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Evaluation of Electronic Vapor Product and Other Substance Use in States that have Legalized Cannabis
Devika Bhatia, MD, Susan Mikulich-Gilbertson, PhD, Joseph Sakai, MDWe do not have any potential or actual conflicts of interest in relation to this study. Funding was provided by NIDA-AACAP Resident Training Award in Substance Use Disorders.
Background
Legalization of recreational and medical cannabis has been implemented in multiple states.
• 33 states have legalized medical cannabis
• 11 of those states have legalized recreational cannabis
One potential unintended consequence of marijuana legalization is changing prevalence of other substance use, including electronic vapor product use (vaping).
Aim 1: Compare prevalence and frequency of vaping by adolescents living in RCL states to vaping prevalence and frequency in MCL and NL states
Aim 2: Compare prevalence and early initiation of use of other substances (alcohol, tobacco, marijuana, prescription opioid misuse, and illicit substances) by adolescents living in RCL states to MCL and NL states
Aim 3 (Exploratory): Compare trajectories of adolescent substance use for RCL, MCL, and NL states for pre- and post-medical legalization and pre- and post-recreational legalization
Results
Methods
Research Aims
We will utilize the Center for Disease Control and Prevention’s 2017 Youth Risk Behavior Surveillance Survey
• Cross-sectional, nationally-representative survey of high school students
• Students were sampled using a three-stage random cluster design
• n=107,665Students assigned to RCL, MCL, or NL group based on state where they lived at time of survey.SAS data used to produce multiple logistic regression analyses, weighted appropriately for survey methodology.
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
Ever Vaped Currently Vaping Currently VapingFrequently
Currently VapingDaily
RCL MCL NL
100.0%
RCL (%) MCL (%) NL (%) Statistic (DF); p-value
SexFemale 48.7 49.0 49.0 2 (2)=0.1; p=1.0
Race/EthnicityWhite 54.6 47.0 59.3 2 (12)=5570;
p<0.0001Black/African American 4.4 12.3 19.3
Hispanic/Latino 28.7 29.1 13.8Asian 4.3 6.2 2.1AI/Alaska Native 0.5 0.8 0.3Hawaiian/ Other Pacific Islander
0.5 0.8 0.3
Multiple-Non-Hispanic 4.6 3.7 3.8
Grade at survey9th 26.7 26.5 26.6 2 (6)=1.7; p=1.010th 25.6 26.0 25.811th 24.4 24.1 24.412th 23.3 23.3 23.2
Aim 1: Demographics
Aim 1: Prevalence of Vaping in RCL, MCL, NL States
aOR: 0.895% CI:0.7-1.0
aOR: 0.895% CI:0.8-0.9
aOR: 1.895% CI:1.4-2.2
aOR: 0.895% CI:0.8-0.9
aOR: 1.795% CI:1.1-2.7
aOR: 0.995% CI:0.7-1.2
aOR: 1.795% CI:1.0-1.2
aOR: 0.995% CI:0.6-1.2
Students in RCL states were significantly more likely to report current vaping and current frequent vaping compared to students in MCL states.
Students in MCL states were significantly more likely to report ever vaping and current vaping compared to students in NL states.
Interpretations:
• Reduced perceived risk of harm
• Vaping cannabis
• Co-use of cannabis and nicotine in electronic vapor products
Important note: we cannot determine causality
Questions for Experts in the Field
Future Directions
Determine prevalence of other substance use by adolescents in RCL, MCL, NL states (Aim 2).
Compare trajectories of onset of substance use by adolescents in RCL, MCL, NL states (Aim 3).
Are there other reasons why vaping may be more popular in RCL and MCL states?
How much does the legal status of substances affect adolescents’ use?
Why might there be differences in ever vaping versus currently vaping?
Which covariates may be important to control for in final analyses?
How can our methods be improved?
Conclusions
Background
Native American communities possess (among racial/ethnic groups):•The largest percentage increase in number of drug overdose deaths overtime (519%) between 2001-2015.
•2nd highest overdose rate from all opioids.
•2nd highest overdose death rates from heroin and the 3rd
highest from synthetic opioids.
Rural communities possess (compared to urban): •Equal rates of drug overdoses despite lower access to substance use and chronic pain treatment.
•Higher opioid prescription rates and higher overdose rates involving natural and semisynthetic opioids and psychostimulants.
Acknowledgements:
•Native American Emergency Medicine Consortium
•Funding: NIDA-EMF Mentored Training Award in Substance Use Disorders Science Dissemination
AIMS
The Emergency Department serves as a safety-net in an era of decreasing healthcare access in critical-need areas.
ED-OUD Interventions
1.Opioid overdose education and naloxone and distribution (OEND)
2. Buprenorphine initiation and referral
Evidence
•Communities with access to OEND have been found to have reduced opioid overdose death rates.
•Treatment with buprenorphine has been found to reduce risk of opioid overdose death by 50%.
•ED-initiated buprenorphine increases engagement treatment, decreases opioid use and use of inpatient addiction treatment services.
Ryan JJ Buckley, MD, MPH, Kathryn Hawk, MD,MHSDepartment of Emergency Medicine, Yale School of Medicine
Development and Dissemination of Resources for Emergency Department-Initiated Interventions for Opioid Use Disorder:
A Focus on Native American and Rural Communities
Current Questions Being Explored
1.What communities (providers, regions, patients) are most interested in theseprograms?2.What are the implications of federal, state, and Tribal regulations inimplementing ED-OUD programs?3.What EDs have already implemented these programs?
(1) Develop a stakeholder network to create and deploy evidence-based practices for ED-OUD interventions with those who provide care to Native American and Rural communities.
(2) Develop a learning collaborative featuring multimodal content delivery (lectures, online toolkit, curriculum).
