforcement (FDLE) Statistical Analysis Center, the Medical Examiners’ Commission at FDLE, and the Agency for Health Care Administration’s (AHCA) State Center for Health Statistics. The Office of Economic & Demographic Research (OEDR) of the Florida Legislature (www.edr.state.fl.us) publishes population data summaries that are prepared for it by the University of Florida Bureau of Economic and Business Research. Those population summaries are considered official for state agencies and are used for calculations presented in this document. Table 1 lists these data sources. The State Board of Medical Examiners was asked to distinguish between drugs as the cause of death and drugs merely present in the body during death investigations. These data were reported for the period January 200 9 through December 2009 and include heroin, methadone, hydrocodone, and oxycodone. Due to the increase in deaths associated with hydrocodone and oxycodone since 2000, the death rate for these medications has been integrated into this report as an added factor in determining the need for methadone maintenance treatment clinics. Opiate overdoses data was prepared by Hal Johnson, MPH (Substance Abuse Program Office, Prevention Team) and the Florida Department of Children and Families’ State Epidemiology Workgroup (SEW) - July 6, 2010. 2010 Methadone Needs Assessment Report Page 4 Opiate Overdoses Data from the Agency for Health Care Administration showed a steady increase in the number of emergency department diagnoses for opiate analgesic overdoses between 2006 and 2008 in most DCF regions. Table 1. ED diagnoses of prescription opiate analgesic overdoses (unintentional poisonings) by DCF region, 2006 - 2008 (Does not include heroin or methadone) Northwest Northeast Central Suncoast Southeast Southern xUnknown Florida Number of diagnoses 2006 2007 2008 138 140 139 278 332 393 377 444 697 608 767 1095 312 435 505 58 84 97 22 40 57 1793 2242 2983 Rate per 100,000 population 2006 2007 2008 10.1 10.1 9.9 11.1 13.0 15.1 8.3 9.5 14.8 13.9 17.1 24.3 10.3 14.2 16.5 2.3 3.3 3.8 9.8 12.0 15.9 Table 2. ED diagnoses of heroin overdoses (unintentional poisonings) by DCF region, 2006 - 2008 Number of diagnoses Rate per 100,000 population 2006 2007 2008 2006 2007 2008 Northwest 1 0 3 0.1 0.0 0.2 Northeast 12 14 12 0.5 0.5 0.5 Central 32 25 52 0.7 0.5 1.1 Suncoast 54 53 58 1.2 1.2 1.3 Southeast 33 39 34 1.1 1.3 1.1 Southern 12 14 15 0.5 0.6 0.6 xUnknown 9 16 21 Florida 153 161 195 0.8 0.9 1.0 2010 Methadone Needs Assessment Report Page 5 Table 3. ED diagnoses of methadone overdoses (unintentional poisonings) by DCF region, 2006 2008 Number of diagnoses Rate per 100,000 population 2006 2007 2008 2006 2007 2008 Northwest 39 23 37 2.8 1.7 2.6 Northeast 83 76 97 3.3 3.0 3.7 Central 72 115 113 1.6 2.5 2.4 Suncoast 160 186 170 3.7 4.2 3.8 Southeast 50 62 69 1.6 2.0 2.3 Southern 11 10 2 0.4 0.4 0.1 xUnknown 4 5 6 Florida 419 477 494 2.3 2.6 2.6 Heroin-Caused Deaths Data from the Florida Department of Law Enforcement plays a key role in determining methadone treatment need in Florida. Since 2001, there has been a fairly steady decline in the number of heroin-caused deaths. In 2001, 271 heroin deaths were reported by medical examiners. In 200 9, there were 95 heroin deaths reported. This represents a 65% decrease in heroin deaths since 2001. See Figure 1 for a comparison of heroin-caused deaths since 2001. Number of Deaths Figure 1. Deaths Caused by Heroin: 2001 to 2009 250 300 200 271 230 150 109 100 93 119 78 0 2001 2002 2003 2004 2005 2006 2007 2008 Year 2010 Methadone Needs Assessment Report 95 Page 6 2009 A review of regional data from 2009 indicates that the concentration of heroin deaths varies significantly based on geographic region. Table 4 shows the number of heroin -related deaths by Department of Children and Families (DCF) region . Table 4: 2009 Heroin Deaths by DCF Region REGION Northwest Region Northeast Region Central Region Southeast Region Southern Region Suncoast Region Total HEROIN DEATHS 2 4 34 13 27 15 95 Oxycodone- and Hydrocodone-Related Deaths Another critical marker used to determine treatment need for opiate abuse in substate regions is the number of oxycodone and hydrocodone “caused” deaths. Figure 2 shows the trend in the number of deaths related to oxycodone or hydrocodone from 2001 to 2009. Number of Deaths Figure 2: Oxycodone/Hydrocodone Deaths: 2001-2009 1,700 1,143 1,200 700 1,204 1,306 1,450 1,364 1,211 957 969 732 200 2001 2010 Methadone Needs Assessment Report 2002 2003 2004 2005 2006 2007 Page 7 2008 2009 The number of oxycodone- and hydrocodone-related deaths increased each year from 2000 until 2005. In 2006, deaths fell 46 percent to 732, however, the rate has since doubled to 1,450 deaths in 2009. Table 5 presents a substate level of reporting of oxycodone and hydrocodone deaths for 2009. Table 5: 2009 Oxycodone and Hydrocodone Deaths by DCF Region