Overcoming Barriers to Prescribing MAT - Brown-CME · 2019. 12. 17. · Overcoming Barriers to Prescribing MAT ... Integrate motivational interviewing and harm reduction Naloxone,

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Practical Solutions to Prescribing Medication Assisted Treatment

Overcoming Barriers to Prescribing MATRahul Vanjani, MD, MSc

Assistant Professor of Medicine, Clinician EducatorWarren Alpert Medical School

Center for Primary Care (CPC) Clinic | Providence, RI

Jointly Provided By

Supported by the CDC Prescription Drug Overdose Prevention for States Grant Academic

Center

Rhode Island Department of Health Academic Center Public Health Grand Rounds

Program Release: December 18, 2019Expiration Date: December 18, 2021Estimated time to complete: 60 Minutes There are no prerequisites for participation.

Method of Participation and How to Receive CME CreditThere are no fees for participating in and receiving credit for this activity.• Review the activity objectives, faculty information, and CME information prior to participating in the

activity.• View the CME presentations• Complete the CME activity evaluation and post-test at the conclusion of the activity. • A passing score of 75% must be achieved in order to receive a credit certificate.

Target AudiencePhysicians, Physician Assistants, Nurse Practitioners and other Healthcare Professionals

Overcoming Barriers to Prescribing MAT

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Privacy Policy: The Office of Continuing Medical Education (CME) and its educational partners protect theprivacy of personal and other information regarding participants and educational collaborators. The CME Office maintains its Internet site as an information resource and service for physicians, other health professionals, and the public. The CME Office will keep your personal information confidential when you participate in a CME Internet-based program. CME collects only the information necessary to provide you with the services that you request.

Disclaimer: This educational program is designed to present scientific information and opinion to healthprofessionals, to stimulate thought, and further investigation.

Disclaimer and Privacy Policy



CME AccreditationThis activity has been planned and implemented in accordance with the accreditation requirements andpolicies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Warren Alpert Medical School of Brown University and the Rhode Island Department of Health Academic Center. The Warren Alpert Medical School is accredited by the ACCME to provide continuing medical education for physicians.

Credit DesignationPhysicians: The Warren Alpert Medical School of Brown University designates this live activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Rhode Island Specific: This program qualifies for 1.0 hour CME Credit in Opioid Pain Management / Chronic Pain Management, one

of the required areas of section 6.0; 6.2.1 Rhode Island CME re-licensure requirements. This training meets the requirements set forth in RI Regulation 3.14 Prescriber Training Requirement for Best

Practices Regarding Opioid Prescribing. This specific training requirement is required only once & must be completed before renewal of controlled substance registration or two (2) years (whichever is longer).

Other Health Professionals: Participants will receive a Certificate of Attendance stating this program is designated for 1.0 hour AMA PRA Category 1 CreditTM. This credit is accepted by the AANP, AAPA, and RI Pharmacy re-licensure.

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In accordance with the disclosure policy of the Brown University CME Office as well as standards set forthby the Accreditation Council on Continuing Medical Education (ACCME), speakers have been asked todisclose any relevant financial relationship with the manufacturers of any commercial products and/orprovider of commercial services discussed in any educational presentation and with any commercialsupporters or exhibitors of this activity

The intent of this policy is not to prevent a speaker with a potential conflict of interest from making apresentation but to identified openly so that the listener may form his/her own opinion. Any potentialconflicts of interest have been resolved prior to this presentation.

This activity may include discussion of off-label or investigative drugs uses. Speakers are aware that it istheir responsibility to disclose to the audience this information. Individual Faculty Disclosure informationmay be found in the conference handouts.

Faculty Disclosure


Faculty Disclosure/Conflict of InterestThe following Speakers* and Planning Committee members have indicated that they have no relevant financial relationships to disclose:

Jaime Bernard, MS, LCDP

Associate AdministratorSubstance Abuse & Program DevelopmentProject Director, Federal MAT-PDOA GrantDepartment of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH)State of Rhode Island | Cranston, RI

Lauren Conkey, MPH

Overdose Prevention Outreach ManagerRhode Island Department of Health | Providence, RI

Jennifer Koziol, MPH

Drug Overdose Prevention Program AdministratorRhode Island Department of Health | Providence, RI

Linda Mahoney, CAADC, CCS

Administrator, Behavioral Health & Substance Use Disorder ProgramsBHDDHState of Rhode Island | Cranston, RIRI State Opioid Treatment Authority

James V. McDonald, MD, MPH (Course Director)

Chief Administrative OfficerBoard of Medical Licensure and DisciplineRhode Island Department of Health (RIDOH) | Providence, RI

Maria Sullivan, BS

Director, Continuing Medical EducationWarren Alpert Medical School of Brown UniversityProvidence, RI

Rahul Vanjani, MD, MSc*Assistant Professor of Medicine, Clinician EducatorWarren Alpert Medical SchoolCenter for Primary Care (CPC) Clinic | Providence, RI


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Please complete the Post-Test and Survey upon conclusion.

A passing score of 75% is required for credit.

