Abdel Fahmy, MD. Board Certified, Internal Medicine Board Certified, Addiction Medicine Board Certified, Palliative Medicine

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1 Board Certified, Internal Medicine Board Certified, Addiction Medicine Board Certified, Palliative Medicine Abdel Fahmy, MD Medical Director, Substance Abuse Access Community Health Network President, IL Society of Addiction Medicine Executive Member, Clinical Trial Network, NIDA 1

2 About ACCESS Largest FQHC network in region Patient-centered medical home approach to care 50+ health centers serving over 200,000 patients annually Our mission: To provide high quality, comprehensive. communitybased health care for the underserved in the greater Chicago area and beyond. 2

3 Age Payer Sources Ethnicity 3

4 Access Achievements in MAT Implemented Buprenorphine program in 2003 Implemented obesity management program in 2004 Implemented SBIRT in 2008 Implemented Vivitrol in 2011 Team-based care includes licensed behavioral health consultants and case managers 4

5 New Era for Treatment of Opiate Addiction 1900: opioid addiction treated in Morphine Clinics 1914: Harrison Narcotic Act federal regulation of medical prescription of opioids in the US 1920: AMA condemns prescription of opioids to addicts; opens door to federal prosecution of physicians who did so : more legislation increasing the penalties for the use and possession of illicit drugs 1961: Joint committee of ABA and AMA releases report questioning these repressive drug policies and encourages research on opioid maintenance treatment 5

6 New Era for Treatment of Opiate Addiction (cont.) Next 30 years: OTP started. Regulation of the use of opioids in addiction treatment by HHS and DEA at federal level, as well as various requirements at the state and local level. Over-regulation results in less treatment and poor compliance. 1978: research showing potential benefits of Buprenorphine in treating opioid addiction May 9, 2000: U.S. House passes Children s Health Act and chairman adds Buprenorphine bill to the act October 8, 2002: FDA approves Buprenorphine for office-based treatment of opiate addiction 6

7 DATA 2000 The Drug Addiction Treatment Act of 2000 (DATA 2000) allows qualified physicians to dispense or prescribe approved narcotic medications for treatment of opiate addiction. DATA 2000 also allows qualified physicians to do this in a setting outside of the Opioid Treatment Program, i.e., in a doctor s office instead of a methadone clinic. 7

8 DATA 2000 (cont.) DATA 2000 also reduces regulation on physicians who practice opioid addiction therapy. DATA 2000 also limits the number of patients that a physician is permitted to treat to 30. 8

9 Increases in Patient Limits In July 2005, Congress removed the 30-patient restriction on medical groups that prescribe buprenorphine for opioid dependence & addiction. The 30-patient limit was then applied to each physician s caseload, rather than to that of the entire clinic. Office of National Drug Control Policy Reauthorization Act of 2006 (ONDCPRA) increased the number of buprenorphine patients a physician can treat to 100, if specific conditions are met. 9

10 What is Bupe? Semi-senthetic partial agonist. Works by strongly binding to the Mu receptors competing with other opiates. Low intrinsic activity compared with other opioids. Bell-shaped curve response. Given sublingually resulting in a feeling of well being. 10

11 More on Bupe No or minimal clinical disruption of cognitive or psychomotor performance. Low level of physical dependence. Metabolized by the P450 enzyme system. Limited side effects and mainly related to agonistic qualities. Care should be taken when given to patients with hepatitis. 11

12 More on Bupe Can precipitate withdrawal when given following administration of a full agonist. Intervention rarely required. Interaction with Benzos and other CNS depressants as well as drugs metabolized by P

13 Formulation Suboxone: Bupe + Naloxone Naloxone is not absorbed sublingually. Main form used in the office setting. Subutex: Bupe alone. Suboxone: Film 13

14 Treatment program components Medical Management Behavioral Support Family involvement Supportive clinical environment Relapse monitoring plan Tolerance to relapses and implementation of remedial steps 14

15 Barriers to treatment Concerns about the safety of medication Concerns about a rowdy patient Concerns about regulatory scrutiny Concerns about medico-legal issues Referral resources Dual diagnosis Concerns about diversion 15

16 Vivitrol for alcohol dependence VIVITROL is indicated for the treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with VIVITROL Patients should not be actively drinking at the time of initial VIVITROL administration 16

17 Vivitrol for opiate dependence VIVITROL is indicated for prevention of relapse to opioid dependence, following opioid detoxification Opioid-dependent patients, including those being treated for alcohol dependence, must be opioid-free for a minimum of 7 10 days before starting VIVITROL treatment 17