REGION Northwest Region Northeast Region Central Region Southeast Region Southern Region Suncoast Region Total OXYCODONE/HYDROCODONE DEATHS 32 158 312 332 51 565 1,450 Opioid-Related Drug Arrests The Florida Department of Law Enforcement (FDLE) provides data that show the number of arrests linked to non -prescription opioid possession, sales, and/or related activities and include mentions of heroin, hydrocodone, methadone, morphine, and oxycodone. Th ese data are reported by local entities and collected by the FDLE-Statistical Analysis Center. As indicated in table 6 below, Circuit 17 (Broward County) has the highest rate of opiate arrests in the state, followed closely by Circuit 6 (Pasco and Pinellas counties), the majority of which were for oxycodone possession (1,156 – Broward, 986 Pasco/Pinellas). Table 6: 2009 Opiate Arrests by DCF Region REGION Northwest Region Northeast Region Central Region Southeast Region Southern Region Suncoast Region Total 2010 Methadone Needs Assessment Report ARRESTS 28 163 394 1,542 137 2,118 4,382 Page 8 Travel Hardship A major barrier to success in drug addiction treatment beyond treatment availability and patient motivation is access to treatment services. Patients recovering from an opiate addiction who are forced to travel long distances to secure treatment incur the greatest risk of relapse or treatment failure. Locating any new methadone maintenance treatment clinic where it has the greatest likelihood of reducing travel hardship multiplies the beneficial effects. For the purposes of the needs assessment, the geographic locations and concentrations of opioid treatment programs were examined to identify areas of the state that required considerable numbers of take-home requests due to travel distance. The expansion of methadone maintenance capacity throughout the state will help to alleviate a significant portion of the travel problem. The 2011 needs assessment will refine the analysis further to concentrate on patients that have a travel hardship, provided they do not attend a clinic for convenience that is 50 or more miles away, i.e., they choose not to go to a clinic within the 50 mile radius for reasons other than 3rd party payer options (including Medicaid). Table 7 shows the largest geographic gaps in clinics by region. Table 7: Geographic Gaps in Clinic Locations Creating Travel Hardship REGION Northwest Northwest Northeast Central Southeast Southern Suncoast Suncoast 2010 Methadone Needs Assessment Report LARGEST GAPS IN CLINIC LOCATIONS Shalimar to Tallahassee Pensacola to Tallahassee Tallahassee to Gainesville Palm Bay to Ft. Pierce Lake Worth to Pompano Beach South Miami to Marathon Bradenton to Ft. Myers Bradenton to Pinellas Park NUMBER OF MILES BETWEEN LOCATIONS 176 200 156 51.3 30.3 89.8 83.7 38.3 Page 9 Opioid-Related Hospital Admissions and Emergency Room Visits The Agency for Health Care Administration (AHCA) reports a total of 3,377 hospital admissions of Florida residents for opioid related illness or accidents in 2009 and an additional 2,161 emergency room visits for opioid abuse/dependence. Regional totals are listed in Table 8 below. Table 8: 2009 Opioid-Related Hospital Admissions and ER Visits by DCF Region OPIOID HOSPITAL ADMISSIONS REGION Northwest Region Northeast Region Central Region Southeast Region Southern Region Suncoast Region Total 2010 Methadone Needs Assessment Report 14 543 379 1,085 550 806 3,377 OPIOID EMERGENCY ROOM VISITS 32 162 490 781 278 418 2,161 Page 10 Determination of Need The following section of the needs assessment provides a profile for each Department region. Each profile contains information on the options for expanding methadone maintenance capacity. Providers wishing to apply for a methadone maintenance license must provide pertinent information on identified regional needs in their response and must demonstrate the capacity to structure services in a manner that best meets the needs of the State of Florida as outlined in this document. All existing opioid treatment programs in each region are indicated on the map as a circle; the square in each regional map highlights the areas where the Department will allow the development of new clinic capacity. 