NEW APPROACHES TO DISSEMINATING TREATMENT:

NEW APPROACHES TO DISSEMINATING TREATMENT: TECHNOLOGY, LOW BARRIER MAT AND PRISON HEALTH Colleen T. LaBelle, MSN, RN-BC,CARN Program Director, Office-Based Addiction Treatment Director, STATE OBOT-B Boston Medical Center BU CTSI 7th Annual Translational Science Symposium May 3, 2018

OVERDOSE DEATHS CONTINUE TO RISE: EPIDEMIC RAPIDLY EVOLVING We are HERE: Polysubstance use the norm, rather than exception Drug supply more lethal and unpredictable Heavy focus on reducing supply = abandonment of many chronic pain patients Identifying high risk populations easier than serving them Addiction workforce must evolve in parallel to the needs of populations impacted 2

AN EVOLVING EPIDEMIC REQUIRES FLEXIBILITY AND INNOVATION Harm reduction approach: low threshold Treatment on demand: ED*, walk in, open access Expanding buprenorphine through mid-level providers Prescriptive authority of NPs in all states Prescriptive authority for all NPs under DATA 2000 (e.g., CNM) Interventions targeted to needs of high-risk populations Use of technology: (ECHO), Telemedicine/Telehealth, Electronic Prescribing, webbased resources 3

WHAT IS EVIDENCE-BASED CARED FOR OPIOID USE DISORDER? Methadone: full opioid agonist Only available in specially licensed opioid treatment programs Buprenorphine: partial opioid agonist Commonly combined with naloxone, an opioid antagonist (to deter injection) Use in office-based setting requires DEA waiver 8 hour training for MDs per DATA 2000 24 hours of training for NPs and PAs per CARA Act Naltrexone: opioid antagonist Use in office-based setting without special certification Evidence of efficacy in specific populations Overall efficacy not well established NIDA (2012). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). SAMSHA (2015). Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. Kampman & Jarvis (2015). American Society of Addiction Medicine (ASAM) National Practice Guideline for the use of medications in the treatment of addiction involving opioid use. Journal of addiction medicine, 9(5), 358-367. 4

VALUE OF MEDICATION FOR ADDICTION TREATMENT (MAT) Medicaid medical costs decreased by 33 % over 3 years following engagement in treatment Decline in expenditures: hospitals, emergency departments, and outpatient services Baltimore study 50% decrease mortality with buprenorphine and methadone treatment Overdose deaths ED and hospital admissions Medical costs Massachusetts decrease ED, and hospital admissions with retention in treatment Alford DP, LaBelle CT, Kretsch N, et al. Arch Int Med. 2011;171:425-431 Walter, L. et al (2006). Medicaid Chemical Dependency Patients in a Commercial Health Plan, Robert Wood Johnson Foundation, Princeton, New Jersey Schwartz et al. American Journal of Public Health. 2013; 103(5): 917-922 Medication for addiction treatment 5

RAPIDLY EXPAND MODELS PROVEN TO INCREASE ACCESS TO MAT 6

THE BMC NURSE CARE MANAGER (AKA MASSACHUSETTS) MODEL FOR OFFICE BASED ADDICTION TREATMENT (OBAT) Nurse Care Managers (NCMs) increase patient access to treatment Nurses working at top of their license Efficient and effective utilization of buprenorphine-waivered prescribers NCM role includes: Case management Brief counseling, social support, patient navigation NCMs able to address Urine toxicology results Insurance issues Prescription/pharmacy issues Pregnancy, acute pain, surgery, injury Concrete service support Intensive treatment, legal/social issues, safety, housing 7

INCREASING ACCESSTO LIFE-SAVING MEDICATION: CREATING A NETWORK OF OBAT PROVIDERS ACROSS MASSACHUSETTS BMC OBAT TTA In 2007 State Technical Assistance Treatment Expansion (STATE) OBAT Program created to expand BMC model to 14 CHCs across MA First 5 years of outcomes: Between 2007 and 2013, 14 CHCs successfully initiated OBAT Physicians waivered increased by 375%, 24 to 114 over 3 years Annual admissions of OBAT patients to CHCs increased from 178 to 1,210 65.2% of OBOT patients enrolled in FY 2013/2014 remained in treatment 10 months 8

STATE OBAT TRAINING AND TECHNICAL ASSISTANCE (OBAT TTA) INITIATIVE IN CHCS: PROJECT GOALS ACCESS Expand treatment & access to buprenorphine Increase number of waivered MDs Increase number of individuals treated for opioid addiction Integrate addiction treatment into primary care settings DELIVERY Effective delivery model for buprenorphine Modeled after BMC s Nurse Care Manager Program Focus on high risk areas, underserved populations SUSTAINABILITY Post-program funding Develop a long-term viable funding plan Collect & analyze outcomes data 9

