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TRANSCRIPT
MEDICATION ASSISTED TREATMENT
COMMUNITY OF PRACTICE
Inducting Patients onto Buprenorphine
Presentation & Discussion
June 21, 2018
Disclosures
No individuals in a position to control
content for this activity has any relevant
financial relationships to declare.
WELCOME
Purpose of MAT CoP
To promote and support the successful implementation
of an integrated MAT approach in healthcare settings.
MAT CoP Resources
• MAT Google Group To join discussions about MAT program development, email Rekha Sreedhara at
[email protected] or Rebecca Sky at [email protected].
• Resources & Tools Resources to support implementation of MAT programs can be accessed on the
Center for Excellence website:
http://nhcenterforexcellence.org/resources/community-of-practice-resources/
• MAT Technical Assistance Submit requests to the Center for Excellence:
http://nhcenterforexcellence.org/center-services/request-ta/
Objectives
1. Describe protocols and tools to conduct home and office buprenorphine inductions;
2. Compare buprenorphine induction protocols and processes used by prescribers based on patient situation; and
3. Apply learned information to determine induction processes that may be most appropriate to use depending on patient situation.
Goals of Discussion Review what induction onto
buprenorphine is… Discuss the evidence around strategies
and outcomes
Explore situations involving induction
Review some tools to assist with induction
“Induction issues were among the top issue for contacts to the PCSS-B” 2010
Lack of understanding regarding MAT
Stigma around the disease of addiction
Logistics: barrier to treatment for busy offices
Goal is to minimize complications and
Create basis for successful treatment
Pharmacodynamics of Buprenorphine
High Affinity for mu opioid receptors
TIP 63: Medications for Opioid Use Disorder;Pub No SMA 18 5063. SAMHSA 2018
Clinical Opiate Withdrawal Scale
(COWS)
5-12 mild
13-24 moderate
25-36 mod severe
>36 severe
Scoring
Typical/Textbook
Abstain from opioid use Short Acting
Long Acting
Precipitated Withdrawal
Usually occurs within the first 1-2 hours after buprenorphine is taken
Nausea and Vomiting
Anxiety
Aches/Pain
Supportive Treatment ~ w/d sx tx OR/AND
Give more buprenorphine
Side Effects
Headache
Nausea
Diaphoresis
Lower extremity swelling
Constipation
Sleep disturbance
Anxiety
Textbook
Patient presents in withdrawal
Brings previously prescribed rx ~ Bup/Nlx 4/1 mg or 8/2 mg film
Perform stat urine drug test
Document COWS of at least 8 (AAAP) 10-12 (MER)
Observe patient self administration of film
Recheck 20-30 min; have patient wait for 1-2 hours
Instructions for home
Dose based on total dose of day #1.
Revisit or phone call
Follow up face to face 1 week
Predictors of Engagement
100 Patients
18 days to induction
Only 40% made it to induction
Neg Predictors:
polysub use,
previous tx history
Conclusions: Need enhanced support
Simon, C Linking Partients with buprenorphine treatment in primary care: Predictors of engagement Drug and Alcohol Dependence Dec 1, 2017 Vol 181 p58-62
Intake RN Visit Provider
visit
Home Induction
Unobserved induction:
Primary care as connection
Less stigmatizing
Reduce the burden for office space and
staff
And, but… FDA bup labeling specifies supervised induction
Initiate with monoproduct
Suboxone® got indication for supervised induction
SAMHSA: TIP 40 and CSAT: (VA) guidelines note importance of inducing patients when documented in w/d
2014 Systematic Review
Studies
Feasibility
Acceptability
Safety
Effectiveness
Outcomes Looked at:
Rates and methods of unobserved induction
Induction related adverse events
Retention: 1 week and longer
Other Clinical: urine drug findings
Lee, J et al., Unobserved “Home” Induction Onto Buprenorphine J Addiction Med Volume 8, No 5, Sept/Oct 2014 pp299-306.
