The Role of Urgent Care in responding to the opioid Crisis Robert S Crausman MD MMS Partner, Ocean State Urgent Care and Primary Care Centers Clinical Professor of Medicine, Brown Rob@OSUC.net
Opioid Crisis 1999-2017 much has changed 1999 Pain was the 5 th vital sign unprofessional conduct not to address pain 4X increase in Overdose Deaths 500,000 deaths last 15 years
Termination of epidemics Break transmission Eradicate causative agents Exhaust susceptibles Modified from www.cdc.gov Area under the curve = Lives
Understand the underpinnings Appraisal of Existing Facts Drivers Homelessness, joblessness, mental illness, broken families, genetics, education, incarceration and failed war on drugs, fentanyl, cheap heroin, permissive attitudes, physician prescribing
Possible Solutions Society level Urgent Care and Primary Care Do no harm proper prescribing Risk Mitigation Narcan Harm reduction education Evidence based treatment SBIRT Medical assisted treatment
Urgent Care and the crisis UCCs have the potential to be very important 9,000 urgent care centers nationally 160,000,000 patient visits per year, every state and most communities, extended and weekend hours convenient and affordable primum non nocere, appropriate prescribing and adherence to guidelines.
4% world population, 80% narcotic prescriptions Both graphics available www.cdc.gov
Safer Prescribing Implementing policies and practices consistent with CDC and literature based guidelines Review of State PMP information identify patients at highest risk for abuse or diversion, Prescribing only limited quantities nonpharmacological approaches start with immediate release preparations start low not prescribing for chronic pain syndromes outside of a longitudinal provider-patient relationship look for red flags
Impact safer prescribing Decreased existential angst for the profession Patients with legitimate needs for opiates may be less likely to receive them Short term Switch to heroin Seeking treatment Long term Priming effect Fewer initiates
What else can we do? Screening, education and treatment
Addiction myths Addicts are easy to spot (TP/FN) Addiction is a choice Prescription drugs prescribed appropriately are not addictive Addicts are liars Addicts are sociopaths/bad people Addicts come from low class families People with jobs can t be addicts (8.6%) Addicts don t care about risks to health and safety Detox is all one needs Addicts have to hit Rock Bottom
SBIRT Should be standard Targeted screening of all patients for addiction Real time behavioral intervention (focused education) Referral for treatment 5-As approach (ask, advise, assess, assist and arrange follow-up) familiar to many by its role in smoking cessation. Medical assistant staff can readily perform preliminary screening The SAMHSA website has helpful resources and validated screening tools (https://www.integration.samhsa.gov/clinical-practice/sbirt/screening). Additional helpful resources are available at the Physician s Clinical Support System websites NIDA Quick screen https://www.drugabuse.gov/sites/default/files/pdf/nmassist.pdf Would you like to talk to a provider about addiction and recovery services?
Stages of Change model 5 A s ask, advise, assess, assist, arrange follow-up Prochaska, J.O. and DiClemente, C.C. (1984). The transtheoretical approach: Crossing the traditional boundaries of therapy. Melbourne, Florida: Krieger Publishing Company.
Harm reduction education Harm reduction education should be widely implemented Importance of using clean, sterile needles and never sharing needles Snorting is safer than injection, and smoking is least risky. Avoid using drugs with strangers, in strange places, or when alone; avoid mixing drugs such as heroin and prescription opiates, opiates and other drug types such as cocaine and benzodiazepines or using alcohol with drugs.; and also to avoid obtaining drugs from unfamiliar sources. Effects of abstinence upon drug tolerance. Specifically, an opioid abuser can overdose on a previously well tolerated dose of narcotics after a period of abstinence such as incarceration. Patients who abuse opioids and their close contacts should be offered a prescription for Narcan (e.g. naloxone nasal 4 mg spray or naloxone auto-injector 2mg Sc or IM) which is rapidly becoming a minimum standard of care. Taught to recognize the signs of an opiate overdose in others and to administer Narcan, and activate emergency services.
UCC and MAT, Not unprecedented UCCs generally focus upon acute care services fully 2/3 offer services traditionally offered in primary care such as routine immunization and 50% actually offer primary care many patients, particularly millennials, identify UCs as their only source of healthcare. Patients with addiction are often recognized by UC providers. Effective treatment is contingent upon availability and access. Too often patients are not offered timely treatment and consequently continue to abuse illicit drugs. This represents both a critical failing of our healthcare system and an incredible opportunity for the field of urgent care medicine informal telephone survey of 123 Massachusetts based UCCs and found that 6% offered treatment with buprenorphine for patients with addiction (81% response rate.)* *Ramos J and Crausman R. The potential role of urgent care in addressing the opiate epidemic. JUCM. submitted
Feeling special
3+1 Urgent care treatment models First, Identify and refer model, minimum standard Second, Federal law now creates the opportunity for prescribers in urgent care settings not only to identify but to also initiate treatment; identify, induce and refer Third, with appropriate referral relationships for mental health treatment, counseling and primary care patients can be identified, induced and safely maintained through an UCC Fourth, office-based buprenorphine detoxification
Dual diagnoses, triangulation Coexisting mental health disorders at presentation Approximately 40% Depression Anxiety ADD/ADHD Bipolar illness Schizophrenia Axis 2
UCC based detoxification Office-based detoxification with buprenorphine One week to 4 week protocols Easier than office-based ETOH detox Long term efficacy much less then with maintenance treatment (85% using within 6 months) Naltrexone may have a role with these patients
Do well by doing good He is ill clothed who is bare of virtue A good conscience is a continual Christmas Individual endeavor can change the course of history forever https://en.m.wikipedia.org/wiki/ben_franklin_effect#/media/file%3afranklin-benjamin-loc.jpg
CASH ONLY PRACTICES For practices that bill cash for management of patients on buprenorphine important to note that there are several pitfalls to this approach Urge that providers review their relevant provider agreements as many insurers consider addiction management to be a covered service; It may also be considered Medicaid and Medicare fraud and abuse
Summary Opioid crisis Biopsychosocial underpinnings Goal is to limit area under the curve UC can play major role Prescribing standards SBIRT Harm reduction education MAT, effective but inadequate availability UC models of care treat and refer vs treat and maintain; outpatient detoxification