Buprenorphine in Primary Care

1. Buprenorphine in Primary Care Lucas Buffaloe, MD Jan Campbell, MD Roopa Sethi, MD April 30, 2019

2. Working with communities to address the opioid crisis. • SAMHSA’s State Targeted Response Technical Assistance (STR-TA) grant created the Opioid Response Network to assist STR grantees, individuals and other organizations by providing the resources and technical assistance they need locally to address the opioid crisis . • Technical assistance is available to support the evidence-based prevention, treatment, and recovery of opioid use disorders. Funding for this initiative was made possible (in part) by grant no. 6H79TI080816 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

3. Working with communities to address the opioid crisis. • The Opioid Response Network (ORN) provides local, experienced consultants in prevention, treatment and recovery to communities and organizations to help address this opioid crisis. • The ORN accepts requests for education and training. • Each state/territory has a designated team, led by a regional Technology Transfer Specialist (TTS), who is an expert in implementing evidence-based practices.

4. Contact the Opioid Response Network • To ask questions or submit a request for technical assistance: • Visit www.OpioidResponseNetwork.org • Email orn@aaap.org • Call 401-270-5900

5. General Information

6. Statistics • National Survey on Drug Use and Health, 2017 • 11.1 million people misused opioid pain relievers in the last year (4.1%) • 1.7 million people met criteria for opioid use disorder (0.6%) • 886,000 people used heroin in the last year (0.3%) • 652,000 people met criteria for opioid use disorder (0.2%)

7. Overdose death rates involving opioids, by type, in the United States, 2000-2017

8. Opioid Use Disorder • A problematic pattern of opioid use leading to clinically significant impairment and distress • Multiple complications and co-morbidities • Other substance abuse • Mental health problems • Infection • Social dysfunction

9. Opioid Use Disorder • A problematic pattern of opioid use leading to clinically significant impairment and distress • Multiple complications and co-morbidities • Other substance abuse • Mental health problems • Infection • Social dysfunction • Plus the same chronic conditions that other people have

10. MAT • Medication-assisted treatment • Long-term use of a prescribed opioid or opioid antagonist to treat opioid use disorder • Most effective option for most patients • Treatment can be lifelong

11. MAT • Medications • Methadone • Buprenorphine • Naltrexone (opioid antagonist) • Goals • Eliminate or reduce illicit substance use • Reduce high-risk behaviors • Promote normal social function • Restore normal brain function

12. DATA 2000 • Drug Addiction Treatment Act of 2000 • Permits qualified physicians to treat opioid addiction with opioid medications that have been specifically approved by the FDA for that indication

13. DATA 2000 • Qualifications • Current state medical license and DEA number • Not less than 8 hours of training in the treatment and management of opioid-addicted patients • Capacity to refer patients for appropriate counseling • Must not have more than 30 patients on such treatment at one time in the first year, more than 100 patients in the following year, or more than 275 patients thereafter

14. Buprenorphine • Unique pharmacology • Partial opioid agonist • High affinity for opioid receptors • Ceiling effect • Long half-life • Administered sublingually • Usually combined with naloxone, an opioid antagonist

15. Buprenorphine • Brand names: Subutex, Suboxone, Zubsolv, Bunavail, Sublocade, Probuphine

16. Buprenorphine • Advantages: • Effective • Can be prescribed in office setting • Few adverse effects • Excellent safety profile

17. Buprenorphine • Limitations: • Limited number of prescribers • Can precipitate opioid withdrawal • High cost

18. US counties with physicians with waivers to prescribe buprenorphine

19. 10 Misconceptions about Buprenorphine

20. Misconception #1 • Addicts don’t need medicine to quit

21. Reality • Most of them do • Few patients with opioid use disorder with achieve long-term remission through psychosocial treatment alone • Medication-assisted treatment with buprenorphine, methadone, or naltrexone is recommended for most patients • Patients are not “trading one addiction for another”

22. Misconception #2 • Buprenorphine is dangerous

23. Reality • No, it’s not • Buprenorphine is very safe and easy to use • The risk of respiratory depression and death is extremely low • Precipitated withdrawal can easily be avoided with proper patient instruction

24. Misconception #3 • The training and paperwork required to obtain a waiver is difficult and time-consuming

25. Reality • It’s not • The training is brief – 8 hours – and free • Multiple training formats available • The waiver application can be completed online in just a few minutes • No need for additional documentation or record keeping

26. Misconception #4 • I don’t know anything about treating addiction

27. Reality • Yes, you do • You already treat patients with nicotine and alcohol addiction • You know how to counsel patients on lifestyle modification • Think of opioid use disorder like any other chronic disease

28. Misconception #5 • This is going to overwhelm my practice

29. Reality • Only if you let it • You’re only allowed to see 30 patients in your first year • Physicians who are still building their practices can accumulate patients quickly • Physicians with established practices will add patients slowly, if at all • Consider prescribing for patients already in your practice

30. Misconception #6 • My waiting room is going to be filled with drug addicts

31. Reality • It might be already! • People with opioid use disorder can’t be identified based on appearance alone • Many have stable employment, homes, and families • Some have chaotic social lives, but you wouldn’t know that right away

32. Misconception #7 • These patients are going to be hard to deal with

33. Misconception #7 • You’re thinking of chronic pain – this is different! • We’ve all had difficult conversations about opioids with our patients • With buprenorphine, you and the patient are on the same page • Some patients do have challenging mental health problems • Most patients get better, and are extremely grateful for your help

34. Misconception #8 • They will need a ton of complicated visits

35. Reality • Visits can be infrequent and brief • The first visit is usually lengthy • Patients need frequent visits when starting treatment • Urine drug testing can easily be incorporated in to clinic flow • Patients in sustained remission can see you monthly or quarterly (maybe even less frequently) • Many follow-up visits are quick – 10 minutes or less

36. Misconception #9 • Patients will misuse their medication, and I’ll get in trouble

37. Reality • No, you won’t • Some patients will relapse, use other substances, stop taking their medication, and give away or sell their medication • Responsible prescribing, clear documentation, regular office visits, and not exceeding your waiver limit will keep you safe • DEA audits are very pleasant

38. Misconception #10 • Family physicians shouldn’t be doing this

39. Reality • Family physicians are exactly who should be doing this • Opioid use disorder is a complex chronic disease with social, psychological, and physical dimensions • Family physicians have the broad training necessary to address addiction and its accompanying problems • This is a natural extension of what you already do

40. Reality • Treating patients with opioid use disorder has been an extremely rewarding part of my practice

41. Medication Assisted Treatment:What’s Treatment?

42. Many varieties of ‘Treatment’ • Drug counseling • 12-step self-help • On-line resources • Individual psychotherapy • Group therapies • Cognitive Behavioral Therapy • Intensive Outpatient Programs

43. DATA 2000 • Requires ability to refer patient to psychosocial treatment • Does not mandate psychosocial treatment or counseling • Does not define what constitutes psychosocial treatment • Does not address clinical decisions about appropriate referrals

44. “Medical Management” • Educate patient and family: chronic course, relapsing pattern, similar to other better known medical disorder, i.e. DM, COPD, • Referrals as needed: medical specialty, psychiatric, • Monitor buprenorphine compliance, UDS • Monitor progress, provide feedback, identify lapses, encourage persistence

45. Course of treatment • Start and stabilize buprenorphine before referring for psychosocial treatment • Patients may be more receptive to referral for psychosocial treatment after they become confident of buprenorphine efficacy to control craving/withdrawal • Let patient choose what type of psychosocial treatment seems most comfortable

46. Questions &Discussion