18 What is Naltrexone? An opioid antagonist with highest affinity for the μ-opioid receptor Little or no opioid agonist activity, and few (if any) intrinsic actions besides its opioid blocking properties Produces some pupillary constriction by an unknown mechanism 18

19 Mechanism of Action Blocks β-endorphin binding, which may prevent excessive dopamine release The mechanism by which VIVITROL exerts its effects in alcohol-dependent patients is not entirely understood. However, involvement of the endogenous opioid system is suggested by preclinical data 19

20 Efficacy of treatment for alcohol dependence with psychosocial support A 24-week, multicenter, double-blind, placebo-controlled trial, published in JAMA Among the subset of patients who were abstinent during the week prior to treatment initiation, patients treated with VIVITROL in combination with psychosocial support experienced: Greater reduction in drinking days Greater reduction in heavy drinking days Greater maintenance of complete abstinence 20

21 Precautions Hepatotoxicity Overdose during reversal For opioid dependence: Does not relief withdrawals or cravings life-threatening opioid intoxication 21

22 Team-based integrated care in the patient centered medical home Treatment approach that provides a patient with comprehensive, coordinated services across all elements of the healthcare system Oriented toward care of the whole patient Treatment team includes behavioral health, case management and/or spiritual care Medical assistant career ladder at ACCESS will help reinforce team-based roles Team works collaboratively 22

23 Primary Care Primary care brings promotion and prevention, cure and care together in a safe, effective and socially productive way at the interface between the population and the health system. The features of health care that are essential in ensuring improved health and social outcomes are person-centeredness, comprehensiveness and integration, and continuity care, with a regular entry into the health system, so that it becomes possible to build an enduring relationship of trust between people and their health care providers. Primary Health Care - Now More Than Ever, World Health Organization (WHO) Annual Report

24 Behavior Issues in Primary Care Up to 70% of Primary Care medical appointments are for problems relating to psychosocial issues (Gatchel and Oordt, 2003) National Co-morbidity Survey Replication Study (2005) More people present to their primary care provider for mental health treatment than seeking specialized mental health treatment 24

25 Key community mental health and community health center characteristics Traditional Setting Scheduled appointment minute session Treatment behind closed door No interruptions Schedule is rigid or set Focus is on mental health diagnosis Individualized Primary care provider uninvolved Primary Care Setting Unscheduled encounter minute intervention Treatment conducted in exam room Frequent interruptions Schedule is flexible Focus is on functional assessment ( here and now ) Population-based Hierarchical (i.e. physician takes the lead) 25

26 Continuum of behavioral health resources Psychiatrists, licensed behavioral health consultants (social workers, clinical psychologists), case managers, chaplains, medical assistants with specialized training Trainees for these roles SBIRT training and implementation of SBIRT practices 26

27 Behavioral health consultant role within the patient-centered team Provides screening and brief assessment--proficient in brief treatment, motivational interviewing Develops behavioral health plan of care Either supervises patient for brief intervention or refers to ACCESS or external resource Facilitates transition to group visit follow up Maintains flexibility; open to un-scheduled patients Pro-active, visible in the health center as a team member 27

28 Case management role within the patientcentered team SBIRT follow up; helps connect patients to proper ACCESS and community resources Co-facilitates group visits; serves as group coordinator Assures patient follow up; addresses issues for patients missing appointments Assists patients to address barriers to access to care Implements evidence-based community prevention approaches such as SISTA group visits 28

29 Reaching beyond the walls Case managers and community engagement staff outreach in community venues correctional facilities, social service agencies, schools, churches Health fairs, community screening events Patient Graduation events and holiday reunions Organic programs such as the Lady ACCESS softball team 29

30 Sustainability FQHC medical encounter, behavioral health encounter Partnerships with pharma 340B program Integration with CDC and SAMHSA funded programs 30

31 Medication-Assisted Treatment of Substance Use Disorders in Community Health Centers Emily Jones, MPP Office of Quality and Data Bureau of Primary Health Care Health Resources and Services Administration

32 Overview The role of medically assisted treatment in patient care Substance abuse screening and treatment in health centers Action items Resources

33 Medically Assisted Therapies Methadone (Symoron, Methadose etc.) Buprenorphine (Suboxone, Subutex) 2002: FDA approval for detox and long-term maintenance therapy for opioid dependence The Drug Addiction Treatment Act of 2000: maintenance & detox treatments = medical care Only physicians can prescribe; patient cap 8-hour training course for DEA certification Convenience: patients allowed 30-day supply Naltrexone (Revia, Depade) Vivitrol: once-monthly injectible

