Jerry Cochran, MSW, PhD University of Utah School of Medicine Department of Internal Medicine Department of Psychiatry

Transcription

1 Jerry Cochran, MSW, PhD University of Utah School of Medicine Department of Internal Medicine Department of Psychiatry

2 Acknowledgements Funding for this work has come from: The Staunton Farm Foundation The University of Pittsburgh National Institute on Drug Abuse

3 Rate Rate Background Neonatal abstinence syndrome (NAS) incidence rates per 1,000 hospital births Utah: 5 Fold Increase Past Year Non medical Use of Prescription Pain Relievers, Utah Source: MMWR years years 26+ years Source: UDHS

4 Background Most people who need Tx for SUD do not receive it

5 Background Not enough providers and specialty programs

6 So, what is the solution?

7 Developing Evidence to Support Service Delivery 4 studies 1. Survey of pharmacists in 2 states 2. Survey of community pharmacy patients in SW PA 3. Intervention development 4. Pilot study Next steps

8 Study 1: Survey of pharmacists in 2 states This pilot survey: Examined pharmacists attitudes and interests toward delivering SBI for opioid misuse Compared views of pharmacists in Utah (one of the most severe states in the US) and Texas (a state with a low but increasing problem).

9 Methods Cross-sectional exploratory survey Licensed pharmacists from Utah Pharmacist members of the Texas Pharmacy Association Pharmacists responded to 31 items Items were developed by investigators or were adapted from previous research questionnaires

10 Results

11 Study 2: Survey of community pharmacy patients in SW PA Purpose: Test the feasibility of screening the behavioral, mental, and physical health of patients filling prescriptions for opioid medications in community pharmacies. In addition: Learn whether patients filling opioid medication prescriptions could be successfully screened for risk of opioid medication misuse. Assess whether patients in this setting would screen positive for risk of misuse. Understand if screened patients would report acceptability of pharmacists screening and possibly intervening for prescription opioid misuse risk.

12 Methods Conducted a cross-sectional survey among individuals filling prescriptions for opioid medications at two independent community pharmacies in southwestern Pennsylvania, two urban and two rural. Participants Study participants were recruited from a convenience sample of pharmacy patients that presented with a prescription for opioid medication to the pharmacist or pharmacy staff. Criteria included: 18 years or older Non-cancer patients Had never completed the survey before

13 Results:

14 Results Major findings across different analyses: Routine screening of patients for opioid misuse in these settings is feasible Patients are okay with pharmacists engaging them around opioid use Depression and PTSD are associated mental health conditions with misuse Previous illicit drug use is associated with misuse 1/5 of patients with Rx opioids are engaged in risk alcohol use

15 Study 3: Intervention development Opioid misuse is a major issue in public health Few resources exist to support community pharmacists identify patients who are either at risk or misusing Community pharmacy workflow may be adaptable to administer Screening, Brief Intervention, and Referral to Treatment (SBIRT) protocol ADAPT-ITT Assessment Decision Administration Production Topical Experts Integration Training Testing

16 Methods Attendees 11 experts and 3 practicing pharmacists from US and UK Goal Opioid overdose prevention and harm reduction expert (1) Health services pharmacy expert (1) Pharmacologic opioid treatment expert (1) Practicing addiction pharmacist (1) Psychosocial addiction treatment expert (1) Practicing community pharmacists (2) Behavioral intervention experts (3) Brief intervention and addiction experts (4) The objective was to promote focused discussion and ensure acquisition of accurate comprehensive data

17 Data Collection & Analysis The data consisted of: Video recordings of the meeting (6 hours) Notes from the attendees Analysis The video transcripts and meeting notes were analyzed in 2 cycles by 2 independent coders Objective coding themes, reflecting thematic discussion Analysis of agreement between coders was conducted using percentage of agreement and Cohen s Kappa, data was managed, coded and analyzed using Nvivo 10 Qualitative statements were also included

18 Results

19 Targeted intervention framework within community pharmacy workflow Electronic Health Screening Opioid medication misuse Physical, mental, and behavioral health Targeted MTM Intervention No Risk Follow up Risk Prevention intervention Follow up Misuse Adherence intervention Naloxone training Addiction Adherence intervention Naloxone training Refer to agonist treatment Acute health needs Refer to integrated care

20 Study 4. Pilot study We know pharmacists want to help We know patients can be identified and need help We have a potentially viable model We have a strong case for testing a pilot intervention.

21 Methods Randomized controlled study 23 patients receive intervention, 23 patients receive standard care UPMC Falk Pharmacy 2 years Collaboration between Social work Pharmacy Psychiatry Psychology

22 Interventions Standard Medication Counseling (SMC) Centers for Medicaid and Medicare Services requirement Offer counseling Document counseling has been offered Document patient refusal of counseling Offer a counseling process for patients not present (i.e., a call-in number for mailed medications; not applicable in the current study), Discuss generic prescription substitution, and Distribute written medication materials.

23 Interventions BI-MTM Brief Intervention Medication Therapy Management BI-MTM Component Target Medication Therapy Management (MTM) Adherence Screening, Brief Intervention, and Referral Misuse Elimination to Treatment (SBIRT) Patient Navigation (PN) Self-management Naloxone Referral Fatal overdose prevention

24 Patient navigation, detail In session 1 the navigator reviews with the participant a report of scores from the baseline assessment to better understand the participant s current health needs/challenges; session 1 also involves development of therapeutic alliance/rapport. Sessions 2-4 focus on goal setting and identifying barriers and problem resolutions. The navigator elicits motivation and discusses this in context to readiness to change heath behavior and self-management skills. These session involve navigators supporting/assisting patients to fill out paperwork and enroll in needed social services and/or mental/behavioral/physical healthcare, including but not limited to primary care. Sessions 5-7 focus on encouraging and reinforcing treatment adherence, reviewing and identifying other care needs, and offering linkages to service providers as applicable. Session 8 examines continued challenges to self-care and goals and formulates plans to continue progress post-pn.

25 Outcomes Acceptability and feasibility Decreased misuse Increased adherence Increased self-management Improved health behaviors

26 So far: 354 patients approached for screening 304 screened 46 patients screened positive for misusing prescribed opioid medications (15%) 29 provided informed consent Participants reported Illicit drug use (n=9) Current hazardous alcohol use (n=3) Current depression (n=9) Post-traumatic stress disorder (n=8) Anxiety (n=4). All BIMTM participants at 3 months report 0% misuse vs 70% misuse among control

27 Next steps Disseminate results to field Publish Present Large multisite randomized trial Network of pharmacies in Western PA Integrate into system through health plans

28 Altogether Identifying and engaging those with misuse in pharmacy settings is paramount Interventions directed at opioid use and comorbid health conditions are likely helpful to decrease transition OUD and improve health Field should move towards implementing these models of care in additional health care settings We likewise have a similar model of care for pregnant women with OUD in OBGYN settings

29 Thank you Questions?