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

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

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 2016. From 2002-2017 there was a 4.1-fold increase in the total number of deaths.

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

Opioid Abuse in North Carolina Source: North Carolina Health News

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

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

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

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

Physician Supply Knudson 2015.

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

Barriers to resident training Suzuki et al. 2016

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

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

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

Questions on Pre/Post Assessment 1 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)

Multiple choice questions 9 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

Knowledge Assessment

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%

How do attitudes change? ≠

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

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):644-654. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014 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.