34 Role of MAT in SA Care Medically-assisted treatment as an adjuvant to other types of interventions: MH counseling services Individual, group, family therapy Structured substance abuse program Social services Housing, jobs training, medical-legal partnerships

35 Substance Abuse Screening 35.5% DO NOT routinely screen for substance abuse 39.9% routinely screen ALL patients for substance abuse 24.6% screen a SELECT group of patients

36 Frequency of Routine Substance Abuse Screening Number of Health Centers % 28.3% 29.5% % 4.8% Annually Every Visit Every 3 Mos Every 6 Mos Other Frequency of Substance Abuse Screening

37 Note: The bar graph is based on the 193 health centers that provide SA services; the pie chart is based on the 130 grantees that specified the number of sites offering SA services. Substance Abuse Service Provision All or Some Sites 67.9% offer SA services in SOME sites only 32.1%: SA at ALL sites

38 Onsite Structured Substance Abuse Program 69.4% do not offer structured substance abuse programs 30.6% offer structured substance abuse programs A structured program is: patients seen in individual and/or group sessions on a regularly scheduled basis to address their substance abuse issues. In contrast, unstructured programs would allow patients to show up as needed or in conjunction with their medical visits and not provide interventions at regularly scheduled times.

39 Note: Pie chart based on the respondents to that question, the bar chart is based on the 121 respondents that reported interest among providers for the training. Buprenorphine Treatment Percent of Grantees Offering Buprenorphine Treatment Number of Physicians Per Health Center Interested in Buprenorphine Training 15.1% offer treatment 84.8% of health centers do not provide buprenorphine treatment Number of centers

40 Summary MAT is underutilized and can boost the effectiveness of substance use treatment Substance abuse services are offered onsite by over 50 percent of health centers Screening for substance use disorders is administered less often than depression screening One in 7 health centers offer bupe treatment, and there is significant interest in expanding capacity in this area

41 Action Items Educate providers and patients on the benefits of MAT and difference from methadone Connect interested providers to training for DEA certification Be sure your referral network includes 24-hour crisis care for behavioral health services, detoxification services, and community organizations to meet psychosocial needs Take advantage of the 340B pharmacy program

42 12 Resources SAMHSA Bupe site: SAMHSA/HRSA Center for Integrated Health Solutions: Promotes integrated primary and behavioral health services to address the needs of patients in specialty behavioral health or primary care settings. Motivational Interviewing for Better Outcomes Peer Support Wellness Respite Centers Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Clinical Settings Person-Centered Health Homes Introduction to Effective Behavioral Health in Primary Care

43 Contact Information Emily Jones Office of Quality and Data Bureau of Primary Health Care (301)

44 The Science of Addictions & Medication Assisted Treatment of Addictions Thomas E. Freese, Ph.D. UCLA Integrated Substance Abuse Programs Pacific Southwest Addiction Technology Transfer Center National Conference on Addiction Disorders San Diego, CA, September 21, 2011

45 We know of 3 ways: 1. Avoid the drug using coping strategies 2. Replace associations using therapy 3. Directly addressing the effect of the drugs in the brain using medication

46 Medication can address many of the changes caused in the brain. Thus, MAT can help the person to function more normally Facilitating the process of recovery.

47 Epidemiology of Alcohol and Opioid Use, Abuse, and Dependence ALCOHOL

48 Drinking Guidelines Men: 2 drinks/day; < 14 drinks per week Women : 1 drink/day; < 7 drinks per week Elderly (men and women): 1 drink/day; < 7 drinks per week SOURCE: NIAAA, 2011; Dufouor and Fuller, 1995.

49 Alcohol Use among Secondary Students: National Findings, th graders 10th graders 12th graders Percent of Respondents Any Alcohol Use Been Drunk Use of Flavored Alcoholic Beverages SOURCE: NIDA, Monitoring the Future Survey, 2008 National Findings.

