META:PHI in Primary Care: Implementing Best Practices for Addictions Long-Term Management of Patients with Substance Use Disorders

What is META:PHI? Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration Collaborative project to implement integrated care pathways for addiction throughout Ontario Partnership between hospitals, withdrawal management services, FHTs, CHCs, and community agencies Goals: Improve care for patients with addictions Improve care provider experience Improve population health Reduce service use Provide sustainable care

How it works Patients presenting with addiction-related concerns receive evidence-based interventions and are referred to rapid access addiction medicine (RAAM) clinics for treatment RAAM clinics offer substance use disorder treatment on walk-in basis; no formal referral/appointment needed Patients stabilized at RAAM clinic referred back to primary care for long-term addiction treatment (with ongoing support from RAAM clinic as required) Key components: Integration of care at hospital, RAAM clinic, primary care Training, support, and mentorship from addictions specialists Capacity-building

Role of PCPs With support from META:PHI team: Follow best practices for prescribing opioids Screen and diagnose patients for substance use disorders Refer patients to treatment at RAAM clinic when necessary Assume long-term addiction care for patients from RAAM clinic (with ongoing support from RAAM clinic doctor)

Why manage addiction in primary care?

Myth-busting (1) “I can’t do anything for addicted patients.” Addiction not just psychosocial; often has a strong biomedical component Several effective treatments for substance use disorders “I can’t manage these patients because I’m not an addiction specialist.” PCPs often manage chronic conditions outside their specialization (e.g., prescribing anti-depressants, diuretics for hypertension, etc.) Research has found that patients do just as well or better with primary care–based addiction treatment as with specialized addiction treatment

Myth-busting (2) “These patients are too complicated.” Managing patients whose substance use disorders are well treated is very clinically satisfying RAAM clinic doctors are available to consult and reassess patients as needed Patients with substance use disorders need primary care as much as any other patient

An ideal setting Primary care is the ideal setting for treating substance use disorders Greater capacity than specialized care for long-term management Other health concerns can also be addressed Length of treatment more important than intensity of treatment Patients prefer primary care setting Good relationship with care provider important determinant of effective counselling Less stigmatizing environment than a specialized addiction clinic

Patients with alcohol use disorder (AUD)

Goals for patients with AUD Prescribe anti-craving medication Monitor drinking through self-report, GGT, MCV Monitor mood, functioning, and other substance use Manage chronic medical conditions (e.g., liver disease) or psychiatric conditions (e.g., anxiety, depression) Perform regular screening and health maintenance (e.g., pap tests, mammograms, immunizations, etc.)

Pharmacotherapy Patients with AUD should be routinely offered pharmacotherapy Patients may have been initiated at RAAM clinic Maintain patient on dose, monitor effectiveness and side effects Duration of medication six months or longer May discontinue when: Patient has achieved drinking goal (abstinent or reduced drinking for at least several months), minimal cravings, social supports and non-drug ways of coping with stress, and is confident that it is no longer needed to prevent relapse Can be restarted if patient relapses

Naltrexone Action Blocks opioid receptor, reduces euphoric effect Side effects Nausea, headache, dizziness, insomnia, anxiety, sedation Blocks analgesic action of opioids Can cause reversible elevations in AST and ALT; order at baseline and at 3–4 weeks Contraindications/ precautions Pregnancy Triggers severe withdrawal in patients on opioids Discontinue if AST/ALT rise more than 3x baseline at 3–4 weeks Dose 25 mg OD x 3 days to reduce GI side effects; then 50 mg PO OD Titrate to 100–150 mg per day if 50 mg has minimal effect on craving Patients do not need to abstain before starting Note: Use LU code 532 “For the treatment of AUD in patients who meet clinical criteria for AUD; express a commitment to reduce or abstain from alcohol; and have confirmed participation in counselling and treatment for AUD”

Acamprosate Action Glutamate antagonist Relieves subacute withdrawal symptoms Side effects Diarrhea Contraindications/ precautions Pregnancy Renal insufficiency Dose 666 mg tid; 333 mg tid if renal impairment or BW < 60 kg Works best if patient is abstinent several days prior to initiation Note: Use LU code 531 “For the treatment of AUD in patients who meet clinical criteria for AUD; express a commitment to abstain from alcohol; have been abstinent from alcohol for at least 3 days prior to starting acamprosate; and have confirmed participation in counselling and treatment for AUD”

Disulfiram Action Acetaldehyde accumulates when alcohol consumed Most effective when dispensed by family member Side effects With alcohol: Vomiting, flushed face, headache Without alcohol: Headache, anxiety, fatigue, garlic-like taste, acne, peripheral neuropathy (with prolonged use) Contraindications/ precautions Cirrhosis Pregnancy Unstable cardiovascular disease Alcohol reaction can cause severe hypotension and arrhythmias, especially in patients with heart disease or on antihypertensives May trigger psychosis at higher doses (500 mg) Can cause toxic hepatitis Dose 125 mg PO OD; increase to 250 mg if patient reports no reaction to alcohol Wait at least 24–48 hours between last drink and first pill Wait at least 7–10 days between last pill and first drink

