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

Disclosures I have no conflicts of interest to report.

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

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

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

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

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.

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.

Opioid Use Disorder Epidemic

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)

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)

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)

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

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

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

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

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

Shared Medical Visits Chronic medical conditions 6-12 patients 60-120 minutes All components of an individual exam are completed Additional time for providing education and facilitating peer support

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

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

Chronic Care Model and Substance Use Disorders (McLellan 2014)

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

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 $185-192 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

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

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

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

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

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

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

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

Questions?