50 Binge Drinking: Not Just for Kids More than one in five men ages report binge drinking within the past month Nearly one in ten older women reported recent binge drinking. Among those over age 65, 14% of men and 3 percent of women reported binge drinking. Also, 19% of older men and 13% of older women consumed enough alcohol on a daily basis to be classified as heavy drinkers by the American Geriatric Society. SOURCE: Join Together Online, August 18, 2009; SAMHSA, NSDUH,

51 Past Month Heavy Alcohol Use, by Age Group, National Findings SOURCE: SAMHSA, NSDUH, 2007 Results.

52 Treatment Admissions for Alcohol Abuse: National Findings Alcohol as a primary substance accounted for 40% of all admissions in 2007 (down from 50% in 1997). 45% of primary alcohol admissions reported secondary drug abuse, as well. About three-quarters of admissions for abuse of alcohol alone and for abuse of alcohol with secondary drug abuse were male. For alcohol-only admissions, the average age at admission was 39 years, compared with 35 years among admissions for primary alcohol with secondary drug abuse.

53 Epidemiology of Alcohol and Opioid Use, Abuse, and Dependence HEROIN AND OTHER OPIOIDS

54 Rates of Current Heroin Use Drug demand data show that, nationally, current heroin use is stable or decreasing. Rates of Past-Year Heroin Use NSDUH, 2009 % of US population Individuals (12 & older) Adolescents (12-17) Adults (18-25) Adults (26 & older) (SAMHSA, NSDUH, 2009)

55 Prevalence of Use Rates of heroin use are declining among youth - 8 th grade use peaked in th grade use peaked in th grade use peaked in 2000 Rates of non-medical use of opioids are increasing Rates in all ages peaked in 2007 Rates highest in year olds (Johnston et al., 2009; SAMHSA, OAS, NSDUH, 2009)

56 Emergency Department Visits Related to Heroin/Other Opioids According to the Drug Abuse Warning Network : An estimated 200,666 drug misuse/abuse ED visits were related to heroin. One-third (33%) of nonmedical use ED visits were related to Central Nervous System (CNS) agents. Among CNS agents, the most frequent drugs were opiates/opioid analgesics, specifically: Hydrocodone/combinations (22,912 visits) Oxycodone/combinations (44,489 visits) Methadone (23,498 ED visits) (SAMHSA, OAS, DAWN, 2009)

57 Primary Heroin Treatment Admissions vs. Primary Other Opiate Treatment Admissions: A Side-by-Side Comparison (SAMHSA, OAS, TEDS, 2009)

58 New Non-Medical Users of Prescription Pain Relievers In million new non-medical users (a decline from 2.5 million in 2003, but still a lot!) 6,000 new users per day Among youth aged 12-17, females more likely to use non-medically Among young adults aged 18-25, males more likely to use non-medically SOURCE: SAMHSA, OAS, NSDUH, 2009.

59 Treatment Admissions for Primary Prescription Drug Abuse: U.S., Opiates/Synthetics Tranquilizers Stimulants Sedative/Hypnotics 5 4 Percent SOURCE: SAMHSA, Treatment Episode Data Set, 2007 results.

60 Estimated Number of Drug-Related Emergency Dept. Visits Related to the Misuse or Abuse of Pharmaceuticals & Illicit Drugs: ,400,000 1,200,000 1,000,000 1,244,679 Misuse or Abuse of Pharmaceuticals 991, ,591 Misuse or Abuse of Illicit Drugs 800, , , , , SOURCE: SAMHSA, Office of Applied Studies, Drug Abuse Warning Network, 2010.

61 Substance Abuse Challenge: Prescription Drug Sources (Non-medical use of pain relievers accounts for 73% of prescription drug abuse) 18 SOURCE: SAMHSA, 2005 National Survey on Drug Use and Health, September 2006.

62 Medical and Psychological Effects of Alcohol and Opioids ACUTE AND CHRONIC EFFECTS ALCOHOL

63 Alcohol: Basic facts Description: Alcohol or ethylalcohol (ethanol) is present in varying amounts in beer, wine, and liquors Route of administration: Oral Acute Effects: Sedation, euphoria, lower heart rate and respiration, slowed reaction time, impaired coordination, coma, death 20

64 Alcohol: Chronic Effects Withdrawal Symptoms: Tremors, chills Cramps Hallucinations Convulsions Delirium tremens Death 21

65 Long-Term Effects of Alcohol Use Decrease in blood cells leading to anemia, disease, and slow-healing wounds Brain damage, loss of memory, blackouts, poor vision, slurred speech, and decreased motor control Increased risk of high blood pressure, hardening of arteries, and heart disease Liver cirrhosis, jaundice, and diabetes Immune system dysfunction Stomach ulcers, hemorrhaging, and gastritis Thiamine (and other) deficiencies Testicular and ovarian atrophy Harm to a fetus during pregnancy 22

