Integrating SUD Treatment in Primary Care
Please be aware that viewing the training video on this page will not result in continuing education credits.
Hello everyone and welcome to our talk today we're going to be discussing integrating substance use disorder treatment into a primary care practice my name is Dr. Holly Russell I am a family doctor by training and I'm part of the Recovery Center of Excellence at the University of Rochester today our objectives are going to be review approaching opioid abuse disorder as a chronic disease then we're going to talk about describing how to integrate substance use disorder treatment into primary care practices we'll move on to discuss the potential barriers to treatment of opioid use disorder and primary care and how to overcome these barriers and then we'll discuss fears versus the reality of treating substance use disorder in a primary care setting I do not have any disclosures I'm going to start off by talking about the definition of addiction from the National Institute of Drug Abuse addiction is defined as a chronic relapsing brain disease that is characterized by a compulsive drug seeking in use despite harmful consequences it is considered a brain disease because drugs change the brain they change its structure and how it works these brain changes can be long lasting and can lead to harmful behaviors the emphasis here is ours because I think it's important to really focus and understand substance use disorders as chronic and relapsing this helps frame why it's so important for us as primary care clinicians to be able to treat and manage these as we do all other chronic diseases on the right you'll see an image that shows the ongoing effects of continued use patients usually start with binge or intoxication from the substance when they stop using this leads to withdrawal which is quite a negative experience for patients it is that withdrawal and the negative consequences from not using that lead to continued use or preoccupation and anticipation of continued use the characteristics of a chronic disease in general include that it's influenced by behavior it's well studied it tends to worsen if untreated and it's heritable chronic diseases have predictable course effective treatment no known cure and high relapse rates chronic diseases require continued care adherence to treatment ongoing monitoring and long-term understanding between the patients and caregivers we all accept these as characteristics of most of the chronic diseases that we treat in primary care such as hypertension and diabetes however our expectations often differ when we think about substance use disorder when we think about a patient with substance use disorder we expect that after they attend a treatment for 30 days or 6 months there will be a cure in their symptoms we expect that once they stop using the medicine that treated their substance use disorder that there will still be lasting decreases in their drug use we often think that if we stop the medication that was treating them if the symptoms re-emerge that that demonstrates that the medicine didn't work rather than the other way we would think about it which is that we shouldn't have stopped it and we call pharmacotherapy for substance use disorders MAT or medication-assisted treatment whereas for all other disorders and diseases we call it pharmacotherapy the principles of treatment of any chronic disease involves changing deeply embedded behaviors when we think about management of diabetes we think about promoting good nutrition and physical activity and this can be very challenging as these are deeply embedded behaviors we often think about return to use with substance use disorder as I mentioned as a moral or willpower failure however when we have relapses and other chronic diseases for example a period of time when a blood pressure is less well controlled or a spike in a blood blood sugar for patients with diabetes we think of that as a common and part of the long-term management of it you'll see on the right a comparison of relapse rates between substance use disorders and other chronic diseases and you'll see that in fact the rates are quite similar if anything the rates for relapse or return to use are lower with substance use disorders when a patient with long-term substance use disorder relapses that indicates that alternative methods should be tried not that the person has a moral or will power failure issues and obstacles for treating substance use disorder the current treatment workforce is inadequate to treat the potential patient population in fact we know that the vast majority of people with substance use disorder do not receive treatment currently particularly of concern in rural communities is that substance use treatment center's geographic location may not allow for coverage of the target population area oftentimes patients will have to drive for hours to reach a substance use disorder treatment center pharmacotherapy for opioid use disorder may require a change in culture and workflow it's often not something that's taught in medical school or primary care residencies staffing and financial models need to be designed with sustainability in mind so while there are a lot of grants right now working on expanding treatment for opioid use disorder we have to think about the long-term management of this chronic disease and make sure that the plans that we put in place are sustainable outside of grant funding a quick review about the pharmacotherapy I'll start again with a note about the terms as I mentioned earlier you may have heard the term medication assisted treatment or MAT we are trying to move towards using pharmacotherapy or medications for opioid use disorder as it's felt to be less stigmatizing we would never say using Lisinopril as medication-assisted treatment for blood pressure management and so we're trying to think of this long-term treatment of this chronic disease in the same framework that we do other chronic diseases there are three types of medicines that are approved by the FDA for treatment of opioid use disorder there is full agonist treatment with methadone which means that it acts similarly to other opioids and is a full agonist on the opioid receptors in the brain there's partial agonist treatment with buprenorphine this is often prescribed in combination with naloxone which is an antagonist and the brand name is