implementing technology and medication assisted treatment...

IT MATTTRs™

Implementing Technology and

Medication Assisted Treatment and

Team Training in Rural

Primary Care and Interdisciplinary Practice Team Training

Copyright 2018 Regents of the University of Colorado. All Rights Reserved.For permission to use content for purposes other than IT MATTTRs Practice Team Training, please contact

[email protected]

mailto:[email protected]

Why we’re here

• The U.S. in the midst of an epidemic of opioid addiction –

impacting quality of life and causing death.

• We have effective, evidence-based tools for treatment.

• We can and need to translate the science into practice.

Montana Counties: Drug Use Disorders death rates: 2002

3


Source: Institute for Health Metrics and Evaluation Substance Abuse Mental Health Services Administration

4

IT MATTTRs Partners

• University of Montana

• Family Medicine Residency of Western Montana

In Colorado:

• High Plains Research Network (rural eastern Colorado)

• State Network of Colorado Ambulatory Practices and Partners

• University of Colorado Dept of Family Medicine

• Agency for Healthcare Research and Quality (AHRQ)

What will you get from

IT MATTTRs™ Team Training?

▪ Training and education for your practice team

• What you can do to identify your patients that need help and

referral options to medication assisted treatment (MAT).

• What your patients will experience when receiving MAT

(whether here or elsewhere).

• Steps involved with MAT to help your practice determine

MAT plans or to take next steps to implement MAT.

IT MATTTRs:

Monitor patients in MAT in primary care practices.

Team Training (BHPs, MD, PA, NP, front desk, RN, billing, MA, navigators…)

Buprenorphine waiver training for providers (MD, DO, PA, NP)

Screen for OUD in primary care practices.

Diagnose OUD in primary care practices.

Engage the patient in MAT delivered in primary care practices.

Prescribe buprenorphine by primary care physicians in primary care practices.

Refer patients to behavioral health in primary care practices.

Care for the practice MAT Team.

Creating the practice environment

conducive to care for OUD using MAT

What will you get from IT MATTTRs ™?

▪ MATerials Resource Toolkit

❑ Patient consent form and contract for buprenorphine treatment

❑ Payment schedule with diagnostic and billing codes

❑ Diversion Control plan templates

❑ Urine drug testing protocol and system templates

❑ MAT resource/protocol book for practice

❑ Electronic Health Record documentation templates

Available at: https://www.asam.org/education/live-online-cme/waiver-training/materials

https://www.asam.org/education/live-online-cme/waiver-training/materials

Objectives (over 4 modules):

• Describe how your practice will engage in treating patients with opioid use disorder.

• Explain your role within your team in treating patients with opioid use disorder.

• Increase your ability to determine which patients presenting with opioid use disorder

are appropriate for medication assisted treatment.

• Understand the role of buprenorphine in the treatment of opioid addiction.

• Describe components of managing patients who are receiving medication assisted

treatment.

• Describe the common co-morbidities (medical and behavioral health) associated with

opioid addiction.

• List the considerations for special populations when choosing medication assisted

treatment for opioid use disorder.

Whole Practice Training Modules

4 modules (1 hour each)

1. Opioids, Receptors, Montana, and You

2. The Patient: What is your role in helping a patient?

3. The Practice: What does a practice need to support a patient getting MAT or provide MAT?

4. Special Populations

5. SBIRT: Screening, Brief Intervention, and Referral to Treatment (optional)

Opioids, Receptors, Montana, and You

David

52 year old male former oil field worker, now on

disability for back injury. Placed on fentanyl patch

by worker’s comp, began buying additional short-

acting opioids from others to supplement. WC

physician learned of purchases and discontinued

opioids. David now self-medicating by purchasing

pills and smoking heroin.

Lauren

30 year old mother of 2 with obesity, depression/

anxiety and longstanding knee arthritis. Started on

opioids after failing NSAIDs, and steroid injections.

Escalating use of oxycodone over past year. Multiple

requests for early refills after lost prescriptions and

unsanctioned dose escalations. Spends most of the day

on the couch (“because of the pain”) and coming to

medical appointments.

Questions

• Are David or Lauren benefiting from opioids?

• What are the risks of continuing opioids?

• Are there any “red flag” behaviors? Do they

constitute a use disorder?

• What are options?

Module I: Opioids, Receptors, Montana, and You

• Opioid Pharmacology: What are opioids? Mu receptors?

• Neurobiology of Opioid Use Disorders:

Tolerance, Dependence, Cycle of Addiction

• Epidemiology: Opioid and heroin misuse

• Legislation: Drug Addiction Treatment Act (DATA 2000)

• Medication Assisted Treatment (MAT):

What is buprenorphine? How does it work? How effective is it?

Is it safe?

Opioid

Pharmacology

What are opioids?

• Drugs that bind to the opioid receptors

• Mu, Kappa, and Delta

• Can be naturally-occurring or derivatives of

naturally-occurring compounds (“Opiates”)

• Morphine, Codeine

• Heroin: 10x more potent than morphine

• Can be synthetic (“Opioids”)

• Fentanyl: 100x more potent than morphine

17

Mu receptor mediates opioid effects

• Euphoria, sedation,

relaxation, pain and

anxiety relief, sleepiness

• Chemical opioids

stimulate the receptor

much more powerfully

than the body’s natural

(endogenous) opioids

18

All chemical opioids may cause physical dependence and addiction

Agonist (here, the opioid) – activates the receptor

Antagonist – blocks the receptor

Neurobiology

of

Opioid Use Disorders

Opioid Tolerance & Physical Dependence

Both tolerance and physical dependence are

physiological adaptations to chronic opioid exposure

Tolerance:• Increased dosage needed to produce specific effect• Develops readily for central nervous system and

respiratory depression

Physical Dependence:• Signs and symptoms of withdrawal by

abruptly stopping the opioid, rapid dose reduction, or administration of antagonist

The cycle of addiction

21

How addiction hijacks the brain

Koob, 2003 22

Why do some turn to heroin?

Borrowed with permission from NOPE-RI 23

Epidemiology of Heroin Use

and

Prescription Opioid Misuse

Overdose death rates: U.S.

