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ACCESSTOMEDICATIONASSISTEDTREATMENTUSINGNURSECARE
MANAGERS
ColleenTLaBelleMSN,RN-BC,CARNBostonUniversityMedicalCenterProgramDirectorSTATEOBOT
DISCLOSURE
Thespeakersandplannersofthiswebinarhavenorelevantfinancialrela6onshipstodisclose
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TheAddicHonCrisis
• Prolongedsubstanceusecausesneurochemicalandmolecularchangesinthebrain,whichalter1:
o MetabolicbrainacHvity
o Geneexpression
o Receptoravailability
o SensiHvitytoenvironmentalcues
Effects of Heroin Dependence on Brain Dopamine D2 Receptors2
1. Leshner AI. Science. 1997;278:45-47. 2. Wang GJ et al. Neuropsychopharmacology. 1997;16:174-182.
Addic%on is a Treatable Brain Disease
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OpioidDetoxifica.onOutcomes
• LowratesofretenHonintreatment• Highratesofrelapsepost-treatment
§ <50%absHnentat6months§ <15%absHnentat12months§ Increasedratesofoverdoseduetodecreasedtolerance
O’Connor PG JAMA 2005 Mattick RP, Hall WD. Lancet 1996 Stimmel B et al. JAMA 1977
Medica.onAssistedTreatment
• Goals• Alleviatephysicalwithdrawal• Opioidblockade• Alleviatedrugcraving• Normalizedderangedbrainchangesandphysiology
• SomeopHons• Naltrexone(opioidantagonist)• Methadone(fullopioidagonist)• Buprenorphine(parHalopioidagonist)
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34,140BUPRENORPHINEWAIVEREDPHYSICIANSASOFNOV2015
220
113
111
Source:CenterforSubstanceAbuseTreatment,SubstanceAbuseandMentalHealthServicesAdministraHon.2015.
BARRIERSTOPRESCRIBINGBUPRENORPHINEINOFFICE-BASEDSETTINGS
[VALUE]%[VALUE]%
[VALUE]%[VALUE]%
[VALUE]%[VALUE]%[VALUE]%[VALUE]%[VALUE]%
InsufficientPhysicianKnowledgeOfficeStaffSHgma
LowDemandPharmacyIssues
InsufficientStaffKnowledgeInsufficientInsHtuHonalSupport
PaymentIssuesInsufficientOfficeSupport
InsufficientNursingSupport
55%ofwaiveredproviders
reported1ormorebarriers
Source:Walleyetal.JGenInternMed.2008;23(9):1393-1398.
N=156waiveredphysicians;66%responserateamongallwaiveredinMAasof10/2005
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ONLYDEAWAIVEREDPHYSICIANSCANPRESCRIBE
BUPRENORPHINE.(NOTFORLONG!!!!)
HOWEVER…
…ITTAKESAMULTIDISCIPLINARYTEAMAPPROACHFOREFFECTIVE
TREATMENT.
DrugAddicHonTreatmentAct(DATA)2000
v AmendmenttotheControlledSubstancesActv AllowsphysiciantoprescribenarcoHcdrugsscheduledIII,IVorV,FDAapprovedforopioidmaintenanceordetoxificaHontreatment§ Prior10/2002nodrugexisted§ Methadonedoesnotqualify
ANewLaw
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DATA2000:PhysicianIni.ally…SoonNPandPA’s
v MD’s:licensedtopracHcebyhis/herstatev Havethecapacitytoreferforpsychosocialtreatmentv LimitnumberofpaHentsreceivingbuprenorphineto30paHentsforatleastthefirstyear,filetoincreasein1year
v Canapplyfornewwaiver;expandto275paHentsifaddicHoncerHfiedandworkinmedicalsenngsfor24hourservices
v CARA:NPandPAwillbeallowedtoprescribewith24hourstraining(8whichincludeswaivercourse)v CURESAct:FundingforCARAImplementaHonv SAMHSA:Definingthetrainingrequirements
BUPRENORPHINE
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100
90
80
70
60
50
40
30
20
100
-10-9-8-7-6-5-4
%Efficacy
LogDoseofOpioid
FullAgonistMethadone
Par.alAgonistBuprenorphine
FullAntagonistNaltrexone
Opioideffect,
seda.on,respiratorydepression
OpioidPotency
Dr.LauraMcNicholas
OBAT
BMC’SOFFICEBASEDADDICTIONTREATMENT(OBAT)MODEL
¡ CollaboraHveCare/NurseCareManagerModeldevelopedatBostonMedicalCenter(BMC)
§ Nursecaremanagers(NCMs)workwithphysicianstodeliveroutpaHentaddicHontreatmentwithbuprenorphineandinjectablenaltrexone
¡ Morerecentlydubbedthe“MassachuseqsModel”
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Arch Intern Med. 2011;171:425-431.
