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MEDICATION ASSISTED TREATMENT USING NURSE CARE

MANAGERS

May 14, 2014 Colleen T LaBelle BSN, RN-BC, CARN

IntNSA Webinar Series

Funding for this webinar was made possible (in part) by (1H79T1022022) from SAMHSA. The views expressed in written webinar materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Disclosure of Relevant Financial

Relationships: I have no disclosures or

Financial Interest to Report

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Objectives

1. Describe the role of DATA 2000 in treatment of opioid dependence

2. List barriers to treatment of opioid dependence in office based practices

3. Describe buprenorphine as a partial agonist

4. Describe the role of nurses in integration of OBOT in outpatient settings i.e office practice, community health centers

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Drug overdose deaths outnumbered motor vehicle traffic deaths in 10 states in 2005

CDC NVSS, MCOD. 2010

More deaths from drug overdose

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By 2010, drug overdose deaths outnumbered motor vehicle traffic deaths in 31 states

CDC NVSS, MCOD. 2010

More deaths from drug overdose

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Opioid Detoxification Outcomes

Low rates of retention in treatment

High rates of relapse post-treatment

< 50% abstinent at 6 months

< 15% abstinent at 12 months

Increased rates of overdose due to decreased tolerance

O’Connor PG JAMA 2005Mattick RP, Hall WD. Lancet 1996Stimmel B et al. JAMA 1977

Medication Assisted Treatment

Goals

• Alleviate physical withdrawal

• Opioid blockade

• Alleviate drug craving

• Normalized deranged brain changes and physiology

Some options

• Naltrexone (opioid antagonist)

• Methadone (full opioid agonist)

• Buprenorphine (partial opioid agonist)

Drug Addiction Treatment Act (DATA) 2000

Amendment to the Controlled Substances Act

Allows physician to prescribe narcotic drugs scheduled III, IV or V, FDA approved for opioid maintenance or detoxification treatment

Prior 10/2002 no drug existed

Methadone does not qualify Schedule II

A New Law

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DATA 2000: Physician Qualifications

Physicians must: Be licensed to practice by his/her state Have the capacity to refer patients for psychosocial

treatment Limit number of patients receiving buprenorphine

to 30 patients for a least the first year File for a new waiver after first year to increase their

limit to 100 patients. Be qualified to provide buprenorphine and receive a

license waiver

BUPRENORPHINE

100

90

80

70

60

50

40

30

20

10

0

-10 -9 -8 -7 -6 -5 -4

%Efficacy

Log Dose of Opioid

Full AgonistMethadone

Partial AgonistBuprenorphine

Full AntagonistNaltrexone

Opioid effect,

sedation, respiratory depression

Opioid Potency

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How Does Buprenorphine Work?

“Ceiling effect” on opioid effects

High affinity for opioid receptor

Slow dissociation from opioid receptor

Formulated with naloxone

Naloxone blocks opiate effect if injected

Naloxone is degraded (inert) if taking orally

Goals of Pharmacotherapy with Buprenorphine:

Prevention or reduction of withdrawal symptoms

Prevention or reduction of drug craving

Prevention of relapse to use of addictive drug

Restoration to or toward normalcy of any physiological function disrupted by drug abuse

Needs Assessment in MA with Bureau of Substance Abuse Services

High rate of opioid addiction High number of fatal and non-fatal opioid overdoses Long waits for opioid treatment, both methadone and

buprenorphine Some people refuse MMT Not enough MA physicians had waivers Some waivered physicians were not prescribing

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Surveys mailed to 356 addresses

256 respondents

235 included

21 excludedNo office-based practice

156 (66%) prescribers 79 (34%) non-prescribers

20 not at address80 non-respondents

October/November 2005MDPH sent survey to all 356 waivered physicians

Walley AY et al. J Gen Intern Med 2008; 23(9): 1393-8

TotalPrescriber

N=156Non-prescriber

N=79

Total 235 (100) 156 (66) 79 (34)

Psychiatrist 126 (54) 74 (47) 52 (67)

Primary Care 102 (44) 78 (50) 24 (31)

Other 6 (3) 4 (3) 2 (3)

Walley AY et al. J Gen Intern Med 2008; 23(9): 1393-8

Prescriber Status and Specialty (n=235)

