1. 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/tannernissly OR
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2. 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.

4. 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

5. 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, National Center for Health Statistics Data Brief. 2015:190:1-8.

6. 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. Accessed on 11/2/16.

7. 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. Accessed 11/4/2016

8. 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):

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

12. 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

13. Our Bup Practice - Provider Certification
Under DATA providers allowed to take 8 hour training to apply for a waiver to prescribe buprenorphine
Online training and webinars through ASAM:
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

14. 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

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

16. 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

17. 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

18. 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

19. 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

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

21. 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

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