BMC’SNCMOBATMODEL:5-YEAREXPERIENCE
¡ PaHent-leveloutcomescomparabletophysician-centeredapproaches
¡ EfficientuseofphysicianHmeallowsfocusonpaHentmanagement(e.g.,doseadjustments,maintenancevstaper)
¡ ImprovedaccesstoOBATanddailymanagementofcomplexpsychosocialneeds(e.g.,housing,employment,healthinsurance)
¡ OpencommunicaHonbetweenNCMandotherprovidersincludingbehavioralhealthimprovecompliance
Source:Alfordetal.ArchInternMed.2011;171:425-431.
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J Subst Abuse Treat. 2016;60:6-13.
0 1000 2000 3000 4000 5000 6000 7000 8000 9000
2007 2008 2009 2010 2011 2012 2013 2014
PATIENTSRECEIVINGBUPRENORPHINEINSTATEOBATCHCSBYYEAR
Between2007-2014>8,000pa.entstreatedwith
buprenorphineusingNCMmodelin14fundedCHCs
Source:LaBelleetal.JSubstAbuseTreat.2016;60:6-13.
No.ofp
a.en
tstreatedw/Rx
forO
UD
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10
1.53
1.17 1.17 1.24
0.580.69 0.65 0.67
0.54 0.55 0.62 0.61
2008 2009 2010 2011Prior6Months Future6Months Future7-12Months
AVERAGENO.EDVISITSPERSTATEOBATENROLLMENT:2008-2011
Source:OfficeofDataAnalyHcsandDecisionSupport,Bureauo5SubstanceAbuseServices,MADepartmentofPublicHealth.2014
AVERAGENO.HOSPITALADMISSIONSPERSTATEOBATENROLLMENT:2008-2011
0.260.23
0.2
0.26
0.1 0.1 0.09 0.10.12 0.12 0.12
0.08
2008 2009 2010 2011Prior6Months Future6Months Future7-12Months
Source:OfficeofDataAnalyHcsandDecisionSupport,BureauofSubstanceAbuseServices,MADepartmentofPublicHealth.2014
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STATEOBATINITIATIVEINCHCS:PROJECTGOALS
Expandtreatment&accesstobuprenorphineACCESS
• IncreasenumberofwaiveredMDs• IncreasenumberofindividualstreatedforopioidaddicHon• IntegrateaddicHontreatmentintoprimarycaresenngs
Effec.vedeliverymodelforbuprenorphineDELIVERY
• ModeledauerBMC’sNurseCareManagerProgram• Focusonhighriskareas,underservedpopulaHons
Post-programfundingSUSTAINABILITY
• Developalong-termviablefundingplan• Collect&analyzeoutcomesdata
TECHNICAL ASSISTANCE AND TRAINING PROVIDED TO CHCS
¡ NCM Orientation § Bupe 101: 8 hr training on SUDs and OBAT model (RNs, MAs, SWs)
¡ Initial on-site TA § Addiction 101: all staff training on OBAT and disease model of addiction § Meetings with key members of care team (RN, MDs, Mas) § Special-topic trainings: stigma, special populations, etc.
¡ Ongoing provider support (nurses and waivered providers) § Provided via telephone, email or on-site visits § Address issues such as: MD or nurse leaving, practice closures, clinical
questions (e.g., transfers, surgery, pregnancy, administrative issues, linkage to other treatment options, insurance changes, prior authorizations, etc.)
¡ Quarterly provider meeting § Opportunity for further education, networking, support
¡ Maintain list server for addiction providers § Relevant research, news articles, patient resources, group discussions, new
clinical guidelines, regulatory issues, job postings, etc.