(3) Facilitate ongoing access to developed resources through incorporation into the ACEP Medication for Treatment of Opioid Use Disorder Toolkit, and by partnering with other organizations.
Improving the Treatment of Substance Use Disorders Across a Large Health System
Hoa Kevin Luong, PA-C
Introduction
Project Goals
Project Description
Evaluation Strategy
Implications
Acknowledgement
Contact Information
UPMC is a world-renowned health care system that spans the western and central parts of the Commonwealth of Pennsylvania and Southwestern corner of New York state. UPMC operates 40 hospitals, 700 physician offices and employs 4,900 physicians and over 2000 Advanced Practice Providers. UPMC has expanded geographically over the past few years to include hospitals and practices that are over 200 miles away from the clinics of our Addiction Medicine Services and Opioid Use Disorder Center of Excellence in Pittsburgh, PA. This geographic expansion and the central location of its substance use disorders (SUDs) treatment services has created an opportunity that limits our ability to fulfill the hospitals mission. The current model relies on physicians and Advanced Practice Providers, especially in the regions that are classified as medically underserved or health professional shortage areas, to be proficient in the competencies of screening, motivational interviewing, clinical management, identification of available resources, and coordinating with other professionals according to the continuum of care model. While various members who work in these practices have expressed interest in serving their communities by identifying and treating substance use disorders, UPMC has not fully assessed the key factors of providing this care including APPs who have received XDEA waiver to treat Opioid Use Disorder, their caption of their patient population and the opportunities to screen and engage patients regarding SUDs, and perceived barriers to successfully treating SUDs in their community.
The goal of this project is to enhance the health of the large population served by UPMC across western and central Pennsylvania and southwestern New York state, as those patients affected by SUD will have increased access to more proficient providers who have assess and overcome barriers to SUD treatment. The objectives of this project are:1. Accelerate and deepen the understanding of fellow Advanced Practice
Providers and other clinicians about the models of treatment for SUD, specifically Opioid Use Disorder (OUD), and their barriers through a systematic review of the literature;
2. Better understand the barriers that our more than 2000 Advanced Practice Providers experience in providing treatment for SUD, especially OUD, to various communities across the UPMC health system;
3. Use published evidence and a knowledge of the above barriers to develop and implement online educational modules that will promote the adoption of evidence-based approaches to patients with SUDs, especially OUD, by our Advanced Practice Providers regardless of their practice setting and across the various communities they serve;
4. Disseminate the project findings as evidence for consideration by health systems , providers, and policymakers as they work to improve the practices of treating SUDs, especially OUD, across the networks of clinicians.
The project will span from January 2020 to December 2020. The methodology of the project will follow the Plan-Do-Study-Act (PDSA) model.
Plan: The first phase of the project will be to research and develop a survey to assess Advanced Practice Providers’ knowledge, barriers, and level of comfort with caring for SUD patients.
Do: The second phase of the project will be to distribute the survey to every Advanced Practice Providers within the UPMC health network.
Study: The third phase of the project will be to obtain all feedback from the surveys. The data will be analyzed. The data will then be used to develop educational modules through WISER online training center.
Act: The fourth phase of the project will be to distribute the educational modules to every Advanced Practice Providers within UPMC. The modules will address the common barriers to treatment that providers experience.
This project evaluates Advanced Practice Providers on two separate intervals. The initial evaluation is to gauge Advanced Practice Providers current barriers to treatment. The next evaluation is to assess Advanced Practice Providers’ knowledge gained through participating in the training modules. Our strategy may be to use The Kirkpatrick Model to assess the effectiveness of the educational models.
The Kirkpatrick Model can be used once every Advanced Practice Provider completes the educational modules. A post-test will be used to measure the degree to which participants acquired the intended knowledge, skills, and attitudes as a result of participating in the training. A follow up survey can also be considered to solicit opinions from the learning experience. The goal of this survey will be to assess participants on whether the training was relevant and if they felt engaged in the training. The survey can also be used to measure the degree to which the participant’s behaviors will change as a result of the training. The evaluation method can help us determine if providers will likely benefit from the training, which may translate to the level of overall success of the training.
The goal of this project is to enhance Advanced Practice Providers’ knowledge and address barriers to treatment of SUDs. By providing educational materials to address providers’ deficiencies, providers can better be prepared to treat SUDs. This goal is in alignment with UPMC’s Center of Excellence for Addiction Medicine. As more providers, especially those in remote rural areas, are able to participate in SUD treatment, it will benefit the local community as well as the nation’s opioid crisis.
Hoa Kevin Luong, [email protected] Locust StreetSuite 411Pittsburgh, PA 15219412-232-4040
Funding: NIDA Mentored Outreach Aware in Substance Use Disorder (SUD) Treatment Dissemination, supported by the National Institute on Drug Abuse (NIDA) from the National Institutes of Health (NIH) in partnership with the PA Foundation
Support: David Beck, PA- C, Benjamin Reynolds, PA-C, Ajay Wasan, MD, MSc, University of Pittsburgh Physician Assistant Program, UPMC WISER Institute, UPMC OAPP
Increasing Comprehensive Opiate Use Disorder Care in an Academic Emergency Medical Center: An Implementation Science Approach
Emily Johnson, MD MPH; Chun Nok Lam MPH, PhD, R. Bluthenthal PhD; Todd Schneberk, MD, MS, MADepartment of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles
Background• Aim I: Implement X waiver training for all Emergency
Medicine Residents at Los Angeles County + University ofSouthern California and increase the rate ofbuprenorphine treatment and prescriptions offered topatients with OUD from the Emergency Department.
• Aim II: Perform a secondary analysis on a previouslyplanned, departmental survey on regarding OUDtreatment and prescribing in the ED.
