Soraya Azari, MD · Soraya Azari, MD 1 Context • CSAM Webinar Series – 12 monthly webinars to support implementaon of medicaon-assisted treatment in primary care – Survey sent

CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement

Friday,October28,16

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Office-BasedBuprenorphine:Pa9entSelec9on,Induc9on,and

ManagementSorayaAzari,MD

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Context

•  CSAMWebinarSeries– 12monthlywebinarstosupportimplementa9onofmedica9on-assistedtreatmentinprimarycare

– SurveysentouttoHRSAMAT-grantrecipientclinicsinCAtosolicittrainingneeds

– UpcomingWebinars•  Checkthewebsite!

– HowtoRegister

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Bytheendofthissession…

•  Tobemoreconfidentindecidingbetweenhome-andoffice-basedinduc9onwithbuprenorphineforpa9entswithopioidusedisorders

•  Tounderstandbestprac9cesforconversionfrommethadoneorlong-ac9ngopioidstobuprenorphine

•  Toknowhowto“triage”apa9entwithanopioidusedisorder:methadonemaintenancev.officebasedoutpa9enttreatment(OBOT)

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Case1

•  MOisa34yoSpanish-speakingFwithahistoryofapriormotorvehicleaccidentleadingtochronicbackpainforwhichshewasprescribedlong-ac9ngmorphineandoxycodone.Shecon9nuedtakingopioidpainrelieversfor4years.

•  Shepresentsforanewprimarycareappointmentandsays,“Ineedtogetoffthese”andputsabo]leofMSCon9n60mgpillsontable.

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Case1con9nued•  Pa9entdescribesthatwhilesheoriginallystartedusing

theseforpain(Vicodin®),nowsheneedsthemtofeelnormal.Shetriedtostopusingthemaaershelostprimarycare,butfoundthatshecouldn’t.Shecon9nuestohaveintermi]entbackpain.

•  Shestartedpurchasingpillsoffthestreet,taking1-2MScon9n60mgpills,dependingonwhatshecanfind.

•  Sheworksashousekeeper.Liveswithhusbandand2kids.•  Shedeniesalcohol,benzodiazepine,heroin,s9mulant,or

tobaccouse.•  Shetakesnoothermedsandhasnoallergies.•  Examisnormal.Shehasnoevidenceofopioidintoxica9on

orwithdrawal.

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Ques9on

•  Whichofthefollowingrepresentsthebestapproachtomanagementforthispa9ent?– A)Prescribelong-ac9ngmorphineforchronicpain– B)Prescribebuprenorphine-naloxonefortreatmentofopioidusedisorder

– C)Admitfordetox– D)Taperdownthelong-ac9ngmorphine– E)Transi9ontoXR-naltrexone

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TheNewEpidemic

•  OpioidUseDisorders–  2012es9mates(NSDUH)

•  2.1millionrxpainrelievers

•  467,000heroin

June2015

Needles/heroin=addic9on

goo.gl/NNpwgx

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Pa9entSelec9on:WhenShouldIThinkBupe?

•  SAMHSAGuidelines(TIP40)–  Diagnosisofmoderate-severeopioidusedisorder–  InterestinTreatment–  Understandrisks/benefits–  Nocontra-indica9ons(allergy)–  Canfollowsafetyprecau9ons–  Reasonablyadherent–  PregnantorChild-bearingage–  LiverDisease–  Drug-druginterac9ons–  Needdetoxfirst–  Priortreatmentexperience–  PsychiatricStability–  PsychosocialCircumstances–  Co-morbidsubstanceusedisorder:alcoholandbenzodiazepines–  Readiness? 8


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FromSAMHSA:TIP40AvailablefreeatSAMHSA.gov 9

Diagnosis

–  Opioidusedisorder•  4Rs

–  Riskofbodilyharm–  Rela9onshiptrouble–  Rolefailure–  Repeateda]emptstocut

back•  4Cs

–  LossofControl–  Con9nuedusedespite

harm–  Compulsion(9me&

ac9vi9es)–  Craving

•  Withdrawalandtolerance

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Diagnosis

–  Opioidusedisorder•  4Rs

–  Riskofbodilyharm–  Rela9onshiptrouble–  Rolefailure–  Repeateda]emptstocut

backtriedtostop

•  4Cs–  LossofControltakingmore–  Con9nuedusedespiteharm–  Compulsionseekingstreet

drug–  Craving“can’tstopthem”

•  Withdrawalandtolerance

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CaseCon9nued

•  Youdiscusswiththepa9entyourconcernthatsheisopioiddependent.Youexplaintoheraboutbuprenorphine-naloxone,whichcouldprovideherwithbe]ertreatmentforpainandopioiddependence.

