Posts Tagged ‘ECHO UNC’

Buprenorphine in the Primary Care Setting

 

 

 

 

 

I was asked to participate in a project to help primary care doctors provide buprenorphine in office-based settings. This grant, awarded to some very smart people at the University of North Carolina, uses the ECHO model to help physicians in the community become more comfortable with treating patients with opioid use disorder in their offices.

This ECHO model, originally conceptualized at the University of New Mexico, uses a hub-and-spoke model to connect experts at UNC and other locations with primary care doctors at their North Carolina locations. The ECHO model can help not only the physicians and physician extenders, but also nurses, social workers and other staff members who are a part of patients’ treatments, using teleconferencing.

Other hub-and-spoke models have placed physicians and the hub and patients at the spokes, so this is a little different. It’s also different from telemedicine, since the participants at the hub and spoke are all care providers, not providers and patients.

It’s a great program, and gives free continuing medical education hours to the physicians who participate, at the same time they get help with problematic situations in their practice.

Our group is prepared. We’ve done practice sessions and we’ve gotten comfortable with the technology (no small achievement for me!).

Now all we need are providers to participate.

We’ve had some interest, but of course would like to reach as many providers as possible. We had some brainstorming sessions about how to get more participants. We would like to reach primary care providers who have a waiver to prescribe buprenorphine, or who may be interested in prescribing.

As it turns out, many physicians who get the waiver to prescribe buprenorphine don’t end up prescribing, or only prescribe to a few patients. These providers could see more patients with opioid use disorder, and help our nation’s situation with the treatment gap.

This treatment gap is the number of people who need treatment compared to the number of people who are able to receive it. At present, experts estimate that only about 20% of people who need treatment for opioid use disorder actually get it. Of course, some of the remaining 80% aren’t yet interested in treatment, but many are desperate for help, and can’t access it.

Due to changes in the DATA 2000 law, physician extenders like nurse practitioners and physicians assistants will be allowed to prescribe buprenorphine to treat opioid use disorder, after they take a 24-hour course. Of course…many extenders in my area have been prescribing buprenorphine for years, off-label “for pain” with a wink and a nod, but the new law will allow them to be legitimate prescribers. This may expand the number of prescribers a great deal, and help to close the treatment gap.

So why do providers, after getting the training to be able to prescribe buprenorphine, not end up prescribing?

A study done by Walley et al., published in the Journal of Internal Medicine, 2008, surveyed all 356 physicians in Massachusetts who were waivered to prescribe buprenorphine. The study was done in 2005, so that was relatively early in the history of office-based treatment. Out of that total, 235 responded to the survey. Of the 235 that answered the survey, 66% had prescribed at least once, and 34% had never prescribed buprenorphine.

Of the non-prescribers, around half said they would prescribe if some barriers were removed. Nearly a third of these doctors felt like they had insufficient office support. Other barriers, in rank of descending importance, were insufficient nursing support, lack of institutional support, insufficient staff knowledge, low demand for services, and payment issues. So this study showed physicians didn’t feel like they had the support staff that they needed.

Of the physicians who were already prescribing buprenorphine in their office-based practices, the biggest barriers, in descending order of importance, were payment issues, insufficient nursing support, insufficient office support, insufficient institutional support, and pharmacy issues.

Some additional tidbits of data emerged from this study. For example, psychiatrists were less likely to prescribe buprenorphine than were primary care physicians, and physicians in solo practice were more likely to prescribe than those in group practices.

I suspect it’s easier to implement changes to medical practice when you are the boss and the lone provider. In groups of physicians, it’s probably harder to change the status quo to take on new projects and ideas, even when more support staff are presumably available.

This trend, where many of the physicians waivered to prescribe buprenorphine don’t end up prescribing, or prescribe for very few patients, has continued through the last fifteen years.

A study from 2014 by Hutchinson et al., published in the Annals of Family Medicine, looked at 120 physicians in Washington State who received training in 2010 and 2011, to prescribe buprenorphine for opioid use disorder. Out of the 120 providers trained, 92 participated in the post-training survey. Of those providers, some were excluded because they were still in their residencies, or were prescribing buprenorphine before they took the course, leaving 78 physicians newly qualified to receive a waiver to start prescribing buprenorphine for opioid use disorder

Of these 78 physicians, only 64% actually applied for the waiver. Of these 50 physicians, only 22 actually ended up treating at least one patient with buprenorphine. In other words, only about a fourth of physicians who could start prescribing to treat opioid use disorder actually did so. Of these 22 physicians, half prescribed for only three or fewer patients.

Physicians in a practice where there was already another physician prescribing buprenorphine were significantly more likely to actually start prescribing than physician in practices where no other physicians prescribed. Younger physicians were more likely to prescribe buprenorphine than older physicians. Fewer than half of these physicians were willing to have their names listed on SAMHSA’s buprenorphine treatment locator site. (http://buprenorphine.samhsa.gov)

Another study by DeFlavio et al., Rural Remote Health, 2015, was done with an anonymous survey of all of Vermont’s primary care doctors. As it turns out, 10% were buprenorphine prescribers, while 80% said they saw patients addicted to opioids. The barriers that these physicians saw for buprenorphine treatment were inadequately trained staff, insufficient time, insufficient office space, and cumbersome regulations.

