"Group Based Opioid Treatment in Primary Care: The Nuts and Bolts” Randi Sokol, MD, MPH, MMedEd

1. "Group Based Opioid Treatment in Primary Care: The Nuts and Bolts” Randi Sokol, MD, MPH, MMedEd December 18, 2018

2. Housekeeping • Webcam and microphone features will be muted for attendees • Please submit all questions through the Q&A feature at the bottom of your screen • After Dr. Randi Sokol presents, we will try to answer all questions live • The webinar will be recorded and available on ncibh.org • Please complete the brief survey at the end of the webinar

3. Q&A • Please submit questions through the Q&A function at the bottom of the screen • We will try and answer all questions live • If you have a question after the webinar, feel free to email us at ncibh@uphs.upenn.edu

4. National Center for Integrated Behavioral Health • This presentation was made possible by UH1HP29964 from the Health Resources and Services Administration (HRSA), an operating division of the U.S. Department of Health and Human Services. • NCIBH was established as a trans-disciplinary partnership through funding by HRSA • Academic unit of primary care training and enhancement • Project Officer: Nancy Douglas-Kersellius • Email us at: ncibh@uphs.upenn.edu • Vision: To improve access to the highest quality of care for mental health and substance use disorders in primary care • Mission: Prepare primary care clinicians with the expertise and leadership for integrated behavioral health care

5. "Group Based Opioid Treatment in Primary Care: The Nuts and Bolts”Randi Sokol, MD, MPH, MMedEdDecember 18, 2018

6. Objectives • Explain addiction as a chronic disease and a treatment approach that supports this framework • Identify levels of care and resources to support patients with addiction • Explain the role and efficacy of medication for addiction treatment • Describe group-based model to treat opioid use disorder “GBOT”: benefits for patients, providers, clinic • Explain the operational logistics to implementing GBOT

7. Mike’s Story Disclaimer: NCIBH uses person first language and does not endorse the use of the term “addict” to refer to a person in recovery

8. What happens on snow days?

9. SUD = CHRONIC Disease Model Approach + Behavioral Medication Develop healthy coping mechanisms & support systems Manage Cravings & Withdrawals

10. Addiction? • 4 “C’s” • C= ↓ control • C= compulsive use • C= continued use despite harm • C= craving

11. Levels of Care for SUD Detox → Inpatient→ Residential→ Intense Outpatient → Outpatient

12. OUD: Medication for Addiction Treatment

13. Treatment Medications

14. Medication maintenance for OUD 90% of patients who undergo detox will resume opioid use within the first 60 days ---meds to prevent relapse can effectively decrease the relapse rate (Weiss, Potter, et al 2011) Compared to patients in treatment, patients not receiving medication maintenance have a significantly higher risk of death from overdose (Kakko et al 2003)

15. Medication maintenance for OUD • *Methadone and Suboxone have most evidence for recovery • At 1 year, 40-60% of patients maintained on methadone or Suboxone remain sober (slightly higher for methadone) • Naltrexone- less is known effective (recent comparative effectiveness trials- equal to Bup in efficacy; harder to transition to)

16. Buprenorphine vs Methadone • Bup is equally effective as moderate doses of methadone (< 60 mg/day) in terms of treatment retention (59% at 6 months) (Stein et al. 2005); at higher methadone doses (>60 mg/day), treatment retention increases up to 80% (Hser et al. 2014) • Bup and methadone have similar relapse rates (Strain et al 1998; Johson et al. 2000)

17. Drug Addiction Treatment Act (DATA) 2000 • Allows qualified physician to prescribe scheduled III - V • Narcotic FDA approved for opioid maintenance • Detoxification treatment limit 30 patients per practice • 2002: Suboxone and Subutex FDA approved • 2005: Limit to 30 patients per physician • 2007: Limit to 100 patients per physician after 1 year • 2016: JUST increased to 275 patients/year

18. Do patients divert? Buprenorphine Diversion 86 programs 30 states 19,000 surveys • National study examined diversion and abuse of buprenorphine/naloxone as reported in various data sources • The y axis represents the % people using the drug to get high. Johanson CE et al. Drug Alc Dependence 2013 • Although ~ 20% of bup diverted is used to get high, we still have ~ 80% likely used for maintenance, as an alternative to heroin so people don’t go into withdrawal. • This number is comparable to how diverted amitriptyline is being used. Buprenorphine is more like amitriptyline (in it being used for its purpose and not to get high) compared to other diverted drugs, like heroin, methadone, and oxycodone.

19. The Next Stage of Buprenorphine Care for Opioid Use Disorder Annals of Internal Medicine Martin SA, Chiodo LM, Bosse JD, Wilson A. The Next Stage of Buprenorphine Care for Opioid Use Disorder. Ann Intern Med. ;169:628–635. doi: 10.7326/M18-1652

20. GBOT: Group Based Opioid Treatment

21. What happens in group? • Urine drug screens • Introductions • Ground Rules • Didactic • Check-in • Open discussion • Prescriptions

22. Triage system: Connection to Office-Based Opioid Treatment (OBOT) • ED/ Inpatient • Detox/ CSS/ TSS OBOT Program: • -Group • -Individual Connect to OBOTRNCM IOP (At OAS) PCP within clinic Methadone Clinic New Patient Inpatient: Detox + Inpatient or Residential (ie ≥ 30 day stay) -IOP -Methadone Clinic

23. Estimated Staff Resource Time/Week(care of 40-50 pts) Front Desk: 3 hours 2 hours calls/ appointment management/schedule prep 1 hour Team meeting MA: 7 hours 2 hours group 2 hours group prep/follow up 3 hours paperwork Resident: 5 hours 4 hours group afternoon 1 hour didactic prep Doctor: 7 hours • 2 hours group • 1 hour Team meeting • 3 hours group prep • 3 hours screening + intakes • 2 hours coordinating care • 1 hour notes LPN: 10 hours • 2 hours group • 1 hour Team meeting • 3 hours intakes • 4 hours phone follow ups + care coordination

24. What do patients say about this model?

25. Patient perspective: group keep them honest/ holds them accountable • It’s showing up every week and knowing that you have to be accountable for your actions. For me, I’m all about consequences … there’s another 80 times where I’ve almost slipped up and thought about this group, and didn’t do it because I didn’t want to look at all y’all in the face and say I did it again.

