1. Sara Olack, MD, PhD Cecilia Lau, MD Advisor: Jane Gagliardi, MD
Psychiatry Resident Training in Buprenorphine and Office-Based Treatment for Opioid Use Disorder
Sara Olack, MD, PhD
Cecilia Lau, MD
Advisor: Jane Gagliardi, MD

2. Outline Background Barriers to clinical use of buprenorphine
Aims of our project
Results
Conclusions

3. National Overdose Deaths Number of Deaths Involving Opioids
National Overdose Deaths—Number of Deaths Involving Opioid Drugs. The figure above is a bar chart showing the total number of U.S. overdose deaths involving opioid drugs from 2002 to 2016 and provisional 2017 data. Included in this number are opioid analgesics, along with heroin and illicit synthetic opioids. The chart is overlayed by a line graph showing the number of deaths of females and males from 2002 to From there was a 4.1-fold increase in the total number of deaths.

4. 42,249 opioid overdose deaths in 2016
Data from CDC WISQARS Fatal Injury Reports

5. Opioid Abuse in North Carolina
Source: North Carolina Health News

6. Goals of treatment
Minimize harms from ongoing use
Sustained recovery with abstinence from all substances

7. FDA Approved Medications
• Buprenorphine – partial agonist at μ‐opioid receptor
• Methadone – full agonist μ‐opioid receptor
• Extended-release naltrexone – antagonist at μ‐opioid receptors S

8. Evidence for buprenorphine
New term for detox = “medically supervised withdrawal”

9. Barriers to Use of Buprenorphine
Financial
High out-of-pocket costs
Medicaid coverage across states is variable
Pre-authorizations
Regulatory
DEA waiver (8 hr training for physicians)
Limited number of patients
Geographic
Lack of waivered providers, especially in the South, Midwest, and West
Sharma et al. 2017

10. Physician Supply
Knudson 2015.

11. Psychiatry Residency Training and Buprenorphine
Residents who receive training may be more likely to prescribe in future practice
38% of trained residents vs. 0% of non-trained residents in one study
Suzuki et al. 2014

12. Barriers to resident training
Suzuki et al. 2016

13. Resident Education Project: Aims
To increase psychiatry residents’ knowledge about buprenorphine
To increase the likelihood that residents will consider incorporating buprenorphine into their future clinical practice
To encourage resident completion of waiver training

14. Methods
Residents were offered two optional hour-long educational sessions on office-based opioid treatment
Based on APA’s online waiver training
An optional, anonymous pre- and post- assessment to with multiple-choice questions
Offered before and after the sessions
Assessed knowledge and attitudes
Duke IRB exemption and waiver for consent was obtained

15. Results Participation
30 residents (55%) completed a pre-session assessment
28 residents (51%) completed a post-session assessment

16. Questions on Pre/Post Assessment1
Is there a financial cost for Duke residents to complete the required training to apply for a waiver? 2
Which type of receptor does buprenorphine act on? 3
Why is naloxone added to buprenorphine for opioid replacement therapy? 4
Buprenorphine has an analgesic ceiling. (T/F) 5
Buprenorphine can be used for treatment of both acute and chronic pain. (T/F) 6
What are the three FDA-approved medications for maintenance treatment of opioid use disorder? 7
Which of the following is an important difference between methadone treatment and buprenorphine/naltrexone treatment in adolescents? 8
Which of the medications below is not recommended for use in pregnant patients with active opioid use disorder?
Multiple choice questions unless specified (T/F)

17. Multiple choice questions9
When should buprenorphine induction occur? 10
What is the most accurate statement regarding hepatotoxicity risks associated with buprenorphine use as a medication for people with opioid use disorders? 11
Which of the following is required for prescribing BUP/NX in an office-based setting? 12
Which of the following is not considered a potential adverse effect of buprenorphine? 13
For how long is buprenorphine waiver training valid? 14
The use of which of the following substances would be most concerning in someone prescribed buprenorphine for opioid use disorder?
Multiple choice questions

18. Knowledge Assessment

19. Attitudes Assessment
Do you plan on prescribing buprenorphine in your future practice?
Yes No
Maybe
Pre-assessment
33%
17%
50%
Post-assessment
25% 7%
68%

20. How do attitudes change?≠

21. Conclusions
Residents are interested in learning about buprenorphine for OUD
Targeted teaching sessions increased knowledge about buprenorphine, but overall attitudes regarding use of buprenorphine in future practices remained the same
Without robust clinical and educational opportunities, residents may be less likely to use buprenorphine in future practice

22. References
Knudsen HK. The Supply of Physicians Waivered to Prescribe Buprenorphine for Opioid Use Disorders in the United States: A State-Level Analysis. Journal of Studies on Alcohol and Drugs. 2015;76(4): Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev Feb 6;(2). Sharma, A., Kelly, S.M., Mitchell, S.G. et al. Update on Barriers to Pharmacotherapy for Opiate Use Disorder. Curr Psychiatry Rep (2017) 19:35. Suzuki J, Connery HS, Ellison TV, Renner JA. Preliminary survey of office-based opioid treatment practices and attitudes among psychiatrists never receiving buprenorphine training to those who received training during residency. The American journal on Addictions. 2014;23(6). Suzuki J, Ellison T, Connery HS, Surber C, Renner JA. Training in Buprenorphine and Office-Based Opioid Treatment: A Survey of Psychiatry Residency Training Programs. Acad Psychiatry (2016) 40:498–502.