META:PHI in Primary Care: Implementing Best Practices for Addictions

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

2. 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

3. 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

4. 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)

5. Why manage addiction in primary care?

6. 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

7. 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

8. 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

9. Patients with alcohol use disorder (AUD)

10. 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.)

11. 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

12. Naltrexone 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”

13. Acamprosate 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”

14. Disulfiram

15. Gabapentin

16. Topiramate

17. Baclofen

18. 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)

19. Patients with opioid use disorder (OUD)

20. 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.)

21. What is buprenorphine? Medication used to manage OUD Partial opioid agonist with a ceiling effect Relieves opioid withdrawal symptomsand 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

22. 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

23. 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

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

25. 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

26. 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)

27. Wrap-up: Key Messages

28. 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

29. 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 Hardykate.hardy@wchospital.ca Knowledge broker: Sarah Clarke sarah.clarke@wchospital.ca