If not us, who? - Community Care Network of Kansas€¦ · Accept bupe maintenance patients....

If not us, who?The case for treating addiction in primary care

September 2019Community Care Network of Kansas Annual Conference

Kelly.Pfeifer@dhcs.ca.gov

Disclosures:

• I never received money from pharma.

• I am not representing the State of California.

• I spent the first 5 years of my career fueling the opioid epidemic.

Beth

Name and picture changed

The cause was clear… we made a plan.

California, 2015-2018:Dramatic drop in opioid prescribing

It’s not just opioids

Credit: Matt Willis, MD MPH

We won’t stop the deaths until we change

how we think about addiction

12California Health Care Foundation www.chcf.org

We need three things to survive: food, water and dopamine

How opioids change the brain https://www.youtube.com/watch?v=bwZcPwlRRcc

R Corey Waller, MD

13California Health Care Foundation www.chcf.org9/9/2019 13

Dopamine changes over time

Addiction is a brain disease: living in a tempest

15www.chcf.orgCalifornia Health Care Foundation

Medication calms the brain, facilitates participation in behavioral health and social support, and allows recovery

• Methadone: cuts death rates by 67%• Buprenorphine: cuts death rates by 50%• Naltrexone:

Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies, BMJ 2017; 357;j1550; Larochelle, et al. Ann Intern Med. 2018;169(3):137-145; DOI: 10.7326/M17-3107

works for some populations; no impact on death rates in large, long-term trials

Detox then drug-free tx: 2-3x death rates compared to maintenance

So how do we build a bigger boat?

9/9/2019 17Source: Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

AIDS Deaths, United States: 1981-1995

• 1995: 55,000 AIDS deaths

• Continuous rise over prior decade

1995: 55,000 AIDS deaths

“We’re just one part of the system. We can’t do this alone.”

“They brought this on themselves. They knew the

risks and made their choices.”

“These patients are too complex– we don’t have the clinical expertise.”

“These patients are too disruptive for our practice.”

Primary care Responses to HIV in the ‘90s

HIV nowUbiquitous routine screening

Treatment access widespread

Almost normal life expectancy

What can HIV teach us about bigger boats?

1. Screen widely

2. Make treatment easy to find: no wrong door

3. Stop the stigma

4. Promote harm reduction

5. Don’t do it alone

6. Tackle racism

Lessons from HIV

1.Screen widely2. Make treatment easy to find: no wrong door

3. Stop the stigma

4. Promote harm reduction

5. Don’t do it alone

6. Tackle racism

Lessons from HIV

Screen widely: We can’t help if we don’t know.We won’t know if we don’t ask.Support evidence; support MAT.

1. Screen widely

2.Make treatment easy to find: no wrong door

3. Stop the stigma

4. Promote harm reduction

5. Don’t do it alone

6. Tackle racism

Lessons from HIV

26California Health Care Foundation www.chcf.org

NOT

<

Make treatment easy to find. No wrong door.

• Treat the disease, not the symptom• Train and support clinicians• If you can’t integrate, coordinate• Step-up and step-down care (like any other chronic disease)

Treatment starts here: MAT at every health care touchpoint

1. Screen widely

2. Make treatment easy to find: no wrong door

3.Stop the stigma4. Promote harm reduction

5. Don’t do it alone

6. Tackle racism

Lessons from HIV

Stop the stigma

Patients need help combatting stigma: friends, family, 12-step groups, treatment centers…

Words can heal; words can harm

We need to replace this:

With this:

1. Screen widely

2. Make treatment easy to find: no wrong door

3. Stop the stigma

4.Promote harm reduction5. Don’t do it alone

6. Tackle racism

Lessons from HIV

Promote Harm Reduction• Risky behavior won’t go away• Some behaviors are safer than

others• Our goal is improved life for people

and communities• We should help minimize harm

We are good with harm reduction – for diabetes.Cause? Genes, environment, and behavior

Prevention? Environmental and behavior change

Treatment? Long-term chemical replacement; lifestyle changes

Noncompliance: Support small changes. Keep treating.

Diabetes vs. Addiction: what can you lose?Treatment

Custody of children

Freedom (probation)

Yes

Yes

No

No Yes

Yes

No

The list goes on.. housing, family, work, and more

The cost of expecting perfection

People cut off opioid pain meds are twice as likely to use illicit drugs

Veterans: higher risk of suicide and mental health crisis when opioids tapered to zero

Half of people discontinued off opioids were stopped abruptly; half of those were admitted to the ED or hospital for opioid-related diagnoses.

Pre-publication from Phillip Coffin’s study of tapering outcomes.Demidenko, M., et al, Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users, Gen Hosp Psychiatry 2017 Jul; 47:29-35, https://www.ncbi.nlm.nih.gov/pubmed/28807135http://www.bmj.com/content/357/bmj.j1550

1. Screen widely

2. Make treatment easy to find: no wrong door

3. Stop the stigma

4. Promote harm reduction

5.Don’t do it alone6. Tackle racism

Lessons from HIV

Don’t do it alone• Warmline: free addiction

specialist expertise to help you with cases and commonly asked questions

• Resources: SAMHSA, Provider’s Clinical Support System (PCSS-MAT), CHCF

• Relationship with opioid treatment program (step-up and step-down)

• Telehealth: direct to patient, e-consultation, or shared management

https://www.chcf.org/publication/innovation-landscape-telehealth-mat/

Telehealth providers specializing in MAT

Telepsychiatry providers adding MAT

www.chcf.org

Levels of care: primary care MAT

Level 3

Level 2

Level 1

Hire addiction counselors and/or peers.Train staff and clinicians in management of other SUDs.Contract with counties and plans as SUD treatment provider.

2 clinicians get a waiver. Treat simple OUD; transfer complex patients (persistent + drug screens) to opioid treatment program.Accept bupe maintenance patients. Transition high-dose pain patients onto bupe

Train staff in SBIRT screening.Train behavioral staff in motivational interviewing for SUD.Have MA do check-in calls during buprenorphine starts.Do buprenorphine group visits, co-led by clinician and behaviorist.

HIV care got a bigger boat.

What happened?

Source: Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

AIDS deaths: 1981-2007

--- AIDS deaths

Widespread screening Access to effective treatment

Anti-stigma campaignHarm reduction

Team care

The French Experience: 80% Drop in Deaths

Heroin OD deaths

Methadone treatment

Buprenorphineprescriptions

Source: Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Why not zero?

--- AIDS deaths

1. Screen widely

2. Make treatment easy to find: no wrong door

3. Stop the stigma

4. Promote harm reduction

5. Don’t do it alone

6.Tackle racism

Lessons from HIV

https://www.youtube.com/watch?v=-4YDUDhMcvM

Apologies in advance: it is impossible to beep out profanity from Wanda

1. Screen widely

2. Make treatment easy to find: no wrong door

3. Stop the stigma

4. Promote harm reduction

5. Don’t do it alone

6. Tackle racism

Start simple. But start now.

Lessons from HIV

Level 3

Level 2

Level 1

Helping people recover can support our own recovery.

Rediscover the joy of medicine.

If not us, who?

Kelly.Pfeifer@dhcs.ca.gov