The Role of Primary Care Teams and the Medical Neighborhood in Addressing the Opioid Crisis in Maine. March 10, 2016

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1 The Role of Primary Care Teams and the Medical Neighborhood in Addressing the Opioid Crisis in Maine March 10, 2016

2 Objectives Review current state of opioid crisis in Maine Briefly review physiology of addiction and need for treating addiction as chronic disease Understand definition of MAT and significance as treatment method for individuals suffering from opioid addiction Identify importance of providing MAT in primary care and in medical neighborhood to help improve care and reduce readmissions for individuals coping with opioid addiction Understand current barriers to utilization of MAT in region; explore strategies to address barriers in primary care Identify partners and resources in region to support practices & patients 2

3 Definition by ASAM Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one s behaviors and interpersonal relationships, and a dysfunctional emotional response.

4 Reward Pathway

5 Opioid Addiction and the Brain Opioids attach to specific receptors in the brain called mu receptors Activation of these receptors causes a pleasure response Repeated stimulation of these receptors creates a tolerance requiring more drug for same effect This is a biologic function that is static across age, gender, ethnicity and financial status

6 Chronic Care Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment and engagement in recovery activities, addiction is progressive and can result in disability and premature death Primary Care is an appropriate clinical environment, for the identification and maintenance phase of Chronic Disease Management Adherence, functionality and plans for relapse are important aspects of managing all chronic diseases in the Maintenance Phase of Care

7 Stages of Change Chronic Disease Model

8 Context: Opioid Use in ME* Maine has high opioid use rates 2014, avg 60.4 prescribed narcotic pills per capita Maine has high opioid death rate: 16.8 (27.3% ) (vs. natl avg 14.7) 2013: 174 (13.2) 2014: 216 (16.8) 2015 YTD: on track to exceed 2014 level Maine has seen rapid rise in drug-affected babies 2013: : 961 Increase of 480% from 2005 to 2014 *Maine State Epidemiological Outcomes Workgroup (SEOW) Oct

9 Context: Primary Care s Contribution to Opioid Prescribing* *Distribution of Opioid Prescribing by Provider Specialty, JAMA IM, Dec

10 Medication Assisted Therapy (MAT) Use of FDA-approved opioid agonists, partial agonists, and antagonist medications, in combination with counseling and BH therapies Strong evidence for effectiveness of both methadone & buprenorphine for treatment of opioid dependence. Huge gaps in MAT treatment: ~5 million Americans suffer from opioid addiction <1 million currently receiving MAT* *Availability Without Accessibility? State Medicaid Coverage & Authorization Requirements for Opioid Dependence Medications, Avisa Group/ASAM,

11 Medication Assisted Therapy (MAT) Medications: Methadone: opioid agonist Use restricted to specialized Opioid Tx Programs Buprenorphine (Subutex): partial agonist Requires DEA-X license; current rx limited to physicians Buprenorphine/Naltrexone(Suboxone): partial agonist + antagonist Requires DEA-X license; current rx limited to physicians Naltrexone (Vivitrol): antagonist No special license required; can be administered via monthly IM injections; Indicated for treatment of alcoholism and prevention of opioid relapse 11

12 MAT: Unique Features of Buprenorphine Novel opioid with both partial agonist & antagonist properties Low intrinsic activity creates feeling of well-being without full opioid effects Tightly binds to μ-opioid receptors competes with full μ agonists (e.g. heroin) Very slow dissociation rate gives prolonged therapeutic effects, creates ceiling effect Antagonist actions on κ-opioid receptors may decrease stress, lessen depression 12

13 Social Outcomes of Treatment Data courtesy of David Roll, M.D., Cambridge Health Alliance, slide courtesy of Steve Martin, MD 13

14 American Society Of Addiction Medicine (ASAM) Levels Of Care, Or Flavor Of Treatment; Based On Medical Necessity

15 Multidisciplinary Team Benefits Of Coordinated Care Capacity for physician to refer to treatment is required under the law (DATA 2000) Substance abuse treatment providers have expertise in managing and coordinating care for substance using clients Combines goals of the medical and behavioral health systems holistic care rather than compartmentalized care Treatment modality (e.g., inpatient vs. outpatient), type (e.g., methadone vs. buprenorphine), and setting (office based vs. OTP) can be made to maximize fit with patient needs 15