Gabapentin Action Modulates dopamine Side effects Dizziness, sedation, ataxia, nervousness Contraindications/ precautions Can cause suicidal ideation (rare) Dose Initial dose 300 mg bid–tid; optimal dose 600 mg tid

Topiramate Action Modulates GABA system May improve sleep/mood disturbance in early abstinence Side effects Sedation, dose-related neurological effects (dizziness, ataxia, speech disorder, etc.) resolve over time Contraindications/ precautions Can cause weigh loss (risk for underweight patients) Can clause glaucoma or renal stones Dose Initial dose 50 mg OD; titrate by 50 mg to a maximum dose of 200–300 mg daily Lower dose needed in renal insufficiency

Baclofen Action GABA agonist Side effects Drowsiness, weakness, can cause or worsen depression Contraindications/ precautions Use with caution in patients on tricyclic anti-depressants or MAO inhibitors Dose Initial dose 5 mg tid, increase to 10 mg tid; maximum daily dose 80 mg Lower dose needed with renal insufficiency

General management Ask about drinking and use GGT/MCV to confirm self-reports Acknowledge patients’ successes Ask about mood, cravings, triggers Encourage activities that improve mood and promote health (exercise, hobbies, walks, alcohol-free socializing, consistent schedule for eating/sleeping) Discuss coping strategies to deal with cravings (call someone, take a time-out, grounding exercises, leave the environment) Brainstorm strategies to avoid triggering people/places and replace problematic habits with healthier ones Consider pharmacotherapy/psych referral for persistent mood problems (depression, anxiety)

Patients with opioid use disorder (OUD)

Goals for patients with OUD Prescribe buprenorphine Monitor withdrawal symptoms and cravings Collect urine drug screens Monitor mood, functioning, and substance use Manage chronic medical conditions (e.g., hepatitis C) or psychiatric conditions (e.g., anxiety, depression) Perform regular screening and health maintenance (e.g., pap tests, mammograms, immunizations, etc.)

24h What is buprenorphine? Medication used to manage OUD Partial opioid agonist with a ceiling effect Relieves opioid withdrawal symptoms and cravings for 24 hours without causing euphoria or sedation Even very high doses rarely cause respiratory depression (unless combined with alcohol/sedatives) Binds tightly to receptors, displacing other opioids Optimal maintenance dose: 8–16 mg SL OD Maximum maintenance dose: 24 mg SL OD Usually combined 4:1 with naloxone as abuse deterrent 24h

Addressing concerns “I don’t have a methadone exemption.” In Ontario, no special license required for buprenorphine “I don’t know how to prescribe buprenorphine.” Buprenorphine is easier to prescribe than other opioids! Lower abuse potential Lower risk of overdose Small dose range Online courses to increase knowledge and confidence “What if the patient relapses?” RAAM clinic physician available for consultation, advice, patient reassessment

How to prescribe Patients being transferred from a RAAM clinic should be at stable dose (usually 8–16 mg) At each visit, ask about withdrawal symptoms (nausea, sweating, aches, anxiety) and cravings Minor dose adjustments of 2–4 mg may be required if patient does not have full 24 hours’ symptom relief Two formulations of buprenorphine/naloxone: 2 mg/0.5 mg 8 mg/2 mg

Prescriptions Specify pharmacy and send by fax Specify observed and take-home doses

Tapering buprenorphine Indications Wants to taper At least six months without any substance use Socially stable, supportive family or social network Stable mood, good coping strategies Protocol Decrease by small amounts (1–2 mg) Leave at least two weeks between dose decreases Hold taper at patient’s request Return to original dose if opioid use restarts Provide regular support and encouragement: it is not a “failure” if taper has to be held/reversed

General management Ask about withdrawal symptoms or cravings Sometimes minor dose adjustments required (2–4 mg) Perform monthly urine drug screens as patient stabilizes Ask about alcohol and cannabis use (usually not tested on urine drug screen) Ask about overall mood and functioning Encourage activities that improve mood and promote mental/physical health Consider pharmacotherapy/psych referral for persistent mood problems (depression, anxiety)

Wrap-up: Key Messages

Our responsibility Managing substance use disorders is our responsibility as health care providers Addiction is the same as any other chronic illness: patients need specialist referrals, medication, treatment of co-occurring conditions, and regular follow-up Effective addiction interventions are simple, safe, and satisfying Purpose of META:PHI project is to facilitate adoption of best practices and support clinicians

Resources META:PHI website: www.metaphi.ca META:PHI mailing list for clinical questions and discussion (e-mail sarah.clarke@wchospital.ca to join) META:PHI contacts: Medical lead: Dr. Meldon Kahan meldon.kahan@wchospital.ca Manager: Kate Hardy kate.hardy@wchospital.ca Knowledge broker: Sarah Clarke sarah.clarke@wchospital.ca