Embed Size (px)
Citation preview
If not us, who?The case for treating addiction in primary care
September 2019Community Care Network of Kansas Annual Conference
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?
