Patient Selection and Visit Structure in Medication-Assisted Treatment" (97 characters)

1. NEOMED TEMPLATE Ohio Opiate Project ECHO™: Expanding Access to Medication-Assisted Treatment Continuing Education ECHO Session 11.10.17 “First Things First”: Patient Selection and Visit Structure

2. Continuing Education ECHO:Global Learning objectives • Evaluate patients for appropriate referral to medication-assisted treatment (MAT) using a collaborative, person-centered approach • Describe effective treatment strategies for prescribers using MAT in emergency departments, primary care, and obstetric settings • Recognize the level of care needed for complex patients in MAT programs utilizing team-based warm handoffs during transitions of care • Educate patients, families and other community/ social supports about the emotional and behavioral aspects of opioid use disorders in order to reduce stigma

3. Session Learning Objectives • Consider who is a “good candidate” for MAT, likely to achieve recovery or harm reduction • Review a structure of a MAT visit that meets clinicaland regulatory requirements • Reflect on our own practices concerning these objectives

4. Confirm An Indication for MAT • Methadone and buprenorphine (or buprenorphine/naloxone) are approved to treat opioid dependence (a feature of moderate/severe opioid use disorder) • Extended-release injectable naltrexone is approved to treat alcohol use disorder and for prevention of relapse to opioid use disorder • Short-acting oral naltrexone is approved to treat alcohol use disorder and for the blockade of exogenous opioids • Naloxone reverses opioid overdose (temporarily)

5. ESTABLISH A DIAGNOSIS • Is Opioid Use Disorder (OUD) present? • Mild, moderate, severe OUD • Are co-morbidities compatible with safe medication use and participation in the program? • Medical • Psychiatric • Chronic pain • Chronic pain alone ? • SO FAR, only 2 formulations FDA approved: Butrans and Belbuca- DEA waiver not required

6. CONSIDER APPROPRIATENESS 1. Does the patient have a diagnosis of opioid use disorder? 2. Is the patient interested in office-based buprenorphine treatment? • Does the patient understand the risks/benefits? 4. Are they expected to be reasonably compliant? 5. Are they expected to follow safety procedures? • Is the patient psychiatrically stable? • Is the patient taking other medications that may interact with buprenorphine? 8. Is the psychosocial setting of the patient stable and supportive? 9. Can the office provide needed resources for the patient (either on or off site)? 10. Can the patient understand and sign an informed consent (treatment agreement)?

7. “less appropriate” Patients?? • What about: 1. Dependence on high doses of benzodiazepines, alcohol, or other CNS depressants!! • Significantpsychiatric co-morbidity?? • Activeor chronic suicidal or homicidal ideation or attempts!! 4. Multiple previous treatments and relapses?? 5. Non-response to buprenorphine in the past?? • High level of physical dependence/risk for severe withdrawal ?? • Patient whose needs can’t be met with existing office resources?? 8. High-risk for relapse?? 9. Pregnancy?? 10. Current medical condition(s) that could complicate treatment? 11. Poor support systems?

8. Think of safety first • Some approaches: • Benzodiazepines, alcohol, or other CNS depressants: MSW, induction or continuance when abstaining from alcohol and illicit drags OR when co-prescribed CNS depressant is minimized and supervised; consider methadone MAT • Significant psychiatric co-morbidity: induction when patient has capacity, and co-occurring psychiatric care • Active or chronic suicidal or homicidal ideation or attempts: acute assessment, management; consider methadone MAT 6. High level of dependence: consider inpatient PH induction and IOP; may do better with methadone MAT • Patient whose needs can’t be met : Network your resources • High risk for relapse: More resources and requirements 9. Pregnancy- standard is methadone MAT, but buprenorphine is permitted and may become standard 10. Current medical condition(s) that could complicate treatment? 11. Poor support systems? Coordinate care when possible!

9. Other concerns • What about non-CNS-depressant illicit drugs? • …Buprenorphine treatment retention is not worse in cocaine users than nonusers, with clinically meaningful improvements in self-reported opioid use. These findings suggest that opioid-dependent cocaine users attain considerable benefits from office-based buprenorphine treatment and argue for the inclusion of these patients in office-based buprenorphine treatment programs. Chinazo et al 2013 • Sustainability • Insurance  vs. self pay XX • Transportation and scheduling to avoid missed visits

10. OFFICE FLOW • Here’s what I do (not evidence based!) : • Pre-prescribing: • Print requisitions for reflexing urine drug screen, buprenorphine confirmation, sometimes UA • Obtain OARRS to check date of next prescription, other prescriptions (staff could do this part!) • Review UDS and OARRS reports • Review other needs ( Hepatitis, HIV, syphillis screening etc.)

11. OFFICE FLOW • At the appointment : • Use a template to capture information: • Urine sample, unobserved or observed • “Establish focus protocol” to decide how to use time for additional preventive and co-morbidity care- may need an extra visit! • Review use of medication, withdrawal, sedation, recovery activity (meetings, counselling, other), life; meeting log; plan random DS if needed; treatment agreement review if needed • Focused RoS for withdrawal, sedation, side effects ; focused Px considering co-morbidities • Prescription- check for errors • Make next appointment(s) at conclusion of visit

12. OFFICE FLOW • Between visits: • Prior authorization as needed (staff helps a lot!) • Verify lab results- note and/or phone call to patient if abnormal, chart addendum re: intensifying plan • Contact other providers as needed (rare) • Patient may see me or another provider for well care, co-morbidity care, other acute or chronic concerns anytime at a separate appointment

13. Safety-Based Approaches to “less Appropriate Patients” • Dependence on high doses of benzos, alcohol, other CNS depressants!! • Significantpsychiatric co-morbidity, activeor chronic suicidal or homicidal ideation or attempts • Multiple previous treatments and relapses, non-response to buprenorphine in the past • MSW, start or continue when abstaining from alcohol and illicit drugs OR when co-prescribed CNS depressant is minimized and supervised; consider methadone MAT • Induction when patient has capacity, and co-occurring psychiatric care • Acute assessment, management; MI; consider methadone MAT

14. Safety-Based Approaches to “less Appropriate Patients” 6. High level of physical dependence/risk for severe withdrawal 7. Patient whose needs can’t be met with existing office resources 8. High-risk for relapse • Consider inpatient PH induction and IOP; may prefer methadone MAT • Network your system or “outside” resources • More resources, requirements and supervision

15. Safety-Based Approaches to “less Appropriate Patients” 9. Pregnancy 10. Current medical condition(s) that could complicate treatment 11. Poor support systems 9. Methadone MAT is current standard of care, but bup, bup/naloxone are permitted and may become standard in the future 10,11. Assess, treat, coordinate care- we are Family Medicine!