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Pa9entSelec9onCon9nued:WhenShouldIThinkBupe?

•  SAMHSAGuidelines(TIP40)–  Dxofmoderate-severeopioidusedisorder–  InterestinTreatment–  Understandrisks/benefits–  Nocontra-indica9ons(allergy)–  Canfollowsafetyprecau9ons–  Reasonablyadherent–  PregnantorChild-bearingage–  LiverDisease–  Drug-druginterac9ons–  Needdetoxfirst–  Priortreatmentexperience–  PsychiatricStability–  PsychosocialCircumstances–  Co-morbidsubstanceusedisorder:alcoholandbenzodiazepines–  Readiness? 13

CaseCon9nued:TalkingtoPa9ents&GeqngBuy-In

•  Pros– Won’tgointowithdrawal;lesshussle–  Possibilityofimprovedpaincontrol–  Safe/provenmedica9on–  Possiblean9-depressanteffect??

•  Cons–  dangerousifcombinedwithalcoholorbenzodiazepines–  Havetogothroughwithdrawalbeforestar9ngthemedicine(Iwillhelpyouwiththis)

–  Livertoxicity(rare)–  Can’tgethigh

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VAExperience:Co-occurringdisordersclinic

•  VAretrospec9vecohortof143ptswithchronicpainandaddicitoninducedonbupe-nal–  93/145(65%)con9nued

onthemeds•  Takenoffif:uncontrolled

pain>28mg,tox+3+,miss3+visits,3+earlyrefills

–  Painscoresmodestly,butsignificantlyimproved

•  Observa9onalcohort:dec2.3pointsonbupe

PadePAetal.JSAT2012;43(4):446-50.DaitchetalPainPhyscian2012;15:Es59.15

MoreInforma9on

•  www.naabt.org–  Buprenorphineeduca9onàPa9entstories

–  Onlinesupportcommuni9es

•  SAMHSA(samhsa.gov)–  Infochinese,russian,spanish,&vietnamese

h]p://www.samhsa.gov/medica9on-assisted-treatment/treatment/buprenorphine

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Alterna9vesforOpioidUseDisorder

•  Methadonemaintenanceprogram–  MOA:fullagonistatmuopioid

receptor–  Partofcomprehensivedrug

treatmentprogram•  Mandatorycounseling•  Dailya]endance•  Rulesguidingtake-home

privilegesandotherallowances–  Evidence-base:

•  Decreasedillicitdruguse,decreasedcriminalbehavior,decreasedmortality

–  Candidatepa9ents:•  Ac9veMHdisorders•  Highpsychosocialchaos•  Co-morbidsubstanceuse

disorders

•  Naltrexone–  MOA:compe99veantagonistat

opioidreceptor–  Forms:

•  Oral•  Intramuscular(XR-NTX;Vivitrol®)

–  Evidence-base:•  Meta-analysisnodifference

betweenoralformula9onandplacebo

•  Reduceddrugusewithintramuscularformula9on

–  CandidatePa9ents:•  Highlymo9vated(highrisk-high

reward);commi]edtoabs9nence•  Criminaljus9ceseqng(limitedMAT

op9ons)•  Intensiveadherencesupport•  Nootherillicitdruguse,lesssevere

usedisorder•  Abs9nentbuthighriskrelapse17

Alterna9vesforOpioidUseDisorder

•  Methadonemaintenanceprogram –  Pros:

•  Structure/support•  Observa9on&safety

–  Cons•  “liquidhandcuffs”•  Inadequatepaincoverage•  S9gma;culturalfit

•  Naltrexone–  Pros:

•  Supportfullabs9nence–  Cons

•  Followsopioiddetoxifica9on•  Cost/coverage

–  CaliforniaMedicalCoverage(TAR):»  Chargedwith,orconvicted

of,afelonyormisdemeanor,AND

»  Undercountyorstatesupervision,includingsubstancesabusemonitoring(AB109)

»  MustgothroughSpecialtyPharmacyNetwork

–  Upfrontcosttoorderproduct:$1570/380mg

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Pa9entSelec9onCon9nued:OurPa9ent

