Tanner Nissly DO, Bob Levy MD FASAM, Michele Mandrich MSW, CMPE Buprenorphine Prescribing as a Patient-Centered Medical Home Enhancement Tanner Nissly DO, Bob Levy MD FASAM, Michele Mandrich MSW, CMPE AS YOU ENTER, PLEASE SET UP TO PARTICIPATE IN OUR POLL EVERYWHERE SURVEY DURING THE PRESENTATION ON YOUR MOBILE DEVICE OR COMPUTER. Go To PollEv.com/tannernissly693 OR Text “TANNERNISSLY693” to 22333

Objectives Upon completion of this session, participants should be able to: 1. Generate plans to start/expand medication assisted treatment (MAT) in primary care clinics. 2. Identify and avoid common pitfalls in regulation around buprenorphine prescribing. 3. Assess methods used to expand buprenorphine clinic.

Opioid Epidemic In 2014 18,893 deaths from Rx pain meds 29,467 deaths from opioid overdose Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, Mortality File. (2015). Number and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 2000–2014. Atlanta, GA: Center for Disease Control and Prevention. Available at http://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014.pdf.

Opioid Epidemic 4 of 5 heroin users started out misusing prescription pain pills Hedegaard MD MSPH, Chen MS PhD, Warner PhD. Drug-Poisoning Deaths Involving Heroin: United States, 2000-2013. National Center for Health Statistics Data Brief. 2015:190:1-8.

Opioid Epidemic What is addiction? Moral Failing Trauma in Childhood Addiction is a primary, chronic disease of brain reward, motivation, and memory dysfunction that leads to biological, psychological, social and spiritual manifestations reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Myths: Moral Failing Trauma in Childhood Poverty Lack of Education Truth – It’s a chronic relapsing disease What specialty deals with chronic disease? Definition of Addiction. Quality and Practice section, ASAM. http://www.asam.org/quality-practice/definition-of-addiction. Accessed on 11/2/16.

Opioid Epidemic CDC Recommends: Careful Opiate Prescribing Expand access to naloxone Expand PMP MAT as a treatment (methadone, buprenorphine, naltrexone) Injury Prevention and Control, Opioid Overdose. www.cdc.gov/drugoverdose/epidemic. Accessed 11/4/2016

Buprenorphine info Partial opiate agonist SL, Buccal, depot, IV Milder withdrawal symptoms due to partial-agonist property (maybe) Minimal oral bioavailability and combo with naloxone, leading to less potential for diversion As effective as methadone treatment for reducing opioid use in addicts, though retention may be lower (Mattrick et al, 2002). Low overdose risk due to ceiling effect Mattick RP1, Ali R, White JM, O'Brien S, Wolk S, Danz C. Addiction. Buprenorphine versus methadone maintenance therapy: a randomized double-blind trial with 405 opioid-dependent patients.2003 Apr;98(4):441-52.

Our Bup Practice North Memorial Family Medicine Residency Program 10-10-10 Practice at Broadway Family Medicine North Minneapolis Socioeconomically disadvantaged area Medical home practice with integrated clinical pharmacists, nutrition, and behavioral health

Our Practice: History Grow! Added 2 residents Started with 1 faculty expert, Dr. Robert Levy 5 pts, no clinical systems Added 2 residents Grow! Added 3 faculty champions

Our Bup Practice - Provider Certification Under DATA 2000 - providers allowed to take 8 hour training to apply for a waiver to prescribe buprenorphine Online training and webinars through ASAM: http://www.buppractice.com/ APA constructing training site as well AOA has split webinar/online training After course, apply through DEA for a waiver Takes 4-8 wks to receive waiver Need to have DEA license to receive this (only licensed physicians) Consider whether publishing your name on the website is the best option Structured way for 1st years to receive training

Our Bup Practice - Charting Infrastructure EPIC Smart Stuff Suboxone SmartSet Includes documentation, labs, buprenorphine formulations/doses, opioid withdrawal medications, naloxone, patient instructions, billing, etc Smart phrases include: Initial bup visit Subsequent bup visit Opioid overdose safety Treatment resources Patient instructions Clinic Guidelines

Our Bup Practice - Provider Training What are the expectations when dealing with chronic disease? Harm reduction while working towards abstinence.

Our Bup Practice - Intake and Waiting List One designated front desk person All calls/referrals are sent to her Gathers intake information Current use status Previous treatment Currently on methadone or Suboxone Discuss current PCP status, we will take over primary care Gathers several contact points BFM primary patients to the top of the list

Our Bup Practice - Staff Support Urine drug screens Obtain at every Bup visit Rapid Urine Test - Available in 15 min Comprehensive urine screen possible if concerned Have piloted/standardized witnessed urine screens Prior Authorization Triage nurses navigate insurance PAs Triage Calls Adherence to rules of Bup clinic Discuss problem patients directly with primary doctors Scripting is in place for common issues

Our Bup Practice - Monthly Meetings Meeting two weeks prior to each 4-week scheduling block Attendees: Clinic manager, nursing manager, front desk champion, physician champions, triage nurses 30 min meeting, quick review Agenda: Review of active patient list (pulled from EPIC) Review of suboxone provider primary patients Scheduling new patients Review of waiting list Problems experienced from each group

Pitfalls Prior authorizations Different states may have different laws Caution with induction due to inability to predict PA response time Patient influx - publishing your information When applying for waiver, you can publish your info - cause flood of patients Could consider establishing relationships with treatment centers Methadone to Suboxone transition First question is always: “Why?” Transition is tough due to pharmacologic interactions Resident Transition Gap between 3rd years graduating and 1st years obtaining DEA license and bup waiver Also transition 3rd years patients to a new provider Preceptor/faculty to resident mismatch Building this can be tricky

Pitfalls Unifying harm reductionist philosophy Everybody practices slightly differently – can cause conflict if there are different ideas on how to treat patients

Future Directions More integrated behavioral health Addiction clinic Due to transitions don’t have fully staffed BH team currently Currently consulted on prn basis No structured or required referrals Group Visits Addiction clinic One half-day weekly Clinic to staff new starts, complex cases Able to take referrals from other primary providers who are less experienced with MAT OB clinic MOTHER study Working with hospital obstetricians to create a referral center for OB patients struggling with addiction Jones HE, Johnson RE, Jasinski DR, et al. Buprenorphine versus methadone in the treatment of pregnant opioid-dependent patients: effects on the neonatal abstinence syndrome. Drug Alcohol Depend 2005; 79(1): 1–10

if we can help or if you have further questions. THANK YOU!!! Please contact me: NISSL003@umn.edu (Tanner Nissly) if we can help or if you have further questions.