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ACCESSTOMEDICATIONASSISTEDTREATMENTUSINGNURSECARE

MANAGERS

ColleenTLaBelleMSN,RN-BC,CARNBostonUniversityMedicalCenterProgramDirectorSTATEOBOT

DISCLOSURE

Thespeakersandplannersofthiswebinarhavenorelevantfinancialrela6onshipstodisclose

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TheAddicHonCrisis

•  Prolongedsubstanceusecausesneurochemicalandmolecularchangesinthebrain,whichalter1:

o  MetabolicbrainacHvity

o  Geneexpression

o  Receptoravailability

o  SensiHvitytoenvironmentalcues

Effects of Heroin Dependence on Brain Dopamine D2 Receptors2

1.  Leshner AI. Science. 1997;278:45-47. 2.  Wang GJ et al. Neuropsychopharmacology. 1997;16:174-182.

Addic%on is a Treatable Brain Disease

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OpioidDetoxifica.onOutcomes

•  LowratesofretenHonintreatment•  Highratesofrelapsepost-treatment

§ <50%absHnentat6months§ <15%absHnentat12months§ Increasedratesofoverdoseduetodecreasedtolerance

O’Connor PG JAMA 2005 Mattick RP, Hall WD. Lancet 1996 Stimmel B et al. JAMA 1977

Medica.onAssistedTreatment

•  Goals•  Alleviatephysicalwithdrawal•  Opioidblockade•  Alleviatedrugcraving•  Normalizedderangedbrainchangesandphysiology

•  SomeopHons•  Naltrexone(opioidantagonist)• Methadone(fullopioidagonist)•  Buprenorphine(parHalopioidagonist)

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34,140BUPRENORPHINEWAIVEREDPHYSICIANSASOFNOV2015

220

113

111

Source:CenterforSubstanceAbuseTreatment,SubstanceAbuseandMentalHealthServicesAdministraHon.2015.

BARRIERSTOPRESCRIBINGBUPRENORPHINEINOFFICE-BASEDSETTINGS

[VALUE]%[VALUE]%

[VALUE]%[VALUE]%

[VALUE]%[VALUE]%[VALUE]%[VALUE]%[VALUE]%

InsufficientPhysicianKnowledgeOfficeStaffSHgma

LowDemandPharmacyIssues

InsufficientStaffKnowledgeInsufficientInsHtuHonalSupport

PaymentIssuesInsufficientOfficeSupport

InsufficientNursingSupport

55%ofwaiveredproviders

reported1ormorebarriers

Source:Walleyetal.JGenInternMed.2008;23(9):1393-1398.

N=156waiveredphysicians;66%responserateamongallwaiveredinMAasof10/2005

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ONLYDEAWAIVEREDPHYSICIANSCANPRESCRIBE

BUPRENORPHINE.(NOTFORLONG!!!!)

HOWEVER…

…ITTAKESAMULTIDISCIPLINARYTEAMAPPROACHFOREFFECTIVE

TREATMENT.

DrugAddicHonTreatmentAct(DATA)2000

v AmendmenttotheControlledSubstancesActv AllowsphysiciantoprescribenarcoHcdrugsscheduledIII,IVorV,FDAapprovedforopioidmaintenanceordetoxificaHontreatment§ Prior10/2002nodrugexisted§ Methadonedoesnotqualify

ANewLaw

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DATA2000:PhysicianIni.ally…SoonNPandPA’s

v MD’s:licensedtopracHcebyhis/herstatev Havethecapacitytoreferforpsychosocialtreatmentv LimitnumberofpaHentsreceivingbuprenorphineto30paHentsforatleastthefirstyear,filetoincreasein1year

v Canapplyfornewwaiver;expandto275paHentsifaddicHoncerHfiedandworkinmedicalsenngsfor24hourservices

v CARA:NPandPAwillbeallowedtoprescribewith24hourstraining(8whichincludeswaivercourse)v CURESAct:FundingforCARAImplementaHonv SAMHSA:Definingthetrainingrequirements

BUPRENORPHINE

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100

90

80

70

60

50

40

30

20

100

-10-9-8-7-6-5-4

%Efficacy

LogDoseofOpioid

FullAgonistMethadone

Par.alAgonistBuprenorphine

FullAntagonistNaltrexone

Opioideffect,

seda.on,respiratorydepression

OpioidPotency

Dr.LauraMcNicholas

OBAT

BMC’SOFFICEBASEDADDICTIONTREATMENT(OBAT)MODEL

¡ CollaboraHveCare/NurseCareManagerModeldevelopedatBostonMedicalCenter(BMC)

§ Nursecaremanagers(NCMs)workwithphysicianstodeliveroutpaHentaddicHontreatmentwithbuprenorphineandinjectablenaltrexone

¡ Morerecentlydubbedthe“MassachuseqsModel”

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Arch Intern Med. 2011;171:425-431.