•  SAMHSAGuidelines(TIP40)–  Dxofmoderate-severeopioidusedisorder–  InterestinTreatment–  Understandrisks/benefits–  Nocontra-indica9ons(allergy)–  Canfollowsafetyprecau9ons–PLANFORSAFESTORAGE–  Reasonablyadherent-ATTENDSPRIMARYCAREAPPOINTMENTS–  PregnantorChild-bearingage–YES.UPTNEGATIVE.USINGCONDOMS

WPARTNER–  LiverDisease–LFTSNORMAL–  Drug-druginterac9ons–NODRUG-DRUGINTERACTIONS–  Needdetoxfirst–CURRENTLYNOEVIDENCEOFWITHDRAWAL–  Priortreatmentexperience–HASFAILEDDETOXATTEMPTS–  PsychiatricStability–YES–  PsychosocialCircumstances–STABLE–  Co-morbidsubstanceusedisorder:alcoholandbenzodiazepines–NO–  Readiness?–YES

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CaseCon9nued

•  Youandthepa9entdecidetoproceedwithatrialofbuprenorphine-naloxone.Whichofthefollowingistrueaboutunobservedhomeinduc9ons?– A)DuringDEAinspec9on,itismandatorytoreportwhetherhomeinduc9onhasoccurred.

–  B)Thereisanincreasedriskofprotractedwithdrawal.–  C)Evidencefromacademicseqngsandcommunity-basedclinicssupportthesafetyofhomeinduc9ons

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CaseCon9nued

•  Youandthepa9entdecidetoproceedwithatrialofbuprenorphine-naloxone.Whichofthefollowingistrueaboutunobservedhomeinduc9ons?– A)DuringDEAinspec9on,itismandatorytoreportwhetherhomeinduc9onhasoccurred.

–  B)Thereisanincreasedriskofprotractedwithdrawal.–  C)EvidencefromacademicseLngsandcommunity-basedclinicssupportthesafetyofhomeinduc9ons

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WhatAboutInduc9on?YourOp9ons

•  3Models1.  In-officeapproach2.  Specialtyclinicapproach3.  Unobservedhomeinduc9on

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Buprenorphine-Naloxone

SublingualFilm=Suboxone®;2/0.5,4/1,8/2,and12/3mgSublingualTablet=generic(2/0.5mgand8/2mmg)andbrandZubsolv®Buccalfilm=Bunavail®**ONLYFORMAINTENANCE

NOTDISCUSSING:Buprenorphineformula9ons(Butrans®,Buprenex®,Probuphine®

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In-officeInduc9on

•  About:Taughtin8hrwaivercourse;recommendedinTIP40,CSAT

•  Steps:–  Pre-visit&counselingtopreparept

•  Periodofabs:nence:12-16hforshort-ac9ng,17-24hintermed-ac9ng,and~30-48hrsformethadone

•  Mild-moderatewithdrawal(COWSscoreof12-16)–  Rxforbupe-naloxone(i.e.,2-0.5mg#8,or8-2mg#2)– Dose:2-4mgini9al,16mgmaxonday1– Monitor:1+hours–  Follow-up:phone(day2)+visit(day3or4)

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MaxScore=485-12=Mildwithdrawal13-24=Moderate25-36=Severe

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In-officeInduc9on

•  Pros:– Structured–observeddosing;lowcomplica9onrate

•  Cons– Labor,resourceand9meintensive– Staff/providereduca9on– Pa9entmaynotbe“ready”– Notpar9cularlypa9entcentered

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SpecialtyClinic•  Outpa9entBuprenorphine

Induc9onClinic(OBIC)–SanFranciscoModel–  Outpa9entclinicstaffedbyaddic9onpsychiatryandnurseprac99oners

–  Pa9entsseenonwalk-inandappointmentbasis

–  Ini9alIntakevisitàInduc9onvisitàStabiliza9on

–  Allowsfordailyfollow-up,ifneeded–  Afilliatedwithpharmacyonsitetopickupmeds

–  Freeforpa9entsinSF–  Transfertoprimarycareoncestabilized

CourtesyofMa]Tierney27

SpecialtyClinicInduc9on

•  Pros:–  convenientforprimarycareprovidersJ– Structure,support– Greaterexper9se

•  Cons:– Cost,resources,ins9tu9onalinvestment– Siloed– Communica9onandcarecoordina9onchallenges– Capacity

