2013 Treatment Services for Opiate Addiction Determination of Need Report Florida Department of Children and Families Substance Abuse and Mental Health Services February 28, 2014 Table of Contents I. SUMMARY..........................................................................................................................................3 II. FLORIDA POPULATION.................................................................................................................4 III. CRITERIA ...........................................................................................................................................5 IV. APPLICATION ...................................................................................................................................7 V. CONCLUSION ....................................................................................................................................9 VI. APPLICATION FOR LICENSURE ............................................................................................... 10 APPENDIX A. IMPUTED 2013 AGE DISTRIBUTION .................................................................. 11 APPENDIX B. DATA TABLES............................................................................................................. 12 1 Treatment Services for Opiate Addiction Determination of Need Report Public Domain Notice All material appearing in this report is in the public domain and may be reproduced or copied without permission from the Department of Children and Families (DCF), Office of Substance Abuse and Mental Health Programs. However, citing the source provides credibility and reliability of the information presented. This publication may not be reproduced or distributed for a fee without the specific, written authorization of the DCF Office of Substance Abuse and Mental Health Program. Electronic Copy of the Publication This publication may be accessed electronically website:http://www.dcf.state.fl.us/programs/samh/pubs_reports.shtml Prepared by: Florida Department of Children and Families Substance Abuse and Mental Health 1317 Winewood Boulevard, Building 6 Tallahassee, Florida32399-0700 Completion Date: February 28, 2014 2 through DCF’s Determination of Need Report I. Summary Pursuant to s.397.427 (2),F.S., the Department of Children and Families (Department), must determine need for establishing providers of medication-assisted treatment services for opiate addiction. This report serves as the determination of need by the Department for FY13-14. The criteria used in determining need were promulgated in Rule 65D-30.014(3)(a), F.A.C. Based upon these criteria, the Department has determined the statewide need for medication-assisted treatment 1 services for opiate addiction to be seventy-two (72) licenses. Currently, there are forty-one (41) facilities. As a result of this determination, an additional thirty-one (31) licenses are needed. The Department is 2 required to determine the need by substate entity, Table 1 outlines this distribution. Table 1.Determination of Need by Substate Entity Determination of Need by Substate Entity Current Facilities Additional Licenses Needed Central 9 7 Northeast 6 4 Northwest 6 0 Southeast 6 8 Southern 3 6 Suncoast 11 6 41 31 Region TOTAL 1 This figure does not include the need determination identified in the 2012 Methadone Needs Assessment Report, as no licenses have been issued in response to that determined need. That report identified the need for two licenses in the Suncoast region, and three licenses in the Northeast Region. 2 Section 397.427(2)(b), F.S., requires determination of need by substate entity. The substate entity has been interpreted to refer to the Department’s administrative structure, pursuant to s. 397.311(38), F.S. Note: Rule 65D30.014(3)(a), F.A.C., refers to “districts” which has been superseded by “regions” pursuant a legislative amendment to s. 20.04(4), F.S. 3 Treatment Services for Opiate Addiction Determination of Need Report II. Florida Population To determine need, the Department must first establish the relevant state population. The Florida Office of Economic and Demographic Research (EDR) provides annual population estimates for legislative planning. At the February 2013 Demographic Estimating Conference, EDR estimated that the total 3 population for Florida in 2013 was 19,266,706. For purposes of establishing population for the determination of need, the Department notes the following in relation to the reported population: • • • • There is no age restriction in s. 397.427, F.S., for medication-assisted treatment for opiate addiction. The Department has promulgated rules to provide a standard for people under the age of 18 to 4 receive medication-assisted treatment for opiate addiction. Because of the absence of an age restriction in statute, the Department has included ages 15 and up in the total eligible pool of people that could receive medication-assisted treatment for 5 opiate addiction. This determination of need excludes ages 0-14. To impute a population estimate for each age range, the Department applied the age distribution from the 2010 Decennial Census to the aggregated 2013 population estimate of Florida. As a result, the relevant population base for determining need is based upon a population of 16,043,525 people. 