BMC’SNCMOBATMODEL:5-YEAREXPERIENCE

¡ PaHent-leveloutcomescomparabletophysician-centeredapproaches

¡ EfficientuseofphysicianHmeallowsfocusonpaHentmanagement(e.g.,doseadjustments,maintenancevstaper)

¡ ImprovedaccesstoOBATanddailymanagementofcomplexpsychosocialneeds(e.g.,housing,employment,healthinsurance)

¡ OpencommunicaHonbetweenNCMandotherprovidersincludingbehavioralhealthimprovecompliance

Source:Alfordetal.ArchInternMed.2011;171:425-431.

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J Subst Abuse Treat. 2016;60:6-13.

0 1000 2000 3000 4000 5000 6000 7000 8000 9000

2007 2008 2009 2010 2011 2012 2013 2014

PATIENTSRECEIVINGBUPRENORPHINEINSTATEOBATCHCSBYYEAR

Between2007-2014>8,000pa.entstreatedwith

buprenorphineusingNCMmodelin14fundedCHCs

Source:LaBelleetal.JSubstAbuseTreat.2016;60:6-13.

No.ofp

a.en

tstreatedw/Rx

forO

UD

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1.53

1.17 1.17 1.24

0.580.69 0.65 0.67

0.54 0.55 0.62 0.61

2008 2009 2010 2011Prior6Months Future6Months Future7-12Months

AVERAGENO.EDVISITSPERSTATEOBATENROLLMENT:2008-2011

Source:OfficeofDataAnalyHcsandDecisionSupport,Bureauo5SubstanceAbuseServices,MADepartmentofPublicHealth.2014

AVERAGENO.HOSPITALADMISSIONSPERSTATEOBATENROLLMENT:2008-2011

0.260.23

0.2

0.26

0.1 0.1 0.09 0.10.12 0.12 0.12

0.08

2008 2009 2010 2011Prior6Months Future6Months Future7-12Months

Source:OfficeofDataAnalyHcsandDecisionSupport,BureauofSubstanceAbuseServices,MADepartmentofPublicHealth.2014

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STATEOBATINITIATIVEINCHCS:PROJECTGOALS

Expandtreatment&accesstobuprenorphineACCESS

•  IncreasenumberofwaiveredMDs•  IncreasenumberofindividualstreatedforopioidaddicHon•  IntegrateaddicHontreatmentintoprimarycaresenngs

Effec.vedeliverymodelforbuprenorphineDELIVERY

• ModeledauerBMC’sNurseCareManagerProgram• Focusonhighriskareas,underservedpopulaHons

Post-programfundingSUSTAINABILITY

• Developalong-termviablefundingplan• Collect&analyzeoutcomesdata

TECHNICAL ASSISTANCE AND TRAINING PROVIDED TO CHCS

¡  NCM Orientation §  Bupe 101: 8 hr training on SUDs and OBAT model (RNs, MAs, SWs)

¡  Initial on-site TA §  Addiction 101: all staff training on OBAT and disease model of addiction §  Meetings with key members of care team (RN, MDs, Mas) §  Special-topic trainings: stigma, special populations, etc.

¡  Ongoing provider support (nurses and waivered providers) §  Provided via telephone, email or on-site visits §  Address issues such as: MD or nurse leaving, practice closures, clinical

questions (e.g., transfers, surgery, pregnancy, administrative issues, linkage to other treatment options, insurance changes, prior authorizations, etc.)

¡  Quarterly provider meeting §  Opportunity for further education, networking, support

¡  Maintain list server for addiction providers §  Relevant research, news articles, patient resources, group discussions, new

clinical guidelines, regulatory issues, job postings, etc.

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INSUMMARY,EXPANSIONOFBMC’SNCMOBATMODELACROSSMAHAS…

¡ Expandedtreatment§ >10,000paHentstreatedthroughSTATEOBATsince2007§ TreatmentavailableinpaHents’communiHes

¡ Developedasustainablereimbursementmodel§ FQHCs§ Insurance

¡ ImplementedevidencebasedtreatmentforSUDsandbestpracHcesasthestandardofcare

¡ SupportedandengagedCHCprovidersandstafftotreatSUDs§ ReducedsHgma

BMC’SNURSECAREMANAGER(NCM)OBATMODEL

Training• RegisteredNurses• 1-daytraininginaddicHonandtreatmentofSUDs

Fidelity

• PerformpaHenteducaHon&clinicalcarefollowingtreatmentprotocols

• Maintaincompliancewithfederallaws

Collabora.on

• CoordinatecarewithOBATphysicians• Collaboratecarewithpharmacists(refillsmanagement)• Off-sitecounselingservices