Non-prescribers

If barriers improved:

54% (33/61) of those who had never prescribed buprenorphine, will prescribe

67% (10/15) of those who had prescribed, will prescribe

Walley AY et al J Gen Intern Med 2008; 23(9): 1393-8

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Only physicians can prescribe

However, it takes a Multidisciplinary Team Approach for effective treatment

Barriers to Buprenorphine PrescribingInsufficient nursing support 20 %Insufficient office support 19 %Payment issues 17 %Lack of institutional support 16 %Insufficient staff knowledge 12 %Pharmacy issues 8 %Low demand 7 %Office staff stigma 5 %Insufficient physician knowledge 3 %One or more barriers 55%

Walley AY et al J Gen Intern Med 2008; 23(9): 1393-8

Certified Buprenorphine Physicians by State

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MA Responded to Unmet Need

MA Department of Public Health Bureau of Substance Abuse Services Released two RFR’s: Funding for a Nurse Care Manager Model in 19

Community Health Centers (CHC) Required CHC to partner with SA provider

Funding for training and technical assistance to the CHC OBOT’s

Funding awarded for 3 years with an 8/07 start date, renewable for a total of 7 years

Nurse Care Manager Model

Screener by coordinator or nurse

RN intake: labs, UTS, consents, treatment agreement, education

Counselor - intake, refer to psych if warranted

Intake reviewed by the OBOT team (RN, MD)

Bupe MD visit: review, assess, clear for prescription

Induction: stabilization, management Management by RN/MD Visits, assessments, education, UTS, labs, MD contacts

Script refills by MD, medical monitoring, counseling check

Intake Screening

Substance history/Current use

Treatments, inpatients, detox

Medical history

Current, pending surgeries

Mental health history

Diagnosis, treatment :past /present

Social Supports

Family, housing, recovery systems

Treatment Goals

What they hope to accomplish

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OBOT RNNursing Assessment:

Intake assessment Review medical hx, pain issues, mental health, current use,

medications

Consents/Contracts Program requirements

Review, sign

Education Treatment, opioid medication, administration, safety

Urine toxicology screen Screen drug of use and ? others

LFT’s, Hepatitis serologies, RPR, CBC, pregnancy test

Patient Agreement

Set the stage for ongoing relationship

Clear message about rules

Patient involvement

Behavior is part of treatment

OBOT MD

Review of history Mental health, substance use, medical, social

Physical Exam

Lab and urine review Assess contraindications, toxicology

Confirm Opioid Dependence diagnosis DSM IV criteria

Confirm appropriate for office treatment

Writes the orders and prescription

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OBOT RN Induction Preparation:

Review the requirements program: Nurse/ Physician Appointments: frequency, times, location

Counseling: weekly initially

Urine screening: at visits, call backs

Abstinence From opioids is the goal

Safety: medication storage

Patient Education

Patient Education

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OBOT TeamPatient instructions for induction day:

Insurance verification: assure prescription access

Prior authorizations, co-pays

Dispose of paraphernalia, phone numbers, contacts

Medication pick up: 2mg/8mg tabs/film

Don’t plan to drive for 24 hours

Plan to be at clinic or office for 2-4 hours

Bring a support person if possible

Last use: long acting vs. short acting

Precipitated withdrawal

Side effects

OBOT RN, MDPlanning for Induction:

Asking patient to show up in withdrawal requires a great deal of….. TRUST

Build a Relationship, support….

Review with patient ahead of time usage history, withdrawal and make a plan

Written materials, ongoing education

Emergency and contact numbers Need to know what to do if they can’t get their prescription

OBOT RN’sInitial dose buprenorphine per protocol

COWs >8-12

Objective signs are key to making dx

Slow and steady

Avoid precipitated withdrawal

Instruct patient on administration: 2-4mg sl

Assess 40min-1 hour after dosing

Better, worse, or the same….

Repeat dose of 2-4mg per protocol. Reassess 1 hour

Send home with instructions to call OBOT Team

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OBOT RNFrequency of Visits:

Phone contact daily, daily visits for first few days, or more if needed Support

At least weekly until stabilized: dose, negative urines, counseling, social stability, usually

4-6 weeks

Progress to every two weeks, monthly, random, PRN Change treatment plan as needed Chronic relapsing disease….Check in!

