1 Best Practices in Opioid Dependence Treatment Anthony L. Jordan Health Center Linda Clark, MD, MS Medical Director Alana Ramos, BS Suboxone Clinic Manager
2 Case Studies Nicole White female 27 years of age Drugs of choice: narcotic pills Joshua White male 24 years of age Drugs of choice: heroin and narcotic pills *Siblings
3 DATA 2000 The Drug Addiction Treatment Act of 2000 (DATA 2000) allows qualified physicians to dispense or prescribe specifically approved narcotic medications for the treatment of opioid addiction in treatment settings other than the traditional Opioid Treatment Program (i.e., methadone clinic). In addition, DATA 2000 reduces the regulatory burden on physicians who choose to practice opioid addiction therapy by permitting qualified physicians to apply for and receive waivers of the special registration requirements defined in the Controlled Substances Act.
4 Physician Qualifications According to DATA 2000, licensed physicians are considered qualified to prescribe SUBOXONE if at least 1 of the following criteria has been met: Holds an addiction psychiatry subspecialty board certification from the American Board of Medical Specialties Holds an addiction medicine certification from the American Society of Addiction Medicine (ASAM) Holds an addiction medicine subspecialty board certification from the American Osteopathic Association (AOA) Completion of not less than 8 hours of authorized training on the treatment or management of opioid-dependent patients
5 Physician Qualifications In addition, physicians must satisfy BOTH of the following criteria: Have the capacity to provide or to refer patients for necessary ancillary services, such as psychosocial therapy Agree to treat no more than 30 patients at any one time in an individual or group practice during the first year following certification or 100 patients upon re-notification of the need and intent to treat up to 100 patients after one year
6 Buprenorphine/Naloxone SUBOXONE is a tablet for the treatment of opioid dependence. SUBOXONE combines a partial opioid agonist (buprenorphine) and an opioid antagonist (naloxone) in a 4:1 (buprenorphine: naloxone) ratio.
7 Opioid Intoxication
8 Opioid Withdrawal
9 The Mechanism of Buprenorphine Buprenorphine (the primary active compound) reduces patients' opioid cravings and withdrawal symptoms. In addition, buprenorphine may discourage patients' use of non-prescribed opioids by binding to the mu receptor, thereby blocking other opioids' effects. The naloxone component in SUBOXONE is included to help discourage diversion and misuse. Naloxone has very limited bioavailability when administered sublingually, as intended. However, if SUBOXONE is crushed and injected, the naloxone will precipitate opioid withdrawal. In the absence of an opioid, the antagonist has no effect.
10 The Mechanism of Buprenorphine
11 The Past
13 Clinic at ALJHC 3-4 providers treating approximately 200 patients Trained Suboxone providers for per diem positions Clinic days on Saturdays and Wednesdays, sequestered from primary care. Average number of visits for Suboxone patients per year = 30.2 vs. average number of visits for general population patients = 2.5
14 Insurance Breakdown Center Population
15 Insurance Breakdown Suboxone Patients
16 Race General Clinic Population
17 Race Suboxone Population
19 Screening potential patients Pre-Treatment screen If referred by outside agency, a referral packet must be sent Internal referrals and use of ecw for tracking patients If patient meets criteria, patient is scheduled for an intake and CD evaluation
20 Intake and CD Evaluation CAGE, DAST, MAST, DSM criteria Discussion of current and previous substance use, length and start of addiction, history of treatment, etc. Appropriate consents obtained Patient is scheduled for initial visit Patient is sent to the lab for blood test (CMP, CBC, urinalysis, RPR) and urine tox screen
21 Appointments with the provider Induction: 3 day process (unless already stable on prescribed buprenorphine) Discussion of expectations Letter sent to PCP to inform him/her of pt s start in program PPD and rapid HIV Follow-up visits are scheduled according to compliance in program (1 week vs. 2 weeks vs. 1 month vs. 2 months) At each visit: Urine screen Discussion of progress in treatment Therapy Progress Report
22 Treatment Compliance Unannounced medication count and urine screens Spreadsheet to calculate discrepancies Contact with outpatient programs/counselors Communication with pharmacy Communication with PCP and other providers Frequency of visits Treatment contracts
24 Dismissal From the Program Reasons: Continued substance use Non-compliance with treatment recommendations 3 missed medication count/urine screen appointments Referral to higher level of care MOU with treatment facilities Re-apply to program at AJHC
25 Urine Collection Protocol Unobserved Cups with temp strips Patient given 2 hours to provide sample Limited access to water in the bathroom Unable to wash hands in bathroom Screen for: buprenorphine confirmation, benzodiazepine confirmation, clonazepam confirmation, expanded opiates, cocaine, methadone, amphetamines, ecstasy confirmation, THC semi-quant with THC:Cr, alcohol (optional)
26 Treatment of Special Populations Pregnant patients Subutex vs. Methadone Consent form HIV+: 6 HIV specialist and clinic at AJHC Hep C +: ~40 % Hep C treatment program at AJHC 11 Suboxone patients in Hep C program
27 Hep C HRSA Initiative Baseline: 4.9% One-year goal: 20% Four-year goal: 40% 74% of patients in program have been tested
28 MH Support 2 MH therapists (LCSW-R) Psychiatrist specializing in addiction Psych NP Psych Nurse
29 The Future MAT? Creating universal templates in ecw for providers? Expanding the program to additional sites, additional hours
30 Where are they now? Nicole Currently receiving treatment at ALJHC Adjusted well to program guidelines Continued compliance Delivered baby Joshua Dismissed from ALJHC program Did not adjust well to changes in program N/S for med counts/urine screens N/S for MH referrals N/S for Hep C treatment Continued substance use
31 More information ACOG 58 th Annual Clinical Meeting 2010 ASAM 42 nd Annual Medical-Scientific Conference 2011
Behavioral Health Medical Necessity Criteria Effective January 1, 2013 Revised and approved on 8/09/2012 Anthem Blue Cross 21555 Oxnard St. Woodland Hills, CA 91365 Toll free: 1-800-274-7767 The Office
MassHealth Substance Abuse Treatment Manual Subchapter Number and Title Table of Contents Transmittal Letter SAT-15 Page iv Date 07/01/06 4. Program Regulations 418.401: Introduction... 4-1 418.402: Definitions...
