Rationale & Strategy For Integrating Buprenorphine Treatment Into Community Health Centers Marwan S. Haddad, M.D. Community Health Center, Inc. Connecticut September 16, 2008
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Outline Buprenorphine: What is it? Integrated Healthcare Theoretical Models of Care/BHIVES CHC Model
Buprenorphine Partial opioid agonist at the mu receptor It has a ceiling effect at moderate doses It has a high affinity for the opioid receptor It has a slow dissociation rate from the opioid receptor Must be taken sublingually Is usually co-administered with naloxone as Suboxone May be prescribed by the primary physician if 8 hour course completed
39 year old male Using heroin for the last 14 years Injecting for the last 10 years Patient MH Has been erratically in care and in ERs (abscesses, anxiety, overdose) over 12 years Methadone program for 8 months kicked out because of continued cocaine use
Case Continued Heard about the buprenorphine program at CHC Interested in enrolling in program Tried buprenorphine off the streets and thought it worked really well for him Called the front desk and asked for an appointment with the doctor who does Suboxone
Front Desk Substance abuse counselor Initial MD Assessment for BPN Program CHC Providers HIV Program Mental Health
Initial Assessment: 1-2 History (determination for opioid dependence) Focused Physical Baseline phlebotomy including routine HIV and viral hepatitis screening Urine toxicology and pregnancy screening Screening for mental illness Explanation of buprenorphine/naloxone How and why it works How to take it Side effects Precautions (benzodiazepines) Induction phase (requires being in withdrawal) Stabilization phase Maintenance phase
Initial Assessment (cont) Suboxone Program description and expectations Honesty Respect of all staff Urine tox screens, supervised Substance abuse counseling Frequency of visits Contracts and Agreements signed (this could be done at the initial assessment visits by MD or RN or by substance abuse counselor)
Three agreements that patients sign Explanation of the program Contract Release with the pharmacy Contracts & Nurse or substance abuse counselor has these signed by the patient Copies of agreements available if interested
Conundrums In Buprenorphine Clinic organizational constraints (scheduling, ancillary services, etc.) Clinician autonomy (individual preferences vs. programmatic approach, numbers of patients on program) Urgency of the patient s needs (IDU vs. non-idu, addiction severity, etc.) Working closely with a single pharmacy
Voucher System Voucher system designed to reduce diversion and improve retention in counseling and care Voucher is embossed and signed by the patient and staff member Coordinate with one pharmacy Allows various team members (MD, counselor or nurse) to approve continued buprenorphine treatment based upon contingency management
Induction Visit Comes in in withdrawal, having last used 16 hours before Had objective signs and symptoms of opioid withdrawal (COWS): Irritable but pleasant; myalgias, runny nose, abdominal pains Patient given an initial voucher for suboxone and he goes to pick it up at the pharmacy across from the health center First dose is observed in the clinic
Sublingual administration Preparation For Abstinence symptoms do NOT disappear immediately, but don t typically worsen (BE PATIENT!) Vistaril 50mg often used for the first few days to help with insomnia Most patients will try to get high, but soon learn that there is no benefit from using opiates with BPN
Initially, received 4mg as observed dose Induction Day 1 Instructed to hang around for about 45 minutes If feeling fine then, could leave for the rest of the day Instructed to take another 4 mg in about 1-2 hours Encouraged to call in toward the end of the day to report how he was doing, particularly if not doing well Instructed to return the next day for a dose determination
Nursing assessment of previous 24 hours Did well overnight Induction Day 2 Took another 4 mg last evening and 8 mg this morning Used ii 50mg Vistaril and helped take the edge off and slept 6 hours She gives him a voucher for ii 8mg pills per day for 1 week with her and 2 week follow-up with MD
Still craving a little 1 Week Nursing Finding by the end of the day, beginning to feel jittery and anxious. Nurse speaks to me and I instruct her to increase the dose to 2 ½ pills.
Week 2 MD visit He is doing better; he feels no craving; medication dose seems to be lasting him 24 hours He will continue at this dose. I arrange an appointment with the substance abuse counselor
Substance Abuse Adjunctive counseling improves outcomes in substance abuse treatment (motivational enhancement initially and CBT later) * In-house substance abuse counselor for individual and group counseling Community or hospital based substance abuse treating organizations They sign a release so I or my staff could contact their counselors and make sure they are attending Considering having them carry a log to have it signed and dated by the counselor, then have the nurse call for verification every 2-4 weeks * Copenhaver, Bruce & Altice, AJDAA, 2007
Maintenance As the weeks go on, he complains of feeling down and being anxious. Cocaine is appearing in his urine BDI suggestive of depression (no evidence of bipolar disorder) and SSRI initiated After several weeks, his mood and anxiety symptoms have improved Positive cocaine urines becoming less frequent, but not absent
Yet his cocaine continues to be positive in urine. Suboxone is not a treatment for cocaine I meet with substance abuse counselor and we decide that IOP is best option for him at this point An alternative if resources are available is increased CBT Maintenance The three of us meet and we express our concern about his positive cocaine urines still present after 12 weeks of therapy and that we believe IOP would be better for him I will continue to prescribe him the suboxone but he needs to attend the IOP 3 times a week for enhanced counseling.
He had tested positive for HIV and Hep C infection. Co-Morbidities He was immediately referred to the Ryan White Program (HIV) nurse for intake. Work-up and possible treatment for Hep C discussed over the next several months. BP, glucose, lipids screened as well.
Urine tox screens done at every visit End Of Case While in in-house group, sees counselor weekly and sees provider monthly If outside counseling, visits are as often as provider deems necessary (usually every 1-2 weeks to start); these visits may be shared with nursing AA/NA meetings encouraged Mental health visits arranged if necessary Primary care, Hep C and HIV visits usually done with suboxone visits
Model Of Care Buprenorphine-prescribing physician (usually primary care provider but could be psychiatrist) Nursing +/- substance abuse counselor on site +/- mental health Have community resources where can send patients for substance abuse counseling or mental health
Need some administrative oversight of program and patients (resources) Limitations Need enhanced counseling to ensure sufficient integration of services onsite Cross-coverage for BPN prescription when providers absent
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Summary BPN treatment can and should be integrated into Community Health Care Centers where opioid dependence is a problem. The various models that exist can be adapted (and improved upon) to fit each individual health center. May require some additional resources to optimally improve outcomes.
Contact Marwan Haddad, MD Community Health Center, Inc 134 State Street Meriden, CT 06450 203.237.2229 haddadm@chc1.com