25


26


Source: Institute for Health Metrics and Evaluation Substance Abuse Mental Health Services Administration

27

http://resolvemontana.org/

Sources of diverted opioids

30

55%

17%

12%

5%4%

7%Obtained free fromfriend or relative

Prescribed by onedoctor

Bought from friend orrelative

Took from friend orrelative without asking

Got from drugdealer/stranger

Who Can Provide Treatment?

▪ Historically, only certified Addiction Treatment Centers

could treat opioid addiction.

▪ Drug Addiction Treatment Act of 2000 allows a waivered

physician to prescribe an opioid for the treatment of the

opioid use disorder, with certain restrictions

▪ Update 2016: allows Nurse Practitioners and Physician

Assistants to prescribe

Use

Addiction

Treatment – in primary care, it’s buprenorphine

As a primary care practice team member:

• Help identify patients with an opioid use disorder (addiction).

• Refer patients to treatment and behavioral health care.

• KNOW what your patients will and are going through in treatment.

Buprenorphine

• Metabolism

• In liver with N-dealkylation by cytochrome P450 3A4 enzyme system into an active metabolite norbuprenorphine

• Norbuprenophine undergoes further glucuronidation

• Elimination• Excreted in feces (70%) and urine (30%)

• Mean elimination half-life = 37 hours

• Commercial screening urine drug test for parent compound and metabolite

• Does NOT show as opiate positive on standard drug screen

• Partial mu-opioid agonist:

How does buprenorphine work?

Affinity = how tightly it binds the mu receptor

Activity = What does it do? Activate(agonist) or block(antagonist)

35

From: Practical Pain Management

https://www.practicalpainmanagement.com/treatments/pharmacological/opioids/office-based-

treatment-opioid-dependence

Buprenorphine Formulations

• Approved for moderate to severe OUD

• Sublingual forms (tablets and films)

• “Combo” (buprenorphine/naloxone)

• “Mono” (buprenorphine only) generic tablets

Opioid levels over time

• More effective than placebo

• Equally effective to methadone on primary

outcomes of:

• Abstinence from illicit opioid use

• Retention in treatment

• Decreased opioid craving

Johnson et al. NEJM. 2000. Fudala PJ et al. NEJM. 2003.Kakko J et al. Lancet. 2003.

Buprenorphine Efficacy Summary

Why Use Medications?

Because they Work…

• 80-90% relapse without MAT

• Increased treatment retention

• 80% decrease in drug use, crime

• 70% decrease in death from any cause

NIH Consensus Statement et al. JAMA. 1998.NIH Consensus Statement et al. JAMA. 1998

Why Use Medications?

NIH Consensus Statement et al. JAMA. 1998.

Buprenorphine Maintenance vs Taper Method

(Heroin Use Disorder)

Kakko J et al. Lancet. 2003.

Results

Completion 52 week trial:

▪ Taper method = 0%

▪ Maintenance

(buprenorphine) = 75%

Mortality:

▪ Taper method = 20%

▪ Maintenance


Module I Wrap-up

• The opioid use disorder is an extraordinary public health risk.

• Addiction has a neurobiological basis. It is a chronic disease –

not simply a lack of willpower or a personal weakness.

• Federal law allows office-based therapies, which are supported

by decades of high quality evidence.

• Buprenorphine is the most effective treatment available to

primary care providers and practices.

• And…it takes a team to support patients.

Module II – Sneak Preview

The Patient: • What is your role in helping David or Lauren? What comes next?

• There is a standard process for identifying and diagnosing patients

(just like diabetes).

• What does your patient experience on buprenorphine? Like you

understand some medications and insulin, teams can/should

understand how buprenorphine works.

• How does the practice want to define success? Like diabetes,

treatment is a lifetime.

The IT MATTTRs Primary Care and Behavioral Health Team Training curricula were created with support from the Agency for Healthcare Research and

Quality (grant number 5R18HS025056-02).


[email protected]


IT MATTTRs™



Team Training in Rural Montana



[email protected]


The Patient

Module II: The Patient

• What is your role in helping David or Lauren? What comes next?

• There is a standard process for identifying and diagnosing patients

(just like diabetes).

• What does your patient experience on buprenorphine? Like you

understand insulin, teams can/should understand how

buprenorphine works.

• How does the practice want to define success? Like diabetes,

treatment is a lifetime.

Module II: The Patient

• Patient Assessment

• Preparation for Treatment

• Treatment Agreement

• Informed Consent

• Buprenorphine efficacy, safety, diversion risk

Lauren

30 year old female with longstanding knee arthritis,

depression, anxiety. Escalating doses of opioids over the

last year along with ‘red flag’ behaviors including

multiple unsanctioned dose escalations. Admits to

purchasing additional oxycodone “off the street” when

she runs out and to using alcohol to manage her pain

and anxiety when opioids aren’t available.

Questions• Is there an opioid use disorder?

• Is this patient appropriate for outpatient treatment?

• What would you recommend?

• How would you discuss your recommendations with

the patient?

What does IT MATTTRs ™ provide?

Tool/Material With

Bup

Prescriber

Without

Bup

Prescriber

Patient consent form for buprenorphine ✓

COWS and SOWS, DAST-10 templates ✓

Patient treatment agreement and contract ✓ ✓

Screening process (and screening tool) for patients ✓ ✓

Patient assessment checklist ✓ ✓

MAT resource book/handouts for patients ✓ ✓

Side effect management protocol ✓ ✓

And lots of tools and templates for your practice – Session III

Assessing Patient for OUD and Need for MAT

Qualities of the healthcare team interviewer:• Non-judgmental, curious, respectful

• Attentive to responses, persistent

• Follow up on vague or “qualified answers”

To facilitate effective treatment:• Acknowledge some information is difficult to talk about

• Ask questions out of concern for patient’s health

• Avoid using labels or diagnoses

• Assure confidentiality

Assessment Overview

1. Establish diagnosis of opioid

use disorder and current

opioid use history

2. Document use of alcohol

and other drugs and need for

medically supervised

withdrawal management

3. Identify comorbid medical

and mental, emotional, and

behavioral health conditions;

how, when, where they will

be addressed

4. Screen for and address

communicable diseases

5. Evaluate level of physical,

psychological and social

functioning or impairment

6. Determine patient’s

readiness to participate in

treatment

Practices can observe but can also screen

patients for opioid use disorder.