Interestingly, Vermont also used a “hub and spoke” model, where experts at the hub stabilize patients newly starting buprenorphine, and after stabilization they transfer to the “spokes” which are primary care providers who continue the prescribing for these patients. This model seemed to work well for the patients and physicians who participated.

As of today, SAMHSA’s website (https://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/physician-program-data accessed 6/6/17) says there are almost 38,000 physicians with waivers to prescribe buprenorphine from an office setting to treat opioid use disorder. Around 3200 have permission to treat up to 275 patients; nearly 9000 can treat up to 100 patients, and around 26,000 can treat up to thirty patients.

In other words, if all of these physicians were prescribing to their maximum, and were located in areas with the highest rates of opioid use disorder, we’d have enough manpower to treat all patients who wanted help.

But these providers aren’t at their maximum.

How can we convince these doctors to prescribe for more people? How can we recruit new providers, who will follow through with a commitment to treat people with opioid use disorder? How can we remove the barriers, which largely appear to fall under the category of insufficient support to give good care?

Some smart people have been working on this for some time, and we now have several models available to assist buprenorphine providers help patients with opioid use disorders.

“Collaborative Care Model,” also known as the Massachusetts model, uses nurse care managers to expand access to treatment. This model is based on how patients with other difficult chronic diseases are managed, such as diabetes and HIV infection. In other chronic illnesses, nurse care managers help the patient with day-to-day care management. This helps the physician know what is going on with the patient and gives the doctor much-needed support to manage the health of these patients.

Studies done on this model showed that patients did as well or better than patients managed only by physicians. This program expanded into community health centers, and the numbers of waivered physicians participating increased by 375%, though this was at a time when buprenorphine was first taking off anyway. The patients treated under this model also had significantly fewer hospital stays.

In this model, nurse managers were doing much of the medical management: doing inductions, doing follow-up on patients, and troubleshooting any problems the patients were having. Providers participating in the model mentioned that RNs can’t charge as much for the care they provide as physician extenders or physicians, so that’s a possible problem.

This year at the American Society of Addiction Medicine’s annual conference, Dr. Andrew Saxon spoke during a session which addressed how to engage practitioners to treat opioid use disorders. He treats patients in the Veterans Administration system, and describing an intriguing method that he called “academic detailing” that they use at the VA.

He said that pharmaceutical companies have already found a model that works, when it comes to getting doctors to prescribe new medications. These companies hire charming people to go to doctors’ offices to spend time talking with the physicians and physician extenders, explaining the new medication and giving them brochures with information.

Dr. Saxon started doing the same thing with VA doctors. Experienced providers make an appointment to speak with a doctor, and bring him or her information, perhaps bring lunch, and generally talk about the process and pleasures of treating opioid use disorders in an office setting. This one-on-one approach appears to work well, and the VA increased treatment availability a great deal using this approach.

The VA made a slick brochure, called “Opioid Use Disorder Provider Guide” which is a pretty good summary of information needed by providers starting to prescribe buprenorphine. Since it’s in the public domain, you can access this document at: https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Opioid_Use_Disorder_Educational_Guide.pdf

I think this academic detailing idea is a winner. It makes sense – pharmaceutical companies wouldn’t have used this method for years if it didn’t work.

To veer off-topic for a moment…it strikes me that I’ve been trying to “detail” local providers for five years, not to get them to prescribe, but just to get them to stop telling patients to get off buprenorphine and methadone. It would be a huge relief if local doctors encouraged these patients, rather than belittling them.

I exaggerate, of course. There are many physicians in my area who are great to work with, but I guess the more difficult doctors tend to stand out in my mind.

Maybe local doctors need detailing from a physician with credentials and/or clout. Perhaps I lack the credibility or personal charisma that makes other doctors listen to me. I’d like to enlist that kind of doctor to “detail” in my area.

Back to the topic at hand.

The VA isn’t the only agency that’s created guidelines.

The American Society of Addiction Medicine (ASAM) has had a similar document, composed by experts as a guide for prescribers: https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf

There’s also information published by SAMSHA (Substance Abuse and Mental Health Services Administration):

https://store.samhsa.gov/product/Medication-Assisted-Treatment-of-Opioid-Use-Disorder-Pocket-Guide/SMA16-4892PG

However, the last time I tried to download this one, there seemed to be a glitch.

So there’s plenty of information available for new prescribers, and there’s a nationwide support network called PCSS MAT, for Providers’ Clinical Support System. It’s an organization dedicated to training and mentoring medical providers in the treatment of opioid use disorders with medication-assisted therapies.

If you go to their website, (http://pcssmat.org/) you can access archived trainings about various topics relating to MAT. They have online modules, podcasts, and basic information. It’s possible to be connected with a one-on-one mentor with experience treating the disease. This helps the provider feel connected and supported, particularly with difficult issues that often arise.

So currently, there’s a ton of data and support for providers who want to treat patients with opioid use disorders, more than there’s ever been before.

With our ECHO UNC launch, providers can get specific recommendations for managing complex patients (with patient privacy protected, of course). Their staff can learn how to support the prescriber, and it’s all free, paid for under grant money. The prescriber can even earn continuing education credit hours, so it’s a win-win-win prospect for them.

I’ll keep my readers updated about how it’s going.

If you are a provider or know a provider who’d like to take advantage of this opportunity to learn, get help with issues that are vexing you, and get free credit hours for doing so, send me an email so I can connect you with the ECHO UNC hub. The technology is free and easy to use.

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