2010 Methadone Needs Assessment Report Page 11 Northwest Region Circuit 1 - Escambia, Okaloosa, Santa Rosa, Walton Circuit 2 - Franklin, Gadsden, Jefferson, Leon, Liberty, Wakulla Circuit 14 - Bay, Calhoun, Gulf, Holmes, Jackson, Washington 2010 Population 18 and Older: 1,107,612 Number of Opioid Treatment Programs: 3 Medicaid OTPs: 1 Opioid Treatment Programs Needed: Option 1: 1 Full Clinic, 3 Satellites Option 2: 2 Full Clinics, 2 Satellites Expansion Options The Northwest Region is comprised of 16 counties with the concentration of opioid treatment programs at the east and west extremes of the region. Bay County is the most populated area without methadone treatment programs. The Northwest Region does not currently have any Medicaid capacity for methadone maintenance east of Shalimar. Providers wishing to submit competitive applications for full clinics must indicate planned service catchment areas (counties) and the capacity to bill for Medicaid services. Prospective providers must also account for fluctuations in patient census due to seasonal increases in population and individuals from South Alabama and South Georgia seeking methadone treatment in this area of Florida. Based on applications received from interested providers, the State Methadone Authority will decide which of the options to select. Full clinics will only be considered for counties lying between Leon (Tallahassee) and Okaloosa (Shalimar). Demonstration of need for satellite programs shall be the responsibility of existing licensed methadone providers. 2010 Methadone Needs Assessment Report Page 12 Northeast Region Circuit 3 - Columbia, Dixie, Hamilton, Lafayette, Madison, Suwannee, Taylor Circuit 4 - Clay, Duval, Nassau Circuit 7 - Flagler, Putnam, Saint Johns, Volusia Circuit 8 - Alachua, Baker, Bradford, Gilchrist, Levy, Union 2010 Population 18 and Older: 2,025,457 Number of Opioid Treatment Programs: 4 Medicaid OTPs: 2 Opioid Treatment Programs Needed: Option 1: 1 Full Clinic, 1 Satellite Option 2: 2 Satellites Expansion Options The North east Region is comprised of 20 counties with the concentration of opioid treatment programs in Jacksonville, Gainesville, and Daytona Beach. Columbia, Flagler, and St. Johns counties are the most populated areas without methadone treatment programs. The North east Region does not currently have any Medicaid capacity for methadone maintenance outside of Jacksonville and Gainesville. Providers wishing to submit competitive applications for full clinics must indicate planned service catchment areas (counties) and the capacity to bill for Medicaid services. Prospective providers must also account for fluctuations in patient census due to seasonal increases in population and individuals from south Alabama and south Georgia seeking methadone treatment in northern sector of this area of Florida. Based on applications received from interested providers, the State Methadone Authority (SMA) will decide which of the options to select. Full clinics will only be considered for areas outlined above. Demonstration of need for satellite programs shall be the responsibility of existing licensed methadone providers. 2010 Methadone Needs Assessment Report Page 13 Central Region Circuit 5 – Citrus, Hernando, Lake, Marion, Sumter Circuit 9 - Orange, Osceola Circuit 10 – Hardee, Highlands, Polk Circuit 18 – Brevard, Seminole Circuit 19 – Indian River, Martin, Okeechobee, St. Lucie 2010 Population 18 and Older: 3,137,667 Number of Opioid Treatment Programs: 9 Medicaid OTPs: 5 Opioid Treatment Programs Needed: Option 1: 1 Full Clinic, 1 Satellite Option 2: 2 Satellites Expansion Options The Central Region is comprised of 16 counties with the concentration of opioid treatment programs in and around the Orlando metropolitan area. Hernando, Citrus, and Highlands counties are the most populated areas without methadone treatment programs. The Central Region does not currently have any Medicaid capacity for methadone maintenance in the Northern and Southern extremes of the region. Providers wishing to submit competitive applications for full clinics must indicate planned service catchment areas (counties) and the capacity to bill for Medicaid services. Prospective providers must also account for fluctuations in patient census due to seasonal increases in population. Based on applications received from interested providers, the SMA will decide which of the options to select. Full clinics will only be considered for areas outlined above. Demonstration of need for satellite programs shall be the responsibility of existing licensed methadone providers. 2010 Methadone Needs Assessment Report Page 14 Southeast Region Circuit 15 – Palm Beach Circuit 17 - Broward 2010 Population 18 and Older: 2,354,463 Number of Opioid Treatment Programs: 5 Medicaid OTPs: 1 Opioid Treatment Programs Needed: Option 1: 1 Full Clinic, 1 Satellite Option 2: 2 Satellites Expansion Options The Southeast Region is comprised of two (2) large counties with the concentration of opioid treatment programs near Fort Lauderdale and West Palm Beach. Although Broward County currently has three (3) programs, it has the highest rate of opioid medication prescriptions in Florida and, as indicated earlier in the assessment, has the highest rates of opioid possession arrests and hospitalizations/ER visits due to opioid abuse/dependence. Medicaid capacity for methadone maintenance is non -existent in Palm Beach County and only one (1) provider in Broward County is a Medicaid provider. Providers wishing to submit competitive applications for full clinics must indicate planned service catchment areas (counties) and the capacity to bill for Medicaid services. Clinics will not be approved in close proximity to existing programs in Lake Worth, West Palm Beach, Sunrise, Hollywood, or Pompano Beach. Prospective providers must also account for fluctuations in patient census due to seasonal increases in population. Based on applications received from interested providers, the State Methadone Authority will decide which of the options to select. Full clinics will only be considered for areas within these two counties as outlined above. Demonstration of need for satellite programs shall be the responsibility of existing licensed methadone providers. 