• Aim III: Disseminate work to meetings with keystakeholders in our treatment community, connect withmultiple outlets, including presentation at nationalemergency medicine conferences.
• Aim IV: Establish a Substance Use Disorder workgroupand resident champions to sustain OUD treatment andbuprenorphine initiation goals and engage with community
• based organizations in the surrounding area.
• Buprenorphine administration in acute withdrawal can lead to improved outcomes for patients with opiate use disorder,increased follow up with addiction treatment programs, as well as reduced illicit drug use and medical system costs fordrug related ED visits [1-3].
• Emergency Department (ED) providers are on the frontlines of service to patients with opiate use disorder. Emergencyproviders may serve to provide an induction to medication-assisted therapy (MAT), decreasing the risk of use afterdischarge, and referring patients to outpatient MAT providers [4, 5].
• Los Angeles County + University of Southern California Hospital, (LAC+USC), is the safety net hospital closest to the highconcentration of undomiciled persons in the downtown Los Angeles ‘skid row’ area; patients who can be disproportionatelyimpacted by SUD and OUD [2, 3, 6, 7].
• Best practices proposed include education of providers about opiate withdrawal and use of buprenorphine to controlsymptoms [4, 5]. However, there continue to be barriers to utilization of buprenorphine for withdrawal treatment includingfears of precipitating withdrawal, fears of diversion or overdose, and beliefs that additional licenses are needed to offertreatment [10-12].
• Targeted resident training can impact patient care effectively [13-15]. Additionally, residents in training have been shown tocarry forward practices learned while in residency; thus, targeting educational interventions to this emerging group ofphysicians has the potential to affect practice patterns downstream [16, 17].
References: 1. Busch, S.H., et al., Cost-effectiveness of emergency department-initiated treatment for opioid dependence. Addiction, 2017. 112(11): p. 2002-2010. 2. D'Onofrio, G., et al., Emergency Department-Initiated Buprenorphine for Opioid Dependence with Continuation in Primary Care: Outcomes During and After Intervention. J Gen Intern Med, 2017. 32(6): p. 660-666. 3. Lo-Ciganic, W.H., et al., Association between trajectories of buprenorphine treatment and emergency department and in-patient utilization. Addiction, 2016. 111(5): p. 892-902. 4. Herring, A.A., J. Perrone, and L.S. Nelson, Managing Opioid Withdrawal in the Emergency Department With Buprenorphine. Ann Emerg Med, 2019. 73(5): p. 481-487. 5. Weiner, S.G., et al., Opioid-related Policies in New England Emergency Departments. Acad Emerg Med, 2016. 23(9): p. 1086-90. 6. Authority, L.A.H.S., LAHSA Homeless County Community Dashboard 2016-
2019. 7. HUD, U.S. Department of Housing and Urban Development (HUD). (2011). The 2010 Annual Homeless Assessment Report to Congress. Washington, DC. . 2011. Johns, S.E., M. Bowman, and F.G. Moeller, Utilizing Buprenorphine in the Emergency Department after Overdose. Trends Pharmacol Sci, 2018. 39(12): p. 998-1000. 9. Ronquest, N.A., et al., Relationship between buprenorphine adherence and relapse, health care utilization and costs in privately and publicly insured patients with opioid use disorder. Subst Abuse Rehabil, 2018. 9: p. 59-78. 10. Cisewski, D.H., et al., Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting. Am J Emerg Med, 2019. 37(1): p. 143-150.
11. Winetsky, D., R.M. Weinrieb, and J. Perrone, Expanding Treatment Opportunities for Hospitalized Patients with Opioid Use Disorders. J Hosp Med, 2018. 13(1): p. 62-64. 12. McMurphy, S., et al., Clinic-based treatment for opioid dependence: a qualitative inquiry. Am J Health Behav, 2006. 30(5): p. 544-54. 13. Lancaster, E., et al., Residents as Key Effectors of Change in Improving Opioid Prescribing Behavior. J Surg Educ, 2019. 14. Ury, W.A., et al., Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents? J Gen Intern Med, 2002. 17(8): p. 625-31. 15. VanLangen, K.M., et al., Evaluation of a multifaceted approach to antimicrobial stewardship education methods for medical residents. Infect Control Hosp Epidemiol, 2019: p. 1-6. 16. Chen, C., et al., Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA, 2014. 312(22): p. 2385-93. 17. Sirovich, B.E., et al., The association between residency training and internists' ability to practice conservatively. JAMA Intern Med, 2014. 174(10): p. 1640-8.
Aims
Knowledge/awareness
Persuasion Decision Implementation Confirmation/ continuation
# Not X waivered, not yet using buprenorphine for treatment of withdrawal
Not X Waivered inconsistent to no treatment.
X Waivered, inconsistent to no treatment.
X waivered and routine treatment, not prescribing
X waivered, treating and prescribing
Innovators 2 x
Early Adopter x
Early Majority
x
Late Majority x
Laggard 68 x
Innovators
Early Adopters
Early Majority
Late Majority
Laggards
knowledge persuasion decision implementation confirmation
100%
time
Diffusion of Innovation
Implementation Model Questions1. Our goal is to nudge providers from one category to thenext. What behavioral or educational nudges have beenmost effective in your system to change prescriberbehavior regarding buprenorphine?
2. In your experience changing provider behavior, howlong did it take to see an effect of this change regardingprescribing habits?
3. Can we demonstrate specific change in buprenorphineadministration and prescribing in comparison to othersafety net hospitals in the region? Any other measuresthat would make for a more effective comparison group?
4. Will this enhanced program demonstrate significantdifferential buprenorphine use, as measured by adifference in differences analysis?
5. Any pitfalls of the buprenorphine program expansionand analysis plans?
Baseline Data
Special thanks to EMF-NIDA for their support.