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INSUMMARY,EXPANSIONOFBMC’SNCMOBATMODELACROSSMAHAS…
¡ Expandedtreatment§ >10,000paHentstreatedthroughSTATEOBATsince2007§ TreatmentavailableinpaHents’communiHes
¡ Developedasustainablereimbursementmodel§ FQHCs§ Insurance
¡ ImplementedevidencebasedtreatmentforSUDsandbestpracHcesasthestandardofcare
¡ SupportedandengagedCHCprovidersandstafftotreatSUDs§ ReducedsHgma
BMC’SNURSECAREMANAGER(NCM)OBATMODEL
Training• RegisteredNurses• 1-daytraininginaddicHonandtreatmentofSUDs
Fidelity
• PerformpaHenteducaHon&clinicalcarefollowingtreatmentprotocols
• Maintaincompliancewithfederallaws
Collabora.on
• CoordinatecarewithOBATphysicians• Collaboratecarewithpharmacists(refillsmanagement)• Off-sitecounselingservices
Addi.onalServices
• Urgentcaredrop-inhours• Manageinsuranceissues(priorauthorizaHons)
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NCMsincreasepa:entaccesstotreatment!¡ Frequentfollow-ups¡ Casemanagement¡ Abletoaddress
§ posiHveurines§ insuranceissues§ prescripHon/pharmacyissues
¡ Pregnancy,acutepain,surgery,injury¡ Concreteservicesupport
§ Intensivetreatment,legal/socialissues,safety,housing¡ Briefcounseling,socialsupport,paHentnavigaHon¡ Supportproviderswithlargecaseloads
WHATMAKESTHEBMCNCMOBATMODELSUCCESSFUL
BMCOBOTbecameknownasMassachusefsModelofOBOT
v ProgramCoordinatorintakecall
§ ScreensthepaHentoverthetelephone§ OBOTTeamreviewsthecaseforappropriateness
v NCMandprescriberassessments
§ NursedoesiniHalintakevisitandcollectsdata§ Prescriber:PE,andassessesappropriateness,DSMcriteriaofopioidusedisorder
v NCMsupervisedinducHon(on-site)andmanagedstabilizaHon(on-andoff-site(byphone))
§ FollowsprotocolwithpaHentselfadministeringmedicaHonperprescripHon
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NurseCareManagers(NCM)
v Registerednurses,completed1daybuprenorphinetrainingv PerformedpaHenteducaHonandclinicalcarebyfollowingtreatmentprotocols(e.g.,UDT,pillcounts,periopmgnt)
v Ensuredcompliancewithfederallawsv CoordinatedcarewithOBOTprescribersv Collaboratedcarewithpharmacists(refillsmanagement)andoff-sitecounselingservices
v Drop-inhoursforurgentcareissuesv Managedallinsuranceissues(e.g.,priorauthorizaHons)v OnaverageeachNCMsaw75paHents/wk
MassachusefsModelofOBOT
v MaintenancetreatmentpaHentincare(atleast6months)
§ NCMvisitsweeklyfor4-6wks,thenq2wks,thenq1-3monthsandasneeded
§ OBOTprescribervisitsatleastevery4months
v MedicallysupervisedwithdrawalconsideredbasedonstabilityifthepaHentrequestedtotaper
v TransferredtomethadoneifconHnuedillicitdruguseorneedformorestructuredcare
v Dischargedhigherlevelofcareforunsafebehavior
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Conclusionsv PaHent-leveloutcomescomparabletophysician-centeredapproaches
v AllowsefficientuseofproviderHmetofocusonpaHentmanagement(e.g.,doseadjustments,maintenancevs.taper)§ Allowedprescribertomanaged>numbersofpaHentsduetosupportofNCM
Alford DP, LaBelle CT, Kretsch N, et al. Arch Int Med. 2011;171:425-431.
v ImprovedaccesstoOBOTanddailymanagementofcomplexpsychosocialneeds(e.g.,housing,employment,healthinsurance)
TASupportv Nursingtrainingandongoingsupport
§ Phone,email,sitevisits,chartreviews§ QuarterlystatewideNCMmeeHngs:− addicHoneducaHon,support,networking
v Sitesupport:§ EducaHonallproviders− Trainings:addicHon,buprenorphine,sHgma,management,
setup§ SupportpracHce:providersandnursingissues§ CareforortriagepaHentstoothersitesduetoclosures,staffchanges,emergencyissues
§ DEASupport:EducaHonandpreparaHon,supportatvisits§ Waiverassistance,insurancesupport,coverage,carrierissues
MA Department of Public Health Bureau of Substance Abuse Services 2007
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UMassStudyFindingsinMassachusefs
v Studied5,600MassHealthClientsprescribedbuprenorphineandmethadone(2003-2007)
v OverallMassHealthexpenditureslowerthanforthosewithnotreatment
v ClientsonMedicaHonshadsignificantlylowerratesofrelapse,hospitalizaHonsandEDvisits:nomorecostlythanothertreatments
v BuprenorphineaqracHngyoungerandnewerclientstotreatment
Clark RE, Samnaliev M, Baxter JD, Leung GY. Health Aff. 2011;30:1425-1433.
