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NEW APPROACHES TO DISSEMINATING TREATMENT: TECHNOLOGY, LOW BARRIER MAT AND PRISON
HEALTH
Colleen T. LaBelle, MSN, RN-BC,CARNProgram Director, Office-Based Addiction Treatment
Director, STATE OBOT-B Boston Medical Center
BU CTSI 7th Annual Translational Science SymposiumMay 3, 2018
OVERDOSE DEATHS CONTINUE TO RISE: EPIDEMIC RAPIDLY EVOLVING
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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
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, web-
based 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
4
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.
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
• Massachusetts decrease ED, and hospital admissions with retention in treatment
Alford DP, LaBelle CT, Kretsch N, et al. Arch Int Med. 2011;171:425-431Walter, L. et al (2006). Medicaid Chemical Dependency Patients in a Commercial Health Plan, Robert Wood Johnson
Foundation, Princeton, New JerseySchwartz et al. American Journal of Public Health. 2013; 103(5): 917-922
Overdose deathsED and hospital
admissionsMedical costs
Medication for addiction
treatment
5
RAPIDLY EXPAND MODELSPROVEN TO INCREASE ACCESS
TO MAT
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THE BMC NURSE CARE MANAGER (AKA MASSACHUSETTS) MODEL FOROFFICE 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
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INCREASING ACCESS TO LIFE-SAVING MEDICATION:CREATING A NETWORK OF OBAT PROVIDERS ACROSS MASSACHUSETTS
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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
STATE OBAT TRAINING AND TECHNICAL ASSISTANCE (OBAT TTA) INITIATIVE IN CHCS: PROJECT GOALS
Expand treatment & access to buprenorphineACCESS
• Increase number of waivered MDs• Increase number of individuals treated for opioid addiction• Integrate addiction treatment into primary care settings
Effective delivery model for buprenorphineDELIVERY
• Modeled after BMC’s Nurse Care Manager Program• Focus on high risk areas, underserved populations
Post-program fundingSUSTAINABILITY
• Develop a long-term viable funding plan• Collect & analyze outcomes data
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WE HAVE SHOWN SUCCESS SCALING IN MASSACHUSETTS AND ARENOW SHARING OUR LEARNINGS NATIONALLY
We’ve shown scalability in Massachusetts… . . . Now sharing model nationally
201623
201732
201856
0
10
20
30
40
50
60
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
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PAST 3 MONTH HEALTH CARE UTILIZATION OUTCOMES MA OBAT SITESJUL 1 – SEP 30, 2017 (N=6,506)
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4.4%5.3%
16.6%
1.1%
3.8%
10.9%
1+ night detox 1+ night inpatient hospital 1+ ED
% o
f pat
ient
s in
STA
TE
OB
AT
P
rogr
am
In treatment <= 12 mos.
In treatment > 12 mos. Retention in OBAT
Detox, inpatient, ED admissions
LOWERING BARRIERS TORECEIPT 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
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REACH OF BMC OBAT TTA TEAMAPR 2017 – APR 2018
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• 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
• Provided >140 hours of on site technical assistance to >50 community OBAT sites
Program responsive to
changing needs of providers and
patients
LOWERING THRESHOLD FOR TREATMENT IN OFFICE-BASED SETTINGS
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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.
Fewer requirements for MAT in new BMC Clinical Guidelines
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
185
543144679
4579 665
CT = 832
DC = 158
DE = 136
2276
821
GU = 2
HI = 159
119
139
966650
167 817
483
MA = 2339
MD = 1233
563
1179
458
524
MP = 1
229
70
968
43
100
NH = 292
NJ = 1307
502
278
4168
1921
343
702
2433
PR = 528
RI = 369
459
54
865
1466
51
787
VI = 2
VT = 307
1516
610
341487
States with Highest % of
Waivered MDs/DOs*
Vermont = 14.1%
Maine = 12.6%
Alaska = 10.2%
New Mexico = 9.3%
Rhode Island = 7.8%*Not including U.S. Territories
2018 WAIVERED MDS AND DOS BY STATEN = 42,015
16
36
2313205
309 130
CT = 182
DC = 30DE = 25
165
41
GU = 0
HI = 20
23
35
89 135
14 150
61
MA = 306
MD = 282
118
74
72
36
MP = 0
24
25
191
13
8
NH = 87
NJ = 150
96
53
449
410
18
116
203
PR = 0
RI = 47
77
7
0
142
91 96
VI = 0
VT = 42233
63
57
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States with Highest % of
Waivered NPs
Vermont = 11.3%
Maine = 10.8%
New Mexico = 9.6%
New Hampshire = 8.5%
Maryland = 8.5%
2018 WAIVERED NURSE PRACTITIONERS BY STATEN=5,284
17
19
2244
123 61
CT = 23
DC = 4
DE = 7
41
15
GU = 0
HI = 2
5
7
30 20
4 0
4
MA = 69
MD = 50
19
51
17
1
MP = 0
3
8
91
3
9
NH = 10
NJ = 17
15
15
153
59
14
38
90
PR = 0
RI = 13
15
1
0
34
35 20
VI = 0
VT = 1084
16
11
5
States with Highest % of
Waivered PAs
Alaska = 5.6%
Utah = 4.4%
Washington = 4.4%
Rhode Island = 4.2%
Vermont = 4.0%
2018 WAIVERED PHYSICIAN ASSISTANTS BY STATEN = 1,389
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NO. OF MDS, NPS AND PAS THAT COMPLETED 8 HOUR BUPRENORPHINE WAIVER TRAININGAPR 2017- APR 2018
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MDs138
NPs94
PAs 26
0
20
40
60
80
100
120
140
No. completing waiver training
MDs Nurse Practitioners Physicians Assistants
BMC OBAT TTA continues to
dedicate resources to engage mid-level providers to meet requirements to
prescribe buprenorphine
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 scarceMcCleery 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.
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TAILORING SERVICES TO HIGHRISK POPULATIONS: A FOCUS
ON POST-INCARCERATION
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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 >45An 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
ENGAGING INCARCERATED PERSONS AT TIME OF RELEASE: BMC OBAT’S PARC CLINIC
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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
TECHNOLOGY AS A TOOLFOR WORKFORCE
DEVELOPMENT
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LEVERAGING TECHNOLOGY:OBAT TTA WEBSITE AND RESOURCES
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
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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
Community providers learn from specialists
Community providers learn from each other
Specialists learn from community providers as best practices emerge
• Two main components of all teleECHO© clinic:1. Brief didactic presentation2. Case-based learning ( pt. case by spoke
participant)
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REACH OF BMC’S ADDICTION ECHO HUBS
National Opioid Addiction Treatment ECHO
Mass Office Based Addiction Treatment (OBAT) ECHO
A national collaboration between the ECHO Institute, HRSA, the American
Society of Addiction Medicine (ASAM), and 5 expert addiction hubs
OBAT ECHO is for Mass cites implementing office based addiction treatment, funded by Opioid STR
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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
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AN EVOLVING EPIDEMIC REQUIRES…
• Flexibility• 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.
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• 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).
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