3 This estimating conference was selected because it included the most recent total county population estimate from EDR. See http://edr.state.fl.us/Content/population-demographics/data/CountyPopulation.pdf (site accessed, December 19, 2013). 4 Rule Chapter 65D-30.014(5)(a), F.A.C. 5 Appendix A provides both the age distribution, and imputed population. 4 Determination of Need Report III. Criteria Having established an estimated relevant population base, this section outlines the criteria, in accordance with Rule65D-30.014(3)(a), F.A.C.: New providers shall be established only in response to the Department’s determination of need, which shall occur annually. The determination of need shall only apply to medication and methadonemaintenance treatment programs.In its effort to determine need, the Department shall examine information on treatment, the consequences of the use of opioids (e.g., arrests, deaths, emergency room mentions, other incidence and prevalence data that may have relevance at the 6 time, etc.), and data on treatment accessibility. The Department examined the following information: • • • • • 7 Eligible population; 8 Treatment admissions; 9 Staffing ratio in current medication-assisted treatment centers for opiate addiction; 10 Emergency Room (ER)admissions; and Prevalence on Florida’s National Survey of Drug Use and Health (NSDUH) rates for 11 treatment and dependence. The Department notes the following: • • The administrative division of the Department pursuant to s. 20.04 (4), F.S., is the aggregate of counties into regions. Therefore, counties with small populations may be under represented; and Most current prevalence information comes from U.S. Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA)’s National Survey on Drug Use and Health (NSDUH) for 2012, which is based on a household survey of 12 Florida and other states. In accordance with Rule 65D-30.014, F.A.C., the Department also examined information related to the treatment accessibility, arrests and opiate death data. Upon review, the Department determined the following: Treatment Accessibility: 13 • 4,573 out of 16,915 people in the Central Registry had invalid zip codes as result of input error; • Distance traveled from a person’s residence to a facility may involve intervening factors such as program criteria, funding sources (i.e., Medicaid availability), or other personal reasons, rather than proximity to their residence; • The Department does not have a way to determine the distance from more than one facility at a time; and 6 Rule Chapter 65D-30.014(3)(a), F.A.C. “[T]he consequences of the use of opioids (e.g., arrests, deaths, emergency room mentions, other incidence and prevalence data that may have relevance at the time, etc.).”Id. 8 “…examine information on treatment,” Id. 9 “… and data on treatment accessibility.”Id. See also, supra, note 13. 10 Supra, note 13. 11 Id. 12 The National Survey on Drug Use and Health (NSDUH) series primarily measures the prevalence and correlates of drug use in the United States. The surveys are designed to provide estimates. Information is provided on the use of illicit drugs, alcohol, and tobacco among members of United States households aged 12 and older. 13 Population data as of December 19, 2013 as determined by EDR. 7 5 Treatment Services for Opiate Addiction Determination of Need Report • Arrest Data: • • The Central Registry does not capture individuals who do not seek treatment because of travel hardship. 