Staten Island MAT for OUD Learning Collaborative

SESSION #2

MARCH 18, 2019

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This program is supported by the NYS Opioid STR Grant funding from the NYS Office of Alcoholism and Substance Abuse Services

(OASAS)

The contents provided are solely the responsibility of the authors and do not necessarily represent

the official views of OASAS

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SI MAT LEARNING COLLABORATIVE: OVERVIEW

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Introductions ▪ Harshal Kirane MD (Course Director)

➢ Director of Addiction Services, Northwell Health – SIUH

➢ Assistant Professor of Psychiatry, Zucker School of Medicine at Hofstra/Northwell

▪ Amanda Wexler, LCSW, CASAC-T (Co-Facilitator)➢ RCDA HOPE Director of Navigation; Former Sr. Program Director at YMCA Counseling Service;

➢ Facilitator, Continuing Education Workshops, Rutgers University

▪ Salvatore Volpe, MD, FAAP, FACP, FHIMSS, CHCQM➢ Chief Medical Officer, Staten Island PPS

▪ Victoria Njoku-Anokam, MPH➢ Director, Behavioral Health & Care Management Initiatives, Staten Island PPS

▪ Jazmin Rivera, MPH ➢ Director of Behavioral Health, Staten Island Partnership for Community Wellness

▪ Nadeen Maklouf, PharmD, MPH ➢ Director, Clinical Engagement, Staten Island PPS

▪ Pat Lincourt, LCSW (OASAS Director - Division of Practice Innovation and Care Management)

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STRUCTURE ▪5 monthly sessions from February, 2019 to June, 2019

FOCUS on MAT for Opioid Use Disorder

▪Each session = 2 hours

▪Sessions will consists of :

1) Didactic Presentation

2) Case Conference YOUR participation is KEY!!!

3) Discussion

▪Up to 10 hours of CME/CEU credits available - you MUST complete pre and post tests

▪Target Audience: Clinical providers from substance use disorder/mental health treatment organizations, primary care practices, and hospital emergency departments who provide care for individuals with opioid use disorders

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PARTICIPANT ASSESSMENT ▪ Focus at program level to monitor progress

▪ Assessment to be completed at Sessions 1, 3, and 5

▪ Use online tool to complete assessment:

1. To login to your own account, complete assessment, and review current/past results, refer to FlexiQuiz Welcome message in your email inbox

2. To complete without creating account, click https://www.flexiquiz.com/SC/N/1a75abdb-962c-4005-b542-8a0df9856061

▪ Completion is required and results will support final program evaluation

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SESSION PRE and POST TESTS

▪ Use online tool to complete brief tests:

1. To login to your own account, complete assessment, and review results, refer to FlexiQuiz Welcome message in your email inbox

2. To complete without creating account, click https://www.flexiquiz.com/SC/N/915c8098-4c05-4422-96ce-900258ae181a

▪ Hand-Written Option

▪ Completed tests must be submitted to get CME/CEU credits

▪ For CMEs and participation certificates, sign-in to EEDS (see handout for Code and instructions)

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Accreditation

Accreditation Staten Island University Hospital is accredited by the Medical Society of the State of New

York (MSSNY) to provide continuing medical education for physicians.

Staten Island University Hospital designates this live activity for a maximum of 2 AMA PRA Category 1

CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in

the activity.

Disclosure Policy

Policies and standards of the Medical Society of the State of New York and the Accreditation Council for

Continuing Medical Education require that speakers and planners for continuing medical education

activities disclose any relevant financial relationships they may have with commercial interests whose

products, devices or services may be discussed in the content of a CME Activity.

The planners and faculty participants do not have any relevant financial relationships to disclose.

No commercial support was received for this activity.

Note: Documentation of participation will be provided to non-physicians that states that the activity was certified for AMA PRA Category 1 CreditsTM

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Expectations of Participants

▪ Timeliness

▪ Enthusiasm

▪ Respectful Dialogue and Exchange

▪ Constructive Feedback

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“How a Police Chief, a Governor and a Sociologist Would Spend $100 Billion to Solve the Opioid Crisis”

https://www.nytimes.com/interactive/2018/02/14/upshot/opioid-crisis-solutions.html

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Today’s AgendaTopic Time

1 Screenings, Assessment, and Admission Requirements

• Harshal Kirane M.D.Director of Addiction Services, Northwell Health – Staten Island University Hospital; Assistant

