WCA + CODA, Inc: our shotgun wedding
part one of a collaborative interview with Alison Noice
Since this newsletter is about WCA and its partnerships -- including how those partnerships tie in to the coalition for 5NP in Oregon -- I wanted to include an interview with Alison Noice, Executive Director of CODA, Inc. Founded in 1969, CODA is one of Oregon’s largest not-for-profit substance use treatment providers. WCA has had one or more onsite clinics at CODA’s facilities since 2016.
The partnership between WCA and CODA happened so fast and so comprehensively, under such unusual circumstances, that I think of it as our shotgun wedding. (No actual shotguns were involved.) Last week Alison and I had a conversation at the Bison Coffeehouse that I’m going to try to translate into newsletter form. Happy Valentine’s Week!
Me: So do you remember how we met? It was in early 2016, right? CareOregon introduced us. There was a discussion group we were both invited to.
Alison: It must have been right around when the CCOs (coordinated care organizations) were forming. That meant Medicaid had expanded to include many more people, and CCOs were trying to understand their role in advancing the quality and cost-effectiveness of healthcare. At the same time, there was a lot of urgent discussion about how pain management needed to change. We were all now fully aware of how excessive opioid prescribing was contributing to the opioid epidemic. Guidelines for pain management (specifically, limiting opioid prescriptions) were changing and the CCOs were looking to to promote alternate forms of pain management. Secondarily, we feared the impact of changing how and when people would be prescribed opioids, knowing we were likely to discover they had opiate use disorders once they started trying to reduce their pain medication.
Me: I felt a little out of place.
Alison: I believe what you said to the group was, “I don’t know what I’m doing here.” And then you proceeded to tell them how they were doing it all wrong.
Me: Oh dear.
Alison: You used your “public utility” metaphor, how access to acupuncture should be more like building a pipe than doling out expensive individual treatments.
Me: Right. Yes. I’m still amazed that you reached out to me after that.
Alison: I wasn’t exactly sure what you meant at first, but I was struck by how well and how plainly you spoke. I’m always looking for that in those rooms. I also remembered when there was a lot more acupuncture being used in behavioral health in Portland. My first behavioral health employer in Portland partnered with PAHC (Portland Alternative Health Center). I still remember how much the patients benefited from it; how excited they were about it. These were individuals with serious psychiatric disorders and it brought them real peace.
CODA hadn’t used acupuncture in its programs before. I wanted more information, I wanted someone to tell me what this is and what this isn’t ---
Me: And you were like, hmm I just met this weirdo --
Alison: Who I bet will tell me what I want to know. So I emailed you.
Honestly, the impetus for the call was pretty logistical. Prior to 2016, our opioid treatment program could only get reimbursed to prescribe methadone to treat opioid use disorders. Buprenorphine was available but still considered too costly. Medicaid expansion and high rates of opioid use disorder were making that an increasingly unjustifiable position. CareOregon was further along than other payers at that time, to their credit, and they had finally agreed to pay CODA to dispense it. At that time the standard of care was for a nurse to dispense a sublingual tab of buprenorphine and then observe the patient while the tab dissolves, which we found could take anywhere from five to fifteen minutes. That was going to be a big shift for us.
When you run an opioid treatment program, you rely on a certain pace in your operations, a consistent flow. You don’t want patients waiting, and you need to be able to project when and how many nurses to have available. Dispensing buprenorphine was obviously going to be very different from dispensing methadone, where a nurse hands a patient a little cup and they swallow it. There’s a real rhythm to it that we relied on. This new standard of sublingual tabs and everyone having to wait around was really going to jam up the flow.
Best practice at the time was also very clear that observation was expected, and the patient can’t speak because of the dissolving tablet. Having someone stand face to face with a nurse for as much as 15 minutes seemed ridiculous for a million reasons. So I thought, what would be a therapeutic way for people to spend that waiting time? We need to give people a place to be for twenty minutes, it would be nice to also give them something to do. Maybe this is the right time to introduce acupuncture to CODA?
I had no idea, but it turned out you were in the initial accreditation phase for POCA Tech at that point. Again, I was just looking to you as an expert in acupuncture because I didn’t know anything about requirements, licensing, delivery, or anything really. I think it took about 5 minutes for us to shift from a simple exchange of information to planning a student clinic.
Me: Yes, fun fact, in order to have an accredited acupuncture school, you need a student clinic -- and shortly before you emailed me, our student clinic had literally gone up in flames, it was gutted by a fire, and that really threw a wrench into our accreditation process. We were trying to figure out what to do with our first class of student interns. So when you floated this possibility and asked (hypothetically) how soon we could start, I was like, how about now? Now would be great.
I was like, I know you just asked to have coffee but hey, would you like to get married? Not to sound desperate or anything but I am in fact desperate.
Alison: This is one of things that I love about our partnership–the one between you and I. We seem to have this kismet, where our timing just lines up over and over again (spoiler alert).
Me: I’m very grateful for that. Tell me about what you see as the value of acupuncture for CODA.
Alison: LIke I mentioned earlier, the starting place was just practical — I knew acupuncture was a reimbursable service, but we weren’t qualified to offer it. More importantly, it fit into how CODA operates. We mean it when we say we say we only do what works. We let science guide what we do, which is why we have been a leader in addiction medicine for decades. That also meant I could be confident acupuncture would fit into our array of services.
On a different level, though, it just feels good to offer acupuncture to people -- to add another option that’s supportive and respectful. Our patients often come to us having cycled through treatment before and failed, sometimes repeatedly. But acupuncture is maybe something that nobody has offered them before. It’s one more way to say to someone, we want more and better for you. Try this if you’d like to.
The first thing that let us know that acupuncture was having an impact was when a patient showed up at CODA on a day that she wasn’t required to be there — because she wanted to get acupuncture. It’s really hard to get people to do that. So that was huge.
Me: One of the elements of our partnership that I really like is, because of WCA’s size, we can offer to treat patients for free at our clinics after they’ve completed treatment at CODA. Of course most people don’t take us up on it, but every now and then somebody does and maybe they even come in every day for awhile. It’s great to be able to give people that option to continue with acupuncture, and there’s nothing more validating for us as acupuncturists than seeing somebody engage like that.
I feel like WCA and CODA are really on the same page about offering acupuncture as a resource for people to use on their own terms.