Project ECHO: Extending Opioid Treatment Statewide. Brian Grahan, M.D., Ph.D. Friday, Jan. 11, :20 5:20 p.m. Northland Ballroom

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1 Project ECHO: Extending Opioid Treatment Statewide Brian Grahan, M.D., Ph.D. Friday, Jan. 11, :20 5:20 p.m. Northland Ballroom

2 Brian Grahan, M.D., Ph.D. Dr. Brian Grahan was introduced to addiction medicine by happenstance during his research on decision making and health outcomes during his M.D.-Ph.D. program at the University of Wisconsin. Once he learned to see it, he noticed it everywhere but rarely addressed. Yet, when treated appropriately by healthcare providers, people had outcomes better than diabetes and high blood pressure with immense impact on individuals, families and their communities. He never turned back. He moved north to the University of Minnesota s combined residency in internal medicine and pediatrics to learn how to care for the sickest people across the life course, completed a chief residency in quality and patient safety at the Minneapolis VA Healthcare System to continue building organizational change skills, then did the Minnesota Addiction Medicine Fellowship. He now practices as the medical director of office-based addiction medicine, a primary care provider in the Coordinated Care Center, and director of the Integrated Opioid and Addiction Care ECHO program at Hennepin Healthcare in Minneapolis, Minnesota.

3 Project ECHO: Expanding Opioid Treatment Statewide Minnesota Hospital Association Winter Trustee Meeting January 11, /08/2018 Disclosures I have no financial conflicts of interest. I will not be discussing off-label use of medications 1

4 Learner objectives 1. Describe status of opioid epidemic in Minnesota 2. Understand background and implications of DHS opioid report card 3. Appropriately refer patients to addiction medicine services 4. Access Project ECHO sessions as a forum to learn about and discuss complicated opioid-related patient cases Adjusted difference in physical health scores in chronic opioid users versus non-opioid users Dose of opioids in morphine equivalents Sullivan Dillie K, et al. J Am Board Fam Med. 2008;21:

5 Impact of chronic opioid use and opioid agonist maintenance therapy Normal baseline Normal variation. Your body s opioid level increases with exercise, friendship, sex, food. Also rises in response to acute trauma to compensate for pain. Level decreases with depression, etc. In the predisposed person, exposure to an opioid results in an outsized response that dwarfs other stimuli. Persistent use resets homeostasis. Other behaviors may become secondary, and drug use may become compulsive. Withdrawal develops, and goal Treatment of goals: use gradually shifts from get 1. No opioid cravings high to feel less bad. 2. No illicit opioid use 3. Feel normal 4. Safe dose, no diversion Buprenorphine/Methadone At the new baseline level, a person s own opioid system is suppressed. They re less able to cope with new painful stimuli, including withdrawal. Time Some patients expect to taper eventually. Recovery of function is uncertain.??? Studies suggest >85% of people relapse without agonist medication. A few people do well; unfortunately, we poorly predict who, how, or when to taper successfully. Planned tapers should include close support, and recommendation to continue buprenorphine if destabilizing symptoms arise. Created by Brian Grahan, MD, PhD on 4/1/18 Hennepin Healthcare Opioid & Addictions Care Project ECHO Conceptual framework: Addictive behaviors Stage of Addiction Shifting Drivers Resulting from Neuroadaptations Binge and intoxication Feeling euphoric Feeling good Escaping dysphoria Withdrawal and negative affect Preoccupation and anticipation Feeling reduced energy Looking forward Feeling reduced excitement Desiring drug Feeling depressed, anxious, restless Obsessing and planning to get drug Behavioral Changes Voluntary action Abstinence Constrained drug taking Sometimes taking when not intending Sometimes having trouble stopping Sometimes taking more than intended Impulsive action Relapse Compulsive consumption Volkow ND et al. N Engl J Med 2016;374:

6 What distinguishes addiction from chronic opioid use? Impaired control Social impairment Risky use Physical dependence Volkow ND et al. NEJM 2016;374:

7 Scope of the Epidemic 16% primary care Medicaid patients on chronic opioids MN DHS M patient years >600,000 opioid Rx 5

8 Child protective services involvement Reasons for (CPS) involvement #1: parent with substance use disorder #2: prenatal opioid exposure Foster care due to parental drug use 1,200 in ,800 in

9 Geography of the problem Highest volume of misuse and related deaths are in the seven-county metro area Community prevalence highest in rural areas Cass, Clearwater, and Mahnomen Counties have the highest rates of youth prescription drug misuse Mahnomen and Cass have the highest rates of drug poisoning deaths; Clearwater has the fifth highest rate Cass, Clearwater, and Mahnomen Counties in the top ten highest counties for percentage of treatment admissions involving opioids as the primary substance of abuse Prescriptions filled per 100 population were higher in Cass (189), Clearwater (194) and Mahnomen (183) as compared to metro/urban Hennepin (140) or Ramsey (138) Geography of the problem Density and number of addiction specialists and treatment options highest in seven-county metro area Scope of problem statewide Opioid use disorder can be diagnosed and treated in usual clinic settings People across MN already innovating How to get a handle on the problem? 7

