5/24/2018

1

Troubleshooting MAT Integration

in Primary Care

John Bachman, PhD

Troubleshooting MAT Integration in Primary Care

Barriers:

Stigma: Widespread belief that drug-addicted people perpetrate their own problems; denies they are

victims of a chronic disease requiring treatment.

Sustainability: Many insurance plans deny or provide inadequate coverage for substance use

disorder treatment services. Payment rules prohibit reimbursement for necessary

services and additional staff.

Patients’ Complexity: Solo providers cannot adequately manage complex OUD and chronic

pain patients without RN case management, behavioral therapy &

support staff.

5/24/2018

2

Troubleshooting MAT Integration in Primary Care

Solutions:

EDCHC educating community partners

Judges, Law Enforcement Officers/Probation Staff, CPS Social Workers,

Jail and School Nurses, OB/GYNs

EDCHC and CA H&W are conducting a fiscal analysis of MAT costs vs cost savings from team-based care. Inpatient and pharmacy costs show the greatest preliminary reduction.

Team-based MAT care reduces burden of competing demands on primary care providers.

Behavioral assessment and therapy, case management, urine drug screenings & appointment monitoring are done by the Team for efficiency and lowered provider burnout.

Troubleshooting MAT Integration in Primary Care

MAT barriers exacerbate societal burden because ineffectively treated OUD patients:

● Die prematurely and spread blood-born infectious disease

● Over utilize EMS, ERs and are frequently (re)hospitalized

● Commit crimes, resulting in increased criminal justice system costs

● Have high rates of absenteeism from, and lower productivity, at work

● Drop out of school, disrupt families and/or become homeless

● Receive inadequate pre- and post-natal care and give birth to high risk newborns

5/24/2018

3

Not In My BackyardGuess what… It already is

Troubleshooting MAT Integration

A Leadership Approach to Treating

Opioid Use Disorder

Terri Stratton, MPH, CEO

Where We Began…Late 2015• Limited experience with Suboxone

• Grant Opportunity with CA HealthCare Foundation

• Must Have – Support from clinical leadership (Medical Director)

• Ah ha moment – We are already treating these patients

(review of data with local hospitals)

• Many complex care patients (pain and OUD)

• Recognition as New Tool in our Toolkit

5/24/2018

4

Building a MAT Team

• Taping Experts and Resources (Experts/Trainings/TA)

• Identify Team Positions:

• X-waivered providers – had 1; 2 others secured.

• LCSW (had)

• RN Case Manager – recruited,

• SUD Counselor – new, recruited

• MAs – trained

• Manager – part time FNP

Organizational Perspective What was our prescribing habits – what needed to change

Getting the following on board:

Providers

Patients – letter to all patients with policy

Staff

Board

Community partners/influencers

Enforcement of patient contract for opioid use

Development of policies/procedures/workflow for MAT

5/24/2018

5

Building Resources for SustainabilityFinancial

• CA HealthCare Foundation Implementation Grant

• HRSA AIMS Grant

• Hub and Spoke Grant

Professional/Emotional

• Moving patient stories

• Team support

• Partner recognition

• Community support

Christina Lasich, MD

Chief Medical Officer

5/24/2018

6

Community Health Center

Federally Qualified Health Center/ FQHC:

federally designated primary care delivery

system

Provide access to care regardless of

ability to pay

Meet health needs of community

Who we serve

Quality health care to all income levels

Scope includes uninsured, Medi-Cal,

Medicare, private and no insurance

Treat newborns to seniors

5/24/2018

7

Who we are

Nonprofit, community health center

Largest outpatient provider

in Nevada County

Sites: Grass Valley, CoRR, Downieville,

Auburn

Just opened in Penn Valley and Kings

Beach-Tahoe

What we do

One-stop health center: Grass Valley

5/24/2018

8

Services

Medical

Dental

Behavioral health with psychiatrist

Maternity with OB/GYN

Pediatrics

On-site lab

Pain and Addiction Medicine

Services

Nutrition

Diabetes education

Reduced cost prescriptions

Case managers

Care teams

Naloxone distribution for WSMC clients

5/24/2018

9

On-site Pharmacy

Urgent Care

5/24/2018

10

What is Medication-Assisted

Treatment for substance use disorder?

Combination of medication, counseling and

behavioral health for treatment of

substance use disorder

The prescribed medication operates to

stabilize brain chemistry, block euphoric

effects, relieve cravings and improve

function.

Which medications are used

for the MAT program at WSMC?

Buprenorphine

Naltrexone

Acamprosate

Disulfiram

Supportive medications: Gabapentin

Psychotropic medications such as SSRI’s, Depakote and Trazodone

Tizanidine

5/24/2018

11

What are the myths about

Buprenorphine?

Because it is a partial agonist, it isn’t a good analgesic

Has a ceiling effect for analgesia

Blocks other opioids, thus: Cannot be used peri-operatively

Blocks the potential lethal effects of other opioids like heroin

*Reference: cme.csam-asam.org:

Buprenorphine report by Andrea Rubinstein, MD

What are the facts about

gabapentin for alcoholism?

2013 study published in JAMA

Alcohol Use disorder treated with 900mg/day or 1800mg/day vs Placebo

Gabapentin Increased rate of abstinence

Gabapentin Reduced rate of heavy drinking

2013 Annuals of Pharmacotherapy

RC/DB Gabapentin vs chlordiazepoxide for managing withdrawal symptoms

1200 mg of gabapentin for three days followed by a three day taper resulted in less sedation and less cravings than those that took chlordiazepoxide for same amount of time.