Addi.onalServices

• Urgentcaredrop-inhours• Manageinsuranceissues(priorauthorizaHons)

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NCMsincreasepa:entaccesstotreatment!¡ Frequentfollow-ups¡ Casemanagement¡ Abletoaddress

§ posiHveurines§ insuranceissues§ prescripHon/pharmacyissues

¡ Pregnancy,acutepain,surgery,injury¡ Concreteservicesupport

§ Intensivetreatment,legal/socialissues,safety,housing¡ Briefcounseling,socialsupport,paHentnavigaHon¡ Supportproviderswithlargecaseloads

WHATMAKESTHEBMCNCMOBATMODELSUCCESSFUL

BMCOBOTbecameknownasMassachusefsModelofOBOT

v ProgramCoordinatorintakecall

§  ScreensthepaHentoverthetelephone§  OBOTTeamreviewsthecaseforappropriateness

v NCMandprescriberassessments

§  NursedoesiniHalintakevisitandcollectsdata§  Prescriber:PE,andassessesappropriateness,DSMcriteriaofopioidusedisorder

v NCMsupervisedinducHon(on-site)andmanagedstabilizaHon(on-andoff-site(byphone))

§  FollowsprotocolwithpaHentselfadministeringmedicaHonperprescripHon

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NurseCareManagers(NCM)

v Registerednurses,completed1daybuprenorphinetrainingv PerformedpaHenteducaHonandclinicalcarebyfollowingtreatmentprotocols(e.g.,UDT,pillcounts,periopmgnt)

v Ensuredcompliancewithfederallawsv CoordinatedcarewithOBOTprescribersv Collaboratedcarewithpharmacists(refillsmanagement)andoff-sitecounselingservices

v Drop-inhoursforurgentcareissuesv Managedallinsuranceissues(e.g.,priorauthorizaHons)v OnaverageeachNCMsaw75paHents/wk

MassachusefsModelofOBOT

v MaintenancetreatmentpaHentincare(atleast6months)

§ NCMvisitsweeklyfor4-6wks,thenq2wks,thenq1-3monthsandasneeded

§ OBOTprescribervisitsatleastevery4months

v MedicallysupervisedwithdrawalconsideredbasedonstabilityifthepaHentrequestedtotaper

v TransferredtomethadoneifconHnuedillicitdruguseorneedformorestructuredcare

v Dischargedhigherlevelofcareforunsafebehavior

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Conclusionsv PaHent-leveloutcomescomparabletophysician-centeredapproaches

v AllowsefficientuseofproviderHmetofocusonpaHentmanagement(e.g.,doseadjustments,maintenancevs.taper)§  Allowedprescribertomanaged>numbersofpaHentsduetosupportofNCM

Alford DP, LaBelle CT, Kretsch N, et al. Arch Int Med. 2011;171:425-431.

v ImprovedaccesstoOBOTanddailymanagementofcomplexpsychosocialneeds(e.g.,housing,employment,healthinsurance)

TASupportv Nursingtrainingandongoingsupport

§  Phone,email,sitevisits,chartreviews§  QuarterlystatewideNCMmeeHngs:−  addicHoneducaHon,support,networking

v Sitesupport:§  EducaHonallproviders−  Trainings:addicHon,buprenorphine,sHgma,management,

setup§  SupportpracHce:providersandnursingissues§  CareforortriagepaHentstoothersitesduetoclosures,staffchanges,emergencyissues

§  DEASupport:EducaHonandpreparaHon,supportatvisits§ Waiverassistance,insurancesupport,coverage,carrierissues

MA Department of Public Health Bureau of Substance Abuse Services 2007

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UMassStudyFindingsinMassachusefs

v Studied5,600MassHealthClientsprescribedbuprenorphineandmethadone(2003-2007)

v OverallMassHealthexpenditureslowerthanforthosewithnotreatment

v ClientsonMedicaHonshadsignificantlylowerratesofrelapse,hospitalizaHonsandEDvisits:nomorecostlythanothertreatments

v BuprenorphineaqracHngyoungerandnewerclientstotreatment

Clark RE, Samnaliev M, Baxter JD, Leung GY. Health Aff. 2011;30:1425-1433.