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3.HomeInduc9on

•  BasicProcedure:–  Seepa9entinprimarycarevisit&describethehomeinduc9onprocess

–  Providepa9enteduca9onmaterials

–  Pa9entinducesher/himselfathome

–  Closefollow-upbyphoneand/oroffice,typicallywithin1week

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HomeInduc9on

•  Pros–  Pa9ent-centered–  Provider-centered

•  Cons–  Lessstructureandoversight(thinkaboutpa9entselec9on)

–  Requiresmorerobustpa9entself-managementskills– Allotmentandreimbursementforprovider9me(i.e.,phonevisits)

–  Providerexperience

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Evidence-BaseforHomeInduc9ons

•  Academiccenters– Montefiore:

•  Nodifferencein30dreten9onintreatment(~78%),oradverseevents

–  NYU:Intakevisit,labs/urineàrec4/1mg,followedby1-2addi9onaldoses(max12mg).F/U:callcliniccoordinated1-3,f/uat1week.Typically#14of8/2mgtablets•  73%reten9on,nocasesofsevereprecipitatedwithdrawal

•  Communityprimarycare–  2006-2010:228pa9entshome-induced

•  1/228experiencedprecipitatedwithdrawal•  Conveniencesample:82%nega9veUDT,88%posforbupe

Dooli]le&Becker.SubstanceAbuse2011.LeeJetal.JGIM2009.SohlerNetal.JSubAbusTx2009..

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WhoDidn’tDoWell?

•  Studyofoffice-(56%)andhome-based(43%)induc9onsofpa9entsatMontefiore(n=107)–  16%“complicated”induc9ons

•  55%precipitatedwithdrawal,44%protractedwithdrawal–  Characteris9cs

•  Methadoneuse•  BZDuse•  Lowini9aldoseofbupe-nal(2-0.5mg)•  Startofprogram•  Hadn’tusedbupeinthepast

–  Lower30dreten9onintreatment

Whitleyetal.JSubstAbuseTreat.201032


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BacktoOurPa9ent

•  Youtalkaboutdoingthehomeinduc9on.•  Shecandescribethatshestartstogetsickabout12hoursaaertakinganMScon9n.Firstshefeelsanxiousandnauseous,thenshegetsbackandlegpain.Bythenshe’susuallyfoundanotherpill.

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HomeInduc9on:theDetails

•  Time:shewillhavetogo~24-30hourswithoutmorphine(longerisbe]er)–  Pa9enthandoutfromNYU–  SOWS

•  AncillaryMeds:–  Zofran4-8mgpoTIDPRNnausea–  Prochloreperazine10mgpoTIDPRNnausea/vomi9ng

–  Clonidine0.1mgpobid-9dPRNagita9on(cau9onhypotension)

– Hydroxyzine25-50mgpoqbed9mePRNinsomnia34


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•  PharmacyPrepara9on:–  Callinorwriteprescrip9on– Makesuremedica9oniscovered

•  IfmanagedMedical,billFFSMedical(carve-out)•  IfMedicare,bepreparedtodoPA•  Dx:F11.20(opioidusedisorder);nottakingotheropioids

•  Timing– Daypa9entwillinduce;–  Phonecallonday1aaerinduc9on+/-day2– Day3-5:appointmentinclinic

•  Checksymptoms,dose•  Urinedrugscreen,urinebuprenorphine 35


•  Dose– Day1:4-16mg;NTE16mg•  Formula9ons:

–  2/0.5,4/1,8/2,and12/3mgSLstrip–  2/0.5,8/2SLtab–  BuccalfilmNOTFDAapprovedforinduc9on

•  Schedule3medica9on•  Pro-9ps:notalkingfor15min,tweezers,candy

– Expecteddose:16-24mgdaily;mayneedtosplitdose

– Half-life=36hours36


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Case

•  Pa9entdecidesthatshewillstartthemedicineonTuesdaysincesheisoffwork.Shecanteachbackhowshewillstartthemedandhowlongsheneedstowait.