Selection criteria of no history of seizures and/or kindling

5/24/2018

12

What are the available counseling

& behavioral health treatments?

On-site substance use disorder counselor for

on-demand assessments and treatment

WSMC Behavioral Health Dept.

Licensed Clinical Social Workers

What are the available counseling

& behavioral health treatments?

Community Partners: Community Recovery

Resources (CoRR), 12 step meetings,

Celebrate Recovery, Common Goals

5/24/2018

13

Who is appropriate for an

Outpatient MAT program?

Dependency to substances of abuse: opioids, alcohol, and/or benzodiazepines

Medically stable

Mentally stable

Ready for change

No potential for harm to self or others

Safe living environment

ASAM’s treatment criteria uses six

dimensions for assessmentAcute intoxication or

Withdrawal Potential

Exploring an individual’s

past or current experiences

of use and/or withdrawals

Biomedical

Conditions and

complications

Exploring an individual’s

health history and current

condition

Emotional, Behavioral,

or Cognitive Condition

Exploring an individual’s

thoughts, emotions, and

mental health issues

Readiness for Change Exploring an individual’s

readiness or interest in

changing

Relapse, Continued

Use, or Continued

Problem Potential

Exploring an individual’s

unique relationship with

relapse or continued use

Recovery/Living

Environment

Exploring an individual’s

recovery or living situation,

and surrounding people

5/24/2018

14

Special patient populations

that may benefit from MAT service

Chronic pain

Co-occurring disorders

Pregnant women

Polysubstance use

Methadone dependency

Naloxone distribution

at Western Sierra Medical Clinic

California law

Nasal Naloxone

Team approach

Target at-risk populations

High doses or rotating opioids

Recent overdose

Recent release from detoxification or incarceration

5/24/2018

15

Goals of Naloxone distribution for

WSMC patients

Opioid-overdose death prevention

Education about safe opioid use

and storage

Prevention and screening for

substance use disorders

All patients at WSMC will be screened

annually for SUD

All patients receiving controlled

substances are randomly screened with

UDT and regularly checked on PDMP

Youth outreach and prevention Program

to target disease onset

5/24/2018

16

How do we measure

success in our MAT program?

Reduction of dysfunction

Improved birth outcomes

Reduction in SUD-related deaths

Healthy Families= Healthy Community

Better Health Together

christinal@WSMCmed.org

5/24/2018

17

Christina Lasich, MD

Chief Medical Officer

What happens when pain and addiction collide?

5/24/2018

18

Case of Opioid PLUS Benzodiazepine Dependency

53 year old woman with lumbar pain following lumbar discectomy with laminectomy presents to you because of worsening pain and to establish care. She is currently taking hydrocodone/APAP 10/325 tablet every 4 hours (6/day) and has been taking it for over 5 years. Two years ago she began taking alprazolam 0.5mg three times per day for anxiety as prescribed by previous primary provider. She is also using zolpidem 10mg at bedtime. Her CURES report shows that hydrocodone is frequently filled a week early. Her urine drug test is consistent accept for positive test result for oxazepam. When questioned, she admits to using a friends diazepam when she ran short of her medications. Her pain has been a 9/10 lately and she is feeling depressed.

How do you Open up a conversation or Broach the subject of chemical dependency???

5/24/2018

19

What are you able to do now with the use of

opioids that you were not able to do before?

• Sleep better

• Return to work

• Resume activities of enjoyment

• Play with children

• Exercise

STAGE 5

Begin a slow TAPER:5

STAGE 4

Step through the doorway of

HEALTH:

4

STAGE 3

Introduce OTHER SOLUTIONS

for pain:

3

STAGE 2

Promote Chemical STABILITY2

STAGE 1

Motivate the patient for

CHANGE

1

Pain and Chemical Dependency

Roller-Coaster

Step-wise Solution

5/24/2018

20

Neutralize the Nervous System

The Neutralizing Medications: “calm the nerves”

• Beyond Gabapentin is Zonisamide, Topiramate, Tiagabine

and Pregabalin

• TCA= Tricyclic Analgesics (amitriptyline, imipramine,

desipramine)

• Baclofen, a muscle relaxant and NMDA antagonist

STAGE 5

Begin a slow TAPER:5

STAGE 4

Step through the doorway of

HEALTH:

4

STAGE 3

Introduce OTHER SOLUTIONS

for pain:

3

STAGE 2

Promote Chemical STABILITY2

STAGE 1

Motivate the patient for

CHANGE

1

Pain and Chemical Dependency

Roller-Coaster

Step-wise Solution

5/24/2018

21

Anti-Inflammatory Diet

STAGE 5

Begin a slow TAPER:5

STAGE 4

Step through the doorway of

HEALTH:

4

STAGE 3

Introduce OTHER SOLUTIONS

for pain:

3

STAGE 2

Promote Chemical STABILITY2

STAGE 1

Motivate the patient for

CHANGE

1

Pain and Chemical Dependency

Roller-Coaster

Step-wise Solution

5/24/2018

22

What happens when pain and addiction collide?

Pain is a physiological experience,

Suffering is a perception

Suffering is created by the way we think

about time, threats, meanings,

circumstances and stories

5/24/2018

23

How can You Ease Suffering in Your Patient?

• Encourage patients to anchor into the moment instead of

using the past as a source of comparison and the future as

a source of worry

• Help patients to develop outlets for frustration like hobbies

and exercise

• Reframe the story as a story of survivorship and strength

• Be present for your patient

Pain and Addiction are doorways to TRANSFORMATION

5/24/2018

24

Better Health Together….

WSMCmed.org