14 Infers there is a correlation between opiate-related arrests and a clinical diagnosis of opiate dependence (opiate dependence being a necessary precondition to medicationassisted opioid treatment); Infers a person with an opiate related arrest would seek or qualify for treatment; and Opiate Death Data: • • • 15 Infers there is a correlation between the presence of an opiate at the time of death and opioid treatment. It is unclear that such a person would have sought medication-assisted opioid treatment. Does not indicate that an opiate was the direct cause or a contributing factor to death; and Does not distinguish between individuals that would have qualified for medicationassisted opioid treatment. A necessary precondition for medication-assisted opioid treatment in the context of substance use disorders is a diagnosis of heroin or opiate dependence. Upon examination of the criteria above, the data sets used do not appear to include information specifically related to medication-assisted opioid treatment, or such a diagnosis. Based on the data quality issues related to medication-assisted opioid treatment, this has been excluded as insufficient to build an inference related to the determination of need for treatment. The following steps outline the approach for calculating the total number of facilities needed: 16 17 Step 1-Multiply rates for heroin and prescription opiate dependence bythe relevant population base. Step 2-Add these results together to determine opiate dependent individuals. 18 Step 3-Multiply Step 2 by the persons seeking treatment: 20%. 19 Step 4- Divide the total clinical staff (336) by the total number of persons receiving treatment reported into the Central Registry as of December 19, 2013 (16,915). Step 4(a)-Divide Step 3 into the result of Step 4. Step 5-Divide the total number of staff (336) by the total number of facilities (41). Step 5(a)-Divide Step 4(a)by Step 5. 14 The Florida Department of Law Enforcement (FDLE) Statistical Analysis Center: 2012 opiate-related arrest data, Analysis ran on 2013-12-12 (04:50 PM EST). http://www.fdle.state.fl.us/Content/FSAC/FSAC-Home.aspx 15 The Florida Department of Law Enforcement (FDLE) 2012 Medical Examiners Commission Interim Drug Report, analysis ran on 2013-12-13 (04:50 PM EST)http://www.fdle.state.fl.us/Content/getdoc/9c4df7c2-4b07-4f7a-acfb6461719c0e44/2012-interim-drug-reportFINAL.aspx 16 National Survey of Drug Use and Health: (2012), Analysis ran on 2013-12-12 (04:50 PM EST) using SDA 3.5 Tables. Variable used= II2HERFY, see Appendix B for chart. 17 National Survey of Drug Use and Health: (2012), Analysis ran on 2013-12-12 (04:50 PM EST) using SDA 3.5 Tables. Variable used= DEPNDANL, see Appendix B for chart. 18 National Institute of Health Fact Sheet: http://report.nih.gov/nihfactsheets/viewfactsheet.aspx?csid=123 site accessed: December 12, 2013. 19 Based upon Methadone Central Registry (2013), Analysis ran on 2013-12-13 (02:00 PM EST) 6 Determination of Need Report Step 1:16,043,525 relevant population base x 0.6% NSDUH state percent of person’s prescription opiate dependent Step 2:+16,043,525 relevant population base x 0.33% NSDUH state percent of persons heroin dependent = 149,205 projected number of Floridians dependent on opiates Step 3: x 20% average percentage of clients dependent on opiates seeking treatment = 29,841indication of prevalence for person dependent on opiates seeking treatment Staffing Ratio/Case Load Analysis (Rule Chapter 65D-30, F.A.C.) Step 4: 16,915 number of clients currently in treatment =50.34 current staff ratio 336 number of total staff in facilities Step 4(a):29,841 Indicator of prevalence forthose needing treatment =593 number of staff needed 50.34 current staff ratio Step 5:336 number of staff=8.2 average staff per facility 41 number of licenses Step 5(a):593 number of staff to meet current staffing ratio=72 total number of facilities needed 8.2 average staff per facility IV. APPLICATION The Department estimates approximately 29,841 people to be both opiate dependent and seeking treatment. Tables 4and 5show by region: • • • Estimate of opiate dependent people; Estimated people who are opiate dependent and seeking medicated-assisted treatment; and Staff and facilities required to serve the population seeking medicated-assisted treatment. 7 Treatment Services for Opiate Addiction Determination of Need Report Table 2. Distribution Function Table Prevalence of Opiate Dependent Individuals and Treatment Region Potentially Eligible Population (2013 Census) Estimated Prevalence for Prescription Opiate Dependence (pop.x .6%) Estimated Prevalence for Heroin Dependent (pop. x .33%) Estimated Prevalence Opiate Dependent (c+d) Estimated Dependent and Seeking Treatment (e*.2) a b c d e f Central 3,493,447 20,961 11,528 32,489 6,498 Northeast 2,148,294 12,890 7,089 19,979 3,996 Northwest 1,143,712 6,862 3,774 10,637 2,127 Southeast 3,096,594 18,580 10,219 28,798 5,760 Southern 2,278,946 13,674 7,521 21,194 4,239 Suncoast 3,882,531 23,295 12,812 36,108 7,222 Total 16,043,525 96,261 52,944 149,205 29,841 Region 8 Table 3. Total Facilities Needed By Region Estimated Dependent and Estimated Client to Staff