Findings
Few studies
Insufficient evidence supporting unobserved induction as more, less or as effective as observed induction
“The predominantly observational and naturalistic studies of unobserved induction reviewed, all of which have significant sources of bias and limited external validity, document feasibility and low rates of adverse events”
Not your typical textbook
NYC Public Hospital Primary Care office: 2006-2013
“Low Threshold OBOT”
Typical provider visits
Screening/diagnosis
Unobserved Inductions
Pamphlet and telephone support
Weekly follow up
No additional psychosocial counseling requirements
Bhatraju, E, et al Public Sector Low Threshold office based buprenorphinetreatment:Outcomes at year 7; Addiction Sci Clin Practice 2017; 12:7
Findings of “Low Threshold OBOT”
Treatment retention: 38 weeks
Older age, baseline heroin abstinence, later years of study (v 2006/7)
Not Dependent
OBSERVED DOSING RECOMMENDED
1 mg daily with increase by 1 mg per day per week up to 4 mg
Increase by 2 mg per day per week to 8 mg
Can increase gradually from there and use symptoms of craving and urine drug testing finding
SO…
Unobserved induction is:
Feasible
Some evidence that: “no difference in adverse outcomes”
Insufficient/weak evidence of differences in overall effectiveness
Treatment retention
Medication adherence
Opioid abstinence
Scenario 1:
Patient seen in office and determined to meet criteria for: OUD, OBOT, has agreed to office terms
Opioid use was ‘heroin’ 1-2 g IV daily
Patient returns: has not used opioids for >12 hours
Brings in rx of 2 buprenorphine/nlx films 8/2 mg
COWS = 10 (anxious, sweaty, pupillary dilation, mm aches, hr = 90)
Have him take 4/1 mg SL and let saliva pool in mouth
Scenario 2: Patient seen in office and determined to meet
criteria for: OUD, OBOT, has agreed to office terms
Opioid use was ‘heroin’ 1-2 g IV daily
States last used opioids 6 hours prior to visit
COWS = 6 (anxious, not sweaty, no pupillary dilation, c/o mm aches, hr = 74)
Plan home induction with specific instructions
Rx for 2 bup/nlx films 8/2 mg: ½ film at time of moderate SOWS; may repeat after 1-2 hours; may repeat after 2 hours
Call/revisit with provider or coordinating RN
Scenario 3: Patient seen in office and determined to meet
criteria for: OUD, OBOT, has agreed to office terms
Taking between 2 and 8 mg subutex daily (street)
States last used subutex 1 hour prior to visit
COWS = 4 (anxious, not sweaty, no pupillary dilation, c/o mm aches, hr = 74)
Plan home induction with specific instructions
Rx for 2 bup/nlx films 4/1 mg take ONE daily SL
Could plan to have them return to witness taking med
Could plan to call in am and see on day 2 or 3
Conclusion
Home induction described in guidelines
Unobserved induction is feasible
Comfort levels (and probably staff) will dictate plan
Most important tenet is to follow physiology of body
Vocci, Frank J. et al. “Buprenorphine Dose Induction in Non-Opioid-Tolerant Pre-Release Prisoners.” Drug and alcohol dependence 156 (2015): 133–138. PMC. Web. 3 June 2018. Simon, C. et al., Linking patients with buprenorphine in primary care: Predictors Of engagement Drug and Alcohol Depenedence December 1, 2017 vol 181 p 58-62 The National Practice Guideline to the Use of Medications in the Treatment of Addiction involving Opioid Use. ASAM May 27, 2015 pp72, 86
Discussion: Inducting Patients onto Buprenorphine
Describe a few situations you have
experienced that do not fit text book
induction protocol.
What advice would you give to MAT
programs related to inducting patients
onto buprenorphine?
Patient Scenarios:
Inducting Patients onto Buprenorphine
In small groups…
Review and discuss cases that illustrate induction strategies.
4 patient scenarios - Each of these cases is of someone who meets criteria for OUD by DSM.
10 minutes per scenario
LARGE GROUP
DISCUSSION
Highest responses received:
– MAT Care Teams
– Screening/Assessment
– Care Coordination
– Harm Reduction Strategies
What questions do you have related to
these topics (or any others) that we can
address in an upcoming session?
Future Topics
CoP Meetings
Meeting schedule TBD
Continuing Education Credits
• 2 CEUs and CNEs available.
• A completed evaluation survey is required
for those who want to receive credits.
• First two pages of evaluation survey is
required of all other participants.
REKHA SREEDHARA, MPH ANNA GHOSH, MPH
[email protected] [email protected]
REBECCA SKY, MPH ALLISON PIERSALL, BS
[email protected] [email protected]
SANDRA KIPLAGAT, MS MOLLY ROSSIGNOL, DO FAAFP FASAM
[email protected] [email protected]
PETER MASON, MD REGINA FLYNN, BS
[email protected] [email protected]
LINDY KELLER, MLADC