66 Medications for alcohol addiction: Reduce post-acute withdrawal (acamprosate) Block or ease euphoria from alcohol (naltrexone) Discourage drinking by creating an unpleasant association with alcohol (disulfiram)

67 Research about Alcohol Medications Research shows that when compared to placebo, medications help participants to: Maintain complete abstinence throughout the study duration (acamprosate) Have a lower number of drinking days during the entire study (disulfiram, naltrexone, acamprosate) Regain complete abstinence after one relapse more frequently (acamprosate) Maintain compliance with medication dosing schedule (extended-release naltrexone)

68 Medical and Psychological Effects of Alcohol and Opioids ACUTE AND CHRONIC EFFECTS HEROIN AND OTHER OPIOIDS

69 What are opioids? Opiate: derivative of opium poppy Morphine Codeine Opioid: any compound that binds to opiate receptors Semisynthetic (including heroin) Synthetic Oral, transdermal and intravenous formulations Narcotic: legal designation

70 27 Opioids

71 Opioids: Basic Facts Description: Opium-derived or synthetic compounds that relieve pain, produce morphine-like addiction, or relieve symptoms during withdrawal from morphine addiction. Route of administration: Intravenous, smoked, intranasal, oral, and intrarectal 28

72 Opioids: Basic Facts Acute effects: Euphoria Pain relief Suppresses cough reflex Histamine release Warm flushing of the skin Dry mouth Drowsiness and lethargy Sense of well-being Depression of the central nervous system (mental functioning clouded)

73 Opiates and Reward Opiates bind to opiate receptors in the nucleus accumbens: increased dopamine release

74 Endogenous Opioids Produced naturally in body Act on opioid receptors Examples: endorphins, enkephalins, dynorphins, endomorphins Produce euphoria and pain relief; naturally increased when one feels pain or experiences pleasure

75 Pain: the Fifth Vital Sign JACHO Guidelines 2000: Mandated pain assessment and treatment Nurse and physician education required When opioids prescribed properly for pain, addiction rare in patients without underlying risk factors Vulnerabilities same as for other addictions: genetic, peer and social influences, trauma and abuse history

76 Pain Pathway

77 Pain Control and Addiction Pseudoaddiction : Presence of drug-seeking behavior in context of inadequate pain control Behavior stops with adequate pain relief Description of a clinical interaction (not a true diagnosis) Physical dependence with continued use, withdrawal syndrome produced by rapid dose reduction; occurs via neuroadaptation Not synonymous with addiction

78 Opioids: Basic Facts Withdrawal symptoms: Intensity of withdrawal varies with level and chronicity of use Cessation of opioids causes a rebound in functions depressed by chronic use First signs occur shortly before next scheduled dose For short-acting opioids (e.g., heroin), peak of withdrawal occurs 36 to 72 hours after last dose Acute symptoms subside over 3 to 7 days Ongoing symptoms may linger for weeks or months

79 Symptoms of Opioid Withdrawal Dysphoric mood Nausea or vomiting Diarrhea Tearing or runny nose Dilated pupils Muscle aches Goosebumps Sweating Yawning Fever Insomnia

80 Medically Assisted Withdrawal Medications used to alleviate withdrawal symptoms: - Opioid agnonists (methadone, buprenorphine) - Clonidine - Other supportive medications anti-diarrheals, anti-nausea agents, ibuprofen, muscle relaxants, anti-anxiety medications

81 Opioid Replacement Goals CH 3 CH 2 O CH 2 CH N CH 3 CH 3 CH 3 Reduce symptoms & signs of withdrawal Reduce or eliminate craving Block effects of illicit opioids Restore normal physiology Promote psychosocial rehabilitation and nondrug lifestyle

82 What Does the Research Say? Naltrexone is effective for opioid and alcohol addiction: Reduces risk of re-imprisonment Lowers risk of opioid use, with or without psychological support Extended-release naltrexone addresses the issue of patient compliance 39

83 Treatment Outcome Data: Methadone 8-10 fold reduction in death rate Reduction of drug use Reduction of criminal activity Engagement in socially productive roles; improved family and social function Increased employment Improved physical and mental health Reduced spread of HIV Excellent retention

84 Relapse to IV drug use after MMT 105 male patients who left treatment Percent IV Users Treatment Months Since Stopping Treatment

85 Buprenorphine Research Outcomes Buprenorphine is as effective as moderate doses of methadone. Buprenorphine is as effective as moderate doses of LAAM. Buprenorphine's partial agonist effects make it mildly reinforcing, encouraging medication compliance. Relapse likely after withdrawal.