If you have any questions regarding this activity, contact the Office of Continuing Medical Education at 401-863-2871 or [email protected]

Obtain Credits/Certificate


At the conclusion of this session, attendees should be able to:

1. Identify the major barriers to prescribing buprenorphine among waivered providers

2. Develop an approach to managing concomitant benzodiazepine/alcohol/stimulant use disorder in patients with opioid use disorder (OUD) already in treatment

3. Identify management strategies for patients with OUD experiencing acute pain or undergoing surgery

4. Evaluate and treat precipitated withdrawal in a patient maintained on methadone treatment

Learning Objectives


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Overcoming Barriers to Prescribing Buprenorphine

RAHUL VANJANI, MD, MSC

ASSISTANT PROFESSOR OF MEDICINE, ALPERT MEDICAL SCHOOL

MEDICAL DIRECTOR, PROVIDENCE TRANSITIONS CLINIC

DisclosuresNo conflicts of interest to disclose

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Objectives1. Identify the major barriers to prescribing buprenorphine among waivered providers

2. Develop an approach to managing concomitant benzodiazepine/alcohol/stimulant use disorder in patients with opioid use disorder (OUD) already in treatment

3. Identify management strategies for patients with OUD experiencing acute pain or undergoing surgery

4. Evaluate and treat precipitated withdrawal in a patient maintained on methadone treatment

Outpatient Treatment of OUD

• 41 patients with OUD (57% unemployed)• 71% retained in treatment at day 90

• 131 patients treated in a primary care setting vs 867 in a non-primary care setting

• Primary care group:• Higher 6-month treatment retention

(79% vs 61%)• Fewer hospital stays over 12 months

(0.22 vs 0.41)• Lower total cost ($10,942 vs $13,097)

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Barriers to prescribing buprenorphine

Despite positive attitudes toward buprenorphine, only 28% of providers reported prescribing buprenorphine

Lack of psychosocial support | time constraints | no specialty backup | lack of confidence

Lack of psychosocial support | Time constraints | No specialty backup | Lack of confidence

Previous Approach: Traditional counseling is needed to benefit from buprenorphine treatment

New Approach: Traditional counseling is not necessary for successful outcomes. Individualize care –some patients find counseling helpful, others do not

Evidence: Review of four RCTs testing addition of behavioral counseling to buprenorphine maintenance treatment found no benefit and four additional studies found some incremental benefit, but primarily among contingency management, and not, for example, cognitive behavioral therapy

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“Buprenorphine treatment is onerous and time-consuming”

Prescribing insulin and warfarin is more burdensome than treating opioid use disorder

Rare opportunity in primary care to see dramatic clinical improvement

Home inductions are just as safe and effective as office-based inductions

Buprenorphine provided by a PCP is effective with or without additional psychosocial interventions

Home Visit Instructions

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Maintenance Visit Template (EMR)# Opioid use disorder

Prescribed buprenorphine dose:

Interval history:Buprenorphine adherence: {SUBOXONE_ADHERENCE:21405}

Last use of opioids:

Last use of other substances: -Alcohol:-Benzodiazepenes:-Cocaine/crack:-Marijuana:-Other:

Cravings/Triggers/Pain:

Coping strategies/social supports/mental health counseling:

Buprenorphine Resources

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“Titrating insulin, starting anticoagulants, and prescribing full agonist opioids for pain are often more challenging and potentially harmful than prescribing buprenorphine.”

UCSF Warm Line: 855-300-3595 (9am – 8pm ET)


Knowing your resources

Start treating patients – you’ll learn from them

Back up: UCSF Warm Line: 855-300-3595 (9am – 8pm ET) and Centers of Excellence

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CasesCase #1 (Diversion)

Case #2 (Urine toxicology)

Case #3 (Acute pain)

Case #4 (Precipitated withdrawal)

Case #1Mr. Levitt is a 37-year-old who presents to your clinic for routine primary care follow up. During the discussion, it comes to light that Mr. Levitt has been self-treating his back and knee pain with IV fentanyl. His history of self-treatment begins 3 years ago when he began buying Percocet off the street. For financial reasons, he transitioned to IV fentanyl a few months ago. Upon further questioning, he meets the DSMV 5 criteria for OUD.

You recommend that he consider starting buprenorphine. He responds that he would like to do this. He last used a week ago; he has since run out of money. Withdrawal has come and gone, but intense craving remains.

You’ve already spent 45 minutes with Mr. Levitt and have to move on to your next patient. You’ve ordered a urine toxicology, but it takes a few hours to result and 7 days to confirm results with chromatography.

What would you do next?

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Case #1 ContinuedYou decide to start the patient on buprenorphine. You instruct him to start at 8mg once today and then to increase to 16mg daily for the next week and to then follow up with you in a week, when you next have an opening.

Case #1: Take-home pointsDiversion is most commonly the result of high threshold prescribing – the solution is to lower the threshold to prescribing buprenorphine to people who need it

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Case #2Mr. Jones is a 60yo with h/o injection heroin use and recurrent cellulitis who presents for follow-up of OUD. He has been in buprenorphine treatment with you for 1 year. He reports daily adherence to buprenorphine/naloxone 8-2mg twice a day, and regularly attends his appointments. He states things are going well now that he has started a new job. His most recent urine drug screen shows buprenorphine and cocaine.

