1. Integration of Opioid Use Disorder Treatment in Primary Care
Nicholas Piotrowski, MD
Addiction Psychiatrist, IU Health Arnett

2. Disclosures
I have no conflicts of interest to report.

3. Question 1
Which of the following is / are diagnostic criteria of an opioid use disorder according to DSM V?
Tolerance
Withdrawal
Craving
A and B
All of the above

4. Question 2
Three models for integrating medication-assisted treatment into primary care are:
Family Systems, One Stop Shop, Hub and Spoke
Hub and Spoke, Project Echo, Peer Support
Project Echo, Peer Support, Family Systems
Hub and Spoke, Family Systems, Massachusetts Nurse
Massachusetts Nurse, Hub and Spoke, Project Echo

5. Question 3
All of the following are recommended changes in primary care to improve management of substance use disorders except:
Screening and brief intervention
Expand and restructure healthcare team
Detoxification services
Collaboration with local addiction specialists

6. Overview Opioid use disorder (OUD) epidemic
Evidence-based treatment of OUD
Models of combining medication-assisted treatment (MAT) with primary care
Shared medical visits and MAT
Chronic care models and substance use disorder treatment
MAT at IU Health Arnett

7. Opioid Use Disorder Epidemic
DSM V definition of opioid use disorder:
Problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
1. Opioids are often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
4. Craving, or a strong desire or urge to use opioids.
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
8. Recurrent opioid use in situations in which it is physically hazardous.

8. Opioid Use Disorder Epidemic
DSM V definition of opioid use disorder:
9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of an opioid.
Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.
11. Withdrawal, as manifested by either of the following:
a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal).
b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

9. Opioid Use Disorder Epidemic

10. Opioid Use Disorder Epidemic
Percentage of the total heroin-dependent sample that used heroin or a prescription opioid as their first opioid of abuse. (Cicero 2014)

11. Opioid Use Disorder Epidemic
Demographic shift: minority, inner-city to white, rural men AND women (Cicero 2014)
Numbers are dramatic (NSDUH 2014):
1.9 million people age 12 or older (700 per 100,000) with prescription OUD
586,000 people age 12 or older (200 per 100,000) with heroin OUD
Indiana 3.0% of the population has illicit drug dependence or abuse compared with 2.7% nationally, and only 13.3% receive any treatment (NSDUH 2014)

12. Evidence-Based Treatment
MAT with opioid agonists (buprenorphine or methadone, NEW implantable buprenorphine) increases retention in treatment, reduces illicit opioid use, and reduces dangerous behavior, including the transmission of HIV (Mattick 2014 – Cochrane Review)
MAT with opioid agonists is more effective than detox or psychological treatments (Mattick 2014 and Nielsen 2016 – Cochrane Review)
MAT with opioid antagonists (ER Naltrexone) has high dropout rates (Kjome 2011)

13. Models for Combining MAT and Primary Care
Agency for Healthcare Research and Quality (AHRQ) completed scoping review of 12 representative MAT models of care for OUD, with a focus on primary care settings
4 key components of MAT models in primary care: (Korthuis 2016)
Pharmacotherapy
Psychosocial services
Integration of care
Education and outreach

14. Models for Combining MAT and Primary Care
Practice-Based Models:
Office-based opioid treatment (OBOT) – all done in primary care office, typically with support of clinic staff member/ coordinator; variable scope of psychosocial services
BHIVES (HIV), One Stop Shop (Indiana), Integrated Prenatal Care are variations on OBOT

15. Models for Combining MAT and Primary Care
Systems-Based Models:
Medicaid Health Home – demonstration project in Maryland and Rhode Island in OTPs or psychiatric clinics; robust psychosocial services; requires state government involvement
Hub and Spoke – Vermont; triage to 2 levels of care: “Hub” mostly regional OTPs care for complex patients and “Spoke” mostly primary care offices with embedded social services providing MAT for less complex patients; program incentivized buprenorphine training

16. Models for Combining MAT and Primary Care
Systems-Based Models:
Project ECHO – rural New Mexico; links primary care clinics with university health system support and training primarily online; emphasis on building capacity
Co-Op – Hub and Spoke adaptation using OTPs in Baltimore
Massachusetts Nurse Care Manager – Medicaid reimbursement of FQHC; nurse care manager has substantial role in screening, intake, education, and coordination of care