Suboxone for this or there is treatment with naltrexone which is a full opioid agonist the determination of which medication type is based on the individual patient's needs psychosocial treatment is also very important however all of the evidence that's been studied for this shows that the medications save lives and they should not be withheld if behavioral treatment is not easily available or if the patient is currently not open or interested in behavioral treatment on the right is a graph that shows again that pattern that we talked about at the beginning which is that when patients first start to use they experience a high or euphoria when they first begin using opioids after their acute use transitions into chronic use and it's important to note that this can happen in a matter of two to three weeks the patients become physically dependent on the opioids in this chronic disease phase of use patients actually experience withdrawal in the setting of not using and they have to use the opioids in order to feel normal so at this point they're really chasing the avoidance of that withdrawal it's really hard to overstate what a driver of use the withdrawal feelings are you'll often hear it's a like a bad flu or something like that but it's when you talk to patients about the withdrawal they'll say it's the worst feeling they've ever experienced and so there's the need to avoid that feeling is really what drives continued use and this is where the medications come into play so when we give a patient opioid agonist therapy which would be either the methadone or the buprenorphine this helps them return to that normal stage there right there in the middle where they're not chasing the withdrawal feeling but they're also not feeling that feeling of euphoria it really gets them back to their normal baseline so switching gears and talking specifically about primary care practices one thing that we've heard a lot is worries about what we're asking we are not asking primary care offices to become drug treatment referral destinations we're not asking them to provide medications to unstable patients we're not asking them to open closed panels to new patients or to write a high risk medication we're also not asking you to divert office staff or resources to drug treatment we commonly get asked well I don't have enough staff to have a Suboxone nurse or my schedule is so full I can't schedule a specific time for buprenorphine we are not asking you to do that we're asking you to treat your own patients who are stable and require a long-term buprenorphine treatment and when or if that patient becomes unstable or asking you to assist them in getting back to a more intensive substance use disorder treatment program for example an outpatient substance use treatment that's it quite simple really but we know that there are a lot of barriers and as I mentioned earlier this is a change to the culture of what we've been doing in primary care so one of the biggest things is really to gain acceptance that this is actually a reasonable thing to do so we're here to help you do that one of the things we can do is provide easily accessible education and clinical exposure for clinicians so that's part of what this video series is for but also if you want actual clinical exposure to shadow you're more than welcome to shadow any member of our team even for one session just to see how our workflows work and actually what an enjoyable and satisfying clinical experience it is we can also provide training for your administrative and support staff to help overcome any fears that they might have and to learn about treating addiction in primary care I can't overstate the importance of training the administrative and support staff they are the keys to making this a successful project in primary care additionally part of our other work is to provide education for medical students and residents with the goal eventually of treating opioid use disorder and primary care becoming a standard practice one of the things we hear commonly is a concern about bringing "those patients" into your office so I have a few things to say about that but the first thing is those patients are already in your office what we know about how common substance use disorders and opioid use disorders are tells us that all of us in primary care have patients with opioid use disorder and substance use disorder so they are already there what we can do is provide a safe place for them to share their concerns and their fears with us so that we need to involve education around decreasing stigma so that these patients we know they're there and we can treat them with respect and dignity again this involves education for both clinicians as well as support staff and clinical support staff one of the ways to find out that those patients are already in your office is by screening so part of our program is suggesting increasing screening for the patients that you already see we're going to talk about several different ways to do that so the DAST screening is one that is a two question screen that is very easy to combine with another screen I'm going to share with you called the AUDIT that allows for a practical application now both the DAST and the AUDIT have longer versions these are the shorter versions that have been studied in a primary care setting that are very short and fairly easy to use so for the DAST screening you're going to ask how many days in the past 12 months have you felt bad or guilty about your drug use and then how many days in the past 12 months have you used drugs other than those required for medical reasons a response of one or more days for either question meets criteria for substance use disorder and negative consequences of drug use now you see that the DAST focuses on drug use the AUDIT focuses on alcohol use because there are huge differences in what people consider to be a drink it is important that you start by setting the stage for what a standard drink is when you ask these questions after setting the stage it's important to then ask these three questions how often did you have a drink containing alcohol in the past year how many drinks do you have on a typical day when you were drinking in the past year and then how often did you have six or more drinks on one occasion in the past year you'll see the scoring below for men a score of four or more is considered positive and for women a score