Professor of Psychiatry, Zucker School of Medicine at Hofstra/Northwell

• Amanda Wexler, LCSW, CASAC-TRCDA HOPE Director of Navigation; Former Sr. Program Director at YMCA Counseling Service;

Facilitator, Continuing Education Workshops, Rutgers University; Former Adjunct Professor, CASAC

and Master Social Work Programs, College of Staten Island

4:00-4:40pm

BREAK (10 mins) 4:40-4:50pm

2 Case Presentation & Discussion 4:50-5:40pm

3 “Safe Prescriber Pledge” Campaign

• Salvatore Volpe, MD, FAAP, FACP, FHIMSS, CHCQM

Chief Medical Officer, Staten Island PPS

5:40-5:45pm

4 Reminders/Next Steps 5:45-6:00pm

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Session #2 Learning ObjectivesUpon completion of this course, participants will be able to:

▪Gain an understanding of tools/scales for screening and assessing OUD

▪Gain an understanding of regulatory requirements for admission including toxicology screenings

▪Gain an understanding of best practices for conducting screenings and assessments in various settings particularly primary care and EDs

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SCREENINGS, ASSESSMENT, AND ADMISSION REQUIREMENTS

Staten Island MAT FOR OUD Learning Collaborative

Session #2 – MARCH 18, 2019

HARSHAL KIRANE, MD

N O R T H W E L L H E A LT H - S TAT E N I S L A N D U N I V E R S I T Y H O S P I TA L

Z U C K E R S C H O O L O F M E D I C I N E AT H O FS T R A / N O R T H W E L L

AMANDA WEXLER, LCSW, CASAC-T

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Financial Disclosures

▪ I have no financial disclosures related to the content of this lecture.

▪ I received an honorarium from the SIPPS to serve as the course director of this collaborative.

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Outline I. Key Screening and Assessment Tools for OUD

II. Best Practices for Conducting Screenings and Assessments

III. Admission Requirements

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Key Screening Tools and AssessmentHARSHAL KIRANE, MD

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From 2016-2025, over 700,000 Americans are predicted to die from opioid overdoses

Chen, Q. et. al, JAMA Network Open 2(2) 2019

19www.altarum.org

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= YOU!!!

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22D’Amico EJ. Et al. Pediatrics. 2016;138(6)

A fundamental clinical dilemma:

▪Guidelines propose screening for drug and alcohol starting in middle school

▪Most adolescents are NOT screened

▪At-risk youth remain unidentified and never receive preventive services

23D’Amico EJ. Et al. Pediatrics. 2016;138(6)

Lack of primary care screening is attributed to:▪Provider time constraints

▪Discomfort discussing substance use

▪Insufficient training

▪Lack of referral options

24Harris B. et al. Substance Abuse, 37:1, 161-167

25Harris B. and Yu J. Public Health. 2016 Oct;139:70-78.

26Miller PM. et al. Alcohol and Alcoholism 41 (3) 2006

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29Journal of Addiction Medicine Vol11;4;315-319

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SBIRT Screening, Brief Intervention, and Referral to Treatment

Harris B. et al. Substance Abuse, 37:1, 161-167

It is an approach to screening and early intervention for substance use

disorders and people at risk for developing substance use disorders.

SBIRT emphasizes combined effort of screening and treatment services

as part of a cooperative system of early intervention.

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So who should I screen?

US Preventive Services Task Force

…”current evidence is insufficient to assess the balance of benefits and

harms of screening adolescents, adults and pregnant women for illicit drug use” …

American College of Surgeons

REQUIRES screening for all level I and II trauma patients for alcohol misuse

American Academy of Pediatrics

RECOMMENDS screening of all patients starting in middle school

Committee on Trauma, ACS, 2006; D’Amico EJ. Et al. Pediatrics. 2016;138(6)

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So what should I use to screen?

Four (4) Validated Tools:

FOR ALCOHOL (AUD)

CAGE – Fast, reliable, prompts further assessment

AUDIT/AUDIT-C – reliable, captures up to 95%

FOR DRUGS (SUD)

CRAFFT – Adolescents

DAST 10 – Self-Report Tool

https://www.integration.samhsa.gov/clinical-practice/screening-tools

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Single-Item Screening Questions (SISQs)Clinician or Self-administered and validated

The alcohol SISQ:

“How many times in the past year have you had X or more drinks in a day?”