Assessment Step 1a:

Criteria for Opioid Use Disorder - Part 1 (DSM V):

❑ Who does screening for other conditions in your practice?

❑ Who can do these screenings? Anyone? Just the prescriber?

❑ Screening tool(s) are included in your IT MATTTRs MATerials Toolkit.

What are we looking for when diagnosing

opioid use disorder?

Assessment Step 1a:


❑ Opioids taken in larger amounts or over longer period than intended

❑ Persistent desire or unsuccessful efforts to cut down or control opioid use

❑ Great deal of time spent in activities necessary to obtain, use, or recover

from effects of opioids

❑ Craving/strong desire or urge to use (new to DSM-5)

❑ Recurrent use resulting in failure to fulfill major role obligations at work,

school, or home

Assessment Step 1a:


❑ Continued use despite persistent or recurrent social or interpersonal

problems caused by exacerbated by effects of opioids

❑ Important social, occupational, or recreational activities given up or

reduced because of use

❑ Recurrent use in situations where physically hazardous

❑ Use continued despite persistent or recurrent physical or psychological

problem likely to have been caused or exacerbated by opioids

❑ Tolerance

❑ Withdrawal

Opioid Use Disorder = score of ≥4; moderate OUD.

Assessment Step 1b: Opioid use history

• Quantity used per day

• Type: heroin, prescription opioids

• Routes: IV, IM, SC, PO, intranasal, inhaled

• Last used, date and time

• Previous attempts to discontinue

• Past treatment experience

• Nonpharmacologic

• Pharmacologic with agonist (methadone, buprenorphine) and antagonist (naltrexone) therapies

Assessment Step 2: Alcohol & other drugs?

• Screen for unhealthy alcohol and other drug use

• Assess for a substance use disorder (DSM 5)

• Assess for other consequences, e.g., medication interactions,

medical complications

• Provide feedback and assess readiness for change

• Enhance motivation in low readiness, support motivation in

moderate to high readiness

• Action plan in high readiness, e.g. MAT?

• Use of other drugs does not mean patient cannot receive

buprenorphine treatment***

Screening for Unhealthy Substance Use

Smith PC et al. J Gen Intern Med. 2009; 24(7):783-8. Smith PC et al. Arch Intern Med. 2010; 170(13):1155-60.Image source: SBIRT Clinician’s Toolkit www.MASBIRT.org

“How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?”

(positive: > never)

Drugs

(positive: > never)

“How many times in the past year have you had 5 (4 for women) or more drinks in a day?”

Alcohol“Do you sometimes drink beer, wine or other alcoholic beverages?”

*Substance Use Disorders

Assessment Step 3a: Medical Co-morbidity?

• Past and present medical illnesses, hospitalizations, surgeries,

accidents/injuries

• Current medications, drug allergies

• Is the patient taking other medications that may interact with

buprenorphine, e.g., opioids, naltrexone, sedative-hypnotics?

Assessment Step 3b: Mental, Emotional,

and Behavioral (MEB) Health Problems?

• History of inpatient and/or outpatient treatment

• Untreated episodes of MEB illness

• Treatment adherence to MEB medications

• Is the patient psychiatrically stable?

• Are the psychosocial circumstances of the patient stable

and supportive?

Assessment Steps 4 & 5: Physical Examination

• Vital signs

• Standard physical examination

• Pay attention to (does not preclude treatment):

o Stigmata of injection drug use, e.g., needle tracks,

skin and soft tissue infections

o Stigmata of chronic infections, e.g., HIV, hepatitis C

o Neurocognitive function

o Liver disease and dysfunction

Assessment Steps 4 & 5: Laboratory Evaluation

• Liver function tests

• Hepatitis and HIV serologies

• Pregnancy test for women

• Urine drug testing• Naturally occurring opiates (morphine (heroin), codeine)

• Synthetic and semisynthetic opioids (methadone, oxycodone)

• Other commonly used drugs (cocaine, amphetamines, benzodiazepines)

Assessment Step 6: Is the patient ready

to participate in treatment?

• What motivates the patient to do this?

• Patient understands the risks and benefits of (and

alternatives to) buprenorphine treatment

• Patient expects to follow safety procedures

• Demonstrates reliability, e.g., steady employment,

adherence to other medications and appointments?

Are you ready to help your patient?

• Are there resources available in the office to provide appropriate

treatment? Medical or psychiatric care?

• Behavioral health care?

• Are there treatment programs available that will accept referral for

more intensive levels of service if needed?

• Words of wisdom:

• Don’t start with the most complicated patient

• Start with 1 patient, not 30

• Know your limits

• Don’t be afraid to consult with colleagues or other resources

Who are Better Candidates for Agonist

Therapy (Buprenorphine?)

• Patients with history of overdoses, particularly following

detoxification

• Patients who have been opioid-free but never felt “normal”

• Patients in whom MEB illness emerged/worsened after

previous detoxes

• Patients with mild to moderate chronic pain requiring

chronic opioid pain treatment

Lauren

Lauren admits she has been unable to take her pills only

as prescribed. She has tried to cut back multiple times

in the past but has been unsuccessful. Her husband is

angry with her constant focus on the medications and he

reports that her kids “want their mom back.” She

spends most of her day on the couch except when she

has medical appointments or has run out of medications

and has to find extras. She thinks her depression and

energy are worse since taking higher doses.

LaurenCriterion Present/Absent

Taken in larger amounts/longer period than intended?

Desire to cut down or unsuccessful efforts to control use?

Great deal of time spent acquiring/using/recovering?

Craving/strong desire or urge to use?

Failure to fulfill major role obligations at work/school/home?

Continued use despite persistent social/personal problems?

Important social, occupational, recreational activities lost?

Recurrent use where physically hazardous?

Recurrent psychological or physical problems caused or exacerbated

by drugs?

