In June, the U.S. Drug Enforcement Administration (DEA) announced that it would allow all opioid treatment programs to add mobile units to help increase access to medications for opioid use disorder, lifting a 13-year moratorium on new vehicles.
As the assistant commissioner for the New Jersey Division of Mental Health and Addiction Services in the Department of Human Services, Valerie Mielke oversees the state’s community public mental health system as well as all substance use prevention, treatment, and recovery support services.
This interview with her has been edited for length and clarity.
Q: Now that the DEA has finalized regulations that allow opioid treatment programs to add mobile units, what’s the next step for states?
A: States should think about how the mobile units can help fill treatment gaps. In some states, particularly in rural areas, there may not be an opioid treatment program, or OTP, that’s easily accessible for residents. Here in New Jersey, for example, we didn’t have an OTP in each of our counties until just a few months ago.
States can also use mobile units to help bring medications to patients in residential treatment programs that are not OTPs and therefore unable to prescribe methadone. And states should look at where underserved populations [those without ready access to treatment] are, and locations where high degrees of overdose and opioid misuse exist—places where bringing methadone would be most helpful.
Q: What does a mobile unit allow OTPs to do that they can’t do in a brick-and-mortar treatment facility?
A: A few things. One, our vans provide flexibility: We can send staff out at different times of day and reach people who may find it difficult to access treatment during an OTP’s hours of operation.
Mobile units can also go where people diagnosed with OUD may congregate—such as homeless shelters, tent cities, and correctional facilities. Mobile units are a great way to engage people in these settings with treatment services. Imagine someone who’s homeless and can’t easily access a pharmacy; providing them with buprenorphine via a mobile unit eliminates that problem.
In New Jersey, we’re also pursuing what we call low-barrier buprenorphine treatment, where individuals can receive a prescription and immediately start treatment. Mobile units can be used to provide low-barrier buprenorphine treatment.
Q: In what other ways has New Jersey used mobile units?
A: I would point to our work combining treatment services with harm reduction services, as well as our work bringing medications to correctional facilities: Jails don’t have to worry about obtaining OTP certification when a mobile unit can bring methadone, buprenorphine, and naltrexone directly to the facility. We take these medications to one jail now and hope to expand to other locations.
Our mobile units have also been critical in emergencies. After Superstorm Sandy in 2012, downed wires and trees kept people from moving around the state easily, but we used our vans to get medications to people in need, including people in shelters. We were even able to engage new people in treatment during that time.
Q: How do you envision using mobile vans now that the moratorium has been lifted?
A: We hope to allow new mobile units to both prescribe and dispense medication, which we couldn’t do under the moratorium. And thanks to new funding from the Substance Abuse and Mental Health Services Administration, we can move forward with purchasing new vehicles.
Q: What funding have you used for mobile units in the past, and what were some of the unexpected costs?
A: A 2006 New Jersey statute authorized mobile units to provide medication treatment and counseling, and the state chose to retrofit buses. Because the moratorium put a halt to the use of new mobile units, we couldn’t replace them. Significant repairs were needed over time; we put a lot of resources into maintaining and keeping the buses on the road, because if a bus breaks down, it impacts our ability to provide mobile services.
Q: Can you describe the mobile units you’ve been using?
A: The vehicles are about the size of a school bus. We use one part of the vehicle to dispense medication and another part for counseling. We also have lavatories for urine drug screens, and space for exams and blood tests, as well as space to store medication appropriately. There are other components too, like security, that are in place for us to meet requirements set forth by DEA. And states need to understand their own regulations for mobile units, which sometimes are more stringent than the federal government’s requirements.
We may take a different approach moving forward. When you have a van or a bus and something goes wrong with the engine, then the vehicle is down. But we’ve seen mobile units that are small box trucks with a separate cab; if something happens to the cab itself, you can rent a cab on a temporary basis and still use the truck to provide services.
Q: Are there any special requirements around who can work in or operate a mobile unit?
A: Not in New Jersey. Our mobile unit staffing is generally the same as an OTP, with a nurse and doctor on board. And our mobile units are tied directly to a brick-and-mortar OTP site, which a medical director oversees. The vehicles are small enough that they don’t require staff to have a commercial driver’s license.
Q: Regulations aside, what do states need to get a mobile unit up and running?
A: The biggest challenge is community buy-in. How will you combat the “not in my backyard,” or NIMBY, mentality and get people to accept having this service in their community?
Fifteen years ago, we had New Jersey communities refusing to allow vans in their neighborhoods. The misperceptions and stigma associated with addiction were awful. We had mayors, councilmen, and very passionate residents concerned about the populations these mobile units would bring to their communities and asking questions like, “Are my children at risk?” This mentality kept us from being able to provide services where they were wanted and needed.
Q: Is that still the case?
A: Thankfully, much has changed since 2006. There is a broader recognition among people that their neighbors, children, parents, spouses, friends, work colleagues—and, at times, they themselves—are impacted by addiction. We see a lot more conversation around the disease of addiction, and how medications can help treat this disease and support recovery.
Q: So then, what’s one thing states should know before adding a mobile unit?
A: Stigma still exists, so states need to work with communities to get their buy-in. They could face great resistance in sitting a mobile unit in their community. But OUD is a disease that does not discriminate, and mobile units are a great way to meet individuals where they are and break down barriers to treatment and recovery.
Q: We’ve talked about resistance that might exist at the community level. What about among OTPs? What would you say to an OTP that may be skeptical of starting a mobile unit?
A: I would say that mobile units are literally a great vehicle to reach individuals with OUD who may be reticent to go to a clinic setting for treatment—and that the vehicles provide an opportunity to bring not just medication but also education about the disease of addiction and recovery support to people in need.
For example, in New Jersey, we have harm reduction programs that send vans into communities to provide free naloxone, sterile syringes, and educational materials about addiction. Additionally, more than half of the counties in New Jersey operate or contract with an entity to operate county mobile outreach units. These units travel throughout their communities providing free resource and educational materials about addiction, facilitate referrals to services, and provide free naloxone accompanied with training in opioid overdose response. States could couple these services with mobile medication and reach people in need of treatment who may otherwise not seek care.
Q: Any final thoughts?
A: States may not realize this, but Medicaid can help support the treatment provided in mobile units. Many of the people served by mobile units are Medicaid enrollees, and states can bill for services provided. These dollars have been critical in sustaining mobile medication unit services in New Jersey.