(X=5 for men, X=4 for women)

The drug SISQ:

“How many times in the past year have you used an illegal drug or used a

prescription medication for non-medical reasons (for example, because of the

experience or feeling it caused)?” (Response > 0)

McNeely J et al. J Gen Intern Med 30(12) (2015)

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So what should I use to screen for…? RISK of OUD

Many Tools but no validated “Gold Standard” !!!

ORT OPIOID RISK TOOL

STAR Screening Tool for Addiction Risk

SOAPP Screener and Opioid Assessment for Patients in Pain

SISAP Screening Instrument for Substance Abuse Potential

PDUQ Prescription Drug Use Questionnaire

Moore, TM. et al. Pain Medicine, 10(8) Nov (2009) 1426–1433

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Agreement between clinical interview and measures of aberrant drug-related behavior

Moore, TM. et al. Pain Medicine, 10(8) Nov (2009) 1426–1433

36Webster LR. and Webster R. Pain Med 6(6):432 (2005)

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So what should I use screen for …? CLINICAL ASSESSMENT

COWS CLINICAL OPIOID WITHDRAWAL SCALE

CINA Clinical Institute for Narcotic Assessment

SOWS Subjective Opioid Withdrawal Scale

CIWA Clinical Institute Withdrawal Assessment (ETOH and BNZs)

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CIWA vs. CINA vs. COWS

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Clinical Opiate Withdrawal Scale (COWS)

1. 11-item scale (0-48 range), Clinician-administered

2. Results stratified

Mild 5-12

Moderate 13-24

Moderate Severe 25-36

Severe > 36

3. Its true utility is a function of measurements over time

4. Must be interpreted in context of entire clinical picture

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41Drug Alcohol Depend. 2009 Nov 105 (1-2) 154-159

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So what should I use screen for …? OBJECTIVE MEASURES

PAST MEDICAL RECORDS

PRESCRIPTION DRUG MONITORING PROGRAM (NY I-STOP)

URINE DRUG SCREENS

Christo PJ et al. Pain Physician. 14(2) (2011)

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So how do I screen? 5 A’s!!!

NIDA

ARRANGE

ASSIST

ASSESS

ADVISE

ASK

45NIDA

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Keys to Effective Screening

ASK PERMISSION

EMPHASIZE CONFIDENTIALITY

FRAME YOUR INTENTIONS

BE DIRECT and NON-JUDMENTAL

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Let’s watch a few brief examples

SBIRT = Screening, Brief Intervention, and

Referral to Treatment

This case example demonstrates an ideal SBIRT

Brief Negotiated Interview (BNI) between an

emergency department (ED) doctor and a patient

actively using heroin. These skills are based in

motivational interviewing techniques.

https://www.youtube.com/watch?v=TGhj06-sM2Y

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Admission RequirementsAMANDA WEXLER, LCSW, CASAC -T

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“No Wrong Door”

▪OASAS has been committed to the concept that there is “no wrong door” to quality health care.

▪Reason for OASAS providers to do a MH screening and OMH providers to do a SUD screening.

OASAS Treatment of COD https://www.oasas.ny.gov/treatment/cod/index.cfm

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According to OASAS…▪Individuals should be welcomed into treatment wherever they enter and should be assisted in accessing services regardless of whether the client is appropriate for the agency service.

▪But how many times do clients/patients feel “turned away”?

OMH & OASAS Assessment Guidance Document https://www.omh.ny.gov/omhweb/resources/providers/co_occurring/adult_services/assessment.html

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Admission Criteria - ATC

https://www.oasas.ny.gov/atc/southbeach/admission.cfm

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Admission Criteria - Outpatient▪Individual must have a SUD

▪LOCADTR (Level of Care for Alcohol and Drug Treatment Referral):

▪Least restrictive setting that is likely to be successful.

▪Prior difficulty at outpatient should not lead to higher level of care.

▪LOCADTR Override

OASAS Part 822 Regulations Document: https://www.oasas.ny.gov/regs/documents/822.pdf

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Toxicology Testing▪Routine part of SUD assessment and treatment.

▪Positive/Negative rather than Dirty/Clean

▪Use results in a non-punitive manner ad to support and encourage recovery goals.

▪Presenting the results to the client can be empowering for the client as long as patient centered techniques are used.