WE HAVE SHOWN SUCCESS SCALING IN MASSACHUSETTS AND ARE NOW SHARING OUR LEARNINGS NATIONALLY We ve shown scalability in Massachusetts... Now sharing model nationally 60 50 40 30 20 10 0 2016 23 2017 32 2018 56 No. of sites provided OBAT TTA in last 3 years NIDA CTN-0074: Primary Care Opioid Use Disorders Treatment (PROUD) Trial Testing BMC Nurse Care Manager Model against standard of care in 6 health systems nationwide in ~10,000 patients 10

PAST 3 MONTH HEALTH CARE UTILIZATION OUTCOMES MA OBAT SITES JUL 1 SEP 30, 2017 (N=6,506) 16.6% % of patients in STATE OBAT Program 4.4% In treatment <= 12 mos. In treatment > 12 mos. 5.3% 1.1% 3.8% 10.9% Retention in OBAT Detox, inpatient, ED admissions 1+ night detox 1+ night inpatient hospital 1+ ED 11

LOWERING BARRIERS TO RECEIPT OF MEDICATIONS FOR ADDICTION TREATMENT (MAT) You need a little love in your life and some food in your stomach before you can hold still for some damn fool s lecture about how to behave Billie Holiday 12

Trained over 1,400 individuals at 36 state-wide trainings 13 buprenorphine waiver trainings 7 CARN Review Courses 5 Essentials of OBAT Trainings 4 Advanced Topics in Buprenorphine Practice and Beyond 3 Addiction 101Trainings 2 trainings for Early Intervention providers 1 Buprenorphine implant training 1 statewide conference REACH OF BMC OBAT TTA TEAM APR 2017 APR 2018 Provided >140 hours of on site technical assistance to >50 community OBAT sites Program responsive to changing needs of providers and patients 13

LOWERING THRESHOLD FOR TREATMENT IN OFFICE-BASED SETTINGS Fewer requirements for MAT in new BMC Clinical Guidelines LaBelle, C. T.; Bergeron, L. P.; Wason, K.W.; Ventura, A. S.; and Beers, D. Policy and Procedure Manual of the Office Based Addiction Treatment Program for the use of Buprenorphine and Naltrexone Formulations in the Treatment of Substance Use Disorders. Unpublished treatment manual, Boston Medical Center, Mar 2018. 14

CARA LEGISLATION: NPS AND PAS ABLE TO PRESCRIBE BUPRENORPHINE! Ultimate goal of extending outreach to non-physicians and non-addiction specialty settings NPs and Pas must obtain waiver, same as physicians As of July 2016: allowed to prescribe Requirements include: 24 hours of education in addiction 8 hours of a waiver training (maybe a part of 24hour requirement) Supervised practice by waivered provider in states with supervised practice 30 patient limit year one Maximum 100 limit can apply after year one Approval for period of time then a review by HHS 15

2018 WAIVERED MDS AND DOS BY STATE N = 42,015 States with Highest % of Waivered MDs/DOs* Vermont = 14.1% Maine = 12.6% Alaska = 10.2% New Mexico = 9.3% 1516 70 702 139 51 278 487 4579 665 679 502 43 458 4168 610 54 1179 2433 119 100 966 650 1921 341 787 167 524 817 968 865 343 459 144 229 543 821 1466 483 2276 563 VT = 307 NH = 292 CT = 832 MA = 2339 RI = 369 NJ = 1307 DE = 136 MD = 1233 DC = 158 Rhode Island = 7.8% *Not including U.S. Territories 185 HI = 159 GU = 2 MP = 1 PR = 528 VI = 2 16

2018 WAIVERED NURSE PRACTITIONERS BY STATE N=5,284 States with Highest % of Waivered NPs Vermont = 11.3% Maine = 10.8% New Mexico = 9.6% 233 25 13 72 116 449 35 7 63 74 12 203 23 8 410 53 89 135 57 91 96 309 130 14 36 150 191 0 18 205 96 13 77 23 41 24 61 142 165 118 VT = 42 NH = 87 MA = 306 RI = 47 CT = 182 NJ = 150 DE = 25 DC = 30 MD = 282 New Hampshire = 8.5% Maryland = 8.5% 36 PR = 0 GU = 0 MP = 0 VI = 0 HI = 20 17

