Patient-centered Care for Opioid Use Disorder

David R. Gastfriend, M.D., DFASAMPI: “A Simple Large Trial of Patient-Centered Care for Opioid Use Disorders in FQHCs & Specialty Care Settings”Senior Research Scientist: Public Health Management Corp., Philadelphia PANovember 1, 2018

#PCORI2018

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David Gastfriend, MD, DFASAM

DisclosuresRelationship Company(ies)

Speakers Bureau blank

Advisory Committee blank

Consultancy BioCorRx, Horizon BCBS of NJ, IBM Watson

Review Panel blank

Board Membership blank

Honorarium blank

Ownership Interests Alkermes Inc., Am. Soc. of Addiction Medicine, DynamiCare Health Inc., Intent Solutions Inc.

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Objectives

At the conclusion of this activity, participants should be able to

• Describe evidence-based treatments for Opioid Use Disorder (OUD)• Describe current practices for OUD treatment• Describe challenges regarding patient access to treatment

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Current & Emerging Practice for Opioid Use Disorder• Current Practice: Specialty counseling and detox

• Office-based opioid treatment (OBOT) is rising• Abstinence Model is dominant model• Motivational Enhancement Therapy growing

• American Society of Addiction Medicine (ASAM) Criteria• Six dimensions of assessment and treatment: Withdrawal, Biomedical, Psychological,

Readiness, Relapse Potential, Environmental• Use the least intensive resource(s) known to yield optimal outcomes

• Personalized Addiction Treatment-to-Health Model (PATH) Study• Randomized control trial (N=800)• Compares PATH to community standard (specialty addiction programs)

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Evidence-based Treatments for Opioid Use Disorder

• Medication-assisted treatment (MAT)• Agonists: Methadone• Partial agonists: Buprenorphine SL/XR• Antagonists: Naltrexone PO/XR

• Contingency management (CM)• Cognitive behavioral therapy (CBT)• Peer support

Environment

Agent

Host

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Challenges & Solutions for Opioid Use DisorderChallenges• 90% do not seek or receive care• Limited resources and access• Impaired motivation• Stigma• Highly fragmented system

Proposed Solution: PATH in Federally Qualified Health Centers (FQHCs)• Multidimensional assessment• Evidence-based treatment: MAT, CBT, CM, peer support and collaborative care

MATPrimary Care

Behav’lHealth CM

Peer Support

CM

CBT

Psych Care

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Patient Need & Patient Choice Issues

Marked Heterogeneity in the Patient Population Due to• Opioid type (i.e.: prescription, heroin, or fentanyl)• Route of administration• Age, chronicity, and level of function• Prior treatment experience and phase of recovery• Chronic pain or pain orientation• Co-occurring disorders• Social chaos or disenfranchisement• Discontinuation concerns

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Patient Need & Patient Choice Issues, continued

• MAT selection• No predictors yet identified for extended-release naltrexone (XR-NTX)

selection (except need for detox)• The best basis for methadone vs. buprenorphine vs. XR-NTX treatment

may be patient preference• More evidence needed for initiation and termination decisions

• Psychosocial services• Recovery Model vs. Harm Reduction?• Scheduled vs. flexible approaches?• Best basis may be patient preference

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PATH Pilot Study: Six Implementation Findings

• In medication-assisted treatment,• Most buprenorphine-waivered prescribers don’t prescribe• XR-NTX induction is limited

• Group therapy and peer specialists need reimbursement• Contingency management faces policy obstacles, but solutions exist• Primary care has brief behavioral focus, but needs a longitudinal focus• There is a need more for addiction knowledge, resources are welcome• Peer-mediated street recruitment can be very successful

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Opportunity for Impact

• U.S. has 1,367 FQHCs• Reach more than 10,000 communities• Serve more than 25 million people (or

~1 in 12 Americans)

• If PATH shows similar or better retention/abstinence to usual care, then dissemination of this successful, feasible model of care could substantially improve access and outcomes in the epidemic

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Learn More• www.pcori.org

• info@pcori.org

• #PCORI2018

• https/empower.Stanford.edu

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Thank You!

David R. Gastfriend, M.D., DFASAMPI: “A Simple Large Trial of Patient-Centered Care for Opioid Use Disorders in FQHCs & Specialty Care Settings”

Senior Research Scientist: Public Health Management Corp., Philadelphia PA

November 1, 2018