OBOT RNComfort Measures:

Taste perversion

Headaches

Nausea

Sweating

Insomnia

Anxiety

Pain

Follow protocols

Consult with MD as needed

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OBOT RN/MDPrescriptions

Early On:

Small prescriptions 1 week with or without refills

Increase as patient stabilizes (negative UTS)

2 week prescriptions with/without refills

At point of stabilization:

Monthly or random visits

Monthly prescriptions with or without refills

Keep file of pharmacy contact info May fax prescriptions

OBOT RNFollow up Visits:

Assess dose, frequency, cravings, withdrawal

Ongoing education: dosing, side effects, interactions, support.

Counseling, self help check in

Psychiatric evaluation and follow up as needed

Medical issues: vaccines, follow up, treatment HIV, HCV…Engage in care

Pregnancy

Social supports: housing, job, family, friends

OBOT TeamMonitoring

Toxicology testing

Pill counts

Pharmacy Check-in

Observed Dosing

Random call backs

Scheduled visits

Counseling check in

Check in with support/family/parent/partner

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OBOT TeamMonitoring: Pharmacy

PMP: Prescription monitoring program

Important Collaboration

Identify one pharmacy for all meds

Keep record: Name, number, address, fax on file

Obtain refill history Other controls and prescribers

Refills allowed on Scheduled III

Pharmacy alerts you to: Other meds Early refill requests Behavior issues

OBOT RNRandom Call Backs

Urine toxicology screen

Pill count

Observed dosing

Pharmacy confirmation

Request when to bring pills in, not to each visit due to medication safety

Maintenance summary:

Expect stability

Expect improvement in drug use, employment, criminality, detox admissions, housing, social supports

Counseling engagement

If not abstinent, evaluate progress in treatment:

Evaluate need change in treatment plan

Higher level of care

Additional supports, services

Involve the patient Is the treatment failing the patient?

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Length of Treatment

Length of treatment: We ask patients to commit to 6 months on suboxone and then reassess

Patients should be actively involved in development of treatment plan

Everyone is different: Need to meet patients where they are at

Individualize treatment

Discharge Options from OBOT

Suboxone not the “miracle drug”

It is a Tool………..

Establish linkages with programs

Assist with detox admission

Holding, residential, step-down, transitional

Transfer to Methadone Maintenance

Short or Long term option

Clinical Pathway Review

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Treating the “Whole” Person

Comprehensive attention to all medical and psychosocial co-morbidities;

Pharmacotherapy rarely achieves long-term success without concurrent psycho-social, behavioral therapies and social services;

Special attention to those at risk of misusing their medications or whose living arrangements pose increased risk for misuse or diversion;

Individualize Treatment………….

Collaborative Care of Opioid-Addicted Patients in Primary Care Using Buprenorphine:Five-Year Experience

Alford DP, LaBelle CT, Kretsch N, Bergeron A, Winter M, Botticelli M, Samet JH.

Archives of Internal Medicine. 2011;171 (5):425-431

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BMC Collaborative Care

Program Director Registered Nurse

Supervised NCMs & Program Coordinator

Program Coordinator Former medical assistant

Collected standardized intake information over the phone or in-person

On average 20 intake calls/week

OBOT Physicians Prescribed to average 35 patient (range 13-68)/month

Alford DP et al. Arch Intern Med. 2011

BMC Collaborative Care Model

Program Director (0.4 FTE)

Nurse Care Managers [NCM] (2.2 FTE)

22 clinical half-day sessions/wk

Program Coordinator (1 FTE)

9 OBOT Physicians with part-time practices

Ave 3 primary care half-day sessions/wk/MD, ranging from 1-6 sessions

Alford DP, LaBelle CT et al. Arch Intern Med. 2011

BMC Collaborative CareNurse Care Managers (NCM)

Registered nurses, completed 1 day training

Performed patient education and clinical care by following treatment protocols (e.g., UDT, pill counts, periop mgnt)

Ensured compliance with federal laws

Coordinated care with OBOT physicians

Collaborated care with pharmacists (refills management) and off-site counseling services

Drop-in hours for urgent care issues

Managed all insurance issues (e.g., prior authorizations)

On average each NCM saw 75 patients/wk

Alford DP et al. Arch Intern Med. 2011

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BMC Collaborative Care

Program Coordinator intake call

NCM and physician assessments

NCM supervised induction (on-site) and managed stabilization (on- and off-site (by phone))

Alford DP et al. Arch Intern Med. 2011

BMC Collaborative Care

Maintenance treatment (at least 6 months)

NCM visits weekly for 4-6 wks, then q2 wks, then q1-3 months.