of three or more is considered positive when they looked at this three question questionnaire they did a variety of different cutoffs and if you're interested in catching more patients using three for everyone increases the sensitivity to 90 percent of patients with an alcohol disorder will screen positive and actually 98 percent of patients with heavy drinking will screen positive if you only use three as a cutoff however the specificity goes down to 60 percent whereas if you use four as the cutoff that gives you about an 86 percent sensitivity and a 72 percent specificity so that will decrease your number of false positives so in general it's suggested to use four for men and three for women and again we recommend combining the DAST-2 and the AUDIT-C that allows you to have a five questions screener that gives you very good sensitivity and specificity for both alcohol use disorder and substance use disorder an alternative option is to use the CAGE- AID this is a version of the classically used CAGE questionnaire that you may already be familiar with this four item questionnaire is the briefest effective screening test for lifetime alcohol use and or dependence but it is insensitive for detecting heavy drinking and it does not distinguish between active and past problem drinking and that's really in my mind the biggest limitation is that if a patient screens positive you need to ask them more to see if this was a problem in the past and they are currently drinking less or if it's a current problem so another common barrier that we hear about is this concern about having to get a special DEA waiver and if you have to do that it must be kind of dangerous and a highly specialized thing to try so to answer those barriers as I mentioned we provide clinician to clinician support so that is a way to help you kind of gain firsthand knowledge that this is not a dangerous or highly specialized thing so we invite you all to reach out to us to just ask questions or like I said to shadow us but additionally the regulation changed last April of 2021 they changed the rules so while you still do need to submit to get your waiver you do not need special training so previously for physicians it was eight hours and for advanced practice practitioners it was 24 hours you had to submit evidence that you had gotten training when you went to this website to get your DEA waiver so you do not need that special training now for up to 30 patients you can just go to this website below and actually complete the waiver form without any additional special training if you want to treat above 30 patients you are required to attend that previously mentioned eight hour or 24 hour training one of the biggest concerns we hear is what do we do if a patient relapses and this can be quite a challenge and I will say that no relapse is the same right and so we are going to provide some guidelines for you in the next recording which is called Practical Applications for Integration however what's really important in all of this is to provide patient-centered care so we really approach all of this from a harm reduction standpoint and our biggest goal is to keep patients alive because we know that patients with opioid use disorder have a very high risk of overdose death so whatever you do however you're managing patients with their relapse my number one goal is for you to continue to engage the patient we know that that will help keep them alive the other part of this is to provide easy connections so that patients who return to use or otherwise become unstable can be easily referred back to more intensive treatment programs so again if we use the framework from other chronic diseases if we think about patients who have heart disease when they're stable it's very common that we manage patients with their beta blockers and their aspirin for their heart disease and primary care however if the patients have an active MI or if they have active heart failure we would ask them to see a cardiologist the same thing is true for substance use disorder when patients are doing well and they're taking their medicines and then no changes are needed we can manage very easily in primary care but when patients are unstable or we feel that they need a higher level of care we need to make those connections and again we'll talk more about this in the Practical Applications module about how to form those connections there are specific challenges in rural populations around treatment and management of substance use disorders as I mentioned before some of it is the distance and so we know that the treatment centers are quite spread out and patients may have to drive hours to get to treatment with the advent of COVID-19 the regulations have been relaxed for using telemedicine for prescribing controlled substances we all hope that this continues this is kind of a matter of active discussion right now amongst the regulators however even before COVID-19 it was possible to use telemedicine for buprenorphine this was actually a common misconception because there are tight rules around using telemedicine for controlled substances or there were prior to COVID one of the things that people didn't understand was that actually you could use telemedicine to prescribe buprenorphine the rule technically said that you couldn't do it for the first visit so you'd have to see the patient in person for the first visit but follow-up visits were fine over telemedicine so my hope is that the relaxed guidelines will continue but even if we go back to a pre-COVID-19 telemedicine regulation you still can use it for buprenorphine the other thing which is a big problem everywhere is the stigma around substance use disorders but especially in rural populations where everybody knows everyone it's not uncommon that we hear from patients that they don't want to be seen at a treatment center because they might know the nurse they might know the medical assistant it might be their neighbor it might be the mother of their children's friends and they don't want to be seen there because of the stigma around having a substance use disorder so this is a great reason for expanding treatment into primary care because attending a visit at a primary care office could be for anything and it can help reduce the stigma associated with substance abuse disorder and help expand treatment and comfort with treatment so hopefully we're convincing