OASAS Guidance on Urine Drug Testing: https://www.oasas.ny.gov/admed/recommend/guide3test.cfm

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BREAK

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CASE PRESENTATION

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Let’s watch a few brief example

Advanced Motivational Interviewing

https://www.youtube.com/watch?v=_VlvanBFkvI

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Let’s watch a few brief example

Motivational Interviewing

https://www.youtube.com/watch?v=67I6g1I7Zao

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Case 1 Vignette “My elbow hurts.”

HPI: E.H. is a 42 y.o. M with no significant past medical or psychiatric history presents with left arm cellulitis and fever. He reports he punctured his arm with a screwdriver while repairing his car 3 days ago and he is admitted to your team for IV antibiotics.

Day 2 of his hospitalization, he complains of vomiting and diarrhea and terrible joint aches “like he has the flu.”

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Case 1 Vignette cont’“My elbow hurts.”

On DAY 3

PE notable for:

Vitals – T: 102.1F, BP is 150/90, HR 125, RR 20

He is diffusely sweating, has difficulty sitting still and is constantly wiping his nose. His pupils are dilated, he has piloerection and a faint tremor when he is asked to hold out his hands.

So what do you want to do next ??? …

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Case 1 Questions1. What tool can assist your assessment of opioid withdrawal?

2. Estimate what the patient would score on Day 1 and Day 3. (i.e. mild, moderate or severe)

3. What options can be offered to manage this patient’s withdrawal symptoms?

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SMALL GROUP DISCUSSIONCASE 1

(10 MINUTES)

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“Standards” of Care 1. Provide PRN meds for nausea, vomiting, pain, etc.

2. Order standing meds of nausea, vomiting, pain, etc.

3. Start Clonidine regimen

4. Order “detox” consult

5. Order psych consult

6. Change pain regimen to oxycodone and fentanyl patches

7. Change to oral antibiotics and discharge patient with PCP f/u

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1. Nod empathically

2. UDS? Review Results

3. PDMP (NYS – ISTOP) checked?

-------------------------------------------------------------------

1. Clinical Assessment

1. Clarify history !!! (DAST 10)

2. COWS

3. Engage patient in collaborative treatment

2. Update your Treatment Plan

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CENTRAL DOGMA of ADDICTION TREATMENT

DETOXIFICATION REHABILITATION MAINTENANCE

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Case 1 Vignette cont’“My elbow hurts.”

▪Day 5 of hospitalization: (Day 3 of BUP taper)

▪E.H. expresses to you, “I’ve not felt this comfortable in so long, I feel like a huge weight is lifted off my shoulders. Thank you so much. I want to stay on this medication as a maintenance regimen which you told me about initially”.

▪So what do you want to do next? …

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“Standards” of Care 1. Refer patient back to PCP to sort out

2. Provide list of substance abuse services in the area

3. Order psych consult

4. Order “detox” consult

---

5. “That’s terrific to hear, let’s adjust your regimen and coordinate appropriate aftercareoptions.”

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Transition to Maintenance 1. BUP dose titration per protocol

▪BUP maintenance (8mg-16mg/daily)

▪Methadone → must refer to a MMTP

▪Naltrexone → requires 7-10 days opiate-free

2. Coordination of Aftercare

3. Overdose education and naloxone distribution

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Case 2 Vignette “My family is tired of me.”

36 yo M with hx of Bipolar Disorder, ADHD, and no known medical hx, presents for evaluation and referral for care of ongoing poly-substance use. He presently reports injecting 30 bags of heroin daily and sporadic Xanax use weekly.

Within the past year, he abstained from substances for a 7-month period following a Suboxone taper and transition to Vivitrol injections, which were effective. He reports that his last relapse was 6 months ago when he missed his Vivitrol injection.

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Case 2 Vignette cont’“My family is tired of me.”

Of note, client has 3 prior inpatient psychiatric hospitalizations, which he reports resulted from incidents between him and his wife after he was intoxicated on alcohol.

He is currently monitored by a private psychiatrist, and on a regimen of Seroquel, Effexor, and Adderall. His psychiatrist is receptive to coordinate care.

For the last week the client was taking “street Suboxone” (8mg daily), but has none left.

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Case 2 Vignette cont’“My family is tired of me.”

This client presented at your facility before and staff recommended inpatient rehab, but the client declined. Staff felt he required a higher level of care because of the amount of heroin he is injecting and because his wife requested he leave their home until he is “clean”.

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Case 2 Questions1. What’s your first step with this client? What are your concerns?

