The path forward: How can we develop a rational system for addressing Opioid Use Disorder?

Transcription

1 The path forward: How can we develop a rational system for addressing Opioid Use Disorder? Miriam Komaromy, MD, FACP Associate Director, ECHO Institute University of New Mexico Bernalillo County Opioid Summit 2015

2 Heroin use has increased 79% since 2007 Clark, Senate Testimony, 2014

3 Top leaders call for increase in access to Medication Assisted Treatment..id Sales, Admissions for Opioid-Abuse Treatment, and Deaths Due to Opioid Overdose in the United States, Volkow ND et al. N Engl J Med 2014;370:

4 Trial of buprenorphine 40 Heroin addicts Buprenorphine 16 mg/day vs taper + placebo All received counseling, groups Followed for 1 year Retained at 1 yr (p=0.0001) % died Buprenor -phine Placebo 75% % Kakko et al, Lancet 2003

5 Evidence continues to grow showing that buprenorphine saves lives Heroin overdose deaths fell by 2/3 as buprenorphine MAT availability increased in Baltimore Schwartz, AJPH, 2012

6 Evidence continues to grow showing that PCPs can treat effectively.. PCPs in an FQHC (non-academic medical center environment) can treat OUD effectively with buprenorphine 60% reten at 6 month

7 Maintenance treatment with buprenorphine or methadone cuts the risk of hepatitis C infection by 2/3 K Page, JAMA IM, 2014

8 Lynch, Addict Sci Clin Pract, 2014 Evidence continues to grow showing that buprenorphine is cost effective Costs of care for persons with opioid dependence in commercial integrated health systems

9 Ms. L is a 46 year old woman who is enrolled in a program designed to help super-utilizers of medical care. She was diagnosed with Idiopathic Pulmonary Fibrosis and is on high-flow oxygen. At the time of enrollment she was receiving high-dose benzodiazepines and opioids to treat anxiety and pain in her chest. She spent most of her time in bed, had a pulmonary embolus, was hospitalized every 2-6 weeks for pneumonia and respiratory decompensation, and walked with a walker. After several months of working with our team she was willing to consider that her frequent hospitalizations could be due to sedation and respiratory suppression from her medications. She agreed to taper off of benzodiazepines, which she did over 2 months. Then she was transferred to buprenorphine/ naloxone. Although she reports ongoing anxiety and chest pain, she has been able to turn down her oxygen from 6 to 2 liters. She has stopped using a walker, swims every day, and has not been hospitalized in the 5 months since switching to buprenorphine. She says she feels more alive than she has in years, and she is applying for jobs.

10 The evidence for the benefits of treatment with buprenorphine/ naloxone is overwhelming

11 And yet Providing training and support to physicians has not resulted in adequate numbers of prescribers of buprenorphine in NM More than 350 physicians trained through ECHO More than 500 total physicians trained in NM 10,000 hours of CME credit given to PCPs who receive training and support from ECHO for treatment of addiction and mental illness And yet, last year only 144 physicians prescribed for 10 or more patients

12 So with all of these good reasons to treat, why don t more PCPs actually prescribe buprenorphine/naloxone?

13 Among waivered physicians, not prescribing is associated with having no practice partners who prescribe; lacking institutional support; and lack of psychosocial resources Hutchinson, Ann Fam Med, 2014

14 What do PCPs actually experience when they become buprenorphine prescribers?

15 If you prescribe buprenorphine you are made to feel like you are doing something wrong. Mandatory 8-hour course, not required for any other medication, no matter how dangerous (chemotherapy, methadone, insulin) Special DEA license, required only for this medication Extra paperwork, often a lot of it, that feels discriminatory, and again like you are doing something wrong (for what other disease would you have to submit monthly prior authorizations, with treatment plans, urine drug screens, counseling records?) Your medical judgment and the patient s success may be undermined by restrictions on dose and duration of therapy imposed by Medicaid or other insurers Little support from your clinic administration, and from your practice partners because of stigma, ignorance, fear of decreased productivity Colleagues in your community are waiting to refer their most difficult patients to you Limits on the number of patients you are allowed to treat, as though you would do something irresponsible if you didn t have a patient limit No organized system to support you in providing treatment for this very challenging and lethal disease (for example, by systematically linking PCPs with addiction counselors or specialists)

16 And most humiliating of all: Even if you are doing everything exactly right you will be audited by the DEA If you were prescribing lethal combinations of fentanyl and alprazolam no one would audit you, but almost every buprenorphine prescriber in our community has been audited DEA agents will come into your waiting room and show their badges and frighten everyone, and disrupt your entire schedule They will make you feel like you are under suspicion, and doing something questionable If you haven t prescribed in awhile they will strongly suggest that you surrender your license If you try to get it back you won t be allowed to You will not feel proud or be thanked for doing something lifesaving for your community. Instead you will feel overwhelmed, unsupported, and humiliated. Now, why would you choose to do this?

17 If we are serious about expanding access to medical treatment for Opioid Use Disorder we need to start doing things very differently

18 Exciting Recent Developments Federal: Opioid Treatment Programs can now prescribe buprenorphine Increasing numbers of OTPs nationally and in NM Senate bill to allow NPs and PA s to prescribe buprenorphine (Markey) State: Expansion of Medicaid eligibility (Martinez) State plan to enroll individuals prior to release from incarceration Removal of buprenorphine prior authorization requirements by Medicaid (Foster, Weinberg) Medicaid coverage for methadone

19 Local: Expanding access in OTPs HAC preparing to open Transitional Living Center for addicted youth Recent collaborative task force on mental health and addiction (State, County, City) (Stebbins) 69% of County voters supported raising GRT 1/8 Cent to support mental health treatment (would generate 20 m per year) (11/14) City funding (1.1 m) for housing and mental health services for people coming out of MDC (11/14, Winter, Benton)

20 We need to leverage these developments and the work of this committee in order to catalyze system-level change

21 Invite administrators to the table Why? They control the supply of treatment for Opioid Use Disorder How? Medicaid expansion means these are paying patients Who? CEOs of Federally Qualified Health Centers CEOs of Opioid Treatment Programs Leaders within DOH UNM ASAP and Mental Health Center Administrators City of Albuquerque leadership Bernalillo County leadership What should we be asking for?

22 All publicly funded health care organizations should be pushed to provide treatment for OUD Require bup certification in order to be credentialed as a PCP Require all PCPs to treat at least 30 patients Coordinate medical and psychosocial treatment

23 City and County must collaborate to fund coordination and provision of effective referral and treatment of OUD Triage/referral Medication Counseling Service Coordination

24 Program funding must be provided through implementation of 1/8 c tax and/or other public funds that target mental health Medicaid funds alone are not enough to build an effective, coordinated system

25 Imagine

26 We cannot let stigma, ignorance, or apathy get in our way. We need to seek an effective response from our elected and publicly-funded officials, and from administrators of all organizations that receive public funds. We know how to treat opioid addiction; now we need to do it.

27 Miriam Komaromy, MD