•  YoucallherTuesdayaaernoonaaerherfirstdose(2/0.5mgfilm)– Feeling“ok,”notreallysick,buts9llhavingpain– Youadviseanaddi9onal2/0.5mgfilm&thenaskhertotake4mgtomorrowAMor2/0.5BID

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Case•  Day2(phone):took2/0.5mgfilmthisAMandplanningtotakeanotherfilmlaterintheday

•  Day4(clinic):taking1-3of2/0.5mgfilmsperday.Feeling“be]er”withlesspainandmoreenergy.Deniesanymorphineuseorcravingformorphine.–  Urinedrugscreenandurinebuprenorphinesent–  Rxfor1weeksupplyofmeds

•  Day11(clinic):mostdaysonlyrequiring2filmsperday,butaaerharddayofwork,willtake3.–  Urinedrugscreen&urinebupesent– Warmhandofftobehavioralhealth–  Agreementsigned–  F/uin2weeks

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Case2•  LEisa56yoMwithahistoryofanopioidusedisorder(~25

years),inmethadonemaintenancestableonadoseof80mgdaily.Hehasbeendoingwellinprogramwithnofurtherillicitopioiduse(previousheroin&opioidpills).

•  Heisworkingasasecurityguardonthenightshiaandthisismakingitdifficulttogettomethadoneclinic.Hehashadsomeabsencesbecauseofthisandhaslosthistake-homeprivileges.Hehasnoac9veMHcondi9ons.Heishousedwithhiswife.

•  Heiswonderingifyoucanprescribehimbuprenrophine-naloxone.Hereallywantstostaycleanbutit’sbeentoodifficulttogettoclinic.Hehashadtobuystreetmethadoneonthedayshemisses.

•  Exam:normal(notracks).Labs:UDT+methadone.LFTsnormal,hep,HIVneg

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Ques9on

•  Whichisthebestmanagementplanforthispa9ent?– A)Signreleaseofinforma9ontotalkwithmethadoneclinicproviders

– B)Homeinduc9onwithbuprenorphine-naloxonewithpa9entabs9nentofmethadonefor48-72hoursbeforestar9ng

– C)Taperpa9entdownby40%priortoinduc9on

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MethadoneversusBuprenrophine-NaloxoneforMAT

•  FactorstoConsider– Doingwell?Whyrocktheboat?...–  Recoverysupports–  Co-morbidsubstanceuse(especiallyetohandBZDs)– Mentalhealthdisorder

•  BestPrac9ce–  Signreleaseofinforma9on&talktomethadonecliniccounselorand/orprovider•  Absentrecords,utoxresults,BAresults,func9onalrecovery

–  Tapermethadonedosedownto~30mgx1weekpriortoinduc9on 41

Case2•  LEisa56yoMwithahistoryofanopioidusedisorder,in

methadonemaintenancestableonadoseof80mgdaily.Hehasbeendoingwellinprogramwithnofurtherillicitopioiduse(previousheroin&opioidpills).

•  Heisworkingasasecurityguardonthenightshiaandthisismakingitdifficulttogettomethadoneclinic.Hehashadsomeabsencesbecauseofthisandhaslosthistake-homeprivileges.Hehasnoac9veMHcondi9ons.Heishousedwithhiswife.

•  Heiswonderingifyoucanprescribehimbuprenrophine-naloxone.Hereallywantstostaycleanbutit’sbeentoodifficulttogettoclinic.Hehashadtobuystreetmethadoneonthedayshemisses.

•  Exam:normal(notracks).Labs:UDT+methadoneonly.LFTsnormal,hep,HIVneg

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Casecon9nued•  Pa9entsignsreleaseofinforma9on.Youtalktothepa9ent’scounselorandlearnthatthepa9enthasbeendoingverywell.– Absent~2-4dayspermonth– UDT1/6withmorphine– Workingwithcounselor– Notgoingtoaddi9onalrecoveryprograms(i.e.,mee9ngs);wifeissourceofsupport

•  Pa9entisfrustratedandreally“wantstostart”thebupe-nal.Saysheknowssomeonewhodiditandhaslikedit.

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Casecon9nued

•  Youadvisethepa9entthatyouwanthimtohavethebestpossibleoutcomeandtomaintainhisrecovery.Youadvisethathetaperwiththesupportofhismethadoneclinic.

•  Thepa9entisfrustratedandleavesyourofficeangry.

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Casecon9nued

•  Oneweeklateryougetcallfromyourpa9ent.Hesaysheonlywenttomethadonecliniconceinthepastweek(80mg,2daysago)andisinwithdrawal.He’swonderingifyouwillgivehimbuprenorphine-naloxone?