How would you interpret the urine drug screen?

How would you discuss the test results with the patient?

How do you counsel him about his cocaine use?

How would this influence your buprenorphine prescribing? What else can be recommended for him?

Case #2: Take-Home PointsUrine drug test = adjunct to patient self-report for identifying relapse, other substance use, and adherence

Concomitant substance use - especially cocaine - is NOT a contraindication to continuation of OUD treatment

Integrate motivational interviewing and harm reduction

Naloxone, safe injection practices, evaluate other substance use, continue to engage in OUD treatment

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Case #3Mrs. Smith is a 52 yo W with OUD on buprenorphine/naloxone 16mg/4mg daily who is scheduled for a L knee replacement in one week. She has been stable on buprenorphine for three years. Urine screens show expected results.

How do you manage her buprenorphine/naloxone during the peri-operative period?

How do you manage her pain during the peri-operative period?

How do you coordinate her care?

Case #3: Take Home PointsIntrinsic activity and affinity do not translate to clinical analgesic efficacy

Maintain patients on current buprenorphine dose

◦ Split into TID dosing to take advantage of analgesic property

◦ Follow standard principles of pain management

◦ Adjunctive medications

◦ Full agonist opioid

Inpatient team should coordinate with outpatient buprenorphine prescriber

◦ Schedule an appointment with buprenorphine prescriber within one week of discharge

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Pain Prior to surgery Day of surgery After surgery Pain control Discharge

Mild pain Coordinate with outpatient buprenorphine provider

Check PDMP

Continue full dose

Continue full dose

Split TID

Update outpatient buprenorphine/naloxone provider

TID dosing may be sufficient

Schedule appointment with outpatient buprenorphine/naloxone provider within one week

Moderate pain

Coordinate with outpatient buprenorphine provider

Check PDMP

Continue full dose

Continue full dose

Consider splitting TID


Adjunctive therapies may be necessary


Severe pain Coordinate with outpatient buprenorphine provider

Check PDMP

Continue full dose

Continue full dose

Consider splitting TID


Adjunctive therapies will be necessary

Full agonist opioids may be necessary


Case #4Mr. Blue is a 43yo M with h/o OUD who had been managed in a methadone maintenance clinic for several years with a baseline dose of 120 mg. A recent ECG shows a QTc of 510. Given this and his desire to avoid daily clinic visits for methadone, you decide to do an in-office induction after discussion with the methadone clinic.

Ahead of the induction, he is able to titrate down over several weeks to a dose of Methadone 40mg daily.

How do you safely and effectively manage the transition from methadone to buprenorphine?

What do you when, 15 minutes after taking the SL buprenorphine, he starts reporting nausea, vomits, is sweating profusely, pacing and agitated?

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Case #4: Take-Home PointsTransitions from methadone to buprenorphine are likely to go more smoothly if patient is on 30 mg per day of methadone (or less) for at least 1 week

When doing a standard transition from methadone to buprenorphine, due to long half life of methadone, it is important to wait until patient is in moderate to severe withdrawal (COWS > 13-15); this may take 36-96 hours

If precipitated withdrawal occurs in the outpatient setting, the best approach is to continue to dose the patient with low doses of buprenorphine (2 mg) every 1-2 hours until patient’s withdrawal improves

Concurrent dosing with supportive medications, including Clonidine, can help alleviate symptoms of precipitated opioid withdrawal

For patients who cannot self-taper their Methadone to tolerate a standard induction, transdermal buprenorphine (Butrans) may ease the transition to sublingual buprenorphine

Symptoms Management

Sweats/palpitations Clonidine 0.1-0.2mg PO Q6hrs PRN (hold for BP<90/60)

Anxiety, dysphoria, lacrimation, rhinorrhea Hydroxyzine 25-50mg PO Q8hrs PRN

Diarrhea Loperamide 4mg POx1, then 2mg PRN (max 16mg/day)

Muscle aches Menthol/m-salicyclate cream QID PRN

Muscle spasms Methocarbamol 1000mg PO Q6hrs PRN

Nausea/vomiting Ondansetron 4-8mg PO Q6hrs PRN

Pain Acetaminophen 650mg PO TID PRN

Sleep disturbance Trazodone 50mg PO QHS PRN

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ReflectionsTake 2 minutes to write down (or tweet)…

◦ One take-home point from this talk that you plan on sharing with colleagues

◦ One change in your practice of managing patients with OUD that you plan on implementing when you return to work

Please complete the Post-Test and Survey upon conclusion.

A passing score of 75% is required for credit.

If you have any questions regarding this activity, contact the Office of Continuing Medical Education at 401-863-2871 or [email protected]

Obtain Credits/Certificate

Documents

Overcoming Barriers to Prescribing MAT - Brown-CME · 2019. 12. 17. · Overcoming Barriers to Prescribing MAT ... Integrate motivational interviewing and harm reduction Naloxone,