Tolerance

Withdrawal

Total Score

✓

✓

✓

✓

✓

✓

✓

No

N/A

N/A

8

✓

Buprenorphine Safety

• Highly safe medication (for both acute and chronic dosing)

• Primary side effects:

o nausea and constipation (which are also common with opioids)

• No evidence of significant disruption in cognitive or

psychomotor performance with buprenorphine

maintenance

• No evidence of organ damage with chronic dosing of

Buprenorphine “mono” or “combo” formulations

Buprenorphine Effectiveness: Treatment Retention in Maintenance vs Taper for

Prescription Opioid Use Disorder

Fiellin DA et al. JAMA Intern Med. 2014.

Results:

Completion 14 week trial:

• Taper = 11%

• Maintenance


Potential Abuse of Buprenorphine

• Slight euphoria in non-opioid dependent individuals

• Abuse potential less than full opioid agonists

• Abuse among opioid-dependent people is relatively low

• Combination product theoretically less likely to be

abused by IV route

• Most illicit use is to prevent or treat withdrawal and

cravings

Yokel MA et al. Curr Drug Abuse Rev. 2011.

Lofwall MR, Walsh SL. J Addic Med.2014.

Buprenorphine/Naloxone “Combo” to

Decrease Diversion

• Naloxone has limited bio-availability orally or sublingually, but is

active parenterally (if injected beneath skin, in muscle, or in vein).

• If combo product is crushed, dissolved and injected:

• Naloxone may cause initial withdrawal if the person is opioid

dependent, which decreases diversion and misuse.

• Naloxone will block, or decrease, the opioid agonist effect of the

buprenorphine. A person won’t get high. Most people get sick

(headache and nausea). Therefore, the combination medication is

safer, if it is diverted and misused.

Comer S et al. Addiction. 2010

Buprenorphine/Naloxone Bioavailability

▪ If dissolved sublingually ▪ Buprenorphine is active

▪ Naloxone is not active

▪ If swallowed▪ Buprenorphine not active (minimal oral bioavailability)

▪ Naloxone not active

▪ If injected▪ Buprenorphine active, but

▪ Naloxone active x 20 minutes so attenuates (decreases) the parenteral “rush”

▪ Not time-released so tablets/film strip can be cut/split

74

Do not

swallow!

Do not

inject!

Alternatives to BuprenorphineSee handout on other medication treatments for your review.

▪ Injectable Naltrexone

▪ Methadone Maintenance Treatment

▪ What they are is, possible benefits, potential candidates, limitations

Tools: Treatment Agreement

Expectations of patient

❖ No disruptive behavior

❖ No medication diversion

❖ Adherence to treatment

protocols❖ Induction, maintenance

❖ monitoring strategies (i.e., urine drug tests, pill counts)

❖ Additional treatment

❖ Appointments and refills

❖ Contact with other caregivers

and pharmacies

❖ Safe storage

Expectations of provider

❖ Scheduling visits

❖ Medication supply/refills

❖ Night coverage

❖ Response to

❖ “Lost” prescriptions

❖ Unexpected UDT results

❖ Nonadherence or unexpected

results

❖ Maintenance vs. detox

Tools: Informed Consent

• Physical dependence

• Side effects: sedation, constipation

• Risk of impairment, overdose

• Possible medication interactions

• Limited pain control options

• Neonatal abstinence syndrome

• Other treatments available: naltrexone,

detoxification

Lauren

Lauren asks to be weaned off of opioids. Over a

three month period, she is unable to follow the

weaning schedule and eventually agrees to a trial of

buprenorphine. Physical exam and labs are

unremarkable. You explain the risks and benefits,

including pregnancy concerns. She signs the

consent and agrees to return to the office in active

withdrawal for her induction appointment.

Module II Wrap-up

• Patients should be diagnosed with a moderate or

severe opioid use disorder (≥4 criteria) to benefit

from buprenorphine therapy.

• Assessment includes screening for medical and MEB

health issues, other drug and alcohol use, relapse

potential, patient motivation, and social supports.

• Physical exam and lab testing to include liver tests,

pregnancy, STIs, HIV, and Hepatitis.

• Informed consent/treatment agreements are common.

Module III – Sneak Preview

The Practice: • What does the MAT Team do?

• Front desk, nursing, prescriber, behavioral health, billing.

• Induction

• Stabilization

• Maintenance

• The full spectrum of MAT

• Who can help?

You can

help


Quality (grant number 5R18HS025056-02).


[email protected]


IT MATTTRs™






[email protected]






3. The Practice: What does a practice need to provide support to their patients getting MAT?



The Practice

Implementing Office Based Opioid Treatment (OBOT)

Module III: Treatment – The Practice

• Patient Centered Practice

• Office Management: billing issues

• Medication Management

• Induction and Stabilization

• Role of Non-Pharmacotherapy

• Behavioral health integration

• Patient Monitoring

• Long term follow-up

David

52 y.o. male formerly on worker’s comp for back

injury now buying opioid pills and smoking heroin.

Recently separated, working day labor “when I

can.” Currently couch surfing, stays with friends,

many of whom use drugs and drink. Prior DUI

arrest, on probation. Here for buprenorphine

induction. He complains of irritability, nausea, and

leg pains. On exam, he has a fast heart rate, is

mildly anxious, and is sweating.

Implementation Check List

REMINDER:

What will you get from IT MATTTRs ™?

Practice Tools and Materials

❑ Staff and Prescriber Training

❑ Patient consent form and contract for buprenorphine treatment

❑ Payment schedule with diagnostic and billing codes

❑ Diversion Control plan templates

❑ Urine drug testing protocol and system templates

❑ MAT resource/protocol book for practice

❑ Electronic Health Record documentation templates

Also learn about Opisafe, an opioid registry and tracking system

Anticipate Insurance Issues

• Is buprenorphine a covered benefit? What tier? What co-pays?

• Is behavioral treatment covered?

• Beware behavioral health carve outs!

• Are lab services covered?

• Restrictions on duration of treatment?

• Anticipate prior approval procedures

• Collect forms from each payer

• Submit forms in advance of fill

• Consider cash for first few days supply

• Monitor patient’s pharmacy benefits

• 340B coverage in some Community Health Centers

Billing for Office-based Opioid

Treatment (OBOT) $$$

• OBOT is standard medical care. Billing procedures are standard. You use codes everyday.