86 Contact Information Thomas Freese

87 Physician Clinical Support System Primary Care (PCSS-P) A NIDA Supported Educational Resource for Those Addressing Substance Abuse in Primary Care Eric Henley, M.D., MPH Chief Medical Officer North Country HealthCare Flagstaff, AZ.

88 Unhealthy substance use is prevalent 20-30% with at-risk drinking > 4 drinks on occasion or > 14 drinks/wk > 3 drinks on occasion or > 7 drinks/wk 20 million people over age 12 use illicit substances Prescription drug use rising Only 9% of patients (over 20 million individuals) in need of treatment receive it Physician Clinical Support System

89 How is substance abuse relevant to primary care? Substance abuse can: Lead to unintentional injuries Exacerbate medical conditions Exacerbate psychiatric problems (anxiety, depression) Induce medical diseases (stroke, cancer, dementia, hypertension) Induce infectious diseases (HIV, HCV) Affect the efficacy of prescribed medications Be associated with abuse of Rx medications Result in low birth weight, premature deliveries, developmental delays Result in addiction

90 How is substance abuse relevant to primary care? Higher Prevalence of Medical Conditions in Substance Abusers vs. Controls Source: Mertens JR et al, Arch Intern Med 163: , 2003

91 Screening, Brief Intervention and Referral to Treatment Universal screening for substance use Brief interventions (5-15 minutes) for those at low risk Feedback, Reflection, Advice, Motivation Referral to specialized treatment for those at high risk and with substance use disorders

92 Evidence for SBIRT in primary care Using SBIRT procedures in general medical settings can make a difference in drug use behaviors Research has demonstrated that SBI can reduce alcohol and tobacco use. Tobacco - USPSTF Grade A (strongly recommended) servicestaskforce.org/us pstf/uspstbac.htm Alcohol - USPSTF Grade B (recommended) servicestaskforce.org/us pstf/uspsdrin.htm

93 SAMHSA SBIRT Service Program - Reductions in Substance Use at 6 Month Follow-up *** *** ***p<0.001 *** *** *** Source: Madras et al., 2008 Drug and Alcohol Dependence

94 What is the PCSS-P? Federally funded program designed to provide educational assistance for those in primary care addressing substance abuse Clinical Advisors Website Warmline Outreach Physician Clinical Support System

95 Core Services of the PCSS-P Medical Directors and Clinical Advisors Trained in Internal Medicine, Family Medicine, Emergency Medicine Chosen for clinical and teaching experience Available to provide: and telephone support Website (www.pcssprimarycare.org) PCSS-P registration Links to National Institute on Drug Abuse (NIDA) MED resources Screening tools Clinical Resources Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocols Substance abuse education and related websites PCSS for Buprenorphine (PCSS-B) and PCSS for Opioids (PCSS-O coming soon) Physician Clinical upport System

96 Core Services of the PCSS-P Warmline National system of telephone and triage Requests for clinical advisors, general information, treatment locator, training information Outreach Liaison efforts with national, state and local medical societies Newsletter Focus groups Society of General Internal Medicine Society for Academic Emergency Medicine National Association of Community Health Centers Physician Clinical Support System

97 PCSS-P Based on Successful Implementation of a Mentor PCSS for Buprenorphine Egan, et al, J Gen Intern Med Sep;25(9): Physician Clinical Support System

98 PCSS-P Website Activity April to July 3141 pages viewed 1045 visits 794 unique visitors Most frequently viewed pages were: Resources for your Practice (893 hits) Resources for Teaching (289 hits) Resources for your Patients (288 hits) About the PCSS-P (152 hits) About the Medical Directors and Clinical Advisors (131 hits) Physician Clinical Support System

99 PCSS-P Website Provides access to NIDA MED resources NIDA MED Quick Screen NIDA MED ASSIST Physician Clinical Support System

100 NIDAMED Online Screening Tool NIDA Quick Screen NMASSIST - Based on the WHO ASSIST Screens for tobacco, alcohol, illicit, and non-medical prescription drug use Based on patients responses, automatically: o Leads to next appropriate question o Determines substance involvement score (i.e., risk level not a diagnosis) Links to additional resources

101

102

103 Conclusion The NIDA funded Physician Clinical Support System (PCSS-P) is designed to help facilitate screening, intervention and referral to treatment for patients with substance use in primary care Access information and assistance through: Physician Clinical Support System

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