OPIOID DEPENDENT PREGNANT WOMEN: TREATMENT OPTIONS TO DECREASE NEONATAL ABSTINENCE SYNDROME Monjama Korngor, MSN, FNP-CDoctor of Nursing Practice Student
Widener UniversityABSTRACT
Opioid use disorder in pregnancy results in adverse consequences for the fetus, often resulting in neonatal abstinence syndrome and lengthy stays in Neonatal Intensive Care Unit (NICU). The purpose of this practice improvement project was to design, implement, and evaluate an evidence-based practice medication-assisted treatment (MAT) intervention for opioid-dependent pregnant women to reduce neonatal abstinence syndrome outcomes. Internal data from hospital admissions (March 2017-October 2019) was used to determine the duration of neonatal abstinence syndrome and length of stay in the NICU according to which medication (methadone versus buprenorphine) was used to treat maternal opioid disorder. Structure, process and outcomes were evaluated using a logic model, which along with the application of Johns Hopkins Nursing EBP model served to develop an educational program aimed to improve care among MAT providers who work with opioid-dependent pregnant women within the hospital system. Intent to change practice was evaluated at the end of the educational program and has initiated conversation among the providers in standardizing evidence-based MAT treatment within the system.
BACKGROUND and SIGNIFICANCE
Opioid-dependent pregnant women are at higher risks for complications such as NAS, preterm labor, fetal convulsions, and fetal death. Other indirect threats to the fetus includes hepatitis C, hepatitis B, HIV, malnutrition, and inadequate prenatal care • The opioid epidemic among pregnant women affects 6.5 out of
1000 delivery hospitalization (Haight et al. 2018).• Admissions into drug detoxification/rehabilitation treatment
facilities for pregnant women increased from 2% to 28% from 1992 to 2012 (Krans and Patrick, 2016).
• Every 25 minutes a baby is born with NAS and the hospital care cost of 1.5 billion USD (Loudin et al. 2017).
PICO QUESTION
PICO Question: Among MAT privilege providers that treat opioid-dependent, pregnant women, how using methadone compare to using buprenorphine in reducing NAS?
CRITICAL APPRAISAL of the EVIDENCESynthesis of the Evidence
LOGIC MODEL
EVIDENCE-BASED FRAMEWORK
APPLICATION OF THE JOHNS HOPKINS NURSING EVIDENCE-BASED PRACTICE
MODEL
METHODOLOGY• Citi Training• IRB approval for QI project • Retrospective chart review and data collection• Data analysis using SPSS• Education of MAT providers• Provider assessment of MAT practices
IMPLICATIONS FOR ADVANCED NURSING PRACTICE
• Lead to change healthcare culture to accommodate substance use disorder as a treatable disease
• .Decrease stigmatization around opioid use and the misunderstanding of MAT program in the communities
• Enable nonjudgmental education, community support, and advocacy for substance use
• Collaborate to develop and evaluate relevant policies and legislations that impact pain management and opioid addiction
• Influence state and federal laws on substance addiction
• .
IMPACT ANALYSISStandardization of EBP MAT treatment option will:
• Reduce complications such as NAS in newborns• Reduce NICU treatment cost • Increase cost savings for the hospital and the health
insurance companies
SUSTAINABILITY AND DISSEMINATION
• Promote evidence-based standardization using Medication Assisted Treatment in treating opioid-addicted pregnant women to reduce NAS and LOS in the NICU
• Design, vet and distribute patient educational materials to regional health care communities, providers and policy makers to positively impact this critical health care crisis
0 2 4 6 8 10
Strongly Disagree
Neutral
Strongly Agree
Has this evidence-based presentation influenced your decision on MAT?
CONCLUSIONS
• Critical appraisal and clinical data analysis evidence supports that Buprenorphine yields better neonatal outcomes than Methadone
• The evidence also suggests t. hat buprenorphine use in the Crozer system to treat opioid dependent pregnant women will lead to cost savings for the treatment of NAS babies
• The MAT providers were agreeable to change prescribing policies to buprenorphine over methadone to treat opioid addiction in pregnancy
0
10
20
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
MAT ASSESSMENT POST PRESENTATION
buprenorphine as better choice for NAS reduction
methadone as better choice for NAS reduction
CURRICULUM
Dissemination of an evidence-based public health curriculum in pain and addiction forinterprofessional learners using the Project ECHO model
Alison C. Essary, DHSc, MHPE, PA-C; Nandita Keole, MD; Andrew Hills, MD; Hayden Pond; Priya Radhakrishnan, MDHonor Health Academic Affairs, Scottsdale, AZ
REFERENCES
CONCLUSION
OUTCOMES MEASURES
In the Project ECHO model, technology is used to amplify and leverage limited resources; best practices are shared to reduce disparities in care; case-based learning is used to master complexity; and a web-based database is used to monitor outcomes.5Project ECHO directly addresses structural barriers for
patients and clinicians, by providing front-line (primary care) clinicians with the knowledge required to manage patients with complex conditions, including SUD, where patients live, work, pray, and play to positively and meaningfully improve the health of the population. Using the ECHO model to disseminate the Arizona Pain
and Addiction Curriculum4 will engage clinicians in an evidence-based, multi-disciplinary approach to effectively manage patients with pain and addiction.
1. Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2018. Accessed May 9, 2019 from https://www.cdc.gov/ drugoverdose/pdf/pubs/2018- cdc-drug-surveillance-report.pdf
2. Davenport S, Weaver A, Caverly M. 2019. The Economic Impact of Non-Medical Opioid Use in the United States: Annual Estimates and Projections for 2015 through 2019. The Society of Actuaries. Available at https://www.soa.org/globalassets/assets/files/resources/research-report/2019/econ-impact-non-medical-opioid-use.pdf
3. Saitz R, Daaleman TP. Now is the time to address substance use disorders in primary care. Ann Fam Med. 2017. https://doi.org/10.1370/afm.2111
4. Arizona Department of Health Services. 2019. The Arizona Pain and Addiction Curriculum. https://www.azdhs.gov/audiences/clinicians/arizona-pain-addiction-curriculum/index.php5. Project ECHO. https://echo.unm.edu/about-echo/model
OBJECTIVES
1. Integrate, adapt and disseminate the Arizona Pain and Addiction Curriculum,4 an evidence-based public health curriculum for interprofessional learners, through the Project ECHO© model.2. Identify training and educational materials to supplement the Arizona Pain and Addiction Curriculum4 (e.g. NIDA, CDC, SAMHSA, etc.).
INTRODUCTION
More than 630,000 people died due to drug overdose inthe U.S. between 1999 and 2016.1
One recent report quantified the total cost of the opioidepidemic as almost $180 billion per year.2
Most primary care physicians are either not waivered orreluctant to prescribe buprenorphine to patients formanagement of SUD.3
Arizona disseminated the Opioid Action Plan in responseto state-wide public health emergency.
In 2018, the Arizona Department of Health Servicespublished the Arizona Pain and Addiction Curriculum4
which ‘redefine(s) pain and addiction as interlinked,complex, public health processes, requiringinterprofessional care and involvement of the communityand health-based systems.’4
Demographics – number of clinicians, professional identity, practice site/setting, gender, etc.
Self-reported outcomes of participants – self-efficacy, knowledge, support, support, quality of care
Number of teleECHO sessions attended, participation over time, etc.
Other – supplemental evidence-based training and educational materials
TIMELINE
Stigma Introduction to OUD Evidence-based screening
and SBIRT MAT medication overview MAT induction Non-judgmental
communication Case management
Harm reduction Treatment of pregnant
women Adolescent care Legal and policy issues Behavioral health
considerations Clinic workflow Use of drug testing
THE ECHO MODEL
[email protected] @AlisonCEssary
Mentored Training to Combat the Opioid Crisis: Emergency Medicine Meets Addiction MedicineMoschella PC, Litwin A2, Raja A3
Prisma Health Department of Emergency Medicine1, Prisma Health Department of Medicine2, Mass General Department of Emergency MEdicine3
Aims• 1: Education-Utilizing the mentorship
from both the EM and IM physician leaders, this program will focus on dissemination of the specialty-specific resources manual from NIDA and DEA waiver training for implementation of MAT and overall SUD/OUD treatment within the applicant’s health system.
• 2: Research- Following on-site training in best practices from around the country, the applicant will disseminate these results and implement these models at local sites. Utilizing the mentors’ expertise and additional embedded collaboration at the applicant’s local site, research on the implementation and results will be disseminated within regional and national academic venues.
• 3: Patient Care- Timely implementation of proven models from around the country will be leveraged against a structured mentored pathway toward independent practice within a new Addiction Clinic that will culminate with a new ED consult service led by the applicant.
Background● The Opioid Epidemic is a major US
health concern.● Deaths due to opioids have surpassed
that caused by automobiles ● the rise in opioid and heroin related
admissions represents a 221% and 26% increase respectively.
● The Emergency Department (ED) has been studied as a unique venue for screening and initiation of treatment of these vulnerable populations.
Methods● IRB exempt/approved ● We implemented an SBIRT= Screening Brief Intervention and Referral to Treatment program in one of 6
EDS in our Health System. ● GMH ED is the regions only level 1 Trauma Center (~95K adult visits/year). ● Universal triage based SUD/OUD Screening of all adult patients aged 18+ years using the AUDIT-C questions
and a modified NIDA Quick Screen● Audit-C scores of 8 or higher and any responses on the NIDA quick screen prompt a Brief Intervention. ● BI was conducted by a non-profit community partner program FAVOR which uses Peer Recovery Coaches ● Referral to Treatment was setup with a next day appt. ● We also perform a COWS assessment and initiation of MAT with a single film of 8mg/2mg Bup/Naloxone
Results
AcknowledgmentsFunded as sub award of a DHHS Grant
Funded by NIDA/SAEM Mentorship Award
ConclusionFirst Quarter Goals:1- Background Training and Assimilation of NIDA resources, published results, and the protocols.(On Going)2- First Site Visit: Mass General Hospital, Dr. Raja (on hold 2/2 COVID-19)3- Begin Needs Assessment for Upstate and Midland Regions of Prisma Health (On Going)4- Begin the Plan Do Study Act (PDSA) Cycle for QI projects-Plan for MOUD and Linkage to Care Implementation within Upstate and Midlands Regions of Prisma Health (On Going)Second Quarter Goals:1- Complete Needs Assessment for Upstate Region PrismaHealth2- Develop Limited Implementation of MOUD protocols and Linkage to Care at 2 of 7 EDs in Upstate Region of PrismaHealth (1 rural site and at Level 1 Trauma Center)3- Begin MOUD and enhanced Linkage to Care at these 2 Sites and PDSA cycleThird Quarter Goals:1- Evaluate limited implementation effectiveness- continue PDSA Cycle2- Amend protocols as necessary based on data- continue PDSA Cycle3- Develop plan for full implementation across Upstate Region4- Begin full implementation across Upstate Region (all 7 EDs)5- Complete Needs Assessment for Midlands Region of Prisma Health6- Second Site Visit to Mass General Hospital, Dr. Raja other Local/State Resources to assist with mentorship for local advocacy goals for SC based on Needs AssessmentFourth Quarter Goals:1- Evaluate full implementation effectiveness- continue PDSA2- Amend protocols as necessary based on data- continue PDSA Cycle3- Develop Plan for Limited Implementation of MOUD protocols and Linkage to Care at 2 of 4 EDs in Midlands Region of Prisma Health (1 rural site and at Level 1 Trauma Center)4- Begin MOUD and enhanced Linkage to Care at these 2 Sites and PDSA cycle5- Evaluate limited implementation effectiveness- continue PDSA Cycle6- Develop plan for full implementation across Midlands Region