Patients seen less than monthly had up to 6 random callbacks/yr

OBOT physician visits at least every 6 months

Medically supervised withdrawal considered after 6 months of stability

Transferred to MMT if continued illicit opioid use or need for more structured care

Discharged if refused MMT,

Discharged if continued non-adherence or disruptive behavior

Alford DP et al. Arch Intern Med. 2011

BMC Collaborative Care Preadmission Factors Associated with

Treatment Success

Characteristic OR (95% CI)

Older age 1.40 (1.09-1.80)

Employed 2.24 (1.33-3.77)

Illicit buprenorphine use 3.04 (1.32-7.00)

African American 0.50 (0.26-0.99)

Hispanic/Latino 0.45 (0.22-0.93)

Alford DP et al. Arch Intern Med. 2011

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BMC Collaborative Care Urine Drug Tests

Alford DP et al. Arch Intern Med. 2011

Month 3 6 9 12

Illicit Opioid

NEG95% 94% 93% 95%

Cocaine

NEG 95% 96% 95% 98%

Alford DP et al. Arch Intern Med. 2011

BMC Collaborative Care ModelConclusions

Patient-level outcomes comparable to physician-centered approaches

Allows efficient use of physician time to focus on patient management (e.g., dose adjustments, maintenance vs taper)

Improved access to OBOT and daily management of complex psychosocial needs (e.g., housing, employment, health insurance)

Open communication between NCM and addiction counselors improved compliance

Alford DP et al. Arch Intern Med. 2011

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State Initiative Project Goals

Treatment expansion and access to buprenorphine

Create a model for the effective delivery of buprenorphine services

Integrate addiction treatment into primary care settings

Increase the number of MD’s with waivers

Project Goals (cntd.)

Increase the number of individuals treated for opioid dependence

Focus on high risk areas, homeless individuals and pregnant women

Collect data on treatment efficacy

Sustainability of project after funding ends

STATE OBOT B MD’s Waivered in Community Health Centers:

0

20

40

60

80

100

120

140

160

2007 2008 2009 2010

Providers Waivered

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Patients Served in OBOT at CHC’s

Aug 07-July 10

Patients treated with buprenorphine

UMass Study Findings

Studied 5,600 Mass Health Clients prescribed buprenorphine and methadone

Overall Mass Health expenditures lower than for those with no treatment

Clients on MAT had significantly lower rates of relapse, hospitalizations and ED visits: no more costly than other treatments

Buprenorphine attracting younger and newer clients to treatment

R.E. Clark; Health Affairs, August 2011

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Next Steps

Utilizing nurse care manager models to expand treatment to more sites

Increase level of education among providers in addiction treatment

Look at drop out rates and reasons: improve retention

Utilizing a multidisciplinary approach similar to HIV models of care

Outreach to Hispanic, and African American opioid dependent

PCSS-MAT Website

Home Page:

Mentoring Page:

Provider Clinical Support System for Medication Assisted Treatment PCSS-MAT

• National training and mentoring project developed in response to:

• prescription opioid misuse epidemic • underutilization of medications for opioid

use disorders• The goal is increase availability of MAT in a variety

of settings, including primary care, psychiatric care, and pain management settings.

• Funded by SAMHSA

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Websites: Buprenorphine/ Addiction Nursing

www.buprenorphine.samhsa.org www.asam.org Intnsa.org (International Nurses Society on

Addiction) Addictionnurses.org (MA Chapter for

addiction nurses) Email or phone support: Colleen.Labelle@bmc.org 617-414-7453

Thank You

”

“If we do nothing people will die“

Dr Wesley Clark Director Center for Substance Abuse Treatment and Mental Health Services Administration,

U.S. Department of Health and Human Services

Questions?