The Outpatient Treatment Manual for the Care of Opioid- Dependent Pregnant Women with Buprenorphine Neal Gillis/Flickr Alane O Connor DNP, FNP Maine Dartmouth Family Medicine Residency MaineGeneral Medical
12-H37 Improving Community Health Through Policy Research Opioid Treatment Programs in Indiana The Use of Medication in Addiction Treatment Addiction to opioids (e.g., heroin, morphine, prescription pain
22 Kislev, 5770 29 November, 2010 Document No. 38299410 The Health Ministry's of Substance Abuse's Policy Regarding: Treating Opiate Addicts with Medication for an Extended Period of Time (using agonist
SUBSTANCE ABUSE PROGRAM OFFICE CHAPTER 65D-30 SUBSTANCE ABUSE SERVICES Title Definitions 65D-30.001 65D-30.002 Department Licensing and Regulatory Standards 65D-30.003 Common Licensing Standards 65D-30.004
Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy 2010 Update What is New in this Revised Guideline New data, including
Drug Abuse & Alcoholism PRESENTED BY: ROBERT SWOTINSKY M D FOR MEDICAL EXAMINER COURSE 978-337-4479 P SWOTINSKY@COMCAST.NET Drugs, Drinking, and Driving CMV drivers - more fatalities than any other occupation.
Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain July 2013 The recommendations contained herein were adopted as policy by the Executive Committee of the Federation of State
Follow-up information from the November 12 provider training call I. Admission Orders 1. Clarification regarding whether an admission order must be completed before any therapy evaluations are initiated.
Invitation to Tender for Wandsworth Integrated Drug and Alcohol Treatment and Recovery Service Reference: WAND-Q0157 Attachment 3: Specification PURPOSE The Aims of the Integrated Drug and Alcohol Treatment
MENTAL HEALTH CHAPTER 7 ADDENDUM H TRICARE/CHAMPUS STANDARDS FOR RESIDENTIAL TREATMENT CENTERS (RTCS) SERVING CHILDREN AND ADOLESCENTS I. ORGANIZATION AND ADMINISTRATION A. Definition A Residential Treatment
Uniform Record Manual For Alcohol and Drug Treatment Providers (June 2014) CLIENT FILE ORDER Form # Section 1: Intake/Financial 101 DMC Tracking Form* 101a Non-MC Tracking Form 102a,b QAR Review Worksheets*
Introduction Healthy Start legislation requires that all pregnant women and infants be offered screening for risk factors that may affect their pregnancy, health, or development. The prenatal and infant
LEVEL OF CARE AND TREATMENT CRITERIA Level of Care Criteria Psychiatric Criteria Adult Half Day Partial Hospital Treatment Adult Psychiatric Home Care Child and Adolescent Half Day Partial Hospital Treatment
Page 1 5 of 44 DOCUMENTS NEW JERSEY REGISTER Copyright 2011 by the New Jersey Office of Administrative Law VOLUME 43, ISSUE 17 ISSUE DATE: SEPTEMBER 6, 2011 RULE PROPOSALS HUMAN SERVICES DIVISION OF ADDICTION
FORWARD The purpose of the following document is to provide a general framework of common principles, policies, and practices for the Kane County Drug Court (KCDC). These standards and policies will: Minimize
DEPARTMENT OF HUMAN SERVICES SENIORS AND PEOPLE WITH DISABILITIES DIVISION OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 66 REGISTRATION AND CERTIFICATION STANDARDS FOR ADULT DAY SERVICES PROGRAMS Table
Sastry K. Topalli, MD Diplomate of the American Board of PM&R Board Certified in PM&R 676 Battlefield Blvd N, Suite B Chesapeake, VA 23320 Phone: 757-410-4219 Fax: 757-410-4237 www.atlanticpaininterventions.com
University of South Alabama College of Nursing Bachelor of Science Degree in Nursing Application for Registered Nurses to apply for: The RN-BSN Online Track & RN-BSN/MSN Online Track Pre-Admission Advisement:
Joint Commissioning Panel for Mental Health Guidance for commissioners of drug and alcohol services 1 www.jcpmh.info Guidance for commissioners of drug and alcohol services Practical mental health commissioning