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5/24/2018
1
Troubleshooting MAT Integration
in Primary Care
John Bachman, PhD
Troubleshooting MAT Integration in Primary Care
Barriers:
Stigma: Widespread belief that drug-addicted people perpetrate their own problems; denies they are victims of a chronic disease requiring treatment.
Sustainability: Many insurance plans deny or provide inadequate coverage for substance use disorder treatment services. Payment rules prohibit reimbursement for necessary
services and additional staff.
Patients’ Complexity: Solo providers cannot adequately manage complex OUD and chronic pain patients without RN case management, behavioral therapy &
support staff.
Troubleshooting MAT Integration in Primary Care
Solutions:
EDCHC educating community partners
Judges, Law Enforcement Officers/Probation Staff, CPS Social Workers,
Jail and School Nurses, OB/GYNs
EDCHC and CA H&W are conducting a fiscal analysis of MAT costs vs cost savings from team-based care. Inpatient and pharmacy costs show the greatest preliminary reduction.
Team-based MAT care reduces burden of competing demands on primary care providers.
Behavioral assessment and therapy, case management, urine drug screenings & appointment monitoring are done by the Team for efficiency and lowered provider burnout.
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Troubleshooting MAT Integration in Primary Care
MAT barriers exacerbate societal burden because ineffectively treated OUD patients:
● Die prematurely and spread blood-born infectious disease
● Over utilize EMS, ERs and are frequently (re)hospitalized
● Commit crimes, resulting in increased criminal justice system costs
● Have high rates of absenteeism from, and lower productivity, at work
● Drop out of school, disrupt families and/or become homeless
● Receive inadequate pre- and post-natal care and give birth to high risk newborns
Not In My BackyardGuess what… It already is
Troubleshooting MAT Integration
A Leadership Approach to Treating
Opioid Use Disorder
Terri Stratton, MPH, CEO
Where We Began…Late 2015• Limited experience with Suboxone
• Grant Opportunity with CA HealthCare Foundation
• Must Have – Support from clinical leadership (Medical Director)
• Ah ha moment – We are already treating these patients
(review of data with local hospitals)
• Many complex care patients (pain and OUD)
• Recognition as New Tool in our Toolkit
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Building a MAT Team
• Taping Experts and Resources (Experts/Trainings/TA)
• Identify Team Positions:
• X-waivered providers – had 1; 2 others secured.
• LCSW (had)
• RN Case Manager – recruited,
• SUD Counselor – new, recruited
• MAs – trained
• Manager – part time FNP
Organizational Perspective What was our prescribing habits – what needed to change
Getting the following on board:
Providers
Patients – letter to all patients with policy
Staff
Board
Community partners/influencers
Enforcement of patient contract for opioid use
Development of policies/procedures/workflow for MAT
Building Resources for SustainabilityFinancial
• CA HealthCare Foundation Implementation Grant
• HRSA AIMS Grant
• Hub and Spoke Grant
Professional/Emotional
• Moving patient stories
• Team support
• Partner recognition
• Community support
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Christina Lasich, MD
Chief Medical Officer
Community Health Center
Federally Qualified Health Center/ FQHC:
federally designated primary care delivery
system
Provide access to care regardless of
ability to pay
Meet health needs of community
Who we serve
Quality health care to all income levels
Scope includes uninsured, Medi-Cal,
Medicare, private and no insurance
Treat newborns to seniors
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Who we are
Nonprofit, community health center
Largest outpatient provider
in Nevada County
Sites: Grass Valley, CoRR, Downieville,
Auburn
Just opened in Penn Valley and Kings
Beach-Tahoe
What we do
One-stop health center: Grass Valley
Services
Medical
Dental
Behavioral health with psychiatrist
Maternity with OB/GYN
Pediatrics
On-site lab
Pain and Addiction Medicine
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Services
Nutrition
Diabetes education
Reduced cost prescriptions
Case managers
Care teams
Naloxone distribution for WSMC clients
On-site Pharmacy
Urgent Care
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What is Medication-Assisted
Treatment for substance use disorder?
Combination of medication, counseling and
behavioral health for treatment of
substance use disorder
The prescribed medication operates to
stabilize brain chemistry, block euphoric
effects, relieve cravings and improve
function.
Which medications are used
for the MAT program at WSMC?
Buprenorphine
Naltrexone
Acamprosate
Disulfiram
Supportive medications: Gabapentin
Psychotropic medications such as SSRI’s, Depakote and Trazodone
Tizanidine
What are the myths about
Buprenorphine?
Because it is a partial agonist, it isn’t a good analgesic
Has a ceiling effect for analgesia
Blocks other opioids, thus: Cannot be used peri-operatively
Blocks the potential lethal effects of other opioids like heroin
*Reference: cme.csam-asam.org:
Buprenorphine report by Andrea Rubinstein, MD
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What are the facts about
gabapentin for alcoholism?
2013 study published in JAMA
Alcohol Use disorder treated with 900mg/day or 1800mg/day vs Placebo
Gabapentin Increased rate of abstinence
Gabapentin Reduced rate of heavy drinking
2013 Annuals of Pharmacotherapy
RC/DB Gabapentin vs chlordiazepoxide for managing withdrawal symptoms
1200 mg of gabapentin for three days followed by a three day taper resulted in less sedation and less cravings than those that took chlordiazepoxide for same amount of time.