15832• Total patients
seen in ED (2 months)
5814• Patients
Screened (37%)
439
• AUDIT C =<8220
• Positive NIDA Quick Screen
23• Naloxone• Nasal Take-
home
8 • Suboxone• MAT induction
5 • 1st appt• 63%
2• Follow-
up• 40%
SourcesRaja AS, as Chair of the MHA MAT for OUD Workgroup. Guidelines for Medication for Addiction Treatment for Opioid Use Disorder within the Emergency Department. 2019 Jan.https://www.mhalink.org/MHADocs/MondayReport/2019/18-01-04MATguidelinesNEWFINAL.pdfD’Onofrio, G., O’Connor, P. G., Pantalon, M. V. and et al., Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial, JAMA, 2015, 313(16):1636-1644
RESEARCH POSTER PRESENTATION DESIGN © 2019
www.PosterPresentations.comRESEARCH POSTER PRESENTATION DESIGN © 2019
www.PosterPresentations.com
Stigma exists with substance use disorders (SUD). SUD often co-exist with mental illness. Both conditions are often stigmatized and poorly understood by the general public and health care providers. A bidirectional relationship exists between SUD and comorbid mental illness (CMI) that can negatively impact health care outcomes such as morbidity, and mortality rates compared to the general population. By addressing both conditions, it is proposed that health care outcomes and access to care can be improved. The aim of this project is to design an innovative curriculum to educate physician assistant (PA) students on SUD and CMI in an effort to reduce stigma, improve access to mental health care, and improve health outcomes. Curricular additions will be added to the PA training program and contact based educational opportunities will be added to foster inter-professional collaboration in order enhance substance use disorder and mental health literacy, reduce stigma, and improve access to care.
INTRODUCTION
OBJECTIVES
Two cohorts of A.T. Still PA students will receive core curriculum:• Mental health first aid training • Medication assisted treatment (MAT) waiver training• SBIRT training • Motivational interviewing training • Health literacy training• Social determinants of health training• Nonviolent crisis intervention training • Contact based panel discussions with individuals receiving treatment for SUD and CMI • Online interactive inter-professional SUD training module • Arizona Pain and Addiction Curricular modulesExperiential Learning:• History and physical exams and SBIRT at Crossroads substance use treatment center
Students • Inter-professional Education (IPE) collaborative learning with multidisciplinary team at
ATSU and Crossroads Inc. • Interactive simulated SUD and CMI patient communication drills• Participation in twelve-step program and SUD group therapy sessions
MATERIALS AND METHODS• Clinical shut downs subsequent to
coronavirus precautions• University shut down and
transition to online learning indefinitely
• Measuring qualitative data and lessons learned
CHALLENGES RESULTSPending:• Pre-survey and post-survey using validated tool, Opening
Minds Scale for Health Care Providers (OMS-HC-15) • Reflective writing assignments • Debriefing sessions after contact based educational
experiences• Interprofessional Collaborative Competency Attainment
Survey (ICCAS) validated tool post IPE learning activities• Objective Structured Clinical Examination Rubric for
simulated communication drill
REFERENCES1. Baingana, F., Al'Absi, M., Becker, A. E., & Pringle, B. (2015). Global research challenges
and opportunities for mental health and substance-use disorders. Nature, 527(7578), S172.2. Carroll, S. M. (2018). Destigmatizing mental illness: An innovative evidence-based
undergraduate curriculum. Journal of psychosocial nursing and mental health services, 56(5), 50-55.
3. Gensinger, M. (2015). ICCAS: Interprofessional Collaborative Competency Attainment Survey. Retrieved from https://nexusipe.org/informing/resource-center/iccas-interprofessional-collaborative-competency-attainment-survey
4. MacCarthy, D., Weinerman, R., Kallstrom, L., Kadlec, H., Hollander, M. J., & Patten, S. (2013). Mental health practice and attitudes of family physicians can be changed!. The Permanente Journal, 17(3), 14.
5. Modgill, G., Patten, S. B., Knaak, S., Kassam, A., & Szeto, A. C. (2014). Opening Minds Stigma Scale for Health Care Providers (OMS-HC): examination of psychometric properties and responsiveness. BMC psychiatry, 14, 120. https://doi.org/10.1186/1471-244X-14-120
6. Tetrault, J. M., & Petrakis, I. L. (2017). Partnering with psychiatry to close the education gap: an approach to the addiction epidemic. Journal of general internal medicine, 32(12), 1387-1389.
ACKNOWLEDGEMENTS
Susan Harrell DNP, Crossroads Inc., and AT Still University-Arizona School of Health Sciences
• Provide students with foundational evidence- based knowledge of SUD and CMI and their confounding relationship.
• Educate students to screen, educate, and work collaboratively with an inter-professional healthcare team to refer and improve access to mental health services via referrals and warm hand offs.
• Enhance PA skills, comfort, and confidence in working with patients through contact-based education to reduce SUD and CMI related stigma, improve the patient experience and partnership, and to increase mental health and substance use disorder literacy.