• The ICD-10 Code for opioid dependence is F11.20.

• Physicians billing codes: (CPT, E & M Codes) billing codes, accepted by all payers:

• 99215: $200 - $250 (or higher)

• 99354: $150 - $200

• 99408: $50 - $75

• No specific Addiction Medicine codes. Same codes as other ambulatory care services.

• More information provided in MATerials toolkit.

Maximize Collaborative Care

Care responsibilities

• Screening and intake

• Pretreatment assessments

• Treatment planning

• Medication management

• Monitoring (UDTs, pill counts, PDMP checks)

• Individual and/or group counseling

• Drop in groups

• Family support

• Relapse prevention

• Recovery Monitoring

Team

• Provider (waivered)

• Nursing

• Social worker

• Counselor

• Medical assistant

• Administrative staff

Alford DP et al. Arch Intern Med. 2011.

Maximize Collaborative Care

Care responsibilities

• Screening and intake

• Pretreatment assessments

• Treatment planning

• Medication management

• Monitoring (UDTs, pill counts, PDMP checks, OpiSafe)

• Individual and/or group counseling

• Drop in groups

• Family support


• Recovery Monitoring

Team

• Provider (waivered)

• Nursing

• Social worker

• Counselor

• Medical assistant

• Administrative staff

• Peer counselor

Alford DP et al. Arch Intern Med. 2011.

Who are Better Candidates for Agonist

Therapy (Buprenorphine?)

• Patients with history of overdoses, particularly following

detoxification

• Patients who have been opioid-free but never felt “normal”

• Patients in whom mental, emotional, behavioral health illness

emerged/worsened after previous detoxes

❑Induction

❑Stabilization

❑Maintenance

Buprenorphine Treatment

Overall GoalsTo find the right dose of buprenorphine at which the patient:

• Has no opioid withdrawal symptoms

• Discontinues or markedly reduces use of other opioids

• Experiences decreased cravings

• Has minimal/no side effects

• Return to usual activities (work, school, family)

Buprenorphine Induction:

Why are we doing this?

Patient Instructions

• Come in with moderate withdrawal

• Plan to be at clinic for up to 3 hours (may bring a snack)

• Bring buprenorphine medication bottle, or have it

delivered if applicable (prescribe vs. dispense)

• Accompanied by significant other, if possible

Buprenorphine Induction:

COWS: Clinical Opioid Withdrawal Scale

How one HPRN practice does Day 1:

1. MA does the COWS with the patient.

2. The Informed Consent/Agreement form (which we’ll cover later) is done the

previous week.

3. Physical. Usually short because the person feels miserable.

4. Provider gets the medication. Open box. Give it to the patient. Make sure

they let it dissolve. Tell the patient you’ll be back in 30 minutes.

5. Upon return, get more history of why the patient uses? When he/she uses?

Confirm past medical history, other conditions. Identify patient’s goals. What

motivates them? What do they want to get out of this?

6. Come back in another 30 minutes. Complete another COWS. MA can do

this. Allows patient to bond with entire team. Administer another dose.

Watch for another hour.

7. Complete another COWS. Aim for score between 0-5. Align patient’s

motivation with feeling better.

8. Send home.

#1: Patients not currently dependent on opioids (not on opioids, i.e., just got out of jail, completed detox, no opioids for 30 days)

• Uncommon

• Can still meet DSM-5 diagnostic criteria

• No precipitated withdrawal concerns

• Start low (2 mg); go slow to avoid opioid side effects

• Give the patient general parameters for adjusting buprenorphine dose to find “sweet spot”

Induction – Day 1, Scenario 1

#2: Patients dependent on opioids (typical induction case)

▪ Dependent on short-acting opioids (Vicodin, Percocet, heroin):

• Instruct patients to abstain from any opioid use for 12-24 hours (so they are in at least moderate withdrawal at time of first buprenorphine dose).

• Sunday at 12noon is a good time to stop (for a Monday Day 1).

▪ Dependent on long-acting opioids (Methadone, Oxycontin, MS

Contin/Morphine):

• If on methadone, wean down to ≤ 30 mg/d.

• Begin induction at least 48-72 hours after last dose of methadone, ≥ 36 hours after last dose of Sustained Release (SR) oxycodone or morphine.

• Saturday at 12noon is a good time to stop (for a Monday Day 1).

Induction – Day 1, Scenario 2

• If patient is not in withdrawal at time of arrival, assess

time of last use and consider having patient either:

1. Return another day

2. Wait in the office until evidence of withdrawal is seen

3. Leave office and returning later in day (with strict instructions

to not take opioids while away from the office)

Induction – Day 1

• Typical first dose: buprenorphine/naloxone 4/1 mg sublingual

• Monitor in office for 30 minutes to 1 hour after first dose and subsequent dose

• Relief of opioid withdrawal should begin within 30-45 minutes

• Period of greatest severity of buprenorphine-related precipitated

withdrawal occurs in the first few hours (1-2 hours) after a dose

• Practice needs a place for patient to sit and wait.

Induction – Day 1

Sublingual Use & Bioavailability

• Sublingual tablets/film strip must be held under

tongue or cheek for several minutes to dissolve

• Instruct patient to:

• Not talk

• Keep under tongue or in cheek (1-2 minutes)

• Don’t swallow until entire tablet/film dissolved. Film—

able to talk and swallow

• The length of time the patient is monitored in the office varies depending upon:

• Clinician’s familiarity with the patient

• Clinician’s familiarity with using buprenorphine

• Patient’s level of support at home

• Patient can re-dose if needed (every 2-4 hours, if opioid withdrawal

subsides then reappears).

• Maximum Day 1 dose of buprenorphine/naloxone = 8mg to 16mg

• Patient can determine how they feel and take more as needed.

• Dose equivalent of other formulations; e.g. 5.7—11.4 mg of branded SL tablets. (Depends on what medication you’re using. Just be familiar with it.)

• Day 2 and beyond dose: 4-24 mg. Adjust dose like you do insulin, HTN meds!