Selection criteria of no history of seizures and/or kindling
What are the available counseling
& behavioral health treatments?
On-site substance use disorder counselor for
on-demand assessments and treatment
WSMC Behavioral Health Dept.
Licensed Clinical Social Workers
What are the available counseling
& behavioral health treatments?
Community Partners: Community Recovery
Resources (CoRR), 12 step meetings,
Celebrate Recovery, Common Goals
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Who is appropriate for an
Outpatient MAT program?
Dependency to substances of abuse: opioids, alcohol, and/or benzodiazepines
Medically stable
Mentally stable
Ready for change
No potential for harm to self or others
Safe living environment
ASAM’s treatment criteria uses six
dimensions for assessmentAcute intoxication or
Withdrawal Potential
Exploring an individual’s
past or current experiences
of use and/or withdrawals
Biomedical
Conditions and
complications
Exploring an individual’s
health history and current
condition
Emotional, Behavioral,
or Cognitive Condition
Exploring an individual’s
thoughts, emotions, and
mental health issues
Readiness for Change Exploring an individual’s readiness or interest in
changing
Relapse, Continued
Use, or Continued
Problem Potential
Exploring an individual’s
unique relationship with
relapse or continued use
Recovery/Living
Environment
Exploring an individual’s
recovery or living situation,
and surrounding people
Special patient populations
that may benefit from MAT service
Chronic pain
Co-occurring disorders
Pregnant women
Polysubstance use
Methadone dependency
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Naloxone distribution
at Western Sierra Medical Clinic
California law
Nasal Naloxone
Team approach
Target at-risk populations
High doses or rotating opioids
Recent overdose
Recent release from detoxification or incarceration
Goals of Naloxone distribution for
WSMC patients
Opioid-overdose death prevention
Education about safe opioid use
and storage
Prevention and screening for
substance use disorders
All patients at WSMC will be screened
annually for SUD
All patients receiving controlled
substances are randomly screened with
UDT and regularly checked on PDMP
Youth outreach and prevention Program
to target disease onset
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How do we measure
success in our MAT program?
Reduction of dysfunction
Improved birth outcomes
Reduction in SUD-related deaths
Healthy Families= Healthy Community
Better Health Together
Christina Lasich, MD
Chief Medical Officer
5/24/2018
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What happens when pain and addiction collide?
Case of Opioid PLUS Benzodiazepine Dependency
53 year old woman with lumbar pain following lumbar discectomy with laminectomy presents to you because of worsening pain and to establish care. She is currently taking hydrocodone/APAP 10/325 tablet every 4 hours (6/day) and has been taking it for over 5 years. Two years ago she began taking alprazolam 0.5mg three times per day for anxiety as prescribed by previous primary provider. She is also using zolpidem 10mg at bedtime. Her CURES report shows that hydrocodone is frequently filled a week early. Her urine drug test is consistent accept for positive test result for oxazepam. When questioned, she admits to using a friends diazepam when she ran short of her medications. Her pain has been a 9/10 lately and she is feeling depressed.
How do you Open up a conversation or Broach the subject of chemical dependency???
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What are you able to do now with the use of
opioids that you were not able to do before?
• Sleep better
• Return to work
• Resume activities of enjoyment
• Play with children
• Exercise
STAGE 5
Begin a slow TAPER:5
STAGE 4
Step through the doorway of
HEALTH:
4
STAGE 3
Introduce OTHER SOLUTIONS
for pain:
3
STAGE 2
Promote Chemical STABILITY2
STAGE 1
Motivate the patient for
CHANGE
1
Pain and Chemical Dependency
Roller-Coaster
Step-wise Solution
Neutralize the Nervous System
The Neutralizing Medications: “calm the nerves”
• Beyond Gabapentin is Zonisamide, Topiramate, Tiagabine and Pregabalin
• TCA= Tricyclic Analgesics (amitriptyline, imipramine, desipramine)
• Baclofen, a muscle relaxant and NMDA antagonist
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STAGE 5
Begin a slow TAPER:5
STAGE 4
Step through the doorway of
HEALTH:
4
STAGE 3
Introduce OTHER SOLUTIONS
for pain:
3
STAGE 2
Promote Chemical STABILITY2
STAGE 1
Motivate the patient for
CHANGE
1
Pain and Chemical Dependency
Roller-Coaster
Step-wise Solution
Anti-Inflammatory Diet
STAGE 5
Begin a slow TAPER:5
STAGE 4
Step through the doorway of
HEALTH:
4
STAGE 3
Introduce OTHER SOLUTIONS
for pain:
3
STAGE 2
Promote Chemical STABILITY2
STAGE 1
Motivate the patient for
CHANGE
1
Pain and Chemical Dependency
Roller-Coaster
Step-wise Solution
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What happens when pain and addiction collide?
Pain is a physiological experience,
Suffering is a perception
Suffering is created by the way we think
about time, threats, meanings,
circumstances and stories
How can You Ease Suffering in Your Patient?
• Encourage patients to anchor into the moment instead of using the past as a source of comparison and the future as
a source of worry
• Help patients to develop outlets for frustration like hobbies and exercise
• Reframe the story as a story of survivorship and strength
• Be present for your patient
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Pain and Addiction are doorways to TRANSFORMATION
Better Health Together….
WSMCmed.org