16 A Model For Coordinated Care Role Physician Nurse Pharmacist Addiction Counselor 12 Step Program Community Support Provider Screening and Assessment X X X X Diagnosing Opioid Addiction X X X Patient Education X X X X X Referral for Treatment X X X X Prescribing or Dispensing Buprenorphine Urinalysis Testing X X X Psychosocial Treatment X Recovery Support X X X X X X Case Management & Coordination X X X Family Services & Treatment X X Meeting Ancillary Needs of the Patient X 16

17 Buprenorphine Prescribing in Primary Care DEA requires Drug Addiction Treatment Act (DATA) 2000 waiver - special DEA-X license DATA 2000 waives requirement for obtaining separate Narcotic Tx Program license for physicians with Schedules III-V narcotic controlled substances Currently limited to physicians Requires prescriber to take 8-hour CME Once obtained, prescriber limited to treating 30 patients at time; after 1 year, can apply to increase to 100 patients 17

18 MAT in Primary Care Slide courtesy of Steve Martin MD 18

19 19 Slide courtesy of Steve Martin MD

20 MAT in Primary Care in Maine Est. ~30-35 Maine primary care practice sites currently offering MAT (out of ~500!) Often limited to 1-2 prescribers/site; many not taking new patients Some associated with addiction tx center with referral relationship; others identify and tx patients independently Several are cash practices 20

21 MAT in Primary Care in Maine Varied MAT models: Primary care sites providing maintenance MAT, with relationship to addiction treatment centers for initial induction, referral, & specialty back-up Primary care practices doing both induction & maintenance Cash practices offering induction & maintenance Varied approaches to induction Varied models for, frequency of SUD/OUD counseling (group, individual; significant to minimal) 21

22 Barriers to MAT in Primary Care* Lack of insurance coverage for uninsured adults!!! Lack of institutional support for delivering MAT Lack of MH and counseling/psychosocial supports Time & access constraints for delivering MAT Lack of confidence in ability of clinicians (& practice) to manage opioid addiction Resistance from practice partners Lack of specialty backup, referring challenging patients Lack of systems to support appropriate monitoring (e.g. pill counts, urine drug screens), & related tension between therapeutic & monitoring/ policing fxns * From interviews with Maine MAT prescribers 22

23 What is the Medical Neighborhood? Consists of all individuals, teams, organizations in community or region PCMH & HH practices, the primary care teams are often at the hub in individual s 23 neighborhood This Hub, however, may be or may not be Hub initially for MAT 23

24 MAT in the Medical Neighborhood Support from major health systems: System Hub Spokes Central ME Health Care?? EMHS Acadia EMMC Fam Med MaineGeneral MaineHealth MidCoast Health MaineGeneral Detox, IOP, OP Developing services Partnering for 100 Knox Co Addiction Resource Center 300 pts ME-Dartmouth FP Winthrop FP MMP Ptld, Westbrook MMC FP Center Developing Capacity Knox Co. MidCoast Int Med (1 provider) 45 pts. planning 90 more 24

25 Maine Hub and Spoke Scale Up Potential MOU between Primary Care Provider and Specialty SUD Treatment Center w/mat Induction, Stabilization, Primary Treatment (HUB) Agreement details pt. charateristics appropriate for hand-off to Primary Care Details timeframes for clinical consultation and with whom Details process and timeframes for re-admission to HUB for re-stabilization if/as needed. Details patient volumes 25

26 Primary Care Providers Do This Work How did we get started? Challenges and barriers in your region Why did we begin to provide MAT in practice? Lessons learned? How 26 are we integrating those learnings? Next steps? How are we doing with Implementation? What Partnerships have we developed? 26

27 Discussion Who is in your neighborhood? What are the relationships or the potential relationships? What are the resources? 27

28 Discussion What are some ideas, strategies and relationships collectively that are or could be available for primary care, specialty care, and the neighborhood to address the barriers? 28

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