ASAM Recommendations: Induction – Day 1

Precipitated Acute Opioid Withdrawal

• Precipitated in a physically opioid dependent person,

by administration of either:

• an opioid antagonist drug (e.g. naloxone, naltrexone) or

• an opioid partial agonist drug (e.g. buprenorphine)

• Similar to spontaneous withdrawal but faster onset

• Duration depends upon half-life of drug

Precipitated Acute Opioid Withdrawal

• Treatment

• If a patient has precipitated withdrawal consider:

• Give another dose of buprenorphine to provide enough agonist effect from

buprenorphine to suppress withdrawal. (If given 4mg, then give 8mg.)

• Stopping the induction, provide symptomatic treatments for the withdrawal

symptoms and have patient return the next day.

• Since stopping induction would risk loss of the patient, the first

option should be preferred.

Day 2: Stabilization Begins

• On Day 2, be in contact with patient (in office, phone)

• Adjust dose accordingly based on patient’s Day 1

experiences

o Lower doses if they have sedation

o Higher doses if they have persistent withdrawal symptoms

Day 3 and beyond: Stabilization

• Patient may need daily contact for several days,

depending on response

• Stabilization continues for first 4-12 weeks as patient’s

dose is adjusted and all other opioid use (hopefully)

resolves

• Don’t expect abstinence after first dose of buprenorphine!

The Rest of Stabilization

• Monthly contact

• Behavioral Health

• Buprenorphine level is stable after 4-5 half-lives

(28 – 36 hours is typical half-life)

Maintenance

• Usually after initial 4-12 weeks

• Withdrawal symptoms resolved

• Cravings improved

• Side effects managed

• Able to start dealing with other stuff that got them to the point

of opioid use disorder in the first place

• Monthly visits typical for stable patients

How Long Should Buprenorphine

Maintenance Continue?

• We don’t know. No data to provide guidance on how long to treat a patient with buprenorphine/naloxone maintenance.

o <16 weeks of treatment is associated with high levels of withdrawal (which leads to relapse)

o Patients can be retained long term; approximately 75% retention at one year with buprenorphine maintenance (Kakko et al., 2003)

• Continue maintenance as long as patient is benefitting from treatment (opioid/other drug use, employment, educational goals pursued, improvement in relationships, improvement in medical/mental illnesses, engaged in psychosocial treatment).

• Celebrate with patient!

Buprenorphine Discontinuation

• First question is “Why discontinue?”

• Comprehensive discussion with patient and significant

others to explore reasons for discontinuation

• Naltrexone therapy might be considered (deterrent; “sick

high”)

• Psychosocial treatments should continue

• Patients should be followed by provider after

discontinuation

• Patients should be told they can resume buprenorphine

treatment if cravings, lapses, or relapses occur

Role of Non-Pharmacological

Treatment

Opioid Use Disorder (OUD):

Behavioral Treatment Components

• Psychosocial Services: • Often helpful for treatment of OUD.

• Can be delivered directly by physician and/or by referral when needed.

• The DEA waiver law (DATA 2000): “…the practitioner has the capacity to refer the patients for appropriate counseling and other appropriate ancillary services.”

• Refer patient as clinically determined to individual and group therapy, family therapy, 12 Step

• Higher psychiatric severity patients are more responsive to increased services.

• DEA recognizes that MAT is not just a pill

Primary Care Management

Critical Elements: Medical Care Team

• Monitoring compliance with buprenorphine maintenance

• Monitoring of patients’ drug use, symptoms, and progress

• Education regarding opioid use disorder and buprenorphine

maintenance treatment

• Encouragement to achieve abstinence from illicit opioids and to

adhere to all treatment recommendations

• Identification and treatment of side effects and complications of

opioid use

Primary Care Management

Critical Elements: Behavioral Care Team

• Encouragement to attend self-help groups

• Cognitive behavioral therapy (CBT / DBT)

• Addiction counseling

• Lifestyle changes that support recovery and to avoid potential

triggers of drug use


• Peer counseling

Medication Monitoring Visits – Part 1

• Face to face visits to check safety, adherence

• Initial frequency every 2-4 weeks until stable; monthly once

stabilized

• Check dosing, intervals, sublingual technique

• Safety issues: Side effects, safe storage

• Tobacco, alcohol, and other drug use

• Urine drug tests (UDT)

o Frequency varies with treatment stage and the systems the practice has available. Some patients will already be dropping UAs, (i.e., at parole officer)

Medication Monitoring Visits – Part 2

• Confirm behavioral treatment

• 12 step facilitation

• Medical problems & symptoms

• Psychiatric problems & symptoms

• OpiSafe (accesses prescription drug monitoring program and more)

• Outside medications and providers

• Withdrawal/craving/triggers

• Housing

• Employment

• Family/Relationships

• Legal issues…

Setting and Monitoring Treatment Goals

• Discuss and document specific, simple goals

• Set specific time periods

• Document progress on goals at each visit

• Examples:

o Achieve abstinence from illicit and non-prescribed drugs

o Meet with clinician

o Attend meetings

o Job applications

Relapse: Consider Goals of Treatment

• Abstinence from illicit and non-prescribed drugs

• Identification and diagnosis

• Engage/retain in treatment

• Facilitate and accelerate behavior change

• Treatment/prevention of medical co-morbidities

• Harm reduction

• Identification and treatment of psychiatric co-morbidities

• Decrease impact on society

• To what degree is patient meeting treatment goals?

Urine Drug Testing (UDT)(for use of non-prescription illicit drugs)

• Monitoring of treatment progress and safety

• Reinforces success with treatment

• Part of standard of care for:

• Monitoring for ongoing opioid use

• Monitoring for use of non-opioids

• Monitoring for adherence with buprenorphine medication administration

• Identifying those who may need higher level of care

• Every 1-2 weeks early in treatment; monthly after

• You want to find buprenorphine and nothing else!

• Don’t find bup? Patient might be diverting (selling) medication.

Pill/Film CountsThis is standard care.