you that this is a reasonable thing to do and you might be asking well what are the next steps how do we move forward so one of the biggest things is that we like to share the materials we've already developed for our program so that you don't have to reinvent the wheel on any of this so on our website you'll see that there is an intake packet an agreement of responsibilities for patients as well as smart phrases if you're using eRecord or things that you can use for whatever electronic health record to make templates for your notes these are all available on our website but if you want tools that are customizable you can contact our Recovery Center Excellence Technical Assistance team so I did tell you I would share the fears versus reality at one PCP office so this is our experience and we've been providing buprenorphine and other treatments for opioid use disorder at our office which is a family medicine office for the last eight and a half years when we first started we had a lot of fear and concern from our front staff worry that the phones would be ringing off the hook from patients that wanted buprenorphine and requests from patients that weren't our primary care patients the reality of our experiences was that when we first started we got a handful of calls initially and nearly all of them were patients from one specific outpatient facility where we had a personal relationship with one of the clinicians there so it was a connection that we were happy to facilitate and it did not at any point overwhelm our front desk staff from our nursing staff we heard concerns that patients will be demanding that there will be frequent phone calls and questions and lots of work with prior authorizations the reality is that in fact the patients are quite respectful they know the limits and the expectations because we set them clearly with that agreement of expectations document there's very minimal phone calls and while there are some prior authorizations it's no more so than any other medicine that we use in primary care we do urine drug screens at the visits routinely which include buprenorphine levels and help us keep a close eye on these patients I will say in fact we just recently got a message from one of our front desk staff about a concern that a patient had one of our buprenorphine patients and when I wrote back to answer the question I apologize for any confusion and she said oh no no apology needed the patients with opioid use disorder actually bother us far little and have far less phone calls than almost all of our other patients and so it was kind of some really good positive feedback that I got just last week about this so another one is what about my practice partners what about those who don't have the DEA X -Waiver those practice partners might have fear that they'll get acute visits and after hours calls related to buprenorphine or addiction that they will not know how to manage or that my partners will have to cover the refills if I'm away in reality that really has not been our experience and for the practice partners there's the added benefit that they can refer their patients to treatment within the office should their patients need it we schedule our visits so that all refills are done at the time of the office visit and we arrange emergency backup for the rare occasions that this has been needed again we'll talk about this a little more in some of the Practical Applications module but we schedule our patients every 28 days and we write our prescriptions every 28 or 56 days so that the patient's refills will happen at the time of their follow-up visits this helps us avoid a lot of phone calls and concerns about timing of refills on the weekend that kind of thing we do offer ourselves as emergency backup on the off chance that a provider without a waiver is covering while somebody is away usually there's a way to plan around that but in the case of emergency medical leaves it's been in the eight and a half years that we've been doing this I've had this happen twice where we've needed to use the emergency backup offer as I mentioned when the patient is actually checking out we make sure that their follow-up visit matches with their prescription with telemedicine that does make it a little bit more complicated because the patients aren't checking out in the way that they traditionally would so what I usually do is offer the patient a time and a date for their follow-up visit and write it in a specific message to our front desk staff so that they don't have to call the patients back and play phone tag around follow up this also helps to plan around vacations so when the patient is scheduling their follow-up visit if it's found that oh you usually come back in four weeks but Dr.
Smith is on vacation in four weeks then you can change the follow-up to be three weeks or five weeks and you can make sure that the follow-up interval and prescription length match so that it's a time when the waivered physician will be back again I mentioned unplanned time off we just asked that you have an emergency backup so if none of your practice partners have the DEA waiver we suggest that you reach out to another clinician either any of us at the Recovery Center of Excellence we're happy to be back up or if there's somebody at a local treatment agency just so that your staff has
somebody to contact in the case of unplanned time off again as I mentioned extremely rare but it's always good to plan just for the worst case scenario thank you so much for following with us for our talks this has been Integrating Substance Use Treatment into Primary Care Practice and please stay tuned for our upcoming modules you can see the list we have quite a variety of excellent topics for you here's our references and I'll end with our contact information for any questions about anything we talked about today or additional information please contact our Technical Assistance Center
you'll see there's an email a website or also on Twitter and Linkedin and there's also of course a phone call if that's easiest thank you again for your attention and please feel free to reach out with any questions
Holly Russell, MD
This session will provide a review of substance use disorder (SUD) as a chronic disease, discuss integrating SUD treatment into primary care practices, review the barriers to treatment, and discuss myths versus reality of treating individuals with an SUD.