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Ques9on

•  Whichofthefollowingisthebestmanagementplan?– A)Bringpa9entinforin-officeinduc9on– B)Instructpa9enttoreturntomethadoneclinic– C)Referpa9enttoanacutedetoxfacility

Alwayswanttosupportrecovery

Pa9ent’sgoalsv.yourgoals

Pa9entunlikelytohavesuccesswithdetoxgivenlonghxofdisease

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Casecon9nued

•  Pa9entcomesintoclinic.Heishavingrunnynose,wateryeyes,agita9on,andnasalstuffiness.HRis90.YoucalculatehisCOWSscoreas12.

•  Pa9entpicksupprescrip9onforbuprenorphine-naloxone8-2mgfilmsandreturnstoyouroffice.

•  Yougivenhima½ofafilm(4mg)àhefeelsworseaaer30minutes.

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PrecipitatedWithdrawal•  Assess

–  Didpa9entswallowbupeinsteadofletitdissolve?–  Didhetakeanotheropioidheforgettotellyouabout?

•  Reassure–  Youwarnedhimofthisrisk.Thereistreatment&hewillgetthroughthis.

•  HowtoManage:–  Stopinduc9on,or–  Con9nueinduc9on(typicallyfavored)

•  Giveaddi9onal2/0.5mgq30m–1hrun9lpa9entfeelingmorecomfortable

•  Somepa9entsmayrequireupto32mgtoalleviatewithdrawalsymptoms(wouldseekconsulta9on&support)

•  Ancillaryagentsforsymptomcontrol•  An9cipatoryguidance:maynotfeel*well*forseveraldays&mayhavedysphoriaupto2weeks

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Casecon9nued

•  Pa9entcon9nuedthebuprenorphineandgot16mgonday1.Hetook24mgthenextday.Byday5hewasstar9ngtofeelbe]er.

•  Cametofollow-upaptoneweeklateron24mgdaily,spliqnghisdose.Urinedrugscreennegforopioidsandotherillicits,posforbuprenorphine.

•  S9llworkingassecurityguard.Havingmildheadachefrombupe-naloxone,buthappytonotbegoingtomethadoneclinic.

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Summary•  Buprenorphine-naloxoneisahighlyeffec9vetreatmentforpa9entswithopioidusedisorders.

•  Carefula]en9onshouldbepaidtopa9entselec9onandeduca9onattheoutsettoensuresuccess.

•  Therearevariousmodelsforinduc9onontobuprenorphine–in-office,specialtyclinic,andunobserved“home”induc9on.

•  Homeinduc9onsarenotassociatedwithanincreasedriskofprecipitatedwithdrawalorpoorreten9onintreatment.

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Summarycon9nued•  Successfulhomeinduc9onisdependentonexcellentpa9ent

educa9onpriortostar9ng.•  Forpa9entswan9ngtotransi9onfrommethadoneto

buprenorphine-naloxone,bestprac9ceistoweandoseto30mgfor1weekandcollaboratewithmethadoneclinicduringthetransi9on.

•  Methadonemaintenanceprogramsarehighlyeffec9veforpa9entswithsevereopioidusedisordersthatrequireahigherlevelofaddic9ontreatment,eitherrelatedtopsychiatric,medical,orsocialinstability.

•  Ifyouhaven’talready,startprescribingbupe-naloxone.Bestlessonswillcomefromworkingwithpa9ents.

•  Helpisavailable:–  Substanceusewarmline,UCSF:1-855-300-3595.10a-6pmEST–  PCSS-Bmentor:psccmat.org/mentoring–  Localpeers

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Ques9on•  Whichofthefollowingrepresentsanop9malcandidatefor

buprenorphinetreatment?–  A)anHIVposi9vepa9ent,housed,psychiatricallystable,OUDtakingefavirenz-emtricitabine-tenofovir(Atripla)EFVlowersbupelevels

–  B)anewpa9enttoyourclinic,homeless,frequentlyadmi]edtothehospitalduetoLEpain,usingIVmethamphetamineandheroinsafestorage,poly-substanceuse,medicalinstability

–  C)56yoMhoused,INherointotreatpain,sporadicdiazepam,priorMMTbutledtoproblemsw/hisjob

–  D)long-termprimarycarepa9entofyourswithanalcoholandopioidusedisorder,currentCIWAscoreof12needsdetox

–  E)youngwoman,housed,employed,on160mgMMEforchronicpainwithnoconcerningbehaviorsnoOUD

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Documents

Soraya Azari, MD · Soraya Azari, MD 1 Context • CSAM Webinar Series – 12 monthly webinars to support implementaon of medicaon-assisted treatment in primary care – Survey sent