2. What level of care do you recommend?

3. What’s the plan if your MAT provider isn’t back at the facility for 5 days?

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SMALL GROUP DISCUSSIONCASE 2

(10 MINUTES)

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Case 2: ““My family is tired of me.”▪Would it be different if this client presented at the Emergency Room vs. an outpatient clinic?

▪At what point does an inpatient referral make sense?

▪How does his psychiatric history play into your decisions?

▪How many assessment visits would your clinic want this client to complete? How long would it take him to see the MD?

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“Safe Prescriber Pledge” CampaignDR. SALVATORE VOLPE

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“Safe Prescriber Pledge” Campaign▪ As part of the Staten Island Performing Provider System’s ongoing efforts to help curb the opioid epidemic we are pleased to announce the “Safe Prescriber Pledge” campaign.

▪ “Safe Prescriber Pledge” will serve as a tool to help clinicians and patients receive the latest evidence-based prescribing recommendations and care to manage pain.

▪ Healthcare providers will agree to/sign our “Safe Prescriber Pledge” elements

▪ It will start the conversation between patient and clinician on the various options that can be used to help patients protect themselves, and their loved ones from the risk of accidental overdose of opioids as well as the risk of addiction to opioids.

▪ Help us help in our prevention efforts to:

▪ Reduce mortality related to opioid abuse

▪ Enhance patient education regarding pain management

▪Target audience for the “Safe Prescriber Pledge”:

▪ Physicians, Nurse Practitioners,, Physicians Assistants, Dentists, Podiatrists, Pharmacists

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“Safe Prescriber Pledge” ElementsI, ____________________________, pledge to:

▪Prioritize non-opioid treatment options for pain

▪Utilize the Opioid Risk Tool (ORT)* to screen all patients before prescribing controlled substances

▪Use the NYS Prescription Monitoring Program (I Stop) before writing any prescription for opiates, benzodiazepines, Medication Assisted Treatment (MAT) medications

▪Follow Centers for Disease Control (CDC) guidelines for initial and chronic medication dosing*

▪Obtain informed consent on the risks and benefits of opioids to patients who would be receiving acute and chronic opioid prescriptions*

▪Maintain an office policy and procedure* on safe and effective management of prescribing Controlled Substances (CS) Prescribe Narcan for all patients on chronic opiates and MAT and:

▪ Demonstrate how to use Narcan

▪ Share information about Narcan

▪ Distribute Narcan educational materials

▪Offer patients on chronic opiates, benzodiazepines and MAT information on “Tamper Resistant” caps, bottles or other medication containers*

▪Complete a three-hour CME course in Pain Management, Palliative Care and Addiction every 3 years

▪Promote safe return of unused controlled medications

* Supporting documents found in Staten Island PPS “I Pledge” Toolkit

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“Safe Prescriber Pledge” Kickoff▪ April 10th, 6:30 – 8:00 PM

▪ Dinner to follow

▪ Williamson Theatre, College of Staten Island

▪ 2800 Victory Blvd., Staten Island, NY 10314

▪ You may earn $200 for attending the "Safe Prescriber Pledge" educational event and complete the post educational assessment if you have one of the following credentials: MD, DO, NP, PharmD, or PA.▪ Payments will be made only until you register successfully, attend the full-session event, and complete the post educational

assessment. Please contact Val Lajqi at (917) 830-1147 or Vlajqi@statenislandpps.org to register or with any questions.

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REMINDERS / NEXT STEPS

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Next session▪Date & Time: Monday, April 15, 2019 4:00-6:00pm

▪Didactic: ▪ Buprenorphine Induction and Management – Advanced Topics

▪Case Presentation:▪ Forms due April 1st, 2019

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Reminders ▪Log into FlexiQuiz to complete post-test and receive CME/CEU credits

1. To complete without login, click https://www.flexiquiz.com/SC/N/7e980ee4-ae50-4a62-bbde-fd92cf3e8b92

▪For CMEs and participation certificates, sign-in to EEDS (see handout for code and instructions)

▪For travel/mileage reimbursement, submit the completed form with receipts to vnjoku-anokam@statenislandpps.org OR Fax 917-830-1179

▪Questions? Contact

▪ Victoria Njoku-Anokam (vnjoku-anokam@statenislandpps.org, 917-830-1153)

▪ Jazmin Rivera (jazmin@sipcw.org, 718-226-0264)

▪ Visit www.statenislandpps.org/mat-learning-collaborative