1. Don Teater MD Medical Advisor National Safety Council Itasca, IL Medical Provider Behavioral Health Group Asheville, NC Medical Provider Meridian Behavioral Health Services Waynesville, NC

2. Background Board certified Family Physician in a solo family practice in the southern Appalachian Mountains since 1988. In the early 2000s I began to see more patients who were addicted to prescription opioid medications. In 2004 I took the DATA 2000 training to prescribe buprenorphine. –That changed my life more than anything else that I have done in medicine!

3. Our system 1.Initial phone call/screen 2.Secondary screen by CMA or nurse 3.Initial physician visit 4.One-day follow-up 5.One week follow-up 6.Ongoing visits every 4 weeks.

4. Initial phone call Initial screen when they call for admission for treatment. –Why do you think you need treatment? –What drugs are you taking and how often?

5. Secondary screen For the secondary screen, they come in and meet with a CMA. –Review of all drugs they are taking Prescribed Illicit –Brief past medical history –Sign consent for us to talk with primary care doctor and all prescribing doctors –Sign treatment agreement Example at: http://www.ncbi.nlm.nih.gov/books/NBK64238/http://www.ncbi.nlm.nih.gov/books/NBK64238/ –Schedule initial visit with me. Inform them that they MUST be in withdrawal. IR opioids: None for 24 hours ER opioids: None for 48 hours Methadone: None for 3 or more days –Do a urine drug screen now!

6. 1 st visit with physician Is buprenorphine appropriate? Determine that the patient does have OUD. –PDMP –UDS Do H&P. Is buprenorphine/naloxone the best choice for them? –Consider also methadone (at an OTP) or naltrexone injection (Vivitrol®)

7. 1 st visit with physician Initiation Determine that they are in withdrawal –Restless –Rhinorrhea –Diaphoretic –Pupils dilated –Tachycardic –Tremor Give initial dose and wait 1 hour then recheck. –Completely safe and often dramatic Give rx for 2-4 pills and send them home.

8. Day 2 follow-up How did they do overnight? Did they take any extra? Calculate daily dose, give 1 week rx, schedule f/u in 1 week.

9. Buprenorphine/naloxone Always use the combination product (unless pregnant)! Allergy to naloxone is extremely rare!

10. Week 1 follow-up How have they done on the prescribed dose? Develop a plan for counseling or groups If doing well then f/u in 4 weeks.

11. Recheck q 4 weeks Discuss dose Cravings? Any drug use? Other addictions (nicotine)? Social situation? Any signs of withdrawal? Pupil size Alertness Check PDMP (in your state and neighbor states if they are close by) UDS This can be charged as a 99213 visit.

12. Pearls A dose higher than 16 mg per day is seldom necessary Encourage patients to take their dose once a day in the morning Drug screening should be done at every visit but can be done randomly when the patient is stable and doing well.

13. Pearls Trust nobody! –Have a system where people are randomly called back for pill counts and witnessed UDS. –Occasionally check for buprenorphine/norbuprenophine in the urine.

14. Pearls Addiction is a disease. –Some will need to be on MAT the rest of their lives –There will be relapses

15. Resources TIP 40 – SAMHSA (Its free!) Guide for treatment of OUD with bupe. http://store.samhsa.gov/product/TIP-40-Clinical-Guidelines-for-the-Use-of- Buprenorphine-in-the-Treatment-of-Opioid-Addiction/SMA07-3939 http://store.samhsa.gov/product/TIP-40-Clinical-Guidelines-for-the-Use-of- Buprenorphine-in-the-Treatment-of-Opioid-Addiction/SMA07-3939 Treatment agreement: http://www.ncbi.nlm.nih.gov/books/NBK64238/http://www.ncbi.nlm.nih.gov/books/NBK64238/ Clinical Opioid Withdrawal Scale: https://www.drugabuse.gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf https://www.drugabuse.gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf Efficacy of pain medications: http://safety.nsc.org/painmedevidencehttp://safety.nsc.org/painmedevidence Other NSC resources: Go to nsc.org and click on “Learn” then “Prescription Painkillers”.nsc.org My email: don.teater@nsc.org