• Have the patient bring in all their medicines at first visit

• Frequency varies with patient progress

• Best option when diversion suspected

• Patient brings in medication supply

• Confirm patient ID and fill date on bottle/box

• Have patient count them in front of staff member

• All tablets/film should be identical

• Amount should match expected quantity

Prescription Drug Monitoring Program (PDMP)

• Montana Prescription Drug Registry:

o State-wide system tracks controlled substance prescriptions

o Requires DOB, SSN. Patient can change name, but other

information will identify patient.

o Helps detect doctor shopping

o Improve clinical decision making

• Montana Substance Use Disorder Strategic Plan (2017) aims to

increase functionality of MPDR, integrate it into EHRs, and

teach prescribing guidelines.

OpiSafe: Your one-stop shop!

• Developed by RxAssurance, in partnership with the University of

Colorado Skaggs School of Pharmacy, to make it easier for physicians

to safely prescribe opioids and monitor prescriptions.

• Comprehensive opioid management program

• Comprehensive assessment and risk stratification (risk for addiction)

• Check every patient’s PDMP report automatically

• You can set custom parameters for notification, patient by patient:

• Number of prescribers

• Number of pharmacies

• Track urine toxicology results and frequency (if using OpiSafe collaborative lab)

David

1. Is he ready for buprenorphine induction?

2. Why is his prior DUI concerning?

3. How will you manage him today?

4. When will someone in your office see or speak with him again?

5. What other services will you offer?

Module III Wrap-up• Time frame:

o Induction = Day 1

o Stabilization Phase generally lasts 1-4 weeks

o Followed by Maintenance Phase

• OUD is a chronic disease.

• Regular monitoring with frequent follow-up, urine toxicology

testing, OpiSafe.

• Practices must have the ability to refer for counseling.

o Though robust counseling is ideal, studies show good outcomes even

with low intensity models.

• Optimal duration of buprenorphine therapy isn’t known but longer

probably better.


Quality (grant number 5R18HS025056-02)


[email protected]


IT MATTTRs™






[email protected]


Special Populations

Module IV: Special Populations

• Pregnancy, Neonatal Abstinence, Breastfeeding

• Adolescents and Young Adults

• Medical Co-Morbidities:

• Psychiatric Co-Morbidities [i.e., psychiatric Assessment, Major

Depression, Anxiety Disorders, Trauma and Stressor-related Disorders

(PTSD), Personality Disorder]

• Acute and Chronic Pain

o Pain and addiction

o Use of opioid analgesics

• Buprenorphine Maintenance

Lauren

30 y.o. female with prior history of prescription opioid use

disorder. Has been doing well on buprenorphine/naloxone

for 8 months with improvements in function and quality of

life. Returns for routine follow up appointment and

mentions that her last period was 6 weeks ago. Doubts she

could be pregnant as she and her husband practice the

rhythm method. Her urine pregnancy test comes back

positive. She wants to know if she should stop her

buprenorphine/naloxone immediately, like her husband is

telling her to do.

Pregnancy

Neonatal Abstinence

Breastfeeding

Pregnancy: Initial Evaluation

• Know if specialized treatment services are available in the

community for pregnant, opioid-dependent patients.

• Recommend consultation with addiction specialist who works

with pregnant females or high-risk obstetrics.

• Buprenorphine dose may need to be increased.

Should women undergo

detoxification in pregnancy?

• Initial studies from 1970s demonstrated fetal distress and 5 fold increase in still birth rates with antepartum detoxification.(Zuspan et al. 1975; Rementeria et al. 1973)

• More recent data shows 2nd trimester detoxification can be safe for the fetus; however, maternal relapse rates prior to delivery range from 70-98%. (Luty et al. 2003; Maas et al. 1990; Dashe et al. 1998)

• Maintenance therapy in pregnancy has been shown to increase retention in prenatal care, addiction recovery and in-hospital deliveries. (Jones et al. 2008.)

Pregnancy:

Benefits of buprenorphine treatment

Maternal Benefits Fetal Benefits

• 70% reduction in overdose related

deaths

• Decrease in risk of HIV, Hep B,

and Hep C

• Increased engagement in prenatal

care and recovery treatment

• Reduces fluctuations in maternal

opioid levels, reducing fetal stress

• Decrease in intrauterine fetal demise

• Decrease in intrauterine growth

restriction

• Decrease in preterm delivery

Pregnancy: Maintenance

Therapy Remains the Standard of Care

• Methadone and buprenorphine (both category C) are safe and

effective treatment options in pregnancy.

• The decision of which therapy to start should be individualized

for each woman.

• Based on available options, patient preference, patients’ previous

treatment experiences, disease severity, social supports, and intensity of

treatment needed.

Fischer et al. 1998, 1999; Jones et al. 2010

Management of Buprenorphine

Patient: Newly Pregnant

For women stable on buprenorphine/naloxone who become pregnant:

• Current standard of care is to switch to buprenorphine

monotherapy at the same dose.

• Combination therapy avoided due to the unknown exposure risk

of naloxone in pregnancy and concern for misuse.

Maintenance Therapy in Pregnancy:

Neonatal Abstinence Syndrome (NAS)

• Generalized disorder with dysfunction of the autonomic nervous

system, GI tract and respiratory system.

• Occurs in 60-80% of infants with intrauterine exposure to

opioids. This includes buprenorphine.

• Onset: majority present within 72 hours after delivery.

• Duration: up to 4 weeks (prolonged if exposed in-utero to more

than one substance associated with NAS).

Maintenance Therapy in Pregnancy:

Neonatal Abstinence Syndrome (NAS)

The good news is…

• Infants of buprenorphine-treated moms do better than infants of

methadone-treated moms

• Meta-analysis of 12 studies from 1996-2012 showed

buprenorphine exposed neonates (515) compared to methadone

exposed (855) had shorter mean length of hospital stay

(-7.23 days, 95% CI: -10.64, -3.83 – statistically significant)

Brogly et al. 2014.

Opioid Use Disorder

and Breastfeeding

• Buprenorphine has poor oral bioavailability and is also

compatible with breastfeeding.

• The amount of buprenorphine in human milk is small and

unlikely to have negative effects on the infant.

• Both are considered Category L3 (probably compatible benefits

of breastfeeding for newborns with NAS o 30% decrease the development of NAS

o 50% decrease in neonatal hospital stay

o Improved mother-infant bonding

o Positive reinforcement for maternal recovery

JJ 2000; Begg EJ 2001; Jansson LM 2007 & 2008; Hale 2008; Grimm 2005; Lindemalm 2008; Ilett 2012.