Seeking Treatment Ratio (from previous chart) (b/50.34) Estimated Facilities Needed (c/8.2) a b c D Central 6,498 129 16 Northeast 3,996 79 10 Northwest 2,127 42 5 Southeast 5,760 114 14 Southern 4,239 84 10 Suncoast 7,222 143 17 Total 29,841 593 72 Determination of Need Report V. Conclusion Based upon the Department’s examination of the criteria established in Rule 65D-30.014 and pursuant to s. 397.427, F.S., the Department has determined a need of thirty-one (31) additional treatment centers, across the state. Based on the application of Tables 2 and 3, Table 4 shows the final recommendations for treatment facilities. Table 4. Final Recommendation for Additional Medication-Assisted Opioid Treatment Facilities Region Additional Licenses Central 7 Northeast 4 Northwest 0 Southeast 8 Southern 6 Suncoast 6 TOTAL 31 9 Treatment Services for Opiate Addiction Determination of Need Report VI. Application for Licensure Pursuant to s. 397.427(2), F.S. and Rule 65D-30.014, F.A.C., the Florida Department of Children and Families (Department), this report satisfies the statutory requirement requiring a determination of need for medication-assisted treatment services for opiate addiction. In accordance with Rule 65D-30.014(3)(b), F.A.C., the Department directs interested parties to submit an application for licensure to the Department’s regional office where need has been demonstrated. The regional office shall conduct a formal rating of applications using the form titled MEDICATION AND METHADONE MAINTENANCE TREATMENT NEEDS ASSESSMENT, September 6, 2001, incorporated in Rule 65D-30.014, F.A.C. A copy of this rating sheet is attached hereto. In accordance with Rule 65D-30.014(3)(b), F.A.C., the Department is requiring that interested parties submit applications no later than April 30, 2014. The regional contact information for submission is as follows: Region Northwest Northeast Central Suncoast Southeast Southern Contact Sheila Barbee, Regional SAMH Director 2383 Phillips Road Tallahassee, Florida 32308 Jayme Carter, Regional SAMH Director 5920 Arlington Expressway Jacksonville, Florida 32211 Mailing Address: Post Office Box 2417 Jacksonville, Florida 32231 Carolann Duncan, Regional SAMH Director 400 West Robinson Street Suite S-1106 Orlando, Florida 32801 Jeff Watts, Regional SAMH Director 9393 N. Florida Ave., Suite 1000 Tampa, FL 33612-7236 Pat Kramer, Regional SAMH Director Broward Regional Service Center 201 West Broward Blvd.; Suite 511 Fort Lauderdale, Florida 33311 Kate Prendiville, Regional SAMH Director 401 NW 2nd Avenue Room 812, North Tower Miami, Florida 33128 (305) 377-5029 Should you require additional information, please contact Linda Loy 850-717-4424. 10 Determination of Need Report Appendix A. Imputed 2013 Age Distribution Age Range Distribution Imputed 2013 Population Estimate 0-4 5.7% 1,098,202 5-9 5.7% 1,098,202 10-14 6.0% 1,156,002 15-17 3.8% 732,135 18-19 2.7% 520,201 20-24 6.5% 1,252,336 25-29 6.3% 1,213,802 30-34 5.9% 1,136,736 35-39 6.3% 1,213,802 40-44 6.7% 1,290,869 45-49 7.5% 1,445,003 50-54 7.1% 1,367,936 55-59 6.4% 1,233,069 60-64 6.0% 1,156,002 65-69 5.1% 982,602 70-74 4.1% 789,935 75-79 3.3% 635,801 80-84 2.6% 500,934 85 and up 2.3% 443,134 100.0% 19,266,706 20 20 http://edr.state.fl.us/Content/population-demographics/data/Pop_Census_Day.pdf (site accessed, December 19, 2013). 11 Treatment Services for Opiate Addiction Determination of Need Report Appendix B. Data Tables Data for heroin and opiate dependency and use were taken from the National Survey of Drug Use and 21 Health 2012/SDA/DAMHDA/34933-001 dataset. This dataset reflects the most recent information related to heroin and opiate dependence. The most current available state-level data is five years old, 2002-2009 aggregate dataset. Many policies and practices have changed during this time period that impact opiate use and consequences. The NSDUH survey provided the most relevant and accurate data. The NSDUH survey also uses statistical imputation for selected variable following logical inference to replace missing data with appropriate response codes. The statistical imputation for heroin dependence is used to better 22 reflect trends in use. Figure A. Prescription Pain Reliever Dependence 21 National datasets regarding substance use, mental health, and treatment can be obtained at the following address: https://www.icpsr.umich.edu/icpsrweb/content/SAMHDA/rdas.html 22 th Goode, Eric, (2012). “Drugs in America.”McGraw Hill.8 ed., Stony Brook, NY. 12 Determination of Need Report Figure B. Imputed Heroin Dependence Based on Frequency Indicator(Part 1) Figure C. Imputed Heroin Dependence Based on Frequency Indicator(Part 2) 13