OBOTRNNursingAssessment:

v Intakeassessment

§  Reviewmedicalhx,treatmenthx,painissues,mentalhealth,currentuse,andmedicaHons

v Consents/Treatmentagreements§  ProgramexpectaHons:visits&frequency,UDT,behavior§  UnderstandingofmedicaHon:opioid,potenHalforwithdrawal§  Review,sign,copiestopaHentandreviewatlaterdate

v EducaHon§  OnthemedicaHon(opioid),administraHon,storage,safety,responsibiliHesandtreatmentplan

v UDTv LFTs,HepaHHsserologies,RPR,CBC,pregnancytest

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Patient Agreement

Set the stage for ongoing relationship Clear message about rules Patient involvement Behavior is part of treatment

OBOTRNInduc.onPrepara.on:

Reviewtherequirementsprogram:

v Nurse/PrescriberAppointments:§  frequency,Hmes,locaHon

v Counseling:§  weeklyiniHally

v UrineDrugToxicology:§  atvisits,callbacks

v AbsHnence:§  fromopioidsisthegoal

v InsuranceverificaHon:§  priorauthorizaHons,co-pays

v Safety:§  medicaHonstorage(bankbag)

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OBOTTeamPa.entinstruc.onsforinduc.onday:

v InsuranceverificaHon§  PriorauthorizaHons,co-pays

v Disposeofparaphernalia,phonenumbers,contacts

v MedicaHonpickup:2mg/8mgtabs

v Nodrivingfor24hoursv Plantobeatclinicorofficefor2-4hours

v Bringasupportpersonifpossiblev DiscusspotenHalsideeffects(e.g.precipitatedwithdrawal)

OBOTPrescriber

v Reviewofhistory§ Mentalhealth,substanceuse,medical,social

v PhysicalExamv Labandurinetoxicologyresults

§  AssesscontraindicaHonsv Confirmopioidusedisorderdiagnosis

§  DSMVcriteriav Confirmappropriateforofficetreatmentv SignsordersandprescripHonv DeveloptreatmentplanwithOBOTteam

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OBOTRN,PrescriberPlanningforInduc.on:

v AskingpaHenttoshowupinwithdrawalrequiresagreatdealofTRUST

v BuildarelaHonship:Support

v ReviewwithpaHentaheadofHmeusagehistory,withdrawalandmakeaplan

v Wriqenmaterials,ongoingeducaHon

v Emergencyandcontactnumbers

OBOTRNsIni.aldosebuprenorphine

v COWs>8-12v ObjecHvesignsarekeytomakingdxv Ask:WhattheylastUsedandWhen

v Startwith2-4mgslv Assess40min-1hourauerdosing

§  Beqer,worse,orthesamev Repeatdoseof2mg,assess1hour

§  SendhomewithinstrucHonstocallRN

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OBOTRNPa.entinstruc.onsduringfirstdose:

v Puttablet(s)filmundertongue(sublingual)orbuccalmucosa

v Don’ttalk,don’tswallow:salivapools

v Mayusemirror,watchthetablet(s)graduallyshrinkassistswithposiHoning's

v Don’tdrinkorsmokebeforeorimmediatelyauer

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OBOTRNFrequencyofVisits:

v Phonecontactdaily,ordailyvisitsforfirstfewdays,assessindividualneeds

v AtleastweeklyunHlstabilized(usually4-6weeks)

§ dosage,UDT,counseling

v Progresstoeverytwoweeks,monthly,random,q3-4months

OBOTRNComfortMeasures

v Tasteperversionv Headachesv Nauseav SweaHngv Insomnia•  Morecommonwithmethadonetransfers

Consult with OBOT Prescriber as needed

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OBOTRN/PrescriberPrescrip.ons

v EarlyOn:§  SmallprescripHons1weekwithrefills§  IncreaseaspaHentstabilizes(UDT)§  2weekprescripHonswithrefills(cancelPRN)

v AtpointofstabilizaHon:§ Monthlyvisits§ MonthlyprescripHonswithrefills

v Keepfileofpharmacycontactinfo§  Pharmacistpartoftreatmentteam

OBOTRNFollowupVisits:

v Assessdose,frequency,cravings,withdrawalv OngoingeducaHon:dosing,sideeffects,interacHons,support.v Counseling,selfhelpcheckinv PsychiatricevaluaHonandfollowupasneededv Medicalissues:vaccines,followup,treatmentHIV,HCV,engageincare

v AssistwithpreparingprescripHonsv FacilitaHngpriorapprovalsandpharmacyv Pregnancy:ifpregnantengageinappropriatecarev Socialsupports:housing,job,family,friends..stability

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OBOTTeamMonitoring

v UDTv Pill/Filmcounts??v PharmacyCheck-inv ObservedDosingv Randomcallbacksv Scheduledvisitsv Counselingcheckinv Checkinwithsupport/family/parent/partnerv Socialstability