Pritham UA et al. J Obstet Gynecol Neonatal Nurs. 2012. Welle-Strand GK et al. Acta Paediatr. 2013. Wachman EM et al. JAMA. 2013.Abdel-Latif ME et al. Pediatrics. 2006.

Adolescents

and

Young Adults

Pharmacologic Treatment

with Adolescents

• Pharmacologic therapy is recommended for adolescents with

severe opioid use disorder.

• Buprenorphine is considered first line treatment. Most methadone

clinics cannot admit patients under 18 years old.

• The optimal length of time for medication treatment is not known.

• Buprenorphine does not put adolescents at a higher risk for suicide

than adults, and it’s harder to overdose.

ConfidentialityTeens Presenting with Parents

• In many cases, adolescents will present for treatment with the

knowledge, and often with the support, of parents.

• In these cases, managing confidentiality is a clinical decision of

what information to share with parents in the context of parents

already being aware of the “big picture.”

ConfidentialityTeens Presenting without Parents

• Teens may present for treatment without the knowledge or

consent of their parents

• In most states, adolescents above a certain age may consent for

treatment for an SUD without their parents. In Montana, teens

can consent at 16.

• Regarding insurance…if child is on parents’ insurance, it’s

difficult to keep treatment from them.

ConfidentialityManaging Teens that Refuse to involve Parents

• Ask adolescent their reasons for excluding parents. Many teens

could benefit from the support of parents, but are too embarrassed

to discuss the problem.

• In these cases, offer to treat confidentially and leave the decision of

how to proceed up to the teen.

• Ask what would happen if a parent learned about a drug problem

by accident.

• Offer to help “break the news” to parents.

• Emphasize that teens who enter treatment should be proud of their

decision to get help.

ConfidentialityTips on “Breaking News” to Parents

• If an adolescent asks for help in disclosing a SUD:• Choose words that are acceptable to the teen and convey the message

accurately. “Pain meds” may be preferable to “narcotics.”

• Share diagnosis and treatment plan; avoid details from the history.

• Support self-efficacy by congratulating the teen on recognizing his/her

problem and seeking help.

• Support parents who may be shocked and disappointed:• Focus on the positive: treatment-seeking behavior.

• Reassure that you can help.

• Redirect if a parent becomes very angry or invasive.

• Offer education about opioid use disorder and medication assisted treatment

Medical Co-Morbidities

Nothing New Here

• Chronic Care Management 101

• Persons with opioid use disorders frequently have or at risk of

other comorbid medical conditions.

• Office-based buprenorphine treatment provides an opportunity

to combine substance use treatment with medical care.

Hepatitis C virus infection The silent epidemic

• Most common blood-borne infection in U.S., 3.2 million people.

o 70-90% of people who inject drugs have Hep C

o ~30% are <30 years old

• 40-60% of chronic liver disease cases.

o Leading indication for liver transplantation.

• Hep C-related deaths outnumber deaths due to HIV.

Psychiatric Co-Morbidities

Induced vs Independent Disorder

Distinguish between substance-induced disorders versus independent psychiatric disorders.

• Substance-induced: Disorders related to the use of psychoactive substance; typically resolve with sustained abstinence.

• Independent: Disorders which arise during times of abstinence; use of psychoactive substances not the etiology.

Substance Induced

Psychiatric Disorders

• Patient’s history suggests symptoms occur only when

he/she is actively using substances.

• Symptoms are related to intoxication, withdrawal, or

ongoing neurobiologic perturbation from substances.

• Onset and/or offset of symptoms are preceded by

increases or decreases in substance use.

• Goal should be sustained abstinence followed by

re-evaluation of symptoms.

Substance Independent Psychiatric Disorders

• Earliest psychiatric symptoms often precede onset of substance

use disorder.

• Patient’s history suggests symptoms occur during periods

when not using psychoactive substances.

• May also find a family history of the disorder.

• Goal of substance use disorder treatment should still be

cessation of substance use, but treatment must also address

psychiatric symptoms simultaneously.

General Treatment Principles

• Patients with opioid use disorder and independent depressive, anxiety, or stress disorders (PTSD) can respond to medication (typically antidepressants) and/or psychotherapy

• Generally avoid use of benzodiazepines

o Risk of misuse

o Possibility of interactions with buprenorphine

• Buprenorphine can be a good replacement treatment for benzos

• Systematic review (no randomized control trials, rather observational).

• All studies reported effectiveness in treating chronic pain.

• Current evidence reported some effectiveness of SL buprenorphine

for treatment of chronic pain. Increase frequency of dosing.

(2-4x a day vs 1x daily OR 4, 4, 4, 4, vs 16)

• Use of buprenorphine for chronic pain treatment is increasing.

Cotes, J; Montgomery, L. Pain Medicine. 2014.

Chronic Pain –Buprenorphine Maintenance Treatment

Module IV Wrap-up

• Adolescents and pregnant females with OUDs can be managed

successfully with buprenorphine.

• Buprenorphine is an excellent analgesic, although it is ideally

dosed as often as 4x/day for pain.

• OUD is a chronic condition that can co-occur with other

medical and psychiatric problems.

IT MATTTRs ™ Wrap-up

What we’ve covered:

• Neurobiology of addiction

• Efficacy of MAT

• Creating a successful multidisciplinary team

• Patient Assessment

• Induction, Stabilization, and Maintenance

• Appropriate monitoring and Montana PDMP

• Management of special populations

IT MATTTRs™ Wrap-up

• The opioid epidemic is an unprecedented public health problem.

• As unintentional contributors to the problem, primary care

practices must be part of the solution.

• These trainings aim to allow your practices to feel empowered

and equipped to:

o identify and diagnose patients in need of treatment

o monitor patients

o understand what their treatment experience will include

o continue providing care for co-morbidities in context of MAT

o implement buprenorphine-based treatment of OUD

What’s Next

• Review your MATerials Toolkit

• What do you need?

• When are you going to evaluate and schedule

your first induction?

• Optional SBIRT Review (Module 5)

• Contact us!


Quality (grant number 5R18HS025056-02)


[email protected]

Thank you!


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