10 Where to start? Many communities & organizations already doing the work! 8

11 DHS Opioid Sentinel Measures Acute prescribing rates Acute prescribing doses Stopping acute opioids early Chronic prescribing rates High dose chronic prescribing Mixing high dose chronic opioids and benzos Prescribing to doctor shoppers Example First report early 2019 Only DHS and you will see it 9

12 Opioid Prescribing Work Group (OPWG) Mandate Generate recommendations for opioid prescribing based on current literature Analyze 2016 MN Medicaid opioid prescribing data Develop sentinel measures for opioid prescribing Provide feedback on sentinel measures to Minnesota providers Quality improvement for outlying prescribers Educational campaign Not OPWG Goals: Not a comprehensive opioid strategy for the state Not a comprehensive pain strategy for the state Punish or hinder providers working in good faith Dis-incentivize care of Medicaid patients Worsen the care of patients in acute pain Make chronic opioid, chronic pain patients unstable 10

13 Best practices for patients on chronic opioids Avoid sedatives (benzo, alcohol) Obtain routine urine drug tests (universal precaution) Frequently re-evaluate indication and consider taper Focus on functional outcomes Assess for aberrant behavior Check PMP Ask about Bad day use Screen for opioid use disorder Prescribe naloxone 11

14 Managing Problematic Opioid Use Screening strategies Review indication for all patients on chronic opioids Taper opioids when indication unclear or high dose (per DHS/ICSI thresholds) Consider Pain Committee review for challenging patients Diagnosis of OUD often emerges from series of unexpected or inexplicable behaviors Universal precautions when prescribing controlled substances Intermittent urine drug screens Check PMP When help advertised in familiar setting, patients sometimes present seeking it 12

15 Systems of care Establish clinic-wide expectations DHS & ICSI standards DHS provider-specific opioid reports coming in 2019! Promote an internal pain or controlled substance committee as resource for difficult case discussions Encourage pharmacy and lab partnerships Leverage statewide expert case consultation for difficult patients with possible addiction ECHO: Wednesdays & Thursdays 12:15-1:15 Managing Opioid Use Disorder 13

16 Managing Opioid Use Disorder Managing opioid use disorder (OUD) Build clinic capacity to recognize and treat OUD with buprenorphine Get at least 2 waivered prescribers Develop systems of care consider nurse care manager Connect with a network of mentors & colleagues Develop referral relationships to treatment programs and higher levels of medical care (specialty OBAT clinics or OTPs) 14

17 Addiction Care Continuum within Hennepin Healthcare Specialty Officebased Addiction Treatment (OBAT) Consultations Opioid Treatment Program (OTP) LADC for treatment program coordination OBAT clinic Primary care Chronic disease management Addiction Care Continuum across Minnesota? Specialty Officebased Addiction Treatment (OBAT) Consultations Opioid Treatment Program (OTP) LADC for treatment program coordination OBAT clinic Primary care Chronic disease management 15

18 How does Project ECHO work? Moving knowledge, not patients How does Project ECHO work? Moving knowledge, not patients 16

19 How does Project ECHO work? Complex conditions Guided practice over time Brief didactics De-identified case review Workforce Multiplier Integrated Opioid & Addiction Care Thursdays 12:15 1:15p Case-based interactive learning series via Zoom videoconference No travel, no fees, participate via plug-and-play videoconference AMA PRA Category 1 Credits TM per session 17

20 Why Project ECHO? Is Project ECHO telemedicine? 18

21 Hub Team Source: Michelle Iandiorio, MD, Project ECHO New Mexico In the end, it s always all about the people ECHO works by leveraging personal relationships Joy of work Adapting new innovations to clinical practice Sharing best practices for each clinic setting 19

22 Buprenorphine Boot Camp 1:00p on February 21 st 2:00p on February 22 nd Goal: To support implementation of clinical teams interest in prescribing buprenorphine for opioid addiction in their clinics Recommend each clinic bring at least a team of 2-3 prescribers, a nurse, and a clinic manager $159/person No fee for providers getting waivered to prescribe buprenorphine for OUD Crowne Plaza Minneapolis West in Plymouth, MN Hosted by Hennepin Healthcare and MN Hospital Association Supported by ECHO partners: CHI-St Gabriel s in Little Falls and Wayside Recovery Center HCMC.Opioid.ECHO@hcmed.org or (612) for details and registration Brian.Grahan@hcmed.org HCMC.Opioid.ECHO@hcmed.org Office: Questions? 20