OBOTRNNursingAssessment:
v Intakeassessment
§ Reviewmedicalhx,treatmenthx,painissues,mentalhealth,currentuse,andmedicaHons
v Consents/Treatmentagreements§ ProgramexpectaHons:visits&frequency,UDT,behavior§ UnderstandingofmedicaHon:opioid,potenHalforwithdrawal§ Review,sign,copiestopaHentandreviewatlaterdate
v EducaHon§ OnthemedicaHon(opioid),administraHon,storage,safety,responsibiliHesandtreatmentplan
v UDTv LFTs,HepaHHsserologies,RPR,CBC,pregnancytest
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Patient Agreement
Set the stage for ongoing relationship Clear message about rules Patient involvement Behavior is part of treatment
OBOTRNInduc.onPrepara.on:
Reviewtherequirementsprogram:
v Nurse/PrescriberAppointments:§ frequency,Hmes,locaHon
v Counseling:§ weeklyiniHally
v UrineDrugToxicology:§ atvisits,callbacks
v AbsHnence:§ fromopioidsisthegoal
v InsuranceverificaHon:§ priorauthorizaHons,co-pays
v Safety:§ medicaHonstorage(bankbag)
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OBOTTeamPa.entinstruc.onsforinduc.onday:
v InsuranceverificaHon§ PriorauthorizaHons,co-pays
v Disposeofparaphernalia,phonenumbers,contacts
v MedicaHonpickup:2mg/8mgtabs
v Nodrivingfor24hoursv Plantobeatclinicorofficefor2-4hours
v Bringasupportpersonifpossiblev DiscusspotenHalsideeffects(e.g.precipitatedwithdrawal)
OBOTPrescriber
v Reviewofhistory§ Mentalhealth,substanceuse,medical,social
v PhysicalExamv Labandurinetoxicologyresults
§ AssesscontraindicaHonsv Confirmopioidusedisorderdiagnosis
§ DSMVcriteriav Confirmappropriateforofficetreatmentv SignsordersandprescripHonv DeveloptreatmentplanwithOBOTteam
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OBOTRN,PrescriberPlanningforInduc.on:
v AskingpaHenttoshowupinwithdrawalrequiresagreatdealofTRUST
v BuildarelaHonship:Support
v ReviewwithpaHentaheadofHmeusagehistory,withdrawalandmakeaplan
v Wriqenmaterials,ongoingeducaHon
v Emergencyandcontactnumbers
OBOTRNsIni.aldosebuprenorphine
v COWs>8-12v ObjecHvesignsarekeytomakingdxv Ask:WhattheylastUsedandWhen
v Startwith2-4mgslv Assess40min-1hourauerdosing
§ Beqer,worse,orthesamev Repeatdoseof2mg,assess1hour
§ SendhomewithinstrucHonstocallRN
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OBOTRNPa.entinstruc.onsduringfirstdose:
v Puttablet(s)filmundertongue(sublingual)orbuccalmucosa
v Don’ttalk,don’tswallow:salivapools
v Mayusemirror,watchthetablet(s)graduallyshrinkassistswithposiHoning's
v Don’tdrinkorsmokebeforeorimmediatelyauer
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OBOTRNFrequencyofVisits:
v Phonecontactdaily,ordailyvisitsforfirstfewdays,assessindividualneeds
v AtleastweeklyunHlstabilized(usually4-6weeks)
§ dosage,UDT,counseling
v Progresstoeverytwoweeks,monthly,random,q3-4months
OBOTRNComfortMeasures
v Tasteperversionv Headachesv Nauseav SweaHngv Insomnia• Morecommonwithmethadonetransfers
Consult with OBOT Prescriber as needed
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OBOTRN/PrescriberPrescrip.ons
v EarlyOn:§ SmallprescripHons1weekwithrefills§ IncreaseaspaHentstabilizes(UDT)§ 2weekprescripHonswithrefills(cancelPRN)
v AtpointofstabilizaHon:§ Monthlyvisits§ MonthlyprescripHonswithrefills
v Keepfileofpharmacycontactinfo§ Pharmacistpartoftreatmentteam
OBOTRNFollowupVisits:
v Assessdose,frequency,cravings,withdrawalv OngoingeducaHon:dosing,sideeffects,interacHons,support.v Counseling,selfhelpcheckinv PsychiatricevaluaHonandfollowupasneededv Medicalissues:vaccines,followup,treatmentHIV,HCV,engageincare
v AssistwithpreparingprescripHonsv FacilitaHngpriorapprovalsandpharmacyv Pregnancy:ifpregnantengageinappropriatecarev Socialsupports:housing,job,family,friends..stability
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OBOTTeamMonitoring
v UDTv Pill/Filmcounts??v PharmacyCheck-inv ObservedDosingv Randomcallbacksv Scheduledvisitsv Counselingcheckinv Checkinwithsupport/family/parent/partnerv Socialstability
• Balance clinical safety and risk of diversion vs. concerns of overburdening patient unnecessarily