2018 WAIVERED PHYSICIAN ASSISTANTS BY STATE N = 1,389 States with Highest % of Waivered PAs Alaska = 5.6% Utah = 4.4% Washington = 4.4% Rhode Island = 4.2% Vermont = 4.0% 84 8 3 17 38 153 7 16 1 51 5 90 5 9 30 20 59 15 11 35 20 123 61 4 1 0 91 0 44 14 15 15 2 3 2 15 34 4 41 19 HI = 2 19 VT = 10 RI = 13 NH = 10 MA = 69 CT = 23 NJ = 17 DE = 7 MD = 50 DC = 4 GU = 0 MP = 0 PR = 0 VI = 0 18

NO. OF MDS, NPS AND PAS THAT COMPLETED 8 HOUR BUPRENORPHINE WAIVER TRAINING APR 2017- APR 2018 140 120 100 80 60 40 20 0 MDs 138 NPs 94 No. completing waiver training PAs 26 MDs Nurse Practitioners Physicians Assistants BMC OBAT TTA continues to dedicate resources to engage mid-level providers to meet requirements to prescribe buprenorphine 1 9

EVIDENCE OF COMPARABLE CARE NP VS. MD Evidence for Quality Improvement, high quality care Similar patient outcomes to physician-provided care Patients report high levels of satisfaction. NPs can address shortfall of primary care providers Empowering NPs to diagnose and prescribe without physician oversight is important to ensuring there is an adequate primary care workforce to serve this new population NPs are more likely than MDs to treat patients in settings where provider resources are scarce McCleery et al. Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses. 2014 Sep. In: VA Evidence-based Synthesis Program Evidence Briefs [Internet]. Washington (DC): Department of Veterans Affairs (US); 2011. 20

TAILORING SERVICES TO HIGH RISK POPULATIONS: A FOCUS ON POST-INCARCERATION 21

Risk of opioid overdose death following incarceration is 56x higher than for the general public Risk is greatest during first following release Of those incarcerated, young people (18-24) are 10x more likely to die than those >45 An Assessment of Opioid-Related Deaths in Massachusetts (2013-2014). MA Department of Public Health. September 2016. Accessed at: file:///c:/users/alventu1/downloads/dph-legislative-report-chapter-55-opioid-overdose-study-9-15-2016.pdf 22

ENGAGING INCARCERATED PERSONS AT TIME OF RELEASE: BMC Partnership with South Bay House of Corrections Services advertised throughout HOC for people with SUD Providers present inside HOC during community meetings on services offered by BMC s OBAT Clinic For those interested, providers meet with people incarcerated inside the HOC Establishes relationship Documentation of substance use history Medical clearance Aim: direct linkage upon release Clinic will accept and prioritize post-release walk-ins during all clinic hours Partnerships with other jails/prisons in place OBAT S PARC CLINIC 23

TECHNOLOGY AS A TOOL FOR WORKFORCE DEVELOPMENT 24

Between Apr 2017 and Apr 2018.. 9,222 unique individuals have visited OBAT TTA website (bmcobat.org) 16,293 total sessions 74,012 total page views OBAT TTA website visitors from: 58 countries 49/50 of States 222 unique municipalities across Massachusetts LEVERAGING TECHNOLOGY: OBAT TTA WEBSITE AND RESOURCES 25

LEVERAGING TECHNOLOGY: ADDICTION ECHO (EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES) HUBS AT BMC Using teleconferencing technology, primary care providers connect to other learners and expert Hub teams Hub and spoke model increases access to specialty care Two main components of all teleecho clinic: 1. Brief didactic presentation 2. Case-based learning ( pt. case by spoke participant) Community providers learn from specialists Community providers learn from each other Specialists learn from community providers as best practices emerge 26

REACH OF BMC S ADDICTION ECHO HUBS National Opioid Addiction Treatment ECHO A national collaboration between the ECHO Institute, HRSA, the American Society of Addiction Medicine (ASAM), and 5 expert addiction hubs Mass Office Based Addiction Treatment (OBAT) ECHO OBAT ECHO is for Mass cites implementing office based addiction treatment, funded by Opioid STR 27

OVERVIEW OF BMC S OBAT (OBAT TTA) PROGRAM Statewide Waiver Trainings Other statewide addiction trainings (e.g., Essentials of OBAT) On-site technical assistance provided by expert consultant OBAT TTA Website Addiction Hotline National and State-specific Guidelines for NCM OBAT model National Opioid Addiction Treatment ECHO MA Office Based Addiction Treatment ECHO Addiction provider list server 28

Flexibility AN EVOLVING EPIDEMIC REQUIRES Responsive to current and changing needs Change Agents Innovation Nurses will continue to play key role in addressing the current epidemic of addiction and overdose deaths. 29

Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020 Ensure that nurses engage in lifelong learning Nurses should be full partners with physicians and other health professionals, in redesigning health care in the United States Prepare and enable nurses to lead change to advance health Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). 30

QUESTIONS? Colleen.labelle@bmc.org 31