17. Models for Combining MAT and Primary Care
Systems-Based Models:
ED and Inpatient Initiation of OBOT – buprenorphine induction in the hospital and linkage to OBOT
Southern Oregon – ACO with various organizations in a rural area

18. Shared Medical Visits Chronic medical conditions 6-12 patients
minutes
All components of an individual exam are completed
Additional time for providing education and facilitating peer support

19. Shared Medical Visits and MAT
Shared medical visits with buprenorphine been used extensively at West Virginia University, and now being pioneered at other sites
However, little published
2 small observational studies from Massachusetts, both from Cambridge Health Alliance

20. Shared Medical Visits and MAT
In primary care clinic population (Roll 2015)
60% learned more about HCV
43% received hepatitis vaccines
Of 32% with unsuitable housing 80% had improvement
35% increased time working
Increase in outside recovery groups from 30% to 80%
In a subspecialty program (Suzuki 2015)
52% retention at 6 month, and 52% retention at 6 weeks
Depression, anxiety, and craving scores decreased significantly
Bottom Line: Similar outcomes to MAT with opioid agonists in traditional formats, generally liked by patients, and more efficient delivery

21. Chronic Care Model and Substance Use Disorders
(McLellan 2014)

22. Chronic Care Model and Substance Use Disorders
Focus on early identification and intervention in primary care
Under ACA, substance use disorder treatment is essential benefit
Parity law defines scope of treatment

23. Chronic Care Model and Substance Use Disorders
Three key practices to adopt in primary care recommended by NIDA panel: (McLellan 2014)
Implement screening and brief intervention
Use of EHR to facilitate screening
Brief counseling interventions (reimbursable)
Washington state pilot program showed reduction in Medicaid costs $ per month (ONDCP 2012)
Expand and restructure the healthcare team
“Behavioral care manager” for screening/ brief interventions, linkage to resources, and teaching patient self-management skills
Collaboration with local addiction specialists

24. MAT at IU Health Arnett
SBIRT – universal primary care screening and interventions with embedded behavioral health counselors
Hub and Spoke adaptation with centralized location for buprenorphine inductions/ early treatment
Long-term MAT with buprenorphine in primary care clinics
Shared medical visits with mandatory group counseling/ behavioral interventions
Available psychiatric consultation/ management
Future directions – emphasis on pregnant women, patients with chronic pain, on-site inductions in ER or inpatient settings

25. MAT at IU Health Arnett
Hub and Spoke adaptation with centralized location for buprenorphine inductions/ early treatment
Long-term MAT with buprenorphine in primary care clinics
Shared medical visits with mandatory group counseling/ behavioral interventions
Available psychiatric consultation/ management
Future directions – emphasis on pregnant women, patients with chronic pain, on-site inductions in ER or inpatient settings

26. MAT at IU Health Arnett
“Spokes” – Primary care clinics (90k+ patients) – screening, brief intervention, brief therapy extended management
“Hub” – Buprenorphine induction and early management within psychiatric clinic
Ob/Gyn ER
Pain

27. Review
MAT with opioid agonists have the best evidence for treatment of OUD
Several models of combining MAT with primary care have been piloted nationally
Shared medical visits may be a more efficient and equally efficacious way of prescribing MAT
Improved screening and early intervention in primary care will reduce the future need for expensive subspecialty addiction services

28. Question 1
Which of the following is / are diagnostic criteria of an opioid use disorder according to DSM V?
Tolerance
Withdrawal
Craving
A and B
All of the above

29. Question 2
Three models for integrating medication-assisted treatment into primary care are:
Family Systems, One Stop Shop, Hub and Spoke
Hub and Spoke, Project Echo, Peer Support
Project Echo, Peer Support, Family Systems
Hub and Spoke, Family Systems, Massachusetts Nurse
Massachusetts Nurse, Hub and Spoke, Project Echo

30. Question 3
All of the following are recommended changes in primary care to improve management of substance use disorders except:
Screening and brief intervention
Expand and restructure healthcare team
Detoxification services
Collaboration with local addiction specialists

31. Questions?