Training for Some or All? Successful Strategies to Overcome Obstacles for Buprenorphine Education and Practice Jeffrey Baxter, MD, Christy Martinez, MD, Ken Saffier, MD, Maureen Strohm, MD April 27, 2015

Disclosures All presenters and authors have nothing to disclose.

Overview 11:15 Introductions and learning objectives 11:25 Summary of your challenges 11:35 What has worked in your or other programs? Smaller group discussions. 11:55 Report out with resident perspectives on the value of these experiences. 12:10 What will you do? Commitment to Act Statements, Evaluate seminar 12:15 End

Learning Objectives - 1 Develop strategies for strengthening buprenorphine education in family medicine residency curricula, including integrating certification courses for residents and faculty into family medicine programs.

Learning Objectives - 2 Create your own individual and residency action plans to develop and promote buprenorphine education in your residency program. Develop and integrate buprenorphine education as part of a larger, comprehensive approach to teaching about substance use disorders and chronic disease management.

Challenges for Implementing New Curricula – e.g., buprenorphine

What are/were your challenges? 10 minutes:

What has worked in your program? Successful approaches: 20 minutes Small group discussion One person to summarize

Summary of your or others’ programs. Overcoming obstacles. 15 minutes, large group discussion and summary

What will you do? Commitment to Act Specific Measureable Attainable Relevant Timely stfm.org/sessionevaluation

Special Thanks STFM Valerie Carrejo, MD, Sally Bachofer, MD –U New Mexico FMR Paul Gianutsos, MD, James Walsh, MD –Swedish Hospital, Cherry Hill FMR James Ledwith, MD, Peter McConarty, MD Jeff Baxter, MD –U Mass Medical School, Dept Family Medicine

Please fill out your: Statement to Act Statements Now And Evaluate this session at: stfm.org/sessionevaluation Thanks for your participation, now and in the future!

Examples of model programs Contra Costa Regional FMR Swedish Hospital Cherry Hill FMR U Mass Fitchburg FMR U New Mexico FMR

Buprenorphine Training for Residents Contra Costa Regional FMR Program Summary Ken Saffier, MD Lisa Rodelo, MD Michael Macioci, MFT

Buprenorphine Treatment Clinic Group visits with individual patient appointments before and after. Facilitated by MD and Co-facilitator (MD or substance abuse counselor) Groups meet weekly Patients attend weekly initially (or 2x/wk), then monthly. Rx given initially by clinic MD, then by waivered PCP

Resident Involvement and Education R – 1: 4 hours per week (Behavioral Medicine rotation) R – 2: 4 hours per week carved out of Pediatric Outpt (at another affiliated site) When waivered, become PCP for patients on buprenorphine (some before waivered with faculty partnership). Supervised/mentored in person (less) and by phone (more) by waivered faculty.

Continuum of learning and clinical experiences R-1 rotation: introduction to buprenorphine and group visits. –Assume more group facilitation roles with time. –Apply motivational interviewing to groups. R-2 rotation: –Continue group facilitation roles and MI –More focus on co-occurring disorder treatment

Looking to the Future… Beginning this academic year, R-1’s will take the AOAAM waiver course via webinar during their BM rotation. We’ll continue to offer AOAAM trainings once or twice yearly and promote attendance for faculty, PCPs and residents by “attraction”.

Swedish Hospital Cherry Hill FMR Buprenorphine Training Paul Gianutsos Presented STFM 2014

Curriculum R-2’s: Complete an addiction medicine and chronic pain management rotation (required) Annual waiver course “Buprenorphine rounds” dedicated to case management From 2013, all residents have buprenorphine patients as a part of their panel.

Supporting Factors On-site detox and in-patient treatment center. Faculty decided in 2010, all residents required to have a waiver before graduation (done as R-2). Residents have on-site or telephone access to waivered faculty, ADM fellow, ADM certified faculty (one of whom is PD)

U Massachusetts Medical School Dept of Family Medicine Buprenorphine Training Jeff Baxter, MD, James Ledwith, MD Peter McConarty, MD And Faculty at all 4 Clinical Sites

History Started with 1 champion in 2004 Additional faculty followed over few years At least one faculty at each site Proposal for all residents to be trained accepted by (and including) their program director Yearly training for all R-2 residents

Current Status All sites do treatment All residents at all sites required to complete the course and obtain waiver All preceptors required to have waiver at largest site Other sites, preceptors strongly encouraged Residents have management experience

University Of New Mexico Residency Buprenorphine Training Sally Bachofer, MD Valerie Carrejo, MD Presented STFM 2014

Program Summary 13 residents participate in a required buprenorphine training during the first month of the second year of training The training became part of the curriculum in 2009 as part of a resident community project UNM supported program performs training Waivered faculty precept residents in 3 of 4 continuity clinics UNM

Program Summary Milagro Clinic –Prenatal clinic for women with substance abuse –Inpatient buprenorphine inductions –Prenatal care with buprenorphine –Labor and post partum management –Care for NAS babies UNM

Program Summary FOCUS clinic Patients from Milagro clinic are cared for, along with their children and other family members Residents can work with young families with addiction history Integrated into the FMC clinic Provides engagement in larger spectrum "recovery" UNM

Using supporting factors to overcoming barriers Main barriers –Organizing a yearly training –Department and faculty “buy-in” –Institution and Clinic support UNM

Organizing training Barrier overcome by the use of another UNM organization with experience in these trainings, Project ECHO Residents are trained yearly using AOAAM half and half training Project ECHO is a “well greased system for training” –We pick the date and they come in and do the training –Project ECHO is a program through UNM and well funded and supported UNM

Department and faculty buy-in Dr. Bachofer was the residency program director and implemented the annual training A few waivered faculty helped press forward Once the residents were all trained, faculty began to see the need to be trained –Faculty are offered training along with the residents UNM

Institution and clinic support The more difficult barrier Education of staff and administration Motivated and caring physicians Still not fully supported by the institution Not openly advertised as a “service” in the institution UNM