2010 Methadone Needs Assessment Report Page 15 Southern Region Circuit 11 – Miami-Dade Circuit 16 - Monroe 2010 Population 18 and Older: 1,946,700 Number of Opioid Treatment Programs: 3 Medicaid OTPs: 0 Opioid Treatment Programs Needed: Option 1: 1 Full Clinic, 1 Satellite Option 2: 2 Satellites Expansion Options The Southern Region is comprised of two (2) counties with the concentration of opioid treatment programs in Miami. Program capacity in the Keys was eliminated by the closure of clinics, leaving lost distances for methadone clients to travel (South Miami). The Southern Region does not currently have any Medicaid capacity for methadone maintenance. Providers wishing to submit competitive applications for full clinics must indicate planned service catchment areas (counties) and the capacity to bill for Medicaid services. Prospective providers must also account for fluctuations in patient census due to seasonal increases in population. Based on applications received from interested providers, the State Methadone Authority (SMA) will decide which of the options to select. Full clinics will only be considered for counties lying between South Miami through the Florida Keys. Demonstration of need for satellite programs shall be the responsibility of existing licensed methadone providers. 2010 Methadone Needs Assessment Report Page 16 Suncoast Region Circuit 6 - Pasco, Pinellas Circuit 12 - DeSoto, Manatee, Sarasota Circuit 13 - Hillsborough Circuit 20 - Charlotte, Collier, Glades, Hendry, Lee 2010 Population 18 and Older: 3,569,197 Number of Opioid Treatment Programs: 8 Medicaid OTPs: 4 Opioid Treatment Programs Needed: Option 1 : 1 Full Clinic, 1 Satellite Option 2: 3 Satellites Expansion Options The Suncoast Region is comprised of 11 counties with the concentration of opioid treatment programs in the Tampa/St. Petersburg areas of the region. Collier and Sarasota counties are the most populated areas without methadone treatment programs. The Suncoast Region currently has a number of Medicaid programs for methadone maintenance. Providers wishing to submit competitive applications for full clinics must indicate planned service catchment areas (counties) and the capacity to bill for Medicaid services. Prospective providers must also account for fluctuations in patient census due to seasonal increases in population. Based on applications received from interested providers, the SMA will decide which of the options to select. Full clinics will only be considered for counties not otherwise covered by the 50-mile radius of an existing licensed methadone program. Demonstration of need for satellite programs shall be the responsibility of existing licensed methadone providers. 2010 Methadone Needs Assessment Report Page 17 Application Process In September 2010, the Department will post competitive application packets to its website at the following web address: http://www.dcf.state.fl.us/programs/samh/SubstanceAbuse/treatment.shtml The web posting will also include dates/times for application submission and explain the Department’s review/approval process. Once opened, the application process will last 30-45 days. All questions received during the application process will be posted to the website, along with the Department’s response. An additional period of 45-60 days will be allowed for the Department review process, beginning with the day following closure of the application process. Prospective providers can use the following criteria as a guide to begin the development process, however, while the list is not all inclusive it does provide key areas of focus for Department review: ü ü ü ü ü ü Experience operating opioid treatment programs (does not have to be confined to Florida); Knowledge, skills, and abilities of key staff that will handle initial operation of propose clinic(s); Plan for hiring/use of sponsor, medical director, and pharmacist; Plan for becoming Medicaid provider (for areas indicated in this needs assessment) and contingency fund development for indigent patients; Annual program capacity and staffing; and Description of planned services areas, indicating awareness of existing opioid treatment programs’ catchment areas (to avoid duplicate coverage). 2010 Methadone Needs Assessment Report Page 18