•  Balance clinical safety and risk of diversion vs. concerns of overburdening patient unnecessarily

•  Induction or early maintenance period relatively small amounts: next clinical visit

•  Rationale/protocol prescribing interval should be documented EMR

MISUSEDIVERSIONCONCERNS

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§  UDT is important initial comprehensive evaluation §  Compliance with prescribed MAT (methadone or

buprenorphine) can be monitored §  Use of other opioids, substances can be detected and treatment plan

adjusted accordingly •  Results of urine drug testing and rationale for frequency of testing should

be documented in the medical record •  Self-report often insufficient to determine status of substance use •  Other clinical characteristics, e.g., social and occupational functioning,

external contingencies, should be considered when determining urine drug testing frequency

•  Inappropriately burdensome testing may damage therapeutic alliance §  Patients may interpret excessive demands for testing as not being

trusted or believed

URINEDRUGSCREENING

•  Track of medication supply in EMR •  Obtain urine toxicology screens

§  Absence of buprenorphine in urine •  Involve family if appropriate to monitor medication supply •  Emphasize adherence not on “as needed” basis •  Discuss safe storage and not advertising/sharing medications

with others •  Clinical follow up •  Call backs/check in’s as needed •  Transfer: Risk outweighs the benefit

MISUSERISKREDUCTIONSTRATEGIES

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•  May divert all or some of medication money, drugs •  Dose of buprenorphine narcotic blockage

§  Patients can lower maintenance dose below that of prescribed dose and divert “extra”

•  Signs of misuse or diversion include: §  Repeated lost prescriptions §  Discordant pill count §  Multiple prescribers: PMP

•  Beware of misinterpreting pseudoaddiction §  Patients maybe fearful of disruptions in medication

supply and resultant opioid withdrawal

DIVERSIONCONCERNS

OBOTRNRandomCallBacks

•  Urinetoxicologyscreen•  Pillcount•  Observeddosing•  PharmacyconfirmaHon•  PrescripHonMonitoringProgramReview•  Requestwhentobringpillsin,nottoeachvisitdueto

medicaHonsafety

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OBOTTeamMonitoring:Pharmacy

•  ImportantCollaboraHon•  IdenHfyonepharmacyforallmeds•  Keeprecord:Name,number,address,faxonfile•  Obtainrefillhistory:PrescripHonMonitoringProgram

§  Othercontrolsandprescribers•  RefillsallowedonScheduledIII•  Pharmacyalertsyouto:

§  Othermeds§  Earlyrefillrequests§  Behaviorissues

PaHentSafetyEducaHon

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ClinicalPathwayReview

Maintenancesummary:

•  Expectstability•  Expectimprovementindruguse,employment,criminality,

socialsupports•  Counselingengagement•  IfnotabsHnent,evaluateprogressintreatment:

§  evaluateneedchangeintreatmentplan§  higherlevelofcare

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LengthofTreatment

•  Lengthoftreatment:WeaskpaHentstocommitto6monthsonbuprenorphine/naloxoneandthenreassess

•  PaHentsshouldbeacHvelyinvolvedindevelopmentoftreatmentplan

•  Everyoneisdifferent:NeedtomeetpaHentswheretheyareat§  Individualizetreatment§  Howlong…LongEnought

DischargeOp.onsfromOBOT

•  Buprenorphinenotthe“miracledrug”

ItisaTool………..

•  Establishlinkageswithprograms

•  Assistwithdetoxadmission§  Ongoingtreatment:holding,residenHal

•  TransfertoMethadoneMaintenance§  ShortorLongtermopHon

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NextSteps

v UHlizingnursecaremanagermodelstoexpandtreatmenttomoresites

v IncreaselevelofeducaHonamongprovidersinaddicHontreatment§  Nurses,doctors,supportstaff,and

administraHon

v Integrateintothemedicalhomemodelofcare

v ExamineandimproveretenHonandsustainabilityv ACOmodel:prevenHon

Trea.ngthe“Whole”Person

•  ComprehensiveaqenHontoallmedicalandpsychosocialco-morbidiHes;

•  Pharmacotherapyrarelyachieveslong-termsuccesswithoutconcurrentpsycho-social,behavioraltherapiesandsocialservices;

•  SpecialaqenHontothoseatriskofmisusingtheirmedicaHonsorwhoselivingarrangementsposeincreasedriskformisuseordiversion;

•  IndividualizeTreatment………….•  NoOnesizefitsall

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THANKYOUFORYOURTIMEANDATTENTION

COLLEENLABELLECOLLEEN.LABELLE@BMC.ORG