26. Patient perspective: Group fosters shared identity • It’s good to have, and to be in an atmosphere with those other people like you that understand you… you know, I feel like I’m not alone, there’s other people, you know, with similar situations. I have support? I don’t really have support outside of here. My family, you know, they’re there, but they’re not -- my sisters aren’t addicts, so they don’t understand it. My parents don’t understand it. So it just feels good. I don’t feel alone coming here.

27. Patient perspective: over time, group creates supportive community In the beginning, I really didn’t care about anybody, I didn’t care about myself. Ididn’t care what anybody had to say, I’m like, “Is it three o’clock yet? Like, can I get the f*ck out of here?” Now I look forward to coming, coming here and seeing everybody

28. What does the clinic think of this model?

29. Clinic perspective • Destigmatizes addiction • Comprehensive care: treat addiction while treating other medical problems in 1◦ care • Lucrative + minimal staff: • 1 clinic session: • 1 FD, 1 RN 1 MA, 1 MD • 20-30 patients

30. What are common guiding principles across all OBOT groups?

31. Key features to GBOT Variable across sites: Individual appointments offered types of providers present in group MD/PA lead: FM, IM Behavioral support ranges: ALL nurse case manager Some: psychotherapist Additional support: designated MA, Front Desk Mix of patients in group: “level” (same stage of recovery) vs “mixed” Rx given at end of group or with individual prescriber Common across sites: • UDS testing before group • Pre-visit survey • Ground rules • Check-ins + psycho-education • Team based approach • Rewards for doing well (based on attendance, UDS results, functionally doing well) • How patients who are struggling are handled (enhance support: 12 step meeting, psych, higher level of care); pulled aside before/after group or called • Patients with co-morbid psych dx (exclusion criteria: inability to participate in group) • Option to refer to “higher level” (IOP) • Size: 5-16 • Duration: 45 -60 min • Bill as 99213 if no individual appt/ 99214 if individual appt

32. What does psycho education look like? • Support • CBT • Skills development • Psycho-educational Addiction self-management skills • Examples: • Triggers, relapse prevention, cravings, contingency planning, support system • Self-care and healthy coping • Anger management, mindfulness, meditation, nutrition and exercise • Associated medical problems • Smoking cessation, hepatitis C

33. Common philosophy • “Relapse is part of recovery” • Importance of honesty • Polysubstance use: harm reduction approach, tailor to patient (ex: if cannot do higher level of care, work with patient)

34. Schedules Patients • Manages incoming calls • Follow-up for missed visits • Participates in team wrap-up • Triaging: reviews, charts, directs to appropriate treatment • Conducts intakes • Provides continuity with patients as contact for questions/ issues • Submits prior authorizations • Follows up with patients during the week • Collects urine • Participates in team wrap-up • Writes buprenorphine prescriptions • Communicates progress with PCP • Leads team wrap-up • Bills visits appropriately • Direct precepting of resident • Follows up with patients during the week • Learns to lead group, employing small group facilitation skills • Leads didactic • Participates in medical decision making around addictions management

35. Common Features of OBOT groups: Documentation & Billing: • Individual notes (templated): 3-5 mins • Billed as individual visits, most CPT code 99213; some CPT code 99214 (if individual appt); if lead by behaviorist, CTP code 90853

36. Summary • Group delivery of office-based opioid treatment with B/N provides: ↑ access, enhances patient experience, supports providers through an interdisciplinary, collaborative team-based approach • Importance of having infrastructure to provide ongoing support to all providers (regular meetings, e-mail list-serve) • Importance of having higher level to refer to

37. References • About the Epidemic. (2017). U.S. Department of Health & Human Services (HHS). Retrieved from https://www.hhs.gov/opioids/about-the-epidemic/index.html • Galea, S., & Vlahov, D. (2002). Social determinants and the health of drug users: Socioeconomic status, homelessness, and incarceration. Public Health Reports, 117. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1913691/pdf/pubhealthrep00207-0140.pdf • Ravi, A., Pfeiffer, M.R., Rosner, Z., & Shea, J.A. (2017). Trafficking and trauma: Insight and advice for the healthcare system from sex-trafficked women incarcerated on Rikers Island. Medical Care, 55, (12). • Social Determinants of Health. (2017). Healthy People 2020. Office of Disease Prevention and Health Promotion. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health • Spooner, C. & Hetherington, K. (2004). Social determinants of drug use. National Drug and Alcohol Research Centre, University of New South Wales. Retrieved from https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/TR.228.pdf • Volkow, N., Koob, G., & McLellan, T. (2016). Neurobiologic advances from the brain disease model of addiction. The New England Journal of Medicine, 374. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMra1511480#t=article

38. Q&A Submit questions through Q&A feature NCIBH email: ncibh@uphs.upenn.edu Dr. Sokol email: rsokol@challiance.org