Annette Bettridge MS, PA-C, FNP
Stamp Out Stigma-De-stigmatizing Substance Use Disorders and Comorbid Mental Illness Through Innovative Curricular Strategies
0
0
5
37
66
0 10 20 30 40 50 60 70
1. MUCH WORSE NOW
2. SOMEWHAT WORSE NOW
3. ABOUT THE SAME
4. SOMEWHAT BETTER NOW
5. MUCH BETTER NOW
Compared to the time before this learning activity, would you say your ability to collaborate interprofessionally to address SUD and
CMI is:
Sample image of data results: Question 6 of ICCAS survey post PA/PT IPE activity
Dana Sacco MD, Angela Mills MD, Betty Chang MD, Bernard Chang MD PhD Columbia University Irving Medical Center, New York, NY
1 D’Onofrio G, et al. Emergence department-initiated buprenorphine/ naloxone treatment for opioiddependence: a randomized clinical trial. JAMA. 2015 Apr 28;313(16): 1636-44.
Opioid use disorder (OUD) is a major problem in the UnitedStates, and effective treatment has been immenselychallenging. There is growing evidence that medication, suchas buprenorphine, can assist in the recovery of patients withOUD. Buprenorphine can be safely initiated from theemergency department (ED)1. This project seeks to educateemergency physicians in an emergency department in NewYork City regarding the safe and effective use ofbuprenorphine and to increase the number of providerslicensed to prescribe it.
1. Increase awareness of the evidence supportingbuprenorphine for opioid use disorder among EPs
2. Encourage more EPs to become licensed to prescribesuch medication (X-waivered) and examine its impacton buprenorphine initiation therapy from the ED
Opioid overdose deaths have been a major burdennationwide, with New York state having more than thenational average in 2017, a rate of 16.1 deaths per 100,000persons compared to the nationwide average of 14.6 deaths(CDC/NIDA).
Treatment for individuals with opioid use disorder hasbeen remarkably difficult, but medications such asbuprenorphine are showing promise. Studies have shownthat treating ED patients with sublingual buprenorphine andproviding referral for ongoing treatment is superior to referralalone.1 However, few emergency medicine physicians (EPs)are trained or licensed to prescribe buprenorphine. Currentlyin our ED in New York City there are 10 attending physicianswith X-waivers out of a total of over 60 full time faculty. Thisprovides a unique opportunity as we see many patients withOUD and are not yet offering buprenorphine induction in theED.
Prior to intervention, a survey to examine provider attitudes wasadministered to our EPs with a response rate of n=33 (approximatelyhalf of our full-time providers). Overall our EPs indicated that theysupport the use of medication assisted therapy (MAT) for patients withOUD, and many of them (69.7%) agree that there is a role for inductionof MAT in the ED, though identified multiple barriers.
The ED represents a valuable opportunity to intervene in thecare of patients with OUD
Lack of provider education regarding buprenorphine and timecommitment to get X-waivered were among the mostcommon barriers identified
We will increase provider awareness of buprenorphinethrough targeted education
We will provide encouragement and incentives to providerswho get X-waivered
We will track the increase in X-waivered providers as well asthe impact that this has on our treatment of ED patients withOUD
Figure 1. Responses of ED attendings to the statement “Patients with opioid usedisorder who are started on the appropriate medication therapy can have meaningfulrecovery and avoid future overdose and death.”
Increasing provider awareness and prescription of buprenorphine for opioid use disorder
ABSTRACT
BACKGROUND
OBJECTIVES
METHODOLOGY
SUMMARY
REFERENCES
Figure 2. Responses of ED attendings to the statement “ED providers should offerbuprenorphine/ suboxone treatment to patients who present with opioid overdoses oropioid use disorder who are interested”.
The target population of patients to start on MAT includespatients in moderate to severe opioid withdrawal. To identifythese patients protocols will be put in place to screen patients intriage for the presence of OUD and this information, similar todomestic violence and suicide risk, will be easily visible in themedical record.
A concise presentation of evidence regarding buprenorphine’ssafety and effectiveness in treating patients with OUD from theED will be shared with the faculty in group settings andindividually.
Efforts will be made to make X-waiver training accessible andconvenient for the faculty, and faculty will be providedincentives for following through with training, including giftcards.
Provider feedback will be provided to the faculty as a groupand individually regarding numbers of X-waivered providers aswell as numbers and rates of buprenorphine prescriptionsprovided in the ED, 30-day follow up in community substanceabuse treatment clinics, and return ED visits.
0 2 4 6 8 10 12 14 16 18 20
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Can MAT help patients with OUD avoid future overdose and death? (n=33)
0 2 4 6 8 10 12 14
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Should ED doctors offer buprenorphine to patients with OUD? (n=33)
0 5 10 15 20 25 30 35
Lack of outpatient resources to help thesepatients after ED discharge
Time commitment to get X-waivered
Concern about abuse or diversion ofbuprenorphine
Lack of effectiveness of treatment (thesepatients will just overdose again)
Lack of provider education regardingbuprenorphine
Lack of time
Barriers to prescribing buprenorphinein the ED (n=33)
Figure 3. Responses of ED attendings to the question “What do you consider (if any) tobe barriers to prescribing buprenorphine in the ED to patients with opioid use disorderwho are interested? Check all that apply”.