• Induction or early maintenance period relatively small amounts: next clinical visit
• Rationale/protocol prescribing interval should be documented EMR
MISUSEDIVERSIONCONCERNS
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§ UDT is important initial comprehensive evaluation § Compliance with prescribed MAT (methadone or
buprenorphine) can be monitored § Use of other opioids, substances can be detected and treatment plan
adjusted accordingly • Results of urine drug testing and rationale for frequency of testing should
be documented in the medical record • Self-report often insufficient to determine status of substance use • Other clinical characteristics, e.g., social and occupational functioning,
external contingencies, should be considered when determining urine drug testing frequency
• Inappropriately burdensome testing may damage therapeutic alliance § Patients may interpret excessive demands for testing as not being
trusted or believed
URINEDRUGSCREENING
• Track of medication supply in EMR • Obtain urine toxicology screens
§ Absence of buprenorphine in urine • Involve family if appropriate to monitor medication supply • Emphasize adherence not on “as needed” basis • Discuss safe storage and not advertising/sharing medications
with others • Clinical follow up • Call backs/check in’s as needed • Transfer: Risk outweighs the benefit
MISUSERISKREDUCTIONSTRATEGIES
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• May divert all or some of medication money, drugs • Dose of buprenorphine narcotic blockage
§ Patients can lower maintenance dose below that of prescribed dose and divert “extra”
• Signs of misuse or diversion include: § Repeated lost prescriptions § Discordant pill count § Multiple prescribers: PMP
• Beware of misinterpreting pseudoaddiction § Patients maybe fearful of disruptions in medication
supply and resultant opioid withdrawal
DIVERSIONCONCERNS
OBOTRNRandomCallBacks
• Urinetoxicologyscreen• Pillcount• Observeddosing• PharmacyconfirmaHon• PrescripHonMonitoringProgramReview• Requestwhentobringpillsin,nottoeachvisitdueto
medicaHonsafety
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OBOTTeamMonitoring:Pharmacy
• ImportantCollaboraHon• IdenHfyonepharmacyforallmeds• Keeprecord:Name,number,address,faxonfile• Obtainrefillhistory:PrescripHonMonitoringProgram
§ Othercontrolsandprescribers• RefillsallowedonScheduledIII• Pharmacyalertsyouto:
§ Othermeds§ Earlyrefillrequests§ Behaviorissues
PaHentSafetyEducaHon
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ClinicalPathwayReview
Maintenancesummary:
• Expectstability• Expectimprovementindruguse,employment,criminality,
socialsupports• Counselingengagement• IfnotabsHnent,evaluateprogressintreatment:
§ evaluateneedchangeintreatmentplan§ higherlevelofcare
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LengthofTreatment
• Lengthoftreatment:WeaskpaHentstocommitto6monthsonbuprenorphine/naloxoneandthenreassess
• PaHentsshouldbeacHvelyinvolvedindevelopmentoftreatmentplan
• Everyoneisdifferent:NeedtomeetpaHentswheretheyareat§ Individualizetreatment§ Howlong…LongEnought
DischargeOp.onsfromOBOT
• Buprenorphinenotthe“miracledrug”
ItisaTool………..
• Establishlinkageswithprograms
• Assistwithdetoxadmission§ Ongoingtreatment:holding,residenHal
• TransfertoMethadoneMaintenance§ ShortorLongtermopHon
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NextSteps
v UHlizingnursecaremanagermodelstoexpandtreatmenttomoresites
v IncreaselevelofeducaHonamongprovidersinaddicHontreatment§ Nurses,doctors,supportstaff,and
administraHon
v Integrateintothemedicalhomemodelofcare
v ExamineandimproveretenHonandsustainabilityv ACOmodel:prevenHon
Trea.ngthe“Whole”Person
• ComprehensiveaqenHontoallmedicalandpsychosocialco-morbidiHes;
• Pharmacotherapyrarelyachieveslong-termsuccesswithoutconcurrentpsycho-social,behavioraltherapiesandsocialservices;
• SpecialaqenHontothoseatriskofmisusingtheirmedicaHonsorwhoselivingarrangementsposeincreasedriskformisuseordiversion;
• IndividualizeTreatment………….• NoOnesizefitsall