Developing a Child & Adolescent Psychiatry Training Series to Address Educational Gaps in Substance Use Disorder Care and Treatment
(CAP-Gap): Pre-survey analysis
Discussion
Pre-Survey Results
Gaurav Vishnoi, MD1,2; Laura Harrison, MPH3,4,5; Vera Feuer, MD1,2; Richard Pleak, MD1,2; Victor Fornari, MD1,2; Sandeep Kapoor, MD2,3,4,5
1Child and Adolescent Psychiatry, Zucker Hillside Hospital; 2Zucker School of Medicine at Hofstra/Northwell; 3Emergency Medicine, Northwell Health; 4Addiction Services, Northwell Health; 5Division of General Internal Medicine, Northwell Health
References
Conclusion
Future Plans
1. Welsh JW, Schwartz AC, DeJong SM. Addictions Training in Child and Adolescent Psychiatry Fellowships. Acad Psychiatry. 2019;43(1):13–17. doi:10.1007/s40596-018-0959-6
2. Schwartz AC, Frank A, Welsh JW, Blankenship K, DeJong SM. Addictions Training in General Psychiatry Training Programs: Current Gaps and Barriers. Acad Psychiatry. 2018;42(5):642–647. doi:10.1007/s40596-018-0950-2
3. US Department of Health and Human Services: Best Practices and Barriers to Engaging People With Substance Use Disorders In Treatment https://aspe.hhs.gov/report/best-practices- and-barriers-engaging-people-substance-use-disorders-treatment/introduction
4. Ahrnsbrak R, Bose J, Hedden SL, Lipari RN, Park-Lee E, Tice P. Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. 2017;7(1) https://www.samhsa.gov/data/sites/default/files/NSDUH- FFR1-2016/NSDUH-FFR1-2016.pdf.
5. Gorfinkel LR, Giesler A, Dong H, Wood E, Fairbairn N, Klimas J. Development and Evaluation of the Online Addiction Medicine Certificate: Free Novel Program in a Canadian Setting. JMIR Med Educ. 2019;5(1):e12474. Published 2019 May 24. doi:10.2196/12474
Methods
Expected outcomes
• Marked improvement in knowledge, attitudes, and perceived skills
• Qualitative comments by fellows and faculty
• Self-reported changes in behaviors post-educational series
Keys to Success of this Educational Intervention
• High visibility of topic
• Buy-in of key stakeholders
• Securing protected time to match depth of topic
• Interprofessional/interdisciplinary approach to planning and execution
• Learner feedback on self-identified content areas
Limitations
• Variations in professional and personal experience, education, and interest in addressing substance use among participants based on different level of training in medical school and residency
Background
Aim 1: Develop and conduct pre-survey to identify gaps
in education and knowledge regarding substance
use disorder
Aim 2: Develop, disseminate, and evaluate asynchronous
online training series to backfill identified gaps
• Based on pre-survey results, a customized educational series in effort to empower CAP fellows and clinicians will serve to facilitate comfort in addressing substance use and addiction with an informed approach
• Development and execution of this CAP Educational Series
• Dissemination of lessons learned to additional training programs via presentation at AACAP and AADPRT meetings
Objective
Evident Gaps in
Education
We are in the midst of a large-scale epidemic that impacts our patient populations and communities
without discrimination or short-term relief
Motivation
Comfort
Education
In order to prepare our CAP Fellows and Faculty to serve as ‘Conduits of HOPE’, we need to
offer education, build motivation and investment, and approach
this topic with comfort and compassion
• Develop mixed quantitative and qualitative pre-survey
• Administer pre-survey
This disease process places demands on the healthcare industry to evolve
Step 1
• Analyze pre-survey data and score into domains
• Determine topic areas for 3-part online training series
• Disseminate asynchronous online training series
• Conduct post-session surveys
• Analyze survey data
Step 2
Step 4
Evaluation Plan
pre-survey questions were grouped
into the following domains:
Humanizing Substance Use
Screening and the Brief Negotiated
Interview
Opioid Overdose Prevention
Assessment and Diagnosis of
Substance Use Disorders
Landscape of Addiction Treatment
Medication for Addiction Treatment
Vaping Resources in community
Dosing for adolescents for other medications for SUD (Chantix, naltrexone, Antabuse, etc.)
Overdose signs Treatment referral center information,
List of medication treatment options for SUD
How to address opioid abuse in adolescents
Prescribing strategies for Suboxone How to treat vaping
Info on juuling and other newer substances
Fellows
Faculty
Educational Topics requested
by survey participants (free text)
• Draft voiceover scripts and record training series
• Format videos and insert into online platform
Step 3
• Conduct 3-month follow-up survey to assess sustained knowledge & perceived behavior changes
• Analyze survey data
Step 5
AIM
1
AIM
2
Overall 1st Year
Fellows
2nd Year
Fellows Faculty
Participants
n (%)
28
(100%)
10
(35.7%)
10
(35.7%)
8
(28.6%)
In the past five years, have you spent time rotating through the following settings:
Adult Outpatient Addiction
Treatment
16
(57.1%)
7
(70.0%)
9
(90.0%)
0
(0.0%)
Adolescent Outpatient
Addiction Treatment
15
(53.6%)
5
(55.6%)
9
(90.0%)
1
(12.5%)
Inpatient
Addiction Treatment
14
(50.0%)
5
(62.5%)
5
(50.0%)
0
(0.0%)
Table 1: Demographics
Table 2: Attitudes & Perceived Skills
N= 28 Strongly
Disagree Disagree
Neither
Agree nor
Disagree
Agree Strongly
Agree
I prefer not to work with patients
with SUDs.
2
(7.1%)
10
(35.7%)
6
(21.4%)
8
(28.6%)
2
(7.1%)
I’m confident in my ability to treat
SUDs.
1
(3.6%)
12
(42.9%)
10
(35.7%)
3
(10.7%)
2
(7.1%)
I am comfortable prescribing
buprenorphine to adolescent
patients with OUD.
6
(21.4%)
14
(50.0%)
4
(14.3%)
2
(7.1%)
2
(7.1%)
I have a good understanding of
pain management.
2
(7.1%)
10
(35.7%)
8
(28.6%)
7
(25.0%)
1
(3.6%)
I am confident that I can navigate
the appropriate level of care for a
patient dealing with addiction.
0
(0.0%)
7
(25.0%)
4
(14.3%)
16
(57.1%)
1
(3.6%)
32%
78%
58%
of survey participants currently
have a buprenorphine waiver
of waivered physicians have
prescribed buprenorphine
of unwaivered physicians
would be interested in
obtaining a waiver
